derm middle tier

Question 1

venous ulcer presentation

Answer 1

Commonly lower leg
Takes 2w+ to heal
Pain - worse when standing
Varicose veins
Large, shallow, irregular
Normal pulses
Warm skin
Oedema in other leg

Question 2

venous ulcer pathophysiology

Answer 2

High pressure (in superficial veins) forces fibrinogen out of vessels → perivascular fibrin deposition → poor oxygenation of skin in this area

Question 3

venous ulcer risk factors

are they common?

Answer 3

Due to sustained venous hypertension in superficial veins
Incompetent valves
DVT
Atherosclerosis 
Vasculitis - RA, SLE

common, more common with age

Question 4

ulcer =

Answer 4

abnormal break in epithelial surface eg skin

Question 5

arterial ulcer risk factors

Answer 5

Smoking
Arterial disease - atherosclerosis ! 
DM
Hypercholesterolemia 
History of claudication, hypertension, angina

Question 6

arterial ulcer presentation

Answer 6

Punched out
Small, defined
Necrotic base
Painful - worse at night / legs elevated 
Higher up on leg / foot
Absent peripheral pulses
Cold, pale leg
No oedema
Occurs at pressure/trauma sites

Question 7

what must not be given to arterial ulcer

Answer 7

compression bandages

Question 8

what investigation results suggest arterial ulcer

Answer 8

ABPI (ratio of blood pressure at ankle to upper arm). arterial insufficiency <0.8

doppler ultrasound confirms arterial disease

Question 9

neuropathic ulcer risk factors/causes

Answer 9

DM
Neurological disease
Leprosy

Question 10

neuropathic ulcer presentation

Answer 10

Painless! 
Peripheral neuropathy
Variable size/depth
Warm skin
At pressure sites - soles, heels, toes

Question 11

• vasculitis
  ulcer
• causes

Answer 11

Vasculitis = Inflammatory disorder of blood vessels → endothelial damage

Mainly idiopathic
Drugs
Infection
Inflammatory disorder
Malignant disease

Question 12

vasculitis ulcer presentation

Answer 12

Usually lower legs
Symmetrical
Palpable purpura 
Non-systemic 
Do not blanch
Pyrexia
Arthralgia

Question 13

general ulcer risk factors

Answer 13

Neuropathy eg DM
Lymphoedema
Vasculitis
Malignancy
Infection (TB, syphilis)
Trauma (pressure sores)
Drugs 

may be multiple

Question 14

leg ulcer = most likely to be what

Answer 14

mainly venous disease

some - arterial disease

Question 15

dermatitis artefacta

Answer 15

ulcer self induced by patient, usually as result of psychological suffering
skin/ ulcer biopsy

Question 16

ulcer treatment

Answer 16

• Treat cause
• Focus on prevention —Nutrition
• Risk factor control (eg drug addiction)
• Bandages -
• – Compression — Never for arterial ulcers
• Keep it clean and covered
• Antibiotics for infection
• Analgesia
• Steroids - if vasculitis
• Surgery inc debridement , vascular reconstruction

Question 17

complications of necrotising fascitis

Answer 17

multi organ failure
mortality high
amputation

Question 18

treatment of necrotising fascitis

Answer 18

Aggressive and immediate treatment

Antibiotics

• Group A strep (pyogenes ) aka type 2 necrotising factor == IV benzylpenicillin + clarithromycin/clindamycin
• Unknown cause = broad spectrum IV antibiotics

Radical debridement
Amputation

Question 19

investigations and results for necrotising fascitis

Answer 19

X ray - soft tissue gas is seen

Bloods
FBC- v high wbc
Raised CRP

Question 20

presentation of necrotising fascitis

Answer 20

• Intense pain in area ( Disproportionate to skin findings (initially skin spared))
• Erythematous
• Necrotic (due to vascular supply - may be black and slough (shedding) → dry gangrene
• Blistering
• Sometimes crepitus
• Systemically unwell
• – Fever
• – tachycardia

Question 21

what is necrotising fascitis

types

Answer 21

• Life threatening infection of the deep fascia causing necrosis of subcut tissue fascia and fat
• Skin is initially spared but is eventually destroyed
• Progresses rapidly

1 : mixture of aerobic and anaerobic bacteria
- Following abdominal surgery
diabetes

2 : Group hemolytic streptococcus (strep pyogenes) (this is aerobic)
- Previously healthy patients

Question 22

risk factors for necrotising fascitis

Answer 22

Abdominal surgery
Diabetes
comorbidities
Immunosuppression

Question 23

impetigo seen mainly on what ages

Answer 23

infants kids

Question 24

impetigo presents

Answer 24

Often on face, hands, feet
Itchy
Red
Growing 
Weeping
Crusting

Question 25

impetigo treatment

Answer 25

antibiotics

Question 26

gangrene =

types

Answer 26

Death of tissue from poor vascular supply

Types

• Dry = Necrosis WITHOUT infection
• Wet = Necrosis WITH infection
• – Tissue becomes necrotic, usually after burn/ trauma injury
• – More likely to be infected

Question 27

amyloidosis =

Answer 27

Misfolded amyloid fibril (protein) deposits

• In multiple organs (systemic)
• In one organ (localised)

Question 28

name 5 effects of amyloidosis on organs

Answer 28

Kidneys

• Podocyte damage → proteinuria
• Oedema (as result of hypoalbuminemia / lower oncotic pressure)
• –Tiredness
• – Weakness
• – Loss of appetite
• Hyperlipidaemia

Heart

• Stiffens walls → HF
• Interferes with electrical conduction → arrhythmias
• – Oedema
• – SOB

Intestines

• Damages villi → less absorption
• – Weight loss
• – Nausea
• – Diarreha
• – Constipation
• Enlarged liver, spleen, tongue (macroglossia)

Brain

• Alzheimers
• Decreased brain function
• Increase risk of haemorrhage

Nerves

• Damage in somatic (sensory and motor) and autonomic nerves
• – Numbness

Skin
- Purpura esp periorbital