NR 511 MIDTERM REVIEW ON DIFFERENTIAL DIAGNOSIS WITH COMPLETE RESOURCES AND RATIONALE FOR A GUARANTEED PASS(2023/2024)

NR 511 MIDTERM REVIEW ON DIFFERENTIAL DIAGNOSIS WITH COMPLETE RESOURCES AND RATIONALE FOR A GUARANTEED PASS(2023/2024) • Actinic keratosis: pre-cancerous lesion. The main assessment technique is INSPECTION, which will show as flesh colored, hard and sand paper like. ▪ TX: cryotherapy o Risk factor: sun exposure, can progress to squamous cell carcinoma o Referrer pt to dermatology to prevent progression • Fungal skin infection: assess rash and satellite lesions. o DX: based on clinical presentation, most common is candida albicans o Tx: antifungal cream, pills, keep area as dry as possible. The fungus likes moisture and poor air circulation o At risk: opportunistic, pts who are immunocompromised, older and younger pts, diabetics, and antibiotic therapy. o Refer patient if there's no improvement • Common types of fungal infections: o Tinea vesicolor: flat to slightly elevated brown papules and plaques that scale when they are rubbed along with areas of hypopigmentation, pruritic, most commonly found on trunk and shoulders. o Balanitis: candidiasis in the glands of the penis o Tinea corporis: annual lesions with scaly borders and central clearing on the trunk o Tinea pedis: athlete's foot, and between toes o Tinea cruis: jock-itch groin • Bacterial skin infections: warm, red, painful w/o sharply demarcated border o Cellulitis: is a spreading infection of the epidermis and sub-cut tissue that usually begins after a break in the skin. o Folliculitis: bacterial infection of the hair follicle, papules are characteristics of folliculitis • Viral skin infections o Erythema infectiosum (fifth disease) erythematous, warm rash, gives the appearance of slapped cheeks. Sore throat, slight fever, upset stomach, headache, fatigue, and itching. Resolves on its own. o Varicella rash: contagious 48 hours before the onset of the vesicular rash, during the rash formation and during the several days it takes the vesicles to dry up. Characteristics rash appears 2-3 weeks after exposure. o Warts: caused by the human papillomavirus, most warts recur despite treatment. Contrary to popular opinion, warts do not have roots, the underside of a wart is smooth and round. Abrading the skin can spread the virus, vigorous rubbing, shaving, and nail biting can do the same. • Skin inflammations: o Pityriasis rosea: common, self-limiting, usually asymptomatic eruption with a distinct initial lesion. This "HERALD PATCH", which appears suddenly and without symptoms, usually is on the chest or back. ▪ Secondary lesions appear 1-2 wks later while the herald patch remains. ▪ The collarette scaling is another classic symptom of pityriasis rosea. ▪ The lesions usually resolve suddenly in 4-12wks w/o scarring. ▪ Outbreaks are known to occur in close quarters like military barracks or dormitories. o Hives: look at the location of the rash, the first step is to determine the need for epinephrine. Look for respiratory symptoms, SOB, hoarseness, look at location. If the rash is on the neck, face- admin epinephrine. o Cholinergic urticaria: hives or wheals that are pruritic and occur on the trunk and arms following exercise, anxiety, elevated body temp. hot bath and showers. ▪ Hx taking about when the rash started is important for dx o Contact dermatitis: poison ivy: a form of contact dermatitis, it is not contagious and it cannot be spread from one area of the body to another by touching it. Type of SPORE reaction. ▪ Another type is Latex sensitivity o Keratosis pilaris: mild pruritic and looks like GOOSEFLESH, the rash appears as small, pinpoint, follicular papules on a mildly erythematous base. It is a benign conditions that resolves by adulthood. o Atopic Dermatitis: consider ALLERGY!! ▪ Atopic triad: ASTHMA, ECZEMA, ALLERGIC RHINITIS ▪ RAST may be done to ID the antigen-specific mast cell activation or to quantify levels of antigen-specific IgE. RAST is usually available to PCPs, where as scratch testing is usually done by allergists. ▪ RAST results requires specialized knowledge, and should be used as general atopic screening tool. • Hair loss o Alopecia areata: systemic cause of alopecia, nonscarring hair loss of rapid onset, the pattern of which is most commonly sharply defined round or oval patches. o Trichotilomania: non-scarring, non-systemic causes of alopecia include trauma, bacterial or local fungal infections, and radiation to the head. o Minoxidil(Rogaine) vasodilator and may stimulate vertex hair growth. • Parasitic skin infections o Pediculosis: (LICE!!) client education is important in the tx of pediculosis b/c pts should be informed that itching may cause for up to a week after successful tx b/c of the slow resolution of the inflammatory reaction caused by the lice infestation. • Ear disorders o Otitis externa: classic sign of acute otitis externa is tenderness on traction of the pinna and/or pain on applying pressure over the tragus. There is typically an erythematous ear canal, and usually a hx of recent swimming. ▪ Using ear drops made of a solution of equal parts alcohol and vinegar in ea. Ear after swimming is effective in drying the ear canal and maintaining an acidic environment, therefore preventing a favorable medium for the growth of bacteria, the cause of swimmer's ears. o Acute otitis media: ear infection that is dx by otoscopic examination. The tympanic membrane will appear red and bulging with or w/o visible effusion. ▪ Light reflex is usually diminished or absent, and mobility id decreased NOT INCREASED!! ▪ The external auditory canal is red and erythematous ▪ Tx of choice: amoxicillin 80-90mg/kg/day in children in daycare ▪ Note: it is important to note that if a child w/ O.M. with effusion has a change in hearing threshold greater than 25 dB and has notable speech and language delays, more aggressive tx is indicated. It is important that the provider evaluates the child's developmental milestone in speech and language. Abnormal findings warrant a referral. o Meniere's disease: the triad of symptoms associated with Meniere's disease: PROGRESSIVE HEARING LOSS, TINNITUS, AND VERTIGO. • Hearing loss o Sensorineural loss: come from exposure to loud noises, inner ear infections, tumors, congenital, and familial disorders, and aging. ▪ Sensorineural loss comes from exposure to tumors such as acoustic neuromas, Meniere's disease, medications, trauma, and certain disease. o Conductive hearing loss: presbycusis- the conductive hearing loss- bone conduction is greater than air conduction, so the patient will report the bone conduction sound longer than the air conduction. ▪ Serous otitis media can result in conductive hearing loss. o The Weber test- a vibrating tuning fork is placed on the top of the head mid center from the patient's ears. ▪ In the normal pt: the tuning fork sound is head equally loud on both ears ▪ In abnormal pt: the tuning fork is heard LOUDER in the BAD ear. • Eye disorders o Conjunctivitis- viral or bacterial: the causative organism of viral conjunctivitis ad adenovirus. It can be present w/ or w/o cold symptoms. Pts complain of itchy, watery, red eyes and may have clear to no discharge. ▪ Preauricular lymph node swelling and tenderness is hallmark for viral conjunctivitis ▪ Skin vesicles (if present) and corneal infection with a "dendrite" appearance are hallmark characteristics of HSV-1 or HSV-2 conjunctivitis. ▪ Education: teach pts to put drops in and advise to avoid touching the tip of the bottle to any conjunctival or skin surface. • Women should be told to throw away all eye makeup products due to contamination and to start with new products when the infection clears. • Likewise, disposable contact lens wearers will need to discard the contacts, refrain from wearing any during tx, and start with a new pair when clinical symptoms have resolved. • Bacterial conjunctivitis is very contagious so the pt should stay home from work or school until 24 hours of antibiotic tx or as soon as clinical improvement (decreased redness and d/c) is noted. o Blepharitis: inflammation around the eyelid margins, that is caused by staphylococcal injection at the lash base and dysfunctional Meibomian glands. o Subconjunctival hemorrhage: bright red blood in a sharply defined area surrounded by normal- appearing conjunctive indicates subconjunctival hemorrhage. ▪ Risk factors: blood thinners, DM2, HTN, Valsalva type maneuvers. ▪ The condition is self-limiting and resolves on its own ▪ Patient w/ visual changes or with more extensive hemorrhage should be referred to an ophthalmologist or ER. o Corneal abrasion: aka as an eye scratch- DX: fluorescein stain is done to detect abrasion or foreign body objects in the cornea. • ENT o Sinusitis: invasive complications such as infection of an adjacent cranial structure (mastoiditis, meningitis, etc) require referral to a specialist. ▪ With Ethmoid sinus problems: the pain is felt behind the eye and high on the nose ▪ Maxillary sinus: the largest of the paranasal sinuses and is the most commonly affected sinus. There is usually pain and pressure over the cheek. The inability to transilluminate the cavity usually indicates a cavity filled with purulent material. • Discolored nasal drainage, as well as poor response to decongestants, may also indicate sinusitis. ▪ If the patient has a URI for at least 7 days, the presence of 2 or more of the following signs/symptoms: • Colored nasal drainage • Poor response to decongestants • Facial or sinus pain (aggravated by postural change) • Headache ▪ Viruses may produce all of the clinical manifestations described, however, patients who meet the 7-day criteria are more likely to have bacterial rather than a viral URI. o Mononucleosis: fatigue, sore throat, low grade fever, nasal and throat mild erythema ▪ Edematous, enlarged tonsils bilaterally, with erythema of the pharyngeal wall and tonsillar exudates.