GP3 Flashcards
Which general areas does eczema commonly present in adults? [1]
Name three areas
In adults, eczematous lesions commonly involve flexural areas
- antecubital fossae (inner elbows), popliteal fossae (behind knees), wrists, ankles, neck folds, axillae, and inguinal folds. However, eczema can also involve other sites such as the face, hands, feet, and trunk.
Name this complication of chronic ezcema [1]
What is it characterised by? [3]
Lichen Simplex Chronicus:
- may develop secondary to chronic scratching or rubbing in response to pruritus
- characterized by well-demarcated plaques with lichenification, hyperpigmentation, and scaling.
Name this complication of ezcema [1]
Why does it occur? [1]
Prurigo nodularis
- Characterized by multiple firm, itchy nodules that result from repeated scratching or picking at eczematous lesions.
What are the requirements for diagnosis of ezcema?
An itchy skin condition in the last 12 months
Plus three or more of
* Onset below age 2 years (not used if below 4)
* History of flexural involvement
* History of generally dry skin
* Personal history of other atopic disease
* Visible flexural dermatitis
Describe the conservative and medication used to treat eczema [+]
Conservative:
- Education to prevent remission / relapsing and complications
- Explanation medications do not cure but majority of children will grow out of it
- simple measures: cotton clothing / bedding, keep cool, avoid pets, rinse clothes adequately, moisturizer at school, avoid all soaps, house dust mite avoidance
Topical Preparations:
- Emollients - varies from water based to oil based; use all the time even when skin is clear
- bath oils/soap substitutes
Topical steroids - e.g. hydrocortisone 1%
- acute - strong steroid for 5-7 days
- chronic - use lowest appropraite potency, 10-14 days
- USE WITH EMOLLIENT
Phototherapy:
- Narrowband ultraviolet B (NB-UVB) phototherapy can be considered for patients with moderate-to-severe eczema who have not responded adequately to topical therapies
Topical immunomodulators
- calcineurin inhibitors - tacrolimus & pimecrolimus
.
Describe the NICE CG 57 (2021 update) describes the following stepped apprach to management of eczema [+]
Mild:
* Emollients
* Mild potency topical corticosteroids
Moderate:
* Emollients
* Moderate potency topical corticosteroids
* Topical calcineurin inhibitors
* Bandages
Severe:
* Emollients
* Potent topical corticosteroids
* Topical calcineurin inhibitors
* Bandages
* Phototherapy
* Systemic therapy
Which drugs can be used to manage itch in eczema? [2]
The use of sedating antihistamines, such as hydroxyzine or chlorphenamine, can be considered for short-term relief of itch and sleep disturbance
Describe the stepwise ladder for treating eczema using steroids [4]
Mild:
- Hydrocortisone 0.5%, 1% and 2.5%
Moderate
- : Eumovate (clobetasone butyrate 0.05%)
Potent:
- Betnovate (betamethasone 0.1%)
Very potent:
- Dermovate (clobetasol propionate 0.05%)
Which steroids might be used to treat areas such as face and genitals eczema [1]
Which steroids might be used to treat the rest of the body for eczema [1]
Face and genitals:
- hydrocortisone 1%
Rest of body:
- betamethasone valerate 0.1% - if severe or thicker skin
How do emollients work to treat eczema? [1]
How often should patients apply it? [1]
They provide symptomatic relief by hydrating the skin, reducing transepidermal water loss and restoring the skin barrier function
Patients should be advised to apply emollients liberally and frequently (at least twice daily) even when their skin appears clear. Emollient choice should be tailored to individual preferences (e.g., creams, ointments or lotions) to improve adherence.
eczema herpeticum
- Eczema herpeticum is a viral skin infection in patients with eczema caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). Patients can be very unwell.
Wiskott-Aldrich syndrome causes primary immunodeficiency due to a combined B- and T-cell dysfunction. It is inherited in a X-linked recessive fashion and is thought to be caused by mutation in the WASP gene.
PKU
What condition is shown? [1]
Where can / does eczema present differently in black ethnicities compared to white skin? [1]
Eczema
Those of black ethnicity may demonstrate a different distribution with rashes affecting the extensor surfaces. Affected skin can develop patches of both hypo and hyperpigmentation.
Infection to which pathogen often occurs in eczema? [1]
How do you treat? [1]
Secondary S.aureus: patients present with crusty, oozing rash with associated erythema. Disease is often mild and antibiotics may be avoided in those who are systemically well. New supplies of emollients and topical corticosteroids should be given and regular review organised.
Treatment is with oral antibiotics, particularly flucloxacillin.
Describe what is meant by psoriasis [2]
Psoriasis is a common, chronic, inflammatory papulosquamous disorder typically characterised by well-demarcated, scaly plaques and a relapsing-remitting course.
It is frequently associated with systemic diseases (e.g. psoriatic arthritis) and can also impact **individuals’ self-esteem and mental wellbeing. **
Describe the pathophysiology of psoriasis [1]
Psoriasis is an immune-mediated disease featuring hyperproliferation of the epidermis.
The pathophysiology of psoriasis is complex and incompletely understood. It has been demonstrated that the immune system plays a key role - becoming activated and resulting in inflammatory plaques on the skin.
It is estimated that a third of patients with psoriasis will develop psoriatic []
It is estimated that a third of patients with psoriasis will develop psoriatic arthritis.
Describe the following subtypes of psoriasis:
- Psoriatic nail disease [6]
Psoriatic nail disease
- Fingernails are involved in around 50% of cases and toenails in 35%. In patients with psoriatic arthritis, nail changes are very common affecting 90%.
- Subungual hyperkeratosis
- Nail pitting
* Oil drop discolouration (yellow/pink patches)
* Leukonychia (white discolouration)
* Onycholysis (detachment of the nail from the nail bed)
* Splinter haemorrhages
Describe the the subtypes of psoriasis:
- chronic plaque psoriasis
- raised, scaly, well-demarcated plaques
- symmetrically distributed
- scalp, extensor surfaces, trunk, gluteal cleft and knees.
- Lesions are typically itchy and may become fissured and painful over joint lines, on the palms of the hand or soles of the feet.
What is Auspitz’s sign in psoriasis? [1]
If the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)
Describe what is meant by Guttate psoriasis [1]
Also termed raindrop psoriasis:
- it presents as a sudden eruption of small circular plaques classically 2 weeks following a streptococcal sore throat.
- It can also occur as a flare of disease in patients with pre-existing psoriasis.
It is generally self-limiting resolving over 3-4 weeks but around a third will develop classic plaque psoriasis.
Localised pustular psoriasis effects which parts of the body? [1]
What is a strongly associated RF? [1]
Localised pustular psoriasis:
- Localised (palmoplantar) psoriasis generally affects the hand and feet
- . Pustules develop along with plaques. It is strongly associated with smoking.
Describe how you treat psoriasis
Regular emollients may help to reduce scale loss and reduce pruritus
1st line:
- topical potent corticosteroid OD AND vitamin D analogue (e.g., calcipotriol)
- should be applied separately, one in the morning and the other in the evening
- for up to 4 weeks as initial treatment
- - if no improvement by 8 weeks go to…
2nd line:
- vitamin D analogue BD
- if no improvement by 8-12 weeks go to…
3rd line:
- potent vitamin D BD for up to 4 weeks, tar, short-acting dithranol
Describe the secondary care management of psoriasis
Phototherapy
* narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week
* photochemotherapy is also used - psoralen + ultraviolet A light (PUVA)
adverse effects: skin ageing, squamous cell cancer (not melanoma)
Systemic therapy
* * oral methotrexate is used first-line. It is particularly useful if there is associated joint disease
* ciclosporin
* systemic retinoids
* biological agents: infliximab, etanercept and adalimumab
* ustekinumab (IL-12 and IL-23 blocker) is showing promise in early trials
How do you treat Scalp Psoriasis [2] and Face, Flexural and Genital Psoriasis? [2]
Scalp Psoriasis Management:
- 1st line topical potent corticosteroids (OD, 4 weeks), no improvement different formation, different topical agent
Face, Flexural and Genital Psoriasis Management:
- mild or moderate potency corticosteroid corticosteroid applied once or twice daily for a maximum of 2 weeks
What is important to note about calipotriol (vit d analagoues) treatment for psoriasis? [3]
they tend to reduce the scale and thickness of plaques but not the erythema
they should be avoided in pregnancy
the maximum weekly amount for adults is 100g
The following factors may exacerbate psoriasis [5]
- trauma
- alcohol
- drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
- withdrawal of systemic steroids
What does
What are the key types of depression?
Major depressive disorder (which we typically refer to as depression)
Persistent depressive disorder - ⩾ 2 years of a depressed mood for most of the day, for most days.
Premenstrual dysphoric disorder - low mood +/- anxiety and irritability in the luteal phase that impacts daily function.
Which features are core to a depression diagnosis? [3]
Which other emotional, cognitive, physical and behavioural symptoms might be present? [4]
Depression is typically characterised (core features) by…
* Decreased interest or pleasure (anhedonia) in most activities.
* Fatigue
* Depressed or irritable mood
AND:
Change in…
* Weight (↑/↓)
* Sleep (↑/↓)
* Activity (agitated/slowed)
* Concentration (low/more indecisiveness)
Suicidality
Guilt/worthlessness
Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe).
The updated NICE guideline uses a simpler 2 category definition of depression: [2]
Describe which levels of depression fall into^
Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe).
The updated NICE guideline uses a simpler 2 category definition of depression: less severe or more severe depression.
- Less severe depression encompasses subthreshold and mild depression
- More severe depression encompasses moderate and severe depression
Thresholds on validated scales were used in this guideline as an indicator of severity
a score < [] on the PHQ-9: less severe depression
a score of ≥ [] on the PHQ-9: severe depression
Thresholds on validated scales were used in this guideline as an indicator of severity
a score < 16 on the PHQ-9: less severe depression
a score of ≥ 16 on the PHQ-9: severe depression
Which symptoms, and how long do they need to last for, for a diagnosis of clinical depression?
Typically, a clinical diagnosis: ≥5 of the below symptoms, present for ≥2 weeks
How do you treat the following levels of depression
- Mild [2]
- Moderate [2]
- Severe [3]
GP notes
Mild:
- guided self-help
- CBT
Moderate:
- interpersonal therapy
- medication: first line - SSRIs are first line (sertraline in adults, fluoxetine in paediatrics).
Severe:
- interpersonal therapy, medication +/- admission or antipsychotics.
Treatment options, listed in order of preference by NICE for depression are [++]
Treatment options, listed in order of preference by NICE
* a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
* individual CBT
* individual behavioural activation (BA)
* antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
* individual problem-solving
* counselling
* short-term psychodynamic psychotherapy (STPP)
* interpersonal psychotherapy (IPT)
* guided self-help
* group exercise
What are side effects of SSRIs such as sertraline? [4]
Side effects: GI bleeding, GI discomfort, sexual dysfunction, nausea.
Very high doses or use of other medication that increases serotonin levels (e.g., tramadol) can lead to serotonergic syndrome (emergency).
Define General Anxiety Disorder [GAD]
GAD is defined as chronic, excessive worry for at least 6 months that causes distress or impairment.
Remember anxiety is a broad term encompassing GAD alongside other conditions such as obsessive-compulsive disorder, panic disorder and social anxiety disorder. These other conditions are 🧠Differentials for GAD
Describe the treatment for mild [3] and moderate-severe GAD [3]
Mild:
- guided self-help, CBT, mindfulness
Moderate-severe:
- CBT, relaxation therapy, medication
💊Typically, SSRIs or SNRIs (serotonin-noradrenaline reuptake inhibitor) are first line
- SSRIs: duloxetine or escitalopram in adults
- SNRIs: venlafaxine in adults
Osteophytes are a hallmark of
Osteomalacia
Osteopenia
Osteosarcoma
Osteoarthiritis
Osteoporosis
Osteophytes are a hallmark of
Osteomalacia
Osteopenia
Osteosarcoma
Osteoarthiritis
Osteoporosis
This CT is suggestive of a patient with
Osteomalacia
Osteopenia
Osteosarcoma
Osteoarthiritis
Osteoporosis
Osteoporosis - kyphosis present
Which of the following is associated with RA?
- Heberden’s nodes
- Boutonniere deformity
- Bouchard’s nodes
- Sadness
Boutonniere deformity
Name this RA symptom [1]
Boutonniere deformity
Label A-D of RA symptoms
A: ulnar deviation
B: z-deformity
C: swan neck
D: Boutonniere deformity
RA
Label A & B
A: swan neck deformity
B: Boutonniere deformity
Which of these joints would you least likely see swollen & painful joints in RA?
metacarpophalangeal (MCP)
Metatarsophalangeal (MTP)
proximal interphalangeal (PIP)
distal interphalangeal (DIP)
distal interphalangeal (DIP)
Rheumatoid factor is found on which Ig
IgG
IgA
IgM
IgD
IgE
IgM
A 58 year old woman is seen by her GP after a left wrist fracture. She was standing on a chair to change a lightbulb, lost her balance and feel off onto her outstretched hand. She was seen in A&E, where a cast was applied. She was followed up in the fracture clinic, where the cast was removed and she was discharged. The discharge letter requested that her GP review her risk of future fractures. She says she leads a healthy lifestyle, with a balanced diet and regular exercise. She does not smoke or drink alcohol and has no significant ongoing medical problems.
A DEXA scan is arranged, which shows a T-Score at the hip of -2.1.
What term best describes her bone mineral density?
Osteopenia
Osteosclerosis
Normal
Osteoporosis
Osteomalacia
Osteopenia
A 58-year-old male presents with severe pain in his left knee. This came on suddenly this morning and is not relieved by paracetamol. He is systemically well and has no significant past medical history, except for a BMI of 31. He was assessed by colleagues in the emergency department, with joint aspiration showing positively birefringent, rhomboid-shaped crystals.
What is the most likely diagnosis?
Osteomyelitis
Septic arthritis
Gout
Psoriatic arthritis
Pseudogout
Pseudogout
Pseudogout presents with positively birefringent crystals, often described as “rhomboid” in shape. In comparison, gout crystals are negatively birefringent crystals, often described as “needle” in shape.
A 58-year-old woman goes to see her GP complaining of enlarging nodules around the olecranon processes of both elbows. She originally noticed them a year ago, but has attended today as they have been getting slowly larger, more unsightly and tender. She reports no longer being able to rest on her elbows.
She is known to be under a Rheumatologist for a chronic inflammatory arthropathy and has been taking Methotrexate for the last eight months.
An image of her elbow is provided below.
What disease is her rheumatologist treating her for?
Source: Dr J.Atkins
Ankylosing Spondylitis
Gout
Psoriatic Arthritis
Seropositive Rheumatoid Arthritis
Seronegative Rheumatoid Arthritis
Seropositive Rheumatoid Arthritis
This is a typical rheumatoid nodule. They can occur in any tissue, but the commonest sites where they are clinically apparent are the olecranon area of the elbow and the extensor surfaces of the fingers/wrists. They are only found in seropositive rheumatoid arthritis.
A 40-year-old man presents to the emergency department with an acutely swollen and extremely painful left knee. This started suddenly and woke him from sleep. He has no past medical history and takes no regular medication. The man is overweight and admits to having at least 4 pints of beer a night for as long as he can remember.
On examination, he has a temperature of 37.6°C, but observations are otherwise normal. He is systemically well. The left knee appears erythematous and tender to touch. Urine dipstick is normal.
Synovial fluid is aspirated from the left knee, and microscopy is performed and demonstrated below.
Euthman. License [CC BY 2.0].
What is the most likely diagnosis?
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
Gout
Platelet rich plasma (PRP) is a novel treatment process for
Osteoporosis
Osteomalacia
Osteoarthritis
Rheumatoid arthritis
Osteoarthritis
OA
Red arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
symmetric joint space narrowing (because it is harder to see what is not there, this is best appreciated by mentally contrasting with the NORMAL joint space, shown by red arrow on the figure to the left),
OA
Orange arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
Osteophytes
OA
Blue arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
Subchondral cysts
Green arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
subchondral sclerosis (the white line at the surface green arrow),
Erosive OA typically has erosion of cartilage in
Thumb DIP
Index finger PIP
Middle finger DIP
4th finger PIP
Little finger DIP
Middle finger DIP
This is a patient with OA. The arrow points to
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
Subchondral cysts
Name this symptom of gout [1]
Gout tophi
Name this symptom of gout [1]
Podagra
This histological slide is suggestive of
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
Gout
Figure 1. Typical granuloma in gout. The central part is formed by urate crystals. The inflammatory cells surrounding the area of crystals typical include macrophages, lymphocytes, plasma cells and giant cells. This is typical morphology within tophi. No histologic morphology of a coexisting rheumatoid arthritis was present. Fixation: formalin. H&E: amplification, × 20.
Name the molecule that would be elevated in this patient
Monosodium urate crystal
(patient has gout)
A patient has synovial fluid extracted and it looks like this. What is the patient most likely suffering from
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
Gout
A 55-year-old man presents to the emergency department with acute knee pain. There is no history of fever or trauma. He has a past medical history of hypertension.
On examination, he is afebrile. His left knee looks swollen and erythematous; there is a positive patellar tap and restricted passive and active joint movement.
His left-knee X-ray is normal, with no acute pathology seen.
The results of his joint aspiration are shown below.
What is the most likely diagnosis?
Pseudogout
Psoriatic arthritis
Gout
Rheumatoid arthritis
Septic arthritis
Gout
Name this sign of RA [1]
Bakers cyst: cyst in the popliteal fossa
Name this complication of RA [1]
scleromalacia perforans
Name this complication of RA [1]
Keratoconjunctivitis sicca
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
episcleritis
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
scleritis
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
keratoconjunctivitis sicca
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
scleromalacia perforans
OA
What change has undertaken at A [1]?
Eburnation of cartilage: complete loss of cartilage, exposing bone
OA
What change has undergone at the A? [1]
Eburnation of cartilage: complete loss of cartilage, exposing bone
OA
Name the change that the arrow is pointing to [1]
Fibrillation: saw tooth surface irregularity of cartilage
State which disease causes A-C
A: RA
B: OA
C: gout
Name the condition for pain at the tendon at the arrow [1]
De Quervain’s tenosynovitis
Name the condition for this tendon condition [1]
Trigger finger
What pathology is depicted here? [1]
Trigger finger
Superficial and deep flexor tendons with local tenosynovitis at the metacarpal head subsequently develop localised nodal formation on the tendon, distal to the pulley (Fig. 1). The A1 pulley is the most frequently involved ligament in trigger finger.
