Dermatology - Short Answer Questions (SAQ)

Question 1:

A 72 year old man presents to the emergency department complaining of an itchy rash.

Photo: Dermanet.com

1. Give 3 possible diagnoses


2. Give 2 investigations that can be performed in the ED


3. How would you manage this patient in the ED?


4. What definitive treatment is required

Answer

Answer

A 72 year old man presents to the department complaining of an itchy rash.

1. Give 3 possible diagnoses

• Bullous pemphigoid


• Pemphigus


• Dermatitis herpetiformis


• VZV infection


• Bullous erythema multiforme

2. Give 2 investigations that can be performed in the ED

• Aspiration of bullous fluid for PCR ? HSV/VZV


• Nikolsky’s sign – sliding of skin in pemphagus (not in pemphigoid)

(Definitive diagnosis involves biopsy for histology and immunoflurescence)

3. How would you manage this patient in the ED?

• Anlagesia


• Anti-histamine for itching


• IV Fluids if dehydrated secondary to decreased intake (mucous memb involvement), fluid loss


• Dermatology referral

4. What definitive management is required

• Dermatology referral for biopsy and steroids/immunosuppression


• Exclusion of malignancy in pemphagoid

Few more pictures

Bullous Pemphigoid

Bullous Pemphigoid

Bullous Pemphigoid

 

Question 2:

A sixty-five year old man has an itchy generalised rash. Your new FY2 doctor thinks the rash is scabies.

1. Describe the rash.                                                                                           (2 marks)


2. What is the differential?                                                                              (2 marks)


3. Why is this rash itchy?                                                                                  (1 mark)


4. What is the treatment of choice?                                                              (1 mark)


5. What two features in the history would suggest the diagnosis? (2 marks)


6. What would you tell the patient?                                                             (2 marks)

Answer

Answer

A sixty-five year old man has an itchy generalised rash. Your new SHO thinks the rash is scabies.

1. Describe the rash.                                                                (2 marks)

• Erythematous papular rash, with excoriations and evidence of burrows.


• On the dorsum of the hand

 2. What is the differential?                                                      (2 marks)

• Scabies


• 
  Pompholyx
  

3. Why is this rash itchy?                                                       (1 mark)

• Allergic/ dermatitic reaction to faeces of scabies mite

 4.  What is the treatment of choice?                                        (1 mark)

Permethrin, Malathion

 

1. What two features in the history would suggest the diagnosis? (2 marks)

Nightime itchy and after hot shower, Genital Itching

 

f. What would you tell the patient?                                        (2 marks)

Apply at bedtime. Wash off in the morning. Repeat in 1 week.

Treat all household contacts, Launder all bedlinen/clothes/towels 

 Question 3:

A 45 year old female presents with a wide spread itchy rash and sore mouth.

1. What is pemphigus?


2. What is pemhigoid?


3. How would you differentiate between the two?


4. How would you manage this patient in the ED?

Answer

Answer

3. A 45 year old female presents with a wide spread itchy rash and sore mouth.

1. What is pemphigus?

• Autoimmune disease with deposition of Ig G within epidermis leading to epidermal separation and bullae formation.  Commonly  begins in middle age, on trunk, face, groin and axillae.  Involvement of mucous membranes common, especially oral cavity.

2. What is pemhigoid?

•  Autoimmune disease with deposition of IgG and C3 on basement membrane with sub-epidermal bullae formation.  It is pruritic.  Small association with malignancy, increased incidence in 70s.  Usually seen on lower limbs especially in inner aspect thigh, then trunk.  mucous membrane involvement less than pemphigus vulgaris

3. How would you differentiate between the 2?

•  Skin biopsy for histology and immunofluorescence.

4. How would you manage this patient in the ED?

• Oral or IV analgesia


• Anti-histamine to decrease pruritis


• IV access and fluids if dehydrated due to oral involvement and fluid loss


• Dermatology referral.

Question 4:

An 8 year old boy presents with pain in the wrists, elbow and knee.  He has a sore throat 3 weeks ago.  Temp 37.8C, other observations normal.

 

1. Outline the principles of the Jones criteria in the diagnosis of rheumatic fever (3)


2. Which four features does this child have (2)


3. Which other investigation is required? (1)


4. What are the principles of the treatment of rheumatic fever? (4)

Answer

Answer

An 8 year old boy presents with pain in the wrists, elbow and knee.  He has a sore throat 3 weeks ago.  Temp 37.8C, other observations normal

1. Outline the principles of the Jones criteria in the diagnosis of rheumatic fever (3)

• Diagnosis of rheumatic fever using the Jones criteria requires evidence of recent infection with Group A beta haemolytic streptococci and either 2 major diagnostic criteria or 1 major and 2 minor criteria.

2. Which four features does this child have (2)

• Elevated temperature


• Prolongation of PR interval


• Arthritis of several joints


• Erythema marginatum

3. Which other investigation is required? (1)

• ASO titre

4. What are the principles of the treatment of rheumatic fever? (4)

• Bed rest


• Analgesia and anti-pyretic


• Aspirin


• Use of steroids if evidence of carditis


• Penicillin in treatment dose and prophylactically for 5 years if no carditis and life long if carditis


• Investigation and treatment of heart valve disease


• Splints for arthritis, pain relief

More info

Question 5:

A 22 year old female presents with a painful rash to her legs.

 

1. What is the diagnosis?


2. Give four causes of this rash?

Answer

Answer

A 22 year old female presents with a painful rash to her legs.

1. What is the diagnosis?

•  Erythema nodosum

2. Give four causes of this rash?

•  Infective:  Tuberculosis, Group A streptococcal throat infections (Scarlet fever, Rheumatic fever), salmonella gastroenteritis, campylobacter colitis, Lymphogranuloma Venereum


• Malignancy: Hodgkin’s and Non Hodgkins lymphoma


• Inflammatory bowel disease eg Crohn’s, Ulcerative colitis


• Drugs:  Penicillin, sulphonamides, sulphonylurea, tetracyclines, OCP


• Sarcoidosis

More pictures 

Photo: Patient.co.uk

Photo: Life In The Fast Lane

Question 6:

42 year old male presents with a rash

 

1. Describe the rash.  What is the diagnosis?


2. Give 6 causes of this condition.

He returns one week later having deteriorated.  Temp 38.3C

     3. What is the diagnosis?

4. How would you manage the patient in the ED.  Assume patent airway and adequate ventilation.

Answer

Answer

A 42 year old male presents with a rash.

1. Describe the rash.  What is the diagnosis?

• Multiple macular papular lesions, target shaped suggestive of erythema multiforme

2. Give six causes of this condition.

• Infection: HSV, HIV, Hep B, Mumps, EBV, Beta haemolytic streptococci, rickettsia, pssitacosis


• Drugs:  penicillin, sulphonylurea, barbiturates, salicylates, anti-malarials


• Sarcoidosis


• SLE


• PAN


• Wergners granulomatosis


• Idiopathic


• Malignancy eg multiple myeloma

He returns 1 week later having deteriorated.  Temp 38.3C

3. What is the diagnosis?

• Stevens-Johnson syndrome

4. How would you manage the patient in the ED.  Assume patent airway, adequate ventilation and oxygen in situ.

• IV access, IV fluids as necessary to keep pulse <100bpm and U/O >0.5ml/kg/hr


• Intra venous analgesia eg morphine titrated to effect


• Assess skin lesions, cover denuded areas with cling-film, non-adherent dressing


• Refer to burns unit

 

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Dermatology - Short Answer Questions (SAQ)