Dermatology Flashcards
Your next patient is a 25 year old patient who has presented to your general practice complaining of a rash.
Hemodynamic Stability
Examiner: Are there any questions?
D: May I know the vital signs of the patient? The BP, PR, RR, Temp.
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you?
Address concern
D: I understand that this can be distressing. But let me just ask you a few questions, examine you, we’ll find the cause together and we’ll make the best management plan for you.
Explore the Rash
Timing
D: Since when did you first notice the rash?
D: Is it the first time that you’ve had this rash?
D: Is the rash spreading or getting worse?
Alleviating and aggravating factors
D: Is there anything that makes it better or worse?
Character
*If a photo is given, then perfect. If not, ask the character in history
D: Where is the site of the rash?
D: What color is the rash?
D: Is it a raised rash or a flat discoloration?
D: Do you see any discharge?
D: Are there any blisters?
D: Is it warm to touch?
D: is it painful to touch?
D: Is the rash itchy?
D: Do you feel a rough surface on the rash?
Differentials
Infective
Viral exanthems
Meningococcemia
STI (HIV, syphilis)
EBV
Travel-related infections
Dengue
Ross river
Scabies
Autoimmune
IBD
Celiac
Psoriasis
SLE
Allergic
Allergic dermatitis
Contact dermatitis
Urticaria
Purpuric
HSP
HUS
ITP
Bleeding disorders
Malignancy
Infective
D: Do you have any fever and chills?
URTI/LRTI
D: Do you have a runny nose?
D: Any sore throat?
D: Any cough?
EBV
D: Did your rash appear after taking antibiotics?
GI Group virus
D: Do you have any nausea and vomiting?
D: Do you have any diarrhea?
Meningococcemia/Meningitis
D: Are you feeling drowsy/tired?
D: Do you have any headache?
D: Do you have any sore neck?
Travel-related infections
D: Have you had any travel lately?
D: Any contact with sick people?
D: Any contact with animals?
D: Are your immunizations up to date?
Autoimmune
Celiac
D: Have you had long-term diarrhea?
D: Do you have any greasy stools?
IBD
D: Do you have any blood in the stools?
D: Do you have any blurring of vision?
D: Any mouth ulcers?
D: Do you have any joint pains?
D: Any family history of any arthritis or autoimmune conditions?
Allergic
Allergic Dermatitis
D: Any family history of atopic conditions like asthma, eczema or hay fever?
D: Any new food that you’ve taken?
D: Any new medicine that you’ve taken?
D: Any insect bites?
Anaphylaxis
D: Do you have any shortness of breath, wheezing, swelling in your lips?
Contact Dermatitis
D: Any contact with chemicals at work?
D: Any new creams, lotions, body wash, detergents?
Purpuric
Henoch Schonlein Purpura/ITP
D: Any recent flu-like symptoms?
D: Do you have any abdominal pain?
D: Any joint pains?
D: Have you noticed any blood in your urine?
Hemolytic Uremic Syndrome
D: Do you have any diarrhea?
Bleeding Disorders
D: Any family history of bleeding disorders?
D: Any history of easy-bruising?
Malignancy
D: Any loss of weight, loss of appetite, lumps and bumps around the body?
D: Any tiredness, night sweats?
Your next patient is a 20 year old lady who has presented to your general practice complaining of a rash on her legs.
Tasks:
Take history
Ask PE from examiner
Explain your diagnosis and differentials to the patient
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you?
Address concern
D: I understand that this can be distressing. But let me just ask you a few questions, examine you, we’ll find the cause together and we’ll make the best management plan for you.
Explore the Rash
Timing
D: Since when did you first notice the rash?
D: Is it the first time that you’ve had this rash?
D: Is the rash spreading or getting worse?
Alleviating and aggravating factors
D: Is there anything that makes it better or worse?
Character
*If a photo is given, then perfect. But still ask the character in history
See
D: Where is the site of the rash?
D: What color is the rash?
D: Is it a raised rash or a flat discoloration?
D: Do you see any discharge?
D: Are there any blisters?
Feel
D: Is it warm to touch?
D: is it painful to touch?
D: Is the rash itchy?
D: Do you feel a rough surface on the rash?
Rule Out Red Flags
Malignancy
D: Any loss of weight, loss of appetite, lumps and bumps around the body?
D: Any tiredness, night sweats?
Meningococcemia
D: Are you feeling drowsy/tired?
D: Do you have any headache?
D: Do you have any sore neck?
D: Do you have any fever/chills?
D: Are you light-sensitive?
Rule Out Other Differentials
HSP
D: Do you have any abdominal pain?
D: Any joint pains?
D: Have you noticed any blood in your urine?
ITP
D: Any recent flu-like symptoms?
D: Did you take any antibiotics?
D: Have you had any nose bleeds, or gum bleeding?
D: Have you had any dizziness, headaches? (brain bleeding)
Bleeding disorders
D: Any family history of bleeding disorders?
D: Any history of easy-bruising?
Hemolytic Uremic Syndrome
D: Do you have any diarrhea?
Chronic Liver Disease
D: Have you had any yellowish discoloration of your skin?
D: Any itchiness of your skin?
D: Have you noticed any pale stools?
D: Have you noticed any dark urine?
Past Medical/Family History
D: Any past medical history or family history of other diseases?
History Findings:
Flu-like symptoms last week
No other symptoms
Physical Examination from Examiner
General appearance
D: Do I have any cachexia?
D: Any scratch marks?
D: What is the level of consciousness?
D: Any pallor?
Vital Signs (if you have not asked it in HD)
*the examiner will usually say it’s the same
Rash
D: Is my rash palpable?
D: Is it non-blanching?
D: Is it tender?
Lymph nodes
D: I would like to do a full examination of the lymph nodes, do I have any lymphadenopathy or enlarged lymph nodes?
ENT
D: Is there any tonsillar enlargement?
D: Is there any redness?
D: Do I have any petechiae in the oral/buccal mucosa?
D: Is there any neck stiffness?
CVS
D: Is S1/S2 normal?
D: Are there any murmurs/ abnormal sounds?
Respiratory
D: Is air entry equal?
D: Any added sounds?
Abdominal
D: Any hepatosplenomegaly?
D: Is there any tenderness?
Joint Exam
D: I would like to do a full joint examination, are there any tender, swollen joints?
Urine dipstick
D: Is there hematuria in the dipstick?
PE Findings (Version 1)
Temp normal
No LAD
No splenomegaly
Diagnosis
Most likely you have a condition called immune-mediated thrombocytopenic purpura (ITP). In this condition, your immune system is triggered by a viral infection and it starts attacking the clotting cells in your blood which are called platelets.
The reasons I came to this are: looking at the type of rash you have, it is purpuric; it is on both of your legs, which is a typical site for ITP; and you had a recent viral infection; this is a diagnosis of exclusion, as your PE is normal and I did not find any findings for other conditions, I am concluding that you may have ITP.
I was also thinking about malignancies in your blood like leukemia, hemolytic uremic syndrome, HSP and vasculitis.
I was thinking about infections like meningococcemia, viral infections.
I was thinking about bleeding disorders, chronic liver disease, or if you are on medication like blood thinners.
PE Findings (Version 2)
Temp normal
2 enlarged cervical lymph nodes, rubbery
No splenomegaly
No other features
Diagnosis
In your case, I am concerned about the possibility of having a malignancy called leukemia or lymphoma. These are cancers in the blood cells and your lymph nodes.
The reasons I came to this are: the type of rash that you have, it is purpuric; on your examination, I found 2 large glands in your neck.
I was also thinking about other conditions like ITP, HSP and vasculitis, hemolytic uremic syndrome.
I was thinking about infections like meningococcemia, viral infections.
I was thinking about bleeding disorders, chronic liver disease, or if you are on medication like blood thinners.
Your next patient is a 25 year old lady who has presented to your general practice complaining of a rash which started yesterday.
Tasks:
Take history from the patient
Explain your diagnosis and differentials to the patient
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you?
Address concern
D: I understand that this can be distressing. But is it okay if I ask you a few questions, examine you, we’ll find the cause together and we’ll make the best management plan for you.
Explore the Rash
Timing
D: Since when did you first notice the rash?
D: Is it on/off or is it constantly there?
D: Is it the first time that you’ve had this rash?
D: Is the rash spreading or getting worse?
Alleviating and aggravating factors
D: Is there anything that makes it better or worse?
D: Have you noticed that hot showers make it worse?
D: What were you doing immediately before the rash started?
Character
*If a photo is given, then perfect. But still ask the character in history
See
D: Where is the site of the rash?
D: What color is the rash?
D: Is it a raised rash or a flat discoloration?
D: Do you see any discharge?
D: Are there any blisters?
Feel
D: Is it warm to touch?
D: is it painful to touch?
D: Is the rash itchy?
D: Do you feel a rough surface on the rash?
Explore Differentials
Anaphylaxis
D: Do you have any shortness of breath?
D: Do you have any wheezing?
D: Any swelling in your lips or tongue?
D: Any dizziness?
Triggers
D: Any insect bites that you’ve had?
D: Any new food that you’ve taken? (nuts, seafood, spices)
D: Any new medications that you’ve taken?
D: Any new creams, body wash, lotions that you’ve used?
D: Any contact with animals or plants?
D: Any pressure in your skin that triggers it?
D: Does exposure to cold trigger it?
D: Any recent flu-like symptoms or viral infections?
R: Yes, I’ve had a runny nose days before
D: Did you take any antibiotics or any medications for it?
Differentials
SLE
D: Any fever?
D: Any joint pains?
D: Have you ever had any color changes in your fingers on exposure to cold weather? (Raynaud phenomenon)
Malignancy
D: Any loss of weight, loss of appetite, lumps and bumps around the body?
D: Any tiredness, night sweats?
Erythema Multiforme
D: Any mouth ulcers?
Good Closure
D: Do you smoke?
D: Do you drink alcohol?
D: Do you have any known allergies?
D: Do you have any past medical or family history of eczema, asthma or hay fever?
Diagnosis
Most likely you have a condition called Urticaria, also known as Hives. This is an allergic reaction in your skin which causes an extremely itchy rash and it can be triggered by food, medicine, insect bites, infections, exposure to cold, exercise. But in your case, I believe that it has been triggered by your recent viral infection.
The reasons I came to this are: I can see that it’s a raised rash with clear borders, it’s extremely itchy; and because you had a recent viral infection which can be a trigger.
I made sure that you don’t have a severe allergic reaction called anaphylaxis.
I was also thinking about SLE, erythema multiforme, malignancy like leukemia, lymphoma, vasculitis like HSP.
I was thinking about contact dermatitis, allergic dermatitis, drug reactions/eruptions, viral exanthems.
Version 2:
Your next patient is a 25 year old lady who has had a skin rash for the past 3 hours. The rash is itchy. She has had a recent upper respiratory tract infection. She has not used any antibiotics, no recent new food or cosmetics. Patient is stable and has no swelling in the lips and no breathing difficulty.
Tasks:
Explain the diagnosis, cause of the rash and the mechanism to the patient
Explain your differentials
Explain your management plan
Open-ended Question
D: Hi, my name is ____. May I know your name?
D: I’ll just be explaining the type of rash that you have and it’s management. Is that okay with you?
Address Concern if she has a concern
Diagnosis
Most likely you have a condition called Urticaria, also known as Hives. This is an allergic reaction in your skin which causes an extremely itchy rash and it can be triggered by food, medicine, insect bites, infections, exposure to cold, exercise. But in your case, it has been triggered by your recent respiratory tract infection and the flu that you had.
In this condition, the trigger which is your case is a viral infection, activates/triggers part of your immune system called mast cells. This cell releases a chemical called histamine. This chemical dilates the blood tubes creating inflammation, itchiness and a red rash.
Differentials
I made sure that you don’t have a severe allergic reaction called anaphylaxis.
I was also thinking about SLE, erythema multiforme, malignancy like leukemia, lymphoma, vasculitis like HSP.
I was thinking about contact dermatitis, allergic dermatitis, drug reactions/eruptions, viral exanthems.
Management
Pharmacological
I will give you an antihistamine, like fexofenadine/cetirizine, loratadine. If this doesn’t help, we can try a single dose of steroids like oral prednisolone, although it’s our last resort because of the side effects.
Non-pharmacological
I want you to avoid heat, hot showers. Avoid spicy food. Avoid other medications like anti-inflammatory pain killers.
A cold compress will help.
Support
I can give you reading materials from ASCIA (Australian society of immunology and allergies)
If your rash gets worse, if you start getting dizzy, if you have shortness of breath, swelling in your lips, call the ambulance and go the ED.
Your next patient is a 25 year old lady who has presented to you complaining of a rash.
Tasks:
Take history
Explain diagnosis and differentials to the patient
Hemodynamic Stability
Examiner: Are there any questions?
D: May I know the vital signs of the patient? The BP, PR, RR, Temp.
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you?
Address concern
D: I understand that this can be distressing. But is it okay if I ask you a few questions, examine you, we’ll find the cause together and we’ll make the best management plan for you.
Explore the Rash
Timing
D: Since when did you first notice the rash?
D: Is it on/off or is it constantly there?
D: Is it the first time that you’ve had this rash?
D: Is the rash spreading or getting worse?
Alleviating and aggravating factors
D: Is there anything that makes it better or worse?
D: Have you noticed that hot showers make it worse?
D: Is the itchiness worse at night?
D: What were you doing immediately before the rash started?
Character
*If a photo is given, then perfect. But still ask the character in history
See
D: Where is the site of the rash?
D: What color is the rash?
D: Is it a raised rash or a flat discoloration?
D: Do you see any discharge?
D: Are there any blisters?
Feel
D: Is it warm to touch?
D: is it painful to touch?
D: Is the rash itchy?
D: Do you feel a rough surface on the rash?
Explore Differentials
Infective
D: Do you have any fever and chills?
URTI/LRTI
D: Do you have a runny nose?
D: Any sore throat?
D: Any cough?
EBV
D: Did your rash appear after taking antibiotics?
GI Group virus
D: Do you have any nausea and vomiting?
D: Do you have any diarrhea?
Meningococcemia/Meningitis
D: Are you feeling drowsy/tired?
D: Do you have any headache?
D: Do you have any sore neck?
Travel-related infections
D: Have you had any travel lately?
D: Any contact with sick people?
D: Any contact with animals?
D: Are your immunizations up to date?
Autoimmune
Celiac
D: Have you had long-term diarrhea?
D: Do you have any greasy stools?
IBD
D: Do you have any blood in the stools?
D: Do you have any blurring of vision?
D: Any mouth ulcers?
D: Do you have any joint pains?
D: Any family history of any arthritis or autoimmune conditions?
Allergic
Allergic Dermatitis
D: Any family history of atopic conditions like asthma, eczema or hay fever?
D: Any new food that you’ve taken?
D: Any new medicine that you’ve taken?
D: Any insect bites?
Anaphylaxis
D: Do you have any shortness of breath, wheezing, swelling in your lips?
Contact Dermatitis
D: Any contact with chemicals at work?
D: Any new creams, lotions, body wash, detergents?
Purpuric
Henoch Schonlein Purpura/ITP
D: Any recent flu-like symptoms?
D: Do you have any abdominal pain?
D: Any joint pains?
D: Have you noticed any blood in your urine?
Hemolytic Uremic Syndrome
D: Do you have any diarrhea?
Bleeding Disorders
D: Any family history of bleeding disorders?
D: Any history of easy-bruising?
Malignancy
D: Any loss of weight, loss of appetite, lumps and bumps around the body?
D: Any tiredness, night sweats?
Diagnosis
Version 1: Urticaria
Itchy rash
All over chest
Red
Had an URTI
Heat makes it worse
Version 2: Scabies
Rash on hands
Between fingers
Worse at night
Worse on hot showers
Recent travel, similar symptoms with other family members
Human to human transfer/human to linens
Most likely you have a condition called Scabies. This is a small mite/bug that can infect the skin and cause itchiness and a rash.
Management:
Permethrin cream: apply it jawline down, in all creases of the body, leave it overnight and repeat it in 1 week
Side effect: for the first 3 days, the itchiness can get worse
Oral ivermectin
Do it on all household members
Wash clothes, bed linens in warm water
Antihistamine for the itchiness
Your next patient is a 17 year old boy who has presented to you concerned of acne which has been present for 1 year. He was initially on antibiotics but has recently been changed to isotretinoin.
Tasks:
Take history from the patient
Explain the impact and side effects of retinoids
Open ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you?
Address Concern
D: I am sorry to hear that you have been going through this. I understand how distressing this can be. Is it okay if I ask you a few questions? Let me assure you that everything that we discuss will be kept confidential.
Explore Acne
Timing
D: How long have you had this acne?
D: Is it on/off or continuously there?
D: Is it getting worse?
Character
D: Is it only on the face, or is it also on your back and body?
D: Are they red bumps, whiteheads or blackheads?
D: Have you had any scarring on your face?
D: Is there anything that makes it better or worse?
D: How is this affecting your life?
Treatment
D: What treatment have you tried so far?
D: Did they help?
D: Are you compliant with the medications?
D: Have you noticed any dry skin, dry eyes, tiredness?
Risk Factors
D: Do you have any exposure to hot and humid environments?
D: Are you working?
D: Do you go swimming frequently?
D: Any other medications that you are using?
D: Any creams, sunscreen that you use?
D: If female:
D: Have you noticed any irregular hair growth in your body?
D: Do you have irregular periods?
D: Any recent weight gain?
Psychosocial Assessment
D: How is your mood?
D: How is your sleep?
D: Do you have problems falling asleep or do you wake up in the middle of the night?
D: How is your appetite?
D: Have you ever thought of harming yourself or others?
Social History
D: Who do you live with?
D: How’s your relationship with them?
D: Do you have enough support at home?
D: Any significant stress at home?
D: How are things at school?
D: Any bullying or any significant stress in school?
D: Are you still enjoying the activities that you used to enjoy before?
Past Medical/Family History
D: Any past medical or family history of any diseases?
Counselling
What is Acne?
D: You have a condition called Acne Vulgaris. Acne happens in the oil-secreting glands in the skin. Initially, you have an increase in the oil production and then these glands become blocked and this leads to overgrowth of bacteria and inflammation.
Side effects of Retinoid
D: The medication that you are using, the oral isotretinoin, this reduces the oil secretion and prevents the blocking of the gland.
D: Minor side effects of this is dry skin, dry lips, dry eyes, dry nose. You may have nosebleeds, tiredness, muscle aches, body aches. You can be sensitive to sunlight so use sunscreen when you go out.
D: Major side effects are it can affect your liver and increase your liver enzymes, and it increases the fats in your blood. If female, please do not get pregnant while you’re on this medication as it is a potent teratogen.
Psychosocial Impact
D: I do understand that you are having a hard time at school, but we are here to support you. I can send you to a psychologist for cognitive behavior therapy where they can talk to you, teach you techniques to cope with your stress, teach you some relaxation techniques.
D: If ever you have thoughts of harming yourself, you can come back to me, go to the emergency department, or you can use this hotline to get some help.
Management
Topical (mild)
Benzoyl peroxide
Comedonal: adapalene
Inflammatory: clindamycin
Antibiotics
Male and females: Doxycycline x 6 weeks
Females: COCPs with cyproterone
Spironolactone
Severe version
Oral isotretinoin
