BREAST/DERM/INFECTIOUS DISEASES Flashcards
What are the 3 components of the triple assessment?
- Clinical assessment
- Imaging - USS or mammogram
- Biopsy
What are some risk factors for developing breast cancer?
- PROLONGED OESTROGEN EXPOSURE
= early menarche, late menopause, 1st birth over 30y, nulliparity, no breast feeding, COCP, HRT - ENDOGENOUS FACTORS
= post-menopausal, greater breast density - LIFESTYLE
= obesity, smoking, lack of physical activity, alcohol, radiation - FHx
= 2x risk if 1st degree relative. BRCA1 + 2
Where are the sites that breast can metastasise to?
- Lungs
- Liver
- Bone
- Brain
Where do breast lumps tend to occur?
Upper outer quadrant
- swelling, skin irritation/dimpling, breast/nipple pain
- skin fixation or skin tethering
What is the 2ww criteria for suspected breast cancer?
- Aged over 30y + have an unexplained breast lump with or without pain
- Aged over 50 with any of the following in one nipple only:
- discharge
- retraction
- other changes of concern
When is a mastectomy indicated for breast cancer?
- multifocal disease
- local recurrence
- invasion more than 4cm
What are some causes of microcalcification?
- fibroadenoma
- cysts, trauma or surgery
- DCIS must be ruled out
How is DCIS managed?
Low grade = WLE
Moderate grade = WLE + radiotherapy
High grade = mastectomy + reconstruction
How is DCIS followed-up?
annual mammogram for 5-yrs
When do you consider excision of a fibroadenoma?
- lesion is over 4cm
- it is growing
- on request from the patient
What are the clinical features of cyclical mastalgia?
- heaviness
- affects both breasts
- radiates to axilla + arms
- worse at end of cycle
- no point tenderness
How do you manage cyclical mastalgia?
- Look for focal lesions e.g. cysts
- Wear supportive bra
- Flaxseed oil/evening primrose oil
When do you suspect infectious mastitis?
- nipple fissure that looks infected
- no improvement after 24hrs of effective milk removal
- breast milk culture is +ve
How do you manage mastitis?
- Continue to breast feed
- US-guided drainage of abscess
- Flucloxacillin
- Breastfeeding counselling
What are the nail signs which are seen in psoriasis?
- Onycholysis = lifting of nail plate from nail bed
- Subungal keratosis = chalky material under nail
- pitting
- beau’s lines
- splinter haemorrhages
How do you manage chronic plaque psoriasis?
- Regular emollients to reduce scale loss + reduce pruritus
- Potent steroid + Vit D analogue applied OD
- continue for 4 weeks - Vit D analogues 2x daily if no improvement w/in 8 wks
- Potent steroid 2x daily for 4wks if no improvement after 8-12 wks
What do NICE suggest in terms of topical steroid treatment duration?
Do not use potent steroids for longer than 8-weeks at a time
Or v.potent for more than 4-weeks
- Aim for a 4 wk break before starting topical steroids again
How do vitamin D analogues work?
Work by reducing cell division + differentiation
- adverse effects uncommon
- may be used long term
- do not smell or stain
- reduce the scale + thickness of plaques but NO erythema
AVOID IN PREGNANCY
When should you refer psoriasis pts same-day to a dermatologist?
Generalised pustular psoriasis or erythroderma
What is general pustular psoriasis?
Pustules within the plaques
- triggered by withdrawal or inappropriate use of steroids
- requires emergency hospital admission
What type of skin cancer are you at risk of from UVB phototherapy?
Squamous cell carcinoma
What are some systemic treatments that can be used in psoriasis?
1st = Methotrexate others = ciclosporin, acitretin, fumaderm
Can then step up to biologicals - adalimumab
What are closed + open comedones?
Closed = whiteheads
Open = blackheads
What grading system is used to define the severity of acne?
Leeds revised grading system
When + what oral antibiotics should you use in treatment of acne?
Acne resistant to topical treatment
- use tetracycline for 3-months
- switch to lymecycline if ineffective
Continue with topical treatments
What features would trigger a dermatology referral for starting isotretinoin?
- severe acne
- acne unresponsive to prolonged Abx
- scarring
- acne associated with psychological problems
What is rhinophyma?
Skin of nose is coarse + grossly thickened
- happens in chronic rosacea
What are the clinical features of rosacea?
- facial flushing
- persistent erythema
- telangiectasia
- inflammatory papules
- pustules
- oedema
What conditions are associated with rosacea?
- conjunctivitis
- blepharitis
- eyelid oedema
How do you manage rosacea?
Identify trigger factors + avoid them
Avoid skin irritants, use sunscreen
1. Topical metronidazole
2. Oral Abx = doxycycline, erythromycin
What is pityriasis alba?
Variant of atopic eczema
Pale patches develop on the face of children
What differences are seen clinically between allergic + irritant contact dermatitis?
ALLERGIC = intensely itchy, erythema, oedema, vesicles, chronic lesions are lichenified IRRITANT = itchy or sore, erythema, fissuring
What are the symptoms you should tell pts about to recognise infected eczema?
- weeping
- pustules
- crusts
- atopic eczema failing to respond to treatment
- rapidly worsening
- fever + malaise
How do you manage infected eczema?
1-2 week course of flucloxacillin or erythromycin or clarithromycin
With topical steroids, how much body surface area will 1 FTU cover?
2 adult palms
What is the steroid hierarchy? Going from mild to potent
- Hydrocortisone
- Eumovate
- Betnovate
- Dermovate (beclometasone)
What are the criteria for referring a mole on 2ww?
Refer any:
- new mole, growing quickly
- long standing mole changing shape or colour
- any mole which has 3 or more colours OR lost its symmetry
- new nodule growing is pigmented + vascular
- new pigmented lines in nails
- something growing under nail
What patients are at particular risk of SCC?
Immunosuppressed + transplant pts
What are some differentials for a pt presenting with fever, abdominal pain + jaundice?
- Acute cholecystitis
- Ascending cholangitis
- Acute viral hepatitis
- Liver abscess
- Malaria
What is the management of hepatitis A?
- Supportive therapy = basic analgesia, typically resolves within 3-months
- Avoid alcohol
- Rarely, interferon alpha for fulminant hepatitis
What is HBsAg?
Surface antigen - first to appear
Active infection = active for 1-6 months
Chronic = over 6 months +ve
What is anti-HBs?
Implies immunity
- may mean resolved infection or immunity
What is anti-HBc?
Implies past/current infection
IgM = acute, remains for 4-8 months
IgG = chronic infection, carrier
What is HBeAg?
Marker of infectivity
- appears early in acute infection
- more than 3 months implies chronic
What does Anti-HBc +ve, HBsAg -ve indicate?
= previous HBV (>6-months ago), not a carrier
How do you manage hepatitis B?
ACUTE
= supportive care, antivirals, stop smoking + alcohol, fibroscan for cirrhosis + USS for hepatocellular carcinoma
CHRONIC
= peginterferon + antivirals
Can hepatitis B be spread by breastfeeding?
NO
How do you manage acute alcoholic hepatitis?
- Screen for infections + perform ascitic fluid tap
- treat SBP with cefotaxime if present - STOP alcohol - use IM lorazepam for withdrawals
- Pabrinex
- Prednisolone - for 5-days then tapered over 3 wks
Who does autoimmune hepatitis tend to affect? How will they present?
young + middle-aged women
- fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, or glomerulonephritis
What antibodies are associated with autoimmune hepatitis?
ANA, SMA and LKM1 antibodies
How do you tell the difference between amoebic + pyogenic abscesses?
On USS Amoebic tend to be singular whereas pyogenic abscess tends to be multiple
What investigations should be performed in suspected TB?
- CXR
- Cultures - Ziehl-Neelsen staining shows bright red
- NAAT
- Histology - cavitating graulomata
- Mantoux test + IGRAs
What treatment is given for TB?
Rifampicin + Isoniazid for 6-months
Pyrazinamide + Ethambutol for 2/3 months
What is given alongside isoniazid? What complication is this to avoid?
Pyridoxine (vit B6)
- prevent peripheral neuropathy
What are the side effects of rifampicin?
Red/orange discolouration of secretions
- cP450 inducer = reduces effects of drugs metabolised in this system such as COCP
Hepatotoxicity
What are the side effects of isoniazid?
Peripheral neuropathy
Hepatotoxicity
What are the side effects or pyrazinamide?
Can cause hyperuricaemia resulting in gout
Hepatotoxicity
What are the side effects of ethambutol?
Colour blindness
Reduced visual acuity
What are the treatment options for pts with suspected influenza who are at risk of complications?
- Oral oseltamivir 75mg BD for 5-days
OR - Inhaled Zanamivir 10mg BD for 5-days
Treatment should be started within 48h of symptom onset to be effective
Who are influenza vaccinations given to?
- aged over 65
- young women aged 2-7
- pregnant women
- chronic health conditions e.g. asthma, COPD, heart failure + diabetes
- healthcare workers + carers
- long stay care-homes, nursing homes + residential homes
How do you diagnose malaria?
Malaria blood film - send in EDTA bottle
- 3 samples over 3 consecutive days
What are the 2 main malaria treatment options to remember for exams?
Oral = quinine IV = artesunate
What is the classic triad of infectious mononucleosis?
- Fever
- Pharyngitis
- Lymphadenopathy - may be in anterior + posterior triangles of neck - whereas in tonsilitis it is typically in upper anterior cervical chain being enlarged
What investigation + management should be performed in suspected infectious mononucleosis?
Monospot test - perform FBC + monospot in 2nd week illness to confirm diagnosis
- Rest, lots of fluid, avoid alcohol
- Simple analgesia
- Avoid contact sports for 8 wks to avoid splenic rupture
What classification system is used to determine the severity of cellulitis?
Eron classification
What pts are at risk of necrotising fasciitis?
IVDU
How do you manage necrotising fasciitis?
Surgical debridement + supportive Abx
