Keloid: benign fibrous growth that develops in scar tissue. These lesions can be painful and disfiguring. Rx with intralesional steroids. Look for hx of traum a(ex earring piercings)ActinicKeratosis:Presentsasslowlygrowingreddishbrownskinlesion.Itspre-malignant,withpotential to become squamous cell cancer of the skin.Tetracycline: often used for Rx of acne. Doxycycline is a phototoxic agent and make ppl more susceptible to sunburn. On a side note, doxy can also cause esophageal ulceration if you dont drink itwith enough liquid. Rx for sunburn includes replacement of lost fluids and relief for pain/pruritis withNSAIDs. Diphenhydramine can be used for the itching.Isotretinoin (systemic retinoid): can cause hypertriglyceridemia in up to 25% of pt. Thus, there is a riskof acute pancreatitis. Look for the kid who is getting isotretionoin for acne Rx who developspancreatitis. If a pt develops triglyceridemia > 800, should d/c the drug.Topical Retinoid: teratogenic. Topical retinoids arent associated systemic side effects (hyperTG orhepatotoxic).Herpes Zoster: d/t reactivation of latent VZV infectio earlier In life. Any kind of stress on the body(fracture, infection, surgery) can reactivate the latent infection. Presents with grouped vesicles in aspecific dermatome, usually unilateral. Pain is another prominent feature. Rx with acyclovir. Localizedzoster lesions are transmitted only via direct contact with the open lesions. Contact prevautions arentnecessary in the community setting. In the hospital, however, should put the pt in contact isolationuntil all the lesions have crusted. As age increases, there is a higher chance that a recurrence willhappen.Postherpetic neuralgia (PHN): Defined as persistence of pain or other symptoms for > 1 month afterresolution of skin lesions of herpes zoster. Its described as a burning sensation in the involveddermatome. Agents proven to be effective for the pain include TCA, topical capsaicin cream,gabapentin, and long acting oxycodone.Photoaging: arises from aging and UV light damage. Intrinsic aging tends to cause fine wrinkles on anotherwise smooth skin surface. If there is photodamage, it can result in coarse, deep wrinkles on arough skin surface. Photoaged skin is often marked with actinic keratoses, telangiectasias, and brownspots. Cigarette smoke can have significant impact on skin (more wrinkles, especially at lateralcorneres of eyes). Rx with tretinoin. It helps reduce fine wrinkles, mottled hyperpigmentation, androughness of the face. It can also reduce actinic keratoses.Erythrasma: infection of skin that occurs most often in intertriginous spaces and is d/t C.minutissimum. Use of wood lamp shows coral red fluorescence cause by Corynebacteriumporphyries.Pityriasis rosea: self limited condition, manifests first as a single primary plaque (herald patch). Ageneralized eruption develops 1-2 weeks later, with fine, scaling papules and plaques in a christmastree distribution.Poison Ivy dermatitis: presents with a pruritic dermatitis composed of papules and vescicles which aredistributed in a linear fashion. Multiple lesions can be present in various areas around the bodhy,since touching other parts of body will transfer the poison ivy resin. More serious reactions can evolveinto vescicles which can exude a serous fluid.Tinea pedis: MC dermatophyte infection. Usually accompanied by involvement in another area(hands, necknails, or groin). Presents as a slowly progressive, pruritic, erythematous lesion, usuallybtw the toes and extending to the sole and side of the foot. There is a sharp border btw the involvedand uninvolved skin. Selflimting, but recurrent.Rx with antifungalcream.Seborrheic Dermatitis (dandruff): Pink-red erythema and scaliness in the scalp, face, and sometimesupper trunk. Pruritis is usually mild. Rx with selenium shampoo. Sometimes its the first presentingsign of HIV infection.Lichen Planus: generally presents in middle age. Involves skin, nails, mucous membranes of themouth and external genitalia. Lesions are shiny, discrete, intensely pruritic, polygonal shapedviolaceous plaques and papules that are present on the flexural surfaces of the extremities. Wristssare commonly involved. A characteristic whitish lacy pattern is often seen on the surfaces of thepapules and plaques. Mucous membranes of the mouth and external genitalia can also be involved.Dx is clinical. Histology can show hyperkeratotic epidermis with irregular acanthosis and focalthickening in the granular layer of the epidermis. Lichen planus is seen in association with liverdisease, especially advanced disease 2/2 hep C infection. Consider screening for it with H and P ifyou see lichen planus.AcneRx: Mildacneis Rxinitially withtopicalretinoid. Moderateacne canbe Rxwith topicalretinoidand benzoyl peroxide or topical antibiotic. More severe acne is treated with adding a topical antibioticor systemic abx. Abx are used only in combination with the other stuff. Very severe cases can be rxwith oral isotretinion is no response after 3-6 omnths with combo of abx, topical retinoid, and benzoylperoxide.Pressure Ulcer: Stage 1 has nonblanchable erythema of intact skin. Stage 2 has a partial thicknessloss of the epidermis, dermis, or both. Stage 3 are deeper, causing a full thickness loss with damagewhich might involve underlying fascia. Stage 4 are very deep, and can possibly extend into the bone,muscle. Should cover wound with dressing/saline moistened gauze. Pt should be turned every 2hours to prevent.Sporotrichosis: funal infection d/t sporothrix schenckii. Usually seen in ppl who do outdoor activities.Starts as a popular lesion over the site of inoculation. Eventually, the lesion ulcerates and tehr eisnon-=purulent drainage over the lesion. Dx is clinical, and with culture. Itraconazole for 3-6 months isRx.Tattoo: Laser removal of tattoos can be done, but they lead to scar marks and skin discoloration.Porphyria curanea tarda: d/t deficiency of oroporhyinogen decarboxylase. Painless blisters, and anicreased fragility of the skin are seen. There can also be facial hypertrichosis and hyperpifmentation.Dx is with elevated urinary uroporphyrins. Phlebotomy or hydroxychloroquine can provide relief. Thereis often an association with hep C, and if pt also has Hep C, can give interferon alpha.ElectrolytesHyperCa: usually lack of specific findings on physical exam. Some possibilities include anxiety,depression, mild muscular weakness, constipation, and PUD.hypoCa: Can occur during or immediately after surgery (esp if lots of transfusions were involved).hyperreflexia may be present, chvosteks sign is present (facial m. contract with tapipnof the facialnerve).Plasma osmolality: calculated as 2 x Na + glucose / 18 + BUN / 2.8. Normal is Around 280-290Euvolemic Hypoosmolar hypoNa: Has various etiologies. HypoTH, adrenal insufficiency, SIADH arecommon ones. Treating the underlying condition will also correct the electrolyte imbalance.hypoNa: if pt is symptomatic, or if the number is very severe (ex 110), then needs Na placement usinghypertonic saline solution. Postop hypoNa is common, d/t SIADH 2/2 anesthesia. Rx severe hypoNawith infusion of 3% hypertonic saline, increasing Na by 3 in the first 3 hours, and 0.5-1 per hour for thenext 12-18 hours. Frequent monitoring is necessary to prevent a rapid increase (can lead to centralpontine myelinolysis). Dont raise Na by more than 12 in the first 24 hours. The increase in serum Nalevel for a pt achieved by infusion of 1 L of 3% hypertonic saline can be calculated with the wollowing.(513 Na)/(total body water + 1).Remember small cell cancer causing SIADH.Hyperosmolar Hyperglycemic state (HHS): complication of poorly controlled T2DM. Characterized byAMS,sugars>800,bicarb>15,Osm>320,andpresenceofminimalketones.Hyperglycemiacancause either hypoNa or hyperNa in uncontrolled DM. Hyperglycemia can cause increases in serumosmolality, which acuses osmotic water movement out of the cells, diluting the ECF and leading todilutional hypoNa. TO correct this, have to calculate the corrected value of serum Na. Add 1.6 to theNa for each 100 of glucose over baseline (100). Thus, these pt are often much more hyperNa thantheir number would indicate. Rx with hydrating by half-normal saline solution.hypoK: can cause a paralytic ileus. Rx with K replacement (for GI stuff) and to prevent any cardiaccomplications. Some causes include diuretic induced hypoK (esp if pt is on HTN, CHF therapy). Loopdiuretics are a big cause. hypoK itself can actually precipitate hepatic encephalopathyhyperK: Some warning signs are if K is > 7, if there are EKG changes (peaked T waves), and acuity.First thing to do in an emergent situation is to give IV Ca gluconate to stabilize membrane of cardiacconduction tissue and prevent arrhythmias.Alcoholicketoacidosis:presentswithiketonuriaandmildlyelevatedglucose.Canimpairmentalfunction. Glucose can be low, high, or normal. Rx with D5W and thiamine. Insulin is usually notneeded.hypoMg: can mimic some signs of hypoCa (hyperactive DTR,),muscle cramp. But is often associatedwith alcoholism, prolonged NG sunction, diarrhea, or diuretic use.Hypophosphatemia: MCC is continuous glucose infusion in hospitalized pt. Pt are usually alcoholic ordebilitated. Hypophosphatemia can impair ATP generation and muscle weakness can result. If theresp muscles get weak, is an indication to not wean from mechanical ventilation. Cardiac contractilityis also decreased in hypophosphatemia, and can cause cardiomyopathy.Zinc deficiency: common in ICU, d/t prevalence of RF (diarrhea, diuresis, malnutrition, CRF, burns).There can be increased susceptibility to infection and a skin rash