Q - Quickly and accurately assess the patient (Gather information and identify the problem

E - Establish that the patient is an appropriate self-care candidate (Identify Exclusions for Self-Treatment......aka.....is he/she retarded?)

S - Suggest appropriate self-care strategies (Identify alternative solutions, select an optimal solution

T - Talk with your patient (Prepare and Implement a plan, educate patient)

Precipitating event - What do you think caused the symptoms? Have you changed your routine?

Pallitative - Have you tried anything to help the symptoms? Does it work? Does anything make symptoms worse?

Quality - Can you describe your condition a little more for me? Does it itch? Is there any pain involved? Is there any color?

Site - Where exactly are your symptoms?

Severity - How bad would you describe this problem?

- Make patient comfortable

- Wash hands

- Ask permission

- Eye contact

- Non-threatening

- Explain what you will be doing

- Level of consciousness

- Distress

- Appearance

- General state of health

- Skin and lesions

- Height, weight, and build

- Posture, gait, motor activity

- Dress, grooming, personal hygiene

- Body and breath odor

- Facial expressions and affect

- Appearance and behavior

- Level of consciousness

- Orientation

- Affect and Mood

- Memory and judgement

- Abstract reasoning and processing

Men = 50 + 2.3 (Height(in) - 60)

Women = 45.5 + 2.3 (Height(in) - 60)

 BMI = Weight (kg)/Height(m²)

Normal BMI = 18-24 kg/m²

Measure for 6 seconds then multiply by 10....or...

Measure for 30 seconds then multiply by 2.  If abnormal, measure for 1 minute.  Normal pulse is 60-100 bpm

- Should be 98.6 degrees F (37 degrees C)

- "Not" for kids under the age of 4 (why the "not"? Dumbass)

- No eating or drinking for 20-30 minutes prior

- Besides being really gay, it can be 0.5-1 degree F higher than oral temperature

- Must lubricate tip (#$@#$)

- Insert 1/2-1 inch into rectum (wtf)

- 0.5-1 degree F lower than oral temperature

- Accuracy?

- 0.5-1 degree F higher than oral temperature

- Not for kids less than 3 months old.

- Forehead

- Pacifier

- Mercury

- Blood pressure is systolic pressure / diastolic pressure.

- It is in mmHg (millimeters of mercury)

- Weight

- Exercise

- Diet

- Stress

- There are others but I don't have my notes right now

- Mercury

- Aneroid

- Oscillometric Electronic devices (available for home and office use)

- Stethoscope

- Manometer

- Cuff

- Valve

- Inflation Bulb

- Arm (Typical site of measurement, most accurate)

- Wrist

- Finger

- Length of cuff should be 80% of the circumference of patient's dominant arm. 

- Width of the cuff should be 40% of the arm circumference (4 general sizes of cuffs, exact LXW for the cuffs slightly varies by manufacturer)

- Sitting, standing, or lying down

- Arm at level of the heart

- Place cuff on bare upper arm with its legnth midpoint over the brachial artery

 - Place 2 fingers over brachial artery to locate pulse

- Inflate cuff until pulse disappears

- Record the pressure at which pulse disappears

Phase 1 - A tapping sound

Phase 2 - a soft swishing sound

Phase 3 - A crisp sound

Phase 4 - A blowing sound

Phase 5 - Silence

- Mentally record the pressure of the first 2 consecutive beats of phase 1

- Mentally record the pressure of Phase IV for children and Phase 5 for adults

- Listen for 10 mmHg more, then rapidly release cuff pressure by opening valve completely

- Record the date, time, blood pressure, arm used, and position of patient on the "Blood Pressure Measurement Patient Record."

- Take a second set of measurements by completing setps 7-12 (average the measurements, wait 1 minute in between measurements if patient is standing, wait 3 minutes in between measurements if patient is sitting or lying down)

- Instruments

- Patient specific factors

- Technique (put variables of technique here once you get notes)

- Auricle

- Ear Canal

- Tympanic membrane

- External surface

- Nasal Mucosa

- Septum

- Sinuses

Lips - Color, lesions, swelling

Mucosa - color, ulcerations, hydration, lesions

Teeth and gums - missing teeth, color, inflammation, bleeding, lesions, receding

Tongue - Midline, color, lesions, movement

Tonsils - Color, edema, exudative, swelling

Breath - Odor

Pharynx - Pain, hoarseness

Movement - range of motion

Gland and nodes - enlargement, size, shape, mobility, consistency, tenderness

Veins - Jugular venous distension

Carotids - Pulses, bruits (?)

Thyroid - Symmestry, masses, scars, size, consistency, shape, temperature, mobility

- Inspect neck, trachea, chest, fingernails

- Observe respiration (rate, rhythm, depth, and effort)

- Listen to breathing (wheezes, prolonged expiration)

Hollow Organs - tympany (This is because of the stomach, the air-filled bowel, and bladder)

Solid Organs - dull (liver, spleen, kidneys, pancreas, uterus, ovaries, stool filled bowel) 

Inspection of arms and legs - Edema, Size and symmestry, venous patterns, skin and nails (nail-bed color), texture, scars, rashes, temperature

Palpation - pulses,  temperature 

1+ Slight - No visible distortion, disappears rapidly

2+ Somewhat deeper - No visible distortion, disappears in 10-15 seconds

3+ - Noticeably deep, dependent extremity looks full and swollen, lasts > 1 minute

4+ Very Deep - Dependent extremity grossly distorted, lasts 2-5 minutes. 

I - Olfactory

II - Optic

III - Oculomotor

IV - Trochlear

V - Trigeminal

VI - Abducens

VII - Facial

VIII - Acoustic

IX - Glossopharyngeal

X - Vagus

XI - Spinal Accessory

XII - Hypoglossal 

- Pain

- Temperature

- Light Touch

- Vibration

- Proprioception

- Discriminative sensation (Stereognosis, 2 point discrimination, point localization, extinction)  

- Involuntary movements

- Muscle bulk, tone

- Muscle Strength

- Coordiation and balance (Rapid alternating movements, point to point movements, gait) 

Grade 1 - 10% Some contractility, no movement

Grade 2 - 25% - Full ROM, gravity enhanced

Grade 3 - 50% - Full ROM, against gravity

Grade 4 - 75% - Full ROM against gravity, some resistance

Grade 5 - 100% - Full ROM against gravity, full resistance

Deep Tendon Reflexes: UE (Tricpes, biceps, brachioradialis), LE (patellar, Achilles)

Superficial Reflexes - Plantar and abdominal 

4+ - Very brisk, hyperactive

3+ - Brisker than average

2+ - Average

1+ - Somewhat diminished

Trace - response only with reinforcement

0 - No response 

- Localized, self treatable problems (dandruff)

- Underlying systemic problems (fungal infection)

- Adverse drug reactions 

- The patient exhibits systemic symptoms

- It is non-diagnosable

- It is an infection

- The patient is immunocompromised

- Prior treatments have failed

- The condition has an abnormally long duration. 

- Trauma

- Temperature Variations

- Moisture and Humidity

- Microorganisms

- Radiation

- Penetration 

- Divided into three layers (Epidermis, Dermis, and Subcutaneous, or hypodermis layer)

- Epidermis protects dermis

Stratum Corneum - Dead squamos cells (Keratin) protects from environment/restricts water loss

Stratum Ludicum, Spinosum, Germinativum - Synthesizes Keratin cells

Stratum Basale - Melanocytes, pigments protect from UV rays 

Under what conditions should you examin the skin?

- In a well lit, private area

- Tools should include centimeter ruler, gloves, and magnifying glass.

- Visually inspect color and appearance, thickness, symmestry, hygiene, and presence of lesions on skin.

- Palpate to check for moisture, temperature, texture, turgor, and mobility of skin. 

- Characteristics (size, shape, color, texture, elevation/depression)

- Presence of exudate (color, ordor, amount, consistency)

- Configuration (annular, grouped, linear, arciform, diffuse)

- Location and distribution (generalized/localized, body region, pattern) 

- Physical alterations of the skin caused by pathologic process.

- These include non-raised (macule, patch), fluid-filled (vesicle, bulla, pustule, cyst), and raised (papule, nodule, plaque, wheal) 

Macule - A flat, non-raised colored <0.5cm in diameter (freckle)

Patch - Macule with scale or fine wrinkles >0.5cm in diameter (vitiligo)

*These are examples of non-raised lesions 

Papule - Solid, elevated lesion <0.5cm in diameter (wart)

Nodule - Solid, elevated lesion >0.5cm in diameter (Lipoma)

*These are examples of raised lesions 

Plaque - Marginal depth, >0.5cm in diameter (psoriasis)

Wheal - Papule or plaque rising from edema caused by pruritis (allergic reaction)

*These are examples of raised lesions 

Vesicle - Blister filled with clear fluid, <0.5 cm in diameter (Herpes Simplex)

Bulla - Blister filled with clear fluid, >0.5 cm in diameter (2nd Degree Burns)

*These are examples of fluid-filled lesions
 

Pustule - Vesicle filled with purulent liquid (Folliculitis)

Cyst - Nodule containing semi-solid or solid (sebaceous cyst) 

- Result from changes in primary lesions caused by external factors (Scratching, infection)

- Loss of skin could result (erosion, ulcer, fissure, excoriation)

- Build-up of skin could result (lichenification, scar, crust, scale) 

Scale - Dandruff

Crust - Scab

Fissure - Athlete's foot

Erosion - Ruptured Vesicle

Ulcer - Pressure Sore

Lichenification - Chronic Atopic Dermatitis 

- Hair primarily consists of root, shaft, and follicle

- Papilla (loop of capillaries at base of follicle), supplies nutrients for growth

- Melanocytes provide color

- Vellus (short, fine, soft, nonpigmented hair)

- Terminal (coarser, longer, thicker, and pigmented hair

- Hair goes through cyclic changes (Growth, atrophy, and rest (hair sheds)) 

- Note hair loss, inflammation, or scarring

- Questions to ask (Regarding alopecia).....

Gradual or sudden onset?

Does it occur anywhere else?

Family history?

Recent illness, stress, trauma, or new drugs? 

Androgenic Alopecia - Male-pattern baldness

Alopecia Areata - Localized areas of hair loss

Infective Alopecia - Caused by Tinea Capitis 

Nail Plate - Keratin

Nail bed - Vascularized

Nail matrix - Site of growth

Lanula - Marks end of nail matrix

Cuticle - Layer of skin covering nail root 

Visually Inspect Nails - Observe color of nail beds, nail plate (smooth, pitted, ridges, flat) and nail base angle (should be 160 degrees)

Palpate the Nail - Should feel hard and smooth with uniform thickness.  Squeeze nail to test for adherence of nail bed.   

Nail clubbing - results from chronic low blood oxygen levels

Koilonchyia/Spooning - Soft, scooped out nails, associated with iron deficiency anemia.

Onychomycosis - Fungal infection, nails thicken and become discolored 

- Effects 10-20% of population

- Most common infections are in the following order.....

1.  Foot - Tinea Pedis

2.  Body - Tinea Corporis

3.  Groin - Tinea Cruris

4.  Scalp - Tinea Capitis

5.  Trunk - Tinea Versicolor

6.  Nails - Tinea Unguium 

- Trichophyton

- Microsporum

- Epidermophyton

- Candida 

- People

- Animals

- Soil

- Objects 

- Clothing that is too tight and causes moisture buildup

- Anything that is moist and warm breeds fungus

- Can occur in healthy person

- Walking around damp wet locker room

- Can get from someone else

- Daycare, wrestling mat

- Contact with animals

- Those who are immunocompromised 

- Short duration

- Isolated

- Self limiting

- Can be recurring but are superficial, not a bad infection

- Itchy or red

- May resolve without treatment 

- Fissures

- Odor

- Scaling

- Usually involves both feet

- Slowly progressing

- Pustules

- It may also burn

- Will not resolve without treatment

- Start between toes and then spread 

- Can occur anywhere

- Rounded, not a perfect circle, edges have pustules or vesicles.

- This fungal infection, like any, can spread on the person to another person 

- Mostly present in groin and thigh area.

- Red, circular, and peeling in appearance.

- Those affected are mostly athletes and the obese 

- Yellow, brittle, cracking nails.

- Can lose nail if infection is bad enough.

- On feet it usually starts on the big toe

- Infection of the nail bed, which is where it starts

- Can't treat fungal nail infections over the counter. 

- Clear the infection

- Prevent another infection

- Help with symptoms 

- Involves their nails or if it is a severe case or covers a large part of the body

- Infection lasts more than 2 weeks

- Treatments aren't working

- Immuno-compromised patient

- If it's systematic

- If patient has a fever

- Secondary infection going on: Scratch leads to also having a bacterial infection 

- Could become a systemic infection

- Could become a secondary infection

- Lose a nail

- Lose hair

- End up with scarring 

- Maintain hygiene

- Stay clean, try to stay dry

- Avoid contact with contaminated clothing or towels

- Launder the contaminated items separately

- Make sure sneakers are dry, change your socks, cotton socks, sandals without socks

- Wear protective footwear in public areas: dorms, hotel, schools 

Classes:

- Azoles

- Benzylamine

- Allylamine

- Hydroxypyridone

Other agents:

- Clioquinol

- Undecylenic Acid 

Imidazoles- Lotramin, Lotramin AF (clotrimazole), Spectazole (econazole), Nizoral (Ketoconazole), Desenex (Miconazole)

Triazoles - Diflucan (Fluconazole)

Method of Action:

- Reduce egerosterol production by inhibiting fungal P450 enzymes

- Broad-spectrum action including some gram (+) bacteria. 

Uses: Treats tinea infections of the body, foot, groin, scalp, and nails 

Strength - 1%

Dosage - Cream, powder, solution

Administration - Apply BID for 1 month 

Strength - 1%

Dosage form - Cream

Administration - Apply QD for 1 month 

Strength - 50, 100, 150, or 200 mg

Dosage Forms - Tablets or suspension

Administration - Depends on type of infection 

Strength - 100mg

Dosage Forms - Tablets, Suspension

Administration - See Tinea Unguium Treatment 

Strength - 1%, 2%, 200mg

Dosage Forms - Cream, Shampoo

Administration - Depends on type of infection 

Strength - 1%, 2%

Dosage Forms - Cream, Lotion, Powder, Spray

Administration - Apply BID for 1 month 

- Irritation and burning

- Itching 

- N/V (wtf does this mean?)

- Fatigue

- Edema

- Elevanted LTF's (?)

- HA (?), more common for fluconazole

- Gynecomastia  (ketoconazole only)

- Impotence

- Decreased Libido

- Photophobia 

- None when applied topically

- Oral ketoconazole - Inhibits P450 enzyme 3A4

- Oral Intraconazole - Inhibits P450 enzyme 3A4

- Oral Fluconazole - Inhibits P450 enzyme 2C19, 3A4 

- None when applied topically

- Oral Ketoconazole:

Achlorhydria/Hypochlorhydria

Pregnancy Category C

Lactation 

Examples - Lotramine Ultra or Mentax (Butenafine)

Method of Action - Causes fungal cell death by inhibiting squalene epoxidase

Use - For the treatment of tinea corporis, cdruris, versicolor, and interdigitale pedis 

Strength - 1%, contains benzyl alcohol and sodium benzoate.

Dosage Form - Cream

Administration - Tinea Corporis, Tinea Cruris, Tinea Versicolor: Apply once daily for 2 weeks to affected area and surrounding skin 

Side Effects - Mild Burning

Drug Interactions - None

Contraindications - Not approved for children <12 years old 

Examples - Naftin (Naftifine), Lamisil AT, Desenex Max (terbinafine)

Method of Action - Causes fungal cell death by inhibiting squalene epoxidase.  Naftin may have some anti-inflammatory effects

Use - For the treatment of tinea capitis, cruris, coporis, interdigitale pedis, unguium, and versicolor 

Strength - 1%

Dosage Forms - Cream or Spray

Administration - Should be applied sparingly to affected area twice daily 

Examples - Loprox, Loprox TS, Penlac (Ciclopirox)

Method of Action - Causes fungal death by blocking the uptake of essential intracellular substrates such as potassium ions.  Broad Spectrum including yeast and some bacteria.  

Use - For the treatment of Tinea Cruris, Corporis, Pedis, and Versicolor 

Strength - Cream 0.77%, Gel 0.77%, Shampoo 1%, Solution 8%, Suspension 0.77%

Dosage Form - Cream/suspension, gel, solution, and shampoo

Administration - Cream/suspension; apply twice daily, gently massage in to affected areas 

Side Effects - Low Incidence of side-effects.  May include Pruritis, burning, and worsening of sx (wtf is this?).  Rash and erythermia.  Nail discoloration (Nail lacquer only)

Drug Interactions - None

Contraindications - Do not use in children < 10 years of age.   

Examples - Asorbine, Aftate, Tinactin

Method of Action - Distorts Hyphae and stunts fungal growth.  Narrow spectrum.

Use - For the treatment of Tinea Capitis, Cruris, corporis, and pedis.   

Strength - Aerosol, Spray/powder/cream/liquid/solution 1%

Dosage Form - Aerosol spray, powder, cream, liquid, solution.

Administration - Wash and dry affected area; spray aerosol or apply 1-3 drops of solution or small amount of cream or powder and rub in to the affected areas twice daily 

Side-effects - Irritation and burning

Drug Interactions - None

Contraindications - Do not use in children < 2 years of age 

Examples - Aluminum Salts (Aluminum Acetate)

Method of Action - Astringent agents that may decrease inflammation

Strength - 20% have antibacterial activity, aluminum chloride 20%

Dosage Form - Solution or powder packets, powder, and effervescent tablets to be dissolved in water.

Administration - Aluminum Acetate for use in tinea pedis is generally diluted with about 10-40 parts of water.  Depending on the situation, the patient should immerse whole foot in solution for 20 minutes up to three times a day, or apply solution to affected area in the form of a wet dressing.   

Side-Effects - Burning, irritation

Drug Interactions - None

Contraindications - Deep fissures of the skin, external use only. 

Topical vs. Systemic - Topical preferred but systemic can be considered if large surface area are involved, extensive dermatophytosis infection, or if topical treatment fails

Which one would you recommend? - There are a few direct comparisons between products.  Current evidence suggests that there is no therapeutic advantage of one antifungal ove another but consider length of therapy in decision 

Cream/Solution - Use on non-oozing, moderately scaling lesions

Gel/Ointment - Use on hyperkeratotic lesions

Lotion - Use on interdiginous or hairy areas, and on oozing lesions

Powder/Spray - May be helpful in preventing reinfection, also may contain talc (in powders)

Shampoo - Use on scalp only 

- Pyrithione Zinc

- Selenium Sulfide

- Coal Tar

- Salicylic Acid

- Sulfur

- Pyrithione Zinc

- Selenium Sulfide

- Sulfur

- Ketoconazole

- Salicylic Acid

- Coal tar

*Patient should shampoo several times weekly

**None of the above medications should be used in children.

- Found on face, neck, chest, back

- Provide sebum to follicular canal and the skin surface (via pore)

- Increased sebum production

- Sloughing of keratinocytes

- Bacterial growth

- Inflammation

- Genetics

- Stress

- Hormonal (excess androgen)

- Physical occlusion

- Medications (PIMPLES acronym)

- Phenytoin

- Isoniazid

- Moisturizers

- Phenobarbital

- Lithium

- Ethionamide

- Steroids

-Follicular microcomedone

- Non-inflammatory lesions (Open comedone or blackhead, closed comedone or whitehead)

- Inflammatory lesions (Papule <1cm, Pustule, Nodule >1cm)

- Scarring/Hyperpigmentation

Mild - Closed and open comedones

Moderate - Papules and Pustules

Severe - Papules, Pustules, Nodules, and Scarring

1.  Treat current acne

2.  Prevent future outbreaks

3.  Minimize Scarring

4.  Relieve patient discomfort

- Proper cleansing techniques

- Minimize controllable exacerbations

- Don't pick at skin!

- Topical retinoids

- Topical antibiotics

- Oral antibiotics

- Hormonal therapy

- Isotretinoin

- All are mild comedolytic and antibacterial treatment, available in variety, but not very effective

- Disadvantages are skin irritation in salicylic acid, unpleasant smell in Sulfur, and reversible brown scale formation in resorcinol.

- Non antibiotic with bacteriostatic activity

- Available in soap, lotion, cream, wash, gel (1-10%)

- Apply 1-3 times a day

- Increase application by 15 minute intervals until 2 hours tolerated

- Could bleach hair and cloths, irriate skin, sun sensitivity rxns.

- Includes Tretinoin, Adapalene, Tazarotene

- Comedolytic, Keratolytic, anti-inflammatory

- "Acne will get worse before it gets better"

- Clinical clearing in 8-12 weeks

- Reformulation of tretinoin w/ porous beads, epidermal deposition enhanced

- Efficacy > adapalene, but more ADR's

- Less irritating than tretinoin

- Antibacterial, anti-inflammatory, comedolytic

- Alternative for BPO intolerance (Benzol peroxide)

- Skin lightening properties

- Could experience burning and itching

- Effective in inflammatory acne

- Duac

- Clindamycin, Erythromycin

- Resistance is problem with monotherapy, used with BPO to decrease resistance

- Treatment duration 6-8 weeks

- For inflammatory acne when topical products have failed

- Follow up in 6 weeks

- 3-6 month course --> topical treatment

- ADR: Tetracycline, Minocycline, Doxycycline: avoid taking w/ antacids and dairy, sun sensitivity, GI (take w/ food)

- Erythromycin (macrolide): GI, CYP450 inhibitor

- Drug interactions with birth control

- Ortho Tri-Cyclen (Anti-androgen)

- FDA approved for moderate acne in women

- Pregnancy is contraindication

- Adverse reactions could be nausea, vomiting, weight gain, and clotting

- Also called Accutain, Sotret, Amnesteem

- 6 month course of therapy

- Skin sensitivity, acne flare up, dryness, depression, alopecia, lipid effects are all side effects

- A teratogenic

- Regulated via iPLEDGE program.

- Females must not become pregnant before, during, and 1 month after therapy

- If of child bearing age, must have 2 neg. pregnancy tests, 1 at MD office, 1 at lab office.

- 2 forms of effective contraception (1 month before, during, and 1 month after therapy)

- Monthly online questionnaires

Oily - Gels, solutions

Normal - Gels, Solutions, Lotions, Creams

Dry - Lotions, Creams

Sensitive - Creams

Non-sensitive - Gels

What are some signs and symptoms of a brown recluse spider bite?

What are some signs and symptoms of a flea bite?

What are some signs and symptoms of a scabies bite?

What are some signs and symptoms of a bedbugs bite?

- Parasite that burrows into stratum corneum

- Clinical presentation is intense pruritis secondary to allergic reaction, papular rash with excoriations, and characteristic distribution

- Treatment is 5% permethrin cream to eradicate scabies, symptomatic treatment for itching

- An inflammatory systemic infection caused by Borrelia burgdorferi spirochete transmitted by deer ticks.

- Infected perrson will get Erythema migrains, rash, and flu like symptoms

- Papule will become a "bulll's eye"

- Will appear 3-30 days after the bite

- Disappear spontaenously within 3-4 weeks (days with antibiotic)

- If left untreated, could result in neurologic symptoms, cardiac disturbances, and musculoskeletal symptoms

- Avoid exposure to vector ticks!

Prophylatic treatment may be offered if....

- Deer tick

- Attached >36 hours (takes at least 36 hours for transmission)

- Local tick infection rate >20%

- Meidcation can be started within 72 hours of removal

- Doxycycline is not contraindicated

Dosing - Adults: Doxycycline 200mg x 1 dose; Children >8 yrs 4mg/kg (Max 200mg) x 1 dose

In Early Disease......

-Most respond to antibiotics (20% can resolve untreated)

- Preferred regimens include.......

Amoxicillin 500mg PO TID

Doxycycline 100mg PO BID

Cefuroxime 500mg PO BID

All of these treatments for 14-21 days

-Late disease treatment options include longer duration of oral antibiotics and IV antibiotics

- Residual subjective symptoms may remain.  5-15% at 6-12 months post-treatment, 10% at 5 years post-treatment

- Initially isolated in 1937 from the blood of a woman with a febrile illness in the West Nile district of Uganda

- Caused major outbreaks of meningoencephalitis in Romania in 1996 and in Russia in 1999.

- First detrected in NY state in 1999, approx. 200 cases statewide since 2000

- Virus has been isolated from mosquitos, more than 4000 birds, 58 horses, and a few small mammals.

- Asymptomatic (80%)

- West Nile fever (20%); Flu-like symptoms and fatigue

- West Nile encephalitis or meningitis (1/150 pts); includes disorientation, tremors, convulsions, paralysis, coma.  CDC reports 3-15% mortality

- Elderly are at greatest risk

- Treatment includes supportive measures, and control of mosquito population

- Relieve Symptoms

- Prevent secondary bacterial infections; these can occur if skin is abraded during scratching (Impetigo)

Avoid Insects - Cover skin, avoid swamps and dense woods etc., keep pets free of pests, remove areas of standing water, minimize prolonged personal contact with scabies.

Repellents - Not effective vs. stinging insects, 7-40% DEET, 50-100% DEET (Adults with high exposure for long periods with high heat/humidity, <30% DEET: Children older than 2 months, usually apply every 4-8 hours, could irritate skin, MAY APPLY ICE PACKS. 

- For insect bites/stings, minor cuts, burns, or abrasions

- Blocks local nerve impulses --> loss of sensation

- Apply to bite area bid-tied for up to 7 days

- ADRs/Precautions; Relatively non-toxic and well tolerated, may cause contact dermatitis, WARNING: overuse may result in systemic absorption and cause seizures, respiratory depression and death.  Do not apply large amounts or over a large surface area, do not apply to open wounds, do not ocver with occlusive dressing.

- Creams, lotions, ointments, sprays

Examples - Benzocaine, Lidocaine, Dibucaine, Pramoxine, Benzyl Alcohol, Phenol, Combination products (Lidocaine/Prilocaine is Emla, not over the counter, Pramoxine/Benzyl alcohol is Itch-X, Phenol/Benzocaine/Camphor/Diphenhydramine is Sting Eze)

- Insect bites, minor cuts/burns, or poison ivy

- MOA: relieve pain or itching by depressing skin receptors

- Administration: Apply to bite area tid-qid for up to 7 days

- ADR's/Precautions:

Contact dermatitis: Increase risk and increase duration

Avoid applicatoin to large areas in small children

Products: Diphenhydramine (Benadryl, Dermarest, etc.) 0.05% to 2% cream, gel, or spray 

- For itching and dry skin

- MOA: Paradoxical, produces a less severe pain to "hide" the more intense one; also produces a mild analgesic effect. 

- Administration: Apply to bite area tid-qid for up to 7 days

- ADRs/Precautions: Well tolerated, Camphor is toxic if ingested - keep out of reach of children

- Products: Menthol 0.1% - 1% and Camphor 0.1% - 3% (Sarna Lotion, Gold bond medicated powder, etc.)

- For insect bites, contact dermatitis, and poison ivy

- MOA: Inhibits inflammation and urticaria

- Administration: Apply to bite area tid-qid for up to 7 days

- ADRs/Precautions:

Burning, contact derm., and dryness

Skin atrophy and folliculitis if used > 7 days

Can mask other types of infections, don't use for scabies!

- Products: Hydrocortisone 0.5% to 1% OTC cream, spray, and ointment (Cortaid, Cortizone-10, Lanacort, etc.)

What are some characteristics of skin protectants?

 - For minor skin irritations (Insect bites, cuts, burns, etc), should be used for children under the age of 2.

- MOA: Reduce irritation and inflammation; absorb fluid from weeping sores

- Administration: Apply to bite area as needed up to qid

- ADRs/Precautions: None

- Products include Zinc Oxide, Calamine, Titanium Dioxide.

- Available as cream, ointment, or lotion

- Combination products of calamine/pramoxine available as Caladryl or Aveeno.

- Apply tid-qid for a max of 7 days

- Avoid excessive application

- Contact dermatitis (Local anesthetics, topical diphenhydramine for prolonged use)

- Hydrocortisone use may mask skin infections

- Infants/Children can use skin protectorants, but camphor is innappropriate.  DEET use is inappropriate for infants under 2 months of age.

- Get out of area ASAP (lol!)

- Remove stinger immediately; swipe with credit card (but it doesn't take American Express) or fingernail

- Wash area with soap and water

- Apply ice or cool wet cloth in 10 minute intervals

- Observe for systemic reaction

- Systemic antihistamines

- Hyposensitization therapy

What are symptoms and treatments for a local reaction?

- Localized burning, itching, or swelling

- Treatment includes local anesthetic, skin protectorant, antiseptic, steroid or counterirritant, oral antihistamine; raw meat (neutralizes venom? wtf)

- Symptoms include hives, swelling of the face or mouth, difficulty speaking, SOB (?), dizziness, abdominal pain, or vomiting

- Should seek medical attention immediately; injectable epinephrine, antihistamines

DOC - Epinephrine (alpha1, beta1, beta2, agonist)

A1 - Constricts BV to increase BP

B2 - Bronchial dilation

- Epipen auto-injector - Self inject into thigh

- Make sure to observe product for discoloration, and regularly monitor expiration date

- Often used with oral or parenteral antihistamines

- Remove plastic tube

- Remove safety release cap

- Hold with black tip pointing toward outer thigh

- Inject forcefully through clothing at 90 degree angle

- Hold for 10 seconds

- Massage area for 10 seconds

- Check for red plunger and needle

- Place back into plastic tube

- Call 911

- Wears off after 15-20 mins (may repeat)

- New Rx for Epipen

- Wingless parasites

- Carriers and transmitters of epidemic diseases

- Three different types: Pediculus humanus capitis, Pediculus humanus corporis, Phthirus Pubis

- Called head lice

- Most common species

- Common in children (those bastards)

- Outbreaks associated with crowded places

- See increase in number of outbreaks from August-November

- Route of transmission (what about it?)

- Scalp, behind the ears, and near the neckline

- Grab on to hair shaft (that's awesome)

- Commonly called body lice

- Live and lay eggs in clothing and bedding

- Often found in seams and folds of undergarments

- Infestation due to poor hygiene

- Route of administration (?)

What are some characteristics of Phthirus Pubis?

- Pubic Lice

- Most commonly found in genital area

- May also be found in other areas

- Route of transmission (?)

- Pruritis

- Wheal and papule at site of bite

- Presence of nits and nit casings

- CDC based, finding "X" amount of eggs within a quarter inch of skin

- Finding a living, moving louse

- Visual inspection with a fine toothed "nit" comb

- Application of pediculicide agent

- Nit removal

- Cleaning of personal items (Clothing and bedding, hairbrushes and combs)

 - Removal of nits with specialized comb

- Avoid close contact with infected individuals

- Wash clothing and bedding in HOT water and dry for at least 20 minutes

- Dry clean clothes that cannot be washed

- Soak combs and brushes in rubbing alcohol or Lysol for 1 hour or wash with soap and hot water

- Vacuum furniture and floors

- "Not nit policies"

- Synergized Pyrethrins (Block insect's nerve transmission

- Permethrin (Disrupts insect's nerve cell membrane

Application - Apply medication to DRY hair for 10 minutes.  Shampoo and rinse.  Comb hair every 2-3 days.  Repeat after 7-10 days. 

- Remove all clothes from waist up

- Do not use conditioner prior to treatment

- Change into clean clothing after treatment

- Do not wash hair for 2-3 days after treatment

- Adverse effects generally mild

- Resistance (?)

- Children under 2 years of age

- Pregnancy or breast-feeding

- Infestation of the eyebrow or eyelid

- Chrysantemum or ragweed allergies

- Secondary skin infection

Malathion Lotion (Ovide)

To apply:

1.  Thoroughly cover dry hair and scalp

2.  Allow hair to dry naturally

3.  Shampoo hair after 8-12 hours

4. Comb out dead lice and nits

5.  Repeat after 7-9 days ONLY if lice are still present

- Not f or children under the age of 2

- Medication is flammable and poisonous

- May cause stinging

- Able to kill lice and nits

- Acitvity against pyrethrin resistant lice

- Lindane

- Use shampoo when other options fail

To apply:

1.  Shampoo dry hair with 15-30mL shampoo

2. After 4 minutes, begin lathering with small amounts of water

3.  Immediately rinse away all lather

4.  Towel dry and remove nits with comb

5.  DO NOT REPEAT (lol) 

- Risk of CNS toxicity; could cause mild dizziness, seizures. Don't apply to broken skin, avoid use in elderly and patients <50kg

- Less severe adverse effects are dry skin/scalp, and pruritus. 

- Issues with resistance

- Vinegar

- Isopropyl Alcohol

- Olive oil

- Mayonnaise

- Melted Butter

- Petroleum Jelly

- Nuvo Lotion (Cetaphil)

Advantages:

- Avoids fear associated with pediculides

- No issues with resistance

Disadvantages:

- Lack of efficacy data

- Time consuming application and removal

- Possible toxicity

Petroleum Jelly - Appears to be more effective than vinegar, isopropyl alcohol, olive oil, mayonnaise, or melted butter, but still not as effective as convential pediculides

Nuvo Lotion - Method of action is to suffocate lice.  96% cure rate in two clinical trials.  Not FDA approved.  DO NOT RECOMMEND TO PATIENTS (ok?)

- Members of family only need to be treated if they experience signs/symptoms

- Lice do NOT live on animals

- Sexual partners should be warned of pubic lice, no sexual contact until treatment is completed

DON'T......

- Spray insecticide treatment in rooms of the house or on furniture

- Mix treatments

- Use extra lice medication unless instructed to do so by your physician

- Treat with the medication more than 2 times if it does not seem to be working.

1-2: Low

3-5: Moderate

6-7: High

8-10: Very High

11+: Extreme

- Vitamin D

- Temperature Regulation

- Antidepressant Effects

- Skin cancer

- Wrinkles --> premature aging or photo aging

Suntan/Sunburns - Inflammatory reaction that infovles histamines and prostaglandins

Third Degree Burns -Swollen, painful, and can lead to exfoliation

Second Degree Burns - Bright red

First Degree Burns - Skin is pink

Fourth degree burns - detachment of the skin

Ocular damage

Sun Allergy - Photo allergy

Drug use with the first exposure

Hypoglycemic

- Fair skin

- Light hair, blonde or red

- Freckles

- A history of one or more serious sunburns

- Family history

- Excessive lifetime exposure; cumulative sun damage

- Having moles

- Age; older you become the more sun you have seen

- Latitude; where you are and how much sun you are actually getting

- Any kind of chemical exposure

- Gender

- Job; always outside

- Slow growing

- Small pink flesh colored patch

- Common sites include face, ears, hands, arms.

- Aggresive, invasive, it involves the epidermis and the dermis

- Rarely metastasizes

- Most common type of skin cancer

- Most commonly seen on the face, back of hands

- Very treatable

- Slow growing

- Affects the epithelial keritocytes

- Cumulative sun exposure increased

- Face, ears, back of hands, neck, or on the lips

- 30% arrives from existing moles

- Starts growing horizontally across the skin and then begins to grow deep into the skin

- Can see metastatic disease; it will spread

- Usually seen in women on the legs

- For men and women will be on the back

ABCD

A- Asymetrical lesion

B - Border irregularity, uneven, rigid

C - Color variation, more than one shade of color; red, brown, white, blue, black

D - Diameter; size is greater than 6mm which is larger than a pencil eraser

- Avoid the sun especially between 10am-4pm, when the UV index is high

- Sunscreen

- If you have to go outside wear sunscreen and cover your body (hat, tightly, woven, pants, shirts, sunglasses)

- Regular skin exams (MD marks everywhere there is a mole and then measure the size)

- Is a drug

- Available OTC

- Helps prevent and minimize sunburn, skin damage, freckling, and uneven coloring of your skin

- SPF stands for Sun Protection Factor; most sunscreens have both UVA and UVB.  Want to protect against both types of rays

- Absorbs and blocks the radiation that comes into contact with the epidermis

Can contain:

Aminobenzoic Acid (PABA)

Anthranilates

Benzophenones

Cinnamates

Dibenzoylmethane 

- Able to reflect the sun and helps scatter the radiation

- A lot more difficult to apply than chemical sunscreens

- Not extremely fashionable

Can contain - Zinc oxide or titanium dioxide

- Any where from 2-12 is minimal skin protection

- 12-30 - moderate

- 30 or higher is high

- If you use a SPF of 30 you can still get a tan even thought it may take you longer

- SPF 15 blocks about 90% of UVB

- SPF 30 blocks about 97.3% of UVB

- SPF 40 blocks about 97.5% of UVB

- SPF only measures the amount of UVB

- For a product to claim to have UVA protection it has to have an absorption of 360 - which only blocks some. (what does this mean?)

- Not immunologic

- Often seen on first exposure to chemical agent or drug

- Dose related

- Often appears as an exaggerated sunburn

- Immunologic response

- Relatively rare

- Not dose related

- Characterized by urticaria, bullae, and/or sunburn