ICA Flashcards
A patient with the following rash presents with bloating and abdominal pain. What is the most likely diagnosis?
Dermatitis hypertiformis - coeliacs rash.
What is dermatitis hypertiformis?
A rash associated with elbows, knees and buttocks, seen in Coeliac’s disease.
What is the blood test associated with Coeliac’s disease?
IgA TTG.
What may be seen on a skin biopsy for a patient with dermatitis hypertiformis?
IgA deposits in a granular pattern.
What is the most likely diagnosis for the following rash?
Erythema nodosum.
What is the most likely diagnosis, based on the following image?
Erythema multiforme.
What is the most likely diagnosis for the following condition?
Pyoderma gangrenosum.
How does inflammation appear in black skin?
It may appear slightly red, darker brown, grey, purple or even black.
In dark skin, what should be looked at in central cyanosis?
Mucous membranes, as it is harder for darker skin tones’ tongue to appear blue.
Why may the capillary refill time of a black person not be useful?
A large proportion of black people do not blanch.
What is traction alopecia?
Certain hairstyles such as weaves, braids or even tight ponytails can result in the hairline being pulled back significantly.
Where does basal cell carcinoma usually present in black people?
On the soles of the feet.
What is dermatitis papulosa nigra?
Multiple small, dark bumps on the skin that only affects people of colour. It is harmless.
How does smoking affect the skin?
It causes poor wound healing.
Predisposes to skin cancer.
Nicotine staining on the fingers.
What should be done in a dermatology examination?
SCAM:
- Site and distribution for a rash/ size and shape of a lesion.
- Colour and configuration.
- Associated changes.
- Morphology.
What should be done for pigmented lesions examinations?
ABCDE:
- Asymmetry.
- Border (regular or irregular).
- Colour.
- Diameter.
- Evolution.
What are different sites and distributions that skin conditions can affect?
Flexor surfaces.
Extensor surfaces.
Generalised.
Follicular - affected individual hair follicles.
Dermatomal distributions.
Seborrhoeic - around oily areas.
Photo-sensitive - areas exposed to the sun.
What is this distribution?
Follicular.
What are the following two distributions?
Left is seborrhoeic.
Right is photo-sensitive.
What is a hive?
An area of raised skin due to dermal oedema.
What is leichenification?
Thickening of the epidermis with exaggerated skin lines, often seen in chronic itching or rubbing.
What is hypertrichosis?
Increased hair growth in non-androgenic areas.
What do the following terms mean:
- Intertriginous
- Discoid/ nummular
- Annular
- Abscess
- Comedone
- Affecting the skin folds.
- Round lesion.
- A circle or ring with a different morphology in the middle to the edges.
- Localised accumulation of pus on the dermis or subcutaneous tissue.
- Pores or hair follicles that have gotten blocked with bacteria, oil and dead cells forming a bump.
What is the difference between an erosion and ulcer?
Erosion - loss of epidermis.
Ulcer - loss of epidermis and dermis.
What is oncholysis? State some causes.
Separation of the distal end of the nail plate from the nail bed.
Trauma, psoriasis, fungal nail infection, hyperthyroidism.
How is atopic eczema/ dermatitis diagnosed and what is the history of it?
Based on a clinical diagnosis (history and examination).
Begins in childhood, but can occur later.
Atopy.
Family history/ genetic predisposition.
What are the clinical features of atopic eczema/ dermatitis?
Pruritis.
Typically in the flexural surfaces.
Can occur in response to a trigger - occupation/ changes to soaps/ fragrances/ pollution, etc.
Often in flares and remissions.
What is the treatment for atopic eczema/ dermatitis?
Education and support.
Avoidance of triggers.
Topical:
- Emollients.
- Soap substitutes.
- Steroids.
- Calcineurin inhibitors (immunosuppressants).
- Phototherapy (UV).
Systemic therapy.
What is the history of a patient with acne vulagris?
Adolescents and young adults, usually 7-12 and resolves by the 3rd decade of life.
Chronic skin disease due to blockage of hair follicles.
What are the multifactorial causes of acne vulgaris?
Increased sebum production due to androgen influences.
Excessive deposition of keratin in the pores.
Overgrowth of cutibacterium acnes, a skin commensal that proliferates in oily skin.
Pro-inflammatory chemicals released in the skin.
Can be triggered by drugs.
What are the treatments of acne vulgaris?
Topical:
- Retinoids.
- Antibiotics, such as erythromycin.
Systemic:
- Antibiotics.
- Oral contraceptive pill and hormone blockers.
- Isotretinoin.
Psychological impact.
Why should isotretinoin not be given to pregnant mothers?
It is teratogenic.
What is the history of a patient with psoriasis?
Chronic skin condition.
Usually between 20-30 and 50-60 years old.
Has a strong genetic predisposition.
Is remitting and relapsing.
Triggers/ iatrogenic causes - medications.
What is the cause of psoriasis?
T-cell cytokines production is stimulated, causing keratinocyte proliferation.
What is the treatment of psoriasis?
Topical, such as vitamin D analogues.
Phototherapy.
Oral or injectable systemic treatments.
How can urticaria be classified?
Acute if less than 6 weeks.
Chronic is longer than 6 weeks.
What are some triggers and the pathophysiology of urticaria?
Triggers - foods, inhaled allergens, medications, etc.
Mast cell degranulation and histamine release leads to increased capillary permeability and leakage of fluid into surrounding tissue.
What are the treatments for urticaria?
What is molluscum contagiosum, and how does it present?
A pox virus that is common in children.
They acquire it from direct contact with a skin lesion or object with the virus.
Small, firm spots that are umbilicated (dimple in the middle) that can appear anywhere.
It can be itchy, but is self-limiting.
What is shingles, the presentation and treatment?
What bacterial infection commonly affects the skin of children?
State the cause, presentation and treatment.
Impetigo - highly contagious.
It is caused by staphylococcus or streptococcus infections, seen in areas of broken skin - more common in eczema and psoriasis.
Red sores with blisters that burst, forming a gold/ brown crust.
It is treated with topical antibiotics and hydrogen peroxide, where patients resolve within 7-10 days.
What is dermatophytosis?
Superficial fungal infection of the skin.
What are dermatophytes?
Fungal organisms that need kertain to grow.
How is dermatophytosis spread and diagnosed?
Spread via direct contact from other people, animals, soil and fomites.
It is diagnosed clinically, where patients are seen to have superficial lesions of erythema and alopecia, depending on where it impacts.
What is the common causes of dermatophytosis and how it treated?
Excessive sweating, contact sports and use of public showers.
Treated with topical antifungals.
What is malignant melanoma, what are the causes and risk factors?
Cancer from melanocytes.
It is caused by UV light exposure which can come from the sun and sunbeds.
Risk factors are:
- Pale skin.
- Red/ blonde hair.
- Family history.
What is the appearance of malignant melanoma and how is it treated?
A new mole or change in appearance of an existing mole.
It is treated with surgery and/ or radio- or chemotherapy.
What is squamous cell carcinoma characterised by, and where do they usually develop?
Abnormal and accelerated growth of squamous cells, found in the epidermis.
It is a crusted lesion with a central ulcer.
They develop in area of skin exposed to the sun:
- Nose.
- Forehead.
- Cheeks.
- Back.
- Lower legs.
Who does squamous cell carcinoma usually present in and how is it treated?
Middle aged and older patients.
Treated with surgery.
What is basal cell carcinoma, who does it occur in and how is it treated?
The most common type of skin cancer that is slow growing and rarely spreads. They are often dark in colour and spontaneously bleed.
It occurs usually in older adults when one of the skin’s basal cells develops a mutation in its DNA, usually from UV light.
It is treated with surgery.
What is a collateral history?
Information gathered from someone other than the patient.
What are non-syncopal falls?
Falls not due to cerebral blood flow issues, that can occur with or without a loss of consciousness.
What are some causes of non-syncopal falls with and without a loss of consciousness?
With (can be partial or full):
- Epilepsy.
- Metabolic; hypoglycaemia, hypoxia or hypocapnia.
- Intoxication.
Without:
- Psychogenic.
- TIA/ stroke.
What is postural hypotension?
A drop in blood pressure greater or equal to 20mmHg in systolic and/or greater or equal to 10mmHg in diastolic blood pressure, that occurs within 3 minutes of standing.
Why write a problem list?
Helps to contextualise an acute problem within the patient as a whole, ensuring that other, potential problems or indications are not forgotten or abandoned.
What is the physiological definition of frailty?
Clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems. The ability to cope with everyday or acute stressors is compromised.
What is the phenotypic definition of frailty?
Low grip strength.
Low energy.
Slowed walking speed.
Low physical activity.
Unintentional weight loss.
What are the geriatric giants?
Immobility.
Instability - falls.
Incontinence.
Impaired memory - dementia, delirium.
Iatrogenesis.
What is delirium?
An acute, fluctuating syndrome of encephalopathy causing disturbed consciousness, attention, cognition and perception.
What does a ‘non-specific’ presentation in frailty mean?
Frail, older people often present without the ‘classic’ symptoms of a common illness.
What is the comprehensive geriatric assessment?
A multidimensional interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail older person, in order to develop a coordinated and integrated treatment plan.
What are some intrinsic and extrinsic causes of aging?
Intrinsic:
- Chronological ageing.
- Biochemical degenerative process.
- Cortisol and hormone levels.
- DNA damage.
- Telomere shortening.
- Oxidative stress.
Extrinsic:
- Biochemical process.
- Environmental; radiation and chemical exposure.
- Mechanical.
- Lifestyle; sleep and diet.
- Behaviour.
What are some age related changes for the skin?
Progressive structural and functional generation:
- Atrophy of the dermis, making it more friable.
- Destruction of the dermal-epidermal junction, decreasing nutrient and waste exchange.
- Thinning of the dermis due to collagen fragmentation and elastin degradation.
What is this condition seen in the elderly?
Senile purpura - fragility of the skin leads to extensive bleeding under the skin.
What are some age related changes for the respiratory system?
Change in the structure of the chest wall, decreasing compliance - increased residual volume and functional residual capacity and decreased vital capacity.
Destruction of the ECM within the lung, leading to senile hyperinflation, air trapping and decreased gas exchange.
Increased infection susceptibility.
What are some age related changes for the myocardial structure?
Left ventricular hypertrophy.
Interventricular septal hypertrophy.
Decreased sympathetic innervation.
Aortic sclerosis and aortic valve calcification.
What are some age related changes for the myocardial function?
Decreased diastole as less compliance.
Decreased cardiac output.
Decreased maximal heart rate as decreased beta-1 adrenoceptor responsiveness.
Increased cardiac workload.
Decreased baroreceptor response.
What are some age related changes for the myocardial electrophysiology?
SA node atrophy.
Prolongation of action potentials.
What are some age related changes for the vascular structure and function?
Structure:
- Large arteries dilate.
- All arterial walls thicken.
Function:
- Decreased arterial compliance.
- Endothelial vasodilation is impaired.
What are some age related changes for the GI system?
Oesophagus, stomach, liver and colon.
Oesophagus:
- Decreased peristalsis.
- Delayed transit time, which can cause dysphagia and anorexia.
- Decreased relaxation of the lower oesophageal sphincter; achalasia.
Stomach - atrophic gastritis, which is pre-malignant.
Decreased size of the liver.
Colon:
- Decreased intestinal motility and increased water absorption (constipation).
- Diverticulosis.
What are some age related changes for the brain?
Ventricular enlargement.
Cortical thinning.
Volume loss.
Sulcal widening.
What is malnutrition?
A state of nutrition in a deficiency or excess of energy, protein, and other nutrients, leading to adverse effects on tissue form and function.
What are the consequences of malnutrition?
Impaired immune response.
Reduced muscle strength - increasing the risk of falls.
Inactivity - pressure sores and ulcers.
Loss of temperature regulation.
Impaired wound healing.
Impaired psycho-social function.
State the class, uses and method of action of diazepam.
State how it contributes to falls.
Class - benzodiazepine.
Uses - mild sedation, muscle spasms, anxiety, status epileptica (seizures don’t stop) and acute alcohol withdrawals.
Method of action - activates to GABA receptors, causing hyperpolarisation.
Contributes to falls by increasing drowsiness, syncope, hypotension and muscle weakness.
State the class, uses and method of action of amlodipine.
State how it contributes to falls.
Class - calcium channel blocker.
Uses - hypertension and heart failure.
Method of action - blocks L-type calcium channels.
Contributes to falls by causing hypotension, syncope, dizziness, drowsiness and headaches.
State the class, uses and method of action of olanzapine.
State how it contributes to falls.
Class - anti-psychotic.
Uses - schizophrenia, mania and disturbed sleep.
Method of action - binds to dopamine D2 receptors.
Contributes to falls by causing confusion, postural hypotension, dizziness and gait dysfunction.
State the class, uses and method of action of codeine.
State how it contributes to falls.
Class - opiate.
Use - pain relief, and treat diarrhoea.
Method of action - binds to mu-opioid receptors.
Contributes to falls by causing confusion, dizziness, drowsiness and sedation.
State the class, uses and method of action of oxybutynin.
State how it contributes to falls.
Class - muscarinic anti-cholinergic.
Uses - overactive bladder syndrome and urgency incontinence.
Method of action - inhibits mAChRs.
Contributes to falls by causing dizziness, drowsiness and visual disorders.
State the class, uses and method of action of tamsulosin.
State how it contributes to falls.
Class - alpha-1 blocker.
Uses - benign prostatic hyperplasia.
Method of action - blocks alpha-1 adrenoceptors.
Contributes to falls by causing dizziness, hypotension and visual disorders.
What is primary palliative care?
Dying, death and bereavement in the community.
Who might a good death be considered for?
People with life-threatening progressive incurable disease which is far advanced with a limited prognosis, who’s focus of care is quality of life.
People who are likely to die within a short period of time.
What is holistic care?
The physical, psychological, emotional, social and spiritual - total - care of a person.
What proportion of deaths occur in medicalised UK institutes?
State the impact of this.
Greater than 70%.
This means that dying is not longer a regular, natural part of the life cycle seen by people.
What are the aspects of achieving a good death, as a doctor?
Truthfulness with patients.
Enabling informed consent.
Allowing time for the patient to prepare for their death.
Avoiding isolation of the patient.
Overcoming the wall of silence - talking to the patient.
Maintaining hope by accompanying them on their journey.
What it futility?
Where curative treatment is continued where the is no prospect of success - prolonging life unnecessarily.
What are the aspects required for a good transition to palliative care?
Informed consent.
Caring when cure is no longer possible.
Enabling acceptance as part of the healing process.
What are the 5 stages of anticipatory grief?
Anger.
Denial.
Bargaining.
Depression.
Acceptance.
How can spiritual pain be resolved?
Being informed about the event of death and their condition.
Resolving conflicts.
Letting go.
Saying goodbye.
What is good dying?
Avoiding medicalisation that prolongs the dying process.
Agreements for care plans - ReSPECT and DNACPR forms.
Ability to die their own death.
Adequate symptom control.
Avoiding medical captivity.
What should be done for the informal carer after the death of their loved one?
Support them and give them opportunities for respite care.
Allow/ facilitate grief before and after the death.
Ensure they do not feel guilty for the death of their loved one.
What is euthanasia?
The act of deliberately ending a person’s life to relieve suffering.
What are the 4 aspects of euthanasia?
The agent.
Intention.
Subject.
Outcome.