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  • Question 1 - A 47 year old female comes to the emergency department with a 4...

    Incorrect

    • A 47 year old female comes to the emergency department with a 4 day history of pain on the left side of her torso. The patient describes the pain as burning and noticed a rash develop in the painful area a few days ago. Upon examination, you observe blotchy erythema with clustered vesicles on the left side of her torso, extending from the left side of her back to the midline in the distribution of the T10 dermatome.

      What is the most probable organism responsible for this condition?

      Your Answer: Herpes simplex type 1

      Correct Answer: Varicella zoster

      Explanation:

      Shingles, also known as herpes zoster, occurs when the varicella zoster virus becomes active again in a specific area of the skin. This results in a rash characterized by clusters of fluid-filled blisters or vesicles on a red base. Over time, these blisters will dry up and form crusts before eventually healing.

      Further Reading:

      Chickenpox is caused by the varicella zoster virus (VZV) and is highly infectious. It is spread through droplets in the air, primarily through respiratory routes. It can also be caught from someone with shingles. The infectivity period lasts from 4 days before the rash appears until 5 days after the rash first appeared. The incubation period is typically 10-21 days.

      Clinical features of chickenpox include mild symptoms that are self-limiting. However, older children and adults may experience more severe symptoms. The infection usually starts with a fever and is followed by an itchy rash that begins on the head and trunk before spreading. The rash starts as macular, then becomes papular, and finally vesicular. Systemic upset is usually mild.

      Management of chickenpox is typically supportive. Measures such as keeping cool and trimming nails can help alleviate symptoms. Calamine lotion can be used to soothe the rash. People with chickenpox should avoid contact with others for at least 5 days from the onset of the rash until all blisters have crusted over. Immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops, IV aciclovir should be considered. Aciclovir may be prescribed for immunocompetent, non-pregnant adults or adolescents with severe chickenpox or those at increased risk of complications. However, it is not recommended for otherwise healthy children with uncomplicated chickenpox.

      Complications of chickenpox can include secondary bacterial infection of the lesions, pneumonia, encephalitis, disseminated haemorrhagic chickenpox, and rare conditions such as arthritis, nephritis, and pancreatitis.

      Shingles is the reactivation of the varicella zoster virus that remains dormant in the nervous system after primary infection with chickenpox. It typically presents with signs of nerve irritation before the eruption of a rash within the dermatomal distribution of the affected nerve. Patients may feel unwell with malaise, myalgia, headache, and fever prior to the rash appearing. The rash appears as erythema with small vesicles that may keep forming for up to 7 days. It usually takes 2-3 weeks for the rash to resolve.

      Management of shingles involves keeping the vesicles covered and dry to prevent secondary bacterial infection.

    • This question is part of the following fields:

      • Dermatology
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  • Question 2 - A child presents with a headache, high temperature, and a very itchy rash...

    Incorrect

    • A child presents with a headache, high temperature, and a very itchy rash on their face and body. The doctor diagnoses the child with chickenpox. When would it be necessary to administer acyclovir through injection in this patient?

      Your Answer: Intensely itchy rash

      Correct Answer: Chronic skin disorder

      Explanation:

      Chickenpox is a highly contagious illness caused by the varicella-zoster virus, a DNA virus from the Herpesviridae family. Most cases are mild to moderate, and the infection usually resolves on its own. Severe complications are rare but can occur, especially in individuals with weakened immune systems or underlying health conditions.

      The incubation period for chickenpox is typically between 14 to 21 days. It is contagious from a few days before the rash appears until about a week after the first lesions show up.

      The common clinical features of chickenpox include:

      – Fever, which lasts for approximately 3-5 days.
      – The initial rash starts as flat red spots and progresses into raised bumps.
      – These bumps then turn into fluid-filled blisters and eventually form pustules surrounded by redness.
      – The lesions are extremely itchy.
      – The rash reaches its peak around 48 hours in individuals with a healthy immune system.
      – The rash tends to be more concentrated on the face and trunk, with fewer lesions on the limbs.
      – The blisters eventually dry up and form crusts, which can lead to scarring if scratched.
      – Headache, fatigue, and abdominal pain may also occur.

      Chickenpox tends to be more severe in teenagers and adults compared to children. Antiviral treatment should be considered for these individuals if they seek medical attention within 24 hours of rash onset. The recommended oral dose of aciclovir is 800 mg taken five times a day for seven days.

      Immunocompromised patients and those at higher risk, such as individuals with severe cardiovascular or respiratory disease or chronic skin disorders, should receive antiviral treatment for ten days, with at least seven days of intravenous administration.

      Although most cases are relatively mild, if serious complications like pneumonia, encephalitis, or dehydration are suspected, it is important to refer the patient for hospital admission.

      For more information, you can refer to the NICE Clinical Knowledge Summary on Chickenpox.
      https://cks.nice.org.uk/topics/chickenpox/

    • This question is part of the following fields:

      • Dermatology
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  • Question 3 - A 3-year-old girl comes in with a low-grade fever and rosy cheeks. You...

    Incorrect

    • A 3-year-old girl comes in with a low-grade fever and rosy cheeks. You suspect a diagnosis of slapped cheek syndrome.
      Which ONE statement about this condition is accurate?

      Your Answer: It is caused by parvovirus B16

      Correct Answer: It is also known as erythema infectiosum

      Explanation:

      Slapped cheek syndrome, also known as fifth disease or erythema infectiosum, is caused by parvovirus B19. It is most commonly seen in children aged 4-12, but can affect individuals of any age. In the UK, the peak occurrence of this condition is in April and May. Slapped cheek syndrome is contagious, with the period of infectivity occurring before the appearance of the characteristic rash. The rash itself is painless.

      Diagnosing slapped cheek syndrome is typically based on clinical presentation, characterized by the sudden onset of bright red cheeks resembling a slap mark. In some cases, a faint rash may also appear on other parts of the body. The rash usually lasts for a few days, but in rare instances, it may persist for a few weeks. Treatment for this condition is usually focused on managing symptoms. Additional symptoms that may accompany the rash include a mild fever and joint pain.

      While slapped cheek syndrome is generally mild and resolves on its own, certain groups of individuals require extra caution. Pregnant women, for instance, are at an increased risk of miscarriage if exposed to fifth disease. Patients with sickle cell disease or weakened immune systems also need to take extra precautions.

    • This question is part of the following fields:

      • Dermatology
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  • Question 4 - A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris...

    Incorrect

    • A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris and bullous pemphigoid.
      Which of the following features would indicate a diagnosis of bullous pemphigoid?

      Your Answer: Skin biopsy showing intra-epidermal deposition of IgG between cells throughout the epidermis

      Correct Answer: Prominent pruritus

      Explanation:

      Bullous pemphigoid (BP) is a chronic autoimmune disorder that affects the skin, causing blistering. It occurs when the immune system mistakenly attacks the basement membrane of the epidermis. This attack is carried out by immunoglobulins (IgG and sometimes IgE) and activated T lymphocytes. The autoantibodies bind to proteins and release cytokines, leading to complement activation, neutrophil recruitment, and the release of enzymes that destroy the hemidesmosomes. As a result, subepidermal blisters form.

      Pemphigus, on the other hand, is a group of autoimmune disorders characterized by blistering of the skin and mucosal surfaces. The most common type, pemphigus vulgaris (PV), accounts for about 70% of cases worldwide. PV is also autoimmune in nature, with autoantibodies targeting cell surface antigens on keratinocytes (desmogleins 1 and 3). This leads to a loss of adhesion between cells and their separation.

      Here is a comparison of the key differences between pemphigus vulgaris and bullous pemphigoid:

      Pemphigus vulgaris:
      – Age: Middle-aged people (average age 50)
      – Oral involvement: Common
      – Blister type: Large, flaccid, and painful
      – Blister content: Fluid-filled, often haemorrhagic
      – Areas commonly affected: Initially face and scalp, then spread to the chest and back
      – Nikolsky sign: Usually positive
      – Pruritus: Rare
      – Skin biopsy: Intra-epidermal deposition of IgG between cells throughout the epidermis

      Bullous pemphigoid:
      – Age: Elderly people (average age 80)
      – Oral involvement: Rare
      – Blister type: Large and tense
      – Blister content: Fluid-filled
      – Areas commonly affected: Upper arms, thighs, and skin flexures
      – Nikolsky sign: Usually negative
      – Pruritus: Common
      – Skin biopsy: A band of IgG and/or C3 at the dermo-epidermal junction

    • This question is part of the following fields:

      • Dermatology
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  • Question 5 - A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest...

    Incorrect

    • A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest and back. She recently returned from her vacation in Ibiza and the areas have become more noticeable after sun exposure. What is the most suitable treatment for her condition?

      Your Answer: Oral terbinafine

      Correct Answer: Ketoconazole shampoo (Nizoral)

      Explanation:

      Pityriasis versicolor, also known as tinea versicolor, is a common skin condition caused by an infection with the yeasts Malassezia furfur and Malassezia globosa. It typically presents as multiple patches of altered pigmentation, primarily on the trunk. In individuals with fair skin, these patches are usually darker in color, while in those with darker skin or a tan, they may appear lighter (known as pityriasis versicolor alba). It is not uncommon for the rash to cause itching.

      The recommended treatment for pityriasis versicolor involves the use of antifungal agents. One particularly effective option is ketoconazole shampoo, which is sold under the brand name Nizoral. To use this shampoo, it should be applied to the affected areas and left on for approximately five minutes before being rinsed off. This process should be repeated daily for a total of five days.

    • This question is part of the following fields:

      • Dermatology
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  • Question 6 - A 60-year-old woman originally from South Sudan has developed a chronic skin condition....

    Incorrect

    • A 60-year-old woman originally from South Sudan has developed a chronic skin condition. She has widespread areas of both hyper- and hypopigmented skin along with areas of skin atrophy and lichenification. The hypopigmented areas are mostly confined to her forearms. Over the past few years, her vision has gradually deteriorated, and she has now been registered blind.
      What is the SINGLE most likely causative organism?

      Your Answer: Schistosoma mansoni

      Correct Answer: Onchocerca volvulus

      Explanation:

      Onchocerciasis is a parasitic disease caused by the filarial nematode Onchocerca volvulus. It is transmitted through the bites of infected blackflies of Simulium species, which carry immature larval forms of the parasite from human to human.

      In the human body, the larvae form nodules in the subcutaneous tissue, where they mature to adult worms. After mating, the female adult worm can release up to 1000 microfilariae a day.

      Onchocerciasis is currently endemic in 30 African countries, Yemen, and a few isolated regions of South America. Approximately 37 million people worldwide are currently infected.

      Symptoms start to occur around a year after the patient is infected. The earliest symptom is usually an intensely itchy rash. Various skin manifestations occur, including scattered, red, pruritic papules (acute papular onchodermatitis), larger, chronic, hyperpigmented papules (chronic papular onchodermatitis), lichenified, oedematous, hyperpigmented papules and plaques (lichenified onchodermatitis), areas of skin atrophy with loss of elasticity (‘Lizard skin’), and depigmented areas with a ‘leopard skin appearance, usually on shins.

      Ocular involvement provides the common name associated with onchocerciasis, river blindness, and it can involve any part of the eye. Almost a million people worldwide have at least a partial degree of vision loss caused by onchocerciasis. Initially, there may be intense watering, foreign body sensation, and photophobia. This can progress to conjunctivitis, iridocyclitis, and chorioretinitis. Secondary glaucoma and optic atrophy may also occur.

      In a number of countries, onchocerciasis has been controlled through spraying of blackfly breeding sites with insecticide. The drug ivermectin is the preferred treatment for onchocerciasis.

    • This question is part of the following fields:

      • Dermatology
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  • Question 7 - A 6 year old male is brought to the emergency department due to...

    Incorrect

    • A 6 year old male is brought to the emergency department due to a rash on the flexural surfaces of both elbows. Dad informs you that there is usually some dry skin here but the redness has increased and the child has been scratching the area a lot over the past few days. You diagnose a moderate severity eczema flare.

      What is the most suitable course of action?

      Your Answer: Advise regular use of emollients and prescribe topical tacrolimus twice daily for 7-14 days

      Correct Answer: Advise regular use of emollients and twice daily clobetasone butyrate

      Explanation:

      Dermovate (Clobetasol propionate) is a strong steroid used for treating skin conditions. It is important to continue using emollients alongside steroid treatment. If the flare-ups are not effectively controlled by steroids, Tacrolimus can be considered as a secondary treatment option.

      Further Reading:

      Eczema is a chronic inflammatory skin disease characterized by dry, itchy skin with eczematous lesions. It often follows a chronic relapsing course and can lead to chronic skin changes such as lichenification and pigment changes. The term eczema is often used interchangeably with dermatitis, but strictly speaking, dermatitis refers to inflammation of the skin while eczema refers to specific conditions where skin inflammation is a feature.

      Atopic eczema, also known as atopic dermatitis, is the most common type of eczema. It is usually first diagnosed in young children, with 90% of cases diagnosed before the age of 5. However, it can affect individuals of any age. Symptoms often improve as patients progress into their teens and adulthood. Around 10-20% of children are affected by atopic eczema, but only 3% of adults experience symptoms.

      The exact cause of atopic eczema is not fully understood, but it is believed to be multifactorial, with both genetic and environmental factors playing a role. Genetic defects in genes that aid in the functioning of the skin barrier have been identified, which may predispose individuals to breaks in the skin barrier and increased exposure to antigens. Environmental factors such as pollution, allergen exposure, climate, and others also contribute to the development of the disease.

      Diagnosing atopic eczema involves assessing the presence of key clinical features, such as pruritus (itching), eczema/dermatitis in a pattern appropriate for age, early age of onset, and personal or family history of atopy. Various diagnostic criteria have been established to aid in the diagnosis, including those set out by the American Academy of Dermatology and the UK working party.

      The severity of atopic eczema can vary, and treatment options depend on the severity. Mild cases may be managed with emollients (moisturizers) and mild potency topical corticosteroids. Moderate cases may require moderate potency topical corticosteroids, topical calcineurin inhibitors, and bandages. Severe cases may necessitate the use of potent topical corticosteroids, topical calcineurin inhibitors, bandages, phototherapy, and systemic therapy.

      In addition to medical treatment, identifying and avoiding triggers is an important aspect of managing atopic eczema. Common triggers include irritants, contact allergens, certain foods, skin infections, inhalant triggers, stress and infection.

    • This question is part of the following fields:

      • Dermatology
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  • Question 8 - A 72-year-old man has been experiencing a worsening of his arthritis symptoms lately....

    Incorrect

    • A 72-year-old man has been experiencing a worsening of his arthritis symptoms lately. His knees have been especially painful, and he has been using a hot water bottle in the evenings for relief. Upon examination, you observe pigmented areas with some redness on both of his knees.
      What is the SINGLE most probable diagnosis?

      Your Answer: Erythema nodosum

      Correct Answer: Erythema ab igne

      Explanation:

      Erythema ab igne is a condition that is frequently observed in older individuals. It typically occurs when they spend extended periods of time near a fire or utilize a hot water bottle in an attempt to relieve pain symptoms. This condition arises due to the harmful effects of heat on the skin, resulting in the appearance of reddened and pigmented areas. Fortunately, erythema ab igne tends to resolve on its own without any specific treatment.

    • This question is part of the following fields:

      • Dermatology
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  • Question 9 - A child presents with a headache, high temperature, and a very itchy rash...

    Incorrect

    • A child presents with a headache, high temperature, and a very itchy rash on their face and body that has been there for 3 days. The doctor suspects the child has chickenpox. When should aciclovir be considered for this patient?

      Your Answer: Intensely itchy rash

      Correct Answer: Immunocompromised

      Explanation:

      Chickenpox is a highly contagious illness caused by the varicella-zoster virus, a DNA virus from the Herpesviridae family. Most cases are mild to moderate, and the infection usually resolves on its own. Severe complications are rare but can occur, especially in individuals with weakened immune systems or underlying health conditions.

      The incubation period for chickenpox is typically between 14 to 21 days. It is contagious from a few days before the rash appears until about a week after the first lesions show up.

      The common clinical features of chickenpox include:

      – Fever, which lasts for approximately 3-5 days.
      – The initial rash starts as flat red spots and progresses into raised bumps.
      – These bumps then turn into fluid-filled blisters and eventually form pustules surrounded by redness.
      – The lesions are extremely itchy.
      – The rash reaches its peak around 48 hours in individuals with a healthy immune system.
      – The rash tends to be more concentrated on the face and trunk, with fewer lesions on the limbs.
      – The blisters eventually dry up and form crusts, which can lead to scarring if scratched.
      – Headache, fatigue, and abdominal pain may also occur.

      Chickenpox tends to be more severe in teenagers and adults compared to children. Antiviral treatment should be considered for these individuals if they seek medical attention within 24 hours of rash onset. The recommended oral dose of aciclovir is 800 mg taken five times a day for seven days.

      Immunocompromised patients and those at higher risk, such as individuals with severe cardiovascular or respiratory disease or chronic skin disorders, should receive antiviral treatment for ten days, with at least seven days of intravenous administration.

      Although most cases are relatively mild, if serious complications like pneumonia, encephalitis, or dehydration are suspected, it is important to refer the patient for hospital admission.

      For more information, you can refer to the NICE Clinical Knowledge Summary on Chickenpox.
      https://cks.nice.org.uk/topics/chickenpox/

    • This question is part of the following fields:

      • Dermatology
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  • Question 10 - A 35 year old male comes to the emergency department complaining of a...

    Incorrect

    • A 35 year old male comes to the emergency department complaining of a growing area of redness that has been spreading from a mosquito bite for the past two days. Upon examination, you observe slightly tender redness on the right lower limb, which feels warm and mildly painful to touch. The patient does not have a fever, and vital signs are within normal range.

      You determine that the patient has mild cellulitis. What is the most suitable course of action?

      Your Answer: Discharge with oral metronidazole

      Correct Answer: Discharge with oral flucloxacillin

      Explanation:

      Flucloxacillin is recommended as the initial treatment for mild cellulitis, according to NICE guidelines. The recommended dosage for flucloxacillin is 500-1000 mg taken four times a day for a period of 5-7 days. However, if a patient is allergic to penicillin or if flucloxacillin is not suitable for them, alternative medications such as clarithromycin, doxycycline, or erythromycin can be used as second-line options. It is important to note that for cellulitis near the eyes, co-amoxiclav is advised as the first-line treatment, while for cellulitis in patients with lymphedema who do not require hospital admission, amoxicillin is recommended as the first-line treatment.

      Further Reading:

      Cellulitis is an inflammation of the skin and subcutaneous tissues caused by an infection, usually by Streptococcus pyogenes or Staphylococcus aureus. It commonly occurs on the shins and is characterized by symptoms such as erythema, pain, swelling, and heat. In some cases, there may also be systemic symptoms like fever and malaise.

      The NICE Clinical Knowledge Summaries recommend using the Eron classification to determine the appropriate management of cellulitis. Class I cellulitis refers to cases without signs of systemic toxicity or uncontrolled comorbidities. Class II cellulitis involves either systemic illness or the presence of a co-morbidity that may complicate or delay the resolution of the infection. Class III cellulitis is characterized by significant systemic upset or limb-threatening infection due to vascular compromise. Class IV cellulitis involves sepsis syndrome or a severe life-threatening infection like necrotizing fasciitis.

      According to the guidelines, patients with Eron Class III or Class IV cellulitis should be admitted for intravenous antibiotics. This also applies to patients with severe or rapidly deteriorating cellulitis, very young or frail individuals, immunocompromised patients, those with significant lymphedema, and those with facial or periorbital cellulitis (unless very mild). Patients with Eron Class II cellulitis may not require admission if the necessary facilities and expertise are available in the community to administer intravenous antibiotics and monitor the patient.

      The recommended first-line treatment for mild to moderate cellulitis is flucloxacillin. For patients allergic to penicillin, clarithromycin or clindamycin is recommended. In cases where patients have failed to respond to flucloxacillin, local protocols may suggest the use of oral clindamycin. Severe cellulitis should be treated with intravenous benzylpenicillin and flucloxacillin.

      Overall, the management of cellulitis depends on the severity of the infection and the presence of any systemic symptoms or complications. Prompt treatment with appropriate antibiotics is crucial to prevent further complications and promote healing.

    • This question is part of the following fields:

      • Dermatology
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  • Question 11 - A 45-year-old woman presents with a severe, widespread, bright red rash covering her...

    Incorrect

    • A 45-year-old woman presents with a severe, widespread, bright red rash covering her entire torso, face, arms and upper legs. The skin is scaling and peeling in places and feels hot to touch. She is referred to the on-call dermatologist and a diagnosis of exfoliative erythroderma is made.
      What is the SINGLE most likely underlying cause?

      Your Answer: Psoriasis

      Correct Answer: Atopic dermatitis

      Explanation:

      Erythroderma is a condition characterized by widespread redness affecting more than 90% of the body surface. It is also known as exfoliative erythroderma due to the presence of skin exfoliation. Another term used to describe this condition is the red man syndrome.

      The clinical features of exfoliative erythroderma include the rapid spread of redness to cover more than 90% of the body surface. Scaling of the skin occurs between days 2 and 6, leading to thickening of the skin. Despite the skin feeling hot, patients often experience a sensation of coldness. Keratoderma, which is the thickening of the skin on the palms and soles, may develop. Over time, erythema and scaling of the scalp can result in hair loss. The nails may become thickened, ridged, and even lost. Lymphadenopathy, or enlarged lymph nodes, is a common finding. In some cases, the patient’s overall health may be compromised.

      Exfoliative erythroderma can be caused by various factors, including eczema (with atopic dermatitis being the most common underlying cause), psoriasis, lymphoma and leukemia (with cutaneous T-cell lymphoma and Hodgkin lymphoma being the most common malignant causes), certain drugs (more than 60 drugs have been implicated, with sulphonamides, isoniazid, penicillin, antimalarials, phenytoin, captopril, and cimetidine being the most commonly associated), idiopathic (unknown cause), and rare conditions such as pityriasis rubra pilaris and pemphigus foliaceus. Withdrawal of corticosteroids, underlying infections, hypocalcemia, and the use of strong coal tar preparations can also precipitate exfoliative erythroderma.

      Potential complications of exfoliative erythroderma include dehydration, hypothermia, cardiac failure, overwhelming secondary infection, protein loss and edema, anemia (due to loss of iron, B12, and folate), and lymphadenopathy.

      Management of exfoliative erythroderma should involve referring the patient to the medical on-call team and dermatology for admission. It is important to keep the patient warm and start intravenous fluids, such as warmed 0.9% saline. Applying generous amounts of emollients and wet dressings can help alleviate

    • This question is part of the following fields:

      • Dermatology
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  • Question 12 - A 4-year-old boy comes in with a mild fever and symptoms of a...

    Incorrect

    • A 4-year-old boy comes in with a mild fever and symptoms of a cold. He has a rash that looks like measles on the backs of his arms and legs, and a red rash on both of his cheeks.

      What is the MOST LIKELY diagnosis for this child?

      Your Answer: Rubella

      Correct Answer: Fifth disease

      Explanation:

      Fifth disease, also known as ‘slapped cheek syndrome’, is a common childhood exanthem caused by parvovirus B19.

      The clinical features of fifth disease include:

      – A mild coryzal illness usually occurs as a prodrome.
      – The classic ‘slapped cheek’ rash appears after 3-7 days, characterized by a red rash on the cheeks with pale skin around the mouth.
      – A morbilliform rash develops on the extensor surfaces of the arms and legs 1-4 days after the facial rash appears.

      This disease is generally harmless and resolves on its own in children. However, it can be dangerous for pregnant women who are exposed to the virus, as it can cause intrauterine infection and hydrops fetalis. Additionally, it can lead to transient aplastic crisis. Therefore, it is important to keep affected children away from pregnant women and individuals with weakened immune systems or blood disorders.

    • This question is part of the following fields:

      • Dermatology
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  • Question 13 - You evaluate a 7-year-old girl with a rash covered in honey-colored crust on...

    Incorrect

    • You evaluate a 7-year-old girl with a rash covered in honey-colored crust on her face and diagnose her with impetigo. You prescribe a topical fusidic acid treatment. The parents of the child would like to know the duration she should be kept away from school.

      What is the recommended period for keeping her away from school due to this infection?

      Your Answer: 5 days after starting antibiotic therapy

      Correct Answer: 48 hours after starting antibiotic therapy

      Explanation:

      Public Health England advises that children with impetigo should not attend school, nursery, or be under the care of childminders until the sores have formed a crust or until 48 hours after starting antibiotic treatment. Antibiotics help accelerate the healing process and decrease the period of contagiousness.

      For more information, please refer to the Guidance on Infection Control in Schools and other Childcare Settings.
      https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf

    • This question is part of the following fields:

      • Dermatology
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  • Question 14 - A young patient presents with a blistering rash. The differential diagnosis includes pemphigus...

    Incorrect

    • A young patient presents with a blistering rash. The differential diagnosis includes pemphigus vulgaris and bullous pemphigoid.

      Which of the following features would indicate a diagnosis of pemphigus vulgaris?

      Your Answer: Prominently affecting limb flexures

      Correct Answer: Age 50 at presentation

      Explanation:

      Pemphigus, derived from the Greek word for bubble ‘pemphix’, refers to a group of autoimmune disorders that cause blistering of the skin and/or mucosal surfaces. The most common subset is pemphigus vulgaris (PV), which accounts for approximately 70% of cases worldwide. PV is characterized by an autoimmune response where autoantibodies target cell surface antigens on keratinocytes, specifically desmogleins 1 and 3. This leads to a loss of cell-to-cell adhesion and separation, resulting in blister formation.

      On the other hand, bullous pemphigoid (BP) is a chronic autoimmune blistering skin disorder that affects the subepidermal layer. It occurs when the basement membrane of the epidermis is attacked by IgG and sometimes IgE immunoglobulins, as well as activated T lymphocytes. The binding of autoantibodies to proteins and the release of cytokines from T cells trigger complement activation, neutrophil recruitment, and the release of proteolytic enzymes. These enzymes destroy the hemidesmosomes, leading to the formation of subepidermal blisters.

      To summarize the differences between pemphigus vulgaris and bullous pemphigoid, the following provides a comparison:

      Pemphigus Vulgaris:
      – Age: Middle-aged people (mean age 50)
      – Oral involvement: Common
      – Blister type: Large, flaccid, and painful
      – Blister content: Fluid-filled, often haemorrhagic
      – Areas commonly affected: Initially face and scalp, then spread to the chest and back
      – Nikolsky sign: Usually positive
      – Pruritus: Rare
      – Skin biopsy: Intra-epidermal deposition of IgG between cells throughout the epidermis

      Bullous Pemphigoid:
      – Age: Elderly people (mean age 80)
      – Oral involvement: Rare
      – Blister type: Large and tense
      – Blister content: Fluid-filled
      – Areas commonly affected: Upper arms, thighs, and skin flexures
      – Nikolsky sign: Usually negative
      – Pruritus: Common
      – Skin biopsy: A band of IgG and/or C3 at the dermo-epidermal junction

    • This question is part of the following fields:

      • Dermatology
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  • Question 15 - A 45-year-old woman presents with a severe, widespread, bright red rash covering her...

    Incorrect

    • A 45-year-old woman presents with a severe, widespread, bright red rash covering her entire torso, face, arms and upper legs. The skin is scaling and peeling in places and feels hot to touch. She was recently prescribed a new medication by her doctor a few days ago and is concerned that this might be the cause.

      What is the SINGLE most likely diagnosis?

      Your Answer: Stevens-Johnson syndrome

      Correct Answer: Exfoliative erythroderma

      Explanation:

      Erythroderma is a condition characterized by widespread redness affecting more than 90% of the body surface. It is also known as exfoliative erythroderma due to the presence of skin exfoliation. Another term used to describe this condition is the red man syndrome.

      The clinical features of exfoliative erythroderma include the rapid spread of redness to cover more than 90% of the body surface. Scaling of the skin occurs between days 2 and 6, leading to thickening of the skin. Despite the skin feeling hot, patients often experience a sensation of coldness. Keratoderma, which is the thickening of the skin on the palms and soles, may develop. Over time, erythema and scaling of the scalp can result in hair loss. The nails may become thickened, ridged, and even lost. Lymphadenopathy, or enlarged lymph nodes, is a common finding. In some cases, the patient’s overall health may be compromised.

      Exfoliative erythroderma can be caused by various factors, including eczema (with atopic dermatitis being the most common underlying cause), psoriasis, lymphoma and leukemia (with cutaneous T-cell lymphoma and Hodgkin lymphoma being the most common malignant causes), certain drugs (more than 60 drugs have been implicated, with sulphonamides, isoniazid, penicillin, antimalarials, phenytoin, captopril, and cimetidine being the most commonly associated), idiopathic (unknown cause), and rare conditions such as pityriasis rubra pilaris and pemphigus foliaceus. Withdrawal of corticosteroids, underlying infections, hypocalcemia, and the use of strong coal tar preparations can also precipitate exfoliative erythroderma.

      Potential complications of exfoliative erythroderma include dehydration, hypothermia, cardiac failure, overwhelming secondary infection, protein loss and edema, anemia (due to loss of iron, B12, and folate), and lymphadenopathy.

      Management of exfoliative erythroderma should involve referring the patient to the medical on-call team and dermatology for admission. It is important to keep the patient warm and start intravenous fluids, such as warmed 0.9% saline. Applying generous amounts of emollients and wet dressings can help alleviate

    • This question is part of the following fields:

      • Dermatology
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  • Question 16 - A 3-year-old boy has a fever accompanied by a sore throat and a...

    Incorrect

    • A 3-year-old boy has a fever accompanied by a sore throat and a decreased desire to eat. His mother has observed itchy patches on the palms of his hands and soles of his feet. During your examination, you observe small red sores in his mouth.
      What is the SINGLE most probable causative organism in this scenario?

      Your Answer: Herpes simplex

      Correct Answer: Coxsackie A

      Explanation:

      Hand-foot-and-mouth disease is a viral syndrome characterized by a unique rash and sores. The main culprit behind this condition is typically the Coxsackie A16 virus. After being exposed to the virus, it takes about 3-5 days for symptoms to appear. The disease spreads through droplets in the air. Before the rash and sores develop, individuals may experience a pre-illness phase with symptoms like a sore throat and mouth ulcers. This condition primarily affects children under the age of ten. In addition to the rash, most children will also develop spots on their hands and feet.

      When it comes to treatment, the focus is mainly on providing support. This involves using antipyretics to reduce fever and ensuring that the affected individual stays well-hydrated. Due to the mouth ulcers, loss of appetite is common, so it’s important to encourage adequate fluid intake.

    • This question is part of the following fields:

      • Dermatology
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  • Question 17 - A 3-year-old child is brought in by his father complaining of itchy skin...

    Incorrect

    • A 3-year-old child is brought in by his father complaining of itchy skin on his arms. He has a history of allergies, and over the past few days, both of his arms have become covered in small red bumps. His father also reports that he has had a low-grade fever of 37.8°C. During the examination, you observe significant swelling of the lymph nodes in his neck. While speaking with his father, you notice a scabbing sore on the right side of his mouth.

      What is the SINGLE most likely diagnosis?

      Your Answer: Impetigo

      Correct Answer: Eczema herpeticum

      Explanation:

      Eczema herpeticum occurs when an individual with atopic eczema comes into contact with the herpes simplex virus. While some patients may only experience typical cold sores, others may develop a more extensive infection. This condition is often accompanied by systemic disturbance and can be quite painful. Administering antiviral treatment can help reduce the duration of the illness. In cases where the rash is widespread or there are concerns about eye complications, hospital admission may be necessary for intravenous antiviral therapy.

    • This question is part of the following fields:

      • Dermatology
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  • Question 18 - A 62 year old male comes to the emergency department with a painful...

    Incorrect

    • A 62 year old male comes to the emergency department with a painful swollen right arm that has developed over the past 24 hours. On examination there is redness over most of the forearm and upper arm on the right side which is tender and warm to touch. The patient's vital signs are as follows:

      Blood pressure 138/86 mmHg
      Pulse 96 bpm
      Respiration rate 21 bpm
      Temperature 38.1ÂșC

      What is the most probable diagnosis?

      Your Answer: Deep vein thrombosis

      Correct Answer: Cellulitis

      Explanation:

      Cellulitis is a common cause of swelling in one leg. It is characterized by red, hot, tender, and swollen skin, usually affecting the shin on one side. Other symptoms may include fever, fatigue, and chills. It is important to consider deep vein thrombosis (DVT) as a possible alternative diagnosis, as it can be associated with cellulitis or vice versa. Unlike cellulitis, DVT does not typically cause fever and affects the entire limb below the blood clot, resulting in swelling in the calf, ankle, and foot. Necrotizing fasciitis is a rare condition. Gout primarily affects the joints of the foot, particularly the first metatarsophalangeal joint. Erythema migrans usually produces a distinct target-shaped rash.

      Further Reading:

      Cellulitis is an inflammation of the skin and subcutaneous tissues caused by an infection, usually by Streptococcus pyogenes or Staphylococcus aureus. It commonly occurs on the shins and is characterized by symptoms such as erythema, pain, swelling, and heat. In some cases, there may also be systemic symptoms like fever and malaise.

      The NICE Clinical Knowledge Summaries recommend using the Eron classification to determine the appropriate management of cellulitis. Class I cellulitis refers to cases without signs of systemic toxicity or uncontrolled comorbidities. Class II cellulitis involves either systemic illness or the presence of a co-morbidity that may complicate or delay the resolution of the infection. Class III cellulitis is characterized by significant systemic upset or limb-threatening infection due to vascular compromise. Class IV cellulitis involves sepsis syndrome or a severe life-threatening infection like necrotizing fasciitis.

      According to the guidelines, patients with Eron Class III or Class IV cellulitis should be admitted for intravenous antibiotics. This also applies to patients with severe or rapidly deteriorating cellulitis, very young or frail individuals, immunocompromised patients, those with significant lymphedema, and those with facial or periorbital cellulitis (unless very mild). Patients with Eron Class II cellulitis may not require admission if the necessary facilities and expertise are available in the community to administer intravenous antibiotics and monitor the patient.

      The recommended first-line treatment for mild to moderate cellulitis is flucloxacillin. For patients allergic to penicillin, clarithromycin or clindamycin is recommended. In cases where patients have failed to respond to flucloxacillin, local protocols may suggest the use of oral clindamycin. Severe cellulitis should be treated with intravenous benzylpenicillin and flucloxacillin.

      Overall, the management of cellulitis depends on the severity of the infection and the presence of any systemic symptoms or complications. Prompt treatment with appropriate antibiotics is crucial to prevent further complications and promote healing.

    • This question is part of the following fields:

      • Dermatology
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  • Question 19 - A 45 year old female with a history of alcohol-related visits to the...

    Correct

    • A 45 year old female with a history of alcohol-related visits to the emergency department is currently in the emergency department after tripping while intoxicated. She has a 7 cm laceration on the frontal area of the scalp. You examine the wound using local anesthesia. What tissue layer lies directly beneath the scalp skin?

      Your Answer: Dense connective tissue

      Explanation:

      The scalp is composed of five layers, starting from the outermost layer, which is the skin, and moving towards the deepest layer, which is the periosteum of the skull. These layers can be remembered using the mnemonic: SCALP – Skin, Connective tissue, Aponeurosis, Loose areolar connective tissue, and Periosteum.

      Further Reading:

      The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.

      The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.

      The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.

      In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.

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      • Dermatology
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  • Question 20 - A 25-year-old soccer player comes in with a pustular red rash on his...

    Incorrect

    • A 25-year-old soccer player comes in with a pustular red rash on his thigh and groin region. There are vesicles present at the borders of the rash.
      What is the SINGLE most probable diagnosis?

      Your Answer: Shingles

      Correct Answer: Tinea cruris

      Explanation:

      Tinea cruris, commonly known as ‘jock itch’, is a fungal infection that affects the groin area. It is primarily caused by Trichophyton rubrum and is more prevalent in young men, particularly athletes. The typical symptoms include a reddish or brownish rash that is accompanied by intense itching. Pustules and vesicles may also develop, and there is often a raised border with a clear center. Notably, the infection usually does not affect the penis and scrotum.

      It is worth mentioning that patients with tinea cruris often have concurrent tinea pedis, also known as athlete’s foot, which may have served as the source of the infection. The infection can be transmitted through sharing towels or by using towels that have come into contact with infected feet, leading to the spread of the fungus to the groin area.

      Fortunately, treatment for tinea cruris typically involves the use of topical imidazole creams, such as clotrimazole. This is usually sufficient to alleviate the symptoms and eradicate the infection. Alternatively, terbinafine cream can be used as an alternative treatment option.

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      • Dermatology
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  • Question 21 - With freezing temperatures anticipated, your consultant requests that you organize a teaching session...

    Incorrect

    • With freezing temperatures anticipated, your consultant requests that you organize a teaching session for the junior physicians regarding the management of frostbite. What imaging modality is preferred for evaluating perfusion abnormalities in extremities impacted by frostbite?

      Your Answer: Doppler ultrasound

      Correct Answer: Technetium 99 (Tc-99) pertechnetate scintigraphy

      Explanation:

      Technetium 99 (Tc-99) pertechnetate scintigraphy is the preferred imaging method for evaluating frostbite. This technique is highly accurate in detecting tissue damage and provides both sensitivity and specificity.

      Further Reading:

      Hypothermia is defined as a core temperature below 35ÂșC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

      In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

      Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ÂșC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

      Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

    • This question is part of the following fields:

      • Dermatology
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  • Question 22 - You review a 6-year-old boy with a fever, rash, photophobia, and conjunctivitis for...

    Incorrect

    • You review a 6-year-old boy with a fever, rash, photophobia, and conjunctivitis for the past 24 hours. On examining his mouth, you observe Koplik’s spots on the buccal mucosa. The parents of the child would like to know how long he should stay home from school.
      What is the recommended duration for keeping this infection away from school?

      Your Answer: 24 hours from onset of rash

      Correct Answer: 4 days from onset of rash

      Explanation:

      This child has been clinically diagnosed with measles. The typical presentation includes a high fever accompanied by symptoms of a runny nose and sensitivity to light. Conjunctivitis, or pink eye, is often present as well. The associated rash is a widespread red rash with raised bumps. Koplik spots, which are white lesions on the inside of the cheeks, are a telltale sign of measles.

      According to Public Health England, it is recommended that children with measles stay away from school, nursery, or childminders for four days starting from when the rash first appears.

      For more information, you can refer to the Guidance on Infection Control in Schools and other Childcare Settings.
      https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf

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      • Dermatology
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  • Question 23 - A 45-year-old woman comes in with a severe skin rash. After being evaluated...

    Incorrect

    • A 45-year-old woman comes in with a severe skin rash. After being evaluated by the dermatology consultant on call, she is diagnosed with Stevens-Johnson syndrome.
      Which of the following statements about Stevens-Johnson syndrome is correct?

      Your Answer: It cannot be distinguished from toxic epidermal necrolysis without skin biopsy

      Correct Answer: Epidermal detachment is seen in less than 10% of the body surface area

      Explanation:

      Stevens-Johnson syndrome is a severe and potentially deadly form of erythema multiforme. It can be triggered by anything that causes erythema multiforme, but it is most commonly seen as a reaction to medication within 1-3 weeks of starting treatment. Initially, there may be symptoms like fever, fatigue, joint pain, and digestive issues, followed by the development of severe mucocutaneous lesions that are blistering and ulcerating.

      Stevens-Johnson syndrome and toxic epidermal necrolysis are considered to be different stages of the same mucocutaneous disease, with toxic epidermal necrolysis being more severe. The extent of epidermal detachment is used to differentiate between the two. In Stevens-Johnson syndrome, less than 10% of the body surface area is affected by epidermal detachment, while in toxic epidermal necrolysis, it is greater than 30%. An overlap syndrome occurs when detachment affects between 10-30% of the body surface area.

      Several drugs can potentially cause Stevens-Johnson syndrome and toxic epidermal necrolysis, including tetracyclines, penicillins, vancomycin, sulphonamides, NSAIDs, and barbiturates.

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      • Dermatology
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  • Question 24 - A child with a skin infection that is not improving with initial antibiotics...

    Incorrect

    • A child with a skin infection that is not improving with initial antibiotics comes back for a follow-up. Upon reviewing the culture results, it is found that Methicillin-resistant Staphylococcus aureus has been identified.
      Which of the following antibiotics is typically ineffective against Methicillin-resistant Staphylococcus aureus?

      Your Answer: Vancomycin

      Correct Answer: Imipenem

      Explanation:

      Methicillin-resistant Staphylococcus aureus (MRSA) has become a significant issue in hospitals and other healthcare facilities in recent years. MRSA refers to any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics, such as penicillins and cephalosporins. This resistance is caused by the presence of the mecA gene, which produces a penicillin-binding protein with low affinity. Fortunately, MRSA is typically susceptible to teicoplanin, vancomycin, daptomycin, and linezolid. On the other hand, imipenem is an intravenous beta-lactam antibiotic that belongs to the carbapenem subgroup.

    • This question is part of the following fields:

      • Dermatology
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  • Question 25 - A 42 year old female attends the emergency department after developing an intensely...

    Incorrect

    • A 42 year old female attends the emergency department after developing an intensely itchy red rash to the entirety of her body over the past 48 hours. The patient mentions having a history of eczema and had noticed a few eczematous patches appear in the days before the rash started. On examination, there is erythema to almost the entirety of the body (>90% of total body surface area) with areas of scaling, excoriation marks, and lichenification. The patient's vital signs are as follows:

      Blood pressure: 118/76
      Pulse: 106 bpm
      Respiration rate: 22 bpm
      Temperature: 35.8 ÂșC

      What is the diagnosis?

      Your Answer: Pityriasis rosea

      Correct Answer: Erythroderma

      Explanation:

      This explanation describes the observation of a patient with psoriasis, the most common associated condition in adults. The observations suggest that the patient may be experiencing dehydration, which is a complication of this condition.

      Further Reading:

      Erythroderma is a rare inflammatory skin condition that affects the majority of a person’s skin surface area. It is characterized by widespread redness, intense itching, and peeling of the skin. The condition can occur in people of all ages and races, but it is more common in males. Erythroderma is considered a dermatological emergency due to the potential for life-threatening complications.

      The most common causes of erythroderma are exacerbations of pre-existing skin conditions, such as atopic dermatitis, psoriasis, and lichen planus. However, approximately one-third of cases are idiopathic, meaning the cause is unknown. Other less common skin conditions and systemic illnesses, including certain types of lymphoma and leukemia, can also lead to erythroderma.

      Clinical features of erythroderma include generalized redness and swelling of at least 90% of the skin surface area. This is often preceded by a rash or dermatitis. The intense itching associated with the condition can lead to scratching and thickening of the skin. Skin scaling or peeling typically occurs a few days after the onset of redness. Other symptoms may include hair loss, yellowing of the palms and soles, nail abnormalities, and swollen lymph nodes. Patients may also feel generally unwell.

      Erythroderma can lead to significant complications, including dehydration, electrolyte imbalances, hypothermia, heart failure, and secondary skin infections. Diagnosis is typically made based on clinical presentation, but further investigations may be done to assess the patient’s overall condition and identify any underlying causes.

      Treatment of erythroderma involves addressing the underlying cause, if known. Trigger medications should be discontinued, and supportive measures such as fluid resuscitation, correction of electrolyte imbalances, and treatment of secondary infections should be implemented. Medications for symptom relief, such as painkillers and antihistamines, may also be prescribed. Emollients are often recommended to soothe the skin. In some cases, steroids and immunosuppressants may be used, depending on the underlying cause of the erythroderma.

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      • Dermatology
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  • Question 26 - A 45-year-old woman presents with multiple reddish-purple nodules on her arms and chest...

    Incorrect

    • A 45-year-old woman presents with multiple reddish-purple nodules on her arms and chest that have developed over the past month. She has a known history of HIV infection.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Erythema multiforme

      Correct Answer: Kaposi’s sarcoma

      Explanation:

      Kaposi’s sarcoma (KS) is a type of cancer that affects the connective tissues. It is caused by a virus called human herpesvirus 8 (HHV-8). This cancer is more likely to occur in individuals with weakened immune systems, such as those with HIV or those who have undergone organ transplants.

      The main symptom of KS is the development of skin lesions. These lesions initially appear as red-purple spots and quickly progress to become raised bumps and nodules. They can appear on any part of the body, but are most commonly found on the lower limbs, back, face, mouth, and genital area.

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      • Dermatology
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  • Question 27 - A 25-year-old woman arrives at the emergency department with complaints of lip swelling...

    Incorrect

    • A 25-year-old woman arrives at the emergency department with complaints of lip swelling that began 30 minutes ago. During her medical history, she mentions that her sister experienced a similar episode and was recently diagnosed with hereditary angioedema (HAE). What is the main treatment for this condition?

      Your Answer: Pyridostigmine

      Correct Answer: C1 Esterase Inhibitor Replacement Protein

      Explanation:

      The explanation states that the increased activity of the enzyme kininogenase is caused by hormonal factors, specifically oestrogen, as well as genetic factors.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

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      • Dermatology
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  • Question 28 - You review a 25 year old male who presented to the emergency department...

    Incorrect

    • You review a 25 year old male who presented to the emergency department after developing a raised red itchy rash to the arms, legs, and abdomen shortly after going for a hike. The patient informs you that he had eaten some trail mix and drank some water during the hike, but he had not had a reaction to these in the past. On examination, the mouth and throat are normal, the patient is speaking without difficulty, and there is no wheezing. The patient's vital signs are as follows:

      Respiratory rate: 16 bpm
      Blood pressure: 120/70 mmHg
      Pulse rate: 75 bpm
      Oxygen saturations: 98% on room air
      Temperature: 37.0ÂșC

      You diagnose urticaria. What is the most appropriate treatment to administer?

      Your Answer: Apply hydrocortisone 1% to affected areas

      Correct Answer: chlorpheniramine 10 mg PO

      Explanation:

      Most histamine receptors in the skin are of the H1 type. Therefore, when treating urticaria without airway compromise, it is appropriate to use an H1 blocking antihistamine such as chlorpheniramine, fexofenadine, or loratadine. However, if the case is mild and the trigger is easily identifiable and avoidable, NICE advises that no treatment may be necessary. In the given case, the trigger is not obvious. For more severe cases, an oral systemic steroid course like prednisolone 40 mg for 5 days may be used in addition to antihistamines. Topical steroids do not have a role in this treatment.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

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      • Dermatology
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  • Question 29 - A 45-year-old man comes to the Emergency Department with a painful rash that...

    Incorrect

    • A 45-year-old man comes to the Emergency Department with a painful rash that seems to be indicative of shingles. The rash is vesicular in nature and affects a single dermatome.

      What is the most frequent location of reactivation of the varicella zoster virus in individuals with a healthy immune system?

      Your Answer: Ophthalmic division of the trigeminal nerve

      Correct Answer: Thoracic nerves

      Explanation:

      Shingles is caused by the varicella-zoster virus (VZV), which primarily infects individuals during childhood as chickenpox. However, the initial infection can also be subclinical. After the primary infection, the virus remains dormant in the sensory nervous system, specifically in the geniculate, trigeminal, or dorsal root ganglia.

      During the dormant phase, the virus is kept under control by the immune system for many years. However, it can later become active and cause a flare-up in a specific dermatomal segment. This reactivation occurs when the virus travels down the affected nerve over a period of 3 to 5 days, leading to inflammation within and around the nerve. The decline in cell-mediated immunity is believed to trigger the virus’s reactivation.

      Several factors can trigger the reactivation of the varicella-zoster virus, including advancing age (with most patients being older than 50), immunosuppressive illnesses, physical trauma, and psychological stress. In immunocompetent patients, the most common site of reactivation is the thoracic nerves, followed by the ophthalmic division of the trigeminal nerve.

      Diagnosing shingles can usually be done based on the patient’s history and clinical examination alone, as it has a distinct history and appearance. While various techniques can be used to detect the virus or antibodies, they are often unnecessary. Microscopy and culture tests using scrapings and smears typically yield negative results.

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      • Dermatology
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  • Question 30 - A 68 year old is brought into the emergency department due to worsening...

    Incorrect

    • A 68 year old is brought into the emergency department due to worsening confusion. A urinary tract infection is suspected as the probable cause. During assessment, you observe partial thickness loss of dermis in the sacral area, which appears as a shallow open ulcer with a red pink wound bed, without slough. What grade of pressure ulcer would this be classified as?

      Your Answer:

      Correct Answer: Grade 2

      Explanation:

      In the UK, the classification of pressure ulcers is done using the international NPUAP-EPUAP system. This particular description refers to a pressure ulcer of grade 2. Please refer to the notes below for more information on the classification of pressure ulcers.

      Further Reading:

      Pressure ulcers, also known as bedsores, are localized damage to the skin and underlying tissues caused by pressure or pressure combined with shear force. They most commonly occur over bony prominences but can develop on any part of the body. Pressure ulcers develop due to five main factors: pressure, shear, friction, moisture, and circulation and tissue perfusion. Pressure is the most important factor, with intensity and duration playing key roles in the development of pressure ulcers.

      Assessment of pressure ulcers in adults should be done using a validated classification tool. The International NPUAP-EPUAP pressure ulcer classification system is preferred in the UK. This system categorizes pressure ulcers into four stages. Stage I is characterized by non-blanchable erythema, which is non-blanchable redness of the skin. Stage II involves partial thickness loss of the dermis, presenting as a shallow open ulcer with a red pink wound bed. Stage III is full thickness skin loss, with subcutaneous fat visible but no exposure of bone, tendon, or muscle. Stage IV is also full thickness tissue loss, but with exposed bone, tendon, or muscle. In addition, some pressure ulcers may be classified as suspected deep tissue injury or unstageable.

      Management of pressure ulcers involves general measures such as pressure reducing aids, repositioning, hygiene, cleansing, dressings, analgesia, and dietary optimization. It is also important to optimize or treat underlying health conditions, such as diabetes. For grade 3 and 4 ulcers, additional measures to consider include antibiotics and surgical debridement with or without skin flap coverage.

    • This question is part of the following fields:

      • Dermatology
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Dermatology (8/29) 28%
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