NR 511 Completed Midterm study guide (2020) Complete A+ Guide., Exams of Nursing

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Disease Risk Subjective Finding Objective Findings Diagnostics Treatment Education GI DISORDERS Appendicitis -Most common between 10-30yrs; but can occur at any age; rare in infants and older adults -men more at risk - Diets low in fiber, high in fat, refined sugars, & other carbs at increased risk. - Obstruction of appendix is cause of majority of appendicitis - contributing factors: Intra-abdominal tumors, positive family hx - Recent roundworm infection or viral GI infection -Dx made clinically, based primarily on H&P exam - Classic presentation includes acute onset of mild to severe colicky, epigastric, or periumbilical pain - Pain is vague at first then localizes within 24hrs to RLQ - Pain exacerbated by walking\coughing - Men may feel radiated pain in testes - Abd muscle rigidity, N\V, anorexia - Mildly elevated temp 99-100F common - If RLQ accompanied by shaking chills, perforation should be suspected - Older adults may present with weakness, anorexia, abd distention, mild pain leading to delayed dx and increased morbidity. -May have HTN\tachy proportional to pain\symptoms -When lying flat, may flex R knee to relieve tension in abd muscle -Pain with palpation in abd, diffuse in early stages. Localized to RLQ later -Positive for rebound pain; ask pt to cough to localize pain location -Sudden cessation of pain means perforation and is ER -Labs are not diagnostic and nonspecific -Women should have urine human chorionic gonadotrophin to r\o ectopic pregnancy - +Rovsing’s Sign- deep palpation & release in LLQ causes rebound pain in RLQ - +Psoas Sign- lift R leg against gentle pressure causes pain - +Obturator Sign- flex R hip & knee and slowly rotate internally causes pain - +McBurney’s Sign- pain with pressure applied to point between umbilicus & ilium - x-ray\CT helpful when paired with positive H&P findings -Surgical; preoperative care, NPO, correction of fluid\electrolyte imbalances -Avoid narcotics -Atb with 3rd gen cephalosporin; Ex: ampicillin, gentamycin, flagyl -F\U with surgeon -Ambulation after surgery -Adv diet when bowel sounds return -Return to hosp with s\s of infection -Avoid heavy lifting for at least 2 wks Celiac disease ** (autoimmune disorder caused by an immunologic response to gluten) Mostly diagnosed in adulthood. A family member with celiac disease or dermatitis herpetiformis Type 1 diabetes Many asymptomatic. May complain of diarrhea, gas, dyspepsia, wt loss. Atypical symptoms: fatigue, bone or joint pain, arthritis, osteoporosis, or Muscle wasting (anemia), reduces subcutaneous fat, ataxia, & peripheral neuropathy (vitamin B12 deficiencies) osteoporosis or osteopenia (bone loss) Serologic testing for anti-tTG IgA antibody Total IgA (2% of pts have IgA deficiency and will falsely test negative) duodenal biopsies lifelong adherence to a strict gluten-free diet. Referral to a dietician to help. Some pts may need treatment with immunomodulating teaching related to gluten free diet. Some people with celiac disease have vitamin or nutrient deficiencies that do not cause them to feel ill, such as anemia due to iron NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Down syndrome or Turner syndrome Autoimmune thyroid disease Microscopic colitis (lymphocytic or collagenous colitis) Addison's disease osteopenia (bone loss) liver and biliary tract disorders (transaminitis, fatty liver, primary sclerosing cholangitis, depression or anxiety peripheral neuropathy seizures or migraines missed menstrual periods infertility or recurrent miscarriage canker sores inside the mouth dermatitis herpetiformis (itchy skin rash) hypothyroidism Pts with dermatitis herpetiformis found to have signs of celiac disease on intestinal biopsy. Test for nutritional deficiencies associated with malabsorption of C.D. (hemoglobin, iron, folate, vit B12, Calcium, and Vitamin D.) agents. deficiency or bone loss due to vitamin D deficiency. However, these deficiencies can cause problems over the long term. Untreated celiac/developing certain types of gastrointestinal cancer. This risk can be reduced by eating a gluten-free diet. Cholelithiasis is the formation of gallstones and is found in 90% of patients with cholecystitis. --Risk factors--2 types of stones (cholesterol and pigmented) a. Cholesterol (most common form): female, obesity, pregnancy, increased age, drug- induced (oral contraceptives and clofibrates: cholesterol lowering agent), cystic fibrosis, rapid weight loss, spinal cord injury, Ileal disease with extensive resection, Diabetes mellitus, sickle cell anemia. b. Pigmented: hemolytic diseases, increasing age, hyperalimentation Patient complaint of indigestion, nausea, vomiting (after consuming meal high in fat), and pain in RUG or epigastrium that may radiate to the middle of the back, infrascapular area or right shoulder. Right side involuntary guarding of abdominal muscles, Positive Murphy's sign, possible palpable gallbladder, Low grade fever between 99-101 degrees. Possible jaundice from common bile duct edema and diminished bowel sounds. Mild elevation of WBC up to 15, 000 Abdominal Xray: Quick, noninvasive, reliable, and cost- effective means of identifying the presence of cholelithiasis. a. Initial management-- begins with definitive diagnosis. When asymptomatic (normally an incidental finding while exploring another problem) require no further treatment except teaching s/sx of "gallbladder attack". Nonsurgical candidate can be treated with dissolution therapy or lithotripsy. Acute includes hydration (IV fluids), antibiotics, analgesics, GI rest. b. Treatment of choice for Acute cholecystitis is early surgical intervention after stabilization. Poor surgical risk may benefit from cholecystectomy operatively or percutaneously. Nonsurgical intervention: weight loss, avoidance of fatty foods to decrease attacks, alternative birth control for persons taking oral contraceptives, menopausal women taking estrogen informed about alternative sources of phytoestrogens (soy products). NR 511 Completed Midterm study guide (2020) Complete A+ Guide. adrenergics, CaChannel blockers, diazepam, Estrogen\ progesterone, Nicotine, Theophylline -May present with dysphagia; dysphagia should only occur with first bite dysphagia, bleeding, anemia, weight loss, or recurrent vomiting -EGD with Barrett’s esophagus q3-5yrs Giardia Can harbor in intestine, protozoan attaches to mucosa of small bowel. In US, risk in adults is oral-anal intercourse, children in daycare. In third world countries, risk of contamination through water sources. Bloating, flatulence, nausea, watery diarrhea, weight loss, anorexia, Malabsorption Stool testing positive for trophozoites 50% of the time. Duodenal aspirate or small bowel biopsy Quinacrine Hydrochloride (Atabrine) 100 mg TID after meals for 5-7 days or Metronidazole (Flagyl) 250 mg TID for 5-7 days Teach good hand washing technique, sanitize surfaces, and avoid swimming in all types of water sources to avoid further contamination. H. Pylori Infection Risks: Increased age, living in crowded conditions, no clean water source (nonfiltered water), smoking Ache or burning pain in abdomen. Abdominal pain that is worse when stomach is empty. Nausea/loss of appetite/unintentional weight loss. Frequent burping/bloating Objective Findings RUQ/LUQ tenderness -Fecal antigen assay -Urea breath Test -Biopsy with histological examination -Serological antibody Standard triple drug therapy is clarithromycin and either amoxicillin or metronidazole with a PPI BID for 14 days. Amoxicillin preferred over metronidazole b/c there are some resistant strands of metronidazole. -Complications (PUD) -Medication side effects Irritable bowel syndrome ** Women more than men, rate 3:1; starts in late adolescence and early adulthood; rare in pts >50 -2 kinds of patients- those with abdominal pain and altered bowel habits, and those with painless diarrhea. -Left lower quadrant pain, sharp and burning with cramping or a diffuse, dull ache, precipitated by eating, The physical exam tenderness in LLQ and over the umbilicus or epigastric area in those with small bowel involvement. Digital rectal exam may reveal tenderness and may exacerbate CBC, ESR, CMP (electrolytes, serum amylase), urinalysis, stools for occult blood, ova and parasites, and cultures. Labs mostly normal and any diagnostic clue as to the cause is Producing IBS include caffeine, legumes (and other fermentable carbohydrates), and artificial sweeteners. alleviate symptoms by eating a lower-fat diet that contains more protein. High fiber diet is good, introduced slowly to avoid Recognize triggers and avoid them. Patients must understand that the goal of treatment is to improve their symptoms, not cure the disease, and that improvement in symptoms can be NR 511 Completed Midterm study guide (2020) Complete A+ Guide. stress and relieved with a bm or flatus. -The pain does not interfere with sleeping, frequent complaints of abdominal distention, gas, and belching, urgency to defecate, passage of large volumes of mucus within the stool. -frequently associated with psych dg, which presents in the form of anxiety, depression, and somatoform disorders (marital discord, death, or abuse) symptoms. -No weight loss or deterioration in health. -Key to diagnosis is the lack of fever, leukocytosis, or bloody stools. pg579 advanced assessment helpful. If WBC found in the stool = infectious or inflammatory process and not IBS. Rule out food intolerance, lactase deficiency (hydrogen breath test or lactose tolerance test). IBS is often confused with lactose intolerance and can be evaluated by removing lactose from the diet for 2 weeks and monitoring the symptoms. the sensation of bloating, 8 glasses of water per day, probiotic VSL#3 one packet bid, Antidiarrheal medications only temporary. -If diarrhea is severe, episodic use of loperamide (Imodium) 2 mg or diphenoxylate (Lomotil) 2.5–5.0 mg every 6 hours can be used as needed. -Constipation- lactulose or magnesium hydroxide. -Postprandial pain- dicyclomine 10 to 20 mg 3- 4x a day by mouth or hyoscyamine 0.125 to 0.75 mg twice a day. Anticholinergics avoid in glaucoma and bph. Tricyclic antidepressants and ssri in some pt a time-consuming process. Dietary education- fiber intake increase Peptic ulcer disease ** (includes gastric ulcers and duodenal ulcers) 3 major causes: (1) Infection w/ H.Pylori, (2) chronic ingestion of ASA and other NSAIDs, (3) acid hypersecretion such as in Zollinger- Ellison syndrome. Genetics, blood type, personality type, and cigarette smoking may also play a role in the development of PUD. Pts w/ COPD, cirrhosis, renal failure, and renal transplant have higher incidence. Hallmark: c/o burning or gnawing (hunger) sensation or pain (dyspepsia) in epigastrium, often relieved by food or antacids. Pts describe pain episodic pattern of c/o in which the pain tends to cluster and last for minutes, w/ episodes separated by periods of no sx. Almost half w/ NSAID- induced ulcers are asymptomatic. Nocturnal pain: in 2/3 of pts w/ duodenal Pts w/ duodenal ulcers often demonstrate epigastric tenderness 2.5cm to right of midline, but this may also be present in cholecystitis, pancreatitis, non- ulcer dyspepsia, and other GI disorders. Reports of melena or coffee-ground-like emesis usually indicate bleeding ulcer, and perforated ulcer may present w/ abdominal rigidity. Routine lab tests: normal unless significant bleeding or vomiting. Pt actively bleeding à CBC w/ diff. to eval HGB levels is paramount. Most pts w/ upper GI bleeding should have restrictive strategy, defined as transfusing when HGB levels fall below 7 g/dL. Diagnostic standard à upper GI endoscopy. Serology test or direct bacteriological analysis via an esophagogastroduode Aim to relieve pain, heal ulcer, & prevent complication and recurrences. -PPIs: drugs of choice & includes omeprazole, raveprazole, lansoprazole, esomeprazole, dexlansoprazole, pantoprazole. PPIs heal duodenal ulcers in 4 wks therapy and gastric ulcers after 8 wks. -H2-R eceptor Antagonists: Used for mild symptoms with no complication or serious Smoking cessation; avoid foods that precipitate dyspepsia. MUST follow treatment regimen. Educate about side effects such as change in stool color to black with bismuth preparations. If sucralfate with antacid, PPI, H2RA being taken, stress that sucralfate cannot be taken with other meds or NR 511 Completed Midterm study guide (2020) Complete A+ Guide. ulcers and 1/3 of those w/ gastric ulcers. -Nausea & anorexia sometimes occur in pts w/ gastric ulcers. Vomiting and weight loss indicate more serious complications like gastric malignancy or pyloric obstruction. Pts w/ duodenal ulcers may report a reduction in pain after eating; pts w/ gastric ulcers tend to experience more intense pain after eating. noscopy (EGD) Bx à to check for H. Pylori. EGD is ordered for pts who have failed the standard triple-drug therapy for H. Pylori. A serological antibody (enzyme-linked immunosorbent assay) test can be used detect infection w/ H. Pylori, doesn’t distinguish between active or past (treated) infection and is expensive. Urease is plentiful in pts w/ H.Pylori infection. Breath tests for H. Pylori are based on the production of ammonia from the metabolism of urea by urease à indicate active infection and are noninvasive way of dx H. Pylori. In pts w/ increase in gastric acid secretion is suspected, a fasting serum gastrin level should be drawn. Levels higher than 200 pg/mL should be confirmed on repeat testing and followed by basal and peak acid-output measurements. Zollinger-Ellison syndrome should be suspected in pts disease; treatment for 2 wks. If symptoms persist past 2 weeks, EGD considered. If used for peptic ulcer tx, standard therapy is daily x 6 wks or half the dose bid x 8 weeks (cimetidine, ranitidine, nizatidine, famotidine) -Other agents: antacids were mainstay of ulcer treatment. Do not use antacids with calcium in PUD because calcium causes rebound acid secretion. Sucralfate 1g QID heals duodenal ulcers, bismuth (also has antimicrobial action against H. Pylori), misoprostol (Cytotec) used for prophylactic measure to prevent gastric ulcer formation in pts who use NSAIDs. Triple therapy for H. Pylori is a combination of 2 antibiotics (clarithromycin and either amoxicillin or metronidazole) w/ a PPI BID x 14 days. Amoxicillin preferred over metronidazole due to resistant h. pylori strains. Bismuth subsalicylate & 2 antibiotics is also effective but dosing is QID. with digoxin, ciprofloxacin, phenytoin due to it binding with these meds. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. bowel lymphatics, causing bacteremia, headache, and myalgias. Tissue abscesses may develop. Stools may be foul smelling. left colon or rectum. Bloody stools suggest mucosal damage and an inflammatory process secondary to invasive pathogens. Frothy stools and flatus suggest a malabsorption problem. suggest a source in the left colon or rectum. Bloody stools suggest mucosal damage and an inflammatory process secondary to invasive pathogens. Frothy stools and flatus suggest a malabsorption problem. is necessary unless associated with fever and systemic disease. Shigella One of the most common causes of bacillary dysentery. Several species: S. sonnei is isolated in 75% of cases in the United States. Because of poor hygiene and overcrowding, it is spread via the fecal–oral route and requires only a small number of organisms to produce disease. Organism causes epithelial invasion of intestinal mucosa. Duration usually 4–7 days and is self-limiting. Incubation period of 1– 2 days after exposure or ingestion of pathogen. See Salmonella See Salmonella Diagnosis is made by isolation of organism in stool or rectal swab. In severe cases sigmoidoscopy shows mucosal hyperemia, friability, and ulceration. Initially patients present with watery diarrhea and high fever. Later colitis- type symptoms develop: Abdominal cramps, tenesmus, urgency, frequent small stools with blood and mucus. Low-grade fever may persist for 2–20 days. Complications can include hemolytic- uremic syndrome and colitis. Treat with Bactrim DS twice daily for 3 days if infection was acquired in the United States. Stress proper handling of food, thorough cooking, and good hand washing. Ulcerative Colitis ** Peak age of onset: 15 to 30 y/o, but may occur at any age. More common Mild: 4 or fewer loose BMs per day associated w/ Tenderness in LLQ or across the entire abdomen, often Digital Rectal Exam: to assess for anal and perianal Initial: nutrition counseling. Parenteral nutrition may be Colonoscopy should be avoided w/ NR 511 Completed Midterm study guide (2020) Complete A+ Guide. in males. Familial tendency. abdominal cramps relieved w/ defecation, small amounts of blood and mucus in the stool, and sometimes tenesmus Moderate: 4-6 loose BMs per day w/ more blood and mucus. Systemic Sx: tachycardia, mild fever, weight loss and mild edema depending on serum albumin levels Severe: more frequent blood BMs (6-10 per day, abdominal pain and tenderness, Sx of anemia, hypovolemia, and impaired nutrition If Ulcerative Colitis (UC) confined to rectal or sigmoid area, stools can be normal or hard and dry; however, the rectum will continue to dispel mucus containing both RBCs and WBCs. As disease process moves proximally, the stools become looser. Pts may report eating less to decrease BM frequency, which leads to further nutritional deficiencies. accompanied by guarding and abdominal distention. Depending on severity: S/S of ileus and peritonitis may be found. Serological: + for antineutrophil cytoplasmic antibodies (pANCA). Fever & malaise w/ severe disease. Early disease: mucous membrane is granular, friable, and edematous w/ loss of normal vascular pattern. May be scattered areas of hemorrhage that bleed w/ minor trauma. Resulting ulcerations develop after mucosa breaks down, leaving the mucous membranes dotted w/ numerous bleeding and pus- oozing ulcers. Severe disease: Copious amounts of purulent exudate. Periods of remission, sigmoidoscopy always shows some friability and granulation present inflammation, rectal tenderness, and blood in the stool. Dx made by correlating sx w/ hx and physical exam. Stool analysis and Cx are obtained to r/o bacterial, fungal, or parasitic infection (ova & parasites) as cause for diarrhea. Stool is examined for mucus and blood. Contrast radiography and endoscopy primary diagnositic tool to confirm IBD (Irritable Bowel Disease). Sigmoidoscopy, defines the actual extent of the mucosal inflammation. Bx results à chronic inflammation. Colonoscopy to determine the extent of the disease, to avoid perforation, usually reserved for pts who have started tx. necessary w/ severe anorexia or uncontrollable diarrhea. Pts w/ mild-mod diarrhea may benefit from diphenoxylate w/ atropine (Lomotil) 2.5 to 5.0 mg PO BID up to 4x daily, loperamide (Imodium) 2 mg after each BM, or codeine 15 to 30 mg PO Q4-6H. Disease limited to rectosigmoid area: topical steroids or mesalamine. Steroid enemas and foams (hydrocortisone [Cortifoam] 100 mg) nightly x 2 wks. PO formulation of Asacol (5-ASA) med help maintain remission after enemas have been d/c’d More advanced disease: Systemic glucocorticoid in combo w/ sulfasalazine or 5-ASA therapy. Glucocorticoids esp. helpful in controlling extracolonic manifestations à peripheral arthritis, ankylosing spondylitis, erythema nodosum, anterior uveitis, and pyoderma gangrenosum: Oral prednisone (Prelone), up to 40 to 60 mg in single or divided doses, tapered and not d/c’d abruptly. Severe or fulminant: (10 or > bloody stools per day): severe colitis or deep ulcerations because of risk of perforation or development of toxic megacolon. Pts should avoid caffeine, raw fruits, vegetables, and other foods high in fiber à can cause trauma to the already inflamed mucosal surface. Some pts may benefit from lactose-free diet, but not recommended unless a trial produces symptomatic relief. Bland diet high in calories and protein yet low in fat can help to control diarrhea and flatulence and maintain nutrition and weight. Antidiarrheal meds should be avoided in acute phase but can be helpful for pts w/ mild sx. All pts should be informed of disease process, tx options, and expected outcomes. Education about diet and lifestyle NR 511 Completed Midterm study guide (2020) Complete A+ Guide. abdominal tenderness, fever, colon dilation and tachycardia à require hospitalization, monitor closely for development of toxic megacolon and colonic perforation. If no improvement after 7-10 days; consider surgical intervention. Surgery: Subtotal or total colectomy à prevent perforation of bowel and its complications. Some pts may need fluid/electrolyte management and/or blood transfusions. Most common procedure protocolectomy: Brooke ileostomy, curative and functional procedure. Immunosuppressive agents: azathioprine (Imuran), cyclosporine, and metabolit 6- mercaptopurine (6MP) à used in cases unresponsive to other medical management and in pts who are not surgical candidates. For disease unresponsive to other therapies: anti- tumor necrosis factor (anti-TNF) agents can be used à infliximab (Remicade) 5 mg/kg and adalimumab (Humira) administered SubQ 160 mg @ wk 1, 80 mg @ wk 2, then maintenance of 40 changes. Importance of adequate rest and stress reduction to decrease bowel motility and promote healing. Stress management techniques: guided imagery, referred for counseling if necessary. Provided information and addresses for national organizations à Crohn’s and Colitis Foundation of America: up-to-date info and local support groups. If no S/S of acute attack, they can eat whatever they want or can tolerate. About possibility of parenteral nutrition or oral supplementation during acute attacks. Foods that can cause diarrhea and gas-producing foods should be avoided during acute attacks. Female pts require special guidance and counseling before attempting pregnancy. If pregnancy occurs, NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Direct contact with secretions or with contaminated objects and surface. morning. Sandy, gritty feeling in eye. Unilateral but usually becomes bilateral due to contamination. photophobia. Lymph nodes NOT palpable. Reddened conjunctiva (both over the eyeball and inside lid) and eyelid swelling. Hallmark symptom of bacterial conjunctivitis is purulent discharge. recurrent conjunctivitis but rarely indicated. Bacterial form is also self- limited. Treatment shortness course if initiated early. Self-limiting in 5-7 days; can delay treatment until third day -Eyedrops or ointment: trimethoprim/polymyxin B (Polytrim), erythromycin, tobramycin, gentamicin, sodium sulfacetamide, or ciprofloxacin, levofloxacin -Contact lens wearers: fluoroquinolones are first line Tobramycin (These medicines include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin (Floxin) Children: ointment preferred over drops One exception to the rule in regards to the effectiveness of antibiotic drops for all bacterial conjunctivitis cases is gonococcal infections. Gonococcal conjunctivitis is sight threatening because it can affect the cornea, so patients should be sent to the ER immediately. Gonococcal conjunctivitis is associated washcloth each time face is washed. -Change pillowcases daily. -Warm compresses for infectious origin. -do not wear contact lenses until inflammation resolved (1 week); discard current contact lenses. -Discard makeup used. -Symptoms should improve in 2-4 days -Instruct patients to treat the eye that is affected but to start treatment in the other eye if symptoms develop -Bacterial conjunctivitis very contagious; stay home from work or school until 24 hours of antibiotic treatment or as soon as clinical improvement (decreased redness and discharge) NR 511 Completed Midterm study guide (2020) Complete A+ Guide. with hyper-purulent discharge Corneal abrasion Mechanical or chemical means; Trauma induced by contact lenses, damaged contact lenses, or foreign body. Spontaneous induced and often known as recurrent erosions that stems from a previous injury. More common in young, active patient. Uncommon in older adults. Excessive tearing, severe eye pain and inability to open eye due to foreign body sensation, photophobia, conjunctival hyperemia. Hx of scratching the eye, contact lens irritation, or actual trauma. Patients with recurrent corneal erosion syndrome experience searing pain in the middle of the night. It awakens them, or they feel pain on awakening -Constricted pupil, foreign body, lacrimation. Profuse tearing. -Invert eyelid to r/o foreign body underneath. Stain the eye with fluorescein and use a cobalt blue filter light or slit lamp to inspect the eye for foreign objects or scratches. Areas of epithelial disruption fluoresce green when exposed to a Wood’s lamp. Access visual acuity: should be normal unless abrasion is large. Treatment includes antibiotic eye drops or ointment for 5 – 7 days to prevent bacterial infection. Traumatic/foreign body/recurrent abrasions: Erythromycin ointment OR sulfacetamide Contact lens abrasion: ofloxacin, ciprofloxacin OR tobramycin drops/ointment Oral analgesics for pain Only ophthalmologists should prescribe topical anesthetics due to delayed wound healing and risk of ulceration, scarring, perforation and blindness Tetanus prophylaxis Normal saline to irrigate eye. Patching is not usually necessary. The patient should avoid wearing contact lenses until the abrasion heals. f/u in 24-48 hours if no improvement f/u in 24 hours to assess healing f/u by eye doctor Epiglotittis Common in young children 2-4 years; most common >7 years; may occur in older children and adults. Men > women. Infection with Haemophilus influenzae B (Hib) (most common); streptococci now major pathogen of cause. Odynophagia (pain on swallowing), dyspnea, drooling, stridor. Never use tongue blade or light due to laryngospasm and airway obstruction may occur. Transport to OR for fiberoptic laryngoscope visualization showing that epiglottis is swollen and erythematous (cherry red). Endotracheal tube should be inserted. ER care for adequate airway control. Needs hospitalization for IV antibiotics such cefuroxime (Ceftin), ceftriaxone (Rocephin), or ampicillin/sulbactam (Unasyn). Dexamethasone (Decadron) should also be administered IV and tapered as signs and symptoms resolve. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Continuous pulse oximetry and careful monitoring of the patient’s airway are critical. Patients who develop hypoxemia and respiratory distress will require intubation. Eustachian tube disorder Some of the most common causes include conditions causing nasal congestion as is seen with allergic rhinitis, sinusitis, URIs, enlarged adenoids, and pregnancy. Additionally, those who have recently traveled in an airplane or who have been scuba-diving are at risk for ETD. Often people complain of decreased hearing or a fullness in the ears. Hearing may be muffled or diminished. May report an inability to “pop” or “clear” their ears, which normally occurs with changes of barometric pressure. They may have accompanying tinnitus or disequilibrium. Patients may come to you thinking that they have an ear infection due to pain or pressure. They may also be concerned of cerumen impaction if they are experiencing hearing loss. Physical exam findings with ETD depend on precipitating event. Nasopharyngeal examination may reveal findings consistent with allergic rhinitis, sinusitis, or URI. On the affected side, typically you will see a TM that appears retracted or “sucked back.” Diagnosis of ETD is based on the history and physical exam. If pneumatic otoscopy is performed, the affected TM will be immobile. A Weber and Rinne hearing test will reveal conductive hearing loss on the affected side. Key it to treat underlying problem. -If a cold, then nasal saline drops or a neti pot may help. -AOM and sinus infections are treated with antibiotics. -Allergic rhinitis should be treated with nasal steroids and decongestants; however, decongestants are contraindicated in children under 6 years of age. Comfort measures can include acetaminophen or ibuprofen. Patients can be instructed to attempt to relieve pressure by yawning, chewing, or sucking. Holding the nose and blowing out is not recommended due to risk of TM performation. For chronic ETD unresponsive to tx, refer to ENT. Tympanostomy tubes may be placed to equalize pressure. Hyphema (a layer of RBCs - hemorrhage) Usually a result of blunt or penetrating trauma. Vision loss and eye pain; may be Conjunctival injection noted; blood in Based on physical findings but may Possible evacuation of blood by ophthalmologist. Immediate referral to ophthalmologist. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. -Posterior cervical lymphadenopathy (90%) *OCC. OCCURS -significant tender lymphadenopathy of the draining anterior cervical lymph nodes. -Liver enzymes: abnormal liver function -US-dx splenomegaly -consider rapid strep/throat culture: pharyngitis is similar to presentation of strep. (rash). -Steroids unless severe pharyngeal erythema or tonsillar hypertrophy develops, resulting in obstruction (may prolong illness) -Aspirin (risk of Reye’s syndrome) through saliva, bodily fluids such as blood, sexual contact, organ transplant, cough, sneeze, kissing, sharing food/drinks. Nasal polyps Caused by poorly controlled rhinitis. increases with age, female>male. Associated with cystic fibrosis, Asthma, bronchiectasis, ASA hypersensitivity, chronic sinusitis, primary ciliary dyskinesia (Kartagener syndrome), and laryngopharyngeal reflux. Rhinorrhea, nasal congestion, postnasal drainage, hyposmia (inability to smell), inability to breath through nose, dull headache, facial pain/pressure over middle 3rd of face or No symptoms in some cases. Usually bilateral; if unilateral is reported; check for malignancy Gray-blue to yellow- tan nasal polyps may present with chronic perennial rhinitis If large posterior nasal polyps, examine tympanic membrane for ETD. If unilateral, check for malignancy. Flexible/rigid endoscopy (gold standard of diagnosis) Pale-translucent mass on anterior rhinoscopy. CT scan may help reveal extent of disease and differentiate a polyp from another mass. MRI if neoplasia, mycetoma, or encephalocele suspected. Goal – reduce size or eliminate polyp. Daily intranasal corticosteroid use with saline irrigation 1st-line therapy. Treat for minimal of 12 weeks. Use budesonide, beclomethasone dipropionate, fluticasone, mometasone furoate. Mometasone furoate preferred for children. Short course of oral corticosteroids (14-21 days) and/or doxycycline (21 days) in symptomatic patients despite initial tx. (prednisone, prednisolone, doxycycline) Otitis Externa (AKA swimmer’s ear) ** Common in warmer months. No ethnic predisposition. Men/women equally affected. Those at risk: Immunocompromised pts on corticosteroid therapy or with chronic conditions such as DM. Pseudomonas infection common from excess Acute, often severe otalgia of sudden or gradual onset; may be bilaterally. Pain may be worse at night, more severe when pulling on pinna or earlobes or applying pressure to tragus. Ear canal may be erythematous and edematous; absence or presence of cerumen or accumulation of purulent drainage. Tenderness on traction of pinna and/or pain with Rarely needed if symptoms fits classic pic or otitis externa. Fluid from ear may be cultured and antibiotic sensitivity tested if organisms found. Done for those who Treat pain: local application of heat or ice- pack to outer ear. Nonprescription pain relievers: aspirin or acetaminophen or NSAIDS - 1st line agents. Extreme pain: Acetaminophen/codeine 325mg/5mg 1-2 tabs po Keep ear dry, avoid swimming or submersion of ear during and after acute episodes for 4-6 wks. Use shower caps and ear plugs to shower. Those susceptible to repeated infections, a 2% acetic acid NR 511 Completed Midterm study guide (2020) Complete A+ Guide. swimming in hot, humid weather, especially in polluted water. Highly chlorinated pool water leads to drying out of ear canal creating potential entry of bacteria and fungi. Inadequate cerumen (a protective barrier). Patients with seborrhea due to excess sebum production. Manual ear picking; forging bodies in auditory canal(like leaving cotton in ear); long use of ear plugs, hearing aids, cotton swabs may lead to local irritation and predispose to infection. Previous ear infections and hx of skin allergies. Chewing may elicit pain. Initially, ear may feel full or obstructed with temporary conductive hearing loss if edema present. May be pruritic. Purulent drainage. Fever/chills. chronic otitis externa may have dryness and pruritus of ear canal. pressure over tragus. May be diffused with complete involvement of auditory canal or localized with focal lesions (pustules or furuncles) along auditory or external ear structures. Sebaceous secretions in those with seborrhea. Fluid may be apparent: Pseudomonas -copious green exudate Staphylococcus infection - yellow crusting with purulent exudate. Fungal infections - fluffy white or black malodorous carpet of growth. Allergic reactions - seen as scaly, cracked, and/or weepy tissue. Frank invasive disease - granulation tissue spreading out from primary site of infection and eroding into temporal bone, do not respond to treatment or those with chronic otitis externa, especially those with purulent exudates indicating bacterial infection. Culture also done for immunocompromised pts. Rule our fungi and mycobacteria in these pts. ESR level may be elevated. CT and MRI used to determine soft tissue or bony involvement in malignant disease. Temporal bone 1st bone affected. q6h OR Acetaminophen/hydrocod one (Vicodin) 325mg/5mg po q8h for 1st 24-48 hours (risk for abuse). To facilitate healing: Clean ear canal to remove Cerumen, exudate, debris with cotton pledget or gentle irrigation using warm water. 1st line agents: Acetic acid/aluminum acetate, acetic acid/hydrocortisone, ciprofloxacin/hydrocortiso ne, ciprofloxacin/dexamethas one, neomycin/polymyxin B/hydrocortisone, and ofloxacin. Liquid ophthalmic preparations of gentamicin and tobramycin may be used otically to cover both P. aeruginosa and S. aureus. Bacterial otitis externa Safe with perforated tympanic membrane (TM): include ciprofoxacin 0.3% and dexamethasone 0.1% (Ciprodex otic); not for 6 months of age. Ofloxacin 0.3% (Floxin otic) 6 months-13 years 5 drops in affected ear daily for 7 days; adults 10 drops in the affected ear for 7 days Not safe with perforated solution may be used prophylactically to acidify ear canal whenever ears get wet. Teach proper method to clean ears using soft cotton pledget NOT swabs, sticks, or agents. Excessive cleaning harmful; small earwax necessary to prevent infection. Cured 7-10 days of treatment. F/U 1 week for uncomplicated pts. If ear wick placed, F/U 2 days for removal and canal cleaning and symptoms should begin to subside in 48h - pt to call if unresolving. F/U daily in hospitalized patients immunocompromis ed on IV therapy. F/U closely in healthy pts with invasive disease. Gallium scans performed to evaluate efficacy NR 511 Completed Midterm study guide (2020) Complete A+ Guide. outer auricle, or through perforated tympanic membrane. Neck lymphadenopathy not detected. TM: Chloroxylenol 1mg+pramoxine HCL 10 mg + hydrosortisone 10mg/mL (cortone B Aqueous) Colistin 3 mg Neomycin 3.3 mg, hydrocortisone Acetate 10 mg Thonzonium bromide 0.5 mg (Cortisporin-TC Otic) Refractory cases to initial therapy or involve auricular cellulitis required systemic ABX covering both Staphylococcus and Pseudomonas. Given for those immunocompromised or with factors such as DM. 1st -gen cephalosporins or penicillins with narrow coverage, like cephalexin (Keflex) 250 to 500 mg PO four times daily and dicloxacillin 250 to 500 mg PO QID. 2nd-gen cephalosporins with broader-spectrum coverage, like cefuroxime (Ceftin) 250 to 500 mg PO BID or cefdinir (Omnicef) 300 mg PO BID, or beta- lactamase–resistant penicillins like amoxicillin/clavulanate (Augmentin XR) 1,000 mg PO BID based on the amoxicillin component. during follow-up (not CT or MRI). Neomycin, an antibiotic commonly found in otic preparations, is known to cause skin reactions and ototoxicity; limit duration of therapy. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. or both ears affected/unaffected ear is louder). Rinne (air should be 2 as long as bone conduction; but in sensorineural loss, the ratio is equal). excessive noise and ototoxic drugs should be avoided. Rhinosinusitis - viral URI, airplane travel, smoking, air pollution, sneezing with mouth closed, chronic use of decongestants, cold damp weather, dry indoor heat, dental abscesses, swimming in contaminated water, nasal trauma URI, airplane travel, smoking, air pollution, sneezing with mouth closed, chronic use of decongestants, cold damp weather, dry indoor heat, dental abscesses, swimming, nasal trauma. All sinusitis – present with nasal congestion, mucopurulent rhinorrhea, head pressure, maybe cough, maybe sore throat, eye pain, malaise, fatigue. Pain exacerbated by sudden head movements. Frontal sinus pain worsen when lying down; maxillary sinus pain worsen when erect; ethmoid sinusitis associated with retro- orbital pain. Subacute or chronic sinusitis – painless as with some cases of acute sinusitis. Tender sinuses on palpation, nasal congestion, opacification of sinuses on transillumination, red/swollen nasal turbinates Acute sinusitis: total opacification on transillumination On palpation, the affected sinuses may be tender to palpation. Sphenoid sinusitis presents as tenderness over the vertex or mastoids, ethmoid sinusitis as retro-orbital or nasal bridge tenderness, maxillary sinusitis as cheek or dental tenderness, and frontal sinusitis as tenderness of the forehead. In the event of maxillary sinusitis related to a dental abscess, percussion over the affected sinus will produce Noncontrast head CT recommended in more complicated cases, will show sinus opacification, air-fluid level or mucosal thickening Saline nasal flushes, cool- mist humidifier, increase fluid intake, hot shower or compress for facial pain; ibuprofen, tylenol for pain, OTC decongestant (not longer than 4 days r/t rebound congestion); expectorants such as guaifenesin. Prescription drugs: fluticasone (Flonase), mometesone (Nasonex), triamcinocole (Nasocort). Oral antihistamines not indicated unless allergic component is evident. They dry the mucosa, thicken purulent sinus fluid, & slow mucosal drainage. Majority of acute rhinosinusitis cases are caused by viruses rather than bacteria, antibiotics are largely unhelpful Increase fluids to thin nasal secretions, avoid aggravating factors such as smoke, air pollution. Report complications such as peri-orbital swelling, visual impairments, AMS, visual impairments, facial palsy. Avoid OTC decongestants with antihistamine. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. marked tenderness in the teeth and gums Rhinosinusitis - bacterial Similar to above + persistent blockage of nasociliary sinus drainage, deviated septum, adenoidal hypertrophy nasal polyps, nasal neoplasms, Dx such as immunoglobulin A deficiency, immobile cilia syndrome (Kartagener’s syndrome), cystic fibrosis, HIV, diabetes Similar to above, postnasal and nasal drainage tends to be mucopurulent, yellow/green and pt reports symptoms longer than 7-10 days Similar to above + more mucopurulent drainage Anteroposterior, lateral, and particularly occipitomental sinus x-ray examinations can be done if symptoms show no improvement after 4 to 5 days of pharmacotherapy; Air–fluid levels, mucosal thickening beyond 4 mm, or complete opacification of the sinuses on any of these views is strongly suggestive of sinusitis. Presence of at least 10,000 organisms per mL on Gram stain of sinus aspirates may confirm local sinus infection. No routinely done since nairs have a diverse array of organisms. If allergic disease suspected perform allergy testing. Eosinophilia and elevated total or allergen specific IgE levels. If symptoms last longer than 7-10, antibiotic may be warranted. First-line is Amoxicillin alone or Augmentin 1000 mg/125mg PO BID. May use Bactrim or doxycycline Same as above, in addition to report no signs of improvement with antibiotic Streptococcus NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Tinnitus Hearing loss Labyrinthitis Meniere’s Disease Otitis media Otitis externa Otosclerosis Ear canal blockage (from cerumen or foreign body) History of high or low BP Head trauma Anemia Hypothyroidism Hyperthyroidism Allergies Chronic exposure to noise damage cilia & auditory hair cells tinnitus Taking certain medications Reversable tinnitus Salicylates Quinine Alcohol Indomethacin Irreversible tinnitus Kanamycin Streptomycin Gentamicin Vancomycin Me: Hearing loss, labyrinthitis, Meniere’s disease, otitis media, otitis externa, otosclerosis, earcanal blockage (from ear wax Significant subjective findings “Sound of escaping air or running water” “buzzing, ringing, or humming noise” Unilateral or bilateral Often not affected by tinnitus until in an usually quiet environment Me: Sound of escaping air, running water, sound heard in seashell, or as ringing, humming, buzzing sound or roaring or musical sound in one or both ears when no environmental noise is present. Subjective tinnitus is more common and heard only by patient. Sound more prevalent and bothersome in quiet environments; less bothersome around noise. May affect sleep, concentration, and cause depression. Significant objective findings Subjective ringing = will not see objective signs of ringing in ears Do orthostatic BP’s Gross hearing tests, Weber & Rinne fork tests Thorough ear exam If unilateral Check for bruit on affected side Palpation of carotid may reveal weak pulse on affected side Consider cardiovascular studies Doppler ultrasound – assess carotids for stenosis EKG – detect changes of atherosclerotic disease Neuro exam Rule out neuro deficits that may suggest a neurologic etiology Me: Objective tinnitus heard with a stethoscope placed over head and neck structures near ear. High blood pressure via orthostatic MRI – diagnostic procedure of choice May reveal ear- related pathology in detail Lab Tests – confirm possible underlying causes of tinnitus CBC – rule out anemia or infection Metabolic studies – rule out thyroid disease, hyperlipidemia, vitamin deficiency, zinc deficiency, electrolyte abnormalities If see drainage in canal culture drainage Me: Lab tests, CBC to r/o anemia or infection. Metabolic studies to r/o thyroid disease, high lipids, vitamin deficiency, zinc deficiency, electrolytes abnormalities. CUlture ear if drainage present. MRI - procedure of choice to evaluate ear pathology or a CT if MRI not possible. Tympanometry to check for presence of 1st line treatment Typically not treated successfully Manage symptoms Treat underlying causative disorder 2nd line treatment Oral antidepressants Effective in reducing symptoms Physical interventions – minimize distress caused by tinnitus Hearing aids Tinnitus-masking devices Eliminate possible offending medications. No successful treatment. No oral meds to help; however, oral antidepressants prove effective in reducing symptoms. Nortriptyline (Elavil), Diazepam (Valium), and Meclizine HCL (Antivert) have been used depending on the reason for tinnitus. If tinnitus due to otitis media, tx with antibiotics or if needed myringotomy. . Find caucaustive factor to Teach coping mechanisms. Avoid excessive noise, wear protective earplugs. Tinnitus-masking devices may help. External white-noise machine. Hearing aids to amplify environmental sounds and suppress tinnitus. Biofeedback for psychological problems may help. Stop smoking, decrease caffeine, chocolate, alcohol, and salt intake. Proper sleep hygiene. Chew gum or swallowing during descent of airplanes. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. characterized by velvety, hyperpigmented, hyperkeratotic plaques insulin resistance but can be a marker to malignancy. A sign of risk of developing metabolic syndrome. Etiologies include obesity, insulin resistance, genetic syndromes, familial AN, malignant AN, and drug reactions. Most common between 11- 40 and in those with BMI >30; indicator for risk of DM and subclinical atherosclerosis. . URL’s and inter trig IOU’s surfaces (axillae, elbow, inframammary areas, groin and anogenital regions), most often asymptomatic but may cause pruritus. Skin exam: early or mild lesions may appear as a macular discoloration. May have dirty appearance on the affected skin with rough texture. Symmetric hyper- pigmented, hyperkeratotic, velvety to verrucous brown plaques. fasting lipids, thyroid test, electrolytes to r/o DM or other endocrinopathies. Screen for malignancies. Low testosterone levels may be a predictor if AN in male, obese patients. malignancy is associated with malignancy. Tx usually not indicated but Metformin has been shown to reducing AN lesions. It also improves insulin levels and promotes weight loss. Gastric bypass for weight reduction. Acne Acne is a condition that is manageable but not curable. A provider must emphasize this to their patients so there are realistic expectations. Adolescent who has already tried self- treatment for several months Females more likely to verbalize emotional distress over their appearance Some patients’ c/o pain and tenderness if acne is severe Acne can occur at any age, and there are different levels of severity. Acne is classified into three categories mild, moderate, and severe. Facial involvement and other locations such as back, chest, and upper outer arms Mild is a patient with a few papules and some pustules. Lesions are primarily noninflammatory comedones with occasional small papules Moderate acne patients have papules, Adolescent who has already tried self- treatment for several months Females more likely to verbalize emotional distress over their appearance Some patients’ c/o pain and tenderness if acne is severe Diagnosed by its classic location and characteristic lesions. A complete history is crucial to the diagnosis and supplants the importance of most diagnostic tests which are only needed when an underlying predisposing conditions is suspected Good cleanser: benzoil peroxide or salicylic acid Benzoil peroxide can be drying and does tend to bleach towels or sheets, so make sure you educate your patient and parents on these side effects. (first- line therapy) Treating mild acne is best accomplished with a good cleanser and a retinoid with the possibility of a topical antibiotic. For a moderate case of acne, one would prescribe a retinoid, a topical antibiotic, and oral antibiotics. Adapalene is the lowest potency retinoid and good to use Education is a vital component of acne treatment because of the long duration of treatment and potential adverse reactions Wait at least 30 minutes after washing the face before applying topical acne medications (topicals should not be used on sunburned or irritated skin) Sunscreen should be used with all acne medications Avoid oily makeup, NR 511 Completed Midterm study guide (2020) Complete A+ Guide. pustules, and nodules. Severe acne consists of papules, multiple pustules, and multiple nodules that can be painful. Acne lesions can appear on the face, neck, chest, back, and upper arms. The differential diagnosis should include: rosacea, folliculitis, perioral dermatitis for mild acne. Retin-A Micro is a mid-potency retinoid and good to start with for mild or moderate acne. A patient with moderate acne will need a good cleanser, medium to high potency retinoid, topical antibiotics, and oral antibiotics. For severe acne, treatment includes a good cleanser, topical and oral antibiotics, as well as a medium to high potency retinoid. Medications: Acutane/ Isotrentinoin Used to treat severe acne Derivative of Vitamin A: which is a good option for moderate to severe acne that has failed other treatment options and in whom scarring is a concern. The patient takes the medication for 4 to 6 months and some patients may need a second round of treatment. The medication can cause elevation in triglycerides and liver enzymes. Labs need to be monitored prior to starting medication, at midpoint and at completion. There is a possible risk of developing an inflammatory bowel disorder and a slight increased risk of suicide oily hair conditioners, excessive scrubbing of face, excessive handling of the face NR 511 Completed Midterm study guide (2020) Complete A+ Guide. from depression (1%). Therefore, patients need to be properly evaluated and advised of this prior to treatment. The most common side effect is chapped lips (which can be really severe) and dryness of skin overall. Accutane will cause serious birth defects if taken during pregnancy so all females who are on Accutane must be tested for pregnancy prior to treatment and started on oral contraceptives. ● Patients should be referred to dermatology for Accutane treatment. Actinic keratosis: Premalignant lesion that can progress to SCC. Most common precancerous skin lesion in light skinned patients, more common in patients 50 years or older (most common in Celtic, Irish, and Scottish descent) Found in sun exposed areas Caused by skin cells that accumulate from repeated sun exposure Continued sun damage from UV radiation damages the DNA in Patient complains of irritated, rough or scaly rash, pruritus, tenderness or stinging sensation Reddened, scaly, rough, or uneven surfaces. Hard or spiny lesion. Sandpaper like texture. Flesh-colored; irregular. Fluorescence using photosensitizing drug (methyl ester of 5- aminolevulinic acid) over area of concern will have a pink fluorescence with the wood’s lamp No evidence to support removal of lesion as most will not turn cancerous however it is standard to REMOVE the lesion(s) Topical Therapy: 5-fluorouracil (5-FU) cream (Efudex, Carac) applied in a thin layer over the lesion BID for 3 weeks, avoid eyelids, lips, and folds of the nose. This treatment causes red, raw, and painful skin in the areas applied which may lead to noncompliance. Exposure to sunlight makes this worse Centered around prevention, avoidance of excessive sun exposure, use of protective clothing, and use of sunscreen. Should teach patients ABCDE mnemonic A= asymmetry B= border irregularity C= color change D= Diameter larger than a pencil eraser NR 511 Completed Midterm study guide (2020) Complete A+ Guide. or ointment, topical minoxidil solution and foam, or topical corticosteroid creams. Topical treatment with a potent corticosteroid is preferred by PCPs because it is not invasive and is simple to use, although it is not as effective as intralesional injections Atopic dermatitis (eczema) is not considered a distinct entity but is a descriptive term for a group of skin disorders characterized by pruritus and inflammation whose distinct cause is unknown. Eczema is a more general term that is often used collectively to describe skin of an erythematous and inflamed appearance Family history of atopic disease Skin infections Stress Temperature extremes Contact with irritating substance (wearing new clothing prior to washing, harsh soaps, skin products with perfumes) With atopic dermatitis it characterized by an extremely low threshold for pruritus and has been called “the itch that rashes” because the itch almost always comes before the rash appears, and scratching the rash worsens it clinically. A cardinal sign of atopic dermatitis is severe pruritus and diagnosis cannot be made without the history of pruritis. The patient may also report a personal or family history of other atopic conditions (asthma, allergic rhinitis). Rash is often reported as better in the warmer months and worse in the fall and Atopic dermatitis usually begins as infantile eczema, with lesions on the cheeks, face, and upper extremities. Erythema is often seen before pruritus and the acute lesion are excoriated, maculopapular, and inflamed. Eczema presents as a group of pinpoint pruritic vesicles and papules on a coin- shaped, erythematous base and usually worsens in winter. In infancy and early childhood, oozing, and crusting usually characterize the erythema. As children become older, the disease can go into remission or change Usually none done Skin biopsy to rule out other skin disorders 80% of patients may have eosinophilia during episodes of disease activity Serum allergy testing available Nonpharmacologic management: Avoid excessive dry skin Use emollient Soak bathes preferred with lukewarm water Pat dry Moisturize liberally after partial drying Avoid fragrance perfumes and bath oils, avoid cosmetics, deodorants, and preservatives Avoid agents that contain alcohol, lactic acid, or other alpha- hydroxy/glycolic acids that would aggravate their condition Humidifiers are helpful at maintain skin hydration Avoid skin trauma: use Sunscreen Bleach baths: 3 times weekly ¼to ½ cup household bleach in a full tub of water; soak 20 minutes. And liberally apply moisturizer Pharmacologic First step in treatment is to avoid known triggers: Liberal use of emollients to prevent dry skin Avoid known precipitating factors (wool clothing, detergent or soaps with fragrance, etc) Keep environment free of dust as possible Use of air purifiers and humidifiers Eliminate carpets; clean bedding weekly, use mattress protectors to reduce dust mites Wash bedding in 120 to 130 degrees F Humidity in the home should be no more that 50 % Education on NR 511 Completed Midterm study guide (2020) Complete A+ Guide. winter. to flexural distribution occurring in the antecubital fossa and neck area. Flexural eczema last between ages 4 to 10 but can last into adulthood. In adults, eczema presents with symmetrical lesions that are crusting and excoriated. In its early stages, lesions may be erythematous, papulovesicular, edematous, and weeping. Later the rash becomes crusted, scaly, thickened, and lichenified. The classic locations are noted to correspond to areas that are most accessible to rubbing and scratching, flexural areas are involved. management If skin lesions are wet or have exudate wet soaks or compresses with cool tap water, Burrows (aluminum acetate) solution (1:40 dilution), saline (1 tsp per int of water), or silver nitrate solution (1 to 10%) can be used to dry the lesions and provide comfort. Burrows solution can be applied as a compress for 20 to 30 minutes Topical corticosteroids (creams are preferred) are the mainstay therapy (use lowest potency to control symptoms) Antihistamines (oral or topical) for itching Emollients 2 to 3 times per day (Eucerin, Lubriderm, Cetaphil) Oral corticosteroids may be used in severe cases only for short bursts Topical calcineurin inhibitors Elidel cream 1% or Tacrolimus ointments 0.03% and 0.1% maintenance dosing twice a week for 12 months, use moisturizers on other days Dry skin treated with corticosteroid therapy will exhibit minimal response; however, use for 7 days or less may ease symptoms of erythema and pruritus watching for signs and symptoms of secondary bacterial infection and to report them immediately so that oral antibiotics can be prescribed Bleach baths, are helpful at reducing secondary bacterial infections Keep nails clean, smooth, and short to reduce risk of skin trauma Basal Cell carcinoma Chronic accumulated Adult or elderly patient Appears in areas of Suspicious lesions (if Simple excision of area; Avoidance of NR 511 Completed Midterm study guide (2020) Complete A+ Guide. (most common”): malignant tumor of the skin that originates in the basal cells of the epidermis. It is a slow-growing and locally invasive tumor that rarely metastasizes. sun exposure. Seen more in older adults and elderly. UV light and IVB exposure. Those of Celtic background (Irish, Scottish, English), light skinned, light haired, blue eyed, freckles, and who sunburn easily. Men more at risk. Hx of skin cancer, basal cell nevus syndrome, precancerous lesions including acitinic keratosis, hx of burn scars or areas of skin damaged by chronic inflammation or ulcers and hx of immunosuppression. Environment hx: us radiation (sunlight), exposure to arsenic, polycyclic aromatic hydrocarbons, or radiation. who presents with complaints of a spot or a bump that is getting larger or a sore that is not healing. Often the lesion appears as a thick, rough patch that may bleed if scratched or scraped. Some patients think they are warts with a raised border and crusted surface. The skin lesion may be pruritic or asymptomatic. skin that are chronically exposed to the sun, such as the face, ears, cheeks, nose, and the neck. Nodulo-ulcerative BCC is characterized by elevated papules that have a pearly appearance, with some crusting. When the crusts are removed, a small amount of bleeding ensues. On close examination, telangiectatic blood vessels are seen on the border of the lesion. Borders appear rolled. A central ulceration is seen during the later stages of BCC lesions. BCC lesions may be the same color as the patient’s skin or have areas of variegated color such as blue, black, or brown. Superficial BCC appears similar to dermatitis, with erythema and scaling bordered by a fine rim. The sclerosing, or morpheaform, type of not located on the face) can be biopsied by an experienced primary-care practitioner or referred to a dermatologist. Because BCC rarely metastasizes, staging of the lesions is not necessary. electrodesiccation and curettage; cryosurgery (liquid nitrogen), and laser surgery. Moths microsurgery has highest cure rate. This method involves less scarring and suited for areas of cosmetic important. imiquimod cream (used five times weekly), topical 5-fluorouracil (5-FU), and photodynamic treatment (used for both nodular and superficial forms) utilizing a photosensitizer with blue wavelength phototherapy to create reactive oxygen species. excessive sun exposure is an important factor in preventing these skin cancers. F/u with dermatologist or oncologist for any suspicious skin cancers. Survivors of nonmelanomatous skin cancer should be informed of their increased risk of developing a second lesion or of recurrence of the original lesion. Thus, these patients in particular should be instructed to report any changes in existing moles or the development of new or rapidly growing lesions. Avoid sun exposure from 11am-4pm; wear protective clothing like long sleeves and hats; wear sung glasses; avoid tanning beds; apply sunscreen as directed. Learn the ABCDEs of malignancy NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Increased cell turnover ( hemoglobinopathy, SS, thalassemia) are at increased for TAC. Immunodeficiency (HIV; congenital), 40% of pregnancy women not immune. this stage. Begins 1-4 days after stage 1 and last 1-6 weeks. Stage 3: 2-3 weeks of the body rash. This rash may come and last up to 3 weeks. Rash may be pruritis and recurrent, exacerbated by bathing, exercise, sun exposure, heat, or emotional stress. B19 may manifest as painful pruritic papules and purpura on the hands and feet. Been exposed to b19. for b19 related refractory anemia or PRAC, especially in immunodeficiency states. Intrauterine RBC transfusions reduce mortality in cases of fetal hydrosphere. Joint symptoms subside in weeks (often by 2 weeks but may last months). Full recovery from aplastic crisis in 2-3 weeks. Erythema migrans (bull’s eye rash) associated with Lyme Disease Tick infested area from April through November. Where ixodid ticks are found. These ticks are common on deer. Initially patient may complained of flu-like symptoms, including fever, chills, and myalgia. May report a rash that grew in size. Most patients with Lyme disease don’t remember a tick bite. Later in the coarse, malaise, fatigue, neck pain and stiffness, and generalized pain may occur. When left untreated, it progresses to arthritis or one or more joints. May complain of memory loss, cognitive disturbances, mood Erythema migrans is typically located on parts of the body where the tick selectively feeds, such as the axilla, groin, and waistline. occasionally pruritic and/or burning, may develop central clearing, and is typically greater than 5 cm in size This rash usually diagnostic of LD. Carditis, neurological manifestations, and radiculoneuritis (triad 2 step process EIA and then Western Blot assay. Children 8 years and > and no pregnant adult patients, give single dose of doxycycline 200mg. Alternative agents include amoxicillin (Amoxil), cefuroxime (Ceftin), and erythromycin (E- MycinAlternative agents include amoxicillin (Amoxil), cefuroxime (Ceftin), and erythromycin (E-Mycin). Wear appropriate clothing to prevent tick bites and avoid high risk areas where ticks reside. Wear tick repellant. After removing cloths, inspect Alikhan groin, waistband areas for ay attached ticks or bites. For those already infected, teach treatment action plan with possible residual symptoms. Re-infection possible if in high NR 511 Completed Midterm study guide (2020) Complete A+ Guide. changes, and peripheral neuropathy in addition to arthritis. known as Bannwarth syndrome). risk area. Folliculitis: a superficial to deep skin infection of the hair follicles. Mainly caused by gram- positive bacteria, occasional by fungus or by gram-negative bacilli. Bacteria infect the hair follicle at a superficial level which leads to the clinical presentation of little pustules or erythema surrounding the base of the hair follicle. Pseudomonas folliculitis presents as follicular erythematous papules, pustules, or vesicles over the back, buttocks, and upper arms. Associated features include pruritus, malaise, low- grade fever, sore throat and eyes, and axillary lymphadenopathy. This type of folliculitis usually resolves spontaneously within 10 days. Common in middle-age (40-60) and children, especially if immunocompromised. Predisposing factors include diabetes, obesity, a chronic carrier of Staphylococci (present in the nares, axillae, or perineum), poor hygiene, hyperimmunoglobulin E (Job’s syndrome, a primary immunodeficiency disorder), exposure to chemicals and solvents (cutting oils), and chronic skin friction. Wet environment, inadequate chlorinated pools. Those on long term, oral ABX like tetracycline for acne or rosacea or older men with seborrhea. Prolonged steroid users. At risk for Candida folliculitis due to antibiotic use which kills normal flora May occur anywhere on Pt shaves, burrowed someone razor, or was recently in a hot tub. Complains of bumpy rash that can appear anywhere on the body. Rash located on hair follicles of face, forehead, back of earlobes, neck, shoulders, buttocks, torso, or extremities. Usually NOT accompanied by itching. No hx of previous skin eruptions or of pertinent hx of diabetes. Lesions can range from minute white- topped pustules in newborns to large, yellow-white tender pustules in adults. NO involvement of surrounding skin. Eyelids, face, scalp, and extremities most common sites. A hair in the center of the pustule sometimes perforates the lesion. This presentation is a hallmark for diagnosis. Pustules resolve into red macules, which fade to leave post inflammatory hyperpigmented scars in susceptible persons. Folliculitis is usually asymptomatic, but it can be very pruritic and is sometimes accompanied by burning Check adjacent lymph nodes for spreading lymphadenitis. H&P; sampling pustule to identify pathogen for gram strain and culture to help differentiate folliculitis from other bacterial infections. Obtain KOH prep to see under microscope in office if a fungal infection is suspected. Topic ABXs: mupirocin (Bactroban), Retapamulin (altabax), Clindamycin, Erythromycin. Antifungal for fungal – ketoconazole (Nizoral) may be in cream, shampoo, or tablet form With deeper forms of folliculitis, especially in the presence of positive blood cultures or systemic symptoms, an ER referral for hospitalization and IV antibiotics are recommended. Clearance of nasal colonization of Staph. Aureus by treatment with mupirocin intranasally BID x 5 days has been shown to significantly reduce the incidence of recurrent folliculitis. Eosinophilic folliculitis treated with anti- inflammatory agents. 1st- line is systemic indomethacin AND topical corticosteroids. Large pustular lesions with necrotic areas should first be cleansed with a weak soap solution, followed by Gentle cleansing by washing the skin twice daily with an antibacterial soap. Hand-hygiene and good hygiene. Avoid shaving during treatment to allow healing. Electric shaver preferred once shaving is resumed. Avoid burrowing or using older razors when shaving infected areas. Avoid tight fitting cloths. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Shaving folliculitis is the result of sebaceous follicles which are colonized by gram negative bacteria become infected due to trauma from shaving. “Hot tub” folliculitis is a form of folliculitis that is caused by pseudomonas aeruginosa, which can withstand temperatures of up to 107 degrees F and chlorine levels up to 3mg/L. skin as a result of trauma or damage to hair follicle from chronic irritation or friction soaking of (or the use of compresses on) the affected skin with saline or aluminum subacetate twice daily. When the skin is softened, the clinician can gently open the large pustules and trim away necrotic tissue. Hand Foot and Mouth Disease (HFMD) a contagious virus mostly occurring in young children which is caused by the coxsackievirus A16 and enterovirus 71. Prior to the rash the patient may a have low- grade fever, fatigue, or sore throat 1–2 days prior to rash Vesicles on the hands and feet with mouth sores. Mouth sores are in almost 90% of the cases and are usually the first sign. There can be more than 10 mouth aphthae (sores) anywhere in the oral cavity and frequently are asymptomatic. The hand vesicles appear with erythematous halos and appear mostly on the soles and palms. Vesicles might appear on the legs, buttocks, and face. The lesions do usually resolve The management is symptomatic care for the patient. The patient or the patient’s parents need reassurance that there won’t be scarring and/or that it is not some other rare skin disorder. The patient is considered contagious 4–6 days prior to outbreak and should not return to school or activities until the lesions are scabbed. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Family History: Melanoma Environmental History: Excessive exposure to ultraviolet radiation, exposure to indoor tanning. with an irregular border, notching, and a diameter greater than 6 mm. Often exhibits variegation in color with blue, red, tan, brown, black, and white. Rarely, tumors might be amelanotic. Early nodular tumors are typically flat and may lack typical characteristics of melanoma. There is an increase in thickness which causes elevation into a firm nodule as the tumor advances. Even though there is an emphasis placed on lesions being more than 6 mm, early melanoma can be smaller than 6 mm in diameter. Diagnosis usually requires skin biospy. Nailbed or subungual melanoma may be observed in older patients and is most commonly found on the thumb or great toe. Posterior nailbed involvement, staging, which is useful as a predictor of prognosis and a guide for treatment. Thickness or depth of melanoma is a critical factor in determining both prognosis and choice of therapy. Breslow depth classification system has been used as a prognostic factor and Clark staging system of tumor invasiveness is used. Clark’s Levels: I - confined to dermis II - extends through the basement membrane and into the papillary dermis (upper portion) III- Extends into the papillary dermis IV- Extends into the reticular dermis V- Invades the deep subcutaneous tissue Breslow’s Method: (% = 5-year survival rate) Less than 1 mm = 92%-97% 1.01-2mm = 81%-92% be managed. If melanoma is located on a limb, high-dose chemotherapy via isolated limb perfusion is available. Circulation of the limb is isolated by a tourniquet at the root of the affected limb. High-dose chemotherapy is infused and limited to the affected limb only, minimizing adverse systemic effects. External beam radiation is usually reserved for palliative treatment. For metastatic lesions of the lung, brain, or viscera that cause pressure on tissue, radiation therapy is used to reduce the tumor’s size and provide pain relief. Biological therapy such as high-dose interferon and interleukin-2 in high-risk patients has shown promise with preventing recurrence. Vaccines are currently being developed that stimulate immune function against melanoma tumors. A- Asymmetry B- Border irregularity C- Color change D- Diameter larger than a pencil eraser (6mm) E - Evolving (changing) over time; elevated (raised) lesion. Proper use of sunscreen (risk doubles with more than five sunburns). Should avoid the sun during the hottest part of the day, daily application of high- SPF sunscreen, wear hats to protect scalp and back of neck. Wearing loose fitting clothing provides some protection if all areas of skin are covered. Tanning beds are hazardous and considered a moderate risk (Class II). Survivors of melanoma should be informed of NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Hutchinson’s sign, is an ominous physical finding associated with advanced disease. 2.01-4 mm = 70%- 81% More than 4 mm = 53%-70% Diagnosis of melanoma requires excision of melanoma and margins by dermatologist or oncologist. Excisional biopsy is sufficient for removal of atypical nevi. A patient who has dysplastic nevi should receive regular skin surveillance, about every 6 months by dermatologist. Subsequent testing may include a lymph node biopsy via computed tomography (CT) - guided needle aspiration. Lymphatic drainage mapping and sentinel node biopsy have been shown to identify occult metastases by employing a technique that identifies the lymph node specifically draining the area of increased risk of second primary tumor or recurrence of previous lesion. Any change of existing lesion or new pigmented skin lesion should be reported to PCP and dermatologist. Should also report swelling in lymph nodes of neck, axilla, or groin area. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. the skin that contains the melanoma. This node, called the sentinel node, is excised and examined for melanoma cells. If any cancer cells are present, the remaining nodes in the area are dissected. If biopsy of the sentinel node is negative, metastasis is unlikely and recurrence rates are low. If metastatic disease is suspected, a thorough physical examination, laboratory tests, x-ray studies, and CT scans are done to evaluate for distant metastases. Melasma Butterfly face Pregnancy mask Sun exposure and hormones (e.g. pregnancy, oral contraceptives),; tanning beds. This is seen mostly in women Darkening of skin “hyperpigmentation of certain areas of the skin,” typically on face Clinical impression Skin-bleaching creams (hydroquinone), topical retinoids, laser therapy. Avoid sun exposure,, use sun- screen, wear hats in sun; otherwise a benign condition. Molluscum Most common among -itchy, red, swollen, Tiny pustules which -Thorough H&P; can There is a consensus that -Keep your NR 511 Completed Midterm study guide (2020) Complete A+ Guide. the scalp with medications wash hand after treatment Pityriasis rosea Affects people of both sexes; more common in females, and in 15–30 years age group although also seen commonly in elderly and children The eruption is usually preceded by a prodrome of sore throat, gastrointestinal disturbance, fever, upper respiratory tract infection, viral infection, and arthralgia. Rash can be itchy and patient may have a low-grade fever, headache, and fatigue. 1st a herald patch appears, typically on the trunk. The large lesion is commonly 2 to 10 cm in diameter, ovoid, erythematous, and slightly raised, with a typical collarette of scale at the margin. Collarette scaling is seen typically. 2-3 weeks later, a general rash appears. Resembles shape of Christmas tree on the trunk. Face, Palmar, and sole surfaces usually spared. H&P Management includes antihistamines, and unlike Fifth’s disease the sun could help the rash instead of exacerbate the rash. Acyclovir for 1 week may decrease severity. . Patients may be contagious 7-14 days prior to rash eruption Rash can possible last 1-2 months or even longer. Returning to activities will depend on the patient’s symptoms, by the time the rash has appeared though, the patient is not contagious anymore. Psoriasis Prevalence is highest among Scandinavians, with rates slightly higher in northern rather than southern Sweden, further supporting the role of climate and sunlight exposure in the expression of the disease. Adult men and women are affected with equal frequency. The two peak ages of onset are Patients with psoriasis usually present to the practitioner with concern over “itchy, red, inflamed and dry, scaly plaques that have gotten worse.” Statements about the onset and course of the disease are highly variable among patients. Symptoms usually begin gradually and are confined to Physical examination reveals erythematous plaques surrounded by a thick, silvery scale (which is not easily removed), resembling mica. When these micaceous scales are traumatically removed, multiple small sites of bleeding appear (Auspitz’s sign). In intertriginous areas, maceration and Initial laboratory studies include routine testing with a CBC with differential to assess for infection and a serum chemistry profile with a serum uric acid level. Laboratory tests are generally within normal limits in psoriasis, except for the serum uric acid level, which may be The goal of therapy for psoriasis is to control the disease so that the patient no longer feels physically or psychologically hindered by the skin lesions. For sparse or mild lesions that do not bother the patient, no treatment may be needed. When treatment is indicated, however, the disease is controlled by decreasing epidermal proliferation Psoriasis presents many challenges to both the patient and the health-care provider. For patients with disfiguring and difficult-to-control psoriasis, education and support are central to the treatment process. The patient should be informed of NR 511 Completed Midterm study guide (2020) Complete A+ Guide. during the late teens to early 20s and in the late 50s to early 60s. Women and adolescent girls tend to have an earlier onset than males, and earlier onset is associated with a more severe disease. There is little to no epidemiological evidence that psoriasis is mediated by infectious agents. Psoriasis has a strong genetic influence, with one-third of patients with psoriasis reporting having a relative with the disease. In family studies, when one parent is affected, 8% of offspring develop psoriasis and tend to have an earlier onset. When both parents have psoriasis, the percentage increases to approximately 40%. The mode of genetic transmission is not yet defined, however. Trauma to normal skin (in patients with preexisting psoriasis) that develops into new psoriatic lesions (Köbner phenomenon) Physical, chemical, electrical, surgical, infective, or inflammatory insults only a few areas (e.g., one or both elbows, the knees, buttocks, or scalp), but psoriasis can also be explosive in onset. Three tools commonly used to assess the severity of psoriasis are as follows: 1. The Psoriasis Area and Severity Index combines the assessment of plaque severity (erythema, induration/thickness, and scaling) and the extent of skin surface area affected; it is the most widely used assessment tool for psoriasis in clinical research and practice settings. 2. The Dermatology Life Quality Index has the patient self-rate the impact of the condition on important aspects of his or her life. 3. Affected body surface area is an assessment of the overall skin area involved by percentage. moisture prevent dry scales from accumulating, but the lesions remain red and sharply defined. Lesions usually are distributed symmetrically over areas of bony prominences such as the elbows and knees. Scaly plaques also occur frequently on the trunk, scalp, intergluteal cleft, and umbilicus. The latter three areas are frequently overlooked by the patient and clinician but are important in making the diagnosis, especially in patients with associated psoriatic arthritis and limited skin lesions. In fact, the nature of such inflammatory arthritis may only become apparent after typical psoriatic skin lesions are recognized. Nail involvement may include stippling or pitting of the nail plate or a yellow to red-brown coloring (“oil-staining”) of the nails (nail psoriasis). elevated (hyperuricemia). In more severe variants of psoriasis, other specific tests may be ordered. Throat culture is appropriate if Streptococcus pyogenes infection is suspected as the precipitating factor (as in guttate psoriasis). Immunoglobulins are generally normal, but selective IgA and IgG deficiencies are observed in some patients. In pustular psoriasis, leukocytosis and hypocalcemia are seen. An elevated erythrocyte sedimentation rate and decreased albumin levels, along with anemia, can be observed in chronic disease. X-ray studies of the hands are sometimes helpful to search for associated psoriatic arthritis in patients who complain of joint pains in their hands. X-ray of patients with psoriatic arthritis will show extensive erosion and luxation of distal and underlying dermal inflammation through the use of topical corticosteroids and other immunomodulatory agents, along with phototherapy in some patients. Systemic agents are reserved for moderate to severe or recalcitrant cases. Topical agents are first-line pharmacotherapeutics for psoriasis that are usually effective. If less than 20% of the body (e.g., no more than the elbows, knees, ears, and scalp) is involved, topical agents are usually sufficient. However, if more than 20% of the body is affected and manifestations are moderate to severe, systemic therapy may be warranted, and referral to a dermatologist is recommended. For stubborn, persistent, and widespread lesions, ultraviolet (UV) light treatment should be strongly considered. Systemic therapy in psoriasis is usually used as a last resort because the significant effectiveness of biological agents must be weighed against their high cost and side-effect available community resources and support groups. Explanation of the disease process and treatment, including potential adverse effects of medications, is helpful. A newly diagnosed patient and his or her family should be reassured that the disease is not contagious or infectious. Patients need to understand that psoriasis may be an added risk for health problems in the future, such as cardiovascular and psychological comorbidities. Overweight and obese patients should also undergo dietary counseling. Although the genetic aspects of psoriasis are complex and incompletely characterized, it may be explained to family members of a patient that if neither of the patient’s parents has psoriasis, the NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Infections: HIV, Streptococcus Endocrine and metabolic factors: Postpartum period Hypocalcemia (e.g., after dialysis and parathyroidectomy) Weather-related factors: Extreme cold weather Prolonged exposure to sunlight* or hot, humid weather (more exacerbations occur in summer) Medications: Systemic corticosteroids Lithium Beta-adrenergic blockers Antimalarial drugs NSAIDs Psychogenic factors: Stress Mood disorders, e.g., depression Other factors: Fatigue Alcoholism Smoking An accumulation of yellow debris under the nails, simulating a tinea infection (tinea unguium), is seen in some patients. Swelling, redness, and scaling of the paronychial margins occur often and are associated with arthritis of the distal interphalangeal joints. The clinical course of this disease is characterized by chronicity and seasonal fluctuations, with improvement in the summer (due to sun exposure) and worsening in the winter as dry skin leads to epidermal injury. Up to 10% to 20% of patients with psoriasis may also have an inflammatory arthritis known as psoriatic arthritis, although the most common form of arthritis seen in psoriasis patients, as in the general population, is osteoarthritis. interphalangeal or metatarsophalangeal joints bilaterally, with characteristic “pencil- in-cup” erosive abnormalities of the interphalangeal joints. In these abnormalities, the distal head of a bone becomes pointed like a sharp pencil, while the adjacent articular surface becomes rounded, like a cup. Biopsy is seldom necessary because the clinical features of psoriasis are so distinctive. Of note, the sudden onset of psoriasis, in particular erythrodermic forms, may be associated with HIV; thus, the presence of underlying HIV infection should be ruled out in such patients, if unknown. profile. Systemic therapy is reserved for patients with severe incapacitating disease—pustular, guttate, and/or arthritic psoriasis. It is administered only by expert specialists such as rheumatologists or dermatologists who regularly use systemic antimitotic agents, including methotrexate, etretinate, and cyclosporine. Monitoring of blood counts, including platelets, should be done weekly in patients taking methotrexate, followed by monthly testing. Renal and liver function tests (baseline and follow-up studies) should be done. Intermittent liver biopsies may be needed with chronic dosing because hepatic fibrosis may occur with prolonged use. Methotrexate is teratogenic and should not be given to those who are pregnant or who want to become pregnant. Utilization of complementary therapies for psoriasis is growing. Therapies include dietary modifications, herbs and supplements, mind–body therapies (e.g., chances are less than 10% that another child will develop the disease. If one parent is affected, the chance of a child developing psoriasis increases to 15%. If both parents are affected, the chance increases to approximately 60% that one or more children will have the disease. The clinician should educate the patient that there are several ways of remaining in remission, once treatments have taken effect. Patients with psoriasis should avoid skin trauma and should keep the skin relatively dry to decrease pruritus, scratching, and scaling. They should avoid photosensitizing medications such as tetracyclines, sulfa drugs, or phenothiazines. If drugs of these types are necessary, patients should be NR 511 Completed Midterm study guide (2020) Complete A+ Guide. hot or cold weather, wind, overheating during exercise, excessive alcohol ingestion, hot beverages, spicy or aged food products such as cheese, emotional stress, irritating cosmetics, hot baths, saunas, hot tubs, smoking, caffeine, and excessive washing of the face. Inflammation instead of infection seems to be the primary mechanism. eyes. Although the lesions tend to be symmetrical bilaterally, they may appear on only one side. Seborrhea may also be seen. If there has been ocular involvement resulting in blepharoconjunctivitis , there will be redness of the eyelids and conjunctiva. With prerosacea, the clinician will note a rosy-cheeked, ruddy complexion on a patient who never develops the full clinical spectrum of the disease. There is no effective treatment for prerosacea, nor is any needed. Patients should just be observed for signs of developing rosacea and encouraged to use sunscreen. There are four subtypes of rosacea classified by the pattern and grouping of symptoms: • Subtype 1: erythematotelangiect atic rosacea—flushing and persistent 8 weeks for a therapeutic response to be seen. If metronidazole (0.75% or 1%) is not effective, other topical antibiotics may be tried. Topical ointments such as tretinoin and azelaic acid are also recommended. Antibiotics should be reserved for flare-ups or when initiating therapy with topical medications, after which antibiotics should be discontinued. Clinicians should taper the dose as soon as possible; typically patients can readily learn how to taper the dosage at home. Treatment with tetracycline, minocycline, or doxycycline typically delivers a rapid therapeutic response. Antibiotic therapy is usually effective in reducing acneiform lesions, and this helps confirm the diagnosis of rosacea. These antibiotics typically work more as anti-inflammatory agents rather than as anti- infectives. The flushing and flat telangiectasias of rosacea tend to persist and do not respond well to antibiotic therapy. In refractory cases, isotretinoin may succeed hot days and protect their face from cold air and wind by using a scarf. Caution should be used when exercising, and patients should be encouraged to exercise for shorter, more frequent intervals, using a cool towel around the neck and taking frequent water breaks. Gentle cleansing with fragrance-free facial cleansers should be encouraged. Proper use of topical creams and lotions should be stressed, along with the use of minimal antibiotics. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. redness, which may include visible blood vessels • Subtype 2: papulopustular rosacea—persistent redness with transient bumps and pimples • Subtype 3: phymatous rosacea— skin thickening usually with hyperplasia of the nose, resulting in a large, bumpy, and bulbous appearance • Subtype 4: ocular rosacea—ocular manifestations with dry eye, tearing and burning, erythematous eyelids, recurrent styes, and possible vision loss from corneal damage. when other measures have failed. Electrocautery with a small needle may be used to destroy small telangiectasias. Larger telangiectatic vessels may require laser treatment (intense pulsed light therapy). For men with rhinophyma, surgical reduction may be used to reduce the bulbous appearance of the nose. Roseola Infantum (AKA 6th disease) – caused by the human herpes virus types 6 and 7. Virus is mild and common in children under age 2; spread via saliva. Short lives 3-5 days Symptoms: high fever, irritability, diarrhea, cough, and cervical lymphadenopathy. The skin rash presents with light pink, erythematous macules and papules on the face, neck, and extremities. Rash resolves in 1-3 days. Scabies Poverty, overcrowding, poor hygiene, malnutrition, sexual promiscuity Generalized itching and is occurring in finger webs, flexor surfaces of wrist, Lesions (inflammatory, erythematous, pruritic papules) Easily missed Consider diagnosis in patient of any age with persistent & 1st line treatment Lotions containing scabicides: Permethrin lotion Do not exceed recommended exposure times of medication (wash NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Occurs mainly in children, young adults, health-care workers, institutionalized persons Hot tropical climates; immunocompromised patients elbows, axillae, buttocks, genitalia, feet, ankles, and spared head/neck in adults Potential contact with infected person. Asymptomatic for 3-4 wks after initial/primary infection commonly found in finger webs, flexor surfaces of wrist, elbows, axillae, buttocks, genitalia, feet, ankles, and spared head/neck in adults Pustules may be from secondary infection Prutitic nodules in covered areas (buttocks, axillae, groin) Crusted scabied (or Norwegian scabies) is a psoriasiform dermatosis occurring with hyperinfestation with thousands/millions of mites (more common in immunosurpressed patients) severe pruritus Burrow Ink Test Rub felt-tip marker over suspected burrow Remove excess ink with alcohol wipe Remaining ink will concentrate in the burrow tunnel Once burrow identified Drop mineral oil over burrow Scrape off burrow with #15 scalpel blade Scrapings onto slide identification of S. Scabiei mite, eggs or fecal matter = + diagnostic Just because no + diagnostic, does not rule out scabies 2nd line treatment Lindane 19% (gamma- benzene hexachloride) Most toxic off lotion as prescribed) Signs of toxicity irritability seizures Secure storage of treatment products (prevent children from ingesting) Itching may last up to 1 week after treatment (due to local irritation) May need to repeat treatment All persons in household & close contact should be treated All environmental reservoirs (bedding, clothing, towels, etc) must be cleaned with HOT water & detergent Spraying pesticides is ineffective & not recommended Trim fingernails (reduce risk of harboring mites) Children in daycare/school can return after treatment Squamous Cell carcinoma: a malignant tumor originating from keratinocytes, can invade the dermis and occasionally men are twice as likely to develop BCC and three times as likely to develop squamous skin cancers compared with women. adult or elderly patient who presents with complaints of a spot or a bump that is getting larger or a sore that is not healing. Found on sun- exposed areas, such as the lips, the tips of ears, the nose, the upper cheeks, the scalp (in bald men), the dorsa of the Suspicious lesions (if not located on the face) can be biopsied by an experienced primary-care practitioner or referred to a Management of nonmelanomatous skin cancers is dependent on several factors: size and depth of the invasion, location, cosmetic concerns, and metastasis Recurrence may occur within 3 years of treatment Avoid sun exposure; wear protective clothing, hats, sunglasses, apply NR 511 Completed Midterm study guide (2020) Complete A+ Guide. hyperpigmented spots. Will complain of these macules to back, upper chest, arms, and sometimes neck and face. neck. In children, rash common on face or forehead. Sometimes very fine scales are visible, especially if patient has not showered or bathed for several days. Daily bathing usually eradicates the scales. lesions) or Pityrosporum ovale (which produces oval lesions); Clotrimazole 1% cream and solution (Lotrimin) twice daily for 2-8 weeks Terbinafine 1% solution (Lamisil solution) twice daily for 1 week. Education: Do not use on face or mucous membranes; avoid broken or irritated skin. Ciclopirox 0.77% cream, lotion (Loprox) twice daily for 2-4 weeks. Do not use in children younger than 10 years. Avoid occlusion. Ketoconazole 2% shampoo (Nizoral) 1 application applied to damp scalp, leave for 5 minutes and rinse Econazole 1% cream, foam (Spectazole) (Ecoza) once daily for 2 weeks Sulconazole 1% cream, solution (Exelderm) 1-2 daily for 3 weeks Oxiconazole cream, lotion (Oxistat) 1-2 times daily for 2 weeks Fluconazole (diflucan) 150- 300mg single weekly dose for 2-4 weeks of 300mg weekly for 2 weeks Itraconazole 200mg daily for 7 days of recurrence because P. orbiculare (M. furfur) is a normal habitant of the skin. sunlight can speed up resolution of hypopigmented spots. High risk of hepatotoxicity with systemic (oral) antifungals and treatment does not prevent recurrence. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Some success with photodynamic therapy Trichotillomania (hair pulling) - jenna Seen more commonly in children and teens. Family hx, age, stress, depression, anxiety, obsessive-compulsive disorders (OCD). Reports balding, sense of pleasure with pulling hair, or pull hair without realizing it. Pull hair due to stress, anxiety, tension. Compulsive hair pulling may be observed. Nonscarring alopecia. Usually on the same side of the dominant hand and may include more than just scap hair (eye lashes, eye brows, and beards) Observation Refer to dermatologist or psychologist. An SSRI for 1st line treatment of OCD in children and adults. Cognitive behavior therapy is another option as a first line management for OCD. Varicella Immune compromised such as AIDS and HIV Risk -No prior history of varicella -No vaccination -Immunocompromised **Patients are contagious for 2 days prior the appearance of the rash and until all lesions have crusted. **infection in adults is more likely to produce serious illnesses subjective -Malaise -Anorexia -Abdominal pain -Headache -fever/chills -arthralgia -Childhood: onset of exanthem Then 1-2 days later, the urticarial (or itching) erythematous macules and papules appear, which quickly turn unto vesicles and pustules. Rash starts on the face and chest then spreads over the entire body. The blisters may even appear in the ear canal or mouth. Lesions dry up within 1 week. Rash with widely distributed papules and vesicular lesions; appear on head and neck area objective rash phase -small erythematous macules appear on the scalp, face, trunk and limbs with rapid progression within 12- 24 hrs to papules, clear vesicles and pustules with central umbilication and form crusts. -vesicles appear on palms, soles, mucous membranes, oropharyngeal area and urogenital areas Diagnostic none indicated unless in pregnant women -tzanck smear -vesicular fluid culture -serology -chest xray if pneumonia suspected -PCR Treatment is symptomatic care with oral antihistamines for itching, NSAIDS, cool compresses, and oatmeal baths. Valacyclovir (Valtrex ) 1 gm po q8h for 7 days or Acyclovir (Zovirax) 800mg po 5 times a day for 7-10 days or Famciclovir (Famvir) 500mg po TID for 7 days plus topical silver sulfadiazine for skin lesions. No evidence of fetal harm if used during pregnancy. treatment *Non pharmacologic -Supportive therapy -good hygiene to prevent bacterial secondary infections -cut fingernails short to prevent scratching in education -Do not immunize pregnant women -In pregnant woman who has never had chicken pox or immunization, avoid contact with recently vaccinated individuals for 6 weeks Prevention includes vaccination. A patient is contagious 2-3 days before rash erupts and may return to school, sports, or work after lesions have scabbed over. A client who has a varicella rash can return to work once all the vesicles are crusted over. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. younger children -Tepid bath, oatmeal bath for itching *Pharmacologic Skin protectant such as calamine antipyretics: avoid aspirin due to increased risk of Reye’s syndrome with varicella patients -Antiviral agents: consider in adolescents, adults and high-risk patients to decrease viral shedding and duration of fever Acyclovir (2-16 years old) 20mg /kg/dose (max 800 mg /dose, 4 times daily for 5 days Famciclovir (adults): 500 mg 3X daily for 7 days-10 days Valacyclovir (adults) : 1g 3 X daily for 7-10days diphenhydramine, hydroxyzine or other antihistamine for itching Varicella is contagious 48 hours before the onset of the vesicular rash, during the rash formation (usually 4-5 days), and during the several days it takes the vesicles to dry up. The characteristic rash appears 2 to 3 weeks after exposure. Verruca vulgaris (Common warts): p.203 Small, hardened growths of keratinized tissue. Warts usually grow around nails, on fingers, and the backs of hands, but can appear Skin trauma, contact with wart exudate after treatment, immunocompromosed state Patients typically complain of a wart or small “bump” (or group of bumps) that has been present for several weeks to many months and sometimes for years. Some patients report the same wart being treated before and then recurring in the Common wart: rough-surfaced, elevated, flesh- colored papules None needed but if unable to distinguish lesions, small specimen can be sent for identification. Salicylic acid solution/plasters Cryotherapy with liquid nitrogen Surgical excision Studies suggest that one- half of warts resolve without treatment within Avoid contact with wart exudate from self and others by covering wart; avoid skin trauma Can cause scarring, autoinoculation, and nail deformity The clinician should educate the patient NR 511 Completed Midterm study guide (2020) Complete A+ Guide. (HAV) (HCV) (HDV) Virus (HEV) Transmission Fecal–oral through sewage- contaminated water and shellfish; possibly through blood Percutaneous and permucosal through infected blood and body fluids; sexual transmission Percutaneous through infected blood and body fluids; community, many infected individuals have no known risk factors Percutaneous, but must have co- infection with HBV Fecal–oral Incubation period (days) 15–50 (average 20–37) 25–160 (average 60–110) 42–49 Same as for HBV 10–56 Laboratory tests Anti-HAV IgM (acute); anti-HAV IgG (resolving) HBsAg (confirms), IgM anti- HBs (acute phase), IgG anti- HBs (resolving/immunity), HBeAg, anti-HBe, anti-HBc (persists in carriers) Anti-HCV appears in 6–37 weeks Anti-HDV appears late Anti-HEV IgM detected within 26 days of jaundice; IgG antibody persists Immunity/immunizatio n 45% of United States population has antibodies against HAV; HAV vaccine available 5%–15% of U.S. population has anti-HBs; HBV vaccine available Unknown; no vaccine available People immune to HBV are also protected against HDV Unknown Prevalence Increasing in adults Decreasing in the United States 4% of post- transfusion hepatitis; 50% IV drug users Common in IV drug abusers Rare in United States; endemic in Southeast Asia, India, North Africa, Mexico Course/mortality Does not progress to chronic state; mortality is 0– 0.2% with fulminant hepatitis Chronic liver disease occurs in 1%–5% of adults and 80%–90% in children; mortality rate is 0.3%–1.5% Chronic active hepatitis develops in 70%–90% of cases; 20% develop chronic liver disease; mortality Chronic liver disease develops if present in chronic HBV; mortality rate is 2%–20% for acute icteric Does not progress to chronic liver disease; mortality rate is 1%–2% but as NR 511 Completed Midterm study guide (2020) Complete A+ Guide. rate is the same as for HBV hepatitis high as 10%– 15% in pregnant women TABLE 15.2 Herpes Simplex Infections Infection Location Commonly Affected Age Group Oral—labial herpes simplex Lips, oral cavity Children age 2–5 years, adults Herpetic keratoconjunctivitis Eyelids, periorbital area, cornea Newborns, adults Herpetic tracheobronchitis Pharynx, trachea, bronchi Older adults Herpes simplex encephalitis Temporal lobe of the brain Any age, primarily immunocompromised adults Herpes gladiatorum Shoulder, neck, knuckles, areas of contact Age 14 years and older (commonly seen in wrestlers) Herpetic whitlow Fingertip Age 1 year and older Lumbosacral herpes Trunk or back Adult Herpes simplex of the buttocks Buttocks Adult women Genital herpes Labia minora, labia majora, vagina, cervix, urethra, penis, rectal area Young and older adults, 1% of pregnant women Eczema herpeticum Face or any area of active or recently healed atopic dermatitis Infants, children, and adults, commonly with a history of atopic dermatitis Erythema multiforme Extremities, palms, soles of feet Age 20–30 years; more commonly seen in men than women Question 1. Treatment for achalasia may include: Balloon dilation of the lower esophageal sphincter. Question 2. Which oral medication might be used to treat a client with chronic cholelithiasis who is a poor candidate for surgery? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Ursodiol (Actigall). Question 3. All of the following medications are used for the control of nausea and vomiting. Which medication works by affecting the chemoreceptor trigger zone, thereby stimulating upper gastrointestinal motility and increasing lower esophageal sphincter pressure? Antidopaminergic and cholinergic agents, such as metoclopramide (Reglan). Question 4. Which is the most common presenting symptom of gastric cancer? Weight loss. Question 5. Margie, age 52, has an extremely stressful job and was just given a diagnosis of gastric ulcer. She tells you she is sure it is going to be malignant. How do you respond? “About 95% of gastric ulcers are benign.” Question 6. Marcie just returned from Central America with traveler’s diarrhea. Which is the best treatment? Supportive care. Question 7. Rose has gastroesophageal reflux disease (GERD). You know she misunderstands your teaching when she tells you she will: Have a snack before retiring so that the esophagus and stomach are not empty at bedtime. Question 8. Marty, age 52, notices a bulge in his midline every time he rises from bed in the morning. You tell him that it is a ventral hernia, also known as an: Epigastric hernia. Question 9. You are trying to differentiate between functional (acquired) constipation and Hirschsprung disease in a neonate. Distinguishing features of Hirschsprung disease include which of the following? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. As having metabolic syndrome. Question 3. Timothy, age 68, complains of an abrupt change in his defecation pattern. You evaluate him for: Colorectal cancer. Question 4. Ruby has a colostomy and complains that her stools are too loose. What food(s) do you suggest to help thicken the stools? Cheese Question 5. Martina, age 34, has AIDS and currently suffers from diarrhea. You suspect she has which protozoal infection of the bowel? Cryptosporidiosis. Question 6. When Sammy asks you what he can do to help his wife, who has dumping syndrome, what do you suggest he encourage her to do? Eat foods with a moderate fat and protein content. Question 7. Lucy, age 49, has pain in both the left and right lower quadrants. What might you suspect? Pelvic inflammatory disease. Question 8. You suspect appendicitis in Andrew, who is 18. With his right hip and knee flexed, you slowly rotate his right leg internally to stretch a muscle. He states that it is painful over his right lower quadrant. Which sign did you elicit? Obturator sign. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Rationales Option 1: Rovsing sign is pain elicited with deep palpation over the left lower quadrant (LLQ), with sudden resultant pain in the right lower quadrant (RLQ). This causes tenderness over the RLQ and is considered a positive finding. Option 2: Psoas sign is pain elicited when the patient is instructed to try to lift the right leg against gentle pressure applied by the examiner or when the patient is placed in the left lateral decubitus position, extending the right leg at the hip. An increase in pain is considered positive and is an indication of the inflamed appendix irritating the psoas muscle. Option 3: Obturator sign is elicited when, with the patient’s right hip and knee flexed, the examiner slowly rotates the right leg internally, which stretches the obturator muscle. Pain over the right lower quadrant (RLQ) is considered a positive sign. Option 4: McBurney sign is pain elicited when pressure is applied to McBurney point, which is located halfway between the umbilicus and the anterior spine of the ilium. Question 9. You elicit costovertebral angle tenderness in Gordon, age 29. Which condition do you suspect? Inflammation of the kidney Question 10. Marvin, a known alcoholic with cirrhosis, is frequently admitted for coagulopathies and occasionally receives blood transfusions. His wife asks you why he has bleeding problems. How do you respond? “There is an interruption of the normal clotting mechanism.” Question 11. Olive has an acute exacerbation of Crohn’s disease. Which laboratory test value(s) would you expect to be decreased? Vitamin A, B complex, and C levels. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 12. You suspect that Harry has a peptic ulcer and tell him that it has been found to be strongly associated with: Infection by Helicobacter pylori. 90% of cases are caused by H. Pylori Question 14. Dottie brings in her infant, who has gastroesophageal reflux. What do you tell her about positioning her infant? “Always position infants on their back to prevent sudden infant death syndrome.” Question 15. To differentiate among the different diagnoses of inflammatory bowel diseases, you look at the client’s histological, culture, and radiological features. Mary has transmural inflammation, granulomas, focal involvement of the colon with some skipped areas, and sparing of the rectal mucosa. What do you suspect? Crohn disease. The key is “skipped areas of mucosal involvement” Question 18. What is the best diagnostic test to confirm the diagnosis of celiac disease? Anti-tTG IgA Question 19. A 50-year-old female presents to the urgent care clinic complaining of left lower quadrant pain. She has associated nausea and vomiting, and her vital signs are as follows: temperature 102.5°F, pulse 110, blood pressure 150/90, pulse oximetry 99% on room air. What is the best test to evaluate this patient? Computed tomography (CT) scan with oral contrast. Question 20. The screening guidelines for colon cancer recommend which of the following for the general population? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 2. Nausea is difficult to discern in a young child. What question might you ask to determine if a child has nausea? “Are you hungry?” Question 3. Sally, age 21, is to undergo a tonsillectomy. She has heard about permanent taste changes after a tonsillectomy. What do you tell her? “You may notice a slight difference initially, but there are no lasting changes in taste.” Question 7. Cydney has been given a diagnosis of ascariasis. Which symptoms would you expect to see? Low-grade fever, productive cough with blood-tinged sputum, wheezing, and dyspnea. Question 8. Marian, age 52, is obese. She complains of a rapid onset of severe right upper quadrant abdominal cramping pain, nausea, and vomiting. Your differential diagnosis might be: Cholecystitis. Question 9. A 7-year-old male presents with his mother to the urgent care clinic complaining of abdominal pain. He started to complain of pain prior to going to bed; however, it has gotten progressively worse and is now preventing him from sleeping. He is nauseous but hasn’t vomited and didn’t eat dinner due to the pain. The patient appears pale and is complaining of right-sided abdominal pain. His vitals are as follows: blood pressure 130/85, pulse 120, temperature 100.5°F, pulse oximetry 98% on room air. On physical exam he is tender in the right lower quadrant. His complete blood count (CBC) shows a white blood cell count (WBC) of 17.0. What is the patient’s likely diagnosis? Appendicitis. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 10. What would you expect to see on an abdominal series that would lead toward a diagnosis of small-bowel obstruction? Air-fluid levels. Question 2. What is the most common bacterial pathogen associated with acute otitis media? Streptococcus pneumoniae. Question 4. When the Weber test is performed with a tuning fork to assess hearing and there is no lateralization, the nurse practitioner should document this finding as: A normal finding. Question 6. You are assessing a first grader and find that the tonsils are touching the uvula. How would you grade this finding? Grade 3. Question 1. Which of the following is not a cause of conductive hearing loss? Presbycusis. Question 2. Jill, a 34-year-old bank teller, presents with symptoms of hay fever. She complains of nasal congestion, runny nose with clear mucus, and itchy nose and eyes. On physical assessment, you observe that she has pale nasal turbinates. What is your diagnosis? 1. Allergic rhinitis. Question 3. Mrs. Johnson, a 54-year-old accountant, presents to the office with a painful red eye without discharge. You should suspect: NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Iritis. Question 4. April, age 50, presents with soft, raised, yellow plaques on her eyelids at the inner canthi. She is concerned that they may be cancerous skin lesions. You tell her that they are probably: Xanthelasmas. Question 5. A 62-year-old woman presents to your clinic with a sudden right-sided headache that is worse in her right eye. She states that her vision seems blurred, and her right pupil is dilated and slow to react. The right conjunctiva is markedly injected, and the eyeball is firm. You screen her vision and find that she is 20/30 OS and 20/30 OD. She most likely has: 2. Angle-closure glaucoma. Rationales Option 1: With open-angle glaucoma, the onset is more insidious. Option 2: In angle-closure glaucoma, the patient presents with a sudden onset of symptoms as described in this case. This client has a visual deficit and pain as well as fullness of the affected eye. This is a medical emergency, and she should be referred immediately because, without intervention, blindness can occur within days. Option 3: Herpetic conjunctivitis is generally associated with a herpetic rash, and the pain is dull in character. Option 4: Diabetic retinopathy is a complication of diabetes that affects both eyes. It is caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (ie, the retina). Question 1. A 25-year-old male presents with “bleeding in my eye” for 1 day. He awoke this morning with a dark area of redness in his eye. He has no visual loss or changes. He denies NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 5. What significant finding(s) in a 3-year-old child with otitis media with effusion would prompt more There is a change in the child’s hearing threshold to greater than 25 dB. Rationales Option 1: If a child with otitis media with effusion has a change in the hearing threshold greater than 25 dB and has notable speech and language delays, more aggressive treatment is indicated. When the child’s hearing examination reveals a change in the hearing threshold, it is extremely important that the provider evaluate the child’s achievement of developmental milestones in speech and language. Any abnormal findings warrant referral. Option 2: A child with otitis media with effusion might become irritable during meals. Option 3: A slight delay in language and speech does not warrant aggressive treatment or referral. Option 4: Persistent rhinitis does not warrant aggressive treatment or referral. Question 6. Max, age 35, states that he thinks he has an ear infection because he just flew back from a business trip and feels unusual pressure in his ear. You diagnose barotrauma. What is your next action? Prescribe nasal steroids and oral decongestants. Question 7. Susan is a 19-year-old college student and avid swimmer. She frequently gets swimmer’s ear and asks if there is anything she can do to help prevent it other than wearing earplugs, which do not really work for her. What do you suggest? Start using a cotton-tipped applicator to dry the ears after swimming. Use ear drops made of a solution of equal parts alcohol and vinegar in each ear after swimming. Rationales Option 1: The adage “You shouldn’t put anything smaller than your elbow in your ear” holds true today. Option 2: Using ear drops made of a solution of equal parts alcohol and vinegar in each ear after swimming is effective in drying the ear canal and maintaining an acidic environment, therefore preventing a favorable medium for the growth of bacteria, the cause of swimmer’s ear. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Option 3: A hair dryer operated on the lowest setting several inches from the ear may be used to dry the canal. Option 4: There is no reason for the client to stop swimming. Question 8. Mary, age 82, presents with several eye problems. She states that her eyes are always dry and look “sunken in.” What do you suspect? Normal age-related changes. Rationales Option 1: With hyperthyroidism, the eyes appear to bulge out (exophthalmos), but in hypothyroidism, the eyes do not appear any different. Option 2: Dryness of the eyes and the appearance of “sunken” eyes are normal age-related changes. Option 3: A moon face is apparent with Cushing syndrome, and this might make the eyes appear to be sunken in, although on close examination, they are not. Option 4: With a detached retina, the outward appearance is normal, but the client complains of seeing floaters or spots in the visual field and describes the sensation as like a curtain being drawn across the vision. Question 9. Nystatin (Mycostatin) is ordered for Michael, a 56-year-old banker who has an oral fungal infection. What instructions for taking the medication do you give Michael? “Swish and swallow the medication.” Rationales Option 1: The oral medication should not be diluted, as that may compromise the absorption. Option 2: Taking the medication with meals may compromise the absorption. Option 3: NR 511 Completed Midterm study guide (2020) Complete A+ Guide. When ordering nystatin (Mycostatin) for an oral fungal infection, tell the client to swish the medication in the mouth to coat all the lesions and then to swallow it. Option 4: It is almost impossible to apply this liquid medication to only the lesions; swishing it in the mouth coats all the lesions more effectively. Question 10. The most common cause of a white pupil (leukokoria or leukocoria) in a newborn is: A congenital cataract. Rationales Option 1: The most common cause of a white pupil (leukokoria or leukocoria) in a newborn is a congenital cataract. The incidence may be as high as 1 in every 500 to 1000 live births, and there is usually a family history. Some infants require no treatment; however, in other cases surgery may be performed during the first few weeks of life. Option 2: Retinoblastoma, a common intraocular malignancy, is detected within the first few weeks of life and is the second most common cause of a white pupil. Option 3: Persistent hyperplastic primary vitreous is the third most common cause of a white pupil and is a congenital developmental abnormality. Option 4: Retinal detachment may occur as a result of trauma or disease and only rarely occurs in infancy. Question 11. You diagnose acute epiglottitis in Sally, age 5, and immediately send her to the local emergency room. Which of the following symptoms would indicate that an airway obstruction is imminent? Stridor. Question 12. A 27-year-old female comes in to your primary care office complaining of a perioral rash. The patient noticed burning around her lips a couple days ago that quickly went away. She awoke from sleep yesterday and noticed a group of vesicles with erythematous bases where the burning had been before. There is no burning today. She is afebrile and has no difficulty eating or swallowing. What test would confirm her diagnosis? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Iritis. Question 5. You are the nurse practitioner caring for Martha, a 47-year-old accountant. You have made a diagnosis of acute sinusitis based on Martha’s history and the fact that she complains of pain behind her eye. Which sinuses are affected? 2. Ethmoid. Question 6. Marlene, a 57-year-old cashier, comes to the clinic because she is unable to differentiate between sharp and dull stimulation on both sides of her face. You suspect: A lesion affecting the trigeminal nerve. Question 7. While doing a face, head, and neck examination on a 16-year-old patient, you note that the palpebral fissures are abnormally narrow. What are you examining? 2. The openings between the margins of the upper and lower eyelids. Question 8. A 44-year-old banker comes to your office for evaluation of a pulsating headache over the left temporal region, and he rates the pain as an 8 on a scale of 1 to 10. The pain has been constant for the past several hours and is accompanied by nausea and sensitivity to light. He has had frequent, though less severe, headaches for many years, and they are usually relieved by over-the-counter medicines. He is unclear as to a precipitating event but notes that he has had visual disturbances before each headache and he has been under a lot of stress in his job. Based on this description, what is the most likely diagnosis of this type of headache? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Migraine. Question 9. Your client, a 72-year-old smoker of 50 years, is at the office today for a routine physical. During your inspection of the oral mucosa, you discover a white lesion on the lateral surface of the tongue that you suspect to be cancerous. You document your finding as: A white, painless, firm, ulcerated lesion with indurated borders. Question 10. Which of the following conditions produces sharp, piercing facial pain that lasts for seconds to minutes? 1. Trigeminal neuralgia. Question 11. Mary, age 82, presents with several eye problems. She states that her eyes are always dry and look “sunken in.” What do you suspect? 2. Normal age-related changes. Question 12. A 64-year-old obese woman comes in complaining of difficulty swallowing for the past 3 weeks. She states that “some foods get stuck” and she has been having “heartburn” at night when she lies down, especially if she has had a heavy meal. Occasionally, she awakes at night coughing. She denies weight gain and/or weight loss, vomiting, or change in bowel movements or color of stools. She denies alcohol and tobacco use. There is no pertinent family history or findings on review of systems (ROS). Physical examination is normal, with no abdominal tenderness, and the stool is occult blood (OB) negative. What is the most likely diagnosis? Gastroesophageal reflux disease (GERD). NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 13. Mr. Johnson, age 69, has had Meniere disease for several years. He has some hearing loss but now has persistent vertigo. What treatment might be instituted to relieve the vertigo? A vestibular neurectomy. Question 14. Marjorie, age 37, has asthma and has been told she has nasal polyps. What do you tell her about them? 2. Nasal polyps are benign growths. Cataracts are a common occurrence in patients over 60 years of age. You counsel your patient that the best cure for cataracts is: Corrective lens surgery. In a young child, unilateral purulent rhinitis is most often caused by: A foreign body. Kathleen, age 54, has persistent pruritus of the external auditory canal. External otitis and dermatological conditions, such as seborrheic dermatitis and psoriasis, have been ruled out. What can you advise her to do? Apply mineral oil to counteract dryness. Question 19. At the clinic, you are assessing Kyle, a 4-month-old baby, for the first time and notice that both eyes are turning inward. What is this called? Esotropia. Question 20. Kevin, age 26, has AIDS and presents to the clinic with complaints of a painful tongue covered with what look like creamy white, curdlike patches overlying erythematous mucosa. You are able to scrape off these “curds” with a tongue depressor, which assists you in making which of the following diagnoses? NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Psoriasis. Question 15. Mildred, age 72, presents to the clinic with a blistering rash that is generalized but located mostly in skin folds and on flexural areas. She describes the course of the rash as beginning with pruritic urticarial papules that coalesced into plaques that turned dark red in about 2 weeks, followed by the development of vesicles and bullae. She tells you that the lesions are moderate to severely pruritic. During your exam, you determine the bullae are very tense and do not rupture when pressure is applied. Her daily medications include an angiotensin-converting enzyme (ACE) inhibitor, a loop diuretic, and a nonsteroidal anti-inflammatory drug (NSAID). What is your diagnosis? Bullous pemphigoid. Question 16. Sandra, age 69, is complaining of dry skin. What do you advise her to do? Bathe or shower with lukewarm water and use a mild soap or skin cleanser. Question 17. Caroline has a 13-year-old daughter who has had 2 recent infestations of lice. She asks you what she can do to prevent this. You respond: “Don’t let her share hats, combs, or brushes with anyone.” Question 18. Candidiasis may occur in many parts of the body. James, age 29, has it in the glans of his penis. What is your diagnosis? Balanitis. Question 19. Mr. Swanson, age 67, presents to the clinic for his annual health exam. He asks you if there is anything he can do to prevent the painful, blistering sores that develop on his lip in the summertime when he plays golf. You explain to Mr. Swanson that the way to prevent the development of these lesions is to: Protect the lips from sun exposure with a blocking agent, such as zinc oxide, or a lip balm that contains a broad-spectrum sunscreen. NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Question 20. A biopsy of a small, yellow-orange papulonodule on the eyelid will probably show: Lipid-laden cells. Question 1. A 75-year-old African American male presents to your family practice office complaining of visual impairment. He has worn corrective lenses for many years but has noticed that his vision has gotten progressively worse the past 6 months. He denies pain. He states his vision is worse in both eyes in the peripheral aspects of his visual field. He also notes trouble driving at night and halos around street lights at night. You test his intraocular pressure, and it is 23 mm Hg. What is his most likely diagnosis? Open-angle glaucoma. Question 2. Which of the following is not a complication of untreated group A streptococcal pharyngitis? Hemolytic anemia. Question 3. The antibiotic of choice for recurrent acute otitis media (AOM) and/or treatment failure in children is: Amoxicillin and potassium clavulanate (Augmentin). Question 4. Mattie, age 64, presents with blurred vision in 1 eye and states that it felt like “a curtain came down over my eye.” She doesn’t have any pain or redness. What do you suspect? Retinal detachment. Question 5. While doing a face, head, and neck examination on a 16-year-old patient, you note that the palpebral fissures are abnormally narrow. What are you examining? The openings between the margins of the upper and lower eyelids. Question 6. Mia, a 27-year-old school teacher, has a 2-day history of severe left ear pain that began after 1 week of upper respiratory infection (URI) symptoms. On physical examination, you NR 511 Completed Midterm study guide (2020) Complete A+ Guide. find that she has acute otitis media (AOM). She has a severe allergy to penicillin. The most appropriate antimicrobial option for this patient is: Azithromycin (Zithromax). Question 7. Mario, a 17-year-old high school student, came to the office for evaluation. He is complaining of persistent sore throat, fever, and malaise not relieved by the penicillin therapy prescribed recently at the urgent care center. As the nurse practitioner, what would you order next? A Monospot test. Question 8. Cynthia, a 31-year-old woman with a history of depression, is seen in the office today for complaints of headaches. She was recently promoted at her job, and this has caused increased stress. She describes the headache as a tightening (viselike) feeling in the temporal and nuchal areas. The pain is bilateral and tends to wax and wane. It started approximately 2 days ago and is still present. What kind of headache is she describing? Tension headache. Question 9. Ellen, a 56-year-old social worker, is seen by the nurse practitioner for complaints of fever; left-sided facial pain; moderate amounts of purulent, malodorous nasal discharge; and pain and headache when bending forward. The symptoms have been occurring for approximately 6 days. On physical assessment, there is marked redness and swelling of the nasal passages and tenderness/pain on palpation over the cheekbones. The nurse practitioner should suspect: Acute rhinosinusitis Question 10. Sally, age 19, presents with pain and pressure over her cheeks and discolored nasal discharge. You cannot transilluminate the sinuses. You suspect which sinus to be affected? Maxillary sinus NR 511 Completed Midterm study guide (2020) Complete A+ Guide. Epstein pearls Question 5. Jonathan, age 19, has just been given a diagnosis of mononucleosis. Which of the following statements is true? Jonathan should avoid contact sports and heavy lifting. Question 6. Martin, age 24, presents to the office with an erythematous ear canal and pain on manipulation of the auricle. He is on vacation and has been swimming daily at the resort. What is your diagnosis? External otitis. Question 7. Samantha, age 12, presents with ear pain. When you begin to assess her ear, you tug on her normal-appearing auricle, eliciting severe pain. This leads you to suspect: Otitis externa. Question 8. Which manifestation is noted with carbon monoxide poisoning? Cherry-red lips. Question 9. A 22-year-old African American female presents to your family practice office complaining of progressive skin discoloration. She is adopted and has no known family history of skin problems. The patient notes nonpalpable patches of skin loss and blanching of her forehead and both hands and feet. It has developed over a period of 6 months and appears to have stopped. It is not pruritic, and there is no erythema or sign of infectious etiology. What is the most likely diagnosis? Vitiligo. Question 11. A 16-year-old male presents to your office. He was sent by an orthopedist. He has recently had surgical fixation of a humerus fracture. The patient has been going to physical therapy and has been developing a rash on his arm after therapy that disappears shortly after returning home. He does not have the rash prior to therapy. The patient denies fevers and chills, NR 511 Completed Midterm study guide (2020) Complete A+ Guide. and his incision is well healed, with no signs of infection. Of note, the patient has been experiencing more hand edema than the average patient and has had edema wraps used at the end of therapy to help with his swelling. The wraps are made of a synthetic plastic material. The rash the patient gets is erythematous and blotchy, not raised; it is on the operative upper extremity. What is the most likely diagnosis? Contact dermatitis. Question 13. Maryann, age 28, presents to the clinic because of a rapid onset of patchy hair loss. The skin within these oval patches of hair loss is very smooth. Tapered hairs that resemble exclamation points are seen at the margin of a patch of hair loss. Based on these findings, you suspect Maryann has: Alopecia areata. Question 14. Which treatment is considered the gold standard in tissue-conserving skin cancer removal? Mohs micrographic surgery (MMS). Question 15. You are examining Barbara, age 27, who presents with multiple dry, dusky red, well- localized plaques with a “stuck-on” appearance. They are 5 to 20 mm in diameter and located on her face, scalp, and external ears. You note there is atrophy, telangiectasia, depigmentation, and follicular plugging present. On examination of the scalp, there are areas of total hair loss. There is depigmented scarring of the concha of the ear. Your most likely diagnosis is: Discoid lupus erythematosus. Question 16. Michael, a 25-year-old military reservist, presents to your clinic for a rash that began on his chest and has since developed into smaller lesions that are more concentrated on the lower abdomen and pubic area. In obtaining a history of the present illness, he reports that he NR 511 Completed Midterm study guide (2020) Complete A+ Guide. had an upper respiratory infection 1 month before the rash developed. He tells you it started with 1 large oval-shaped lesion on his left chest, and 1 to 2 weeks later he developed numerous smaller lesions on the lower abdomen and groin. It has been 2 weeks since the smaller lesions developed, and he tells you he is concerned that the rash isn’t improving. As you examine the patient, you note that the lesions are salmon-colored and have a thin collarette of scale within them. The original lesion is still present. You suspect Michael has: Pityriasis rose Question 17. Shelby, age 14, has a blister on her arm that is filled with clear fluid. It is the result of contact with a hot iron. How do you document this? Bulla. Question 18. Deanna, age 6, was bitten by a friend’s dog. Her mother asks you if the child needs antirabies treatment. You tell her: “If the dog is a domestic pet that has been vaccinated, the wound should be cleaned and irrigated.” Question 19. Buddy, age 13, presents with annular lesions with scaly borders and central clearing on his trunk. What do you suspect? Tinea corporis. Question 20. Sandy asks what she can do for Dolores, her 90-year-old mother, who takes a bath every day and who has extremely dry skin. You respond: “Your mother does not need a bath every day.” Question 6. Erica, age 39, has a sudden onset of shivering, sweating, headache, aching in the orbits, and general malaise and misery. Her temperature is 102°F. The nurse practitioner diagnosed her with influenza (flu). What is your next course of action? Prescribe rest, fluids, acetaminophen (Tylenol), and possibly a decongestant and an antitussive.