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.

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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

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.