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HASHMAT A. RAJPUT , MD . MSc . FACP.

HASHMAT A. RAJPUT , MD . MSc . FACP. DIPLOMAT AMERICAN BOARD OF INTERNAL MEDICINE ASSISTANT PROFESSOR OF CLINICAL MEDICINE NEW YORK MEDICAL COLLEGE SENIOR ATTENDING PHELPS MEMORIAL HOSPITAL CENTER. QUESTIONS ?. WHEN DID YOU NOTICE ? IS IT 1 ST . TIME OR HAD IT BEFORE?

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HASHMAT A. RAJPUT , MD . MSc . FACP.

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  1. HASHMAT A. RAJPUT , MD . MSc . FACP. DIPLOMAT AMERICAN BOARD OF INTERNAL MEDICINE ASSISTANT PROFESSOR OF CLINICAL MEDICINE NEW YORK MEDICAL COLLEGE SENIOR ATTENDING PHELPS MEMORIAL HOSPITAL CENTER

  2. QUESTIONS ? WHEN DID YOU NOTICE ? IS IT 1ST. TIME OR HAD IT BEFORE? HOW IT STARTED? ANY CHANGE BETTER, WORSE OR SAME? ANY PAIN, ITCHING , BLEEDING OR SWELLING? DID YOU TREAT IT? WITH WHAT? DID IT HELP? WHAT WERE YOU DOING? ANY THING NEW STARTED USING? ANY ALLERGY TO FOOD OR DRUGS? MEDICATIONS ON? ANY NEW MED? ANY CHRONIC CONDITIONS? TYPE OF WORK? ANY FAMILY OR FRIEND HAS IT? FAMILY HISTORY?

  3. BLISTERS

  4. CONTACT DERMATITISSUPERFICIAL SKIN INFLAMMATION RASH PAPULE,VESICLE, BLISTERS, ERYTHEMA, PRURITIS IRRITANT: 80%. NO PRIOR SENSITIZATION AND HAS IMMEDIATE REACTION TO EXPOSURE, MILD TO MODERATE. SOAPS, COSMETICS, DEODERANT, FORMALDEHYDE ALLERGENS: PRIOR EXPOSURE TO ANTIGEN. TYPE IV HYPERSENSITY REACTION. OCCURS IN 1-3 DAYS AFTER EXPOSURE ANTIBIOTICS, BENADRYL, THIMERASOL HEXACHLOROPHENE POISON IVY, SUMAC, OAK, RAGWEED, PRIMROSE NICKLE, CHROMIUM, MERCURY MASCARA, NAIL POLISH, DEODARANT DYE, RUBBER AND TANNING SHOES CHEMICALS

  5. SKIN PATCH TESTING RESULTS PATCH APPLICATION

  6. TREATMENT CONTACT DERMATITIS AVOID IRRITANTS & ALLERGENS PATCH TEST COOL COMPRESS 30 MINUTES 4-6X/DAY MILD CASE -HYDROCORTISONE CREAM 1%TID MODERATE CASE- FLUCINONIDE CREAM0.05% (LIDEX E CREAM) TID SEVERE CASE-TAPERING PREDNISONE STARTING 60MG/DAY WITH10MG Q3DAY FOR PRURITIS HYDROXYZINE(ATARAX) 50MG PO QHS OR LORATIDINE(CLARITIN) 10MG QD

  7. ACNE VULGARIS MOST COMMON SKIN DISORDER MOSTLY IN PUBERTY BUT CAN BE IN 30’S,OR 40’S RISK FACTOR FAMILY ON FACE, NECK, CHEST AND BACK 15% SEEKS MEDICAL ATTENTION COMEDONES OPEN HEAD, CLOSED HEAD PAPULE, PUSTULE, CYSTIC NODULAR FORM CAN BE MILD,MODERATE OR SEVERE DISEASE SCARING IF PT. HANDLES INAPPROPRIATELY

  8. PATHOPHYSIOLOGY

  9. TREATMENT SALICYLATE: REPAIR DESQUAMATION AND EXFOLIANT (STRIDEX PAD, PROPA PH) BENZOYL PEROXIDE: ANTIBACTERIAL ANTIBIOTICS: BACTERICIDAL (TOPICAL ERYTHROMYCIN, CLINDAMYCIN) ORAL. TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE, ERYTHROMYCIN RETINOIC ACID(TRETINOIN): COMEDOLYTIC REPAIRS EPITHELIUM & INCREASE DRAINAGE (RETIN-A, RETIN-A MICRO, AVITA)TOPICAL CREAM ADAPALENE= SYNTHETIC RETINOID ORAL PREPARATION= ACCUTANE AZELAIC ACID: ANTIKERATIN, ANTIBACTERIAL & ANTIINFLAMMATORY STEROID INJECTION HORMONAL THERAPY SULFUR- KERATOLYTIC & EXFOLIANT EXTRACTORS LASER & PHOTOTHERAPY

  10. TREATMENT MILD: TOPICAL ADAPALENE, BPO EPIDUO TOPICAL (ADAPALENE + BPO) APPLY TO AFFECTED AREA ONCE A DAY x ONE MONTH OR AZELAIC ACID TOPICAL 20% CREAM BID X 3 MONTHS WHEN PT CAN NOT TOLERATE EPIDUO MODERATE: BENZAMYCIN (BPO+ERYTHROMYCIN) TOPIACAL : APPLY TWICE A DAY X 2 MONTHS OR EPIDUO TOPICAL ( ADAPALENE+BPO) APPLY ONCE x2 MONTHS IF NO SIGNIFICANT IMPROVEMENT ADD DOXYCYCLINE 100 MG PO QD X 2 MONTHS THEN 40 MMG QDOR MINOCYCLIN 100MG PO BID X2MONTHS THEN 50 MG QD SEVERE: ORAL TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE, ERYTHROMYCIN ACCUTANE 40 MG PO BID X 4 TO 6 MONTHS STEROID INJECTION IN CYSTIC NODULAR

  11. ACCUTANE USE ONLY WHEN 1st and 2nd line treatment fails IN FEMALE NEVER USE IN PREGNANCY HIGHLY TERATOGENIC, BIRTH DEFECTS FEMALE MUST BE ON TWO FORMS OF CONTRACEPTION MUST ENROLL IN I pledge DRUG PROGRAM SIDE EFFECTS: DRY SKIN, MUCOSA, ARTHRALGIA, HYPERTRIGLYCERIDEMIA, IBS INCREASED SUICIDAL IDEATION & ATTEMPT ACCUTANE CURES 80% OF PTS. FOR LIFE

  12. ACNE ROSACEA MIDDLE AGE OR OLDER ERYTHEMA, ROSY TELANGIECTESIA, PAPULE & PUSTULES CHEEK, NOSE & CHIN RHINOPHYMA (HYPERPLASIA OF NOSE SOFT TISSUE)

  13. DIFFERENTIATE

  14. TREATMENT ACNE ROSACEA METRONIDAZOLE 0.75% GEL BID OR CREAM 1% DAILY OR CLINDAMYCIN(GEL,CREAM,LOTION) DAILY TETRACYCLINE500 MGPO BIDX 2 WEEKS THEN 250 MG QD OR QOD FOR MAINTENANCE ALTERNATIVE ARE DOXYCYCLINE, MINOCIN, OR ERYTHROMYCIN TOPICAL STEROIDS- NO;NO. ACCUTANE 40MG BID X 4WEEKS FOR RECALCITRANT CASE SURGICAL DEBULKING OF RHINOPHYMA

  15. HERPES ZOSTER/SHINGLES COMMON VIRAL INFECTION HZ AFFECTS 300,000 PERSONS/ YEAR FREQUENT IN ELDERLY PEOPLE AFFECTS ONE IN FIVE WHO IS INFECTED WITH CHICKENPOX IN CHILD HOOD VIRUS REMAINS DORMANT & INFECTS DORASL ROOT GANGLION COMES WITH VESICULAR LESIONS & NEURALGIA SERIOUS IN HIV & IMMUNOCOMPROMISED PT.

  16. HZ 2-3 DAYS DERMATOMAL PAIN BEFORE LESION PAIN BURNING, TINGLING, SHARP STABBING GROUPED VESICLES WITH RED BASE VESICLES TURN PUSTLES IN FEW DAYS CRUSTING & HEALING TAKES 2-3 WEEKS MALAISE, FEVER & LYMPHADENOPATHY(+-) DX BY TZANK PREP WITH MULTINUCLEATED GIANT CELL, RISING AB TITERS AT INTERVAL, DNA BY PCRA COPLICATIONS: H.NEURALGIA, BLINDNES, VERTIGO, DEAFNES,BELLS PALSY, PNEUMONIA, MENINGOCOCCEMIA

  17. Dorsal root ganglion

  18. HZ OPHTHALMICUS HZ VIRUS AFFECTS OPH. DIVISION OF TRIGEMINAL NERVE VESICLES APPEAR ON FOREHEAD, EYELIDS, EYE GLOBE & NOSE (HUTCHINSON SIGN) CAUSES ERYTHEMA, EDEMA,PAIN IN AREAS UPPER EYELID EDEMA, BLEPHERITIS, KERATITIS, SCLERITIS, CONJUNCTIVITIS, UVEITIS, RETNAL NECROSIS, BLINDNESS APPLY COOL COMPRESS, MOISTURIZER, APAP & CODEINE FOR PAIN,VALCYCLOVIR, FAMVIR REFER TO OPHTHALMOLOGIST IMMEDIATELY HOSPITALIZE IF MENINGEAL SIGN

  19. HZ OTICUS/RAMSAY HUNT’S SYNDROME . HZV AFFECTS GENICULATE GANGLION OF VII NERVE VESICLES & PAIN IN EAR, FACE, NECK & SCALP CAUSES, TINNITUS,VERTIGO, HEARING LOSS, TASTE LOSS & FACIAL PALSY GIVE ANALGESIC, ANTIVIRAL THERAPY ANTIBIOTIC FOR SECONDARY STAPH. INFECTION REFER TO ENT SPECIALIST HOSPITALIZE IF MENINGEAL SIGN

  20. TREATMENT BURROW’S SOLUTION WET TO DRY COMPRESS QID TO KEEP VESICLE CLEAN & DRY FOR PAIN APAP, ASA, CODEINE ANTIVIRALS: ACYCLOVIR (ZOVIRAX)800MG X 5/DAYX 10 DAYS PO IMMUNODEFICIENT IV 10MG/KG Q8HX7-14DAYS VALACYCLOVIR(VALTREX)1000MGTIDX 7-14 DAYS FAMCYCLOVIR(FAMVIR)500MG TIDX 7 DAYS SECONDARY INFECTION:MUPIROCIN (BACTROBAN)OINTMENT 2% TOPICAL TID x 10 DAYS ORAL DICLOXACILLIN 250MG QID X 10 DAYS NO PROPHYLACTIC ANTIBIOTIC HOSPITALIZE IMMUNODEFICIENT PT WITH PNEOMONIA AND MENINGITIS

  21. POST HERPETIC NEURALGIA MOST COMMON COMPLICATION OF HZ PAIN IS DEBILITATING. MAY LASTS FEW MONTHS TO MANY YEARS IN UNDER 40 YO BUT > 50% IN 60 YO TREATMENT:AMITRIPTYLINE (ELAVIL), GABAPENTIN(NEURONTIN), REGABALIN(LYRICA), OXYCONTIN, MS CONTIN

  22. SCABIES

  23. SARCOPTES SCABIEI( HUMAN ITCH MITE) WORLDWIDE EFFECTS ALL RACES AND CLASSES IT IS MICROSCOPIC AND FEMALE MITE TUNNELS IN STRATUM CORNEUM AND DEPOSIT EGGS STAGES EGG,LARVA,NYMPH & ADULT SPREADS PERSON TO PERSON,PROLONG SKIN TO SKIN CONTACTS COMMON IN CROWDED HOME, PRISON, N.H. DAY CARE

  24. SCABIES: SIGN, SYMPTOMS & DIAGNOSIS RASH IS USUALLY PAPULAR, LINEAR EXCORIATION WITH INTENSE PRURITIS AT NIGHT PT MAY HAVE <10 BURROWS BUT HUNDREDS OF ITCHING PAPULES BETWEEN THE FINGERS,WRIST,ELBOW,AXILLA, SHOULDER, NIPPLE,WAIST,GENITALIA, BUTTOCKS, SHOULDER BLADES IN ADULTS HEAD, NECK, PALMS AND SOLES IN YOUNG CHILD DX BY RASH, ITCHING,BURROWS AND SITES AND SCRAPING THE SURFACE TO SEE MITE, EGGS OR FECAL MATTER (SCYBALA) UNDER MICROSCOPE

  25. SCABIES TREATMENT PERMETHRIN (ELIMITE)5% CREAM APPLY ONCE FROM NECK TO TOE AT PM, LEAVE WHOLE NIGHT AND WASHES OF IN AM. SAFE FOR CHILDREN. MAY REPEAT ONCE AFTER A WEEK OR LINDANE 1% LOTION ONCE NECK TO TOE OVERNIGHT. NOT FOR CHILDREN,PREGNANT WOMAN OR OPEN SKIN. NEUROTOXIC . OR IVERMECTIN(AVERMECTIN)200UGM/KG ONE DOSE TREATMENT OF ALL HOUSEHOLD.SEXUAL PARTNER WASH BEDDING, CLOTHING, TOWELS IN HOT WATER OR DRY CLEAN OR SEAL IN PLASTIC BAG FOR 72 HOURS TOPICAL SARNA LOTION> 2YO 2-3XDAY FOR ITCHING INFECTED SKIN SHOULD BE TREATED WITH ORAL ANTISTAPH. ANTIBIOTIC. HYDROXYZINE (VISTARIL) 25 MG TID ADULT. 10MG TID IN CHILDREN

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