[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;” margin_design_tab_text=””]

Your Role: you are the doctor on duty for the Acute Medical Unit.

You have 10-minutes with each patient. The Examiners will alert you when 6-minutes have elapsed and will stop you after 8-minutes.

In the remaining 2-minutes, one examiner will ask you to report on any abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not already clear from your discussion with the patient).

Scenario

Jessica (26-years)

GP Letter: Please see this young woman who has been complaining of a lesion in her left leg.

Please advise on how to investigate and manage

Physiological observations

Respiratory rate / minute: 16

Pulse rate / minute: 78

Systolic blood pressure (mmHg): 128

Diastolic blood pressure (mmHg): 80

Oxygen saturations (%): 98

Temperature: 36.4°

Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical examination. You do not need to complete the history before carrying out an appropriate examination.

Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for investigation and treatment where appropriate. Respond directly to any specific questions which the patient may have.

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/202968116″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”8″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”2″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This lady has a left leg erythematous papules that have coalesced into atrophic telangiectatic plaques.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Necrobiosis lipoidica (NL) is an uncommon, chronic granulomatous disease that is associated with diabetes mellitus (DM), but not with poorly controlled DM.

The aetiology and pathogenesis of NL is still unclear, but there is a widely accepted theory that microangiopathy resulting from glycoprotein deposition in blood vessel walls. is a significant component of the pathophysiology.

NL has a female predominance to males and occurs most frequently in young adulthood or middle-age.

NL typically manifests with erythematous papules on the anterior of the shins, that may or may not unite into atrophic telangiectatic plaques. NL is most commonly a clinical diagnosis rather than histological one – however, in diagnostic uncertainty, skin biopsy will provide the answer. Differential diagnoses include sarcoidosis, necrobiotic xanthogranuloma, and granuloma annulare. They are usually painless, but can become very painful if they ulcerate, which primarily occurs from trauma to the affected area. A rare, but important complication is squamous cell carcinoma which needs to be monitored for.

In this case, there is also an issue of generally poorly controlled DM. In this quick consultation, it is not possible to fully explore all of the issues and address them. As such, it is appropriate to indicate that this will require ongoing assessment and management.

Management of the condition is primarily to prevent ulceration (and trauma). Topical or intralesional steroids can be applied to the active edge – however, if applied to the central area of atrophy, this can exacerbate the lesion. A number of different types of treatments have been advocated, including intravenous steroids, oral steroids, topical calcineurin inhibitors, anti-TNF agents, thalidomide, anti-malarials and pioglitazone among many others.

It is still a challenging condition to manage and many young people are troubled with the aesthetic implications.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]This young lady has poorly controlled diabetes and has the complication of necrobiosis lipoidica. Her main concern is regarding the physical deformity this has caused on her skin. I will prescribe a steroid cream as well as emollients and have advised about prevention of ulceration. In addition, I have briefly advised about the importance of glycaemic control, however, I believe this needs to be addressed further at another consultation and ongoing support as she is at risk of significant complications.[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]