Group 4 Flashcards
Scabies: Identifying Symptomology
Scabies is usually transmitted by close person to person contact, though can occasionally be
transmitted by fomites such as clothing and linens.
• Scabies usually presents with severe itching, often worse at night, and nondescript
erythematous papules in a characteristic distribution.
• The distribution of scabies usually involves the sides and webs of the fingers, the flexor
aspects of the wrists, the extensor aspects of the elbows, anterior and posterior axillary
folds, the skin immediately adjacent to the nipples (especially in women), the
periumbilical areas, waist, male genitalia (scrotum, penile shaft, and glans), the extensor
surface of the knees, the lower half of the buttocks and adjacent thighs, and the lateral
and posterior aspects of the feet. The back is relatively free of involvement, and the
head is spared except in very young children. Rarely, scabies may be localized to a single
area.
• Typical infestation — The essential lesion is a small, erythematous, nondescript papule,
often excoriated and tipped with hemorrhagic crusts. It is not a dramatic lesion and not
always easy to see. More striking, when present, is the burrow. Pathognomonic when
correctly identified, the burrow is a thin, grayish, reddish, or brownish line that is 2 to 15
mm long. Burrows are often absent, however, or obscured by excoriation or secondary
infection. Miniature wheals, vesicles, pustules, and rarely bullae may also be present.
• The combination of a pruritic eruption with characteristic lesions and distribution and family
involvement strongly suggests the diagnosis.
• Diagnosis of a scabies infestation usually is made based upon the customary appearance and
distribution of the rash and the presence of burrows.
• Symptoms of scabies typically begin three to six weeks after primary infestation.
However, in patients who have previously been infested with scabies, symptoms usually
begin within one to three days after reinfestation, presumably because of prior
sensitization of the patient’s immune system.
( scabies) Mite Identification
• Whenever possible, the diagnosis of scabies should be confirmed by identifying the mite
or mite eggs or fecal matter (scybala).
• This can be done by carefully removing the mite from the end of its burrow using the tip
of a needle or by obtaining a skin scraping to examine under a microscope for mites,
eggs, or mite fecal matter (scybala).
• However, a person can still be infested even if mites, eggs, or fecal matter cannot be
found; fewer than 10-15 mites may be present on an infested person who is otherwise
healthy.
Lab testing (scabies)
Skin scrapings, dermoscopic examination, and the adhesive tape test can be used for
confirmation of scabies infestation, but negative tests do not rule out the diagnosis.
Treatment Scabies
Patients with scabies should be treated both for symptom relief and prevention of transmission.
• Medications:
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o Permethrin 5% cream (applied to all areas of the body from the neck down and washed
off after eight to fourteen hours), or
o Oral ivermectin (200 mcg/kg repeated after two weeks)
• Special Circumstances:
o Patients with crusted scabies be treated simultaneously with oral ivermectin and topical
permethrin 5% cream.
o Simultaneous treatment of the patient and close contacts is recommended based upon
the theory that this may reduce risk for the spread of scabies and the recurrence of
scabies in the treated patient.
• Controlling Transmission:
o Appropriate options for items used within several days before treatment (clothing,
linens, stuffed animals, etc.) include placing in a plastic bag for at least three days,
machine washing with hot water and then ironing or drying in a hot dryer, or dry
cleaning.
o Fumigation of living areas is not indicated.
o Affected individuals can return to work, child care, or school the day after treatment.
• Risks of Ivermectin and Permethrin
o Permethrin acts as a neurotoxin, slowing down the nervous system through binding to
sodium channels. This action is negatively correlated to temperature, thus, in general,
showing more acute effects on cold-blooded animals (insects, fish, frogs, etc.) over
warm-blooded animals (mammals and birds).
o According to the Connecticut Department of Public Health, permethrin “has low
mammalian toxicity, is poorly absorbed through the skin, and is rapidly inactivated by
the body. Skin reactions have been uncommon.”
Scabies Considerations for Clinicians
Wear gloves when examining patients for scabies.
• Examine all close contacts as well, if available.
• Defer Blood Pressure Cuff application if possible
• After the patient and any companion(s) leave the treatment room, special attention
should be paid to discreetly disinfecting the surfaces of treatment tables and chairs.
Suicideality
see notes
Syncope: Initial evaluation of transient loss of consciousness should include:
- careful history,
- physical examination,
- orthostatic blood pressure,
- electrocardiogram (ECG).
Syncope versus other loss of consciousness:
Was loss of consciousness complete?
• Was loss of consciousness transient with rapid onset and short duration?
• Did the patient recover spontaneously, completely and without sequelae?
• Did the patient lose postural tone?
o All answers “yes”, likely syncope;
o Any answers “no”, other forms of loss of consciousness should be excluded.
Physical Examination : syncope
vital signs,
• orthostatic and bilateral blood pressure,
• cardiovascular,
o assess volume status, valvular heart disease, and rhythm disturbance
• neurologic systems,
o seek signs of focal neurologic deficit.
• Signs of occult blood loss should be assessed.
An electrocardiogram (ECG) should be ordered for all patients with syncope
• ECG is suggestive of an arrhythmic cause of syncope if any of the following
abnormalities is present (Table 5)
If syncope occurs with exertion, evaluate for potentially life-threatening causes:
- aortic stenosis
• hypertrophic cardiomyopathy
Syncope diagnosis is uncertain following the initial evaluation?
• Further evaluation and management should be guided by risk stratification.
o Clinical features of high risk of short-term serious event
▪ early intensive evaluation and/or prompt hospitalization.
o Single or rare episodes with low-risk features
▪ no further evaluation is indicated.
• Older patients, organic heart disease or abnormal electrocardiogram may require additional
cardiac evaluation, may include:
▪ prolonged electrocardiographic monitoring, echocardiography, and exercise
stress testing.
Transgender care
see notes
Acute Complicated Cystitis and Acute Complicated Pyelonephritis
Urinary tract infections (UTIs) include cystitis (infection of the bladder) and pyelonephritis (infection of
the kidney). Most episodes of cystitis and pyelonephritis are generally considered to be uncomplicated
in otherwise healthy non-pregnant adults. A complicated urinary tract infection, whether localized to
the lower or upper tract, is associated with an underlying condition that increases the risk of failing
therapy
Acute Complicated Cystitis and Acute Complicated Pyelonephritis underlying condition that increases the risk of failing
therapy, including the following:
Diabetes
• Pregnancy
• History of acute pyelonephritis in the past year
• Symptoms for seven or more days before seeking care
• Broad-spectrum antimicrobial resistant uropathogen
• Hospital acquired infection
• Renal failure
• Urinary tract obstruction
• Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion
• Recent urinary tract instrumentation
• Functional or anatomic abnormality of the urinary tract
• History of urinary tract infection in childhood
• Renal transplantation
• Immunosuppression
Acute Complicated Cystitis
may consist of dysuria, frequency, urgency, suprapubic pain and/or hematuria. Symptoms and signs of
cystitis can be subtle in the very young and very old. Cystitis is considered complicated in the
circumstances outlined above.
