Breakdown of items for exam 1

Diagnostic Reasoning - 2 items

Documentation/Assessment/the exam - 2 items

Health Promotion/Preventive Services(primary, secondary, tertiary, smoking cessation)  - 5 items

Derm (scabies, lice, shingles, Skin CA, primary/secondary lesions, dermatitis, lyme disease, Herpes Zoster, and herpes simplex, Acne, Tinea) 22 item

Scarlet fever- 1 item

HEENT(oral CA, sinusitis, conjunctivitis, strep, OM, OE, pharyngitis)  - 30 items

Respiratory/Pulmonary Disorders (Asthma) - 15 items

TB - 3 items

Differential diagnosis: the process of differentiating between two or more conditions that share similar signs or symptoms

Used to eliminate life-threatening or more serious conditions

Helps narrow focus and guide assessment, testing, and treatment plan

Better health for all – WHO

5 key elements identified by WHO to achieve this goal:

Reducing exclusion/social disparities (universal coverage reforms);

Organizing health services around people's needs and expectations (service delivery reforms);

Integrating health into all sectors (public policy reforms)

Pursuing collaborative models of policy dialogue (leadership reforms); and

Increasing stakeholder participation.

Serves to enhance acquisition & storage of knowledge through repeated exposure to real case examples.

Helps the learner develop memory schemes for representing/relating clinical problems 

Learning is driven by repeated exposures to real cases that illustrate multiple aspects of clinical reasoning

Type 1 – Intuitive

Very fast process

Used by expert clinicians most of the time

Type 2  - Rational

Processes are slower

More reliable

Focus more on hypothesis and deductive clinical reasoning

Hypothetical-Deductive Reasoning

Repetitive operation/use of Type 2 leads to Type 1 reasoning

Recognition occurs with more cases and using Type 2 processes effectively

Ability to use Type 1 process in diagnostic reasoning will improve

SPIN: specificity : a (+) result rules in EX: the rapid throat test for strep in an office (if + it rules in strep) this test isn't very sensitive though because a (-) result does not always rule out. the greater the specificity to greater the percentage of persons with a negative or normal result. A positive result would be used to “rule in” a condition.

SNOUT: Sensitivity : a (-) result rules out. For example throat cultures if (-) it rules out that gram strain they are testing for. Greater percentage of persons with a given condition will have an abnormal result. A test with high sensitivity can be used to rule out a condition for persons who do not have an abnormal result.

Levels of Disease prevention: 

Primary prevention--prevent onset of illness before the disease begins

Removes/reduces disease risk--immunizations/exercise

Immunization is the best means of preventing infection: 

Secondary prevention --preventive measures that lead to early diagnosis and prompt treatment of a disease, illness or injury to prevent more severe problems developing.

BP screening, TB skin testing, 

Hep C one time testing for persons born between 1945 and 1965 without prior ascertainment of HCV risk. 

Routine screening for asymptomatic bacteriuria for pregnant women. 

Screening Tools Chart

Screening Item

Age /Gender

Screening tool used

AAA

O 65-75 males

o 65-75 Females

O US in smokers

o Not for non-smokers

o Not at all smoking or not

ASA use

o 45-79 males when MI benefit > GI risk

o 55-79 females when MI benefit > GI risk

o >80 males and females no data

o <45 women < 55 males not recommended

O Administering a daily dose

Serum Lipids

o 35 and older males

o 20-35 high-risk males

o 45 and older females

o 20-45 high-risk females

Men 20-35 or women 20 and older not high risk. 

o Recommend screen yearly

o Recommend screen yearly

o Recommend yearly screening

Recommends yearly screening

o Not recommended for or against

Diabetes

o Asymptomatic adults w/ sustained BP > 135/80

o Asymptomatic adults w/ sustained BP of 135/80 or lower

o Recommends screening

o Insufficient data on recommend screening

Blood Pressure

o 18yrs and older male and female

o Recommends screening

Tobacco use and Counseling

o 18yrs and older male and female

o Ask all and provide cessation interventions

o Pregnant women get augmented counseling

Breast CA

o 40-49 Females

o 50-74 Females

o 75 or older females

o Individualized screening plan

o Screen every 2yrs

o Not recommended

Colorectal CA

o 50-75 male and female

o 76-85 male and female

o 86 and older male and female

o Fecal occult blood testing, sigmoidoscopy or colonoscopy

o Recommends against routine screening

o Recommends against routine screening

Cervical CA

o 21-65 female

o 30-65 female

o < 21 female or > 65 female

o Every 3yrs with cytology

o Every 5yrs with co-test for HPV

o Not recommended to screen

Prostate CA

o All ages male

o Recommends against routine screening with PSA levels

Lung CA

o 55-80 male and female

o Yearly CT with 30ppy smoking Hx who are currently smoking or quit w/in 15yrs

Osteoporosis

o 65 or older females

o 65 or older males

o Recommended screening

o Insufficient data on screening

Obesity

o 18yrs or older male and female

o Examine BMI

Healthy people 2020..what is in the document and what is not.

Purpose of Healthy People 2020: Healthy People 2020 aims to reach four overarching goals: 

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. 

Achieve health equity, eliminate disparities,

Improve the health of all groups. 

Create social and physical environments that promote good health for all.

Healthy people 2020 includes 12 topics that are composed of 26 indicators of health. Each of these indicators will be tracked, measured, and reported on regularly throughout the decade. 

Access to health services

Persons with medical insurance

Persons with usual PCP

Clinical preventive services

Adults who receive colorectal CA screening based on the most recent guidelines

Adults with HTN whose BP is under control

Adult diabetic population with an A1C value greater than 9%

Children aged 19 through 35 months who receive the recommended doses of DTaP, Polio, MMR, HiB, Hep B, Varicella and PCV vaccines. 

Environmental quality 

Air Quality index exceeding 100

Children aged 3 to 11 years exposed to secondhand smoke. 

Injury and violence

Fatal injuries

Homicides

Maternal, Infant, and Child Health

Infant deaths

Preterm births

Mental Status 

Suicides

Adolescents who experience major depressive disorder

Nutrition, Physical Activity, and Obesity

Adults who meet current federal physical guidelines for aerobic activity and muscle-strengthening activity

Adults who are obese

Children and adolescents who are considered obese. 

Total vegetable intake for persons aged 2 years and older. 

Oral Health

Persons aged 2 years and older who used the oral health care system in the past 12 months. 

Reproductive and Sexual health

Sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months. 

Persons living with HIV who know their serostatus. 

Social determinants

Students who graduate with a regular diploma 4 years after starting 9th grade. 

Tobacco

Adolescents who are current cigarette smokers 

Adolescents who smoked cigarettes in the past 30 days. 

Substance Abuse

Adolescents using alcohol or any illicit drugs in the last 30 days. 

Adults engaging in binge drinking during the past 30 days. 

Screening for tobacco cessation: May just want to read the articles...lots of information and difficult to summarize. The following is an attempt to summarize the info: 

 Professional practice guidelines are in agreement that healthcare clinicians use an evidence-based smoking cessation protocol, known as the 5 As of smoking cessation; to identify their patients who smoke and assist smokers with quitting. The 5 A’s are as follows: 

Ask the patient at every office visit if he or she smokes 

Advise all smokers to quit using language that is clear, strong, and personalized that includes strong warnings about the health effects of smoking and exposure to secondhand smoke

Assess the patient’s willingness to quit and provide motivation to do so

Healthcare clinicians should follow the 5 Rs of motivational intervention for patients not willing to quit: 

Use relevance to indicate why quitting is personally applicable 

Ask the patient to identify risks of smoking 

Ask the patient to identify potential positive rewards for smoking cessation

 Ask the patient to identify personal roadblocks (i.e., barriers) 

Use repetition for motivational intervention with each clinical encounter

Assist the patient in his or her attempt to quit by determining a quit date, helping the patient identify triggers, provide encouragement, providing counseling and pharmacotherapy, as appropriate 

Arrange follow-up with the patient • Clinician use of the 5 A’s appears to be 

Approaches to smoking cessation: 

Specific approaches to smoking cessation include the following:

Stopping completely and abruptly (commonly referred to as “quitting cold turkey”) 

Gradual reduction of nicotine intake, which is used by up to 90% of individuals who successfully stop smoking. This approach minimizes nicotine withdrawal symptoms by slowly reducing the daily intake of nicotine. This is done by changing gradually to cigarettes with lower levels of nicotine and/or reducing the number of cigarettes smoked each day 

Pharmacologic interventions for treating nicotine addiction, which help reduce withdrawal symptoms and nicotine cravings. These interventions include –over-the-counter nicotine replacement therapy delivered by transdermal patches, gum, lozenges, sprays, or inhalers. It is important for patients to understand that these interventions do not remove the risk for negative health effects related to nicotine consumption 

The various nicotine replacement products appear to be equally effective 

It is unclear whether nicotine replacement therapy is safe and effective in pregnant women. For more information, see Evidence-Based Care Sheet … Smoking Cessation and Pregnancy

Oral administration of prescription medications, including varenicline (Chantix), a nicotine receptor agonist that decreases the pleasurable effects of nicotine, and off-label use of - bupropion SR (Zyban), which can reduce the severity of nicotine cravings and withdrawal symptoms - cloNIDine, which may reduce nicotine craving but does not always ameliorate other withdrawal symptoms –CBT is the most effective type of psychological counseling in helping smokers to quit

Smoking cessation:What is recommended.

Smoking is the leading preventable cause of illness and death worldwide, yet smoking cessation remains a challenge. Although nearly 70% of smokers report wanting to quit, just over half attempt to do so. 

Smoking cessation education:    

Patient education about smoking cessation is the process of providing information, guidance, and counseling to aid patients in quitting smoking

A variety of learning and motivational activities (e.g., face-to-face instruction, written materials, Internet and other computer-mediated options, telephone counseling services [commonly called helplines and quitlines], individual counseling, group counseling, support groups) can be utilized to support patient efforts to stop smoking

Desired outcomes: 

better understand the health benefits of smoking cessation 

understand details about smoking cessation, related treatment options, and resources to support quitting and prevent relapse 

identify and rely on sources of support during and after their attempt to quit smoking

Smoking cessation strategies

• Effective smoking cessation strategies include counseling (e.g., individual, group, or telephone counseling services that include strategies for problem solving, skills training, and social support); medication (e.g., tablets, nicotine gum, inhalers, lozenges, nasal spray, and patches); or a combination of counseling and medications

› Nicotine replacement therapy (NRT), bupropion (Zyban), varenicline (Chantix) and cytosine (i.e., a smoking cessation medication that is licensed for use in Russia and Eastern Europe but not in the U.S.) are effective in increasing a patient’s chance of quitting smoking and pose low risk of harm. Varenicline is more effective in helping persons quit smoking than nicotine patches or nicotine gum. Nortriptyline is useful in smoking cessation efforts and there is little evidence of harmful effects associated with its use (Cahill et al., 2013)

There is level 2 (mid-level) evidence to support the following smoking cessation strategies (DynaMed, 2014): 

Behavior modification combined with pharmacotherapy for 12 weeks can increase smoking cessation rates and reduce mortality 

Adding NRT to intensive counseling can increase smoking cessation rates • Adding varenicline to counseling may improve smoking abstinence at 12 months 

Psychosocial interventions may be effective in smoking cessation for patients with coronary artery disease

› Level 1 evidence regarding smoking cessation that is likely reliable (DynaMed, 2014) includes the following: 

Counseling interventions in patients who are hospitalized and at least 1 month of follow-up contact are effective in promoting smoking cessation 

Inpatient counseling plus 4 post-discharge telephone calls helps to prevent relapse 

Smoking cessation interventions by cardiac nurses during patient hospitalization for coronary heart disease and patient follow-up contact for 5 months improves the rate of smoking cessation at 1 year 

Single educational sessions for 20–30 minutes that are delivered during routine patient care are not likely to influence highly dependent smokers 

In the emergency department, multicomponent interventions are no more effective than standard care with brochures regarding smoking cessation

Smoking cessation study: 

Abstract 

Purpose: To perform a smoking cessation intervention by a nurse practitioner in a primary care setting and assess its effectiveness. 

Data sources: The intervention developed was an operationalization of the five As from the U.S. Department of Health and Human Services’ updated Clinical Practice Guideline: Treating Tobacco Use and Dependence. Data were generated from a two-group controlled intervention that compared adult smokers who either received or did not receive an intensive proactive telephone intervention focused on cessation. 

Conclusions: The intervention group showed movement across the stages of change, lower nicotine dependence, and increased confidence to quit. Also, 19% quit smoking and were abstinent at the end of study; none in the control group achieved abstinence. Quit rates were similar to those of other studies. The statistically necessary sample size was not attained, highlighting recruitment difficulties in smoking cessation studies. For a pilot study, the sample size was acceptable. 

Implications for practice: Measuring stage of change and nicotine dependence can assist clinicians in implementing cessation strategies. Although effective, a provider may find the intervention too intensive to employ with more than one patient at a time. This intervention should be evaluated with smokers ready to make a quit attempt.

HEENT 

Top disorders (red eyes, earache, sinusitis, sore throat)

Amblyopia: decrease in the visual acuity of one eye. It is commonly seen in young children and cannot be corrected with either glasses or contact lenses. Most common cause of childhood vision loss.

Pathogenesis: Congenital defect, Develops from a corneal scar or cataract, Occurs from an uncorrected high refractive error, which causes visual blurring, Develops when each eye has a different refractive error that leads to blurred vision.

Blepharitis: dryness and flaking of the eyelashes, resulting from an inflammatory response of the eyelid. The exact incidence is not known; however, blepharitis is one of the most commonly seen eye conditions.

Pathogenesis: Seborrheic: Excessive shedding of skin cells and blockage of glands. Staphylococcus: Most common bacteria found, responsible for bacterial infection of lid margin. Commonly seen with inadequate flow of oil and mucus into the tear duct.

Seborrheic blepharitis: Lid margin swelling and erythema, flaking, nasolabial erythema, and scaling.

Staphylococcus aureus blepharitis: Erythema/edema, scaling, burning, tearing, itching, and recurrent stye or chalazia.

Meibomian gland dysfunction: Prominent blood vessels crossing the mucocutaneous junction, frothy discharge along eyelid margin, thick discharge, and chalazion; may have rosacea or seborrheic dermatitis

General interventions: Wash eye with antibacterial soap and water. May use gentle baby shampoo. Apply warm compresses to the eye for comfort daily for approximately 10 to 20 minutes. Stop use of contacts until the eye is healed. Encourage good hygiene for prevention of recurrent episodes.

Pharmaceutical therapy:  Apply bacitracin or erythromycin ophthalmic ointment to the margin of the eye at bedtime. 

Oral antibiotics: Tetracycline 250 mg by mouth, four times a day, or doxycycline 100 mg by mouth, twice a day, tapering after clinical improvement, for a total of 2 to 6 weeks. 

Alternative: Erythromycin 250 to 500 mg daily or azithromycin 250 to 500 mg one to three times a week for 3 weeks. 

Consider long-term treatment with doxycycline, if infections reoccur.

Azithromycin may lead to abnormalities of heart electrical rhythm; use with caution in patients with a high risk of cardiovascular disease.

Cataracts: opacity of the crystalline lens of the eye, causes progressive, painless loss of vision (functional impairment). Presenile and senile cataract formation is painless and progresses throughout months and years. Cataracts are frequently associated with intraocular inflammation and glaucoma. Cataracts are the most common cause of blindness in the world.

s/s: absent red reflex

Pathogenesis: Age-related changes of the lens of the eye result from protein accumulation, which produces a fibrous thickened lens that obscures vision.

General interventions: Cataracts do not need to be removed unless there is impairment of normal, everyday activities. Surgery is the definitive treatment; however, modification of glasses may improve vision adequately to defer surgery.

Chalazion: chronic lipogranulomatous inflammation of a meibomian gland located in the eyelid margin. Inflammation occurs from occlusion of the ducts.

Pathogenesis: Meibomian glands secrete the oil layer of the tear film that covers the eye. When the glands become blocked, the oil or lipid extrudes into the surrounding tissue, causing the formation of a nodule.

General interventions: Small chalazia, usually, do not require treatment. Warm, moist compresses may be applied for 15 minutes four times a day.

Pharmaceutical therapy: Sulfacetamide sodium (Sulamyd) ophthalmic ointment 10%, four times daily, for 7 days for bacterial infection. Tobradex ophthalmic drops: 1 to 2 drops every 2 hours for first 24 to 48 hours, then every 4 to 6 hours. Reduce dose as the condition improves. Treat for 5 to 7 days as needed. Not recommended in children younger than 2 years. Intrachalazion corticosteroid injection is performed by an ophthalmologist.

DANGER SIGNS: EYES

Herpes keratitis- most common cause of corneal ulceration, corneal epithelial damage resulting in blindness 

HSV1 carriers(herpes simplex keratitis), neonatal keratitis caused by HSV2, Herpes Varicella Zoster(herpes zoster ophthalmicus) 

AVOID STEROIDS

Dx: Fluorescein dye (fern like lines in corneal surface)

EMERGENCY REFERRAL

Acute Angle-Closure Glaucoma- CUPPING OF OPTIC NERVE, INCREASED IOP>50

elderly w. Acute onset of severe eye pain

HA w. N/V, halos around lights, decreased vision, mid-dilated pupil(s), cloudy cornea

EMERGENCY REFERRAL

MS (Optic Neuritis)- young female with new or intermittent loss of unilateral vision w. Or w.o. Nystagmus or other abnormal eye movements

Possible neuro symptoms: aphasia, paresthesia, abnormal gait, spasticity

c/o fatigue on awakening that worsens throughout day, heat sensitivity

Recurrent episodes

REFER TO NEUROLOGIST 

Orbital Cellulitis- acute onset of erythematous swollen eyelid with proptosis(eyeball bulging) w. Eye pain

Pain with eye movement, unable to perform full ROM of eye, EOM abnormal

Ask about hx of URI or rhinosinusitis

Caused by bacterial infection or orbital contents(fat, ocular muscles)

More common in young children

EMERGENT REFERRAL

Retinal Detachment(SHOWER OF FLOATERS, FLASHES OF LIGHTS(PHOTOPSIA), LOOKING THROUGH CURTAIN

EMERGENT REFERRAL

Acute Angle-Closure Glaucoma-increase IOP damage optic nerve, leading to loss of peripheral vision and can lead to central vision loss. 

Increases vascular resistance causes decreased vascular perfusion to optic nerve(ischemia)

Pupil dilates w. Light, iris relaxes, bows forward, blocks trabecular meshwork, occludes outflow of aqueous humor, increase IOP

Predisposing factors: AA, 60>, darkness, anticholinergics, corticosteroids, FH glaucoma

Symptoms: cloudiness vision, halos, HA w. N/V, blurry vision, difficult peri vision

Signs: no pupil response to light, dilated, cornea cloudy, red eye with ciliary flush (adjacent to limbus mostly), hard orbital globe, visual field loss

Diagnostics: funduscopic- cupping of optic nerve visual acuity and peri fields of vision, tonometer or IOP: acute >50 (don’t use is ext. infection), slit-lamp

EMERGENT REFERRAL D/T BLINDNESS W/IN 2-3 DAYS

Diamox 250 mg orally, Pilocarpine 4% every 15 minutes during acute attack. 

SURGERY IF IOP IS NOT MAINTAINED WITHIN NORMAL LIMITS.

Conjunctivitis: Inflammation or swelling of the conjunctiva due to allergies, viral or bacterial infection. 

Bacterial Conjunctivitis 

Sx: 

Fast onset, Unilateral

Last 10-14 days--usually self limited. 

Mild discomfort without blurred vision

Burning stinging gritty sensation

Copious purulent drainage

Matted eyelids upon waking

Contagious until 24 hours after ATB started

Culture if gonococcal infection suspected. 

Tx: Topical ophthalmic solutions used to treat staph, strep, Haemophilus, Pseudomonas, and Moraxella, common causes of bacterial conjunctivitis. 

aminoglycosides

Gentamicin 0.3% 1-2 drops every 4 hours for 5-7 days (mild to moderate)

2 drops every hour and then 1-2 drops every 4 hours for 5-7 days. (severe)

Tobramycin 0.3% 1-2 drops four times a day for 5-7 days. 

Azithromycin drops

fluoroquinolones

Cipro Drops 0.3%  1-2 drops every 2 hours for 2 days and then every 4 hours for 5 days. 

Macrolides

Erythromycin 0.5% 1 drop each eye four times daily for 5-7 days. 

Trimethoprim-polymyxin  B ointment in each eye QID for 7 days. 

Secondary: RA, Lupus, U.C., Crohn’s, Kawasaki’s disease

Allergic: same time Q yr

Sx:

Bilateral Itching(hallmark sign), watering eyes

Eyelid edema without vision changes

Peripheral injection

Ropy mucoid discharge. 

Possible eczema, urticaria, or asthma flare. 

Treatment: 

Use cold compresses and artificial tears

OTC allergy eye drops

Azelastine(Optivar) one drop affected eye BID (ages 3 and up)

Olopatadine(Pataday) one drop affected eye daily ( ages 3 and up) 

Olopatadine(Patanol) 1-2 drops BID to affected eye (ages 3 and up) 

Mast cell stabilizers - Cromolyn 1-2 drops 4-6 x daily. 

Topical NSAIDS such as acular one drop QID

Artificial tears

Oral antihistamines(Loratadine/diphenhydramine)- if other s/s, congestion, runny nose

If OM present tx with systemic ATB

Viral (MOST COMMON TYPE): HIGHLY CONTAGIOUS (48-72HRS, UP TO 2WKS), ADENOVIRUS

Sx: 

Foreign body sensation

Acute onset in one eye that progresses to both 

Photophobia, impaired vision at times

Watery discharge, no pain. 

Sx of URI, +lymphadenopathy 

Tx: No specific treatment 

Cool compresses clean eyes, hand washing, discard eye makeup, 

ATBs not generally recommended but topical sulfonamides to prevent secondary bacterial infection (erythromycin or Polytrim for 5 days.) 

10-14 days recovery

Oral antivirals (trifluridine and valacyclovir) may be used for herpes simplex keratitis. 

Gonococcal conjunctivitis (hyperacute bacterial conjunctivitis) EMERGENT

Sx: 

Severe, rapidly progressing, sight threatening

Sexually active young adults and newborns are affected. 

Bilaterally Yellow-green purulent drainage. 

Preauricular lymphadenopathy

Tx: Ceftriaxone 1G IM once PLUS ... 

Azithromycin 1g PO once or Doxycycline 100mg twice daily for 7 days. 

Chlamydial conjunctivitis EMERGENT

Sx: 

Usually unilateral 

Thin mucoid discharge

Enlarged tender preauricular nodes

Sx may be present for months. 

Tx: 

Azithromycin 1 g PO single dose or Doxycycline 100mg BID for 7 days. 

Pregnant women should be treated with Erythromycin 250mg QID for 21 days. 

Corneal Abrasion: loss of epithelial tissue, either superficial or deep, from trauma to the eye. Change in vision and Redness, swelling, inability to open the eye.

Diagnostic Test: Perform fluorescein stain test: epithelial defect that stains (hallmark)

General interventions: Deeper abrasions, apply a patch that prevents lid motion 24-48 hours. should not use/wear contact lenses until the eye is completely healed.

Pharmaceutical therapy: Antibiotic drops or ointment. Ointments are suggested over drops as they provide lubrication for the eye. 

-Adults and children: Sulfacetamide sodium ophthalmic solution 10% (Sulamyd), 1-2 drops Q 2-3hrs during the day; may instill every 6 hours during the night × 5-7 days. 

-interacts with gentamicin. Avoid using them together. 

-Adults and children: Polymyxin B sulfate (Polytrim) 10,000 U/g, bacitracin zinc 500 U/g ophthalmic ointment (Polysporin), a small ribbon of ointment PRN

-Adults and children: Erythromycin ophthalmic ointment 0.5% (Ilotycin), 1-cm ribbon of ointment 4-6xs/d.

-Bacitracin 500 U/g ointment, 1/2-inch ribbon 2-4xs/d. x 7d. 

-Contact lens wearers are often colonized with Pseudomonas, and should be treated with either a fluoroquinolone or an aminoglycoside. Ciprofloxacin 0.3% solution, 1 to 2 drops four times a day, for 3 to 5 days; gentamicin 0.3% solution 1 to 2 drops, four times a day, for 3 to 5 days; or tobramycin (Tobrex) ointment or drops, four times a day for 3 to 5 days.

-Analgesics: Topical analgesics should be used sparingly. Diclofenac (Voltaren) 0.1% solution 4xs/d PRN, or ketorolac (Acular) 0.5% solution

Dacryocystitis: Infection or inflammation of the lacrimal sac, or dacryocystitis, can be acute or chronic. Dacryocystitis is usually secondary to obstruction.

Pathogenesis: Bacterial infection of the lacrimal sac usually is caused by Staphylococcus or Streptococcus.

Diagnostic Tests: Check visual acuity. Culture discharge for Neisseria if suspected.

General interventions: Apply warm, moist compresses at least 4xs/d. discard old makeup

Pharmaceutical therapy: Dicloxacillin 250 mg by mouth four times daily for 7 days. Erythromycin 250 mg by mouth four times daily for 7 days

Dry Eyes: insufficient lubrication of the eye, or dry eyes, is caused by a deficiency of any one of the major components of the tear film. Defects in tear production are uncommon but may occur in conjunction with systemic disease. 

Pathogenesis:  Decreased production of one or more components of the tear film results in dry eyes. The tear film comprises three layers: An outermost lipid layer, excreted by the lid meibomian glands. A middle aqueous layer, secreted by the main and accessory lacrimal glands. An innermost mucinous layer, secreted by conjunctival goblet cells

-defect in production of the aqueous phase by lacrimal glands causes dry eyes or keratoconjunctivitis sicca. most often occurs as a physiological consequence of aging, commonly exacerbated by dry environmental factors.

General interventions: If no ocular disease is present, reduce environmental dryness by use of a room humidifier for a 2-week trial. Apply artificial tear substitutes and nonprescription drops. 

Pharmaceutical therapy: Topical artificial tears 1 or 2 drops four times daily, preferably one without preservatives (i.e., Thera-tears, Dry Eye Therapy, Tears Naturale).

Excessive Tears: an overproduction of tears. Complaints vary from watery eyes to overflowing tears that run down the cheeks, a condition known as epiphora.

Pathogenesis: The most common cause is reflex overproduction of tears (as occurs in the elderly) due to a deficiency of the tear film. Lacrimal pump failure and obstruction of the nasolacrimal outflow system are other causes of excessive tears.

General interventions: Eliminate identifiable irritants. Treatment is mainly aimed at the underlying condition (i.e., ocular infection).

Eye Pain: pain may affect the eyelid, conjunctiva, or cornea.

Pathogenesis: The external ocular surfaces and the uveal tract are richly innervated with pain receptors. As a result, lesions or disease processes affecting these surfaces can be acutely painful. Pathology confined to the vitreous, retina, or optic nerve is rarely a source of pain.

A.Eye pain (sharp, dull, deep): The quality of the pain needs to be considered. Deep pain is suggestive of an intraocular problem. Inflammation and rapidly expanding mass lesions may cause deep pain. Displacement of the globe and diplopia may ensue.

B.Eye movement may cause sharp pain due to meningeal inflammation (the extraocular rectus muscles insert along the dura of the nerve sheath at the orbital apex). Most cases are idiopathic, but 10% to 15% are associated with multiple sclerosis.

Eyelids- Tenderness, Sensation of foreign body, Redness, Edema.

Conjunctiva- Mild burning, Sensation of foreign body, Itching (allergic).

Cornea- Burning, Foreign-body sensation, Considerable discomfort, Reflex photophobic tearing, Blinking exacerbates pain, Pain relieved with pressure (i.e., holding the lid shut). With a foreign body or a corneal lesion, pain is exacerbated by lid movement and relieved by cessation of lid motion.

Sclera: Redness

Uveal tract (uveitis or iritis)- Dull, deep-seated ache and photophobia. Profound ocular and orbital pain radiating to the frontal and temporal regions accompanying sudden elevation of pressure (acute angle-closure glaucoma), Vagal stimulation with high pressure may result in nausea and vomiting. Usual history of mild intermittent episodes of blurred vision preceding onset of throbbing pain, nausea, vomiting, and decreased visual acuity. Halos around light.

Orbit- Deep pain with inflammation and rapidly expanding mass lesions. Eye movement causing sharp pain due to meningeal inflammation.

Uveitis-Idiopathic, inflammation of uveal tract.

s/s: BLURRED VISION, dull ache, photophobia, n/v w. Vagal stim.

Signs: unilat. Or b/l smaller pupil, poor response to light, mod. Ocular pain

Diagnostic: slit-lamp, flashlight test (slightly cloudy ant. Chamber in the uveitic)

TX: treat underlying cause if known. IMMEDIATE REFERRAL

top./systemic corticosteroids for uveitis and colitis often flare up at the same time. 

Iritis (ant. uveitis)

s/s: unilateral (sm. Pupil r/t spasm), redness around cornea (ciliary flush), RED RING AROUND IRIS, pain/photophobia with movement and light, pupil constricted, black spots, halos

REVIEW COMPLETE MEDICAL HX FOR COMORBID

Diagnostic: slit-lamp, flashlight test (slightly cloudy ant. Chamber in the uveitic)

Causes: trauma, eye surg., arthritic psoriasis, HSV, SARCOIDOSIS, aids, tb, crohn’s, lupus

TX: EMERGENT REFERRAL 

Recurrent uveitis- needs further work up (meds, inflammatory dis., infections, MS)

Hordeolum (stye)- bacterial (staph) infection of eye glands-hair follicle

Internal(under conjunctival side of eyelid) or External(swelling under eyelid skin)

s/s: tenderness, sudden purulent d/c, redness swelling eyelid

TX: contain infectious agent; Sulfacetamide sodium 10% (ointment 4xs/d., drops 2gtts q4h-7d.), polymyxin b sulfate w. Bacitracin zinc oinment 4xs/d.-7d.)

If CROPS, TETRACYCLINES, CONSULT W. PHYSICIAN (MUST EXCLUDE DM)

WScleritis: severe pain, red eye, decreased vision, NO DISCHARGE

Possible systemic cause

EMERGENT REFERRAL

Strabismus: eye disorder in which the optic axes cannot be directed toward the same object due to a deficit in muscular coordination. It can be nonparalytic or paralytic.

Esotropia is a nonparalytic strabismus in which the eyes cross inward.

Exotropia is a nonparalytic strabismus in which the eyes drift outward. Exotropia may be intermittent or constant.

Pseudostrabismus gives a false appearance of deviation in the visual axes.

Pathogenesis: Paralytic strabismus is related to paralysis or paresis of a specific extraocular muscle. Nonparalytic strabismus is related to a congenital imbalance of normal eye muscle tone, causing focusing difficulties, unilateral refractive error, nonfusion, or anatomical difference in the eyes.

Diagnostic Tests: Test visual acuity. Perform the cover–uncover test: In this test, the “lazy eye” drifts out of position and snaps back quickly when uncovered. Corneal light reflex (Hirschberg’s) test: Perform the Hirschberg’s test for symmetry of the pupillary light reflexes to help detect strabismus. Normally, the light reflexes are in the same position on each pupil, but not with strabismus (positive Hirschberg’s test). Test EOMs: If a nerve supplying an extraocular muscle has been interrupted or the muscle itself has become weakened, the eye fails to move in the direction of the damaged muscle. If the right sixth nerve is damaged, the right eye does not move temporally. This is paralytic strabismus.

General interventions: When poor fixation is present, patch the stronger, dominant eye to promote vision and muscle strengthening in the weaker eye. Patient teaching: Reinforce the need to consistently wear an eye patch, especially with children.

Pharmaceutical therapy: None.

Subconjunctival Hemorrhage: presents as blood patches in the bulbar conjunctiva. Frequently seen in newborns, subconjunctival hemorrhage may also be seen in adults after forceful exertion (coughing, sneezing, childbirth, strenuous lifting).

Pathogenesis: This disorder is believed to be secondary to increased intrathoracic pressure that may occur during labor and delivery or with physical exertion.

General interventions: Reassure the patient. The hemorrhage is not damaging to the eye or vision, and the blood reabsorbs on its own over several weeks.

EMERGENT REFERRAL FOR CHANGES IN VISUAL ACUITY/COLOR VISION, FIXED PUPILS, SEVERE HA. W. N/V, HERPES ZOSTER INVOLVING FACE/NOSE (ORAL ANTIVIRAL IMMEDIATELY), NO IMPROVEMENT 24HRS, CAN’T OPEN EYE, OCULAR PAIN, SUSPECTED HYPERACUTE CONJUNCTIVITIS

Ear:

DANGER SIGNS 

Cholesteatoma- cauliflower like growth, foul smelling d/c, unilateral hearing loss

Signs: no TM or ossicles visible d/t destruction via tumor, otorrhea, superior TM retraction

Can erode into bones of face and damage CN VII

TX: ATB, surgical debridement

REFER OTOLARYNGOLOGIST

Battle sign(Raccoon eyes)- periorbital ecchymosis and bruising behind ear(mastoid area)

Appears 2-3 d. After trauma 

Search for CL/GOLD D/C (BASILAR OR TEMPORAL BONE SKILL FX)

TEST D/C W. URINE DIP (+ GLUCOSE=CSF)

BASILAR FX CAN CAUSE INTRACRANIAL HEMORRHAGE

EMERGENT REFERRAL

RED FLAGS(from youtube) 

Mastoiditis-osseous infection, symptom-mastoid tenderness

Malignant otitis externa- s/s: 7th CN Palsy,unilateral hearing loss

Ulceration of auditory canal- tumor (myosarcoma, lymphoma) causing erosion of ear canal

Non Healing lesion of auditory canal-tumor (rhabdomyosarcoma, lymphoma)

Ear lobule erythema- erysipelas: requires rapid ATB tx to prevent spread to surrounding neck tissue

Ear: otalgia(ear pain)-if norm findings (referred pain)

Ask about URI, fever, swimming, air travel, dm(MALIGNANT [NECROTIZING] OTITIS EXTERNA), radiation, dizziness, tinnitus, smoking, alcohol, dysphagia, weight loss, >50yo, unilateral hearing loss

Possible causes: OE, AOM, OME, cholesteatoma(ct of temporal bone), mastoiditis, trauma, TMJ, cerumen impaction., FB 

AOM: inflammation of middle ear, with bacterial infection (Strep, H. Influenze, Morxella)

Predisposing factors: DS, aids, smoke, bottle propping, FH allergies, <12 months of age

PE: palpate mastoid area(tenderness with protrusion of auricle-mastoiditis[xray]), lymphs, tmj(CN5,7,9)

Signs: perforated TM with ear drainage (otitis media will require tympanostomy tube otorrhea)

Redness, bulging of TM or purulent effusion(acute otitis media)

Bullae, redness, or mass involving TM(Myringitis, cholesteatoma, malignancy)

TX: 1ST LINE-AMOXICILLIN(500 MG TID 5-7D.) 90 mg/kg/d divided into 2 doses daily for 10 days.

IF NO IMPROVEMENT IN 48-72HRS SWITCH TO: AMOXICILLIN-CLAVULANATE(AUGMENTIN) TID, CEFDINIR OR CEFPODOXIME, CEFUROXIME, AND CEFTRIAXONE.

MACROLIDES(AZITHRO, ERYTHRO W. SULFA, CLARITHRO), BACRIM

<6 weeks old refer to ENT

W. Effusion- asymptomatic middle-ear fluid without signs of bacterial infection

Resolve within 12 weeks, no Medication tx recommended 

Otitis Externa- self-limiting, meatus acute inflammation, tender, weeping

Pseudomonas, proteus, fungi aspergillus

Predipos. Fact: DM, immunocompromised, swimming, mechanical trauma

Signs: purulent exudate, fungal(pruitus), normal TM movement

TX: remove debris, wick (1’’) for severe edema to allow ear drops into canal, swimmers ear(50/50 isopropyl alcohol/white vinegar)

    Cipro and Cortisporin

Infection: aminoglycoside or fluoroquinolone w. Or w.o. corticosteroids

Cipro 500mg BID 7d-periauricular cellulitis

Cerumen Impaction (Earwax): earwax buildup, can cause conductive hearing loss or discomfort.

Pathogenesis: Wax builds up in the external canal. With age, the normal self-cleaning mechanisms of the ear fail. Cilia, which have become stiff, cannot remove cerumen and dirt from the ear canal. The pushing of cotton swabs, paper clips, bobby pins, and so forth, into the ear canal may also impact cerumen.

General interventions: Remove impaction by means of lavage or curettage. Be sure to inspect the canal and tympanic membrane after removal of the cerumen.

Pharmaceutical therapy: Debrox, mineral oil, or olive oil two to three drops in the ear every day for 1 week to loosen the cerumen before lavage or curettage. Do not use Debrox if perforation of tympanic membrane is suspected. For prevention, have the patient use the aforementioned softeners for 2 to 3 days. Then have him or her use one capful of hydrogen peroxide in the ear twice daily, allow it to bubble for 5 to 10 minutes, then turn head to allow it to run out.

Hearing loss: Impaired hearing (complete or partial hearing loss) results from interference with the conduction of sound, its conversion to electrical impulses, or its transmission through the nervous system. 

There are three types of hearing loss:

Conductive hearing loss

Sensorineural hearing loss

Combined conductive and sensorineural loss.

Pathogenesis: Conductive hearing loss presents with a diminution of volume, particularly low tones and vowels. Caused by either: Otosclerosis disorder of the architecture of the bony labyrinth fixes the footplate of the stapes in the oval window. Exostoses are bony excrescences of the external auditory canal. Glomus tumors are benign, highly vascular tumors derived from normally occurring glomera of the middle ear and jugular bulb.

-Sensorineural hearing loss characteristically produces impairment of the high-tone perception. Affected patients can hear people speaking, but they have difficulty deciphering words because discrimination is poor. It may be caused by either: Presbycusis is hearing loss associated with aging and is the most common cause of diminished hearing in the elderly; onset is bilateral, symmetric, and gradual. Drug-induced hearing loss can be caused by aminoglycoside antibiotics, furosemide, ethacrynic acid, quinidine, and aspirin. Ménière’s disease produces a fluctuating, unilateral, low-frequency impairment usually associated with tinnitus, a sensation of fullness in the ear, and intermittent episodes of vertigo. Acoustic neuroma is a benign tumor of the eighth cranial nerve (rare).Sensorineural hearing loss is generally bilateral and symmetric, and it may be genetically determined.

Dx: weber and rinne's (if to affected ear conductive, non affected ear sensorineural)

General interventions: Treat any primary cause (i.e., remove impacted cerumen). Discuss avoiding loud noises, using earplugs, and so forth.

Pharmaceutical therapy: Treat primary condition if applicable.

Tinnitus: refers to any sound heard in the ears or head.

Pathogenesis: Tinnitus is poorly understood. It is best described as a nonspecific manifestation of pathology of the inner ear, eighth cranial nerve, or the central auditory mechanism.

- Address underlying conditions if present (depression, insomnia, hearing loss, drug toxicity). Consider behavioral therapy, such as biofeedback or cognitive behavioral therapy, to teach patient coping strategies.

Pharmaceutical therapy: No medication “cures” tinnitus. Vasodilators, tranquilizers, antidepressants, and seizure medications have been shown to reduce symptoms. Placebos are also of therapeutic value.

Nose:

Epistaxis: a nosebleed or hemorrhage from the nose.

Pathogenesis: caused by disruption of the nasal mucosa. More than 90% of nosebleeds are related to local irritation rather than underlying anatomic lesions and are self-limiting. Most start in the anterior nasal cavity (Kisselbach’s plexus). Posterior nasal bleeding usually originates from the turbinates or lateral nasal wall.

-Anterior epistaxis- Unilateral, Continuous, moderate bleeding from septum of nose

-Posterior epistaxis- Brisk (arterial) bleeding, Blood flowing into pharynx (indicates a more serious problem).

General interventions: Main goal is to control episodes of bleeding.

Pharmaceutical therapy/medical/surgical management: 

To control anterior septal bleeding: lean forward, apply pressure, cotton pledget with phenylephrine (Neo-Synephrine), oxymetazoline HCl (Afrin), or epinephrine 1:1,000, pressure against bleeding site for 5-10 min. check after 10 minutes. If this fails, anesthetize mucous membrane by applying cotton with 4% lidocaine (Xylocaine) plus topical epinephrine (1:10,000), cocaine 4%, or phenylephrine 0.25% for 10-15 min. Then apply a silver nitrate stick to the bleeding site, until gray eschar appears. If bleeding still does not stop (rare), repeat last two steps. Then place a small amount of oxidized regenerated cellulose (Surgicel) against the bleeding artery, or pack a small petroleum gauze strip in the nasal vestibule for 24 hours. 

To control posterior septal bleeding: lean forward, spray nose with topical anesthetic + vasoconstrictor, apply pressure. Consult a physician. The patient needs emergency department care immediately because of rapid blood loss.

Nose: Rhinitis, Sinusitis

CC: sneezing, post nasal dripping w. Difficulty sleeping

HPI: method of birth control, r/o pregnancy

PE: Dennie’s line (dark lines under eyes), allergic salute (rubbing nose upward), transilluminate sinuses, MENINGEAL IRRITATION(brudzinski's and kernig’s)

Dx: CBC for eosinophil count to r/o infection

DDs: Thyroid, pregnancy, drug use, URI, influenza, OM

Allergic Rhinitis-pale, boggy, blue turbinates, polyps(chronic)

Causes: IgE mediated, allergies, seasonal pattern inhaled pollen and spore allergens, food allergies

Histamine release-local vasodilation, mucosal edema, mucous production

Difficult to tx year round (mold, dust mites, animal danger

Age 10-20

HALLMARK: SAME TIME Q YR

s/s: dark circles under eyes, allergic salute, clear mucus, cough r/t post nasal drip, freq. Sneezing, Palatal click- clicking sound in throat from clear mucus, post. pharynx -thick mucus, cobblestoning

Dx: H&P, Skin test for IgE antibody (gold standard), RadioAllergoSorbent Test(RAST)

Tx: Antihistamine-second gen.(H1 receptor antagonist)- may need to try many and switch up d/t tolerance

1ST LINE TX: Azelastine hydrochloride nasal spray(5yo or older)-5-11yo(1gttBID), adults(2gttsBID)

Loratadine, 10mg, PO, QD(adults), 5 mg, PO, QD(2-5yo)

Fexofenadine HCL(60mgPOBID/180mgQD), 6-11yo(30mgPOBID)

Cetirizine HCl5-10mgQD, 5MG FOR HEPATIC/RENAL,

2-6yo(2.5mgPOQD)

Steroid spray- may cause pharyngeal fungal infections

Beclomethasone dipropionate(6yo-adult):1-2gtts/BID

1ST LINE Fluticasone propionate(adult-2gtts/QD or 1gtt/BID), 

Maintenance 1gtt/QD

4yo-older start w. 1gtt/QD, may increase to 2gtt/QD

1ST LINE Triamcinolone acetonide 2gtt/QD

2-12yo(1gtt/DQ)

1st LINE Cromolyn sodium(spray TID)-less effectice than steroids

IF NO RELIEF TRY A COMBINATION OF STEROID AND TOPICAL ANTIHISTAMINE 

Topical decongestants(3days)-may cause nervousness, insomnia

    Oxymetazone HCl0.05%(2-3gtts/sprayBID), 2-6yo use 0.025%

    Phenylephrine(2-3gtts/1-2sprays/sm. Amt. jelly-Q4PRN, 6-12yo use 0.25%, 5yo and younger 0.125%

F/U- if symptoms worsen after 3 days

Nonallergic Rhinitis-unknown etiology, adult onset(Rhinitis Medicamentosa

Possible causes: chronic inflammatory disease, overuse topical decongestants, hypersensitive cholinergic reflex(eating cold/hot food)

Progressive deterioration of nasal mucosa and bones

No FH of allergies 

Tx: saline spray, nasal antihistamines(azelastine 2 sprays in each nare daily), Fluticasone (Flonase), decongestants not recommended unless antihistamine and glucocorticoids failed and then only for 2-3 days at a time. 

Rhinosinusitis: inflamed mm of paranasal sinuses and nasal mucosa

d/t URI or allergy, dental abscess, smoking

Acute viral rhinosinusitis-shorter, self limited. 

Sx: 

Clear, watery nasal drainage, erythemic nasal mucosa, Symptoms last <4 weeks and typically <10 days. 

TX: 

ZINC GLUCONATE 13.3mg lozenge(first 24-48hrs), 

Buffered NS irrigations

Decongestants

Acute bacterial rhinosinusitis(ABRS): s. Pneumoniae, H, influenzae

Common Case: unilateral facial pain or upper molar pain(maxillary sinus), congestion for 10 days or longers, OTC meds not working, purulent nasal and/or postnasal drip, cough from post nasal drip

Sx: 

Purulent yellow-green nasal discharge or expectorant

Facial pain/pressure over sinuses; teeth

Nasal obstruction; halitosis

1-4wk duration

Cough, malaise, FEVER, HA

Dx: H&P, for chronic, recurrent, complicated X Ray, CT sinuses if suspect fungal sinusitis or osteomeatal complex occlusion

Tx of mild w. Healthy pt.: F/U 10d., if no improvement initiate ATBs

Tx of severe(>10days, pain, 2-3d. Post nasal drip, immunocompromised): 

ADULTS:

FIRST LINE: AMOXICILLIN-CLAVULANATE, 500MG OR 875MG TID X 10-14D.

PCN/BETA LACTAM ALLERGY/ FAILED: LEVOFLOXACIN 500MG, MOXIFLOXACIN 400MG

FAILED/ 2ND LINE: AMOXICILLIN-CLAVULANATE 2G, BID X10D.

2ND LINE: DOXY 100MG BID X 10-14D

SAME FOR CHRONIC BUT LAST 3-4WKS., oral corticosteroid bursts, topical nasal corticosteroids

May use NSAIDs and decongestants 

Invasive fungal sinusitis

MEDICAL SURGICAL EMERGENCY IN IMMUNOCOMPROMISED

EMERGENT: MENINGITIS, SUBDURAL/EPIDURAL DRAINAGE, BRAIN ABSCESS, AMS, CAVERNOUS SINUS THROMBOSIS, FACIAL CELLULITIS, ORBITAL CELLULITIS, IMMUNOCOMPROMISED

THROAT

EMERGENT: DROOLING, UNABLE TO SWALLOW OR LIE DOWN, UNABLE TO TALK

Pred. fact: smoking, allergies, URI, oral sex, drug, debilitating illness, immunizations, medications, old age

PE: skin for rashes, percuss abdomen(spleen) and chest, palpate for organomegaly and suprapubic tenderness, CVA tenderness, nuchal rigidity and meningitis

DDs: stomatitis, trench mouth, epiglottis, peritonsillar abscess, mono, HSV, HIV, sinusitis, rhinitis, coxsackie A virus, candida albicans

Dx: rapid strep(if neg. Do throat cult.), monospot, cbc w. Diff, gonorrhea cult

Dental Abscess: is a space infection of the gingiva and periodontal tissues.

Potential Complications

Risk of complications increases with valvular disease. The following are complications:

A.Sepsis

B.Leukocytosis associated with facial cellulitis

Refer to dentist

Drug of choice: Penicillin V potassium 250-500 mg orally every 6 hours while the patient awaits dental consultation

2.Other medications

Cephalexin (Keflex) 500 mg every 6 hours until dental consultation

Clindamycin (Cleocin) 300 mg orally every 6 hours until dental consultation

For discomfort/fever: Ibuprofen 400-600 mg PO Q6-8 hours, not to exceed 1,200 mg/d

Epiglottitis: inflammation and swelling of the epiglottis and is an EMERGENCY.

Incidence- usually occurs in children between ages 2 and 8 years, but it may also occur in adults. Incidence has decreased dramatically since the Haemophilus influenzae vaccine was introduced.

Pathogenesis-almost always caused by H. influenzae, although Streptococcus pneumoniae and Streptococcus pyogenes have also been implicated.

CC: Sudden onset of fever, Sudden onset of dysphagia, Sudden onset of drooling, Sudden onset of muffled voice, Respiratory distress, Stridor, Very ill appearance

Physical Examination: Do not examine the throat—airway occlusion may result.

Diagnostic Test: Lateral neck radiograph confirms diagnosis

Avoid moving child as much as possible

Patient teaching: Educate the patient and the family that epiglottitis is a medical emergency.

If patient has drooling and no cough, diagnosis is most likely epiglottitis. If the child has cough and no drooling, then diagnosis is most likely croup.

Tx:

Cefotaxime (Claforan) 100 to 200 mg/kg/d every 8 hours IV

Ceftriaxone (Rocephin) 50 to 100 mg/kg/d every 12 hours IV

Ampicillin-sulbactam (Unasyn) 150 mg/kg/d every 6 hours IV

Amoxicillin-clavulanic acid 100 mg/kg/d every 8 hours IV.

Never place a child in supine position because respiratory arrest has been reported.

All close contacts tx prophylactic atb rifampin, 20 mg/kg, not to exceed 600 mg/day x 4 days

Oral CA: buccal mucosa, tongue, gingiva, hard palate, soft palate, or lips

Premalignant lesions: 

Leukoplakia- white patches 

Erythroplakia- red velvety patches

Death rate high d/t late dx (50% dx after mets)

RFs: Rises 50-fold among smokeless tobacco users, EBV, HPV, sun exposure, etc.

CC: non healing oral sores, poor fitting dentures, dysphagia, bleeding mucosa

Sub: changes in taste, sensation, foul breath, CA hx, ASA use, ETOH, dental hx, weight loss

PE: quality of voice, mouth tenderness/pain

Leukoplakia ranges from slightly raised, white, translucent areas to dense, white, opaque plaques, with or without adjacent ulceration

Mucosal erythroplasia is red, inflammatory, or shows erythroplastic mucosal changes. It appears smooth, granular, and minimally elevated, with or without leukoplakia, and it persists more than 14 days.

Erythroplakia may mimic inflammatory lesions, but it can be differentiated by failure of the affected area to blanch with light pressure. Erythroplakia is a malignant change seen as a red, velvety, plaque-like lesion 

Other oral lesions appear black, blue, or brown.

Approximately 90% of cancers are squamous cell carcinomas, and most occur in sites accessible by clinical examination: Tongue, oropharynx (soft palate, lingual aspect of retromolar trigone, anterior tonsillar pillar), and floor of mouth.

Cancer of the lip is a lesion that fails to heal.

s/s of cancer of the tongue are swelling, ulceration, areas of tenderness or bleeding, abnormal texture, limited movement.

Palpate mouth for masses. Try to remove or scrape patches.

Diagnostic Tests: 

Staining of oral lesion with toluidine blue: Lesion stains dark blue after rinsing with acetic acid. Normal tissue does not absorb the stain.

Perform chest radiography to rule out metastasis.

Consider CT, MRI, or bone scan to rule out metastasis.

Dxs: Oral leukoplakia, Pulpitis, Periapical abscess, Gingivitis, Periodontitis, Lichen planus, Oral candidiasis, Discoid lupus, Pemphigus vulgaris

General interventions

1.If oral cancer is suspected, refer to a physician or an otolaryngologist/dentist for evaluation.

2. Suspicious lesions should be biopsied.

Follow-Up

If immediate biopsy is not indicated, ask the patient to return for reevaluation in 2 weeks, after eliminating irritants and noxious agents.

Consultation/Referral: otolaryngologist and/or a dentist for immediate biopsy for deeply ulcerative or fungating lesions

Individual Considerations

Adults: ages 20 and 40 years undergo an oral cancer screening every 3 years

Oral screening should be considered annually regardless of age who use tobacco and/or alcohol and those older than 40

PHARYNGITIS:INFLAMED PHARYNX & LYMPH 

Types:

Viral agents include coxsackievirus, enteric cytopathic human orphan (ECHO) viruses, and Epstein–Barr virus.

Bacterial agents include Group A beta-hemolytic Streptococcus, Neisseria gonorrhoeae, and Corynebacterium diphtheriae.

The fungal source is Candida albicans.

Atypical agents include Mycoplasma pneumoniae and Chlamydia trachomatis (rare).

Noninfectious causes include allergic rhinitis, post nasal drip, mouth breathing, and trauma.

Predisposing Factors:smoking, allergies, URIs, drugs (antibiotics and immunosuppressants)

CC: Sore and/or scratchy throat, Fever, Headache, Malaise, Oral vesicles, Exudate on throat or “beefy” red throat without exudate, Lymphadenopathy, Fatigue, Dysphasia, Abdominal pain, vomiting

MAIN CONCERN: GROUP A BETA HEMOLYTIC STREPTOCOCCUS (GAS)!

GAS(sudden onset of fever w. Malaise, HA, painful swallowing, hoarseness RARE, petechiae on hard palate)

4 centor criteria: fever>100.4F, no cough, tender ant. Cervical adenopathy, pharyngotonsillar exudate

IF ALL 4 PRESENT, TX FOR GAS REGARDLESS OF LAB RESULTS

IF 3 PRESENT-RAPID ANTIGEN DETECTION TEST(RADT) W.O. REFLEX THROAT CULTURE SENSITIVITY>90%

HIGH RISK ADULTS SHOULD HAVE THROAT CULT. EVEN IF RADT IS NEG.

IF 1 PRESENT GAS UNLIKELY

No coryza(inflammation of nasal mm, watery eyes) 

TX: 1st line Penicillin V Potassium or Amoxacillin

Child-250mg 2-3xs/d. X 10d.

adolescents/adults-(1G./d)-500mg BID or 250mg QID x 10D.

Child-Amoxicillin 50mg/kg/d(1G/d. max) x 10D.

PCN G benzathine: <27kg 600,000U IM, > 27kg =1,200,000U IM

PCN allergy: Cephalexin(20mg/kg BID (500mg max dose) x 10D

    Avoid cephalosporins in severe pcn allergy

Recurrent:Clindamycin, PCN and Rifampin, Amoxicillin-clavulanic, Benzathine PCN IM plus oral rifampin

F/U-3-4 days, re-culture after tx

GAS LEFT UNTREATED CAN CAUSE RHEUMATIC AND SCARLET FEVER

Gonorrhea- Ceftriaxone 500mg-1g IV,IM

 Child 50-75mg/kg IM

M.Pneumoniae/C. trachomatis -Erythromycin 250mg 3-4xs/D. X 10D

Candidiasis in immunocompromised- Nystatin (suspension), swish and swallow QID/ Clotrimazole troche 10mg TID

Inspect skin for rashes.

-Pastia’s lines are petechiae present in a linear pattern along major skin folds in axillae and antecubital fossa that are seen with Group A Streptococcus.

-Erythema marginatum, caused by Group A Streptococcus, is an evanescent, nonpruritic, pink rash mainly on the trunk and extremities.

Diagnostic Tests

Rapid strep test; if negative, then perform throat culture and sensitivity. Throat culture and sensitivity are the gold standard for diagnosis.

General interventions- Patients with a history of rheumatic fever and those who have a household member with a documented Group A streptococcal infection need immediate treatment without prior testing.

Pharmaceutical therapy:

Drug of choice: Prescribe one of the following penicillins for bacterial pharyngitis. Penicillin V potassium (Pen-Vee-K). Children: 250 mg orally two to three times daily for 10 days. Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days

-Children: Amoxicillin 50 mg/kg/d once daily for 10 days (maximum 1,000 mg); alternative, 25 mg/kg (max = 500 mg) twice daily for 10 days

-If the patient is allergic to penicillin:

a.Cephalexin, oral: 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days

b.Cefadroxil, oral: 30 mg/kg once daily (max 1 g) for 10 days

-Recurrent bacterial pharyngitis

Clindamycin: 20 to 30 mg/kg/d in three doses (max 300 mg/dose) for 10 days

Penicillin and rifampin: Penicillin V: 50 mg/kg/d in four doses for 10 days (max 2,000 mg/d); rifampin: 20 mg/kg/d in one dose for last 4 days of treatment (max 600 mg/d)

Amoxicillin-clavulanic acid: 40 mg amoxicillin/kg/d in three doses (max 2,000 mg amoxicillin/d) for 10 days

Stomatitis, Minor Recurrent Aphthous Stomatitis

tender, round, discrete, oval, shallow, 1- to 5-mm ulcers in the oral cavity

ulcers are gray white or yellow, on non keratinized skin and surrounded by erythematous halos

They typically involve the labial and buccal mucosa and tongue, and adjacent tissue appears healthy.

Major recurrent aphthous stomatitis (RAS) has larger, deeper ulcers; lasts a longer period of time; usually recurs up to 4xs/yr and frequently leaves scars. 

It can cause significant dysphagia.

CC: Painful sore in mouth, Burning sensation in mouth for 24-48 hours before lesions

Physical Examination: palms and soles, for lesions; indicates hand, foot, and mouth disease

Pharmaceutical therapy

Mouthwash made of diphenhydramine (Benadryl), with Kaopectate, or Maalox or sucralfate, and viscous lidocaine three to four times a day.

Leave out lidocaine when using in children. Tell the patient not to swallow medication.

Sucralfate (Carafate) suspension 1 teaspoon four times a day may be used to swish in mouth and spit out for oral comfort.

Glucocorticoid gel, such as fluocinonide gel (Lidex), 0.05% two to four times a day, one of which is always at bedtime.

Any lesion lasting longer than 3 weeks should be evaluated by a dentist or oral surgeon to rule out cancer.

Individual Considerations

Preg. and peds: Avoid use of fluocinonide and triamcinolone acetonide (Kenalog)

Thrush: is a fungal infection of the oral cavity and/or the pharynx caused by Candida.

Thrush is an overgrowth of yeast cells, Candida albicans, which leads to desquamation of the epithelial cells, creating a pseudomembrane over the normal oral mucosa.

PFs: Children:Endocrine disorders (thyroid disease, diabetes mellitus, and Addison’s disease)

CC: .Irritability in infants, Refusal to eat in infants

Diagnostic Tests- If uncertain of diagnosis, swab lesion for KOH testing.

General interventions: If breastfeeding, instruct the mother to clean breasts and nipples well with warm water between feedings. Consider prescribing antifungal cream to be applied to breasts; this should be washed off before feedings. If bottle feeding, boil all bottles, nipples, and pacifiers to kill the organism. Removal of large plaques with a moistened cotton-tipped applicator and/or small, moist gauze pad before inserting medication in mouth. If thrush is recurrent or resistant, consider checking the mother for candidal vaginitis. For adults, instruct the patient/family on proper use and cleaning/rinsing of inhalers/dentures to prevent recurrence of thrush.

Pharmaceutical therapy:

Oral candidiasis: Nystatin (Mycostatin) oral suspension 1 mL four times a day for 1 week. Place medication in front of mouth on each side. Rub directly on plaques with a cotton swab. Adults: Pastilles: 200,000- unit lozenge four times a day for 14 days, or swish-and-swallow 500,000 units four times a day for 14 days or two 500,000-unit tablets three times daily for 14 days.

-Clotrimazole troche (Mycelex): 10 mg five times daily for 14 days; monitor for side effects.

-Fluconazole: Adults: 200 mg × 1, then 100 mg daily for 5 to 7 days. Children: 5 mg/kg by mouth every day for 5 days or 6 to 12 mg/kg on first day, then 3 to 6 mg/kg for 10 days.

Respiratory

c/o cough:

ARBs and ACE Inhibitors may cause cough during any time of tx

child: check for foreign body 

Asthma (2nd leading cause of cough): defined by airway inflammation, intermittent airflow obstruction secondary to increased smooth muscle tone and bronchial hyperresponsiveness. Episodes are associated with widespread, variable, often reversible airflow obstruction and bronchial hyperresponsiveness when airways are exposed to various stimuli or triggers.

Step 1—Mild intermittent: Symptoms less than or equal to two per week; asymptomatic with normal peak expiratory flow rate (PEFR) between attacks; nighttime symptoms less than or equal to two per month; PEFR greater than 80% is predicted with a variability of less than 20%.

Step 2—Mild persistent: Symptoms greater than two per week but less than one per day; exacerbations may affect activity; nighttime symptoms greater than two per month; PEFR greater than or equal to 80% is predicted with variability of 20% to 30%.

Step 3—Moderate persistent: Daily symptoms require beta 2 agonist use; attacks affect activity; exacerbations greater than or equal to two per week; nighttime symptoms greater than one per week; PEFRs between 60% and 80% with a variability greater than 30%.

Step 4—Severe persistent: Continuous symptoms with limited physical activity; frequent exacerbations; frequent nighttime symptoms; PEFR less than or equal to 60% is predicted with greater than 30% variability.

Pathogenesis: progresses to airway hyperresponsiveness, bronchoconstriction, airway wall edema, chronic mucus plug formation, and chronic airway remodeling.

General interventions:

-Use of a SABA more than twice a week for symptom relief indicates that the patient has inadequate asthma control and needs an inhaled corticosteroid (ICS) as controller therapy.

Pharmaceutical therapy: The following treatments are recommended for children aged 5 years and older and for adults:

Step 1: Mild: Use SABAs as rescue medication. up to four times a day to treat exacerbations. Alternative medications include cromolyn, nedocromil, leukotriene modifier, or theophylline.

Step 2: Mild to moderate: Low-dose ICSs are used daily as a long-term preventive medication. Only budesonide inhalation suspension is approved(FDA) for use in infants and children younger than 4 years. Alternative medications include an ICS plus either a leukotriene modifier/Theophylline.

Step 3: Moderate: Consider referral to asthma specialist. Use low-dose ICS plus a long-acting beta 2 agonist (LABA) or a medium-dose ICS. Use ICS plus either a leukotriene modifier or theophylline or zileuton.

Step 4: Moderate to severe: Medium- to high-dose ICS plus either a LABA or Montelukast. Medium-dose ICS plus either a leukotriene modifier or theophylline. Second alternative: Medium-dose ICS plus either leukotriene modifier, theophylline, or zileuton.

Step 5: Severe: High-dose ICS plus LABA and consider omalizumab for patients with allergies.

Step 6: Severe: High-dose ICS plus LABA plus oral CS and consider omalizumab for patients who have allergies.

LABA, two inhalations are effective for 10 to 12 hours.

Triggers: allergens viral infections of upper airways, meds(BB, ACEI, ASA, Cyclooxygenase (COX) inhib., exercise, GERD)

Hx: Atopy: IgE response, allergies, asthma

PE: wheezing, chest tightness, night/early morning, breathlessness 

Dx: Spirometry gold standard

QUICK RELIEF: ALL PATIENTS (SABA, Inhaled Anticholinergics, Systemic Corticosteroids

Peak flow meter zones:

Green- no symptoms, PEF 80-100% of personal best

Regular meds

Yellow- caution symptoms present PEF 50-80%

Regular and rescue meds

Red- IMMEDIATE MEDICAL ATTENTION PEF <50% of personal best

Rescue meds and ER

Bronchiolitis (Child): narrowing and inflammation of the bronchioles, causing wheezing and mild to severe respiratory distress. Infants are affected most often because of their small airways and insufficient collateral ventilation. It is one of the most common causes of acute hospitalizations in infants, especially in the fall and winter. A small decrease in a bronchioles already small airway will have a fourfold increase in airway resistance and accounts for this pathologic manifestation in this age group. The average length of illness with bronchiolitis is 12 days.

-Respiratory infection is seen in one third of children younger than 12 months, with 1 in 10 requiring hospitalization.

Pathogenesis: obstruction of bronchioles from inflammation, edema, and debris, leading to hyperinflation of the lungs, increased airway resistance, atelectasis, and ventilation–perfusion mismatching. Respiratory syncytial virus (RSV) is the most common cause (50%–80%) of bronchiolitis. Human metapneumovirus (HMPV) is the second most common cause (3%–19%). Other causes include parainfluenza virus, adenovirus, influenza Chlamydia pneumoniae, Mycoplasma pneumoniae, and human bocavirus (HBoV).

Lungs. On examination there are fine inspiratory crackles and/or high-pitched expiratory wheezes. A prolonged expiration phase is seen with bronchiolitis.

Diagnostic Tests: Diagnosis is made based on age and seasonal occurrence, tachypnea, and the presence of profuse coryza and fine rales, wheezes, or both on auscultation. Viral isolation from nasopharyngeal secretions or rapid antigen detection (enzyme-linked immunosorbent assay [ELISA], immunofluorescence) for RSV can confirm diagnosis.

General interventions: Use a humidifier in the patient’s bedroom. Clear stuffy nose with saline solution drops and suction out nares with bulb syringe. Infants should not be exposed to secondhand smoking. Monitor respiratory pattern. Use good hygiene practices—handwashing. Encourage fluids, such as juice and water. Dilute juice for younger infants. Offer small, frequent feedings. Breastfeeding should continue.

Medical/surgical management: Patients may only require supportive care. Patients with respiratory distress require hospitalization. Hypoxemic patients need oxygen therapy and possibly mechanical ventilation.

Pharmaceutical therapy: Bronchodilators should not be routinely used. They do not improve the duration of illness or lessen hospitalization. Corticosteroids should not be routinely used. They do not improve the duration of illness or lessen hospitalization. Use of the montelukast (Singulair) has not proven beneficial in resolution of symptoms.

Acute Bronchitis: inflammation of the tracheobronchial tree. Bronchitis is nearly always self-limited in the otherwise healthy individual. Generally, the clinical course of acute bronchitis lasts 10 to 14 days. The cause is usually infectious, but allergens and irritants may also produce a similar clinical profile

Pathogenesis: Most attacks are caused by viral agents, such as adenovirus, influenza, parainfluenza viruses, and respiratory syncytial virus (RSV). Bacterial causes include Bordetella pertussis, Mycobacterium tuberculosis, Corynebacterium diphtheriae, and Mycoplasma pneumoniae. B. pertussis should be considered in children who are incompletely vaccinated.

CC: The most common symptom initially is a dry, hacking, or raspy-sounding cough. The cough then loosens and becomes 

In response to child safety concerns, the American Academy of Pediatrics states that cough and cold medications should not be used for children younger than 6 years.

Bronchitis(leading cause of cough)

Mucus developed, tube becomes inflamed, constricted, mostly viral

FEW SYSTEMIC SYMPTOMS 

PE: Rhonchi, clear with cough

Dx: if need to exclude PNA CXR (dullness to percussion, diminished breath sounds, rales, egophony)

Tx: Acetaminophen(fever, malaise), Expectorants(Guaifenesin w. dextromethorphan), Albuterol for those with wheezes, rhonchi, or hx of bronchoconstriction 

If symptoms persist after 2 weeks consider bacterial cause and start ATBs: Erythromycin, Clarithromycin, Azithromycin

Chronic Bronchitis: excessive mucus secretion with chronic or recurrent productive cough occurring three successive months a year for 2 consecutive years. Others limit the definition to a productive cough that lasts more than 2 weeks despite therapy. Patients with chronic bronchitis have more mucus than normal because of either increased production or decreased clearance.

Pathogenesis: Mucociliary clearance is delayed because of excess mucus production and loss of ciliated cells, leading to a productive cough. This is usually secondary to the number of years of cigarette smoke-induced damage. In children, chronic bronchitis follows either an endogenous response to an acute airway injury or continuous exposure to noxious environmental agents such as allergens or irritants. 

-Bacteria most often implicated are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and Moraxella catarrhalis. The most common causes of chronic bronchitis in the pediatric population include viral infections such as adenovirus, respiratory syncytial virus (RSV), rhinovirus, and human bocavirus (HBoV).

General interventions: Rest during early phase of illness. Encourage smoking cessation and staying away from secondhand smoke. Increase fluids. Eat nutritious food.

Pharmaceutical therapy: Bronchodilators should be considered for bronchospasm. Albuterol sulfate (Proventil, Ventolin, ProAir). Adults: Metered-dose inhaler (MDI)-2 actuations (90 mcg/actuation) inhaled every 4 to 6 hours. Pediatrics: MDI or nebulizer. Younger than 1 year: 0.05 to 0.15 mg/kg dose every 4 to 6 hours. 1 to 5 years old: 1.25 to 2.5 mg/dose every 4 to 6 hours. 5 to 12 years old: 2.5 mg/dose every 4 to 6 hours. Older than 12 years: 2.5 to 5 mg/dose every 6 hours. Analgesics and antipyretics are used to control fever, myalgias, and arthralgias.

-Consider oral steroids to decrease inflammation. Adults: 5 to 60 mg/d by mouth. Pediatrics: 1 to 2 mg/kg by mouth daily or in twice a day divided dosing; do not exceed 80 mg/d. Tapering steroids is not necessary with steroid courses of 10 days’ duration or less. 

-Inhaled corticosteroid (ICS) may be effective. Beclomethasone (QVAR) is available as an MDI that delivers 40 or 80 mcg/actuation. Adults MDI: 40 to 80 mcg inhaled by mouth twice a day, not to exceed 320 mcg twice a day. Pediatrics MDI: 40 mcg inhaled by mouth twice a day, not to exceed 80 mcg twice a day. Fluticasone (Flovent HFA, Flovent Diskus). Available as MDI (44-mcg, 110-mcg, or 220-mcg per actuation) and diskus powder for inhalation (50 mcg, 100 mcg, or 250 mcg per actuation). Adults MDI: 88 mcg inhaled by mouth twice a day, dosage not to exceed 440 mcg twice a day. Diskus: 100 mcg inhaled by mouth twice a day, dosage not to exceed 500 mcg twice a day. Pediatrics MDI: Ages 4 to 11 years: 88 mcg inhaled by mouth twice a day; older than 11 years administer as adults. Diskus: Ages 4 to 11 years: 50 mcg inhaled by mouth twice a day; older than 11 years administer as adults.

Antibiotics for bacterial infection: Erythromycin (EES, E-Mycin, Ery-Tab). Adults: 250 to 500 mg by mouth four times a day or 333 mg by mouth three times daily. Pediatrics: 30 to 50 mg/kg/d by mouth divided four times a day; do not exceed 2 g/d. Clarithromycin (Biaxin). Adults: 250 to 500 mg by mouth twice a day. Pediatrics: 7.5 mg/kg by mouth twice a day

Azithromycin (Zithromax). Adults: 500 mg by mouth on day 1, then 250 mg by mouth on days 2 to 5. Pediatrics: 10 mg/kg/d by mouth on day 1, then 5 mg/kg on days 2 to 5; do not exceed adult dose. Amoxicillin-clavuanic acid (Augmentin). Adult: 250 to 500 mg by mouth every 8 hours. Pediatrics, Younger than 3 months: 30 mg/kg/d by mouth divided to every 12 hours. 3 months or older: 40 to 80 mg/kg/d by mouth divided to every 12 hours

Over-the-counter cold and cough products: The American Academy of Pediatrics do not recommend use of cold and cough products for use in children 6 years of age or younger. These products have been associated with serious adverse effects.

Chronic Obstructive Pulmonary Disease (COPD): progressive, chronic, expiratory airway obstruction due to chronic bronchitis or emphysema. The relief of bronchoconstriction due to inflammation has some reversibility. Emphysema is an abnormal, permanent enlargement (hyperinflation) and destruction of the alveoli air sacs, as well as the destruction of the elastic recoil. Many patients have both types of air-restriction symptoms of chronic bronchitis and emphysematous destruction leading to COPD. When asthmatic patients do not have complete reversible airflow obstruction, they are considered to have COPD.

Irreversible airflow obstruction is a key factor in the patient’s disability. The goal of COPD management is to improve daily quality of life (QOL) and the recurrence of exacerbations. Smoking cessation continues to be the most important therapeutic intervention.

Stage I—Mild obstruction: Forced expiratory volume in 1 second (FEV1) greater than 80% of predicted value, some sputum, and chronic cough

Stage II—Moderate obstruction: FEV1 between 50% and 80% of predicted value, shortness of breath (SOB) on exertion, and chronic symptoms

Stage III—Severe obstruction: FEV1 between 30% and 50% of predicted value, dyspnea, reduced exercise tolerance, and exacerbations affecting QOL

Stage IV—Very severe obstruction chronic respiratory failure: FEV1 less than 30% of predicted value or moderate obstruction FEV1 less than 50% of the predicted value and chronic respiratory failure.

It is still an underrecognized diagnosis although it is the third leading cause of death in the United States. 

Diagnostic Tests: Spirometry is the gold standard for diagnosing COPD. Pulmonary function tests (PFTs) are used to diagnose, determine severity, and follow the disease progression of COPD. Spirometry before and after using a bronchodilator. FEV1 is used as an index to airflow obstruction and evaluates the prognosis in emphysema.

Pharmaceutical therapy: Treatment guidelines are based on spirometry.

.

Stage I (mild FEV1 80% or greater)—The patient may be unaware that he or she has COPD. Give influenza vaccine and use short-acting beta 2 agonist bronchodilators as needed.

Stage II (moderate FEV1 between 50% and 79%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilators, as needed, plus long-acting bronchodilator(s) plus cardiopulmonary rehabilitation.

Stage III (severe FEV1 between 30% and 49%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilators as needed, plus long-acting bronchodilator(s), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid steroids if patient has repeated exacerbations.

Stage IV (very severe FEV1 less than 30%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilator, as needed, plus long-acting bronchodilator(s), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid steroids if repeated exacerbations plus long-term oxygen therapy (if the patient meets criteria for O2). 

-Consider phosphodiesterase-4 (PDE-4) inhibitors (Roflumilast or Cilomilast) as needed when necessary. Mucolytic agents have small benefits and are not usually recommended. Antitussives are not recommended. Long-term oxygen has been shown to increase survival in patients with severe resting hypoxemia. 

Common Cold/Upper Respiratory Infection: a self-limiting acute respiratory tract infection (ARTI) resulting from viral infection of the upper respiratory tract. It is also called acute nasopharyngitis. ARTI is characterized by mild coryzal symptoms, rhinorrhea, nasal obstruction, and sneezing.

Upper respiratory tract infections are among the most frequent reasons for office visits. Most children have six to eight colds a year; most adults have two to four.

Pathogenesis: Over 25% to 80% of ARTIs are caused by a rhinovirus (greater than 100 antigenic serotypes). Other viral agents include coronavirus (10%–20%), RSV, adenoviruses (5%), influenza viruses (10%–15%), and parainfluenza viruses.

Pharmaceutical therapy:

Health care providers should refrain from recommending cough suppressants and OTC cough medicines for young children because of associated morbidity and mortality. The American Academy of Pediatrics reminds consumers to avoid the use of OTC cough and cold products in children younger than 4 years.

Topical decongestants for rhinorrhea and nasal congestion Adults and children older than 6 years, pseudoephedrine (Afrin) nasal spray 0.05% two to three sprays per nostril twice daily, or phenylephrine (Neo-Synephrine) nasal spray 0.25% to 1% two to three sprays per nostril every 4 hours as needed. Using decongestant-type nasal sprays longer than 2 to 3 days can result in rebound congestion and abuse of the drug. Children younger than 6 years, saline nasal drops 2 to 3 drops per nostril two to three times daily. Oral decongestants are available such as pseudoephedrine (Sudafed). Adults: Pseudoephedrine (Sudafed) 60 mg every 4 to 6 hours or 120 mg every 12 hours Children 2 to 6 years: Pseudoephedrine (Sudafed) liquid 2.5 mL every 4 to 6 hours. Children older than 6 years: Pseudoephedrine (Sudafed) liquid 5 mL every 4 to 6 hours, or pseudoephedrine (Sudafed) 30 mg every 4 to 6 hours. Analgesics, such as acetaminophen (Tylenol) and ibuprofen (Advil), may be used for headache relief. Cough suppressants, if necessary: Dextromethorphan (Benylin DM, Robitussin, Vicks Formula 44 pediatric formula).

-Parents should return to the doctor’s office if their child’s fever exceeds 102°F, if respiratory symptoms increase, or if symptoms do not resolve in 10 to 14 days.

Cough: mechanism that clears the airway of secretions and inhaled particles. The act of coughing has the potential to traumatize the upper airway (e.g., vocal cords). A chronic cough is one that lasts longer than 8 weeks. Because coughing can be an affective behavior, psychological issues must be considered as a cause or effect of coughing. Pertussis affects infants and young children; however, the incidence is increasing in adults secondary to the lack of booster vaccination.

Pathogenesis: Stimulation of mucosal neural receptors in the nasopharynx, ears, larynx, trachea, and bronchi can produce a cough, as can acute inflammation and/or irritation of the respiratory tract. Cough is a reflex response that is mediated by the medulla but is subject to voluntary control. There is clear evidence that vagal afferent nerves regulate involuntary coughing.

-Nocturnal cough may be caused by chronic interstitial pulmonary edema and may signal left-sided heart failure. Cough caused by asthma is also worse at night. Morning cough with sputum suggests bronchitis.

-Inquire about the cough’s characteristics. Dry, irritative cough suggests viral respiratory infection. Severe or changing cough should be evaluated for bronchogenic carcinoma. Rusty-colored sputum suggests bacterial pneumonia. Green or very purulent sputum is due to degeneration of white cells. HIV cough produces purulent sputum.

-Inquire whether the cough is associated with eating and choking episodes. Wheezing or stridor with coughing may indicate a foreign body or aspiration.

-Ask whether the cough is associated with postnasal drip, which produces a chronic cough, clear sputum, edematous nasal mucosa, and a “cobblestoned” pharyngeal mucosa.

-Find out whether if the cough is associated with heartburn or a sour taste in the mouth, indicating GERD.

-Cough from asthma can be triggered or exacerbated by exposure to environmental irritants, allergens, cold, or exercise.

-Cough related to ACE inhibitors usually subsides within 2 weeks, but the median time is up to 26 days.

General intervention: If sputum is purulent, obtain a sample for examination.

Pharmaceutical therapy: Therapy depends on various acute inflammatory and chronic irritating processes and on the cause of the cough.  

-When a cough lasts more than 2 weeks without another apparent cause and it is accompanied by paroxysms of coughing, post-tussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a Bordetella pertussis infection should be made unless another diagnosis is proven.

Croup (Viral): acute inflammatory disease of the larynx, also called laryngotracheobronchitis. Croup is the most common cause of stridor in febrile children. The uncomplicated disease usually wanes in 3 to 5 days but may persist up to 10 days. Croup is most often self-limited, but occasionally is severe and rarely fatal. Lethargy, cyanosis, and decreasing retractions are indications of impending respiratory failure.

Pathogenesis: Parainfluenza viruses types 1, 2, and 3 cause about 80% of croup. The initial port of entry is the nose and nasopharynx. Other viral causes include enterovirus and rhinovirus. 

General interventions: Treatment is supportive for patients without stridor at rest. Stress rest and minimal activity. Hot steam should be avoided due to the potential of scalding. Give plenty of fluids.

Medical/surgical management: If pulse oximetry shows desaturation, administer oxygen and monitor carefully.

Pharmaceutical therapy: Acetaminophen (Tylenol) 5 to 15 mg/kg/dose for fever. In moderate to severe cases requiring hospitalization: Nebulized racemic epinephrine (asthmanefrin solution) 0.5 mL of 2.25% solution in 2.5 mL sterile water may relieve airway obstruction up to 2 hours. Treatment may be repeated three times. Steroid use is controversial but may be considered if the preceding therapy is ineffective. Steroids are used to decrease subglottic edema by suppressing the local inflammatory process. Decadron (dexamethasone) is the drug of choice. Pediatric dosing is 0.6 mg/kg in single dose orally or intramuscularly. Budesonide (Pulmicort Respules inhalation suspension) has been shown to be equivalent to oral dexamethasone. Pediatric dosing is 2 mg (2 mL of suspension) nebulized. Prednisone (deltasone) pediatric dosing is 1 to 2 mg/kg/d orally daily or in a divided dose twice a day for 5 days.

-Most children improve within a few days. Virus is most contagious during the first few days of fever. Children may return to daycare or school when temperature is normal and they feel better, even if cough lingers.

Emphysema: abnormal dilation and destruction of alveolar ducts and air spaces distal to the terminal bronchioles. Lung function slowly deteriorates over many years before the illness develops. Emphysema is one of the chronic obstructive pulmonary diseases (COPDs)—a term that refers to conditions characterized by continued increased resistance to expiratory airflow. 

There are three morphological types of emphysema.

Centriacinar emphysema, is associated with long-term smoking and primarily involves the upper half of the lungs.

Panacinar emphysema is predominant in the lower half of the lungs. Panacinar emphysema is observed in patients with alpha 1-antitrypsin (AAT) deficiency.

Paraseptal emphysema involves the distal airway.

Emphysema typically occurs in people older than age 50 years, with peak occurrence between ages 65 and 75 years.

Medical management: Supplemental oxygen therapy. Develop a smoking-cessation plan: Assess readiness to quit. Nicotine chewing gum produces better quit rates than counseling alone. Transdermal nicotine patches have a long-term success rate of 22% to 42%. The use of an antidepressant, such as Zyban (150 mg twice a day), has been shown to be effective for smoking cessation and may be used in combination with nicotine replacement therapy. Chantix is a partial agonist selective for alpha 4, beta 2 nicotinic acetylcholine receptors.

Pharmaceutical therapy: Drugs of choice are inhaled beta 2 agonists. Beta 2 agonists are used primarily for relief of symptoms and, in stable patients, have an additive effect when used with an anticholinergic agent (e.g., ipratropium bromide). A spacer/chamber device should be used to improve delivery and reduce adverse effects. The following inhaled preparations have rapid action and fewer cardiac side effects:

-Ipratropium bromide (Atrovent) has bronchodilatory activity with minimum side effects.

-Metered-dose inhaler (MDI): Two to four puffs every 4 to 6 hours

-Nebulizer: 250 mcg diluted with 2.5 mL normal saline every 4 to 6 hours

-Tiotropium (Spiriva) is a bronchodilator similar to ipratropium. Available in a capsule form containing a dry powder or oral inhalation via a HandiHaler inhalation device. Adults: 1 capsule (18 mcg) inhaled every day via the inhaler device

-Metaproterenol sulfate (Alupent) is available as a liquid for nebulizer and MDI.

-MDI: Two puffs every 3 to 4 hours

-Nebulizer: 0.2 to 0.3 mL of 5% solution diluted to 2.5 mL with normal saline three to four times a day

-Albuterol (Proventil, Ventolin) is available as a liquid for nebulizer, MDI, and dry powder inhaler (DPI).

-MDI: One to four puffs every 3 to 4 hours

-Nebulizer: 0.2 to 0.3 mL of 5% solution diluted to 2.5 mL with normal saline three to four times a day

-If improvement is not satisfactory or tachyphylaxis occurs, give theophylline. Theophylline improves respiratory muscle function and stimulates the respiratory center as well as bronchodilators. Initial dose: 10 mg/kg/daily divided in oral doses every 8 to 12 hours. Maintenance: 10 mg/kg/daily divided in oral doses every day or twice a day; adjust doses in 25% increments to maintain serum theophylline level of 5 to 15 mcg/mL—not to exceed 800 mg/d. 

-Oral steroids should be used to treat outpatients with acute exacerbations. Corticosteroids reduce mucosal edema, inhibit prostaglandins that cause bronchoconstriction, and increase responsiveness to bronchodilators. Taper the dose as soon as bronchospasm is controlled. 

-Trivalent influenza vaccine is essential for all COPD patients. Give the patient the vaccine each October, at least 6 weeks before onset of flu season. Pneumococcal vaccine is essential for COPD patients. Give as a single intramuscular injection of 0.5 mL.

-AAT is needed for significant antitrypsin deficiency (less than 80 mg/dL). Patients get weekly or monthly infusions. Consult with a physician before therapy. A history of smoking rules out candidacy.

Obstructive Sleep Apnea (OSA): periodic reduction (hypopnea) or cessation (apnea) of breathing due to a narrowing or occlusion of the upper airway during sleep. OSA has been linked to traffic accidents, cardiac diseases, stroke, diabetes, and visceral obesity. OSA is also associated with nocturnal cardiac arrhythmias and chronic and acute cardiac events, and is a risk factor for strokes. OSA worsens in the supine sleeping position. The following are diagnostic criteria for OSA if either of these two conditions exists:

The presence of 15 or more apneas, hypopneas, or respiratory effort-related arousals per hour of sleep in an asymptomatic patient. More than 75% of the apneas and hypopneas must be obstructive.

Five or more obstructive apneas, obstructive hypopneas, or respiratory effort-related arousals per hour of sleep in a patient with symptoms or signs of disturbed sleep. More than 75% of the apneas or hypopneas must be obstructive.

Pathogenesis: Increased tissue thickness of the structures of the tongue and soft tissues in the pharyngeal cavity, which decreases the passageway for air to the trachea, is thought to be the mechanism of OSA. During the night, the muscles of the oropharynx relax, which result in the relative obstruction of the airway. 

General interventions: Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) is the mainstay of treatment for moderate to severe OSA. Even a modest weight loss of 10% to 20% has been associated with an improvement. Oral appliances (OAs): Require a thorough dental examination, Custom-made OAs may improve airway patency during sleep by enlarging the upper airway and/or by decreasing the upper airway collapse. Mandibular repositioning appliances (MRAs) cover the upper and lower teeth and hold the mandible in an advance position. Tongue retaining devices (TRDs) hold the tongue in a forward position without mandibular repositioning.

Surgical treatment: Tracheostomy can eliminate OSA but not central hypoventilation syndromes. This procedure should be considered only when other options have failed or when it is considered necessary by clinical urgency. Maxillomandibular advancement (MMA) is indicated when the patient cannot tolerate/refuses CPAP and an OA is not appropriate/effective.

PNA (CAP, HAP, HCAP)Inflammation and consolidation of lung tissue

s/s: fever, chills, sweats, deep breath causes pain, crackles, tachy, course

PE: tachypnea #1 indicator of PNA in children/elderly, spo2 <92 indicator of severity and need for oxy

CURB-65: confusion, urea, respiratory rate, bp, age

Dx: GOLD STANDARD- presence of infiltrate on CXR w/ supportive clinical features 

Tx: Bacterial 7-10d. ATBs 

Macrolide first line for healthy adults(E.g. Azithromycin)

Amoxicillin first line in peds

Avoid cough suppressants

Tx: Viral, consider antivirals in compromised pts. #1 for Influenza A: Zanamivir if started within 24-48 hours of onset of fever and symptoms. 

Respiratory Syncytial Virus Bronchiolitis: most frequent cause of viral respiratory tract infection in infants. Most infants develop upper respiratory tract symptoms; 20% to 30% develop lower respiratory tract disease with their first infection. Infection with RSV may produce minimal respiratory symptoms. Most previously healthy infants who develop RSV bronchiolitis do not require hospitalization. Preterm infants with respiratory symptoms with lethargy, irritability, and poor feeding may require admission for treatment. There is no specific treatment for RSV infection.

The period of viral shedding usually is 3 to 8 days, but shedding may continue up to 4 weeks. The incubation period ranges from 2 to 8 days. .Full recovery from RSV illness occurs in about 1 to 2 weeks.

Pathogenesis: RSV is an enveloped, nonsegmented, negative strand RNA virus of the Paramyxoviridae family. Two major strains (Groups A and B) have been identified, and strains of both often circulate concurrently.

Diagnostic Tests: Rapid diagnostic assay of nasopharyngeal secretions is reliable in infants and young children.

Contact precautions are recommended for the duration of RSV-associated illness among infants and young children. Adhere to appropriate hand-hygiene practices.

Pharmacological therapy: Ribavirin is an antiviral drug that may be delivered by means of aerosol, but it is reserved for severely ill children or those at high risk. The use of bronchodilators and corticosteroids is controversial, but they may be indicated for hospitalized patients. Palivizumab (Synagis) immunoprophylaxis is extremely costly and should be limited to infants at risk of hospitalization related to RSV. Adults: Palivizumab (Synagis) is not approved for adults.

Shortness 0f Breath (SOB): Dyspnea may be experienced by patients with or without respiratory disorders. SOB/dyspnea is clinically significant when it interferes with normal functioning. Dyspnea is considered chronic when it persists longer than 4 to 8 weeks. 

Pathogenesis: The sensation of SOB can involve psychological, physical, social, and environmental factors. A sensation of SOB is stimulated by chemoreceptors that respond to changes in pH and carbon dioxide. Mechanoreceptors are located in upper airways, lungs, and the chest wall. A sensation of SOB occurs with ventilation–perfusion mismatch, metabolic acidosis, increase in respiratory dead space, or stimulation of chest wall or pulmonary respiratory receptors.

General interventions: The underlying etiology of the SOB should be considered and treated. Discuss the underlying etiology of SOB with the patient and family and establish strategies to prevent further episodes of SOB. Swallowing studies should be considered for patients at risk for aspiration.

Pharmaceutical therapy: Medications should be prescribed according to the underlying etiology. 

TB(Mycobacterium tuberculosis): an infectious disease caused by mycobacteria. 

Humans are the only reservoirs for M. tuberculosis. May involve multiple organs. 60% of children and 5% of adults with primary TB are asymptomatic. When pulmonary macrophages are unable to contain the bacilli, this leads to clinically apparent infection progression of TB. 

Evaluate for TB in pts. With: FUO, failure to thrive, significant weight loss, unexplained lymphadenopathy

Morbidity occurs from TB osteomyelitis, chronic renal insufficiency, and CNS TB

Patho: Mycobacteria are non-spore forming bacilli that transfer through droplets from a host with active pulmonary TB. 2-10 wk intubation but may occur later or never

Pred. fact: steroid therapy, cancer chemo, hematologic malignancies,tumor necrosis factor-alpha (TNF-alpha) antagonists tx (TB skin test should be done before starting TNF-alpha tx)

CC: fever that increases with progression of disease, malaise, wt. Loss, chills, nights sweats, cough, occ. Hemoptysis, fatigue

Dx:tuberculin skin test,purified protein derivative testing, and sputum cultures

Tuberculin skin test using Mantoux test is the recommended method, read in 48-72 hrs.

Tx: first line agents- Isoniazid, rifampin, pyrazinamide, and Ethambutol 

F/U Q 4-8 wks

Dermatology 

Primary lesions are physical changes in the skin considered to be caused directly by the disease process. Types of primary lesions are rarely specific to a single disease entity. 1.MACULE. A macule is a change in the color of the skin.

Secondary Lesion - Modification of a primary lesion that results from traumatic injury, evolution from the primary lesion, or other external factors. Secondary lesions include scale, crust, erosion, fissure, ulceration, excoriation, or lichenification.

Primary lesions:                        

Macule: Discrete flat <1.5cm:freckle purpura--freckle, purpura                

Papule: palpable elevation <1.5cm-- Nevi, seborrhic keratosis

Patch: Large macule>1.5cm-- Pityrasis rosea, lentigo

Nodule: Elevation of skin >1cm. -- Nevi, basal cell carcinoma

Plaque: Raised lesion, typically flat, scaling common. -- Psoriasis, mycosis fungoides

Wheal: Transient pink swelling of skin, central clearing-- urticaria

Tumor: Large papule or nodule >1cm. -- BCC or SCC

Pustule: raised lesion <0.5 with yellow cloudy fluid. -- Folliculitis, acne

Cyst: Semi solid lesions, various sizes. -- Sebaceous cyst

Vesicle: <0.5cm containing fluid. --herpes simplex, herpes zoster, contact dermatitis

Secondary lesions:

Crust: liquid debris that has dried on the surface of the skin.--Impetigo, herpes zoster. 

Scale: Visible fragments of the stratum corneum as it is shed from the skin. --Xerosis, ichthyosis, psoriasis. 

Lichenification: Thickening of the epidermis with accentuation of skin lines. --Contact Dermatitis. 

Erosion: loss of superficial layers of upper epidermis by wearing away as from friction or pressure. --Herpes zoster, herpes simplex, pemphigus. 

Fissure: Sharply defined linear or wedge shaped tears in epidermis.--Xerosis, angular cheilitis, severe exzema. 

Excoriation: skin abrasions due to scratching of skin. --Contact dermatitis. 

Common Shapes and Configurations of Lesions –

Annular – or circular begins in the center and spreads to the periphery (tinea corporis or ringworm) 

Confluent – lesions that run together ( hives) 

Discrete – distinct, individual lesions that remain separate (acrochordon, skin tags) 

 Gyrate – twisted, coiled spiral, snakelike lesions 

 Linear – a scratch, streak, line or stripe lesion 

Zosteriform – linear arrangement along a unilateral nerve route (herpes zoster)

Grouped – clusters of lesions (contact dermatitis) 

 Target or Iris – resembles iris of eye, concentric rings of color in lesions 

 Polycyclic – annular lesions that grown together (psoriasis)

Derm Disorders

An uncommon presentation of a common problem occurs more frequently than a common presentation of an uncommon problem

Increase skin conditions in pt.s with chronic medical condition(s)(DM, obesity)

CC: I HAVE A RASH (COULD THE RASH BE ASSOCIATED WITH LIFE-THREATENING ILLNESS?)

Hair loss, changes in moles, changes in finger or toe nails, abnormal bruising, excessive dry/oily skin?

PE: symmetrical rash(internal causes common), asymmetrical(external causes are common), scaling around hair and lymphadenopathy in tinea capitis, inspect mm (syphilis, herpes, hand, ft, mouth), perform abd. exam(detection of organomegaly may be a critical clue in dx of a systemic cause of skin dis.)

Dx: diascopy, wood light, skin scraping and potassium hydroxide prep, tzanck smear, cult., punch or excisional bx

Chloasma-irregular, brown patch on face when pregnant

Cherry Angiomas- common on trunk in adults > 30 years and usually increase in size and number with aging

Not significant, sm (1-5mm), smooth, slightly raised, bright red

Acne Vulgaris:

Def: disorder of the sebaceous glands and hair follicles of the skin. Glands become inflamed. 

Grading Acne

1-10 inflammatory lesions (open and closed comedones, few papules/pustles)= mild

11-20 inflammatory lesions with several papules and pustules = moderate

Numerous inflammatory lesions and many nodules=severe

First line therapy for mild to moderate acne (1-3 months to see visible results) 

Benzoyl Peroxide (BPO) 2.5%, 5%, 10% start low and increase. 

T-Stat (erythromycin topical solution) to dried areas twice daily (avoid eyes, nose, mouth, creases.) 

Topical Retinoids--Creams derived from Vitamin A

Desquam E (Benzyol peroxide gel)

Use at bedtime after washing face with soap and water. 

First-line therapy for moderate-resistant acne

Use of topical agents above PLUS one of the following: 

Oral tetracycline 500mg twice daily for 3-6 weeks as condition improves begin to taper ATB to 250mg twice daily for 6 weeks, then to daily or every other day. 

 Erythromycin

250mg PO four times daily after meals or... 

Topical erythromycin 2% twice daily

Minocycline 100 mg BID taper to 50 mg BID once it is effective 

 Clindamycin

Pads or gel can be applied twice daily. 

 Bactrim

Single strength twice daily. 

Good for acne when other forms have failed due to efficacy against gram - folliculitis. 

In general:    

Follow up at 6-8 weeks. 

ATB coverage should be 6-8 weeks if no improvement at that time refer to dermatology. 

Maximum ATB coverage is 12 weeks to 6 months.

Folliculitis: bacterial infection of the hair follicle. Malassezia folliculitis, also known as pityrosporum, is an inflammatory skin disorder of the hair follicle triggered by yeast. This is often confused with acne vulgaris; the defining difference is itch.

Pathogenesis: Bacterial organisms (most commonly Staphylococcus aureus) invade the follicle wall and cause an infectious process. For malassezia folliculitis, fungal organisms invade the follicle walls and cause a fungal infection that causes a pruritic rash.

Diagnostics: Culture and sensitivity to verify appropriate antibiotic coverage. Gram stain.

Potassium hydroxide (KOH)/wet prep. Fungal culture hair if fungi suspected (tinea of scalp). Skin biopsy for the diagnosis of malassezia folliculitis.

General interventions: Apply warm, moist compresses to site for comfort. If razors are used on the area, have the patient use clean, sharp razors, throw old razors away, and not share razors. Bleach bath (0.5–1 cup of bleach to 20 L water) reduces spread of Staphylococcus infection.

Pharmaceutical therapy:

Mild cases: Apply mupirocin (Bactroban) ointment to affected area three times daily until resolved.

S.aureus: Dicloxacillin (Dynapen) 250 mg by mouth four times daily for 10 to 14 days. Erythromycin 250 mg by mouth four times daily for 10 to 14 days. Cephalexin (Keflex) 500 mg by mouth for 10 to 14 days

Pseudomonas aeruginosa: Ciprofloxacin (Cipro) 500 mg by mouth twice daily for 10 days. Ofloxacin 400 mg by mouth twice daily for 10 days

Antistaphylococcal antibiotics: Cephalexin 250 to 500 mg four times a day (children:25–50 mg/kg/d given in two divided doses). Clindamycin 150 to 300 mg four times a day (children:8–16 mg/kg/d in three to four doses/d). Dicloxacillin 125 to 500 mg four times a day (children:12.5 mg/kg/d four times a day). Erythromycin 250 to 500 mg four times a day (children:30–50 mg/kg/d four times a day).

Methicillin-resistant Staphylococcus aureus (MRSA): Bactrim DS 160/800 twice a day (children: 8–10 mg/kg/d divide and give q12h). Doxycycline 100 mg twice daily for 1 day and then once a day for the remainder of the duration (children: 2.2 mg/kg twice daily for 1 day and then for the remainder of the duration once a day). Severe cases may be treated with oral antibiotics with topical permethrin every 12 hours every other night for a 6-week period or itraconazole 400 mg daily, isotretinoin 0.5 mg/kg/d for up to 4 to 5 months with ultraviolet B (UVB) light therapy.

Treatment for malessezia folliculitis is as follows: Oral antifungal medications (itraconazole, fluconazole, or ketoconazole) should be prescribed for at least 4 weeks for treatment.

Seborrheic Dermatitis: common chronic, erythematous, scaling dermatosis. Occurs in areas where there is the most active sebaceous glands such as face, scalp, body folds, and presternal region. 

Possibility that it is hormonal dependent. Currently identified as an inflammatory disorder caused by a dysfunction of sebaceous glands. 

Often no presenting complaints are found on a routine physical examination.

Diagnostic: none required. Consider fungal culture if in children and adolescents. Possible skin biopsy to rule out other conditions.

Shampooing is the foundation of treatment.

Infants: Rub petroleum jelly into scalp to soften crusts 20 to 30 minutes before shampooing. Shampoo daily with baby shampoo using a soft brush. Toddlers or adolescents: Shampoo every other day with antiseborrheic shampoo (Selsun Blue, Exsel, or Nizoral). If skin does not clear after 1 to 2 weeks of treatment, it is appropriate to use ketoconazole 2% cream.

Seborrheic blepharitis- Hot compresses plus gentle debridement with cotton-tipped applicator and baby shampoo twice a day. For secondary bacterial infection, sulfacetamide sodium 10% (ophthalmic Sodium Sulamyd). Continue treatment for several days after lesions disappear.

C.Pharmaceutical therapy

Most shampoos should be used two times per week. Those with coal tar can be used three times per week. Medicated shampoos- Coal tar (Denorex, T/Gel, Pentrax, Tegrin) shampoo, apply as directed. Salicylic acid (Ionil Plus, P and S) shampoo, apply as directed. Selenium sulfide (Exsel, Selsun Blue) shampoo, use daily. Ketoconazole 2% (Nizoral) cream, apply to affected area twice daily for 4 to 6 weeks. Combination shampoos: Coal tar and salicylic acid (T/Sal); salicylic acid and sulfur (Sebulex). These shampoos may be used one to two times a week, alternating with other shampoos during the week. Always apply corticosteroids in a thin layer only; avoid the eyes.

Topical corticosteroid lotions or solutions: Use in combination with medicated shampoo if 2 to 3 weeks of treatment with shampoo alone fails.

Adults: Scalp

Start with medium potency, for example, betamethasone valerate 0.1% lotion twice daily. If treatment is not effective in 2 weeks, increase potency, for example, fluocinonide 0.05% solution twice daily, or fluocinolone acetonide 0.01% oil 120 mL nightly with shower cap.

As dermatitis is controlled, decrease to mild potency, for example, hydrocortisone 1% to 2.5% lotion once or twice daily.

Adults: Face or groin.

Low-potency agents, for example, hydrocortisone 1% cream or desonide 0.05% cream once or twice daily. Consider lotion for eyebrows for easier application. Metronidazole 1% gel on face once or twice daily.

Recalcitrant disease- Add ketoconazole 2% cream (15, 30, or 60 g) every day. Use sulfacetamide sodium 10%, with sulfur 5%, lotion 25 g once or twice daily.

Tinea Corporis (Ringworm) - a fungal infection of the skin tissue commonly seen on the trunk, face, and extremities. Circular, erythematous, well-demarcated lesions on the skin with hypopigmentation in the center of the lesion: usually pruritic 

Tinea Cruris (jock itch) - well-demarcated scaling lesions on groin (not scrotum) and thigh: usually pruritic 

Tinea Pedis (athlete's foot)  - scaly, erythemic vesicles on feet, between toes, and in arch, with extreme pruritic 

    Pharmaceutical Therapy for corporis, pedis, and cruris- 

Use wet dressings with Burow’s solution along with one of the following:

Clotrimazole 1% (Lotrimin) cream or econazole nitrate 1% cream twice daily for 14-28 days 

Terbinafine 1% cream (Lamisil) apply once or twice daily for 1-4 weeks. * Not recommended for children 

Tinea Capitis (ringworm of the scalp) - erythema, scaling of scalp, with hair loss at site 

    Pharmaceutical Therapy - 

Adults: Griseofulvin 500mg PO daily for 4-8 weeks 

Children: Griseofulvin 10 to 20mg/kg/d for 4-8 weeks 

Ketoconazole may also be used. 

Monitor liver function tests (LFTs) at 6 weeks after starting 

Best absorbed with high fat foods! 

Tinea Unguium (nail fungus) (onychomycosis) - thickening and yellowing of toenail or fingernail, often with other fungal infections 

    Pharmaceutical Therapy - 

Itraconazole (Sporanox) 100mg, two tablets by mouth twice daily for 7 days. Repeat in 1 month and then repeat in 1 more month. 

Terbinafine 1% cream (Lamisil) 

Fingernail 250mg daily for 6 weeks 

Toenail 250mg daily for 12 weeks 

Tinea Versicolor - a fungal infection of the skin, which is chronic in nature. HYPOPIGMENTED MACULES/ patches on the skin usually seen in the upper trunk, and may spread to the extremities 

    Pharmaceutical Therapy -

Selenium sulfide 2.5% (Selsun Blue Shampoo) 

Apply to skin at bedtime and shower off in the morning. 

For 12 days, apply Selsun Blue to skin lesions, wait 30 mins and wash off 

Clotrimazole 1% twice daily for 4 weeks 

Ketoconazole (Nizoral) cream daily for 14 days or an oral pill 200mg by mouth daily for 3 days. Caution for liver toxicity! 

Impetigo: a bacterial infection of the skin, most commonly caused by Staphylococcus aureus or Streptococcus pyogenes, or both.

Pathogenesis: alteration in the skin integrity allows bacterial invasion into the epidermis, causing an infection. Small, moist vesicles ranging from red macules to honey-colored crusts or erosions occur singly or grouped together.

-Tender sores around the mouth and nose area in which the lesions continue to spread and worsen, despite over-the-counter (OTC) medication treatment.

General interventions: Crusted lesions may be removed with thorough, gentle washing with mild soap three to four times daily. Impetigo must be adequately treated and resolved to prevent postinfection complications such as the following: Poststreptococcal acute glomerulonephritis, cellulitis, ecthyma, and bacteremia. Encourage good handwashing and hygiene to reduce spreading infection.

Pharmaceutical therapy:  If few lesions are noted without involvement of face or cellulitis: Mupirocin (Bactroban) ointment—to site four times daily for 10 days. Systemic antibiotics- Children older than 3 months: Amoxicillin/clavulanate 40 mg/kg/d divided every 12 hours. Adults: Amoxicillin/clavulanate 875/125 mg every 12 hours. Children: Cephalexin 30 mg/kg/d po divided every 12 hours. Adults: Cephalexin 500 mg every 12 hours. Other effective antibiotics include cefaclor, cephradine, cefadroxil, clindamycin, and amoxicillin.

Psorasis: common benign, chronic, inflammatory skin disorder, characterized by whitish scaly patches commonly seen on the scalp, knees, and elbows.

Pathogenesis: Etiology is unknown; this is a multifactorial disease with a definite genetic component. Hyperproliferation of the epidermis and inflammation of the epidermis and dermis are seen, with epidermal transit time rapidly increased (six- to ninefold). A T-lymphocyte-mediated dermal immune response may occur because of microbial antigen or autoimmune process.

S/S: Pruritic and/or painful lesions, Silvery scales on discrete erythematous plaques. Onset commonly occurs as a guttate form with small, scattered, teardrop-shaped papules and plaques after a streptococcal infection in a child or young adult. Larger, chronic plaques occur later in life. Glossitis or geographic tongue: Small pits or yellow-brown spots (oil spots). Positive Auspitz sign: Punctate bleeding points with removal of scale. Periarticular swelling of small joints of fingers and toes. Joint pain and involvement signals psoriatic arthritis.

Diagnostic: If joint inflammation is present, consider rheumatoid factor, erythrocyte sedimentation rate, and uric acid.

General interventions: This is a chronic disorder that requires long-term treatment, a high degree of patient involvement, and therapy that is simple and inexpensive. Aim of treatment is control, not cure. Exposure to sunlight may be beneficial. However, symptoms worsen in a small percentage of patients with exposure to sunlight. Mild to moderate disease may be treated with phototherapy if allowable because of cost.

Sequence of agents for involvement of less than 20% body surface is as follows:

    - Emollients (Eucerin cream or Aquaphor cream)

    - Keratolytic agents (salicylic acid gel or ointment)

    - Topical corticosteroids: Use lowest potency to control disease.

    - Calcipotriene ointment: Vitamin D analogue (calcipotriene ointment 0.005%)

    - Anthralin: Use as short-contact therapy 1% to 3%.

    - Coal tar (Estar, PsoriGel): Use in conjunction with topical steroids or anthralin. May apply at bedtime or in the morning for 15 minutes and then shower off.

    - Medicated shampoos: Useful for scalp psoriasis, in conjunction with topical steroids and other treatments.

Pharmaceutical therapy: If the disease is not controlled with the first agent, then an alternative agent may be tried.

- Mild to moderate disease: Topical steroids as first-line therapy. Emollients to start treatment (e.g., Eucerin Plus lotion or cream, Lubriderm Moisture Plus, Moisturel). Scalp: Use coal tar shampoo (Zetar, T/Gel, Pentrax) in place of regular shampoo two times per week. Apply lather to scalp, allow to soak for 5 minutes, and then rinse. If plaques are very thick, use P and S Liquid (over the counter [OTC]). Massage in at night and wash out in the morning.

For additional treatment as needed, apply triamcinolone acetonide 0.1% (Kenalog 0.1%) lotion or equivalent to scaly, stubborn areas once or twice daily until controlled. Avoid face. Dovonex scalp solution: Apply on dry scalp as directed. Face and skin folds: Hydrocortisone cream 1%, apply sparingly up to 4 weeks, preferably no more than 2 weeks. If lesions are unresponsive, consider increasing to 2.5% and taper quickly with improvement. Body, arms, and legs: Use triamcinolone acetonide 0.025% (Aristocort A) cream twice daily up to 2 weeks. Avoid normal skin. For thick plaques, try Keralyt gel (6% salicylic acid), then corticosteroids. Use coal tar (Estar gel) once or twice daily in combination with corticosteroids. Anthralin (Dritho-Creme) is beneficial as an alternative to steroid lotion for scalp psoriasis. Avoid sunlight.

Vitamin D3 analogue: (Calcipotriol), twice daily up to 8 weeks, is comparable to mid potency corticosteroids. Avoid face and skin folds.

Systemic agents for moderate to severe psoriasis may be used if other measures fail. Systemic agents should be prescribed by a dermatology specialist; these medications include retinoids, methotrexate, cyclosporine, and apremilast. These medications should be monitored closely for liver/kidney function changes.

Medical management: For involvement greater than 20% of body, refer the patient to a dermatologist for the following:

-Light therapy with ultraviolet A (UVA) or UVB. UVB light therapy is often used in conjunction with keratolytic agents. Synthetic retinoids: Etretinate or acitretin are options.

Low-dose cyclosporine or Azulfidine can be effective.

-Refer patients with extensive disease, psoriatic arthritis, or inflammatory disease to a rheumatologist. New medications, called biologics, are used to suppress the immune system’s response, which include adalimumab (Humira), alefacept (Amevive), etanercept (Enbrel), infliximab (Remicade), and ustekinuman (Stelara).

Lichen planus: a relatively common acute or chronic inflammatory dermatosis. It affects skin and mucous membranes with characteristic flat-topped, shiny, violaceous (purplish color) pruritic papules with lacy lines on the skin, and milky-white papules in the mouth.

Pathogenesis: Etiology is unknown, although it is possibly a cell-mediated pimmune response. Most cases remit within 7 years. Lesions may heal with significant post-inflammatory hyperpigmentation.

Primary lesions: Small, flat-topped papules that are polygonal, lightly scaly, and violaceous.

Secondary lesions: Erythema, scales, and erosions

Distribution: Volar aspect of wrists, ankles, mouth, genitalia, and lumbar region. Wickham’s striae (white, lacelike pattern on surface). Scalp: Atrophic skin with alopecia. Nails: Destruction of nail fold and bed, especially in the large toe. Men: Lesions of glans penis. Women: Erosive lesions of labia and vulva

Diagnostic: A drop of mineral oil accentuates the papule. If necessary to confirm diagnosis, deep shave or punch biopsy of developed lesions. Hepatitis testing should be completed to assess for hepatitis C as lichen planus has been shown to have a correlation.

General interventions: Discontinue any suspected drug agent. Instruct patients that the disease may be chronic; most cases resolve spontaneously. Encourage the patient to avoid severe emotional stress. Encourage the patient to avoid scratching and prevent secondary infection. Reassure the patient that lichen planus is not contagious.

Pharmaceutical therapy: Oral antihistamines: Hydroxyzine hydrochloride 10 to 50 mg four times daily as needed for pruritus, or cetirizine Hcl (Zyrtec) 10 mg daily. Medium- to high-potency topical corticosteroids. 

-Mouth lesions: Fluocinonide 0.05%, ointment or gel, two or three times daily. 

-Body lesions: Betamethasone dipropionate (Diprolene) 0.05%, triamcinolone (Kenalog), clobetasol (Temovate, Cormax) 0.05%, or other class 1 cream or ointment, two times daily for 2 to 3 weeks and then stop use. Caution patients about steroid atrophy. 

-Genital lesions: Desonide cream 0.05% twice daily initially, although higher potency creams may be necessary. Topical corticosteroids should be used on genitalia in short bursts only.

-Hypertrophic lesions: Intralesional injections, such as injecting triamcinolone 5 to 10 mg/mL, 0.5 to 1 mL per 2-cm lesion, are helpful for pruritus relief. Use cautiously in dark-skinned patients because of risk of hypopigmentation.

Oral prednisone is rarely used, but if necessary use with a short course only and taper.

Lice (Pediculosis):  an infestation of the louse on human beings in one of three areas: Head (Pediculosis capitis), Pubic area (Pthirus pubis), Body (Pediculosis corporis)

Pathogenesis:

Head and body lice are transmitted by direct contact from person to person, that is, through sharing hats, combs, brushes, and so forth. The parasite hatches from an egg, or nit. Once hatched, the lice live on humans by sucking blood through the skin. The average adult louse lives 9 to 10 days. The nits appear as small white eggs on the hair shaft. Nits are very difficult to remove and survive up to 3 weeks after removal from the host. Body lice lay nits in the seams of clothing.

-Pubic lice are found at the base of the hair shaft, where they lay nits. Pubic lice are transmitted through sexual contact.

General interventions: Treat immediately with appropriate pediculicides. After treatment, it is imperative to remove each nit and louse; use fine-tooth comb for nit removal.

= Malathion lotion 0.5% (Ovide): Pediculicidal and partially ovicidal. Permethrin lotion 1% (Nix): Pediculicidal only. Available over the counter (OTC) for treatment. Synergized pyrethrins (Rid 0.3%; Available OTC). Apply, repeat in 24 hours, and then again in 1 week.

Do not use a shampoo/conditioner or conditioner before using head lice treatments. Do not wash hair for 1 to 2 days after using lice treatment regimen.

- Pthirus pubis: Lindane (Kwell) or permethrin (Nix); apply to pubic area as directed

Lyme disease: 

Multisystem infection that may be acute or chronic. Leading vector-borne disease in the U.S. 

Pathogenesis: Borrelia burgdorferi, a spirochete bacterium is the infectious agent carried by deer tick to humans.

Common complaints: Flu like symptoms, fatigue, headache, joint pain.

Stage 1 (Acute): Rash, Erythema migrans- “bulls eye” shape. Begins as a red macule at the site of the tick bite and spreads out to form a large annular lesion with red secondary outer rings, an intense red outer border (measuring at least 5cm) and some clearing at the site of the bite. Body aches, fever or chills, and swollen lymph nodes.

Prophylactic therapy after tick bite is usually no advised. Start prophylactic therapy with doxy for tick bites that are “swollen.” 

Early localized lyme disease: doxycycline 14-21 day antibiotic course (warn about photosensitivity). Adults: 100 mg Doxycycline, PO, BID. Children older than 8: 2mg/kg PO BID max 100mg. 

Contact Dermatitis: :irritant/allergic response of epidermis layer 

Irritant contact dermatitis- nonimmunologic response of the epidermis.

Allergic contact dermatitis- immunologic response after one or more exposures to a particular agent. 

Cc: redness to pruritic inflammation poss progression of blisters

Poison oak, ivy, and sumac induce classic presentation: Lesions (vesicles) and papules on an erythemic base presenting in a linear fashion with sharp margins

Diffuse pattern with erythema may be seen when oleoresin is contacted from pets or smoke from burning fire

Exposure to some type of irritant known to the patient. Round or annular lesions may have an internal cause such as a drug reaction

Note the pattern of inflammation. The shape of irritation may mimic the shape of the irritant, such as the skin under a ring or watch, for example. 

Dx: If source is known no diagnostics needed. Otherwise may need wet mount(KOH) to make sure its not fungal. Patch test to rule out allergic contact dermatitis. 

Tx: 

Irritant contact dermatitis- remove irritating agent, use topical soaks with saline orBurow’s solution for weeping areas. Lukewarm bath or oatmeal bath. For dry, erythematous skin, Eucerin or Aquaphor. 

Allergic contact dermatitis: avoid contact with agent, wash affected area with cool water. Lukewarm bath with oatmeal 3-4 times per day. Apply calamine lotion after baths. 

Hydrocortisone 2.5% ointment 3-4 times/day for 2 weeks for irritant dermatitis. 

Hydrocortisone 2.5% ointment 3-4 times/day for 1-2 weeks after blisters for allergic contact dermatitis--low dose or 0.025% Triamcinolone acetonide 0.1% twice daily, 

Triamcinolone acetonide 0.1% twice daily for intermediate dose

High dose=Fluocinonide 0.05% ointment three to four times per day. 

Antihistamines--25 to 50mg benadryl or hydroxyzine four times daily. 

If rash severe consider prednisone 60 to 80 mg/d to start and taper over 10 to 14 days.

Triamcinolone acetonide 40 to 60 mg IM.  

Diaper dermatitis: Prominent red, shiny rash on buttocks and genitals

PE: Note the pattern of inflammation. The shape of irritation may mimic the shape of the irritant, such as the skin under a ring or watch

DX: Consider none if source is known, wet mount (potassium hydroxide [KOH], saline) to r/o fungal infection if suspected, Culture/sensitivity of pustules, Patch test to r/o allergic contact dermatitis

Change diaper frequently, clean with water only. Allow skin to dry 15 to 30 minutes 4 times a day. Do not use powders or lotions 

Tx: Apply zinc oxide (DEsitin ointment or powder), or Happy Hiney with every diaper change.--only if NOT fungal.

Atopic Dermatitis

Def: Skin inflammation features erythema, itching, scaling, lichenification, papules, and vesicles in various combinations. Eczema is used interchangeably with dermatitis. Typically seen as a triad: Asthma, dermatitis, and allergic rhinitis. 

Caused by family history, exposure to allergens, topical medications, or skin irritants. 

Sx: Itching, dryness, Discoloration, lichenification, scaling, skin thickening, associated bleeding or oozing of the skin. 

Dx: Culture skin lesions to determine, bacterial, viral, fungal etiology. Serum IgE is elevated with atopic dermatitis. 

Tx: 

Use emollients( Eucerin cream and Aquaphor), pat, do not rub skin, only bathe children 2-3 nights a week with gentle cleansers. Avoid wool products and lanolin preparations. Keep fingernails short. Eliminate trigger foods one month at a time. 

treat secondary infections(augmentin 875 mg BID 10-14 days) or kelfex500 mg PO 4XD for 10-14 days, allergy testing may be considered if continued issues, ointments are recommended over creams. 

Wet dressings with Burow’s solution every 2-3 hours. 

Potent topical corticosteroid: Betamethasone 0.1% 2-3 times daily for 2-3 weeks

Antihistamine of choice: Cetirizine (zyrtec) or benadryl 

Severe cases: 1mg/kg prednisone 40-60mg total for 2-3 weeks. 

Precautions should be given regarding possibility of hypopigmentation of skin even with short term use of steroids on skin.  

Erythema Multiforme: dermal and epidermal inflammatory process with symmetric eruption of erythematous, iris-shaped papules (“target” lesions) and vesiculobullous lesions

Believed to be caused by immunologic reaction to the skin.

Primary: macules, papules, and plaques. 

Secondary: erythema, dull, red target-like lesions that blanch to pressure, distribution is symmetric, primarily on flexor surfaces. Classic target lesions develop abruptly and symmetrically and are heaviest peripherally; often involve palms and soles. 

Tx: NO ATBS identify and treat precipitating causes or triggers. Burrow’s solution or warm compresses for mild cases. Oral lesions can be treated with saline solution, warm salt water, and/or Mary’s mouthwash. D/C any meds suspected of precipitating symptoms. Provide adequate pain relief, lesions remain fixed for 7 days. 

Antihistamines such as Benadryl or Claritin. Tylenol as needed. Potent topical steroids, betamethasone dipropionate 0.05% or clobetasol propionate 0.05% BID for 2 weeks. 

Acne Rosacea

Def: vascular skin disorder in which flushing and dilation of the blood vessels occur on the face resulting in inflammatory mediator release, extravasation of inflammatory cells and formation of inflammatory papules

Pred fact: Tendency to flush, exposure to heat, cold, or sunlight, hot or spicy foods and alcoholic beverages, some topical medications, astringents, or toners

Hallmark: for diagnosis are the small papules and papulopustules. Many presenting erythematous papules have a tiny pustule at the crest. No comedones are present.

Sub:R/O possible exposure to industrial or domestic toxins, insect bites, and possible contact with venereal disease or HIV

PE: ocular manifestation, rosacea keratitis, may cause corneal ulcers to develop

Dx: skin bx r/o lupus, sarcoidosis if hnp exam findings warrant further testing

General interventions: 

Face washing with mild cleanser such as Cetaphil or Cerave in morning and night. 

Avoid direct sunlight exposure. 

Tx: Treatment: 

Drug of choice: Tetracycline 500mg to 1000mg twice to four times daily for 2-4 weeks. 

Second line drugs:

Erythromycin 500mg twice daily until clear 

Minocycline 50 to 200mg daily divided into two doses

Doxycycline 100mg daily

Start at higher dose on these and then taper to maintenance dose. 

Can also use topical ATBs like metrogel, erythromycin and clindamycin  twice daily after cleansing skin 

Refractory cases may respond to isotretinoin (Accutane)

Topical steroids may worsen skin irritation!.

Follow up in two weeks to evaluate therapy.

Skin cancer/oral cancer/skin lesions

Diagnostic tools for skin lesions

Benign Skin Lesions: cutaneous growth with no harmful effects. Must be distinguished from BCC, SCC, and malignant melanoma. 

Common in elderly. 

S/S seborrheic keratosis, dermatosis papulosa nigra, cherry angioma, solar lentigines (liver spots), sebaceous hyperplasia, actinic keratoses.

If unsure of malignancy, do a biopsy. 

Reassure patient lesions are benign, no treatment needed unless wants it removed for cosmetic purposes. 

Refer to dermatologist if lesion is suspected or confirmed for malignancy.  

Precancerous or cancerous skin lesions- potentially malignant or malignant cutaneous cells from precancerous or cancerous skin lesions. 

SCC (Squamous Cell Carcinoma) accounts for 20% of all skin cancers, mostly middle-aged to elderly population. 

BCC (Basal Cell Carcinoma) is most common form of skin cancer. Usually 6th or 7th decade of life.

Malignant melanoma less than 5% of all skin cancers but responsible for 60% of skin cancer deaths. Frequently seen in younger people, median age in low 40s.

SCC: abnormal cells or the epidermis penetrate basement membrane of the epidermis and move into dermis, creating SCC. Begins as actinic keratosis that undergoes malignant change.

Skin lesions are seen in sun-exposed areas or skin damaged by burns or chronic inflammation. Ex. lower lip- firm, irregular papule with scaly, bleeding, friable surface like sandpaper. GROWS RAPIDLY.

Bowen’s Disease(SCC in situ): chronic non-healing erythemic patch with sharp, irregular borders, on skin and/or mucocutaneous tissue. Resembles eczema but does not respond to steroids. 

Basal Cell Carcinoma(BCC): abnormal cells of the basal layer of the epidermis expand, surrounding stroma supports basal cell growth. UV rays are major contributor to BCC. Usually SLOW growing and RARELY METASTASIZES. 

Tumor seen on face and neck, nodules greater than 1 cm that appears shiny, pearly color with telangiectasia, center caves in. 

MALIGNANT MELANOMA: abnormal cells proliferate from melanocyte system. First grow superficially and laterally into epidermis and papillary dermis then grow into reticular dermis and subcutaneous fat.

Malignant tumors occur because of the inability of the damaged cells to protect themselves from long-term exposure of UV rays. 

Asymmetrical tumor, irregular border, variation in color, greater than 6mm in diameter, can metastasize to any organ. 

Keratoacanthoma: Sun exposed-area lesion that first appears as smooth, skin-colored, or reddish dome-shaped papule, then may grow to 1-2 cm in a few weeks with crusted interior.

PLAN: monitor progress/change of lesions. Biopsy and suspicious lesions with narrow margins. Repeat biopsy if results are inadequate the first time. Be sure to include all clinical history info with specimen when sending for pathology. 

If diagnosis was made then follow up every month for 3 months and then twice a year for 5 years, then yearly. 

Pityriasis Rosea- acute, self-limiting, benign skin eruption characterized by a preceding “herald patch” (2-10 cm with central clearing) a few days to several weeks that is followed by widespread papulosquamous lesions. 

75% of cases are 10-35 years old. Is idiopathic. Possibly a viral origin or autoimmune disorder. Rash: Salmon, pink, or tawny-colored lesions generally are concentrated in the trunk, can develop on arms, legs, and rarely on the face. Mild itching.

Early lesions may be papular but may progress to 1 to 2 cm oval plaques. Long axes of oval lesions run parallel “Christmas tree distribution”. 

Must distinguish “herald patch” from tinea corporis with wet mount. If herald path is not identified then syphilis testing should be ordered.

Treatment: Direct sunlight decreases appearance of lesions and itchiness. UVB light in 5 consecutive daily exposures can shorten rash and decrease itchiness. Self-limiting and clears by itself in 1-3 months. 

No medication treatment. Itching medications that could be prescribed are Group V topical steroids and oral antihistamines. Prednisone 20 mg BID for 1-2 weeks in rare cases of intense itching. Impetigo could develop as a secondary infection. 

Candidiasis: fungal infection of mucous membranes and/or skin caused by Candida albicans. Grows when exposed to moisture, warmth, and alteration in the membrane barrier. Can occur oral, vaginal, genital (male or female). 

Screen for STIs, specimen to include wet prep/potassium hydroxide 10% solution, gram stain vaginal culture for candida. 

Treatment: good hygiene, keep areas cool and dry. 

Oral: Nystatin suspension 100,000 U/mL, 2mL for infants and 4-6 mL for older children and adults. Gentian violet aqueous solution 1% for infants and 2% for adults 1-2 times a day. Lotrimin buccal troches, 5 times a day for 2 weeks, adults only. 

Diaper: Nystatin cream, 3-4 times a day for 7-10 days. Mycolog II, apply sparingly to skin twice daily until resolved.

Vaginal: Clotrimazole 1% cream, 5g intravaginally for 7-14 days. Miconazole 2% cream, 5 g intravaginally for 7 days. Terconazole 0.8% cream, 5g intravaginally for 3 days. Terconazole 80 mg vaginal suppository, at bedtime for 3 days. Fluconazole 150 mg, PO one time. 

Scabies: mites infestation(burrows) Sarcoptes scabiei.

Cc: intense itching(differentiates the rash from acne or mosquito bite) worse at night

Dx: Examine all skin with pt unclothed. Use magnifying glass to detect burrows in finger webs, wrists, and penis. Inspect adult pubic area for lesions. Burrows can be identified by using a felt-tipped pen and alcohol swabs. Ink the suspecting area and then wipe with alcohol swab. The alcohol will clean the ink on the skin but some ink will go into burrow and will be seen as a black spot. If black spots are already seen it is likely the eggs, fecal pellets or mites at the end of the burrow. 

Diagnostic findings include: Microscopic mites, eggs, or fecal pellets. 

Household members should be treated prophylactically. 

Tx:First line 5% permethrin (Elimite cream) applied to all body areas from the neck down and washed off in 8 to 14 hours. One application is highly effective, but some dermatologists recommend retreatment in 1 week. Lindane (Kwell), can cause neurotoxicity and convulsions with overuse, cream is an alternative therapy with same directions. Do not use with infants. 

A single dose of ivermectin (200 mcg/kg) has been shown to be effective in controlling pruritus.

HERPES ZOSTER/SHINGLES-viral infection manifested by painful, vesicular lesions on the skin, limited to one side of the body, following one body dermatome.

May occur at any age, more common in older adults and elderly. After primary episode of chickenpox (varicella zoster), virus remains dormant in body. Occurs when varicella virus has been stimulated and reactivated in the dorsal root ganglia, producing the clinical manifestations of herpes zoster. Infection usually lasts 14 to 21 days, may be longer in elderly or debilitated patients. 

Prodrome- itching, burning, tingling, or painful sensation at lesion sites. Active- Malaise, fever, headache, or pruritic rash on skin. Lesions- clusters of vesicles on erythematous base that burst and produce crusted lesions. 

Commonly found on chest and back area but can be found in other areas. Can culture lesions, consider Tzanck smear. 

Apply wet dressings (Burrow’s Solution) on site for 30-60 min at least 4 times a day. Antivirals should be started within 24-48 hours. Acyclovir 800 mg every 4 hours while awake for 7-10 days, famciclovir 500 to 750 mg by mouth TID for 7 days, Valtrex 1000 mg PO TID for 7 days. Tylenol or Ibuprofen as needed. Narcotics may be used for severe pain such as postherpetic neuralgia. 

Long term medications may be needed for pain, gabapentin 100-600 mg TID, amitriptyline 25 mg HS, lryica start 150 mg/d divided into 2-3 doses a day, may be increased to 300 mg/d, BID or TID within 1 week, then increased to 600 mg/d, BID or TID. 

Use of steroids is controversial and may increase risk for dissemination. 

HSV1- mostly associated with oral lesions (mouth and lips). 

Has 3 stages, primary, latent, and recurrent infections

 Viral infection that can be transmitted from a vesicular lesion or fluid (saliva) containing the virus to the skin or mucosa of another person by direct contact. Incubation period of 2 to 14 days. Trigeminal ganglia are the host of the oral virus. Virus can be reactivated, and travel along the affected nerve route and produce recurrent lesions. 

Common sites are lips, face, buccal mucosa and throat. Primary lesion: fever, blisters on lips. Malaise, and tender gums. Recurrent episodes: fever blisters with prodrome of itching, burning, and tingling sensation at the site before vesicles appear. 

Plan- ice to reduce swelling, vaseline or other lip ointments with SPF. Medication therapy- precaution in immunocompromised and renal disease. 

Lidocaine 2% as needed for comfort, Benadryl elixir to rinse mouth. Tylenol for pain. Campho-phenique application as needed. 

Initial episode- acyclovir 200 mg by mouth 5 times a day for 7-10 days or until resolved. 

Recurrent episodes begin one of the following when prodrome begins or within 2 days of onset of lesions to get maximum effect. Acyclovir 200 mg by mouth 5 times a day for 5 days. Acyclovir 800 mg by mouth 2 times a day for 5 days. Other alternative antivirals: Famciclovir (Famvir) or Valacyclovir (Valtrex). 

Suppressive therapy acyclovir 200 mg by mouth 2-5 times a day for one year or acyclovir 400 mg by mouth twice daily for 1 year. Can be transmitted sexually when having oral sex. Avoid contact when lesions are present. Avoid sharing toothbrushes or eating utensils. .

Staphylococcus Aureus- Gram (+) common in soft tissue infections and abscesses

Treatment: If abscess is localized and > 5 cm in diameter 1st line and afebrile: 

1st line treatment: incision drain and localized care. Obtain a wound culture and sensitivity

If > than 5 cm add localized ATB treatment

MRSA: has beta lactamase (breaks down PCNs, certain cephalosporins and select macrolides

TREATMENT OF MRSA: TMP-SMX/Bactrim, Doxy, clinda

Scarlet Fever: caused by GAS, tx with PCN (allergy: Azithro/Erythro

http://athena.targetwoman.com/antibiotics