Chamberline college of Nursing FAMILY NUR NR667/661 vise study guide- UPDATED 7.2022 /2023, Exams of Nursing

Download Chamberline college of Nursing FAMILY NUR NR667/661 vise study guide- UPDATED 7.2022 /2023 and more Exams Nursing in PDF only on Docsity! 1 Chamberline college of Nursing FAMILY NUR NR667/661 vise study guide- UPDATED 7.2022 /2023 1. Hypertension Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, blurry vision, Assessment: • Asymptomatic • Occipital headache • Blurry vision • Headache upon wakening • Look for AV nicking • LVH Exam: • Carotid bruits • Abdominal bruits • Kidney bruits Diagnostic studies: to look for secondary causes of HTN like target organ damage and establish ASCVD risk: EKG, fasting lipid profile, fasting blood glucose, CBC, CMP (electrolyte, creatinine, & calcium levels), and urinalysis (checking for proteinuria). Diagnosis: Measure BP 5 minutes apart. Average of 2 or more BP readings on two different visits at > 140/90 mm Hg start then can be diagnosed with HTN. If Stage 1 (ASCVD <10%) then non-pharmacologic management only: • First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per week. • Limit alcohol • stop smoking • stress management. • DASH • Medication compliance • Reduce sodium intake • Measure BP daily If Stage 2 (ASCVD >10% and known CAD) initiate lifestyle + Pharmacologic Management: • Alone: hydrochlorothiazide (HCTZ) 25 mg/day (chlorthalidone is preferred over HCTZ) • Alone: lisinopril 10mg/day complicated HTN first line • Combo: thiazide + ACE or ARB • Alternative CB (especially in isolated HTN seen mainly in older adults) • Black population: thiazide + CCB is recommended first line Follow up: 2 • 2-4weeks Referral: • Cardiology if EKG is abnormal Differential: • Secondary hypertension • Pregnant • Pregnancy induced hypertension Hollier: page 62 2. Hyperlipidemia Etiology: may be familial, dietary, obesity, hypothyroid, renal disorders, thiazide or beta blocker use, alcohol and/or caffeine intake Presentation: few physical findings • Xanthomata (lipid deposits around the eyes) • Corneal Arcus prior to age 50 years (white iris), normal • Angina • Bruits • MI • Stroke Diagnostics: • Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL minimally affected by eating) • Glucose, • UA and creatinine (for detection of nephrotic syndrome which can induce dyslipidemia), • TSH (for detection of hypothyroidism) Diagnosis: Pt with LDL >= 190mg/dL Non-pharmacologic Management: • Lifestyle Modification; diet and exercise. Pharmacologic Management Those who benefit most from statin therapy include: • hx of CVD or stroke, • LDL 190 or greater, • DM with LDL 70-189, • no evidence of ASCVD or DM but have LDL 70-189 PLUS an estimated ASCVD risk of 7% or greater • High risk: o Atorvastatin 40 or 80 mg daily o Rosuvastatin 20 or 40 mg daily • Moderate risk: o Atorvastatin 10 or 20 mg daily o (other statin medications also listed in Hollier) • If statins not tolerated, temporarily stop, decrease dose, and re-challenge with 2-3 statins of differing metabolic pathways and intensities. Follow up: • after initiating therapy, follow-up every 6-8 weeks until goal attained then every 6- 12 months to evaluate compliance • evaluate lipids every 5 years starting at age 20 if normal values obtained Refer: Nutritionist Differentials: consider secondary causes • Hypothyroidism • Pregnancy • Diabetes 5 • routine imaging is not recommended for patients with acute or non-specific back pain, lack of clinical improvement may warrant imaging with x-ray after 4 weeks (consider systemic illness when there is no relief after a period of time and nothing relives the pain) • X-ray to r/o fracture/disc degeneration (with injury only). • MRI and CT (the study of choice for evaluation of disc disease). • Labs: CBC, CMP, Urinalysis, CRP • Rule out cauda equina – loss of bladder control, saddle anesthesia, incontinence – refer to ED Non-pharmacologic Management: • Restrict activities that aggravate symptoms and avoid heavy lifting. • Gradually resume activities as tolerated, • Core strengthening workouts – abs/rectus muscles • Apply heat for 20-30 min several times a day. • Manage weight. Pharmacologic Management: • NSAIDS are most effective first line pharm management: Naproxen 250-twice a day. • Muscle relaxants have NOT been proven more effective than NSAIDS either alone or concomitantly but helpful for spasm Follow up: • Severe pain 24-48 hours • 7-10 days moderate pain Referral: • Physical Therapy Imaging: • If not resolved or improving in 4 weeks • X-ray/ct after 4 weeks unresolved Differentials: • Muscle strain • Herniated disc • Compression fracture • Cauda equina • Osteoarthritis • Spinal stenosis Hollier: page 511 5. Anxiety Etiology: conditioned response to specific environmental stimuli; often genetic component (first degree relative increase likelihood 8 fold); Presentation: complaints of apprehension, restlessness, edginess, distractibility insomnia; Somatic complaints like fatigue, paresthesia, near syncope, dizziness, palpitation, tachycardia chest pain/tightness, dyspnea, hyperventilation, nausea vomiting diarrhea. Etc Diagnostic: TSH (hyperthyroid), CBC, CMP (electrolyte disturbances), UA, Urine drug screen, Glucose, EKG (rule out cardia issues, arrhythmias), Hamilton Anxiety scale Diagnosis: Assess tools like Hamilton Anxiety scale- Positive Greater than 18 ; PROMIS assessment 6 Non-pharmacological: • Psychotherapy/Counseling, • Exercise, • healthy diet • Avoid stressors as much as possible. • Relaxation • Regular exercise Pharmacological: • Benzodiazepines should be of limited duration (up to 1-3 months with planned taper) • Drugs should play an adjunct role to CBT, except in panic disorder • Drugs reduce, not eradicate, symptoms • Log term use of SSRI may be required • First line is SSRI o Fluoxetine, escitalopram, paroxetine o Older adults start low and go slow • Anxiolytics like S1A partial agonist o Buspirone 7.5mg PO BID-TID (range of 20-30mg daily) • Benzo o clonazepam initially 0.25-0.5mg PO BID-TID with max 4mg PO in divided doses o Older adults start low and go slow Follow up: • 2-4 weeks • 4-6 weeks for effect • Max effect of SSRI in 8-12 weeks before trying a new SSRI or alternate Referral: • Psychologist/Psychiatrist Differentials: • Substance abuse withdraw • Substance abuse reaction • Anemia • Asthma • COPD • Arrhythmias Hollier: page 611 6. Depressive Disorder Etiology: still not well understood; impaired synthesis of norepinephrine, serotonin, dopamine, and/or other neurotransmitters Presentation: loss of interest or pleasure, suicide Ideology, early morning wakening Hopelessness, depressed mood, fatigue, loss of energy, feelings of worthlessness Risk factors: • Female • Physical or chronic illness, like migraines, back pain • Prior episodes of depression or suicide attempts 7 • Postpartum period • Family history of depression • Alcohol substance abuse • Retirement, aging, significant losses Diagnostic: • CBC (anemia), CMP, TSH (rule out hypothyroidism), • urine drug screen, • ECG baseline to rule out arrythmias or heart block before initiating a tricyclic med. • Fasting blood sugar, • Vit D, Vit B12, folate levels Diagnosis: • Patient Health Questionnaire 9 (PHQ-9) score of 5 and above • DSM-5 • Geriatric depression scale Non-pharmacological: • Hotline resources, • Identify suicide risk plan • sleep hygiene at same time every day, routine schedule • home safety • Counseling. Pharmacological: Identify coexisting substance use disorders and any general medical conditions • SSRI are first line in all age groups due to safety o Fluoxetine, escitalopram, paroxetine o Older adults start low and go slow • All antidepressants carry a black box warning in children and adolescents, refer to specialist, if possible, for pharmacological management • TCAs pose greater suicide and overdose risk because lethal in small amounts o Amitriptyline, use in caution with heart conduction issues (causes prolonged QT), periodically monitor drug level Follow up: • within 2 weeks of initiating medication, • continue for at least 4-6 weeks before seeing effects • should be tapered rather than abruptly stopped Referral: Psychologist for counseling. Differentials: • Bipolar • substance abuse • medication abuse • medication withdrawal • hypothyroidism • B12/Folate deficiency • Dementia Hollier: page 628 10 • Mouth breathing and dry lips • Sore throat or dry mouth when waking, due to mouth breathing at night plus drainage irritation • Palpable lymph nodes; enlarged adenoids and tonsils • Evaluate medication compliance • IgE reaction – allergic reaction – elevated eosinophiles Diagnostic: none • CBC may show increased eosinophils in acute reaction • CT is primary imaging study to look at structure • Allergy testing for those who don’t respond to treatment Diagnosis: Conjunctival injection, pale, boggy turbinates’ with clear nasal secretions, sore throat, palpable lymph nodes Non-pharmacological: • Avoidance/elimination of offending allergen • frequent vacuuming, dusting, remove feather pillows from the bedroom, • change air conditioner filter frequently, • removal house plants, remove carpet • immunotherapy may be offered when not reactive to pharmacology therapy • enlarged turbinates or deviated septum, refer to ENT Pharmacological: • Saline nasal spray • Antihistamines (sedating- Zyrtec and non-sedating- Claritin) daily • Nasal steroids (preferred first line) like Flonase 2 sprays in each nostril daily. Follow up: in 2-4 weeks after initial evaluation Referral: • ENT for sinus related etiologies or nasal polyps • Allergist if no responsive to treatment • ED for severe allergic responses Differentials: • Infection • Nasal foreign body • Tumors • Rhinitis medicametosa Hollier: page 169 10. URI (common cold) Etiology: • self-limiting and lasting about 4-10 days • most contagious from day 2-3 • common in crowded areas and small children • transmitted by resp droplets, highly contagious and most cases occur in winter months Presentation: • acute onset of fever, sore throat, frequent sneezing in early phase • nasal congestion, rhinorrhea, of clear mucus (coryza) and runny eyes • May complain of headache Assessment: 11 • Swollen nasal turbinates with clear mucus • Reddened anterior pharynx • Cervical nodes are smooth, mobile, and small or “shotty”, submandibular and anterior cervical chain • Lungs are clear Diagnostic: • nasal washing culture/ flu wash Diagnosis: mostly objective Nonpharmaceutical: • Increase fluid and rest. • Humidifier. • Lozenges for scratchy throat • Saline nose drops. Education: • Frequent HAND washing • Wash bedding • Change toothbrush Pharmaceutical: Symptoms relieve that can be taken are • Tylenol/ibuprofen for fever and aching body pain OTC • Oral decongestants like Sudafed • saline nasal spray, topical nasal decongestants like Afrin BID (do not use for more that 3 days, rebound) • antitussives (Robitussin) • Antihistamines (Benadryl) • throat lozenges • antibiotics not necessary unless illness lasts greater than 10 days. (secondary sinusitis) Follow up: usually not needed unless symptoms persist over 10 days. Referrals: NONE Liek: page 231 11. Acute laryngopharyngitis - Etiology: acute inflammation of the pharynx/tonsils most commonly causes by viruses like rhinovirus, adenovirus, parainfluenza, Epstein-Barr (mononucleosis), and respiratory syncytial virus. Other times may be causes by Group A beta-hemolytic strep where accurate dx and tx is important to prevent rheumatic fever, poststreptococcal glomerulonephritis, reduce the spread, and limit complications Presentation: • Sore throat, pharyngeal edema, tonsillar exudate and/or enlarged tonsils, malaise Clinical findings alone are not specific to viral or bacterial infection because so many s/s of strep pharyngitis overlap with other conditions • Suggestive of strep etiology - o cervical adenopathy, fever >102, absence of other respiratory findings (cough, runny nose, nasal congestion), abdominal pain and headache, petechiae on soft palate, beefy red tonsils, sandpaper rash (bridge of nose, neck, and/or torso), strep tonsilitis has a distinct odor • Suggestive of viral etiology - 12 o Concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash May use the Modified Centor Clinical Predictor Rule for Group A Strep infection diagnosis (Hollier, page 196) Diagnostic: • Rapid strep test • in children and adolescence, it should be confirmed with a throat culture) • uncommon in children <3 years old, if high risk should be tested • *10% of patients with mononucleosis have concomitant strep infection Nonpharmacological: • Gargling with warm saltwater, • increase fluids, • change toothbrush after treatment, Pharmacological: • antipyretics to control pain and fever • For strep (adult): o Pen V K 500 mg PO BID for 10 days o Amoxicillin 500-875mg PO BID for 10-14 days (higher dose for severe infection) o Cephalexin 500 mg PO BID for 10 days o PCN allergy: Azithromycin 500mg PO daily for 3 days Follow up: • not generally needed unless not getting better • no longer contagious after 24 hours of antibiotic tx • expected course of 4-10 days, peak fever and pain on days 2 and 3 Referral • not needed Hollier: page 196 12. Acute maxillary sinusitis Etiology: inflammation of the maxillary sinus due to viral, bacterial, or fungal infection or allergic reaction. Acute sinusitis- symptoms last < 12 weeks • Common bacterial causes: strep pneumoniae, haemophilus influenzae, Moraxella catarrhalis • Common viral causes: rhonovirus, coronavirus, flu A and B, parainfluenza, RSV Recurrent acute sinusitis- at least 3 episodes of acute bacterial sinusitis in a year Chronic sinusitis- symptoms of varying severity > 12 weeks; further classified with or without nasal polyps, abnormal findings on CT scan or nasal endoscopy • Gram negative is more likely • Staph aureus • Pseudomonas aeruginosa • Anaerobic organisms Presentation: • Fever may or may not be present • Persistent symptoms of URI (> 10-14 days) • Congestion, purulent nasal discharge 15 14. Asthma Presentation: a chronic, inflammatory respiratory disease-causing reversible airway constriction (narrowing of the airway) and hyperresponsiveness. • Between attacks, patients with asthma are generally free from symptoms • Initially, airway constriction causes Expiratory Wheezing, • non-productive cough in the earliest symptoms, SOB, chest tightness, prolonged expiration • Tachypnea, tachycardia, • Accessory muscle use in severe attack, • sudden nocturnal dyspnea, decreased exercise tolerance. • Cough and wheezing due to narrowed airway lumens/bronchioles Diagnostics: • PFT/spirometry • Consider allergy testing Non-pharmacological/prevention: • avoidance of allergens and irritates • take prescribed asthma meds • Learn early signs and symptoms of asthma exacerbation • Asthma action plan. Always before leaving office. • Immunizations, • monitor peak flow values Pharmacological: (adults) Inhaled corticosteroids are the mainstay of treatment and are indicated in all categories of persistent asthma o Mild intermittent asthma: symptoms 2 or less times per week OR 2 or less nights per month o SABA for exacerbations ▪ Albuterol inhaler 2 inhalations Q4-6 hours as needed o Mild Persistent: symptoms 2 or more times per week but less than once per day OR < 2 night per month o Low dose ICS & SABA for exacerbations ▪ Albuterol inhaler 2 inhalations Q4-6 hours as needed ▪ Flovent HFA 88mcg inhaled twice a day (maintenance) ▪ Singular 10mg once a day (maintenance) o Moderate persistent: daily symptoms OR more than 3-4 nights per month o Low to medium dose ICS and LABA plus SABA for exacerbations ▪ o Severe persistent: continual symptoms OR frequent nighttime symptoms > 1 night per month o high dose ICS and LABA AND (if needed) oral corticosteroids (2mg/kg/day not to exceed 60mg/day) plus SABA for exacerbations Follow Up: • 1 week • As needed, 3-6 months for stable disease Referral: • pulmonary if not tolerating treatment or those with severe persistent asthma 16 • allergist Differentials: • respiratory infection (URI) • CHF • GERD • Habitual cough • TB • Foreign body Hollier: page 662 15. Hypothyroidism (everything slows down) Etiology: results from a reduction in circulating free thyroid hormone or from the resistance to the action of thyroid hormone. Majority due to primary thyroid gland failure resulting from autoimmune destruction (Hashimoto’s thyroiditis). Other causes are congenital, secondary or tertiary, and due to pituitary or hypothalamic disease Presentation: • Lethargy and delayed tendon reflexes • mild weight gain, swelling of hands and feet, • Intolerance to cold, constipation, • menstrual irregularities, decreased libido, infertility, • memory loss, flat affect, depression, • muscle cramps, coarse hair, dry skin, hair loss, brittle nails, bradycardia, enlarged heart • anemia, hyponatremia, enlarged thyroid, decreased sweating • Age greater than 40 Expect lipid levels to be elevated in hypothyroidism: treat lipids if still elevated after TSH <10 Diagnostic: TSH, T4, T3, CBC (rule out anemia), CMP (electrolyte), Lipid panel, EKG Diagnosis: • Hypothyroidism: TSH (increased), T4 (decreased), T3 (maybe decreased) • Subclinical hypothyroid: slightly elevated TSH and nonspecific symptoms- monitor Q3 months (treatment increases risk of osteopenia/osteoporosis) Nonpharmacological: • High fiber diet to prevent constipation • diet for weight loss • Educate regarding the need for lifelong compliance with thyroid replacement medication • need to report signs of toxicity, infection or cardiac symptoms. Pharmacological: • Levothyroxine Synthroid 12.5-25mcg (if older), 50mcg daily (empty stomach) • In young, healthy: 1.6mcg/kg/day • Levo helps prevent mental retardation in babies of expectant mothers with hypothyroid • Reassess every 6-8 weeks, once stable reassess every 6-12 months • Pregnant monitor monthly and adjust accordingly, medication needs ay increase • See improvement within 2 weeks; symptoms resolve in 3-6 months Follow up: • 6 Weeks, recheck in 3-4 months Referral: 17 • None at this time Education: • Increase vegetables and fruits, • Increase exercise, • Lipid assessment annually, • Compliance need lifetime treatment Differentials: • Depression • Dementia • CHF • Kidney failure Hollier: page 230 16. Osteoarthritis – Presentation: Generalized disease with no known cause. • Most common joint disease (destruction). • Progressive destruction of the articular cartilage and bone due to osteophyte formation. • Joint pain, usually asymmetrical, develops insidiously and accompanies or follows physical activity. • Constitutional symptoms are absent • Assess for Morning stiffness lasting <1 hour. Stiffness resumes towards the day end and after periods of activity. • Assess for crepitus and limited range of motion. Assess for bunions (MTP joints) • Assess for site warm and redness (rheumatoid) • (Bouchards nodes @PIP) Heberden’s nodes @DIP (B before H) or D for DIP • Not symmetrical • Cool joints – not warm like RA • Based on physical and history Diagnostic: • No diagnostic lab tests are available for OA, diagnosis is based on history, physical, and x-ray findings • x-ray findings: osteophytes (joint space narrowing), • Inflammatory markers will be negative • For differential or rule out: ESR, Rheumatoid factors, ANA Nonpharmacological: • Weight loss • braces to stabilize joints while exercising, • apply heat/cold to affected joints Pharmacological: • Exercise first line treatment • Medications only to be used when symptoms are present, prophylaxis not shown to be beneficial • Acetaminophen is no longer considered first line due to side effects and lack of efficacy • Short acting NSAIDs preferred over long acting (ibuprofen preferred over Aleve) 20 • a combo of shoulder symptoms that cause pain and dysfunction most commonly due to compression of structures in and around the glenohumeral joint • overuse, trauma, OA, RA • Neer test, hawlins-kennedy test • Crepitus • Drop-arm test, cross arm test, empty can test Diagnostics: • X-ray results typically normal, history of injury or presence of arthritis • Ultrasound may be useful with full thickness cuff tears • MRI to diagnose, empty gas can, apley test, stratch test, positive arm drop test, Nonpharmacological: • Rest • physical therapy • cold/heat pack Pharmacological: LOWEST EFFECTIVE DOSE FOR SHORTEST PEROD OF TIME • Tylenol 650 Po as needed for pain every 6 hours, • Naproxen 250 mg twice a day. • Pain over 5/10 Tramadol 50 mg once a day Follow up: • 2-4weeks Referral: • Ortho for positive rotator cuff tear or concern for injury requiring surgical repair • physical therapy/ortho after 4-6 weeks of failed therapy Education: • Avoid overhead lifting or reaching Differentials: • Adhesive capsulitis (frozen shoulder) • Degenerative arthritis • Cervical radiculopathy • Suprascapular nerve impingement/entrapment Liek: page 351 Hollier: page 538, page 535 19. Hip pain Pediatrics: read • slipped capital femoral epiphysis, Hollier page 539 • toxic synovitis of the hip in children, Hollier page 545 • legg-calve-perthes disease, Hollier page 510 Presentation: (info retrieved from UpToDate) Young adults: Hip joint labral injuries or synovitis Middle age & older adults: trochanteric pain syndrome, osteoarthritis Dangerous Exclude: referred pain from lumbosacral radiculopathy, aortoiliac arterial insufficiency, septic arthritis, osteonecrosis, and tumor. Assess: pain history including PMH FMH of RA or OA & gait (heels and toes): ●Onset (eg, sudden, gradual, traumatic or nontraumatic) ●Provocative and palliating factors (eg, increased pain with weight-bearing) 21 ●Quality ●Radiation (eg, to or from the low back) ●Site (lateral, anterior, posterior hip or other joints; focal weakness- r/o radiculopathy) ●Symptoms (paresthesia, mechanical catching, systemic-fever, etc; Trendelenburg; rash/ psoriasis hx= r/o psoriatic arthritis; GI- r/o IBD; Iritis/uveitis r/o inflame i.e. spondylarthritis; leg length?) ●Time course (overall duration, length of episodes) Diagnostic: Labs not typically needed; imaging only needed in acute hip pain to exclude fracture/SCFE, moderate to severe chronic hip pain, or initial hip OA assessment; CT or MRI if inconclusive or inconsistent; Ultrasonography for hip effusion or joint aspiration (interventional radiology or ortho not FP) External, internal rotation, abduction, adduction Nonpharmacological: • Rest • physical therapy • cold/heat pack • Pain nerve blocks (not 1st line) Pharmacological: • Tylenol 650 Po as needed for pain every 6 hours Follow up: • 2-4weeks Referral: • physical therapy • Ortho 20. Nail Fungus (tinea ungium, onychomycosis) Presentation: nail becomes opaque, yellow, and thickened with scaling under the nail; can become infected with yeasts and mold • Oncholysis – separation of nail from bed • Hyperkeratosis – thickening and scaling under skin • Most common location – great toe Diagnostic: • nail specimen will be sent to the lab, KOH slide for microscopy check • hepatic function before starting medication and after medication! Liver function 2-3 months. Non-pharmacological: • spray shoes with Lysol daily • change socks twice a day, moisture wicking shoes (like dress socks) • keep feet clean and dry, • do not share shoes/socks, • avoid walking barefoot in gyms/shared spaces Pharmacological: • Severe cases: Terbinafine (Lamisil) oral 250mg daily for 6 weeks for fingernail and 12- 16 weeks for toenail up to one year. 22 • Mild to moderate cases: topical antifungals like efinaconazole (Jublia) or ciclopirox (Penlac) as a nail lacquer x several weeks; works best on fingernails Follow up: periodically for liver function test and progression. Referral: Dermatology if treatment does not work Liek: page 168 21. Tinea Corporis (ringworm) - Presentation: fungal infections of the skin. • Rash, itching, well-circumscribed red scaly plaque usually on the trunk, may occur in groups of three or more lesions. • Has central clearing, red ring on outside Risk factor: close contact with animals, warm climates, obesity, prolonged use of topical steroids, immunocompromised state, wrestling (contact sports) Diagnostic: KOH Prep (potassium hydroxide Preparation) Non-pharmacological: • Good hygiene, • keep dry and expose to air and light • avoid contact with lesions pharmacological: • Ketoconazole 2% cream x2 weeks Follow up: • 2 weeks Referral: • None Differentials: • Pityriasis rosea, psoriasis, atopic dermatitis Hollier: page 157 22. UTI (Cystitis) – Presentation: • Mostly E-coli, • mostly impacts females, • infection of your urinary system from bacteria (kidneys, ureters, bladder, urethra). • Urgency and frequent to void. burning, frequency, and or urgency during urination fever, chills, • Sensation of incomplete bladder emptying, • Hematuria, lower abdominal pain, • Dribbling of urine in men, foul-smelling urine, small volume and/or frequent voiding • Child and pregnant women progress to pyelonephritis/ nephron death Assessment: • Burning, frequency, and urgency • Pain during or after urination • Sensation of incomplete emptying • Fever, chills • Hematuria • Lower abdominal pain 25 • Medication side effects • Urinary tract infection • Bladder cancer Hollier: page 398 24. Eczema (atopic dermatitis) – part of atopic triad (allergies, asthma, allergic rhinitis) Presentation: chronic pruritic skin eruption that presents as a patchy, plaque like rash with inflammation • Eczema is the acute stage of the pruritic irritation of atopic dermatitis • Personal family history of asthma, allergies, allergic rhinitis • Contact with irritating substances Diagnostics: none needed; 80% of patients have eosinophilia during episodes of disease activity Located: knees, hands, neck, antecubital and popliteal space, arms, legs, face Assessment: • Pruritus • Erythema • Dry skin • Facial erythema • Infraorbital folds • Antecubital fossa, posterior patella areas, scalp area Nonpharmacological: • Prevent dry skin by using ointment/petroleum based • manage stress • avoid wool clothing, • fragrance-free detergents, • keep the environment free of dust as possible • oatmeal bath • products without scents/for sensitive skin. • Avoid sun trauma. • Moisturize. Pharmacological: • Topical Corticosteroids (NOT ON FACE) low potency steroids • Hydrocortisone butyrate 0.1% 15g apply thin film 2-4 times daily. No more than 3 weeks. • Oral steroids reserved for extreme cases • Antihistamines for itching • Eucerin, Lubriderm, cetaphil Education: • Limit baths • Avoid sunburns • Daily moisturization Follow up: • 2-4 weeks • Important to ensure compliance and that steroid isn’t being overused or used inappropriately Refer: 26 • Dermatology Differential: • Contact dermatitis • Seborrheic dermatitis • Scabies • Psoriasis Hollier: page 100 25. Fibromyalgia / myositis – disease of exclusions Presentation: • patients present with chronic widespread body pain accompanied by fatigue, sleep, memory, and mood issues o Pain and stiffness, fatigue and tiredness, depression and anxiety o Sleep problems, thinking and memory, o Headaches and migraines o Tingling and numbness in hands and feet, pain in jaw or TMJ o Digestive problems with abdominal pain, bloating, constipation, IBS • Physical examination is typically normal but may have tenderness Diagnostics: ACR uses several criteria to diagnose • Widespread pain index o Neck, jaw, shoulder girdle, upper and lower arm, upper and lower leg, and hip • Symptoms present at similar levels for at least 3 months • Presence of pain or tenderness at certain body sites • ESR/C-reactive protein (to exclude inflammatory cause), Thyroid function test (exclude hypothyroidism), CBC (exclude anemia), Rheumatoid factor (r/o RA), ANA (R/o Lupus), vitamin D (Vit D deficiency). Diagnosis: Based on symptoms Nonpharmacological: • Patient education about the disease (chronic pain disorder that affects connective tissues, muscles ligaments cause is unknown. • exercise • cognitive behavior therapy • sleep hygiene Pharmacological: Exact cause is unknown, so treatment is symptomatic: • Tricyclic antidepressant- Amitriptyline (Elavil) 10 mg once daily at bedtime • Flexeril 5-30mg once daily at bedtime. • Doxlenatine (Cymbalta) anxiety/depression and pain indication Follow up: 2-4 weeks Referral: • psychologist for therapy • Pain clinic if interested/ applicable Liek: page 667 and 730 27 UNLIKELY BUT POSSIBLE QUESTIONS FOR VISE HEENT & Respiratory Asthma DD: TYPES: Extrinsic (Allergic triggers); Intrinsic (Irritant triggers); Mixed (Extrinsic and Intrinsic Asthma) Occup. [Toluene diisocyanate, Polyvinylchloride, Phthalic anhydride, Trimellitic anhydride, Plicatic acid (Western Red Cedar trees), Metal salts, Platinum, Nickel]; Aspirin or NSAID induced Asthma; Exercise Induced; Cough Variant Asthma URI Chronic Obstructive Pulmonary Disease (COPD) GERD Bronchiolitis (kid); Congestive heart failure; Chronic Sinusitis; PE; Foreign body aspiration; Sarcoidosis; Bronchiectasis; CF; Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome) Bronchitis DD: Pneumonia; asthma; URI/ cold; Allergic rhinitis; CHF (esp RHF); Reflux esophagitis; Pertussis infection; Lung cancer COPD DD: Chronic asthma (good SABA/LABA response & normal DLCO on PFT); Acute bronchitis; CHF; Bronchiectasis; chronic cough; Bronchiolitis obliterans (young, nonsmoker, collagen-vascular diseases); PE. Cough Differential Dx: URI, bronchitis, rhinitis/sinusitis (upper airway cough syndrome), asthma, GERD, and ACE inhibitors Dx tests: Sputum culture, chest x-ray/CT scan, and pulmonary function tests are useful diagnostic tests Subacute cough 3 to 8 weeks chronic cough > 8 weeks Influenza DD: URI; Adenovirus/ Arenaviruses; Parainfluenza Virus; Legionnaires Disease Acute Respiratory Distress Syndrome; Cytomegalovirus (CMV); Dengue; Hantavirus Pulmonary Syndrome; HIV Infection and AIDS Pneumonia DD: asthma; bronchitis; viral/bacterial URI; COPD; atelectasis; Bacteremia; Legionairres; ASD or PDA (peds); cardiomyopathy; FB aspiration; Pertussis; Empyema; Pneumothorax; URI Differential Diagnoses: Allergic Rhinitis; Asthma Community-Acquired Pneumonia (CAP); GERD Epstein-Barr Virus (EBV) Infectious Mononucleosis (Mono); Obstructive Sleep Apnea (OSA); Bronchiectasis 30 Required only if the patient has pain in the midfoot and one or more of the following: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight for 4 steps, both immediately after the injury and in the emergency department Hematology DD: Anemia DD: Vit B12 or folate (B9) deficiency; CKD; Chronic liver disease; pregnancy; Low LDL Cholesterol (Hypobetalipoproteinemia); Other types of anemias (Alpha/beta Thalassemia; Aplastic Anemia; Hemolytic Anemia; IDA; Megaloblastic Anemia; Myelophthisic Anemia; Pernicious Anemia; Sickle Cell Anemia; Spur Cell Anemia); hepatitis; CMV; myelodysplastic syndrome; leukemias (ALL, AML, CML, HCL) Anemia Normocytic "NORMAL SIZE" Normal Pregnancy; Overhydration; Renal Disease; Myelophthistic; Acute Blood loss; Liver Disease; SI - Systemic Infection/Inflammation; Zero production – Aplastic; Endocrine: Hypothyroid, hypoadrenal, decreased androgen Index Anemia Microcytic "TICS": Thalassemias; Iron Deficiency (GI Bleed, Menses, Diet); Chronic Inflammation; Sideroblastic-lead toxicity Anemia Hemolytic: "HEMATOLOGIST" Hemoglobinopathy (Hb SS, SC, S beta Thal), Hemoglobinuria (Paroxysmal Nocturnal Hemoglobinuria); Enzyme Deficiency ( Inherited Pyruvate Kinase (PK) deficiency and pyrimidine-5'-nucleotidase deficiency); Medication - Drug- induced immune hemolytic anemias; Antibodies, autoimmune; Trauma to the red cells. Fragmentation (Microangiopathic); Ovalocytosis - This is an autosomal dom disorder in pts from SE Asia- min s/s.; Liver disease; Osmotic fragility in Hereditary spherocytosis and in Hereditary Eliptocytosis; Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD); Infection: Intra- erythrocytic parasites (malaria and babesiosis); Splenic destruction in hypersplenism. Splenomegaly; Transfusion-related, Thalassemias Psychological DD: Anxiety DD: Generalized Anxiety Disorder; OCD; hyperthyroid; Panic Disorder; Social Anxiety Disorder Depression Differential Diagnosis: Adjustment disorder with depressed mood; Anxiety disorders; Hypothyroidism Vitamin B12 or D deficiency; Substance/ETOH/ medication- or medical illness-associated (OSA, hypothyroid), other depressive disorders Bipolar disorder; Premenstrual dysphoric disorder (PMDD); Grief reaction Integumentary DD: Contact Dermatitis Differential Diagnoses: Allergy versus Irritant Contact Dermatitis; Eczema; Contact Urticaria Syndrome; Drug-Induced Bullous Disorders; Drug-Induced Photosensitivity; Seborrheic Dermatitis; Tinea Corporis 31 Drug Eruption/ Allergic Reaction to Med DD: viral exanthems {Measles (rubeola), Rubella, Erythema infectiosum/5th disease (human parvovirus B19), Roseola infantum or exanthem subitum (human herpesvirus 6 or 7), mono (EBV or CMV), HIV infection}; bacterial exanthems {Scarlet fever, Mycoplasma infection}, rashes associated with systemic diseases {Juvenile idiopathic arthritis and adult-onset Still disease}, and cutaneous diseases { Acute cutaneous lupus erythematosus} Ingrown Nails (toenail= unguis incarnatus or onychocryptosis) DD: Paronychia (tender bacterial or fungal nail infection); Foreign body; Nailbed Injuries; Bunion; Cellulitis; Group A Streptococcal (GAS) or staph aureus Infections; Subungual exostoses; Periungual fibroma; Onychomycosis; Amelanotic melanoma; Osteomyelitis; Herpetic Whitlow; Paronychia; Pyogenic granuloma Note: paronychia is NOT the same as onychocryptosis. Paronychia is a fingernail or toenail area skin infection, which usually affects the cuticle/sides of the nail. Acute paronychia – sudden onset, fingers, short lasting. Chronic paronychia – lasts longer; fingers or toes; doesn’t get better or keeps coming back.