Case History:

So around October of 2017 I was on a work term in a neighbouring city. I started feeling terrible itching in the evenings as I lay in bed trying to sleep. Mainly around my shins, wrists, ankles, inner thighs and upper arms. To the point it was becoming unbearable. I talked to a pharmacist. Many times when I move to a new place I find I itch with different water so they suggested Benadryl. No help at all. I thought it might also be new laundry detergent. Tried calamine lotion which also didn't work.

Around this time I started taking melatonin and an iron supplement. Just thought I'd add that to be thorough.

Went to the small hospital in the town I was working and the doctor immediately diagnosed me with scabies. Terribly embarrassing as I had to tell the people who I were staying with. I did two treatments with Permethrin cream which did not help, in fact burned me terribly. By now the rash was starting to turn to blisters and my itching was not immediately where the blisters were, but I noticed in the areas where I did itch, blisters would eventually form in the same place in a day or two. This was mid-December and my work term was over so it was time to move back home. Not long after returning I went to the larger hospital which was much more thorough but by this time I looked like this:

Possible NSFW https://imgur.com/a/rqVsobf Bonus hospital gown for fashion purposes. Both arms and upper legs looked like this.

I was diagnosed with Bullous Pemphigoid and I was immediately put on 100mg of prednisone and saw a dermatologist the next week. The steroids worked amazingly well and the blisters healed rather quickly and my skin quickly healed. It now looks a just a little splotchy but I'm pretty much back to normal. As I weaned off the steroids I would get to around 20mg and the itching would return. My Derm doctor prescribed Cellcept (Mycophenolic acid 1000mg/daily) that I started around mid-July. I had no coverage for this drug and it was a bit pricey. I paid for 3 months but got no real relief and could not afford any more. I seemed to be stuck around 20mg/day of prednisone. The side effects from the Cellcept were rough. It seemed to cause a colitis flare-up. My Cellcept prescription ran out mid-October and I am again just on prednisone. Around the beginning of October I did feel good below 20mg/day of prednisone and managed to get down to 0mg but after 2 days the itching started again so I went back to 10mg/day. My Derm do

Sorry for the huge question -- I was wondering if anyone knew the reason why bullous pemphigoid alone does not have a positive nikolsky sign. Does anyone have any ideas? Thank you!

Six months ago, as a student nurse (waiting to take boards now), I was taking care of an elderly patient who happened to have bullous pemphigoid skin lesions on the arms, legs, and near the groin.

Patient was stable and speaking normally the first day. I came in the next morning and report said they had developed a hematoma in the back of their throat. Apparently unrelated to reason for admission, and I'm kicking myself because I can't remember what that was now, either.

I went in and assessed the patient and their speech was garbled and there definitely was something in the back of the throat, but didn't really look like a hematoma to me. Doctor was in and they made plans to take the patient to ICU in case the patient needed to be intubated.

Well, the patient started having bloody stool. Within the hour, it progressed from a little bit to the all of it being maroon-brown.

I left the room to confer with the primary nurse. I noticed their call light went off. I went in and there was about a golf ball sized bloody red mass sitting on the patient's chest. Patient was speaking and breathing normally at that point. I called for help and looked at the back of their throat again and it looked like most of whatever was in the back of their throat dislodged. The nurses who flooded in had no idea what the mass was and sent it up to ICU with the patient.

The patient was bleeding/coughing up blood by the time we took them to ICU. No one I asked, including my clinical instructor, had ever seen that happen or had any idea what it was.

So my question is, could this have been something related to bullous pemphigoid? Could some kind of mass like that have developed so quickly at the back of the throat? I tried reading up about it but it sounds like having them in the mouth/throat is rare.

This patient literally haunts me to this day. I wasn't able to figure out what happened to them or what exactly was going on. I don't know how much you could glean from the limited information I remember, but thought I would try anyway.

Just wanted to vent a moment. (TW: Eating Disorder)

Tldr I developed a very rare autoimmune disorder where my immune system is attacking my skin. I have horrific looking painful and itchy lesions all over my feet. The moment I finished my steroid prescription, the flare-ups spread to my legs, arms and chest. I'm going to scar very badly. Doc made the diagnosis that it is bullous pemphigoid and put me back on the steroids (prednisolone).

Supposedly the cause of this is unknown but stress is a huge trigger. I have a really stressful deadline based job and I've started the year terribly by being behind on everything because I'm just too itchy and depressed to adequately function.

To top it off, this whole skin episode was made worse by the steroid use: it leaves me feeling constantly hungry and so I eat.

Mom observes what I eat, looking over my shoulder and giving me a judgemental look if I've taken seconds. I got comments like "just because the medication is making you hungry doesn't mean you need to give into it." + "if you're going to eat, I also hope you're planning on exercising," + "I think you should consider untucking your shirt," (to hide my "ponch" in a work ensemble) + "she has such nice skin but I'm concerned with her increased appetite which she ~blames~ on the medication"

All these various comments have come within the last few weeks. I was an anorexic teen and my mother knows this, so while I'm a health weight now, food and body image are things that definitely can make me spiral into an unhealthy mix of self-weighing, calorie counting, very reduced portions, skipping meals, moments of saying FUCK IT and binge-eating, you get the drift. I don't have much time or energy for exercise, not trying to make excuses it's just not something I was raised with so it's hard to get into healthy patterns when you don't even know where to begin.

Following my mum's comments about food combined with everything else, I think I've just had a kind of total mental breakdown. I'm not speaking to either parent and they're not talking to me and everyone is just okay with this.

My siblings don't live at home and don't think my parents behaviour is destructive or rather they've just accepted that's how they are. I get a lot of "it's up to you to decide how you want the actions of others to affect you," which is valid advice and all.

It's just. I'm here, all alone just about with a fun, new incurable illness. A bunch of looming deadlines and co-workers fr

Hello all, my father has Lewy body dementia and alzeimers. He lives in a nursing home now having had a couple of stints in hospital after several falls and then later a skin condition called Bullous Pemphigoid. My Dad is on a palliative wing of the nursing home. I was able to get my father assessed and his nursing care paid for by NHS CHC - so he has no financial worries. He still receives his state pension and a small company pension. This essentially goes to my mother now.

Over the course of my father's illness there has been a total unravelling of the past such as:

• Finding I have a half brother (my father's - who I managed to track down and meet). He was conceived around the time my parents met. My mother told us about it indirectly once Dad was in hospital.
• My mother having an affair the moment my Dad went into hospital (with an old friend of my Dad's)
• My mother telling me we may have a half sister, but she won't say more as she thinks it will ruin her new relationship
• My mother continually trying to gaslight the rest of the family about my father
• My mother talking of trying to divorce my father (even though he lacks capacity)
• My mother giving his possessions away either to my full brother and I or selling them
• Mother generally acting childlike and narcissistic

My mother has a history of alcoholism, but will deny she has a problem (which I'm well aware is not unusual in the situation). I am also aware of another affair she had around 20 years ago. She argues my Dad has had affairs in the past - but obviously he is not in a position to refute it.

My mother and I are both LPA for health and welfare. Also for financial matters for my Dad. I do also have LPA for my mother.

The crux of my problem is I can no longer trust my mother. The nursing home recently contacted me to say they were concerned about the impact she had on her visiting him and for his safety when she visited.

Fortunately she has recently agreed to no longer visit him.

I am giving it serious thought to ask her to resign as LPA. This is because I do not think she can advocate for him.

What can I do in addition to this?

I am now at a point where I am at least satisfied my Dad is safe and as comfortable as possible.

However, I would be a barefaced liar if I did not say I was concerned about what happens to the house my father paid for when he is gone. Like most children I have been told over the years that my parents always wanted to leave something for us.

My mother

Transfeminine individual here, but I recently got a minor case of Bullous Pemphigoid (a skin condition that causes large, fluid-filled blisters), but the doctor I saw theorised that the cause was my recent change from estradiol patches (estradot, specifically) to Progynova tablets. BP is pretty rare, especially considering I'm only 20, but has this happened to anyone else?

link on Bullous Pemphigoid:

Okay, very new to this thread. I have had no support or communication with other CFS/ME people before now.

Everyone keeps mentioning PEM and how it is bad. I finally had to look it up. Why is PEM bad? Other than the obvious, you feel bad.

I must admit I get it 2-4 times a week. I work full time. I have 2 sons and no support system.

I am getting ready to take my son to college tomorrow. 12+ hour drive one way, move in, etc. Whole 9 yards. I fully expect to be in tremendous pain and do nothing but eat, sleep, and work for at least 2 weeks when I get back.

I always thought that was life now. Am I doing damage to myself? I also have Fibromyalgia, diabetes, high blood pressure, liver disfunction, heart arrhythmia, Bullous Pemphigoid, asthma and allergies.

Just took the exam 2 days ago: Here are my ACTIONABLE pieces of advice for those trying to break a 260.

1. As you study and review your blocks, each pathology you come across, ask yourself "do I know if I can treat empirically? Or do I need a diagnostic step". Most Qs on the exam are written assuming you will know the pathology being asked but will test your comprehension in what to immediately do once you know what's wrong. {EX: patient has classic BPH, do you need to a renal US or do you just treat}
2. As you come across pathologies, ask yourself, do I need an imaging to confirm this or is it a clinical diagnosis, the test loves asking you to do nothing or get imaging once they describe a pathology. {ex: classic bullous pemphigoid on exam, do you need to biopsy or can you do nothing after seeing it}
3. review in DETAIL what to do regarding giving vaccines to geriatric, immunocompromised, and pregnant patients. the test will get very specific about which vaccine type, how many doses and what age is it given. {ex: which specific vaccine do you give an immunocompromised pt over 65? do you need boosters for them?}
4. know the screening guidelines, to everything, for everyone. they love to use the nitty gritty on screening guidelines to stratify us. {if a father is Rh -, does you still need to screen mom for Rh Ab?}
5. Ethics: Do NOT rely on UW, everyone, from the 270+ gang to the 220 squad struggles with ethics and that is because they rely too heavily on UW which is not sufficient. I suggest Conrad fishers ethics book along with Amboss library. Divine intervention also has some good podcasts to help. {ex: he helps you know when you should act in best interest of patient in times where you are unsure if you should vs giving autonomy, Fischer explains lots of good ethics knowledge}
6. Social sciences/process improvement/error reductions: Same sentiment as ethics: I find the Amboss library to do a decent job, but combine it with divine lectures and INDEPENDANT RESEARCH on the internet to read more about RCA, FMEA, the use of fishbone diagrams AND review the specifics. know every exact step of all these systems because that is what they test. they do not test root cause vs failure mode anymore. they go one level deeper at least. for process improvement and error reduction, specify the best advised system to fix errors caused by OMISSION of information, vs error caused by FAILURE of communication between PROVIDERS, vs lack of communication to the patient. The

Happened upon a guide from a dermatology magazine from ye olde days of circa 2004 which outlined in laymen's terms the core principles of cleansing and moisturizing for different skin types and conditions. These basic key points haven't changed in well over several decades, despite all the gimmicks and new breakthroughs. Thought it'd be an interesting read for both skincare newbies just embarking on their journey and enthusiasts alike.

Making the Choice

Every patient needs to cleanse and moisturize skin properly using suitable cleansers and moisturizers containing the appropriate ingredients. In patients with compromised or sensitive skin, proper cleaning and moisturizing is even more critical. Using too harsh a cleanser or an inappropriate moisturizer can, in many cases, exacerbate certain conditions and can cause contact dermatitis and other problems.

The plethora of cleansers and moisturizers available today makes it difficult to keep current with new ingredients and their actions — or to guide patients in the selection of these products. In addition, few trials have looked at cleansers and moisturizers and their therapeutic value.

“Dermatologists must understand the ingredients in the products their patients use and what they do to or for the skin. However, the market changes quickly and it is very difficult to keep up,” says Zoe Diana Draelos, M.D., P.A., Clinical Associate Professor, in the Department of Dermatology at Wake Forest University. “They need to keep abreast of this as much as they keep abreast of any aspect of their medical practice by reading journals and going to meetings This aspect of the dermatology practice is just as important as any other since cleansers and moisturizers have a dramatic impact on the skin.”

• What to Look for in a Moisturizer:

Xerosis occurs when the water content in the skin is less than 10% to 20% — depending on the measurement method, and there is a loss of continuity of the stratum corneum. While moisturizers cannot repair skin, they can help restore the skin barrier and protect the skin as it heals.

“Moisturizers need to stop water loss, decrease itching and burning, and make the skin feel smooth and soft,” says Dr. Draelos. “This creates an optimal environment for healing. Because the skin turns over every two weeks, healing can occur rapidly.”

A good moisturizer should also be hypoallergenic, non-sensitizing, and non-comedogenic. The ingredients in moisturizers are often divided int

Hi Mum,

Having a bit of a tricky time recently. Dad has been in hospital since Friday as he had an accident. In the past few months he’s been diagnosed with bullous pemphigoid which is a rare autoimmune disorder that affects the skin, and because it’s damaged his feet so much he slept on the sofa as he couldn’t get upstairs. He fell off it in the night (probably reaching for cigarettes knowing him!) and managed to rip a lot of the skin off his arms.

The doctors have been great whilst he’s been there and they think the arms will recovery well after a skin graft. But whilst he’s been there they’ve got very worried about his feet, admitted he should have had better care before, and believe he has serious tendon damage that might mean he can’t walk again.

I’m doing my best to support my Dad, brother and sister from afar but it’s really hard. I live a long way from them but they have both - particularly my brother - been living with and caring for him during this. I want to go down and visit so badly but Dad isn’t allowed any additional visitors due to COVID, and my husband was told yesterday he has to self isolate for a week (also due to COVID; he’s a teacher so high risk of transmission). I hope I can see them soon.

I really miss you right now Mum. I know you’d be finding this really hard but we’re all doing our best to look after each other and I know you’d be proud of that xx

My dad was admitted to ICU Tuesday morning (02/09). He had shortness of breath/difficulty breathing whenever he would cough so he decided to go to the hospital. My mom said he had a slight fever, chills and headache since Friday but they just assumed it was from the treatment he has been receiving for his autoimmune skin disorder (bullous pemphigoid). He tested positive for covid and my mom did as well. He was on a breathing machine for the first 3 days and the nurse and doctor kept my brother updated via phone calls. He was apparently on maximum oxygen. This morning they sedated him, intubated and placed him on a ventilator. They also updated us later on in the day that they also placed a feeding tube in him so I guess he’ll stay sedated? I tend to be a private person and don’t really like showing emotions but there’s something about not knowing the outcome of if I’ll get to speak to my dad again that terrifies me. There are times when I’m alone before my partner comes home from work where I’ll just breakdown and cry. Calls to my mom went from cheerful positive tones in her voice to now that my dad is sedated she sounds hollow and sad, soft spoken now, kinda like defeated. She tested positive as well and is quarantined at home alone in their bedroom. What sucks as well is not being able to just get on a plane and fly to California and be there to comfort her because of this virus. The first days in the hospital we’d call my dad and his voice was raspy with labored breathing. My parents came up with a system where since he wouldn’t be able to speak she’d just call him and if he rejected the call that was a signal that he was fine but she says now she can’t even call him. Like I said, the tone in her voice sounds defeated. My parents always wore masks if they went out and always limited going out. My dad was terrified of catching the virus because of his skin condition, plus he’s obese with high blood pressure. My mom has diabetes but doesn’t show any symptoms. My dad and I literally talked about how scared he was of either one of them getting the virus a couple of weeks ago and would always remind me and my partner to stay home, wear a mask and watch out for one another. I remember back when I lived with them every Saturday morning my dad and I would get coffee at 7-Eleven and run errands all morning before coming home but not before picking up a coffee for my mom. I’m so scared of losing him. I’m not a religious person but for those of you who are, please

Big bad blisters, what’s the cause?

She is: 5.5 ft 50kg 60 years of age Nz European

I am posting on behalf of my mother who has fallen victim to multiple painful blisters over the last 2+ months. Her gp has seen the blisters twice and taken a biopsy then made a referral to a specialist. The gp is unsure of a diagnosis which has left us on a long waiting list.

This is not your classic hand, foot and mouth.

The blisters are forming over the hands/ feet and are hot and painful while taking months to heal. As you can see from the pictures they are red and full of clear liquid (not pus) and appear to be close to joints.

Please, any input or advice will be appreciated! Refer to the link for pictures Open to questions.

(https://imgur.com/a/W89IQQk)

Hello /r/NBME,

This post will contain the answers to the Step 1 - NBME 21 Exam for educational discussion purposes. More info may be found here.

Please remember to read the following rules carefully before contributing:

1. Read the Comment Rules and Policies found here.
2. Do not quote, link to, or otherwise reproduce any exam content.
3. Paraphrase as much as possible.
4. Remember to be kind and thank you for your contribution in advance.

Block 1

1. Area labeled F (Efferent arteriole)
2. Squamous cell carcinoma
3. Lung
4. Alanine
5. External carotid
6. Absorption atelectasis
7. Free T4
8. Most people find it difficult to stick to a routine. How did you do it?
9. Increased parathyroid hormone
10. Shrunken eosinophilic (red) neurons
11. Breast: antagonist; Uterus: partial agonist
12. Tubulin polymerization
13. Libido: normal; Nocturnal erections: normal
14. Shoulder dystocia
15. Atrioventricular bundle
16. Macrophages producing interleukin-1 (IL-1)
17. 50% in females but near 0 in males
18. Embolectomy
19. I’m concerned about how bad you’ve been feeling lately. Have you had any thoughts about death or wanting to be dead?
20. Didanosine
21. Enterococcus faecalis
22. Serum calcium concentration
23. Area labeled B (Internal capsule)
24. Mammillary bodies
25. Linoleic acid
26. Increased resting cardiac output
27. Pyloric stenosis
28. Fructose
29. Inferior rectus and inferior oblique
30. Craniopharyngioma
31. Surgical procedure group: 400; Medical management group: 400
32. Cysteine
33. Flagellin
34. Predictive value of a positive test
35. Odds ratio
36. Left thalamus
37. NMDA receptors are blocked by Mg2+ at the resting membrane potential
38. Dysplastic nevi
39. Donepezil
40. Descending colon
41. Primary metabolic acidosis with increased anion gap
42. Bullous pemphigoid antigen
43. Rosacea
44. Posterior inferior cerebellar
45. Decreased alveolar Po2
46. Four-chamber dilation
47. Antagonizes VLDL-cholesterol secretion
48. The B line on the graph
49. Serum parvovirus B19 IgM antibody test
50. Exercise-induced asthma

Block 2

1. Penicillin
2. Metabolic acidosis and respiratory acidosis
3. Extensor carpi radialis brevis
4. Parasympathetic efferent activity: decreased, Sympathetic efferent activity: increased, Number of impulses from carotid baroreceptor: decreased
5. Candida albicans
6. Baclofen
7. Deletion of a hydrophobic amino acid sequen

I don't want to step on anybody's toes here, but the amount of non-dad jokes here in this subreddit really annoys me. First of all, dad jokes CAN be NSFW, it clearly says so in the sub rules. Secondly, it doesn't automatically make it a dad joke if it's from a conversation between you and your child. Most importantly, the jokes that your CHILDREN tell YOU are not dad jokes. The point of a dad joke is that it's so cheesy only a dad who's trying to be funny would make such a joke. That's it. They are stupid plays on words, lame puns and so on. There has to be a clever pun or wordplay for it to be considered a dad joke.

Again, to all the fellow dads, I apologise if I'm sounding too harsh. But I just needed to get it off my chest.

Do your worst!

I'm surprised it hasn't decade.

Lupine Publishers | LOJ Pharmacology & Clinical Research

https://preview.redd.it/ne69gerlcfe61.jpg?width=166&format=pjpg&auto=webp&s=d6c710a0b2e00ec181dd54b348ed9e5ac50f0221

Abstract

SARS-COV-2, a novel β-coronavirus, is the cause of a severe inflammatory infectious disease of the respiratory tract (COVID-19). The spread has already taken on pandemic proportions, affecting over 2,5 million people and causing more than 170,000 deaths. The mechanisms and strategies underlying the virus power of penetrating human cells and causing the well-known spectrum of diseases induced by SARS-COV-2 have been explored worldwide. Two host receptors able to specifically inducing virus-host linkage, entry and, consequently, productive infection, have been suggested to interact with the outer membrane spike viral glycoprotein: the angiotensin converting enzyme 2 (ACE2) and the dipeptidyl-peptidase 4 (DPP4), also known as CD26. Both these receptors are highly expressed on several human tissues (i.e. kidney, pancreas, gut, lung, endothelium, pleura, myocardium, connective tissue) accounting for the variable clinical manifestations of COVID-19. CD26 is also over-expressed in stimulated T, B, and NK cells, thus representing an activation marker of the immune system. However, CD26 is not only the functional host receptor for SARSCoV- 2. Indeed, published data available from the previous SARS-CoV and MERS-CoV outbreaks showed that CD26 is also utilized for sustaining inflammation and counteracting the host immune response. Specifically, through CD26, coronavirus may increase inflammatory cytokine production, down- modulate the autophagy, and increase levels of adenosine, hence further deactivating the host immune response. Thus, compounds able to inhibit the DPP4/CD26 pathway might be useful against COVID-19. In this respect, promising therapeutic approaches could include: 1) DPP4 inhibitors, such as sitagliptin, already used for treating diabetic patients; 2) Begelomab, the anti-CD26 monoclonal antibody already successfully employed in the treatment of graft-versus-host disease, and 3) adenosine deaminase agonists, already used in the immunodeficiencies sustained by the adenosine deaminase gene mutations. The article will review some pathogenic landscapes and will hypothesize some promising drugs to face the COVID-19 emergency.

Keywords: COVID-19; SARS, CD26; DPP4; Autophagy; Inflammation; Sitagliptin; Begelomab; Adenosine deaminase

Introducti

For context I'm a Refuse Driver (Garbage man) & today I was on food waste. After I'd tipped I was checking the wagon for any defects when I spotted a lone pea balanced on the lifts.

I said "hey look, an escaPEA"

No one near me but it didn't half make me laugh for a good hour or so!

Edit: I can't believe how much this has blown up. Thank you everyone I've had a blast reading through the replies 😂

It really does, I swear!

They’re on standbi

Pilot on me!!

Nothing, he was gladiator.

Dad jokes are supposed to be jokes you can tell a kid and they will understand it and find it funny.

This sub is mostly just NSFW puns now.

If it needs a NSFW tag it's not a dad joke. There should just be a NSFW puns subreddit for that.

Edit* I'm not replying any longer and turning off notifications but to all those that say "no one cares", there sure are a lot of you arguing about it. Maybe I'm wrong but you people don't need to be rude about it. If you really don't care, don't comment.

When I got home, they were still there.

What did 0 say to 8 ?

" Nice Belt "

So What did 3 say to 8 ?

" Hey, you two stop making out "