AMC 2006 April Melbourne . -GP1154, Pt EducP187 8. Contact dermatitis Photo dorsum of hand. (Not from AMC book —scaly lesions on whole dorsal surface of hand, red).Pt is a brick layer started new job 6 months ago, comes to your GP practice The 32 years old man came to tour surgery. Presented with hand (the picture attached: swelling with sign of dermatitis and infection between the fingers) Take relevant history Explain the condition to the patient: Management Role player asked: ‘* How long you going to put me on antibiotic? ‘Should | stop worléng? How to prevent in the future Hx When and where it began?it's distribution?Does i change overtime? Any telationship to sun exposure or heat or cold? And any response to Tx? How long have you had this problem? Can you teli me more about it? How does it started? What have you done for it? ‘What medication did you use? What cream have you tried? Anything that makes it worse? Anything that makes it better? Does it itchy? Painful? Warmth sensation? Redness? Swelling? Pus discharge, fever? Any constitutional symptoms? Ask if'any feveryheadache/fatigure/anorexia/wt loss Past Hx ~fashes or allergic reactions pig Pasttofastims, eczema and hay fever -Do you have FH of eczyma, asthma, or allergic skin problems? A detailed social Hx -What's your occupation? Cement contact because I'm a brick layer. + _-How long have you been a brick layer? ‘Smoking Alcohol Medication Allergy Summary of hx Role-palyer one: Rash has been there for 3 months, 3 months after he started his work, at ‘work: does everything with hands, no gloves. Rash very itchy, holidays made it better. Pt loves his Job. Brother has psoriasis (to confuse you} From history the patient said it came suddenly, he doesn't have any allergy, hay fever or asthma, as well 35 family history of those concitions. He is a builder and recently he worked with cementbe Allergy skin tests (patch test) and RAST Dx. Contact Dermatitis Ux Tall pt: It is a skin inflammation caused by an allergic or irrtating reaction to certain substances (cemant most likely) coming into contact with skin. © Tx Referto Dermatologist fur pate Hertiny ‘© Stop contact with allergens— stop working as a brick layer, but it seems to be impossible, so advise use of gloves which there are cotton in inner layer, plastic in outer layer. (Wear protective work gloves such as cotton-lined PVC gloves) © Antihistamines for very itchy cases. ‘© Avoid soap and other irritant at this point because of possible infection. wash wits water or © Topical corticosteroid cream 4 poe bey, © Oral corticosteroid for severe cases (60 mg for adults) © Give antibiotics orally if sign of infection (pus discharge, fever) My answer: contact dermatitis, Examiner expected to hear oral steroids as tx, not only topical steroids and gloves as protection. | told the role-player he does not have to change the jab, ‘whieh he liked. The examiner asked about complications. (My answer cellultis, treat with oral Fluctoxacillin after checking BSL and lymph nodes) 17d read at least from Murtagh and Pt’s education re: this topic | explained to him that he had an allergy probably due to cement complicated by bacteria. 1 gave him prednisolone and antibiotic. 1 talked about referring him to allergic elinio to have @ test done and avoidance to the materials that you allergic to. Then report to your employer regarding his condition. There's possibilty thet they'll move you to another department2006 April Adelaide - A.17y man complaining of worsening vision over the last few months. He has difficulties with striving and cannot see the road signs clearly. His father and brother wear glasses. ‘Do the novessery tests, explain the results and manage the case (Lie hud decreased visual aouity, all ‘other tests NAD) Exarainati visual acuity(snellon chart)—with pinhole test visual ficld( using red oin) colour vision opi reaction(ight reflux, socommodation) eyemovernent ‘fundus examination ‘A complete eye test is the only sue way to determine whether your vision is normal) ana wr Rxplain 1. myopia is short-sighledness. people who have it do not see distant objects clearly. It is a kind of reftuctive errors. 2. ima normal eye, the lens end comea focus light into on the retina. In a myopic eye, the light is focused in front ofthe reting and so the image is blurred. 3. myopia is a very common condition which affects about 30%of Australien} 4. myopia usually begins to develop in toenage year, thou it may progressively inorease over the following yearsSlowing in the mid to late twentieglin most people. 5. reftactive errors ends to stabilise once a person stop growing, so tht from their late 20s to their exrly 40s most people do not experience any major changes in their eyes. 6. most people stop changes below 6 dioptres? 7. ifmyopia progresses above 6 dioptres (sometimes up to over 20 dioptres) called pathological myopia. Ii is rare less 3%. 8. this has serious consequences later in life because secondary degeneration of the vitreous and retina can Iead to: retinal detachment ,choroidretinal atrophy and macular bleeding 9. main causes are genetic (chromosome 18p&12q) end excessive close work in the early Geondes, ‘Manegement ‘Noa—surgicel measures 1, when reading ensure good lighting? 2. advocate a balatice of physical activity and reading} 3. some peuple also advocate doing eye exercise(nown as"bates methods” but thers is no solid scientifid evidence) 4. Speckdeles (glasses with concave lens) 5. contac ei? 6. for childcen, cheek their eyes every 6 month (avild over-correction as this can make myopia worse)Surgery 7. radial keratotomy 8. photoreftactive keratotomy (PRK) it is an cotircly laser treatment where the curvature of the front of the comea is altered by ebletion of part of it using a laser it is less predictable than lasik with some people having under-correction and others over-correction ‘most have good outcome but itis very painful fora few days 9. Insih(leser assisted in situ keratomilensis) «thin flap of corneal tissue is created witha fine instrument known microkeratome. This flap is then lifted out of the way. The excimer laser reshapes the underlying tissue and the flap is replaced to cover the newly recontoured surface. Serious complications are rare but trauma to / infection of the flap may result in permanent corneal scarring. ‘Reason for surgery 1 they cen't wear contact lenses end would prefer net to wear glasses for cosmetic reasons 2 they want to engage in work or leisure activities that can not be dane while glasses or contact Tenses medical issues to consider 1 atleast more than 20 years old ‘2 the refractive error should be stable 3 pexple with diabeteumeontrolled rheunmlie conditions/diseases of immune system/famity history of keratocomus should be careful in proceeding with leser eye surgery. 4 laser oye surgery carries extra risks if performed on patients with ebnormally shaped or very thin comes.ation <@40 AMC 2006 April Adelaide “devitP35 (vary good case) in combined with our surgeon's note. Case-11 (Neck lump/ Warthin’s tamour) 70 years old lady com to you with lump in front of leit ear in the ost & years (slow growing) no pain. , Task; take history for 3 mints, ask examination finding from examiner and examine relevant system and talk fo the patient. Hx HOPC (detail of the jump) -Slow growing and painless swelling below his left ear (in the parotid region} tors yrs ~The lump has been getting slowly larger, but has not noticed any other swelling. resome. ~No change in the size of the lump when eating nor-painful, No discharge or bleeding from the lump. ~Only left side swelling Associated symptoms -He has no night sweats nor loss of weight, no cough/fever -she had no vision problem, no headache, no teeth ache, ~and no difficulty with swalfowing, no voice change. Past Hx -In general good health Fhe nji0t Previous history of surgery and no hx of any trauma on the face. Nit Social Hx ‘Smoking: 20/day for 40 yrs Alcohol: Nil Medicacation: Nil Allergy: Nil OE GA: well, no palefwt loos -V'signs: Normal Detail of lump exam, look for the following “Site, size, shape, consistency, surface, edge, and deep/superficial attachment -Relationship to nearby anatomical structures {mandible and pre-auricular) its anatomical layer (skin, subcutaneous tissue and muscle) -whether it impinges on adjacent structures (facial N) -Look inside the mouth. Look for ca of tounge and deep lobe tumour -examine for lymphadenopathy ~Check facial nerve function -Examine the extemal auditory canal Comment on the other side (important) Note: Skin (moved when the skin is moved) -Sebaceous cyst Epidermoid cyst Papilloma ~ Subcutaneous (skin moved over the lump} Neurofibroma Upoma