Nr 511 Final Exam Study Guide. Week 5

NR 511 FINAL EXAM STUDY GUIDE. Week 5 1. Identify the population most commonly affected by bacterial prostatitis o Acute - Sexually active men 30 to 50 years - Chronic bacterial prostatitis common in men older than 50 years old - Athletes who run long distance are predisposed - Complaints of fever, chills, LBP, malaise, arthralgia, myalgia, frequency, urgency, dysuria, nocturia, and bladder outlet obstruction o Chronic bacterial prostatitis- men over age 50 years of age. Symptoms often absent , perineal pain, lower abdomen pain, scrotal or penile pain, pain with ejaculation, dysuria, irritative voiding 2. Discuss the physical exam characteristics of acute bacterial prostatitis Abdominal exam to detect distended bladder, costovertebral angle tenderness, genital exam, and digital rectal exam Acute bacterial prostatitis- warm, tense, swollen , boggy and very tender prostate. Most common pathogen Strep faecalis and staph aureus 3. Discuss how the Phren sign can differentiate between testicular torsion and epididymitis Epididymis characteristic is relief of discomfort with elevation of testis. Positive Prehn’s sign = pain relief. Testicular torsion elevation of the affected testicle does NOT relieve the pain (Negative Prehn’s sign = pain is NOT relieved) Epididymis Positive Prehn’s sign = pain relief. Neg = no pain relief = testicular torsion). 4. Discuss common symptoms reported from a patient with BPH Affects men age 40 years and older. Obstructive symptoms include • Decreased stream • Hesitancy • Postvoid dribbling • Sensation of incomplete bladder emptying • Overflow incontinence • Inability to voluntarily stop the urine stream • Urinary retention • Straining Irritative symptoms include • Nocturia • Urinary frequency • Urinary urgency • Dysuria Urge incontinence Erectile dysfunction should be assessed on patient taking finasteride. 5. Discuss the hallmark characteristic of a varicocele The hallmark characteristic of varicocele is the sensation that the testes feel like a “bag of worms.” Varicocele can be bilateral, but if it is unilateral it is almost always on the left side due to the anatomy of the vasculature drainage in the testes. Tortuous veins posterior and above testes can be seen with patient sitting upright Venous engorgement may increase with Valsalva maneuver; resolves when patient lies down. Grade 1 varicocele is one that is palpable only when the patient performs the Valsalva maneuver. Grade 2 varicocele is palpable when the patient is standing. Grade 3 varicocele may be assessed with light palpation and visual inspection 6. Identify the population most affected by testicular cancer Males between the ages of 15 and 35 7. Explain spinal stenosis Narrowing of the spinal canal w/ compression of nerve roots - Congenital or acquired (age) - Most commonly from enlarging osteophytes at the facet joints, hypertrophy of the ligamentum flavum and protrusion/buldging of the intervertebral discs - May produce symptoms by directly pushing on nerve or interrupting the blood supply to nerve Common source of chronic low back pain, seen most with aging. All older people have some degree of this. 8. Discuss common characteristics (subjective and objective findings) of patients with lumbar spinal stenosis Subjective - Radicular complaints in calves, buttocks, upper thighs - Pain w/ walking or prolonged standing o Vascular claudication – pain stops w/ rest o Psuedoclaudication – pain doesn’t stop immediately at rest - Short term relief by leaning forward/stooping - Sometimes relief w/ sitting - Pain in back/leg when sleeping on back at night - Pain w/ walking/standing Objective - Muscle weakness - Impaired proprioception - Diminished reflexes - Sensory changes (numbness/tingling) - Bowel or bladder symptoms o Sphincter tone decreased o Don’t confuse w/ prostate problems in older men 9. Identify the red flags associated with back and neck complaints which warrant further investigation “TUNA FISH” T- Trauma F- Fever U- Unexplained weight loss I – IV Drug User N- Neurologic symptoms S – Steroid Use A- Age50 H – History of cancer (prostate, renal, breast, lung) 10. Define chronic pain • Pain that extends beyond the expected period of healing • Pain 3 months in duration • More generalized, less localized to the site of injury/initial complaint • Referral patterns can shift in location, intensity, frequency & quality • Pain does not change with movement, rest or time • Usually reported as constant/continuous (less likely intermittent) • Mood or current psychological status tends to affect/worsen c/o pain 11. Identify the number of joints involved in a poly-articular disorder Monoarticular: One joint Periarticular: Two to four joints Polyarticular: Four or more joints 12. Describe the four cardinal signs of joint inflammation 1. Erythema 2. Warmth 3. Pain 4. Swelling 13. Differentiate between DeQuervain’s Tenosynovitis and Carpal Tunnel Syndrome Carpal Tunnel Syndrome: - Peripheral nerve compression of the medial nerve - Caused by repetitive flexion and extension of the wrist or direct compression of medial nerve - Pain and/or numbness are usual presenting symptoms o Burning, tingling, or itching numbness of the hand and fingers, especially the thumb, middle, and index fingers - Most often dominant hand – may be bilateral - Pain increases with wrist flexion or extension - Paresthesia and numbness along thumb, index, long and radial half of ring fingers - Nighttime wakening of N/T in affected limb - Positive Phalen’s test, Positive Tinel’s sign - - - Diagnostics o Median nerve conduction velocity study most useful o xray if limited wrist movement only - Treatment o Rest, splinting o NSAIDS, NO CORTICOSTEROIDS o Vitamin B6, and management of concurrent diseases o Often resolves after pregnancy if symptoms related DeQuervain’s Tenosynovitis - Inflammation involving the synovial sheaths and tendons of the abductor pollicis longus and extensor pollicis longus, and brevis tendons (snuff box) - Pain at base of thumb or at the radial styloid process on abduction and extension of the thumb or on radial side of wrist with lifting - Generally seen in patients that perform pinch-grip activities like using hand tools, sewing, assembly - More often middle-aged women - Physical Exam o Allen’s test o Phalen’s test (negative) o Tinel’s sign (negative) o Confirmed by Finkelstein’s test (grasp the thumb in the palm while you deviate the wrist to the ulnar side) o Xray only if history of trauma - - Treatment o Rest, splinting for 3-6 weeks o NSAIDS o Injected corticosteroids o Tendon release surgery. 14. Differentiate between lateral and medial epicondylitis Lateral epicondylitis (AKA tennis elbow) is an overuse syndrome or tenosynovitis (inflammation involving synovial sheaths surrounding the tendon and the tendon) – typically from wrist extension and pronation and supination of the forearm. Presents with pain (worse with motion such as gripping) in elbow and forearm. Diagnosis made with PE. Xray can be used to r/o other causes of pain. MRI will show severe tenosynovitis but not necessary. Treated with rest, ice, NSAIDS, PT, and possible corticosteroid injections and splinting. Medial epicondylitis (AKA golfer’s elbow) is less common. Overuse syndrome of wrist flexion. Pain on medial epicondyle worsens with wrist flexion. Treated same as lateral epicondylitis. Imaging: Usually unnecessary, but it may be useful if needed to rule out alternative diagnoses. 15. Discuss at least 3 vital body functions which thyroid hormones regulate Body Function Hyperthyroidism Hypothyroidism Metabolic Increased appetite (Polyphagia), Weight Loss, hypercalcemia, K wasting, increased alkaline phosphatase Decreased appetite, Weight Gain General Fatigue, Muscle Atrophy, Tremors Fatigue, decreased libido, hypersomnia, periorbital puffiness Integumentary Diaphoresis, Heat Intolerance, thinning hair, pruritus, onycholysis Hair loss, ankle swelling, cold intolerance, dry cool rough skin, alopecia, dry course thick hair GI Diarrhea, Increase in BM Constipation, nausea, hypoactive bowel sounds, ascites, enlarged tongue Eye Blurred vision, tearing, double vision, decreased visual acuity, photophobia, increased orbital pressure, lid lag, exophthalmos, corneal ulcer N/A Neurological Tremors in hands, hyperactive reflexes Memory deficits, personality changes, hyporeflexia, bradykinesia Cardiopulmonary Palpitations, SOBOE, tachycardia, HTN, CHF, A-Fib Exercise intolerance, bradycardia, cardiac enlargement, pleural effusion GU Decreased menstrual flow, gynecomastia Irregular menses, decreased fertility Head & Neck Increased neck size, enlarged thyroid gland Enlarged neck, enlarged tongue (late), hoarseness Psychosocial Anxiety, nervousness, insomnia, irritability, restlessness, Depression, slowing of mental processes emotional lability, Increase in HR, RR, and BP Musculoskeletal Weakness, loss of muscle tone, Osteoporosis in women Muscle weakness and cramping Hematological Fatigue, normochromic normocytic anemia 16. Describe a goiter and the type of thyroid dysfunction that can be associated with it A goiter is the hypertrophy and hyperplasia of the thyroid gland in response to TSH levels. Most commonly seen with Hashimoto’s thyroiditis (hypothyroidism) in the United States. Toxic multinodular goiter (hyperthyroidism) in iodine deficiency. Grave’s Disease (hyperthyroidism) has a firm goiter. 17. Differentiate between overt hypothyroidism and subclinical hypothyroidism - Overt hypothyroidism o TSH above 10 and FT4 is decreased o Too little hormone is being produced o Pituitary is attempting to get the thyroid to produce more ▪ Low FT4 and high TSH - Subclinical hypothyroidism o TSH levels are increased, but the FT4 is within range o Some have symptoms, others do not 18. Differentiate between Hashimoto’s thyroiditis and Grave’s disease Both are autoimmune, attacking thyroid cells. Graves – overproduction of thyroid leading to hyperthyroidism - 90% of hyperthyroidism cases Hashimoto’s – underproduction of thyroid leading to hypothyroidism -Identified via TPO and TBG Abs in blood 19. Identify at least 3 risks associated with obesity Diabetes, CVD, Afib, HTN, NSTEMI, varicosities, cancer, skin infections, arthritis Gallbladder disease, GERD, acute pancreatitis, NAFLD Stress incontinence, infertility, OSA 20. Identify at least 3 causes of obesity Calorie excess—either overeating or high intake of carbohydrates Food insecurity—eating from a fear of potential hunger or past experience with poor availability of food on a regular basis Genetic predisposition with familial history—influences of ghrelin and leptin levels Medication influences—antidepressants, anti-seizure, steroids, insulin, oral contraceptives Psychological factors—self-soothing, large CHO intake = increased serotonin Disease states—hypothyroidism, insulin resistance, PCOS, Cushing’s 21. Discuss one primary prevention for obesity Obesity occurs when one’s intake of calories exceeds metabolic needs. Primary prevention for obesity includes increasing activity level, and managing caloric intake. Triad—Identify, Food, Activity • Identify those at risk—both adults and children—calculate BMI at every preventative visit: adult’s minimum yearly and children at each preventative visit following routine schedule. • Provide targeted nutritional advice—low CHO diets with high protein, small frequent meals throughout the day. • Eliminate sweetened liquid calories including juice. • Recommend 60 minutes of activity on most days of the week for adults and children. • Encourage good nutrition and activity at the family level, not just the individual level. • 24-hour diet recall and use motivational interviewing techniques. • Promote good sleep hygiene. 22. Identify the categories of obesity based on the BMI Overweight BMI is 25-29.9; relative weight is 100%-120% Obesity BMI is 30-40 140%-200% Severe (morbid) obesity BMI is greater than 40 greater than 200% 23. Discuss how acute low back pain without neurological dysfunction does not warrant radiological imaging Acute back pain may have several differential diagnoses. If pain isn’t found to be related to any neurological complaints, radiological imaging is not warranted. 24. Identify the roles of TSH, FT4, TT3, and TPO Abs in determining thyroid function Thyroid Stimulating Hormone (TSH)—Pituitary “messenger” to thyroid to increase or decrease thyroid hormone production. used to diagnose hypothyroidism. TSH and FT4 should be used to follow treatment. If the TSH is low or insufficiently elevated in the presence of low T4, central hypothyroidism caused by hypothalamic or pituitary disease should be excluded before starting replacement therapy. Free T4 (FT4)—Circulating unbound thyroid hormone produced by the thyroid, replaced by levothyroxine medication, useful for the diagnosis of hypothyroidism both overt and subclinical *Primary hypothyroidism is associated with a low FT4 and elevated TSH *Subclinical hypothyroidism is a mildly increased TSH with a normal FT4 Total T3 (TT3)—Circulating unbound thyroid hormone that has been converted from T4. T3 is not routinely used as a diagnostic tool because it isn’t sensitive or specific to the hypothyroidism. T3 levels may be normal in early disease, and may not fall until late in the disease. Thyroperoxidase antibodies (TPO Abs)—Useful in detecting autoimmune thyroiditis (Graves’ or Hashimoto’s) Diagnostic for Hashimoto’s thyroiditis when found in high titers (1:400). Higher levels TPO = more thyroid destruction = more severe hypothyroidism - No universal screening recommendations for thyroid disease. - ATA recommends screening for o Baseline at 35 o Pregnant women o Women older than 60 o Individuals with autoimmune disease. 25. Identify at least one “at-risk” population who should be considered for thyroid screening -Pregnant women -Women older than 60 years -Persons with other autoimmune diseases -Persons with pernicious anemia -Persons with a family history (1st degree relative) of thyroid disease -Persons with a history of prior thyroid surgery or dysfunction or neck radiation -Persons with Abnormal thyroid exam -Persons with psychiatric disorders (Dunphy, p. 847 & 859 and “Thyroid Disorders” Lecture) 26. Discuss one physical characteristic seen in a hyperthyroid patient -Smooth, velvety skin -Soft, thin hair -Skin with increased pigmentation, spider angiomas, and vitiligo -Onycholysis (splitting and spooning of the nails) -Exophthalmos (buldging eyes) (Dunphy, p. 851 & Hollier, p. 231) Muscle atrophy, tremors, hyperpigmentation, warm flushed moist skin, fine silky hair, thin hair, increased LFT, Exopthalamos, lid lag and edema, corneal ulceration, sinus tach, elevated BP, A.Fib, symptoms of CHF, gynecomastia, osteoporosis, hypercalcemia, potassium wasting 27. Identify the CDC recommended antibiotic class for treatment of acute bacterial prostatitis -Flouroquinolones (Ciprofloxacin, levofloxacin, ofloxacin, or norfloxacin) (Dunphy, p. 657 & “Male GU Problems” Lecture) Alternatives to a fluoroquinolone include Doxycycline 100 mg Q 12 hours; and TMP-SMX [160 mg/800 mg] (Bactrim DS) one tab Q 12 hours 28. Identify at least one treatment for BPH -Medication (conservative): -Alpha Blockers (Terazosin, Tamsulosin) -5-alpha Reductase Inhibitors (finasteride, dutasteride) -Surgical -TURP (transurethral resection of the prostate) 29. Identify treatment options for obesity based on BMI and comorbid conditions Overweight BMI: 25-29.9kg/m2 Obesity BMI: 30-40 kg/m2 Severe (morbid) obesity BMI: 40kg/m2 Treatment options: lifestyle changes (diet, exercise- 45-60 minutes/day), managing behavior (i.e. H.A.L.T. – hungry, angry, lonely, tired, behavior modification), reduce caloric intake, drugs (i.e. fenfluramine/Fen Phen, dexfenfluramine/Redux, phentermine, diethylopropion, orlistat). Surgical intervention (vertical-banded (mason) gastroplasty and roux-en-Y bypass) for BMI over 40 OR over 35 with comorbities A structured weight loss diet is most effective. Encourage formal programs or weight loss groups (WW, etc.). Diet goals should include a program with 1200–1500 calories per day for women and 1500–1800 calories per day for men; 500–750 calorie deficit per day; low CHO diet, increased fiber, and decreased saturated fats; and less than 800 calories per day in certain circumstances under medical supervision. 30. Describe the Spurling test and what condition it is used to diagnose Spurling’s maneuver assesses nerve root compression (i.e. radiculopathy) in the neck resulting in pain. - Spurling’s maneuver: o With patient’s neck in extension, rotate the neck to the affected side o Apply downward pressure on the head o Assess for patient complaint of or accentuation of limb pain or paresthesia (THIS IS A POSITIVE SIGN). Also, observe for neck atrophy. 31. Describe how to perform a Phalen and Tinnel test A. Phalen test: Purpose: Assess for median nerve compression Procedure: Have the patient maintain forced flexion of the wrist for 1 minute or more, with the dorsal surface of each hand pressed together. If the patient complains of numbness and paresthesia in the fingers =TEST IS POSTIVE B. Tinel test: Purpose: Assess for compression neuropathy Procedure: Percuss the median nerve at the wrist. If the patient complains of tingling in the digits (POSITIVE TINEL SIGN), compression at the site of percussion is likely. 32. Identify at least 3 physical exam maneuvers to assess the knee 1. Diagnosing ACL injury: Lachman’s, anterior drawer test, 2. Diagnosing meniscal tears: McMurray and Appley 3. Diagnosing PCL injury: posterior drawer test and Thumb sign 4. Diagnosing collateral (MCL and LCL) injury: Valgus and Varus stress test Week 6 1. Differentiate between resting, postural and intention tremors and describe each Resting tremor-Occurs at rest, against gravity, or sitting still with arms resting in lap. The most common condition that causes resting tremors is Parkinson’s Disease and medication tremors. Postural tremor-Seen when the patient is asked to extend the arm in front of them. The most common type is an essential tremor. It's bilateral and generally symmetric. There’s often a family Hx. Drinking alcohol can reduce the tremor. Intention (Kinetic) tremor-Characterized by an increase in amplitude when the patient attempts movement. Can be checked by having the patient perform finger to nose coordination. 2. Describe one disease with resting tremor as a clinical finding Parkinson’s Disease. It is a progressive neurological disease - 4 hallmark signs: o resting tremor o cogwheel rigidity o bradykinesia, o postural instability - Other characteristics are facial masking, difficulty staining from sitting in a chair, “freezing”, reduced arm swing, festinating (quick, short stride, with head down) and shuffling gait. Wilson's disease is another condition that is associated with resting tremor. This is a very rare genetic disorder associated with copper toxicity. Patients who are affected may have extrapyramidal symptoms [similar to Parkinson's] with a slow and progressive course. There may be symptoms of incoordination in the hands, dysarthria, and gait disorder, bradykinesia, rigidity, and ophthalmologic changes. The work up for Wilson’s includes serum ceruloplasmin and copper. Diagnosis is confirmed with liver biopsy, which identifies the copper toxicity. Treatment is aimed at lowering copper levels. 3. Describe a medication commonly associated with tremors Extrapyramidal side effects similar to Parkinson's disease. Antipsychotics are the most common offending agent. Metoclopramide (Reglan) Phenothiazine -Compazine Steroids Caffeine Anti-epileptics Antidepressants Asthma medications Intention tremor may be associated with medications, alcohol or drug abuse, multiple sclerosis, stroke, or a mass affecting the cerebellum. 4. Identify at least 3 laboratory tests to rule out systemic causes of tremor □ Electrolyte/ABGs (metabolic imbalances, drugs, caffeine, physiological fatigue) □ Serum glucose (hypoglycemia) □ Toxicology screen/drug levels (toxic conditions, antipsychotic drugs, caffeine) 5. Describe at least one at-risk population that is recommended to have HIV screening Anyone who had unprotected sex should be screened for HIV Men who have sex with men Those who exchange sex for drugs/money Those who have other STIs IV drug users Healthcare workers 6. Describe at least one pharmacologic treatment option for tremor Primidone (Mysoline) - beta blocker benzodiazepine (lorazepam) If monotherapy is ineffective, REFER TO NEURO If the tremor is medication induced, that agent may be reduced or eliminated. Parkinson’s disease - Dopamine agonist o Carbidopa/levodopa (Sinemet) o Pramipexole (Mirapex) o Ropinirole (Requip) - Anticholenergics o Benztropine (Cogentin) o Trihexyphenidyl (Artane) - If pharmacological therapy has been ineffective, localized botox injections may be considered - Deep brain stimulation in severe cases. - If tremor is due to alcohol withdrawal: diazepam, lorazepam (mild symptoms) 7. Describe an appropriate empiric antibiotic treatment plan for cellulitis Cellulitis = bacterial infection most commonly group A beta-hemolytic streptococcus or staphylococcus aureus (gram positive) tx = dicloxacillin or cephalexin for 10-14 days if PCN allergy, erythromycin If caused by animal or human bite: amoxicillin-clavulanic acid (augmentin) for 2 weeks 8. Discuss an intervention to prevent HIV and HIV-associated behaviors *safe sex practices - latex condoms *needle exchange programs *universal testing of donated blood products *education to HIV positive women of childbearing age about c-sections, arv drugs for mother and baby *voluntary HIV testing a routine part of medical care *new models for HIV diagnosing outside medical setting *prevent new infection by working with HIV infected and their partners to minimize risk 9. Identify physical exam findings in the patient with HIV fever, sore throat, myalgia, headaches, cervical lymphadenopathy, night sweats, majority are asymptomatic flu-like sumptoms 6 days to 6 weeks after viral transmission dark purple colored spots (karposi's sarcoma) non-productive cough, SOB, and fever for several weeks pulmonary symptoms: pcp pneumonia, tb, bacterial pneumonia localized candida infections other STD's weight loss anemia, leukopenia, and/or thrombocytopenia 10. Describe symptoms, DDx, pathogens, testing, and treatment for the following conditions: Cellulitis, impetigo, MRSA, Bites (dogs, cats, humans), Erysipelas - Cellulitis o Pathogens ▪ Strep (A,B,C,G,F) ▪ Staph o Symptoms ▪ Skin erythema, edema, warmth, pain, possible fever ▪ Lymphangitis, lymphadenopathy, peau d’orange (orange peel texture) ▪ No fever/chills, localized symptoms only ▪ Underlying infection, lymphedema, venous insufficiency o Treatment ▪ I&D if abscess is involved - Erysipelas o Pathogens ▪ Group A Strep o Symptoms ▪ Skin erythema, edema, warmth, pain, possible fever ▪ Lymphangitis, lymphadenopathy, peau d’orange (orange peel texture) ▪ Acute onset with systemic symptoms (fever, chills) ▪ Clear demarcation ▪ Butterfly involvement on face or ear o Milian’s Ear Sign ▪ Involvement of ear, classic for erysipelas o Treatment ▪ I&D if abscess is involved - MRSA o Risk factors ▪ ATB use • Cephalosporins • Fluoroquinolones ▪ HIV infection ▪ Hemodialysis ▪ ECFs o Signs and Symptoms ▪ Skin abscess • Painful, fluctuant, erythematous nodule, with or without surrounding cellulitis • Spontaneous drainage may occur • Regional lymphadenopathy may be observed • Fever, chills, and systemic toxicity are unusual • Also manifested as furuncles (abscess of hair follicles) or carbuncles (coalesced masses of furuncles) ▪ Experts recommend oral ATB for patients undergoing I&D of an abscess if • Single abscess is equal or greater than 2cm or multiple lesions • Extensive surrounding cellulitis • Immunosuppression or systemic signs of toxicity (fever100.5/38) • Presence of an indwelling medical device • High risk of transmission of S aureus to others o Athletes or military personnel ▪ ATB with coverage for CA-MRSA include • Bactrim DS 2x day • Doxycycline 100mg 2x day • Minocycline 200mg PO once, then 100mg Q12 hours • Clindamycin 300-450 mg 4xday ▪ Treatment should be offered for at least 5 days • Beta-lactam drug should be added if the abscess is peri-rectal or peri-oral - Impetigo o Primary ▪ Infection of previously normal skin o Secondary ▪ Infection arises at sites of minor skin trauma o Microbiology ▪ S. aureus ▪ Group A Strep (GAS) causes a minority of cases ▪ Occasionally MRSA o Signs/Symptoms ▪ Non-bullous impetigo • Most common form • Begins as papules – vesicles – pustules – thick, adherent golden crusts ▪ Bullous impetigo • Seen primarily in young children • Vesicles – flaccid bullae with clear yellow fluid – darker – thin brown crust o Treatment ▪ Topical choices • Mupirocin 3xday for 5 days • Retapamulin 2x day for 5 days ▪ Oral Treatment • Extensive impetigo and Ecthyma should be treated with an ATB effective for BOTH S. aureus and strep infections • Dicloxacillin and cephalexin for 7 days are appropriate treatments • PCN is the preferred agent if only strep are detected • MRSA impetigo can be treated with doxycycline, clindamycin, or Bactrim - Human Bites o Pathogens ▪ Staph aureus ▪ Strep o Agent of choice: Amoxicillin/clavulanate 875/125 2xday - Cat & Dog Bites o Pathogens ▪ Pasturella multocida & capnocytophaga canimorsis o Alternative ATB w/ activity against Pasturella ▪ Doxycycline 100mg 2xday ▪ Bactrim DS 2xday ▪ PCN VK 500mg 4xday ▪ Ciprofloxacin 500mg 2xday • PLUS o Metronidazole 500mg 3xday o Clindamycin 450mg 3xday - ALL bites treatment considerations o Treatment ▪ Copiously irrigate with sterile saline ▪ Remove grossly visible debris ▪ Prophylactic ATB are given if • Deep puncture wounds • Wounds requiring surgical repair • Moderate to severe wounds w/ associated crush injury • Wounds in areas of underlying venous and/or lymphatic compromise • Wounds on the hands or in close proximity to a bone or joint • Wounds on the face or in the genital area • Immunocompromised hosts