Skin

“EBD”. CREAM: Apply one fingertip worth per each hand’s worth.

Infective:

Candida FUNGUS – folds and moist areas, like ahem down there. Itchy red macules/papules. Nystatin/azole  antifungal.

Impetigo – Staph aureus or strep pyogenes. Honey coloured, can be bullous. PO ABX.

Cellulitis – Group A strep or staph. Amoxicillin.

Scabies – fingers, nipples, genitalia.
Malathion, permetrin from neck down for 24 hours. Wash after 24 hours, new bedsheets.

Lichen planus – red shiny papules, white streaks. Topical steroids, antihistamines, pred.

HSP – Vasculitis in skin and kidneys. Can occur after URTI.
HSP = Purpura rash on legs and buttocks, joint pain, abdo pain. Also, haematuria + proteinuria –> nephrotic syndrome (leak protein, oedema, proteinuria, hypoalbuminaemia, also happens with Group A strep)
Supportive treatment. Cyclophosamide, azathioprine. Self-limiting, but chase kidneys for a year.

Drug reactions:

Erythema multiforme – target lesions on PALMS and soles, drug reaction.

Erythroderma – cover in vaseline
Bullous pemphigoid – vaseline + betnovate.
Toxic epidermal necrolysis – admit! Skin falls off.

Vasculitic rashes – drug reactions.

Dermatitis in the DIPS: Itchy red dry skin. FLEXURES.
Beware eczema herpeticum (Clustered blistered, punched-out ulcerated lesions, systemic signs); bacterial superinfection; chronic hand eczema.
Refer if unresponsive facial, contact allergic, 1-2 flares/month, reaction to emollients

a) Emollient QDS.
b) Mild steroids in flexures, else potent steroids BD.
c) Tacrolimus and pimeocrolimus

If exudative, permanganate and steroid.
Infective, fluclox/erthyro for two weeks.

Contact dermatitis: Allergic i.e. biological (delayed IV); Irritant i.e. chemistry; Phototoxic i.e. physical.

Psoriasis – too many keratinocytes –> plaques of psoriasis, then inflammation:
Psoriasis: EXTENSORS. Patellar, back of elbow, scalp, nails. Itchy red plaques in extensors with silvery scales.
– EtOH/B-blockers/NSAIDs/Lithium can cause psoriasis
– Nails, pitting, onycholysis. Koebner’s. Pinpoint bleeding on removal of plaque. Hands/feet can have pustules.

Treatment – messy:

a) Topical:
– Emollients.
– Tar
– Vit D: Calcipotriol.
– Topical steroids

– Dithranol cream – it burns, arrgh, and stains, arggh my silk sheets.
– Phototherapy – 2 months, three times a week.

b) Systemic:
– Acitretin retinoid
– MTX
– Cyclosporin
– Biologics

SCC & BCC & melanoma.

BCC: Commenest. Pearly nodules with raised red edge aka Rodent ulcer. Excise simply.

SCC: Red nbump, bleeder or crusty. Can go to nodes.
Act kays (red-brown scales) –> SCC. Bowens is SCC in situ. Sun or smoker.

MM:
A – asymmetry
B – border is irregular
C – colour – lesion of >1 colour
D – diameter > 7mm
E – enlarging/evolving
– See more at: http://almostadoctor.co.uk/content/systems/dermatology/skin-cancer#sthash.7BZOPGSE.dpuf

7mm.

Lentigo MM – Face, flat dark lesion.
Superficial spreading MM – Commonest – legs/back, raised plaque
Nodular MM – Anywhere, quick growers.
Acral/subungal – Palms, soles, fingernails.

4mm depth = 60% mets chance. Mets = 10 year% 5 yr survival. Breslow thickness = prognostic marker.

General practice notes

Diabetes: All get statins. If BP up, give ACEi for protecting diabetic kidneys. If over 75, or under 75 and CV risk, give low-dose aspirin. I.e. ACEi, statin, and possible aspirin for oldies or at risk in DIABETES.

1st-line: Metformin (if not tolerated and not fat, sulphonylurea)
2nd-line: + Sulphonylurea if not fat. If fattie, gliptins. [MSG]
3rd-line: GLP-1 antagonists or insulin (start with long-acting). .

MSG-GLP/Insulin. If fat, no sulphonyureas, give gliptins.

HTN:
Under 55 = ACEi. Then ACEi + CCB. Then ACEi + CCB + Thiazide. Then further diuretic or alpha or beta blocker. Young people are ace.

Oldie or black = CCB. Then ACEi + CCB. Then ACEi + CCB + Thiazide. Then further diuretic or alpha or beta blocker.
Crumbly crumbly black.

130/80 if DM or CVD. 140/85 if high-risk.
LDL under 2, TC under 4.

NICE advise 24 hour BP management if BP is over 140/90 (same as PET threshold!!).
From this:-

If over 150/95, treat.
If over 135/85 and DM or organ damage or high-risk CVD – TREAT. Else annual review.
135/85 is normal on 24 hour test.

Lipids:
If CVD or FH or high CVD risk –> treat with statins.
If low risk –> lifestyle advice, assess in 5 years.

COLORECTAL – red flags:
– 40+ and PR bleed AND frequent/loose stools for 6 weeks
– 60+ and PR bleed for 6 weeks OR frequent/loose stools for 6 weeks
– Mass.
– Fe def anamemia below 11 in MEN. 11 Hb.
– Women with no menses, Hb under 10 and Fe def

[Weight loss, bowel habit change, PR bleed, fatigue/SOB, Fhx]

Crohn’s: Mucusy poo, diarrhoea, weight loss, MOUTH ULCERS IN CROHN’S, strictures, fistulae, abscesses, skin rashs, arthritis, uveitis. Fe def anaemia, high ESR/CRP.
U/C: BLOODY DIARRHOEA of U/C, tenesmus, urgency, again skin rashes, arthritis, uveitis.

U/C – bloody diarrhoea, Crohn’s – mouth ulcers!

IBS: Constip/diarrhoea Fibre. Mebeverine anti-spasmodics. Peppermint oil before meal prevents spasms/bloats. Bulking laxatives or loperamide. TCA’s, hypnotherapy, CBT.

Diverticular: Constipation. Ache with colicky exac. Distension, farts, burps. Fibre + laxatives. If colicky, anti-spasmodics. FBC (?wcc) and barium enema.

Coeliac: Diarrhoea and steatorhoea, abdo distension and pain. Follow-up due to growth in kids, cancer risk. Endomysial antibiotics or TTG, FBC/film for iron defiency (as can be deficient in Fe, folate, Vit K, Vit D). Refer for jejunal biopsy –> villous atrophy.

Piles: Bulking laxatives e.g. husks. LA. Steroid ointments. Suppositories. Else: Sclerotherapy. Rubber bands. Surgical removal.

RA = morning stiffness. Degenerative disease = worse on activity. Many joints, early morning stiffness, systemic symptoms. [Back involvement = ank spond/psoriatic] NSAIDs, refer. Naproxen = long t1/2.

Gout = purines, psoriasis, leukaemiae, diruetics, subthryoidism, EtOh//renal impairment, aspirin, diuretics, subthryoidism, EtOH. Attacks triggered by starvation, deydration, stress. Urate can be normal. NSAID’s/Colchicine/Pred acutely. Long-term allopurinol + NSAID initially.

Stiff knee = inflammation: RA, psoriasis, ank spond
Swelling = Synovitis, effusion, bursa
Locking = meniscus fragments.
Instable/give ways = ligament injury

Dyspepsia is a symptom.
– Functional
– GORD
– Peptic/Gastric ulcer.
– Cancer

?Food (fatty foods –> bilary pain) ?Worse at night (ulcer) ?Worse on lying down or bending (GORD)
GORD worsened by smoking, obesity, chocolate, coffee, pregnancy.
NSAID’s, bisphonates, CCB worsen dyspepsia.

Red flags GI:
– Chronic GI bleeds.
– Progressive dysphagia.
– Progressive weight loss.
– Persistent vomiting
– Fe def anaemia.
– Mass
– Dodgy barium meal.
– 55+ and new/unexplained/persistent dyspepsia.

H pylori: C13 urea breath test [no PPI 2 weeks pre-test, no ABX 4 weeks before testing. If test positive, PPI + amox + clarithr for a week), stool antigent, or lab serology
?FBC ?WCC ?LFT (gallstones, ca, etoh), serum amylase.

Tx: Either PPI for 1/12 or test/treat H Pylori. Then try other if no effect.
Then step down to lowest PPI dose.

Skin, eww:

Eczema – flexors (extensors in kids). Pink scaly rash with possible vesicles in eczema. Avoid triggers, emollients, topical steroids, tacrolimus, cycsporin, azathioprine.
Psioriasis – epidermal excess, Koebner’s phenomenon. Improves with Sun. Well-demarated plaques of psoriasis – extensors (PE, FE!) Guttate psiorasis after strep throat. Nails – pits, onchylosis, thickening, joints, CVD risk. Emollients, topical salicyclic acid, Vit D analogues, coal tar, diathranol, tar shampoo.

Moles = 6mm.
– BCC = rolled pearly edge, telangiectasia, ulcer in middle. Benign –> excise.
– SCC = malignant sun exposure, horny rodent ulcer. Excise. Solar kertosis are an early form of SCC.
– Seb kay’s: Black stuck on lesions. Oldies. No treatment.

Murmurs

JVP: Falls as you stand, disappears as you breathe in. Not a pulse, can be obliberated. Sitting lowers, lying raises.

Thrill = palpable purring murmur.
MTPA is your order of listening, and the paired valves shutting.
Systolic = Pansystolic systolic murmur of MR (in apex to axilla, louder on rolling to left side), soft s1. MR = Rheumatic, post-MI, AF.
OR slow-rising pulse of (ejection) AS (loud at neck., crescendo-decrescendo. Later peak = worse.) with a soft s2. Sit up + exhale. Heavy, displaced beat. ?HTN
AS –> CCF, cold peripheries, low BP.

Diastolic = AR/MS.
Early-diastolic fast-rising waterhammer, fast-collapsing Collapsing pulse of AR insufficiency – forwards and left sternal, after S2 decrescendo. (Lift arm up)
Mid-diastolic murmur of MS – axilla, roll onto left. Opening Snap of MS with a tapping apex and loud S1, blue flush. AF –> MR! MR AF+RF.

Regurgitations cause big left ventricles. Diffuse displaced beat in lvf/dilatation.
TR – big left pressure. Often MR + TR together. TR worse on inhalation.
S3, LVF or MR/AR, bell in mitral area. S4 before S1, not normal e.g. AS, HTN, HF. Tachy + S3/S4 = gallop

breathe out and hold your breathe for MS + AR.
LVF = pulm oedema.

MS – Malar flush, pulm HTN
AS – Slow rising pulse
AR – Collapsing waterhammer.
Radio-radial – dissection. Radio-femoral: Co-arct.

Hyperkalaemia K+ Potash

High K+: Broad PR, Broad QRS, no P, Tall Tented T-waves/asystole/sine/VT.  7!

Peaked T-waves, Long PR interval, then no P wave with BROAD QRS, VT/VF.

-10% 10ml Ca Gluconate every 10 mins up to fifty (cardioprotective – but lasts 30 mins);
– Lower plasma K+ with Insulin/Dex (10 units actrapid to 50ml 50% glucose over 30 mins) while checking BM’s before, during, after
– 10mg Neb Sab to drive K+ into cells where it belongs.

Calcium resonium + lactulose to remove K+. Or haemodialysis.

Treat in long-term by giving: Furosemide or Thiazide.

Don’t give AMILORIDE, SPIRO (K+ sparing diuretics). Don’t give ACEi, ARB’s, NSAID’s, HEPARIN. Beware: Ciclosporins, tacrolimus, pentamidine, co-trimoXazole.

Don’t give BETA-BLOCKERS OR DIGOXIN.
DKA can cause high K+, as can DIGOXIN TOXICITY or beta-blockade or too long a tourniquet.

“In patients with renal impairment, the ACE inhibitors and angiotensin-II receptor antagonists are very effective and reduce blood pressure and possible albumin loss but they must be used with care to prevent hyperkalaemia. “

Insulin pushes glucose AND potassium into cells, geddit?
Muscle weakness/flaccid paralysis, depressed or no tendon reflexes.

No P-waves, PEAKED TALL T-WAVES:

3-5ss (0.12 to 0.20). FIST THE PEE WAVE!

Short PR – WPW. Broad PR – block.
Broad QRS – BBB, hi K+, ventricular rhythm.

T-wave: 5mm in Roman limb leads, 10mm praecordial leads (V1-V6).  5mm roman, 10mm V.

Long QT – Sotatol, amiodarone, lo Ca, Eloise’s neck.

ST depression: PE, acute posterior MI, dig effect (and small T-waves).
ST elevation: LBBB, acute pericarditis

Upper GI bleed: (Malaena, coffee-ground)
Gastric and duodenal ulcer
Gastritis and oesophagitis
Oesophageal and gastric varices
Mallory-Weiss tear
Aortoenteric fistula

Lower GI Bleed:
Diverticulosis
Angiodysplasia
Carcinoma
Colitis (infectious, ischemic, inflammatory bowel disease)
Anorectal (hemorrhoids, fissures)

Taken from: http://www.cdemcurriculum.org/ssm/approach_to/gi_bleed.php

CXR

IQ: Identify + Quality – White = underpenetrated. Dark = Overpenetrated. 10 ribs.
ABCDE

A: Airway.
B: Bones + breasts.
C: Cardiac shadow. RML? Lingula? PA – size.
D: Blunted = pleural effusions. Free air?
E: Everything else: Soft tissue, trachea etc.
F: Fields, fluid, FO. Arteries above veins in peirhilar.
G: Gastric air bubble.

Hi Mr PaCO2. | Resp acid: Hi CO2, resp alk Low CO2. (hi paco2 lo, lo ph hi, lo bicarb hi)

Resp acidosis: COPD! 
Raised CO2 and acid = Lack of ventilation = RESP ACIDOSIS. COPD/asthma. Status. MG.

Met acidosis:
DKA ==> Metabolic acidosis. Low bicarb and acid. if Low CO2 –> resp compensation.
Raised AG: Lactate, Ketoacidosis, Ureamia from renal failure, poisoning e.g. salicycates or anti-freeze.
No increase in AG – lost bicarb and raised Cl e.g. RTA or severe diarrhoea.

Resp alk: LUNG INFECTION! PE!
Respiratory alkalosis –> Low Co2 and high PH –> Hyperventiliation (which causes low serum Ca.)
Resp alkalosis: PE, Pneumonia, anaemia, high altitude hypoxia, meningitis, anxiety. Early asp overdose = resp alkalosis with hyperventilation.

Met alk: VOM! (Co2 tends not to correct this.)
Vom. Diuretics (low K+ –> met alk; cf resp alk –> low Ca). Conn’s.

Resp acid = raised CO2. Resp alk = low Co2.

—

Resp acidosis (hi Co2):
a) Lungs COPD/CF/Pulm oedema. b) Opiates. c) MS/Guillian-barre.
Treat with NIPPV/IPPV/Naloxone etc.

Metabolic acid (lo bicarb):
RF/DKA/Lactate/DIARRHOEA. (Ergo, compensate via resp alk).

Resp alk (lo Co2):
Hyperventilation (PE, acute aspirin!), Hypoxia. Head injury. Tx: O2.

Met alk (hi bicarb):
Vomiting of protons/GI fistula – loss of protons. Diuretics causes metabolic alkalosis as does vomiting, while diarrhoea causes metabolic acidosis.
Met alk: Compensate badly by BRADYPNEOA – low RR.

-3 BE = acid! +3 BE = alk. Alkalosis give rise to Spasm/low K+.
If PCO2 abnormal = resp issue; if bicarb abnormal = met issue.
Compensation: patient’s cannot over-compensate. FiO2 of 0.4 if on 40% venturi.

THE AMAZING ABG CHART:

Hi PaCo2 Lo (Hi-Lo’s smoking bar) 6 to 4.5
Lo Bicarb Hi 22-26
Lo pH Hi 7.35-7.45

If on same side: cause. If other side: compensation.

Electrolytes, again

Low Na:
– Hypervol: HF/RF/Liver failure/Nephrotic.
Urine Na will be LOW (under 20). Fluid restrict. Diuretics. If severe: Hypertonic saline.
– Euvol:
Urine Na will be high. Fluid restrict 1l/d. Consider demeoclocyline in euvol.

– Dry: (Raised urea with normal or raised creat).
Urine Na will be HIGH (over 20). Treat with N saline.

Urine osmol is over 500 in dry or euvolaemia.

High plasma Na = vol depletion. Ensure no DKA/HONK. Inspidus? Initially treat with N saline 8-hourly.

Low Na:

Na loss –> volume depletion –> ADH released —> water is retained –> even more low Na.
N + V + headache confusion + spasms/cramps/weakness + LOC.

Fluid-heavy: Failures of heart, liver, nephrotic (kidney).
—> Treat or fluid restrict.

Euvolaemic: SIADH! Steroid deficiency! BRAINS! Exclude artefact (lipids or paraproteins).
—> Fluid restrict. VAPTANS.

Dry: Hypovolaemia (vom, diarrhoea), diuretics, Addison’s (gluco + mineralocorticoid def), pain. (Vol depletion –> ADH! —> dry low Na).
—> Correct SLOWLY!

Low potassium = Diuretics/GI loss.
Cardiac monitoring. Under 2.6? KCl, based on renal function.
Low K+ assoc with Low Mg (give Mg So4 – if both low, replace in same bag).

High potassium = Renal failure. Addison’s (morning serum cortisol or short synacthen).

K+ 6.5 = ECG!
– 10ml 10% Ca gluconate over 10 mins.
– 10 Units Actrapid 50ml of 50% Dextrose IV over 10 mins.
– Then: Insulin/Dex infusion. Ca resonium. Haemodialysis. Neb sabs.

Low Ca2++: Renal failure, Vit D deficiency (like Eloise), low PTH.

– If tingling or under 1.5mMl:
10ml 10% Ca gluconate over 10 mins. (low calcium, high potassium = calcium gluconate).
Then bag of Calcium gluconate (40ml of 10% in 500ml N saline 12 hourly?)

– If no sx: Consider IV Mg need. Calichew D3 BD.

High Ca+:
Check PTH. Any thiazides –> high calcium. REHYDRATE & Palmidronate.

ABG – Hi CO2 = Acidosis. Lo CO2 = Alkalosis i.e. co2 is like anti-bicarb.

Site, Size, Shape, Surface, Skin, Scar. Tenderness, Temperature, Transillumination. 
ROME – Resp opp, Metabolic equal. Direction of pH and CO2/HCO3.
Big spleen = Malaria/cMl/Myelofibrosis.

High Anion Gap: KUSSMAL

KUSSMAL:
– dKA
– Uraemia
– Salicylates
– Sepsis
– Methanol
– Alcoholic ketoacidosis
– Lactate.

OR:

CAT MUD PILES.

C – CO/HCN; A – Alcoholic ketoacidosis; T – Toluene

Methanol
Uraemia
DKA

Paraldehyde
Isoniazid
Etyhlene glycol
Salicylates

Normal anion gap – USED CARB – i.e. used up bicarb. RTA/DIARRHOEA/FISTULA!

USED CARP

U = Ureteroenterostomy
S = Small bowel fistula
E = Extra chloride
D = Diarrhea

C = Carbonic anhydrase inhibitors
A = Adrenal insufficiency/Acetazolamide/Addison’s
R = Renal tubular acidosis
P = Pancreatic fistula

Lots of saline can cause hyperchloremic metabolic acidosis with normal anion gap

Not sure about this:

Respiratory if pH is up and Paco2 is down or if pH down and Paco2 is up
Metabolic if pH and HCO3 are both up or if pH and HCO3 are both down
Compensating if Paco2 and HCO3 both up or if pH and Hco3 both are down
Mixed if Paco2 up and HCO3down or if Paco2 down and HCO3 is up

Random O2 bits. Ass-mar

Nasal cannula 2-6L/min. Face mask 5 – 10 L/min

If COPD + abg shows normal pCO2 –> increase sats to 94-98% unless prior hx of hypercapnic respiratory failure.

Sabs –> lower K+.
Ipatropium –> anticholingeric hence causes dry mouth. BEWARE anticholinergics in BPH or Glaucoma.
Steroids suppress adrenals and cause osteoporosis.

Life-threatening asthma: PaO2 under 8, PEF 1/3 of best, sats under 92%, cyanosis.
Near-fatal: Raised PaCo2.

Acute exac: Hi-flow O2; neb sab every 15 mins; neb ipratropium four hrly; pred 40mg or hydrocort 100mg.
Then Mg IV if not responding; consider Iv aminophylline.