Posted: February 14th, 2023

Week 9 The Integumentary and Musculoskeletal Systems Discussion Assignment

Week 9 The Integumentary and Musculoskeletal Systems Discussion
Assignment
Complete only the History, Physical Exam, and Assessment sections of the Aquifer case study: Family Medicine 16: 68-year-old male with skin lesion.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Bookshelf
bookshelf.vitalsource.com
Username: Dayinthelife4@yahoo.com
Password: Williams21!
References
Bickley, L. (2016). Bates’ Guide to Physical Examination and History Taking (12th Ed.). Philadelphia, PA: Lippincott, William & Wilkins. ISBN: 9781469893419

Bickley, L.S. (2016). Bates’ Pocket Guide to Physical Examination and History Taking (8th Ed.). Philadephia, PA: Lippincott, Williams & Wilkins. ISBN: 9781496338488
Goolsby, M. J. & Grubbs, L. (2015). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). Philadelphia, PA: F. A. Davis Company. ISBN: 9780803643635
Perrin, R. (2017). Pocket Guide to APA Style (6th ed.). Stamford, CT; Cengage Learning. ISBN: 9781305969698

RUBRIC

Quality of Initial Posting:
Exemplary:
The information provided is accurate, providing an in-depth, well thought-out understanding of the topic(s) covered. An in-depth understanding provides an analysis of the information, synthesizing what is learned from the course/assigned readings.

Participation in Discussion
Exemplary:
Comments to two or more classmates’ initial posts and to the instructor’s comment (if applicable) on two or more days. Responses demonstrate an analysis of peers’ comments, building on previous posts. Comments extend and deepen meaningful conversation and may include a follow-up question.

Writing Mechanics (Spelling, Grammar, Citation Style) and Information Literacy
Exemplary:
Minor to no errors exist in grammar, mechanics, or spelling in both the initial post and comments to others. Formatting of citations and references is correct. If required for the assignment, utilizes sources to support work for both the initial post and the comments to other students. Sources include course and text readings as well as outside sources (when relevant) that are academic and authoritative (e.g., journal articles, other text books, .gov Web sites, professional organization Web sites, cases, statutes, or administrative rules).

68-year-old male with skin lesion

REVIEWING PRIMARY SKIN LESIONS
TEACHING
You are working in a family medicine clinic with Dr. Hill. She asks you to see Mr. Fitzgerald, a 68-year-old male who has been her patient for several years.
Dr. Hill tells you, “I spoke with Mr. Fitzgerald’s daughter at church yesterday. She is a nurse and is very concerned about her father’s skin condition along with his other medical problems. He was not particularly interested in coming to see me, but his daughter encouraged him to do so.”
She continues, “Before we go in and see Mr. Fitzgerald together, let’s briefly talk about the way to describe skin conditions. The terminology used to describe primary and secondary skin lesions is the basic language of dermatology, the means by which you can accurately describe the lesion to a colleague.”
TEACHING POINT
Primary and Secondary Skin Lesions
Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.
Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.
Question
List six nouns for primary lesions of the skin.
Answer Comment
Terms used to describe primary skin lesions are: macule, patch, papule, plaque, nodule, tumor, vesicle, bulla, pustule and wheal.
TEACHING POINT
Primary Skin Lesions
Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes “macule” is used for flat lesion of any size.
Patch: A patch is a macule greater than 1 cm in diameter.
Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.
Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau.
Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue.
Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.
Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid.
Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter.
Pustule: A pustule is a circumscribed elevated lesion that contains pus.
Wheal: A wheal is an area of elevated edema in the upper epidermis.
You and Dr. Hill enter the exam room. After introducing you to Mr. Fitzgerald, Dr. Hill receives permission from him to let you interview him and then steps out.
You sit down across from Mr. Fitzgerald and ask a few questions:
“Can you tell me what brought you here today?”
You look at on Mr. Fitzgerald’s left forearm to see the lesion he shows you.

Right away you note that the lesion is erythematous. Remembering what Dr. Hill just taught you about dermatology terminology, you run your finger over the lesion. Since the skin over the lesion does not feel raised to you, you decide you would call it either a macule (if it is smaller than one centimeter), or a patch (if it is larger than one centimeter). You estimate it is larger than one centimeter, and determine it is a “patch.”
“How long have you had this lesion?”
“I am not really sure, but it has been there a few years, maybe three or four years, and it seems to be growing a little bit recently.”
“Have you hurt your arm at all where the lesion is?”
“No.”
You decide to gather information about the rest of his history.
Past medical history: Seizure disorder diagnosed about 20 years ago. Takes carbamazepine.
Surgical history: Splenectomy done about 15 years ago because he fell from a ladder and injured his spleen.
Family history: He denies family history of skin cancers.
Social history: He is divorced and lives by himself, but is thinking about dating someone. He states that he does not smoke and stopped drinking alcohol about 10 years ago. He says that he used to be a heavy drinker. Retired from work as a brick layer for more than 30 years. Used to bike about 50 to 60 miles a week until his hip bothered him too much. Babysits for his daughter’s kids on the weekend, walks once daily.
Review of systems: Decreased stream and dribbling of urine for the past four to five months, but denies any chest pain, shortness of breath, or headaches. Slight right hip pain.
You thank Mr. Fitzgerald for the opportunity to interview him and inform him that you will step out of the room to discuss your findings with Dr. Hill. In the mean time, you instruct Mr. Fitzgerald to change into a gown.
TEACHING POINT
Full Skin Exam
When performing a skin exam at annual visits and/or evaluating a patient presenting with a skin lesion — have the patient change into a gown so you can perform a full skin exam.
Question
What is the grade of evidence of full skin examination by a primary care clinician for skin cancer screening in the adult general population by United States Preventive Service Task Force? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Grade A
• B. Grade B
• C. Grade C
• D. Grade E
• E. I statement
SUBMIT
Answer Comment
The correct answer is E.
In this clinical setting, the patient presents to the office with a suspicious skin condition, so a whole body skin examination by a physician may be warranted.
TEACHING POINT
Skin Cancer Screening Recommendations
The annual skin cancer screening by full body skin examination by health care provider is an I recommendation by USPSTF. I recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a whole body skin examination or a patient doing a skin self-examination for the early detection of skin cancers.
However, the American Cancer Society recommends appropriate cancer screening by a physician, including a skin examination, during a periodic health examination. The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the general population through the Academy’s Melanoma/Skin Cancer Screening Program. It also encourages regular self-examinations by individuals.
In the context of apparently conflicting recommendations by different organizations and when there is no sufficient evidence for the benefit or harm of certain recommendations, (like USPSTF I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Physicians, however, should be able to discuss the possible outcomes of the patient’s choice.
Question
In examining the skin, which of the following basic features of any lesions must be noted and considered? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. The distribution of the skin lesions.
• B. The shape of individual lesions.
• C. The arrangement of lesions.
• D. The size of the lesions.
• E. Associated symptoms.
SUBMIT
Answer Comment
The correct answers are A, B, C, D, E.
TEACHING POINT
Skin Examination
Distribution
The distribution of the skin lesions is important in diagnosing skin diseases. Many conditions have typical patterns or affect specific regions of the body. For example, psoriasis commonly affects extensor surfaces of joints, and atopic eczema impacts flexor surface of joints. Involvement of the palms and soles is seen in erythema multiforme, secondary syphilis and eczema.
Shape
Descriptions like oval, round, linear etc. can be used to describe the shape of the lesions. Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull’s eye lesion).
Arrangement
A linear arrangement of lesions may indicate a contact reaction to an exogenous substance brushing across the skin. Zosterform refers to lesions arranged along the cutaneous distribution of a spinal nerve.
Size
It is important to measure some lesions, especially nevi and skin malignancies like squamous cell carcinoma. Squamous cell carcinoma of the skin greater than 2 cm in diameter is regarded to be high risk for recurrence and metastasis. Nevi larger than 6 mm in diameter are more likely to be malignant than smaller nevi.
Associated symptoms
Associated symptoms, like itching, pain, or burning sensation are helpful to make a diagnosis of certain skin diseases. Eczema tends to be itchy compared to fungal skin infections. Pain is usually associated with herpes simplex or herpes zoster.
TEACHING POINT
Risk For Skin Cancer
Risk factors for nonmelanoma skin cancers include:
1. Previous skin cancer of any type gives 36% to 52% five-year risk of second skin cancer
2. 80% of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor)
3. Celtic ancestry
4. Fair complexions
5. People who burn easily
6. People who tan poorly and freckle
7. Red, blonde or light brown hair
8. Increasing age
9. Use of coal-tar products
10. Tobacco use
11. Psoralen use (PUVA therapy)
12. Male >>> female
13. Living near equator (UV exposure)
14. Outdoor work
15. Chronic osteomyelitis sinus tracts
16. Burn scars
17. Chronic skin ulcers
18. Xeroderma pigmentosum
19. Human papillomavirus infection
Risk factors for melanoma skin cancer include:
1. Previous melanoma
2. Celtic ancestry
3. Fair complexions
4. People who burn easily
5. People who tan poorly and freckle
6. Red, blonde or light brown hair
7. Early adulthood and later in life
8. “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk”
9. Radiation exposure
10. Melanoma in 1st or 2nd degree relative
11. Familial atypical mole-melanoma syndrome (FAMMS)
12. Male > female (slight)
13. Living near equator (UV exposure)
14. Indoor work
15. Higher incidence in those with more education and/or income
16. Nonfamilial dysplastic nevi
17. Large number of benign pigmented nevi
18. Giant pigmented congenital nevi
19. Nondysplastic nevi (markers for risk, not precursor lesions)
20. Xeroderma pigmentosum
21. Immunosuppression
22. Previous nonmelanoma skin cancer
23. Other malignancies
While incidence of skin cancer is higher among individuals with fair skin, patients with darker skin are also at risk for developing skin cancer and should also undergo regular screenings; conduct self examinations; and protect themselves from UV radiation.
You and Dr. Hill enter the room and perform the physical exam:
Vital signs:
• Temperature: 36.8 Celcius
• Heart rate: 64 beats/minute
• Respiratory rate: 18 breaths/minute
• Blood pressure: 124/76 mmHg
Head, eyes, ears, nose and throat (HEENT): Unremarkable.
Cardiovascular: Regular heart rhythm without a murmur.
Respiratory: Lungs clear to auscultation and percussion.
Abdominal: Well-healed linear scar on his left upper quadrant.
Skin: Entire skin examined from top to bottom, including his scalp, soles, and palms. Left forearm oval erythematous patch measures 18 by 16 mm.
Then Dr. Hill instructs Mr. Fitzgerald to get dressed while you both step out of the room, promising to return in a moment.
CONTINUE
SUMMARY STATEMENT
CLINICAL REASONING
Dr. Hill asks you, “What do you think are the most important findings so far?”
Question
Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.
More on summary statements.
Your response is recorded in your student case report.

Letter Count: 0/1000
SUBMIT
Answer Comment
Mr. Fitzgerald is a 68-year-old previously healthy male with a history of significant sun exposure who presents with a progressively enlarging 18-by-16 mm erythematous, pruritic, oval patch on his left forearm that has been present for three to four years.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
1. Epidemiology and risk factors: 68-year-old previously healthy man, history of significant sun exposure.
2. Key clinical findings about the present illness using qualifying adjectives and transformative language:
• pruritic, erythematous, oval 18-by-16 mm patch on left forearm
• chronic and progressively enlarging
CONTINUE
SUMMARY STATEMENT
CLINICAL REASONING
DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
Question
Dr. Hill then asks you to consider your differential diagnoses for Mr. Fitzgerald’s skin condition on his left forearm (oval-shaped, erythematous 18 mm x 16 mm patch), based on your findings from his history and physical examination. From the following, select the top six diagnoses on your differential.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Eczema (dermatitis)
• B. Psoriasis
• C. Squamous cell carcinoma of the skin
• D. Actinic keratosis
• E. Basal cell carcinoma of the skin
• F. Melanoma
• G. Lichen planus
• H. Seborrheic Keratosis
• I. Fungal skin infection
SUBMIT
Answer Comment
The correct answers are A, C, D, E, F, I.
Psoriasis is unlikely in this case because. Mr. Fitzgerald’s skin lesion is unilateral and on the flexor aspect of his left forearm. Lichen planus is unlikely because Mr. Fitzgerald’s skin lesion is a unilateral, well demarcated patch. Mr. Fitzgerald’s lesion is not characteristic of seborrheic keratoses.
TEACHING POINT
Differential of Oval-Shaped, Erythematous 18 x 16 mm Patch
Most Likely Diagnoses
Eczema • Eczema can appear erythematous and is often pruritic.
• Typically occurs behind the ears and on flexural areas.
Squamous cell carcinomas • Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend have a raised base.
• Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center.
• Borders are often irregular and bleed easily.
• Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance.
• Squamous cell carcinoma comprises 20 percent of all cases of skin cancer.
• History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.
Actinic keratoses • Actinic keratoses are scaly keratotic patches that are often more easily felt than seen.
• A history of significant sun exposure is a risk factor for actinic keratosis.
Basal cell carcinomas • Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia.
• Usually there is no associated itching or change in skin color.
• Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere.
• Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize.
• A long history of sun exposure is a risk factor for basal cell carcinoma.
Melanoma • In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases occurring in those younger than 40 years.
• Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern for melanoma.
• Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.
• The lesions of superficial spreading melanoma are dark brown or black.
• Slowly spreading irregular outline in the initial phase. Some areas may be a lighter shade.
• Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma.
• More than half of melanoma in females occurs on the legs.
• Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator.
• Persons with skin types that burns easily and tans with difficulty, and with red or blond hair, and freckles are at higher risk.
• Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.
Fungal infection • Can have acute, erythematous appearance.
Less Likely Diagnoses
Psoriasis • Psoriasis is usually bilateral and involves extensor surfaces of elbows and knees.
• Although psoriasis can present with involvement in patches, it usually plaque-like, with scaly, elevated lesions.
Lichen planus • Lichen planus typically presents as 2-10 mm flat-topped papules with an irregular, angulated border (polygonal papules) that are commonly located on the flexor surface of wrists and and on the legs immediately above the ankles.
• Most of the times, the lesions are multiple.
• Lichen planus is common in middle age.
Seborrheic keratoses • Elevated hyperpigmented lesions with a well-circumscribed border, stuck-on appearance, and variable tan-brown-black color and are most commonly located on the face and trunk.
CONTINUE
SUMMARY STATEMENT
CLINICAL REASONING
DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
TOPICAL CORTICOSTEROIDS
TEACHING

You discuss Mr. Fitzgerald’s diagnosis with Dr. Hill.
As you reflect on your differential diagnoses, you tell Dr. Hill that even though you are leaning toward the diagnosis of skin cancer (either squamous cell carcinoma, basal cell carcinoma, or melanoma), you have not completely ruled out the possibility that this is either eczema or a fungal skin infection.
“Well, this is a good topic for us to talk about,” Dr. Hill replies. “Suppose we decide this is eczema, how should we treat it?”
TEACHING POINT
Eczema Treatment
Eczema treatment: Medium-strength corticosteroid cream to decrease inflammatory process. In addition, regular use of emollient to soften the lesion and prevent exacerbations. If the lesion is dry, ointment may be a better vehicle for the corticosteroid.
Question
What are important aspects in selecting a topical corticosteroid when treating skin conditions? Select all that apply.
• A. Accurate diagnosis of skin disease.
• B. Steroid vehicles.
• C. Potency of steroid.
• D. Frequency of administration.
• E. Side effects.
Answer Comment
The correct answers are A, B, C, D, E.
TEACHING POINT
Topical Corticosteroids
Accurate diagnosis
An accurate diagnosis is essential in selecting a topical corticosteroid. Topical corticosteroids are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement. They can also provide symptomatic relief for burning and pruritic lesions.
Vehicle
The vehicle, or base, is the substance in which the active ingredient is dispersed. The base determines the rate at which the active ingredient is absorbed through the skin. There are several types of vehicles:
• Creams: The cream base is a mixture of several different organic chemicals (oils) and water, and usually contains a preservative. It can be used in nearly any area and therefore most often prescribed. It is cosmetically most acceptable. It has a drying effect with continuous use, therefore best for acute exudative inflammation.
• Ointments: The ointment base contains a limited number of organic compounds consisting primarily of grease such as petroleum jelly, with little or no water. Ointment is desirable for drier skin and has a greater penetration of medicine than a cream and therefore has enhanced potency.
• Lotions and gels: Lotions contain alcohol, which has drying effect on an oozing lesion. Lotions are most useful in the scalp area because they penetrate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflammation, such as poison ivy.
Potency
The anti-inflammatory properties of topical corticosteroids result in part from their ability to induce vasoconstriction to the small blood vessels in the upper dermis. The potency of corticosteroids are tabulated in seven groups, with group I the strongest and group VII the weakest.
Potency Examples Use to treat
Group I Augmented betamethasone dipropionate 0.05%, Halobetasol propionate 0.05% Psoriasis, lichen planus, severe hand eczema, and alopecia areata.
Group II Desoximetasone, Fluocinonide 0.05% Psoriasis, lichen planus, severe hand eczema, and alopecia areata.
Group III Betamethasone dipropionate 0.05%, Triamcinolone acetonide 0.5% (ointment or cream) Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group IV Floucinolone acetonide 0.025% (ointment), Triamcinolone acetonide 0.1% (ointment) Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group V Floucinolone acetonide 0.025% (cream), Triamcinolone acetonide 0.1% (lotion) or Triamcinolone acetonide 0.025% (ointment) Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group VI Alclometasone dipropionate 0.05%, Desonide 0.05% Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.
Group VII Hydrocortisone 1%, 2.5% Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.
Administration
Once or twice daily application is recommended for most preparations. More frequent administration does not provide better results.
Side effects
The most common side effect of topical corticosteroid is skin atrophy. It also can cause hypopigmentation. This is more apparent with darker skin tones. Topically applied high and ultra high potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension and other systemic side effects have been reported.
“Excellent,” Dr. Hill continues, “What if we decided Mr. Fitzgerald has a fungal infection, how would we treat that? Let’s talk about the basics of antifungal treatment and when to use systemic versus topical antifungal agents.”
Question
Among following conditions, which need to be treated with systemic antifungal agents? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Tinea pedis/tinea manuum
• B. Tinea corporis/tinea cruris
• C. Tinea capitis
• D. Tinea unguium (onychomycosis)
SUBMIT
Answer Comment
The correct answers are C, D.
In this case, if Mr. Fitzgerald had a fungal infection, you would treat it with an antifungal cream.
TEACHING POINT
When to Treat with Systemic vs Local Antifungal Agents
Systemic Therapy
Tinea capitis
Oral therapy is required to adequately treat tinea capitis, as they are able to penetrate the infected hair shaft where topical therapies cannot.
• Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.
• Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.
• In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans. However, in children with microsporum infection, new evidence suggests that the effect of griseofulvin is better than that of terbinafine.
Tinea unguium
Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis)are as follows:
• terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only)
• itraconazole 200 mg twice daily as pulse therapy
one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole
two pulses: fingernails
three pulses: toenails
Local Therapy
Tinea pedis, tinea manuum, tinea corporis, and tinea cruris can be treated with topical antifungal medications.
A wide variety of topical agents are available, in cream, gel, lotion, and shampoo formulations. A majority of the agents are of the ‘azole’ antifungal family (clotrimazole, miconazole, econazole, coiconazole, ticonazole, etc.). Terbinafine and naftifine represent the ‘allylamine’ family of agents. Both families of drugs are known for their high efficacy against the dermatophytes.
Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.
“Okay,” Dr. Hill summarizes, “so we’ve talked about how we would treat Mr. Fitzgerald if he has eczema or a fungal infection. Do you think we should treat his skin lesion with an antifungal cream or a corticosteroid cream?”
After you think about this for a moment, you reply, “I’m not really sure. I don’t think we can decide how to treat the lesion until we know the diagnosis.”
Question
Which of the following is the best next step to manage Mr. Fitzgerald’s skin lesion? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Observation
• B. Trial with antifungal or corticosteroid cream
• C. Trial with a combination of antifungal and corticosteroid cream
• D. Excisional biopsy
• E. Shave biopsy
• F. Incisional biopsy or punch biopsy
SUBMIT
Answer Comment
The correct answer is F.
TEACHING POINT
Skin Biopsy
Type of biopsy Procedure Tool & specimen size
Incisional / punch biopsy • Incisional biopsy means taking out a part of the skin lesion
• Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool. • Disposable punches are very convenient and available from two to eight millimeters in size.
• A full thickness of skin can easily be obtained with a punch biopsy.
• If a lesion is less than three millimeters in size, it does not need stitches after biopsy.
Excisional biopsy Excisional biopsy involves removing the whole lesion with a two to three millimeter margin, depending on the nature of the lesion. • Larger-sized punches may be useful for excisional punch biopsies.
• Diagnostic method of choice if there is a strong suspicion of malignant melanoma.
Shave biopsy Shave biopsy is feasible when the lesion is elevated above the surface. • Some experts occasionally elevate the lesion with lidocaine and shave in certain circumstances in order to avoid stitches.
Type of biopsy Relevance to Mr. Fitzgerald’s case
Incisional / punch biopsy This is feasible for Mr. Fitzgerald’s lesion.
Excisional biopsy In this case, malignant melanoma is much less likely based on observation.
Shave biopsy This is not an option for Mr. Fitzgerald’s lesion because his lesion is flat.
Observation (A)
Observation may not be the best choice at this time because of possible malignancy and the long duration of the lesion.
Treat with antifungal or corticosteroid cream (B & C)
It is not the best option to treat with a trial of antifungal or corticosteroid cream because this is not an acute problem necessitating a rapid response and the diagnosis is indeterminate.
You tell Dr. Hill that you think the best option for Mr. Fitzgerald is a punch biopsy. She smiles at you and replies, “Excellent. That was a bit of a trick question. In some cases, if there’s not a good diagnostic procedure, or if there is not huge risks associated with a condition, it is appropriate to treat empirically. But, in this situation, we have a good diagnostic test and the risks associated with skin cancer are too great to treat empirically or observe. I agree with you that a punch biopsy is the most suitable course of action for Mr. Fitzgerald at this point in time. Of course, we’ll have to obtain his consent first.”
She picks up a sheet of paper and shows you the consent form (.pdf).
Question
Aside from patient data and signatures, what information should be included in a procedural consent form? Include five items.
The suggested answer is shown below.

Letter Count: 0/1000
SUBMIT
Answer Comment
Please see the Teaching Point below for the full answer explanation.
TEACHING POINT
Consent Form for Procedures
A procedure consent form aims to document adherence to one of the four principles of medical ethics: respect for autonomy. Patients can not be viewed as making their own autonomous decisions if they are not adequately informed as to the true nature of the decision. An autonomous decision to allow providers to perform a procedure requires an understanding of the the reason for the procedure, the nature of the procedure, as well as its risks, benefits, and alternatives.
Thus, a consent form should contain:
• the name of the procedure
• the diagnosis
• the risks of the procedure
• the benefits of the procedure
• the alternative to the procedure that was proposed
• Now you and Dr. Hill return to the room to speak with Mr. Fitzgerald. Dr. Hill says, “The skin lesion on your left forearm seems to be a patch of long duration. As you were exposed to the sun during your working years and even now through biking, there is a possibility that this lesion could be either a condition that leads to skin cancer, or an early stage of skin cancer. We would like to take a small piece of tissue out of the lesion and take a look at it under a microscope. Then we can tell you exactly what the diagnosis is. We call this procedure a biopsy. There are different ways of doing biopsies, but the best way for your case is to use a cylindrical punch to take the tissue out under local anesthesia.”
• Mr. Fitzgerald says, “What if I don’t want to do the procedure?”
• “Well, if that is the case,” Dr. Hill answers, “we would not know the exact diagnosis and do not know how to treat your skin condition. And if it is truly a skin cancer, it could get worse and may proceed to advanced stage, which is difficult to treat.”
• “Well then I guess it is better for me to do it,” sighs Mr. Fitzgerald.
• “I agree.” Dr. Hill tells him. “Here is the form for you to sign. The risk with this procedure is that obviously you will have a scar after the procedure. There is also a small chance of bleeding and infection, even though we do our best to prevent these things. Do you have any questions?”
• Mr. Fitzgerald does not have further questions and signs his name on the form. Dr. Hill also signs her name on the form and asks the medical Helpant to sign their name as a witness. Then, Mr. Fitzgerald is escorted to the procedure room and the area of skin lesion is cleansed with povidone solution.
• CONTINUE

PROCEDURE
TESTING

Dr. Hill performs a punch biopsy on the skin lesion.
Dr. Hill and you enter the procedure room. She washes her hands and wears a disposable sterile gown and gloves with the help of a medical Helpant. You watch as she verifies that the area is disinfected with povidone solution and infiltrates the area of biopsy with 1% lidocaine solution using a 25 gauge needle.
After properly draping the area, she uses a three millimeter sized disposable punch and performs the punch biopsy at the periphery of the lesion. After taking out a small portion of the lesion and putting it in a formalin jar, Dr. Hill places a Steri -Strip to approximate the edge of the skin of the biopsy site.
She then applies compressive dressing and tells Mr. Fitzgerald to keep the wound dry for the next three days, and after that, to air dry the area. She mentions that the Steri-Strip may fall off after a few days. She instructs Mr. Fitzgerald that if he sees that the wound is red about six to seven days after the procedure, or sees pus coming out, he should contact Dr. Hill without delay. She finally mentions how to manage possible bleeding.
The specimen is being sent to the pathology lab and Dr. Hill asks Mr. Fitzgerald to come back to the office in about seven to ten days for follow up.
CONTINUE
PROCEDURE
TESTING
RECEIVING RESULT OF TEST
MANAGEMENT
A week has passed, and you see that Mr. Fitzgerald is on the schedule for his follow-up appointment.
You look up Mr. Fitzgerald’s electronic medical record (EMR) and find:
Pathology report of the punch biopsy: Squamous-cell carcinoma in-situ (Bowen’s disease).
You do some research on the office computer to figure out what the treatment options are. You discover that one factor to consider when determining which treatment to prescribe is the risk of recurrence and metastasis.
Question
Which of the following treatments would you choose for Mr. Fitzgerald’s skin cancer? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
• A. Wide excision under local anesthesia in the office
• B. Refer Mr. Fitzgerald for Mohs surgery.
• C. Treat the lesion with topical 5-fluorouracil (5-FU).
• D. Treat the lesion with cryotherapy.
• E. Refer Mr. Fitzgerald for radiation therapy.
• F. Observation for now, because it is still carcinoma in-situ.
SUBMIT
Answer Comment
The correct answer is A.
Squamous-Cell Carcinoma Treatment
Surgical excision (A) is the best option for Mr. Fitzgerald’s lesion. Topical treatments and radiation destroy the malignant cells. However they do not offer the opportunity to examine the margins of the tissue to confirm complete eradication of malignant tissue. In contrast, Mohs microscopic surgery is more extensive than what Mr. Fitzgerald’s lesion requires, as his lesion is relatively low risk in a cosmetically insignificant area, so there’s no reason to be overly careful about sparing tissue in this region, and a wide excision should suffice.
Observation (F) is not acceptable because of the proven diagnosis of SCC.
TEACHING POINT
Skin Lesion Therapy
Therapy Conditions treated More details
Surgical excision Most widely used treatment for cutaneous squamous-cell carcinomas (SCCs), particularly high risk lesions. Well defined, small (< 2 centimeters) SCC lacking any high-risk features requires a four millimeter margin of normal tissue around the visible tumor to result in 95% histologic cure rate.
Mohs microscopic surgery Patients with any nonmelanoma skin cancer greater than two centimeters, lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs micrographic surgery, with possible plastic repair. The surgeon can immediately review the pathology to confirm complete excision during a staged excision. Since this allows removal of the least necessary amount of tissue, this procedure is indicated in cosmetically sensitive areas. This ability to immediately confirm pathology is also useful in lesions with indistinct margins where more tissue than clinically apparent may require removal. If a difficult repair is anticipated or a poor cosmetic result is expected, referral is appropriate. To learn more about Mohs surgery, read an article from the American Academy of Family Physicians.

Topical 5-fluorouracil (5-FU) Approved by the United States Food and Drug Administration (FDA) for the treatment of actinic keratoses. Although topical 5 -FU is not approved for the treatment of Bowen’s disease (squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in these diseases when other treatment modalities are impractical and for patients who refuse surgical treatment.
Cryotherapy Useful for small, well defined, low risk invasive SCCs and Bowen’s disease. Destroys malignant cells by freezing and thawing. Cryotherapy does not permit histologic confirmation of the adequacy of treatment margins; thus, a substantial amount of training and experience is required to achieve consistently high cure rates.
Radiation therapy An option for the initial management of small, well-defined, primary SCCs, especially older patients and those who are not surgical candidates. However radiation therapy is contraindicated on tumors located on trunk and extremities. These areas are subjected to greater trauma and tension than skin on the head and neck, and they are more prone to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.
DEEP DIVE
After you have discussed treatment options with Dr. Hill and agree that wide excision is the best treatment for Mr. Fitzgerald, you and Dr. Hill go together to see him.
You find him seated in the exam room next to a young woman whom he introduces as his daughter Sarah, who is a nurse.
Dr. Hill begins, “We’ve received the results from your biopsy and you have what is called cutaneous squamous cell carcinoma in situ.”
“Just what we were afraid of, cancer,” sighs Sarah.
“I know that sounds scary, but these skin cancers are usually treatable. In fact, you have a particularly slow-growing form of squamous cell carcinoma called Bowen’s Disease. This has a very good prognosis. How are you feeling Mr. Fitzgerald?” Dr. Hill asks, looking at him in the eyes.
Mr. Fitzgerald says, “I thought that something was wrong and that was why I did not want to come to see you, but am I going to be OK?”
Dr. Hill puts her hand on his arm and continues. “As I said, it is very likely treatable without any harm. There are a few treatment options for this. I recommend what we call a wide excision. This can be done right here in the office under local anesthesia. We simply cut out the lesion and a margin of normal tissue around it. I send in the margin of normal tissue for histological testing to make sure that we’ve gotten all the cancer. This procedure has a 95% cure rate.”
“I can also refer you to a surgeon who can take the lesion off via Mohs micrographic surgery. The surgeon can confirm complete excision by immediately reviewing pathology, and then removing more tissue if necessary. I don’t think this is necessary in your case since I can see the edges of your lesion very clearly, so I should be able to get all of the cancer on the first attempt. Furthermore, your lesion is on your arm, not near any important structures like your eyes or nose; so we can make sure to excise enough area to get the cancer, and we won’t need to worry about plastic surgery.”
“Are there options other than surgery?” Mr. Fitzgerald wants to know.
“Because this lesion could spread if untreated, surgical removal is the best approach as excision allows me or the surgeon to confirm that the surgical margins are free of disease. But if you feel you really don’t want surgery, we can offer you alternative treatments that destroy cells such as topical 5-florouracil (5-FU), or cryotherapy.”
“Sounds like I’d better have the surgery done that you said you can do here,” Mr. Fitzgerald decides.
After obtaining the consent form, the excision of the lesion is done successfully by Dr. Hill and the specimen is sent to pathology. After the procedure, Dr. Hill gives Mr. Fitzgerald detailed postoperative wound care instructions and asks him to return for follow-up in ten days.
Patient Education for Protection Against Sun Damage
The key to preventing a skin cancer is to stay out of the sun and not to use a sunlamp. If you are going to be in the sun, you should wear clothes made from tightly woven cloth so the sun’s rays can’t get to your skin. You should also stay in the shade when you can. Wear a wide-brimmed hat to protect your face, neck, and ears.
Remember that clouds and water won’t protect you from the sun’s rays. The sun’s rays can also reflect off water, snow, and white sand.
If you can’t stay out of the sun or wear the right kind of clothing, you should use sunscreen to protect your skin. But don’t think that you are completely safe from the sun just because you are wearing sunscreen.
Use sunscreen with a sun protection factor (SPF) of 15 or more. Put the sunscreen everywhere the sun’s rays might touch you, including your ears, the back of your neck, and bald areas on your scalp. Put more on every two to three hours and after sweating or swimming.
Ten days later, Mr. Fitzgerald returns for follow-up. After examining his skin, Dr. Hill says, “There is no drainage from the wound and the margins are well-approximated; the wound is well-healed.” She then takes out stitches and continues, “Make sure that you wear a wide brimmed hat when you go out in the sun and do not expose yourself to the sun unnecessarily. Do you have any questions?”
“Doctor, my daughter, Sarah, is very worried about me and she’s asking me to get some information about what to look for on my skin.”
Dr. Hill advises Mr. Fitzgerald on what to look for.
TEACHING POINT
Patient Education on Skin Examination
What’s the best way to do a skin self-examination?
The best way is to use a full-length mirror and a hand-held mirror to check every inch of your skin.
• First, you need to learn where your birthmarks, moles and blemishes are and what they usually look like. Check for anything new, such as a change in the size, texture or color of a mole, or a sore that doesn’t heal.
• Look at the front and back of your body in the mirror, then raise your arms and look at the left and right sides.
• Bend your elbows and look carefully at your palms and forearms, including the undersides, and your upper arms.
• Check the back and front of your legs.
• Look between your buttocks and around your genital area.
• Sit and closely examine your feet, including the bottoms of your feet and the spaces between your toes.
• Look at your face, neck and scalp. You may want to use a comb or a blow dryer to move hair so that you can see better.
By checking yourself regularly, you’ll get familiar with what’s normal for you. If you find anything unusual, see your doctor. The earlier skin cancer is found, the better.
Question
What is the “ABCDE” rule of skin cancer detection?
The suggested answer is shown below.

Letter Count: 0/1000
SUBMIT
Answer Comment
Asymmetry, Border, Color, Diameter, Enlargement
Asymmetry: Asymmetry in two or more axes.
Border: Irregular border.
Color: Two or more colors.
Diameter: Six millimeters or greater.
Enlargement: Enlargement of the surface of the lesion. (Some references refer to alternate E’s: evolution or elevation)
When a hyperpigmented skin lesion shows asymmetry, irregular borders, mixed colors, a diameter of six millimeters or larger, or recent growth in size, your suspicion of melanoma becomes higher.
Mr. Fitzgerald thanks you both for the information regarding the care of his skin. Then he says, “Doctor, I have another question about something totally different. I have to get up during the night several times, maybe two or three times, to go to bathroom. It takes long time to start urination. Do I have a prostate condition?”
Dr. Hill asks you what could be your differential diagnoses in this case.
You say, “Considering the age and symptoms, BPH may be one of my top differential diagnoses, but I also think that we need to rule out acute or chronic prostatitis, and prostate cancer could be a very remote possibility.”
Dr. Hills says, “You are right in your differential diagnoses.”
Now, Dr. Hill speaks to Mr. Fitzgerald, “It is quite likely that you may have a condition called benign prostatic hyperplasia. Why don’t you make an appointment with me in a week or two so that we can look into this more? In the meantime, I’d like you to have a few tests done so we can have the information we need on hand the next time you come in. Also, please complete this questionnaire which will help us to better understand your condition.”
As Dr. Hill speaks with Mr. Fitzgerald, you think about how to assess Mr. Fitzgerald’s condition.
TEACHING POINT
Prostatitis Syndrome Symptoms
Prostatitis syndromes tend to occur in young and middle-aged males. The symptoms of prostatitis include pain (in the perineum, lower abdomen, testicles and penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen.
Question
Which of the following are necessary to evaluate when you suspect benign prostatic hyperplasia (BPH)? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Presence of classic lower urinary tract symptoms (LUTS).
• B. Examination of prostate.
• C. Urinalysis.
• D. Serum prostate specific antigen (PSA).
• E. Residual volume of urine.
• F. Urine flow rate.
• G. Serum BUN and creatinine.
SUBMIT
Answer Comment
The correct answers are A, B, C, D, G.
TEACHING POINT
Recommended Assessment of Suspected Benign Prostatic Hypertrophy
When evaluating for BPH, consider:
Clinical manifestation
Lower urinary tract symptoms (LUTS) • increased frequency of urination
• nocturia
• hesitancy
• urgency
• weak urinary stream
These symptoms typically appear slowly and progressively over a period of years.
Other conditions with similar symptoms • urinary tract and prostatic infections
• medication side effects, overactive bladder
• prostate cancer
Complications of untreated BPH • urinary tract infections
• acute urinary retention
• obstructive nephropathy
When evaluating for BPH, perform:
• Digital rectal exam should be done to assess prostate size and consistency and to detect nodules, indurations, and asymmetry — all of which raise suspicion for malignancy. Rectal sphincter tone should also be determined.
• Urinalysis should be done to detect urinary tract infection and blood, which could indicate bladder cancer or stones.
• Serum prostate specific antigen (PSA) level determination is recommended for males with a life expectancy of 10 years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5-alpha reductase inhibitor. This practice should be distinguished from recommendations about utilizing the PSA as a screening test. In this case, the patient actually has symptoms that could represent prostate cancer; screening is only for asymptomatic individuals.
The next week, Mr. Fitzgerald returns to the office for Assessment of his prostate problem. You look up the laboratory results.
PSA: 1.6 ng/ml.
Urinalysis: normal
You also review the results of his AUA BPH Symptom Index questionnaire.
You and Dr. Hill visit Mr. Fitzgerald together. With his permission, Dr. Hill performs a digital rectal exam and tells you, “Mr. Fitzgerald’s prostate is slightly enlarged, but I could not appreciate any nodule from each lobe of the prostate. He does not have any prostate tenderness either.”
Question
What is the first step in managing Mr. Fitzgerald’s prostate problem? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
• A. Start with 5-alpha-reductase inhibitor.
• B. Start with combination treatment of an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor.
• C. Behavior modifications to decrease symptoms.
• D. Refer the patient to urology service for surgical intervention like TURP (transurethral resection of the prostate).
• E. Start with alpha-adrenergic antagonists.
SUBMIT
Answer Comment
The correct answers are C, E.
TEACHING POINT
Management of Symptomatic Benign Prostatic Hyperplasia (BPH)
Behavior modifications to decrease lower urinary tract symptoms:
• avoiding fluids prior to bedtime or before going out
• reducing consumption of mild diuretics such as caffeine and alcohol
• limiting the use of salt and spices
• maintaining voiding schedules
Alpha-adrenergic antagonists decrease urinary symptoms in most males with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin and doxazosin. The American Urology Association (AUA) Guidelines Committee believes that all four medications are equally effective.
5-alpha-reductase inhibitors are more effective in males with larger prostates. Their effect on preventing acute urinary retention and reduction in need of surgery require long term treatment for more than a year. There are two 5-alpha-reductase inhibitors approved in the United States: finasteride and dutasteride.
In males with severe symptoms, those with a large prostate (>40 g), and in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, combination treatment with an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor may be desirable.
In general, if bladder outlet obstruction is creating a risk for upper urinary tract injury such as hydronephrosis, renal insufficiency, or lower urinary tract injury such as urinary retention, recurrent urinary tract infection, or bladder decompensation; surgical intervention is needed. Surgery also should be considered if combination treatment fails to improve symptoms of BPH.
You and Dr. Hill step out of the room to allow Mr. Fitzgerald to change back into his clothes.
When you return, Dr. Hill begins, “Mr. Fitzgerald, as we suspected, you have what is called ‘benign prostatic hyperplasia’ or BPH. This refers to the increase in size of the prostate that often occurs in middle-aged and older adult males. As you see in this picture, this enlargement of the prostate can compress the urethral canal to cause partial obstruction of the urethra, which interferes with the normal flow of urine; causing the urinary symptoms you have described.”

Mr. Fitzgerald wants to know,
“Does this mean I’m going to have prostate cancer?”
You explain to Mr. Fitzgerald what he can do to improve his symptoms.
Mr. Fitzgerald indicates that he doesn’t have any other questions. He thanks you and Dr. Hill for your time and prepares to leave.
TEACHING POINT
Benign Prostatic Hyperplasia (BPH) Treatment
BPH treatment focuses on relieving symptoms.
Instruct patients to:
• Give yourself time to urinate completely.
• Do not drink alcohol, drinks with caffeine in them (coffee, tea, colas), or other fluids in the evening.
• Do not take decongestants like Sudafed.
• Do not take antihistamines like Benadryl.
For moderate to severe symptoms (AUA score of 8 or more), prescribe alpha blockers to cause the muscles of the urethra to relax. Side effects of alpha blockers: feeling tired or sleepy.
As he was leaving Mr. Fitzgerald says, “Oh, I almost forgot to mention this, but I have one unrelated question. I’ve been having some trouble with my feet lately. Can we address that now as well?”
“Sure!” Dr. Hill smiles and agrees to hear out Mr. Fitzgerald’s concern, although you know she has patients waiting to be seen.
“It is a relatively minor matter.” He claims, “But I have been noticing this burning sensation for the last week after I stepped in a mud puddle as I changed my bike route. I rode the bike continually in a damp right shoe and sock as I did not bring spare socks with me. Do you want to take a look at them?”
Dr. Hill nods, and proceeds to examine Mr. Fitzgerald’s feet. After removing his shoes and socks the patient points to his toes, drawing your attention to the redness present in the inter-digital spaces. “Do you have any fever, swelling or other problems associated with this?” you inquire.
“No, just the burning and this redness” The patient says.
Dr. Hill steps aside to allow you to inspect Mr. Fitzgerald’s feet. You check between each toe looking for broken skin and find dry, red skin with occasional cracks in each web space. There is also redness proximal to the toes on the dorsum of the foot with the same dry appearance. You feel no warmth and Mr. Fitzgerald denies any pain to palpation. You further inspect finding no swelling and noting equal pulses in each of the feet.
Dr. Hill asks you,
“What condition may be causing Mr. Fitzgerald’s dry, cracking, erythematous skin between toes?”
You suggest a one-week course of terbinafine 1% cream. Dr. Hill concurs and provides Mr. Fitzgerald with prescription and instructions.
Mr. Fitzgerald thanks you and Dr. Hill for your help and heads out the door.

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