12 ⼀PSYCH/DERM Flashcards
What is the clinical criteria for hypOmania -2
- ≥3 [BIPOLAR] sx PLUS
- [Elevated | irritable mood 4< x <7 days]
How do you risk assess patients with [possible/confirmedSuicidal ideation] ?
i[SAD PERSONS]
i = { finish test (iNTENT with PLAN?) HOSPITALIZE NOW! }
___(if “i” no, cont to “[SAD PERSONS]” & finish test )____
Sex Male
[Age external to 19-45]
Depression diagnosis
[PREVIOUS SUICIDE ATTEMPT (STRONG RISK FACTOR!)]
EtOH/drug abuse
[Rational thinking impaired (psychosis, delusions, hallucinations)]
Social support lacking
Organized plan
No spouse
[Sickness physically (i.e. chronic pain)]
_________________
each 1 point: [normal <-4 -(Outpt tx)-7–>HOSPITALIZE!]
diagnosis?
________________
How do you confirm diagnosis for this? (4)
Bullous Pemphigoid
________________
bx showing
{[IgG and C3 autoantibody deposits]
at basement membrane
attacking hemidesmosomes}
initial tx for Insomnia
CBT
_________________
sleep hygiene / sleep restriction / relaxation techniques
cp for Mild Drug Allergy
________________
What type of hypersensitivity reaction is this?
[Pruritic Urticarial RASH with NO systemic sx]
_________________
[Type 1 IgE Hypersensitivity reaction]
What is the age limit for removing Tattoos?
NO HOST|INK AGE LIMIT FOR REMOVAL!
________________
tattoos can be removed whenever
Diagnosis? | Tx?
[vpHPV (Verrucae Plantar wart HPV)]
_________________
[saliCylic acid topical (or liquid nitrogen) x ≥2 wks –(if success)–> cont 2 more weeks]
hyperkeratotic papules on soles of the foot
Somatic Symptom disorder clinical presentation
excessive thought and behavior toward ≥1 unexplained (but proven to be benign) SYMPTOM
Describe a Dermatofibroma
benign fibroblast proliferation that forms hyperpigmented nodule usually on LE that causes center dimpling when pinched
In addition to skin, Patients with Rosacea may also experience ⬜ symptoms
Ocular
burning/foreign body sensation/blepharitis/keratitis/conjunctivitis/recurrent chalazion
Diagnostic criteria for Panic disorder - 2
- Panic attacks +
- Persistent concern about additional attacks and +/- attempts to avoid them
Be sure to r/u medical conditions that mimic them
Rash description: scaly, erythematous, pruritic rash with a raised border and central clearing
________________
tx?-2
[Tinea Corporis ringworm]
________________
Tx = [topical clotrimazole] or [topical terbinafine]
Identify
[Epidermal Inclusion Cyst]
diagnosis? | Tx?-2
dx= [Pityriasis Rosea “Christmas tree”]
tx = [self limited x 2 months], sunlight
Basal Cell Carcinoma
_________________
although usually [shiny, pearly, skin-colored nodule with telangiectasia, rolled border and ulceration] ⼀atypical presentations are frequent
List all possible Treatments? (6)
INDIVIDUAL coverage: [[excision] or [destruction via liquid nitrogen cryotherapy]]
_________________
FIELD coverage(widespread/numerous):
-top[5FU cream] |
-imiquimod |
-Photodynamic therapy |
-tirbanibulan
dx = [Actinic-Solar Keratosis] ||5FU: 5-Fluorouracil
[Pressure decubitus Ulcers] require local wound care, repositioning and pain/nutrition control
How are shallow ulcers managed?
_________________
How are Full-Thickness ulcers managed?
s: [occlusive or semipermeable dressings to maintain moist wound environment]
FT: DEBRIDEMENT OF DEVITALIZED TISSUE
This diagnosis of ⬜ is made based on what?
Psoriasis
- well demarcated, erythematous, scaly plaques covered by thick silvery scales*
- _________________*
skin physical exam
Sx of EtOH Withdrawal are similar to [Benzodiazepine withdrawal which onsets ⬜]
_________________
List the Sx of [EtOH (& Benzo)] withdrawal (9)
(Benzo withdrawal starts) [within 7 days] of abrupt Benzo cessation
PAST NITE
Psychomotor agitation but oriented
Anxious Irritable
Seizures
Tremor
NV
Insomnia
Transient Hallucinations
[Excitable autonomics (⬆︎HR, BP) –(if ⊕[Delirium and TempFever]) = ⊕DELIRIUM TREMENS]]
{[PAST NITE=EtOH🅆[⊕{D&T}=⊕🅳T]}
After last drink, [EtOH withdrawal/DT] sx onset after 0.5 Days, PEAKS after 2D, and resolves after 5D of EtOH abstinence
Sx of EtOH Withdrawal are similar to [Benzodiazepine withdrawal which onsets ⬜]
_________________
Describe sx timing for EtOH Withdrawal
(Benzo withdrawal starts) [within 7 days] of abrupt Benzo cessation
_________________
After last EtOH⼀MonAM [EtOH withdrawal_“PAST NITE”]:
🍺[onsets after 0.5 Days]⼀MonPM,
🍺🍺[PEAKS Day2 {+/- DT_“D&T”}]⼀TUE,
🍺🍺🍺[resolves by Day5]⼀FRI
{[PAST NITE=EtOH🆆[⊕{D&T}=⊕🅳T]}
🔎DT_D&T = [Delirium Tremens is ⊕(Delirium/Confusion & Temp/FEVER)]
Dx? | etx?
[PPP (Pearly Penile Papules)] | [(NORMAL (NON-STI) IDIOPATHIC VARIENT] row(s) of PPP wrapped circumferentially around corona of glans penis onset 20-30 yo
What size is concerning for a skin lesion?
_________________
How is an excisional biopsy done?
GOE 6 mm
_________________
Excise ENTIRE SKIN LESION with 1-4 mm margins of surrounding fat
A patient disagrees with plan and wants to go home
As the physician, what are your options?
[EMERGENCY HOLD] <–(absent)– [CURE Decision Making Capacity] –(present)– > [AMA is Ok]
_________________
dx?
Tinea Corporis
pink annular plaques with scaly border and central clearing
Differentiate [Pemphigus vulgaris] from [Bullous pemphigoid] using:
Demographic affected
P = YOUNG
________________
b = old
What is Factitious disorder?
________________
which 2 demographics does it occur most in?
faking/inducing illness solely to assume the sick role - WITHOUT OBVIOUS EXTERNAL BENEFIT
________________
Women | healthcare workers
b. diagnosis?
a. [Erythema “bull’s eye”MIGRANS]
b. Lyme disease
▶If multiple [Erythema *b/e*Migrans] are present = early disseminated disease.
▶If Amox started → Fever/HA/Myalgia, c/s Jarisch-Herxheimer rxn
Management? -3
[Poison Ivy Type 4 Contact Dermatitis]
________________
[Minimize spread (remove contaminated clothes + gently clean exposed areas)] ➜ [Symptomatic Tx (topical CTS+cool compress] ➜
[PO CTS if dermatitis SEVERE/facial/genitalia]
________________
pruritic linear papules and clear fluid-filled vesicles on exposed areas - after camping
Causes? -2
STAPH A > GASP
________________
IMPETIGO
What tx regimen is considered for Bipolar MANIA that does NOT respond to [mood stabilizer monotherapy] ? -3
ADD [antipsychotic 2ND GEN]
_________________
Treat Bipolar MANIA b4 they go B(aL)D!
{[a prn for → L|V]= Bipolar MANIATx}
_________________
[antipsychotic 2ND GEN] + [Lithium or Valproate]
prognosis for Alopecia areata?
PERSISTENT = reoccurs even after [successful treatment with temporary hair growth]
Tx for Acute Bipolar Mania -3
{[AntiPsychotics (2nd gen)] > (Lithium = Valproate)}
NO ANTIDEPRESSANTS
Diagnosis? | Treatment?-5
BCC | [Mohs micrographic surgery]
Dx? | how do you confirm diagnosis?
[HAWCA (HPV Anogenital Warts Condylomata Acuminata)]; shave biopsy
What is the treatment for [sunburn superficial thickness burn]? (2)
cool compress / NSAID
Describe Trichotillomania is
________________
what’s a serious complication of this?
compulsive Hair pulling DO in which pt attempts to stop pulling hair out of scalp, eyebrows and eyelashes BUT CAN’T!
________________
Possibly ➜ trichophagia (swallowing hair) which ➜ bowel obstruction
Related to OCD and has ⬆︎morbidity in those with hx or fam hx of OCD
Pt with severe mania is treated with ⬜-2.
If this patient does not respond to monotherapy, what should you do?
{(L|V) —A}
= [L or V] —(prn)–>add A =
_________________
L = Lithium mood stabilizer
V = Valproate mood stabilizer
A = Antipsychotic 2ND GEN
Diagnosis? | Tx?-4
Irritant Contact Dermatitis (PESTY)
Tx = CTSTopical, Emollients, [Identify/avoid offending agent], [lukewarm handwashing]
How should you work up melanoma?
excisional bx with initial margins of 1-3 mm of normal tissue also
Describe clinical presentation for alopecia areata (5)
- well-demarcated
- round patches of complete hair loss
- NO scarring
- [+/- exclamation point hairs (pathognomonic)]
- [+/- nail pitting]
_________________
usually in patients with fam hx of autoimmune disease
How do you manage Patient agitation when it’s escolated to violence? -2
- PHYSICAL RESTRAINTS
- INTRAMUSCULAR ANTIPSYCHOTIC
Pediatric patient p/w new diagnosis of Major Depressive Disorder
In addition to CBT, what’s 1st line pharmacotherapy for pediatric MDD?
________________
What’s the black box warning of this drug in pediatrics?
”Sad peds need Fluoxetine”
Fluoxetine
________________
increased risk of suicidal thinking in pediatric patients
[Nevus Simplex] are ⬜ , classically located on ⬜-3
[blanchable pink patches ➜ fade with time]
________________
[eyelids / glabella (between eyebrows) / nape of neck]
Which dermatologic condition is Hepatitis C associated with?
🅄ROPorph[Porphyria Cutanea Tarda] with skin fragility and photosensitivity
[HCV|OCP|EtOH] can → PCT → [🅄ROPorph-PCT heme enzyme❌]
MOD | Treatment?
Keloids
overproduction of extracell matrix and dermal fibroblast within a scar
_________________
[intralesional CTS]
Number of weeks given for a trial of SSRI?
6
Tx for Somatic Symptom disorder
Regularly scheduled Med visits (Goal: Improve functionality)
DO = preocupation with unexplainable (but proven to be benign) somatic sx
diagnosis?
What condition is this lesion associated with?
[HHV8 Kaposi Sarcoma]
deep red purple brown macules on face, trunk, extremities
_________________
HIV⼀[AIDS defining illness]
Contact Dermatitis or Urticaria?
Contact Dermatitis
Erythematous papules and vesicles
schizoAffective disorder
________________
dx -2
- [ISOLATED (Schizo Criteria A) x GOE2wk]
+ - [Major Mood (Bipolar vs MDD) Episode]
common causes of death following [2nd degree and 3rd degree] burn -3
Loss of: Fluids, Protection, Oxygen
1. hypOvolemia
2. infection
3. hypoxia⬇︎O2 delivery 2/2 smoke → {[mechanical airway injury] + [inhalational ⇪ [carboxyhgb>25%]}
[respiratory smoke injuryairway + inhalation ] [smoke inhalation injury] ➜ [INC carboxyhemoglobin>25%] ➜ [DEC oxygen delivery]
Clinical features of
Seborrheic Dermatitis -4
________________
✔︎[oily greasy scales & flakes on pruritic erythematous plaques]
✔︎scalp, eyelids, postauricular and nasolabial folds
✔︎usually occurs alone but (sometimes a/w HIVacute & severe Seborrheic Dermatitis→r/o HIV!| Parkinson’s)
✔︎[Topical CAC](Calcineurin⛔ /Antifungals / CTS) = tx
⛔ = inhibitor
how do you mitigate [DEC appetite] in kids taking Stimulants for ADHD? -3
- [growth❌? –(If yes)➜ drug holiday vs nonstimulant alternative]
- adjust administration time (i.e. after breakfast)
- eat nutrient-dense meals around medication’s active period
When should [Actinic⼀Solar Keratosis] be biopsied? -5
≥ 1 cm
rapid growth
ulcerated
TTP
initial tx failure
________________
1-20% transforms to SQC
ASK = [AK on SK (+/- ➜ SQC)]
[⬜ and ⬜] are the tx options for [any (FACIAL or intertriginous) plaque psoriasis]
Lipomas and Epidermal inclusion cyst can both present as painless benign nodules
How do you differentiate the two? - 3
- EIC resolves spontaneously and can come back. Lipoma don’t resolve w/out surgery!
- EIC are FIRM vs Lipoma which is soft rubbery
- EIC may drain cheesey white discharge +/-
What is Functional Neurological Symptom Disorder?
________________
tx?
unexplainable neurological symptoms 2/2 emotional stressors
________________
EDUCATION about the Disorder!
AKA CONVERSION DISORDER
How should you manage a nonsuicidal teen who cuts themself ?
full psych eval (if suicidal ideation ➜ inpatient)
Tx for Rosacea -5
- Avoid Triggers (hot/spicy foods/EtOH/cold/stress)
________________
[Erythema + Telangiectasia] only
2. Topical Brimonidine
________________
+papules or pustules
3. Topical Metronidazole
4. Azelaic acid
5. oral abx (severe / refractory)
Diagnosis?
Describe this lesion- 4
[Cherry Senile Angioma]
_________________
1. [multiple small vascularized dome-shaped papules]
2. IN ADULTS that (although they are senile = ⇪ with age)…
3. [do NOT PROgress to maligancy = do not req tx] but…
4. [do NOT REgress either]
[________white lacy lesion] is caused by Lichen Planus, and Lichen Planus is caused by ____
[Wickham Striae] ; [Hep C Advanced Liver Disease]
Although this disease ( ⬜ ) typically occurs alone, it is also a/w with 2 conditions. What are they?
Seborrheic DERMATITIS ;
HIV |Parkinson’s
oily greasy scales & flakes on pruritic erythematous plaques(sometimes) a/w HIV|Parkinson’s
[Actinic⼀Solar Keratosis] cp (3)
⭐[AK on SK (+/- ➜ SQC)] ⭐
🌞{[(AK):SANDPAPER papules|plaque lesions] on
🌞[(SK):Solar damaged skin background(telangiectasia/dyspigmentation/atrophy)]*}
🌞…and possibly→SQC*
When treating EtOH withdrawal, why must [Thiamine B1 IV] be given 1st!? (before [Dextrose IVF])?
1st: [Thiamine B1] is used in glucose catabolism and Alcoholics have high Glucose diet ➜Alcoholics have DEC [Thiamine B1]
2nd: Giving Glucose without [Thiamine B1] ➜ Wernicke Korsakoff Syndrome
Which medication clinically decreases Suicide Risk?
Lithium
When is it appropriate to trial a different rx for ADHD? - 2
- [Continued Side Effects] after 4 wk trial
- [Poor clinical response] after 4 wk trial
For Bipolar I dx, you need [__ mania sx +/- ___] that last for ___ duration.
________________
What are the mania sx? (7)
[≥3 sx +/- major depression episode]; 1 week duration;
BIPOLAR
Buying excessively (⬆︎ in pleasurable activity)
Inflated self-esteem
Psychomotor agitation (pacing)
awOke - won’t sleep
Lots of Language
ADD distractability
Racing thoughts
Lithium is eliminated exclusively by the ⬜ and has a narrow therapeutic index (serum level ⬜ = toxic )
Which drugs INC serum Lithium level? (6)
Kidney ; [≥1.5 “gotta NAC for lithium” = sx]
_________________
- [HCTZ, chlorthalidone (compensatory PCT Na-Lithium reabsorption 2/2 DCT Na inhibition)]
- NSAIDs (DEC GFR)
- [Angiotensin inhibitors (ACE/ARB)] (DEC GFR)
- Tetracycline
- metronidazole
- any Volume Depletion med
There are 4 options to screen for Alcohol Use Disorder
Describe the SINGLE ITEM SCREENING method
How many times this past year have you had more than {[4 –(women)–>] [5–(MEN)–>]} drinks in 1 day?
SIS ≥1= positive result
give a description of skin with
photoaging -2
_________________
What social factor worsens this?
[ROUGH skin] with [coarse deep wrinkles]
possibly accompanied by [Actinic⼀Solar Keratosis] / telangiectasia / brown liver spots
_________________
smoking
Diagnosis?
[Kaposi Sarcoma HHV8]
Which patient demographics in the ED always need Suicide Risk Assessment ? -3
psychotic
neurotic
[drunkotic (inebriated)]
_________________
Suicide Risk Assessment: [ iSAD PERSONS ]
Describe the difference between Factitious Disorder and Malingering
F = purporting unreal Sx or injury for Fun \ fufill “sick role” (but NO obvious external reward)
_________________
M = purporting unreal Sx or injury for Money/External Reward
Antipsychotics (___ generation) can be used to treat the depressive phase of [Bipolar Depression]
Which 2 are the best to be used?
“Treat Bipolar pts b4 they go BALLD, [Quiet or Lurky!
_________________
2nd gen;
QuetiapineBPD_dysthymia
or
LurasidoneBPD dysthymia
2nd generation Antipsychotics for Bipolar Depression =
Quetiapine and Lurasidone
“*[BPD Depression] is Quiet or Lurky””
[Pyogenic granuloma telangiectaticum]
[dome shaped papule with recurrent bleeding] caused by capillary proliferation after trauma during pregnancy
What are the 2 nonstimulant medication options for ADHD?
ATOmoxetine
[alpha 2 R agonist]
Diagnosis?
What conditions is this diagnosis associated with? (3)
[Acrochordon skin tag] ⼀benign pedunculated outgrowth of normal skin
describe meLasma
management? (4)
[Minimize sun exposure]
[Broad spectrum Sunscreen]
[skin-lightening agents]
[Topical retinoid creams (ctd in pregnancy)]
MOD for Lentigo
________________
demographic?
intraepidermal melanocyte hyperplasia that –> UNEVEN pigmentation
________________
elderly
Physicians should screen for ⬜ in veterans reporting insomnia, substance use and interpersonal conflict longer than ⬜
________________
What is the diagnostic criteria -2
PTSD
> 1 month
________________
[LIFE THREATENING TRAUMA]
+
P.A.I.N. sx
________________
Pysch_ed_ (arounsal ∆ /sleep* ∆/hypervigilance/concentration ⬇︎)
Avoidance (avoids distressing thoughts/feelings/external reminds of the event)
Intrustion (nightmares/flashbacks)
Negative mood (guilt/ anhedonia/detachment/anger/self-esteem ⬇︎)
For all patients at risk for suicide, what item if present in the home must physicians absolutely address for removal ?
FIREARM
Guns are a/w high suicide completion rate if used in suicide attempt and removal is a protective factor
Which Second Generation Antipsychotics are most associated with
Prolonged QTc -5
ZIPRASIDONE >> CORQ
________________
CORQ = Clozapine/Olanzapine-Risperidone/Quetiapine
Which Second Generation Antipsychotics are most associated with
ExtraPyramidal Side effects ( TADD ) -2
Risperidone >> Lurasidone
________________
CORQ = Clozapine/Olanzapine-Risperidone/Quetiapine
[Nevus Flammeus Port-Wine Stain] are [⬜ common | NOT common] and may be a/w with what syndrome? Explain
NOT common ; sturge weber = possible leptomeningeal vascular malformations = obtain brain MRI for evaluation
NFPWS respect midline and do NOT regress
When does Delirium Tremens : Onset? Peak? Resolve?
same as EtOH 🅆ithdrawal (but i/⊕D&T!])
After last EtOH⼀MonAM [EtOH 🅆ithdrawal_“PAST NITE”]:
🍺[ONSETS 0.5 Days]⼀MonPM,
🍺🍺[PEAKS Day2]⼀TUE,
🍺🍺🍺[ENDS by Day5]⼀FRI
describe Bullous Pemphigoid (3)
_________________
how is it diagnosed? (2)
- [Anti-HemiDesmosome IgG +/-C3] (a/w [Dementia/Parkinson/Depression]) collect along basement membrane
- [pts>60 yo]
- [pruritic prodrome ➜ TENSE BULLAE]
_________________
Dx = Skin Biopsy
demonstrating:
1.Supepidermal cleavage
2.Linear [IgG and/or C3]along basement membrane
Pt just began an antidepressant
How long should they give for a trial?
≥6 weeks
How do you assess if a patient has Decision Making Capacity? (4)
“a DMC patient can “CURE” themself”
patient can …
Communicate choice
Understands info about choice & condition
Recognizes CONSEQUENCES of choice
Explains rationale for choice
DMC = Decision Making Capacity
choice = preferred [tx (or no tx)]
Recognizes any/all CONSEQUENCES of their [tx (or no tx) of choice]
Explains rationale for their [tx (or no tx) of choice]
given regarding their condition and the their selected [tx (or no tx) of choice]
[Drug-induced parkinsonism] is an EPS component caused by ⬜ blockers.
________________
[⬜ and ⬜] are the tx of choice for immediate relief from both [(D2🟥)Dystonia] and/or [(D2🟥)Drug-induced parkinsonism]}
EPS = TADD sx
D2 R blockers;
[Diphenhydramine IV (DD)]
[Benztropine IV (DD)]
________________
Obviously⬇︎ (not d/c) D2🟥 as well
EPS = TADD sx
pregnant patient
Diagnosis?
Tx?
MOD?
pemphigoid gestationis ;
_________________
topical Triamcinolone
_________________
* Autoimmune* [Pregnancy Induced abd pruritus without rash)] ➜ gzd urticarial papular RASH starting umbilicus and trunk ➜ eventually tense bullae*
schizophrenia
________________
how is it diagnosed -4
• must meet all ABCD
A= [Active (GOE2 DNDDH Sx) x GOE1mo]
B= [Bad social occupational dysfunction]
C= [Chronicity x GOE6mo]
D= [Dx from other cause RULED OUT FIRST]
s/s of Opioid Withdrawal -7
the MAILMAN went through opioid withdrawal!
MyDriasis
Abd cramps
Irritability
Lacrimation
Myalgia
Arthralgias
NV
What is [Cholinergic Inducible Urticaria] ?
rapid-onset type of [Inducible Urticaria] induced by rise in body temperature (hot shower/exercise) ⼀that resolves 1-2h after stimulus. Tx = H1 blocker
diagnosis?
Psoriasis
affects extensor surfaces
Treatment?
Salicylic Acid
_________________
Cutaneous Warts
diagnosis?
________________
Treatment?
bullous pemphigoid
________________
[high potency topical CTS]
▶This skin rash can be induced by which 3 things?
▶Diagnosis?
“AND phototoxic!”
[Abx / NSAIDs / Diuretics] with sunexposure
Phototoxic dermatitis
[erythema(+/- bullae or vesicles)] over sunexposed areas (dorsal hand, forearm, upper chest, face)
Diagnostic criteria for Bipolar II ? - 3
- Major Depressive Episodes +
- hypOmanic episode +
- NOT functionally impaired
SQC is the most common Cancer of the lower lip
What would microscopy show for SQC? (2)
Squamous cells with KERATIN PEARLS
What are the risk factors for [Hidradenitis Suppurativa Acne Inversa]? - 5
- DM
- Obesity
- Smoking
- Mechanical stress (friction, pressure)
- Fam hx
Painful intertriginous nodules that can –> abscess and scarring
clinical presentation of [HAWCA]
_________________
Tx? -4
HAWCA = HPV Anogenital Warts Condylomata Acuminata
[multiform (cauliflower|verrucous|smooth|dome|flat)] anogenital wart lesions
_________________
“Treat HAWCA with picA”
-podophyllotoxin
-imiquimod
-cryotherapy
-⭐ACID (TriChloroAcetic ACID) ⭐
What is the CAM score and describe its criteria
CAM “[aiD|L]” score = Diagnosis Delirium and differentiates it from Dementia/Depression
Delirium dx = [aiD|L]Requires a and i, but only either D or L
acute confusion
inattentive (can not spell “world” backwards & forward)
Disorganized thinking (rambling/illogical)
LOC fluctuates (intermittently not alert?)
treatment?
AmoxicillinPO
[Scarlet fever GASP sandpaper rash]
etx for pemphiGus vulGaris
________________
cp?-2
[DesmoGlein3 (which adhere epidermal cell lateral keratinocyte anchors to one another)] are attacked by [antiDesmoGlein3 IgG autoantibodies] →pemphiGus vulGaris
________________
- [Flaccid Bullae with Nikolsky] PLUS
- Mucosal Erosions
________________
Nikolsky sign = light rubbing of skin separates epidermis
describe MeLasma
_________________
What are the 3 major risk factors?
acquired irregular hyperpigmentation of [sun-exposed face] that occurs when UVA and UVB radiation triggers melanocyte proliferation of [sun-exposed face]
_________________
- [Female (worse with pregnancy and/or OCP)]
- dark skin
- cosmetic usage
What type of cellular reaction is responsible for [Allergic Contact Dermatitis]?
erythematous papules and vesicles
[Type 4 Delayed T-cell mediated]
hypersensitivity
Tinea Corporis ringworm
annular plaque with raised borders and central clearing (also well demarcated & scaly)
Diagnosis?
Clinical Presentation
Sporothrix schenckii nodular lymphangitis
_________________
contact with decaying plant matter ➜ tame (painLESS) distal nodule at inoculation site ➜ ulcerates ➜ several similar lesions form proximally along lymphatic channel over weeks = nodular lymphangitis
Describe 2nd degree burn -2
[PAINFUL blistering]
with
[white fibrinous exudate]
a. Describe this diagnosis
b. Describe the treatment (5)
a. Ichthyosis Vulgaris = chronic inherited DO characterized as
* diffuse dermal scaling resembling fish or reptile scales, MUCH WORST than eczema*.
_________________
b. Remove scales via
▶[keratolytic topicals (urea, [alpha-hydroxy lactic acid], salicylic acid, retinoids)]
-▶long baths
⚠️DSM5: Panic DO is now only a specifier for other conditions
If they meet its clinical criteria, other Conditions can be modulated by adding “[Panic Attack Specifier]” to final dx
Clinically define “Panic Attack”? -2
❗️ “PAK(🔎Panic AttacK)” =[ ≥ 4 Panic sx -image] + [abrupt rapidly intense fear in min]❗️
___________________________x____________________________________
⚡{[≥4 Psx+ abrupt fear] = PAK –(if)–> Recurrent + Unexpected + Anticipatory = [PANIC ATTACK SPECIFIER]}⚡
_________________
⚠️DSM5 no longer considers Panic DO its own DO but now solely a Specifier for other conditions
⚠️DSM5: Panic DO is now only a specifier for other conditions
If they meet its clinical criteria, other Conditions can be modulated by adding “[Panic Attack Specifier]” a final dx
What is the clinical criteria for the addition of “[Panic Attack Specifier]” to a final dx ? - 3
📖add “[PANIC ATTACK SPECIFIER] to Final Dx if pt (in the absence of drug etx|alt dx ) has :
1.PAK Recurrently
2.PAK Unexpectedly
3.{≥1 PAK followed by ≥1mo of [PAKAnticipatory Anxiety +/- Avoidance Behavior]}
_________________
🔎{PAK (Panic AttacK) = [≥4 Panic sx + intense fear]}
___________________________x____________________________________
⚡{[≥4 Psx+ abrupt fear] = PAK –(if)–> Recurrent + Unexpected + Anticipatory = [PANIC ATTACK SPECIFIER]}⚡
_________________
⚠️DSM5 no longer considers Panic DO its own DO but now solely a Specifier for other conditions
There are 4 options to screen for Alcohol Use Disorder
Describe the CAGE method
[0 = negative / 1 = obtain further eval / ≥2 = POSITIVE]
- ever tried to Cut back on drinking?
- Angry when someone criticizes ur drinking?
- Guilty about how much you drink?
- need Eye opener in morning to prevent withdrawal/calm nerves?
patient has hx of Crohn’s disease
diagnosis?
Pyoderma Gangrenosum
_________________
rare neutrophilic dermatitis starting as tender papule that degrades into bluish/violaceous ulcer - a/w IBD
Burns management -3
A. [3rd degree burn: DEC subeschar infection with Surgical resection and grafting]
B. [Debridement ➜ Dressing]BID
C. [TOP Silver Sulfadiazine]
Malar Butterfly Rash
Patients with OCD can experience Obsessions, Compulsions or both
Tx for OCD -3
[high dose SSRI]
+
[CBT (Exposure & Response prevention)]
_________________
+/- {[TCA clomiporamine] with antipsychotic augment}
treatment?
topical Nystatin
(treats Candida skin infections)
* * *
Intertrigo
Tardive Dyskinesia is an EPS component caused by ⬜ blockers.
________________
What’s the antidote for Tardive Dyskinesia?
EPS = TADD sx
[D2 R blockers]
________________
switch current antipsychotic to Clozapine
Obviously ⬇︎ (not d/c) D2 blocker as well
What is the difference between [Alopecia areata] and [Alopecia androgenetic MPB]?
MPB = Male Pattern Baldness
aAMPB starts frontal or temporal
_________________
tinea capitis = scaly inflammaed hair loss of the scalp
What rash is Rheumatic Fever associated with?
________________
describe the rash
This condition is associated with which infectious disease ?
[Hep C ⼀advanced liver disease]
_________________
Lichen Planus
Diagnosis?
How is this diagnosis confirmed?
Sporothrix schenckii nodular lymphangitis
_________________
Diagnostic criteria for Bipolar I ? - 3
- Major Depressive Episodes +
- Manic episode +
- Functionally impairing
In skin SQC, what is Photodynamic therapy used to treat? (2)
[Actinic⼀Solar Keratosis] and [Bowen SQC in situ]
ASK = {[(AK):SANDPAPER papules|plaque lesions] on [(SK):Solar damaged skin]} …[possibly→SQC]*
Contact Dermatitis or Urticaria?
Urticaria
Causes = infection, NSAIDs, IgE, radiocontrast
well circumscribed raised erythematous plaques with central pallor
This condition is often triggered by ⬜ (4). Diagnosis?
Management? (2)
[allergic contact dermatitis] = faint vesicular erythema s/p exposure
- [urushiolpoison Oak/poison Ivy]
- topabx
- fragrances
-
RPL processing agents
* * *
d/c offending agent , [topCTS ⼀if itching/discomfort intolerable]
_________________
RPL: Rubber/Plastics/Leather
[High Risk SQC (on face/ears/sensitive areas)] is treated using ⬜. Why is this tx used?
________________
low risk SQC = < 2 cm lesions on trunk or extremities (excluding hands/feet)
[HRS] = [Mohs micrographic surgery] ; has higher cure rate than standard exicision and is great for cosmetic or functional areas
________________
[LRS] = curettage + electrodesiccation (mechanically + electrically destroys CA)
Tx? -2
- topMupirocin abx = local
- POCephalexin abx = extensive
IMPETIGO
[⬜ and ⬜] are the tx options for [SEVERE (nonfacial) plaque psoriasis]
What is the step wise approach to treating Acne Vulgaris (5)
“Losers Treating Bad Acne Is vulgar”
1st: Lifestyle ∆ (avoid chocolate, water-based makeup)
2nd: [Topical Retinoids with salicylic acid] = [Noninflammatory Comedonal Acne]
3rd: add Benzoyl peroxidePGX = Inflammatory Acne
4th: add Antibiotics (Topical before Oral) - erythromycin, clindamycin = Inflammatory Acne
5th: add [Isotretinoin PO]PGX = Nodulocystic Acne
_________________
PGX = PREGNANCY CONTRAINDICATED/TERATOGENIC
MOD for this condition? | Management? (2)
Psuedofolliculitis barbae
Close Shaves of [“nappy” tightly curled hair] below skin surface➜ allows penetration of the resultant [angled tip hair shaft] into interfollicular skin ➜ [small painful papules in beard]
and possibly ➜ [hyperpigmentation / 2º bacterial infection / keloid]
_________________
D/C SHAVING (or use clippers that leave hair longer)
Diagnosis?
[Actinic⼀Solar Keratosis]
## Footnote
<sub>*ASK = {[(AK):SANDPAPER papules|plaque lesions] on [(SK):Solar damaged skin]*} ...[possibly→SQC]*</sub>
diagnosis? | tx?
[Atopic dermatitits Eczema Herpeticum]
_________________
[Acyclovir IV]
painful vesicles, erythematous base, punched out erosions ➜ hemorrhagic crust
note: [Zoster Ophthalmicus] is dermatomal. [ADE herpeticum] is fully facial
Lithium is eliminated exclusively by the ⬜ and has a narrow therapeutic index (serum level ⬜ = toxic)
Which 2 BP medications can you give to a patient on Lithium?
Kidney ; ≥1.5
_________________
[Amlodipine CCB] > [Furosemide (Loop Diuretics)]
“gotta NAC for lithium”
clinical features for this condition (4)
Seborrheic Keratosis
- [benign epidermal tumor ([Leser Trelat explosive onset] may = Lung/GI CA)]
- face/trunk/UE
- well demarcated pigmented lesions with verrucous surface and “stuck on” appearance
💊Tx:[REASSURANCE-← N-(Sx/Cosmetic?)–Y ➜ > Cryotherapy]
_________________
⼀benign and slow growing so tx not necessary unless symptomatic or cosmetically unpleasant
Describe Wickham Striae - 4
- White
- Lacy pattern
- buccal mucosa
- a/w Lichen Planus
pt p/w [single annular patch @ trunk] that develops into [crops of oval lesions, following cleavage lines, in an oblique direction]
Treatment?
[self limited x 2 months]
_________________
[Pityriasis rosea “Christmas Tree”]
Identify
________________
When does this onset and regress?
________________
Describe composition
Capillary Hemangioma
________________
Birth - 6 mo and regresses by 7 yo.
________________
Small Capillaries that BLANCHES on pressure
treatment? (3)
mild = [TMCtopical antifungals(terbinafine | miconazole | clotrimazole)]1-4w
[moderate/failed topical] = [FITPO antifungals(Fluconazole | itraconazole | Terbinafine)]1-4w
[Severe/with onychomycosis] = [FITPO antifungals(Fluconazole | itraconazole | Terbinafine)]12w
* * *
[Tinea Pedis Athlete’s Foot (superficial pruritic fungal 👣infxn)]
Describe 1st degree burn
Superficial erythema only
PTSD dx requires sx > 1 month
[PTSD (P.A.I.N.) sx] [3 days -1 month] duration = ⬜
[Acute Stress Disorder]
⬜ is the most common CA of the eyelid. It presents as ⬜ and prognosis includes ⬜
Basal Cell Carcinoma ; [pearly skin colored nodule with telangiectasia];
[local invasion( → exenteration → blindness) but no distant metz]
Dx? | What is this condition caused by?
Keratosis Pilaris | retained keratin plugs in the hair follicles
small papules over rough texture mostly on POST upper arm
treatment?
excision (snip or shave)
_________________
filiform cutaneous wart
Patients with postpartum depression can be treated with ⬜ or ⬜ antidepressant and can continue to breastfeed
[Paroxetine | Sertraline]
treat Postpartum Sadness w [Paroxetine | Sertraline]
these have the lowest/undetectable levels in breast milk
Wernicke-Korsakoff syndrome tx
[Thiamine B1]
how is this diagnosis confirmed? (2)
_________________
1st line tx?(2)
(Onychomycosis = dx)
KOH preparation or culture of nail scrapings
_________________
Terbinafine| itraconazole
What does microscopy for [Apthous Ulcer Canker Sores] show?
Fibrin coated ulcerations with underlying mononuclear infiltrates
What’s the single greatest indicator of a teenager being in an abusive or coercive sexual engagement
sexual partners who occupy POSITIONS OF POWER OR AUTHORITY over the teenager is s/f abuse/exploitation
_________________
MDs are obligated to notify CPS or law enforcement about abuse/exploitation
Tx for skin suffering from photoaging
[Tretinoin (all-trans-retinoic acid)]
_________________
⬇︎ROUGH&WRINKLED photoaged skin, [Actinic⼀Solar Keratosis] and brown liver spots
Rosacea and [SLE Malar Rash] may sometime look similar
What are 2 major discerning features?
[nasoLabial folds]R ⊝ S and [telangiectasia]R ⊝ S
{note: rOsacea = Older / acne vulgaris = younger}
- {ROSACEA = [⊕telangiectasiaplus pustules, papules and tissue hyperplasia ⊕nLF]}
- {[SLE Malar Rash (Lupus)] = [⊝telangiectasia ⊝nasoLabialFold]}
Describe Lichen Planus (7)
p7
- papules
- plaques
- “planar” flexural surfaces (MOSTLY WRIST, buccal and genitalia)
- pruritic
- polygonal
- purple
- pattern that’s lacy in the buccal = wickham striae
⬜ are the 1st line tx for [mild/moderate (nonfacial) plaque psoriasis].
This 1st line tx is prescribed (in addition to ⬜ for maximizing treatment) , ⬜ per day for ⬜ weeks
▶[High Potency topical CTS(fluocinonide, augmented betamethasone)]
-( [Topical Vitamin D derivative = alternative])
▶occlusive barrier (plastic wrap/occlusion tape)
▶[___x___ BID x 4w]
In psychiatry, what is splitting? Which demographic is it commonly seen in?
Splitting people into either all good, or all bad; Borderline PD (PESSP)
What is a Marjolin Ulcer?
SQC that comes from wound or burn and has higher risk for metastasis
[⬜ and ⬜] are the tx options for [any (Guttate) plaque psoriasis]
Although this disease ( ⬜ ) typically occurs alone, it is also a/w with 2 conditions. What are they?
HIVacute+severe_SD = r/o HIV! | Parkinson’s
Seborrheic DERMATITIS
{[oily greasy scales & flakes on pruritic erythematous plaques(sometimes) a/w HIV|Parkinson’s]*[Top CAC]tx*}
Delirium is defined by what 3 fundsmentals?
When is it appropriate to use antipsychotics to manage delirium?
😵[aiD|L]
{[acute confusion(may present as psychosis vs agitation) → 💊] and [inattention] plus Disorganized Thinking and/or LOC flux]}
_________________
😵 2/2 underlying med condition
_________________
😵reversible
(may manifest with psychosis or agitation)–>if so give antipsychoticsLD if severe
Delirium= [aiD|L]Requires a and i, plus D or L
book;
s/s of Anorexia Nervosa (3)
_________________
Tx for Anorexia Nervosa typically includes ⬜ and ⬜ but When should these patients be hospitalized?(4)
- knuckle calluses (indicates self-induced vomiting)
- [BMI <15]
- distorted body image
_________________
Tx = [CBT + Nutritional Rehab] –(BESO sx)–> HOSPITALIZATION
_________________
BESO
Bradycardia / [Electrolyte ∆] / Syncope / [Orthostatic hypOtension]
Skin SQC is the 2nd most common Skin CA
What factors qualify Skin SQC has HIGH Risk? (3)
_________________
Tx for [Skin SQClow risk]? (4)
LARGE / [poorly differentiated histo] / perineural invasion
_________________
[Surgical exicision] 🆚 cryotherapy 🆚 electrosurgery 🆚 radiation
Where all would you expect to find Psoriasis skin rash? (6)
- scalp
- neck
- back
- extensor elbows
- [nail plate pitting–(if severe)–> onycholysis]
- knees
well demarcated, erythematous, scaly plaques covered w silver scales
This condition is known as ⬜. How is it characterized?
It is a/w ⬜ and can be triggered by what? -2
Porphyria Cutanea Tarda; (Nonpainful blisters with increased fragility of dorsal hand +/- facial hypertrichosis & hyperpigmentation)
; Hepatitis C ;
[ethanol or estrogen]
HCV skin rashes = PCT | Lichen Planus
diagnosis? | describe mechanism of treatment
HAWCA
_________________
Topical Imiquimod
(immunomodulatory that speeds up clearance of lesions)
_________________
HAWCA = HPV Anogenital Warts Condylomata Acuminata
Tx for Panic Disorder - 6
CBT (can be used alone)(breathing technique, exposure therapy) +/-
- SSRI (1st line rx)
- SNRIs
- [Benzo or BBlocker for situational]
- TCA
- MAOi
* Similar to Social Phobic Anxiety Disorder tx*
How do Corticosteroids affect the skin?
CTS ➜ [Monomorphic papular ACNE]
[Normal Grief Bereavement] overlaps [Major Depressive Disorder]
Name 4 major qualities of NGB that distinguishes it from MDD
In [Normal Grief Bereavement]:
1. if Patient wishes to die it’s only to join the deceased
2. visual/auditory hallucinations of deceased person is normal
3. [sadness (Triggered by reminders) ➜ PRESENTS IN “WAVES” and ⬇︎ Intensity over time]
4. NO PERVASIVE SUICIDALITY
Dx?
________________
Tx?-2
[Tinea versicolor Malassezia]
________________
[selenium sulfide] or ketoconazole
salmon colored hypo or hyperpigmented macules that appears more readily after sun exposure since surrounding skin is tanned
Diagnostic criteria for [Adjustment disorder with depressed mood] - 3
- [≤ 4 SIGECAPSS] within 3 mo. of acute stressor(EXCLUDING nGB) that –>
- FISD
- NOT 2/2 more specific disorder
Tx = CBT
_________________
🔎FISD = Functional impairment\Significant Distress
🔎nGB = normal Grief Bereavement
Patient presents with Suicidal Ideation
What 2 factors determine if this patient should receive inpatient tx or outpatient tx?
[+INTENT with +PLAN?] = Inpatient Tx
[No Plan and No Intent] = Outpatient tx
________________
i[SAD PERSONS]
What’s the tx for Severely depressed patients who require URGENT treatment
Electroconvulsive Therapy
Name all the Body Surface Area % for Burns -8
[HAA - BALL - P]
Head = 9
Arm L = 9
Arm R = 9
Back = 18
Anterior = 18
Leg L = 18
Leg R = 18
perineum = 1
- Patients with OCD can experience Obsessions, Compulsions or both*
- ________________*
a. define Obsessions
b. Give 4 examples
________________
c. define Compulsions
Obsession = Recurrent intrusive anxiety-provoking urges or thoughts or images about..
([killing/unwanted taboo urges], fear of arm, contamination, symmetry/bad luck)
_______________
Compulsion = rituals/behavioral response used to combat the obsessions (> 1h/day or causing significant distress)
EtOH withdrawal can progress to ⬜ (which is an acute medical emergency)
🅳ELIRIUM 🆃REMENS
_________________
[((PAST NITE)EtOH Withdrawal
plus
{🅳elirium & 🆃emp/fever}] = DT
{[PAST NITE=EtOH🅆[⊕{D&T}=⊕🅳T]}
After last EtOH⼀MonAM [EtOH 🅆ithdrawal_“PAST NITE”]:
🍺[ONSETS 0.5 Days]⼀MonPM,
🍺🍺[PEAKS Day2 {+/- 🅳T_“D&T”}]⼀TUE,
🍺🍺🍺[ENDS by Day5]⼀FRI
⬜ side effects are common when 1st starting an SSRI, but should improve over a recommended drug trial of ⬜
________________
what should u do if side effects are intolerable or inadequate response?
GI ; 6 weeks
________________
change antidepressant
treatment?
POdoxy
- Rosacea*
dx? | is this rash painful or painless?
Erysipelas ; painFUL
What are the treatments for this condition? (3)
Bullous pemphigoid
- [CTSHIGH POTENCY Topical]
- [CTS PO]
- doxycycline PO
Tx for EtOH withdrawal -6
Benzos Treat Drunk Fairly Mean Alcoholics
- [Benzo > barbituate] EARLY
- ([Thiamine B1 IV ➜ 3. Dextrose IVF])
- [Folic Acid B9] IV
- Mg Sulfate
- Admit
Differentiate [Pemphigus vulgaris] from [Bullous pemphigoid] using:
Blister characteristics (3 each)
Papa = SUPERFICIAL / FLACCID / NIK+
________________
bravo = deep / tense/ nik-
________________
Nik = Nikolsky sign
How are Tattoos done?
Solid bore needles repeatedly puncture skin to install tattoo pigment in the dermis ➜ dermis macrophages take up pigment ➜ permanence
Psych pts who’ve taken [D2 R Blockers] chronically may develop EPS
Why would abrupt discontinue of [D2 R Blockers] –> worsening of EPS sx?
Chornic blockade of D2 Receptors –> ⬆︎D2 receptors and sensitivity. With abrupt [D2 R blocker] d/c, these receptors are over stimulated even with low dopamine levels –> Exaggerated EPS
EPS = TADD sx
S/S of Amphetamine and Cocaine withdrawal - 4
Coke/Meth withdrawal hits HARD
- Hungry
- Angry irritable
- Rest a lot w/unpleasant dreams
- Depressed (can mimic MDD vs Bipolar)
can last several days
Name the factors of Schizophrenia a/w a good prognosis -6
Delirium Tremens is a dangerous graduation from [EtOH Withdrawal] that may onset Day ⬜ of EtOH abstinence
What addtl 2 sx indicate graduation to Delirium Tremens from EtOH Wtihdrawal?
[Day2 (when EtOH_🅆ithdrawal PEAKS)]
_________________
⊕[🅳eliriumConfusion and 🆃empFever]
with
[PAST NITE]</sub>
After last EtOH⼀MonAM [EtOH🅆 ithdrawal_“PAST NITE”]:
🍺[onsets after 0.5 Days]⼀MonPM,
🍺🍺[PEAKS Day2 {+/- DT_“🅳&🆃”}]⼀TUE,
🍺🍺🍺[resolves by Day5]⼀FRI
Electroconvulsive Therapy indications -6
- unipolar depression (with psychosis or suicidality)
- bipolar depression (with psychosis or suicidality)
- bipolar mania
- depression requiring rapid treatment
- depression during pregnancy when rx contraindicated
- catatonia
________________
ECT is safe for pregnancy!
Tx for Bipolar I and II - 6
Treat Bipolar pts b4 they go BALLD!
-Benzos adjunct prn
-AntiPsychotics (Only use 2nd gen for Depressive phase)
-Lamotrigine (depression phase only)
-Lithium or Valproate **
-DepakOte **
Treatment? (5)
Remove scales via
▶[keratolytic topicals (urea, [alpha-hydroxy lactic acid], salicylic acid, retinoids)]
▶long baths
Ichthyosis Vulgaris
diffuse dermal scaling resembling fish or reptile scales, MUCH WORST than eczema
How do you manage suspected melanoma skin lesion? (2)
EXcisional biopsy with [1-3 mm margin surrounding skin & fat]
When is it ok for Bipolar pts to discontinue their Rx therapy?
________________
Explain
NEVER!!
________________
It is a lifelong illness requiring maintenance tx for years (and forever in severe bipolar pts)
Dx?
Varicella Zoster shingles
This condition ( ⬜ ) is common in ⬜
[Tinea Corporis trichophyton] ; [atheletes who participate in contact sports]
pruritic but nontender rash with central clearing and raised borders
Psoriasis is a ⬜. It is typically located ⬜ ; and although mostly asymptomatic, some pts may have ⬜
▶[common inflammatory skin DO characterized by erythematous, well defined silvery scale plaques]
▶[over scalp, back, knees, elbows, nail plates]
▶mild itching
Physicians should screen for ⬜ in veterans reporting insomnia, substance use and interpersonal conflict
________________
Tx for this condition? -4
PTSD
________________
[Trauma Focused CBT]
[SSRI] or
[SNRI]
[Prazosin for nightmares]
[T or F]
Stimulant therapy for ADHD is associated with ⇪ risk for Substance Use Disorder
FALSE
_________________
Stimulant rx for ADHD does NOT increase risk of developing Substance abuse
▶Which abx is most associated with phototoxic drug eruptions?
▶Name the other 3 drugs that cause phototoxic drug eruptions
Tetracyclines
(SAT For photo) = Sulfa|Amiodarone|TETRACYCLINES|5FU
especially in sun-exposed areas
Describe the process for receiving gifts from patients -2
You CAN receive gifts from patients as long as they are
- NOT excessive
- NOT intended to influence care
Rash description: scaly, erythematous, pruritic rash with a raised border and central clearing.
What is the diagnosis?
________________
how do you confirm this diagnosis?
[Tinea Corporis ringworm]
________________
KOH of skin scrapings
[Actinic⼀Solar Keratosis] is a precursor to ⬜ and should be biopsied if concerning
SQC
ASK = {[(AK):SANDPAPER papules|plaque lesions] on [(SK):Solar damaged skin]} …[possibly→SQC]*
In [2nd and 3rd degree burns] what % body surface area causes hypOvolemic shock?
> 25%
(Remember: Give IVF within FIRST 24 HOURS)
Diagnosis?
Tx? (2)
[Strawberry infantile hemangioma] ; {[spontaneous regression by 8 yo]–(if persist)–>[Propranolol]}
Why are the Negative symptoms of Schizophrenia treated differently?
and what are Negative Schizo sx treated with?
NEGATIVE Schizo Sx respond poorly to Antipsychotics so…
_________________
➜ Negative Schizo symptom tx = [social skills training]
Burn patient may present with laryngeal edema and respiratory failure _______ hours after injury
6-24 hrs
Wernicke-Korsakoff syndrome sx -3
CAN
- Confusion
- Ataxia
- Nystagmus Ophthalmoplegia
Pityriasis Rosea
______________________
clinical presentation
[single annular Herald Patch @ trunk] ➜ [Christmas tree oval lesions @ trunk]
What type of hypersensitivity is Nickel allergy?
4T
[Type 4 T-cell mediated Delayed hypersensitivity reaction]
What is the strongest single risk factor for suicide?
Previous suicide attempt
i[SAD PERSONS]
Acne Treatment for females with [premenstrual acne flares] is different
What is it?
________________
MOA
[Combined OCP]
________________
[combined OCP] ⬇︎ sebum production and are antiandrogenic
For patients who have been involuntarily hospitalized , how can you acknowledge their distress, be empathetic and explain rationale for the involuntary hospitalization ?
“You’ve been dealing with depression on your own for a while; getting treatment in the hospital can help you feel better in a safe place.”
What is the clinical criteria for Mania-2
- ≥3 [BIPOLAR] sx PLUS
- Elevated or irritable mood > 7 days
Which antiHTN causes [photosensitive sun rash]?
HCTZ
HCTZ are sulfonamides = causes [photosensitive sun rash] = d/c, suncreesn, avoid sun
Diagnosis?
Treatment?
Sporothrix schenckii nodular lymphangitis
_________________
Lithium is eliminated exclusively by the ⬜ and has a narrow therapeutic index. (serum level ⬜ = toxic)
Which drugs DEC serum Lithium level? (2)
Kidney ; ≥1.5
_________________
- Mannitol (osmotic diuretics)
- Theophylline
“gotta NAC for lithium”
what’s the treatment for this? (5)
Remove scales via
▶[keratolytic topicals (urea, [alpha-hydroxy lactic acid], salicylic acid, retinoids)]
-▶long baths
________________
- Ichthyosis Vulgaris*
- diffuse dermal scaling resembling fish or reptile scales, MUCH WORST than eczema*
[Drug-induced parkinsonism] is an EPS component caused by ⬜ blockers.
________________
What’s the antidote for EPS?-6
EPS = TADD sx
[D2 R blockers;
- Clozapine (use for Tardive Dyskinesia in extreme cases)
- Propranolol (use for Akathisia)
- [Diphenhydramine IV (DD)]**
- [Benztropine IV (DD)]**
- Trihexyphenidyl (DD)
- Lorazepam (DD)
- Obviously ⬇︎ (not d/c) D2 blocker as well*
- EPS = TADD sx*
Tx for acute Mania -3
(m): A > [L = V]
(m)ania: [Antipsychotics (1st or 2nd)] > Lithium = Valproate
________________
[Antipsychotics for Agitation] since Lithium & Valproate have slower onset
Lithium is eliminated exclusively by the ⬜ and has a narrow therapeutic index (serum level ⬜ = toxic)
How do you manage Lithium toxicity ? (4)
Kidney ; ≥1.5
_________________
- “gotta NAC for lithium”*
a. IVF
b. [Lithium level]q2-4h
c. [Bowel irrigation](for asx acute OD)
d. [HemoDialysis (if any below):
- Lithium > 4
- Lithium > 2.5 with sx or AKI
- Lithium INC despite IVF
etx? | Tx?-2
Papular urticaria = INSECT BITES➜ [1cm pruritic papules with pale halos] 2/2 [Type 4 delayed hypersensitivity rxn] ➜ spontaneous resolution in months
________________
[2nd gen H1 blockers (cetirizine/loratidine)] + [Topical CTS]
What’s difference between initial ADHD tx in [preSchool 3-5 yo] vs [older > 6 yo]?
initial ADHD tx:
[preSchool 3-5 yo] = [behavioral therapy 1st] –(if persist)–> [pharmacotherapy 2nd]
_________________
[older > 6 yo] = pharmacotherapy 1st]
[Hidradenitis Suppurativa Acne Inversa] management for:
mild
Moderate
SEVERE -2
[Topical Clindamycin]
________________
sinus tracts/scar formation
[PO Doxy]
________________
EXTENSIVE SINUS TRACT/DIFFUSE
[surgical incision + infliximab (TNFα-inhibitors)]
list the 4 main characteristics of Histrionic personality disorder
- sexually provocative behavior
- excessive but shallow emotions
- influenced easily
- attention seeking - considers relationships more intimate than they are
_________________
MUST set firm boundaries to protect doctor-patient dynamic
teen Depression has different cp than Adult MDD
________________
What are 3 discerning features?
- irritability
- somatic sx (tension HA)
- socioeducational decline
{ALL DEPRESSED teens MUST BE “iSADPERSONS” SUICIDE SCREENED}!
Patient presents with papule that developed into lesions progressing distal to proximal
What is this called?
_________________
What causes this?
[Sporothrix Schenckii nodular lymphangitis]
_________________
decaying plant materialwound infxn
Which Skin Cancers are associated with Sun exposure?
________________
How is this prevented?
ALL 3!
(SQC / Basal Cell Carcinoma / Malignant Melanoma)
________________
Daily liberal application of [SPF ≥ 30 sunscreen] before/during outdoors
(Tight clothing and sun avoidance are also important but impractical)
Clinical presentation for [illNess Anxiety disorder]
{[≥6 mo ANXIETY] over having a serious ILLNESS} despite {[(N)EGATIVE somatic sx ≥6 mo]]
…In somatic sym(P)tom DO = [(P)OSITIVE somatic sx (albeit benign)]
Explain the blackbox warning regarding antidepressants and Bipolar Depression
ALL ANTIDEPRESSANTS carry risk of inducing mania (especially in bipolar patients)
and tx for this is d/c antidepressant
Treatment choices? (3)
_________________
What’s the prognosis of this condition after treatment?
treat SD with [topical CAC]
1. topical Antifungal (ketoconazole / selenium sulfide)
2. topical CTS
- topical Calcineurin inhibitors (pimecrolimus)
_________________
SD is a chronic RELAPSING condition so intermittent re-treatment may be necessary!
_________________
Seborrheic DERMATITIS ;
{[oily greasy scales & flakes on pruritic erythematous plaques(sometimes) a/w HIV|Parkinson’s]*[Top CAC]tx*}
Symptoms of fatigue and depression in patients taking Lithium should prompt a workup for ⬜. Explain (2)
Treatment? (2)
[Lithium-induced hypOthyroidism];
▶lithium (usually in first 2 years of tx) interferes with synthesis and release of thyroid hormone → *[hypOthyroidism +/- Goiter]
vs [Hyperthyroidism] (rare)
vs [autoimmune thyroiditis] (rare)
▶assess [Thyroid function TSH/free T4/Goiter] before prescribing Lithium , and then repeat q6month while on Lithium
_________________
-ADD LEVOTHYROXINE
-cont Lithium (DO NOT NEED TO STOP LITHIUM)
Tx for Major Depression with psychotic features - 2
- ECT > antipsychotic ➕
- Antidepressant
Use ECT in elderly as it is more rapid acting
Diagnostic criteria for [Persistent Depressive Dysthymia disorder] - 3
- [Persistent with NO relief x > 2 mo]
of - [≥2/6 siGECA Dysthymia]
for - ≥2y (or 1 year if peds)
Major Depressive Episodes may also occur with this
Describe 3rd degree burn -3
- [loss of epidermis and alldermis]
- ➜ charred leather
- numb (no sensation)
{1E → [2sP → 2DP] → 3F → 4G}
⚠️”3F” dermis = 1E+[2sP+2DP]
clinical features of Psoriatic Arthritis (5)
a. [⅓ of Plaque Psoriasis patients develop PA]
b. [Normally, PP → PA (but 15% have 🔄)]
c. RA-like Morning stiffness, better with activity
d. but at DIP and [axial skeletonsacroiliitis/spondylitis]
e. PP tx: {[Topical CTS|Calcipotriene ← <10%]PP [ ≥10% OR with ⊕PA →MTX) }
_________________
PA: Psoriatic Arthritis | PP: Plaque Psoriasis
why do burn patients develop DEC oxygen delivery to tissue?
tx? why does this work?
burn ➜[smoke inhalation injury] ➜ [INC carboxyhgb>25%] ➜ [DEC oxygen delivery] = 1 of 3 Cause of Death for Burns
tx = 100% OXYGEN (DEC 1/2 life of carboxyhgb)
Alopecia areata
Tx (2)
[Intralesional CTS] 🆚 [Topical CTS]
_________________
note: Alopecia areata is PERSISTENT and can reoccur even after successful initial tx
dx?
filiform cutaneous wart
_________________
tx = excision (snip or shave)
Delusional disorder dx (4)
- [isolated Delusions]≥1 mo
- [NO Mood Sx]
- [NO Criteria A Schizo]
- [NO Criteria B Schizo]
a. diagnosis?
b. treatment
a. Scabies
b. topical permethrin
* * *
* scaly erythematous linear plaques involving hands/wrist/groin*
Which Second Generation Antipsychotics are most associated with
Weight Gain/Metabolic Syndrome -4
CORQ
[Clozapine = Olanzapine] > [Risperidone = Quetiapine]
Autism usually presents by age ⬜
________________
What is the CP?-3
EAAARRRLY intervention for Autism is the KEY!
Presents by age 2
_________________
“the IRS gave him Autism, not vaccines!”
- [Interpersonal deficiency(⬇︎ *+/- impaired* language, ⬇︎eye contact, ⬇︎ plays alone, poor pickup of social cues/metaphors/humor/NONverbals)]
- [Repetitive Behavior(rocking, hand flipping, repetitive speech)]
- [Strict & Fixated Interest (insist on same routines, 1-sided convos on fixated topics)*]</sup
Autism is +/- language or intellectual impairment
Also, consider Fragile X syndrome testing
Lithium is eliminated exclusively by the ⬜ and has a narrow therapeutic index (serum level ⬜ = toxic)
What are the sx of Lithium toxicity ? (4)
Kidney ; ≥1.5
_________________
“gotta NAC for lithium”
[gI NVD]acutely → [Neuromuscular excitability (tremor), Ataxia, Confusion]CHRONIC
Diagnosis?
________________
Demographic?
Non Blanching Blue Grey Sacral patches
[Mongolian Spot dermal melanocytosis] (fades during childhood)
________________
Pretty much every race except white lol
- These should be NON-Tender*
- Often described on test as Non Blanching Blue Grey Sacral Patches*
diagnostic crtieria for Cannabis Withdrawal
[≥1 physical sx (abd pain, sweating, shakiness, fever, chills, HA)]
+
[≥2 post cessation sx (Irritability,anxiety,insomnia, ⬇︎appetite, restlessness, depression)]
Pt p/w rash in the groin
dx? organism that causes it?
Tinea Cruris ; Trichophyton rubrum
[Hidradenitis Suppurativa Acne Inversa] etx
________________
cp?
chronic recurring inflammatory occlusion of the FolliculoPiloSebaceous units –>
Painful intertriginous nodules that can –> abscess and scarring
describe this lesion
[stucK on brown benign epidermal tumors in the elderly]
________________
Seborrheic Keratosis
Using Antipsychotics in elderly dementia patients is relatively contraindicated; why is this?
_________________
When is it clinically indicated to use Antipsychotics for elderly dementia?
[AntipsychoticsBOTH GEN] actually ⇪ risk of all-cause mortality in elderly dementia patients!
_________________
if elderly dementia starts exhibiting psychotic or dangerous sx ➜ AntipsychoticsLd
_________________
(all-cause mortality = ❤️ /stroke/falls/etc) (MUST INFORM family of ⇪ Mortality risk)
Describe Desmoid tumors
________________
how do you differentiate it from lipoma?
Desmoid tumor= slow but locally aggressive benign neoplasm with high recurrence rate (tx = radiation if asx // surgery if sx)
________________
Lipoma will NOT reoccur
Describe Nummular Eczema
[round erythematous patches @ extremities]
perianal [Acrochordon skin tag] is associated with ⬜
Crohn’s IBD
dx? | tx?-2
Allergic Contact Dermatitis 4D
4D= Type 4 Hypersensitivity Rxn
pruritic excoriated lichenified plaques
_________________
[Topical HP CTS] (or Topical Tacrolimus for face)
HP = High Potency (betamethasone/fluocinonide)
A pt has a single episode of major depression but responds well to antidepressant SSRI tx. He is now asking to stop the SSRI since he’s now feeling “great”
How do you manage pt pmhx MDD on SSRI, now at remission and requesting d/c SSRI? (3)
At Remission, if ____ cont Antidepressant tx for additional ____ then d/c
▶[single|mild] MDD = [+ 4-9mo]
▶[Multiple|Mod] MDD = [+ 1-3y]
▶[PERSISTENT|SEVERE] MDD = [+INDEFINITELY]
This is called continuation phase tx
if single MDD → Cont Antidepressant rx for _additional 4-9 months_ then d/c
Explain why Codeine is contraindicated in peds less than ⬜ years old
“In peds, Codeine is ONLY for Teens & Preteens!”
⚠️[N🚷 Codeine for < 12 y/o]
________________
[unpredictable kids metabolism < 12 yo] –(could)–> ⇪codeine conversion to active opioid metabolites ➜ fatal respiratory depression in kids < 12 yo
________________
Morphine / Hydromorphone are OK
How should you counsel on smoking cessation? (5)
5 A’s (KCVSR)
“Kevin Can Voluntarily Stop Rightnow”
AsK patient about their tobacco usage every visit
AsCertain readiness to quit
AdVise to quit
ASsist with Rx or cessation programs
ARrange quit date + follow up appointments
_________________
smoking cessation ⬇︎ [all cause mortality (including Lung CA, CV events and COPD)] within 5 years after you stop
There are 4 options to screen for Alcohol Use Disorder
How do you counsel patients with a positive screening for Alcohol Use Disorder? (3)
treat AUD with EFG
- Express Concern but emphasize pt autonomy and responsibility
- Feedback: Provide personalized feedback on patient’s substance use and their risk
- GOALS: [reduction (AUD or pregnant?)ABSTINENCE]
_________________
[AUD: Alcohol Use Disorder = pt has Alcohol-related problems]
Diagnostic clinical criteria for Generalized Anxiety Disorder consist of a ≥ ⬜ month time period of ≥ ⬜ out of 6 major sx
What are the 6 GAD major sx?
waTCHERS
worry / anxiety that –>
- Tension in muscles
- Concentration ⬇︎
- Hyperarousal /on edge
- Energy ⬇︎
- Restless/ IRRITABLE
- Sleep ∆
6 ; 3
GAD Dx = ≥6 mo of [ ≥3 / 6 (“waTCHERS” sx)]
How do you diagnose lichen Planus?
Skin biopsy
Diagnosis?
________________
Tx?-2
[Tinea Capitis Dermatophytosis]
________________
- [Griseofulvin PO]
- [Terbinafine PO]
Tattoos are removed with ___ and _____
________________
What are the side effects of these procedures? -2
Laser Removal ; Dermabrasion
________________
- Scars
- Pigmentation ∆
Key features for Borderline personality disorder - 5
PESSP
- Pervasive Instability
- Emptiness & fears of abandonment –> ⬆︎suicide
- Self-defeating behavior
- Splitting is common (people are either good or bad)
- Paranoid when stressed
these pts usually have hx of child abuse, will react to stressors with rage and manipulative behavior and tx = DBT only
Dx? Clinical Course?
[Erythema Toxicum Neonatorum] ; [benign asx erythematous papules/pustules in 1st 2 weeks of life ➜ resolve within 1 week]
Buproprion MOA (2)
- NorEpinephrine reuptake inhibitor
- Dopamine reuptake inhibitor
Pt p/w rash after camping
Dx?
[Poison Ivy Allergic Contact Dermatitis] 4T
________________
pruritic linear papules and clear fluid-filled vesicles on exposed areas - after camping
Between flexor and extensor, which is more involved with [Eczema Atopic Dermatitis]
Flexor
If superimposed with HSV –> Eczema Herpeticum which –> hemorrhagic crusting
In psychiatry, what is splitting?
________________
Which demographic is commonly seen in
Splitting people into either all good, or all bad
________________
Borderline PD ( PESSP )
small papules over rough texture mostly on POST upper arm
Dx? | Tx? (2)
Keratosis Pilaris |
[topical salicylic acid / topical urea] = topical keratolytics (softens papules)
What makes up the ExtraPyramidal Symptoms? - 4
EPS = TADD sx
- Tardive dyskinesia (tx=switch to clozapine)
- Akathisia
- Dystonia
- Drug-induced Parkinsonism
What are the 5 major components of [irritant contact dermatitis]”?
“repeated irritant exposure makes ICD PESTY “
- Pruritus
- [Erythema(with UNCLEAR BORDERS) *]
- Scaling
- [Thin areas worse(hand dorsum, finger webs, fingertips)]
- hYperkeratosis & fissuring when chronic
[common in pts with eczema atopic dermatitis and HCP],
ICD = 2/2 repeated exposure to irritants (detergents/solvents/oxidizing agents)
💡*/ [Allergic Contact Dermatitis] = Demarcated Borders)
Skin SQC is the 2nd most common Skin CA
What factors qualify Skin SQC has HIGH Risk? (3)
_________________
Tx for [Skin SQCHIGH RISK]?
LARGE / [poorly differentiated histo] / perineural invasion
_________________
SURGICAL EXICISION
Identify
[Urticaria Hives]
