Frailty- 4 Flashcards
Chancre
- Primary syphilis
- Treponema pallidum
- Small firm red papule which ulcerates to forma painless ulcer
Secondary syphilis
- Widespread rash and flu like symptoms
- Rough, red, or reddish brown macules on palms and soles
- Wart like sores in mouth or genital area
Tertiary syphilis
- Can affect multiple organ systems e.g. neurosyphilis
- Syphillis known as ‘The Great mimic’, as can imitate many other diseases
Viral exanthem
- Exanthem: widespread rash accompanied by systemic symptoms
- Common in childhood i.e. chicken pox, measles, rubella, parvovirus B19
- Drug reaction is an important differential
Herpes simplex virus (HSV)
- Type 1 – usually orofacial
- Type 2 – usually anogenital
- After primary infection, recurrent infections can occur
- Recurrent Type 1 HSV occurs most frequently on face esp lips – herpes simplex labialis
- Dx – viral swabs for PCR
- Rx – mild cases do not required Rx, severe cases may require acyclovir
Eczema herpeticum
- Dissemination Herpes simplex virus (HSV) infection
- Fever, clusters of painful, itchy blisters and punched out erosions
- Usually a complication of atopic eczema
- Complicated by secondary bacterial infection
- Antiviral treatment, IV antivirals required if patient unwell or immunocompromised
Herpes zoster (shingles)
- Localised, painful blistering rash
- Reactivation of Varicella zoster virus (VZV).
- Dermatomal distribution
- More common in adults esp older people and immunosuppressed
- After primary infection, VZV stays dormant in dorsal root ganglia nerve cells in spine for years before reactivation. It then migrates down sensory nerves to skin causing zoster.
*Pain usually first symptom, within 1-3 days blistering rash appears in painful area of skin - Cx – post herpetic neuralgia
- Treatment – Oral antiviral – reduce pain and duration of symptoms if started within 1-3 days
Viral wart
- Caused by Human papilloma virus (HPV)
- Common in children and in immunocompromised
- Keratotic surface
- Tiny dots can be seen – intracorneal haemorrhage (absent in callocities)
- Common on backs of fingers and toes
- Treatment-salicylic acid
Fungal infections
- Superficial (common), Deep (rare, tropical)
- Superficial: Dermatophytes (Tinea), Candida, yeasts
Tinea corporis
- Dermatophyte skin infection
- Prefix tinea + body site
- Tinea pedis (foot), Tinea capitis (scalp),
Onychomycosis
- Fungal infection of nails
- Can be caused by dermatophytes, yeasts, moulds
- Commonly due to Tricophyton rubrum
- Ix-nail clippings for microscopy and culture
- Rx- topical antifungals if limited, usually needs oral
Candidial intertrigo
- Intertrigo describes the rash in body folds
- Candida often affects intertriginous area typically inflammatory
- Pink to bright red moist patches +/- satellite papules and pustules
Scabies
- Sarcoptes scabiei
- Parasitic mite that burrows under skin
- Causes an intensely itchy rash
- Worse at night disturbing sleep
- Burrows – grey irregular tracks
- Look in webspaces of fingers, palms and flexor surfaces wrists
- Also found on elbows, nipples, buttocks, penis, soles
Scabies- treatment
- 5% permethrin cream applied all over skin and left on for 8-10 hours
- Oral ivermectin 200mcg/kg stat
- Treatment repeated a week later to kill newly hatched mites
- Identify and treat contacts
- Itching may persist up to 6 weeks, if it persists after 6 weeks consider if it has been applied correctly or if it’s the right diagnosis
Emollients- creams (dermatology treatment)
- Pros; easy to rub in, doesn’t rub off on clothes, will rub into weepy skin
- Cons: not the best moisturisers, contains preservatives (can cause contact allergy)
Emollients- lotions (dermatology treatment)
- Mainly water based
- Cons: poor moisturisers
- Pros: easy to apply to hairy areas (scalp)
Emollients- Ointments (dermatology treatment)
- Greasy, form waterproof barrier
- Pros: better moisturisers than cream, better for eczema/dry skin
- Cons: don’t rub in as easily as creams, can be more unwieldy, can make clothes/sheets messy
Topical steroids
- Range of potencies
- Essential for all but the mildest eczema: effective and safe with appropriate use
- Toxicity: atrophy, acne, rarely adrenal suppression
Topical steroid; side effects
- Skin thinning (atrophy) usually only seen with strong steroids, prolonged periods, at certain body sites (face, skin creases)
- Acne
Rules of steroid use
- Do not use a strong steroid if a weaker steroid is effective
- Stronger steroids in short blasts are safe
- Use ointment base rather than creams
Treatment for actinic keratosis
- liquid nitrogen cryotherapy
- 5-flurouricil (Efudix)
Treatment with ultraviolet radiation
- Psoriasis: UVB and PUVA
- Atopic eczema: UVB
- Cutaneous T cell lymphoma: PUVA
UV protection
- Appropriate clothing
- Sunscreens
- SPF (UVB)
- Star rating (UVA)
Hyperactive and Hypoactive delirium
Hyperactive delirium: Agitation, Delusions, Hallucinations, Wandering, Aggression
Hypoactive delirium: Lethargy, Slowness with everyday tasks, Excessive sleeping, Inattention
Causes of Delirium
CHIMPS PHONES
* Constipation
* Hypoxia
* Infection
* Metabolic disturbance
* Pain
* Sleeplessness
* Prescriptions
* Hypothermia/pyrexia
* Organ dysfunction (hepatic or renal impairment)
* Nutrition
* Environmental changes
* Drugs (over the counter, illicit, alcohol and smoking)
Malignant melanoma
Melanoma develops from melanocytes which start to grow and divide more quickly. Can metastisise
4 main types of skin melanomas
- Superficial spreading melanoma
- Nodular melanoma
- Lentigo maligna melanoma
- Acral lentiginous melanoma
Can develop from new mole or old mole
Symptoms of a melanoma: ABCDE
- Asymmetry- irregular in shape
- Border- uneven
- Colour- more than one colour such as brown, black, red, pink, white or blue tint
- Diameter- usually more than 6mm wide, tend to get bigger
- Evolving- change in size, shape and colour
Risk factors for melanoma
- Age
- Ultraviolet light exposure- out in the sun
- Fair skin
- Having lots of moles or a large birth mark
- Family history of melanoma
- Reduced immunity
Investigations and treatment melanomas
Investigations
* Excision biopsy: to test the mole
* A sentinel lymph node biopsy- to the lymph node nearest the melanoma
* CT scan- to check for metastasise
Treatment- surgery
Diagnosis and treatment of basal cell carcinoma
Diagnosed through a skin biopsy
Treatment
* Surgery- BCC is removed as well as some clear skin around it, the skin is closed with a few stitches but sometimes a graft is needed
* Mohs micrographic surgery- for more complex BCC’s presenting at difficult sites or recurrent BCC’s. You examine the skin under a microscope to see if all the BCC has been removed
* Radiotherapy: shinning x-rays onto the BCC
Superficial BCC treatment
- Curettage and cautery- the skin is numbed with local anaesthetic and the BCC is scrapped away (curettage) and the skin is sealed by heat (cautery)
- Cryotherapy- with liquid nitrogen
- Creams: 5-fluorouracil (5-FU) and imiquimod
- Photodynamic therapy: a cream is applied to BCC, it is taken up by the cells that are then destroyed when exposed to a specific wavelength of light
Appearance of squamous cell carcinoma
Can appear as scaly red patches, open sores, rough, thickened or wart-like skin, or raised growths with a central depression. At times, SCCs may crust over, itch or bleed. The lesions most commonly arise in sun-exposed areas of the body.
Risk factors for squamous cell carcinoma
- Unprotected exposure to ultraviolet (UV) radiation from the sun or tanning beds.
- Weakened immune system due to illness or certain immunosuppressive medications.
- History of skin cancer including basal cell carcinoma (BCC).
- Age over 50: Most SCCs appear in people over age 50.
- Fair skin: People with fair skin are at an increased risk for SCC.
- Gender: Men are more likely to develop SCC.
- Sun-sensitive conditions including xeroderma pigmentosum.
- Chronic infections and skin inflammation from burns, scars and other conditions.
- Skin precancers including actinic keratosis.
- History of human papilloma virus (HPV)
Treatment for SCC
- Excisional surgery- removes tumour and safety margin of normal skin
- Mohs surgery- repeats surgery till all cancerous cells are removed, looks at the biopsy under a microscope to see if any cancerous cells remain
- Cryosurgery- apply liquid nitrogen to freeze the tumour
- Curettage and electrodesiccation (electrosurgery)
- Laser surgery
- Radiation
- Photodynamic therapy (PDT)
- Topical medications
- Immunotherapy
Difference between replacement, resuscitation and redistribution of fluid
- Replacement: deterioration of patient in hospital
- Resuscitation: used when the patient is haemodynamically unstable, acutely unwell
- Redistribution: when fluid is in the wrong compartment i.e. heart failure
Giving potassium
Do not give potassium at rates >10mmol/hr
Do not give pottassium at concentrations >40mmol/he
In what types of fluid can you add extra potassium
- In 0.9% sodium chloride
- In 5% glucose
Types of fluid bolus
Fluid bolus: 500ml
Cautious bolus: 250- if the patient is frail or has heart failure
How much glucose do you need to give
You need to give glucose to cover 16-18% of BMR so metabolism does not become completely catabolic
How do you calculate the rate fluid is given
You calculate how much is meant to be given over 24 hours then you divide by 24 to get the hourly rate
Normal fluid regimen for a 70kg man
1L Hartman solution over 10 hours
1L 5% glucose over 10 hours with 40mmol of added K+
How long do you give fluid over and how big are the bags
Over 8, 10 or 12 hours. Give over a longer time if they have heart failure
The bags are 250ml, 500ml and 1L
Maximum amount of fluid bolus stat you can give
4 (2L)
How much glucose do you give over 24 hours
50-100 grams
What drugs should be stopped if the patient has an AKI
Ramipril and Metformin
What drugs can cause oral candidiasis
Amoxicillin, Fluticasone and Prednisolone
Causes of eczema
- Stress
- Precipitants of barrier defect i.e. winter, frequent washing, soaps
- Irritant factors i.e. soaps, dusty environment, cosmetics
Causes of psoriasis
- Stress
- Obesity/ smoking/ EtOH
- Streptococcus i.e. guttate
- Trauma i.e. koebnerisation
- Iatrogenic i.e. beta blockers, lithium, anti-malarials, NSAID’s, steroid withdrawal
Topical treatment of eczema
- Emollients: lotions vs creams vs ointments
- Topical steroids
- Calcineurin inhibitors i.e. tacrolimus
Topical treatment of psoriasis
- Emollients: lotions vs creams vs ointments
- Topical steroids
- Calcineurin inhibitors i.e. tacrolimus
- Vitamin D analogues i.e. calcipotriol
- Tar based preparation
Photopherapy: eczema and psoriasis
Eczema: UVB (x2 week for 8-12 weeks)
Psoriasis: UVB (x3/week for 8-12 weeks) and PUVA (x2/week for 12 weeks)
UVB courses can only be once a year whilst PUVA are 5-6 a lifetime
Medical treatment for eczema
- Methotrexate: immunosuppressant, teratogenic, liver fibrosis
- Ciclosporin: immunosuppressant, duration of use limited by significant risk of HTN and renal failure
- Azathioprine: immunosuppressant, requires TPMT enzyme measuring prior to use because if its deficient, azathioprine will accumulate in toxic levels
Medical treatment for psoriasis
- Methotrexate: immunosuppressant, teratogenic, liver fibrosis
- Ciclosporin: immunosuppressant, duration of use limited by significant risk of HTN and renal failure
- Acitretin: vitamin A analogue, teratogenic, associated drying of the skin and thinning of the hair, requires monitoring of LFT’s and lipid profile
Biological treatment for eczema and psoriasis
Eczema: Anti IL-4
Psoriasis: Anti TNF, Anti IL12-23, Anti IL-17
