AKT and KFP Mini Quizzes

Question 1

Differentials for red/brown spotty papular rash on the palms?

Answer 1

• Hand foot and mouth disease
• Secondary syphilis: red/brown scaly rash involving the palms and soles with a prodromal illness
• Scarlet fever: can present with sore throat and red/brown scaly rash, usually more common to start behind the ears and on the trunk before descending
• Pityriasis rosea: typically presents with herald patch but this can be missed and presentation can be with smaller ovoid red macules later in the illness
• Guttate psoriasis: usually occurs 23 weeks following URTI

Question 2

Clinical features of hand foot and mouth disease?

Answer 2

Prodrome (one or more of the following):
* Fever
* Sore throat
* Loss of appetite
* Lethargy

Blisters usually appear one to two days following the fever
* Blisters on the tops of the hands, feet and/or palms, and soles
* Blisters should not be itchy

Lesions usually:
* Feel tender
* Evolve over time from flat pink macules to small, elongated, red-greyish blisters - red skinn rash with a brown scale on it
* Oval rather than round
* Peel off within a week, without leaving a scar
* Can be small, oval, white blisters on the palms, soles of the feet and mouth

Ulcers may develop in and/or around the lips and mouth and the back of the throat

Question 3

How is hand foot and mouth disease spread and what should affected patients be advised?

Answer 3

Spread:
- Contact with the fluid from inside blisters
- Droplets spread from sneezing and coughing

Advice:
- Wash hands thoroughly after touching you child’s bodily fluids
- Don’t share items such as cutlery, drinking cups, towels, toothbrushes and clothing
- Keep your child home from school, kindergarten or childcare until all the fluid in their blisters has dried
- Maintain good hand hygiene after making contact with blisters
* Cover coughs or sneezes with that issue
* Ensure adequate fluid intake to produce clear urine
* Remain isolated from work until blisters have scabbed over

Question 4

What are some other differential diagnosis for hand, food, and mouth disease?

Answer 4

• Bacterial: Bullous impetigo (Group A strep, Staph aureus)
• Viral: Herpes simplex virus, adenoviruses, varicella zoster virus, Epstein Barr virus
• Bullous insect bite reactions
• Pompholyx eczema

Question 5

Clinical features of scarlet fever?

Answer 5

Sudden fever associated with:
* Sore throat
* Swollen neck glands
* Headache
* Nausea and vomiting
* Loss of appetite
* Swollen and red strawberry tongue
* Abdominal pain
* Body aches and malaise

Characteristic bright red rash appears 12-48 hours after the start of the fever
* As the rash spreads, it starts to look like sunburn with goosebumps and may have a sandpaper-like feel

Question 6

Clinical features of guttate psoriasis?

Answer 6

• Sudden onset of multiple drop-shaped, small sized (~5mm), daily erythematous lesions - mostly on trunk and proximal limbs
• Occurs 2-3 weeks after a group a streptococcal pharyngitis

Question 7

Cutey

Clinical features of varicella (chickenpox)?

Answer 7

• One to two days of prodromal symptoms
• Followed by irritated and itchy vesicular rashes which initially start on the face, back and stomach

Question 8

Clinical features of secondary syphilis?

Answer 8

Secondary syphilis is characterised by rash and systemic symptoms.

Systemic symptoms:
* Fever
* Headache
* Malaise
* Myalgia
* Arthralgia
* Lymphadenopathy

Cutaneous features:
* Non itchy rash is present in 90% of patients
* Rough, red or reddish-brown papules or plaques
* Typically on the trunk then frequently affects palms and soles
* Mucosal surfaces - such as inside the mouth, throat, genital area, vagina, and anus - can become raw and red

Question 9

Differentials for rapidly growing red skin lesion?

Answer 9

• Pyogenic granuloma: acquired benign proliferation of capillary blood vessels
• Amelanotic melanoma
• Hemangioma
• Bacillary angiomatosis: opportunistic cutaneous and systemic bacterial infection caused by Bartonella
• Kaposi sarcoma: disease of the endothelial cells of blood vessels and the lymphatic system, can be associated with HIV

Question 10

List some strategies for dealing with a delayed significant result or error?

Answer 10

• Apologise to the patient for the error that has occured
• Ask about any potential signs or symptoms of complications of the error
• Carefully document the explanation of the error to the patient
• Explain to the patient that you will discuss the error with the relevant doctor
• Explain to the patient that you will advise the practise manager of the error to review practise policies

Question 11

What practise processes should be put in place to ensure that abnormal patient results are followed up appropriately?

Answer 11

• Ensure the ordering doctor is responsible for reviewing and actioning abnormal results they have ordered
• Utilise a recall system that includes multiple modes of patient communication to contact patient
• Assign staff member to manage recalls for abnormal results
• Clear procedure on how recalls for abnormal results occur if the initial contact is not made
• Have a clear expectation of how the result will be followed up with a patient at the time of test ordering
• Organise routine audit for results that have remained unreviewed
• Organise an oncall doctor to review results if a colleague is on leave

Question 12

Differentials for psychotic symptoms, agitation and restlessness present for two weeks?

Answer 12

• Brief psychotic episode/disorder - less than one month of symptoms
• Manic episode of bipolar affective disorder one - meets criteria of over one week of mood disturbance
• Depressive episode with psychotic features - meets 2 week criteria for a depressive episode
• Brain space occupying lesion

Question 13

What are the different diagnoses for psychotic/delusional symptoms of varying time frame?

Answer 13

• Brief psychotic disorder: 1 day to 1 month; often associated with an intense stressor or traumatic event
• Delusional disorder: more than 1 month of mainly delusions but not disorganised speech or behaviour
• Schizophreniform disorder: 1 month to 6 months
• Schizophrenia: atleast 6 months

Question 14

Dsm 5 diagnostic criteria for schizophrenia (focusing on the domains only, not time)?

Answer 14

• Delusions
• Hallucinations
• Disorganised speech e.g. Frequent derailment or incoherence
• Grossly disorganised or catatonic behaviour
• Negative symptoms (ie diminished emotional expression or abolition)

Question 15

What questions would you ask to reach a diagnosis when evaluating a patient with psychotic symptoms?

Answer 15

• Observed to be responding to internal stimuli? - interacting with hallucinations
• Minimal need for sleep - features of mania
• Impulsively spending money or disinhibited behaviours - features of mania
• Recent low mood - features of depression
• Anhedonia - features of depression
• Impact on function
• Recent fever or infective symptoms - symptoms to suggest encephalitis
• Recent head injury or vision disturbance or headache - symptoms to suggest possible space occupying lesion

Question 16

What does each of these questions try to elicit (context of mental illness)?

• Have you been especially nervous or fearful? Have you felt tense and shaky, or experience palpitations?
• Have you been feeling sad or down in the dumps recently, not enjoying activities as much as before?
• Have you been feeling especially good in yourself, more cheerful than unusual and full of life?
• Do you hear voices of people talking to you even when there is no one nearby?
• Have you felt that thoughts are being put into your mind? Do you experience telepathy?
• Have you experienced thoughts being taken out of your mind?
• Have you felt that other people are aware of your thoughts?
• Have you experienced voices or people echoing your thoughts?
• Have you felt under the control or influence of an outside force?
• Do programmes on the television or radio hold special meaning for you?
• Do you feel that you are being singled out for special treatment? Is there a conspiracy against you?
• Do you feel special, with unusual abilities or power?
• Do you believe that you have sinned or have done something deserving punishment?

Answer 16

• Have you been especially nervous or fearful? Have you felt tense and shaky, or experience palpitations? Anxiety
• Have you been feeling sad or down in the dumps recently, not enjoying activities as much as before? Depressed mood
• Have you been feeling especially good in yourself, more cheerful than unusual and full of life? Elevated mood
• Do you hear voices of people talking to you even when there is no one nearby? Auditory hallucinations
• Have you felt that thoughts are being put into your mind? Do you experience telepathy? Thought insertion
• Have you experienced thoughts being taken out of your mind? Thought withdrawal
• Have you felt that other people are aware of your thoughts? Thought broadcasting
• Have you experienced voices or people echoing your thoughts? Thought echo
• Have you felt under the control or influence of an outside force? Delusion of control
• Do programmes on the television or radio hold special meaning for you? Delusions of reference
• Do you feel that you are being singled out for special treatment? Is there a conspiracy against you? Delusions of persecution
• Do you feel special, with unusual abilities or power? Delusions of grandeur
• Do you believe that you have sinned or have done something deserving punishment? Delusions of guilt

Question 17

Differentials for a yellow nail?

Answer 17

• Onychomycosis
• Nail psoriasis
• Onycholysis - white discoloration from lifting off nail bed
• Traumatic onychodystrophy - nail dystrophy (often thickening) secondary to trauma
• Lichen planus

Question 18

Management options of onychomycosis?

Answer 18

• First line: terbinafine 250mg daily PO until clinical clearance
• Second line: Fluconazole 150-300mg weekly PO until clinical clearance
• Third line: Itraconazole 100-200mg BD PO for 1 week every month until clinical clearance
• Fourth line: Griseofulvin 500-1000mg daily PO until clinical clearance
• No treatment necessary as benign condition