Ep.

242: Dermatology Part 1 of 3

● Note: NBME likes to give buzzwords for Derm. However, look up pictures!!

Atopic Dermatitis
● Pt presents with dry skin and intense pruritus
● On PE erythematous papules and vesicles crusty lesions and oozing.
● Fam. hx. of asthma.

Eczema presentation:
● adults: flexor surfaces (this is your antecubital fossa)
● children: extensor surfaces first before flexor surfaces
● What is the classic finding in a person with chronic atopic dermatitis? Lichenification
(what happens when you scratch a lot)
● MC infectious agent or complication of eczema? staph aureus.
● What is the type of hypersensitivity reaction in eczema? Type 1

Contact dermatitis
● Pt acquired nickel with a lot of itching around wrists? Contact dermatitis
● What are other types of allergic reactions in contact dermatitis? medication patches,
poison ivy
● Grouped vesicles in a linear distribution -> poison ivy
● This is a type IV hypersensitivity reaction

Psoriasis
● Rash at extensor surfaces

Xerotic eczebma
● Elderly pt (e.g. 79 y/o) presents with really dry skin on left shin (tree-bark appearance at
lower extremities). On PEx skin is red/dry, neck-like fissures. Skin reaction gets worse in
the cold, dry winter months.

Treatment for eczema, general terms

● Tx emollients. Topical glucocorticoids
● Special cases:
○ Do NOT use topical glucocorticoids on dermatitis of the face
○ One of the MCCs of acne on the face on NBME exams? topical corticosteroids

Plaque psoriasis
● 36 y/o Mexican male with thick erythematous plaques with silver scales on elbow
(Extensor surface)
● Show on elbow, knees, scalp, ears, genitalia
● Classic exam findings in psoriasis -> very thick NAILS. yellow, nail-pitting, Hispanic
 ● Things that worsen: beta-blocker, NSAIDS, ace inhibitor, oral steroids, tetracycline

Guttate psoriasis
● Pt. with papules and plaques on their trunk. Looks like tiny tiny drops.
● Patient recently developed group A skin infection (i.e., strep pyogenes)
● Tx. Vitamin D analog - topical calcipotriene; retinol; anthralin; or tar prep

● Note: Do not give oral/IV steroids for psoriasis b/c systemic steroids worsen psoriasis.

Erythroderma
● Pt with a hx of psoriasis and is taking steroids. Skin turns really red.
● Complication: electrolyte abnormality (loss of fluid) risk of skin superinfection.

Lichen planus
● Pt. has noticed a lot of pruritus these past few days on wrists and ankles. Noticed
purplish papules shaped like polygons.
● Tx. topical corticosteroid

Pityriasis rosea
● Pt over the last two weeks has pruritus. Noticed circular or rectangular lesion on trunk
(Herald patch), under axillae and lasts for weeks.
● Tx. topical steroids and antihistamine for pruritus

Seborrheic dermatitis
● Pt. has oily, scaly lesion on eyebrow on scalp, nasolabial folds, chin or perineal cysts
● Tx. selenium sulfide shampoo, also 2nd line-ketoconazole
● If pt is young person sexually active with tons of lesions that resemble seborrheic
dermatitis -> screen for HIV
● Typically also seen in patients with Parkinson's disease

Rosacea
● 35 y/o female with redness of cheeks/nose whenever she eats spicy food or drinks
alcohol has facial flushing. Can see papules/pustules.
● Usually >30 y/o female
● Don't confuse this patient with malar rash on lupus. Rash of lupus SPARES nasolabial
folds. People with lupus DO NOT have papules, pustules on face or flushing eps.

Adrenal Tumor (DHEA) or Gonadal (Sertoli-leydig tumor)

● Woman who suddenly develops severe acne, failure of acne treatment, and hirsutism
with menstrual problems or signs of virilization. DDx between by checking levels of
DHEA highly elevated with adrenal tumors.

Hidradenitis suppurativa
 ● Pt. with a history of diabetes who have had chronic lesions under axilla, breasts or in
gluteal clefts. Nodules, cysts, comedones, a lot of scarring.
● Pathophys: apocrine sweat glands.
● Tx. Clindamycin or Rifampin also TNF alpha inhibitors like Infliximab
● Definitive Tx. excision of lesions

Acne vulgaris
● Open and closed comedones, papules, pustules, nodular lesions. Distribution at face,
neck or upper trunk sebaceous glands are the ones affected.
● Tx. topical retinoid or salicylic acid or benzoyl peroxide.
○ Not work? Add a topical antibiotic (e.g., erythromycin, clindamycin).
■ Not work? Add an Oral antibiotic (tetracycline)
● Not work? Give isotretinoin

● If pt has acne, visual headaches worse in the morning -> idiopathic intracranial
hypertension, seen in treatment with tetracyclines.
● What labs to order before giving isotretinoin? LFT's, B-HCG
● Don't give preggos isotretinoin or tetracycline
● Pt with PCOS + acne (hyperandrogenism) DOC = OCP's.

Bacterial folliculitis
● Athletic patients with pustules and papules on the scalp (anywhere with hair) centered
around hair follicles.
● MCC: staph aureus
● Tx. mupirocin

Hot-tub folliculitis
● Pt in a community pool/hot tub liquidly chlorinated
● MCC: pseudomonas

Hot-tub lung
● MCC: mycobacterium avium intracellularly complex

Dermatophyte Skin Infections (Tinea)

● MCC trichophyton tonsurans > microsporum species > epidermal phyton species

Tinea pedis
● Scaling from toes to areas of achilles heel (athlete's foot)

Tinea corporis (ringworm)

● Erythematous circular red lesion with vesicles with "Central clearing"

Onychomycosis / nail fungus

 ● Yellow, thick nails or really white. Distal edge (farthest away from skin is elevated)

Cutaneous candidiasis.
● Red, itchy skin with red satellite lesions. After scraping- > KOH prep see spores and
pseudohyphae.

Tinea versicolor or pityriasis versicolor

● Hypopigmented macules on upper trunk or back. On prep: "spaghetti and meatball
pattern"
● MCC: malassezia furfur

Tx general
● All tinea: topical antifungals: Clotrimazole (any -azole)
○ Exceptions:
■ Tinea Capitis (head): oral medication - terbinafine, griseofulvin
■ Griseofulvin (penetrates keratin containing tissue)
■ Cutaneous Candida: topical nystatin or other azole
■ Tinea versicolor: selenium sulfide or topical azole

Molluscum contagiosum
● Pt. with umbilicated papule on skin (adult or child)
● Tx: cryotherapy or curettage
● A/w HIV!

CROSS CHECKED? YES

-------------------------------------------------------------------------------------------------------------------------------

Ep. 243: Water Soluble Vitamins

● Pt found on street by police, brought into ED. Swaying side to side + nystagmus +
doesn’t know how he got to hospital → Wernicke’s encephalopathy
○ Population?
■ Alcoholics
■ Hyperemesis gravidarum
■ Eating disorders
■ Starvation
○ Triad? Confusion + ophthalmoplegia + ataxia
○ Pathophys? Thiamine deficiency
■ B1 is part of the TLCFN cofactor group (cofactor for pyruvate
dehydrogenase complex, alpha-ketoglutarate dehydrogenase, branching
ketoacid dehydrogenase)
● Defect in branching ketoacid dehydrogenase → maple syrup urine
disease
■ B1 is a also a cofactor for transketolase
 ● Transketolase dysfxn implicated in Wernicke’s
○ Neuroanatomical association? Hemorrhagic infarction of the mammillary bodies
○ What if they have confabulation + amnesia → Korsakoff syndrome
○ Prognosis?
■ Wernicke’s → reversible
■ Korsakoff → permanent
○ Tx? Give thiamine BEFORE glucose
○ Other presentations of thiamine deficiency?
■ Generalized edema + other signs of CHF → Wet beriberi
■ Ataxia + paralysis + sensory sxs → Dry beriberi

● B2 = riboflavin
○ Required for production of FADH2
■ Part of the TLCFN cofactor group
● B3 = niacin
○ Required for production of NADH/NADPH
○ Presentation of deficiency?
■ dermatitis + chronic diarrhea + dementia → pellagra
○ Causes of niacin deficiency?
■ Hartnup disease
● Can’t reabsorb neutral AAs (e.g. tryptophan, which is used to
make niacin & serotonin)
■ Carcinoid syndrome
● All the tryptophan is being shunted towards serotonin production,
so there’s not a lot available to produce niacin
● Presentation? Flushing eps + chronic diarrhea + holosystolic
murmur at LLSB that increases w/ inspiration (likely tricuspid
regurg)
● Sxs only occur once metastasized
○ Liver metabolizes the serotonin
● Why only R-sided heart murmurs?
○ Lungs also metabolize serotonin
○ Therapeutic use of niacin? Best way to raise HDL
■ Better than statins!
■ AE? Flushing + itching
● Tx? NSAIDs
● B5 = pantothenic acid
○ Used to make coenzyme A
● B6 = pyridoxine
○ Cofactor for transaminases
○ Cofactor for glutamate decarboxylase (glutamate → GABA)
○ Cofactor for ALAS (1st step in heme synthesis)
○ Presentation of deficiency?
■ Sideroblastic anemia
 ■ Seizures
○ Drug that causes B6 deficiency? Isoniazid
■ Other AE? drug-induced lupus
● B7 = biotin
○ Cofactor for carboxylase enzymes
○ Very rare, it’s difficult to get biotin deficiency
○ Odd cause of deficiency? egg whites contain avidin protein, which binds biotin
and can cause deficiency
● B9 = folate
○ Necessary for DNA synthesis
○ Converts homocysteine → methionine
○ Causes of deficiency?
■ Alcoholism
● Alcohol inhibits conjugase, which helps us reab
■ Small bowel reabsorptive disorders
■ Poor nutrition (body stores of folate only last months)
■ Chronic hemolytic anemia (e.g. sickle cell, hereditary spherocytosis)
■ Drugs
● Phenytoin
● Methotrexate
○ Rescue agent? Leucovorin (folinic acid analog)
● TMP-SMX
○ Presentations of deficiency?
■ Megaloblastic anemia
■ Neural tube defects in fetus
○ Lab findings? Elevated homocysteine
● B12 = cobalamin
○ Converts homocysteine → methionine
○ Converts methylmalonyl-CoA → succinyl-CoA
○ Presentations of deficiency?
■ Megaloblastic anemia
■ Dementia
■ Subacute combined degeneration
● Damage to dorsal columns + lateral corticospinal tract
○ Causes of deficiency?
■ Pernicious anemia
■ Crohn’s affecting terminal ileum
■ Strict vegan diet
■ Diphyllobothrium latum (fish tapeworm)
○ Lab findings? Elevated homocysteine AND MMA
● Vitamin C
○ Cofactor for synthesis of collagen
○ Presentation of deficiency?
■ Bleeding gums + poor wound healing → Scurvy
 ○ Therapeutic use? Tx of methemoglobinemia
■ Keeps iron in the Fe2+ form

CROSS CHECKED? NO

----------------------------------------------------------------------------------------------------------------------------
Ep. 242: Dermatology Part 1 of 3
● Note: NBME likes to give buzzwords for Derm. However, look up pictures!!

Atopic Dermatitis
● Pt presents with dry skin and intense pruritus
● On PE erythematous papules and vesicles crusty lesions and oozing.
● Fam. hx. of asthma.

Eczema presentation:
● adults: flexor surfaces (this is your antecubital fossa)
● children: extensor surfaces first before flexor surfaces
● What is the classic finding in a person with chronic atopic dermatitis? Lichenification
(what happens when you scratch a lot)
● MC infectious agent or complication of eczema? staph aureus.
● What is the type of hypersensitivity reaction in eczema? Type 1

Contact dermatitis
● Pt acquired nickel with a lot of itching around wrists? Contact dermatitis
● What are other types of allergic reactions in contact dermatitis? medication patches,
poison ivy
● Grouped vesicles in a linear distribution -> poison ivy
● This is a type IV hypersensitivity reaction

Psoriasis
● Rash at extensor surfaces

Xerotic eczema
● Elderly pt (e.g. 79 y/o) presents with really dry skin on left shin (tree-bark appearance at
lower extremities). On PEx skin is red/dry, neck-like fissures. Skin reaction gets worse in
the cold, dry winter months.

Treatment for eczema, general terms

● Tx emollients. Topical glucocorticoids
● Special cases:
○ Do NOT use topical glucocorticoids on dermatitis of the face
○ One of the MCCs of acne on the face on NBME exams? topical corticosteroids
Plaque psoriasis
● 36 y/o Mexican male with thick erythematous plaques with silver scales on elbow
(Extensor surface)
● Show on elbow, knees, scalp, ears, genitalia
● Classic exam findings in psoriasis -> very thick NAILS. yellow, nail-pitting, Hispanic
● Things that worsen: beta-blocker, NSAIDS, ace inhibitor, oral steroids, tetracycline

Guttate psoriasis
● Pt. with papules and plaques on their trunk. Looks like tiny tiny drops.
● Patient recently developed group A skin infection (i.e., strep pyogenes)
● Tx. Vitamin D analog - topical calcipotriene; retinol; anthralin; or tar prep

● Note: Do not give oral/IV steroids for psoriasis b/c systemic steroids worsen psoriasis.

Erythroderma
● Pt with a hx of psoriasis and is taking steroids. Skin turns really red.
● Complication: electrolyte abnormality (loss of fluid) risk of skin superinfection.

Lichen planus
● Pt. has noticed a lot of pruritus these past few days on wrists and ankles. Noticed
purplish papules shaped like polygons.
● Tx. topical corticosteroid

Pityriasis rosea
● Pt over the last two weeks has pruritus. Noticed circular or rectangular lesion on trunk
(Herald patch), under axillae and lasts for weeks.
● Tx. topical steroids and antihistamine for pruritus

Seborrheic dermatitis
● Pt. has oily, scaly lesion on eyebrow on scalp, nasolabial folds, chin or perineal cysts
● Tx. selenium sulfide shampoo, also 2nd line-ketoconazole
● If pt is young person sexually active with tons of lesions that resemble seborrheic
dermatitis -> screen for HIV
● Typically also seen in patients with Parkinson's disease

Rosacea
● 35 y/o female with redness of cheeks/nose whenever she eats spicy food or drinks
alcohol has facial flushing. Can see papules/pustules.
● Usually >30 y/o female
● Don't confuse this patient with malar rash on lupus. Rash of lupus SPARES nasolabial
folds. People with lupus DO NOT have papules, pustules on face or flushing eps.

Adrenal Tumor (DHEA) or Gonadal (Sertoli-leydig tumor)

 ● Woman who suddenly develops severe acne, failure of acne treatment, and hirsutism
with menstrual problems or signs of virilization. DDx between by checking levels of
DHEA highly elevated with adrenal tumors.

Hidradenitis suppurativa
● Pt. with a history of diabetes who have had chronic lesions under axilla, breasts or in
gluteal clefts. Nodules, cysts, comedones, a lot of scarring.
● Pathophys: apocrine sweat glands.
● Tx. Clindamycin or Rifampin also TNF alpha inhibitors like Infliximab
● Definitive Tx. excision of lesions

Acne vulgaris
● Open and closed comedones, papules, pustules, nodular lesions. Distribution at face,
neck or upper trunk sebaceous glands are the ones affected.
● Tx. topical retinoid or salicylic acid or benzoyl peroxide.
○ Not work? Add a topical antibiotic (e.g., erythromycin, clindamycin).
■ Not work? Add an Oral antibiotic (tetracycline)
● Not work? Give isotretinoin

● If pt has acne, visual headaches worse in the morning -> idiopathic intracranial
hypertension, seen in treatment with tetracyclines.
● What labs to order before giving isotretinoin? LFT's, B-HCG
● Don't give preggos isotretinoin or tetracycline
● Pt with PCOS + acne (hyperandrogenism) DOC = OCP's.

Bacterial folliculitis
● Athletic patients with pustules and papules on the scalp (anywhere with hair) centered
around hair follicles.
● MCC: staph aureus
● Tx. mupirocin

Hot-tub folliculitis
● Pt in a community pool/hot tub liquidly chlorinated
● MCC: pseudomonas

Hot-tub lung
● MCC: mycobacterium avium intracellularly complex

Dermatophyte Skin Infections (Tinea)

● MCC trichophyton tonsurans > microsporum species > epidermal phyton species

Tinea pedis
● Scaling from toes to areas of achilles heel (athlete's foot)
Tinea corporis (ringworm)
● Erythematous circular red lesion with vesicles with "Central clearing"

Onychomycosis / nail fungus

● Yellow, thick nails or really white. Distal edge (farthest away from skin is elevated)

Cutaneous candidiasis.
● Red, itchy skin with red satellite lesions. After scraping- > KOH prep see spores and
pseudohyphae.

Tinea versicolor or pityriasis versicolor

● Hypopigmented macules on upper trunk or back. On prep: "spaghetti and meatball
pattern"
● MCC: malassezia furfur

Tx general
● All tinea: topical antifungals: Clotrimazole (any -azole)
○ Exceptions:
■ Tinea Capitis (head): oral medication - terbinafine, griseofulvin
■ Griseofulvin (penetrates keratin containing tissue)
■ Cutaneous Candida: topical nystatin or other azole
■ Tinea versicolor: selenium sulfide or topical azole

Molluscum contagiosum
● Pt. with umbilicated papule on skin (adult or child)
● Tx: cryotherapy or curettage
● A/w HIV!

CROSS CHECKED? YES

-------------------------------------------------------------------------------------------------------------------------------

Ep. 243: Water Soluble Vitamins

● Pt found on street by police, brought into ED. Swaying side to side + nystagmus +
doesn’t know how he got to hospital → Wernicke’s encephalopathy
○ Population?
■ Alcoholics
■ Hyperemesis gravidarum
■ Eating disorders
■ Starvation
○ Triad? Confusion + ophthalmoplegia + ataxia
○ Pathophys? Thiamine deficiency
 ■ B1 is part of the TLCFN cofactor group (cofactor for pyruvate
dehydrogenase complex, alpha-ketoglutarate dehydrogenase, branching
ketoacid dehydrogenase)
● Defect in branching ketoacid dehydrogenase → maple syrup urine
disease
■ B1 is a also a cofactor for transketolase
● Transketolase dysfxn implicated in Wernicke’s
○ Neuroanatomical association? Hemorrhagic infarction of the mammillary bodies
○ What if they have confabulation + amnesia → Korsakoff syndrome
○ Prognosis?
■ Wernicke’s → reversible
■ Korsakoff → permanent
○ Tx? Give thiamine BEFORE glucose
○ Other presentations of thiamine deficiency?
■ Generalized edema + other signs of CHF → Wet beriberi
■ Ataxia + paralysis + sensory sxs → Dry beriberi

● B2 = riboflavin
○ Required for production of FADH2
■ Part of the TLCFN cofactor group
● B3 = niacin
○ Required for production of NADH/NADPH
○ Presentation of deficiency?
■ dermatitis + chronic diarrhea + dementia → pellagra
○ Causes of niacin deficiency?
■ Hartnup disease
● Can’t reabsorb neutral AAs (e.g. tryptophan, which is used to
make niacin & serotonin)
■ Carcinoid syndrome
● All the tryptophan is being shunted towards serotonin production,
so there’s not a lot available to produce niacin
● Presentation? Flushing eps + chronic diarrhea + holosystolic
murmur at LLSB that increases w/ inspiration (likely tricuspid
regurg)
● Sxs only occur once metastasized
○ Liver metabolizes the serotonin
● Why only R-sided heart murmurs?
○ Lungs also metabolize serotonin
○ Therapeutic use of niacin? Best way to raise HDL
■ Better than statins!
■ AE? Flushing + itching
● Tx? NSAIDs
● B5 = pantothenic acid
○ Used to make coenzyme A
● B6 = pyridoxine
○ Cofactor for transaminases
○ Cofactor for glutamate decarboxylase (glutamate → GABA)
○ Cofactor for ALAS (1st step in heme synthesis)
○ Presentation of deficiency?
■ Sideroblastic anemia
■ Seizures
○ Drug that causes B6 deficiency? Isoniazid
■ Other AE? drug-induced lupus
● B7 = biotin
○ Cofactor for carboxylase enzymes
○ Very rare, it’s difficult to get biotin deficiency
○ Odd cause of deficiency? egg whites contain avidin protein, which binds biotin
and can cause deficiency
● B9 = folate
○ Necessary for DNA synthesis
○ Converts homocysteine → methionine
○ Causes of deficiency?
■ Alcoholism
● Alcohol inhibits conjugase, which helps us reab
■ Small bowel reabsorptive disorders
■ Poor nutrition (body stores of folate only last months)
■ Chronic hemolytic anemia (e.g. sickle cell, hereditary spherocytosis)
■ Drugs
● Phenytoin
● Methotrexate
○ Rescue agent? Leucovorin (folinic acid analog)
● TMP-SMX
○ Presentations of deficiency?
■ Megaloblastic anemia
■ Neural tube defects in fetus
○ Lab findings? Elevated homocysteine
● B12 = cobalamin
○ Converts homocysteine → methionine
○ Converts methylmalonyl-CoA → succinyl-CoA
○ Presentations of deficiency?
■ Megaloblastic anemia
■ Dementia
■ Subacute combined degeneration
● Damage to dorsal columns + lateral corticospinal tract
○ Causes of deficiency?
■ Pernicious anemia
■ Crohn’s affecting terminal ileum
■ Strict vegan diet
 ■ Diphyllobothrium latum (fish tapeworm)
○ Lab findings? Elevated homocysteine AND MMA
● Vitamin C
○ Cofactor for synthesis of collagen
○ Presentation of deficiency?
■ Bleeding gums + poor wound healing → Scurvy
○ Therapeutic use? Tx of methemoglobinemia
■ Keeps iron in the Fe2+ form

CROSS CHECKED? NO

----------------------------------------------------------------------------------------------------------------------------

Ep. 246: Dermatology Part 2 of 3

Pt. is a 31 y/o male who is active military who came back from Afghanistan (Iraq, Saudi
Arabia, Peru etc.) 2 to 3 weeks ago. On his arm (or anywhere typically on upper extremities)
there is a painless, purplish ulcerating papule.
● Dx
○ Leishmaniasis
■ Transmission
● Sandfly
■ How to diagnose?
● Skin Biopsy
■ Treatment
● Amphotericin B or Paromomycin

Pt is 50 or older there is a recombinant zoster vaccine

● NOT live attenuated.
● Can start administer 50 y/o
○ Eligible
● Reduce risk of post-herpetic neuralgia
● Reduce incidence of zoster

Pt is over 60 y/o there is a live-attenuated zoster vaccine

● live -attenuated given to those over 60
● Immunocompetent
○ If has HIV or CLL or immunodeficiency, do NOT give a live-attenuated
vaccine

Typical vignette for zoster: pain, rash dermatomal distribution.

 ● But, if patient has a “zoster explosion” in body
○ NBS: Screen for HIV

Pt has a sudden outbreak of molluscum contagiosum

● NBS: Screen for HIV

Pt has porphyria cutanea tarda

● NBS: Screen for HCV

Pt. with zoster with vesicular rash spread in dermatomal distribution on first branch of
trigeminal nerve, tip of nose and eye (Opthalmic branch)
● NSBIM? Refer to ophthalmologist
○ Zoster ophthalmicus

Pt has vesicles in ear + anterior sensation of taste of ⅔ tongue gone. Paralyzed upper and
lower part on one side of face (like bell’s palsy) in the CN VIII pattern.
● Dx? Ramsay Hunt Syndrome (herpes zoster oticus)
○ Treatment
■ Acyclovir

Post-herpetic neuralgia
● Treatment
○ Gabapentin
○ nortriptyline, amitriptyline (be careful in elderly)

● Note: Do not give steroids in herpes zoster!!

Pt is a young kid, homeless who comes with referral. Itchy rash between finger webs, penis,
scrotum.
● Dx
○ Scabies (sarcoptes scabies)
○ How?
■ Mite burrows in the upper layer of skin
○ Disseminated scabies
■ HIV, immunocompromised
○ How to diagnose?
■ Swab tissue and find mites and eggs on KOH prep
○ Treatment
■ Permethrin (also family members)
■ Ivermectin
■ Wash everything in hot water
■ DO NOT pick Lindane lotion
 ● Neurotoxic, induces seizures in children

Pt. with an itchy lesion in skin. On exams, grouped papules that are very itchy. “Breakfast
lunch and dinner lesions” Red circles in very close approximation. Usually in the morning.
● No real treatment (do antihistamines topical steroid etc)

Pt. with a history of HIV with brown lesions that look like a tan. Well demarcated plaques,
papules with a “Stuck-on” appearance
● Dx
○ Seborrheic keratosis
● What to do with it?
○ Excision
○ Liquid nitrogen

Pt with sudden onset with tons and tons of stuck on appearances. What to screen for?
● GI malignancy (colonoscopy, EGD etc etc)

17 yo female not sexually active. Has warts. Flesh colored papules. Genital warts. Those
are the things known as?
● Condyloma acuminatum [Do not confuse with Condyloma latum (syphilis) - do not
confuse!]
● Treatment
○ Topical salicylic acid (works for acne)
○ Cryotherapy
○ Podophyllin
● Most likely sequelae?
○ Spontaneous resolution

● Red lesion on sun exposed spots (Face, back) lesions with “rough sandpaper
appearance/ texture; bad rough spot”
○ What is it?
■ Actinic keratosis
● Precursor to?
○ Squamous cell carcinoma
● Treatment
○ Topical agent (5-FU)
○ Imiquimod
● Biggest RF for skin cancer -> sun exposure
○ UV-A vs. UV-B light
■ UVB light is worse
● Thymidine-thymidine dimers form
● Primary preventive strategy for skin cancer?
○ Use clothes that will protect you from the sun
■ Pick sunscreen if there is no answer choice that gives you sun
protective clothing or sun avoidance

● Pt was rescued from a fire. Has healed over time with plastic surgery. On his scalp
there are lesions that haven’t resolved. Have been slowly evolving.
○ Dx
■ Squamous cell cancer (usually bottom lip, but you can get it anywhere
- like the scalp, ear, and neck)

● Pt has a red nodule that has continued quickly growing over time, and looks like a
volcano. Contains a lot of keratin, debris at the center. Looks like it’s going to erupt.
○ Dx
■ Keratoacanthoma
○ Treatment
■ Excision of lesion
○ Keratin indicates what?
■ Squamous malignancy

● Pink pearly, translucent lesions with telangiectasias on upper lip

○ Dx
■ Basal cell carcinoma
○ Spread?
■ Likes to spread horizontally
■ Very rapidly destructive
○ Treatment
■ Resection
■ Sometimes Mohs surgery (same as micrograph surgery)

● Pt with a lesion on skin with many different colors (black, brown), which is not round
or oval, more irregular borders
○ Dx
■ Melanoma
● Criteria
○ Asymmetry
○ Borders - irregular
○ Color variation (brown, red, black, blue)
○ Diameter - > 6mm we get worried
○ Evolution - changing over time

● Pt with a history of dysplastic nevus.

 ○ Risk factor for melanoma
○ Looks a lot like melanoma.
■ Dysplasia leads to cancer

● Pt with a family history of melanoma. With a ton of dysplastic nevi.

○ Dx
■ Familial melanoma dysplastic syndrome
● Inheritance
○ Autosomal Dominant

● Melanoma
○ Different types
■ Nodular
● Worse prognosis
■ Acral lentiginous
● African american with melanoma under nail bed
● Not as bad prognosis as nodular
■ Lentigo maligna
● Pt has a melanoma that is on the face, upper-trunk, prominently
exposed to sun
■ Superficial spreading melanoma
● Best prognosis
● Shows up on back in men. Legs in women.
● Good prognosis
○ Treatment
■ Complete excision
■ More than 1 mm thick, send a sentinel lymph node biopsy
■ Prognosis
● Breslow depth/thickness

● Pt sat on couch and has been itching with wheeling of skin

○ Treatment
■ Antihistamine

● Pt with angioedema do NOT have hives!

● What is the most common medication that people report an allergy to?
○ Penicillin
■ If they try to test patient on allergy
● Do skin testing (not RAS(?) or ELIZA test)
■ Pt with anaphylaxis?
● Anti-staph, cephalosporins should be avoided
 ● Pt. is a 6 y/o male with lyme disease. Given doxycycline (or adult that gets treated
for syphilis, lyme disease) develops fever, headache, myalgia, malaise, sweating,
headache, hypotensive
○ Dx
■ Jarisch-Herxheimer reaction
● Treponema pallidum or borrelia etc. when you treat spirochetes
they will explode and release endotoxins (penicillins are cell
wall inhibitors)
● Resolves quickly
● Supportive care
● Continue antibiotic
● Not an allergic reaction

● Pt recently took TMP-SMX for cystitis. Last two days the patient has an edematous
face. Generalized skin reaction. Person AST/ALT and eosinophil elevated, elev.
Lymphocytes and generalized lymphadenopathy
○ Dx
■ Hypersensitivity syndrome (Type IV)
■ Dress Syndrome (same thing)
■ Treatment
● IVIG

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Ep. 304 Floridly HY Trauma/Ortho Podcast Part 2
High-speed MVC + BP is 60 mmHg over palpable + widened mediastinum --> aortic transection
(ligamentum arteriosum torn)
Next best step? Surgery exploration
Pathophys? Bleeding into thoracic cavity
NOTE: pt can have trouble speaking d/t left laryngeal nerve

Chronic HTN + widened mediastinum + left pleural effusion--> aortic dissection

A/w RCA infarct--> ST elevations II, III, avF

Government agency worker + works with sheep or in textile factory + widened mediastinum --> anthrax

Medical pathologies a/w aortic dissection

Connective tissue diseases (e.g., EDS)
Tertiary syphilis
Vaso vasorum supplies the walls of aorta

Child, high speed MVA--> most likely struck on RIGHT side

 USA- driving on RIGHT
Waddell's Triad: femoral shaft fracture + intra-abdominal or thoracic injury + contralateral head
injury
Child will be struck by bumper--> child thrown on hood of car (causes intra-abdominal/thoracic
injury), bouncing off the hood leads to head being hit (contralateral head injury)
First: Non-contrast CT to see any bleeding

Penetrating injury (e.g., gunshot wound)--> what do you do?

Perform surgical exploration

Stab injury--> potential to form arterio-venous fistulas

Long term: high output heart failure
Pathophys? Fistula creations causes blood to go from artery to vein (cutting off arterioles
(resistance vessels!) and capillaries); SVR goes down, CO goes up
Causes tissue hypoxia
At baseline, the CO is going to be high (all the time)- heart is working hard--> will begin to
decompensate (demand ischemia)

Pt with high output CF; MVO2 will be increased (same as in septic shock, also a potential cause of high
output CF)
Oxygen tension of blood returning to right atrium (MVO2) is higher
Refer Episode 273 for more info on this

Severe trauma--> mistakenly cut off finger/other appendage

Next best step: wrap in moist gauze, put in plastic bag, and put bag on ice
NOTE: for teeth, don’t scrub it because it will de-mineralize, rather, you can put it in milk

Trauma/MVA--> on PE has upper spinal tenderness or weakness

Worry about C-spine problems
Next best step: cervical collar + lateral neck X ray (pick this first before CT in answer choices)

Intubations
Classic indications for intubations?
GCS < 8
Gurgling sounds on auscultation
Expanding hematoma in neck

Pt with intubation few mins ago + becomes hypoxic, O2 not rising appropriately + worsening abdominal
rigidity and diameter
Think: Esophageal intubation
Confirm with CXR
Next best step: take out and re-intubate
Pt with 3 day old intubation + ventilator alarm triggered + higher than normal pressure + CXR: left white
out lung
Think: right main stem bronchus intubation (left main bronchus is wider, shorter, more vertical)
Biggest risk factor: emergency intubation
CXR LEFT side because atelectasis--> air not flowing to left side; blood is still flowing to left, which
will reabsorb all the gas in left lung, but it is not replenished--> resorption atelectasis
Compression atelectasis?
Pneumothorax
Pleural effusion

Intubation + After few mins, harder to intubate + Leukocytosis, hyperkalemia

Think: Malignant hyperthermia
A/w with genetic mutation in dihydropyridine/ ryanodine receptors (ryanodine more
common)
Autosomal dominant
Tx: Dantrolene (prevents Ca2+ from being released from sarcoplasmic reticulum)
Sedate first before neuromuscular blockade
Key associations:
Hyperkalemia
Do:
Cardiac monitor
Calcium gluconate
Insulin with glucose
AKI
Do:
Aggressive hydration

If you are having trouble with intubation after multiple attempts + unsuccessful
Next best step: perform cricothyroidotomy (surgical airway)

Intubated for 2-3 weeks + mild resp difficulty several months later + auscultation of chest= stridor
Think: tracheal stenosis
Biggest risk factor: prolonged intubation

Pt has penetrating injury/ stab injury--> what do you do with the penetrating object?
DO NOT pull out
Remove in controlled conditions (e.g., theater)

When should you NEVER send a pt for CT?

-Unstable pt
Bone vascular nerve
Pt with trauma involved in accident --> extremities involved, bone dislocation/fracture/etc.--> XYZ pulse
not palpable, no sensation in area
Always fix the BONE problem FIRST
Quickly done (reduce dislocation, etc.)
Vascular second
Nerve third
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Ep. 305 Upper Limbs Rapid Review 1

Clinical contexts & Clinical Scenarios for upper limb anatomy

Only bony bony connection between AXIAL and APPENDICULAR skeleton?

Clavicle (manubrium of sternum to Acromion of Scapula)

Person with ROTATOR cuff tear, most commonly torn Tendon?

Supraspinatus

Contents of rotator Cuff: SITS

Supraspinatus, Infraspinatus, Teres minor, Subscapularis

Patient with hypertrophy of certain NECK muscles + Brachial plexus symptoms

Anterior and Middle Scalene muscles affected

Patient is unable to extend wrist (wrist drop): Radial Nerve Injury

Radial nerve injury in Borderline Personality Disorder patients who slash their wrists; Lead
Poisoning —> neuropathy

Nerve that innervates ANTERIOR compartment of arm(shoulder to elbow)?

MUSCULOCUTANEOUS nerve

3 HY muscles innervated by musculocutaneous: BBC

Biceps, Brachioradialis, Coracobracialis

Cord of Brachial Plexus that creates Musculocutaneous nerve? LATERAL cord

Nerve that innervates the POSTERIOR compartment of the arm (extension work)? RADIAL
nerve

Anterior/Posterior; Flexion/Extension; MR (musculocutaneous/radial)

Anconeus muscle: Innervated by Radial nerve

Triceps muscle: innervated by Radial Nerve
Blood supply from Subclavian artery to Ulnar artery:
Subclavian artery —> Axillary Artery (lateral border of rib 1) —>Axillary Artery (inferior border of
teres major muscle) —> Brachial Artery —> Radial and Ulnar Artery

HY blood vessel that travels with radial Nerve: Deep Brachial Artery (Profunda Brachii)

Cord of brachial plexus supplied by Axillary nerve? POSTERIOR cord

Other nerve supplied by the posterior cord? Radial Nerve

Cords of brachial plexus that supply the MEDIAN nerve? Lateral and Medial Cord

Cord of brachial plexus that supplies ULNAR nerve? Medial Cord

Nerve and Artery associated with fracture of surgical neck of Humerus?

Axillary Nerve + Posterior Circumflex Humeral Artery

Injury of Axillary Nerve: ANTERIOR shoulder dislocation

Most common type of shoulder dislocation? Anterior

Point of weakness: Move down & forward —> Anterior

Causes of POSTERIOR shoulder dislocation? Electricity

Struck by lightning, Seizures, Electrocution

Nerve and Artery associated with a SPIRAL/midshaft fracture of humerus?

Radial Nerve + Profunda Brachii Artery

Nerve and Artery associated with a supracondylar fracture of humerus?

Median Nerve + Brachial Artery

Breast surgery/mastectomy patient with bulges on upper part of back? Winged scapula
Common complication of breast surgery —> Long thoracic nerve palsy

Long thoracic nerve supplies serratus anterior muscle

SALT: Serratus Anterior, Long Thoracic

Arm Abduction
0-15 degrees: Supraspinatus Muscle (Rotator cuff injury —> difficulty initiating abduction;
empty can test/NEER test)
15-90 degrees: Deltoid Muscle (Issue with Axillary nerve prevents abduction to 90)

Boundaries of Quadrangular spac (Transmits Axillary nerve and Posterior Circumflex Humeral
Artery)
 Superior Border: Subscapularis & Teres Minor Muscle
Inferior Border: Teres Major Muscle
Medial Border: Long head of Triceps Brachii
Lateral Border: Surgical neck of Humerus

Key high yield spaces Bordered by triceps (Quadrangular space, Triangular space, Triangular
interval)

Most common type of shoulder dislocation? ANTERIOR (90% of shoulder dislocations)

Most parts of shoulder joint are held by ROTATOR CUFF (inadequate reinforcement for anterior
shoulder joint)

Key anastamoses:
Scapular Circumflex Artery <—> Suprascapular Artery (Blood supply to Supraspinatus &
infraspinatus muscles)

Subclavian Artery —> Thyrocervical Trunk —> Suprascapular Artery (crosses over the top of
scapula; supply supraspinatus and infraspinatus muscles)

Muscle that does MOST things for the arm? Deltoid Muscle
FEAR (Flexion, Extension, Abduction, Rotation-medial & lateral)

Blood and Nerve Supply of Deltoid Muscle?

Axillary Nerve & Posterior Circumflex Humeral Artery

Muscle that ADducts and medially rotates arm? TERES MAJOR

Supplied by lower Subscapular nerve

Nerve Supply of Teres Minor? Axillary Nerve

ADT: Axillary nerve supplies Deltoid Teres minor

Muscle that laterally rotates the arm innervated by Suprascapular nerve? Infraspinatus Muscle

Teres minor laterally rotates arm, innervated by Axillary nerve

Lateral arm rotators: DIT (Deltoid, Infraspinatus, Teres minor)

Muscle that medially rotates arm and ADducts arm: Subscapularis

Innervated by upper and lower Subscapular nerves

Deltoids ABduct arm and medially rotate (vs Subscapularis ADduct arm and medially rotate)
Innervated by Axillary nerve

Nerve supply of Pectoralis Major? Medial and Lateral Pectoral Nerves

 Radical Mastectomy —> injure these nerves

3 HY Humeral functions of Pectoralis Major?

Flexion, ADduction, and Medial rotation Humerus (FAM)

Muscle that depresses and protracts scapula: Pectoralis Minor

Supplied by Medial Pectoral Nerve

Blood and Nerve supply of Serratus Anterior (SALT)?

Long Thoracic Nerve & Lateral Thoracic Artery

2 HY flexors at shoulder joint? Deltoid & Pectoralis Major

3HY extensors at the shoulder joint? Deltoid, Teres Major, Latismus Dorsii

3 HY Adductors at shoulder joint? Pectoralis Major, Teres Major, Latismus Dorsii

2 HY abductors at the shoulder joint? Supraspinatus, Deltoid

5 HY medial rotators at shoulder joint? Pectoralis, Teres Major, Latismus Dorsii, Deltoid,
Subscapularis

3 HY lateral rotators at Shoulder Joint? DIT: Deltoid, Infraspinatus, Teres Minor

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Ep 310 Floridly HY Knee Exam and Pathologies

1. 1st inspect (look 1st)

2. 2nd Palpate (feel 2nd)
3. 3rd ROM (move 3rd)

4. VaLgus test
a. Lie supine
b. Flex knee 20 degrees (creating small triangle under knee)
c. Apply LATERAL force to test MCL
i. If a lot of displacement --> rupture or torn MCL
d.
5. Valgus vs Varus Test
6. ACL
a. Suddenly slow down while running & smashes lateral aspect of knee
b. Ant Drawer sign- tibia moves anteriorly a lot compared to unaffected knee

c. Lachman test – flex knee 20 degrees

i. If both ant drawer sign & lachman given as ans choices= pick LACHMAN
(more sensitive)
d. 2 HY things about ACL tears
i. Usually a/w fracture of lateral tibial plateau
ii. If pt has meniscal tears --> need to assess for ACL tear

7. PCL
a. If tibial dislocation posteriorly
b. Post Drawer sign – tibia moves posteriorly a lot relative to femur

8. Meniscal tears
a. “clicking/catching/locking of knees” + joint line tenderness (medial or lateral)
b. McMurray test for LATERAL meniscus
1. Positive if click/pop/catch at joint line
ii. Lie supine (on back)
iii. Put knees in 90 degree flexion
iv. Use 1 hand to support ant knee- thumb on medial joint line; index on
lateral joint line
v. Other hand on pt heel/foot
1. Apply VARUS (medial) force for Lateral meniscus (VIRUS)
a. VIRUS for lateral = vaRus force (medial) IR= internal
rotation
2. Apply VALGUS (lateral) force for Medial meniscus
 c. Apley compression test
i. Place prone & flex knee 90 degrees
ii. One hand- stabilize hit
iii. Other hand-grasp feet & compress foot downward 🡪 then internally &
externally rotate legs
iv. Positive=a lot of pain

v.

vi.

9. Plumber or gardener pain/redness/swelling RIGHT in front of patella

a. Prepatellar bursitis
i. TX- aspirate & drain

10. Playing sports & heard popping sound, now cant straighten (extend) knee. Pain,swelling,
palpable defect along superior patella
a. Quadriceps rupture
 11. BELOW INFERIOR BORDER OF PATELLA
a. Tenderness at medial joint line
i. MCL or medial meniscal tear
b. Tenderness in middle of medial joint line & Tibial tuberosity
i. Pes Anserine bursitis
c. Tenderness over tibial tubercle (tuberosity)
i. Osgood Schlatter AKA traction apophysitis
d. Tenderness at lateral joint line
i. Lateral meniscal OR Lateral collateral ligament tear

12. ABOVE patella

a. Tenderness At lateral femoral condyle
i. Iliotibial band syndrome

13. BACK of patella

a. Pain, swelling behind knee (popliteal fossa)
i. Bakers cyst

14. How do you assess for effusion in knee?

a. “Milking technique” – go to medial portion of knee joint &
milk from bottom to top, then milk laterally top to bottom
i. If medial bulge= knee joint effusion

15. Clarks Test

a. Straighten legs & ask pts to contract quadriceps (tighten thighs), then you press
superior pole of patella to prevent from moving
i. If A LOT of pain while doing this= positive test
b. Patello-femoral pain syndrome

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Ep. 411 Clutch Sarcoidosis Podcast
​Sarcoidosis: Classic disease that affects many different body systems
Granulomatous lung disorder

Granulomas: Usually non-caseating granulomas

Hallmark of granuloma: Giant Cells (Epithelioid macrophages)

Main organ affected by sarcoidosis: Lungs

90% of patients will have lung involvement
Long term lung damage by sarcoidosis --> Interstitial Lung Disease (restrictive pattern on
PFTs; compliance decreased, elastance increased, reduced lung volumes with a Normal
to Elevated FEV1/FVC ratio) --> may lead to pulmonary hypertension over time
nd
2 most commonly affected organ by sarcoidosis: SKIN

Patient presentation of sarcoidosis: Lymphadenopathy, dry cough, fatigue, shortness of breath,

joint pain. Dry crackles on lung exam.

Lofgren Syndrome TRIAD: Bilateral lymphadenopathy, Arthritis (knees, ankles), Erythema

Nodosum
GOOD PROGNOSIS/OUTCOME

Labs?
Hypercalcemia (due to epithelial macrophages in giant cells of granulomas expressing
1-alpha hydroxylase --> make a lot of 1,25-dihydroxyvitamin D (calcitriol) from
25-hydroxyvitamin D (calcidiol)--> excess reabsorption of calcium in the gut)
PTH NORMAL

Treatment? Not much

Mild symptoms --> no treatment
Severe symptoms: Steroids (1st line), Methotrexate/Azathioprine (2nd line if steroids not
working)

MOA of methotrexate: Dihydrofolate Reductase inhibitor

Side effects: Hepatotoxic, Pulmonary Fibrosis

Most likely outcome for a patient with sarcoidosis? Resolution without recurrence
 Remission most likely occurs (<5% will have a recurrence)

Geographic/Ethnic association: Very common in the African American population

Also very common in Scandinavian population
Women more likely than men to have sarcoidosis

Dermatologic Findings common in sarcoidosis

Erythema Nodosum: Usually involves lower extremities (red, tender lesion)

Common in Lofgren Syndrome
vs. Lupus Pernio: Raised purple lesion in a “lupoid” distribution (cheeks, nose forehead)
Predictor of POOR outcome for sarcoidosis patient
vs.
Granuloma Annulare: Ring like distribution of bumps, typically affecting the hands and
the feet
Dermatologic findings will usually resolve in 2-4 weeks
How to treat (if pharmacologic treatment option)? Hydroxychloroquine

Side effects of Hydroxychloroquine: Retina issues

Cardiac Sarcoidosis: Conduction issues, Aneurysmal like dilation of ventricles

Granulomas within the walls of the heart
Restrictive pattern of heart disease (restrictive cardiomyopathy)

Eye involvement in Sarcoidosis: Uveitis

CNS involvement: Bilateral Bell’s Palsy

CN VII Problem
Sensory Neuropathy
Sarcoidosis can present as a central Diabetes Insipidus
Granulomas deposit in brain damaging neurons that produce ADH
Dx: ADH/Desmopressin administration will INCREASE urine osmolarity (not an issue of
kidneys NOT responding to ADH)

Sarcoidosis patients have liver granulomas (usually asymptomatic)

If symptomatic liver granulomas: use Ursodiol

Uses of Ursodiol/Urosdeoxycholic acid: Sarcoidosis liver granulomas (if symptomatic), PBC (Dx:
anti-mitochondrial antibodies), intrahepatic cholestasis of pregnancy

Sarcoidosis patients will have unreliable PPD skin test (false positive)

Tay-Sachs Disease: common in Ashkenazi Jewish population AND Cajun population of Louisiana,
French-Canadian populations
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