FNP Final Exam Study Guide
Below is a study guide. The questions needs to be answered accurately and to the best of your ability. The books used for this class is cited below:
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Please utilize course textbooks and resources to review the following topics:
- Ear (evaluation and management)
- Otitis Externa Risk factors and expected findings
- Otitis Media
- Oral antimicrobial therapies, including when cellulitis is present
- Cerumen obstruction
- Perforated Tympanic Membrane
- Oropharynx (evaluation, management, and follow up)
- Strep throat
- Mono
- Tonsillitis
- Sinusitis, Rhinosinusitis, Allergic Rhinitis (evaluation and management)
- Antibiotic use
- Appropriate treatment
- Office emergent/urgent visits (evaluation and management)
- Appendicitis
- MI
- Angina
- Cholecystitis
- Pancreatitis
- Diverticulitis
- Peptic ulcers
- Hepatitis A and B
- IBS
- Burns
- Gastritis or Infectious Diarrhea
- Respiratory Infections (evaluation and management)
- URI’s
- Bronchitis
- Pneumonia
- Asthma
- Skin Disorders (evaluation and management)
- Cellulitis
- Orbital and others
- Animal bites
- Herpes Zoster
- Tinea Versicolor
- Electrical burns
- Chemical burns
- Cellulitis
- Standard of care
- Definition
- Provider-patient relationship definition
- Eye (evaluation and management)
- Bacterial Conjunctivitis, Viral Conjunctivitis, Allergic Conjunctivitis
- Eyelid disorders (such as Hordeolum, Blepharitis, Chalazion)
- Corneal Abrasion
- Pterygia lesions
Final Exam Study Guide Questions with Answers
Ear
Otitis Externa
It is an infectious or non-infectious inflammation of the external auditory canal. Risk factors for external otitis usually compromise the inherent defense mechanism’s integrity against infections. The factors include the removal of the protective cerumen during rigorous cleaning leading to the damage of the fragile skin, skin maceration due to moisture accumulation from swimming, and tissue alterations resulting from wearing devices such as ear plugs (Buttaro et al., 2021). Evaluation findings include pain and tenderness on palpation of the tragus. The canal may be erythematous or edematous, with poor visualization of the tympanic membrane due to edema or cerumen and exudate, enlargement of periauricular lymph nodes, and complete obstruction of the canal. Findings in chronic otitis externa include dry canal, cerumen, excoriations, discharge, and canal narrowing due to thickened walls. Management is through NSAIDs for pain relief and reduced inflammation, opioids, topical anesthetics, topical antifungal agents for fungal infections, and topical antibiotics for uncomplicated cases. Fluoroquinolones are recommended in the case of tympanic membrane perforation. The external ear canal should also be cleaned.
Otitis Media
Otitis media is an inner ear infection and can be viral, bacterial, or a coinfection.Evaluation findings include rapid-onset otalgia, rhinorrhea, fullness sensation, vertigo, frontal and maxillary sinuses tenderness, and mild to significant lymphadenopathy characterized by tender, warm, and enlarged cervical lymph nodes and posterior pinna erythema.Initial management is pain relief with NSAIDs or acetaminophen.Oral antimicrobial therapies in treating otitis media are similar for adults and children. Amoxicillin is the recommended first-line treatment for children and adults with no penicillin allergy (Buttaro et al., 2021). Amoxicillin-clavulanate is recommended when fever is present. In case of allergy, azithromycin, and doxycycline are used as alternatives in adults. A third-generation cephalosporin and azithromycin are alternatives in children (Buttaro et al., 2021). When cellulitis is present, antimicrobial therapy in high doses is extended to 10 days.
Cerumen Obstruction
Refers to ear wax blockage. Evaluation findings include bilateral or unilateral fullness, hearing loss, tinnitus, itching, cough, vertigo, light yellow or a dark brown mass, and honey-colored sanguineous drainage. Three removal methods are recommended: irrigation, cerumenolytic agents, and manual removal. The cerumenolytic agents soften, thin, break, or dissolve the earwax. Irrigation involves using warm water alone or mixed with hydrogen peroxide and using a syringe to discharge it into the canal. Manual removal is the final method and involves using instruments such as a plastic or metal loop, a curette, or alligator forceps (Buttaro et al., 2021).
Perforated Tympanic Membrane
TMP occurs due to a tear in the tympanic membrane resulting in a connection between the middle ear and the external auditory canal. The tear may result from trauma, infection, or rapid changes in pressure. Evaluation findings include fullness sensation in the affected year, pain, vertigo, tinnitus, and suppurative drainage. Usually, heal spontaneously. The ear should be kept dry to avoid infection. Ofloxacin otic drops may be utilized to improve the perforation’s closure rate. Routine antibiotic treatment is usually unnecessary, while surgery is recommended if perforations are in the posterosuperior quadrant (Buttaro et al., 2021).
Oropharynx
Strep Throat
Strep throat is also known as streptococcal pharyngitis. Findings during evaluation include pharyngeal inflammation, cervical lymphadenopathy, and tonsillar exudate. Treatment is usually with penicillin or amoxicillin. If the patient has an allergy to penicillin, they can be treated with azithromycin, clarithromycin, or clindamycin. Acetaminophen or an NSAID is recommended for pain control (Buttaro et al., 2021).
Mono
Mononucleosis is caused by the Epstein-Barr virus and is highly contagious. Evaluation findings include tonsillar pharyngitis, lymphadenopathy, and fever. Findings in infectious mononucleosis include pharyngeal erythema, high fever, tonsillar hypertrophy, petechiae between the soft and hard palate, white to gray-green exudate, and posterior cervical adenopathy. In some cases, splenomegaly and hepatomegaly may be present, while jaundice is present in severe cases. Treatment and management include antipyretics and anti-inflammatory medications to reduce symptoms. Hydration, good nutrition, and rest are recommended. Corticosteroids are recommended in cases of air obstruction. Sports activity should be avoided in the early cause of the illness (Buttaro et al., 2021).
Tonsillitis
Tonsillitis is mainly due to viral or bacterial infection. Symptoms include a sore throat, fever, tonsillar exudates, and cervical chain lymphadenopathy. Non-infectious tonsillitis is mainly characterized by dryness and a sore throat. Clinical findings in viral tonsillitis include mild erythema and swollen, boggy, or pale pharynx. In viral tonsillitis, acetaminophen or nonsteroidal anti-inflammatory medications are recommended for treating symptoms. Anesthetics throat lozenges are used in adults, while voice rest, humidification, and warm saline gargles are recommended to ease discomfort. In bacterial tonsillitis, additional antibiotic therapy with penicillin or amoxicillin. Azithromycin, clindamycin, or clarithromycin are recommended for those with penicillin allergies. Surgery may be performed for tonsillitis with GAS infection (Buttaro et al., 2021).
Sinusitis, Rhinosinusitis, and Allergic Rhinitis
Allergic rhinitis can be described as an inflammatory response that affects the paranasal and sinus mucosa. Evaluation findings will include pale nasal mucosa, swollen nasal turbinates characterized by bleeding, mucus, crusting, enlarged tonsils, conjunctival irritation, postnasal drip, and an allergic salute. The most important aspect of managing allergic rhinitis is environmental control. Antibiotics are not recommended in treating allergic rhinitis. Sinusitis is linked to allergic rhinitis since allergic rhinitis causes a nasal blockage, which in turn blocks the sinus. Due to the interrelationship between nasal and sinus passages, sinusitis is also called rhinosinusitis. Antimicrobial therapy is recommended for sinusitis, with amoxicillin and amoxicillin-clavulanate as the first line of treatment. Other antibiotics may include second and third-generation clindamycin and cephalosporins, which can prescribe alone or in combination with other medications such as ciprofloxacin, a macrolide, or sulfamethoxazole (Buttaro et al., 2021).
Office Emergent or Urgent Visits
Appendicitis
Appendicitis is caused by blockage of the appendiceal lumen resulting in appendix distention due to accumulated intramural fluid characterized by secondary bacterial infection. The sequence of symptoms is key in appendicitis, with severe or persistent pain as the chief complaint, even in emergencies. Patients usually present with pains originating from the epigastrium, migrating to the right lower quadrant, and abdominal rigidity. Anorexia and nausea are common symptoms. Evaluation findings include abdominal tenderness with coughing and localized tenderness in the right lower quadrant is usually determined. Emergency appendectomy is recommended for patients with appendicitis within 24 hours of symptom onset to prevent peritonitis or perforations. For uncomplicated appendicitis, antibiotic therapy is a possible option, although appendicitis may recur. Perioperative systemic antibiotics such as ceftizoxime and metronidazole are recommended (Buttaro et al., 2021).
MI
Acute myocardial infarction results from underlying coronary artery disease. Office visits are characterized by complaints of lightheadedness, cough, anxiety, wheezing, choking sensation, irregular heart rate, and diaphoresis. The physical examination findings include unequal pulses, high blood pressure with hypotension if the patient is in shock, distended neck veins, tachycardia, ventricular arrhythmia, and tachypnea. Acute management includes reperfusion therapy, an intravenous opioid for pain relief, mild anxiolytic for anxious patients, intravenous nitrates for symptom reduction, beta-blockers, and platelet inhibition, especially with aspirin. Long-term management includes antithrombotic therapy, lid-lowering therapy, and lifestyle modification (Ojha & Dhamoon, 2022).
Angina
Angina or chest pain is the most common sign of ischemic heart disease but can also be due to non-cardiac issues such as lung disease, gastroesophageal reflux disease, or panic attacks. Patients will likely present with chest pain, tightness, pressure, or chest heaviness. It may be accompanied by breadth shortness, nausea, or diaphoresis. Possible findings include normal vital signs, tachycardia, or tachypnea (Dains et al., 2019). Medications for angina linked to heart issues include statins, aspirins, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors. Vascular muscle relaxation is one of the techniques utilized in emergency situations using nitrates or dihydropyridine calcium channel blockers to increase perfusion ability. Most angina events are addressed by increasing the heart rate using beta-blockers, calcium channel blockers, and ivabradine.
Cholecystitis
Cholecystitis can be either acute or chronic inflammation of the gall bladder and usually occurs with or without gallstones. It occurs due to tube blockage with gallstones resulting in the building up of bile, causing inflammation, infections, bile duct tumor, or limited blood supply to the gall bladder. For chronic cholecystitis, patients present with progressing right upper quadrant abdominal pain characterized by food intolerance, bloating, vomiting, nausea, midback or shoulder pain, and murphy signs. In emergency situations, a CT shows cholecystitis and gallstones. For acute cholecystitis, lab results may show elevated WBC but normal results for chronic cholecystitis. In severe cases, the patient undergoes laparoscopic cholecystectomy while temporizing percutaneous gall bladder drainage is used for acute cases. Management at the initial stages includes isotonic intravenous rehydration, as oral hydration is contraindicated (Buttaro et al., 2021). Correction of electrolytes is also part of initial management. Pain reduction and gallstone dissolution may be achieved through ursodeoxycholic acid or its combination with chenodeoxycholic acid, but intolerance should be monitored. A diet change to a low-fat diet is recommended (Buttaro et al., 2021).
Pancreatitis
Pancreatitis involves acute pancreas inflammation and varies from mild to severe and complicated cases. Pancreatitis can be classified as interstitial edematous acute pancreatitis, which involves inflammation and necrotizing characterized by necrosis. Evaluation findings include moderate to severe abdominal pain, a sharp pain radiating to the back and has an acute onset, transient hypocalcemia, hyperbilirubinemia may be present, abdominal distention due to fluid leakage, nausea, and vomiting. A common finding is severe pain preventing the patient from taking deep breaths leading to hypoventilation. Crackles may be present during lung examination. Although rare, Cullen and Grey Turner signs may be present and indicate increased mortality (Buttaro et al., 2021). Lipase and amylase levels are usually three times the normal upper limit. Management involves early intravenous hydration with lactated ringer solution as the recommended fluid. Opioid analgesics are used to treat pain. Antibiotic prophylaxis is contraindicated in managing pancreatitis. Nutrition is also a management strategy that involves keeping nothing in the patient’s mouth until vomiting, nausea, pain, and ileus improve. A low-fat diet is recommended for initial feeding. Other interventions include IV insulin drip therapy combined with intravenous hydration, fibrate therapy, Apheresis, and enteral feeding. Open necrosectomy is reserved for cases with severe refractory (Buttaro et al., 2021).
Diverticulitis
It is a complication of diverticulosis, and its severity can range from mild, self-limiting to life-threatening. Evaluation findings include mild to moderate pain and tenderness in the left lower quadrant, fever, leukocytosis, diffuse abdominal pain indicating macro-perforation, change in bowel movements, mild distention, and rectal tenderness. Management includes a low-fat diet of 15g to reduce the amount of feal materials and antibiotic therapy for acute diverticulitis. Common antibiotics used in the U.S include amoxicillin-clavulanate potassium, trimethoprim-sulfamethoxazole combined with metronidazole, and ciprofloxacin. Most patients recover with no medical treatment, especially with no complications. Pain medication is discouraged, and pain relief through warm packs is recommended. If necessary, rifaximin may be used. Hospitalization is recommended for high-risk patients. Aggressive treatment with early surgery may be implemented when the risk of reoccurrences is high (Buttaro et al., 2021).
Peptic ulcers
Peptic ulcers are chronic disorders usually characterized by ulceration of the gastric and duodenal mucosa. The disorder usually occurs due to Helicobacter infections and NSAIDs. Evaluation findings include dyspepsia or epigastric pain, upper abdominal discomfort or pain, and pain relief achieved through food ingestion or antacids. The discomfort is usually described as a sharp, burning, gnawing, and aching pain that occurs 2 to 5 hours after taking meals (Buttaro et al., 2021). Changes in pain patterns may be present, indicating perforation or penetration of the ulcer. Other findings may include anemia and epigastric abdominal tenderness. Management is through antisecretory therapy as the first line of treatment. Medications used include proton pump inhibitors (PPIs), receptor antagonists, histamine, and prostaglandin therapy. A combination of antibiotics and acid-inhibiting therapy is recommended as a treatment for H. pylori. Examples of such therapies include clarithromycin and metronidazole and a combination of clarithromycin and amoxicillin. Other interventions include smoking cessation and stress management (Buttaro et al., 2021).
Hepatitis A and B
Hepatitis A virus is usually transmitted through the oral-fecal route through exposure to contaminated foods and drinks. Typical symptoms include nausea, vomiting, fatigue, malaise, poor appetite, and abdominal pain. Diagnosis is usually through serologic testing to detect the virus. Evaluation findings from blood work show mild lymphocytosis. Extra-hepatic manifestations, which are rare, include pancreatitis, acute kidney injury, glomerular nephritis, and acute cholecystitis. Management of hepatitis A involves supportive care (Mehta & Reddivari, 2022). In rare cases, liver transplantation may be a life-saving measure. Prevention through improved sanitation is recommended. The CDC recommends post-exposure immunization.
Hepatitis B is a life-threatening liver infection usually transmitted through body fluids such as blood, vaginal secretions, and semen. Patients may present with acute symptomatic disease or have an asymptomatic disease to be diagnosed during screening. Evaluation findings include nausea, dark urine, jaundice, anorexia, clay-colored stool, gastrointestinal bleeding, and hepatic encephalopathy, especially with severe liver damage. Viral serology of hepatitis B is also evaluated to determine the virus while the viral DNA detects the viral load. Management involves preventive care. Antiviral treatment is recommended for severe acute hepatitis B. FDA-approved medications include interferons, nucleosides, and nucleotide analogs. Counseling is required to improve prevention and life modification for patients to reduce intake of agents that can increase liver damage, including alcohol and herbal medications. Fulminant liver disease may require surgery (Mehta & Reddivari, 2022).
IBS
It is a common gastrointestinal complaint characterized by chronic pain associated with exacerbation or relief with defecation. Findings during evaluation include non-radiating, crampy, or intermittent pain, usually located in the left lower quadrant, constipation and diarrhea or an alternating pattern between the two, abdominal distention, fibromyalgia, and fatigue. Uncommon findings include a palpable and tender cordlike sigmoid colon and rectal tenderness. Management involves supportive and behavioral therapy, lifestyle modification, mediation, and reassurance. A diet rich in fiber is recommended. Synthetic fiber supplements are recommended since they are more tolerated. Other interventions include antispasmodics to decrease diarrhea and abdominal discomfort, antidiarrheal agents such as loperamide, anti-constipation agents, psychotropic agents, and alternative therapies such as CBT, stress management, hypnosis, probiotics, and guided imagery (Buttaro et al., 2021).
Burn
A burn can be from electrical, thermal, and chemical agents. Burn prognosis is based on severity, associated injuries, inhalation injury, comorbid conditions, patient’s age, and acute organ failure. Burn wound is defined by size or depth. Burn size is quantified by the percentage of the total body surface area burned, while the depth is measured by the skin layers injured. Burns are classified as first-degree, where the burn involves only the epidermis and injury is usually glossy, red, and painful; second-degree burn involves the dermis, and the burn is red, pink, or white pigmentation; and third-degree burn, where the burn extends to the subcutaneous fat. The hallmark of third-degree burn is the insensitivity burn site (Buttaro et al., 2021). The evaluation focuses on the adequacy of airways, breathing, and circulation. The initial treatment for thermal burns is reducing health and tissue injury. The goal is achieved through irrigation with cool water, a process that should not be done for chemical burns. Intact blisters are not to be ruptured. Burn wounds must be cleaned with soap and water or saline, and a dressing must be applied. Pharmacological treatment involves topical therapy using sulfadiazine cream and silver in other forms, such as gels and non-adherent dressing. Analgesics such as naproxen and ibuprofen are recommended for minor burns since they are painful.
Gastroenteritis or Infectious Diarrhea
Gastroenteritis is a diarrheal disease or increased bowel movement with or without abdominal pain, vomiting, or fever. Causes may include fungal, viral, bacterial, and parasitic. Clinical manifestations include diarrhea, vomiting, nausea, abdominal pain, and fever. Evaluation findings may include a soft abdomen and dehydration signs such as decreased skin turgor and dry mucous membranes (Buttaro et al., 2021). Other signs showing severity include bloody stool, tachycardia, altered mental status, comorbidities such as HIV, recent antibiotics, and age above 65 years. Management includes supportive management involving oral or intravenous rehydration and antibiotic therapy with azithromycin, fluoroquinolones, or tetracyclines. Loperamide is recommended for febrile patients with non-bloody diarrhea. For C. difficile infection, the causative antibiotic should be discontinued and another antibiotic therapy initiated. CDC recommends oral vancomycin or fidaxomicin for mild CDI and oral metronidazole for severe CDI.
Respiratory Infections
URI
Upper respiratory infections are self-limited irritation characterized by swelling of the upper airways. They involve the nose, sinuses, or throat. Symptoms usually include cough, sore throat, headache, runny nose, sneezing, malaise, low-grade fever, and nasal congestion. Examples of URIs include colds, influenza, and sinusitis. Management of URI seeks to relieve symptoms. Decongestant medications are used to limit congestion and coughs in adults. The use of antibiotics is not supported due to their ineffectiveness. A vitamin is recommended. Vaccination is recommended to prevent influenza.
Bronchitis
Acute bronchitis involves trachea inflammation and is usually caused by viruses, irritants, or allergens. Bacterial infection is uncommon. Diagnosis is based on acute cough lasting 1 to 3 weeks. The cough may be with or without phlegm. The sputum may be clear, yellowish, or purulent. Purulent sputum does not always indicate a bacterial infection or antibiotic use. A low-grade fever, wheezing, or rhonchi may be present. Management involves non-pharmacological interventions such as hot tea, throat lozenges, ginger, and honey (Singh et al., 2022). Pharmacological interventions include using antitussive agents such as dextromethorphan and codeine to suppress coughs based on their effectiveness. Beta-agonists are utilized in patients with wheezing. Prednisone or other steroids are used to reduce inflammation, while analgesic and antipyretic treat associated malaise, fever, and myalgia. Clinical guidelines recommend against antibiotic use unless pathogens such as pertussis or influenza are identified (Buttaro et al., 2021). Lifestyle modifications such as smoking cessation and avoidance of pollutants are recommended.
Pneumonia
Pneumonia is an umbrella term used to describe a group of syndromes caused by various organisms causing infection of lung parenchyma. Classifications include community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-acquired pneumonia. Pneumonia can be caused by bacteria, viruses, or fungi. Evaluation involves clinical, radiological, and laboratory evaluation. Evaluation findings include lobar or interstitial infiltrate, cavitary lesions with air-fluid levels indicating severe disease process, fever without chills, tachypnea, tachycardia, dullness on percussions, and crackles on auscultation (Buttaro et al., 2021). The initial step in management is determining whether the patient will require care in the outpatient, general ward, or ICU setting. Hospital and ventilator-acquired pneumonia involve broad-spectrum antibiotics compared to community CAP. A macrolide antibiotic is recommendedfor health patients treated in outpatient. Doxycycline is a second recommendation. Fluoroquinolone or β-lactam plus a macrolide is recommended for patients with comorbidities, and a respiratory fluoroquinolone or a β-lactam antibiotic for inpatients treated in non-ICU settings. In ICU settings, a β-lactam including cefotaxime or ampicillin-sulbactam combined with azithromycin or a respiratory fluoroquinolone is prescribed (Buttaro et al., 2021).
Asthma
Asthma involves inflammation of the air passages and the narrowing of airways. Commonly present in childhood and lined with eczema and hay fever. Evaluation can be conducted at the bedside using pulse oximetry to assess severity, laboratory tests to determine kidney functions, and arterial gas to determine respiratory acidosis. An ECG reveals sinus tachycardia due to asthma. Special tests such as spirometry are useful in showing an obstructive pattern. Histamine challenge also determines if the airway is hyper-reactivity. Management involves risk reduction by treating modifiable risk factors and comorbidities. Strategies used include smoking cessation and physical activity. Asthma is treated using controller and reliever mediations. A stepped approach is recommended where doses and medication classes are stepped up as needed (Buttaro et al., 2021). In step one, controllers are a daily low-dose inhaled corticosteroid and a formoterol. Step two entails controllers that are daily low-dose inhaled corticosteroids plus short-acting beta-two antagonists. Step three comprises low-dose inhaled corticosteroids, long-acting beta 2 antagonists, and short-acting beta 2 antagonists. Step 4 comprises high-dose inhaled corticosteroids, long-acting beta 2 antagonists, and short-acting beta 2 antagonists. Step five is a high-dose inhaled corticosteroid, long-acting beta 2 antagonists, and a long-acting muscarinic antagonist. Life-threatening asthma requires high-flow oxygen inhalation, use of systemic steroids, nebulization (back-to-back), intravenous magnesium sulfate, and short-acting muscarinic.
Skin Disorders
Cellulitis
Cellulitis is a bacterial infection that causes inflammation of the deep dermis and the subcutaneous tissue. Evaluation findings include spreading erythematous inflammation in the patient’s deep dermis and subcutaneous tissue, worsening erythema, warmth, edema, and tenderness. Two of the four criteria must be present for a diagnosis. In lower extremities, fissuring or tinea pedis may be present, such as lymphadenopathy and the formation of vesicles. Orbital cellulitis is a serious infection that affects the muscle and fat within the orbit. Distinctive findings include the presence of ophthalmoplegia and proptosis. Imaging the affected area is not recommended except in febrile neutropenia. Blood cultures are recommended for systemic infection or in patients that are immunocompromised. Management is through antibiotics, including oral and intravenous antibiotics and anti-inflammatories. Antibiotics covering MRSA are recommended for purulent cellulitis, while antibiotics covering streptococcal should be used when no systemic infection is suspected. Anti-inflammatory agents, including nonsteroidal anti-inflammatory agents or systemic corticosteroids, should be used. In purulent SSTIs, incision and drainage are recommended. Other interventions include postural drainage and compression (Buttaro et al., 2021).
Animal bites
Animal bites range from superficial injuries to disfiguring wounds that may be fatal. Evaluation should focus on bite location, the type of animal, presence of local erythema, swelling, whether the patient is febrile, or foreign body inoculation. Management includes extensive irrigation, an update of the tetanus status, and prophylaxis for high-risk wounds. For fresh bites, amoxicillin-clavulanic acid is recommended. A combination of clindamycin and doxycycline should be prescribed to patients with penicillin allergy and macrolide for pregnant patients. Intravenous antibiotic therapy is recommended for older infected bites (Maniscalco & Edens, 2022). Local, city, or state guidelines should guide Rabies postexposure prophylaxis. Hospitalization is for severe bites involving joints, bones, and tendons (Buttaro et al., 2021).
Herpes Zoster
Also known as shingles and is caused by the reactivation of the varicella-zoster virus that remains dormant after a varicella infection, also known as chickenpox. Evaluation findings in diagnosis include prodrome of fever, excruciating pain characterized by a vesicle outbreak that appears in one to three crops, and malaise (Nair & Patel, 2022). Lesions usually start as closely grouped erythematous papules and become vesicles on an erythematous and edematous base. Management includes antiviral therapy, which hastens lesion resolution and decreases acute pain. Antibiotic creams such as soframycin and mupirocin prevent bacterial infections. Analgesics helps to relieve pain, while opiates may be used in case of severe pain. Post-herpetic, especially in the elderly, is treated with Emla and capsaicin cream.
Tinea Versicolor
Pityriasis is a benign superficial fungal skin infection. Evaluation findings for the infection include finely scaled macules that are hyperpigmented or hypopigmented (Buttaro et al., 2021). Coppery-orange fluorescence may be observed using a wood lamp. Typical grape-like clusters of yeast cells and long hyphae are usually observed under microscopic scale examination using potassium hydroxide. Management is through topical or systemic agents, with topical agents being the first-line treatment. Ketoconazole is the most common topical treatment. Oral medications such as fluconazole and itraconazole are second-line treatments for severe, widespread, and recurrent cases. Maintenance therapy using systemic antifungal agents is recommended (Karray & McKinney, 2021).
Electrical Burns
Ours when the human body gets into contact directly or indirectly with an electrical source. Evaluation should include urinalysis, cardiac enzymes test, CBC, and an EKG (Bounds et al., 2022). External injuries may not be present at all. Evaluation findings are based on a thorough history that identifies the source of electrical injury, current type, voltage, and duration of the exposure. The burn presentation may be indistinguishable from thermal burns and consistent with the history of body contact with electrical sources and exits. For example, hand and foot burns. Management includes ACLS for patients without a pulse, pain control, fluid management, and large-bore IV access characterized by large-volume fluid resuscitation (Bounds et al., 2022).
Chemical burns
Chemical burns occur to exposure to various substances, including aids, bass, oxidants, or vesicants. Common findings during evaluation include structural changes to the directly affected tissue. Ingestion is the most worrisome event in children due to the risk of long-term changes due to tissue death (VanHoy et al., 2021). Endoscopic evaluation is usually essential. Evaluation of free air is also essential. Management is through copious irrigation to affected external areas. Emetic or neutralizing agents are not recommended in cases of chemical ingestion. No current recommendation for systemic medications. Intraarterial or intradermal injections of calcium and lavage may be used as a treatment regime (VanHoy et al., 2021).
Standard of Care
According to Vanderpool (2021), the standard of care is a legal term used in medical practice to refer to the degree of care a prudent and reasonable provider would exercise under the circumstances. It implies the level of care, skills, and treatment recognized as acceptable and appropriate by other reasonably prudent health providers.
Provider-Patient Relationship
It is a formal or inferred relationship between a healthcare provider and a patient and is usually established when the provider undertakes care and treatment of a patient.
Eye
Bacterial Conjunctivitis, Viral Conjunctivitis, Allergic Conjunctivitis
Evaluation findings for bacterial conjunctivitis include thick and purulent discharge and glued-shut eyes. Although not always necessary, management is through topical antibiotics, as a placebo may be used. Topical antibiotics are recommended for immunocompromised patients and those with comorbidities. Systemic treatment is recommended for H. influenzae, gonococcal, and chlamydia (Buttaro et al., 2021).
Evaluation findings in viral conjunctivitis include recent upper-respiratory infection, acute onset of a red eye characterized by excessive watery eye, and bilateral involvement during the clinical presentation. Three diagnoses include adenoviral, keratoconjunctivitis, and pharyngoconjunctival fever. Managing viral conjunctivitis involves artificial tears and cool compresses, antibiotics to prevent superficial infections, although rare, and combining povidone and steroid to decrease symptoms, although infectivity may be prolonged (Buttaro et al., 2021).
Evaluation findings in acute allergic conjunctivitis include lid discoloration and thickening. It may occur simultaneously in both eyes, and patients may report fatigue and headache. Management involves eliminating allergens, use of oral antihistamines to control ocular symptoms, cooling compresses, and preservative-free artificial tears. Topical cetirizine provides relief from itching. Topical nonsteroidal anti-inflammatory drugs and immunomodulators may be used but under an ophthalmologist (Buttaro et al., 2021).
Eyelid disorders
Evaluation findings of eyelid disorders may differ significantly. All types of blepharitis may present with lid crusting, excess tearing, discharge, inflammation, and conjunctival injection. Hordeolum and chalazion may present with an eye that is palpated for swelling and masses and an averted eyelid. However, a hordeolum is usually acute, warm, tender, and erythematous. A chalazion is usually acute and non-tender (Buttaro et al., 2021). Management for all blepharitis treatments involves lid hygiene to decrease bacterial colonization. Other interventions for the disorders include lid scrubs, artificial tears, and antibiotic solutions, with Tobrex ophthalmic solution as the first option. Hordeola is self-limiting. Systemic antibiotics are used in rare cases of secondary eyelid cellulitis (Buttaro et al., 2021).
Corneal Abrasion
Also known as scratched eye or cornea. Evaluation findings include an abnormally shaped pupil with a penlight exam, conjunctival injection, corneal infiltrate, a hazy cornea indicating edema, presence of hyphema or hypopyon, decreased visual acuity, and foreign body sensation. Management includes the use of topical antibiotics, cycloplegics to relieve photophobia, tetanus prophylaxis for penetrating injuries, foreign body removal through irrigation or metal instrument, and NSAIDs for pain control. Topical corticosteroids are not recommended due to increased infection risk and delayed healing (Domingo et al., 2022).
Pterygia lesions
Common evaluation findings include dryness, irritation, redness, itching, and foreign body sensation. Distinguishing findings include a wider wing aspect at the base of the conjunctiva and the presence of tapers to the head overlying the cornea. Treatment includes artificial tears, over-the-counter eye drops such as naphazoline, and topical steroids such as fluorometholone in case of inflammation (Buttaro et al., 2021).
References
Bounds, E. J., Khan, M., & Kok, S. J. (2022). Electrical Burns. In StatPearls [Internet]. StatPearls Publishing.
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Domingo, E., Moshirfar, M., & Zabbo, C. P. (2022). Corneal abrasion. In StatPearls [Internet]. StatPearls Publishing.
Karray, M., & McKinney, W. P. (2021). Tinea versicolor. In StatPearls [Internet]. StatPearls Publishing.
Maniscalco, K., & Edens, M. A. (2022). Animal Bites. In StatPearls [Internet]. StatPearls Publishing.
Mehta, P., & Reddivari, A. K. R. (2022). Hepatitis. In StatPearls [Internet]. StatPearls Publishing.
Nair, P. A., & Patel, B. C. (2022). Herpes zoster in: StatPearls. Treasure Island (FL). https://www.ncbi.nlm.nih.gov/books/NBK441824/
Ojha, N., & Dhamoon, A. S. (2022). Myocardial Infarction. StatPearls [Internet]. https://pubmed.ncbi.nlm.nih.gov/30725761/
Singh, A., Avula, A., & Zahn, E. (2022). Acute bronchitis. In StatPearls [Internet]. StatPearls Publishing.
Vanderpool, D. (2021). The Standard of Care. Innovations in Clinical Neuroscience, 18(7-9), 50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667701/
VanHoy, T. B., Metheny, H., & Patel, B. C. (2021). Chemical Burns. In StatPearls [Internet]. StatPearls Publishing.
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