Shane recently read an article that explains how to prevent children from spending too much time interacting with online entertainment and social networks. A few days later, Shane refuses to buy his son a new cell phone, explaining his decision by using words and phrases similar to the ones he read in the article.

21/23  that’s 91%
RETAKE

 

21 questions were answered correctly.
questions were answered incorrectly.
1

Which of the following speeches is primarily meant to persuade?

2

Shane recently read an article that explains how to prevent children from spending too much time interacting with online entertainment and social networks. A few days later, Shane refuses to buy his son a new cell phone, explaining his decision by using words and phrases similar to the ones he read in the article.

Shane engaged in the act of __________ when he explained to his son why he could not get a new cell phone.

3

Which of the following actions best fits the remembering stage of the listening process?

4

Which scenario is the best example of culture getting in the way of effective communication?

5

Janet finished making her practice elevator pitch to her husband, Michael. He knew that there was a lot riding on the pitch, and wanted to help his wife get it right. Michael noticed how nervous Janet was: her hands and knees were shaking.

When she finished, Michael told Janet that she did badly because she was so visibly nervous. He reminded her that audiences not only listen to the message, but also look for confidence in the speaker’s body language.

The element of effective criticism that Michael’s feedback did not include is __________.

6

Alejandro was surprised to read negative feedback on his course reviews at the end of the semester. He thought that his students would have been grateful that he had dismissed them from class early on Friday afternoons, as was customary when he taught in Grenada. Unfortunately, many of his current students felt that they weren’t receiving his full attention.

In this example, Alejandro failed to account for __________ when considering his audience.

7

Which of the following situations describes the actions of an ethical speaker?

8

As James prepared his speech, he made sure to stay on-topic and write a well-organized speech.

James remembered the public speaking best practice of __________.

9

Andrea is nervous about presenting her research findings at the local steel-worker’s union meeting. She knows that her information will be appreciated, but she wants to make sure that her speech is well received too.

Although she included stories provided by men she met while conducting her research, she knows that the union has female members too. She revises her speech, using more inclusive language.

In the situation above, Andrea attempts to account for __________ in her speech.

10

Elaine’s boss asks her to take notes on Mark’s client presentation and then discuss it with him. Elaine supervises Mark and has already noted that he struggles with his tone when speaking publicly, which is hindering his ability to pitch advertising campaigns. Mark is presenting to a prospective new client who is looking for a company to market their clothing line. The company recently expanded their line to include new children’s items. Mark missed last week’s briefing on the client and prepared a pitch based on adult clothes.

Mark failed to consider which public speaking best practice?

11

When soliciting information, sometimes a speaker will __________, which enables him or her to ask questions that can tailor the information received in real-time.

12

Lillian was working when Mike entered her office in tears. He told her about the death of his dog, and how devastated his whole family is.

Which situation best fits the responding stage of the listening process?

13

Speakers want well-organized speeches in order to keep their audiences engaged. When developing a speech, a speaker must select a topic, a purpose, and a thesis.

In order to come up with a topic for a speech, a speaker can try __________, a method of problem solving in which individuals or group members contribute ideas quickly and spontaneously.

14

Which of the follow scenarios describes an effective way to provide criticism?

15

Sandy had to give a toast at a party for her parents’ 50th wedding anniversary. Sandy and her siblings organized the party as a surprise for their parents. Sandy’s mother-in-law was at the party, and her husband had just passed away the previous month. They were married 45 years, and he died suddenly of a heart attack.

Determine which of the following circumstances describes an environmental context that will affect Sandy’s speech.

16

John is taking an accounting class at the local community college. The course targets small-business owners and offers students the option to watch prerecorded videos of the instructor delivering a lecture on their own time.

The lectures represent an example of __________.

17

Janet squirmed in her chair as the school board candidate presented his agenda. She had been sitting all day, and her chair was aggravating her lower back pain.

This is an example of __________ leading to poor listening. 

18

Mitch is the vice principal of an elementary school. A monthly assembly is approaching, and it is normal for the staff of the school to give advisory speeches at such assemblies. Mitch is scheduled to give a persuasive speech at this gathering, and he is trying to determine what subject he wants to discuss. He remembers reading a recent article about the amount of time children spend online and decides to address this in his speech.

Which of the following statements represents a good thesis for Mitch’s persuasive speech?

19

James is the newly-appointed director of product development. He plans to host a breakfast for his new team members on Monday, at which he will give a speech.

Which of James’s speeches has the purpose of informing his audience?

20

Determine which of the following views on public speaking would be attributed to Aristotle.

 

21

Which of the following is an example of an informative speech?

 

22

Which of the following is an example of a physical contextual factor that Jessica should consider when preparing for her speech to the school board?

23

Jose was nervous because he had to make a presentation at work. After telling his wife about his uneasiness, she suggested that he practice by making his speech to their family every night after dinner. Jose found that speaking to his family in this way increased his confidence.

This experience shows how Jose benefited from __________ through public speaking.  

Which ethical theory (of the 6 approved ones ONLY – Kant; Act Utilitarianism; Rule Utilitarianism; Care Ethics; Virtue Ethics; and Social Contract) would you apply to this topic to defend your stance?

Which ethical theory (of the 6 approved ones ONLY – Kant; Act Utilitarianism; Rule Utilitarianism; Care Ethics; Virtue Ethics; and Social Contract) would you apply to this topic to defend your stance? Explain fully. 250 words AND COMPLETE TEMPLATE

A)  In this reflection you must first define the key terms of the debate (for example, define what Euthanasia/Abortion/Stem Cell/Public Health/PreNatal Testing/Animal Research/Health Care, etc. means and what are the different types depending on which topic you are discussing)

B)  Define and explain the ethical theory you chose (show me you know exactly what the theory is and does – in your own words)

C)  Present the evidence both pro and con and follow up how using your ethical theory is the best way to determine whether or not your stance is really ethical

D)  Conclusion – any final thoughts and opinions would go here

E)  2 to 3 resources as support for your evidence (text book counts as 1)

8085 Module2 Assignment: Professional Development of Others

For this Assignment, you will assume the role of a director of an early childhood setting of your choice. Imagine that you have just been awarded a generous grant to promote the professional development and leadership capacity of your staff. The focus of this Assignment, however, focuses less on the content of your professional development, and more on how you design professional development opportunities that serve to develop, support, and nurture staff.

To prepare:
You are encouraged to delve more deeply into the advocacy topic you selected in your Module 1 Assignment as a focus of your professional development. Your goal is to share this information with personnel/emerging leaders in your setting. If this is not pertinent to your setting, work with your instructor to identify an alternative topic.

8085 Module2 Assignment: Professional Development of Others

Strong leaders do not only focus on building their own capacity; they also strive to develop leadership capacity in others. Effective leaders serve as mentors, guides, and coaches who support individuals in discovery, provide tools to help solve problems, and inspire others to make decisions, feel success, and grow in their own leadership capacity. Among the great strengths of the collaborative early childhood community are commitments to developing, supporting, and nurturing young children within early childhood classrooms and commitments to developing, supporting, and nurturing staff within early childhood programs.

For this Assignment, you will assume the role of a director of an early childhood setting of your choice. Imagine that you have just been awarded a generous grant to promote the professional development and leadership capacity of your staff. The focus of this Assignment, however, focuses less on the content of your professional development, and more on how you design professional development opportunities that serve to develop, support, and nurture staff.

To prepare:

You are encouraged to delve more deeply into the advocacy topic you selected in your Module 1 Assignment as a focus of your professional development. Your goal is to share this information with personnel/emerging leaders in your setting. If this is not pertinent to your setting, work with your instructor to identify an alternative topic.

Based on the topic you have selected, review relevant, current literature (ideally, within the past five years) to identify at least five current articles that not only provide breadth and depth for the topic you chose, but also provide information you believe is meaningful and appropriate for this particular audience.

Reflect on strategies identified within the Learning Resources that are likely to cultivate leadership capacity in your staff. Identify four to five key strategies that you would like to model or incorporate into your professional development design.

Assignment Task:

Create a tool or artifact that summarizes an experience for developing others’ leadership capacity and knowledge/skills related to the topic you chose.

Topic chosen: “ Exploring Language Development in Early Childhood Education “

· Create and write a training outline that includes the purpose of the training and a general overview of the content, including specific topics, recommended resources, coaching/mentoring activities that support implementation, and how leadership capacity will be cultivated within training activities.

Be sure to cite appropriate references in APA format to substantiate your thinking.

 

 

 

REFERENCES

 

https://www.td.org/Publications/Magazines/TD/TD-Archive/2012/08/Intelligence-360-Instruments-Are-the-Most-Popular-Way-to-Assess-Leadership

 

https://search.ebscohost.com/login.aspx?direct=true&db=poh&AN=87803879&site=ehost-live&scope=site&authtype=shib&custid=s6527200

https://search.ebscohost.com/login.aspx?direct=true&db=eric&AN=EJ1017623&site=eds-live&scope=site&authtype=shib&custid=s6527200

https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=87786454&site=eds-live&scope=site&authtype=shib&custid=s6527200

http://hepg.org/hel-home/issues/28_2/helarticle/four-steps-to-building-leadership-capacity_530

http://ucsfhr.ucsf.edu/index.php/pubs/hrguidearticle/chapter-12-managing-diversity-in-the-workplace/

https://go.galegroup.com/ps/i.do?p=EAIM&sw=w&u=minn4020&v=2.1&it=r&id=GALE%7CA429735027&asid=95c0e214a973df082efdd5802973aabf

 

https://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=87017544&site=ehost-live&scope=site&authtype=shib&custid=s6527200

Family Medicine 16: 68-year-old male with skin lesion

Family Medicine 16: 68-year-old male with skin lesion

Author: Augustine Sohn, MD, MPH; Associate Editor: Martha P. Seagrave RN, PA-C

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 and the terminology used to describe primary and secondary skin lesions.

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 terms for primary lesions of the skin.

The suggested answer is shown below.

 

Letter Count: 40/1000

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 a 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 of a plateau.

Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis, or subcutaneous tissue. Generally larger and deeper than a papule.

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.

Comprehensive PowerPoint resource with skin lesions and images.

References

Habif, Thomas P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Edinburgh; New York: Mosby; 2016; 1-74.

Stanford Medicine. 2021. The General Dermatology Exam: Learning the Language. https://stanfordmedicine25.stanford.edu/the25/dermatology.html#top. Accessed June 10, 2022.

PATIENT INTRODUCTION AND HISTORY

HISTORY
You examine the lesion on Mr. Fitzgerald’s arm.

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:

You look at Mr. Fitzgerald’s left forearm to see the lesion he shows you.

Mr. Fitzgerald’s left forearm lesion

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.”

PAST HISTORY REVIEW

HISTORY
You continue taking Mr. Fitzgerald’s history.

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 reports no family history of skin cancers.

Social history: Mr. Fitzgerlad 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 used to be a heavy drinker. He retired from work as a bricklayer more than 30 years ago. Used to bike about 50 to 60 miles a week until his hip bothered him too much, now he walks once daily and babysits for his daughter’s kids on the weekend.

Review of systems: Decreased stream and dribbling of urine for the past four to five months, but reports no 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 meantime, 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-body skin exam.

Question

What is the grade of evidence of full-body skin examination by a primary care clinician for skin cancer screening in the adult general population by the United States Preventive Service Task Force (USPSTF)?

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. Grade I statement

Answer Comment

The correct answer is E.

In this clinical setting, the patient presents to the office with a suspicious skin condition, so a full-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 a health care provider is an “I” recommendation by USPSTF. Grade I statement recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a full-body skin examination.

The American Cancer Society, however, 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 not sufficient evidence for the benefit or harm of certain recommendations (as with USPSTF Grade I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Clinicians, however, should be able to discuss the possible outcomes of the patient’s choice.

References

American Cancer Society. 2021. Can Basal and Squamous Cell Skin Cancers Be Found Early? https://www.cancer.org/cancer/basal-and-squamous-cell-skin-cancer/detection-diagnosis-staging/detection.html. Accessed May 2, 2022.

American Cancer Society. Cancer Facts & Figures 2022. Atlanta, GA: American Cancer Society; 2022. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2022/2022-cancer-facts-and-figures.pdf. Accessed May 2, 2022.

CDC. Centers for Disease Control and Prevention. Cancer Home. Skin Cancer. Basic Information. What Are the Risk Factors for Skin Cancer? April 18, 2022. https://www.cdc.gov/cancer/skin/basic_info/risk_factors.htm. Accessed June 9, 2022.

Geller AC, Zhang Z, Sober AJ, et al. The first 15 years of the American Academy of Dermatology skin cancer screening programs: 1985-1999. J Am Acad Dermatol. 2003;48(1):34-41.

U.S. Preventive Services Task Force. Final Recommendation Statement: Skin Cancer: Screening. July 26, 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/skin-cancer-screening. Accessed June 9, 2022.

REVIEWING FEATURES OF SKIN EXAM

TEACHING

You step out of the exam room and fill Dr. Hill in on what you have discovered so far, including that Mr. Fitzgerald has a 35 x 25 mm oval erythematous patch on his left forearm.

Dr. Hill suggests, “Before we go back to see Mr. Fitzgerald together, let’s talk a little bit more about what else to look for on a skin exam.”

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. Associated symptoms

  • B. The arrangement of lesions

  • C. The distribution of the skin lesions

  • D. The shape of individual lesions

  • E. The size of the lesions

Answer Comment

The correct answers are A, B, C, D, E.

TEACHING POINT

Skin Examination

Associated symptoms

Associated symptoms—such as 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.

Arrangement

A linear arrangement of lesions may indicate a contact reaction to an exogenous substance brushing across the skin. Zosteriform refers to lesions arranged along the cutaneous distribution of a spinal nerve as seen in herpes zoster.

Distribution

The distribution of 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 surfaces 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).

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.

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 first- or second-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 the 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 undergo regular screenings, conduct self-examinations, and protect themselves from UV radiation.

References

Jerant AF, Johnson JT, Sheridan CD, Caffrey TJ. Early detection and treatment of skin cancer. Am Fam Physician. 2000;62(2):357-82.

Perkins A, Duffy RL. Atypical moles: diagnosis and management. Am Fam Physician. 2015;91(11):762-7.

U.S. Department of Health and Human Services, Office of the Surgeon General. Call to Action to Prevent Skin Cancer. https://www.hhs.gov/sites/default/files/call-to-action-prevent-skin-cancer.pdf. Accessed June 10, 2022.

PHYSICAL EXAM 1

PHYSICAL EXAM

You and Dr. Hill enter the room and perform the physical exam:

Vital signs:

    • Temperature is 36.8 °C (98.2 °F)

    • Pulse is 64 beats/minute

    • Respiratory rate is 18 breaths/minute

    • Blood pressure is 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 head to toe, including his scalp, soles, and palms. Left forearm oval scaly erythematous patch with indistinct borders measures 35 X 25 mm.

Dr. Hill instructs Mr. Fitzgerald to get dressed while you both step out of the room.

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.

Your response is recorded in your student case report.

 

Letter Count: 248/1000

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 35 x 25 mm erythematous, pruritic, oval patch with indistinct borders 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:

    • Epidemiology and risk factors: 68-year-old previously healthy man, history of significant sun exposure.

    • Key clinical findings about the present illness using qualifying adjectives and descriptive language:

    1. Pruritic, erythematous, oval 35 x 25 mm patch on left forearm

    2. Chronic and progressively enlarging

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 35 mm x 25 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. Actinic keratosis

  • B. Basal cell carcinoma of the skin

  • C. Eczema (dermatitis)

  • D. Fungal skin infection

  • E. Lichen planus

  • F. Melanoma

  • G. Psoriasis

  • H. Seborrheic Keratosis

  • I. Squamous cell carcinoma of the skin

Answer Comment

The correct answers are A, B, C, D, 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 a seborrheic keratosis which usually have a raised, “stuck on” appearance.

TEACHING POINT

Differential of Erythematous 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 to 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, although this can vary.

  • 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 outlines 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 burn easily and tan with difficulty, with red or blond hair, and with 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 an 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 is 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 on the legs immediately above the ankles.

  • Classic lichen planus lesions are identified as:

    • Pruritic

    • Purple (actually a slight violaceous hue)

    • Polygonal

    • Papules or plaques

  • Most of the time, the lesions are multiple.

  • Lichen planus are 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.

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 the 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.

The best options are indicated below. Your selections are indicated by the shaded boxes.

  • A. Accurate diagnosis of skin disease.

  • B. Frequency of administration.

  • C. Potency of steroid.

  • D. Side effects.

  • E. Steroid vehicles.

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. The more occlusive the vehicle the more potent it is. There are several types of vehicles:

    • Creams: The white cream base is a mixture of several different organic chemicals (oils) and water, and usually contains some alcohol and 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 it is best for acute exudative inflammation. It can also cause burning when applied to a very irritated lesion.

    • Ointments: The clear 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, which are also white and can be spread easily, contain alcohol, which has a 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% (cream and 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 corticosteroids is skin atrophy. It also can cause hypopigmentation. This is more apparent with darker skin tones. Topically applied high- and ultrahigh-potency corticosteroids over time 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.

ANTIFUNGAL TREATMENTS

TEACHING

“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 the 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 capitis

  • B. Tinea corporis/tinea cruris

  • C. Tinea pedis/tinea manuum

  • D. Tinea unguium (onychomycosis)

Answer Comment

The correct answers are A, D.

In this case of a skin leasion, if Mr. Fitzgerald had a fungal infection, you would treat it with an antifungal cream.

TEACHING POINT

When to Treat with Systemic Versus 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 hydrochloride 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 for children weighing less than 25 kg, 187.5 mg for children weighing 25–35 kg, or 250 mg for children weighing more than 35 kg—once daily for 6 weeks in all cases.

    • 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

Each pulse equals one week of itraconazole followed by three weeks without itraconazole.

Use two pulses for fingernails and

Three pulses for 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 dermatophytes.

Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.

References

Chen X, Jiang X, Yang M, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2016;(5):CD004685. Published 2016 May 12.

Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia. 2008;166(5-6):353-67.

Kreijkamp-Kaspers S, Hawke K, Guo L, et al. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev. 2017;7(7):CD010031. Published 2017 Jul 14.

Westerberg DP, Voyack MJ. Onychomycosis: Current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11):762-70.

MAKING A DIAGNOSIS AND TREATMENT PLAN

THERAPEUTICS

“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. Excisional biopsy

  • B. Incisional biopsy or punch biopsy

  • C. Observation

  • D. Shave biopsy

  • E. Trial with antifungal or corticosteroid cream

  • F. Trial with a combination of antifungal and corticosteroid cream

Answer Comment

The correct answer is B.

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 so removing the entire lesion is not necessary before diagnosis.

Shave biopsy

This is not an option for Mr. Fitzgerald’s lesion because his lesion is flat.

Observation (C) is not the best choice at this time because of possible malignancy and the long duration of the lesion.

It is not the best option to treat with a trial of antifungal or corticosteroid cream (E and F) because this is not an acute problem necessitating a rapid response and the diagnosis is indeterminate.

TEACHING POINT

Skin Biopsy

Type of biopsy

Procedure

Tool and 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 2-8 mm in size.

  • A full thickness of skin can easily be obtained with a punch biopsy.

  • If a lesion is less than 3 mm in size, it does not need stitches after biopsy.

Excisional biopsy

Excisional biopsy involves removing the whole lesion with a 2-3 mm 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.

References

Pickett H. Shave and punch biopsy for skin lesions. Am Fam Physician. 2011;84(9):995-1002.

Shenenberger DW. Cutaneous malignant melanoma: a primary care perspective. Am Fam Physician. 2012;85(2):161-8.

REVIEWING PROCEDURE AND CONSENT

MANAGEMENT

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 are not huge risks associated with a condition, it is appropriate to treat empirically. However, 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: 94/1000

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 cannot 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 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

OBTAINING CONSENT

CARE DISCUSSION
Mr. Fitzgerald is reluctant to do the procedure.

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 an 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 assistant to sign their name as a witness. Then, Mr. Fitzgerald is escorted to the procedure room and the area of the skin lesion is cleansed with povidone solution.

PROCEDURE

TESTING

You and Dr. Hill enter the procedure room. You watch as she disinfects the area 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 3 mm 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 getting inflamed about six to seven days after the procedure, or sees pus coming out at any time, he should contact Dr. Hill without delay. She finally discusses how to manage possible bleeding.

The specimen is 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.

RECEIVING RESULT OF THE 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 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. Observation for now, because it is still carcinoma in-situ.

  • B. Refer Mr. Fitzgerald for Mohs surgery.

  • C. Refer Mr. Fitzgerald for radiation therapy.

  • D. Treat the lesion with cryotherapy.

  • E. Treat the lesion with topical 5-fluorouracil (5-FU).

  • F. Wide excision under local anesthesia in the office

Answer Comment

The correct answer is F.

Squamous-cell carcinoma treatment

Surgical excision (F) 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 the 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. In some cases with smaller lesions, this can be performed by the patient’s family physician which can make it more convenient, cost-effective, and in many cases, less stressful for patients.

Observation (A) 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 cm) SCC lacking any high-risk features requires a 4 mm 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 2 cm, 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 the 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 (Accessed May 17, 2022).

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 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.

Radiation therapy is contraindicated on tumors located on the trunk and extremities. These areas are subjected to greater trauma and tension than the 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.

References

Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001;344(13):975-83.

Bowen GM, White GL Jr, Gerwels JW. Mohs micrographic surgery. Am Fam Physician. 2005;72(5):845-8.

Stulberg DL, Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician. 2004;70(8):1481-8.

Work Group; Invited Reviewers, Kim JYS, et al. Guidelines of care for the management of cutaneous squamous cell carcinoma. J Am Acad Dermatol. 2018;78(3):560-78.

RETURN VISIT TO REVIEW RESULTS

CARE DISCUSSION
Treatment options are presented to Mr. Fitzgerald.

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 Disease. This has a very good prognosis. How are you feeling Mr. Fitzgerald?” Dr. Hill asks.

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 okay?”

“Luckily, 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 in the office under local anesthesia. The spot is cut out and a margin of normal tissue around it. The sample is sent for histological testing to make sure that we’ve gotten all of the cancer. This procedure has a 95% cure rate.”

“Another method to take it out is Mohs micrographic surgery. We 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 we can see the edges of the spot on your forearm very clearly, so we should be able to get all of the cancer on the first attempt. Furthermore, this is on your arm, not near any important structures like your eyes or nose; so we can make sure to remove 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. This allows us 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.

References

Stulberg DL, Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician. 2004;70(8):1481-8.

DISCUSSING SKIN PROTECTION

TEACHING

Dr. Hill asks you to provide Mr. Fitzgerald with some education about protection against further sun exposure and damage. You go online and print out a handout on skin cancer and prevention with information on protection against sun damage.

You discuss this with Mr. Fitzgerald and give him the handout.

TEACHING POINT

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.

References

Familydoctor.org. American Academy of Family Physicians. 2022. Diseases and Conditions: Skin Cancer. Accessed June 10, 2022.

DISCUSSING THE SKIN EXAM

TEACHING
You hand Mr. Fitzgerald an informational pamphlet on skin cancer.

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 handheld 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: 44/1000

Answer Comment

Asymmetry, border, color, diameter, enlargement

Asymmetry: Asymmetry in two or more axes

Border: Irregular border

Color: Two or more colors

Diameter: 6 mm or greater

Enlargement: Enlargement of the surface of the lesion. (Some references refer to alternate E’s: evolution or elevation.)

TEACHING POINT

Applying ABCDE Criteria to Assess for Melanoma

When a hyperpigmented skin lesion shows asymmetry, irregular borders, mixed colors, a diameter of 6 mm or larger, or recent growth in size, your suspicion of melanoma becomes higher.

References

Goldstein BG, Goldstein AO. Diagnosis and management of malignant melanoma. Am Fam Physician. 2001;63(7):1359-74.

Thomas L, Tranchand P, Berard F, Secchi T, Colin C, Moulin G. Semiological value of ABCDE criteria in the diagnosis of cutaneous pigmented tumors. Dermatology. 1998;197(1):11-7.

ADDITIONAL PATIENT CONCERN

HISTORY

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 the bathroom. It takes a long time to start urination. Do I have a prostate condition?”

Dr. Hill asks you what would be your differential diagnoses in this case.

You say, “Considering the age and symptoms, BPH would 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.”

Dr. Hill says to Mr. Fitzgerald, “It is quite likely that you 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 to ensure we aren’t missing anything more worrisome? 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. As men get older they start to have symptoms of benign prostatic hypertrophy.

Question

Which of the following are helpful 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. Examination of prostate.

  • B. Presence of classic lower urinary tract symptoms (LUTS).

  • C. Residual volume of urine.

  • D. Serum BUN and creatinine.

  • E. Serum prostate specific antigen (PSA).

  • F. Urinalysis.

  • G. Urine flow rate.

Answer Comment

The correct answers are A, B, E, F.

TEACHING POINT

Recommended Evaluation of Suspected Benign Prostatic Hypertrophy

When evaluating for BPH, consider:

Clinical manifestation

Lower urinary tract symptoms (LUTS) or outlet blockage symptoms

  • 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.

References

AUA. American Urological Association. 2022. Management of Benign Prostatic Hyperplasia/ Lower Urinary Tract Symptoms: AUA Guideline 2021. https://www.auanet.org/guidelines/guidelines/benign-prostatic-hyperplasia-(bph)-guideline#x8208. Accessed May 2, 2022.

Pearson R, Williams PM. Common questions about the diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2014;90(11):769-74.

USRF. Urological Sciences Research Foundation​ Website. International Prostate Symptom Score (IPSS)​ Questionnaire. Accessed June 10, 2022.

PHYSICAL EXAM 2

PHYSICAL EXAM

The next week, Mr. Fitzgerald returns to the office for evaluation 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. Behavior modifications to decrease symptoms

  • B. Refer the patient to a urology service for surgical intervention like TURP (transurethral resection of the prostate)

  • C. Start with 5-alpha-reductase inhibitor

  • D. Start with alpha-adrenergic antagonists

  • E. Start with combination treatment of an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor

Answer Comment

The correct answers are A, D.

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

Medications:

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, or 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.

References

Kaplan SA. Update on the american urological association guidelines for the treatment of benign prostatic hyperplasia. Rev Urol. 2006;8 Suppl 4(Suppl 4):S10-S17.

CONCLUSION

THERAPEUTICS
Dr. Hill explains age-related prostate symptoms.

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 the 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,

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.

References

Familydoctor.org. American Academy of Family Physicians. Diseases and Conditions: Benign Prostatic Hyperplasia (BPH). Updated, May 2022. Accessed June 10, 2022.

Information from your family doctor. BPH–a problem with your prostate. Am Fam Physician. 2002;66(1):87-8.

ADDRESSING FINAL PATIENT CONCERN

PHYSICAL EXAM

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 about 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 interdigital 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.

You 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 reports no pain to palpation. There is no swelling and noting equal pulses in each of the feet.

Dr. Hill asks you,

TEACHING POINT

Tinea Pedis

This is a ubiquitous dermatophyte infection and the most common of the superficial fungal infections.

Local friction and warmth between the toes, in combination with the patient’s wearing and frequency of changing of socks and shoes as well as wearing of wet shoes for a prolonged period of time, and the accumulation of moisture in his feet, particularly between the toes represent common contributory factors.

Other factors could be diabetes, immune compromising states such as chronic steroid therapy, and chemotherapy. HIV/AIDS can also lead to tinea pedis and onychomycosis.

The diagnosis is often made clinically but can also be aided with microscopy, where scrapings from the affected area are examined under microscopy, after treatment with potassium hydroxide.

You suggest a one-week course of terbinafine 1% cream. Dr. Hill concurs and provides Mr. Fitzgerald with a prescription and instructions.​

Mr. Fitzgerald thanks you and Dr. Hill for your help and heads out the door.

References

Skinsight. Athlete’s Foot (Tinea Pedis). Accessed June 10, 2022.

Familydoctor.org. American Academy of Family Physicians. Diseases and Conditions: Benign Prostatic Hyperplasia (BPH). Updated May 2022. Accessed June 10, 2022.

Ely JW, Rosenfeld S, Seabury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014;90(10):702-10.

Hainer BL. Dermatophyte infections. Am Fam Physician. 2003;67(1):101-8.

Healthline. Athlete’s Foot (Tinea Pedis). Accessed June 10, 2022.


CASE SUMMARY DOWNLOAD

FINISH CASE

Well done! You have completed the case. Click to download the case summary.

RELEASE NOTES

RELEASE NOTES

June 16, 2022

    • Updated Learning Objectives to align them more closely with the STFM National Clerkship Curriculum.

    • Changed skin photos to more accurately reflect the case.

    • Added tinea pedis photos

LEARNING OBJECTIVES

LEARNING OBJECTIVES

The student should be able to:

    • Describe cost-effective approach to diagnosis of common skin lesions including biopsy techniques.

    • Describe a skin lesion using appropriate medical terminology.

    • Identify risks and screening for skin diseases.

    • Discuss who should be screened and methods of screening for skin cancer.

    • Elicit a focused history and perform a focused physical examination of a skin lesion.

    • Differentiate among common etiologies of common skin lesions.

    • Describe the initial management of common and dangerous diagnoses that present with a skin lesion.

    • Propose a cost-effective diagnostic work-up for a patient presenting with a skin lesion.

    • Describe steps in a cost-effective diagnostic procedure for a patient presenting with a skin lesion.

    • Develop a health promotion plan for a patient of any age or gender that addresses skin damage.

    • Summarize the key features of a patient presenting with a change in urinary patterns, capturing the information essential for differentiating between the common and “don’t miss” etiologies.

    • Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient with male genitals presenting with changes in urinary patterns.

    • Propose a cost-effective diagnostic work-up for a patient with male genitals presenting with changes in urinary patterns.

    • Describe the initial management of benign prostatic hyperplasia.

    • Discuss the diagnosis and treatment of tinea pedis.

QUESTION 1

SAQ

Question

A 47-year-old patient presents to the clinic complaining of an “itchy patch” on her skin. On further examination, you note a solid, elevated, flat-topped, 1.5 cm lesion on the extensor surface of the right forearm. How would you best describe the lesion?

  • A. Macule
  • B. Nodule
  • C. Papule
  • D. Patch
  • E. Plaque

QUESTION 2

SAQ

Question

A 12-year-old patient is brought to the clinic with a pruritic, red, scaly rash in the creases of his elbows. He reports no new topical exposures and generally feels well. He has a history of seasonal allergies. Which of the following is the most appropriate course of action?

  • A. Ask the patient to return to the clinic after three days
  • B. Biopsy the skin lesion
  • C. Prescribe oral antibiotics
  • D. Prescribe oral corticosteroids
  • E. Prescribe topical corticosteroids

QUESTION 3

SAQ

Question

A 26-year-old professional football player comes to the clinic with the concern of hair loss. On examination, the scalp is scaly and erythematous, and certain regions are purulent. There are several circular spots where the hair follicles are no longer present. KOH of skin shows hyphae. What is the most appropriate next step in the management of this patient?

  • A. Oral griseofulvin
  • B. Oral prednisone
  • C. Punch biopsy of lesion
  • D. Topical griseofulvin
  • E. Topical prednisone

QUESTION 4

SAQ

Question

A 64-year-old patient comes in for a routine physical examination. He notes that over the past few months he has had to get up to urinate in the middle of the night. Benign prostatic hypertrophy (BPH) is on your differential. What other symptom is consistent with BPH?

  • A. Cloudy penile discharge
  • B. Dysuria
  • C. Erectile dysfunction
  • D. Hematuria
  • E. Urinary urgency

QUESTION 5

SAQ

Question

A 57-year-old patient comes in, concerned about a 1.5 cm dark multicolored mole lateral to her left eye that has been increasing in size over the past six months. A punch biopsy shows pathology indicative of squamous cell carcinoma. What is the most appropriate intervention?

  • A. Avoid artificial sources of UV light, such as indoor tanning
  • B. Cryotherapy extending 4 mm beyond the lesion margins
  • C. Excisional biopsy extending 5 mm beyond the lesional border
  • D. Mohs surgery
  • E. Three-month follow-up visits for the first year; then every six months

Thank you for completing Family Medicine 16: 68-year-old male with skin lesion.

After reviewing these resources, identify one contemporary (still living) creative woman with whom you were previously unfamiliar, and discuss her contributions to contemporary culture.  In your discussion, compare her visibility with creative women from other eras, such as the Renaissance, Victorian, or even the modern period.  How do women continue to face challenges with visibility or representation?

For this week’s forum question, review the article  “Taking the Measure of Sexism: Facts, Figures, and Fixes.”  (Links to an external site.)   Next, explore the  National Museum of Women in the Arts  (Links to an external site.) .  You should begin with artists from the  21st Century  (Links to an external site.) .  Continue to the “Learn” and “Support + Advocate” sections to learn more about diverse women creating culture today.

 

After reviewing these resources, identify one contemporary (still living) creative woman with whom you were previously unfamiliar, and discuss her contributions to contemporary culture.  In your discussion, compare her visibility with creative women from other eras, such as the Renaissance, Victorian, or even the modern period.  How do women continue to face challenges with visibility or representation?

 

In your initial response, embed a multimedia piece such as a video clip, an audio clip, or an image.  You should discuss the multimedia that you include and explain its significance to your argument.  For video and audio clips, please limit the length to five minutes.  You can post a longer clip, but if you do, you should specify the part of the clip that you want the class to view/hear (no longer than five minutes) by including the time stamp range.  Your posts should include textual examples from this week’s required or recommended resources to support your arguments.  If needed, you may supplement your course content with outside resources, but you should select first from our assigned resources (multimedia and readings).

 

Your initial post is due on Thursday, and your replies to classmates are due on Monday.  You should post in the discussion on a total of four days during the learning week.  Your posts should have a combined word count of at least 500 words.

Write three brief policies designed to reach each of the following goals. For each goal use three different instruments

1. Write three brief policies designed to reach each of the following goals. For each goal use three different instruments. a. Improve district test scores. b. Expand the use of computers in schools across the state. c. Increase the number of young women enrolled in engineering programs. d. Reduce student tardiness in a high school. e. Encourage students in the district to become more interested in mathematics.

3. Analyze part of a school handbook or a board policy manual. Describe its use of the five policy instruments.

4. Analyze the No Child Left Behind Act (or the most recent version of ESEA) to determine which policy instruments are used the most in it, which are used the least, and which are not used at all.

Question: Airport Financing

Reply to the posts of the following classmates, respond with constructive commentary with APA references. Your response to your classmates should be thought-provoking and continue the conversation.

 

Question: Airport Financing

You should be familiar with evaluating the needs of an airport and the funding options required to meet these needs. Because airports are public entities and provide a service to their community, there is often a lot of media articles covering these issues. It is important for airport officials to inform and educate their communities on what is needed at their airport in order to meet their aviation needs. You will often see pro and con articles that discuss these issues from varying viewpoints. For this assignment, conduct a literature search for a recent article related to airport financing. Evaluate the airport and what it wants to do, and then evaluate the pros and cons of the article to see how it impacts the airport’s intentions. Do the article and the writer meet the credibility test, and is the article valid for readers to gain correct information on the issue? Ensure that you discuss the various funding programs and complex relationships that exist at airports.

 

Mashan

Any airport that seeks to expand requires a large capital investment to finance the development. Capital can be in the form of government loans and grants, commercial loans from financial institutions, equity and debt. Currently, in India, there is a big drive by the Government to privatize airports within the country. In addition, the Government is allocating land and then making private companies bid for the construction and operation of the airport over a long-term agreement. The article is related to the new airport that is to be constructed in Mumbai. The functioning airport in Mumbai (VABB) is currently the second busiest airport in India. Due to the design of the airport, only one active runway can be utilized at a time as the runways cross each other. The airport has cited that it is the single busiest runway in the world (Pande, 2022). The new airport that is to be constructed possesses greater capacity than the current airport being utilized. In addition, the functioning airport cannot expand any further as the land around the airport is occupied by other tenants. The only negative to the new airport construction is the location. The new airport is in Navi Mumbai which is not on the main island. In order to access the new airport, there will be a significant amount of travel required for the citizens of the city. In addition, the infrastructure to connect the city and airport has not been explored properly. The article provides optimism about the aviation sector within India. In a sector that is mainly filled with negative news, this article presents a good case for optimism. Especially as this not only pertains to Mumbai but has the potential to benefit the entire country. The article is credible as the data seems consistent with other outlets reporting similar numbers and details. The other reports do however touch on more than just Mumbai and acknowledge the other airports that will benefit from the funding. Adani holdings will have a network that has 50% of the top 10 domestic routes, 23% of the total Indian traffic, and 30% of the air cargo market (IAR, 2022).

 

Gabriel

According to Zipkin (2019), a small airport named Paine Field which was located in Everett, Washington upgraded and renovated with funds from a private investor and the fixed based operator was made into a serviceable commercial flight airport. An investment of $40 million by Propellor Airports enabled this private company to renovate the private terminals to allow for more passengers, new services, and allow for more cargo distribution (Zipkin, 2019). Airports typically apply for federal funding from the government using the Airport Improvement Plan in which the government prioritizes which airports will receive large funding based on the need. The article further emphasizes that the local community needed local airport that serviced passengers that was close in proximity, affordable, and accessible as opposed to driving to a major airport that was farther and congested (Zipkin, 2019). The article further describes how airport management circumvented the government process to receive financial aid from the government which shares the potential, impact, and influence from the private sector. The article does meet the credibility test because the author effectively describes what avenue the airport received its fundings and what avenues it used to acquire federal funding but was failed to. From a reader’s perspective, I was able to extract renovation had came from private funds to upgrade the terminal, expand the complex, install a pilot lounge, provide an in-house catering kitchen, concierge service, and make cars available. Additionally, the same funds were used to build additional hangar space and shelter (Epstien, 2021)

Post, describing the two cultures in relation to the one factor you selected that may mark adulthood. Next, explain one potential value and one potential limitation related to the factor that define adulthood in both cultures you selected.

Discussion 1: Defining Adulthood

How cultures define adulthood vary dramatically. For some, adulthood may be religious celebration milestones and for others it may be based on a physical change or event. In still others, it may be based on legal factors such as, chronological age or marital status.

For this Discussion, you will explore cultures and factors that establish adulthood. Also, you will examine the value and limitations of utilizing indicators to define adulthood.

To Prepare
  • From your Learning Resources, select two cultures in relation to one factor that may mark adulthood.
  • Search the Internet and/or the Walden University Library to select an additional scholarly article related to at least one of the two cultures and the one additional factor that mark adulthood to support your Discussion post.

Post, describing the two cultures in relation to the one factor you selected that may mark adulthood. Next, explain one potential value and one potential limitation related to the factor that define adulthood in both cultures you selected.

REFERENCES

 

Required Readings

Jensen, L. A., & Arnett, J. J. (2012). Going global: New pathways for adolescents and emerging adults in a changing world. Journal of Social Issues, 68(3), 473–492.

Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., …. Viner, R. M. (2016, June 11). Our future: A Lancetcommission on adolescent health and wellbeing. The Lancet, 2423–2478. 
Credit Line: Our Future: A Lancet Commission on Adolescent Health and Wellbeing by Patton, G.C., Sawyer, S.M., Santelli, J.S., Ross, D.A., Afifi, R., Allen, N.B., in The Lancet, Vol. 387/Issue 10036. Copyright 2016 by Lancet Publishing Group. Reprinted by permission of Lancet Publishing Group via the Copyright Clearance Center

Gire, J. (2014). How death imitates life: Cultural influences on conceptions of death and dying. Online Readings in Psychology and Culture, 6(2), 1–22.

Credit Line: Gire, J. (2014). How Death Imitates Life: Cultural Influences on Conceptions of Death and Dying. Online Readings in Psychology and Culture, 6(2). https://doi.org/10.9707/2307-0919.1120. ​Licensed under Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Hollis-Sawyer, L., & Dykema-Engblade, A. (2016). Diversity among older women. In L. Hollis-Sawyer & A. Dykema-Engblade, Women and positive aging: An international perspective (pp. 146–166). San Diego, CA: Elsevier.  
Chapter 8: Diversity Among Older WomenCredit Line: Women and Positive Aging: An International Perspective by Hollis-Sawyer, L.; Dykema-Engbalade, A. Copyright 2016 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

Janike, B. R., & Traphagen, J. W. (2009). Transforming the cultural scripts for aging and eldercare in Japan. In J. Sokolovsky, (Ed.), The cultural context of aging: Worldwide perspectives (3rd ed., pp. 240–258). Westport, CT: Praeger.
Chapter 17: Transforming the Cultural Scripts for Aging and Eldercare in JapanCredit Line: The Cultural Context of Aging: Worldwide Perspectives, 3rd Edition by Janike, B.; Traphagen, J. Copyright 2009 by Greenwood Publishing Group, Inc. Reprinted by permission of Greenwood Publishing Group, Inc. via the Copyright Clearance Center.

Norwood, F. (2013). A window into Dutch life and death: Euthanasia and end-of-life in the public-private space of home. In C. Lynch, & J. Danely, (Eds.), Transitions and transformations: Cultural perspectives on aging and the life course. New York, NY: Berghahn Books.
Chapter 6: A Window into Dutch Life and Death: Euthanasia and End-of-Life in the Public-Private Space of HomeCredit Line: Transitions and Transformations: Cultural Perspectives on Aging and the Life Course, by Lynch, C.; Danely, C. (eds). Copyright 2013 by 

Describe episodes or scenes in the lives of these babies that demonstrate the SAME concept, stage or developmental event in each of the 3 areas of development listed above (physical, cognitive, & social-emotional).

Please consider 3 areas of development in these 4 children:  (1) Physical development, (2) Cognitive development, and (3) social-emotional development and submit a written response to the questions below..

1.  Describe episodes or scenes in the lives of these babies that demonstrate the SAME concept, stage or developmental event in each of the 3 areas of development listed above (physical, cognitive, & social-emotional). In other words, what do you see that is the SAME in these children as respects physical development, cognitive development, and social-emotional development?

2.  Describe any DIFFERENCES in these children that might be attributed to environment or nurture (that is, physical environment, family arrangements, parenting style, nutrition, etc.). Again, please note one difference in physical development, one difference in cognitive development, and one difference in social-emotional development. To what do you attribute the differences that you note?

Rubric

Homework Assignment 1: BABIES VideoHomework Assignment 1: BABIES VideoCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeMeets ExpectationsAt least 1 biological developmental issue, 1 cognitive developmental issue, and 1 socio-emotional issue were discussed for both questions 1 & 210 ptsMeets ExpectationsAt least 1 biological development issue, 1 cognitive developmental issue, and 1 socio-emotional developmental issue were discussed for both questions 1 & 2

Implications of a Sleep Deprived Society

The Implications of a Sleep Deprived Society

What are the implications of a largely sleep-deprived society?  How does the amount of sleep you get affect your own life?  How does it affect your health, your emotions, and your performance?

Directions:
  1. Write at least 200 words on this topic.
  2. Save and name your assignment  “Week 3 Research Assignment”, then save it on your computer.  This document will then be uploaded by clicking on “Browse my Computer”.
  3. Make sure to cite your sources in your assignment.
Tips:
  1. Check out some of these websites:
  2. Annotated Bibliography (Stage 1)

    The Impact of Stress on the Developing Child

    Brietzke, E., Kauer-Sant’anne, Marcia, Jackwiski, Andrea, Bicker, Jeanne, Zugman, Andres, Mansour, Rodrigo, et al. (2012). Effect of life as a youngster weight on psychopathology. Revista Brasileirra de Psiquiatria , 34 (4), 480-488.

    The creators are specialists in the Department of Psychiatry at the Federal University of Sao Paulo in Brazil. Their friend surveyed article examines the effect of early life stressors in youth that could affect neurological improvement on the creating kid because of quality and ecological collaborations. The review sheds understanding on the ongoing survey of writing in light of the connection between youth misuse and the gamble of creating behavioral conditions in adulthood. The examination uncovers that in light of MRI studies, there is adequate proof to take note of that openness to early close to home stressors could bring about a decrease of the hippocampus and corpus callosum, which brings about diminished mental working. Idea from research incorporates utilizing a multimodal strategy to shed understanding on switching the harm brought about by youth stress.

     

    Kousha, M., and Tehrani, Shervin. (2013). Standardizing life altering situations and PTSD in kids: How simple pressure can influence youngsters’ cerebrum. Acta Medica Iranica, 51 (1), 47-51.

    The article talks about the effect of unexpected close to home injury, for example, post-horrible pressure issue (PTSD), including explicit injury like brutal wrongdoings, engine vehicle mishaps, and extreme disease on the creating youngster. The scientists led a cross-sectional concentrate on youth confessed to a mental clinic in Iran north of three years by talking kids and their folks in regards to current and previous existence stressors. The aftereffects of the review demonstrated that kids presented to savagery and close to home stressors show high paces of melancholy and nervousness issues. The creators note that the review was and their folks and that further evaluation are expected to decide the effect of stressors in youth.

    Murray, J., and Murray, Lynne. (2010). Parental detainment, connection, and kid psychopathology. Connection and Human Development, 12 (4), 289-309.

    The writers are specialists at the University of Cambridge and the University of Reading brain research division separately. The article set off on a mission to decide the effect of parental detainment and connection on kid psychopathology because of the kid’s current circumstance, which would bring about profound strain and disarray. This friend investigated article surveys proof in view of longitudinal examinations and talks about the significance of parental connection on the youngster’s mental wellbeing. The article suggests that connection hypothesis is a significant compelling part of a youngster’s psychological wellness. Kids whose guardians were detained were not directed productively and were particularly powerless against creating introverted conduct and profound issues. The writers finish up their article by suggesting that connection frailty following parental imprisonment could significantly add to profound strain and psychopathology, particularly in kids who have added adverse impacts. There is a chance for additional exploration wherein to carry out strategies that would emphatically affect offspring of detainees.

    Romens, S., and McDonald, Jennifer. (2015). Relationship between early life stress and quality methylation in kids. Youngster Development, 86 (1), 303-309.

    The reason for this companion surveyed article was to decide the way that a youngster’s social climate could straightforwardly change quality articulation and methylation, which would coincidentally prompt conduct issues in kids further down the road. Moreover, the specialists show that how a climate is seen by the youngster could likewise deliver epigenetic changes. The review was led utilizing a study strategy and a DNA methylation pack with an example of families that had a background marked by youngster abuse and depended on the kid’s age, nationality, and orientation. The creators note that youngsters who were abused showed expanded hereditary changes to the receptor quality. The creators infer that there seems, by all accounts, to be an association between early life youth stress and epigenetic changes. Further exploration is expected to grasp the meaning of ecological variables and kid abuse in youth emotional well-being. It is likewise noticed that the creators suggest that understanding hereditary articulation will affect how people will assist with diminishing psychopathology in weak kids.