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) Actinic Keratosis: Presents as slowly growing reddish brown skin lesion. Its p

re-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 or hepatotoxic).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 after resolution 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. Self limting, but

recurrent. Rx with antifungal cream.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 liver disease, especially advanced disease 2/2 hep C infection.

Consider screening for it with H and P if you see lichen planus. Acne Rx: Mild acne is

Rx initially with topical retinoid. Moderate acne can be Rx with topical retinoidand

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.

Electrolytes

HyperCa: 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

by AMS, sugars > 800, bicarb > 15, Osm > 320, and presence of minimal ketones. Hype

rglycemia cancause 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. Alcoholic ketoacidosis: presents with iketonuria and mildly elevated glucos

e. Can impair mentalfunction. 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 or debilitated. 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