Medicine A Flashcards
What are the differentials for a cutaneous horn?
Differentials include viral wart, seborrhoeic keratosis, actinic keratosis (pre cancerous lesion which often occur with background sun damage), Bowen’s disease (the cutaneous horn has a red rim and often become SCC) and squamous cell carcinoma which have a fleshy red component beneath which is suspicious. SCCs produce keratin whereas BCCs do not. SCC will need excision.
What are the differentials for a red scaly plaque?
Differentials include inflammatory conditions (psoriasis and discoid eczema) or neoplastic (Bowen’s and superficial basal cell carcinoma). BCC is usually pertly, nodular with a rolled edge or central depression and ulceration, scab or even telangiectasia (wide venules with threadlike red lines or patterns on the skin).
How is Bowen’s disease diagnosed and treated?
Bowen’s disease is confirmed clinically or with a biopsy. It is treated with Effudix (5-flurouracil) which is a chemotherapy cream.
How should BCCs be treated?
BCC should be treated with imiquimod which is an immune response modifier or with complete excision.
How should psoriasis be treated?
The main treatment for psoriasis are emollients, vitamin D analogues, steroids, tar and dithranol. Vitamin D analogues should generally be used as first line treatment. For severe localised psoriasis should be treated with potent topical steroids. Scalp psoriasis may need tar shampoo or topical steroids. Some diffuse psoriasis can be given phototherapy.
How is eczema treated?
The main topical treatments of eczema include emollient for dryness and as a soap substitute. Anti-inflammatory drugs such as steroids and calcinerurin inhibitors.
Emollients need to chosen carefully because of the degree of greasiness and length of effect. There is no frequency limit.
Topical steroids are used in a ladder. Hydrocortisone is first choice followed by Eumovate. Bentovate and elocon are the step up with dermovate used last as it is very potent.
Calcineurin inhibitors can be tacrlinus (protopic) or elidel and should be used on delicate sites such as around the eyes. Eczema which has lichenification requires higher potency to treat and should be taken very seriously. Golden crusting may imply infection, never use fusibet as a maintenance treatment because resistance develops very quickly.
How does rosacea present?
Rosacea presents with erythema and pustules. They may also have a history of flushing. This can be treated with topical metronidazole, azeliac acid or oral tetracyclines. Rosacea does not itch but often feels like it is burning.
What are the dermatological symptoms of SLE?
SLE presents with redness over the cheeks and nose like the wolf pattern and looks indurated. There will be no papules and you should ask about other SLE symptoms and ask about photosensitivity.
How does seborrhoeic eczema present?
Seborrhoeic dermatitis is distributed around the nasal folds but can extend onto the cheeks and central forehead. Check the scalp as it may be greasy and yellowish. This is treated with antifungals as it is linked with the overgrowth of pityrosporum ovale. Also hydrocortisone.
How does atopic eczema present on the face?
Atopic eczema on the face usually occurs with pruritus and causes eyelid oedema. This can be treated with hydrocortisone. Allergic contact dermatitis can cause swelling of the eyes and is treated with avoidance and topic steroids. Acute contact dermatitis does not have as much scaling as chronic cases.
How does cellulitis present?
Cellulitis (Erysipelas) also presents with swelling but clear margins to the erythema. The skin will look stretched and is almost always unilateral. Unilateral localised erythema with less swelling may also be cellulitis and both should be given flucoxicillin or other antibiotics which the swab reveals are effective.
How does gravitational eczema present?
Bilateral lightly erythematous legs may be gravitational eczema (otherwise known as stasis eczema, venous or varicose eczema). This is caused by impaired venous drainage or chronic venous insufficiency and will often present with other signs such as oedema and pigmentation. Cellulitis should not itch whereas eczema itches.
How does lipodermatosclerosis present?
Bilateral dark erythema which is asymmetrical and is slowly spreading may be lipodermatosclerosis. The skin may feel thick, bound down and sclerotic. This is often seen in overweight people and is difficult to treat. Compression may have some effect.
How does erythema nodosum present?
Erythematous blotchy patches which are very tender is caused by erythema nodosum. It tends to be bilateral.
How should acne be treated?
Topical treatments: Benzoyl peroxide, retinoid and antibiotics
Oral treatments: Antibiotics, COCP and retinoid
Tetracyclines and lymecyclines are the main oral antibiotics whereas erythromycin or clarithromycin are used topically. Retinoids are vitamin A derivatives. The oral contraceptive pill can be used for patients with acne. Retinoids are the last resort and have considerable side effects but are extremely effective. Always beware of pregnancy and offering treatments.
What does the ‘A’ in the ABCDE approach to X-rays represent?
Projection (is it AP or PA as AP will have a larger heart shadow). Take note of the rotation and the inspiratory effort by counting ribs, at least 6 should be visible.
Look for the trachea and assess whether it is central as pleural effusion, pneumothorax and lobar collapse or lobotomy will change the way it lines. The left and right bronchi should also be visible.
What does the ‘B’ in the ABCDE approach to X-rays represent?
Compare the lung zones on both sides. Increased density implies consolidation, interstitial change, masses, collapse and effusions. Reduced density is seen in pneumothorax. The lower lobes extend below the diaphragm and there may be pathology in this area. Look for hyperinflation seen in COPD.
What does the ‘C’ in the ABCDE approach to X-rays represent?
Assess the heart size. It should be less than 50% of the chest diameter. The cardiothoracic ratio can be used to determine cardiomegaly. Follow the cardiac contours and check for any loss of normal contours. If the retrocardiac region has an increased density which is known as the sail sign it suggests lower lobe collapse.
Check the mediastinal contours for mediastinal widening which is seen in lymphadenopathy, make note of the aorta-pulmonary window which is the dip between the aortic knuckle and the pulmonary trunk. Abnormalities may also indicate lymphadenopathy. Also check the hilae.
What does the ‘D’ in the ABCDE approach to X-rays represent?
There may be loss of normal contours in consolidation or collapse of the diaphragm. Under the diaphragm there may be gas. Assess for an NG tube entering the stomach, foreign objects, gallstones, pancreatic calcification and lumbar vertebrae.
Also assess the pleural spaces. Look for the fluid level/meniscus at the costophrenic angle. Look for Kerley B lines (interstitial fluid) around the CP angle. Pneumothorac has apical lucency and visible lung edge.
What does the ‘E’ in the ABCDE approach to X-rays represent?
Look for any bubbly lucency which may suggest subcutaneous emphysema. Look for pick lines. Look at the bones to check for fractures.
What are the features of Torsades de pointes?
Torsades de pointes is known as twisting of the peaks which is QTc prolongation which can be fatal. Check for drug-induced prolonged QT interval. Drugs which can cause this include antiarrythmics (Disopyramide, procainamide, quinidine and sotalol) but also macrolides, fluroquinolones, antifungals, antipsychotics, antiemetics, opioids and antidepressants such as Citalopram and Escitalopram. Beware of cocaine.
Risk factors include bradycardia, congestive heart failure with poor LV function, previous MI, female gender, over 65, chronic renal impairment, hyperkalaemia and diuretic treatment.
What are the causes of wide complex tachycardias?
The QRS widens as the normal ventricular depolarisation through the His-purkinje system is either impaired or bypassed, and the ventricles rely on the myocyte-myocyte currents for depolarisation which is much slower.
The common causes of Wide complex tachycardia include ventricular tachycardia, supra ventricular tachycardia with aberrant conduction and pre-excitation tachycardia which is seen in people with Wolfe Parkinson White Syndrome.
Aberrant conductions include bundle branch blocks, hyperkalaemia and sodium channel blocking drugs.
Describe ventricular tachycardia
A ventricular tachycardia on ECG will have very broad complexes (>160), extreme axis deviation, AV dissociation, capture beats, fusion beats, positive or negative concordance through the chest leads and brugada algorithm. A capture beat is when the SA node transiently captures the ventricles in the midst of AV dissociation and fusion beats are when the sinus and ventricular beats coincide.
How should wide complex tachycardia be treated?
Acute management depends on the hemodynamic stability of the patient. If they are unstable the patient will need immediate electrical synchronised DC cardioversion. Wide complex tachycardia can be caused by hyperkalaemia which requires emergency treatment with calcium and sodium bicarbonate.
What are the complications of uncontrolled hypertension
LV hypertrophy, heart failure, CKD, stroke, vascular dementia and retinopathy
Why is microalbuminaemia important?
Microalbuminuria is vital as it can alert the physician to vascular disease at other sites of the body in addition to the kidney. It is the earliest detectable sign of diabetic nephropathy and at this stage it is potentially reversible. It is a risk factor for other cardiovascular events as well and antihypertensive treatments can be vital in renal protection, especially ACE inhibitors as they effect the RAAS system.
