Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Um, I'm leave. I'm the doctor who's going to be presenting the final years series of the medicine branch. Um, the lead for that. And I'm starting, uh, Session one with dermatologic, and someone just put in the chat whether they can hear me. Okay, if someone could just put a quick Yes, thumbs up something in the chapter. Sonus. Everyone can hear me. Perfect. Right. Um, so I'll make a start. Um, so a quick shout out, um, all of our webinars are sponsored by Wesleyan, and they support you throughout your first year of foundation. Give you lots of advice, support on your career, finances and well being. If you want to find out more, just scan that QR code. Um, so structure of the session today, I'll do very quickly. History and exam. Obviously you This is based at final year medicine level. So you should be quite familiar with the basics of history taking and examination. But I'll just do what is specific to a dermatology, dermatology, history and exam. And then I'll then go through describing the skin lesions or rashes that you might see in these examinations a bit on inflammatory skin conditions focusing on X men and psoriasis. Um, acne is an inflammatory skin condition, which you might be tested on in finals, and I don't cover it. So that might be something that you want to look up in your own time. Then go into the skin cancers, which will probably come up in your finals. Um, some skin infections again. I've not covered all skin infections, which will come up in your finals or possibly come up. I'm just gonna cover cellulitis, the most common bacterial skin infection and also necrotizing fasciitis, which is one of the most severe skin infections you might see. It might be quite good to have a look at fungal skin infections because the very common and might be tested on in your finals And then last of all, I'm just gonna do kind of exam buzzwords and spot diagnosis something new that I wanted to try. So I'll bring a word up, and I kind of want you to put in the chat anything that you think might be a buzzword in an exam question that makes you get that diagnosis. Or I'll put a photo up of a lesion or a rash and I just want you to kind of mind map brainstorm in the chat. What you think of the doubt? What you think the diagnosis is? How you how you would describe it in an examination? All right, so very quickly. History and exam. So for focusing on the history. So obviously, what is the issue? What's the presenting complaint? Is it a rash, or is it a skin lesion and and then going through the cord? Dermatological symptoms so pain. And if there's pain follows Socrates acronym. Is there any itch, bleeding discharge or blistering? Um, and for each of those, you can kind of use the arts acronym. So, uh, stands for onset associate symptoms. T timing, e exacerbating factors, What makes it worse and the severity of it and and also how How has it evolved over time? How has it changed and why are they coming to you now and important to do a systemic inquiry full top to tour in a dermatological history? As as you know, many other medical conditions present with or have a dermatological manifestation. So, for example, inflammatory bowel disease, you can get everything dose, um, on the shins of patient's UM Ceiling act disease. You can get dermatitis herpetiformis. So have patient's got any other symptoms, which might give you a clue as to what this rash or skin lesion is or focus on past medical history. Do they already have any of these conditions? Um, and that gives you a clue as to what this rash is important thing to ask in a dermatological histories. Sun exposure. So have they got an occupation when they're exposed to sun? Do the work abroad? A lot of the time, do they wear sun cream? Are there someone who tans easily or burns easily? Or somewhere in the middle? Are they a person with a lot of moles or not? A lot of moles And are they're moles changing, Also important to asking sun exposure, whether the person uses sun beds or not. And if they do say that they use sun beds in a examination situation, you'd probably get a mark for encouraging them not to, um and then, just like any other history past medical history, drug history, social history, family history and ice. So the main things that you want to be pulling out there, like I said, do they have any other conditions which might have a dermatological manifestation that you're looking at couldn't have been started on any new drugs that could have caused this social history. So again, a lot of sun bed use holiday in any occupant. What what is their occupation? Any family history. So that's, um, important in kind of systemic conditions, but mainly skin cancers and ice. So it's really important one in ice to ask, How is this affecting? You know, their mental health? How is it affecting their daily life and why they come to you today? A lot of patient's maybe won't volunteer that their skin rash that everyone can see is getting them down to maybe broach that for them and just ask them how they feel about it and then examination. So always ask for a chaperone. You will probably marked down if you don't have, don't at least offer one to the patient, and basically, especially if they're coming in more so if they're coming in with a rash, you need to expose the patient almost to the underwear. Make sure you're doing this in a dignified way, so whether you want them to kind of get down to their underwear and make sure they have a blanket across them and covering the bottom half. As you look at the top top half and keep keeping their dignity with that blanket or whether you want them to kind of take the top off, look around the toss or put the top back on and move on to the bottom half. Do it that way. So, first of all, general inspection. What is the distribution? How many lesions are the how severe is it any signs of overlying infection with the rashes and then close inspection, you kind of need to looking everywhere. So start off with the hands and the nails. Um, some dermatological problems have manifestations in the nails, so in psoriasis you'll see pitting or on a colossus, which is kind of lifting of the nails looking at the hands. Is there any sign of arthritis psoriasis, Um, and are You can get a psoriasis psoriatic arthropathy. So have a look. If there's any signs of arthritis, so any swelling of the joints, any stiffness, it's often multi joint involvement and bilateral when it's related to psoriasis, work your way up through the arms So is the rash on the Flexeril aspect or an extensive aspect? Look in the axilla looking through the hair, the face, the mouth all across the torso and kind of doing the same as you did on the arms and the legs, feet and toenails. And this is really focused on lesion. So, uh, kind of a lesion rather than a rash, and this is how you describe it. So I've split them into a little big flat and raised, so the difference between a little and a big lesion. Usually it's kind of not 0.5 centimeters. So if it's not 0.5 centimeters or less, then you'd call it a macule. If it's over that size so bigger than not 0.5 centimeters and it's flat, it would be a patch if it's little, so less than not 0.5 centimeters and raised. But it doesn't have anything in it that you could kind of squeeze out. That would be a papule if there was fluid within the fluid within the pump, you'll that you see that would be then called a physical. Or if there's puss rather than fluid. That will be a postural If there's if it's bigger than that, so popular, then becomes a nodule. A physical then becomes a bowler and a plaque is raised. But with a flat surface, it's not. It's not curved surface. It's a it's a kind of a raised patch is a plaque. Uh, All right. So that kind of how to describe a primary skin lesion, things that you could use words that you can use in your examination. When you're presenting your findings, you might need to describe kind of secondary changes of a primary skin lesion. So things like, What color is it? What size is it? Any overlying scale, Any crust, any discharge? Is it weeping? These are the kind of words that you need to be using. So I just move on to inflammatory skin conditions, and I'll use some of those words and how we would describe it if you got presented a patient with these conditions. Um, so I'm just gonna focus on eczema and psoriasis with Esma. I'm gonna mainly focus on kind of atopic eczema. But there are other different types of Xmas, such as contact. They're all dermatitis is but kind of a contact dermatitis and allergy dermatitis venous extima. Um, there are different types, but we're just going to focus on the atopic one today. Um, so it's a chronic skin condition but can't have acute flares and acute flare. You'll see itchy pop you ALS and vehicles so that they're small skin lesion's, and some may have fluid within them, and that can cause the weeping over the over top as well. It the red dry, scaly in a chronic when it's chronic, it's dry, scaly, red, and it's on the flexor surfaces. So in between the elbows on the backs of the knees, um, impaler colored patient's that it can be a rhythm Otis red or pink in those with more richly pigmented skin, it can pair dark gray or brown and with the atopic eczema, um, in your history taking, you need to be asking whether they suffer from any other atopic conditions such as asthma and hay. FIFA um, psoriasis. Uh, psoriasis appears on the extensive surfaces as opposed to the flexor. Um, it presents as a, well, well demarcated a rhythm Ettus scaly plaque, um, in those with richly pigmented skin. These plaques can be dark brown, gray or purple, and I'll show you some pictures of, um, psoriasis and different patient's and a few slides time. There are different types of psoriasis. I don't think you need to know all of these for your exam. Um, the main one is plaque psoriasis, and that's the most common. But other ones include gutted psoriasis, which is a widespread psoriasis made up of very small lesion's very small plaques. And it's often in what they call a teardrop distribution. Um, the gut it psoriasis is commonly associated with a strep infection. So your exam question might be a young child presented with a sore throat. A few weeks, letters come out in this widespread, plaque like rash, and that would be gutted psoriasis. And it tends to just get better by itself. Um, slightly mentioned with the examination patient with psoriasis often have arthritis or arthritic changes. Um, so you need to be asking about that in your history, any joint aches, pains, swelling and any nail changes as well. Um, so, um, focusing on the management they both managed very similarly, So you need to avoid the triggers. Um, just make sure the computer doesn't restart. Sorry about that. Um, so yeah, you need to avoid the triggers, um, in both of them and use lots of emollient. So you want to be using thicker millions about four times a day, and it's kind of rubbing it on the skin rather than rubbing it in the skin. Um, with extra anti histamines can help, but it's more likely to help with the itch rather than the underlying problem. It won't make it go away. It'll just help soothe the itch for Patient's and first point of management is topical steroids, and you want to work your way up the steroid ladder, which I've put the bottom there. So hydrocortisone is the weakest. Then you move it better to bit derm of it and a useful pneumonic to remember that is steroids help everybody. Dermatologist, you kind of want to match your steroids. How severe the izmery. So if it's mild eczema, you want to give it a mild steroid to hydrocortisone. If they already present with quite severe um, Esma, you might want to be starting on new more of it or benefit and working up to them of it. But if they come in with already quite moderate eczema, you maybe want to go something a bit harder than hydrocortisone to begin with. If you've worked your way up the steroid ladder and it's not getting any better, if not, maybe getting worse. If they're getting multiple kind of infections within the Xmas, then you want to be referring to secondary care. And that could be considered for some immune modulatory treatments. Um, with psoriasis again, avoiding triggers lots of emollients up to four times a day and working your way up that topical steroid ladder. And you can also give a vitamin D analog or something called calcitriol. And if that's not helping in primary care, you want to be referring to secondary care because they can have things like voter therapy immunotherapy. Biologics won't be uncommon to see a patient that has severe psoriasis on something like methotrexate. So so just some pictures of this is patient's with X may you can see that it's on the Flexeril aspects. So behind the knee, kind of in the wrist crease the middle picture kind of shows acute flare where you can see some weeping and crusting, and it's more erythema Tous, um, and more painful looking than the more chronic pictures that we've got on there and in the bottom right hand side. I've got a patient with darker colored skin and you can see that this the scale and the dryness is great compared to the erythema, um, psoriasis pictures. This is why you need to kind of look everywhere when you're examined. Patient's because obviously this patient here in the top left has got it under her scalp. So unless you lifted a hair up, you wouldn't know that was there. Um, again, it's on the extensive surfaces or backs of arms over the knees is where you see it. The bottom left side again is someone with richly pigmented skin and the skills coming up as gray and on the bottom right? That's an example of gut it psoriasis, so you can see it's kind of widespread the very small plaques compared to the picture above it. And it's in this kind of teardrop distribution. Now I'm just gonna talk about the skin cancers. Um, so a. B C. C. A. Basal cell carcinoma is the most common malignant skin tumor. It's a slow growing, locally invasive malignant tumor of the epidermal keratinized sites, and it rarely metastasizes. There are different types, and I don't think you need to know each of the different types for your exam. Maybe know that a nodular BCC is the most common, and the top picture is a nodular BCC. It's described an exam questions as a small skin colored papule, or nodule, depending on the size. And it'll have surface surface telangiectasia, which is the kind of blood vessels that you can see with a pearly rolled edge. And they do have a tendency to ulcerating the center. And sometimes you might see it in an exam question described as a rodent ulcer. And that's kind of a buzzword that you're thinking about to get to the diagnosis of a B. C. C. So, like I said, the top picture is of a nodular BCC. The middle picture is a different type of B C C. That's a superficial BCC, and again you can see a bit of ulceration, Um, starting on the bottom one. Then it's got the pearly rolled edge. Um, next is a squamous cell carcinoma that's a locally invasive malignant tumor of the epidermal keratinocytes, and it does have the potential to metastasize in exam questions It's typically described as a scaly crusted, ill defined nodule and again has the potential to ulcerates it. Risk factors like with the B C C as well, um, is UV exposure and also pre malignant skin conditions? Um, something called an actinic keratosis can predisposure, and that can turn into a squamous cell carcinoma. Any chronic inflammation, immune suppression or genetic. So any family history. Or if the patient has a past medical history of having an sec, then they're more likely to get one themselves looking at the pictures and the top picture shows that kind of crusty, scaly nodule, which is kind of a classic SEC. The middle picture shows a cutaneous horn, and all those need referring to dermatology as if it is an sec. About 15% of, um, cutaneous horns will have an underlying sec, and the bottom picture is an actinic keratosis. It's kind of this rough, small, small patches, which are commonly found especially in example, questions, um is described as kind of small rough patches on the foreheads or top of the heads of old men have lost their hair and being exposed to a lot of sun. It's often a place that people forget to some cream, Um, if they've got a bald head and they can end up with skin damage from the sun and get air cares and which can lead to an sec. And last one, which everyone worries about when we think about skin cancer is a malignant melanoma, so melanoma is an invasive malignant tumor of the epidermal melanocytes, and it does have the potential to metastasized anywhere in the body. It's typically described an exam questions as an irregular, atypical, rapidly growing mull. And it's success using the A B C D E approach. So a stands for asymmetry be border, see color D diameters or anything above the size of seven millimeters in diameter needs to be referred and e evolving to any evolving symptoms. And that can include the core symptoms that we discussed early. So any any new itching, bleeding discharge, etcetera. There are different types, and again, I don't think you need to know these specifically for finals. Superficial spreading melanoma is the most common, and that's 70% of all melanomas that we see an example of a superficial spreading. Melanoma is the top picture there I am other other example, the different types of melanoma includes a nodular melanoma, which is kind of as it sounds. It's a well defined, hard, very dark colored nodule, which again might have evolving symptoms. It might start bleeding, itching, growing in size, and that needs to prefer to dermatology. Is a militant melanoma? Another? Um, another type of melanoma? Is it April Antegren? ISS Melanoma? And that's the only melanoma that's not related to UV exposure. It's commonly found on the soles of feet or palms of the hands, and can be found in the nail beds as well. And when it's in the nail, it's called a subungual, uh, malignant melanoma. And so, looking at the pictures there, the middle picture is a subungual melanoma. Um, and again, this the one on the sole of the foot is a type of April Integris melanoma and a good pub quiz. Um, fact for you all is that Bob? This was the type of melanoma that Bob Marley died from. After it metastasized, it started in one of his nails. Um, so risk factors, UV exposure, skin type one. So that's someone that burns always burns. Never. Tam's history of over 100 miles, previous melanoma or any family history of melanoma and now just going on to skin infections. So, like I said, I'm not going to be able to cover all skin infections that you will come across either in your foundation years as a junior doctor or even that might come up in your finals. But focus on the most common ones, or cellulitis and one of the most severe ones. Necrotizing fasciitis, so cellulitis. It's a bacterial infection of the dermis and deeper subcutaneous tissues. Risk factors include any skin breaks or wounds, patient's with diabetes and more risk of getting cellulitis that those with poor, poor hygiene. Any lymphedema mix if your legs are swelling and any fluid leakage that can cause irritation. And for the cellulitis. Any IV drug users cause obviously they'll have skin breaks when they inject drugs or any patient with immuno suppression to anyone with on chemotherapy. Low immune systems uh, such as HIV common pathogens, uh, mainly staph aureus or strep pyogenes, and the way it typically presents is pain, swelling, redness and warmth. And you can see on that picture there that the left foot is different to the right foot, and you could probably see the infection extending over time. Patient's may also have some systemic effects or possibly signs of sepsis. High heart rate temperature, low BP. Confusion in the elderly is common. One. Um, if any patient's did have any systemic effects and you were concerned about them if it was a patient with, for example, poorly managed diabetes, they're more at risk of getting a severe infection or if they cellulitis was peri orbital so around the I. These are the patient's that you need to be admitted to hospital for IV treatment investigations so you can do blood tests, other inflammatory markers, high white cells, neutrophils CRP. You can monitor those as a trend as response to treatment. You want to be culturing any wounds that they've got. So if they have got any skin breaks or wounds, swab in them and send off the culture as well as doing blood cultures, especially if they're spiking temperatures and systemically and well can do imaging, you don't really need to be on the really indication as to when you'd start doing imaging. If there was a concern about a deeper infection so worrying about osteomyelitis um, that's when you do imaging. You don't typically need it for a normal cellulitis. Management. Obviously, you follow your own, um, local antibiotic guidelines, but typically it's normally treated with flu. Clocks are Silin if they're okay with penicillin. If the pen allergic, you want to be giving something like erythromycin, clarithromycin or clindamycin and next onto necrotizing fasciitis. So it's a life threatening, rapidly progressing deep soft tissue infection. There are different types again. I don't think you probably need to know these for your finals, but if you did want to look into it, Type one is a polymer is polymicrobial, so there's more than one pathogen causing it. Type two is mono microbial, so there's only one, and it's usually strep pyogenes. Type three is gas gangrene, and that's caused by Clostridium Provenge inns. And the reason why it's called gas gangrene is because that bacteria produces gas and that can be kind of felt on palpation. It can be felt like crepitus, or you might be able to even see the gas on imaging. Um, and Type four is if it's contaminated with kind of marine causes, or if it's fungal risk factors similar to cellulitis, so skin injury, those with impaired immunity and IV drug users. How it presents is initially it will be similar to cellulitis, but they'll be paying out of proportion to the findings to begin with. That might be only mild erythema about the patient's in a lot of pain. It will then progress, um, to discoloration. Blistering There might be some discharge, and like I said, some crap Tous and patient's are likely to have systemic symptoms. With this. They're very unwell. Investigations wise, you'd want to be doing bloods and looking at inflammatory markers, culturing any wounds that their blood cultures sending off swabs. And you can possibly do imaging to kind of see the extent of the infection or to see gas is being produced. Know that it is being gas gangrene. But don't delay any surgical input by getting these investigations. If you suspecting necrotizing fasciitis, you want to be getting on the phone to the surgical team straight away. Management A, B, C D. E. A. Stabilizing the patient broad spectrum antibiotics straight away and getting a surgical review because they'll need to. They'll need to be taken to theater for surgical debridement. So that's kind of all I'm going to focus on kind of in depth. I'm now gonna go through kind of the exam buzzwords and spot diagnosis because mainly focus on, you know, your finals revision at the moment. And so, like I said, if a word comes up, I want you to kind of brainstorm in the chart just anything, anything that you relate to that condition buzzwords that might give you a clue that that's the diagnosis in an exam, um, or risk factors. Whatever you can remember about that, please just put it in the chat. Um, if a picture comes up, it's more of a spot diagnosis. So what is the lesion? What is the rash or how would you describe it to an examiner? So it kind of need you to all be engaging as possible in the chat or it won't work, and hopefully you'll get a lot from it, even seeing other people's answers as well. If there's any problems, I can kind of fill in the gaps or help you out, but please input as much as you can. I've also just put the QR code down there. That's for the the feedback for this session. Just interested as to what kind of how you feel about especially about these examples, where as things if it doesn't work, then we don't have to include in fit future sessions. If it does work, then we can include it. Okay, so start off with a few conditions that we've already covered today. So basal cell carcinoma. Can people put in the chat kind of maybe how it's described in an exam. Question how how you would describe it to an examiner. Maybe risk factors? Yeah, good, Great. I think you've all definitely picked up on the buzzword, so it's raised pearly edges. Telangiectasia UV sun exposure is a risk factor. Um, and nodule is the most common. Great. This is a spot diagnosis. So what do you think this is? How would you describe it to an examiner? Good. So we're getting some descriptions as to how people would perhaps either describe it in a referral or describe it to an examiner. So we've got It's in a regular, regular, irregular share. It's raised. It's a nodule. Obviously, it's hard to say whether it's a nodule or a popular, but I would say that it's a nodule. I think it probably is big enough, even though we've not got the measurements on there. And there's two colors visible, so perhaps suggest that it's evolving and someone suggests it's a melanoma as well. Um, she's great. And this is an example of a nodular melanomas. I think between you there, you've got the diagnosis plaque, Psoriasis. What? What buzzwords would we find in an exam? Or how would you describe the typical presentation to an examiner? Yeah, so we're all saying the right things. We've talked about flat pop plaques at the scale. It might be itchy, well demarcated, erythema, silvery scale, crusty. These are all exactly the right words you need to be using to describe the secondary changes and skin lesion's from the history complaints of, uh, joint pain and nail features grip shingles, the one that we've not covered today. But I presume you all know about how would you describe describe it to an examiner? Anything you know about it? Just pop it in the chat, just kind of brainstorm everything that you think you know at the moment. Yeah, all saying the right things. A blistering brash dermatomal pattern doesn't cross the midline. Great neuropathic pain, often patient's get pain before the rash comes out. Intense burning pain yet it's kind of a neuropathic pain. Let's put advanced form of chickenpox. Yep, So patient will have had to have had chicken pox previously to then get shingles because shingles do the same varicella zoster virus. Kind of reactivating painful vehicles. Yeah. So with the rash, you can often see uh, lesions at different points of change. So they'll go from physicals and postural and you'll see that crusting. Okay, imp a tiger. So again, not covered today. But hopefully you've all heard of it. And it's got some typical examples words to make you think of it. Yeah, Also in the right buzzwords honey honey crusted lesion common in Children. Very infectious. They need to stay at home. So we'll see if he saw this in GP and even child to be giving that advice to adults that their parents, you know not to share towels. Keep them off. Schools commonly caused by staph aureus um, the yellow crust often found on kind of yes, someone's put periorbital put perioral so and on the lips on the face or on the fingers as well. You often see in young Children. Yeah, I'm very contagious. Great. And And you, you're treating to Tiger without a few acidic acid or hydrant peroxide cream. OK, spot diagnosis. So how would you describe this to an examiner? Or what do you think the diagnosis is? Yep. So just got a few on there. How would people describe it to an examiner? We've got Cara Ptotic few spot diagnosis already. Sec. You're right. It is an sec. It's not greasy. It's, uh, it's often it'll be a dry, scaly, crusty Cara Ptotic lesion, locally invasive yet which does does have the potential to metastasize, but not as common as a melanoma to metastasize. You're right. That's an sec. Meningococcal septicemia. So what's the day muscle? Logical kind of present presentation. Just going back there, kind of. What's the best way to describe? I'll just go back. What's the best way to describe it? Um, so the I'd probably say this is a raised keratotic. It's hard to say that it's ill defined. If it's see the border, if it's defined or well defined, can't really see the base of it from the picture, but it be a raised Cara Ptotic. Scaly crusted nodule. Um, for the sec. Yep. So meningococcal septicemia. So what's the dermis? A logical presentation or what? What else would you expect to find in a an exam Question? Buzzwords. Yes. We've got some good buzz words. They're so non blanching. Rash, um, in a systemically unwell patient who might have neck stiffness. Photophobia and fever are all good words. It's not macular popular macular. Papa is often blanching. Um, so the key thing is to press on the rash and does it go away where you where your thumbprints left, or does it stay there and this rash stays there, So it's non blanching. And the class the thing that you might see in a exam question, I guess, is that the glass test which parents are told to use on young Children, are pressing a glass against the rash. And so you'll be able to see through the glass to see if the rash goes away. When you press on it, it's more cope. Eric. Yeah, that's right. Okay. Every theme in order. Some. So again. Not something I've gone over. Maybe briefly mentioned it could be people maybe describe what it looks like or what? Patients'. We might find them in. Yep, so raised red lesion's commonly on the legs associate with IBD sarcoidosis from conditions pregnancy. Yet that's another patient group that we see them in. Um, it's often described as a discrete lesion, so you can often see where, like they, uh, kind of well demarcated. And they're kind of swelling of fat under the skin. Um, I wouldn't be. I don't think it would be. Probably could describe it as a plaque or a patch. Probably a plaque, but it's not got because it's kind of flat and raised. It's definitely not a nodule. Um, kind of a a well demarcated patch. Okay, um, other things that it can be associated with some drugs. So amoxicillin, the combined pill and NSAID and sulfonamide. And these are just some examples of them there and the tender to touch as well. So you can see that they're raised from the shine on that patient's legs. Necrotizing fasciitis. Yeah, everyone's saying the right thing there, so I'll just read out a few of the answers. So we've got the types listed, so type one being multiple organism type two single organism type three gas gangrene. Dishwasher puffs. That's another buzzword I didn't mention, but yet dishwasher puss and finger swipe test. Um, the necrotic tissue, rapidly progressing, spreading strep pyogenes. And yeah, urgent surgical debridement IV antibiotics and might need skin grafting after recovery. Definitely a canthus is now becomes, Yeah, it's a hyperpigmentation. It's kind of a velvety, uh, just a like a velvety overgrowth of the epidemics with hyperpigmentation often in the yeah axillary region. Back of the neck, neck folds common in patients with P costs, polycystic ovary syndrome and diabetes. Um, it can also be a sign of GI malignancy as well. So although you might not see it commonly in practice related to a GI malignancy, that's kind of a buzz exam. Questions if case someone came in with weight loss may be some vague big GI symptoms, and they were found to have dark skin under their armpits. Um, that would be, you know, typical of a patient with a G i gastric malignancy and the darkening of the skin Now be called acanthosis nigricans. Okay, do describe in this rash or, um, spot diagnosis and no, not typically in in insulinoma. Um, just more just gastric cancer, but not an insulin oma for the Yeah, no one's getting this raised chicken pox. And how would you describe the rash to an examiner? Yeah, good. So widespread erythema. I've got some physicals, um, some dried crusted spots of light shingles. You'll see lesions at different stages, so there'll be physicals and postural zoo, and then they'll have crusted over. And when they become crusted over, that's when the patient is typically non infected anymore. It's got a 10 to 21 day incubation period, so it can be quite hard to know you know who exactly the child got the infection from and again caused by varicella zoster virus. I just got a few more dermatitis. Herpetiformis. Does anyone know how it would be described? What patients' do we see it in? Yeah, so it's seen in Patients with Syriac disease can be found on the elbows can be found on the hands, and it's a vesicular kind of just dermatitis, very intensely itchy and obviously exam questions might relate. Might not say they're celiac, but might say they've got a new rash, and they've eliminated a few things out of the diet, which has helped. You want to be thinking about celiac with dermatitis? Herpetiformis. Okay, Koplik spots. What are they? What do they suggest? Yeah, So white white spots on the bugle mucosa and the mucosa is very red and a rhythm Ettus underneath with these white spots on top, and it's associated with measles. And so, obviously, Children with measles systemically very the sirens. Yet they're just outside and the patient be very unwell. And they also have a rash. And the rash typically is a macular popular rash and starts on their face and kind of works its way down. Typically, spot diagnosis. How would you describe it to an examiner? Yep. So this is every theme of migrants related to Lyme disease can be described as a bull's eye rash or a target legion. It's an annular ring shaped good SLE. Any dermatological manifestations of Lupus. Oh, she's referring back to the last one. Someone's put target sign with hemolytic anemia. Think you might be thinking of target blood cells? Yeah. Um, yep. So for SLE, butterfly rash. Photosensitive. It's the mala rash across the nasal bridge and across the cheeks. Yeah. Yeah. So that have other things relating to the Lupus as well that you'd have to ask in the in your history. Taking Mm. There's a few questions on that that'll kind of answer at the end as well. Anti Phospholipids syndrome. Think this is the last one. So what? Dermatological manifestation is kind of related to anti phospholipids syndrome? Or what else would there be in the exam question that might make you think of it? Yeah, it's a livid. A reticular iris. Um, in a young woman, multiple miscarriages, increased risk of clotting that might have history of PS or DVTs. Um, and how would you describe La Vida Reticularis? Anyone know the description of it? Yeah, Lace like rash. It's a lace like rash and mottle yet muscle skin Perfect. Okay, so that's kind of the end of this spot. Diagnosis and buzzwords. I've put some useful links, so most of these are kind of where I got the information from to do the talk and things that I still use in practice. So British Association of Dermatologists brown skin matters on instagram. So I think someone asked, what would every theme of migrants look like on more pigmented skin? So I've not got a complete example on here. I think it would be a dark if you see a darker ring. Um, obviously, it wouldn't be a rhythm Ettus, but brown skin matters on instagram is really good for seeing, um, different skin conditions on patient's with darker skin. It's not something that's commonly taught at medical school, which I think being an issue, which has been raised recently, and it's not typically seen in textbooks. So this Instagram is is really, really good. So I recommend just having a follow. And then it'll pop up on your feed, Um, Derm Net and Primary Care, Dermatology Society as well as really useful and then nice CKs. So when you get into practice and wondering what to prescribe for patient's or following guidelines, uh, the nice clinical knowledge summaries are really, really useful. Okay, so that's the end today. I hope I've kind of covered the basics and provided you with a bit of exam revision. Obviously, I've not covered everything, so you might have to go back and look at a few different skin infections, which I mentioned along the way, which had not covered um, next, we've got a session on the 29th of December on rheumatology. And then in the new year we've got infectious diseases. But there's also other sessions that will follow that. So we've got cardio respiratory gastro hematology. So kind of all the court medicine topics which will come up in your finals if you could all scan the QR code and just give us some feedback on how you felt the session when, how the how you felt the buzzwords section when and whether we should do that in the future. Um, it's great if you didn't if you liked, it's fine. If you didn't like it, just some feedback. So we know what to do for the sessions coming up. That would be really good. And if you fill the feedback in, you'll get a certificate for attendance. Fab Thanks, everyone.