Download DUNPHY PRIMARY CARE IIB TEST and more Exams Nursing in PDF only on Docsity!
DUNPHY PRIMARY CARE IIB TEST 3.
Chief complaint abd pain - Answers- Careful history HPI (especially) Pain assessment Onset, timing Location Duration Characteristics/Associated factors Visceral pain is dull and poorly localized Parietal pain is sharp and localized Colicky pain comes and goes Burning pain is caused by irritation from gastric contents Aggravating factors, what makes it worse? Relieving factors, what makes it better? Treatment, what med./tx has been tried? Visceral pain is - Answers- dull and poorly localized Burning pain is caused by - Answers- irritation from gastric contents Parietal pain is - Answers- sharp and localized Colicky pain - Answers- comes and goes Aggravating factors, - Answers- what makes it worse? Relieving factors, - Answers- what makes it better? Physical Exam GI - Answers- Heart and Lungs Abdominal exam—inspection, auscultation, percussion, palpation Digital rectal exam Vaginal exam Tests CBC Liver function tests (LFTs) Serum chemistries/CMP Urinalysis Stool for occult blood Pregnancy test what would you think about with sudden severe pain - Answers- Appendicitis Intestinal perforation Mesenteric infarction Dissection or rupture of aortic aneurysm
Ectopic pregnancy Burning pain- thoughts on what it would be? - Answers- Gastroesophageal reflux disease (GERD) Gastritis Diverticulitis What would you think about with constant mild to severe pain - Answers- Pancreatitis Cholecystitis-Cholelithiasis What would you think about with crampy or colicky pain? - Answers- Intestinal obstruction Inflammatory bowel dz. Irritable bowel Salpingitis Urinary stones Cholelithiasis Constipation Appendicitis is? - Answers- the inflammation of the variform appendix caused by an obstruction and/or infection Appendicitis is the most common cause of ________ ______ pain requiring surgical intervention? - Answers- acute right lower quadrant abdominal Appendicitis is more common in diets that are_____? - Answers- low in fiber, high in fat, and high in refined sugars and other carbohydrates __________ of the appendix by a variety of pathological processes is the cause of the majority of appendicitis - Answers- Obstruction Appendicitis is ______ of the appendix, followed by obstruction and subsequent bacterial infection - Answers- Dilation In appendicitis ______, is obstructed by hardened feces (fecalith), inflammatory processes (including parasites, viruses, or bacteria), strictures, neoplasms, or foreign bodies (including vegetable or fruit seeds or barium) - Answers- lumen In appendicitisn ______ continues to secrete fluid, which further distends the lumen, impairing the venous blood flow and leading to tissue necrosis - Answers- Mucosa Left untreated, in appendicitis _____ ______is impeded Bacteria continue to proliferate and, in the absence of treatment, perforation of the appendix occurs - Answers- arterial inflow
Diagnostics for Appendicitis? - Answers- Laboratory findings are not diagnostic Diagnosis is made from the history and physical exam (clinical diagnosis) CBC usually reveals a mild to moderate leukocytosis (WBC 10 to 20,000 mcg/L) with a left shift Urinalysis show microscopic hematuria or pyuria in 25% of patients Urine human chorionic gonadotropin (hCG) test completed to rule out (ectopic) pregnancy What might x-rays show of appendicitis? - Answers- X-ray studies become more important as appendicitis progresses Plain x-ray films of the abdomen may show evidence of a fecalith, a gas-filled appendix, small bowel ileus, a deviation in the bowel gas pattern, or a loss of the right iliopsoas shadow what might a CT of the abdomen help with regarding Appendicitis? - Answers- ruling out other diagnostic possibilities Abdominal ultrasound helps visualize the inflamed appendix and is also useful in ruling out other potential diagnoses What might happen with a female patient related to appendicitis? - Answers- Diagnostic laparoscopy may be considered in female patients to rule out ectopic pregnancy, tubo- ovarian processes, or pelvic inflammatory disease (PID) What should be included in DDX for appendicitis? - Answers- Urinary tract infection Ectopic pregnancy Ovarian cyst Pneumonia Gastroenteritis Crohn's disease Diverticulitis Mesenteric adenitis Pancreatitis Pelvic inflammatory disease Cholelithiasis Appendicitis management- what antibiotics? - Answers- Third-generation cephalosporins are the antibiotics of choice Ampicillin, gentamicin, clindamycin, metronidazole (Flagyl), ampicillin-sulbactam (Unasyn), and ticarcillin/clavulanate (Timentin) _______ should be avoided in appendicitis because they mask any developing symptoms that might indicate a complication, such as perforation - Answers- Narcotics Constipation- definition - Answers- change in bowel pattern Decrease in frequency or increase in difficulty of defecation Common in Western society
Most common GI disorder in the United States Elderly Sedentary Causes of constipation - Answers- Lack of dietary fiber Habitual use of laxatives Irritable bowel syndrome (IBS) Sedentary lifestyle Change in environment or travel Medications Suppressing urge to defecate Tumors Hypothyroidism Diabetes Hypercalcemia Pregnancy Simple constipation causes - Answers- Low fiber Suppression of defecation Disordered motility causes - Answers- Slowed transit time IBS Diverticular disease Secondary constipation causes - Answers- Medications (e.g., codeine, morphine, calcium channel blockers, aluminum antacids) Chronic laxative use Immobility Chief complaints constipation - Answers- Abd. pain (crampy) Fecal description Bowel pattern (how frequently etc.) PE- constipation - Answers- Skin-hydration/turgor, color Thyroid Abdominal exam—inspection, auscultation, percussion, and palpation Rectal exam Stool for occult or frank blood Epidermis consist of: - Answers- Stratum corneum Stratum germinativum Stratum germinativum - Answers- forms new skin cells Forms permanent epidermal ridges on hands/feet by 17th week
Stores fat for energy What are the sebaceous glands? - Answers- arise in conjunction with the hair follicle; On all parts of body except palms & soles; Produce sebum (oil) for lubrication of epidermis; Sebum mixes with desquamated cells to form vernix caseosa; Cease production by 6-12 months of age, but become active again around 7 years of age. What do the sebaceous glands produce? - Answers- Sebum for lubrication of epidermis When do the sebaceous glands stop forming? ______ begin again?______ - Answers- 6 - 12 months of age, and 7 years of age Name the 3 sweat glands - Answers- eccrine, apocrine, ceruminous What is the eccrine gland? - Answers- ore the major sweat glands of the human body, found in virtually all skin, with the highest density in palms and soles, then on the head, but much less on the trunk and the extremities. Sweat is a dilute saline solution Wide distribution, including palms and soles; When do the eccrine glands begin to function? - Answers- 2 - 18 days of life, w/ full functioning between 2 & 3 years of age. what is the apocrine gland? - Answers- Sweat is a milky viscid solution, excreted from hair follicles When contaminated by bacteria sweat decomposes & causes body odor Located in genital, axillary, & areola areas Active functioning begins at puberty Requires androgen to stimulate secretions. What is the ceruminous gland? - Answers- Modified sweat glands located in external ear canal and secrete a waxy pigmented substance: cerumen When is hair visible - Answers- 20 weeks fetal development How much does hair grow? - Answers- 1 cm/month what is the visible part of the hair - Answers- shaft what part of the hair is below the skin surface? - Answers- Root Erector pili muscle - Answers- elevates hair when chilled or fearful
Lanugo - Answers- fine, long, colorless neonatal hair disappears by 33-36 weeks gestation Vellus hair - Answers- fine body hair terminal hair - Answers- Darkly colored, long & thick hair primarily on scalp & face of males, eyebrows, pubic area, axillae; Sebaceous glands - Answers- produce sebum to lubricate skin & hair. Hair slows water loss through the skin Fingernails develop at _____ weeks - Answers- 10 Toe nails develop at ______ - Answers- 14 weeks Nails reach fingertips at - Answers- 32 weeks gestation nails reach toe tips by - Answers- 36 weeks Nails are _____ shaped and thin from infancy to 2-3 years of age - Answers- spoon Lunula- - Answers- half moon area above the posterior nail fold Nail matrix - Answers- extends beneath the cuticle & lunula, new keratinized cells form here Nail plate - Answers- visible part of nail, consists of clear keratin Changes in shape, texture, length of nail may indicate - Answers- systemic illness Skin functions - Answers- Barrier - covers the entire surface of the body First line of defense from chemical, physical, & micro-organic injury Communication tool (blanching & blushing); Production of vitamin D Adsorption and secretion Prevent excessive water evaporation Lubrication The skin is continually shedding, controlling growth and colonization of microorganisms Melanocytes account for skin & hair tones by what week? - Answers- 7th Melanin in the skin reaches adult levels by how old? - Answers- 1 year of age what does melanin do? - Answers- protects DNA from damage by UV light radiation In general, localized rashes usually have - Answers- external cause
Part of the normal flora of oropharynx May c/o difficulty with feedings White creamy patches Involves anterior & posterior pharynx & tongue Diagnosed clinically Differential: milk curd, bacterial or viral exudate Thrush treatment - Answers- Treatment: Nystatin 100,000 units/ml suspension ½ ml on each side QID, cont x 48 hrs p sx resolve If breast fed, mom should clean nipples before nursing & apply Nystatin or Lotrimen to nipples after Sterilize bottles, nipples, pacifiers, toys Older kids commonly seen with Candida paronychia Treatment of milia - Answers- No treatment required: spontaneously rupture & exfoliate Milia - Answers- Multiple whitish-yellow papules 1-2 mm diameter, pearly, opalescent Scattered over forehead, nose, cheeks
- presentation in 50% newborns Etiology: retention of keratin within the dermis Intraoral counterparts Epstein's pearls (common) Milaria rubra - Answers- heat rash, prickly heat Presentation of milia rubra - Answers- Erythematous grouped papules Treatment for milia rubra? - Answers- Keep child cool, well ventilated in hot weather Light weight loose fitting clothing Etiology of malaria rubra? - Answers- Prolonged exposure to heat, high humidity causes obstruction of eccrine sweat ducts, deeper in epidermis of face, upper trunk, and intertriginous areas Cradle cap (seborrhea dermatitis) - Answers- Common in 1st month Erythema and greasy scales May affect face, ears & neck Erythema predominates in flexural folds & intertriginous areas Scaling seen mostly on the scalp May spread to diaper area Treatment for seborrrheic dermatitis (cradle cap) - Answers- 1% hydrocortisone x 1 wk Not usually itchy Possible fungal etiology Clotrimazole 1% cream BID x 1 wk
Refer after 1 week Cradle cap treatment - Answers- Watchful waiting Consider soft brushing of scalp after shampooing and application of white petroleum to soften scales Vascular Nevi* - Answers- Structural malformations Nevus simplex salmon patch "stork bite" Nevus flammeus port wine stain Hemangiomas Nevus simplex - Answers- Light pink, salmon colored patch seen in 1 in 2 infants: Small, pale pink, ill-defined **vascular macule Occur on nape of neck, eyelids, upper lip, forehead area of 40% newborns, generally midline Become more visible w/ crying or environmental temperature changes, blanch with compression Benign - no treatment Facial lesions usually fade completely by age 2 Patches at the nape of the neck are usually permanent Other sites permanence varies Nevus flammeus- port wine stain - Answers- Congenital **vascular deformity Common on face, neck of newborns Present at birth in 0.3% infants A flat, irregular red to purple patch Later becoming papular and cobblestone-like May be a few mm to covering an entire limb Not a proliferative process Does not fade with age, size remains stable therefore a cosmetic problem Usually unilateral anywhere on the body May indicate Sturge-Weber syndrome Port-wine stain on face plus associated abnormalities of cerebral vessels, glaucoma, or both Symptoms of struge weber syndrome - Answers- Port-wine stain on face plus associated abnormalities of cerebral vessels, glaucoma, or both
When to consider neurofibramotosis in Café- Au- Lait Spots? - Answers- Over age 5 with 6 or more spots > 1.5 cm Less than age 5 with 6 or more spots > 0.5 cm What are supernumerary nipples? - Answers- During embryogenesis , nipples arise from a pair of mammary ridges extending along the ventral body wall from midaxilla to inguinal area Extramammary glands may also arise, leading to supernumerary nipples May be unilateral, bilateral May include areola, nipple or both May be mistaken for a nevi Considered benign What is atopy? - Answers- 1. refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema).
- typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens. What is the most common skin disease in children and most common cause of pruritis in children? - Answers- Atopic Dermatitis "the itch that rashes" When do 60-85% of children typically outgrow atopic dermatitis? - Answers- age 9 When does atopic dermatitis get worse? Better? - Answers- Worse= winter. Better= summer What is atopic dermatitis characterized by? - Answers- inflammatory hyperreactivity What are café au lait spots? - Answers- Light colored to brown macules May be present at birth, found in 10-20% children Generally increase in number & size w/ age Size varies from .5 to 20 cm What are the 3 phases of atopic dermatitis? - Answers- 1. infantile eczema
- Childhood (2-12 years old)
- Phase 3 Adolescence to adulthood. UNUSUAL AFTER AGE 30
which types of atopic derm lesions require treatment? - Answers- Lesions with function impairment, deep ulceration, facial lesions concerning for cosmetic problems, or infection What are some treatment goals of atopic dermatitis? - Answers- Strive to dry out wet lesions and moisten dry lesions Prevent secondary infections What are atopic dermatitis infections usually caused by? - Answers- Usually due to staphylococcus aureus & streptococcus What antibiotics would be used to treat infections caused by atopic dermatitis? - Answers- Topical mupirocin if excessive crusting is evident Cephalexin for 7 - 14 days Clindamycin for MRSA or if cephalexin fails Flare-ups: Apply moisturizers alternatively w/ topical steroids referral if basic treatment fails Consider nonsteroidal immunomodulator (tacrolimus & pimecrolimus long-term safety questions, not 1st line Infantile eczema - Answers- starts around 2-3 months to 2 years. 1/3rd progress to stage 2, but usually remission by 3 years. Dermatitis begins on cheeks/scalp, may see oval patches on trunk (diaper area may be only area unaffected) may progress to extensor surfaces of extremities: knees, elbows Excoriation, maculopapular, and inflamed. Acute/chronic changes in flexural creases of arm, tops of feet, & buttocks Infantile eczema age of onset - Answers- 2 - 3 months to 2 years of age Spontaneous remission by 3 years 1/3 will progress to phase 2 Phase 2: Childhood 2-12 years of age. Atopic dermatitis - Answers- Predominant involvement is in flexural areas anticubital/popliteal fossa, the neck, wrists, ankles and sometime hands or feet Some children just have cracked, red painful soles of feet (atopic feet) Dennie-Morgan folds extra folds around the eyes Areas of hypopigmentation may occur due to destruction of melanocytes Sleep and school performance deteriorates. What are Dennie Morgan Folds? - Answers- extra folds around the eyes- seen in atopic dermatitis What condition might you find areas of hypopigmentation may occur due to destruction of melanocytes? - Answers- atopic dermatitis
Derma-Smooth/FS (class 6) Triamcinolone supplied in various concentrations: 0.5% (class 3 medium-high), 0.1% ointments (class 4 medium) Use only 1% hydrocortisone on face Risk of hypothalamic-pituitary-adrenal axis suppression is low with use of low to mid- potency topical steroid use, but it depends on the body surface area treated Which class of steroids is strongest? - Answers- Class 1 What is a side effect of steroid use? - Answers- Risk of hypothalamic-pituitary-adrenal axis suppression is low with use of low to mid-potency topical steroid use, but it depends on the body surface area treated Which class of steroids is weakest? - Answers- Class 7 What class of steroids should you use on the face and only if necessary? - Answers- Class 7- hydrocortisone 1% Name a medium class steroid (class 3-4) - Answers- Triamcinolone 0.5%-class 3- medium high Triamcinolone 0.1%-class 4- medium What class of steroids is Hydrocortisone 1%? - Answers- Class 7 Using steroids- patient teaching - Answers- **Risk of cutaneous atrophy increases with potency and duration of use Treat 2-3 times daily Ointments are preferred except with weeping acute contact dermatitis Apply to damp skin to increase penetration Treat until dermatitis subsides, and then taper by decreasing does or strength over a few weeks Chronic use of topical corticosteroids (mid- to low strength should be limited to 2- 4 weeks Reinstitute immediately when dermatitis flares Topical medication. Quantity on face and neck: - Answers- 30 grams Topical medication, Trunk: front and back: - Answers- 60 grams Topical medication, One arm: - Answers- 30 Grams
cetirizine: Zyrtec 5mg/5mL, 10mg tabs nonsedating 2nd generation oral antihistamine: - Answers- 6 months to 2 years: 2.5 mg po qd may give up to 5 mg in children > 12 months 2 - 5 years 2.5 - 5mg po qd or divided BID 6 - 11 years 5-10 mg po qd +12 10 mg po qd Loratidine Nonsedating 2nd generation oral antihistamine: - Answers- 1ml/ml, 10 mg tabs 2 - 5 yrs: 5 mg po QD 6 yr and older: 10 mg po QD List some sedating antihistamines - Answers- Diphenhydramine Hydroxyzine (Atarax) Both cause CNS depression and sedation...use w/ caution hydroxyzine (atarax) dosing - Answers- 10 mg/5 ml; 10, 20, 50, 100 mg tabs < 6 years: 50 mg/day PO divided Q 6-8 hours
6 years: 50-100 mg/day PO divided Q 6-8 hours
or: 2 mg/kg/day divided every 4-6 hours prn May use 1 mg/kg/day divided q 6 hours (2-3 times) and 1 mg /kg @ HS Allergy teaching - Answers- Teach parents/child about chronic nature & how to manage symptoms avoid allergens Emotional support for child & family; there is no cure Chronic itching can cause psychological, behavioral , & social problems for child Family disruptions are common Emphasis on importance of consistent skin care & medication use diphendyramine dosing - Answers- 12.5 mg/5ml ; pills 25 and 50 mg 2 - 11 years:1-2 mg/kg/dose PO q 6 hours max 50 mg/dose: 300 mg/day
12 years: 25-50 mg po q 4-6 hours prn or max dose 100 mg/dose or 400mg/day how to prevent/treat secondary infections of atopic dermatitis - Answers- Usually due to staphylococcus aureus & streptococcus Topical mupirocin if excessive crusting is evident Cephalexin for 7 - 14 days Clindamycin for MRSA or if cephalexin fails
Etiology: Arid climates, inherited disorder, FH of atopy Pathophysiology: Epidermis lacks moisture or sebum; Cracks on epidermal barrier allow loss of water, invasion of irritating substances dermatitis Treatment: Rehydrate: House humidifiers 2 - 5 minute baths/day followed by immediate application of emollients containing urea or lactic acid (Eucerin, Lubriderm), ointment (petrolatum), oils Dry skin dermatitis - Answers- Presentation: Abnormal dryness of skin, mucus membranes, or conjunctiva; Fine lines in skin; Scaling skin; Itching; Large cracked scales w/ erythematous borders Etiology: Arid climates, inherited disorder, FH of atopy Pathophysiology: Epidermis lacks moisture or sebum; Cracks on epidermal barrier allow loss of water, invasion of irritating substances dermatitis Treatment: Rehydrate: House humidifiers 2 - 5 minute baths/day followed by immediate application of emollients containing urea or lactic acid (Eucerin, Lubriderm), ointment (petrolatum), oils Irritant contact dermatitis: non-immunological reaction: common - Answers- Hallmark sign: pruritic, erythematous rash 5 - 20% incidence of all dermatitis cases Severity depends on length of exposure May occur w/i minutes or hours later In diaper area, usually a reaction to disposable diapers or prolonged contact with urine Allergic contact dermatitis: immunologic acquired sensitivity - Answers- Pruritic eczematous papules usually localized to site, but may experience widespread involvement with erythematous pruritic papules distant from site of contact Common contact dermatitis irritants - Answers- Poison ivy, oak, sumac Nickel (buckles, snaps, jewelry) Neomycin, fragrance, Bacitracin, Thimerisol, antihistamines Rubber, latex products, benzocaine Soaps, detergents, organic solvents Education for contact dermatitis - Answers- Avoid irritant Barrier protections such as zinc oxide or petrolatum (for irritant)
Limited use of low-potency steroids (eg. 1% Hydrocortisone) Systemic steroids for severe or widespread reactions Prednisone 2 mg/kg/day divided BID for 7 days diaper dermatitis - Answers- Primary irritant diaper dermatitis in the area covered by diapers. Affect 7-35% of children at some time, & greatest prevalence is 9-12 months of age High potential economic burden Glazed, red plaques; may develop into erosions Mostly on convex surface of perineum Pathophysiology: fecal enzymes activated by contact w/ alkaline urine Maceration (softening) of skin in the presence of moisture, warmth, urine, feces & friction Candidal diaper dermatitis - Answers- Due to infection w/ candida albicans (fungus) Part of normal flora of GI tract Occurs in 80% diaper rashes & becomes more likely if diaper rash persists > 72 hours Beefy red, sharply marginated scaly plaques w/ small papules & pustules Satellite lesions mainly on trunk Found on convex surface & folds of perineum General teaching for diaper dermatitis - Answers- Change diaper as soon as becomes wet Gentle cleansing with water or fragrance- and alcohol-free wipes Pat or air dry, do not rub Use disposable diapers rather than cloth Avoid occlusive clothing Expose rash to air as much as possible Medications for diaper dermatitis caused by candida - Answers- Miconazole (Lotrimen) topical ointment 2-4 times/day Mycostatin (Nystatin)100,000 units/g topically 4 x/day Infection control & hand washing if Candida Irritant diaper dermatitis - Answers- Irritant diaper dermatitis Cover diaper area w/ allergen-free paste or ointment containing zinc oxide &/or petroleum; mineral oil helps remove these products Ointments are water in oil formulations w/ a lipid content of > 50% provide superior moisture barrier Hydrocortisone 1% or less may be considered in moderate or severe case 2x/day for 1- 3 days What are hives - Answers- Well-circumscribed, localized or generalized erythematous raised wheals or welts of various sizes; tend to appear quickly, spread irregularly, & fade within a few hours or up to 24 hours; intensely pruritic Etiology: IgE mediated hypersensitivity reaction common allergic skin disorder
