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NURS 6531 Midterm Exam Review (Week 1-6)
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Competencies of Advanced Nurse Practitioners

SOAP NOTE –
S – Looking for Subjective Evidence
Interview the patient and/or family member about the history of the present illness.

Ask about the presentation of the illness (timing, signs and symptoms, etc.)
Ask whether the patient is on any medication, inquire about past medical history, diet, etc.

P-Plan

This describes what the health care provider will do to treat the patient - ordering labs, referrals, procedures performed, medications prescribed, etc. How you are going to address the patient’s problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work.

Split/Shared E/M Services applies to hospital inpatient/hospital outpatient or emergency department. This is used when BOTH the NP and physician have BOTH had a face to face visit with the patient. The key here is Face to Face. Doctor must physically lay eyes on the patient, not just review documentation. Other third party payers vary on reimbursement from 85-100%.

Coding: is based on the complexity of the visit. E/M Coding represents the health care provider’s cognitive skills and includes office or clinic visits, consultations, preventative medical examinations, and critical care services. Make sure codes are accurate for diagnoses as Over AND Under coding both constitute Medicare fraud. Medicare fraud can result in fines, criminal prosecution, loss of provider status and license.

collaboration with MD.

INTEGUMENTARY DISORDERS
MELANOMA
Differential diagnoses
a. actinic keratosis
b. seborrheic keratosis
c. dysplastic nevi
d. basal or squamous cell carcinoma
Various treatment options
a. surgical biopsy or removal
b. lymph node excision
c. chemotherapy/immunotherapy
Pattern recognition
a. usual age for diagnosis is early 40s
b. abcde (asymmetry, border irregularity, color variation, diameter >6mm, elevation above level of skin) c. hypo or hyperpigmentation, bleeding, scaling, or size change of existing mole or lesion
d. common in caucasians on back, anterior lower leg
e. common in african-americans on nails, hands, and feet
Comments/suggestions/additional information: Accounts for over 65% of skin cancer deaths; metastasizes to any organ.

B. SCC in situ (Bowens disease): slowly enlarging, erythematous, well-demarcated scaly patch or plaque and confined to outer layer of skin
C. Invasive SCC: spread into deeper layers of skin
D. Metastatic SCC: spread to other parts of body
Comments/Suggestions/Additional Information: primary options for treatment include: flurouracil topical: 5% apply to the affected area for 3-6 weeks and imiquimod topical: 5 % apply to the affected area once daily 2-3 times weekly for 3-6 weeks, doing a biopsy is a must for each case you are uncertain of.

ACRAL-LENTIGINOUS MELANOMA (ALM) is a specific type of melanoma that appears on the palms of the hands, the soles of the feet, or under the nails. Melanocytes contain your skin color (known as melanin or pigment). In this type of melanoma, the word “acral” refers to the occurrence of the melanoma on the palms or soles. The word “lentiginous” means that the spot of melanoma is much darker than the

Pattern recognition
A. Physical presentation includes seeing increased dilation of the venous system and increased pressure may lead to venous hypertension.

B. Edema in bilateral lower extremities
C. Lipodermatosclerosis
D. Ulceration

1) 1) Acyclovir: 800 mg five times per day for seven days
2) Valacyclovir: 1 gram three times per day for seven days
3) Famciclovir: 500 mg three times per day for seven days
c) Severe pain treated with NSAIDs for mild pain; Gabapentin for intense pain; opioids for severe pain.

Pattern Recognition:
a) Initial: Erythematous papules following a single dermatome or several adjacent dermatomes b) At 3-5 days: Appear as grouped vesicles or bullae
c) At 4-5 days: Become pustules
d) At 7-10 days: Rash becomes crusted and the patient is no longer considered contagious.

d) Variable sizes
Additional Information: Acute urticaria is a hypersensitivity reaction to drugs, foods, insect bites, bee stings, or infections. The reaction usually lasts less than 6 weeks. Chronic urticarial lasts longer than 6 weeks and causes angioedema to the face, lips, or tongue; is characterized by stridor and wheezing

SHINGLES – Herpes Zoster
Differential diagnoses
A. Herpes simplex
B. Lymphangioma circumscriptum
C. Acne keloidalis nuchae
D. Cellulitis
E. Contact dermatitis
F. Folliculitis
G. Contact stomatitis
H. Early HIV or Poison Ivy
Various treatment options
A. Domeboro-soaked wet frequently compresses to dermatomal rash
B. Limit contact with high-risk individuals for chickenpox
C. Antiviral drugs: acyclovir, valacyclovir, famciclovir
D. Analgesics for pain management
E. Antipruritic: calamine lotion, and nerve blocks
Pattern recognition
A. Prodrome phase (1 or more skin dermatomes 1- 10 days) Initiating iritis, pleurisy, sciatica, cardiac pain B. Acute phase: a unilateral dermatomal rash over 3-4 days fever, malaise, headache, pain,
Maculopapular rash that progress to vesicles on erythematous base
C. Convalescent-phase rashes resolve in 2-3 weeks; burning, throbbing, stabbing pain, prolonged pain in immunocompromised adults
Comments/Suggestions/Additional Information: Prevention: Recommended for adults 50yrs and above Zostavax admin for age 60 and above. Consultation with an ophthalmologist for dermatomes involving the eyes. Referral to infectious disease for young children and immunocompromised individuals. Complications include: Treatment of postherpetic neuralgia Gabapentin 300mg to be titrated for nerve pain, Pregabalin at 75mg bid, Cranial nerve syndromes, corneal ulceration, Guillian-Barre syndrome

FOLLICULITIS – infected hair follicles
Differential Diagnosis:
a) Skin abscess
b) Impetigo
c) Cellulitis
Treatment Options:
a) Symptomatic: warm compresses for 3-4 days
b) Clindamycin 1% lotion or gel BID for 7-10 days
c) Benzoyl peroxide 5% wash during showers for 5-7 days

d) Cephalexin 250-500 mg TID for 10 days.

Can metastasize to any organ

BASAL CELL CARCINOMA– Most common form of skin cancer
Differential diagnoses
a. Seborrheic keratosis
b. premalignant solar (actinic) keratosis
c. dermatosis papulose nigra
d. senile sebaceous hyperplasia
e. keratoacanthoma
Various treatment options
a. electrodessication and curettage
b. total excision
c. biopsy
Pattern recognition
a. change in color
b. change in characteristics of border
c. scaliness
d. erosion
e. oozing / bleeding
Comments/Suggestions/Additional Information: sun screen for all exposed areas

help guide treatment. Topical retinoids are effective in treating inflammatory and noninflammatory lesions by preventing comedones, reducing existing comedones, and targeting inflammation. Benzoyl peroxide is an over-the-counter bactericidal agent that does not lead to bacterial resistance. Topical and oral antibiotics are effective as monotherapy but are more effective when combined with topical retinoids. The addition of benzoyl peroxide to antibiotic therapy reduces the risk of bacterial resistance. Oral isotretinoin is approved for the treatment of severe recalcitrant acne and can be safely administered using the iPLEDGE program. After treatment goals are reached, maintenance therapy should be initiated.

There is insufficient evidence to recommend the use of laser and light therapies. Referral to a dermatologist should be considered if treatment goals are not met.

Repeat in 1-2 weeks. Older patients should massage into hairline
b. Sulfur ointment-older treatment however not popular due to strong odor and messiness of application c. Ivermectin 200 micrograms/kg taken once (but can be repeated in 14 days) is used off label for crusted scabies or if topical treatments are ineffective

d. Lindane 30g cream applied sparingly from neck down and washed off after 8 hours is used as an alternative treatment if other treatments are not available or ineffective
e. Pregnant and lactating women may be treated with permethrin or sulfur preparations. Ivermectin and lindane are pregnancy risk factor C and not recommended in this population
f. antihistamines used to treat pruritis
g. lubrication and topical corticosteroids used to treat persistent pruritic papules and eczematous dermatitis from infestation and treatment
Pattern recognition
a. female mite burrow no deeper than the stratum corneum, lays 2-3 eggs/day for 1-2 months before dying
b. eggs and mites reach maturity in 28-30 days and repeat cycle
c. intense pruritis 2-4 weeks after infection in those not already sensitized; and within a day for infestation d. transmitted by direct, prolonged skin contact with an infected person, commonly through sexual contact
e. animals cannot spread scabies
Comments/Suggestions/Additional Information: Common in crowded living conditions, and institutional facilities (nursing home, jail, day care centers). More prevalent in hot-humid environments and in poor, overcrowded areas. Intra-epidural burrows are linear or serpiginous ridges. Diagnosed by clinical findings. Dermoscopy can allow “jet-plane” appearance of mite at one end of burrow. Adhesive tape test: tape applied to effected area and quickly removed and placed under a microscope to look for mites, eggs, fragments or feces; lack of findings cannot r/o diagnosis as host may have fewer than 10-15 mites. All household clothing and bedding should be machined washed and dried in a hot dryer or dry cleaned; sofas/chairs should be vacuumed; all other items unable to be washed should be placed in plastic bag for a week. All household contacts should be treated. Pt education should be verbal and written for prescription and cleaning procedures. Symptoms can last for 2 weeks after treatment.

darker in color than the surrounding skin and most commonly affect the trunk and shoulders. Tinea versicolor (TIN-ee-uh vur-si-KUL-ur) occurs most frequently in teens and young adults. Sun exposure may make tinea versicolor more apparent. Tinea versicolor, which is also called pityriasis versicolor, is not painful or contagious. But it can lead to emotional distress or self-consciousness. Antifungal creams, lotions or shampoos can help treat tinea versicolor. But even after successful treatment, skin color may remain uneven for several weeks or months. Tinea versicolor often recurs, especially in warm, humid weather.

CELLULITIS
Differential diagnoses
a. Infectious: bursitis, osteomyelitis, erythema migrans, herpes zoster
b. Connective tissue, rheumatologic, immunologic: psoriasis, erythema nodosum, acute gout, urticaria c. Dermatologic: eczema, contact dermatitis, drug reactions
d. Vascular: stasis dermatitis, DVT, thrombophlebitis
e. Other: insect bite or sting hypersensitivity, neoplastic
Various treatment options
a. purulent SSTIs, I & D is key to treatment;
b. Moist heat to promote spontaneous drainage of furuncles
c. moderate or severe purulent SSTIs - systemic antibiotics that primarily target S aureus (Bactrim, Doxy for MRSA) (MSSA- cephalosporin – cephalexin, dicloxacillin)
d. Severe purulent SSTIs- MRSA – IV abx- vanc, daptomycin, zyvox, telavancin, ceftaroline); MSSA – nafcillin, cefazolin, clindamycin.

SNELLEN CHART- Test far vision. consist of 11 lines, pt is directed to stand 20 feet away from the chart.

with each eye, chart is read down until the pt is unable to make out the letters. the patient’s vision is based on the last line that was successfully seen. IE 20/80 would mean that a person with normal vision could stand 80 feet away from the chart and still read the letters this patient is reading from 20 feet away.

AMAUROSIS FUGAX: Also known as Will’s Transient Visual Loss
Differential diagnoses
a.
b.
c.
d.
e.
Various treatment options
a. blood thinner- ASA, Warfarin
b. carotid endarterectomy
c. treat underlying issues i.e. HTN
Evaluate pattern recognition
a. The risk factors for this occurrence include having a history of heart disease, high blood pressure, high cholesterol, smoking, or a history of alcohol or cocaine abuse
b. mild blurring or fogging to complete vision loss
c. painless unless associated with a headache
d. The examination should include testing of visual acuity and visual fields, and examination of the optic fundus

Comments/Suggestions/Additional Information: Amaurosis Fugax is considered a form of TIA (transient

CRITERIA FOR STREP THROAT
Centor criteria for GAS pharyngitis include the following:
Fever (1 point)
Anterior cervical lymphadenopathy (1 point)
Tonsillar exudate (1 point)
Absence of cough (1 point)
A score of 0-1 makes GAS infection unlikely; a score of 4 makes it likely. In adults, the positive predictive value of these criteria is around 40% if 3 criteria are met and about 50% if 4 criteria are met.

CORNEAL ABRASION
Differential diagnoses
a. acute angle closure glaucoma
b. conjuctivitis
c. corneal ulcer
d. dry eye syndrome
e. infective keratitis
Various treatment options
a. opthalmic antibiotic ointments: polymixin B-bacitracin, b. oral anelgesics
c. AVOID steroids and topical anesthetics
Pattern recognition
a. severe eye pain with tearing
b. feeling or sensation of foreign body

RETINAL DETACHMENT

Differential diagnoses
a. retinoschisis (splitting of the retina)
b. diabetic retinopathy
Various treatment options
a. Intraocular gases (air, perfluoropropane, sulfur hexafluoride): contraindicated in patient with poor controlled glaucoma
b. perfluorocarbon liquids
c. Silicone oil
d. Surgery
Pattern recognition
a. unilateral photopsia
b. increasing number of floaters in affected eye
c. decreased visual acuity
d. metamorphopsia (wavy distortion of objects)
Comments/Suggestions/Additional Information: The separation of the neurosensory layer of the retina from the choroid and retinal pigment epithelium. Can lead to rapid degeneration of photoreceptors due to ischemia. Refer immediately to ophthalmologist. 90% of detachments can be reattached successfully surgical procedure.