04. KFP: Case Practice Flashcards
(103 cards)
1
Q
Treatment for chronic stable psoriasis on the trunk and limbs?
A
Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month
2
Q
Management of an acute flare of psoriasis?
A
Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month [tar preparation is preferred for maintenance because it is easier to apply over larger surfaces]
PLUS
Methylprednisone aceponate 0.1% cream, ointment or fatty ointment topically, daily until skin is clear (usually two to six weeks)
IF RESPONSE TO TREATMENT IS INADEQUATE AFTER 3 WEEKS, USE A MORE POTENT TOPICAL CORTICOSTEROID:
* betamethasone dipropionate 0.05% cream or ointment topically, daily until skin is clear (usually 2 to 6 weeks)
3
Q
Management of Psoriasis with only a few scattered plaques that do not respond to a tar preparation, or need longer term control with the topical corticosteroid?
A
Calcipotriol + betamethasone dipropionate 50 + 500microg/g Topically, daily until skin is clear (usually about six weeks)
4
Q
When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for dry and sensitive skin?
A
Topical retinoid creams
5
Q
When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for oily skin?
A
Topical retinoid gel
6
Q
What is the treatment for mild acne that is mainly comedonal with minimal inflammation?
A
Options (topical retinoids):
* adapalene 0.1% gel topically, daily at night for six weeks then review
* Tretinoin 0.025% cream topically, daily at night for six weeks then review
* Trifarotene 0.005% cream topically, daily at night for six weeks then review
7
Q
Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules
A
Benzoyl peroxide + adapalene 2.5% + 0.1% gel topically, daily for 6 weeks, then review
8
Q
Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules
that is not improving but well tolerated on topical combination therapy?
A
Benzoyl peroxide + adapalene 2.5% + 0.3% gel topically, daily for 6 weeks, then review
9
Q
Management of mild acne that is mainly inflammatory papules and pustules, with some comedones?
A
Benzoyl peroxide + Clindamycin 5% + 1% Gel topically, daily for six weeks then review
10
Q
What is the management of mild acne that is a mix of both comedonal an inflammatory papules and pustules?
A
Tretinoin + clindamycin 0.025% + 1% gel topically, daily at night for six weeks
11
Q
What counselling points would you discuss when starting a patient on topical retinoids?
A
- Introduce gradually because it can irritate the skin initially
- Apply every second night (after washing with a low irritant, ph balance, soap free cleanser) for the first two weeks, then apply every night
- Apply the product to the whole area affected by acne, not just to single lesions
- Remove the product by washing the face in the morning because topical retinoids can increase the skin sensitivity to sunlight
- Choose a cream formulation for patients with dry or sensitive skin, and gel formulation for those with oily skin
12
Q
What is the management for facial, flexural and scrotal seborrheic dermatitis?
A
- Use a low irritant skin cleanser
- Hydrocortisone+clotrimazole 1%+1% cream topically, once or twice daily until the skin is clear or for two weeks
- Facial seborrheic dermatitis: wash hair often with an anti yeast shampoo to reduce the yeast burden on the scalp (should contain ketoconazole, selenium sulfide, zinc pyrithione or coal tar)
13
Q
What’s the difference between the butterfly rash of facial seborrheic dermatitis versus systemic lupus erythematosus?
A
- Both are associated with erythema and scaling
- Facial seborrhoeic dermatitis: fix the medial aspect of cheeks, the nose and the nasal labial folds
- SLE: The rash usually spares the nasolabial folds
14
Q
What are reasonable investigations to order in an elderly patient with pruritus without a rash?
A
- Full blood count
- Renal function and electrolytes
- Liver function
- Fasting glucose
- Thyroid function studies
15
Q
Management of generalised itch?
A
- Wet dressings or Quick, cool showers (<2-3 minutes)
- Soap-free substitutes in the shower
- Patting dry skin (hence avoiding vigorous rubbing)
- Liberal use of emolllients on damp skin, after the shower (preferably out of the tub or jar rather than a pump)
- Avoiding excessive heating in winter
- Using a humidifier if possible to enhance ambient indoor humidity, especially in try, cold winter months
- Avoiding use of electric blankets in bed
- Minimising direct contact with woollen and synthetic garments
- Keeping fingernails trimmed short to minimise complications from scratching
- Calamine lotion (contains phenol, which cools the skin) - avoid on dry skin and limit to only a few days
- Topical treatments include antipruritic such as methol 1% in aqueous cream
- Trial antihistamines if predominantly urticarial symptoms
16
Q
Differentials for itch without rash?
A
Skin pathology
* Xerosis (dry skin)
* Scabies
* Dermographism
* Urticaria not apparent at time of examination
Nerve compression or neuropathy
* Notalgia paresthetica
* Meralgia paresthetica
* Brachioradial pruritus
* Vulvodynia
Systemic conditions
* End stage kidney disease
* Cholestasis
* Pregnancy
* Thyroid dysfunction
* Iron deficiency
* Coeliac disease
* Intestinal parasitic infections Eg strongyloidiasis (roundworm)
Adverse effects of drugs and topical irritants
* Opioids
* NSAIDs
* Statins
* Angiotensin converting enzyme inhibitors
* Diuretics
* Recreational drugs Eg methamphetamine
* Soaps, detergents, chlorine and other irritants
Malignancy and haematological disease
* Lymphoma, particularly hodgkin’s disease
* Leukaemia
* Polycythemia rubra vera
* Multiple myeloma
* Disseminated carcinoma
Neurological disorders
* Multiple sclerosis
* Brain tumour, abscess, infarct
* Parkinson disease
Psychological and psychiatric conditions
* Stress
* Anxiety
* Depression
* Phobic disorders eg delusional parasitosis
* Obsessive compulsive disorder
* Hypochondriasis
17
Q
Management of rash caused by dermographism?
A
Oral antihistamine
18
Q
Pharmacological management of each without rash in these settings?:
1) Itch without rash on trunk or limbs?
2) Itch without rash on face?
3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?
A
1) Itch without rash on trunk or limbs?
* Betamethasone valerate 0.02% cream topically, twice daily for two weeks
2) Itch without rash on face?
* Hydrocortisone 1% cream topically, twice daily for two weeks
3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?
* Doxepin 10 to 20 mg (adult only) PO, daily at night for 2 weeks - do not mix with a sedating antihistamine because this may result in increased adverse effects eg anticholinergic effects, sedation
19
Q
What are the indications for acyclovir in the setting of chickenpox?
A
- Premature neonates
- Neonates less than 7 days of age
- Immunocompromised children
- Children with systemic or central nervous system disease
- Unvaccinated child age > 12 years
- Severe eczema
- Chronic pulmonary disease
- Children on salicylate therapy
- Children on oral steroid therapy
- Secondary cases in household contacts, as these are usually more severe
20
Q
What is the management for contacts of chickenpox?
A
- Age 1 month - 1 year: if not at risk of complications, observation. If at risk, consider VZIG
- Age > 1 year: if within 5 days of exposure and no contraindications to vaccine, give VZV vaccine
21
Q
What is the vaccination course for chickenpox?
A
- Children <14 years are recommended to receive two doses of varicella containing vaccine (4 or more weeks apart)
- Usually, the first dose is given at 18 months of age as the MMRV vaccine
- But, children can receive varicella-containing vaccine from as young as 12 months of age (incase they are a contact)
- Note: MMRV vaccine is not recommended as the 1st dose of MMR-containing vaccine in children < 4 years due to the small but increased risk of fever
22
Q
What is the cause of slapped cheek rash (5th disease)?
A
Parvovirus B19
23
Q
Signs and symptoms of slapped cheek (5th disease)?
A
- Prodrome: fever, headache, stomach upsets, aches and pains
- Bright red rash appears on the cheeks after a few days
- Secondary pink lace pattern rash may appear on chest, back, arms and legs
- The rashes can come and go for several weeks, or even months, especially if the skin is exposed to sunlight or after exercise
24
Q
How long is Slapped Cheek (5th disease) contagious for?
A
- Infectious period: until 24 hours after the fever has resolved - non-infectious after this period even while having a rash
25
What is hairy tongue? What are its clinical features? What may cause it?
* It is a harmless condition characterised by a hairy enlargement and discoloration of the filiform papillae of the tongue
* Coloured, usually brown or black, although brown, yellow and green have also been described
* Usually asymptomatic in the main problem is it's unsightly appearance
* Hairy tongue is due to defective shedding of surface cells
* Potential causes: chlorhexidine mouthwash, after a course of antibiotics or in patients who have limited oral intake
26
What is the management of hairy tongue?
It is usually self-limiting but treatment options include:
* Avoiding smoking and excessive alcohol intake
* Discontinuing responsible drugs
* Encouraging good oral hygiene
* Gentle tongue debridment, with a tongue scraper or soft toothbrush and solution containing 3% hydrogen peroxide Or baking soda
* Antiseptic mouthwash
* Topical antifungal if candida albicans is present
* Topical retinoid
27
What is a fixed drug eruption?
* Fixed drug eruption is a distinctive cutaneous allergic reaction that characteristically recurs at the same site on re-exposure
* It is usually due to oral medications, most commonly with antimicrobials and non-steroidal anti inflammatory drugs
28
What are the clinical features are fixed drug eruption?
Categories based on clinical morphology:
* Localised pigmenting type
* Bullous (localised or generalised)
* Non-pigmenting
* Generalised
* Drug eruption typically presents as a single (or small number of) well defined, round or oval red or violaceous patch or plaque which may blister or ulcerate
* It is usually asymptomatic but can be itchy or painful
* Over days and weeks, the surface may become scaly or crusted before peeling, and the colour fades to leave brown post inflammatory hyperpigmentation
* The patient remains systemically well
* Common sites: Hands and feet, eyelids, and anogenital areas
* On the 1st occasion, eruption may develop after weeks to years of regular ingestion of the drug, but subsequent episodes develope within minutes to hours of recommencing the implicated drug
* With subsequent episodes, the original patch may enlarge and more patches may appear
* The post inflammatory pigmentation darkens with each recurrence
29
What is the treatment for fixed drug eruption?
* Discontinuation of suspected medication
* Avoiding implicated medication indefinitely
* Topical steroids or systemic corticosteroids
* Generalised bullous fixed drug eruption requires intensive care or burns unit
30
What is neonatal cephalic pustulosis (AKA neonatal acne)?
* It is a common transient eruption in infants age three to six weeks
* It's caused by a temporary overgrowth of malassezia species (fungi)
* Appearance: Tiny monomorphic pusutles, often on an erythematous base
31
What is the difference between neonatal cephalic pustulosis versus infantile acne?
* Although there are tiny monomorphic pustules, often with an erythematous base, neonatal cephalic pustulosis does not have comedones (i.e. blackheads and whiteheads), whereas infantile acne does
* Neonatal cephalic pustulosis is also limited to the face
* Neonatal cephalic pustulosis presents much earlier at 3-6 weeks whereas infantile acne presents 6-16 months
32
What is the treatment of neonatal cephalic pustulosis?
Resolves in a few weeks without treatment, however responds quickly to a topical imidazole
Options:
* Clotrimazole 1% cream topically, twice daily
* Ketoconazole 2% cream topically, twice daily
If lesions appear very inflamed or itchy, add:
* Hydrocortisone 1% cream topically, twice daily until skin is clear (usually 2-3 days)
33
What is granuloma annulare and its clinical features?
* Granuloma annulare is common inflammatory skin condition typified clinically by annular, smooth, discoloured papules and plaques, and necrobiotic granulomas on histology
* The surface is smooth and the centre of each ring is often a little depressed
* Localised granuloma annulare usually affects the fingers or the backs of both hands, but is also common on top of the foot or ankle, and over one or both elbows
34
How would you differentiate between granuloma annulare and other ovoid rashes?
There is a lack of surface scale compared to other scaly rashes such as discoid eczema or psoriasis or tinea
35
What is the management of granuloma annulare?
Lesions usually clear spontaneously, but may persist for months or years
Options - topical corticosteroid with or without occlusive dressings
* Betamethasone dipropionate 0.05% ointment topically, twice daily for a minimum of four to six weeks
* Mometasone furoate 0.1% ointment topically, twice daily for a minimum of four to six weeks
36
What is the management of onychomycosis?
* First line: terbinafine 250mg orally, once daily until clinical clearance
* Measure liver function test at baseline and at 4-6 weeks (but earlier at two weeks in high risk patients or if clinically indicated)
* Review after 3 months of treatment (note: most nails with extensive onychomycosis still look abnormal after 3 months of treatment because a new nail takes 9-12 months to grow)
* Make a scratch with a scalpel blade at the proximal end of the dystrophy after three months of treatment so the patient can follow the scratches the nail grows out
37
What are the clinical features of flexural psoriasis?
* Shiny and smooth due to the moist nature of the skin folds - therefore it is different to the usual silvery scale of plaque psoriasis
* There may be a crack or fissure in the depth of the skin crease
* The deep red colour and well defined borders characteristic of psoriasis may still be obvious
38
How can you differentiate between flexural psoriasis and seborrheic dermatitis in skin folds?
Seborrheic dermatitis in skin folds tends to present as thin salmon-pink patches that are less well defined than psoriasis
39
What is the management of flexural psoriasis, including genital psoriasis?
Initial: methylprednisolone aceponate 0.1% ointment or fatty ointment topically, daily until skin is clear (may take several weeks), but for no longer than two weeks in a child wearing nappies
* For a child who was still wearing nappies, add an anticandidal cream to the topical corticosteroid eg nystatin
Maintenance (when there is some rash but no excoriation or inflammation):
* LPC 2% in emulsifying ointment topically, daily
* For a child who was still wearing nappies, LPC can be formulated in zinc cream
40
What are some differentials for intertrigo (rash in the flexures)?
Flexural psoriasis - well defined, smooth or shiny red patches; symmetrical
Seborrheic dermatitis - ill-defined salmon pink thin patches
Atopic dermatitis - very itchy
Thrush - rapid development, itchy, moist, peeling, red and white skin
Erythrasma - Corynebacterium minutissimum; persistent brown patches
Tinea - slowly spreads over weeks to months; irregular annular plaques
41
Characteristics of rash: varicella?
* Affects: scalp, eyelids, knows, mouth
* Pleomorphism of rash
* Centripetal distribution - more focused on trunk
* Pruritic rash
42
Characteristics of rash: erythema infectiosum?
* Erythematous slapped cheek appearance in well child
* Erythematous rash, mainly on forearms and thighs
* Possible lymphadenopathy
43
Characteristics of rash: rubella?
* Rash firsts appears on neck and face
* Scattered rash on body
* Postauricular lymphadenopathy
44
Characteristics of rash: Scarlet fever?
* Circumoral pallor - around the mouth
* Strawberry tongue
* Background erythema with tiny fine superimposed puncta (scarlet spots)
* Pastia lines - the accumulation of papules along the flexures
45
Characteristics of rash: measles?
* Red, watering eyes (conjunctivitis)
* Runny nose (coryza)
* Blotchy maculopapular rash
46
What is the cause of roseola infantum?
Virus from the herpes group
47
Clinical features of roseola infantum (sixth disease/exanthem subitum)?
* Usually lasts around four days
* Symptoms are so mild that parents do not realise their child is infected
* Affects children aged between six months - 2 years
* Sudden high fever, usually last between 3-5 days
* Raised red rash can develop when temperature returns to normal
* Rash usually appears on the body and spreads through the arms and legs; it is rarely seen on the face
48
When is roseola infantum infectious?
* Children with roseola infantum can only spread the infection before the fever and/or rash occur
* Once a child has symptoms, they are no longer contagious
49
Clinical presentation of shingles?
* It is characterised by rash that presents with blisters in a dermatomal distribution on an erythematous base
* The blisters erupt over a week and then he'll over two weeks
50
When is antiviral therapy indicated in shingles?
* Immunocompetent adults and adolescents who present within 72 hours of onset of rash
* All immunocompromise adults in adolescence (including those with hiv infection) regardless of duration of rash
51
What are the first line options for pharmacotherapy in shingles?
* Valaciclovir 1g orally, 8hourly for seven days
* Famciclovir 500mg orally, 8hourly for seven days. For immunocompromise patients, the duration is 10 days
52
What are the options for pain management in shingles?
Neuropathic pain:
* Lidocaine 5% patches - They cannot be used on broken skin or lesions
* Gabapentinoids two, or as an alternative to, lidocaine 5% patches
Nociceptive:
* Mild: paracetamol or non steroidal anti inflammatory drugs
* Moderate to severe: Prednisolone 50mg orally, in the morning for seven days
53
What is erythema nodosum?
* Erythema nodosum is a type of panniculitis (an inflammatory disorder affecting subcutaneous fat) from a hypersensitivity reaction
* It presents as tender erythematous indurated plaques and nodules, usually on the shins
* Lesions typically resolve over two to three weeks, leaving discoloration but no scarring
54
What are the causes of erythema nodosum?
Idiopathic (55% of cases)
Infection:
* Throat infections eg streptococcal disease or viral infection
* Chlamydia infection
* Primary tuberculosis
* GIT bacteria: Yersinia, Campylobacter, Salmonella
* Fungal infection eg histoplasmosis, coccidioidomycosis
* Parasitic infection eg amoebiasis, giardiasis
Drugs:
* Amoxicillin
* Oral contraceptive
* Non steroidal anti inflammatory drugs
* Sulfonamides
Inflammatory
* Inflammatory bowel disease
* Sarcoidosis
* Malignancy
* Lymphoma
* Leukaemia
Other:
* Pregnancy
55
What are some investigations you may consider for the workup of erythema nodosum?
* FBC, ESR, EUC, LFT,
* Throat swab
* Streptococcal serology (ASOT, Anti-DNAse B)
* Chest XR
* Biopsy is usually not required but if done, needs to be deep and include fat - biopsy of inflammatory lesions on the lower legs is often associated with scarring and slow healing
56
What is the management for erythema nodosum?
Usually heals over two to three weeks
If symptoms are severe and the patient has no contraindications:
* Prednisolone 25mg daily PO for 2 weeks, then taper the dose according to response
57
What is the cause of cutaneous lupus erythematosus?
* Genetic susceptibility
* Environmental factors: cigarette smoking, sun exposure, medications
* Innate and adaptive immune responses: autoantibodies
58
What is the characteristic rash of localised acute cutaneous lupus erythematosus?
Malar butterfly rash - redness and swelling over both cheeks, sparing the nasolabial folds, lasting hours to days
59
What is the characteristic rash of generalised acute cutaneous lupus erythematosus?
Diffuse or papular erythema of the face, upper limbs (sparing the knuckles), and trunk resembling a morbilliform drug eruption or viral exanthem
60
What are some clinical features of nail psoriasis?
* Nail pitting: Superficial depressions in the nail plate
* Leukonychia: 1-2mm wide white bands that involve more than one nail and are due to the internal desquamation of parakeratotic cells
* Oil spots or salmon patches: Translucid discoloured red-yellow patches located on the nail plate
* Onycholysis: separation of the nail plate from nail bed
* Subungal hyperkeratosis: yellow and oily nails that result from raising the nail plate off the nail bed as a result of deposition of keratinocytes
* Splinter haemorrhages: small, linear structures, 2-3mm long, at the distal end of the nail plate
61
What might nail psoriasis indicate?
* It is highly associated with psoriatic arthritis even in the absence of skin involvement
* It is a market for more severe skin manifestations as well as joint involvement
62
What is the management of nail psoriasis?
Cool therapy for psoriasis of the nails is difficult and often unsuccessful
For a motivated patient, try:
* Calcipotriol + betamethasone diproprionate 50+500microg/g ointment topically, in proximal nail fold and under nail, nocte for up to 3 months
For psoriasis presenting as onycholysis or subungal hyperkeratosis, an alternative is to use a potent topical corticosteroid lotion:
* Mometasone furoate 0.01% lotion topically, once daily under the nail for up to 3 months
If treatment is unsuccessful, refer for dermatologist advice
63
What may dermoscopic features of subungual haemorrhage include?
* Homogenous or variable colours (reddish, purple, brown, or black)
* Peripheral globular structures (clods) and streaks
* Roundish shape with peripheral fading
* Linear white marks on the nail plate due to loss of transparency
* Distal yellowing of the nail plate
* Lack of malignant features - irregularity in pigmentation, irregularity in the midth and spacing of the pigmented bands, ulceration or bleeding, Hutchinson sign where there is pigmentation in the skin proximal to the nail plate
64
What are some differential diagnosis for nail pigmentation?
* Subungal haemorrhage
* Nail unit melanoma originating from the proximal nail matrix
* Benign melanonychia due to a melanocytic naevus or lentigo in the proximal nail matrix
* Nail fold infection e.g. pseudomonas, dermatophyte, yeast, mould
* Drug-induced nail diseases - usually affects multiple nails
* Exogeneous pigment e.g. henna, potassium permanganate, ink, dye
* Inflammatory skin disease eg psoriasis, eczema, lichen planus
65
What are some features of nail unit melanoma?
* Appears as a pigmented linear or triangular band along the entire length of the nail plate
* Irregularity in pigmentation (light brown, dark brown, grey, or black)
* Irregularity in the width and spacing of the pigmented bands
* Ulceration or bleeding
* Hutchinson sign (pigmentation in the skin proximal to the nail plate) and micro-Hutchinson sign (skin pigmentation visible on dermoscopy but not on clinical examination)
* Nail dystrophy (cracking or deformity of the nail)
66
What is oral hairy leukoplakia?
Oral hairy leukoplakia is an epstein barr virus infection of the tongue with a characteristic corrugated or shaggy appearance seen most commonly in immunocompromised patients
67
What are the clinical features of oral hairy leukoplakia?
* Asymptomatic white plaques on the lateral tongue which do not wipe off
* Can be unilateral or bilateral
* Rarely also seen elsewhere in the oropharynx but not on other mucosal surfaces
68
What are some differential diagnosis for oral hairy leukoplakia?
* Oral candidiasis
* Oral lichen planus
* Geographic tongue
69
What are the complications of oral hairy leukoplakia?
* Oral hairy leukoplakia associated with HIV infection is a sign of severe immunosuppression and progression to AIDS
* Secondary candida cases can obscure the clinical and histological features of OHL
* OHL is not a pre-malignant lesion
70
How is oral hairy leukoplakia diagnosed?
* Diagnosis should be confirmed on biopsy
* In situ hybridization for EBV DNA or RNA can also be performed under surface scraping or smear
71
What are some common risk factors for oral candidiasis?
Local Factors:
* Dentures
* Saliva gland hypofunction
* Could steroid inhalers
* Poor oral hygiene
* Smoking
Systemic factors
* Immune compromise e.e. poorly controlled diabetes, HIV/AIDS
* Drugs e.g. Systemic corticosteroids, antibiotics
72
What are the first line pharmacotherapy options for oral candidiasis
* Amphotericin B 10mg lozenge sucked (then swallowed), four times daily, after food, for 7-14 days; continue treatment for 2-3 days after symptoms resolve
* Miconazole 2% gel 2.5mL topically (then swallowed), four times daily, after food, for 7-14 days; continue treatment for 7 days after symptoms resolve
73
What is pseudofolliculitis barbae?
* It is a common inflammatory reaction of the hair follicle, most often on the face as a result of shaving
* It is caused by intrafollicular or transfollicular penetration of tight curly hair
74
What is the treatment and prevention for pseudofolliculitis barbae?
General Measures:
* Ensure proper shaving technique - shave in the direction of the follicle; do not stretch the skin; use short strokes; use sharp blades; avoid shaving in the same area twice
* Washing the skin with warm water and soap-free cleanser before shaving
* Reduce shaving activity e.g. only every other day
Specific Measures:
* Topical acne treatments such as benzoyl peroxide and tretinoin are used to suppress follicular hyperkeratosis - benzoyl peroxide 5% gel or solution topically, twice daily
* Topical steroid cream and/or topical antimicrobials - reduce mild inflammation and itching - benzoyl peroxide + clindamycin 5% + 1% gel topically, once daily
75
What is folliculitis barbae?
* Folliculitis barbae is an itchy and sometimes tender papulopustular eruption of hair follicles in skin
* Most often due to staphylococcus aureus
76
What is the treatment for folliculitis barbae?
General Measures:
* Encourage use of disposable razors or cleaning electric shavers with alcohol based antiseptic solution
Specific Measures:
* Topical antibiotics e.g. clindamycin, mupirocin - limited folliculitis barbae
* Oral antibiotics e.g. flucloxacillin or doxycycline - more wide-spread or refractory folliculitis barbae
* Antiviral and antifungal topical therapies if viral or fungal causes are suspected
* Typical hydrocortisone cream may be helpful to reduce inflammation and itching
77
How would you assess someone's blood alcohol content on physical examination?
* Dysarthria / nystagmus / ataxia / unsteady gait / incoordination - cerebellar impairment
* Condusion / GCS / Level of consciousness / incoherent thoughts
* Impaired judgment
* Tachycardia / hypotension
* Respiratory depression
* Memory impairment
78
Investigations to assess the impact of excessive alcohol intake?
* FBC
* LFT
* EUC
* Albumin
* INR
* Ferritin
* Vitamin B12
* CMP
79
Non-pharmacological management for alcohol reduction?
* Try drinking only at meal times
* Substitute every other drink of alcohol with a non alcoholic beverage
* Use smaller glass sizes
* Drink lower alcohol content beverages
* Limit going to places or occasions where drinking is commonplace
* Keep less alcohol at home
* Monitor alcohol intake or count drinks
* Keep a drinking diary to monitor circumstance or mood around drinking
* Sign up for alcoholics anonymous for ongoing support
* See a psychologist for cognitive behavioural therapy
80
Pharmacological management of longterm alcohol reduction with the aim of abstinence?
* Disulfiram daily PO - 100mg
* Acamprosate TDS PO - 666mg
* Naltrexone daily PO - initially 25mg
81
Congenital causes of hypotonia without other obvious physical examination findings?
* Prader-Willi syndrome
* Klinefelter syndrome
* Spinal muscular atrophy
* Muscular dystrophy
* Global developmental delay
82
What conditions are tested for on newborn bloodspot/Guthrie test?
* Phenylketonuria
* Hypothyroidism
* Cystic fibrosis
* Congenital adrenal hyperplasia
83
Clinical features of Prader-Willi syndrome in infancy?
* Hypotonia
* Feeding difficulties or poor weight gain
* Genital hypoplasia
* Reduced foetal movements
* Motor developmental delay
* Weak cry
84
Clinical features of normal pressure hydrocephalus?
* Wacky: dementia
* Wobbly: wide based gait
* Wet: urinary incontinence
85
Aspects of examination you would look for in female urinary incontinence?
* Elevated BMI
* Abdominal mass
* PV exam for pelvic organ prolapse
* Assessment of pelvic floor muscle strength
* Cough test for urinary incontinence
* Lower limb neurological examination for weakness
* Gait assessment - for glue footed / wide based gait - normal pressure hydrocephalus
86
Non-pharmacological management of urinary incontinence?
* Refer to physiotherapist for pelvic floor strengthening
* Commence bladder training / timed urinary voices / avoid going to the toilet as a precaution
* Reduce/eliminate caffeine intake
* Aim healthy BMI between 18-25
* Eat adeqaute dietary fibre to minimise constipation
87
Pharmacotherapy for urinary incontinence?
* Oxybutynin 5mg TDS PO
* Solifenacin 5-10mg daily PO
* Mirabegron 25-50mg daily PO
88
Truncal rash differentials
* Pityriasis rosea
* Guttate psoriasis
* Tinea corporis
* Discoid eczema
* Non-specific viral exanthem
* Seborrhoeic dermatitis
* Secondary syphilis
89
What condition has a herald patch?
Pityriasis rosea
90
Differentials for recurrent pregnancy loss?
* Antiphospholipid syndrome
* Hypothyroidism
* Diabetes mellitus type 2 - if poorly controlled
* Uterine leiomyoma
* Septate uterus
* Idiopathic
* Chromosomal abnormality in either partner
91
Female investigations for recurrent pregnancy loss?
* Pelvic USS with sonohysterography
* Karyotype
* TSH
* Fasting glucose
* Anti-beta2 glycoprotein
* Lupus anticoagulant
* Anticardiolipin antibodies
92
Advice for recurrent pregnancy loss?
* Referral to fertility specialist for further treatment of recurrent pregnancy loss
* Test for anti-TPO antibody
* Suggest waiting until after next normal period before trying to conceive again
* Advise to limit caffeine intake to maximum 3 serves per day
* Advise weight loss aiming for BMI 18.5 - 25
* Offer emotional support or provide contact information for pregnancy loss support services - pink elephant/PANDA
* Cease smoking and alcohol and illict substance use
93
History questions to assess for risk factors for minimal trauma fracture?
* How much alcohol do you drink?
* Do you smoke?
* Do you get adequate sunlight exposure / 15 min per day of sunlight exposure / take regular vitamin D supplements?
* Do you have a sedentary lifestyle or low levels of physical activity?
* Menopause before 45 years old?
* Family history of minimal trauma fracture / osteoporosis?
* Do you have atleast 4 serves of dairy or 1300mg of calcium/day?
94
Differentials for delayed menstruation?
* Hypothalamic amenorrhoea or functional amenorrhoea - excess exercise, low BMI, psychological stress, severe chronic illness
* Constitutional delay in puberty
* Polycycstic ovarian syndrome
* Hypothyroidism
* Hyperprolactinaemia or prolactinoma
* Turner syndrome
* Imperforate hymen or transvaginal septum
* Vaginal agenesis - Mullerian dysgenesis
* Non-classical congenital adrenal hyperplasia OR Cushing syndrome - adrenal disease
95
History questions to ask when evaluating delayed menarche?
* Family history of delayed menarche - constitutional delay in puberty
* Undergone pubertal growth spurt or breast development or axillary/pubic hair development - clue for oestrogen deficiency
* Significant difference in height compared to other family members - Turner's syndrome are short
* Problems with acne or hirsutism - PCOS
* Any galactorrhoea or recurrent headache or visual changes - pituitary mass/prolactinoma
* Cold intolerance or unintentional weight gain - hypothyroidism
* Cyclical abdominal pain - imperforate hymen
* Body image concerns or frequeny/intensity of physical activity or caloric restriction or intentional weight loss - screening for anorexia nervosa causing functional amenorrhoea
96
Differentials for short stature in 5 year old boy with normal exam, slightly behind in class, meeting milestones and not losing weight?
* Constitutional growth delay
* Genetic short stature
* Hypothyroidism
* Hypopituitarism
* Growth hormone deficiency
* Coeliac disease
97
Investigations for slow weight gain?
* Urine MCS and culture
* FBC, ferritin, EUC, TSH, LFT, glucose
* Coeliac serology and total IgA
* Micronutrients - including vitamin B12
* Stool microscopy, fat globules, fatty acid crystals
* Children older than 12 months: ESR, faecal calprotectin
98
Differentials for hand rash?
* Contact irritant/allergic dermatitis
* Eczema (+/-infected) or nummular eczema
* Tinea manuum
* Photophytodermatitis
* Palmoplantar psoriasis
99
Clinical features of lithium toxicity?
* GI: nausea, vomiting, diarrhoea
* CNS: tremor, hyperreflexia, ataxia and dysarthria
* CVS: QT prolongation and hypotension
100
Management options for chronic regional pain syndrome?
* Reduce opioids
* Commence SNRI e.g. duloxetine
* Commence gabapentinoid e.g. pregabalin
* Commence corticosteroids e.g. prednisone
* Commence anti-epileptic e.g. topiramate
101
Differentials for transient unilateral vision loss?
* Giant cell arteritis
* Carotid artery disease or thromboembolism
* Retinal vein occlusion
* Retinal vasospasm/retinal migraine
* Optic nerve compression by a lesion
* Idiopathic amaurosis fugax
102
Differentials for bitemporal hemianopia with intracranial mass?
* Pituitary adenoma
* Craniopharyngioma
* Meningioma
* Malignant sellar tumour - lymphoma
* Benign sellar mass - cyst
103
