Tony’s Take Home Memo

From Wednesday lectures, 8/3/2014

Week 9 (Block 3 Wk1) Derm [+NYS Fair Week!]

10a – Dermatitis (Kloss)

Eczema ~ Atopic Dermatitis, scaling, crusting, oozing…

Dermatitis ~ “inflammation” of “skin”

Seborrheic, Contact, Irritant, Nummular…

Poison Ivy is common allergic contact dermatitis, Urushiol allergic oil component. Sensitization ~age8. Toxicodendron ~ class IV hypersensitivity rxn, can cause urticaria or E. Multiforme.

4 to 96 hours onset.  “Leaves of 3, let it be”.  Course often lasts 2 to 3 weeks, steroid taper…

Nickel dermatitis is common on neck, arms, infraumbilical dt jewelery & clothing.

“Formication” ~ “coke bugs” (dt cocaine or amphetamines)

Acne ~ DCX c MRSA coverage!

Contact dermatitis can be allergic or irritant.

Benadryl is good drug if any allergic component.

Steroids can be oral or topical depending on severity.

“If it’s dry, make it wet; wet, make it dry.”

Always consider Herpes for vesicular lesions.

Dyshydrotic Eczema may be confused c herpetic whitlow, pruritic vesicular dematitis off palms & soles.

Empiric treatment for tinea appearing rash ~ ketoconazole c steroids for possible nummular eczema. Pruritic dermatitis common on trunk & lower extremities, can be numerous lesions.

1030 – Cellulitis (Wang)

Acute spreading of skin infection c pain, warmth, swelling, & erythema.

Often after wounds or exposure to other ppl c cellulitis ~ MRSA.

Immune compromise, DM2, stasis predispose.  Staph most common.

Crepitance, Streaking, sloughing are bad signs.

Extent, location, systemic Sx, complicating factors are important to consider in Dispo…

Failure of appropriate outpatient treatment? Consider admission strongly.

Paolo says no wound cultures for superficial abscess!

Keflex, Augmentin, Clinda, Bactrim, DCX…

Necrotizing Fasciitis is rare but ~50% Mortality (DM2 biggest risk factor), usually precipitated by minor trauma.  May not have significant overlying cellulitis!  May need surgery & HBO therapy, Strep one of the most common bacterial causes, but among Abx, ALWAYS USE CLINDA! (for alpha toxin suppression in case of Clostridia

11a – Small Groups (Sarsfield)

Name that rash!

1 ~ Measles Rubeola

2 ~ Scarlet Strep

3 ~ Rubella (German Measles)

4 ~ Dukes Dsx? Staph

5 ~ Parvovirus B19 Erythema Infectiosum

6 ~ Roseola (HSV6&7)

Herald Patch, Pityriasis Rosacea ~ Xmas Tree…(self limited)

Erythema Migrans ~ Bulls Eye

Erythema Multiforme (central clearing), SJS, TEN

Nikolvsky’s Sign ~ slough.

Scabies… RMSF… Varicella… Impetigo…

Smallpox… Coxsackie… Nickel Dermatits… HSP v meningococcemia…

1130 Small Groups (ERod)

Salmon Colored Plaques and Papules… Psoriasis.

Scabies in the webs spaces, intensely pruritic. Permethrin creme.

Painless genital lesion. Syphilis Chancre Primary. Pen VK IM.

Secondary Syphilis Palms & Soles lesion… coxsackie, EMult…

*Infxn, Drugs, Autoimmune, CA?

Disseminated Gonococcus needs continuous IV Ceftriaxone…

Toxic Shock Syndrome ~ erythroderma, fever, hypotension, desquam, mult organ involvement.

Erysipelas ~ older pt c sharply demarcated lesions.  Admit for facial lesions c IV Abx (for Strep!)

Staph ~ suppurative.

1230 – Jr/Sr (Cantor)

Autonomic Dysfunction ~ Spinal Shock

Lap Belt sign only ~ consider lumbar spine & small bowel injury (Chance frx)

To decrease ICP, Hyperventilation effective, intubation allows for good access.

Central Cord Syndrome ~ Motor deficits in Upper extremities, but not lower…

Pulmonary Contusion can progress to PTX, so should be observed

Passive & Active Immunizations for Rabies & Tetanus if never previously immunized.

Erythema Multiforme plus mouth lesions, think SJS/TEN…

ASA in young child causes Reye Syndrome. Serum Ammonia & LFTs elevated. ICP increase, hyperventilate!

ITP, Rhogam?! Need Blood Type!

Nonbloody diarrhea ~ Norwalk (calicivirus) is quick on, quick off (v Adeno & Rotavirus)

Blood in stool c diarrhea is dysentery. Canoeing is water… Typhoid Mary & rotten eggs…

Bacterial GastroEnteritis ~ Bloody Diarrhea.

Infantile HIV often has parotid involvement c immune compromise.

130 – Maculopapular Rash (Kolb)

Acute Retroviral Syndrome HIV rash, Dermatomyositis, 2* Syphilis, SLE, Porphyria Cutanea Tarda, Dengue v Dengue Hemorrhagic Fever…

STIs cause many maculopapular rashes, sexual hx?!…

Photosensitive? DCX/TCX side effects…

2p – Vesicular/Bullous Rash (GJ)

Starting IVs!?! ONLY for sick people & infants! Venipuncture does not necessitate IV!

PGY2 should not waste too much time on venipuncture since needed for other critical patients.

Stable for floor requires IV? Probably not…

Peds ED may be moving to hospital 4th floor?!?!

*Rashes… Fever & Vesicles consider: TEN, TSS, SSSS, disseminated HSV/varicella, Pemphygus, Bacteremia…

SJS goes to Burn Unit.

Varicella 2wks incubation period.  Vaccine since 1998.

Hutchinson’s v Ramsey Hunt … beware ophtho keratitis

Nikolvsky’s sign c blisters… TEN, pemphygus, pemphygoid, SSSS…

230 – Peds Exanthems (Thabet)

Erythema Multiforme common for viral infxn treated c Abx.

Tinea ~ oral griseofulvin (no LFTs needed if otherwise baseline)

Coxsackie may be 2 to 3 weeks, may get worse before better.  Coxsackie A is HFM typically, but can be Coxsackie B which is associated c rare myocarditis.  Anterior involvement ~HSV.

Candida in infant should be treated Nystatin for groin, feeding nipples…

Strep can be complicated by Scarlet Fever, Rheumatic Fever, PSGN…

Lyme Dsx is endemic in this area.

Lichen Sclerosis is NOT STI finding!

HSP (hematuria, abd pain, purpura) think kidneys & intussusception…

5th Dsx, Erythema Infectiosum, Reticulated “Cutis Marmorata”

NYS Fair!!!


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