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Question 8
A 25 year old man presents to the emergency department with a three day history of
spreading rash and painful oral lesions. He has the following observations.
HR
BP
RR
O2 Sats
90
/min
110/60 mmHg
15
/min
97
% on room air
A clinical photograph is shown (There are 2 images)
a) Please describe the findings of these clinical photographs (3 marks)
b) What is your differential diagnoses (3 marks)
c) What are your management priorities (3 marks)
Question 8 Answers
a) Please describe the findings of these clinical photographs (3 marks)
Combination of skin and mucosal lesions.
Haemorrhagic blistering and ulceration to the oral mucosa.
Symmetrical target lesions on extensor surfaces of both arms and face
IVC in-situ
b) What is your differential diagnoses (3 marks)
Steven Johnson Syndrome
Erythema Multiforme Major
Toxic Epidermal Necrolysis
Disseminated Herpes Infection
Pemphigus
Idiopathic drug reaction
c) What are your management priorities (3 marks)
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Cessation of offending drug agent
Analgesia
Fluid management / resuscitation
Wound management: not dis-similar to burns management thus
involvement of burns team
Nutritional support: may require NGT if oral mucosa pain is difficult to control
Steroids are controversial dependent if diagnosis is either SJS or EMM
References:
ACEM Examiner’s
VAQ 7
A 55 year old female who was in hospital recently presents with a one day history of fever
and right arm pain.
Question 1
List 2 important positives and 2 important negatives in this photo
Question 2
What is the most likely diagnosis and list 2 possible differentials
Question 3
What would you antibiotics be if and not neutropenia
VAQ 7 Answers
Question 1
List 2 important positives and 2 important negatives in this photo
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Erythema over right chest, right lateral neck extending down right arm in the venous
distribution
Previous mastectomy scar
Short hair may indicate ongoing chemotherapy.
Question 2
What is the most likely diagnosis and list 2 possible differentials.
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Infection – cellulitis. Possible concurrent neutropenia.
Post radiotherapy inflammatory change
Lymphangitis /thrombophlebitis right arm.
Question 3
What would you antibiotics be if and if not immunosuppressed?
If neutropeanic and febrile then
Pip Taz 4.5gm, Gentamicin 4mg/kg
Add Vancomycin if recent surgery or indwelling line. Also Give Vancomycin to cover knonw
MRSA carrier.
If distant from ongoing oncology treatment including no chemo, radiotherapy, steroids then
treat as per normal patient.
Flucloxacillin 2gm QID IV with Lincomycin 600mg if concerned regarding community
resistant Staph and Vancomycin if known MRSA carrier.
Reference – Exam report. Therapeutic Guidelines.