Scarring process and management — MCQs

10 questions

A 30-year-old man comes to the physician for a follow-up examination 1 month after sustaining a chemical burn over the dorsum of his right hand and forearm. Physical examination shows hyperextension of the hand at the wrist. The skin over the dorsum of the wrist is tense and there is a thick, epithelialized scar. Range of motion of the right wrist is restricted. This patient's contracture is most likely due to activity of which of the following cells?

During examination of a stab wound, a forensic pathologist notes that one end is sharp and pointed while the other is square or blunt. The wound track shows a consistent width. Which of the following weapon characteristics is most likely?

A 35-year-old woman with no significant past medical, past surgical, family or social history presents to clinic with a recently identified area of flat, intact, pigmented skin. The patient believes that this is a large freckle, and she states that it becomes darker during the summer when she is outdoors. On physical examination, you measure the lesion to be 6 mm in diameter. Which of the following is the best descriptor of this patient’s skin finding?

A 48-year-old man is brought to the emergency department with a stab wound to his chest. The wound is treated in the emergency room. Three months later he develops a firm 4 x 3 cm nodular mass with intact epithelium over the site of the chest wound. On local examination, the scar is firm, non-tender, and there is no erythema. The mass is excised and microscopic examination reveals fibroblasts with plentiful collagen. Which of the following processes is most likely related to the series of events mentioned above?

A 28-year-old woman and her husband are admitted to the office due to difficulties conceiving a child for the past year. Her menarche was at the age of 15 years, and her periods have been regular since then. Her medical history is positive for an abortion with curettage 5 years ago. A spermogram on the partner is performed, and it shows motile sperm cells. An ultrasound is performed on the patient and it is unremarkable. The laboratory results show that the FSH, LH, TSH, and prolactin levels are within normal ranges. A hysteroscopy is additionally performed and multiple adhesions are found in the uterus (refer to the image). Which of the following is the most likely composition of the scar tissue present in the uterus?

A 65-year-old woman presents to a dermatology clinic complaining about a couple of well-demarcated, dark, round skin lesions on her face. She claims she has had these lesions for 3 or 4 years. The lesions are painless, not pruritic, and have never bled. However, she is moderately distressed about the potential malignancy of these lesions after she heard that a close friend was just diagnosed with a melanoma. The medical history is unremarkable. Physical examination reveals a few well-demarcated, round, verrucous lesions, with a stuck-on appearance, distributed on the patient's back and face (see image). Under a dermatoscope, the lesions showed multiple comedo-like openings, milia cysts, and a cerebriform pattern. What is the best next step of management?

A 16-year-old boy presents to the emergency department after a skateboarding accident. He fell on a broken bottle and received a 4 cm wound on the dorsal aspect of his left hand. His vitals are stable and he was evaluated by the surgeon on call who determined that suturing was not required. After several weeks the wound has almost completely healed (see image). Which of the following is the correct description of this patient's wound before healing?

A 60-year-old male presents with fatigue, dyspnea on exertion, and lower extremity edema. Physical examination reveals an elevated jugular venous pressure and an S3 heart sound. Which of the following medications is most likely to improve this patient's symptoms?

A 30-year-old woman dies shortly after admission to the emergency department. The family requests an autopsy to determine cause of death. During the autopsy, multiple linear, parallel marks are noted across her wrists. Which of the following patterns suggests these are hesitation marks rather than defensive wounds?

Q10

A 45-year-old man comes to his primary care provider for a routine visit. The patient mentions that while he was cooking 5 days ago, he accidentally cut himself with a meat cleaver and lost the skin at the tip of his finger. After applying pressure and ice, the bleeding stopped and he did not seek treatment. The patient is otherwise healthy and does not take any daily medications. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 114/72 mmHg, pulse is 60/min, and respirations are 12/min. On exam, the patient demonstrates a 0.5 x 0.3 cm wound on the tip of his left third finger. No bone is involved, and the wound is red, soft, and painless. There are no signs of infection. Which of the following can be expected on histopathological examination of the wounded area?

Scarring process and management US Medical PG Practice Questions and MCQs

Question 1: A 30-year-old man comes to the physician for a follow-up examination 1 month after sustaining a chemical burn over the dorsum of his right hand and forearm. Physical examination shows hyperextension of the hand at the wrist. The skin over the dorsum of the wrist is tense and there is a thick, epithelialized scar. Range of motion of the right wrist is restricted. This patient's contracture is most likely due to activity of which of the following cells?

A. Fibroblasts
B. Myofibroblasts (Correct Answer)
C. Neutrophils
D. Macrophages
E. Endothelial cells

Explanation: ***Myofibroblasts*** - The patient presents with a **contracture** (restricted range of motion and hyperextension of the hand due to a thick scar) after a burn, which is characteristic of the action of **myofibroblasts**. - Myofibroblasts are specialized cells that possess features of both fibroblasts (synthesizing **collagen** and extracellular matrix) and smooth muscle cells (containing **actin microfilaments**), allowing them to exert contractile force which leads to scar contraction. *Fibroblasts* - While fibroblasts are crucial for **wound healing** by producing collagen and other extracellular matrix components, they primarily lay down the foundation for scar tissue. - They lack the strong contractile capabilities that lead to significant **tissue retraction** and contracture. *Neutrophils* - Neutrophils are **acute inflammatory cells** that primarily function in the early stages of wound healing to phagocytose debris and pathogens. - They do not play a direct role in the formation of **scar tissue** or **contractures**. *Macrophages* - Macrophages are important **immune cells** involved in clearing debris, presenting antigens, and releasing growth factors during the later stages of wound healing. - They also influence fibroblast activity, but they do not directly cause **tissue contraction** or scar formation. *Endothelial cells* - Endothelial cells line **blood vessels** and are essential for **angiogenesis** (formation of new blood vessels) during wound healing. - They are not involved in the **contractile process** that leads to scar contracture.

Question 2: During examination of a stab wound, a forensic pathologist notes that one end is sharp and pointed while the other is square or blunt. The wound track shows a consistent width. Which of the following weapon characteristics is most likely?

A. Ice pick
B. Double-edged knife
C. Scissors
D. Single-edged knife (Correct Answer)

Explanation: ***Single-edged knife*** - A **single-edged knife** has one sharp cutting edge and one blunt or squared-off spine, which accounts for one end of the stab wound being pointed and the other being square or blunt. - The **consistent width of the wound track** suggests that the blade was relatively flat and inserted perpendicular to the skin, with the width matching the blade's thickness. *Ice pick* - An **ice pick** typically produces a small, round, or oval wound that is often deeper than it is wide, and both ends would appear similar rather than one sharp and one blunt. - The wound edges would typically be uniform, not exhibiting a distinct sharp and blunt end indicative of a blade. *Double-edged knife* - A **double-edged knife** has two sharp cutting edges; therefore, both ends of the stab wound would appear sharp and pointed, contrary to the description of one blunt end. - The resulting wound might be more uniformly incised on both sides. *Scissors* - **Scissors**, when used to stab, typically create two parallel incised wounds or a jagged, irregular hole, depending on whether they were open or closed during impact. - It would be unlikely to produce a single stab wound with one sharp and one blunt end unless only one blade penetrated, which would still result in a different morphology than described.

Question 3: A 35-year-old woman with no significant past medical, past surgical, family or social history presents to clinic with a recently identified area of flat, intact, pigmented skin. The patient believes that this is a large freckle, and she states that it becomes darker during the summer when she is outdoors. On physical examination, you measure the lesion to be 6 mm in diameter. Which of the following is the best descriptor of this patient’s skin finding?

A. Wheal
B. Papule
C. Ulcer
D. Plaque
E. Macule (Correct Answer)

Explanation: ***Macule*** - A **macule** is a **flat, discolored lesion** that is less than 1 cm in diameter, which fits the description of a **flat, pigmented skin area** that is 6 mm in diameter. - The darkening of the lesion with sun exposure is characteristic of a **freckle**, which is a type of macule caused by increased melanin production without an increase in melanocyte numbers. *Wheal* - A **wheal** is a **transient, elevated lesion** caused by dermal edema, typically seen in allergic reactions like hives. - This patient's lesion is described as a **flat, pigmented area**, not an elevated, transient swelling. *Papule* - A **papule** is a **solid, elevated lesion** that is less than 1 cm in diameter. - The patient's skin finding is explicitly described as **flat** and intact, not elevated. *Ulcer* - An **ulcer** is a **loss of epidermis and dermis**, resulting in an open sore; it is not a flat, intact pigmented lesion. - The description of the lesion as **intact** rules out an ulcer, which involves a break in the skin surface. *Plaque* - A **plaque** is a **flat-topped, elevated lesion** that is larger than 1 cm in diameter. - While flat-topped, a plaque is **elevated**, and the patient's lesion is described as **flat**, not elevated.

Question 4: A 48-year-old man is brought to the emergency department with a stab wound to his chest. The wound is treated in the emergency room. Three months later he develops a firm 4 x 3 cm nodular mass with intact epithelium over the site of the chest wound. On local examination, the scar is firm, non-tender, and there is no erythema. The mass is excised and microscopic examination reveals fibroblasts with plentiful collagen. Which of the following processes is most likely related to the series of events mentioned above?

A. Development of a fibrosarcoma
B. Foreign body response from suturing
C. Staphylococcal wound infection
D. Poor wound healing from diabetes mellitus
E. Keloid scar formation (Correct Answer)

Explanation: ***Keloid scar formation*** - A **keloid** is a raised, firm, nodular scar that extends beyond the original wound boundaries and is characterized by excessive collagen deposition from **fibroblasts**. - The delayed presentation (3 months), firm nature, absence of inflammation (no erythema, non-tender), and microscopic findings of fibroblasts with plentiful collagen are classic features of a keloid. *Development of a fibrosarcoma* - A fibrosarcoma is a **malignant tumor** of fibroblasts, which would typically present with more aggressive growth, often pain, and possibly ulceration, none of which are described. - While composed of fibroblasts, fibrosarcomas exhibit **cellular atypia**, mitotic activity, and invasion, which are not mentioned in the microscopic description. *Foreign body response from suturing* - A foreign body response usually involves a **granulomatous inflammation** around foreign material, such as suture remnants. - The microscopic description of "fibroblasts with plentiful collagen" without mention of inflammatory cells or foreign bodies makes this less likely. *Staphylococcal wound infection* - A **bacterial infection** would typically present with signs of acute inflammation such as erythema, warmth, pain, and possibly pus, shortly after the wound. - The mass is described as non-tender with no erythema, and the 3-month delay makes an active infection less probable. *Poor wound healing from diabetes mellitus* - Poor wound healing in diabetes often manifests as **delayed closure**, chronic ulcers, and increased susceptibility to infection, rather than an overgrowth of fibrous tissue in the form of a nodular mass. - While diabetes can affect wound healing, the specific description of a firm, nodular mass with excessive collagen points away from typical diabetic wound complications.

Question 5: A 28-year-old woman and her husband are admitted to the office due to difficulties conceiving a child for the past year. Her menarche was at the age of 15 years, and her periods have been regular since then. Her medical history is positive for an abortion with curettage 5 years ago. A spermogram on the partner is performed, and it shows motile sperm cells. An ultrasound is performed on the patient and it is unremarkable. The laboratory results show that the FSH, LH, TSH, and prolactin levels are within normal ranges. A hysteroscopy is additionally performed and multiple adhesions are found in the uterus (refer to the image). Which of the following is the most likely composition of the scar tissue present in the uterus?

A. Type 3 collagen
B. Type 4 collagen
C. Type 2 collagen
D. Type 1 collagen (Correct Answer)
E. Elastin

Explanation: ***Type 1 collagen*** - This patient presents with **Asherman's syndrome**, characterized by intrauterine adhesions, often following uterine surgery like **curettage**. These adhesions are primarily composed of **Type 1 collagen**, which is the most abundant type of collagen in the human body and a major component of scar tissue. - **Type 1 collagen** provides tensile strength and is crucial for wound healing and forming scar tissue in most connective tissues, including the uterus. *Type 3 collagen* - **Type 3 collagen** is found in distensible tissues like blood vessels, the uterus, and skin, and is important during the **early stages of wound healing**. - While present in the uterus and initially involved in wound repair, **mature scar tissue** predominantly consists of **Type 1 collagen**. *Type 4 collagen* - **Type 4 collagen** is a major component of the **basal lamina**, a specialized extracellular matrix that underlies epithelial and endothelial cells. - It does not form fibrillar structures and is not the primary component of robust scar tissue found in Asherman's syndrome. *Type 2 collagen* - **Type 2 collagen** is the main collagen type found in **hyaline cartilage** and elastic cartilage, providing resistance to pressure. - It is not found in significant amounts in uterine tissue or scar tissue formed within the uterus. *Elastin* - **Elastin** is a protein that provides **elasticity** to tissues like blood vessels, skin, and lungs, allowing them to stretch and recoil. - While present in the uterus for its contractile properties, it is not the primary constituent of **fibrotic scar tissue** forming adhesions.

Question 6: A 65-year-old woman presents to a dermatology clinic complaining about a couple of well-demarcated, dark, round skin lesions on her face. She claims she has had these lesions for 3 or 4 years. The lesions are painless, not pruritic, and have never bled. However, she is moderately distressed about the potential malignancy of these lesions after she heard that a close friend was just diagnosed with a melanoma. The medical history is unremarkable. Physical examination reveals a few well-demarcated, round, verrucous lesions, with a stuck-on appearance, distributed on the patient's back and face (see image). Under a dermatoscope, the lesions showed multiple comedo-like openings, milia cysts, and a cerebriform pattern. What is the best next step of management?

A. Shave excision
B. Topical fluorouracil
C. Cryotherapy
D. Excisional biopsy
E. Reassure the patient and provide general recommendations (Correct Answer)

Explanation: ***Reassure the patient and provide general recommendations*** - The description of the lesions (well-demarcated, dark, round, verrucous, stuck-on appearance, comodo-openings, milia cysts, cerebriform pattern) is classic for **seborrheic keratoses**, which are benign. - Given the benign nature and the patient's distress about potential malignancy, reassurance is the primary and most appropriate step. Removal is only indicated for cosmetic reasons, irritation, or diagnostic uncertainty. *Shave excision* - While a shave excision can remove seborrheic keratoses for cosmetic reasons or if symptomatic, it is an invasive procedure and not the **best first step** when the diagnosis is clear and the patient's main concern is malignancy. - The lesions are clinically and dermatoscopically consistent with benign seborrheic keratoses, making a diagnostic excision unnecessary at this point. *Topical fluorouracil* - **Topical fluorouracil** is used to treat actinic keratoses and superficial basal cell carcinomas, not seborrheic keratoses. - Applying this medication for seborrheic keratoses would be ineffective and potentially cause unnecessary side effects. *Cryotherapy* - **Cryotherapy** can be used to remove seborrheic keratoses, but similar to shave excision, it's a treatment for removal rather than an initial management step when the primary need is reassurance regarding a benign condition. - It would be considered if the patient later desired removal for cosmetic reasons or irritation after being appropriately reassured. *Excisional biopsy* - An **excisional biopsy** is typically performed to completely remove a suspicious lesion with adequate margins or to provide a definitive diagnosis, particularly for suspected malignancies like melanoma. - Given the classic presentation of benign seborrheic keratoses, an excisional biopsy is **overly aggressive** and unnecessary as the initial step.

Question 7: A 16-year-old boy presents to the emergency department after a skateboarding accident. He fell on a broken bottle and received a 4 cm wound on the dorsal aspect of his left hand. His vitals are stable and he was evaluated by the surgeon on call who determined that suturing was not required. After several weeks the wound has almost completely healed (see image). Which of the following is the correct description of this patient's wound before healing?

A. Incised wound (Correct Answer)
B. Abrasion
C. Laceration
D. Avulsion
E. Puncture

Explanation: ***Incised wound*** - An **incised wound** is caused by a sharp object, such as a broken bottle, resulting in a clean, straight cut with well-defined edges and minimal tissue damage. - The characteristics of the injury (sharp object mechanism, 4 cm linear wound) and the clinical decision that suturing was not required suggest a relatively clean incised wound with edges that could approximate well. - Incised wounds typically heal with **fine linear scars** as shown in the image, especially when the edges are well-approximated. *Abrasion* - An abrasion is a **superficial wound** caused by friction or scraping, leading to removal of the epidermis and sometimes the superficial dermis. - This mechanism does not match the described injury from a broken bottle, and abrasions produce broad, shallow wounds rather than deep linear cuts. - Abrasions heal with minimal scarring and would not produce the linear scar pattern shown. *Laceration* - A laceration is a wound with **irregular, torn edges** typically caused by blunt force trauma or crushing injury. - While broken glass can sometimes cause lacerations, the description of a clean "4 cm wound" from falling on a broken bottle more strongly suggests a sharp cutting mechanism rather than tearing. - Lacerations have jagged edges with more tissue damage and typically require debridement or careful closure. *Avulsion* - An **avulsion** involves forcible tearing away of tissue, often resulting in significant tissue loss with irregular, gaping wounds. - This injury pattern is much more severe than described and would typically require complex surgical management, including possible skin grafting. - The mechanism (falling on broken glass) and the relatively straightforward healing do not support an avulsion injury. *Puncture* - A puncture wound is caused by a **pointed object** penetrating the skin, creating a small entry hole with depth greater than width. - The description of a "4 cm wound" indicates a linear length, not a deep narrow penetration typical of puncture wounds. - Puncture wounds carry high infection risk and would not produce the linear scar pattern shown in the image.

Question 8: A 60-year-old male presents with fatigue, dyspnea on exertion, and lower extremity edema. Physical examination reveals an elevated jugular venous pressure and an S3 heart sound. Which of the following medications is most likely to improve this patient's symptoms?

A. Metoprolol
B. Furosemide (Correct Answer)
C. Losartan
D. Lisinopril
E. Spironolactone

Explanation: ***Correct: Furosemide*** - The patient presents with classic signs of **heart failure with fluid overload**: dyspnea on exertion, lower extremity edema, elevated jugular venous pressure, and an S3 heart sound (indicating volume overload). - **Furosemide**, a **loop diuretic**, is the most effective medication for **rapid symptomatic relief** in heart failure with congestion. It works by blocking sodium and water reabsorption in the loop of Henle, promoting diuresis and reducing **pulmonary congestion** and **peripheral edema**. - While other medications like ACE inhibitors, beta-blockers, and aldosterone antagonists are crucial for **long-term mortality reduction** and disease modification, loop diuretics provide the **fastest and most direct symptomatic improvement** for fluid overload. *Incorrect: Metoprolol* - **Metoprolol** is a **beta-blocker** that is essential for chronic HFrEF management, providing **mortality reduction** and **reverse cardiac remodeling**. - However, beta-blockers take **weeks to months** to show symptomatic benefit and can initially **worsen symptoms** due to negative inotropic effects, especially in acute decompensation. - While important for long-term management, metoprolol does not provide immediate symptomatic relief from fluid overload. *Incorrect: Losartan* - **Losartan** is an **angiotensin receptor blocker (ARB)** used as an alternative to ACE inhibitors in HFrEF, particularly in patients who develop cough with ACE inhibitors. - ARBs reduce **afterload** and prevent **cardiac remodeling**, contributing to improved long-term outcomes and mortality reduction. - However, they do not directly address fluid overload and do not provide rapid symptomatic relief compared to diuretics. *Incorrect: Spironolactone* - **Spironolactone** is an **aldosterone antagonist** that improves mortality in HFrEF by preventing myocardial fibrosis, reducing cardiac remodeling, and preventing potassium loss. - While beneficial for long-term management, spironolactone has **weak diuretic effects** and takes weeks to provide symptomatic benefit. - It is not the first-line choice for **acute symptomatic relief** of volume overload, though it is an important component of chronic HFrEF therapy. *Incorrect: Lisinopril* - **Lisinopril** is an **ACE inhibitor** and a cornerstone of HFrEF therapy, reducing **mortality**, **hospitalizations**, and preventing **cardiac remodeling** by reducing afterload and preload. - While ACE inhibitors improve symptoms over time, they do not provide the **rapid diuretic effect** needed for immediate relief of dyspnea and edema. - Lisinopril is essential for long-term management but is not the most effective option for acute symptomatic improvement of fluid overload.

Question 9: A 30-year-old woman dies shortly after admission to the emergency department. The family requests an autopsy to determine cause of death. During the autopsy, multiple linear, parallel marks are noted across her wrists. Which of the following patterns suggests these are hesitation marks rather than defensive wounds?

A. Irregular, scattered marks
B. Diagonal, deep lacerations
C. Deep, single cuts
D. Superficial, parallel cuts (Correct Answer)

Explanation: ***Superficial, parallel cuts*** - **Hesitation marks** are typically numerous, **superficial**, and **parallel**, reflecting a tentative or indecisive attempt and often made in the same direction. - They tend to be concentrated in an area of the body chosen for self-harm, such as the wrists, and are usually consistent with a non-fatal intent. *Irregular, scattered marks* - This pattern is more indicative of **defensive wounds**, which are often scattered and irregular due to attempts to ward off an attack. - Defensive wounds are typically found on the palms, forearms, and other areas used for protection. *Diagonal, deep lacerations* - **Deep lacerations**, especially if diagonal and singular, are less characteristic of hesitation marks and more suggestive of a determined attempt to inflict fatal injury or could be defensive. - **Hesitation marks** are typically not aimed at quickly causing fatal harm. *Deep, single cuts* - A single, **deep cut** is often associated with a resolute intent to cause significant injury or death, rather than the hesitant, superficial nature of hesitation marks. - This pattern would warrant further investigation into the intent and circumstances surrounding the injury.

Question 10: A 45-year-old man comes to his primary care provider for a routine visit. The patient mentions that while he was cooking 5 days ago, he accidentally cut himself with a meat cleaver and lost the skin at the tip of his finger. After applying pressure and ice, the bleeding stopped and he did not seek treatment. The patient is otherwise healthy and does not take any daily medications. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 114/72 mmHg, pulse is 60/min, and respirations are 12/min. On exam, the patient demonstrates a 0.5 x 0.3 cm wound on the tip of his left third finger. No bone is involved, and the wound is red, soft, and painless. There are no signs of infection. Which of the following can be expected on histopathological examination of the wounded area?

A. Platelet aggregates
B. Epithelial cell migration from the wound borders
C. Neutrophil migration into the wound
D. Deposition of type III collagen (Correct Answer)
E. Deposition of type I collagen

Explanation: ***Deposition of type III collagen*** - Five days post-injury, the **proliferative phase of wound healing** is active, characterized by the formation of an initial **granulation tissue** matrix primarily composed of **Type III collagen**. - This type of collagen forms thinner, more flexible fibers that provide a temporary scaffold for tissue regeneration before being gradually replaced by stronger Type I collagen. *Platelet aggregates* - **Platelet aggregation** occurs immediately after injury as part of **hemostasis**, forming a plug to stop bleeding. - By five days, this initial phase would have concluded, and the primary focus would be on tissue repair and regeneration. *Epithelial cell migration from the wound borders* - **Epithelial cell migration** for re-epithelialization typically occurs within the first 24-48 hours after injury, forming a new epidermal layer over the wound. - While it continues, the dominant histological feature at day 5 in an open wound of this size would be **granulation tissue formation** in the dermis. *Neutrophil migration into the wound* - **Neutrophil migration** is a hallmark of the **inflammatory phase**, peaking within 24-48 hours post-injury to clear debris and microbes. - By day 5, the inflammatory phase would be subsiding, and macrophages would be more prevalent, signaling the transition to the proliferative phase. *Deposition of type I collagen* - **Type I collagen** is the predominant collagen found in mature scar tissue and is deposited during the later **remodeling phase** of wound healing. - While some Type I collagen may be present, **Type III collagen** is characteristic of the early granulation tissue prominent at day 5.

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