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Clinical med Exam 1

Terms in this set (118)

Tinea Pedis
Most common dermatophyte infection. M>F. Hot, humid weather, occlusive footwear, interdigital presentation. Can go to deeper nail involvement "athlete's foot". Topical azoles or allylamines (aerosols)
Effect of Corticosteroids
Reduce inflammation, decreases mitosis in hyperketatotic cells, constricts blood vessels
Contraindication for systemic antifungal tx (Azoles, Terbinafine, Allylamines)
Any eleveation of GGT (alcohol use) because hepatotoxicity and drug interactions are high risk. Pregnancy
Seborrheic dermatitis
Sebacous gland overactivity. Greasy, yellow-brown scales. Active sebaceous gland areas: Scalp, nasal labial folds, chin, upper back.
Psoriasis
Sharp or well demarcated papules and plaques covered with slivery scales. Symmetrical lesions. Elbows, knees, scalp or NAIL involvement = diagnosis.
Atopic dermatitis
Erythema, scaling-dry, lichenification, pruitus. Family hx (atopic dermatitis, asthma, allergic rhinitis). Flexor surfaces in adults; extensor surface in children. "Itch that rashes". Avoid heat, low humidity, perspiration.
Tx of psoriasis
No 100% cure; emollients. Phototherapy, topical corticosteroids (short term), Tacrolimus, primecrolimus. System tx for failed 6 mo conservative tx, (methotrexate-dangerous s/e's)
Tinea Corporis
Scaly annular patch, CENTRAL CLEARING, sharp demarcation of the lesion.
Contact dermatitis
reaction to irritant/allergen. localized erythema & pruritus. Unknown or known offender. Use corticosteroids.
Best Rx for hair or nail involvement of a dermatophyte infection
Griseofulvin
Time frame for systemic antifungals to take effect
2 weeks - 18 months! (counsel and reassure)
Pityriasis Rosea
"Christmas tree distribution", Herald patch- single, pink/salmon lesion that precedes other eruptions. Very common in young adult males
Acne Vulgaris
Pilosebaceous unit inflammation on the face. Process: 1) follicular hyperkeratinization + desquamation; 2) increased sebum 3) Propionibacterium acnes PROLIFERATION 4) follicular rupture & inflammatory response (pustular, erythema)
Tinea versicolor
Non dermatophyte infection, caused by yeast Malassezia furfur
Tinea Curis
Dermatophyte infection of the pubic, groin & thigh area. Caused by excessive moisture & tight clothing- traps moisture in, obese folds. Associated w/ tinea pedis. M>>W; SPARES SCROTUM
Acne vulgaris exacerbating factors:
Endrocrine hormones + bacteria, emotional stress, pressure on face w/hands, NOT chocolate, pizza, grease
Onychomycosis
Deep invasion of tinea unguium into the nail bed. Nails become opacified and thickened, requires systemic Rx (deep): azoles. Predisposition in athletes like gymnists, runners.
Tx of acne vulgaris
Goals: decrease sebum, eradicate bacteria, regulate hormones, dry skin. Topical antibiotics (Clindamycin, erythromycin), benzoyl peroxide gels (OTC), Topical retinoids (decrease production of sebum) Combination tx is best. Oral Abx, OCPs, Accutane - for nodulocystic acne- worst case scenario
Rx for acne vulgaris that is a known teratogen
Accutane
Acne Rosacea
Central face involvement (the capillaries) Hyperplasia of the epithelium. Nasal involvement (Rhinophyma), earlobe involvement. Chronic central facial erythema, pronounced flushing, >30y/o. No good tx; use of Flagyl (ABx)
Exacerbating factors of acne rosacea
Anything that increases vascular flow: Hot liquids, spicy foods, alcohol, exposure to sun and heat, emotional stimuli, exercise.
Folliculitis
SUPERFICIAL infection of the epidermis of hair follicles. Staphylococcus aureus, yeast, pseudomonas aeruginosa. Hot compress, clean area, topical abx or antifungal.
Carbuncle/ Furuncle
Carbuncle: more then one follicle becomes infected and forms a conglomerate mass. Furuncle: deeper infx of hair follicle into the dermis and subcutaneous layer. Furuncle= huge boil. Require I&D
Impetigo
Honey colored crust around nasal labial folds to periorbital region caused by non-bullous streptococci (Strep pyogenes). Superficial infx. Tx: dicloxacillin or topical mupirocin ointment
Cellulitis
Localized pain, erythema, swelling, heat. Lymph node involvement
Erysipelas
Facial cellulitis. Strep pyogens. Acute onset of firey-red swelling of face or extremities; violaceous raised lesion w/well defined margins, along nasolabial fold.
Verruca
Human papillomavirus infection. Common wart, skin to skin. Sessile, dome-shaped, hyperkeratotic, small filamentous projections
Herpes Simplex
Grouped vesicles that penetrate the vermillian boarder. Tzanck smear. Tx: antivirals - acyclovir
Varicella-Zoster
Highly contagious, crops of lesions; macules-> papules-> vesicles-> pustules-> crusts (stages). Latent state (virus w/in sensory neurons of dorsal root ganglia). Systemic sxs. Tx: oral antivirals, avioid aspirin in kids
Herpes Zoster
Reactivated form of latent varicella zoster virus. Unilateral vesicular eruption within dermatome distribution. Severe pain precedes rash
Extreme complications of Herpes Zoster
Involvement of the face and eye can cause permanent blindness, postnerpetic neuralgia for 1-2 yrs.
Pediculosis
Direct or indirect contamination, must kill eggs. Lice
What does KOH preparation test for?
Deteciton of yeast or fungus
Brown Recluse spider bite
After few hrs, painful & pruritic with central induration surrounded by a pale zone of ischemia (skin and subQ) with a zone of erythema
Sources of dermatophyte infections
Animals, public shower stalls, physical contact, soils
Osteoarthritis
Advanced age, wear & tear degeneration - weight bearing joints, family hx, obesity, most common form of joint disease.
The most common systemic feature of ankylosing spondylitis is what?
Eye involvement - vision threatening uveitis
Affecting DIPs, PIPs but sparing MCPs
Osteoarthritis
Scabies
Crowded areas, intense pruitis, affects webs of fingers, burrows- linear track (where bug is traveling)
Crepitus is a physical finding of this localized joint disease
Osteoarthritis
A patient with nail pitting and joint swelling. You are concerned for
For the purpose of our test, psoriatic arthritis
Pt wakes in middle of night with inflammatory back pain. Top of your differential diagnosis:
Ankylosing spondylitis - SI joint tenderness, poor ROM, sacroiliitis, morning stiffness also
Common joints affected by OA:
PIPs, DIPs, knees, hips, C spine, L-spine, MTPs, CMC joint
Rest improves this condition whereas activity worsens it
Osteoarthritis or mechanical back strain
"Bamboo spine" is a term used to describe the appearance of fused spinal discs on X-ray. What is the probable condition of this pt?
Ankylosing spondylitis; "ankylo" = fusion, "spondylo" = spine
With a family hx of ulcerative colitis, pt complaint of chronic foot pain and an X-ray showing a bone spur, you are concerned for what rheumatologic d/o?
Psoriatic arthritis. OA also has bone spurs
With this condition is takes <30 minutes to "warm up" in the mornings
Osteoarthrtis
What will your labs on OA return?
ESR or C-reactive protein (CRP) will be normal, Rheumatoid factor, CCP Antibody -negative.
Enthesitis is:
Inflammation at a tendon's insertion site. Common in the heel, greater trochanter, and iliac crest. Seen in Psoriatic arthritis or any of the spondlyoarthritis cases
Describe an X ray of a joint affected by osteoarthritis
Joint space narrowing, asymmetry of narrowing, osteophytes, subchondral bony sclerosis or cyst formation
Inflammatory back pain and enthesis are trademarks of what disease?
Spondyloarthritis
Most common body region affected by osteoarthritis
Hands > C-spine / L-spine > Knees > Hips. Think "large" joints
Ulnar deviation is indicative of
Advanced rheumatoid arthritis (given other clinical manifestations)
Oligoarthritis, asymmetric, insidious onset, dactylitis, enthesopathy all describe what condition?
Psoriatic arthritis
Women are at a greater risk of developing this type of arthritis
Rheumatoid Arthritis 3:1, ages 30-40 y/o. Any other autoimmune mediated arthritis.
Name some constitutional sxs of RA
Fatigue, low grade fever, weight loss. Other: MI, stroke, subQ nodules, lymphoma, anemia, secondary infections, RA nodules, dry eye, scleritis, vasculitis, splenomegaly, C1/C2 subluxation
Active synovitis can be a finding of what rheumatologic condition?
Rheumitoid arthritis; destruction of the synovial joints, loss of cartilage and bone
Symmetric joint pain and long morning stiffness (>60 min) are hallmarks of what condition?
Rheumatoid arthritis
DIP joints are spared in this type of arthritis
Rheumatoid arthritis. PIPs and MCPs are usually affected.
HLA-B27 gene has been implicated in what disease?
Spondyloarthritis
Swan neck deformities are seen in what condition?
Rheumatoid arthritis
"Sausage fingers" are seen in what condition?
Psoriatic arthritis; Dactylitis
To diagnose RA you should perform what test/study?
Joint aspiration, WBC >2000; SYNOVITIS; X-rays w/ osteopenia, bony erosions, SYMMETRICAL joint space narrowing, inflammation. +Rf or + CCP does not always mean RA is present.
Who does gouty arthritis commonly affect?
Men 9x> premenopausal women. Alcohol intake, purine eaters (red meats), obesity, hyperuicemia.
Iritis, joint pain, conjunctivitis, skin lesions and scleritis all indicate what rheumatic d/o
Spondyloarthritis; specifically, Psoriatic arthritis
What is the most prevalent cause of gout?
Poor excretion of uric acid via the kidneys and urinary bladder. Having risk factors
What can't people with gout properly metabolise?
Purines which leads to monosodium urate crystals
What is the difference between crystals obtained from an aspiration of a gouty flare up and a pseudogouty flare up under polarizing light microscopy?
The gouty crystals appear needle-like or shards of glass, do not birefringe light. Pseudogout samples are rhomboid shaped and are +Birefringent (polarize light into 2 directions)
Chalky deposits of monosodium urate are known as?
Tophi. What dz are they associated with? Chronic gout
Suspicious serum uric acid level for gout is
>8 mg/dL; >6mg/dL is concerning clinically
On X-ray a patient has "punched-out" erosions on bone. This is characteristic of what rheumatologic disease?
Gout causes "rat-bite" lesions in advanced cases
A key feature of Inflammatory back pain is:
Improves with exercise; worse with rest. (Ankylosing spondylitis)
What is the most common type of skin carcinoma?
Basal Cell Carcinoma
What condition accounts for the majority of skin cancer related deaths?
Malignant Melanoma
Actinic Keratosis are seen in what condition?
Squamous cell carcinoma- the second most common cutaneous malignancy
Violaceous, raised lesions with well-defined margins on the face and high fevers indicate what condition?
Erysipelas.
An infection of the superficial layers of the skin commonly caused by invasion of Streptococcus pyogenes.
Erysipelas
"pearly" or translucent quality of a lesion on the face concerns you for what?
Basal cell carcinoma
What test would you run to rule out or confirm herpes?
Tzanc smear
What medications are used to treat ptyriasis rosea
None - there are no perfect medications for ptyriasis rosea. Pt education, reassurance and lotions are best.
Flat, distinct area of discoloration. non palpable lesion <10mm
Macule
Plateau like lesion >10mm
Plaque
Vesicles are common in what dermatologic conditions?
Herpes simplex, herpes zoster
Pustules are common of what type of dermatologic conditions?
Infected regions: acne
Urticaria is an allergic reaction composed of what type of lesions?
Wheals
What type of lesion is common from a bug bite?
Bulla. Vesicular (serous fluid or blood) >5 mm
what is the Tzanck smear for?
Herpesvirus
Patch testing in allergy tests produce what type of lesion?
Wheals
List the potency level of topical medication forms from highest potency to lowest. (Ointments, creams, lotions, gels)
Highest: ointment, Gels, Creams, Lotions
In a hyperproliferative or hyperkeratotic disease which type of medication is implicated?
Corticosteroids --> Reduce the mitotic rate, constrict small blood vessels, reduce inflmmation
Side effects of topical corticosteroids
Skin atrophy, hypopigmentation, telangiectasias, dermatitis, acneiform eruptions
S/E of systemic corticosteroids
Weight gain, immunosuppressed, sun sensitivity
For which group of dermatologic conditions should you NOT prescribe corticosteroids?
The dermatophyte infections. This will lessen the symptoms of the fungal infection, suppress the patient's immune response, allowing the fungus to proliferate.
What does this condition sound like? Inflammation & redness of the skin, Patchy scaling or thick crusts on scalp. Yellow or white flakes (dandruff) on scalp or hair, eyebrows, beard or mustache, Red, greasy skin covered with flaky white or yellow scales on other areas of body, including chest, armpits, groin or the male scrotum with associated itching or soreness
Seborrheic dermatitis
Flexor surface involvement of a scaly/flaky/erythematous rash would indicate _______, while extensor involvement of a similar rash would indicate ______?
Flexor involvement would indicate atopic dermatitis; extensor involvement would indicate psoriasis.
Make a diagnosis: patches of discoloration that may be white, pink, tan or dark brown. Slow-growing, scaly and mildly itchy. More noticeable after sun exposure. Located on the back, chest, neck and upper arms
Tinea versicolor (aka pityriasis versicolor)
Treatment for tinea versicolor
topical antifingals (azoles) or selenium sulfide shampoos, creams & lotions.
Which of the following is not a dermatophyte infection: Tinea corporis, tinea versicolor, tinea cruris, onychomycosis?
A: tinea versicolor (a.k.a. pityriasis versicolor) is caused by over proliferation of normal yeast, Malessezia furfur. Although it is treated the same as a dermatophyte infection (antifungals)
What's the diagnosis: "Grouped vesicles on an erythematous base, vesicular, penetrates vermillian border"
Herpes simplex virus
Type of fx where The epiphysis is completely separated from the end of the bone or the metaphysis, through the deep layer of the growth plate. May be undetectable on Xray unless you have comparision, then may be "widening at the physis"
Salter Harris Type-I fracture
Most common type of Salter Harris Fx, Separates all of distal end at physis and extends upward into part of the metaphysis.
Salter Harris type-II
Fx through through the epiphysis and along the physis (peds)
Salter Harris type III
Fracture line extends through the epiphysis, physis and metaphysis in pediatric cases.
Salter Harris type IV
Crush injury causes this rare type of salter harris fx. May be indistinguishable on radiography except for "loss of height" at the growth plate with comparison films.
Salter Harris type V
A fracture of the proximal 5th metatarsal is known as a Jones fracture and requires immediate surgical attention because of what?
The blood supply at this region is in the middle of the metatarsal and it would be severed proximally in the event of a fx. Necrosis could result without tx.
Gymnast reports pain in her anterior tibia that worsens with standing and improves with sitting. Plain films 2-view show no gross fracture. What is on your ddx?
Stress fracture
What is the recommended therapy for stress fractures?
Rest, say off the feet! Stop intense activities.
Pt presents with hx of FOOSH now with pain to the dorsal middle wrist with minimal localized swelling. Xrays are negative for fx. What is your dx and tx plan?
Diagnosis: wrist sprain. tx: RICE + splint
A recurrent localized swelling on the dorsal aspect of the wrist with mild TTP and no evidence of metastasis is likely what?
A ganglion cyst
What does Finkelstein's test (thumb tucked in fist and passive ulnar deviation) assess for?
DeQuervains tenosynovitis. "mother's d/o" from picking up toddlers.
What is the treatment for DeQuervains tenosynovitis?
RICE & Spica splint (thumb), cortisone
Most commonly injured ligament in an inverted ankle sprain:
Anterior talofibular ligament + Calcaneofibular ligament.
A "high" ankle sprain (eversion mechanism) like when a patient falls down stairs mainly injures which ligament? Where is tenderness?
Anterior inferior tibiofibular ligament. Tender at the medial malleolus or at the navicular bone.
What is an easy way to differentiate a grade II ankle sprain from a grade III ankle sprain?
If the patient has instability of the ankle and cannot weight-bear it is likely more severe --> grade III sprain. This is a complete tear or rupture of the ligament.
5 y/o Caucasian male presents with pain in the right thigh and knee area. He walks into the office with a limp. What are you concerned for?
Perthes disease. Unilateral dysplasia, associated avascular necrosis, femoral head death. Can progress to OA.
15 y/o Overweight, caucasian boy presents with acute onset of hip pain after a fall off bicycle. What are you thinking?
Slipped capital femoral epiphysis (SCFE). Posterior rotation of the femoral head. Refer immediately for surgical correction.
Externally rotated LE with limb shortening and unable to weight bear concerns you for?
Hip fracture. Also fx/dislocation
You see a crescent sign on MRI, what causes this and what will you do next?
Crescent sign is an ischemic area of the femoral head, visualized on MRI. This is avascular necrosis and requires immediate surgical referral.
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