NURS 6531 Midterm Exam Review, Adult Primary Care

NURS 6531 Midterm Exam Review (Week 1-6) **Save for Final comprehensive Exam Review** Competencies of Advanced Nurse Practitioners  How to apply advanced practice nursing competencies to clinical settings Upon completion of a nurse practitioner program, nine core competencies were defined as the foundational components instilled in the graduate regardless of the areas of specialty. These competencies consist of: 1. Scientific foundation These competencies ensure that nurse practitioners graduate with a comprehensive background in medical sciences. All nurse practitioner students are required to take foundational pathophysiology and pharmacology, but depending on their specialty, they may take additional courses. o Thinks critically about data and applies this evidence to improving practice. o Allows knowledge from the humanities and other disciplines to inform one’s work in nursing. o Incorporates research findings to enhance practice methods and patient outcomes. o Creates fresh evidence-based approaches and techniques, paying thought to research findings, core theory, and experience from practice. 2. Leadership Leadership competencies focus on professional accountability, scholarship, and advocacy. These skills ensure that nurse practitioner students understand their scope and standards of practice and that they are prepared to lead healthcare teams. The leadership competencies also encompass cultural sensitivity, engagement in professional organizations, and communication skills. o Embraces high leadership opportunities to facilitate change. o Liaises effectively between various parties (e.g., healthcare teams, patients, community, policy advocates) in efforts to improve healthcare. o Applies critical and reflective thinking to one’s leadership. o Acts as an advocate for resource-efficient, cost-effective, and quality care. o Elevates practice by incorporating innovations. o Has excellent oral and written communication skills. 1 o Joins professional associations, advocacy groups, and other activities to improve healthcare. 3. Quality Quality care, as defined by the NONPF, refers to the degree to which health services increase the desired health outcomes consistent with professional knowledge and standards. Quality competencies focus on understanding how to access and use information databases and how to critically evaluate research findings.  The quality core competencies include the following: o Applies the best and most contemporary research findings to clinical practice. o Considers the complex relationships between cost, safety, access, and quality in healthcare delivery. o Assesses the effects of organizational structures, financial management, policy, and other factors on healthcare. o Offers feedback in peer reviews to “promote a culture of excellence.” o Tailors care for each practice situation and use interventions as necessary. 4. Practice inquiry Practice inquiry competencies focus on translational research, i.e., taking academic research and applying it to the clinical setting. These competencies ensure that nurse practitioner students understand how to apply research to improve their patients’ health outcomes.  The practice inquiry core competencies include the following: o Translates new knowledge into practice through leadership. o Uses clinical experiences to inform practice and improve patient outcomes. o Applies investigative abilities in a clinical setting to improve healthcare. o Facilitates practice inquiry, both individually and in partnerships. o Transmits knowledge from inquiry to others. o Thinks critically about the individual applications of clinical guidelines. 2 5. Technology and information literacy Information literacy, as defined by the NONPF, refers to the use of digital technology, communications tools, and/or networks to access, manage, integrate, evaluate, create, and effectively communicate information. The goal of these competencies is to teach nurse practitioner students how to use available technology to enhance the safety and health outcomes of their patients. To achieve these objectives, NP schools may require students to take an informatics course.  The technology and information literacy core competencies include the following: o Uses appropriate technology to manage information. o Translates health information for various users. o It helps patients and caregivers understand conditions and treatments. o Informs the design of effective clinical information systems. o Facilitates health information technologies that allow for the evaluation of care. 6. Policy Health policy, as defined by the NONPF, refers to the set of decisions on health, which influence health resource allocation. These can be made at organizational, local, state, national, and global levels. These competencies teach nurse practitioner students on how to influence legislation to improve health issues and social problems like poverty, literacy, and violence.  The policy core competencies include the following: o Understands the interdependence of clinical practice and policy. o Promotes ethical approaches to improving access, cost, and quality. o Pays thought to policy’s context (e.g., legal, social, etc). o Assists in creating health policy. o Examines the cross-disciplinary impact of policy. o Analyzes the influence of globalization on healthcare policy. 7. Health delivery system The health delivery system competencies refer to the planning, development, and implementation of public and community health programs. These competencies also educate students on healthcare reform and organizational decision-making.  The health delivery system core competencies include the following: 3 o Incorporates knowledge of organizations and systems to improve healthcare. o Utilizes negotiation and relationship-building to positively affect healthcare. o Minimizes patient and provider risks. o Develops culturally competent care. o Analyzes the impact of the healthcare system on all stakeholders. o Thinks critically about organizational structures and resource allocation. o Works with others to improve the continuum of healthcare. 8. Ethics These competencies encompass understanding the ethical implications of scientific advances and learning to negotiate ethical dilemmas specific to that student's patient population.  The ethical core competencies include the following: o Uses ethics in decision-making. o Analyzes the ethical impact of all decisions. o Understands ethical complexities in healthcare delivery to individuals and populations. 9. Independent practice The independent practice competencies ensure that a nurse practitioner can function as a licensed independent practitioner. The NONPF defines a licensed independent practitioner as an individual with a recognized scientific knowledge base, who is permitted by law to provide care and services without direction or supervision. These competencies encompass the assessment, diagnosis, and treatment of patients within the student’s population focus. For example, a psychiatric nurse practitioner would learn to diagnose and treat mental illness and addiction.  The independent practice core competencies include the following: o Works effectively as an autonomous practitioner. o Offers health promotion and protection; preventative care; counseling; treatment planning and implementation; and palliative or end-of-life care. o It can distinguish between normal and abnormal health findings. o Knows screening and diagnostic protocols. o Prescribes medications following regional laws. o Provides healthcare over the lifespan of individuals and families. 4 o Respects the patient’s wishes and offers culturally competent care. o Fosters collaborative and empathetic patient relationships. o Cultivates patient-centeredness concerning confidentiality, mutual trust, and support. o Takes into consideration the patient’s spiritual and cultural influences (or other beliefs). o It reassures patients that they have control over decisions and offers expertise in creating a viable healthcare plan.  Theories in nursing practice o Virginia Henderson: Often called "the Nightingale of Modern Nursing," Henderson was a noted nursing educator and author. Her "Need Theory" was based on practice and her education. She emphasized the importance of increasing a client's independence to promote their continued healing progress after hospitalization. Her definition of nursing was one of the first to mark the difference between nursing and medicine. "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. She must in a sense, get inside the skin of each of her patients to know what he needs." o Martha Rogers: Rogers honed her theory through many years of education. She was not only a diploma nurse, but she also held a Master's of Public Health from Johns Hopkins University and completed her Doctorate of Nursing there as well. She saw nursing as both a science and an art. Rogers' theory is known as that of Unitary Human Beings. Nursing seeks to promote symphonic interaction between the environment and the person, to strengthen the coherence and integrity of the human beings, and to direct and redirect patterns of interaction between the person and the environment for the realization of maximum health potential. Her development of this abstract system was strongly influenced by an early grounding in arts and background of science along with her keen interest in space. o Dorothea E. Orem: Known as the Self-Care Theory, Orem's vision of health is a state characterized by the wholeness of developed human structures and bodily and mental functioning. It includes physical, psychological, interpersonal, and social aspects. Her major assumptions included that people should be self-reliant and responsible for their care and the care of others in their family. She said that a person's knowledge of potential health problems is necessary for promoting self-care behaviors. Orem defined nursing as an art, a helping service, and technology. o Betty Neuman: The System Model, developed by Neuman, focuses on the response of the client system to actual or potential environmental stressors and the use of several levels of nursing prevention intervention for attaining, retaining, and maintaining optimal client system wellness. Neuman defines the concern of nursing is preventing stress invasion. If stress is not prevented then the nurse should protect the client's basic structure and obtain or maintain a maximum level of wellness. Nurses provide care through primary, secondary, and tertiary prevention modes. 5 o Hildegard Peplau: Four phases define Peplau's Interpersonal Theory or nursing. She defines the nurse/patient relationship evolving through orientation, identification, exploitation, and resolution. She views nursing as a maturing force that is realized as the personality develops through educational, therapeutic, and interpersonal processes. Nurses enter into a personal relationship with an individual when a felt need is present. Peplau's model is still very popular with clinicians working with individuals who have psychological problems. o Madeleine Leininger: One of the newer nursing theories, Transcultural Nursing first appeared in 1978. According to Leininger, the goal of nursing is to provide care congruent with cultural values, beliefs, and practices. Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature. She says there can be no cure without caring, but that there may be caring with curing. Health care personnel should work towards an understanding of the care and the values, health beliefs, and lifestyles of different cultures, which will form the basis for providing culture-specific care. o Patricia Benner: From Novice to Expert is probably the simplest nursing theory to understand. Benner describes five levels of nursing experience: novice, advanced beginner, competent, proficient, and expert. The levels reflect a movement from reliance on abstract principles to the use of past concrete experience. She proposes that a nurse could gain knowledge and skills without ever learning the theory. Each step builds on the previous one as the learner gains clinical expertise. Simply put, Benner says the experience is a prerequisite for becoming an expert. Benner published her "Novice to Expert Theory" in 1982.  SOAP note – 4 parts S – Looking for Subjective Evidence  Interview the patient and/or family member about the history of the present illness.  Ask about the presentation of the illness (timing, signs and symptoms, etc.)  Ask whether the patient is on any medication, inquire about past medical history, diet, etc.  Be alert for the historical findings because they provide important clues that help point to the correct diagnosis (or differential diagnosis). O - Looking for Objective Evidence  Perform physical exam (general or targeted to the present complaints).  If applicable, perform a physical maneuver (Tinel’s, Kernig’s, drawer, etc.)  Order laboratory/other tests to “rule in” (or “rule out”) the differential diagnosis  If the laboratory test result is abnormal, you may be asked about the next step (such as a follow up lab test that is more sensitive or specific). A-Assessment  The medical diagnoses for the medical visit on the given date of a note written. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong. There may also be other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment. P-Plan  This describes what the health care provider will do to treat the patient - ordering labs, referrals, procedures performed, medications prescribed, etc. How you are going to address the patient’s 6 problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work.  Coding and billing in nursing practice  For reimbursement of services, the first thing that has to happen is the NP needs to obtain a National Provider Identifier (NPI) number. This application is online. You also will need to apply/enroll as a Medicare and Medicaid provider (separate applications) using that NPI number.  Billing: When you have all your appropriate billing numbers, you can submit for reimbursement.  NPs can bill under their own numbers and reimbursement will be at 85% of the physician fee schedule for outpatient and inpatient services.  “Incident to services” is a billing term specific to Medicare for the office/outpatient setting. When NPs bill “incident to”, they are reimbursed at 100% of the physician fee. These instances have specific requirements. #1 The services must in rendered in the physician’s office under “Physician’s direct personal supervision”. This means that the physician must be available on site to provide assistance if needed. It does NOT mean that the physician has to see the patient on that visit or that they must “sign off” on that patient’s visit. The physician DOES have to do the initial visit and see the patient on a frequency that supports that he/she is involved in the patient’s plan of care. “Incident to” does not apply in the hospital setting.  Split/Shared E/M Services applies to hospital inpatient/hospital outpatient or emergency department. This is used when BOTH the NP and physician have BOTH had a face to face visit with the patient. The key here is Face to Face. Doctor must physically lay eyes on the patient, not just review documentation.  Other third party payers vary on reimbursement from 85-100%.  Coding : is based on the complexity of the visit. E/M Coding represents the health care provider’s cognitive skills and includes office or clinic visits, consultations, preventative medical examinations, and critical care services. Make sure codes are accurate for diagnoses as Over AND Under coding both constitute Medicare fraud. Medicare fraud can result in fines, criminal prosecution, loss of provider status and license. “collaborative” does not mean “supervisory”. In Home Health services, physicians must complete medical necessity eval. NP’s cannot bill for Medicare under Medicare A “Delegation from a physician”. Under part B, NP’s can bill provided services are “physician services” i.e. Dx, Tx, consult, care plan management. NP’s can be reimbursed for all care “evaluation and management codes” and diagnostic tests if in collaboration with MD. INTEGUMENTARY DISORDERS 7 Macule < 1 cm flat w/well circumscribed change in skin color EX: freckle, labial muscle Patch > 1 macule Ex: Large birth mark Papule < 1 cm elevated solid skin lesion Ex: Mole (nevus) acne Plaque > 1 cm papule Ex: psoriasis Wheal: transient smooth papule or plaque EX: Hives (urticaria) Vesicle: 1 cm small fluid filled blister EX: chicken pox (varicella) Bulla > 1 cm Bullous pemphigoid Pustule: vesicle containing pus Ex: pustular psoriasis Scale: flaking of the stratum corneum Ex: Eczema, psoriasis, SCC Crust: Dry Exudate Ex: Impetigo o Melanoma: melanocyte that occurs on the skin. o Treatment: Removal and biopsy to determine whether it is benign or malignant. o Malignant Melanomas : Melanoma is a malignant tumor of melanocytes. o Melanocytes predominantly occur in the skin but can be found elsewhere, especially the eye. The vast majority of melanomas originate in the skin. While it represents one of the rarer forms of skin cancer, melanoma underlies the majority of skin cancer-related deaths. o The most fatal form of skin cancer; incidents are higher in women than men before age 50  For early stage melanoma, the definitive treatment choice is surgery, and depending on the stage of the melanoma, intralesional therapy, immunotherapy, signal transduction inhibitors, chemotherapy, or palliative local therapy may be needed  Depending on prognosis, follow-up care for a patient with melanoma should occur every 3- 12 months, and the patient should be educated on monthly self-examinations of the skin and lymph nodes (Tan, 2020). o Treatment: If the biopsy indicates it is malignant melanoma radiation, chemotherapy maybe necessary. o Ethnic considerations: Melanoma rates are about 20 times higher in white people than in black people. 8 o The following factors may raise a person’s risk of developing melanoma : o Sun exposure.  E xposure to ultraviolet (UV) radiation from the sun plays a major role in the development of skin cancer. People who live at high altitudes or in areas with bright sunlight year-round have a higher risk of developing skin cancer. People who spend a lot of time outside during the midday hours also have a higher risk. Avoid recreational sun tanning outdoors to reduce the risk of skin cancer. Exposure to ultraviolet B (UVB) radiation from the sun appears more closely associated with melanoma, but newer information suggests that ultraviolet A (UVA) may also play a role in the development of melanoma, as well as the development of basal and squamous cell skin cancers. While UVB radiation causes sunburn and does not penetrate through car windows or other types of glass, UVA is able to pass through glass and may cause aging and wrinkling of the skin in addition to skin cancer. Therefore, it is important to protect your skin from both UVA and UVB radiation. o Indoor tanning. People who use tanning beds, tanning parlors, or sun lamps have an increased risk of developing all types of skin cancer. Using indoor tanning beds is strongly discouraged. o Moles. People with many moles or unusual moles called dysplastic nevi or atypical moles have a higher risk of developing melanoma. Dysplastic nevi are large moles that have irregular color and shape. A doctor may recommend regular photography of the skin to closely watch the skin of people with many moles. o Fair skin. People with fair complexion, blond or red hair, blue eyes, and freckles are at increased risk for developing melanoma. This risk is also higher for people whose skin has a tendency to burn rather than tan. o Fa mily history. About 10% of people with melanoma have a family history of the disease. If a person has a close relative (parent, brother, sister, or child) who has been diagnosed with melanoma, his or her risk of developing melanoma is 2 to 3 times higher than the average risk. This risk increases if several family members who live in different locations have been diagnosed with melanoma. Therefore, it is recommended that close relatives of a person with melanoma routinely have their skin examined. o Familial melanoma. Although changes, called mutations, in specific genes, such as CDKN2A, CDK4, P53, and MITF, have been identified that may lead to melanoma, these are rare. Only a very small number of families with a history of melanoma actually pass these genetic mutations from generation to generation. Scientists are looking for other genes and environmental factors that might affect a person’s risk of developing melanoma and other cancers. o Other inherited conditions. People with specific inherited genetic conditions, including xeroderma pigmentosum, retinoblastoma, Li-Fraumeni syndrome, Werner syndrome, and certain hereditary breast and ovarian cancer syndromes, have an increased risk of developing melanoma. 9 o Previous skin cancer. People who have already had a melanoma have an increased risk of developing other, new melanomas. People who have had basal cell or squamous cell skin cancer also have an increased risk of developing melanoma. Therefore, people who have had previous skin cancer need ongoing, follow-up care to watch for additional cancers. o Race or ethnicity. Melanoma rates are about 20 times higher in white people than in black people. However, a person of any race or ethnicity can develop melanoma. o Age. The median age at which people are diagnosed with melanoma is just above 50 years old. Median is the midpoint, which means that about half of people with melanoma are diagnosed when they are younger than 50 and about half are diagnosed when they are older than 50. Melanoma occurs in young adults more often than in many other types of cancer. o Weakened or suppressed immune system. People who have weakened immune systems or use certain medications that suppress immune function have a higher risk of developing skin cancer, including melanoma. o Patient Education  Sunscreens should be applied before sun exposure and reapplied every 2 hours or  after swimming.  It is important for patients to know that they should seek medical attention for nonhealing sores (sores usually heal within 4 to 6 weeks) or for any lesion that changes in size, shape, texture, or color.  Early identification of atypical-appearing skin lesions results in timely referral and effective treatment o Acral-lentiginous melanoma  Least common variant of melanoma typically located on distal areas of the body. Due to its presentation, it can be confused with a vascular ulcer.  Accounts for less than 5% of all melanomas  Occurs most often on the hands, feet, nail beds, and occasionally mucosal surfaces of dark-skinned individuals  Very common in African Americans and Asian Americans, with a particular predilection for the soles of the feet  Appears as a dark brown to black, unevenly pigmented patch. If lesions are raised or develops ulceration, the likelihood of invasion should be considered. o Cryosurgery 10  the application of cold, such as nitrogen in its liquid state, to produce herapeutic tissue necrosis. Liquid nitrogen is the most common cryogenic agent because of its low boiling point (−196°  Indicated in the treatment of myriad skin conditions, and is used typically in the destruction of benign lesions that are easily recognizable, such as acrochorda (skin tags), warts, and seborrheic keratosis.  It is also used for the treatment of actinic keratosis—gritty, erythematous patches on typically sunexposed surfaces that are considered precancerous. Cold intolerance, cold urticaria, and cryoglobulinemia are relative contraindications to cryosurgery, as is treatment o Acne vulgaris :  Most common skin condition in the U.S, first observed in pediatrics, progressing to adulthood.  a disorder of the pilosebaceous follicles resulting in increased sebum production, altered keratinization, inflammation, and bacterial colonization. Acne is characterized by the formation of comedones, erythematous papules and pustules, and nodules.  Mild: < 30 lesions is treated with topicals only  Moderate: 30-125 treated with topicals and ATBs  Severe > 125 treated with Accutane  First line therapy is topical  Goals of treatment include normalizing keratinization of the follicular epithelium, decreasing sebum production, reducing P. acnes proliferation, reducing inflammation, and minimizing scarring. o Actinic keratosis:  Persistent or recurrent reddened and roughened areas that scales or crusts. Round, dry, and red colored.  Slow growing and seen on cheeks, face, neck, arms, or back  More commonly seen in the elderly population due to prolonged sun exposure.  Lesions may progress to SCC and is the most common lesion with malignant potential to arise on the skin  Skin biopsy needed to confirm dx and r/o SCC  Treatment:  Avoid sun exposure, sunscreens reduce the development of AK  Lesions are treated with Cryotherapy, liquid nitrogen thru a freeze-thaw technique to obtain a 1- to 3-mm (0.04 to 0.12-inch) rim of freeze, which allows appropriately slow thawing during 20 to 40 seconds 11  A large number of lesions treated with Fluorouracil cream 5%  Surgical Curettage  Chemotherapy (5-FU, diclofenac, imiquimod)  Dermabrasion  Photodynamic Therapy  Gynecologists recommend cancer screenings every 3 years for females 13+ older with actinic keratosis, a precursor lesion.  o Basal cell carcinoma (Most common type of skin cancer)  The most common form of skin cancer, found on the auricle and less likely to be malignant. Usually found in fair skinned patients and patients with history of sun exposure.  Shiny, irregular, painless lesions. 30% of these lesions looks pearly or waxy with a ulcer center that does not heal  Treated with electrodessication and curettage. Definitive treatment is total excision.  Found more in older persons, persons of fair skinned, and in patients with hx of sun exposure.  Due to BCC rarely metastasizing, laboratory and clinical tests aren’t commonly indicated. A skin biopsy is needed to confirm dx o Squamous cell carcinoma  Commonly found on the auricle.  Raised crusted lesions around a center ulcer  Low-risk cutaneous squamous cell carcinoma (cSCC) on the trunk and extremities can be treated with electrodessication and curettage (ED&C). For invasive cSCC, surgical excision and Mohs micrographic surgery are the primary treatment options; with appropriate patient selection, these techniques have comparable cure rates. Radiation therapy is typically used as an adjuvant to surgery, to provide improved locoregional control 12 o Folliculitis :  defined histologically as the presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule.  Typically an acute onset with pruritus and mild discomfort  Treatment includes antibacterial soaps and good handwashing; inflamed lesions respond well to warm compresses; ATBs for infected lesions o Fungal Infections (Superficial) :  Dermatophytes: Most common are Trichophyton, Microsporum, and Epidermophyton organisms.  The treatment of tinea infections include the removal of the infectious organism  Topical Antifungal solutions and creams reduce scaling  Oral Ketoconazole SHOULD BE AVOIDED due to hepatoxicity and serious drug interactions  Tinea cruris (Jock itch) : Appears on the groin and upper inner thigh and extends to the gluteal folds as red scaly patches with raised borders  Tinea Pedis (athletes foot): Presents as interdigital scaling, maceration, and fissuring,  Tinea corporis is the second most common infection passed from dogs and cats to humans  Tinea manus (hand ) is often a dry, diffuse, scaly eruption of the palms, with sharply marginated plaques on the dorsum of the hands. The feet are often also involved  Tinea unguium (nail), also called onychomycosis, most commonly manifests as the distal subungual type.  Tinea versicolor : chronic, asymptomatic, and superficial fungal infection. It is more common during the years of high sebaceous gland activity (teens and young adults).  The causative organism of tinea versicolor is Malassezia furfur. The yeast form of the organism Pityrosporum orbiculare  The fungus is found on normal skin, and the infection is caused by a change in the host's resistance to this organism.  Causes lesions in some individuals during periods of high heat and humidity.  More prevalent during the summer and in hot, humid regions.  Exposure to sunlight often initiates an episode. 1  Clinical Presentation includes  Lesions vary in color and are either white or light pink in the hypopigmented version or tan or brown in the hyperpigmented version.  Hypopigmented lesions are more noticeable in darkly pigmented skin. Patients should be reassured that re-pigmentation will occur after treatment and with exposure to natural sunlight. However, this process can take several months  Lesions are slightly scaly and are round or oval coalescing papules and plaques. 13  Usual sites for these lesions are the sternal region; the sides of the chest, abdomen, or back; the pubis; and the intertriginous areas.  Diagnostics  Diagnosis is by KOH examination (potassium hydroxide preparation), which reveals numerous short, straight hyphae and clusters of rounds, budding yeast; this configuration is commonly referred to as “spaghetti and meatballs.”  Examination may be falsely negative if the patient has just showered.  Skin scrapings may be obtained for fungal culture on lipid-containing medium if diagnosis is still in question  Treatment  Common antifungal creams, such as the imidazoles  Other antifungal oral agents  Topical shampoos or suspensions containing selenium sulfide or pyrithione zinc are affordable and effective in treatment or prophylaxis o Shampoos are applied to affected areas, allowed to dry, and rinsed away after remaining in place approximately 10 minutes. This treatment is repeated for 7 to 14 consecutive days during active infections, followed by periodic use of these shampoos or soaps if the patient is prone to frequent infections  Education  Patients should understand that tinea versicolor commonly recurs but is not a serious disorder.  It is more common in warmer climates and often flares during summer months  The regular use of any selenium sulfide shampoo for 10 minutes each day for a week followed by consistent biweekly treatments will often prevent recurrences. o Folliculitis :  defined histologically as the presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule.  Typically an acute onset with pruritus and mild discomfort  Treatment includes antibacterial soaps and good handwashing; inflamed lesions respond well to warm compresses; ATBs for infected lesions o Fungal Infections (Superficial) :  Dermatophytes: Most common are Trichophyton, Microsporum, and Epidermophyton organisms.  The treatment of tinea infections includes the removal of the infectious organism 14  Topical Antifungal solutions and creams reduce scaling  Oral Ketoconazole SHOULD BE AVOIDED due to hepatoxicity and serious drug interactions  Tinea cruris (Jock itch) : Appears on the groin and upper inner thigh and extends to the gluteal folds as red scaly patches with raised borders  Tinea Pedis (athletes foot): Presents as interdigital scaling, maceration, and fissuring,  Tinea corporis (Ringworm) is the second most common infection passed from dogs and cats to humans  Tinea manus (hand ) is often a dry, diffuse, scaly eruption of the palms, with sharply marginated plaques on the dorsum of the hands. The feet are often also involved  Tinea unguium (nail), also called onychomycosis, most commonly manifests as the distal subungual type.  Tinea versicolor : chronic, asymptomatic, and superficial fungal infection. It is more common during the years of high sebaceous gland activity (teens and young adults).  The causative organism of tinea versicolor is Malassezia furfur. The yeast form of the organism Pityrosporum orbiculare  The fungus is found on normal skin, and the infection is caused by a change in the host's resistance to this organism.  Causes lesions in some individuals during periods of high heat and humidity.  More prevalent during the summer and in hot, humid regions.  Exposure to sunlight often initiates an episode. 1  Clinical Presentation includes  Lesions vary in color and are either white or light pink in the hypopigmented version or tan or brown in the hyperpigmented version.  Hypopigmented lesions are more noticeable in darkly pigmented skin. Patients should be reassured that re-pigmentation will occur after treatment and with exposure to natural sunlight. However, this process can take several months  Lesions are slightly scaly and are round or oval coalescing papules and plaques.  Usual sites for these lesions are the sternal region; the sides of the chest, abdomen, or back; the pubis; and the intertriginous areas.  Diagnostics  Diagnosis is by KOH examination (potassium hydroxide preparation), which reveals numerous short, straight hyphae and clusters of rounds, budding yeast; this configuration is commonly referred to as “spaghetti and meatballs.”  Examination may be falsely negative if the patient has just showered.  Skin scrapings may be obtained for fungal culture on lipid-containing medium if diagnosis is still in question  Treatment  Common antifungal creams, such as the imidazoles  Other antifungal oral agents 15  Topical shampoos or suspensions containing selenium sulfide or pyrithione zinc are affordable and effective in treatment or prophylaxis o Shampoos are applied to affected areas, allowed to dry, and rinsed away after remaining in place approximately 10 minutes. This treatment is repeated for 7 to 14 consecutive days during active infections, followed by periodic use of these shampoos or soaps if the patient is prone to frequent infections  Education  Patients should understand that tinea versicolor commonly recurs but is not a serious disorder.  It is more common in warmer climates and often flares during summer months  The regular use of any selenium sulfide shampoo for 10 minutes each day for a week followed by consistent biweekly treatments will often prevent recurrences. o Herpes zoster (Shingles)  A dermatologic eruption caused by the reactivation of the varicella zoster virus. Initially erythematous and maculopapular and becomes clusters of clear vesicles during the course of several hours  Vesicular lesions appear days later and may last 7-10 days, sometimes longer  Incidence increase with age and immune suppression  Presentation:  Classically seen as unilateral eruption of one dermatome. Prior to eruption, pain (burning, stabbing, aching, or excruciating), dysesthesia, or pruritus  New lesions may continue to develop for several days. Low-grade fever and lymphadenopathy may be present. The most common areas of involvement are the thoracic, cranial (especially the trigeminal), and lumbar nerves.  Diagnosis  Based on the clinical presentation of a vesicular eruption in a unilateral, dermatomal distribution.  Tzanck test is a rapid way to confirm the diagnosis of zoster in the provider's office but does not distinguish between VZV and herpes simplex virus.  The direct fluorescent antibody (DFA) test or polymerase chain reaction (PCR) analysis, or viral culture (least preferred)  Treatment: Symptomatic and prevention of secondary infection  Antiviral therapy (acyclovir, famciclovir, and valacyclovir) initiated within 72 hours reduce the severity of symptoms  Zostavax, a live, attenuated vaccine for the prevention of zoster in patients older than 60 years. (Zostavax is a higher-potency form of Varivax vaccine.) o Patient Education: 16  Lesions of herpes zoster may contain VZV, enabling transmission to susceptible individuals (including infants and women of childbearing age who have not had the varicella vaccine or previous varicella infection)  Patients should avoid direct contact with susceptible persons and cover active lesions until they have crusted over, indicating that the lesions are no longer contagious.  Anyone older than 60 years with no contraindications to live vaccines should be considered for VZV vaccination during routine health maintenance visits o Urticaria (Hives)  Hypersensitivity vascular reaction that occurs after exposure to an allergen or antigen. It usually occurs in the upper dermis of the skin  Characterized by wheals on the body surface. Acute last less than 6 weeks and chronic is 6+ weeks.  Chronic urticaria can be idiopathic or autoimmune  Presentation reveals edematous pink or red wheals surrounded by a bright red flare. The center of the lesions may be clear or, rarely, may develop bullae.  Initially presents as pruritus followed by the development of hives. Lesions appear in crops that last 2 to 3 hours and then disappear, only to flare up elsewhere later. They generally fade in less than 24 hours, leaving no trace. Episodes can occur as often as daily and in chronic urticaria  Diagnostics: Lab tests not needed but may be helpful in cases of chronic urticaria in which physical causative agents have been excluded.  Typical laboratory workup would include a complete blood count (CBC), white blood cell differential, and erythrocyte sedimentation rate (ESR).  Urinalysis, hepatitis panel, thyroid panel, thyroid antimicrosomal antibody, antinuclear antibody, rheumatoid factor, H. pylori testing, serum complement C3 and C4, cryoglobulin, serum IgE and IgM, chest radiograph, and sinus series are less likely to be needed but may be ordered when indicated by history, physical examination, or consultation with a specialist.  A skin biopsy may be done to assess for vasculitis if the sedimentation rate is increased or if hives are accompanied by arthralgia or burning sensation in the skin.  Treatment  H1 receptor antagonists as first-line medication, augmented with H2 receptor antagonists, tricyclic antidepressants, and in some cases, leukotriene receptor antagonists and steroids for resistant episodes o Psoriasis :  an autoimmune, inflammatory papulosquamous eruption characterized by well-circumscribed erythematous macular and papular lesions with loosely adherent silvery white scale. 17  Presents as scaly papules and plaques form and collect on skin surfaces in well-demarcated lesions with an erythematous base and silvery white plaques that are adherent. The dermis is highly vascular, and tiny bleeding points (Auspitz sign) are revealed if the scales are removed  Common sites are elbows, knees, genitals, scalp, and intergluteal cleft. Childhood psoriasis often involve the face  Diagnosis is based on presentation, silvery scales on red, erythematous plaques.  Goal of treatment is the restoration and maintenance of the barrier function of the skin.  Topical therapy and research suggest topical steroid with a Vitamin D analogue is most effective. Ointments are preferred, but cream if patient not able to use ointment.  Phototherapy in the form of ultraviolet B (UVB) light therapy has been shown to be effective for treatment. Most common delivery is a laser at the Derm office.  Retinoids are used occasionally…usually for pustular and erythrodermic psoriasis  Systemic steroids are rarely used due to the patient’s risk of severe rebound (pustular) psoriasis after discontinuation.  Systemic therapy  Methotrexate  Acitretin  Cyclosporine  Biologics Etanercept, Infliximab, Ustekinu mab  Patient education includes proper maintenance to skin, comply with med regimen, avoid injury to skin, including sunburn  Avoid beta blockers, lithium, and antimalarials when possible o Scabies :  Caused by infection of Sarcoptes scabiei mite, sometimes referred to as the human itch mite. Affects people of all ages and more common in crowded living situations and institutional facilities  Two Categories: lesions at the site of infestation and lesions secondary to hypersensitivity to the mite.  Common burrow sites are the interdigital spaces of the hands, flexures of the wrists and arms, genitals, feet, buttocks, and axillae  A hypersensitivity reaction to the mites can manifest as urticaria, eczematous dermatitis, and scabetic nodules.  Excoriations, lichen simplex chronicus, and secondary infection may result from scratching.  Crusted scabies (Norwegian or hyperkeratotic) is found in immunocompromised or debilitated patients, and itching may be only mild.  Diagnostics : Typically by clinical findings  classic burrow, a straight or S-shaped ridge 2 to 10 mm long, is not always present and is less likely to be seen in warm, humid climates. 18  Adhesive Tape Test: Adhesive tape is adhered to the affected area, then rapidly removed. The tape is then applied to a slide and examined under a microscope.  Treatment :  Topical cream: 5% Permethrin Cream  Oral Ivermectin is used off label to treat crusted scabies or if topical therapy is ineffective  Lindane is no longer recommended for treatment because of toxicity  Patient Education:  All household contacts should be identified and treated  All clothing and bedding must be washed in hot water and dried on a hot cycle.  Stuffed sofa and chairs should be vacuumed o Rhus dermatitis : (also called Toxicodendron dermatitis): is an allergic contact dermatitis caused by the oil urushiol found in various plants like: poison ivy, poison oak, poison sumac and the Chinese lacquer tree. Signs/symptoms:  Papulovesicular dermatitis o Linear formation (associated with Rhus oil spread) o Very pruritic rash  Inhalational reaction may also occur o Burned poison ivy leaves- Can result in significant airway inflammation Treatment:  Cool compresses for 15-20 minutes per hour  Colloidal oatmeal bath  Calamine lotion  Topical Corticosteroids  Oral Steroids Prednisone tapering dose- 60mg orally per day divided doses. Decrease by 10mg every third day x 18days o Seborrheic Dermatitis  chronic, common dermatosis characterized by greasy, slightly erythematous scaling that occurs in areas with the highest concentration of sweat glands or sebaceous glands, including the scalp, face, and postauricular and intertriginous areas.  Clinical Presentation  Most common in newborns is yellow or brown scaling lesions on the scalp, which are called cradle cap. 19  Adolescents and adults, another common presentation is dry, flaky scales on the scalp. This disorder is known as dandruff.  Treatment : No cure, only symptom mgmt. Usually treated with Antiseborrheic shampoos o Syphilis  Primary : Painless, firm, round chancre(s) at site of inoculation, lasts 3-6 weeks; Discrete, enlarged, painless regional lymph nodes  Incubation: 10-90 days; average, 21vdays  Secondary : Nonpruritic rash: rough, red, red brown spots, sometimes very faint; may occur on mucous membranes, vagina, anus, palms, soles, trunk  Appears 2-8 weeks after chancre, may be present while chancre is resolving  May cause: Generalized adenopathy, Fever, Sore throat, Patchy alopecia, Malaise, arthralgias, weight loss, Oral mucous patches, Condylomata lata, Hepatosplenomegaly  Increased incidence is associated with crack cocaine and illicit drug use.  Diagnostics for Syphilis (both): Darkfield microscopy; Nontreponemal serology (RPR, VDRL); Confirm with treponemal serology (MHA-TP, FTA-ABS); Sequential serologic testing; use same testing method and laboratory  Treatment for Syphilis (both): Penicillin is drug of choice; Doxycycline is the best alternative for early and latent syphilis o Systemic Lupus Erythematosus (SLE)  a chronic multisystem inflammatory rheumatic disease that may cause diverse symptoms, such as fatigue, joint pain, rashes, seizures, edema, and chest pain.  Hallmark of SLE is the development of antibodies directed against components of “self” tissues, particularly structures found within cell nuclei.  Clinical Presentation:  The classic presentation of a triad of fever, joint pain, and rash in a woman of childbearing age should prompt investigation into the diagnosis of SLE  The disease can develop acutely, with obvious severe manifestations that include arthritis, nephritis, serositis, and vasculitis, or it may become apparent in an individual who has had mild symptoms and subtle physical findings (e.g., fatigue, arthralgia, rashes) sporadically for many years. 20  The disorder is often misdiagnosed because many of the early symptoms of SLE are nonspecific (e.g., fatigue, oral ulcers, joint pain) and the ANA test result is positive in approximately 5% of healthy persons. o Patients may present with any of the following symptoms: (Medscape)  Constitutional (eg, fatigue, fever, arthralgia, weight changes)  Musculoskeletal (eg, arthralgia, arthropathy, myalgia, frank arthritis, avascular necrosis)  Dermatologic (eg, malar rash, photosensitivity, discoid lupus)  Renal (eg, acute or chronic renal failure, acute nephritic disease)  Neuropsychiatric (eg, seizure, psychosis)  Pulmonary (eg, pleurisy, pleural effusion, pneumonitis, pulmonary hypertension, interstitial lung disease)  Gastrointestinal (eg, nausea, dyspepsia, abdominal pain)  Cardiac (eg, pericarditis, myocarditis)  Hematologic (eg, cytopenias such as leukopenia, lymphopenia, anemia, or thrombocytopenia) o Diagnostics  During a disea se exacerbation of SLE, laboratory tests reveal nonspecific evidence of systemic inflammation with an elevated erythrocyte sedimentation rate (ESR), C-reactive protein, and serum gamma globulins o Treatment  Local corticosteroid cream for skin lesions o Education  Should avoid prolong sun exposure due to photosensitivity  Diet can decrease risk for metabolic syndrome or atherosclerosis o Cellulitis (non-purulent SSTI) :  begins when pathogens find a portal of entry through nonintact skin. as is seen after traumatic laceration; at sites of diabetic, vascular, or other types of skin ulceration  Cellulitis may cross these categories (non-purulent/purulent SSTI) because it may be secondary to skin ulcers or other lesions that themselves produce pus, 21  Involves the deeper dermis and subcutaneous fat, cellulitis rapidly spreads and extends deeply from the dermis to the subcutaneous tissue. When it is left untreated, cellulitis may progress to more severe soft tissue infection and osteomyelitis and may even become limb- or life-threatening.  Most common site is BLE, but may occur anywhere.  Initial clinical presentation of cellulitis is characterized by spreading erythema, induration, warmth, and pain and may be associated with systemic symptoms such as fevers, chills, and malaise.  Bullae, abscesses, erosions, necrosis, and even focal areas of hemorrhage manifesting as ecchymosis or petechiae may develop within cellulitis.  The site of entry of the bacteria may be evident as breaks in the skin or ulcerations. Careful inspection of the interdigital areas is crucial in the physical examination for lower extremity cellulitis, because macerated tinea pedis may have provided the portal of entry for bacteria. Left untreated, this predisposes to recurrent cellulitis. Regional lymph nodes may be enlarged and tender, a condition called lymphadenitis o Non-purulent SSTI Presentation ( impetigo, ecthyma, erysipelas, and cellulitis )  Impe tigo (nonpurulent SSTI ) : a toxin mediated skin infection caused by S. Aureus or streptococcus causing dermal-epidermal junction cleavage  Most common presentation is vesiculopustular lesions or bullous lesions. Once lesions rupture and exude their contents, the classic honey colored crusts appear  Treated with Keflex or dicloxacillin (Dynapen)  Erysipelas is an SSTI limited to the superficial dermis including lymphatics  Facial erysipelas may follow streptococcal infection of the upper respiratory tract o Purulent SSTI Presentation  Mild SSTI: defined as occurring in an immunocompetent patient with hemodynamic stability who appears nontoxic: patients with these infections can typically be treated on an outpatient basis with appropriate incision and drainage, and often without need for antibiotics.  Moderate SSTI: occurring in an immunocompetent patient with systemic symptoms and signs  Severe SSTI: defined as those refractory to oral ATBs; and if purulent, refractory to incision and drainage; pts with hemodynamic alteration, incl HR > 90, RR > 24, or leukocytosis > 12,000; and in the immunocompromised  Diagnostics for Cellulitis: For purulent, gram stain and culture is needed. For non-purulent, clinical presentation is mostly used o Venous stasis ulcers 22  A severe complication of post thrombotic syndrome (PTS) and rarely occurs without a hx of DVT  Occur around ankle, particularly medial side, History of phlebitis, Signs of venous stasis, Painful when secondarily infected, Improved by elevation  Pulses may not be palpable due to local swelling or coexistent ischemia  Mgmt includes wound debridement. ATBs if infectious.  Educate patients on compression stockings HEENT o Otitis externa : Cellulitis of the external auditory canal that may extend to the auricle (pinna), also known as swimmer’s ear o Pain develops over 48 hours and usually accompanied by feelings of fullness or itching o Presentation includes pain upon palpation of the tragus or application of traction to the pinna, cellulitis of the face or neck, erythema, edema, or discharge from the ear canal, or hearing loss o Chronic otitis externa presents differently including canal is often dry, and cerumen may be absent. Excoriations may be present secondary to use of objects inserted to relieve the itching that accompanies this condition. Discharge may be present  Diagnostics include a culture of canal drainage; or a microscopic analysis of drainage using potassium hydroxide (KOH) can identify a fungal cause.  Treatment includes: Management of otitis externa focuses on clearing debris from the canal, managing the pain, and treating the infection and inflammation with systemic and/or topical antibiotics. o Otitis Media (OM) : characterized by fluid in the middle ear, is a group of inflammatory or infective processes that may be bacterial, fungal, or viral in origin and is most often associated with upper respiratory tract infections or allergies. o The most frequent childhood infectious illness o Bacteria are the most frequent cause for otitis infections. o Antecedent events may be viral, bacterial, or allergic. Viral upper respiratory tract infections or allergies often precede otitis and result in edema of the eustachian tube and nasopharynx  Acute otitis media (AOM), with bacterial or viral infection of the middle ear fluid, has a rapid onset and short duration.  Otitis media with effusion (OME) describes accumulation of serous fluid in the middle ear without acute inflammation  Can precede or follow AOM, but barotrauma or allergy also can precipitate an occurrence.  Middle ear effusion (MEE) signifies an accumulation of serous fluid in the middle ear and can be associated with AOM, often persisting for weeks or months after an episode of AOM.  Chronic effusion (known also as serous otitis media or glue ear) may persist for several months, with or without signs of infection. 2 Children aged 3 to 7 years old are most commonly affected. 23  Recurrent otitis media is defined as three or more distinct episodes in 6 months or four or more episodes in the preceding 12 months with at least one episode in the past 6 months. o Symptoms can include pain, discharge, hearing loss, tinnitus, headache, fever, irritability, or vertigo  Presence of rapid-onset otalgia, worse in a prone position, remains the common initial complaint of patients with AOM.  Specific symptoms and signs are linked with causative bacteria.  Patients with OME or serous otitis may be asymptomatic or have mild pain with no symptoms of acute infection. o Diagnostics: Otoscopic examination is key is diagnosing  Determine TM position or contour, color, translucency, and mobility.  Positions other than the usual neutral include retracted, full, and bulging.  Moderate to severe bulging is the most important characteristic for the diagnosis of AOM.  Otorrhea may indicate MEE, especially if accompanied by abrupt relief of pain.  Retraction is a common finding in OME. o Treatment o The type of AOM determines the most appropriate treatment for individual patients. The need for antibiotic therapy is determined on an individual basis based on history and presentation. o Treatment decisions should be reconsidered if symptoms worsen or fail to respond to initial antibiotic treatment within 48 to 72 hours. o Pain treatment should be provided for otalgia, whether or not antibiotics are prescribed.  Acetaminophen or ibuprofen for mild to moderate pain.  Narcotic analgesia with codeine is effective for moderate to severe pain. o Antihistamines, decongestants, and steroids are not beneficial for treatment of AOM or OME. o Types of Conjunctivitis : inflammation of the bulbar or palpebral conjunctiva. o Viral Conjunctivitis: Spread by direct contact or proximity to an infected person  s/s: acute onset of a red eye with excessive watery discharge. Classically begins in one eye and then involves the fellow eye within days  Treatment is self-limited and typically lasts 5 to 14 days. Treatment is supportive with artificial tears and cool compresses  Adenoviral conjunctivitis occurs in 3 forms  1) the lower eyelid should be pulled down and the palpebral conjunctiva evaluated. Follicles are clear bumps, ranging in size from pinpoint to 2 mm, with overlying conjunctival vessels  2) Similar s/s. but systemic signs appear fever, headache, and sore throat  3) Epidemic keratoconjunctivitis is clinically striking with significant, bilateral conjunctival hyperemia and chemosis. o Bacterial Conjunctivitis: occurs directly from hand-eye contact with an infected individual or from the transfer of organisms in one's own nasal and sinus mucosa.  Acute conjunctivitis is the most common form 24  s/s include thick, purulent discharge. Patient may c/o sticky or gooey eyes. Symptoms may last 7-10 days. Chronic lasts longer than 4 weeks  Treatment includes Topical treatment with antibiotics is not always necessary. Evidence shows that outcomes with topical antibiotics are equivalent to placebo at 1 week.  The following types of bacterial conjunctivitis require systemic treatment: o H. Influenza, Gonococcal, and Chlamydial o Acute Allergic Conjunctivitis (Hay Fever): secondary to environmental allergens, most commonly ragweed  Boggy conjunctiva; discharge will be clear or stringy and white  Treatment includes the removal of allergens and the use of oral antihistamines. Treatment should start topically with supportive care: preservative-free artificial tears, cool compresses, and removal of contact lenses. o Vernal (in childhood) and Atopic Conjunctivitis (in adults >50): chronic, mast cell–and lymphocytemediated immune processes. Both are considered to be more severe and chronic forms of allergic conjunctivitis.  more severe symptoms of severe itching, burning, and tearing. Other symptoms include blepharospasm and photophobia. Discharge is often white, thick, and ropy. 98% of cases are bilateral.  Treatment is similar to allergic conjunctivitis. The provider should initiate mast cell stabilizers (e.g., cromolyn sodium, lodoxamide tromethamine) 2 weeks before the usual time of presentation for relief in vernal conjunctivitis. o Strep throat o Pharyngitis is condition that encompasses inflammation of pharynx from either infection or irritation. o More common in children, peaking at ages 5-15. Occurs more in winter months. o Symptoms: sore throat, fever (greater than 101.3), and swollen lymph nodes in neck, tonsillar exudate, bad breath, painful swallowing, chills, headache, nausea, vomiting, and abdominal pain o PE: marked erythema of throat, patchy, discrete, white, or yellowish exudate, pharyngeal petechiae, and tender anterior cervical adenopathy o Education: Can spread via droplet or saliva. Educate pts not to share drinks, utensils, etc. Cover cough/sneezes. Strict handwashing. Stress antibiotic adherence!!! Educate on effectiveness of oral contraceptives while on antibiotic and need for additional contraception for entire course of antibiotic. Use a new toothbrush 48 hours after antibiotic therapy has started. o DX: Throat culture, Rapid antigen detection test (RADT), sometimes ASO titer o Treatment: 1. Penicillin V 500 mg BID/TID for 10 days 2. Amoxicillin 250 mg for 3-4 days or 500 mg BID x 10 days 3. Clarithromycin 250 mg BID x 10 days (for PCN allergy) 25 4. Azithromycin daily for 5 days and Clindamycin for 10 days (also are appropriate) 5. OTC- NSAIDS for pain, reduce inflammation or analgesics for pain, throat lozenges o Cornea abrasion :  may be caused by chemical or mechanical debridement resulting from trauma, chemicals, or ultraviolet radiation exposure. Corneal erosions occur if an abrasion disrupts Bowman's layer  Most common symptom is a sudden onset of severe pain in the affected eye that usually resolves after a topical anesthetic eye drop is applied  Diagnostics include the use of topical fluorescein dye can assist in the diagnosis of a corneal surface defect  Treatment includes supportive care; possible ophthalmic ATB drops; or ophthalmic ointment may help with pain. Oral analgesics are the 1st line choice for pain o Iritis (Anterior Uveitis) o Inflammation of the anterior uveal structure, the iris. o Signs and Symptoms: o Acute - Pain, redness, photophobia, excessive tearing, and decreased vision; pain generally develops over a few hours or days except in cases of trauma o Chronic - Primarily blurred vision, mild redness; little pain or photophobia except during an acute episode o Treatment: Urgent referral to ophthalmologist  main goals are to correctly diagnose uveitis, to provide analgesia, and to refer to ophthalmologist (Medscape)  The ophthalmologist tapers steroids and cycloplegics (Medscape)  When the condition is stable, patients are monitored every 1-6 months (Medscape) o Education: Acute iritis can lead to loss of vision if left untreated. Follow-up with ophthalmologist within 24 hours is important o Subconjunctival hemorrhage o Occurs after trauma or Valsalva maneuvers (ex. Lifting, sneezing, vomiting), conjunctival vessels can become compromised and bleed. Blood becomes trapped between the sclera and conjunctiva and results in a deep confluent red appearance that can be focal or diffuse. o Causes no ophthalmic problems and resolves without treatment, usually within 2 weeks. Reassure the patient. Changes from bright red to green or yellow, like a bruise. o Education: monitor for changes or no improvement. 26 o Allergic rhinitis o First step in development of allergic asthma. o Symptoms: intermittent nasal blockage or rhinorrhea, usually bilateral, sneezing, itching or watery eyes, pale bluish hue or pallor turbinates, and frequently associated atopic dermatitis o Onset: Acute or intermittent o Allergens: such as pollen, dust, cedar, grasses, etc. o Timing: typically seasonal, can also be perennial (Spring / Fall) o Diagnosis: based on symptoms and allergy testing o Treatment: intranasal corticosteroids, oral decongestants (pseudoephedrine and phenylephrine hydrochloride) o Pt education: stay away from allergens, should be advised that effect of intanasal corticosteroids may not be noticed for several days to weeks (start them before symptoms start). o Acute Sinusitis : o Inflammatory process in the paranasal sinuses caused by viral, bacterial, and fungal infections or allergic reaction the resolves with treatment within 2-3 weeks. o Most common cause is bacterial infection caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis; S. pneumoniae. o Signs and symptoms: nasal congestion, purulent nasal discharge, and a headache that becomes more intense when the patient bends forward. Fever and fatigue are common. o Onset: Abrupt with infection in one or more paranasal sinuses. o Clinical presentation: nasal congestion, facial or dental pain, postnasal drip, headache, fever, and yellow or green nasal discharge. Sensations of pain in teeth and forehead are worse in morning. “allergic shiners”- dark circles under eyes. Bacterial- ﮿ 101 o Common cold and allergic and idiopathic rhinitis are common antecedents to acute sinusitis. o Acute frontal sinusitis: Pain/tenderness of forehead and drainage from middle meatus of nasal turbinates. Palpate orbital roof. o Maxiallary sinus infections: pain/tenderness over cheek area. Anterior ethmoid cells drain through middle meatus, and posterior cells drain through superior meatus. o Sphenoid sinusitis: rare but may cause pain behind eyes or vertex and facial pain. Sinuses drain through superior meatus. 27 o Diagnostics: History and PE. Treatment:  First-generation antihistamine  NSAID  Decongestant (oxymetazoline/ Neo-synephrine) or cough suppressant  Amoxicilling-clavulanate 500/125 mg PO TID for 5-7 days or Amoxicilling-clavulanate 875/ 125 mg PO BID for 5-7 days. ABX IF BACTERIAL  Doxycycline as alternative to penicillin-allergic pts.  Azithromycin as choice for pregnant women. Pt education:  Do not use topical decongestants for more than 3-5 days to prevent rebound congestion.  Antibiotics are not beneficial for viral sinusitis.  Patients treated for sinusitis should return for further eval if symptoms have not improved in 48-72 hours and if experience periorbital swelling.  If allergic rhinitis is precursor to sinusitis. Humidified air and increased fluid intake are important to relieve nasal discomfort and to liquefy secretions. Warm, moist air in form of steam inhalation/warm compresses may relieve headache and pressure. Avoid swimming or diving.  Smoking cessation and frequent handwashing. o Retinal detachment …..(Most of the info attained from Medscape) o Refers to the separation of the inner layers of the retina from the underlying retinal pigment epithelium o Symptoms: Photopsia (common initially), Visual field defect (developing over time; may help localize detachment), and floaters o may produce a persistent symptom described as a curtain, shadow, or veil falling over part of the visual field. o Diagnostics: Lab testing is not useful in diagnosing retinal detachment, but helpful to determine if surgery is needed. o The history should include inquiries into the following: o History of trauma o Previous ophthalmologic surgery o Previous e