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The Comprehensive Dermatology Guide: Session 4

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Summary

Join Joanna, Derm Socks Treasurer, for an in-depth session on the Comprehensive Dermatology Guide. This final event is a must for any medical professional looking to enhance their understanding of dermatology. Joanna will equip you with crucial knowledge on taking a focused history and making spot diagnoses. Dive into areas such as presenting complaints, lesion characteristics, associated symptoms and their triggers, as well as the importance of inquiring into past treatments and sun exposure. This comprehensive session doesn't stop there: explore how immunosuppressive conditions can impact skin health, and gain insight into the link between dermatological conditions and other diseases. Further delve into pertinent social and lifestyle factors, and learn the importance of assessing a patient's quality of life as part of your consultation. Fully understand how to use appropriate terminology for a more effective diagnosis and explore the Fitzpatrick skin type and its relation to skin cancer risk. Every minute of this session is packed with valuable information, ensuring you can provide the best care possible for your patients.
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Description

This is our fourth and final instalment of our Comprehensive Dermatology Guide which will be covered by Joanna. This session will focus on how dermatology can come up in the OSCEs.

Learning objectives

1. Understand the different types of skin conditions and their presentations. 2. Learn how to conduct a focused history taking for dermatology conditions. 3. Acquire knowledge on the impact of different causes (environmental, occupational, dietary etc.) on various skin conditions. 4. Appreciate the importance of using professional terminology when describing skin conditions for improved communication and record keeping. 5. Develop skills to conduct a detailed skin examination, accurately describing and diagnosing skin conditions.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So maybe we get to off to start now. Um Thank you everyone for joining us on this evening. Um This is Derm Socks final event of the Comprehensive Dermatology Guide and my name is Joanna, I'm Derm Socks Treasurer this year. And just, you're more than welcome to even focusing on Oscar vision. Um So starting off with an overview, this is just what we'll be going over histories exams and then just some key points about conditions counseling and then just a spot diagnosis for you if you want for your, if you want, um, the slides will be available uh later, if you fill in the feedback form provided, you should get an email to you afterwards and then just at any point, stop for any questions or if my, my, my wife has gone bad. So starting off with history taking, I'm not sure what stage everyone's at, but I'm sure everyone at this point is well aware of just your introduction and then how to take a focused history for, for dermatology. It's the same as any other history. Um just as me. Well, so maybe um emphasize the importance of travel history that may not be relevant in other history stations and then as well, ideas concerns and expectations as well for the OK. Starting off with presenting complaint, dermatology can always be a bit of a difficult one because the presenting complaint, you're not really sure what it is like. There's no set to do. So I don't think on the Queen's website. But what I mainly do is just usual find out what the presenting complaint is. Is it new? Is a new lesion? Is it rash redness or is it spots? And then use Socrates for your presenting complaint? Like where, where is the lesion? A rash? Um onset and duration? When was it first noticed? How has it changed over time or is it quite constant? And then also um characteristics would include the number of lesions? Is it one single lesion or are there many? What shape is it roughly, is it hot or tender to touch? And how does it feel? And then if there's any pain or itchiness does like the pain or itchiness move? Has the lesion moved? And then have you noticed any other areas of your body affected associated symptoms we'll cover in a minute and then timing just check. Has it changed over time? And then have you there any other previous episodes of similar lesions or rashes and then exacerbating or relieving factors? Um are also important to check for, for example, um sun exposure may worsen and lip there. The rash in the lesion in lupus, but may improve it in psoriasis and then also consider triggers and then also just ask about severity and how it's impacting their life. So associated symptoms to ask about, I'm sure you're all familiar with this but would just be itching, pain, redness, tenderness and heat, any bleeding or discharge any blistering skin, nail, hair and gum changes. We'll talk about those later. And then also just for any red flag symptoms. If you're worried, it could be some type of skin cancer such as Melanoma. Um, check, always check for weight loss, tiredness, fever, any joint pain, and then also just check for um, exacerbating features and triggers. Some common ones would be sun exposure, hormonal changes, changes to like soaps, cleaning products, new detergents. Um If there's any diets, for example, um Celiac disease and then I, I'll check for occupational exposure. Like, do they think that they're skin worsens when they're working? So for example, like contact dermatitis, working with harsh chemicals? Um, by the way, these sides are quite worthy. Um But I just thought that if you want them to reference later, it's better to have more information and you can just cut, cut out any slides you don't want. Um, other important inquiries would be previous and current treatments. This would be like over the counter ointments, anything previously prescribed. And did they actually help? And then sun exposure cannot emphasis this enough. But um for a dermatology station, you're definitely gonna get marks for it. Um, especially if it's a suspicious lesion. So Ch check their Fitzpatrick skin type. We'll cover that in a minute. But how does their skin react to the sun? Like, just ask, would it tan, would you tan in the sun or would you burn very easily? And then, as I mentioned, if symptoms improve or worsen in the sun and then always ask about a history of sunburn and always, never forget that sunbed and tanning were genus as well, drastically increases your risk of skin cancer, especially in young people. And then do they use or wear sun protection? And then also just ask about any recent stressful events or illnesses. And then if you're thinking of uh like a rash or like infectious disease cause, are there any recent contacts with a similar skin problem or any recent contacts with anyone with infectious disease? And then is there anyone else in the household affected? And then if you're thinking as well, like infectious disease, have they had any recent travel? And what did they do during that time past medical history would be um always ask about skin cancer, any previous biopsies for suspicious lesions if you asked about A to B. So for example, in eczema, there's a link with asthma and allergic rhinitis, ask about diabetes and then also ask about inflammatory bowel disease. Um I've put in the note section just some of the examples of what these conditions would be associated with, what dermat dermatological conditions would be associated with. And then just to be aware, it's been mentioned in previous terms. So videos, but just as well that the kidney transplant can increase your risk of a squamous cell carcinoma. So ask about any previous procedures or surgeries including organ transplant. And then as well just be aware that some medical conditions requiring systemic immunosuppression can increase your risk such as HIV. And then ask as usual, just your normal drug, ask your dr drug history including herbal, recreational drugs and then ask about any topicals, any antibiotics and then any like soaps has been mentioned previously. And then also ask about drug allergies. What was the type of reaction and then any changes in their medication? And also ask about vaccine history and ask this is we mentioned, ask about family history and skin, what age they were when they were diagnosed with their skin disease. Um Social history we mentioned previously uh check their occupation check for smoking. That would include anyone in the household that smokes, for example, in child with eczema. And then also ask about alcohol and diet and then ask about living situation cars and then recently recently changed cleaning products. Ok. And then always ask about quality of life. You can never a if you have to, obviously, you travel history, for example, may not be relevant in all conditions. You may not be able to, there's only what, six or seven minutes for an OS station, you may not be able to go through all of these, but just always ask about the quality of life. If you have, there'll be marks for it and you'll get patient marks for it as well. So, um ask about if there's any been, for example, itching, if there's been any, has itching caused any disruption to their sleep? And then also ask for any skin conditions? Do you think it's causing enough disruption to their daily activities? And have they had to take any time off work or school? Is there any change in their concentration or their efficiency at their job or their studies? And then, has it impacted their self-confidence? Are they missing social events? And then always ask that. So it hadn't cause them to have low mood, anxiety or self esteem cause you'll get marks and you'll probably get patient marks as well if you think that they've really, you really listen to them and then always do I summarize signpost and like the patient? OK. So terminology, I know this has been covered in previous um your previous dermatology lectures at Queens. Um I really recommend the um British Association of Dermatologists um guide for handbook for medical students. Um It's really good about most of the information, but for Dermatology stations just always make sure that you use professional language cause there may not be a lot to ask about, but just getting the um using the correct terminology to get you the right marks. Um So I'll just, I'll open these all up for you. So for example, I'm not gonna go through all of them, but just most of them are based on what, whether they're flat or raised or is there are there pus containing? And then there's always words for if it's a smaller lesion or a larger lesion. So macular pap plaque, nodule, pustule, papule fass umas which are basically blisters and then wheels, for example, in Urticaria and we'll just maybe get you that more marks to make you sound a little bit more slick. OK. So as we mentioned, um the sparic skin type is just based on how your skin reacts to sun. And so someone with a type one, six patric skin type always burns and doesn't tan and they have a greater skin cancer risk. Whereas someone with um type six with darker skin and then they never burn and they always tan darkly or they may rarely burn and they have a lesser, a lesser, a lesser risk of developing skin cancer. So always just even mention it, like ask if always ask the question like do they burn in the sun and then at least you'll sign as if you've mentioned it. OK, going on to skin examination. So starting off with the most important thing to do is after introductions, et cetera is to always check the patient details on the photograph if you're given one and just check it's the correct patient. And this is mentioned, use French professional terminology. And then, so starting off with infection, do your general observations like bedside approach? Do they appear well? Are they comfortable? Are they like pretending? Are they scratching on their skin? Do they appear uncomfortable? Um So starting off with the site, what's if you're shown a photograph or whatever or maybe they're attached a lesion on to someone or they have someone with a condition? What sites it on? Is it affecting their flexor regions? Their extensors is it mainly contained central or uns sun exposed areas? Um Is it dermatomal distribution or would it be a pressure sites? Is it Seric follicular or is it um cours and then also just comment as well on the number of lesions. So they're, if they're solitary, what mo are they localized or are they just quite generalized? And then for describing if you're given one lesion, I use the acronym scan. Um It's so size, shape, color associated secondary change, morphology and margins. So measure the height and dit measure the height if raised and then also measure the diameter. Um And then don't just say large, say approximately this number. If you're, you may be given a tape and then also ask about the shape of it using terms such as discrete confluent, targetoid, annular discoid or linear, if applicable, then check the color. Are they hyperpigment is it hyperpigmented? Is there depigmentation? Is it purple? So purp is it red or ferous or they like multiple colors men for associated secondary sca changes check for scales, erosions, um like an medications like thickening of the skin crusting, keratoses, fission excoriation. And then morphology is just the terms that we've I mentioned briefly earlier and also just check the margin, the edge and elevation. So as I mentioned, these slides are really a really tech savvy, but hopefully it will be helpful. Um This is a stupid, this is a silly kind of acronym that I came up with to help me remember, palpation of an individual lesions. So I feel like you're pressing on a cake to chocolate, it is ready and just some cakes may take time. So I use surf so that I use this for surface consistency, mobility tenderness and temperature. Um in real life, obviously, you may not be able to do this cause it may just be a two D picture, but just in case you happen to get like a lump or on like a lymph node or anything or you know where they like to stick the little plaster at the tape on. OK. So moving on to systemic check, I check the elbows, nails, scalp, hair, and mucosa mucosa. Um We'll be covering this more in the next few slides, but I've also included a stop of a really good sec, the website that you can access for free, you have really good um section on just doing it from head to toe, which I've included in the notes section. And then, so these are some of the examples of some of the terminology you could be using. So Targetoid PTA and then pityriasis first color has the are those areas of depigmentation. So you can see so for a prevented lesion, always use ABCD. So asymmetry on if they're regular border, are there two or more colors is a diameter over six millimeters and then is there a history of change? So, always comment as well, if able to, if you're able to on the Fitzpatrick Skin scale and then as sometimes they can combine an OSC like at previous stations, they can sometimes combine. So you may a patient may ask, come to you with a history, maybe like combined history and an examined at one station. So just always ask about the things you mentioned previously. So there's some of the associated symptoms such as pain, itching, bleeding, ulceration and then your systemic symptoms. And then are there any other changes to our surrounding areas? And then at the end of the station, you'll be asked maybe what would you do next? So, ideally, you'd want an ABCD assessment with a dermoscopes to look at it clear. And you'd want, if you're suspicious of a melanoma, you'd want a two week red flag referral to dermatology and then a suspicion, an excision biopsy and a full body exam. Um This is a really good portal on geeky matics about the different subtypes of Melanomas. So there's your sip and I read as well. One of the previous marks seems I'm not sure what year it was if it was for year four or five, but you may set to get and rather than just saying Melanoma, like excellent candidate said superficial spreading melanoma. So let's just try and use if your confident body is like the correct terminology, we'll maybe get that extra point that helps out. So the superfacial spreading melanomas, the nodular melanomas, which is the most aggressive type. And then the lentigo latigo like me melanoma is, it's a precursor to um oh sorry, it's a, there's lentigo melanoma, which is also, which is a precursor lesion such as lentigo maligna. And then there's a um Lati Melanoma which is more common in people of color and it's usually diagnosed at a later stage. So that can appear in nonsunexposed lesions regions such as the pop soles of your palms and your feet and then also in the, on your nail bed. So let's just double check those. OK. Hope everyone's following. OK. So far, sorry. It's a bit of a whirlwind. But um as I mentioned before, the ABCD and then just for other regions that may be pigmented but are not um not c not Melanomas. So your Sebo keratoses just on elder older people like always described as like a stuck on appearance. And then also there's your different types of your congenital moles and then your acquired moles, I'd say in a station, they'll probably will give you, it's more, it's less likely to be a lot more likely to be. If they want you to assess your ABCD assessment, it's more likely to be a suspicious mole. Ok. And then for, if you're a, this is one is just to check the systemic check for, always check your nails. Um So clubbing can be, they always like to ask with some mores as well, like one of the causes of finger clubbing. So its lung disease or cyanotic heart disease and then it can be idiopathic as well. Um I've just listed the causes underneath each, some of the main causes. So for example, an lysis is when it kind of the skins, the nail beds kind of coming away from the skin. It can be due to trauma, but it's quite common as well in psoriasis and colon IIA is like the spin shaped nails that can be seen in iron deficiency anemia, diabetes and celiac disease, and then nail pitting as well as also feature in psoriasis and eczema as well as alopecia. And then li is there's where there's like whitening of the nails and some people can just have it normally, but it can also be a sign of liver cirrhosis and chronic kidney disease. And then looking at the scalp is there any evidence of dermatitis. This can be common in HIV or Pa Parkinson's. And then M CQ question that like to or like complications, it can lead to blepharitis metiti externa. You won't be asked that. No, I don't, I really don't think so, but it could be a sign, it could be asked in a progress test and then check behind the ears as well. Are there any signs for, um, to get a good look at your scalp? If there's any evidence of scalp psoriasis? And then um her uh so check for hair loss and check for any lesions, check for any sorry um and like check for the scalp changes, but then also check the hair for any regular hair growth. So, Herut which is androgen dependent hair growth and then for um for non androgen dependent hair growth and hypertrichosis. Um So, uh in your history, if you're suspicious of, if someone comes with you with that, always ask about PCO S and Kissing syndrome, et cetera and then ask about medication. If that's the presenting complaint for hypertrichosis, it can be a sign of anorexia or can be congenital and we can do just some medication as well and then check for the pattern if there's any hair loss for alopecia, aata. OK. So I'm checking the for completeness. Also consider checking the mucosa that will include the gums tons and also say that you'd like to examine the genitalia as well. And with the chaperone present. So the gen the gums and mucosa can show you things like oral lichen planus Steven Johnson syndrome, pemphigus, vulgaris, um Harry, oral Harry lecokia. And then for things such as um like oral candidiasis. So let's just check if there's any whiteness, any white patches, if there's any blistering can be a sign of autoimmune conditions. So now what I'm gonna do is I'm gonna cover a couple of conditions that can come up just some of the key points on it that they can maybe be applicable if you're doing a history or an exam and asked about the management after and we won't cover them in a great lot of detail because the other derm so members have covered them really excellent powerpoints earlier, earlier in the year. So, but um so starting off with Acne. So it's increased production and bacterial colonization. So this can be just for counseling stations. It has been asked previously like a hi ac acne history, I think or maybe an acne diagnosis counseling station. But it's just that it is very common this like in fact the face, neck back and chest to see in the, in the picture above and then check for features in your history. Have you noticed any scarring? And then is there any um change, has the skin lost its pigmentation cause you can get hype, postinflammatory hyperpigmentation or hypopigmentation? And then is there any postinflammatory erythema? And then also always ask in an acne history about the psychological and social effects? Ok. And then just check for some, if you ask, ask them for some of the risk factors. So they have in the past medical history, ask, do they have anything such as PCO S um or adrenal congenital adrenal hyperplasia? Um And then also ask, do they take any exogenous testos testosterone or steroids? Ask whether their symptoms be worse during menstruation or puberty. And then also some medications such as steroids and epileptics. Antiepileptics can trigger acne and also check about the cosmetic products, make it worsen. And then pa repeat if you're asked about hair growth, sorry and past medical history as well as in the family with PCOS or diabetes. Ok. And then acne filaments is just um an emergency where the acne kind of becomes really badly infected and they may have to be admitted. Um ok. So your last like last lap was like more likely an AN M CK. So then the classification of acne can be mild, moderate or severe, um moderate, mild acne is mainly open and closed Coumadin. So really your white heads and blackheads and then moderate acne, there'd be more papules and pustules. So it's more starting to get more like inflammatory and in severe acne, there would be the extensive inflammatory lesions. There would be your nodules in your cysts, your pitting and your scarring management. This is a really good table from g hematic cause I find it difficult at times to summarize it. But usually it's combination of topical treatment and then you may move on to then in moderate severe acne, a topical agent with an, an oral antibiotic on a woman as well, considered the combined oral contraceptive pill. And then in severe cases, you may need to refer to dermatology for severe oral, uh you need to need for severe cases. You may need to refer you to dermatology for um consideration of isotone. And then they should patient should be reviewed after 12 weeks, 10 and then eczema. So some of the features that you could comment on in anos, an eczema history or an eczema examination would be if there's any itching, erythema lichenification, excoriations or any fissures as and then the different types of eczema would be atopic um discoid varicose pomx, contact irri urgent dermatitis and contact allergic dermatitis. The main that you'll probably would be asked on is atopic dermatitis and then the complications would be be aware of would be your secondary bacterial infections. So etti or a viral um infection such as eczema herpeticum, and then I'm gonna cover the management in the counseling section and just relax in the station, just always ask about the impact on the patient and the family's quality of life. Like for example, if it's a the station may be counseling a mother and with her five year old asked about how this affected their family and distracted their daily life. So acknowledge not just the impact on the person with eczema but on the wider family as well. And then also inquire as well mentioned previously about sleep impact on sleep mood work and social activities. Psoriasis, psoriasis is a explained to this is a chronic inflammatory condition with well demarcated scaly lesions. And then these may be red violet or silver plaques. And then some of these more like common on extensor sites, your trunk and then also affects your scalp and nails as well. And then nail psoriasis mentioned previously would be include your onycholysis, your pitting loss of the nail bed, yellowing and ring. The main two types to be aware of would be plaque, psoriasis and glottic psoriasis. And then you can also for psoriasis, you can use the passy score which um checks about the severity on the patient and then also the areas affected. And there's an equivalent to the easy score for eczema as well. And then for counseling for a patient with it on based on a psoriasis history or based on counseling psoriasis, um make them aware of the increased risk of other skin conditions. So that can be different types of arthritis. So ask about joint pain and then also can increase the risk of cardiovascular disease, um venous thrombus embolism and then also ask about uh the psychological distress. Ok. So then severe flares could also be um postular or erythrodermic psoriasis. Um I listed some of the main exacerbations and triggers. So just ask maybe about alcohol, stress, smoking and then there's a and there's ner phenomenon where a skin injury can cause, um as shown in the bottom line can cause lesions over that site after it's healed and check if there are any on medications such as beta, any new medications such as beta blockers, ace inhibitors, lithium nsaids, et cetera. And then it can also be exacerbated. This can also be exacerbated by a systemic steroid withdrawal. And then management can include emollient, topical cortico steroids, um, topical Vitamin D analog, topical co tar and then systemic treatments such as your methotrexate, your cycloSPORINE, your biologics. And then another option would be UV phototherapy. Um I haven't really, I just summarized the management really briefly cause it's been covered in previous sessions. Ok. So moving on to suspicious lesion, always inquire about s for always, inquire in a history, always inquire about sun damage. So and then at the end in a counseling station, always check or give advice on how to protect the skin from the sun. So inquire about um the use of tanning beds, any episodes of really bad sunburn, would the high eas or would they tan or burn and then also ask about the use of sun protection. So basal cell carcinomas are, um, are showing up on the top right of the screen. So they usually quite flash pearly and they're fleshy colored. Um, they may have a ectasia, so little blood vessels and later on they can ulcerate and so patient may complain a lot of them like bleeding a lot. Um and then tax is always ro ro per edges. Ok? And then squamous cell carcinomas, there can be um premalignant such as a keratosis, which can be premalignant to squamous cell carcinoma. And then there's also bone's disease as well, which is that bit more rader and bleeds more. And the actinic keratosis can just be, patients can just may, may not even bother them, they may not want it treated. And then also can, as we mentioned, the squamous cell carcinoma is that there's an increased risk if the patient had a renal transplant or HIV. Um and then it can also maybe go on to develop the margins, ulcer. And then so just the bottom, bottom left, you can see some of the examples you can see that is quite like creatinin, there is bleeding and redness around it and just always use the assess use the just always make sure that you have a structured approach to the to the examination I mentioned previously. And it's something you kind of sit down and learn it for like 1015 minutes, practice it with by yourself or with friends and then you should be all right, just say what you say basically and just use the correct terminology and then Melanoma is always covered, we cover the different types of it. So we'll go over it. But then acrogenous is the Hutchinson sign. So that's the black line down the finger or can be across the whole nail. But then, and then as well, um just sometimes the bras no thickness can determine the prognosis. They like to ask that. And M CT s so and then the top bottom corner is just a picture of a superficial spreading melanoma over dermoscopy and you can see the different types of colors, the regular borders. OK? Um Obviously, I've only covered a small number of actions um in this talk. So other cons that I'd recommend obviously for your exams to cover them in your own time, other conditions, but I don't have all the time today, but some of the main presenting complaints could be um itchy eruptions. So for example, scabies consider um causes of your red swollen leg, any drug eruptions, um then revised ulcers, blistering, vitiligo, non accidental injury, rosacea. So it's not an it's not an so it's not all covered here, but I really recommend the bad notebook. It kind of covers most of these complications really well. Um So now we're gonna, if anyone has any questions, we're gonna maybe move on to counseling now. So for counseling, if you're counseling for um if you're coun just general counseling, if you are speaking to a parent or like for example, a grandparent on behalf of a child or say someone on behalf of someone else, always check if you've got consent for the them to speak to you and then confirm the patient details and then on any photographs or any other resources. And then are there any more just like your x-rays? Are there any like more recent or previous photos for a comparison? And then an really big thing to remember is that be speci if you're given a picture and you know, be specific about the diagnosis, for example, that it can be, some examiners may refer you to say atopic eczema over just eczema or plaque psoriasis over psoriasis. And then I'm sure you're aware, just avoid the medical jargon, consider use of diagrams and then plan what you will discuss. So general counseling always do your washing hands, introduction consent, et cetera and then ask that you don't know what you may be your first time meeting the patient. So you don't really know what the situation it will be in the ACY. So it's always nice to start off with. Just ask, can you I understand this is our first time meeting. Um Could you just bring me up to speed what you know so far? So do they know why they're in? Are they here to get something explained to them? Are they here for like results? How they kind of been? Is this a follow up appointment? Maybe they know have they already lived with this condition for a number of years? I always like to for we had a couple of counseling stations last year in third year. And so I always like to ask one of my stations for drug counseling was, do you have any questions you have asked? And the woman like left out and she's like, actually I have five questions. So what I like to do is get answer those questions first because they're the questions that the patient has so that, you know, that they're the marks that are gonna get marks that they the answers you're gonna get ticked. So I usually go over, get those done and then usually they are what you need to say anyway, but um it'll help guide you. But if not, you can do is um so we're gonna discuss this consultation. I'll go over these things with you and stop me at any point and then we'll go back over it or arrange a follow up and always just reassure the patient that it's a lot to take in. You're not alone. Like you'll always be support. We'll give you online support or you can make a follow up appointment and then, but just give them inter opportunities to interrupt. OK. So counseling piga metics once again, have a really good um section on it. So I'm mainly use for information sharing. I use the brief history, understanding concerns expectation and then summarize and then there's another one for explaining a disease. So as we mentioned, um so important to reassure the patient is like, what have you just throughout like what do you understand what I've said so far? And then please stop me if you have any questions and then always, always offer a website or leaflets cause you'll get the mark for it. Um If you have no clue what you're being asked to counsel on, at least you can be like here's a leaflet, here's, here's um there's a nurse we can contact in contact with. You always get the extra help cause it's a lot of information for them to take in. Um I really recommend for, I find really helpful this year and last year is that Gy medics to buy to like either if you wanna buy it by yourself a bunch as a group and get some of the AUS stations really helpful. So they help, go through um explaining a diagnosis of eczema and then it shows you a mark scheme for it. So I'm just gonna start, I'm only gonna counsel on one condition um during this presentation and it's gonna be on atopic eczema. So start off with getting your short history and that could be just really short like 30 seconds. Like what symptoms have they had? What areas are affected? Are there any previous treatments? And just how has it affected their quality of life? I just, I um OK. And then, so what I do is first would be I'd ask, I state what's normal. So norm there's a couple of ways you can go about this. Some people like to use a diagram compared to like draw a diagram. Some people like to use their hands um and go like this. So for example, that it's normally the skin acts as a natural waterproof barer to prevent irritants from entering and to stop the moisture from escaping and drying out the skin. Um However, an eczema like cracks appear and lying irritants in So you can use your hands. Um But I find that the anesthesia, maybe just you're that nervous in the station just to stick with just explaining it to them in the best and most simple terms possible. So in atopic eczema, there's a disruption of the protective barrier and then so bricks may dry out and mortar is lost and this allows moisture to escape and irritants to enter, causing this to again to become itchy, red and inflamed or such as the symptoms you've described. And then it can occur anywhere in the body. But particularly most people are affected in the elbow, knees, creases and the hands. And they may also have areas of their face and scalp affected. And it's important to mention that it's a very common condition. It's relapsing, remitting and it's inflammatory and then itching can make it worse. But they just to explain the itch scratch cycle to them that itching can disrupt the skin barrier and cause more symptoms. But then the inflammation causes them to want to itch. So it's about stopping that cycle and it's all about um we'll do our best to manage symptoms. So for some people, it may take, they may have eczema for years and some people may have, it may eventually grow out of it. Ok. And then you may explain the causes to them. Um So for conditions such as eczema, it can be m multifactorial, um it can be, can run in families. It's always worth asking. Does anyone else in the family have this condition? Um So then they may be like actually, yeah, we know all this already. So you can move on quickly to the next bit. And then um people with eczema are more likely to have conditions like hay fever and asthma and allergic reactions. And then it can be usually diagnosed by um clinical diagnosis. So you do not, don't have to do any extra tests for it. And then the management is based on like baseline management for all the time and then flare management of flareups. And there may be periods when someone can get where it can get worse or when it can get better. So, um problems with it would be the flareups which is the worsening of symptoms and then um repeated scratching may cause the skin to thicken. And then, as you mentioned before that you can get bacterial or viral infections and that you may notice this if your skin starts to ooze cluster um sorry crust and then there may be blisters and you may be really unwell or have a fever. And then there it's usually recommended um to see a GP that day or if in doubt, just go straight to A&E cause you may need treated with um antibiotics or antivirals. So just always make them aware of the minor complications and then the really important complications. Ok. And then management, there's a lot involved counseling and management of it is important just to kind of be brief about the main points. So um it's a long process but it will be supported and there are multiple members of the team involved and that include the family. So it's important to make sure that like the family are included in it. For example, if you're a counseling, a parent and then the GP is there to support them and then if they, if they need it, they may be referred to a dermatologist and then there may also be an eczema nurse that can support them and then if it's really bad and you may consider a clinical psychologist if like for if they're noticing a lot of like a mental health effects and just important as you mentioned, it's important to recognize the effects on the family and then it's important to break the itch scratch cycle and then there will be times where it will get, will get worse and then get better again. Um So just avoid triggers. And then the baseline management would be your emollients, your soap substitutes and your wet wraps and it may be worth explaining to them how to apply it. Um on, on the Medic portal under the peer share. There's some really good um lectures um done by people in the years above previous years and sometimes they um the dermatology ones have good explanations of how to do it. Um But I think just saying like wet wraps to keep the emollients on would be enough. And then flare management could be the use of short term use of topical steroids. And then for further stages of eczema, you could mention um calcineurin inhibitors, um UV V phototherapy. And for example, antihistamines, if someone has problems with, with sleeping, it may take an antihistamine at night to help them sleep and get some relief from the itching, keeping them awake. And then there may be secondary referral for things such as systemics and biologics for really severe cases. Um But obviously you don't have to, don't use all the, don't use all of the, don't use all the technical terminology, just try and keep it as brief as and helpful as possible. And then it's always important to continue the baseline management even if symptoms improve and then always as like with your history and your counseling stations, always just safety net them address if there's anything else they have questions about. Um and then a leaflet and then sure we can come, you can come back and see us, can arrange a review appointment and then always just be aware of the topicals, the steroid ladder. Um So help every everybody. Dermatologist helps you remember the order of the from steroids from least potent to most potent. And then for applying steroids during flares just to use the fingertip units. And then there's a do Giora to help. Ok. Um So now I'm just gonna briefly, we're almost done. Thank you for staying on, but we're gonna do methotrexate counseling. Um I just put it, sorry, it's a lot of taxes mentioned. It's not right considering how images dermatology usually is. Um So I'm just gonna go through the methotrexate. It can come up as a, it may be asked for example, for rheumatology, but can also be used for psoriasis. Um There's not really that many drug counseling stations for dermatology that they can ask. I don't know if they've ever asked it, but it's here anyway, if you need it. So it's a devised d it's disease modifying. Ask talk about first how it works. So, so this what class of drug it is and then it, it can help symptoms by reducing inflammation and um suppressing the immune system to improve the like outcome of the disease and hopefully lessen your symptoms. Um methotrexate can't be used in pregnancy if you're breastfeeding. Um if you have any active infection or you're immunocompromised and if you have any liver impairment. Um for methotrexate, I always tell them that you take it. They may like to ask methotrexate because it has a bit of an awkward or special um ta how to take it. So you have to take it once a week on the same day. So it's recommended to set a reminder on your phone or on your calendar. Um There's multiple ways you can take it, you can take it with tablet oral liquid or injection and then wash your hands after the use. And then on this, take the folic acid, you always have to take folic acid with, it will be prescribed alongside it to reduce the side effects, but that has to be taken on another day. Um The dose of methotrexate will be built up slowly and it can take a few weeks to work and then don't stop it before speaking to your doctor. Ok. And then um monitoring would be your full blood count uni and LFT S um may also test for viral hepatitis and TB. And then um Mo methotrexate has to be monitored every two weeks until this dose is stabilized. And then it will be monitored maybe every 2 to 3 months. And you'll be given a booking a monitoring book and an alert card to let um people know in emergency that you're on methotrexate. Some of the main side effects would be that it can, would be myelo suppression. That would be the main one to explain to counsel them about cause they like asking you to counsel on medication where it can cause unexpected bleeding bruising infection. So for example, last year, one of my ones, the woman asked, um could could she play tennis? And like obviously for someone ones, you have to avoid contact sport but for other ones you don't. Um So so but oh anyway, for my suppression just to seek medical, urgent, urgent medical advice and then to get your annual flu vaccine, some of the common side effects of methotrexate would be hair loss, tiredness, um gi disturbances and headaches and then me methotrexate can be a cause of Steven Johnson syndrome. And then it can also um be toxic to the lungs and also toxic to the kidneys. And then it's really important that if you're speaking to someone um of childbearing age or um a man to start planning a family that it's trato IC. And then, so you must always use long-acting contraception and that m men for men and women that they shouldn't try to get um to plan a pregnancy for um six month until six months. After six months of them stopping the methotrexate and then interactions just to check with the doctor pharmacist before starting any new medication. And that could include just about vaccines. And then um don't NSAID S can increase the risk of toxicity. So wouldn't so prescribe different pain relief and then never um co prescribe trimethoprim or co cotrimoxazole um because it can cause bone marrow suppression. And then this is, I think this is our last bit. So this is last year's station in your, in third year we had um we had skin biopsy results and it never, I don't think it had ever been asked before. And so it was a really difficult station, like 24% did not achieve the pass mark. And apparently it was more of a pathology station rather than an actual dermatology station. But since people didn't do, since it was a really difficult station that they may ask something similar maybe this year. Um So you were asked to in the front of the door, I was, you were asked to explain the results of a skin biopsy to someone in a dermatology clinic and you were given a table of results. So I couldn't really find any similar like pictures of any other examples because it's not really often that you'd be asked to give results in your under the dermatology exposure in like 2nd and 3rd year is really limited. So a lot of people have seen it. Um So, but anyway, for just general, I suppose, just go about it in the way you would for general results for anything. Um always just start with your introduction, your consent and then uh you'll always get a mark. You always, it's always so important to check that the results belong to the correct patient. Start off with open questions. Do you know why you're here or bring me up to speed check a really small focused history on the patient. Um What are the signs and symptoms and number of lesions? What have they actually been told so far? Do they know why this biopsy was carried out what it was looking for? And then for our in last case, last year's case, um the results were for a basal cell carcinoma. Um And I think one of so you can offer reassurance that it was just a basal cell carcinoma. Um For example, I think in the Mark team here, it says that um that it wasn't fatal. So it's just like you can reassure the patient and that we've got a way to manage it and treat it and then it can be caused for a number of reasons such as sun damage, but usu so and then there you can be able to like emphasize the importance of sun damage to the patient and how to protect your skin from the sun. And then also mention that the prognosis is generally like really good and then they may ask what may happen next. So I think in, I forgot what the results were, but I'm not sure if one of the results was um the border was still contained some cells. So I wasn't really, I don't think I was really sure what to do, but it's never hurt to say, discuss with a senior. And then for um any like skin cancer, it just really depends on what the diagnosis is in front of you. For some of them, it may be immediate discharge. Um For other ones, you may need a follow up appointment or a def further excision of the margins, for example, in a Melanoma. Um And then for example, or you may need to have um mole surgery if it's on a certain area in the face. And then also maybe consider like a multidisciplinary team meeting if you're in out and then address the patient's um worries or any questions they have. In this case, the patient was re my patient was really worried because their friend was had a melanoma. And so you just to explain to them that it's a different type of different type of skin cancer, but just reassure them that this, if you're worried about having a Melanoma, these are the signs for it. And then we'll give you a leaflet to um to um for you to understand the different types of what to look out for and changes in your skin. And then as always offer advice, um leaflets helpline and then safety out of the patient if they notice the lesion has or the area has changed, if there's any other new or changing skin lesions to contact the GP and always um regularly check the skin and always wear some protection. OK? And then this is just a spot diagnosis. So I don't know if anyone in, if anyone's still here in the chat and wants to have a go at like the first one. But if not, I'm more than happy to like wrap it up if anyone would like to, I don't know how many are left. So, um, the first one you can see the, I start move, but the first one is the her old patch. So the pityriasis rosea and this is basically, I don't think these questions will be stations will be asked in an osk. It's more just for M CQ brush up and then a blistering skin condition could be the pemphigoid. And then for a, you can definitely be asked about rosacea. So consider that and you can see the sparing of the nasolabial folds and the postular skin changes. Um but vitiligo is quite popular and it's been asked in a coup last couple of progress tests and then also as well. Um rec be able to recognize Steven Johnson syndrome or uh Steven Johnson syndrome covers 10%. And then um SG to the third and then S GST Down syndrome slash toxic epidermal neck is like 10 to 30%. But if it covers over 30% of the skin body area, it would be toxic, epidermal necrolysis. But usually it's quite, usually they only offer one option on M CQ. Um and then measles as well has become really prevalent So let's just check about vaccine status. And then this is an example to finish off with is a diabetic foot ulcer. So it always as well for a third year exams just to make sure that you do like look over how to exa diabetic foot exam and you may be asked to describe that lesion. Ok. So that's if anyone has any questions. Thank you so much for still hanging on during this. Um Yeah, and if you have any questions, feel free to forward them to uh the DERM so society email and then I'm more than happy to answer them or sure they would be more than what I able to. And so just good luck with your ay and your progress tests or MLA S and then just, these are some of the resources. Um Hi Rachel. Um These are the resources that I'd really recommend um for. I find that I tend to use geeky medics quite a lot because they're really good for the um they're really good for the ay stations if you'd like, be willing to like bunch, I think the AK stations are really dearer than the like ones, but they're really good cause they're interactive and they're really helpful for your steering um grip work. Even if you're just in a para like one, it gives you the um the station for the, it gives you the candidate instructions, the examiner instructions, the simulated patient instructions and gives you a mark scheme as well and some questions at the end. So I find that really helpful. But um Skop as well, the textbook is really good. So that would be uh if I recommend two things, it would be me and O stop. Um For Dermatology. The Derm, the bad Dermatology handbook is actually really good. I know sometimes you get recommended random things under and they're just, it's like loads of, it's like 100 pages, 100s of pages and it's not helpful at all. But this is geared towards medical students and it's 90 pages. It goes over everything I've covered and more and it's actually really helpful. And then I'd also recommend mind the gap if you wanna um just to recognize change that how different dermatology dermatological conditions can present in skin of color. And then for general like 30 year onwards, revision, I always ui really like medicine in a minute and then also maybe use recommend zero to finals as well, but they don't really have a dermatology in section. Yeah. And then always just your usual like your past med and your class med. So, so thank you. Um Thank you all for hanging on and thank you for everyone who's joined us for the last couple of years um for the last couple of events. So I'm gonna stop sharing that. But thank you, everyone. Has a good evening.