Acute care and trauma conditions Flashcards

Question 1

Q

hbhb

Question 2

Q

Alcohol withdrawal:

Define alcohol withdrawal

Answer

A

<ul>
<li>The symptoms that may occur when a person has been drinking too much alcohol on a regular basis and suddenly stops drinking.</li>
</ul>

Question 3

Q

Explain the aetiology/risk factors of alcohol withdrawal

Answer

A

<ul>
<li>Chronic alcohol consumption suppresses the activity of glutamate (an excitatory neurotransmitter), so the body compensates by increasing sensitivity to glutamate</li>
<li>So, when alcohol consumption stops, you get increased glutamate activity leading to excitatory symptoms</li>
</ul>

Question 4

Q

Summarise the epidemiology of alcohol withdrawal

Answer

A

<ul>
<li>If untreated, 6% of alcohol-dependent patients develop clinically relevant symptoms of withdrawal</li>
<li>Up to 10% of them will delirium tremens</li>
</ul>

Question 5

Q

Recognise the presenting symptoms and signs of alcohol withdrawal

Answer

A

<ul>
	<li>History of high alcohol intake</li>
	<li>Mild Symptoms:
	<ul style="list-style-type:circle;">
		<li>Insomnia and fatigue</li>
		<li>Tremor</li>
		<li>Mild anxiety/feeling nervous</li>
		<li>Mild restlessness/agitation</li>
		<li>Nausea and vomiting</li>
		<li>Headache</li>
		<li>Sweating</li>
		<li>Palpitations</li>
		<li>Anorexia</li>
		<li>Depression</li>
		<li>Craving alcohol</li>
	</ul>
	</li>
	<li>More severe symptoms:
	<ul style="list-style-type:circle;">
		<li>Hallucinations</li>
		<li>Withdrawal seizures (generalised tonic-clonic)</li>
		<li><strong>Delirium tremens </strong>
		<ul>
			<li>DEFINITION: <em>an acute confusional sate often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol. It can be precipitated by a head injury or an acute infection causing abstinence from alcohol.</em></li>
			<li>FEATURES:
			<ul>
				<li>Anxiety</li>
				<li>Tremor</li>
				<li>Sweating</li>
				<li>Vivid and terrifying visual and sensory <u>HALLUCINATIONS</u> (usually of animals and insects)</li>
				<li>Can be <strong>FATAL</strong></li>
			</ul>
			</li>
		</ul>
		</li>
	</ul>
	</li>
</ul>

Question 6

Q

Identify appropriate investigations for alcohol withdrawal

Generate a management plan for alcohol withdrawal

Answer

A

Identify appropriate investigations for alcohol withdrawal

<ul>
<li>NO investigations</li>
</ul>

Generate a management plan for alcohol withdrawal

<ul>
<li>Chlordiazepoxide - reduces symptoms of alcohol withdrawal</li>
<li>Barbiturates may be used if refractory to benzodiazepines</li>
<li>Thiamine (Pabrinex) - prevents progression to Wernicke-Korsakoff syndrome</li>
</ul>

Question 7

Q

Identify possible complications of alcohol withdrawal

Summarise the prognosis for patients with alcohol withdrawal

Answer

A

Identify possible complications of alcohol withdrawal

<ul>
<li>Patients can have seizures and die if it is left untreated</li>
</ul>

Summarise the prognosis for patients with alcohol withdrawal

<ul>
<li>Delirium tremens has a mortality of 35% if untreated</li>
<li>Mortality is < 2% with early detection and treatment</li>
</ul>

Question 8

Q

Burns Injury

Define burns injury

Answer

A

<ul>
<li>When tissue damage occurs by thermal, electrical or chemical injury</li>
</ul>

Question 9

Q

Explain the aetiology/risk factors of burns injuries

Answer

A

<ul>
	<li>Contact with hot objects (lol)</li>
	<li>Electricity</li>
	<li>UV light</li>
	<li>Irradiation</li>
	<li>Chemicals</li>
	<li><strong>High Risk Patients</strong>
	<ul style="list-style-type:circle;">
		<li>Young children</li>
		<li>Elderly</li>
	</ul>
	</li>
</ul>

Question 10

Q

Summarise the epidemiology of burns injuries

Recognise the presenting symptoms of burns injuries

Answer

A

Summarise the epidemiology of burns injuries

<ul>
<li>UK has > 12,000 admission per year</li>
</ul>

Recognise the presenting symptoms of burns injuries

<ul>
<li>Note the circumstances of the burn</li>
<li>Important to find out the time, temperature and length of contact with the agent</li>
<li>Consider risk of smoke inhalation and carbon monoxide poisoning</li>
</ul>

Question 11

Q

Recognise the signs of burns injuries on physical examination

Answer

A

<ul>
<li>Check for inhalational injury or airway compromise:
<ul>
<li>Stridor</li>
<li>Dyspnoea</li>
<li>Hoarse voice</li>
<li>Soot in nose</li>
<li>Singed nose hairs</li>
<li>Carbonaceous sputum</li>
</ul>
</li>
<li>Check site, depth and distribution of burn</li>
<li>Partial Thickness Burn
<ul>
<li>Subdivided into:
<ul>
<li>Superficial: red and oedematous skin + PAINFUL
<ul>
<li>Heals within around 7 days with peeling of dead skin</li>
</ul>
</li>
<li>Deep: blistering and mottling + PAINFUL
<ul>
<li>Heals over 3 weeks, usually without scarring</li>
</ul>
</li>
</ul>
</li>
</ul>
</li>
<li>Full Thickness Burn</li>
<li>Destruction of the epidermis and dermis</li>
<li>Charred leathery eschars</li>
<li>Firm and PAINLESS with loss of sensation</li>
<li>Healing will occur by scarring or contractures and requires skin grafting</li>
<li>Size of Burn
<ul>
<li>Described as a percentage of body surface area</li>
</ul>
</li>
</ul>

Question 12

Q

Identify appropriate investigations for burns injuries

Answer

A

<ul>
<li>Bloods

~~~
<ul>
<li>Oxygen saturation, ABG and carboxyhaemoglobin (if inhalational injury)</li>
<li>FBC</li>
<li>U&Es</li>
<li>Group and Save</li>
</ul>
</li>
<li>Investigations for electrical burns
<ul>
<li>Serum CK</li>
<li>Urine myoglobin (check for muscle damage)</li>
<li>ECG</li>
</ul>
</li>
</ul>

~~~

Question 13

Q

Heat stroke-pathophysiology and predisposing factors

Question 14

Q

Clinical features Heat Stroke

Answer

A

CNS

<ul>
<li>Oedema and petechial haemorrhages cause focal and generalised damage</li>
</ul>

Muscle

<ul>
<li>Skeletal muscles show widespread degeneration of fibres</li>
<li>Rhabdomyolysis releases myoglobin, K+, CPK and purines (which are metabolised into uric acid) into the circulation</li>
</ul>

Lungs

<ul>
<li>Non cardiogenic pulmonary oedema</li>
</ul>

Kidneys

<ul>
<li>Oliguric acute renal failure due to renal ischaemia, muscle breakdown products, DIC, hyperuricaemia and hypovolaemia</li>
<li>Renal failure occurs in up to 35%</li>
</ul>

Blood

<ul>
<li>DIC (poor prognosis), thrombocytopaenia, leukocytosis</li>
<li>Thermal injury to endothelium releases thromboplastins which result in intravascular thrombosis and secondary fibrinolysis</li>
</ul>

Metabolic

<ul>
<li>Metabolic acidosis, respiratory alkalosis, hypoglycaemia, hyper- or hypokalaemia</li>
</ul>

Question 15

Q

Poor Prognostic Factors in Heat Stroke

Answer

A

<ul>
	<li>Core temperature >41.1°C</li>
	<li>AST >1000 IU in first 24 hours</li>
	<li>Hypotension not responsive to cooling and fluid replacement</li>
	<li>Renal failure or hyperkalaemia</li>
</ul>

Question 16

Q

Differential Diagnosis of Heat Stroke

Answer

A

<ul>
	<li>Meningitis / Encephalitis</li>
	<li>Intracranial haemorrhage</li>
	<li>Thyrotoxic crisis</li>
	<li>Drug induced hyperthermic syndromes</li>
	<li>Delirium tremens</li>
	<li>Malaria</li>
</ul>

Question 17

Q

Question 18

Q

Basal Cell Carcinoma

Define basal cell carcinoma

Answer

A

<ul>
<li>COMMONEST form of skin malignancy, also known as a rodent ulcer</li>
</ul>

Question 19

Q

Explain the aetiology/risk factors of basal cell carcinoma

Answer

A

<ul>
	<li>MAIN RISK FACTOR: prolonged sun exposure or UV radiation</li>
	<li>Seen in <strong>Gorlin's syndrome</strong></li>
	<li>Other risk factors:
	<ul style="list-style-type:circle;">
		<li>Photosensitising pitch</li>
		<li>Tar</li>
		<li>Arsenic</li>
	</ul>
	</li>
</ul>

Question 20

Q

Summarise the epidemiology of basal cell carcinoma

Answer

A

<ul>
<li>COMMON in those with FAIR SKIN</li>
<li>Common in areas of high sunlight exposure</li>
<li>Common in the elderly</li>
<li>Rare before the age of 40 yrs</li>
<li>Lifetime risk in Caucasians = 1 in 3</li>
</ul>

Question 21

Q

Recognise the presenting symptoms of basal cell carcinoma

Answer

A

<ul>
	<li>A chronic slowly progressive skin lesion</li>
	<li>Usually found on the:
	<ul style="list-style-type:circle;">
		<li>FACE</li>
		<li>Scalp</li>
		<li>Ears</li>
		<li>Trunk</li>
	</ul>
	</li>
</ul>

Question 22

Q

Recognise the signs of basal cell carcinoma on physical examination

Answer

A

<ul>
<li>Nodulo-ulcerative (MOST COMMON)</li>
</ul>

<ul>
<li>Small glistening translucent skin over a coloured papule</li>
<li>Slowly enlarges</li>
<li>Central ulcer with raised pearly edges</li>
<li>Fine telangiectasia over the tumour surface</li>
<li>Cystic change in larger lesions</li>
</ul>

<ul>
<li>Morphoeic</li>
</ul>

<ul>
<li>Expanding</li>
<li>Yellow/white waxy plaque with an ill-defined edge</li>
<li>More aggressive than nodulo-ulcerative</li>
</ul>

<ul>
<li>Superficial</li>
<li>Most often on trunk</li>
<li>Multiple pink/brown scaly plaques with a fine edge expanding slowly</li>
<li>Pigmented</li>
<li>Specks of brown or black pigment may be present in any BCC</li>
</ul>

Question 23

Q

Identify appropriate investigations for basal cell carcinoma

Answer

A

<ul>
<li>Biopsy is RARELY necessary</li>
<li>Diagnosis is mainly on clinical suspicion</li>
</ul>

Question 24

Q

CNS Tumours

Define CNS tumours

Answer

A

<ul>
	<li><em>Tumours of the central nervous system.</em></li>
	<li>NOTE: brain tumours cannot be truly differentiated into benign and malignant because supposedly 'benign' tumours can cause significant morbidity and mortality</li>
	<li>Instead they are differentiated into:
	<ul style="list-style-type:circle;">
		<li><strong>High-Grade</strong> = a tumour that grows rapidly and aggressively
		<ul>
			<li>Glioma and glioblastoma multiforme</li>
			<li>Primary cerebral lymphoma</li>
			<li>Medulloblastoma</li>
		</ul>
		</li>
		<li><strong>Low-Grade</strong> = a tumour that grows slowly and may or may not be successfully treated
		<ul>
			<li>Meningioma</li>
			<li>Acoustic neuroma</li>
			<li>Neurofibroma</li>
			<li>Pituitary tumour</li>
			<li>Craniopharyngeoma</li>
			<li>Pineal tumour</li>
		</ul>
		</li>
		<li>Brain metastases commonly arise from:
		<ul>
			<li>Lung</li>
			<li>Breast</li>
			<li>Stomach</li>
			<li>Prostate</li>
			<li>Thyroid</li>
			<li>Colorectal</li>
		</ul>
		</li>
	</ul>
	</li>
</ul>

Question 25

Q

Explain the aetiology/risk factors of CNS tumours

Answer

A

<ul>
	<li>Can arise from any of the cells in the CNS (e.g. glial cells, ependymal cells, oligodendrocytes)</li>
	<li><strong>Risk Factors</strong>
	<ul style="list-style-type:circle;">
		<li>Ionising radiation</li>
		<li>Immunosuppression (e.g. HIV)</li>
		<li>Inherited syndromes (e.g. neurofibromatosis, tuberous sclerosis)</li>
	</ul>
	</li>
</ul>

Question 26

Q

Summarise the epidemiology of CNS tumours

Answer

A

<ul>
<li>Primary brain tumours = 2% of tumours diagnosed in the UK</li>
<li>AIDS patients have an increased risk of developing CNS tumours</li>
<li>Can develop at any age but are more common between 50-70 yrs</li>
</ul>

Question 27

Q

Recognise the presenting symptoms and signs of CNS tumours

Answer

A

<ul>
<li>Presentation depends on the size and location of the tumour</li>
<li>Headache (worse in the morning and when lying down)</li>
<li>Nausea and vomiting</li>
<li>Seizures</li>
<li>Progressive focal neurological deficits</li>
<li>Cognitive and behavioural symptoms</li>
<li>Papilloedema</li>
</ul>

Question 28

Q

Identify appropriate investigations for CNS tumours

Answer

A

<ul>
<li>Bloods - check CRP/ESR to eliminate other causes (e.g. temporal arteritis)</li>
<li>CT/MRI</li>
<li>Biopsy and tumour removal</li>
<li>Magnetic resonance angiography - define changing size and blood supply of the tumour</li>
<li>PET</li>
<li>NOTE: distant metastases are RARE with primary CNS tumours</li>
</ul>

Question 29

Q

Hepatocellular Carcinoma

Define hepatocellular carcinoma

Answer

A

<ul>
<li>Primary malignancy of the liver parenchyma</li>
</ul>

Question 30

Q

Explain the aetiology/risk factors of hepatocellular carcinoma

Answer

A

<ul>
	<li>Associated with:
	<ul style="list-style-type:circle;">
		<li>Chronic liver damage
		<ul>
			<li>Alcoholic liver disease</li>
			<li>Hepatitis C</li>
			<li>Autoimmune disease</li>
		</ul>
		</li>
		<li>Metabolic disease
		<ul>
			<li>E.g. haemochromatosis</li>
		</ul>
		</li>
		<li>Aflatoxins
		<ul>
			<li>E.g. cereals contaminated with fungi</li>
		</ul>
		</li>
	</ul>
	</li>
</ul>

Question 31

Q

Summarise the epidemiology of hepatocellular carcinoma

Answer

A

<ul>
<li>COMMON</li>
<li>1-2% of all malignancies</li>
<li>LESS common than liver metastases</li>
<li>High incidence in regions where hepatitis B and C are endemic</li>
</ul>

Question 32

Q

Recognise the presenting symptoms of hepatocellular carcinoma

Answer

A

<ul>
<li>Symptoms of Malignancy

~~~
<ul>
<li>Malaise</li>
<li>Weight loss</li>
<li>Loss of appetite</li>
</ul>
</li>
<li>History of Exposure to Carcinogens
<ul>
<li>High alcohol intake</li>
<li>Hepatitis B or C (e.g. sexual activity, IV drug use)</li>
<li>Aflatoxins</li>
</ul>
</li>
<li>Abdominal distention</li>
<li>Jaundice</li>
</ul>

~~~

Question 33

Q

Recognise the signs of hepatocellular carcinoma on physical examination

Answer

A

<ul>
<li>Signs of Malignancy

~~~
<ul>
<li>Cachexia</li>
<li>Lymphadenopathy</li>
</ul>
</li>
<li>Hepatomegaly (may be nodular)</li>
<li>Jaundice</li>
<li>Ascites</li>
<li>Bruit over the liver</li>
</ul>

~~~

Question 34

Q

Identify appropriate investigations for hepatocellular carcinoma

Answer

A

<ul>
<li>Bloods

~~~
<ul>
<li>FBC</li>
<li>ESR</li>
<li>LFTs</li>
<li>Clotting</li>
<li>a-fetoprotein - tumour marker for liver cancer</li>
<li>Hepatitis serology</li>
</ul>
</li>
<li>Imaging
<ul>
<li>Abdominal US</li>
<li>CT/MRI - GOLD STANDARD for staging</li>
</ul>
</li>
<li>Histology/Cytology
<ul>
<li>Ascitic tap my be sent for cytological analysis</li>
</ul>
</li>
<li>Staging
<ul>
<li>CT scan (chest/abdo/pelvis)</li>
</ul>
</li>
</ul>

~~~

Question 35

Q

Renal Cell Cancer

Define renal cell cancer

<ul>
<li>Primary malignancy of the kidneys</li>
</ul>

Explain the aetiology/risk factors of renal cell cancer

Answer

A

<ul>
	<li>Renal clear cell carcinoma (80%) - UNKNOWN CAUSE</li>
	<li>Papillary carcinoma (10%) - UNKNOWN CAUSE</li>
	<li>Transitional cell carcinoma (10%)
	<ul style="list-style-type:circle;">
		<li>NOTE: these occur at the <strong>renal pelvis</strong></li>
	</ul>
	</li>
	<li><strong>Risk Factors</strong>
	<ul style="list-style-type:circle;">
		<li>Associated with certain <u>inherited</u> conditions:
		<ul>
			<li>von Hippel-Lindau disease
			<ul>
				<li>Mutation in the von Hippel-Lindau protein, which causes headaches, balance issues, dizziness, limb weakness, vision problems and high blood pressure</li>
			</ul>
			</li>
			<li>Tuberous sclerosis
			<ul>
				<li>A rare genetic disease that causes <u>benign tumours</u> to grow in the brain and other organs (e.g. skin, kidneys, lungs, eyes)</li>
			</ul>
			</li>
			<li>Polycystic kidney disease</li>
			<li>Familial renal cell cancer</li>
			<li>Smoking</li>
			<li>Chronic dialysis</li>
		</ul>
		</li>
		<li>NOTE: renal cell cancer can cause <u>abnormal LFTs</u> in the absence of liver metastases = <strong>Strauffer's Syndrome</strong></li>
	</ul>
	</li>
</ul>

Question 36

Q

Summarise the epidemiology of renal cell cancer

Answer

A

<ul>
	<li>UNCOMMON</li>
	<li>3% of all adult malignancies</li>
	<li>Peak incidence: 40-60 yrs</li>
</ul>

Question 37

Q

Recognise the presenting symptoms of renal cell cancer

Answer

A

<ul>
<li>Renal Cell Carcinoma

~~~
<ul>
<li>Usually present LATE</li>
<li>Asymptomatic in 90%</li>
<li>Triad of Symptoms:
<ul>
<li>Haematuria</li>
<li>Flank pain</li>
<li>Abdominal mass</li>
</ul>
</li>
</ul>
</li>
<li>Transitional Cell Carcinoma
<ul>
<li>Presents EARLIER with haematuria</li>
</ul>
</li>
<li>Systemic Signs of Malignancy
<ul>
<li>Weight loss</li>
<li>Malaise</li>
<li>Paraneoplastic syndromes (e.g. fever, hypercalcaemia, polycythaemia)</li>
</ul>
</li>
</ul>

~~~

Question 38

Q

Recognise the signs of renal cell cancer on physical examination

Answer

A

<ul>
	<li>Palpable renal mass</li>
	<li>Hypertension</li>
	<li>Plethora</li>
	<li>Anaemia</li>
	<li>A left-sided tumour can obstruct the <u>left testicular vein</u> as it joins the left renal vein, and cause a <strong>left-sided varicocoele</strong></li>
</ul>

Question 39

Q

Identify appropriate investigations for renal cell cancer

Answer

A

<ul>
<li>Urinalysis

~~~
<ul>
<li>Haematuria</li>
<li>Cytology</li>
</ul>
</li>
<li>Bloods
<ul>
<li>FBC</li>
<li>U&Es</li>
<li>Calcium</li>
<li>LFTs</li>
<li>High ESR (in 75%)</li>
</ul>
</li>
<li>Abdominal Ultrasound
<ul>
<li>Best first-line investigation</li>
<li>Can distinguish between solid masses and cystic structures</li>
</ul>
</li>
<li>CT/MRI
<ul>
<li>Useful for staging
<ul>
<li>Staging system: Robson Staging</li>
</ul>
</li>
</ul>
</li>
</ul>

~~~

Question 40

Q

Tumour Lysis Syndrome (TLS)

Define TLS

Answer

A

<ul>
<li>A group of metabolic abnormalities that can occur as a complication during treatment of cancer, where large amounts of tumour cells are lysed at the same time by treatment, releasing their contents into the bloodstream.</li>
</ul>

Question 41

Q

Explain the aetiology/risk factors of TLS

Answer

A

<ul>
<li>It is caused by the sudden lysis of many tumour cells, which release their toxic contents into the blood stream</li>
<li>Occurs most commonly after treatment of lymphomas and leukaemias</li>
<li>Risk Factors
<ul>
<li>Tumour Characteristics - high cell turnover rate, rapid growth rate, high tumour bulk</li>
<li>Patient Characteristics - baseline serum creatinine, renal insufficiency, dehydration</li>
<li>Chemotherapy Characteristics - chemo-sensitive tumours (e.g. lymphoma) tends to have a higher risk</li>
</ul>
</li>
</ul>

Question 42

Q

Summarise the epidemiology of TLS

Answer

A

<ul>
<li>Tends to occur most commonly in patients with poorly differentiated lymphomas and leukaemias</li>
</ul>

Question 43

Q

Recognise the presenting symptoms and signs of TLS

Answer

A

<ul>
<li>Hyperkalaemia

~~~
<ul>
<li>K+ is mainly an intracellular ion</li>
<li>Symptoms:
<ul>
<li>Arrhythmias</li>
<li>Severe muscle weakness and paralysis</li>
</ul>
</li>
</ul>
</li>
<li>Hyperphosphataemia
<ul>
<li>Causes acute kidney failure because of deposition of calcium phosphate crystals in the kidney parenchyma</li>
</ul>
</li>
<li>Hypocalcaemia
<ul>
<li>Calcium precipitates to form calcium phosphate, so serum calcium drops</li>
<li>Symptoms:
<ul>
<li>Tetany</li>
<li>Parkinsonism</li>
<li>Myopathy</li>
<li>Sudden mental incapacity</li>
</ul>
</li>
</ul>
</li>
<li>Hyperuricaemia
<ul>
<li>Leads to gout</li>
</ul>
</li>
<li>Lactic Acidosis</li>
</ul>

~~~

Question 44

Q

Identify appropriate investigations for tumour lysis syndrome

Answer

A

<ul>
	<li>Check the levels of all the metabolites that are deranged:
	<ul style="list-style-type:circle;">
		<li>Potassium</li>
		<li>Phosphate</li>
		<li>Calcium</li>
		<li>Uric acid</li>
	</ul>
	</li>
	<li>Monitor for symptoms:
	<ul style="list-style-type:circle;">
		<li>Increased serum creatinine</li>
		<li>Arrhythmia</li>
		<li>Seizure</li>
	</ul>
	</li>
</ul>

Question 45

Q

Squamous Cell Carcinoma

Define squamous cell carcinoma

Answer

A

<ul>
<li>Malignancy of epidermal keratinocytes of the skin.

~~~
<ul>
<li>Marjolin's ulcer is a squamous cell carcinoma that arises in an area of chronically inflamed skin</li>
</ul>
</li>
</ul>

~~~

Question 46

Q

Explain the aetiology/risk factors of squamous cell carcinoma

Answer

A

<ul>
<li>Main risk factor = UV RADIATION</li>
<li>Sun exposure can lead to actinic keratosis (sun-induced precancerous lesion)</li>
<li>Other risk factors:
<ul>
<li>Radiation</li>
<li>Carcinogens (e.g. tar derivatives, cigarette smoke)</li>
<li>Chronic skin disease (e.g. lupus)</li>
<li>HPV</li>
<li>Long-term immunosuppression</li>
<li>Defects in DNA repair (xeroderma pigmentosum)</li>
</ul>
</li>
</ul>

Question 47

Q

Summarise the epidemiology of squamous cell carcinoma

Answer

A

<ul>
<li>SECOND most common cutaneous malignancy (20% of all skin cancers)</li>
<li>Occurs mainly in MIDDLE-AGED and ELDERLY people</li>
<li>LIGHT-SKINNED individuals are at higher risk</li>
<li>2-3 x more common in MALES</li>
</ul>

Question 48

Q

Recognise the presenting symptoms of squamous cell carcinoma

Answer

A

<ul>
	<li>Skin lesion</li>
	<li>Ulcerated</li>
	<li>Recurrent bleeding</li>
	<li>Non-healing</li>
</ul>

Question 49

Q

Recognise the signs of squamous cell carcinoma on physical examination

Answer

A

<ul>
<li>Variable appearance - may be ulcerated, hyperkeratotic, crusted or scaly, non-healing</li>
<li>Often on sun-exposed areas</li>
<li>Palpate for local lymphadenopathy</li>
</ul>

Question 50

Q

Identify appropriate investigations for squamous cell carcinoma

Answer

A

<ul>
<li>Skin Biopsy - confirm malignancy and specific type</li>
<li>Fine-needle aspiration or lymph node biopsy - if metastasis is suspected</li>
<li>Staging - using CT, MRI or PET</li>
</ul>

Question 51

Q

Burns Injury

Define burns injury

Answer

A

<ul>
<li>When tissue damage occurs by thermal, electrical or chemical injury</li>
</ul>

Question 52

Q

Explain the aetiology/risk factors of burns injuries

Answer

A

<ul>
	<li>Contact with hot objects (lol)</li>
	<li>Electricity</li>
	<li>UV light</li>
	<li>Irradiation</li>
	<li>Chemicals</li>
	<li><strong>High Risk Patients</strong>
	<ul style="list-style-type:circle;">
		<li>Young children</li>
		<li>Elderly</li>
	</ul>
	</li>
</ul>

Question 53

Q

Summarise the epidemiology of burns injuries

Recognise the presenting symptoms of burns injuries

Answer

A

Summarise the epidemiology of burns injuries

<ul>
<li>UK has > 12,000 admission per year</li>
</ul>

Recognise the presenting symptoms of burns injuries

<ul>
<li>Note the circumstances of the burn</li>
<li>Important to find out the time, temperature and length of contact with the agent</li>
<li>Consider risk of smoke inhalation and carbon monoxide poisoning</li>
</ul>

Question 54

Q

Identify appropriate investigations for burns injuries

Answer

A

<ul>
<li>Bloods

~~~
<ul>
<li>Oxygen saturation, ABG and carboxyhaemoglobin (if inhalational injury)</li>
<li>FBC</li>
<li>U&Es</li>
<li>Group and Save</li>
</ul>
</li>
<li>Investigations for electrical burns
<ul>
<li>Serum CK</li>
<li>Urine myoglobin (check for muscle damage)</li>
<li>ECG</li>
</ul>
</li>
</ul>

~~~

Question 55

Q

Recognise the signs of burns injuries on physical examination

Answer

A

<ul>
<li>Check for inhalational injury or airway compromise:
<ul>
<li>Stridor</li>
<li>Dyspnoea</li>
<li>Hoarse voice</li>
<li>Soot in nose</li>
<li>Singed nose hairs</li>
<li>Carbonaceous sputum</li>
</ul>
</li>
<li>Check site, depth and distribution of burn</li>
<li>Partial Thickness Burn
<ul>
<li>Subdivided into:
<ul>
<li>Superficial: red and oedematous skin + PAINFUL
<ul>
<li>Heals within around 7 days with peeling of dead skin</li>
</ul>
</li>
<li>Deep: blistering and mottling + PAINFUL
<ul>
<li>Heals over 3 weeks, usually without scarring</li>
</ul>
</li>
</ul>
</li>
</ul>
</li>
<li>Full Thickness Burn</li>
<li>Destruction of the epidermis and dermis</li>
<li>Charred leathery eschars</li>
<li>Firm and PAINLESS with loss of sensation</li>
<li>Healing will occur by scarring or contractures and requires skin grafting</li>
<li>Size of Burn
<ul>
<li>Described as a percentage of body surface area</li>
</ul>
</li>
</ul>

Question 56

Q

Basal Cell Carcinoma

Define basal cell carcinoma

Answer

A

<ul>
<li>COMMONEST form of skin malignancy, also known as a rodent ulcer</li>
</ul>

Question 57

Q

Explain the aetiology/risk factors of basal cell carcinoma

Answer

A

<ul>
	<li>MAIN RISK FACTOR: prolonged sun exposure or UV radiation</li>
	<li>Seen in <strong>Gorlin's syndrome</strong></li>
	<li>Other risk factors:
	<ul style="list-style-type:circle;">
		<li>Photosensitising pitch</li>
		<li>Tar</li>
		<li>Arsenic</li>
	</ul>
	</li>
</ul>

Question 58

Q

Summarise the epidemiology of basal cell carcinoma

Answer

A

<ul>
<li>COMMON in those with FAIR SKIN</li>
<li>Common in areas of high sunlight exposure</li>
<li>Common in the elderly</li>
<li>Rare before the age of 40 yrs</li>
<li>Lifetime risk in Caucasians = 1 in 3</li>
</ul>

Question 59

Q

Recognise the presenting symptoms of basal cell carcinoma

Answer

A

<ul>
	<li>A chronic slowly progressive skin lesion</li>
	<li>Usually found on the:
	<ul style="list-style-type:circle;">
		<li>FACE</li>
		<li>Scalp</li>
		<li>Ears</li>
		<li>Trunk</li>
	</ul>
	</li>
</ul>

Question 60

Q

Identify appropriate investigations for basal cell carcinoma

Answer

A

<ul>
<li>Biopsy is RARELY necessary</li>
<li>Diagnosis is mainly on clinical suspicion</li>
</ul>

Question 61

Q

Recognise the signs of basal cell carcinoma on physical examination

Answer

A

<ul>
<li>Nodulo-ulcerative (MOST COMMON)</li>
</ul>

<ul>
<li>Small glistening translucent skin over a coloured papule</li>
<li>Slowly enlarges</li>
<li>Central ulcer with raised pearly edges</li>
<li>Fine telangiectasia over the tumour surface</li>
<li>Cystic change in larger lesions</li>
</ul>

<ul>
<li>Morphoeic</li>
</ul>

<ul>
<li>Expanding</li>
<li>Yellow/white waxy plaque with an ill-defined edge</li>
<li>More aggressive than nodulo-ulcerative</li>
</ul>

<ul>
<li>Superficial</li>
<li>Most often on trunk</li>
<li>Multiple pink/brown scaly plaques with a fine edge expanding slowly</li>
<li>Pigmented</li>
<li>Specks of brown or black pigment may be present in any BCC</li>
</ul>

Question 62

Q

Summarise the epidemiology of squamous cell carcinoma

Answer

A

<ul>
<li>SECOND most common cutaneous malignancy (20% of all skin cancers)</li>
<li>Occurs mainly in MIDDLE-AGED and ELDERLY people</li>
<li>LIGHT-SKINNED individuals are at higher risk</li>
<li>2-3 x more common in MALES</li>
</ul>

Question 63

Q

Recognise the presenting symptoms of squamous cell carcinoma

Answer

A

<ul>
	<li>Skin lesion</li>
	<li>Ulcerated</li>
	<li>Recurrent bleeding</li>
	<li>Non-healing</li>
</ul>

Question 64

Q

Recognise the signs of squamous cell carcinoma on physical examination

Answer

A

<ul>
<li>Variable appearance - may be ulcerated, hyperkeratotic, crusted or scaly, non-healing</li>
<li>Often on sun-exposed areas</li>
<li>Palpate for local lymphadenopathy</li>
</ul>

Answer 62

A

<ul>
<li>Skin Biopsy - confirm malignancy and specific type</li>
<li>Fine-needle aspiration or lymph node biopsy - if metastasis is suspected</li>
<li>Staging - using CT, MRI or PET</li>
</ul>

Answer 63

A

<ul>
<li>Malignancy of epidermal keratinocytes of the skin.

~~~
<ul>
<li>Marjolin's ulcer is a squamous cell carcinoma that arises in an area of chronically inflamed skin</li>
</ul>
</li>
</ul>

~~~

Answer 64

A

<ul>
<li>Main risk factor = UV RADIATION</li>
<li>Sun exposure can lead to actinic keratosis (sun-induced precancerous lesion)</li>
<li>Other risk factors:
<ul>
<li>Radiation</li>
<li>Carcinogens (e.g. tar derivatives, cigarette smoke)</li>
<li>Chronic skin disease (e.g. lupus)</li>
<li>HPV</li>
<li>Long-term immunosuppression</li>
<li>Defects in DNA repair (xeroderma pigmentosum)</li>
</ul>
</li>
</ul>

Answer 65

A

<ul>
<li>An acute hypersensitivity reaction of the skin and mucous membranes. Stevens-Johnson syndrome is a severe form with bullous lesions and necrotic ulcers</li>
</ul>

Answer 66

A

<ul>
<li>Degeneration of basal epidermal cells</li>
<li>Development of vesicles between cells in the basement membrane</li>
<li>Lymphocytic infiltrate around the blood vessels and at the dermo-epidermal junction</li>
<li>A precipitating factor is only identified 50% of the time</li>
<li>Precipitating Factors:
<ul>
<li>Drugs - e.g. sulphonamides, penicillin, phenytoin</li>
<li>Infection - e.g. HSV, EBV, adenovirus, chlamydia, histoplasmosis</li>
<li>Inflammatory - e.g. rheumatoid arthritis, SLE, sarcoidosis, ulcerative colitis</li>
<li>Malignancy - e.g. lymphomas, leukaemia, myeloma</li>
<li>Radiotherapy</li>
</ul>
</li>
</ul>

Answer 67

A

<ul>
	<li>Any age group</li>
	<li>Mainly in CHILDREN and YOUNG ADULTS</li>
	<li>TWICE as common in MALES</li>
</ul>

Answer 68

A

<ul>
<li>Non-specific prodromal symptoms of upper respiratory tract infection</li>
<li>Sudden appearance of itching/burning/painful skin lesions</li>
<li>Skin lesions may fade leaving pigmentation</li>
</ul>

Answer 69

A

<ul>
<li>Classic target (bull's eye) lesions with a rim of erythema surrounding a paler area</li>
<li>Vesicles/bullae</li>
<li>Urticarial plaques</li>
<li>Lesions are often symmetrical and distributed over the arms and legs including the palms, soles and extensor surfaces</li>
</ul>

<ul>
<li>Stevens-Johnson syndrome is characterised by:</li>
</ul>

<ul>
<li>Affecting > 2 mucous membranes (e.g. conjunctiva, cornea, lips, mouth, genitalia)</li>
<li>Systemic symptoms (e.g. sore throat, cough, fever, headache, myalgia, arthralgia, diarrhoea/vomiting)</li>
<li>Shock (hypotension and tachycardia)</li>
</ul>

Answer 70

A

<ul>
<li>Usually unnecessary - erythema multiforme is very much a clinical diagnosis</li>
<li>Bloods
<ul>
<li>High WC, eosinophils, ESR/CRP</li>
</ul>
</li>
<li>Imaging - exclude sarcoidosis and atypical pneumonia</li>
<li>Skin biopsy - histology and direct immunofluorescence if in doubt about diagnosis</li>
</ul>

Answer 71

A

<ul>
<li>Panniculitis (inflammation of subcutaneous fat tissue) presenting as red or violet subcutaneous nodules</li>
</ul>

Answer 72

A

<ul>
	<li>Delayed hypersensitivity reaction to antigens associated with various infectious agents, drugs and diseases</li>
	<li><strong>Infection</strong>
	<ul style="list-style-type:circle;">
		<li>Bacterial - e.g. streptococcus</li>
		<li>Viral - e.g. EBV</li>
		<li>Fungal - e.g. histoplasmosis</li>
	</ul>
	</li>
	<li><strong>Systemic Disease</strong>
	<ul style="list-style-type:circle;">
		<li>Sarcoidosis</li>
		<li>IBD</li>
		<li>Behcet's disease</li>
	</ul>
	</li>
	<li><strong>Malignancy</strong>
	<ul style="list-style-type:circle;">
		<li>Leukaemia</li>
		<li>Hodgkin's disease</li>
	</ul>
	</li>
	<li><strong>Drugs</strong>
	<ul style="list-style-type:circle;">
		<li>Sulphonamides</li>
		<li>Penicillin</li>
		<li>Oral contraceptive pills</li>
	</ul>
	</li>
	<li><strong>Pregnancy</strong>
	<ul>
		<li>25% of cases have no identifiable cause</li>
	</ul>
	</li>
</ul>

Answer 73

A

<ul>
<li>Usually affects YOUNG ADULTS</li>
<li>THREE times more common in FEMALES</li>
</ul>

Answer 74

A

<ul>
	<li>Tender red or violet nodules bilaterally on <u>both shins</u></li>
	<li>Occasionally on thighs or forearms</li>
	<li>Fatigue</li>
	<li>Fever</li>
	<li>Anorexia</li>
	<li>Weight loss</li>
	<li>Arthralgia</li>
	<li>Symptoms of underlying CAUSE</li>
</ul>

Answer 75

A

<ul>
<li>Crops of red or violet dome-shaped nodules usually present on both shins</li>
<li>Occasionally appear on the thighs and forearms</li>
<li>Nodules are tender to palpation</li>
<li>Low-grade pyrexia</li>
<li>Joints may be tender and painful on movement</li>
<li>Signs of underlying CAUSE</li>
</ul>

Answer 76

A

<ul>
<li>Determine underlying CAUSE</li>
<li>Bloods
<ul>
<li>Anti-streptolysin-O titres (check for streptococcal infection)</li>
<li>FBC/CRP/ESR - check for signs of infection/inflammation</li>
<li>U&Es</li>
<li>Serum ACE (raised in sarcoidosis)</li>
</ul>
</li>
<li>Throat swab and cultures</li>
<li>Mantoux/Head skin testing - for TB</li>
<li>CXR - check for bilateral hilar lymphadenopathy or other evidence of TB, sarcoidosis or fungal infections</li>
</ul>

Answer 77

A

<ul>
<li>Slow-growing, benign adipose tumours that are most often found in the subcutaneous tissues.</li>
</ul>

Answer 78

A

<ul>
	<li>Benign tumours of adipocytes</li>
	<li>Conditions associated with lipomas
	<ul style="list-style-type:circle;">
		<li>Familial multiple lipomatosis</li>
		<li>Gardner's syndrome</li>
		<li>Dercum's disease</li>
		<li>Madelung's disease</li>
	</ul>
	</li>
	<li>Liposarcoma - rare malignant tumour of adipose tissue</li>
</ul>

Answer 79

A

<ul>
<li>Can be seen at any age but more common between 40-60 yrs</li>
<li>Relatively COMMON</li>
</ul>

Answer 80

A

<ul>
	<li>Most are ASYMPTOMATIC</li>
	<li>Compression of nerves can cause pain</li>
	<li>Soft or firm nodule</li>
	<li>Smooth normal surface</li>
	<li>Skin coloured</li>
	<li>Most are < 5 cm in diameter</li>
	<li>Mobile</li>
	<li>Soft/doughy feel</li>
</ul>

Answer 81

A

<ul>
<li>Usually CLINICAL diagnosis</li>
<li>US/MRI/CT used if there is doubt about the diagnosis</li>
</ul>

Answer 82

A

<ul>
<li>Malignancy arising from neoplastic transformation of melanocytes, the pigment-forming skin cells. The leading cause of death from skin disease.</li>
</ul>

Answer 83

A

<ul>
<li>DNA damage caused by ultraviolet radiation leads to neoplastic transformation</li>
<li>50% arise in existing naevi</li>
<li>50% arise in previously normal skin</li>
<li>FOUR histopathological types
<ul>
<li>Superficial Spreading (70%)
<ul>
<li>Arises in a pre-existing naevus, expands in a radial fashion before a vertical growth phase</li>
</ul>
</li>
<li>Nodular (15%)
<ul>
<li>Arises de novo</li>
<li>AGGRESSIVE</li>
<li>NO radial growth phase</li>
</ul>
</li>
<li>Lentigo Maligna (10%)
<ul>
<li>More common in ELDERLY with sun damage</li>
<li>Large flat lesions</li>
<li>Progresses slowly</li>
<li>Usually on the face</li>
</ul>
</li>
<li>Acral Lentiginous (5%)
<ul>
<li>Arise on palms, soles and subungual areas</li>
<li>Most common type in NON-WHITE populations</li>
</ul>
</li>
</ul>
</li>
</ul>

Answer 84

A

<ul>
<li>Steadily increasing in incidence</li>
<li>WHITE races have 20 x increased risk compared to non-whites</li>
</ul>

Answer 85

A

<ul>
	<li>Change in size, shape or colour of a pigmented skin lesion</li>
	<li>Redness</li>
	<li>Bleeding</li>
	<li>Crusting</li>
	<li>Ulceration</li>
</ul>

Answer 86

A

ABCDE criteria for examining moles:

<ul>
	<li>A - asymmetry</li>
	<li>B - border irregularity</li>
	<li>C - colour variation</li>
	<li>D - diameter > 6 mm</li>
	<li>E - elevation/evolution</li>
</ul>

Answer 87

A

<ul>
<li>Excisional Biopsy - histological diagnosis and determination of Clark's Levels and Breslow Thickness (two methods of determining the depth of penetration of a melanoma)</li>
<li>Lymphoscintigraphy - a radioactive compound is injected into the lesion and images are taken over 30 mins to trace the lymph drainage and identify the sentinel nodes</li>
<li>Sentinel Lymph Node Biopsy - check for metastatic involvement</li>
<li>Staging - using ultrasound, CT or MRI, CXR</li>
<li>Bloods - LFTs (because the liver is a common site of metastasis)</li>
</ul>

Answer 88

A

<ul>
<li>A common skin infection caused by a pox virus that affects children and adults. Transmission is usually by direct skin contact.</li>
</ul>

Answer 89

A

<ul>
	<li>Viral skin infection caused by <strong>molluscum contagiosum virus (MCV)</strong></li>
	<li>It is a type of <strong>pox virus</strong></li>
	<li><strong>Risk Factors</strong>
	<ul style="list-style-type:circle;">
		<li>Mainly in CHILDREN</li>
		<li>Immunocompromised</li>
		<li>Atopic eczema</li>
	</ul>
	</li>
</ul>

Answer 90

A

<ul>
	<li>COMMON</li>
	<li>90% of patients are < 15 yrs</li>
	<li>A lot of people will not seek medical attention for it</li>
</ul>

Answer 91

A

<ul>
<li>Incubation period: 2-8 weeks</li>
<li>Usually ASYMPTOMATIC</li>
<li>There may be tenderness, pruritus and eczema around the lesion</li>
<li>Lesions last for around 8 months</li>
</ul>

Answer 92

A

<ul>
<li>Firm, smooth, umbilicated papules</li>
<li>Usually 2-5 mm in diameter</li>
<li>In children - tends to occur on the trunk and the extremities</li>
<li>In adults - tends to occur on the lower abdomen, genital area and inner thighs (suggesting sexual contact)</li>
</ul>

Answer 93

A

<ul>
<li>Usually a CLINICAL diagnosis</li>
<li>Dermatoscopy may be useful if there is doubt</li>
</ul>

Answer 94

A

<ul>
<li>Epithelium-lined, keratinous, debris-filled cyst arising from a blocked hair follicle. Also known as an epidermal cyst.</li>
</ul>

Answer 95

A

<ul>
<li>Occlusion of the pilosebaceous gland</li>
<li>Can be caused by traumatic insertion of epidermal elements into the dermis</li>
<li>Embryonic remnants</li>
<li>Risk Factors
<ul>
<li>Gardner's Syndrome = autosomal dominant condition characterised by the presence of multiple polyps in the colon and in extra-colonic sites (e.g. sebaceous cyst, thyroid cancer, fibroma)</li>
</ul>
</li>
</ul>

Answer 96

A

<ul>
<li>Non-tender slow-growing skin swelling</li>
<li>There are often multiple</li>
<li>Common on hair-bearing regions of the body (e.g. face, scalp, trunk or scrotum)</li>
<li>May become red, hot and tender if there is superimposed infection or inflammation</li>
</ul>

Answer 97

A

<ul>
	<li>Smooth tethered lump</li>
	<li>Overlying skin punctum</li>
	<li>May discharge granular creamy material that smells bad</li>
</ul>

Answer 98

A

<ul>
<li>NONE needed</li>
<li>Skin biopsy or FNA may be used to rule out other differentials</li>
</ul>

Answer 99

A

<ul>
<li>Conservative

~~~
<ul>
<li>May be left alone if its not causing the patient any distress</li>
</ul>
</li>
<li>Surgical
<ul>
<li>Excision of the cyst under local anaesthesia</li>
</ul>
</li>
<li>Medical
<ul>
<li>Antibiotics if there is an infection</li>
</ul>
</li>
</ul>

~~~

Answer 100

A

<ul>
	<li>Infection</li>
	<li>Abscess formation</li>
	<li>Recurrence (if incomplete excision)</li>
	<li>May ulcerate</li>
</ul>

Answer 101

A

<ul>
<li>EXCELLENT</li>
<li>Most do NOT require treatment</li>
</ul>

Answer 102

A

<ul>
<li>Constellation of symptoms caused by systemic release of humoral factors from carcinoid tumours</li>
</ul>

Answer 103

A

<ul>
<li>Carcinoid tumours are slow-growing neuroendocrine tumours</li>
<li>They are mostly derived from serotonin-producing enterochromaffin cells</li>
<li>They produce secretory products like serotonin, histamine, tachykinins, kallikrein and prostaglandins</li>
<li>75-80% of patients with carcinoid syndrome have small bowel carcinoids</li>
<li>NOTE: hormones released into the portal circulation will be metabolised by the liver so symptoms don't tend to appear until there are hepatic metastases or release into the systemic circulation from bronchial or extensive retroperitoneal tumours</li>
</ul>

Answer 104

A

<ul>
<li>RARE</li>
<li>UK incidence : 1/1,000,000</li>
<li>Asymptomatic carcinoid tumours are more common</li>
<li>10% of patients with MEN-1 have carcinoid tumours</li>
</ul>

Answer 105

A

<ul>
	<li>Paroxysmal <strong>FLUSHING</strong></li>
	<li>Diarrhoea</li>
	<li>Crampy abdominal pain</li>
	<li>Wheeze</li>
	<li>Sweating</li>
	<li>Palpitations</li>
</ul>

Answer 106

A

<ul>
	<li>Facial flushing</li>
	<li>Telangiectasia</li>
	<li>Wheeze</li>
	<li>Right-sided murmurs (tricuspid stenosis/regurgitation or pulmonary stenosis)</li>
	<li>Nodular hepatomegaly in cases of metastatic disease</li>
	<li><strong>Carcinoid Crisis Signs</strong>:
	<ul style="list-style-type:circle;">
		<li>Profound flushing</li>
		<li>Bronchospasm</li>
		<li>Tachycardia</li>
		<li>Fluctuating blood pressure</li>
	</ul>
	</li>
</ul>

Answer 107

A

<ul>
<li>24 hours urine collection

~~~
<ul>
<li>Check 5-HIAA levels (metabolite of serotonin)</li>
</ul>
</li>
<li>Blood
<ul>
<li>Plasma chromogranin A and B</li>
<li>Fasting gut hormones</li>
</ul>
</li>
<li>CT or MRI Scan
<ul>
<li>To localise the tumour</li>
</ul>
</li>
<li>Radioisotope Scan
<ul>
<li>Radiolabelled somatostatin analogue helps localise the tumour</li>
</ul>
</li>
<li>Investigations for MEN-1</li>
</ul>

~~~