Transcript Phase 2 - Dermatology 2014 (11)

For Phase 2
Katie Knappett
Phase 3B
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Topics
• Dermatology
– Eczema
– Psoriasis
– Skin Cancers
• Medical Ethics and Law
• Poisoning
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Eczema
• Eczema / Dermatitis
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Atopic
Discoid
Seborrhoeic
Venous
Contact Dermatitis
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Atopic Eczema
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Young children
Often resolves with age
FH of atopy
Asthma / Allergic Rhinitis
Increased IgE
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Atopic Eczema
Clinical Features
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Itchy
Erythematous
Scaly
Flexural pattern
Weeping / Exudative
Nailbed involvement (pitting/ridging)
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Atopic Eczema
Complications
• Staph aureus infection
• HSV infection (Eczema Herpeticum)
Investigations
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Clinical diagnosis
↑ serum IgE
Eosinophilia in differential WCC
RAST (RadioAllergoSorbent Test)
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Atopic Eczema
Treatment
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Education – irritant avoidance
Emollients, bath oils, soap substitutes, bandaging
Topical therapies: steroids, immunomodulators
Adjunct therapies: oral abx, sedating antihistamines
Severe eczema: immunosuppression
• Everyday Rx vs. acute flare Rx
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Discoid Eczema
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Well demarcated scaly patches
Esp on limbs
DDx: Psoriasis
Commoner in adults
Often infective component (s.aureus)
Rx: emollients, topical steroids, antihistamines
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Seborrhoeic Eczema
• Fungal infection
• Yeast overgrowth (Malassezia furfur)
• Childhood – “Cradle cap”
– Yellowish, greasy thick crusts on scalp
– Revolves
• Young adults (>males)
– Erythematous nasolabial folds. Dandruff. May also affect
eyebrows, eyes, axillae, groin & glans penis
• Elderly
– Can be more severe and involve large areas of body
– Erythroderma
Seborrhoeic Eczema
Treatment
• Suppressive, not curative
• Mild steroid (e.g. 1% Hydrocortisone)
• Antifungal cream (e.g. miconazole)
• Emollients/soap substitutes/ketoconazole
shampoo
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Venous Eczema
• Aka varicose / gravitational
• Chronic venous hypertension
– Endothelial hyperplasia
– Extravasation of RBC/WBC
– Inflammation, purpura, pigmentation
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Venous Eczema
Clinical Features
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Older people (>women)
Lower legs/ankles
PMH: VTE, Venous ulcers, varicose veins
Brown pigmentation (haemosiderin)
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Venous Eczema
Treatment
• Emollients
• Moderate potency topical steroid
• Support stockings / compression bandages /
leg elevation
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Contact Dermatitis
• Dermatitis precipitated by an exogenous agent
• Irritants not allergens
• Fluids, abrasives, chemicals, solvents, soaps
Clinical Presentation
- Hands and Face
- Occupation / hobbies
- Nickel sensitivity most common (10% F; 1% M)
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Contact Dermatitis
Management
• Trigger identification and avoidance
• PPE
• Barrier creams
• Topical steroids
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Psoriasis
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Psoriasis
• Well-demarcated red scaly plaques
• Inflammation and hyperproliferation of skin
• 10x normal proliferation rate
• 2 peaks of onset
– Early (age 16-22) associated with +ve FH
– Late (age 55-60)
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Psoriasis
Aetiology
• Polygenic
• Environmental factors
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Infection (Group A Strep)
Drugs (e.g. Lithium)
UV Light
Alcohol abuse
Stress
• T-Lymphocyte driven disorder
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Psoriasis
Pathogenesis
Thickened epidermis ; Keratin build up at horny layer ; Rete ridges
are elongated ; Polymorphs infiltrate into stratum corneum ; Dilated
capillaries ; T-lymphocyte infiltration
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Psoriasis
Chronic Plaque Psoriasis
• Most common
•Well-defined red plaques with
a silver scale
• Extensor surfaces
• Sites of trauma e.g. Surgical
scars – Koebner Phenomenon
• Itchy / Sore
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Psoriasis
Guttate Psoriasis
• Guttate = “rain drop”
• Acute, symmetrical
erruption 2 weeks poststrep throat
• Young adults
• Usually trunk/limbs
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Psoriasis
Flexural Psoriasis
• Well-demarcated red
glazed plaques in flexures
e.g. groin, natal cleft,
sub-mammary
• Older patients
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Psoriasis
Nail Changes
• Onycholysis
• Pitting
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Psoriasis
Complications
• Psoriatic arthropathy
• Erythroderma
• Koebner Phenomenon
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Psoriasis
Treatment
• Long-term therapy required
Topical Therapies:
- Vit D Analogues
- Topical Corticosteroids
- Coal tar preparations
- Dithranol
Systemic Therapies:
- Methotrexate
- Retinoids
- Ciclosporin
- Biological agents
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Skin Cancers
Basal Cell Carcinoma
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“Rodent ulcer”
Sun exposure – found on exposed areas
Pearly nodule, slow-growing
Non-healing ulcertion
Do not metastasise
LOCALLY INVASIVE
Need surgical excision
Radiotherapy/Cryotherapy
Follow up
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Skin Cancers
Squamous Cell Carcinoma
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More aggressive than BCC
Will metastasize if untreated
Sun exposure
Immunosuppression
Keratotic ill-defined nodules
Ulcerated with hard, raised edges
Examine LN
Surgical excision
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Skin Cancers
Malignant Melanoma
• Metastasizes early
• Most serious form
• Risk Factors
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Sun exposure
Pale skin
Immunosuppression
FH
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Skin Cancers
Malignant Melanoma
ABCDE Criteria
A – Asymmetry
B – Border irregularity
C – Colour variegation
D – Diameter >6mm
E - Elevation
Glasgow 7-point Checklist
Major Criteria:
- Change in size
- Change in shape
- Change in colour
Minor Criteria:
- Diameter >6mm
- Inflammation
- Oozing/Bleeding
- Itch/altered sensation
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Skin Cancers
Malignant Melanoma
>1mm thick, refer to MDT
Surgery – Wide excision with good margins
Sentineal node biopsy
Metastatic disease – LN excision, Radiotherapy,
Chemotherapy.
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Medical Ethics and Law
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4 principles
Moral foundations
Negligence
Confidentiality
Consent
Capacity
The Doctor-Patient Relationship
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Obligations and Duties
• Foundation of medical ethics is the Four
Ethical Principles
– Autonomy
– Beneficence
– Non-Maleficence
– Justice
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Moral Foundations
DUTY
CONSEQUENCES
MORAL CHARACTER
We owe a duty to one
another
Consider ends, not
means
May end up telling the
truth without
considering the
consequences
? Can you always tell what the
consequence will be
With the right character,
the best actions and
outcomes will
necessarily flow
Some actions are evidently
wrong even if the
consequences are great
Characteristics which promote
human flourishing (patience,
kindness, compassion, courage)
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Negligence
“Harm caused by carelessness; not intentional
harm”
•How is it decided if one has been negligent in
their actions?
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Negligence
1. Is there a duty of care?
2. Was there a breach in that duty?
3. Did the patient come to any harm?
4. Did the breach cause the harm?
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Negligence
• Bolam [1957]
– If a doctor reaches the standard of a responsible
body of medical opinion, he is not negligent
• Bolitho [1997]
– A judge can choose between differing bodies of
professional opinion and can reject any opinion if
it is ‘logically indefensible’
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Negligence
Was there a breach?
– Are your actions supported by others?
– Would a group of reasonable doctors do the
same? (Bolam Test)
– Would it be reasonable of them to do so? (Bolitho
Test)
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Confidentiality
• GMC Guidelines [2009]
• Confidentiality is an important duty but it is
not absolute
• When can confidentiality be broken by a
doctor?
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Confidentiality
• If it is required by law
– Notifiable diseases
– If ordered by a judge
– Ix of fitness to practice of a health professional
• If it is justified in the public interest
– Serious crime / terrorism
– If the benefits to an individual/society outweigh
the interest of maintaining confideniality
• If the patient has consented
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Confidentiality
• If releasing any information, always attempt to
obtain consent from the patient if practicable
• You CAN go against a patient’s withheld
consent if necessary.
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Consent
• Patients must consent to ANY BODILY
CONTACT else you could be vulnerable to legal
action (Assault & Battery)
• “Doctrine of necessity”
– Emergency situations where it is not possible to
gain consent
– Physician has a higher duty to save life
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Consent
Valid Consent
Patient must:
- Have capacity
- Be acting voluntarily (free from coercion,
constraint or deceit)
- Be aware of what they are consenting to
The action must also be “consistent with public policy”
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Consent
Forms of Consent
• Express consent: Verbal/Non-Verbal but clearly
stated
• Implied Consent: not expressly granted but inferred
from the person’s actions
• Informed consent: A legal process
• Advance decisions: made by a capable adult about
the future if they were to lose capacity
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Consent
Advance Decisions
May be withdrawn / altered at any time
Must be valid
- In writing
- Signed
- Witnessed
- Include express statement that it should
stand even if life is at risk
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Capacity
“The ability to make decisions about one’s life”
-From simple decisions to major ones
-Assessment of capacity is DECISION SPECIFIC
and is for that particular moment in time.
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Capacity
Mental Capacity Act [2005]
5 principles:
• Presumption of capacity
• Maximise decision-making capacity
• Unwise decisions
• Best interests
• Least restrictive alternative
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Capacity
2 Stage Test
-Is there an impairment or disturbance in
functioning of a person’s mind or brain? If so..
-Has it made the person unable to make a
particular decision?
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Capacity
Mental Capacity Assessment
Should be done by the healthcare professional
proposing treatment
1st – do the 2 Stage Test
Then - MCA
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Mental Capacity Assessment
Can the patient:
•Understand the information
•Retain it
•Use / weigh up the information to make a
decision
•Communicate their decision
If the patient cannot perform any one part, they do not have
relevant capacity
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Capacity
So, a patient is deemed NOT to have capacity.
What now?
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Best Interests
• Decision of physicians (Bolam Standard)
– Consider if/when the patient may regain capacity
– Take into account what the patient would have
wanted, though this is not a legal obligation
– Discuss with family but remember
CONFIDENTIALITY
– Consider Lasting Power of Attorney
• Exceptions to best interests?
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Best Interests
Exceptions
• Advance directive refusing treatment
•Enrolment if incapacitated adults in certain
forms of research (pharmaceutical trials, clinical
trials)
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Consent / Capacity of <18s
Who can give consent for minors?
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Consent / Capacity of <18s
• A child who is 16/17 and has capacity as
determined by MCA
• A child under 16 who has “significant
understanding and intelligence” (GILLICK
COMPETENCE)
• Proxy – those with parental responsibility
though this must be in line with best interests
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Consent / Capacity of <18s
However
COMPETENT MINORS CANNOT REFUSE
TREATMENT
If someone who has parental responsibility has consented, a
minor can not override this by their refusal of consent.
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The Doctor-Patient Relationship
• Based on trust
– Confidentiality
– Best Interests
– Honesty
– Shared decision making
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The Doctor-Patient Relationship
Transactional Analysis
•Paternalistic – lack of autonomy
•Adult – Co-operative
•Child-like
Aim for cooperative adult discussion!
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Poisoning (by doctors!)
Adverse Drug Reactions
• Important
• Very common
– 10-95% of people starting a new drug will notice
new symptoms
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Poisoning
‘Type A’ – Anticipated ‘Type B’ – Bizarre
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Pharmacological
Dose-related
Preditable
Common
Usually not serious
Low mortality
Discovered before
marketing
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Idiosyncratic
Not dose-related
Unpredictable
Rare
Usually serious
High mortality
Discovered after
marketing
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Adverse Drug Reactions
• Mild
– No Rx required
• Moderate
– Marked Sx requiring treatment / hospitalization
• Severe
– Fatal / life threatening ; severe organ impairment
lasting >1 month
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Adverse Drug Reactions
Common ADRs
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Anticipated
Warfarin
Digoxin
Prednisolone
Antibiotics
Diuretics
Insulin
Aspirin
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Adverse Drug Reactions
Common ADRs
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Warfarin
Digoxin
Prednisolone
Antibiotics
Diuretics
Insulin
Aspirin
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Bleeding
Toxicity
Multiple S/E
Skin / Gut reactions
renal, gout
Hypoglycaemia
GI Bleeding
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Drug Safety
• Clinical Trials
• “Yellow Card” in BNF
– New drugs: report all suspected reactions,
however minor
– All drugs: report all serious suspected reactions
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Adverse Drug Reactions
– Warn patients about potential side effects
and then they are more likely to accept
them!
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THE END
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