General Practice

Question 1

What is a macule?

Answer 1

A flat area of colour change, <1.5cm in diameter

Question 2

What is a papule?

Answer 2

An elevated lesion, <0.5cm in diameter, may appear as part of a papular rash

Question 3

What is a vesicle?

Answer 3

Elevated lesion containing fluid <0.5cm in diameter

Question 4

What is a Bulla?

Answer 4

Elevated lesion containing fluid >0.5cm in diameter

Question 5

What is a nodule?

Answer 5

Palpable solid lesion 0.5-2cm in diameter

Question 6

What is a pustule?

Answer 6

Elevated lesion which contains pus <1cm in diameter

Question 7

What is a plaque?

Answer 7

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

Question 8

What is a discoid lesion?

Answer 8

Round (coin-shaped) lesion

Question 9

What is an annular lesion?

Answer 9

Lesions grouped together to form a circle

Question 10

What is lichenification?

Answer 10

Accentuation of skin markings associated with thickening of epidermis caused by scratching or rubbing

Question 11

What are excoriations?

Answer 11

Linear crusts and erosions due to scratching

Question 12

What are petechiae?

Answer 12

Extravasation of blood into the skin, non-blanching, <0.2cm in diameter

Question 13

What are purpura?

Answer 13

Extravasation of blood into the skin, non-blanching, 0.2-1cm

Question 14

What is ecchymoses?

Answer 14

Extravasation of blood into the skin, non-blanching, >1cm in diameter

Question 15

What is urticaria?

Answer 15

Elevated lesions formed by local dermal oedema

Question 16

What is pyogenic granuloma?

Answer 16

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.

Question 17

Describe chickenpox

Answer 17

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

Question 18

Describe urticaria

Answer 18

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

Question 19

Describe molluscum contagiosum?

Answer 19

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)

Question 20

Describe shingles

Answer 20

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

Question 21

Describe scabies

Answer 21

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)

Question 22

Describe rosacea

Answer 22

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

Question 23

Describe guttate psoriasis

Answer 23

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

Question 24

Describe venous eczema

Answer 24

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

Question 25

Describe impetigo

Answer 25

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

Question 26

Describe plaque psoriasis

Answer 26

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

Question 27

Describe acne vulgaris

Answer 27

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)

Question 28

Describe atopic eczema

Answer 28

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

Question 29

What are the features of BCC?

Answer 29

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)

Question 30

How are BCCs classified?

Answer 30

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)

Question 31

What is the management of BCCs?

Answer 31

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

Question 32

What are the features of SCCs?

Answer 32

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

Question 33

What is the management of SCC?

Answer 33

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

Question 34

Describe actinic keratoses

Answer 34

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

Question 35

Describe the features of Bowen’s disease

Answer 35

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

Question 36

Describe the features of malignant melanoma

Answer 36

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

Question 37

Describe the management and prognosis of malignant melanoma

Answer 37

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

Question 38

What are the components of the QRISK-3 Score?

Answer 38

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

Question 39

What are the secondary causes of hypertension?

Answer 39

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

Question 40

Describe open angle glaucoma

Answer 40

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

Question 41

Describe acute angle glaucoma

Answer 41

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

Question 42

Describe Drusen of the eye

Answer 42

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

Question 43

Describe cholesteatoma

Answer 43

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)