General Practice Flashcards
What is a macule?
A flat area of colour change, <1.5cm in diameter
What is a papule?
An elevated lesion, <0.5cm in diameter, may appear as part of a papular rash
What is a vesicle?
Elevated lesion containing fluid <0.5cm in diameter
What is a Bulla?
Elevated lesion containing fluid >0.5cm in diameter
What is a nodule?
Palpable solid lesion 0.5-2cm in diameter
What is a pustule?
Elevated lesion which contains pus <1cm in diameter
What is a plaque?
A palpable but flat lesion >0.5cm diameter, most are elevated but may be a thickened area without being visible raised above the skin surface
What is a discoid lesion?
Round (coin-shaped) lesion
What is an annular lesion?
Lesions grouped together to form a circle
What is lichenification?
Accentuation of skin markings associated with thickening of epidermis caused by scratching or rubbing
What are excoriations?
Linear crusts and erosions due to scratching
What are petechiae?
Extravasation of blood into the skin, non-blanching, <0.2cm in diameter
What are purpura?
Extravasation of blood into the skin, non-blanching, 0.2-1cm
What is ecchymoses?
Extravasation of blood into the skin, non-blanching, >1cm in diameter
What is urticaria?
Elevated lesions formed by local dermal oedema
What is pyogenic granuloma?
A vascular lesion that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma, or hormonal factors
Often found to involve the gums, the skin and nasal septum, and has also been found far from the head such as in the thigh
May be seen at any age, and are more common in females than males
In pregnant women, lesions may occur in the first trimester with an increasing incidence up until the seventh month, and are often seen on the gums.
Describe chickenpox
Predominantly childhood viral infection characterised by a prodrome of general malaise followed by the appearance of rapidly spreading macules → vesicles → pustules → crust
Intensely itchy and contagious (up to 90% of susceptible exposed people will develop condition)
Crusts usually form after 5 days and drop off within 1-2 weeks
Considered no longer infectious once all lesions have crusted
Complications include pneumonia, hepatitis and encephalitis and are more common in adults
Describe urticaria
Characterised by weals (hives) or angioedema (swellings, in 10%) or both (in 40%)
Affects 20% of people at some point in their lifetime
There are several types of urticaria - can be acute or chronic
The name urticaria is derived from the common European stinging nettle Urtica dioica
Weals
A weal (or wheal) is a superficial skin-coloured or pale skin swelling, usually surrounded by erythema (redness) that lasts anything from a few minutes to 24 hours
Usually very itchy and may have a burning sensation
Due to release of chemical mediators from tissue mast cells and circulating basophils
These chemical mediators include histamine, platelet-activating factor and cytokines
The mediators activate sensory nerves and cause dilation of blood vessels and leakage of fluid into surrounding tissues
Angioedema
Deeper swelling within the skin or mucous membranes and can be skin-coloured or red
It resolves within 72 hours and may be itchy or painful but is often asymptomatic
Bradykinin release causes angioedema
Aetiology is unknown - but the immune, arachidonic acid and coagulation systems are involved, and genetic mutations are under investigation
Management – avoidance of triggers (including certain medications – eg nsaids), oral anti histamines
Describe molluscum contagiosum?
A viral skin infection caused by molluscum contagiosum virus (MCV), a DNA pox virus, specifically a member of the Poxviridae family
It occurs most often in children
The incubation period is usually between 2-8 weeks
Can last for up to 18 months in healthy individuals (longer in immunocompromised)
Describe shingles
Varicella Zoster Virus - Shingles
Primary infection usually occurs in childhood, producing chickenpox (varicella) although it can be subclinical
After this the virus lies dormant in the sensory nervous system in the geniculate, trigeminal or dorsal root ganglia
It may lie dormant for many years or many decades, kept in check by the immune system before flaring up in a single dermatome segment
The disease can be divided into the pre-eruptive phase (dermatomal burning/itching/paraesthesia and general malaise) and acute eruptive phase (skin lesions appear and some have neuropathic pain)
A few have severe pain without any eruption
Finally, the chronic phase - postherpetic neuralgia (PHN) persistent or recurring pain lasting 30 days or more after the acute infection
Describe scabies
Itchy rash caused by a parasitic mite (sarcoptes scabiei) that burrows in the skin surface
Most common in children, young adults, elderly (especially In institutions)
Treatment – hot wash bedding, topical 5% permethrin cream (head – toe)
Describe rosacea
Papules pustules, surface telangiectasia, flushing, associated eye signs (dry eyes, blepharitis)
More common in females age 30-60, those with fair skin, hx of excessive sun exposure
Often aggravated by sun exposure, spicy foods, hot drinks
Treatments include avoidance of aggravating factors, topical metronidazole and azelaic acid, oral tetracycline’s – AVOID STERIODS
Describe guttate psoriasis
Small drop-like, salmon-pink papules
Primarily on the trunk and the proximal extremities (but it may have a more generalised distribution)
A history of an upper respiratory infection secondary to group A beta haemolytic streptococci often precedes the eruption by 2-3 weeks
Guttate psoriasis may be chronic and unrelated to streptococcal infection
Usually resolves without tx but can take months – topical emollient can help
Describe venous eczema
Eczema to lower legs associated with venous stasis. RFs - overweight, immobility, leg swelling, varicose veins, previous clots in the leg (venous thrombosis) and previous cellulitis
Treatment – emollients, topical steroids, compression bandaging
Describe impetigo
Crusted lesions
Common in children
Bacterial infection - staphylococcus aureus
Treatment is antibiotics – oral for facial/spreading lesions – topical if mild/localised, hygiene measures to avoid spread
Describe plaque psoriasis
Common inflammatory skin disease affecting 2% of the population, M+F, can appear at any age, tends to come and go unpredictably (triggers include stress and concurrent illness)
Plaques are usually minimally itchy and can have silver scaling
Treatment (mild-moderate) – emollients, topical steroids, vitamin d analogues, tar, dithranol (for stubborn plaques)
Psoriasis area and severity index useful in assessing severity
Describe acne vulgaris
Comedones (blackheads and whiteheads) and pustules
Treatment
Mild/moderate; topical retinoid, azelaic acid, topical antibiotics (usually in combination form),
Moderate/severe; oral ab (tetracycline’s), oral Isotretinoin, certain oral contraceptive pills (an option if also needing contraception)
Describe atopic eczema
Common skin condition due to skin inflammation
Onset is usually in childhood - 1 in every 5 children in the UK is affected by eczema at some stage
Atopic associations - asthma, eczema and hay-fever and food allergy
Management – emollient and topical steroids, avoid triggers, oral anti histamines
What are the features of BCC?
Also known as ‘rodent ulcers’
Most common skin malignancy - rare in people of black ethnicity
Malignant tumour of epidermal keratinocytes
Normally affects middle aged-older individuals
RFs - pale skin type, UV exposure, immunosuppression, previous skin cancer, inherited syndromes
Common sites include face, arms, legs (sun exposed areas)
How are BCCs classified?
Nodular most common on face – beware superficial in younger adults
Sclerosing is more commonly known as infiltrative or morphoeic
Most BCCs in black people are pigmented (or contain spots of dark pigment in the rolled edges)
What is the management of BCCs?
Surgical excision is usual treatment of choice - allows histological examination of the tumour and margins
Radiotherapy when surgery is inappropriate
Topical treatment (imiquimod cream) or photodynamic therapy for superficial subtype
Imiquimod is immune response modifier – 5 fluorourical is topical cytotoxic
Prognosis is excellent especially for smaller lesions - locally invasive if untreated but metastatic spread is extremely rare
High risk of developing further lesions (~50% ppl develop further lesion within 5 years) and affected individuals at higher risk of developing other forms of skin cancer
What are the features of SCCs?
Malignancy arising from epidermal keratinocytes
Second most common skin malignancy in all races - most common in black people
Usually grow over weeks – months, can be painful, often ulcerated
Risk factors include UV sun exposure, (HPV infection in Black people), immunosuppression and smoking (particularly SCC of lips)
Most SCCs are found on sun-exposed sites, particularly the face, lips, ears, hands, forearms, lower legs & anogenital region in Black people (often associated with keloid or HPV)
They vary in diameter from a few mm to several cm
What is the management of SCC?
Surgical excision - treatment of choice
Radiotherapy - for large, non-resectable tumours
Early stage tumours >90% 5 year survival
Approximately 10% rate of metastasis overall
Risk of recurrence greatest for tumours >20mm diameter or >2mm thickness
Prevention - avoidance from UV radiation
Describe actinic keratoses
Solar keratosis
Develop in areas of sun damage - face, back of hands, bald scalps and usually affects older individuals
Rarely seen in black people
Premalignant - small minority (<1%) may eventually progress to SCC
Treatment options include cryotherapy and curettage for individual lesions or topical 5-fluorouracil for field treatment
Describe the features of Bowen’s disease
Slowly enlarging, localised area of neoplastic cells confined to epidermis
Pink or lightly pigmented scaly plaques, up to several centimetres in size
Commonly found on the lower leg or trunk, more often in women
Transformation into invasive SCC is infrequent
Bowen’s disease may resemble discoid eczema, psoriasis or superficial basal cell carcinoma
Treated by cryotherapy, curettage, topical 5-fluorouracil or imiquimod, or photodynamic therapy
Describe the features of malignant melanoma
An invasive malignant tumour of the epidermal melanocytes, which has the potential to metastasise
RFs - ↑age, UV exposure, previous melanoma, previous non-melanoma skin cancer, many melanocytic naevi (moles) especially if atypical naevi, strong FH of melanoma (2+ first degree relatives affected), fair skin
Types of malignant melanoma
Superficial spreading - common in the lower limbs, young and middle-aged adults, related to intermittent high intensity UV exposure
Nodular melanoma - common on the trunk, young and middle aged adults, related to intermittent high-intensity UV exposure
Mucosal and ocular melanoma - arising on the lips, eyelids, vulva, penis, anus and on sclera
Lentigo maligna melanoma - common on the face, elderly population, related to long-term cumulative UV exposure
Plantar foot - most common site of malignant melanoma in black people
Describe the management and prognosis of malignant melanoma
Management
Surgical excision - definitive treatment
Sentinel lymph node biopsy for higher risk lesions
Surgery if nodal disease
Radiotherapy - only for metastatic disease
Targeted or immunotherapy if systemic metastases
Prognosis
Recurrence of melanoma based on Breslow thickness
<0.76mm thick – low risk, 0.76mm-1.5mm thick – medium risk, >1.5mm thick – high risk
5 year survival based on TNM
Stage 1 (T <2mm thick, N0, M0) – 90%
Stage 2 (T>2mm thick, N0, M0) – 80%
Stage 3 (N≥1, M0) – 40-50%
Stage 4 (M ≥ 1) – 20-30%
Usually followed up by dermatology for 5 years post diagnosis – aims of early identification of recurrent disease
Black ethnicity
In black skin, diagnosis is often delayed, leading to increased morbidity and mortality
At diagnosis, melanoma in black skin is often deeper, more advanced, and ulcerated, with local spread to lymph nodes
The overall 5-year survival rate of black patients with melanoma is lower than for all other ethnic groups
What are the components of the QRISK-3 Score?
Takes into account age, gender, ethnicity, UK postcode, smoking status, diabetes status, IHD 1st degree relative <60, CKD 3/4/5, AF, on BP medication, RA, cholesterol level, SBP, BMI, migraine, SLE, severe mental illness, atypical antipsychotics, oral steroids, ED, standard deviation of at least 2 SBP
What are the secondary causes of hypertension?
Nasopharynx - OSA
Thyroid - hypothyroid and hyperthyroid
Adrenals - Conn’s, Cushing’s, phaeochromocytoma
Kidneys - renovascular, CKD
Drugs - NSAIDs, oral contraceptives, sympathomimetics, illicit drugs, glucocorticoids, mineralocorticoids, ciclosporin, tacrolimus, EPO, herbal supplements, VEGF inhibitors
Describe open angle glaucoma
May have raised intra-ocular pressure causing damage to the optic nerve
Late presentation of visual loss, usually starts peripherally
Pharmacological management (eye drops)
Prostaglandin analogues (if IOP > 24mmHg & risk visual impairment in their lifetime)
If not tolerated or not reducing IOP try alternative eg. Beta-blocker, sympathomimetic, carbonic anhydrase inhibitor, miotic
Surgery - laser trabeculoplasty or trabeculotomy
Visual field loss in both eyes needs reporting to the DVLA
Describe acute angle glaucoma
Rapid onset raised IOP
Pupil dilated causing iris to block drainage trabecular network
Symptoms - severe eye pain, blurred vision, haloes, headache
Management - eye emergency - immediate referral for surgery
Describe Drusen of the eye
Yellow or white deposits of lipid around the macula
A few (once aged > 40) are normal - possibly caused by eye’s failure to eliminate waste products
Hard drusen (small, discrete, well separated from each other) – more likely to be normal
Soft drusen (larger, softer edge, closer together - like these) are usually associated with ARMD - age related macular degeneration
Describe cholesteatoma
Accumulation of squamous epithelium and keratin debris that usually involves the middle ear and mastoid
Benign but may enlarge and invade adjacent bone
Risk factors include middle ear disease, eustachian tube dysfunction, prior otological surgery, traumatic blast injury to ear, congenital anomalies (e.g., cleft palates, craniofacial abnormalities, Turner’s or Down’s syndrome).
Usually malodorous ear discharge (resistant to abx) with associated hearing loss
Attic crust and retraction pocket on otoscopy
Clinical diagnosis based on history and otoscopic findings
Urgent referral
Investigations - pure tone audiogram (variable - may show a conductive hearing loss), CT of petrous temporal bones (lesion definition and extent)
Mx - surgical removal (topical antimicrobials may help to reduce acute symptoms preoperativley)
