2022/2023 AANP Complete Review 2-2 Study Guide for Brand New Questions

AANP 2022/2023 Complete Review 2-2 Study Guide for Brand New Questions Dermatology Descriptor words are the most words, do not focus on the location that will help you the most. Acne Rosacea “N95 Acne” • Acne around the nose and mouth, pimples are small and cause discoloration of the skin. • Treat with topical metronidazole gel, topical sulfa drugs. Scabies • mites, they burrows they will have a linear lesion, serfientine lesions, it is not an infection. Treat with Prometheren cream 5% for 8-14 hours, wash everything soap and water and treat close contacts. Fifth’s disease (erythema infectiousium) • young patients with slapped rosy red cheeks This is an infection of parvo virus B19 • Confirmed by clinical assessment this is (cheap). Stay hydrated, and prevent fever. ROSEeola inphantom • (maculopapular rash, also known as 6th disease caused by human herpes virus 6) • High fever caused by URI when the fever goes away than a rash forms. Tx by supportive care, hydration, ibuprofen. Hand foot and mouth • (cocksucker of a disease or cocksacky 16 virus) symptomatic care. • Blisters on the hands, feet, inside the mouth, patient will complain of sore throat, anorexia, pain with acidic foods • Treat with salt water gargles, NSAIDs for pain no asprin. RubeOla • It is the Original measles, cOugh, cOryza (runny nose), cOnjectivits, kOplik spot, high grade fever, macular papular rash. • With this disease the rash and fever stay unlike roseola. • You treat these patients with the measles vaccine at 12 months of age because it is a live vaccine. Their immune system needs to be strong. You cannot give this to a pregnant mom, you have to wait four weeks to give this vaccine. If the patient is 13 years old make sure you tell them to wear protection they cannot get pregnant. What if a patient had a blood transfusion when can you give it to them then? It takes 3 months for us to replace our red blood cells so they have to wait three months. • measles, mumps, rubella vaccinations do not give to pregnant ladies, no immunocompromised Rubella • rebel against the Germans for three days (it only last three days). It is a low grade fever and they have a rash with the fever for only three days. The rash macular papular rash is the entire body. Kawasaki’s disease • patients will have a strawberry tongue, desquamation of the hands and feet, swelling of the hands and feet, and hemorrhagic conjunctivitis. • This is from a viral infection and affects the medium size arteries from head to toe. • With these patients we need to give them high doses of aspirin and IGG therapy to avoid blood clots from inflammation of the arteries. Scarlentina or Scarlet Fever (group b strep) • Sandpaper rash, strawberry tongue, and strep throat the three S’s. • Scarlintina is caused by Strep Throat we treat strep throat with Penicillian VK Mumps • complication from the mumps can cause inflammation of testies, mastitis, or inflammation of ovaries. Patients will have puffy cheeks up by the ear, the salivary gland up by the ear that is inflamed called parotitis they will have fever, muscle aches, loss of appetite (ooforitis, orchitis) Ring worm • Annular lesion with central clearing • Tinnia corprus (my body is a corpes) It is superficial you have to use a topical. (azole is antifungals). It is a dry circular lesion with central clearing. Treat with clometrazole. • Tinnia capitis (in the hair) and tinnea innumguinal (in the finger nail) use grycofluvent or turfenapine (6-12 months of treatment usually) orally or any other oral medications that end in “azole” These are in the hair follicles, and hard to reach places requiring oral treatment. Obtain a baseline LFT prior to giving these medications. This type of fungus takes time to heal. Basal Cell Carcinoma • is the most common skin cancer- PUTS (pearly, ulcerated, telegenic vessels, shiny). • Do a shave biopsy to further assess this lesion and refer to dermatology. The most common cancer resulting in mortality is melanoma because it usually metastases before we know about it. Squamous Cell Carcinoma • scaly, bleeds very easily. We do not biopsy benign lesions. Actinic Keratosis is the precursor to squamous cell carcinoma. It is rough, flesh colored, and scaly in sun exposed areas. Tx with cryotherapy (burns skin lesions off) or 5FU cream squamous cell carcinoma. • RUBS (rough, ulcerated, bleeds easy, scaly) this is the key to finding squamous cell carcinoma. • If you rub the lesion and it does not come off, and has been there over time, than it is actinic keratosis. • Do not remove skin cancer lesions on the face, refer them to dermatology, if not on the face do a punch biopsy to give dermatology a reference of how far the cancer is. Melanoma • Assess and refer. This is the cancer that will kill you. It is a silent killer. Cancer does not grow in a symmetrical form it will be asymmetrical, irregular borders. • 6mm or bigger, brown lesion Impetigo “The Florida Creep and Crud” • honey colored lesions on the lips. Treat topical use muporicin or bactroban. Caused by Strep pyogenes, and staph areas are gam positive on our skin. • It travels, and is highly contagious. Erysipelas • Upper dermal layer infection caused by staph aurerus gram positive • Well demarcated lesion, you can see everything that is red on this patients, erythema, induration. • Treat with Keflex or dicloxcillin. If allergic to PCN give macrolide such as azithromycin, erythromycin, clarithromycin. Fun fact levofloxin can cause achillies tendon rupture, do not give to children, and can cause cardiovascular issues such as prolonged QT intervals in elderly. MRSA • purulent drainage, bacterium, clindamycin, and doxycycline are the only treatments. PURLENT drainage key indicator Lyme Disease • Errythemia Nigricans, bulls eye lesions, this is referred to as lymme disease, treat with doxycycline. Rocky Mountain Spotted Fever. • Macular papular rash on the hands and feet. • patient was out camping, fever, rash on hands and feet. Treat lyme disease and RMSF treat with doxycycline 100mg BID for 10-21 days. If patients rash does not clear up and is still sick, the dose will need to be extended. In 21 days if it does not get better THAN refer. • You need to do everything you can in practice. The differential diagnosis is syphilis we diagnose syphillis with RPR tx with PEN G. G is for Gonads. RPR is the cheaper test than a punch biopsy so do an RPR VDL to check between RMSF or syphilis Mollusca Contagiousum • Water bead with a central plug This is a viral infection, it is itchy, no treatment, treat symptoms, give Atatarax, or reinol to stop itching and get rid of fluid. • Take a silver nitrate stick pop and drain the lesion. • This is highly contagious if it is in the gentile region in children we need to consider child abuse, or sexual assult. Condyloma acuminate “Genital Warts” • is genital warts, HPV causative agent. Preventative agent is gardisil vaccination starting at age 9 years old to 25 years old. • Treat with cryotherapy, TCA (tricycloracedic acid), BCA, if pregnant or non pregnant they can use the ointments. Acne • do not give Accutane, you need close monitoring with these patients. You must refer that patient to dermatology NPs cannot prescribe acutane it requires to much monitoring. • Mild acne tx with retinol, benzilporoxide face wash. If patient complains with burning, than you can reduce the daily use. • Moderate acne is deeper in the dermal layer they will need a oral and topical you can do tetracycline. • In pregnant patients and children younger than 8 years old give a macrolide for treatment. Dyshydrotic eczema “Planter Palmer Eczema” • Is a form of eczema, it can be on the hands or feet and contains fluid filled bulla or blisters. • We treat this with steroid creams, or ONE creams. Patients should be well moisturized, cool compresses, and use luke warm water to bathe. Our eczema patients come with the three A’s Asthma, Allergies, Allergic Rhinitis. Seborrheic keratosis “barnacles of aging” • Benign lesions, waxy and brown in nature. Lichen Planus • red raised nodules, with whichem striay (white lines). • Chemicals (cleaning chemicals) so you will see it on the hands and arms. Medications such as beta blockers can cause this, and hepatitis. • Run a panel and rule out for the rest Treat with Atarax or hydrocortisone cream. Psoriasis • silvery plaques this is an autoimmune disorder with inflammation. Treat with topical steroids, UV therapy, TAR creams or other preparations. • When patients pick at the plaques causing bleeding this is called Auspitz sign. Xanthelasma “Fat Pads” • fat plaques on the eyes, fingers, and eye lids caused by high cholesterol levels. Arcus Senallis • normal discoloration of the arch of the eye caused by increase in plaque deposits. But you should not consider this normal in 40 year old or younger patients. Sjorgens Sydrome • check patient for lupus, and RA because this is a immune disorder. They will have dry mouth, dry eyes, dry cough, skin rash, etc. Acanthosis Nigricans • Velvet patch on back of arms or neck of patients. • This is caused by PCOS, diabetes, insulin resistance, and colon cancer. Trepanation “hematoma under the fingernails” • Take an 18 gage needle and drain the hematoma under the fingernail. Stevens Johnsons Syndrome • Patients with HIV with an acute onset of hives, pupura, bulla, petechial, and desquamation of the mucosal membranes (eyes, nose, mouth, bronchial trees.) Patient will have a precursor of a fever. • Patients combining allopurinol and Bactrim develop this disease. Dog Bites or Cat Bites • Leave wound open and clean with normal saline • Treat with Augmentin Malaria • Prophylactic treatment for malaria is doxycycline. Burns • 1st degree burns are considered sun burns, treat these patients with aloe vera. • 2nd degree burn will have blisters, with pain. Do not allow patients to pop the blisters allow them to heel naturally. • 3rd degree burns are painless with blisters, when it is painless they have done nerve damage, patient requires referral. • If patient has clothing on when burned, you must cut around the affected area and than send patient to the ER Varicella or Herpes Zoster • Blisters on the trunk of the body that spread out to the rest of the limbs. • HSV-1 is on the mouth, HSV-2 is on the vagina/penis. • Herpetic whitlow is herpes on the finger. • Patients will complain of pain, burning, or tingling. • Treat patients with acyclovir 400mg three times a day for 20 days. Dermatology 1. Fever, chills, nausea, rash forearms, ankles, palms of hands and soles of feet Rocky Mountain Spotted Fever hiking or camping in the mountains TX: Doxycycline 2. High grass, found tick, target bullseye rash erythema migrans Lyme Disease TX: Doxycycline 3. Skin lesion with irregular border, light brown/dark brown/black Melanoma 4. Red/silvery/white scales and plaques, itchy psoriasis scab with psoriatic plagues called: Koebner phenomenon psoriasis scrap a psoriatic plaque and has pinpoint bleeding called: Auspitz sign 5. Itching at night in the web of the hands/burrowing Scabies TX: Permethrin cream; treat everybody, wash everything in hot water to kill scabies 6. Other name atopic dermatitis: Eczema; two other disease processes associated with eczema (Asthma; allergies) Atopic dermatitis; Asthma; Allergies 7. Itching red ring with central clearing (slowly get bigger) Ringworm/TINEA CORPORIS 8. Precursor to squamous cell carcinoma actinic keratosis (seen on sun exposed areas; face, scalp, hands; dry, pink to red lesion- pokes out the skin) TX: 5FU cream; cryotherapy gold standard DX: punch biopsy (for most skin lesions) 9. Black, tan, scaly lesion seborrheic keratosis (benign; asymptomatic) (usually on back, neck, chest) 10. Cellulitis w/DM most concerned for osteomyelitis (poor wound healing) 11. PAD (peripheral arterial disease) Intermittent claudication pain/painful when walking; feels better when they rest or dangling looks: shinny, hairless key in office test to determine DX: ABI (ankle-brachial index 0.9 or below is indicative of having PAD) STOP SMOKING TX: fem-pop bypass 12. Venous insufficiency lots of edema and discoloration (reddened, purple, dark) patient with varicosed veins at risk pooling blood at risk for DVT; do not elevate legs; must walk around; ASA, or antiplatelet 13. Cellulitis of the face; demarcated lines Erysipelas bacterial infection TX: PCN 14. Skin infections: Keflex and PCNs 15. Mom w/mastitis (breastfeeding) TX: Keflex; other instructions: continue to breastfeed 16. MRSA TX: BCD (Bactrim, Clindamycin, or Doxycycline) 17. Allergy to PCN: give a macrolide (our FAVORITE macrolide: Azithromycin; or, Doxycycline) 18. Most common skin CA: BCC Basel Cell Carcinoma (pearly, waxy, may or may not have an ulcerated center) 19. Papules, white plug, dome shaped lesion (some people say looks like belly button) Molluscum contagiosum benign raised bumps if you see those on a baby (think somebody is going to jail) If seen in the private area of child suspect sexual abuse (spread skin to skin) report ASAP 20. Macule-papular vesicular rash, starts on trunk, chest back and face varicella (chickenpox) When can these patients return to activities: after the lesions have crusted over. 21. ACNE: first line TX: topicals, Retin A gels not working give oral ABX?? Tetracycline not working: refer to dermatology (cause next is usually Accutane) 22. ACNE: topical and oral ABX is working but face is a bit irritated: stay out of the sun; reduce the frequency of the medication (don’t use it every day) 23. Honey crusted lesions impetigo TX: mupirocin/Bactroban 24. Scarlet Fever (Scarletina) key finding: sandpaper rash 25. Harold’s Patch on trunk; then proliferates into a Christmas tree=type rash pityriasis 26. BURNS: memorize the rule of nines First degree burn (redness; stinging; burning) Second degree burn (involves blistering) TX: Silvadene Third degree burns (full thickness) … referral to ER Skin: KEY POINTS TO REMEMBER WITH RULES OF NINES: Chest and Back 18% (child and adult); arm 9% (child and adult); legs 18% (adults); legs 14% (child not fully grown yet) RMSF- Inc. fever, chills, N/v, photophobia, myalgia, arthralgias THEN 2-5 days later you develop a petechial rash on forearms, ankles, wrists, that spreads towards trunk and becomes generalized. Think rocky NC/OK/AK/TN/MO. DX: PCR essay with Rickessetti Antigen TREATMENT- doxycycline. EXAM Erythema Migraines- (stage 1 Lyme) Target bulls-eye, usually appears in 7-14 days POST being bitten by a deer tick. Rash is hot to touch with rough texture, flu like symptoms. DX: B. Burgdorferi via ELISA, then confirm with western blot. Increased ESR. TREATMENT: Less than 7 Amoxicillin or cefuroxime axetil. Older than 7 Doxycycline. EXAM Melanoma- Dark Moles, uneven texture, different colors, irregular, >6mm, could be itchy. EXAM Stevens Johnson Syndrome- Classic is target or bulls-eye. Abruptly, hives, blisters, petechiae, purpura, necrosis, sloughing of tissues. Extensive mucosal involvement. Prodrome of fevers with flu like symptoms. Triggers: Allopurinol, anticonvulsants, pcn, sulfonamides, NSAIDS. HIV ppl have higher risk for this syndrome. Psoriasis- Inherited. Pruritic erythematous plaques, fine silvery-white scales with pitted fingernails. Scalp, elbows, knees, sacrum, intergluteal folds. (Koebner phenomenon- new psoriatic plaques form over skin trauma) (Auspitz sign- pinpoint bleeding when plaques are removed). TREATMENT: Topical steroids, Tar preps (mild). For (severe) do anti-TNF, or immunologic. Acanthros Nigricans- velvet hyperpigmented patches most common on back of neck or skin folds- DM resistance. Scabies- itching bedtime. Primethrin cream treat everyone wash sheets and everything else in hot water. Atopic Dermatitis (eczema)- Inherited. Extremely itchy. On flexural folds, neck, hands. Inc. IgE. “small vesicles that rupture leaving painful, bright-red, weepy lesions” they become lichenified from itching. First line: Topical steroids. Avoid hot water/soaps. PO antihistamines. EXAM Tinea Corporis- “ring like itchy rash, slowly enlarge central clearing”-Treatment: most respond to topical antifungals, if severe do oral Lamisil. EXAM AZOLE ending Actinic Keratosis- Precursor to squamous cell carcinoma. “numerous dry round and pink to red lesions” with a rough and scaly texture. Does not heal. Slow growing in sun exposed areas. Diagnosis: BIOPSY Golden Standard. Treatment: Sm. (cryotherapy), Lrg. (5-FU cream)- which causes ur skin to ooze, crust, scab, redness. EXAM Seborrheic Keratosis- soft round wart light tan to black pasted on. Asymptomatic and benign. Cellulitis- Deep dermis poor demarcated low legs. EXAM/ MULTIPLE QUESTIONS. DVT RISK, DM WITH CELLULITIS WATCH FOR OSTEOMYLITIS. Erysipelas- Group A strep, Upper dermis, clear demarcated, cheeks, shins. TREATMENT- Dicloxacillin QID x10d. Cephalexin, Clinda. PCN ALLERGY? Do Azithro x5d. MRSA TREATMENT: Bactrim, doxy, mino, clinda. If sulfa allergy do not use Bactrim. Basal Cell Carcinoma- pearly, waxy, skin lesions, atrophic, ulcerated center that does not heal. Molloscum Contagiosum- white plug, dome shaped. Highly contagious. EXAM Varicella Zoster Virus- “contagious 48 h. before, until all lesions crusted over” low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “initially on trunk, then scalp and face” TREATMENT supportive, antihistamines, acyclovir 20mg/kg 5xd. If given first 24 hours works best. EXAM Acne Vulgaris (common acne)- ON EXAM mild (topicals only) *open/closed comedone w/ or w/o sm. papules. Retin-A, acne worsens 4-6 weeks if no improvement in 8-12 weeks increase dose or add erythromycin, benzoyl peroxide. Moderate (topicals plus antibiotics)- papules, pustules w/ comedones. Continue with topicals combined with topical antibiotics. Then add ORAL antibiotics tetra, mino, doxy. Severe- with painful indurated nodule, cysts, abscesses, pustules. Accutane- check LFTs, 2 forms of contraceptives, monthly prego testing, only prescribe 1 month supply. Acne Rosacea- chronic small acne like papules/pustules around nose mouth chin. TREATMENT- Metrogel, Azelex. Low dose tetracycline. EXAM Impetigo-Gram positive. Itchy pink-red lesions, evolve into vesiculopustules that rupture. If bullous-large blisters. Severe- Keflex, dicloxacillin. PCN Allergic-Azithro, clinda. If NO BULLAE- Bactroban. EXAM Scarlet fever (Scarlantina)- “sandpaper textured-pink rash with sore throat” strawberry tongue, rash starts on head and neck, spreads to trunk. The skin THEN desquamates. EXAM LICHEN PLANUS: SMALL FLAT TOPPED, RED TO PURPLE BUMPS THAT MAY HAVE WHITE SCALES/FLAKES.. WHISPY GREY WHITE STREAKS CALLED WICHHAMS STRIAE. INNER WRISTS FOREARMS, AND ANKLES. IF ON SCALP CAUSE HAIR LOSS. Causes hep C, medications, contact with chemicals. EXAM Spider bite: fever chills, n/v, located arms, upper legs, or the trunk. Biten area becomes swollen, red, and tender, and blisters appear within 24-48 hours. Necrotic in center, which kills the tissue. Ice packs to wound and cold inactivates the toxin, tx like cellulitis of the skin, abx ointment at first, watch etc. Exam Pityoris rosea itchy, herald patch, xmas tree pattern, rash hands soles/feet think to test for secondary syphilis RPR then VDRL are screening, then dx FTA-ABS. EXAM Helen Stone: Section 2 DERMATOLOGY- Good portion of exam Rocky Mountain Spotted Fever (RMSF)-this will be case study. As soon as you see a question that talks about hiking or farmer..you should be thinking tick, Rocky Mountain Spotted Fever or lyme disease... then break the rest of the question down typical presentation of RMSF-Patient presents after being on a hiking trip with her family a week ago with abrupt onset of high fever, chills, severe headache, nausea/vomiting, photophobia, myalgia, and arthralgia followed by a rash that erupts 2 to 5 days after onset of fever. The rash consists of small red spots (petechiae) that start to erupt on both the wrist, forearms, and ankles (sometimes the palms and soles). It rapidly progresses toward the trunk . This is classical sign of RMSF --- note the difference is NO bulls eye rash(lyme disease, but they will use the medical term Erythema Migrans ) and has a fever after hiking!! TX: doxy for anyone!! tick removal, grasp part of tick closest to the skin (head) and apply steady upward pressure. Do not remove ticks by using nail polish, petroleum jelly, or heat Erythema Migrans aka Lyme disease Case example: Patient presents after working in her garden with an expanding red rash with central clearing that resembles a target