Derm/Rheum/Ortho Flashcards
Non medical complications of acne
- Scarring 2. Social withdrawal 3. Depression 4. Anxiety 5. Anger 6. Unemployment
SE of isorenitonin
- Increased ICP 2. HyperTG and mild increased cholesterol 3. Dry nasopharyngeal mucosa 4. Increased S. aureus colonization 5. Abnormal LFTs 6. Arthralgias 7. Abnormal night vision 8. Possible depression (rare)
Top 3 skin diseases of childhood
- Dermatitis 2. Warts 3. Impetigo
DDx tinea capitus
- Sebborheic dermatitis 2. Atopic dermatitis 3. Psoriasis 4. Alopecia areata 5. Trichotillomania 6. Allopecia folliculitis
Risk factors for atopic dermatitis
- FamHx of AD 2. Aeroallergens (pets, mites, pollen) 3. Food allergens (milk, eggs) 4. Severe infantile disease 5. Concurrent asthma & allergic rhinitis
Atopic dermatitis triggers
- Stress 2. Allergens: food and aeroallergens 3. Infections: SAUR, Malassezia 4. Autoantigens: IgE vs manganese superoxide dismutase (from foreign enzyme)
SLE diagnostic criteria
4/11 1. Discoid rash 2. Malar rash 3. Photosensitivity 4. Oral ulcers 5. Non erosive arthritis 6. Renal: nephritis, HTN, nephrotic syn, RF 7. Neuro dz: encephalopathy, szs, psychosis 8. Heme d/o: pancytopenia 9. Pleuritis/pericarditis 10. Immunologic d/o 11. + ANA
6 y female with acne. Prom is coming. History and physical Manage. Medications. Comment on risk of Accutane DDX Most likely diagnosis
History - Confidentiality statement - Onset, duration, severity - Associated rashes or location o Nose, chest, back - Complications, ex infection requiring antibiotics - Provocative or palliating factors - Management so far – successful or not? o Make up o OTC and prescription medications o Soap, washing face o Assess compliance and technique. Side effects of medications o Gel, lotion or cream - Menstrual history o Heavy flow, irregular bleeding (PCOS) - Hirsutism - Puberty history - Dietary history - Other skin problems o Eczema or atopy- will affect your management - Other adrenarche o Hirsutism, severe BO - Sports equipment (ex. hockey masks) - Review of systems o Headaches, blurry vision (pseudotumor) o Chest pain, cough o Abdominal pain, cramping o MSK findings o GU findings o Hematologic disorders - PMHx - Birth Hx - Medications o Oral steroids o Dilantin - Allergies - Immunizations - Family history o Family history of acne o CAH, PCOS o Metabolic syndrome, DM2 o Infertility o Sudden death - Social history o Part time jobs (aggravating factors – ex. fast food, mechanics working with oil) - HEADS, impact of illness on patient, self-esteem o Sexual activity o Mood Physical Exam - Vitals - Plot growth (BMI) - General appearance o Signs of Cushingoid, insulin resistance (acanthosis) - Skin- emphasis on acne-prone area o Comedones (open and closed), cystic lesions, nodules, pus o Scarring o Dry skin o Is it really acne: TS, rosacea, etc - Hirsutism - Fundoscopy - Thyroid exam - CVS - Respiratory - Abdominal - Tanner staging (breast + PH) - MSK- joint exams - Affect Manage - Diagnose: acne vulgaris - Reassure, counsel re: timing of improvement o Will take 6-8 weeks! Counsel that may not be better by prom. May get worse before it gets better. o Dispel myths (blackheads are not dirt- frequent soaps are worsening, not related to diet- not caused by chocolate or fast foods) o May need to modify part time job, cosmetic choices o Counsel re: relationship with acne and menses - **Psychosocial impact of illness on youth** o Monitor for depression, suicidality - Patient handouts, diary of symptoms - OCP if PCOS symptoms - Lifestyle changes: wash face with mild soap, avoid cosmetics Medications - Topical retinoids in AM o Low threshold to use - Benzyl peroxide at night o Expect dry skin- use moisturizer - Follow up in 2-3 months for improvement. May increase benzyl peroxide or step up treatment. - Topical or systemic antibiotics (ex. minocycline) - End of line: o Dermatology consult o Accutane o AAP: Systemic retinoids to be used by general pediatricians ONLY if very experienced in messaging these conditions. Can monitor or maybe do shared care if remote practice. Specific Risks of Accutane - Comment on liver disease, teratogenicity, suicidality, severe dry skin and dry MM, photosensitivity o Baseline bloodwork and monitoring - 2 methods of contraception - Screen for depression and suicidality - Screen LFTs - Hyperlipidemia - Pseudotumor cerebri? Worsening of UC? - No vitamin A supplementation while on it - Avoid tetracyclines while on it – will worsen ICP and photosensitivity
6 year old girl referred to you for hair loss. General approach to history and physical
History: ChLORIDE FPP Location, patches, % hair loss? Diffuse .vs focal Pattern, Amount, Clumps vs. individual Hair pulling, habit? Hair of different lengths Hair loss in any other areas: eyebrows, axillary Abdo pain, obstruction, Scalp under hair that has been lost PRUITITIS? Travel Sick contacts Triggers: Stress, social, diet, Hair management: Shampoo, conditioner, dying, brushing, hair placed up Infection conditions TIGHT HAIR STYLES NAIL CHANGES OTHER DERM CONDITIONS: Rashes, eczema, pigmentation abN, psoarsis, fungal culture, ROS for Fungal infections: Tinea PSYCH ROS, OCD screening, Anxiety, Depression THYROID ROS Autoimmune conditions:DM, Celiac, Thyroid Pregnancy, crash dieting B Sx: Wt loss, fever, night sweats PMHX: T21 Meds: Chemo, steroid, Allergies FHX: Fungal, alopecia arretia, tinea captis SHx: Affect, embarrassment, school attendance, self esteem Others with hair loss Behavioural issues: trichotillomania, TEASING, BULLY ROS DDX: 1. Alopecia arretia 2. Telogen effugenvem 3. Tineia captis 4. Med SE Physical Exam: Vitals Ht/Wt and Plot DYsmorphisms Nutritional status DERM EXAM Scalp, hair exam Scaling, clean patch of hair loss Pull test Black dot: broken hairs Hair quality Nail changes WHEN WAS THE LAST TIME THE HAIR WAS WASHED H&N Hair in other places Thyroid exam Joints for arthritis Cutis aplasia Common causes: 1. Alopecia arretia 2. Tinea captis 3. Telogen effugen 4. Trauma/Trichotillomania 5. Loose telogen disorder 6. Meds 7. Thyroid 8. Sudden starvation 9. Severe Emotional Stress Healthy with history and physical exam Most likely diagnosis: Telgoen effuigenvum Factors implicated: 1. Stressor 2. Weight loss 3. Diet changes Is an underlying factor always found? No Explanation: How to counsel and management: 1. Explanation: 20-40% to be noticeable. Largely reassured. Do not lose more than 50% of hair, should regrow in 6-12M, benign.If beyond, may need to investigation for systemic disease. May need to refer to derm (outliers). Address underlying etiology. 2. Recommendation: Psychological effects 3. FUin 2-3M 4. Expectation: Counsel things to see sooner 5. Handout/Diary: Handouts from caringforkids handout
5 year old male with limping. Previously healthy. Few days ago: uncomfortable walking, leg hurts.
History - Characterize pain o Location o Character o Onset o Time of day (AM stiffness or pain?) o Waking from sleep o Course (worsening/resolving) o Weight bearing o Red or swollen joints - Provocative factors - Palliating factors o Physio? o Medications? - Recent illness o Viral - Constitutional symptoms o Fever o Weight loss o Pallor o Night sweats - Trauma – injuries, abuse - Other injuries - Review of systems o Bleeding o Oral ulcerations o Abdominal pain o Rash - Travel, camping, sick contacts o Tick bites? - PMHx o JIA o SLE or other autoimmune o Chronic disease o Fractures - Pregnancy and delivery history o Late presentation CP? o NICU admission - Medications o Improving? o Meds that may provoke (growth hormone, steroids) - Allergies - Vaccines - Development o Regression - Family history o Oncologic o Consanguinity, ethnicity o Autoimmunity: SLE, IBD, DM1 o Neuromuscular disorders o Hemophilia o Sickle cell - Social history o Child abuse, neglect o Impact on child and family (missed school) Physical Exam - Vitals - Growth + plot - Fever, pallor, lymphadenopathy - MSK: look, feel, move o Compare both sides o Look for arthritis: ROM, effusion, erythema o Look for joint above and below o Skin changes, muscle atrophy o Gait: alignment, circumduction, pelvis swinging § Walk and run o Look at feet (calluses) and shoe soles (uneven wear) - CNS o Strength, sensation o Uveitis o Fundoscopy - CVS - Respiratory o Air entry, WOB, adventitious sounds - Abdominal o HSM - Head and neck: ulceration - Derm: malar rash, erythema nodosum on bony extremities
LImp DDx
Differential diagnosis (age dependent): - Septic arthritis - Post-infectious arthritis - Malignancy - Autoimmune: JIA, lupus - Vascular: bony crisis - Trauma - SCFE, AVN - Hemarthrosis - Neuralgia - Developmental Investigations - CBC, ESR, CRP, LFTs, BUN, Cr, lytes, blood culture - Ultrasound - Hip XR - Consider: MRI, joint aspirate, lyme disease, rheum workup, oncologic Discuss management and prognosis - Explain diagnosis o Self-limiting, common o No long term sequelae o Expect resolution in
Identify this rash and provide a DDx
Etiology • Infectious Øß-hemolytic Strep ØTB ØSalmonella ØTularemia ØYersinia ØLeprosy ØBartonella ØHSV ØHistioplasmosis ØCoccidiomycosis • Inflammatory Ø UC ØCD ØSarcoidosis ØSpondyloarthropathy Beçets Syndrome • Drugs ØSulfonamides ØPhenytoin ØOCP • Malignancy ØLeukemia ØLymphoma ØCarcinomas Clinical Features • New crops of nodules may develop over weeks, and evolve from erythematous to bluish. • Rash characterized by pretibial or thigh tender erythematous nodules in the deep dermis and subcutaneous tissue. ØIt is thought to be a hypersensitivity reaction. Investigations • Search for underlying disease is always justified. • CXR and CBC are indicated. • Other considerations include throat culture, ASOT, Yersinia titre, TB skin testing, and ESR. Treatment • Treatment is of the underlying etiology. • Supportive treatment includes elevation of the legs, and analgesia. • Medication can be useful in severe cases, choices include NSAIDS, and systemic steroids. ØSteroids should only be used in recalcitrant cases, after an infectious etiology has been ruled out. • The lesions heal without scarring.
A 14 year old girl in your practice presents to your clinic with joint pains and fever for two weeks. She looks well. Her initial work‐up reveals trace blood and protein in her urine. Take history and perform physical exam.
History
Symptoms of SLE
o Fatigue, fever, weight loss
o Photosensitivity
o Arthralgias/arthritis
o Raynaud
o Serositis – pleuritis, peritonitis o Nephritis
o Seizures/psychoses
o Alopecia, rashes
o Anemia
Differential
o Broad, based on symptom complex
Arthritis ‐ infectious, reactive, RA, Rheumatic, sarcoid, FMF, oncologic Nephritis – IgA nephropathy, PSGN, HSP, MPGN, MCD
Fevers ‐ infectious
HEADSS Family history, PMH
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□ □
Physical exam
□ General: Height, weight, wasting
□ Head/neck: Malar rash, lymphadenopathy, oral ulcers, conjunctival pallor □ Chest: Pericardial rub, pleural rub, murmurs (libman‐sacks)
□ Renal: Fluid overload
□ Abdo: Hepatosplenomegaly, ascites
□ MSK: Arthralgias
□ CNS: cranial neuropathies, cerebritis
□ Skin: Discoid/malar rash, petechiae, bruising
PEP: How would you initially manage this patient?
PEP: How many diagnostic criteria do you need to make a diagnosis of lupus?
12 year old referred to you for scoliosis. CARD: Hx, Px, management.
History
HPI
Open‐ended – what brings them in or understanding? OLD SCARS, onset, symptom progression, current state Hx of trauma
Work‐up, treatment
Management at home
Neuromuscular Disorder/myopathy
Gross motor skills
Weakness, hypotonia, hypertonia, toe walking
Hemiplegia
Abnormal gait
Syndromes NF1 – skin changes (coloured spots,freckling, bumps, lumps), development Marfan – body habitus, joint hyperextensibility, chest pain/palpitations/exercise
− intolerance/dyspnea (CVS)
Complications
Back pain (usually painless)
− pulmonale)
Psychosocial
Pubertal History
Changes associated with puberty noticed Hair growth (pubic hair, body hair (+axillary), facial hair Voice change, acne
Breast development
Testicular and Penile changes Menses
Development
Focus on gross motor
Extended family history
Extended screen:
Scoliosis Congenital skeletal deformity Neuromuscular disorder/myopathy Syndromes: NF1, Marfan
Social History
Physical Examination
Usual exam
MSK:
Adam’s forward bend test, assess from anterior and posterior Asymmetric rib prominence, waist line, or shoulder height suggests scoliosis Leg length discrepancy Joint hyperextensibility, arachnodactyly, pectus, other Marfanoid features
Neuromuscular screen if suggested on hx NEURO exam: 20% associated with intraspinal pathology CARDIAC exam (always if considering Marfan)
SKIN and eye exam (NF1)
Differential Diagnosis
IDIOPATHIC (most)
Others
Congenital (eg. hemivertebrae) 2° to neuromuscular disorder/myopathy (eg UMN: CP, LMN: SMA, myopathy: DMD) Syndromes (NF, Marfan)
Compensatory: leg‐length discrepancy
Investigations
X‐rays
o PA and Lateral STANDING of entire spine o Cobb’s Angle:
1) Determine end vertebrae of the curve (upper and lower limits of the curve)
2) Draw two perpendicular lines to measure angle as shown
Curve > 10° = scoliosis
Indication for MRI
o Left thoracic curves and back pain are associated with ↑ intraspinal pathology (syrinx or tumor)
Management
REFERRAL to Orthopedics (these criteria depending on who you ask!) > 20° in skeletal immature for orthosis Rapidly progressive curvature
Respiratory or Cardiac impairment
Cosmesis
Assist with psychosocial Work‐up for underlying syndrome or neuromuscular disease
A 15 year old boy comes to see you with a history of right knee pain for past 6 months. Take history and then do a focused physical exam.
Ensure confidentiality (thinking ahead to STI questioning)
Pain history (how long, etc)
Swelling, warmth, stiffness
Any other joints affected
Back pain, buttock pain, jaw pain
Enthesitis/insertion points
B symptoms (fever, weight loss, night sweats)
Bone pain? Location?
Recurrent fevers
Pain with activity, night pain, pain that wakes from sleep
Travel history
Camping or insect bites
Treatment (alleviating, exacerbating)
Trauma
Sexual activity
How does this affect you now (functional impairment)
ROS (think DDx)
o Head and neck (eye pain, redness, uveitis, photophobia) o Oral ulcers
o Headaches
o Skin changes (malar rash, evanescent rash (JIA)
o Abdominal pain, diarrhea, bloody stools
o GU symptoms (dysuria, discharge)
Past medical history (including previous joint pain, surgeries, etc)
Meds, Allergies, Immunizations, Herbal
Family history (arthritis, inflammatory disorders, rheumatologic history, IBD, bone cancers)
Developmental history
Social history
Physical
Growth parameters and vital signs
Mention joints above and below
Look
o Observe standing (e.g., leg length discrepancy)
o SEADS – swelling, erythema, atrophy, deformity, symmetry)…including muscle bulk o Remember to inspect when patient lying or supine (not sitting → can distort
appearance)
Feel
o Warmth, tenderness, joint line pain
o Enthesitis points (2, 6, and 10 o’clock)
o Baker’s cyst (posterior)
o Tibial tuberosity (e.g., Osgood-Schlatter)
Move (active and passive ROM) → hip and knee!
o Assess for crepitus with passive ROM
o Patellar movement and pain
Examine (at least mention) joint above and below (and other side)
Special tests
o ACL, PCL, medial and lateral ligaments o Assess menisci (McMurray test)
o Effusion (ballot, fluid wave)
o Gait
Consider complete joint exam (e.g., JIA) Differential Diagnosis
Ligamentous sprain/tear (ACL/PCL, MCL/LCL)
Patellar pain (patellofemoral syndrome, patellar dislocation/subluxation, patellar tendonitis)
Osgood-Schlatter, iliotibial band tendonitis (running)
Osteochondritis dissecans (primary necrosis of bone and underlying cartilage)
Septic arthritis, osteomyelitis
Arthritis (e.g., JIA)
Malignancy (e.g., osteosarcoma, Ewing’s)
Referred hip pain (SCFE, LCP, stress fracture of femoral neck)
Spondyloarthropathy
Connective tissue disease
