Maryville Nurs 623 Exam 1 with correct answers

Maryville Nurs 623 Exam 1 Basics with skin conditions - correct answer •Alopecia •Rash •Pruritus •Uticaria •Pigmentation change Skin lesion—New vs. Change HPI questions for skin problems - correct answer Duration of symptoms Precipitating factors •Medications •Food •Occupation •Outdoors •Hobbies/Sport participation •Exposure to insects •Jewelry/metals/chemicals •Family history Is it: Local or systemic Pruritus- all day or worse at night Uticaria - duration Pigmented changes Pigmentation/Changes of the skin Diff diagnosis - correct answer Nevi- brown, beige or pink(< 5mm) Melanoma Related to pregnancy- melasma (mask of pregnancy) Addison disease Side effect of medication- steroid therapy skin lesions - correct answer Macule - flat, nonpalpable (freckle, petechia) Papule - PALPABLE, solid elevation of skin (elevated nevus) Nodule - elevated solid mass, deeper and firmer than papule (wart) Tumor - solid mass deep in subcutaneous tissue (epithelioma) Wheal - irregularly shaped, elevated area (hive, mosquito bite Vesicle - elevation of skin with serous (clear) fluid Pustule - similar to vesicle but filled with pus (acne) Ulcer - deep loss of skin (venous statis ulcer) Atophy - thinning of skin Bullae-Clear fluid-filled blisters > 10 mm in diameter. These may be caused by burns, bites, irritant or allergic contact dermatitis, and drug reactions. primary versus secondary skin lesions - correct answer Primary skin lesions are those which develop as a direct result of the disease process. Secondary lesions are those which evolve from primary lesions or develop as a consequence of the patient's activities. Parasitic Skin Infections - correct answer scabies and lice Scabies - correct answer Highly contagious infestation that occurs mainly in children, young adults, health care workers, and institutionalized persons of all ages. Subjective: Complaints of intense itching that is usually more severe at night. Objective:Earliest physical sign is small 1 to 2 mm red papules located in areas of body most attractive to mites. Itching, excoriation, , crusting, and scaling may be present making it hard to see scabies. Diagnostics:Ink burrow test Scabies treatment - correct answer Permethrin 5% cream (Remember you have 5 fingers)- leave on for 8-14 hours then shower- daily for 7 days. Oral antihistamines for itching, topical steroids for itching. The entire household must be treated. Everything should be washed with hot water/detergent, treat any infection that is present. Starve mites by sealing them in a bag for about 10 days. Lice treatment - correct answer Permethrin 1% leave on for 10 mins then rinse. May repeat in 7 days if needed. Fungal skin infections - correct answer • Candidiasis- bright, beefy red rash treat with topical antifungal, • Dermatophytoses - the tineas (ringworm) • Onychomycosis treat with Terbinafine for 6-12 weeks (only 73-79% effective, educate patient. • Fungal infections survive on keratin, so considered superficial. • Pathogens: Epidermophyton, trichophyton, microsporum. • Those at risk are DM and immunocompromised. • Diagnostics: KOH Tinea corporis (Ringworm of body) - correct answer Hx of erythematous round and elevated pruritic lesion that grows in size & starts to clear in the center Miconazole 2% cream BID x4 weeks, Clotrimazole 1%, Terbafine 1% Tinea capitus (ringworm of head) - correct answer Children common. Painless bald spot, may have kerion that looks like honeycomb, inflammation. Boggy mass containing broken hairs and oozing purulent material from follicular orifices Systemic antifungals - Griseofulvin BID for 2-4 months or 2 weeks after negative cultures. Teratogenic - use 2nd method of contraception. OR terbinafine cream Tinea versicolor (skin, AKA pityriasis versicolor) - correct answer Round or oval lesions of hypo or hyperpigmentation macule, located mainly on back chest, arms, sometimes neck/face. Sometimes very fine scales seen. Agent P oribiculare causes round, pityrosporum ovale causes oval Clotrimazole 1% cream and solution BID up to 4 weeks Bacterial infections of the skin - correct answer • Impetigo • highly contagious Cellulitis • Keflex (1st gen cephalosporine) 10-14 days, or dicloxacillin, • PCN allergy use Erythromycin. • non purulent assume staph aureus Purulent cellulitis • I&D first line • NO 1st gen cephalosporine • Consider MRSA- Bactrim, Cleocin, Doxycycline Impetigo - correct answer Honey crusted plaques, usually on face Bullous: begin as small vesicles that rupture easily with serous fluid turning into crust Nonbullous, vesticulopustular: thick, adherent lesions, dirty yellow-colored crust with erythematous margins Treatment: Clean lesions. Bactroban TID x 7 days. Antibiotic (Keflex, Augmentin, Cloxacillin). With no treatment, it is self-limiting 2-3 wks follilculitis - correct answer Staphylococcus. Multiple small papules on erythematous base, can be large yellow white tender pustules in adults. Common in places hair is present, widespread is characteristic, bumpy rash, no itching. Treatment: Only if becomes infected. Large lesions cleansed with weak soap solution, followed by soaking with saline or aluminum subacetate BID. TAO can be used BID for 5 days. Oral ABT 1st gen cephalo. if resistant Localized cellulitis - correct answer The typical lesion of cellulitis is wide, diffuse area of erythematous skin that is warm and tender to palpation. Infection is occasionally accompanied by severe edema. Systemic symptoms such as fever, chills, and malaise may also be present. CAUSES- Diabetic patient or other immunocompromised patients. Any break in the skin. Skin breaks from surgical incisions, skin tears, wounds, trauma, insect bites or stings, and animal or human bites. PREEXISTING conditions- stasis ulcers, dermatitides, viral skin infections, superficial bacterial infections, and bolus disease all have the risk for secondary infections. Subjective- tender, warm, erythematous areas of skin usually on face, neck, and extremities. Usually report an insect bite or some form of skin break. If recurrent cellulitis may deny any trauma or injury. Objective- Lower leg most common site of infection .If lower extremity cellulites should look for SS of tinea pedis (Athletes foot) infection can be point of entry for bacteria. In children and occasionally adults the checks and periorbital area are more common sites of involvement. Red and warm appearance to the skin will be noted. Red boarders are flat and diffused. Localized cellulitis treatment - correct answer Diagnostic testing- most cases are diagnosed by history and PE . Usually no discharge or obvious wound therefore unable to obtain a culture. If open wound or purulent discharge present a culture and gram stain should be obtained. For patients with fever a CBC should be done . If periorbital cellulitis EOM should be done and test of cranial nerves. Management- Take into consideration severity of infection, site of infection, underlying disease, and virulence of the pathogen. For those who have cellulitis not related to human or animal bites takes DICLOXACILLIN or CEPHALEXIN for 10-14 days. Patients with penicillin allergy get Erythromycin. Infected human and animal bites are treated with Augmentin for at least 2 weeks. LE's cellulitis requires bedrest and elevation of the leg. Need to consider comorbid conditions and consider referral of treatment. Hemophilus influenza can e treated with Ceftin If gram neg microorganism treat with fluoroquinolones such as levofloxacin can be used. Diabetic are typically treated with Augmentin purulent cellulitis treatment - correct answer • I&D first line • NO 1st gen cephalosporine • Consider MRSA- Bactrim, Cleocin, Doxycycline Viral Skin Infections - correct answer chicken pox, shingles, measles, warts, herpes Herpes Zoster (shingles) - correct answer Unexplained pain along dermatome. Unilateral vesicular rash along dermatome lasting 3-5 days, up to 30. Treatment Famcyclovir, Acyclovir, Valacyclovir. Prednisone taper. Vaccine. herpes simplex - correct answer Oral or genital, can be asymptomatic. Tenderness, pain, mild paresthesia's, or burning before onset. Prodrome can include headache, fever, muscle ache, lymphadenopathy, local pain. Grouped vesicles on erythematous base. No cure. Oral: lip ointment Blistex. OTC Abreva. Denavir for extensive lesions. Genital: Valacyclovir and famciclovir better choices acne vulgaris - correct answer Located on face, chest, back, and upper outer arms. • Mild = total lesions <30, noninflammatory. Comedones with small papules. • Moderate = total lesions 30-125, inflammation. Papules & pustules with yellow/green tops. • Severe = lesions > 125, nodulocystic acne. Treatments: Tretinoin, topical vs. systemic antibiotics, Isotretinoin Rosacea - correct answer Chronic, central face, persistent erythema telangiectasia, erythematous papules. Treatment : Avoid triggers, topical flagyl (may take 6-8 wks), PO tetracycline, minocycline, or doxycycline Atopic Dermatitis (eczema) - correct answer o A chronic inflammatory skin disorder with a complex pathogenesis involving genetic susceptibility, immunologic and epidermal barrier dysfunction, and environmental factors. o Pruritus is the primary symptom; skin lesions range from mild erythema to severe lichenification. o Presents as red patches with white scales on top o Chronic and recurring. Atopic dermatitis treatment - correct answer o Moisturizers o Avoidance of allergic and irritant triggers- avoid frequent bathing with hot water •Burrow's solution, silver nitrate solutions (to dry out lesions) •Topical steroids for inflammation •Petrolatum/emollients to maintain hydration Contact Dermatitis - correct answer o a rash that occurs at the site of exposure to a substance capable of producing an allergic or irritant skin response. Cause: o Noxious, irritating substances or substances to which the patient has developed a skin allergy. o Direct exposure to substance that triggers an immune response (T-cell mediated response) o May be allergic or irritant induced Ex: poison ivy Contact dermatitis treatment - correct answer o Treated topically with evaporative measures. • the application of repeated cycles of cool water compresses followed by drying. o Once the weeping and oozing have stopped, application of: •-potent topical steroids two times a day to the affected areas for two to three weeks. o It may be necessary to treat with oral steroids for two to three weeks- if more than 10% of the body It will usually take one to three weeks for the allergen to be entirely removed from the skin so that the rash resolves entirely. Seborrheic Dermatitis - correct answer o Common in Parkinson's patients and patients with HIV. Severe cases should prompt you to look for risk factors of HIV o Caused by Increased production of sebum o Scaly, greasy rash- affected skin is pink, edematous, and cover with yellow to brown scales and crusts. o Usually seen on scalp, forehead, eyebrows, and area surrounding the nose/ears. o Common in infancy and called "cradle cap" Subjective- pink scaling rash located on face and scalp, typically male . May itch Objective- scaly patches that may be slightly papular. Each patch is surrounded by erythema. Greasy and appear yellow. Seborrheic Dermatitis treatment - correct answer OTC dandruff shampoo, leave on 5-7 mins to be effective. Resistant seborrhea dermatitis may require a prescription shampoo 2.5 selenium sulfide shampoo, a ketoconazole shampoo (Nizoral shampoo) and a detoconazole shampoo are available. Keratolytic or oil based lotions are used to soften heavy crust. If significant erythema is present may need topical corticosteroid Hydrocortisone cream. For a superinfection of gram positive skin infection Cephalexin 7-10 days is required. Asteatotic Dermatitis - correct answer Common in elderly •Secondary to aging, dehydrated skin, and malnutrition Pruritus, cracked, erythematous patches •usually shins or extensor surface of arms •Seasonal potentially •Men > women Prevention •Humidifier •Moisturizers Treatment •Avoid hot water showers/baths •Hydrophilic petrolatum or urea 10% cream immediately after shower/bath •Avoid rubbing skin with towel •Class 4 topical steroid ointment bid for 2-3 weeks to break itch cycle (i.e. 0.1% triamcinolone acetonide) Bullous Phephigoid - correct answer Average onset 65y -Primary lesions, tense vesicles or bulla filled with serous or serosanguineous fluid -Pruritus -Autoimmune •Can be caused by drugs -Diuretics -Antibiotics -Ace Inhibitors Dx: Two Biopsies Tx: Topical corticosteroid <5% body •Oral corticosteroids (0.5-1mg/kg tapered slowly over 6-12 months) Psoriasis - correct answer o An inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with *silvery scales. o Bilaterally symmetrical o Commonly occurs in ear canal o Areas of the body most commonly affected are the back of the forearms, shins, navel area, extensor surfaces of the elbows and knees, umbilicus, gluteal cleft, and scalp o Varies in severity from small, localized patches to complete body coverage Five main types of psoriasis: o Plaque psoriasis: presents as red patches with white - silvers scales on top, bilateral, seen on knees, elbows, neck, scalp, between buttock, and back, positive auspitzs sign and kobners phenomenon o Guttate psoriasis: drop-shaped lesions, small red papules less than 1 cm, usually on genital/lips o Pustular psoriasis: small non-infectious pus-filled blisters, persistent or recurrent dry red/scaly rash, first appears infancy, history of dry skin since birth o Inverse psoriasis: red patches in skin folds, armpit,groin, etc, oErythrodermic psoriasis: widespread rash Treatment for Psoriasis - correct answer Topical treatments o Corticosteroids o Vitamin D3 analogs (e.g., calcipotriol [calcipotriene], calcitriol o Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) o Tazarotene o Emollients o Salicylic acid o Coal tar o Anthralin Phototherapy • UV light therapy Systemic treatments • Methotrexate • Systemic retinoids (e.g., acitretin, isotretinoin) • Immunosuppressants • Cyclosporine • Immunomodulatory agents Diagnostics for Psoriasis - correct answer CBC with diff and serum chemistry profile, plus serum uric acid, antinuclear antibody titer, and **URIC ACID USUSALLY ELEVATED Rheumatoid factor Throat culture if strep suspected Xray to search for associated arthritis How Would You Characterize Someone who presents with psoriasis? - correct answer Chronic relapsing disorder. Plaques surrounded by thick silvery scale resembling mica. How would you document/describe skin findings? - correct answer Location, color, shape and size. Measure length, width and depth and document. Detection of tenderness, firmness, and depth with palpation. Documentation: Noted areas of plaque are red patches with white scales on top, measuring 2 cm by 3 cm noted on the back of forearms, localized, bilaterally symmetrical. Squamous cell carcinoma - correct answer *• Red firm bump or • Scaly patch or • Sore that heals then reopens o A malignant tumor originating from keratinocytes, which can invade the dermis and occasional metastasize to distant sites. o More common on head and neck (55%) o More common in fair skinned o 2nd most common type of skin cancer o Tends to form in high sun exposure areas: o Rims of ears o Face o Neck o Arms o Chest o Back Testing: • Test a suspicious area by gently rubbing with a tongue depressor. If it bleeds, be suspicious of squamous cell Treatment: Early diagnosis/treatment can prevent this and stop SCC from spreading. Basal cell carcinoma - correct answer *• Flesh colored, pearly domed nodule with overlaying telangiectatic vessels. • Pinkish patch of skin, Later stage, central ulceration and crusting. o Malignant tumor of the skin that originates from the basal cells of the epidermis; o Slow-growing and locally invasive tumor that rarely metastasizes; o Common in 50-60 year-olds; o Common in fair skinned but can occur in darker skin; o Usually on head and neck but can occur anywhere; o Early diagnosis/treatment is important as it can invade surrounding tissue; Testing: Biopsy Treatment: Simple excision: Electrodesiccation and curettage Cryosurgery Laser surgery Mohs microsurgery - highest cure rate Melanoma (malignant) - correct answer o Deadliest form of skin cancer (75% of all skin cancer deaths) o Arises from malignancy of epidermal melanocytes o >90% arise from skin o few arise from eye (uveal melanoma) o <4% do not have primary site o If >4 mm in depth, poor prognosis (75% mortality) o Frequently develops in a mole with notable changes or o Suddenly appears as a new dark spot on skin, assymetrical lesion with irregular border, notching, and a diameter >6mm. o Variegation in color, with admixtures of blue, red, tan, brown, black, and white. Pneumonic: A = asymmetry B = border is irregular C = colors are different in same region D = diameter > 6 mm E = enlargement (evolution) Malignant melanoma types - correct answer Types: o Superficial spreading (70-85%), extensive lateral or radial growth before vertical growth o Nodular (15-30%), vertical growth only) o Lentigo maligna (5%), in situ form that may persist for years before vertical extension o Acral lentiginous (2-8%), aggressive form most common in darker skinned persons, especially when appearing on hands/feet Malignant melanoma testing and management - correct answer Testing: o Full body inspection o Lesion biopsy o Excisional biopsy is preferred o Classification System: o Clark/Breslow methods o TNM (tumor, node, metastasis) pg 244 Management: o Treatment depends on the stage of the lesion: o Biological therapy o Chemotherapy o Radiation Surgery Actinic Keratosis - correct answer Most common precancerous growth. Fair-skinned pts aged > 40, sun exposure, men. • Head, lips, ears, neck, hands, forearms. • Primary lesions macules or papules poorly circumscribed. Small papules 0.5-2 mm flesh color or hyperpigmented. • Secondary lesions erythematous, scaly with uneven surface. Pruritic, tender, or stinging, sandpaper feel. Treatment: Topical therapy (5-FU) creams: Efudex, Carac Surgical destruction (cryotherapy) Multiple lesions blending together ______ - correct answer Confluent or coalescent Flat discoloration less than 1 cm in diameter _____ - correct answer Macule Circumscribed area of skin edema - correct answer Wheal Narrow linear crack into epidermis, exposing dermis _____ - correct answer Fissure Vesicle like lesion with purulent content ____ - correct answer Pustule 1. Flat discoloration greater than 1 cm in diameter ______ - correct answer Raised lesion, larger than 1 cm, may be same or different color from the surrounding skin - correct answer Plaque Net like cluster - correct answer Reticular Loss of epidermis and dermis____ - correct answer Ulcer 1. Loss of skin markings and full skin thickness _____ - correct answer Atrophy Skin thickening usually found over pruritic or friction areas _____ - correct answer Lichenification In a ring formation - correct answer Annular 1. How many grams of topical cream or ointment are needed for a single application to the hands? A. 1 B. 2 C. 3 D. 4 - correct answer B 1. How many grams of topical cream or ointment are needed for single application to an arm? A. 1 B. 2 C. 3 D. 4 - correct answer C 1. How many grams of topical cream or ointment are needed for a single application for the whole body? A. 10-30 B. 30-60 C. 60-90 D. 90-120 - correct answer B 1. You write a prescription for a topical agent and anticipate the greatest rate of absorption when it is applied to the A. Palms of hands B. Soles of feet C. Face D. Abdomen - correct answer C 1. You prescribe a topical medication and want it to have maximum absorption so you choose the following vehicle: A. Gel B. Lotion C. Cream D. Ointment - correct answer D 1. One of the mechanisms of actions of a topical corticosteroid preparation is as: A. An antimitotic B. An exfoliant C. A vasoconstrictor D. A humectant - correct answer C 1. To enhance the potency of a topical corticosteroid, the prescribed recommends that the patient apply the preparation: A. To dry skin by gentle rubbing B. And cover with an occlusive dressing C. Before bathing D. With an emollient - correct answer B 1. Which of the following is least potent topical corticosteroid? A. Betamethasone dipropionate 0.1% (Diprosone) B. Clobetasol propionate 0.5% (Cormax) C. Hydrocortisone 2.5% D. Fluocinonide 0.05% (Lidex) - correct answer C 1. Antihistamines exhibit therapeutic effect by: A. Inactivating circulating histamine B. Preventing the production of histamine C. Blocking the activity of histamine receptor sites D. Acting as a procholinergic agent - correct answer C 1. A possible adverse side effect with the use of first generation antihistamines such as diphenhydramine in an 80 yr old man is: A. Urinary retention B. Hypertension C. Tachycardia D. Urticaria - correct answer A 1. Which of the following medications is likely to cause the most sedation? A. Chlorpheniramine B. Cetirizine C. Fexofenadine D. Loratadine - correct answer A 1. Clinical features of bullous impetigo include: A. Intense itch B. Vesicular lesions C. Dermatomal pattern D. Systemic symptoms such as fever and chills - correct answer B 1. The likely causative organism of non bullous impetigo in a 6 yr old child includes A. H influenzae and s pneumoniae B. Group A strep and S aureus C. M catarrhalis and select viruses D. P aeruginosa and select fungi - correct answer B 1. The spectrum of antimicrobial activity of mupirocin (Bactroban) includes: A. Primarily gram negative organisms B. Select gram positive organisms C. Pseudomonas species and anaerobic organisms D. Only organisms that do not produce beta lactamase - correct answer B 1. An impetigo lesion that becomes deeply ulcerated is known as: A. Cellulitis B. Erythema C. Ecthyma D. Empyema - correct answer C 1. First line treatment of impetigo with fewer than five lesions of 1-2 cm in diameter on the legs of a 9 yr old girl is: A. Topical mupirocin B. Topical neomycin C. Oral cefixime D. Oral doxycycline - correct answer A 1. An oral antimicrobial option for the treatment of methicillin sensitive S aureus includes all of the following except: A. Amoxicillin B. Dicloxacillin C. Cephalexin D. Cefadroxil - correct answer A 1. Which of the following is an oral antimicrobial option for the treatment of a community acquired MRSA cutaneous infection? A. Amoxicillin B. Dicloxacillin C. Cephalexin D. Trimethoprim-sulfamethaxazole - correct answer D 1. You see a kindergartner with impetigo and advise that she can return to school ____ hours after initiating effective antimicrobial therapy A. 24 B. 48 C. 72 D. 96 - correct answer A 1. The use of which of the following medications contributes to the development of acne vulgaris? A. Lithium B. Propranolol C. Sertraline D. Clonidine - correct answer A 1. First line therapy for acne vulgaris with closed comedones includes: A. Oral antibiotics B. Isotretinoin C. Benzoyl peroxide D. Hydrocortisone cream - correct answer C 1. When prescribing tretinoin (Retin A) the nurse practitioner advises the patient: A. Use it with benzoyl peroxide to minimize irritating effects B. Use sunscreen because the drug is photosensitizing C. Add a sulfa based cream to enhance anti acne effects D. Expect a significant improvement in acne lesions after 1 week of use - correct answer B 1. In the treatment of acne vulgaris, which lesions respond best to topical antibiotic therapy? A. Open comedones B. Cysts C. Inflammatory lesions D. Superficial lesions - correct answer C 1. You have initiated therapy for an 18 yr old man with acne vulgaris and have prescribed doxycycline. He returns in 3 wks complaining that his skin is not any better. Your next action is to: A. Counsel him that 6-8 wks of treatment is often needed before significant improvement is achieved B. Discontinue the doxycycline and initial minocycline therapy C. Advise him that antibiotics are likely not an effective treatment for him and should not be continued D. Add a second antimicrobial agent such as trimethoprim-sulfamethoxazole - correct answer A 1. Who is the best candidate for isotretinoin (Accutane) therapy? A. 17 yr old with pustular lesions and poor response to benzoyl peroxide B. 20 yr old with cystic lesions who has tried various therapies with minimal effect C. 14 yr old with open and closed comedones and a family history of ice pick scars D. 18 yr old with inflammatory lesions and improvement with tretinoin (Retin A) - correct answer B 1. In a 22 yr old women using isotretinoin (Accutane) therapy, the NP ensures follow up to monitor for all of the following tests except: A. Hepatic enzymes B. Triglyceride measurements C. Pregnancy D. Platelet count - correct answer D 1. Leonard is an 18 yr old who has been taking isotretinoin (Accutane) for the treatment of acne for the past 2 months. Which of the following is the most important question for the clinician to ask at his f/u office visit? A. Are you having any problems remembering to take your medication B. Have you noticed any dry skin around your mouth since you started Accutane C. Do you notice any improvement in your skin D. Have you noticed any recent changes in your mood - correct answer D 1. A 14 yr old presents with acne consisting of 25 comedones, and 20 inflammatory lesions with no nodules. This patient is classified as having A. Mild acne B. Moderate acne C. Severe acne D. Very severe acne - correct answer B 1. In a 13 yr old female patient with mild acne and who experiences an inadequate response to benzoyl peroxide treatment, an appropriate treatment option would be to: A. Add a topical retinoid B. Add an oral antibiotic C. Consider isotretinoin D. Consider hormonal therapy - correct answer A hematological common complaints - correct answer Bruising Fatigue Fever Lymphadenopathy Trauma? blood thinners? Acute or chronic fatigue? Survival and Production of RBC - correct answer Formed in bone marrow: if bone marrow doesnt work then your going to have some problems. Life span is 120 days (+/-20 days) Cleared in spleen: again if problems with spleen youll be seeing it here. Reticulocytes are newly formed RBC in circulation Normal about 0.5 -1.5% If high reticulocyte consider hemolytic anemia If no new production, Hgb drops 1 gm/week Anemia classification - correct answer Based on general mechanisms Blood loss Reduced RBC production- problem with the bone marrow? Premature destruction- hemalytic type of problem Morphological classification Size and concentration How do you know what type of anemia? - correct answer Look at WBC and platelets Then look at the size of RBC MCV Reticulocyte count Once you know the size of the RBC: Whats their diet like Do they have blood loss- females mensus, blood in stools? Decreased red blood cell distruction? Increased RBC destruction? Distinguish from pancytopenia -Related to problem in bone marrow: -Decrease in Hgb, WBC count (absolute neutrophil count) Platelet count MCHC (mean corpuscular hemoglobin concentration) - correct answer 31-36% Hb/cell* (commonly used: 32 - 36 g/dL) Concentration of hemoglobin per RBC Micocytic anemia - correct answer Small size MCV is *<80 fl Causes: Iron deficiency- ? GI problem, blood loss Anemia of chronic disease (ACD)- inflammation, infection, malignancy, NSAIDS,ASA Thalassemia -inherited (typically RBC normal, Fe normal, Ferritin normal) Sideroblastic anemia - alcoholism Diagnostic: Serum Ferritin , <30,g/L pathological for Fe deficiency ( TIBC, Serum Iron, Total Iron binding capacity) Signs & Symptoms Microcytic Anemia - correct answer Tachycardia/palpitations Fatigue Shortness of breath/dyspnea on exertion Dizziness Pale mucous membranes Sallow-colored skin Management of microcytic anemia - correct answer Treat and eradicate the cause Possibly transfuse if HCT <27% Iron deficiency—increase dietary iron and/or supplemental iron (what are your concerns with prescribing Iron supplements) ACD—transfuse or growth factors to stimulate erythropoesis Thalassemia—transfuse/folate supplementation/oral iron chelation Sideroblastic—transfusions/vitamin B6 Normocytic Anemia - correct answer Chronic disease state (ACD)0 lupus, RA, long term steroids Acute blood loss Hemolysis Volume overload -Pregnancy -parenteral overhydration Normocytic Anemia: Management - correct answer Initially, symptomatic treatment Correct anemia and stabilize underlying cause -Erythropoietin-alpha- ACD -Prednisone for AIHA -Early delivery for pregnant mothers with HELLP -DIC—heparin (if thrombus), platelets, and FFP Macrocytic anemia - correct answer MCV > 100 Megaloblastic -Vitamin B12 deficiency -Pernicious anemia -Folate deficiency -Antimetabolite drugs (e.g., methotrexate) Miscellaneous macrocytic etiologies (not megaloblastic) -Chronic alcoholism -Liver disease Management of Macrocytic Anemia - correct answer Depends on cause B12 deficiency (not pernicious and malabsorption) -Oral Cobalamin 1000mcg/d (6-12 weeks) Pernicious and malabsorption: -1000mcg Vitamin B12 x days, weekly for 1 month; followed by once per month for life -Serial CBCs and Vit B12 monthly Folic deficiency 1mg/day If related to iatrogenic drug toxicity-stop medication -Monitor for liver dysfunction (liver transaminases, coagulation times (AST/ALT/PT/INR) Classic sign of b12 deficiency - correct answer -beefy red tongue, peripheral nephropathy, decreased reflexes. Hemolytic Anemia - correct answer Would see increase in reticulocyte count Defect to the RBC is either: -Extrinsic to the red cell -Immune -Infection -Angiopathic (schistocytes damaged RBC) -Medications Intrinsic related to the red cell (peripheral blood smear and Coombs test) -Membrane -Cytosol -Hemoglobin Sickle Cell anemia - correct answer Inherited autosomal recessive disorder In crisis: pain in back, chest, abdomen, or extremities unrelieved by rest or position Nausea Anorexia Light-headedness Anxiety Fever Sickle cell management - correct answer Rehydration Oxygen Possible transfusions Folic acid supplementation Hydroxyurea Diet rich in complex B vitamins and vitamin C Polycythemia - correct answer A disorder characterized by an abnormal increase in the number or concentration of red blood cells in the blood Relative polycythemia—dehydration -Decreased fluid intake -Increased fluid loss -Extravasation of fluids Absolute polycythemia -Primary: myeloproliferative disorder -Polycythemia vera Secondary causes -Chronic hypoxemia, carboxyhemoglobinemia, Cushing's syndrome, erythropoietin overactivity Polycythemia symptoms - correct answer Headaches, fatigue, burning in the hands and feet, dizziness. Polycythemia management - correct answer Relative polycythemia -Rehydration Absolute polycythemia -Repeated phlebotomies if HCT >55-60% -Treat Cushing's disease, hypoxia, etc. -Hydroxyurea-inhibits DNA synthesis, alters RBC water content -Nonalkylating agents Leukemia - correct answer Acute: -Hgb decreased -Platelet count decreased -WBC elevated -Granulocytes decreased -Peripheral smear blastocytosis >25% Chronic: -WBC elevated (more so with CML) -Lymphocytes >90% (with CLL) Leukemia signs and symptoms - correct answer Acute -Bone and joint pain, gingival bleeding, fever, chills, easy bruising Chronic -Fatigue, night sweats, low-grade fevers, splenomegaly Leukemia management - correct answer Acute -Combination chemotherapy -CNS prophylaxis Chronic -Watchful vigilance -Hydroxyurea -Treat thrombocytopenia, lymphadenopathy -Exogenous erythropoietin What is the most likely diagnosis for a 30-year old female with the following lab results? Hgb 9 and Hct 27% MCv of 66.1 MCHC of 32 Alcoholic hemolytic anemia sickle cell anemia pernicious anemia - correct answer Sickle cell anemia Thalessemia results with what type of anemia - correct answer microcytic, hypochromic Components of the immune system - correct answer Skin is first line of defense Thymus T cells Bone Marrow Blood stream Lymphatic system Spleen Mucosal tissue respiratory and gut (Peyer's patch) Immune System response - correct answer 1. Scavenger cells arrive early to take care of the invader, but they can last only a few days. 2. Macrophages engulf foreign matter (Ms. Pac Man type activity). The macrophages signal other immune cells such as T-cells to start attacking the foreign invaders. 3. The Macrophages start displaying antigens (cells that belong in the body) from digesting the invaders. 4. T- helper cells multiply and help activate B cells and other macrophages. 5. The B cells divide and form plasma cells, which produce antibodies. 6. The antibodies bind to invaders, and either destroy them or make them easier for the macrophage to find and eat. 7. T- suppressor cells monitor antibody production and slow it down as the infection starts to subside. 8. Killer T-cells destroy infected cells. 9. Some of the B and T cells become memory cells and hang around in case the same foreign invader decides to attack again. These memory cells are there to mount a quick defense. cells in the immune system and their function - correct answer B and T cells adaptive immune cells (immunological memory) B cells secrete immunoglobulin (each B cell makes only one specific antigen type) IgG marks microbe (identifies for other cells)- most abundant IgM (mainly blood and Lymph fluid) kills bacteria; produced immediately after exposure to disease replaced by IgG IgG long term response of body to disease (past exposure) IgA mucus membrane sweat, saliva and tears Where to start with immunological disorder - correct answer Think about the types of Immunological disorders -Hypersensitivity (allergic reactions) -Autoimmune disease- attacks self -Immunodeficiency- inability to appropriately defend autoimmune disorder - correct answer Inflammation classic sign Localized vs. systemic- is this one specific organ or is it something like lupus that is systemic Primary vs. secondary This means does it happen Birth/childhood vs. later in life Immunodeficiency - correct answer Associated with severe infections that are -Persistent -Recurring and/or -Lead to complications Allergies - correct answer Hypersensitivity disorder Causes : Environmental allergens Inhalants: pollens, molds, spores Ingestants: food and drug allergens Injectants: animal and insect venoms Contactants: dust mites, chemical components, animal dander Four Hypersensitivity Reactions - correct answer Dependent on circulating antibodies -Type 1: IgE-mediated immediate hypersensitivity— includes anaphylaxis -Type 2: antibody-dependent cellular cytotoxicity -Type 3: immune complex-mediated response -delayed drug reactions Inhaled hypersensitivity -pneumonitis Dependent on cellular immune components -Type 4: delayed-type cellular hypersensitivity— contact dermatitis PPD response urticaria - correct answer itchy wheals caused by an allergic reaction (hives) type 1 reaction poison ivy dermatitis is a type __ reaction - correct answer Type IV delayed, cell mediated response Management of hypersensitivity reactions - correct answer Avoidance Initial-OTC antihistamines (oral, topical) Corticosteroids Anaphylaxis: systemic -life threatening -Epinephrine 1:1000 (0.3-0.5 mg) upper lateral thigh -Review Seven Step treatment for anaphylaxis -Delayed phase - corticosteroids Long term-immunotherapy (severe allergic asthma with atopic dermatitis) Autoimmune Diseases - correct answer Production of antibodies (T cells ) antigens treated as foreign induces adaptive immune response Organ -specific -Thyroid-Grave's Disease, Hashimoto's thyroiditis -Pancreas -DM type I Widespread (systemic) -Lupus -RA R.A : Signs & Symptoms - correct answer Peripheral symmetric polyarthritis and morning stiffness that improves throughout the day Joints affected: knees, proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints in the hands and feet Affected joints are painful to pressure (tender), swollen, and partially immobile Eventually, joints appear increasingly deformed and rigid RA diagnosis - correct answer Rheumatoid factor (RF): IgM that reacts in an autoimmune fashion against IgG Anti-cyclic citrulinated peptide (CCP) antibodies Erythrocyte sedimentation rate (ESR) and/or C-reactive protein ANA (differentiate RA from SLE) CBC to rule out anemia Platelet count Joint-fluid analysis - if diagnosis uncertain Management of R.A - correct answer Progresses from conservative interventions to aggressive symptom management Goals of management: to reduce pain and inflammation and to preserve joint function Early management: physical and occupational therapies, heat and cold applications, exercise, rest, assistive devices, splints, meditation, chiropractic adjustments, and weight loss Analgesics NSAIDs Steroids DMARDs Older therapies (e.g., methotrexate) Co manage with Rheumatologist after failure with NSAIDS Chronic Fatigue Syndrome and Fibromyalgia Syndrome - correct answer Difficult to diagnose due to similar criteria Patients often with co-morbid psych problems FMS-most common generalized musculoskeletal pain (Females 20-55 yrs) NSAIDs and steroids often do not alleviate symptoms Presentation of Chronic Fatigue Syndrome and Fibromyalgia Syndrome - correct answer Often vague symptoms Malaise Fatigue Multiple joint pain Difficulty concentrating Difficulty sleeping Pale skin Diagnosis FMS & CFS - correct answer FMS: Widespread muscular pain History and pain criteria + 11/18 trigger points Symptoms >3months CFS Severity of fatigue and 4 or more: Impaired memory New headaches Sore throat Tender cervical or axillary lymph nodes Muscle pain Restless sleep Post exertion malaise > 6months CFS & FMS Management - correct answer Cognitive behavioral therapy Exercise Low dose tricyclic anti depressant (TCAs)? 3months? SSRI's ? Patient education Polymyalgia Rheumatica - correct answer Middle age and older adults Women > Men Bilateral shoulder pain (can include proximal arms, hips and thighs) Worse in AM (duration up to 1 hour) ESR >40mm/h, elevated CRP, normocytic anemia Treatment: Corticosteroids 10-20mg (2-4 weeks the taper 1-2 weeks) Sjorgen's Syndrome - correct answer Exocrine disorder Common complaints: Dry eyes Xerostemia (dry mouth) Dysphagia Loss of taste, smell Note: Can be related to other diseases Similar symptoms occur in geriatric patients- medications Lupis SLE dx criteria - correct answer At least 4 of the following 11 criteria (in the absence of drugs or other disorders known to induce these effects) -Arthritis: non-erosive, usually involving at least 2 joints -Photosensitivity: often triggers skin rashes; exposure to the sun's UV-B rays may also trigger SLE exacerbation -Oral or nasal ulcers: typically painless -Malar rash: bilateral butterfly formation across the cheeks and nasal bridge -Discoid rash: red, raised patches -Serositis: inflammation of the pleura or pericardia -Renal disease: more than 0.5 g/day proteinuria, 3+ or more proteinuria, or cellular casts -Hematologic disorders: hemolytic anemia, leukopenia (>4000 WBC/mL), lymphopenia (>1500 lymphocytes/mL), or low platelets -Neurologic disease (e.g., seizures, psychoses) not otherwise explained by iatrogenic or metabolic causes -Positive ANA (anti-nuclear antibodies) -Immunologic abnormalities: positive antiphospholipid antibodies, anti-double-stranded native DNA (dsDNA), anti-Sm (Smith) antibody, or false-positive serologic test for syphilis (VDRL, RPR) Classic symptoms of SLE - correct answer Malaise Fever Anorexia Unplanned weight loss Blurred vision and conjunctival swelling Sleeplessness and depression may be focal complaints Swollen and painful joints Shortness of breath and painful inspiration Vague abdominal pains and/or abdominal cramping SLE skin findings - correct answer Characteristic malar "butterfly" rash Alopecia and scalp exanthems Splinter hemorrhages, periungual erythema, and lesions on the fingertips or toes Lymphadenopathy in systemic disease Scarring and highly inflammatory lesions - discoid lupus Raynaud's phenomenon (in 40% of patients) Management of SLE - correct answer Primary goal is symptom control Nonpharmacologic interventions Emotional support and referral to SLE support groups If conservative management fails, patient may require corticosteroids, antimalarials or cyclophosphamide (refer to rheumatologist) Review triggering factors for acute exacerbations; -Exposure to UVB and UVA -Stress -Pregnancy and post partum hormone fluctuations -Exposure to cigarettes of silica dust (increased risk of inflammatory lung problems) Infectious Mononucleosis - correct answer EBV Kissing disease Usually between 10-35 y.o .age Review subjective/objective findings: fever, sore throat, fatigue, cervical adnopathy, headaches, nausea, anorexia splenic enlargement. Dx: heterophile antibody test (Monospot) CBC w/diff (lymphocytosis) Tx: Symptoms Review patient education Lyme disease - correct answer Multisystem inflammatory disease cause by Borrelia burgdorferi (tick bite) Usually eastern US (but can be found elsewhere) Three phases 1.Initially presentation: Flu-like symptoms Rash (erythema migrans) Bullseye rash 2.Late presentation: Generalize pain stiffness fatigue malaise 3. Untreated: multiple joint arthritis Lyme Disease Dx and Management - correct answer Based on History and Clinical findings Usually Doxycyline 100 mg bid initial management (10-14 days) Review alternatives drug management Review Patient Education HIV: Clinical Presentation - correct answer Flu-like symptoms: 6 days to 6 weeks Darkish, purple-colored spots on the skin: indicative of Kaposi's sarcoma Nonproductive cough, shortness of breath, and fever: present for several days to weeks Other constitutional symptoms: weight loss, night sweats, chronic fever, and/or chronic diarrhea Evaluating risk of HIV infections HISTORY (? Frequent STDs)