23/9/21 Flashcards
What is Koebner’s Phenomenon?
Describes the appearance of new skin lesions on sites of cutaneous injury in otherwise healthy skin.
How Koebner’s Phenonemon it diagnosed?
Diagnosis: Clinical
- develops at sites of cutaneous injury to previously healthy skin
- usually has the same clinical and histological features as the patient’s original skin disease → e.g herpes zoster (shingles) or psoriasis
- NOT due to seeding of an infectious agent, an allergic reaction to a contact agent or skin breakdown
Triggers for Psoriasis (6 points)
- infections (streptococcal) + viral (including HIV)
- skin trauma (e.g Koebner phenomenon) - cuts, abrasions, sunburn
- stress
- smoking, alcohol
- medications - lithium, beta-blockers, antimalarials, NSAIDs
Next step in management in establishing a diagnosis of a clinically concerning pigmented lesions?
Excisional Biopsy with 2 mm lateral margin and as deep as the subcutaenous fat
Why do you need to complete a excisional biopsy with 2mm margins of this clinically concerning lesion? (explain to pt - 2 points)
- Difficult to identify whether a lesion has been completely encompassed in a punch biopsy - incomplete sampling leads to increased risk of underdiagnosis
- Breslow thickness which is important for management + prognostication can only be determined if complete lesion is excised.
If melanoma is confirmed following excisional biopsy, what needs to happen next? How fast does this need to happen and what does this depend on.
WLE of the lesion with margins that depend on tumour thickness.
- if initial excision removed all the lesion - WLE should take place within 4 weeks.
- if some lesion was left behind after first excision → WLE should take place ASAP.
Who should you refer to if suspecting metastatic disease?
oncologist or multidisciplinary specialist melanoma unit
True or False. Pts who have had melanoma are at no increased risk of future skin cancers.
Pts with melanoma are at an increased risk of further melanoma and non-melanoma skin cancers → need life-long surveillance
How many fold is the increase in melanoma risk in first degree relatives of pts with melanoma?
4 fold :O - yearly skin check
Glycaemic Targets for Diabetics with Heart Failure.
Moderate Glycaemic Targets - HbA1c 7.1-8
Medications Choices for Diabetics with Heart Failures (1st and 2nd Line Please) + what class of meds to avoid.
- Metformin
- SGLT2 Inhibitors - flozins
Avoid thiazolidinediones
Recommended combination for HFrEF in hypertensive patients.
ACEi, ARB or ARNI + beta-blocker and MRA
3 drugs to avoid in HFrEF in patients with coronary artery disease OR HTN
Avoid diltiazem, verapamil, moxonidine in patients with HFrEF
Recommended combination in HFpEF in pts with HTN
optimal BP control is important, use MRA with or without an ACE/ARB
Optimal drugs for ventricular rate control in AF in patient with HF.
Beta-blockers and digoxin
Drug used to maintain sinus rhythm in AF in patients with HF
Amiodarone may facilitate attainment/maintenance of sinus rhythm
In patients with coronary artery disease, consider _____ if HR >70 + LV <35% despite max beta blockers.
Ivabridine
When do you use ivabridine in CAD in patients with HF?
If HR >70 + LV <35% despite max beta blockers
SLGT2 Inhibitors aka _______
The Flozins #teamflozins
How to the SGLT2 inhibitors work?
They inhibit the sodium-glucose co-transporter (2) which means less glucose is reabsorbed (SGLT2)
True or False. SGLT2 works in improving glycaemic control in impaired kidney function.
False. not effective for glycaemic control in patients with impaired kidney function
Additional benefits of SGLT2 inhibitors. (2 points)
- can cause modest weight loss → plateaus at 6 months
- weak diuretics → contribute to blood pressure reduction + sustamed increased in haematocrit
Use _____ in HF + T2DM and why?
Use empagliflozin in patients with T2DM and established CVD** → improves overall survival, lowers rate of death from CVD and incidence of heart failure in this population.
Options of Thiazolidinediones
GLITTERZONES
Rosiglitazone
Pioglitazone
Why do we not use thiazolidinediones? (4 reasons)
- precipitation of heart failure due to fluid retention
- increased risk of fracture in menopausal women
- increased rates of bladder Ca associated with pioglitazone
- increased risk of macular oedema
What is Erythema Nodosum? And How does it present?
Type of panniculitis
- inflammatory disorder affecting the subcutaneous fat
Presents as tender red nodules on the anterior shins
Causes of Erythema Nodosum.
Main cause in 55% of patients?
Other Causes - 4 big categories. Name 5 individual causes acorss all those categories please.
Hypersensitivity reaction of unknown cause in up to 55% of patients
Other → associated with an identified drug reaction, infection, inflammation or malignancy
Infection
- Throat Infections (streptococcal disease or viral infections)
- Primary TB
- Yersinia, Chlamydia
- Fungal Infection - histoplamosis
- Parasitic Infection - giardiasis
- Viral or Bacterial → HSV, Hepatitis, HIV, Campylobacter, Salmonella
Inflammation/Malignancy
- Inflammatory Bowel Disease
- Sarcoidosis
- Lymphoma
- Leukaemia
Drugs
- Amoxicillin
- OCP
- NSAIDs
Other
- Pregnancy
How do you diagnose Erythema Nodosum? What are some other investigations you would do in the context of working up erythema nodosum?
- Usually clinical, does not require biopsy
- Diagnostic Test:
FBC, ESR, UEC, Throat Swab, Stretococcal Serology + CXR
Treatment of Erythema Nodosum - 1st line and 2nd line plus additional measures.
- Bed Rest, Leg Elevation + NSAIDs
- Prednisolone 25mg (0.5mg/kg up to 25mg) PO daily for 2 weeks then taper
- compression bandages or stockings can help recovery
Characteristics of Malingering.
- deceptive behaviour to simulate illness
- Illness falsification to obtain obvious external benefits such as money, medications (opioids, benzodiazepines), time off work, child custody or avoiding criminal prosecution
- diagnostic testing is avoided in malingering but accepted in factitious disorder
Characteristics of Conversion Disorder.
- aka functional neurologic symptoms disorder
- neurologic symptoms that are inconsistent with neurologic pathophysiology
- No evidence of falsification of symptoms or deceptive behaviours
- ALWAYS in relation to symptoms related to the nervous system but factitious disorder → manifest in symptoms in any organ system
Clues to the presence of Somatic Symptom Disorder (5 points)
- History of present illness if vague and inconsistent
- Health care concerns are rarely alleviated despite high utilisation of medical care
- Pt attributes normal physical sensations to medical illnesses
- Repeatedly check one’s body for abnormalities
- Pt elicits negative feelings in clinicians
Importance of transillumination of scrotum?
- Transilluminable swellings → hydrocoeles and cysts of epididymis
- Non-transilluminable swellings → testicular tumours and most hernias
Importance of being able to palpate getting above swelling in scrotum?
- scrotal source of lump if able to get above the lump
- inguinoscrotal if not able to get above the lump → large inguinal hernia or a combine hernia and hydrocoele
What is a hydrocoele and what symptoms are associated with this?
collection of clear amber fluid in the tunica vaginalis
- hydrocoeles may be symptomless or can cause dragging discomfort in the scrotom and groin
True or False. in routine antenatal care, cervical testing should be completed if it is due or overdue.
Routine antenatal care should include cervical testing when this is due or overdue
Pregnancy may be the first opportunity for cervical screening and diagnosis of cervical cancer in never screened or underscreened women.
What kind of brush should we use when completing cervical testing in pregnant women?
Broom Brush. This is to deduce the risk of associated bleeding which can understandably be distressing with an endocervical brush.
How do you manage HSIL diagnosed in pregnancy?
Conservative management of HSIL is recommended → colposcopy is performed to exclude the presence of invasive cervical cancer and if normal can reassure woman that she can go ahead with pregnancy. Treatment can be delayed until after delivery → pregression of cervical intraepithelial neoplasia (CIN) to invasive disease DURING pregnancy is rare and regression post-partum is common.
Who is eligible for self-collection of vaginal swab for HPV testing?
Aged 30+ who have declined cervical screening from the clinician AND:
- are overdue for their cervical screening by 2 years or longer
- have never screened
Who is NOT eligible for self-collection of vaginal swab for HPV testing? (5 points)
- pregnant or thinks they may be pregnant
- exposed to DES in utero
- symptomatic - unusual bleeding, pain or discharge
- <30yo
- has had total hysterectomy with PHx of HSIL
If positive HPV not 16/18 on self-collected vaginal sample, what is the next step?
Encourage patient to have clinician collected LBC at next follow-up appointment
If postive HPV 16/18 on self-collected vaginal sample, what is the next step?
Refer for colposcopy and cervical LBC will be collected at this time
Whare at the Ottawa Ankle Rules?
Malleolar Zone
- Bone tenderness at the posterior edge or tip of the lateral malleolus
- Bone tenderness at the posterior edge or tip of the medial malleolus
- Inability to weight bear immediately and in the ED for 4 steps
Midfoot Zone
- Bone tenderness at the base of the 5th metatarsal
- Bone tenderness at the navicular
- Inability to weight bear immediately and in the ED for 4 steps
True or False. If a breast-fed baby only opens their bowels once a week, we should be concerned.
- Breast-Fed Babies → may poo after each feed or may only poo once a week
- Bottle-Fed Babies and Older Children → will usually have a poo at least every 2-3 days
Average Growth of 0-3months, 3-6 months, 6-12 months.
0-3 months - 150-200g/week
3-6 months - 100-150g/week
6-12 months - 70-90g/week
True or False. Umbilical hernia increase in size in the first 6 months of life.
Bonus Q: are they common and when do they resolve?
True. Will spontaneously resolve at 2-3 years of age. Common condition.
When to refer an umbilical hernias to OPD? (2 points)
If still present after 2 years or parental anxiety
Aspects of Glycaemic Control in CKD (3 points)
- Target HbA1c <7%
- Significantly reduces the risk of developing microalbuminuria, macroalbuminuria and/or overt nephropathy
- BP <130/80
- BMI <25kg/m^2
Treatment of Protracted Bacterial Bronchitis
Amoxicillin + Clavulanate 22.5 + 3.2mg/kg up to 875/125mg PO BD for 2 weeks → if symptoms improve then this confirms diagnosis of protracted bronchitis and continue course for full 2 weeks. If no improvement, continue course for 4 weeks total therapy.
Diagnostic Criteria for Kawasaki’s Disease (6 points)
Presence of prolonged, unexplained fever ≥ 5 days (fever > 38.5) with at least 4 of the following criteria:
- Bilateral non-exudative conjunctivitis
- Polymorphous rash
- Cervical lymphadenopathy (at least 1 lymph node >1.5cm in diameter)
- Mucositis → cracked lips, injected pharynx, strawberry tongue
- Extremity Changes - erythema of palm/soles, oedema of hands/feet (acute phase), and periungal desquamation (convalescent phase)
Treatment of Kawasaki’s Disease (broad strokes - 2 points)
Need transfer to hospital
IVIg infusion - to prevent complications (coronary artery aneurysms)
Well’s Criteria for PE (7 points)
Clinical Signs or Symptoms of DVT - 3
PE is most likely diagnosis - 3
Tachycardia HR >100 - 1.5
Previous DVT or PE - 1.5
Immobilisation for 3/7 or Surgery within 4/52 - 1.5
Malignancy Treatment within 6/12 or palliative - 1
Haemoptysis - 1
PERC Rule (8 points)
Age <50yo HR <100bpm SaO2 >95% No Haemoptysis No Oestrogen Use No PHx of VTE No Unilateral Leg Swelling No Surgery or Trauma requiring hospitalisation <4/52
if Wells - LR + PERC positive = ______
D-Dimer
If Wells - LR + PERC negative = _______
PE excluded
If Wells - HR = ______
CTPA or V/Q
Imaging choice for PE diagnosis (2 points + 1 bonus)
- CTPA is the most commonly used modality
- V/Q is modality of choice in pregnancy
- For severely compromised patients → bedside echocardiography findings of RV dilation, RV hypokinesis and high RA pressures → massive PE
