Near Peer Notes

Dermatology Resources

Websites useful for information on common skin conditions and photographs:

https://dermnetnz.org

https://www.blackandbrownskin.co.uk/campaigns

Eczema

• Chronic, inflammatory skin condition characterised by itching, red rash in skin creases

• Clinical features:

  1. Signs: 

     • red inflamed skin initially on face, abdomen, flexures

     • pruritis

     • not well-demarcated

     • excoriation marks

     • lichenification

     • hyper (thickening of skin) / hypopigmentation

     • angular cheilitis (red swollen patches in corners of mouth)

  2. Symptoms:

     • itch

     • bleeding

     • colour change

     • sleep disturbance

     • missing school / career

• Diagnosis: itchy skin + at least 3 of:

  1. history of flexural itchiness 

  2. history of asthma / eczema 

  3. dry skin for past year 

  4. visible flexural eczema 

  5. onset before 2-year-old

• Management:

  1. education to prevent remission / relapsing and complications

  2. explanation medications do not cure but majority of children will grow out of it

  3. simple measures: cotton clothing / bedding, keep cool, avoid pets, rinse clothes adequately, moisturizer at school, avoid all soaps, house dust mite avoidance 

  4. Topical Preparations: 

     • emollients - varies from water based to oil based

       • guidance - use all the time even when skin is clear

     • bath oils/soap substitutes

     • topical steroids

       • acute - strong steroid for 5-7 fays

       • chronic - use lowest appropraite potency, 10-14 days

       • USE WITH EMOLLIENT 

     • topical immunomodulators 

       • calcineurin inhibitors - tacrolimus e.g. 

       • doesn't cause skin atrophy, maintainenance.

Psoriasis

• chronic, often plaque-like skin condition

• hyperproliferative disorder = increased production of epidermal cells = shortened cell cycle 

• Common triggers: infection (HIV, streptococcal), trauma (Koebner), drugs (beta blockers, NSAIDs, ACEis, lithium, anti-malarias: chloroquine), stress, endocrine, sunlight (usually relieves but can exacerbate) 

• Clinical Features: red well demarcated symmetrical plaques covered in slivery scale 

  • Auspitz sign  scraping of scale reveals pinpoint bleeding points

  • symmetrical distribution over extensor surfaces  elbows, knees, scalp (80%)

  • sacrum most affected 

  • Nails: affected in 50% (oncolysis, longitudinal riding, subungual hyperkeratosis)

  • Arthritis (in 15%): can precede disease, DIP involvement, nodules absent. 

• Management

  • Education  not contagious, not their fault, nothing to do with their diet, not cancer, no cure, reduce smoking, reduce alcohol, can offer emollients

  • 1st line: topical potent corticosteroid OD + vitamin D analogue (e.g., calcipotriol):

  • 2nd line:  vitamin D analogue BD

  • 3rd line:  potent vitamin D BD for up to 4 weeks, tar, short-acting dithranol 

  • Photochemotherapy - using narrow band UVB, secondary care

  • Systemic agents: 1st  methotrexate, others  acitretin (vitamin A analogue), ciclosporin

  • Scalp Psoriasis Management: 1st line  topical potent corticosteroids (OD, 4 weeks), no improvement  different formation, different topical agent 

  • Face, Flexural and Genital Psoriasis Management: mild or moderate potency corticosteroid

Mental Health Resources

Mental health continues to be a growing public health concern and is one of the largest causes of disability in the United Kingdom. This page focuses on generalised anxiety disorder (GAD) and depression, the two most predominant conditions worldwide [1]. 

Depression

❕ Risk factors

• Medication side effects: corticosteroids, propranolol, combined oral contraceptive pill.

• Medical conditions: dementia, chronic-illness, hypothyroidism, anaemia [2].

• Social: unemployment, stress, substance use

• Family history

📁Types [2-4]

• Major depressive disorder (which we typically refer to as depression)

• Persistent depressive disorder - ⩾ 2 years of a depressed mood for most of the day, for most days.

• Premenstrual dysphoric disorder - low mood +/- anxiety and irritability in the luteal phase that impacts daily function.

• Other (e.g., due to substance abuse, medication side effects).

🩺Presentation [4]

Depression is typically characterised (core features) by...

• • Decreased interest or pleasure (anhedonia) in most activities.

  • Fatigue

  • Depressed or irritable mood

...alongside a variety of emotional, cognitive, physical and behavioural symptoms.

• Change in...

  • Weight (↑/↓)

  • Sleep (↑/↓)

  • Activity (agitated/slowed)

  • Concentration (low/more indecisiveness)

• Suicidality

• Guilt/worthlessness

🧪Investigations [4,5]

Typically, a clinical diagnosis (≥5 of the above symptoms, present for ≥2 weeks)

• Bedside: PHQ9 questionnaire

• Bloods: thyroid function tests, metabolic panel, FBC.

  • We may need to rule out our medical causes.

🥼 Managment [6,7]

1. Counselling on nature and course of depression, alongside sources of information and support.

2. Provide guidance on activities to improve wellbeing (exercise, diet, sleep hygiene)

3. Therapy (cognitive behavioural therapy (CBT), interpersonal therapy)

4. Medication

Based on severity:

• Mild: guided self-help, CBT

• Moderate: interpersonal therapy, medication

  • 💊Typically, SSRIs (selective serotonin re-uptake inhibitor) are first line (sertraline in adults, fluoxetine in paediatrics).

    • Side effects: GI bleeding, GI discomfort, sexual dysfunction, nausea.

    • Very high doses or use of other medication that increases serotonin levels (e.g., tramadol) can lead to serotonergic syndrome (emergency).

• Severe: interpersonal therapy, medication +/- admission or antipsychotics.

🚨Complications

• Suicide

• Self-harm

• Adverse effects of medication

🧠Differentials [3,4]

There are many differentials for depression, including:

• Bipolar affective disorder: a mental health condition characterised by episodes of (hypo)mania (elevated mood) and depression.

• Bereavement

Generalised anxiety disorder (GAD)

❕Risk factors

• Family history

• Physical or emotional stress

• History of physical, sexual, or emotional trauma

• Other anxiety disorder

• Chronic physical health condition

• Thyroid disease

🩺Presentation [8]

GAD is defined as chronic, excessive worry for at least 6 months that causes distress or impairment.

• Remember anxiety is a broad term encompassing GAD alongside other conditions such as obsessive-compulsive disorder, panic disorder and social anxiety disorder. These other conditions are 🧠Differentials for GAD

Patients may also report:

• Muscle tension

• Poor concentration

• Fatigue

• Sleep disturbance (difficulty falling or staying asleep, or restless sleep)

• Irritability

• Feeling 'on edge' (restlessness)

Anxiety can somatise (manifest as physical symptoms) in a numerous way including chest pain, shortness in breath, and loss of taste.

🧪Investigations [8,9]

Typically, a clinical diagnosis

• Bedside: urine drug screen

  • Only when there is a strong suspicion of substance (e.g., stimulants) use.

• Bloods: thyroid function tests, ECG, pulmonary function tests.

  •  We may need to rule out our medical causes, ensuring any somatization is not due to an underlying physical issue.

🥼Managment [6,8,10]

1. Counselling on nature and course of anxiety, alongside sources of information and support.

2. Provide guidance on activities to improve wellbeing (exercise, diet, sleep hygiene)

3. Therapy (cognitive behavioural therapy (CBT), relaxation therapy)

4. Medication

Based on severity:

• Mild: guided self-help, CBT, mindfulness

• Moderate-severe: CBT, relaxation therapy, medication

  • 💊Typically, SSRIs or SNRIs (serotonin-noradrenaline reuptake inhibitor) are first line

    • SSRIs: duloxetine or escitalopram in adults

    • SNRIs: venlafaxine in adults

🚨Complications

• Panic attacks

• Comorbid depression

• Adverse effects of medication

MSK Resources

Resourches to help with revision:

Geeky Medics - great help for OSCE and for explaining general basics needed for General Practice 

https://geekymedics.com/tag/orthopaedics/

Armando Hasudungan has great videos - drawing and explaining lots of conditions and normal anatomy

https://www.youtube.com/watch?v=pnKaBMvVUs0 - osteoarthritis

https://www.youtube.com/watch?v=ld8PhyAHov8 - rheumatoid arthritis

X-Ray images of arthritis - very useful for spotter, not only MSK

https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/imaging-joints-bones/rheumatoid-arthritis-xray 

https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/imaging-joints-bones/osteoarthritis

Rheumatoid Arthritis - Happy Birthday! (H comes before B, DIP before PIP)

Heberden's Nodes - DIP

Bouchard's Nodes - PIP

Osteoarthritis - remember LOSS

L - loss of joint space (narrowing)

O - osteophytes

S - subchondral sclerosis

S - subcortical cysts