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