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Skin infections and ulcers are common presentations to general practice, have a go at this set of questions and follow it up with part 2!

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Skin infections and ulcers- Part 1

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Question 1

Stem 1, question 1 of 5

Mildred, 86 year old female, present to her GP with a leg ulcer. The symmetrical and well defined ulcer is on the dorsum of the right foot and is very painful especially at night. Mildred takes ramipril, simvastatin, clopidogrel and sitagliptin.

What type of ulcer is this?
A
Venous ulcer
B
Arterial ulcer
C
Neuropathic ulcer
D
Infective ulcer
E
Pressure ulcer
Question 1 Explanation: 
There are three types of ulcers: arterial, neuropathic and venous. Arterial ulcers are due to an inadequate blood supply due to ischaemia and are often found on the lower legs and dorsum of feet. They are painful, especially at night that are symmetrical with well defined borders. The surrounding skin is cool, pale and bluish with minimal bleeding when knocked.
Question 2

Stem 1, question 2 of 5

On examination, the GP notices an ulcer with a punched out appearance on the plantar surface of Mildred's foot. Mildred states she didn't know anything was there. What type of ulcer is this likely to be?
A
Venous ulcer
B
Arterial ulcer
C
Infective ulcer
D
Neuropathic ulcer
E
Pressure ulcer
Question 2 Explanation: 
Neuropathic ulcers are painless ulcers over areas of abnormal pressure and can develop with any condition of peripheral neuropathy due to a loss of protective sensation, leading to repetitive stress and unnoticed injuries. Mildred has two key risk factors: Diabetes mellitus and concurrent peripheral vascular disease, which is shown by her medications.
Question 3

Stem 1, question 3 of 5

Which of the following is not an examination finding of venous ulcers?
A
Lower limb oedema
B
Hair loss
C
Venous insufficiency
D
Thrombophlebitis
E
Ulcers in the gaiter region
Question 3 Explanation: 
Venous ulcers are the most common cause of ulcers, resulting in 60-80% of all ulcers. Hair loss is an examination finding of arterial ulcers, whereas all the other answer options are possible exam findings in venous ulcers.
Question 4

Stem 1, question 4 of 5

What causes venous ulcers?
A
Chronic insufficiency caused by hypertension and atherosclerosis
B
Inadequate blood supply to the limb due to ischaemia
C
Localised injury to skin over a bony prominence as a result of pressure and/or shear stress
D
Loss of protective sensation leading to repetitive stress and unnoticed injuries
E
Chronic venous insufficiency due to venous valve incompetence or impaired calf muscle pump
Question 4 Explanation: 
As the name suggest venous ulcers are caused by venous insufficiency. This leads to sustained venous hypertension which damages the valves thus blood pools in the tissues and furthers the high pressure.
Question 5

Stem 1, question 5 of 5

Pressure sores are preventable injuries to the skin as a result of pressure and/or shear forces. Which of the following are risk factors for pressure sore development? Select all that apply 
A
Immobility
B
Surgery
C
Intensive care stay
D
Malnourishment
E
Sensory impairment
Question 5 Explanation: 
Surprise! All of these are risk factors for the development of pressure sores! It is really important to address these with the use of pressure relieving tools, regular reposition, nutritional support and stopping shear forces.
Question 6

Stem 2, question 1 of 5

Keira, an 8 year old female, is brought into GP by her Mother with an elevated, round, hyperkeratotic skin papule with a rough grey-white surface on her knee.

What is the causative pathogen of this skin infection?
A
Molluscum contagiosa
B
Human papilloma virus
C
Herpes simplex virus
D
Staphylococcus aureus
E
Tinea
Question 6 Explanation: 
Verrucae vulgaris or viral warts are being described here. These are common in children and young adults. The human papilloma virus infects the keratinocytes and leads to koilocytosis and proliferation.
Question 7

Stem 2, question 2 of 5

What is the management of viral warts?
A
Curettage
B
Debridement and salicylic acid
C
Oral acyclovir
D
Calamine lotion
E
Topical mupirocin
Question 7 Explanation: 
The aim of viral wart treatment is to eradicate the lesion and induce some degree of immunity against human papilloma virus to prevent recurrence, there is no cure for common warts. BMJ best practice has a good resource here: https://bestpractice.bmj.com/topics/en-gb/615/management-approach
Question 8

Stem 2, question 3 of 5

12 months later Keira returns with clusters of small round papules that appear umbilicated. The papule are in the left axilla with some associated dermatitis.

What is the most likely diagnosis?
A
Cellulitis
B
Candidiasis
C
Pityriasis veriscolor
D
Molluscum contagiosum
E
Viral warts
Question 8 Explanation: 
The condition being described here is molluscum contagiosum which is a common viral skin infection of childhood causing localised clusters of epidermal papules called Mollusca. It is caused by a poxvirus and frequently induces dermatitis around them.
Question 9

Stem 2, question 4 of 5

Keira's parents ask if she can still attend school. What advice should be given?
A
The individual is infectious while active and so should not attend schools, work or daycare
B
The individual is not infectious and so can attend all normal activities
C
The individual is not infectious but should remain at home until all lesions have cleared.
D
The individual is infectious while active but can still attend daycare, school and work
E
The individual is highly infectious and no sharing of any personal effects should occur.
Question 9 Explanation: 
The individual is infectious while active but transmission can be used by washing hands, covering all visible lesions and not sharing of towels, clothing etc. The individual is able to attend normal activities as the papaules may persist for 2 years. DermNet NZ has a great resource: https://dermnetnz.org/topics/molluscum-contagiosum/
Question 10

Stem 2, question 5 of 5

Which of the following is NOT a risk factor for Molluscum Contagiosum?
A
Close contact with infected individual
B
HIV infection
C
Tropical climate
D
Swimming
E
>50 years
Question 10 Explanation: 
This infection mainly affects under 10 years old. Close contact, HIV infection, tropical climates and swimming are all risk factors for this condition.
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