Module 5 Flashcards
bruise
bruise (ecchymosis) is an integumentary manifestation of extravasated blood. Discoloration of the skin is attributed to a local interstitial pool of erythrocytes, which causes a light to dark blue skin color associated with red pigment
bruise coloring changes
red, blue/purple, green, brown
Spontaneous bruising may be seen with platelet counts below
30,000 cells/mL
Spontaneous bruising may also be associated with the chronic use of
corticosteroid or anticoagulant therapies
fatigue
Fatigue presents as a complaint of tiredness that cannot be explained on the basis of exercise or other activity
acute fatigue
Acute fatigue is most often associated with viral or bacterial infections
functional fatigue
Functional fatigue is more typically characterized by fatigue on awakening that may improve after exercise. The close associations of depression and anxiety with fatigue make for a difficult task in distinguishing functional causes of fatigue from the fatigue itself.
acute fever
tends to be greater than 101.3
The ability of the body to elevate the temperature in the event of infection diminishes with
advancing age, due to a weakening of the immune system as one gets older.
chronic fever
tend to be low grade (100.4)
fever of unknown origin
FUO is defined as a fever of greater than 101.3°F (38.5°C) that occurs on at least three occasions over a 3-week period in an ambulatory patient. A hospitalized patient is diagnosed with FUO if the unexplained fever persists for 1 week.
fevers in excess of 104°F (40°C) tend to be associated with
pancreatitis, pyelonephritis, and intracranial pathology (e.g., bacterial meningitis)
Fevers between 101.3°F (38.5°C) and 104°F (40°C) are associated with
urinary tract infections and some acute viral syndromes
Fevers less than 101.3°F (38.5°C) are characteristic of
infectious hepatitis, some acute viral infections, and TB.
lymphadenopathy is used in clinical practice to designate
any abnormality of lymph nodes and, in particular, enlarged lymph nodes.
Typical sites for allergen exposure are
the skin and respiratory tree, where local reactions may occur.
atopy
Atopy is a term used to characterize an immunoglobulin (Ig)E-mediated immune response that is exaggerated or out of character for exposure to what appear to be innocuous environmental allergens
allergic reaction distribution
equal b/tw sexes, races
incidence higher in children
key cells types involved in allergic response
mast cells
basophils
eosinophils
group 1-3 allergic reaction
dependent on circulating antibodies
group 4 allergic reaction dependent on
cellular immune components
Type 1 allergic reaction
Immunoglobulin E mediated immediate hypersensitivity response
allergic rhinitis, asthma, anaphylaxis
7 step treatment for anaphylaxis
- give epi in upper lateral thigh with head below heart level
- repeat epi q 5-15 min
- support bronchodilation by giving albuterol
- if pulm arrest, intubate and provided resp support
- Start IV fluids to maintain BP above 90
- Give benadryl to relieve cutaneous symptoms
- Transfer to emergency center, give steroids
type 2 allergic reaction
antibody mediated cellular cytotoxicity response
neonatal Rh incompatibility
Type 3 allergic reaction
allergen immune complex response
systemic, delayed drug reactions
type 4 allergic reaction
delayed type cellular hypersensitivity response
contact dermatitis
2 elements common to subjective complaints associated with allergies
- exposure to allergen precedes onset of symptoms
- pts typically attempt to control symptoms with self care
urticaria associated with
type 1 response
type 1 response diagnostics
skin tests- if positive, wheal within 15-20 min
The most common form of asthma is
an allergen-driven atopic disease characterized by type 1 immune responses to environmental allergens, although it is distinct from systemic anaphylaxis
type 2 response diagnostics
rh testing of blood during pregnancy
type 3 response diagnostics
ELISA or biopsied skin reaction
type 4 diagnostic
skin testing
antigen specific igE levels
initial management allergic reaction
avoid further allergenic exposure
sympathomimetic (alpha receptor agonist)
sudafed, afrin
vasoconstrict engorged mucosa, may increase HR, irritability, anxiety, addiction
high abuse potential
immunotherapy
allergens given SQ in 0.5ml allotments with progressive increase in concentration until symptoms controlled for 3-5 years
rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic, progressive, systemic inflammatory disease that primarily affects the synovial joints, although it may affect many organ systems. Joints are destroyed over a long course of disease remissions and exacerbations. Structural deformities, which create emotional as well as physical trauma for the patient, are common as the disease progresses.
RA epidemiology
women
prevalence increases with age, peak between 40-60
family pattern
RA subjective
awaken with joint pain, stiffness, improves as day progresses
RA objective
peripheral symmetric arthritis, morning stiffness >1 hour
PIP and MCP joints most affected, tender, swollen, immobile
RA diagnostics
initial- periph circulating RF
anti- CCP antibodies, ESR, CRP, CBC
xray (may not show anything early)
subsequent checks: monitor ESR or CRP
a positive RF titer of greater than 1:150 indicates
a poorer prognosis and is often accompanied by findings of severe disease, such as rheumatoid nodules
RA initial management
PT, heat/cold, exercise, rest (2h/day), assistive device, splints, meditation, chiropractor, weight loss
meds to treat RA
analgesics (acetaminophen, capsaicin cream)
NSAIDs
Steroids (daily therapy for max 6 months)
Plaquenil, arava, neoral, humira, rituxan
RA follow up
Labs every 90 days- CBC, CMP, CRP (less than 0.8mg)
CFS/fibromyalgia epidemiology
women
occurs in those affected by systemic inflammation disorders
hx: sexual/physical abuse
CFS/fibromyalgia subjective
post exercise malaise, fatigue, polyarthralgia, HA, impaired memory, depression, sore throat
CFS/FMS objective
sudden onset, shotty cervical lymph nodes
widespread muscular pain that is present for 3 months or more in 11/18 or more tedner points
CFS/FMS treatment
cognitive behavioral therapy
graded exercise
very little evidence for med treatment
sjogrens syndrome
chronic inflammatory autoimmune caused by exocrine dysfunction
dryness in all areas of body
sjogren’s epidemiology
women
possible genetic predisposition
40-60 yrs
sjogrens subjective
eye dryness, dry mouth, loss of taste/smell, dental caries, dysphagia
sjogren’s objective
foul breath
beefy red tongue
six defining criteria Sjogren’s
- inadequate tear production
- cornel epithelial damage
- decreased saliva
- lymphocytic infilitration of labil salivary gland tissue
- impaired salivary gland function
- autoantibiodes
sjogren’s diagnostics
CBC, RF, ANA, Y-globulin profile
sjogren’s treatment
symptom supportive care- quarterly dental eval, artificial tears
rituxan
SLE epidem
women
3rd or 4th decade of life
African decent- 4x increase
SLE diagnosis
4/11
arthritis
photosensitivity
oral/nasal ulcers
malar rash (butterfly)
discoid rash (raised red patch)
serositis of pleura
renal disease
hem disorders
positive ANA
neuro disorders
immune abnormalities
SLE subjective
malaise, fever, anorexia, unplanned weight loss, blurred vision, sleeplessness, depression
SLE objective
butterfly rash
alopecia
splinter hemorrhages
lymphadenopathy
raynaud’s
swollen joints
impaired cognition
abdominal tenderness
SLE diagnostics
CBC, BMP, albumin, ANA, UA, antiphospholipid antibodies
SLE treatment
symptom control
NSAIDs, Plaquenil, prednisone, Benlysta, Cellcept
SLE increases risk for
lymphoma, breast cancer, abnormal pap, squamous cell skin cancer
Infectious mononucleosis
viral syndrome characterized by prolonged malaise and fatigue, fever, sore throat, and tender cervical lymphadenopathy.
majority caused by EBV
symptomatic cases of mono most common in
teens, young adults
mono epidem
incidence of clinical infection up to 30x higher in whites than blacks
EBV most commonly spread via
saliva
Mono subjective
fever, sore throat, adenopathy, fatigue, N/v, anorexia
Mono objective
high fever (102.5), tender cervical lymphadenopathy
enlarged tonsils, exudate
enlarged liver, spleen
fine maculopapular rash (viral exanthem)
mono diagnostics
CBC, CMP, monospot
throat culture to r/o strep
monospot
less sensitive in younger pts
mono treatment
supportive care
limit contact sports for at least 4 weeks
Lyme disease
caused by borrelia burgdorferi (tick carrying this)
early signs lyme
fever, chills, HA, fatigue, myalgia, arthralgia, lymphadenopathy
later manifestations of lyme
meningitis, arthritis, facial palsy, arrhythmias, nerve pain, memory loss
erythema migrans
bulls eye rash, lyme disease
most lyme infections occur
in late spring, summer, early fall
likelihood of b. burgdorferi infection depends on
duration of tick exposure
must feed for at least 24-48 hours
Lyme subjective
flu like illness (fever, chills, myalgia), rash, fatigue, HA, neck pain/stiffness
Lyme objective
erythema migrans (pruritic, burning)
arthritis, arthralgias, neuro
bannwarth syndrome
more common in european causes of lyme
lymphocytic meningitis
cranial nerve palsies
radiculoneuritis
Lyme diagnostics
enzyme immunoassay, then western blot
Lyme treatment if attached tick
single dose doxycycline 200mg
early localized lyme disease tx
doxycycline 100mg bid 10-14 days
cardiac, neuro, arthritis manifestations lyme tx
30 days doxycycline 100mg bid
Jarisch-Herxheimer reaction
worsening of symptoms with rigors, fever, hypotension in 1st 24 hours of antibiotics
Often, pts with HIV are
asymptomatic for many years before diagnosis made
HIV epidemiology
2/3 new infections occur in Africa
men who have sex with men, African Americans, latinos
HIV 1
predominant strain in USA and wordwide
HIV 2
West Africa, results in slower disease progression and less transmissible
Transmission of HIV
sexual contact
needle sharing
(previous) blood transfusions
mother to newborn
Following initial HIV infection, pts become more vulnerable to
outbreaks of common infections
if pt presents with thrush
consider testing for HIV
HIV objective
persistent generalized lymphadenopathy
candida infection
STI
weight loss
HIV testing should be
part of routine care for those age 15-65
people with these risk factors should be tested annually
men who have sex with men
sex with HIV positive partner
more than 1 sex partner since last testing
uses injected drugs
exchanged sex for drugs/money
dx with hepatitis, TB
PrEP
given to those with substantial risk of getting HIV
Test for HIV, hep B/c, CMP for renal function
truvada daily
PEP
HIV uninfected has exposure that carries substantial risk of HIV infection
infrequent exposures
Start within 72 hours of exposure
Labs prior: HIV, HBV, HCV, creat, liver enzymes
28 day course of 3 drug ARV reigmen
Post exposure HIV testing
4-6 weeks after initial exposure, test HIV, creat, liver enzymes
Acute HIV/early HIV treatment
ART, regardless of CD4 count
initial disclosure of hiv test results
done face to face
provide immediate interventions
encourage pt to disclose HIV status to partners
Discuss transmission
Initial lab testing for newly diagnosed pt with HIV
CD4
HIV viral load
genotype resistance testing
tropism testing
Hep a, b,c
CBC with diff
CMP
FLP
HgA1C
Tb test
UA
STI
Hcg
baseline viral load HIv
2 separate viral load tests 2-3 weeks apart
repeat viral load testing
4-6 weeks after starting ARV
AIDS
person with HIV with CD4 count less than 200
if HIV pt complains of visual problems (loss of visual acuity, eye pain, photophobia, floaters)
suspect CMV retinitis or fungal endophthalmitis
candidiasis tx AIDS
fluconazole 100mg x1-2 weeks
HSV tx AIDS
acyclovir 200-400mg po tid x7-10 days
