Dermatology

Front 1

Skin - Nonmalignant abnormalities: CORN

Back 1

is a small, painful, RAISED BUMP on the outer skin layer.


soft -caused by the pressure of the bony prominence against softer tissue; these appear as whitish beginnings, commonly between the fourth and fifth toes

hard-sharply delineated and have a conical appearance; they occur most often over bony prominences were pressure is exerted, such as from shoes pressing on the inter-phalangeal joints of the toes

INCREASED SKIN GROWTH

Front 2

Skin - Nonmalignant abnormalities: CALLUS

Back 2

rough, thickened patch of skin. NONTENDER

a superficial area of hyper keratosis

usually occurs on the weight-bearing areas of the feet and on the Palmar surface of the hands

are less well demarcated than corns and are usually not tender

THICKENING FROM CONSTANT FRICTION

Front 3

Skin - Nonmalignant abnormalities: ECZEMA DERMATITIS

Back 3

Definition- most common inflammatory skin disorder; several forms, including irritant contact dermatitis, allergic contact dermatitis, atopic dermatitis

Pathophysiology
1. common factor of the various forms is intracellular edema and epidermal breakdown
2. eczematous dermatitis has three stages: acute, subacute, and chronic
3. excoriation from scratching predisposes to infection causes crust formation

subjective data
1. itching may or may not be present
2. those with atopic dermatitis often report allergy history (allergic rhinitis, asthma)

objective data
1. acute phase characterized by erythematous, pruritic, weeping vesicles
2. subacute eczema characterized by erythema and scaling
3. chronic stage characterized by thick, lichenified, pruritic plaques
4. atopic dermatitis: during the childhood, lesions involve lectures, the nape, and the dorsal aspects of the limbs; and adolescence and adulthood, lichenified plaques affect the fractures, head, and neck
v. AUTOIMMUNE

Front 4

Skin - Nonmalignant abnormalities: FURUNCLE

Back 4

Definition- a.k.a. Boil. a deep-seated infection of the pilo sebaceous units

Pathophysiology
1. Staphylococcus aureus most common organism
2. initially, a small perifollicular abscess that spreads to the surrounding dermis and subcutaneous tissue
3. may occur singly or in multiples; when infection involve several adjacent follicles, a coalescent purulent mass or carbuncle occurs

subjective data
1. acute onset of tender nodule that becomes pustular

objective data
1. skin red, hot, tender
2. center of lesion fills with pus and forms a core that may rupture spontaneously or require surgical incision
3. sites commonly involved by the face and neck, the arms, axilla, breast, thighs, and buttocks
v. ABSCESS

Front 5

Skin - Nonmalignant abnormalities: FOLLICULITIS

Back 5

occurs when hair follicles become infected, often with Staphylococcus aureus or other bacteria

The infection usually appears as small, white-headed pimples around one or more hair follicles — the tiny pockets from which each hair grows. Most cases of folliculitis are superficial, and they may itch, but on occasion they're painful too. Superficial folliculitis often clears by itself in a few days, but deep or recurring folliculitis may need medical treatment.


Definition- inflammation and infection of the hair follicle that surrounds the dermis. RELATED TO SHAVING

Pathophysiology
1. presence of inflammatory cells within the wall and ostia of the hair follicle creates a follicular base pustule
2. inflammation can either be superficial or deep; deep folliculitis can result from the chronic lesion of superficial folliculitis or from lesions that are manipulated
3. persistent reoccurrence lesions may result in scarring or permanent hair loss

subjective data
1. acute onset papules and pustules associated with pruritis or mild discomfort; may have pain with deep folliculitis
2. risk factors: frequency, immunosuppression, pre-existing dermatosis, long-term antibiotic use, occlusive clothing and/or occlusive dressings, exposure to hot humid temperatures, diabetes mellitus, obesity, and use of EGRF inhibitor medications

objective data
1. primary lesion small pustule 1 to 2 cm in diameter that is located over the Pilo sebaceous orifice and may be perforated by hair
2. pustule may be surrounded by inflammation or nodule lesions; after the pustule ruptures, crust forms
3. may have suppurative drainage with deep folliculitis
4. any hair bearing site can be affected; the site's most often involved of the face, scalp, thighs, axilla, inguinal area

Front 6

Skin - Nonmalignant abnormalities: CELLULITIS

Back 6

Definition- diffuse, acute, infection of the skin and subcutaneous tissue

Pathophysiology- majority of cases caused by Streptococcus pyrogenes and Staphylococcus aureus

subjective data
1. break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound
2. pain and swelling at the site
3. may have fever

objective data
1. skin red, hot, tender, and indurated; borders are not well demarcated
2. lymphangitic streaks and regional lymphadenopathy may be present

Front 7

Skin - Nonmalignant abnormalities: TINEA

Back 7

Ringworm is a skin infection due to a fungus. Often, there are several patches of ringworm on your skin at once.

Symptoms of ringworm include:

Itchy, red, raised, scaly patches that may blister and ooze.

The patches tend to have sharply-defined edges.

Red patches are often redder around the outside with normal skin tone in the center. This may look like a ring.

If ringworm affects your hair, you will have bald patches.

If ringworm affects your nails, they will become discolored, thick, and even crumble.

Definition- group of non-candidal fungal infections have involved the stratum corneum, nails, or hair

Pathophysiology-
1. infection of the dermatophytes, typically acquired by direct contact with infected humans or animals; invade the skin and survive and dead keratin
2. lesions usually classified according to anatomic location (tinea corporis), on the groin and inner thigh (tinea cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails (tinea unguium)

subjective data
1. may report pruritis

objective data
1. lesions vary in appearance and may be papular, pustular, vesicular,erythematous, or scaling
2. secondary bacterial infection may be present
3. microscopic examination of skin scrapings with KOH solution shows presence of hyphae
4. infected nails are yellow and thick and may separate from the nail bed

Front 8

Skin - Nonmalignant abnormalities: PITYRIASIS ROSEA

Back 8

unknown cause

typical Christmas tree distribution occurs on the chest.

Lesions in parallel alignment that follow the ribs.

Definition- self-limiting inflammation of unknown cause

Pathophysiology
1. sudden onset with occurrence of a primary (Herald) oval around plaque
2. a ruptured occurs 1 to 3 weeks later and last for several weeks
3. not contagious or infectious

subjective data
1. pruritus may be present with the generalized or option
2. Harold lesion often missed

objective data
1. lesions usually pale, erythematous, and macular with fine scaling, but may be papular vesicular
2. lesions develop on the extremities and trunk; palms and soles are not involved, and facial involvement is rare
3. trunk lesions characteristically distributed and parallel alignment following the direction of the ribs and a Christmas tree light pattern

Front 9

Skin - Nonmalignant abnormalities: PSORIASIS

Back 9

immune system mistakenly activates a reaction in the skin cells, which speeds up the growth cycle of skin cells and causes itchy skin spots, red patches, and thick flaky lesions to form.

Definition- chronic and recurrent disease of keratin synthesis

Pathophysiology
1. multifactorial origin with genetic component and immune regulation
2. characterized by increased epidermal cell turnover, increased numbers of epidermal stem cells, and abnormal differentiation of keratin expression leading to thickened skin with copious scale

subjective data
1. may have pruritus
2. concerns about appearance

objective data
1. characterized by well circumscribed, dry, silvery, scaling papules and plaques
2. lesions commonly occur on the back, buttocks, extensor surfaces of the extremities, and scalp

Front 10

Skin - Nonmalignant abnormalities: ROSACEA

Back 10

is a chronic skin condition that makes your face turn red and may cause swelling and skin sores that look like acne.

Chronic inflammatory skin disorder, usually seen on the middle of the face. Treat with topical antibiotics.

Definition- chronic inflammatory skin disorder

Pathophysiology
1. lasts over years, with episodes of activity followed by quiescent periods of variable length
2. cause unknown; occurs most often in persons with a fair complexion
iv. subjective data
1. itching always absent
2. many patients report a stinging pain associated with flushing episodes
3. common triggers: exposure to the sun, cold weather, sudden emotion, including laughter or embarrassment, hot beverages, spicy foods, and alcohol consumption

objective data
1. eruptions appear on the four head, cheeks, nose, and occasionally around the eyes
2. characterized by telegiectasia, erythema, papules, and pustules that occur particularly in the central area of the face
3. although rosacea resembles acne, comedones are never present
4. tissue hypertrophy of the nose may occur (rhinophyma)
5. Rhinophyma is characterized by sebaceous hyperplasia, redness, prominent vascularity, and swelling of the skin of the nose

Front 11

Skin - Nonmalignant abnormalities: DRUG ERUPTIONS

Back 11

Pathophysiology-

immunologically mediated cutaneous reactions to medications include IGE-dependent, cytotoxic, I mean complex, and cell mediated hypersensitivity reactions

2. nonimmunologically mediated reactions include direct release of mast cells mediators and idiosyncratic reactions
ii. subjective data

1. rash appears from one to several days after taking the drug

2. pruritus characteristic

objective data
1. most common: discrete or confluent erythematous macules and papules on the trunk, face, extremities, palms, or soles of the feet
2. rash fades in one to three weeks

Front 12

Skin - Nonmalignant abnormalities: HERPES ZOSTER

Back 12

is a painful, blistering skin rash due to the varicella-zoster virus, the virus that causes chickenpox.

is a activitated chicken pox virus.



Pathophysiology
1. VZV morphologically and antigenically identical to the virus causing varicella (chickenpox)
2. dormant viral particles (since the original episode of varicella) in the posterior spinal ganglia are cranial sensory ganglia become activated

subjective data
1. pain, itching, or burning of the dermatome area usually perceived irruption by 4 to 5 days

objective data
1. single dermatome that consist of red, swollen plaques or vesicles and become filled with purulent fluid

Front 13

Skin - Nonmalignant abnormalities: HERPES SIMPLEX

Back 13

Pathophysiology
1. two different virus types caused the infection: type I, usually associated with oral infection, and type II, with genital infection
2. crossover infections are becoming common

subjective data
1. tenderness, pain, paresthesia, or mild burning at the infected site before onset of the lesions

objective data
1. groups vesicles appear on the erythematous base and then erode, forming a crust
2. lesions last 2 to 6 weeks

Front 14

Children: Café au lait patches

Back 14

irregularly shaped patches, could indicated underlying disease.

A birthmark is a skin marking that is present at birth. Birthmarks include cafe-au-lait spots, moles, and mongolian spots.

Front 15

Children: Miliaria

Back 15

common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity.

is thought to be caused by blockage of the sweat ducts, which results in the leakage of eccrine sweat into the epidermis or dermis

prickly heat

Pathophysiology
1. caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity
2. results from immaturity of skin structures
3. overdressed babies are susceptible to this condition in the summer

Subjective Data
1. parent reports rash noted when addressing the infant

Objective Data
1. a regular, red, macular rash, usually uncovered areas of the skin

Front 16

Children: Impetigo

Back 16

is a highly contagious skin infection that mainly affects infants and children.

usually appears as red sores on the face, especially around a child's nose and mouth. Although it commonly occurs when bacteria enter the skin through cuts or insect bites, it can also develop in skin that's perfectly healthy.

Definition- comment, contagious superficial skin infection

Pathophysiology
1. caused by staphylococcal infection and/or infection of the epidermis

Subjective Data
1. lesion, typically on the face, that itches and burns

Objective Data
1. an initial lesion is a small erythematous vacuole that changes into a vesicle or bulla with a thin roof
2. lesion crusts with a characteristic honey color from the exudate as the vesicles or bullae rupture
3. may have regional lymphadenopathy

Front 17

Children: Acne vulgaris

Back 17

characterized by areas of skin with seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring.

affects mostly skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back. Severe acne is inflammatory, but acne can also manifest in noninflammatory forms. The lesions are caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland, changes that require androgen stimulation.

Pathophysiology
1. androgens stimulate the Pilo sebaceous units at the time of puberty to enlarge and produce a large amount of sebum
2. simultaneously, the keratinization process in the Pilo sebaceous canal is disrupted with impaction in obstruction of the outflow sebum resulting in comedo formation-open black heads enclosed whiteheads
3. wall of the closed comedo may rupture, spilling the follicular contents into the dermis, leading to the development of inflammatory papules
4. the presence of P. Acnes brings in neutrophils, which causes the inflammatory response

Subjective Data
1. most commonly reported by adolescents
2. may occur initially as an adult or continuing to the adult years
3. patient reports comedones (plugged follicles-blackheads and whiteheads), papules, and pustules over the four head, nose, cheeks, lower face, chest, and back that of all of the face, chest, and back

Objective Data
1. noninflammatory acne: comedones
2. inflammatory acne: papules or nodules
3. characteristic (ice pick) scarring may be present form previous lesions

Front 18

Children: Chickenpox (Varicella)

Back 18

highly contagious disease caused by primary infection with varicella zoster virus (VZV).

It usually starts with vesicular skin rash mainly on the body and head rather than at the periphery and becomes itchy, raw pockmarks, which mostly heal without scarring. On examination, the observer typically finds lesions at various stages of healing

Start on scalp and trunk and move outwards. Vesicles. Several stages of maturation. Contagious until scab over.

Definition
1. acute, highly communicable disease common in children and young adults

Pathophysiology
1. caused by VZV
2. VZV communicable by direct contact, droplet transmission, and airborne transmission
3. incubation period 2 to 3 weeks; the period of communicability last from one or two days before the onset of the rash until lesions have crusted over
4. preventable by immunization
5. after primary infection, VZV remains dormant and sensory nerve roots for life

Subjective Data
1. fever, headaches, sore throat, malaise
2. pruritic rash that started on scalp and then moved to extremities
3. started as macular papular and in a few hours becomes vesicular

Objective Data
1. macular papular and vesicular lesions on trunk, extremities, face, buccal mucosa, palate, or conjunctiva
2. lesions usually occur in successive outbreaks, with several stages of maturity present at one time
3. complications include conjunctival involvement, secondary bacterial infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain-Barré syndrome, and Reye syndrome

Front 19

Children: Measles (Rubeola)

Back 19

Rash

Usually appears 3 - 5 days after the first signs of being sick

May last 4 - 7 days

Usually starts on the head and spreads to other areas, moving down the body

Rash may appear as flat, discolored areas (macules) and solid, red, raised areas (papules) that later join together

Itchy

Measles: Start on face and neck and spread to trunk and extremities. Viral, prodome fever, conjuntvitis, bronchitis. Ends 4 days after the rash appears.

Definition- also called hard measles or red measles

Pathophysiology
1. measles virus infects by invasion of the respiratory epithelium
2. local multiplication at the respiratory mucosa leads to the primary viremia, during which the virus beds of leukocytes to the reticuloendothelial system
3. both endothelial and epithelial cells are infected; infected tissues include thymus, spleen, lymph nodes, liver, skin, conjunctiva, and lung
4. incubation period is commonly 18 days; the period of communicability last from a few days before the fever to four days after appearance of the rash
5. disease preventable by immunization

Subjective Data
1. characteristic prodromal fever, conjunctivitis, coryza, and bronchitis occur, followed by red, blotchy rash first of the face and then spreading to trunk and extremities

Objective Data
1. Koplik spots (discrete white macular lesions) on the buccal mucosa
2. macular rash develops the face and neck
3. maculopapular lesions on trunk and extremities and irregular confluent patches
4. rash last 4-7 days
5. symptoms may be mild or severe
6. complications involve infection of the respiratory tract of central nervous system

Front 20

Children: German measles (Rubella)

Back 20

fine maculopapular eruption on the hariline that spreads rapidly cephlocaudally. Occipital or posterior cervical lymphadenopathy. During first trimester usually leads to birth defects.

Definition- mild, febrile, highly communicable viral disease

Pathophysiology
1. spreading droplets that are shed from respiratory secretions of infected persons
2. patients are most contagious while the rash is erupting, but they may shed virus from the throat from 10 days before until 15 days after the onset of the rash
3. incubation period is 14 to 23 days
4. disease preventable by immunization

Subjective Data
1. prodromal period, low grade fever, coryza, sore throat, and cough
2. followed by macular rash on the face and trunk that rapidly becomes papular

Objective Data
1. generalized light pink to red maculopapular rash
2. by the second day, rash spreads to the upper and lower extremities; it feeds within three days
3. reddish spots occur on the soft palate during the prodromal or on the first day of the rash
4. infection during the first trimester of pregnancy may lead to infection of the fetus and may produce a variety of congenital anomalies (congenital rubella syndrome)

Front 21

Older Adult: Stasis dermatitis

Back 21

can have the following characteristics:

Thin, inflamed, tissue-like skin
Itching, which can be severe
Tingling
Red skin spots, caused by small deposits of hemosiderin from the breakdown of red blood cells
Dry and scaly patches of skin
Darkening of the skin, which appears reddish brown (hyperpigmentation)
Thickening of the skin, caused by ongoing scratching
Slow-to-heal, painful, open sores (venous ulcers)
Discolored pus may ooze from infected skin


from edema and related to peripheral vascular disease.

Pathophysiology
1. occurs on the lower legs in some patients with venous insufficiency
2. incompetent venous valves, inadequate tissue support, and postural hydrostatic pressure contributed development
3. dermatologic changes secondary to the effects of extravasated blood, which induces a mild inflammatory response in the dermis and subcutaneous fat
4. most patients with venous insufficiency do not develop dermatitis, which suggests that genetic or environmental factors may play a role
5. may occur as an allergic response to an epidermal protein antigen created through increased hydrostatic pressure, or because the skin has been compromised and is more susceptible to irritation and trauma

Subjective Data
1. sense of fullness or dull aching in the lower legs and ankles
2. gradual increase in pigmentation and redness
3. area may be itchy and/or painful

Objective Data
1. Erythematous, scaling, weeping patches on lower extremity; ulceration may be present
2. dermatitis may be acute, subacute, or chronic and recurrent

Front 22

Older Adult:Solar keratosis

Back 22

usually rough, scaly patches on sun-exposed areas such as the head and face. They are common, especially in older people, many of whom have more than one. Usually they are harmless but there is a small risk that they may eventually turn into skin cancer. So, treatment is usually advised.

secondary to chronic sun damage, has malignant potential.

Definition- squamous cell carcinoma confined to the epidermis

Pathophysiology
1. occurs secondary to chronic sun damage
2. most lesions remain superficial; lesions that extend more deeply to involve the papillary and/or reticular dermis or termed squamous cell carcinoma

Subjective Data
1. history of chronic sun exposure
2. increasing number of lesions with age

Objective Data
1. slightly raised erythematous lesion that is usually less than 1 cm in diameter with an irregular, rough surface
2. lesion is most common on the dorsal surface of the hands, arms, neck, and face

Front 23

Exam & Findings: Skin: NEVI

Back 23

occur in forms that vary in size and degree of pigmentation

nevi are present on most persons regardless of skin color, and may occur anywhere on the body

they may be flat, raised slightly, dome shaped, smooth, rough, or hairy

there are color ranges from pink, tan, gray, and shades of brown to black

although most nevi are harmless, some may be dysplastic, precancerous, or cancerous

dysplastic nevi tend to occur on the upper back in men in the legs woman

Front 24

Exam & Findings: Skin: NEVI: Pigmented types: Halo Nevus

Back 24

common benign skin lesions that represent melanocytic nevi in which an inflammatory infiltrate develops, resulting in a zone of depigmentation surrounding the nevus

Features
1. sharp, oval, or circular; depigmented Halo around mole; may undergo many morphologic changes; usually disappears and a little re-pigments (may take years)

occurrence
1. usually occurs on back in young adult

comments
1. usually benign; biopsy indicated because same process can occur around melanoma

Front 25

Exam & Findings: Skin: NEVI: Pigmented types: Intradermal Nevus

Back 25

a nevus in which nests of melanocytes are found in the dermis, but not at the epidermal-dermal junction; benign pigmented nevi in adults are most commonly intradermal.

features
1. dome shaped; raised; flesh to black color; may be pedunculated or hair bearing

occurrence
1. cells limited to dermis

comments
1. no indication for removal other than cosmetic

Front 26

Exam & Findings: Skin: NEVI: Pigmented types: Junctional Nevus

Back 26

is a mole found in between the epidermis and dermis layers of the skin. These moles may be pigmented and slightly raised, and have a higher risk of developing into malignant melanoma.

features
1. flat or slightly elevated; dark Brown

occurrence
1. nevus cells lining dermoepidermal junction

comments
1. should be removed if exposed to repeated trauma

Front 27

Exam & Findings: Skin: NEVI: Pigmented types: Compound Nevus

Back 27

features
1. slightly elevated brownish papule: indistinct border

occurrence
1. nevus cells in dermis and lining dermoepidermal junction

comments
1. should be removed if exposed to repeated trauma

Front 28

Exam & Findings: Skin: NEVI: Pigmented types: Hairy Nevus

Back 28

features
1. may be present at birth; may cover large areas; hair growth may occur after several years

comments
1. should be removed if changes occur

Front 29

Exam & Findings: Skin: NEVI: normal

Back 29

color
i. uniformly tan or brown; all moles on one person tend to look like

shape
i. round or oval with a clearly defined border that separates the mole from the surrounding skin surface
ii. begins as flat, smooth spot on skin; becomes raised; forms a smooth bump

size
i. usually less than 6 mm (size of a pencil eraser)
d. number
i. typical adult has 10 to 40 moles scattered around the body

location
i. usually above the waist on sun exposed services the body; scalp, breast, and buttocks rarely have normal moles

Front 30

Exam & Findings: Skin: NEVI: dysplastic

Back 30

color
i. mixture of tan, brown, black, and red/pink; moles on one person often do not look alike

shape
i. irregular borders may include notches; may fade into surrounding skin and include a flat portion level with skin

surface
i. may be smooth, slightly scaly, or have a rough, a regular, "pebbly" appearance

size
i. often larger than 6 mm and sometimes larger than 10 mm

number
i. many persons do not have an increased number; however, persons severely affected may have more than 100 moles

location
i. may occur anywhere in the body, but most commonly on back; may also appear below the waist and on scalp, breast, and buttock

Front 31

Primary Skin Lesion: Macule

Back 31

description
b. Flat, circumscribed area with change in color, less then 1cm.

Examples
i. freckles, flat moles (nevi), petechiae, measles, scarlet fever

Front 32

Primary Skin Lesion: Papule

Back 32

description
b. Elevated, firm, circumscribed lesion, less then 1 cm

examples
d. Lichen planus: Unknown cause, wart (verruca), elevated moles

Front 33

Primary Skin Lesion: Patch

Back 33

description
b. Flat, nonpalpable, irregular shaped macule greater then 1cm

example
d. Vitiligo: loss of epidermal melanocytes, many times from an autoimmune process, also consider tinea corporis
e. port wine stains, Mongolian spots, café au lait patch

Front 34

Primary Skin Lesion: Plaque

Back 34

description
b. Elevated, firm, rough lesion with flat top greater then 1cm

example
d. Psoriasis: inherited condition
e. Seborrheic
f. Actinic keratoses

Front 35

Primary Skin Lesion: Wheal

Back 35

description
i. Elevated, irregular shaped area of cutaneous edema, solid
ii. transient, variable diameter

examples
i. insect bites, urticaria, allergic reaction

Front 36

Primary Skin Lesion: Nodule

Back 36

Description
i. Elevated, firm circumscribed lesion, deeper in the dermis then a papule 1-2cm.

Examples
i. erythema nodosum, lipoma

Front 37

Primary Skin Lesion: Tumor

Back 37

Description
i. Elevated and solid lesion, in dermis, greater then 2cm may or may not be clearly demarcated

Examples
i. Lipoma: benign fatty growth
ii. neoplasms, benign tumor, lipoma

Front 38

Primary Skin Lesion: Vesicle

Back 38

description
i. Elevated, circumscribed superificial, not in dermis. Filled with serous fluid, less then 1cm

Examples
i. Varicella(chicken pox), herpes zoster (shingles)

Front 39

Primary Skin Lesion: Bulla

Back 39

Description
i. Vesicle greater then 1cm in diameter

Examples
i. blister, pemphigus vulgaris

Front 40

Primary Skin Lesion: Pustule

Back 40

Description
i. Elevated, superficial lesion similar to vesicle but filled with purulent fluid

Examples
i. impetigo, acne

Front 41

Primary Skin Lesion: Cyst

Back 41

Description
i. Elevated, circumscribed encapsulated lesion in dermis or sub q
ii. filled with liquid or semi solid material

examples
i. sebaceous cyst, cystic acne

Front 42

Primary Skin Lesion: Telangiectasia

Back 42

Description
i. Fine, irregular, red lines produced by capillary dilation

Examples
i. rosacea

Front 43

Secondary Skin Lesion: Scale

Back 43

Description
i. Heaped up, keratinized cells
ii. Flaky skin, irregular, thick or thin, dry or oily
iii. variation in size

examples
i. Dandruff: consider tinea capitus
ii. Flaking of skin with seborrheic dermatitis following scarlet fever or flaking of skin following a drug reaction; dry skin

Front 44

Secondary Skin Lesion : Lichenification

Back 44

Description
i. Rough, thickened epidermis. Usually related to persistent itching, rubbing and skin irritation.
ii. often involves flexor surface of the extremity

examples
i. chronic dermatitis

Front 45

Secondary Skin Lesion: Scar

Back 45

Description
i. Thin to thick fibrous tissue replaces normal skin following injury to dermis.

Examples
i. healed would or surgical incision

Front 46

Secondary Skin Lesion: Keloid

Back 46

Description
i. Irregular elevated, progressive enlarging scar.
ii. Grows beyond the boundaries of the wound.
iii. Caused by excessive collagen formation during the inflammatory stage of healing.

Examples
i. following surgery

Front 47

Secondary Skin Lesion: Excoriation

Back 47

Description
i. Loss of epidermis, hollowed out crusted area, usually linear

Examples
i. abrasion or scratch, scabies

Front 48

Secondary Skin Lesion: Fissure

Back 48

Description
i. Linear crack or break from the epidermis to the dermis, moist or dry.

Example
i. Athletes foot: tinea pedis
ii. cracks at the corner of the mouth

Front 49

Secondary Skin Lesion: Erosion

Back 49

Description
i. Loss of part of the epidermis, follows ruptures of blisters or vesicles
ii. depressed, moist, glistening

example
i. varicella, variola after rupture

Front 50

Secondary Skin Lesion: Ulcer

Back 50

Description
i. Loss of epidermis and dermis, concave
ii. varies in size

Examples
i. Statsis ulcer: poor circulation
ii. decubitus

Front 51

Secondary Skin Lesion: Crust

Back 51

Description
i. Dried serum, blood or purulent exudate. Elevated
ii. slightly elevated; size varies; Brown, red, black, tan, or straw-colored

examples
i. scab on abrasion, eczema

Front 52

Secondary Skin Lesion: Atrophy

Back 52

Description
i. Thinning skin surface, loss of skin markings, paperlike, translucent

example
i. striae
ii. aged skin

Front 53

Vascular Skin Lesion: Petechia

Back 53

Red-purple nonblanchable discolorations less then 0.5cm

Intravascular defects, infection

Front 54

Vascular Skin Lesion: Pupura

Back 54

Red-purple nonblanchable discoloration greater then 0.5cm

Intravascular defects, infection.

Front 55

Vascular Skin Lesion: Hemangioma

Back 55

Red, irregular elevated well circumscribed lesion

Dilated dermal capillaries.

Front 56

Exam & Findings: Skin Lesions: CHARACTERISTICS: Types: Primary

Back 56

those that occur as initial spontaneous manifestations of a pathologic process

Front 57

Exam & Findings: Skin Lesions: CHARACTERISTICS: Types: Secondary

Back 57

those that results from later evolution of or external trauma to a primary lesion

Front 58

Exam & Findings: Skin Lesions: CHARACTERISTICS:Types: Vascular

Back 58

lesions associated with vascular issues

Front 59

Skin lesion

Back 59

catchall term that collectively describes any pathologic skin condition or occurrence

Front 60

Skin - Malignant abnormalities: Basal cell carcinoma

Back 60

most common malignant neoplasm, commonly on the face. Fair haired people and sun exposure risk factors. Varies in presentation

Definition- the most common form of skin cancer

pathophysiology
1. cancer arises in the basal layer of the epidermis
2. occurs in various clinical forms including nodular, pigmented, cystic, sclerosing, and superficial
3. occurs most frequently unexposed parts of the body-the face, ears, neck, scalp, shoulders

subjective data
1. persistent sore lesions that has not healed
2. may have crusting
3. may itch

objective data
1. shiny nodule that is pearly are translucent; may be pink, red, or white, tan, black, or Brown
2. open sore; may have crusting; may bleed
3. reddish patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs
4. pink growth with a slightly elevated rolled border and a crusted indentation in the center; as the growth slowly enlarges, tiny blood vessels may develop on the surface
5. scar like area that is white, yellow or waxy, and often has poorly defined borders; the skin appears shiny and taut.

Front 61

Skin - Malignant abnormalities: Squamous cell carcinoma

Back 61

Malignant tumor arises from the epithelium. Sun exposed areas most common. Soft, mobile, elevate with scaling surface.

Definition- second most common skin cancer

pathophysiology
1. this malignant tumor arises in the epithelium
2. lesions occur most commonly in sun exposed areas, particularly the scalp, back of hands, lower lip, and ear; the rim of the ear and the lower lip are especially vulnerable

subjective data
1. persistent sore lesion that has not healed or that has grown in size
2. may have crusting and/or bleeding

objective data
1. elevated growth with the central depression
2. wartlike growth; may have crusting, may bleed
3. scaly red patch with irregular borders may have crusting, may bleed
4. scaly red patch with irregular borders
5. open sore; may have crusting

Front 62

Skin - Malignant abnormalities: Melanoma

Back 62

develops from melanocyte cells, migrate into the skin and other structures during fetal development.

Cause is unknown, hereditary and sun exposure are risk factors. Suspect if any change in a nevus.

Definition-lethal form of skin cancer that develops from melanocytes

pathophysiology
1. melanocytes migrate into the skin, eye, central nervous system, and mucous membrane during fetal development
2. less than half of the melanomas develop from nevi; the majority arise de novo from melanocytes
3. the exact cause of malignancy is not known; heredity, hormonal factors, ultraviolet light exposure, or an auto immunologic effect may contribute to causation

subjective data
1. new more pre-existing mole that has changed or is changing
2. new pigmented lesion that has irregularities
3. history of melanoma
4. history of dysplastic or atypical nevi
5. family history of melanoma (first-degree relative)

objective data
1. ABC's
a. A-asymmetry of lesion. One half of the molar birthmark does not match the other
b. B-borders. Edges are a regular, ragged, notched, or blurred. Pigment may be streaming from the border
c. C-color. The color is not the same all over and may have differing shades of Brown or black, sometimes with patches of red, white, blue
d. D- diameter. The diameter is greater than 6 mm (about the size of a pencil eraser) or is growing larger
e. E-evolution. Changes in existing pigmented lesions, particularly in a nonuniform, asymmetric manner

Front 63

Skin - Malignant abnormalities: Kaposi sarcoma

Back 63

Tumor of endothelium and epithelial layers of skin. Soft, vascular and painless. Common in HIV

Macular or papular lesions. Cancer in the endothelium and epithelial layer.

Definition- a neoplasm of the endothelium and epithelial layer of the skin

pathophysiology
1. caused by herpes virus 8
2. commonly associated with human immunodeficiency virus infection (HIV)

subjective data
1. characteristics skin lesions
2. may report peripheral lymphedema
3. may be presenting symptom of HIV/AIDS

objective data
1. cutaneous lesions are characteristically soft, vascular, bluish purple, and painless
2. lesions may be either macular papular and may appear as plaques, keloids, or ecchymotic areas
3. lesions may be limited to the skin or involve the mucosa, viscera, and lymph nodes or any organ

Front 64

Psych: General Considerations

Back 64

Avoid “tunnel vision”
Treat patient with respect
Allow time for the patient to speak
Respect patient personal space
Speak directly, non-technically
Concede what you can
Food, Drink, Phone Call, etc.
Watch your body language

Front 65

Psych: Safety Considerations

Back 65

KEEP YOURSELF and STAFF SAFE
Keep Exit Open
Watch Patients Body Language
Early and Aggressive Control of Agitation
Medication Restraint
Overwhelming Force
Physical Restraint
Constant Observation for High Risk Complaints or Behavior

Front 66

Homicidal/Violent patients: considerations

Back 66

Associated with Panic
Loss of reasoning ability
Perceived emotional or physical self defense
Self or loved one
Locate in a safe room
Have protocols in place for quick response
Duties
Duties: everyone knows their responsibilities.

Self & Staff Safety
De-Escalation
Safe Environment
Matching agitation
have to start with same vocal inflection, tension, passion and bring the pateint down.
Control situation
patient needs you to control the situation because they cannot
Matching aggitation: have to start with same vocal inflection, tension, passion and bring the pateint down.
Control situation: patient needs you to control the situation because they cannot
Consider different approach. Consider that the patient is doing everything to control themselves to not attack you. Early intervention important-chemicals.

Protect Yourself
Exit Plan
Have Help Ready
Protect Your Staff
Early Intervention
Overwhelming Force
Remove clothing and personal items
Search
Restraints
Physical
Chemical

Front 67

PSYCH TERMS

Back 67

Dementia: Gradual onset. Change in personality. Memory loss and disorientation. Paranoid delusions. Sundowning
Delirium: Rapid onset, fluctuating course. Restlessness, insomnia, nightmares. Lose insight into problems. Change in temperment.
Schizo: paranoia, auditory hallucination, delusions, bizarre behavior
Mania: decreased sleep, increased physical activity, impulsive, euphoria, unrealistic plans, thoughts.
Reactive: related to a life event or situation
Depression: command hallucinations, aggitation, decreased communication with others, psychomotor retardation, lack of self care

Rule out organic causes: normal labs. Also include, lymes, veneral disease (VDRL, RPR), meningitis. Hypoglycemia.

Front 68

PSYCH: PEARLS

Back 68

Never Be Condescending
Concede what you can
Gain Trust
“Here to help”
“Know you don’t like to feel this way”
“I have taken care of many people with same problem”
Be careful what you promise
They lack control
You need to take control of situation
Use their delusion if you need to
Break their complaint into smaller pieces
“What do they think is wrong or needed”
Break into smaller pieces
When change started
Stressful event, Precipitating event
Ability to reason
Ability to sleep
Ability to work
Ability to cope with stress
Appetite
Headaches
Suicidal

Front 69

Present Problem:  Breast discomfort

Back 69

Temporal sequence
temporal sequence: onset gradual or sudden; length of time symptom has been present; just symptom come and go or is it always present

Relationship to menses
 timing, severity

Character
 stinging, pulling, burning, drying, stabbing, aching, throbbing; unilateral or bilateral; localization; radiation

Associated symptoms
 lump or mass, discharge from nipple
Contributory factors
 skin irritation under breast from tissue tissue contact or from rubbing of undergarments; strenuous activity; recent injury to breast

Medications
 hormones are bio identical hormones

Front 70

Present Problem: Breast lump/mass

Back 70

Temporal sequence
 length of time since lump first noted; does lump come and go or is it always present; relationship to menses
Symptoms
 tenderness or pain (stinging, pulling, burning, drying, stabbing, aching, throbbing; unilateral or bilateral; localization; radiation), dimpling or changing contour

Changes in lump
 size, character, relationship to menses (timing or severity)

Associated symptoms
 nipple discharge or retraction, tender lymph nodes
Medications
 hormones are bio identical hormones

Front 71

Present Problem: Nipple discharge

Back 71

Character
 spontaneous or provoked; unilateral or bilateral, onset gradual or sudden, duration, color, consistency, odor, amount

Associated symptoms
 nipple retraction; breast lump or discomfort

Associated factors
 relationship to menses or other activities; recent injury to breast

Medications
 contraceptives; hormones, phenothiazines, digitalis, diuretics, steroids

Front 72

Present Problem: breast enlargement in men

Back 72

history of hypothyroidism, testicular tumor, Klinefelter syndrome

medications: cimetidine, omeprazole, spironolactone, finasteride, some antihypertensives, some antipsychotics

treatment for prostate cancer but anti-androgens or gonadotropin releasing hormone analogues

illicit/or recreational drugs: anabolic steroids, marijuana

Front 73

 Breast disease risk factors

Back 73

 The primary risk factors for breast cancer are female sex, age, lack of childbearing or breastfeeding, higher hormone levels, race, economic status and dietary iodine deficiency.

 Most cases of breast cancer cannot be prevented through any action on the part of the affected person. The World Cancer Research Fund estimated that 38% of breast cancer cases in the US are preventable through reducing alcohol intake, increasing physical activity levels and maintaining a healthy weight. It also estimated that 42% of breast cancer cases in the UK could be prevented in this way, as well as 28% in Brazil and 20% in China.

 Smoking tobacco may increase the risk of breast cancer with the greater the amount of smoking and the earlier in life smoking begins the higher the risk.

 In a study of attributable risk and epidemiological factors published in 1995, later age at first birth and not having children accounted for 29.5% of U.S. breast cancer cases, family history of breast cancer accounted for 9.1% and factors correlated with higher income contributed 18.9% of cases.

 Attempts to explain the increased incidence (but lower mortality) correlated with higher income include epidemiologic observations such as lower birth rates correlated with higher income and better education, possible overdiagnosis and overtreatment because of better access to breast cancer screening, and the postulation of as yet unexplained lifestyle and dietary factors correlated with higher income. One such factor may be past hormone replacement therapy, which was typically more widespread in higher income groups.

 The genes associated with hereditary breast-ovarian cancer syndromes usually increase the risk slightly or moderately; the exception is women and men who are carriers of BRCA mutations. These people have a very high lifetime risk for breast and ovarian cancer, depending on the portion of the proteins where the mutation occurs. Instead of a 12 percent lifetime risk of breast cancer, women with one of these genes have a risk of approximately 60 percent.

 In more recent years, research has indicated the impact of diet and other behaviors on breast cancer. These additional risk factors include a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use, radiation, endocrine disruptors and shiftwork. Although the radiation from mammography is a low dose, the cumulative effect can cause cancer.

 In addition to the risk factors specified above, demographic and medical risk factors include:

 Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting a second breast cancer.

 Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer, the risk becomes significant if at least two close relatives had breast or ovarian cancer. The risk is higher if her family member got breast cancer before age 40. An Australian study found that having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk of breast cancer and other forms of cancer, including brain and lung cancers.

 Certain breast changes: Atypical hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are correlated with an increased breast cancer risk.

 Those with a normal body mass index at age 20 who gained weight as they aged had nearly double the risk of developing breast cancer after menopause in comparison to women who maintained their weight. The average 60-year-old woman's risk of developing breast cancer by age 65 is about 2 percent; her lifetime risk is 13 percent.

Front 74

 Exam & Findings: Breast Self-Exam

Back 74

 Have patient demonstrate BSE

 Instruct on correct techniques

 stand before mirror. Inspect both breasts for anything unusual, such as skin redness, discharge from the nipples, puckering, dimpling, or scaling of the skin

 the next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten

 watch closely in the mirror, clasp hands behind your head and swing elbows forward

 next, press hands firmly on hips and bow slightly toward the mirror as you pull your shoulders and elbows forward

 some women do next part of the examination in the shower. Fingers glide over soapy skin, making it easy to appreciate the texture underneath

 raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of your fingers in small circles moving the circle slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the areas between the breast and the armpit, including the armpit itself. Feel for any unusual lumber mass under the skin

 step four should be repeated lying down. Lie flat on your back, left arm over your head and pillow or folded towel under your left shoulder. This position flattens depressed and makes it easier to examine. Use the same circular motion described earlier.

 Repeat on your right breast.

Front 75

 Review breast cancer screening

Back 75

 BSE - Breast Self Exam

 CBE – Clinical Breast Exam

younger than 40 years of age: everyone to three years
older than 40 years of age: annually

 Mammogram

Over 50
Over 40 if high risk

Front 76

When do get a mammogram

Back 76

Over 50 years old

over 40 years old if high risk

Front 77

When to get a clinical breast examination

Back 77

younger than 40 years of age: every 1-3 years
older than 40 years of age: annually

Front 78

how often to do a self breast exam

Back 78

Optional

Monthly starting at age 20s

Women should be familiar with their breasts and report any changes to their health care provider.

Front 79

BREAST: Exam & Findings: Inspection: positions

Back 79

 Seated with arms hanging loosely
 Seated arms over head
 Seated with hands on hips
 Seated and leaning forward
 supine

Front 80

breast inspection

Back 80

Size

Symmetry
 often one breast is somewhat smaller than the other

Contour
 alterations and contour are best seen on bilateral comparison of one breast with the other.
 Retractions in dimpling signify the contraction of fibrotic tissue that may occur with carcinoma.

size
 women's breasts vary in shape, from convex to pendulous or conical, and often one breast is somewhat smaller than the other
 men's breasts are generally even with the chest wall, although some men, particularly those who are overweight, have breasts with a convex shape

Skin color and texture
 the skin texture should appear smooth and the contour should be uninterrupted
 a peau d’orange appearance of the skin indicates edema the press caused by blocked lymph drainage and advanced laboratory occurs,
 the skin appears thickened with large pores and accentuated skin markings
 healthy skin may look similar if the pores of the skin large

Venous patterns
 venous patterns maybe visible, although they are usually pronounced only in the breasts of pregnant or obese women
 venous patterns should be bilaterally similar.
 Unilateral venous patterns can be produced by dilated superficial veins as a result of increased blood flow to a malignancy.
 This requires further investigation

Lesions

Front 81

Breast Masses: fibrotic changes

Back 81

age range
 20 to 49

Occurrence
 usually bilateral

number
 multiple or single

shape
 round

consistency
 soft the firm; tense

mobility
 mobile

retraction signs
 absent

tenderness
 usually tender

borders
 well delineated

variation with menses
 yes

Front 82

Breast Masses: fibroadenoma

Back 82

age range
 15 to 55

Occurrence
 usually bilateral

number
 single; may be multiple

shape
 round or discoid

consistency
 firm or rubbery

mobility
 mobile

retraction signs
 absent

tenderness
 usually nontender

borders
 well delineated

variation with menses
 no

Front 83

Breast Masses: cancer

Back 83

age range
 30 to 80

Occurrence
 usually unilateral

number
 single

shape
 irregular or stellate

consistency
 hard, stone like

mobility
 fixed

retraction signs
 often present

tenderness
 usually nontender

borders
 poorly delineated; irregular

variation with menses
 no

Front 84

 Common Abnormalities: fibrocystic disease

Back 84

Definition
 benign fluid filled cyst formation caused by ductal enlargement

pathophysiology
 usually bilateral and multiple
 common in women 30 to 55 years of age
 associated with long follicular oral luteal phase of the menstrual cycle

subjective data
 tender and painful breasts and/or palpable lumps that fluctuant with menses
 usually worst pre-menstrually

objective data
 round, soft or firm, tense, mobile masses with well delineated borders
 usually tender
 usually bilateral
 multiple or single

Front 85

Common Abnormalities: fibroadenoma

Back 85

Definition
 benign tumors composed of stromal and epithelial elements that represents a hyperplastic or proliferative process in a single terminal ductal unit

pathophysiology
 may occur in girls and women of any age during their reproductive years
 after menopause, the tumors often regress

subjective data
 painful lumps that do not fluctuate with the menstrual cycle
 may be asymptomatic with discovery on clinical breast examination or mammogram

objective data
 round or discoid, firm, rubbery, mobile masses with well delineated borders
 usually nontender
 usually bilateral
 single; may be multiple
 biopsy often performed to rule out carcinoma

Front 86

Common Abnormalities: malignant breast tumor

Back 86

Definition
 ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules

pathophysiology
 mutations in normal cells result in uncontrolled cell division and tumor formation; as the tumor grows and invade surrounding tissues, metastases occur through the length and vascular systems
 peak incidence between ages 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50 years

subjective data
 painless lump; change in size, shape, or contour breasts
 axilla may be tender of lymph nodes involved
 may be asymptomatic with discovery on clinical breast examination or mammogram

objective data
 may have palpable mass that is usually single; unilateral, a regular, or stellate in shape; poorly delineated borders; fixed; harder stone like; and nontender
 breasts may have dimpling, retraction, prominent vasculature
 skin may have peau d’orange or thickened appearance
 nipple may be inverted or deviate in position

Front 87

Common Abnormalities: breast fat necrosis

Back 87

Definition
 benign breast pump occurs as inflammatory response to local injury

pathophysiology
 necrotic fat in cellular the pre-become fibrotic and may contract into a scar

subjective data
 history of trauma to depressed (including surgery)
 painless lump

objective data
 firm, a regular mass, often appearing as an area of discoloration
 may mimic breast malignancy on clinical examination or breast imaging, requiring biopsy for diagnosis

Front 88

Common Abnormalities: Breast Intraductal papillomas

Back 88

Definition
 benign tumors of the subareolar ducts that produce nipple discharge

pathophysiology
 epithelial hyperplasia produces a wartlike tumor in a lactiferous duct
 2-3 cm in diameter
 may occur singly or in multiples

subjective data
 spontaneous nipple discharge
 usually unilateral
 usually serous or bloody

objective data
 single duct unilateral nipple discharge provoked on physical examination
 mass behind the nipple may or may not be present
 may need to be excised and examined to rule out malignancy

Front 89

Common Abnormalities: Paget disease

Back 89

On average, a woman may experience signs and symptoms for six to eight months before a diagnosis is made.

symptoms may vary based on the stage of the disease.

However, the main symptoms that can occur include flaky or scaly skin on the nipple, straw-colored or bloody nipple discharge, skin and nipple changes in only one breast or the flattened nipples.

Patients may also experience crusty, oozing or hardened skin resembling eczema, on the nipple, areola or both and fluctuating skin changes early on, making it appear as if the skin is healing on its own.

Some patients complain of burning sensations on the nipples or breasts. These symptoms usually occur in more advanced stages, when serious destruction of the skin often prompts the patient to consult. Lumps or masses in the breast occur in 50% of the patients. In more advanced stages, the disease may cause tingling, increased sensitivity and pain.

Definition
 surface manifestation of underlying ductal carcinoma

subjective data
 crustiness of the nipple, areola, and surrounding skin

objective data
 red, scaling, crusty patch on the nipple, areola, and surrounding skin
 maybe unilateral or bilateral
 appears eczematous but, unlike eczema, does not respond to steroids

Front 90

Common Abnormalities: gynecomastia

Back 90

Definition
 breast enlargement in men

pathophysiology
 result in increased body fat; hormone imbalance from puberty or aging; by testicular, pituitary, or hormone-secreting tumors; bio liver failure; or by a variety of medications including anabolic steroids, marijuana, some antihypertensives, some antipsychotics, or those containing estrogens or anti-androgens
 when testosterone levels are low relative to estrogen, breasts to grow larger and and more noticeable
 increased body fat, which in turn produces more estrogen, can cause breast enlargement

subjective data
 breast enlargement
 relevant medication history

objective data
 smooth, firm, mobile, tender disk of breast tissue located behind the areola
 usually nontender
 maybe unilateral or bilateral
 amount of breast tissue very; can be small overgrowth of breast tissue around the areola and nipple, the larger more "female"-looking breasts

Front 91

Common Abnormalities: galactorrhea

Back 91

Definition
 lactation not associated with childbearing

pathophysiology
 elevated levels of prolactin, resulting in milk production, occur as a result of disruption of the communication between the pituitary and hypothalamus glands
 common causes include pituitary secreting hormones, hypothalamic-pituitary disorders, systemic diseases, numerous medications and herbs, physiologic conditions, or local causes

subjective data
 spontaneous nipple discharge, usually bilateral; usually serous or milky
 possible related medical history: amenorrhea, pregnancy, postabortion, hypothyroidism, Cushing's syndrome, chronic renal failure
 possible medication history: phenothiazines, tricyclic antidepressants, some antihypertensive agents, estrogens, H2 receptor blockers, marijuana, amphetamines, opiates
 possible physiologic history: suckling, stress, dehydration, exercise, nipple stimulation

objective data
 multi-ductal nipple discharge may or may not be provoked on physical examination
 no mass

Front 92

Common abnormalities: Lactating women: Mastitis

Back 92

Definition
 inflammation and infection of the breast tissue
 pathophysiology
 most infections are staphylococcal, often Staphylococcus aureus
 most common in lactating women after milk is established, usually the second the third week after delivery; however, it may occur at any time
 abscess formation can result

subjective data
 characterized by sudden onset of swelling, tenderness, redness, and heat in the breast
 usually accompanied by chills, fever

objective data
 tender, hard breast mass, with an area of fluctuation, erythema, and heat
 may have discharge or pus (suppuration)
 underlying possibility abscess may impart a blue tinge to the skin

Front 93

Common abnormalities: older adults: Mammary duct ectasia

Back 93

a condition in which there is dilation of the lactiferous duct.

can mimic breast cancer.

It is a disorder of premenopausal age.

Signs can include nipple retraction, inversion, pain, and sometimes bloody discharge.

Histologically, dilation of the large duct is prominent. Pathogenesis may be a reaction to stagnant colostrum.

Definition
 benign condition of the subareolar ducts that produce nipple discharge
 pathophysiology
 subareolar ducts become dilated and blocked with desquamating secretory epithelium, necrotic debris, and chronic inflammatory cells
 occurs most commonly in menopausal women

subjective data
 spontaneously unilateral or bilateral nipple discharge
 often green or brown in color
 may be sticky

objective data
 single or multi-ductal, unilateral or bilateral nipple discharge provoked and physical examination
 mass behind the nipple may or may not be present
 breast may or may not be tender
 nipple retraction may be present

Front 94

normal pelvic findings

Back 94

normal pelvic findings

Front 95

Fundal Height

Back 95

As a rule of thumb, your fundal height in centimeters should roughly equal the number of weeks you're pregnant. For example, at 20 weeks, your fundal height should be about 18 to 22 centimeters.

Measuring large for dates means your fundal height is more than 2 centimeters larger than expected for your stage of pregnancy, based on your due date. Your practitioner will probably schedule an ultrasound to find out why. Among the possible explanations are:
•Your due date is off. (The ultrasound can help your practitioner figure out a more accurate due date.)
•You have looser abdominal muscles than most women, perhaps as a result of earlier pregnancies.
•You have uterine fibroids.
•You're carrying twins or more.
•You have too much amniotic fluid.
•Your baby is positioned high above your pelvis, which might be the case with a breech baby or if you have placenta previa.
•You have a bigger-than-normal baby because of gestational diabetes – a condition known as macrosomia. You may need to be tested to rule it out.

Front 96

Painful genital lesions

Back 96

herpes

Front 97

Painless genital lesions

Back 97

syphillis

Front 98

Common Abnormalities: Cervix; cervical carcinoma

Back 98

Definition
 classified according to the type of tissue from which the cancer arises squamous cell carcinoma and the adenocarcinoma

Pathophysiology
 typically originates from the dysplastic or premalignant lesion present at the active squamocolumnar junction
 lesions gradually progress through recognizable stages before developing into invasive disease
 the transformation from mild dysplastic to invasive carcinoma generally occurs slowly over several years
 HPV is now recognizes the most important causative agent cervical carcinogenesis at the molecular level
 HPV vaccines available

subjective data
 usually asymptomatic
 many report unexpected vaginal bleeding or spotting

objective data
 often no findings on physical examination
 a hard granular surface at or near the cervical os
 lesion can evolve to form an extensive irregular cauliflower growth that bleeds easily
 early lesions are indistinguishable from ectropian
 precancerous in early cancer changes are detected by Pap smear, not by physical examination

Front 99

Common Abnormalities: Uterus: myomas

Back 99

definition
 common, benign, uterine tumors
 mass or tumor inside muscle of uterus

pathophysiology
 arise from the overgrowth of smooth muscle and connective tissue in the uterus
 may occur singly or in multiples and may vary greatly in size

subjective data
 fibroid symptoms are related to the number of tumors, as well as their size and location; symptoms may include the following
 heavy menses
 abdominal cramping usually felt during menstruation
 urinary frequency, urgency, and/or incontinence from pressure on the bladder
 constipation, difficulty defecation, or rectal pain from pressure on the colon
 abdominal cramping from pressure on the small bowel
 generalized pelvic and/or lower abdominal discomfort

objective data
 firm, a regular nodules in the contour of the uterus on bimanual examination
 uterus maybe enlarged

Front 100

Common Abnormalities: Uterus: endometrial cancer

Back 100

Pathophysiology
 occurs most often in postmenopausal women
 nearly all are cancers of the glandular cells found in the lining of the uterus;

most known risk factors are linked to the balance between estrogen and progesterone in the body

 women taking tamoxifen are at increased risk

subjective data
 postmenopausal vaginal bleeding-red flag

objective data
 diagnosed by biopsy

Front 101

Which risk factor is associated with cervical cancer?

Back 101

Multiple sex partners

Front 102

Common Abnormalities: Scrotum: TESTICULAR CARCINOMA: Definition

Back 102

 Seminomas and nonseminomas arise from germ cells (sperm producing cells)
 non-germ cell tumors arise from supportive and hormone producing tissue
 most testicular cancers are germ cell cancers
 germ cell tumors tend to occur in young man and is the most common tumor in males 15 to 30 years of age

Front 103

Common Abnormalities: Scrotum: TESTICULAR CARCINOMA: Pathophysiology

Back 103

 presence of painless mass in testicle
 PAINLESS NODULE
 may report scrotal enlargement or swelling
 sensation or heaviness in the scrotum
 dull ache in the lower abdomen back or groin
 sudden collection of fluid in the scrotum

Front 104

Common Abnormalities: Scrotum: TESTICULAR CARCINOMA: subjective data

Back 104

 presence of painless mass in testicle
 may report scrotal enlargement or swelling
 sensation or heaviness in the scrotum
 dull ache in the lower abdomen, back, or groin
 sudden collection of fluid in the scrotum

Front 105

Common Abnormalities: Scrotum: TESTICULAR CARCINOMA: objective data

Back 105

 a regular, non-tender mass fixed on the testis
 does not transilluminate
 may have hydrocele (does transilluminate)
 may have associated inguinal lymphadenopathy

Front 106

An enlarged, painless testicle in an adolescent or adult may indicate

Back 106

a tumor

Front 107

Prostate Gland: size

Back 107

4×3×2 cm

composed of muscular and glandular tissue

Front 108

Prostate Gland: Location

Back 108

located at the base of the bladder and surrounds the urethra

the posterior surface is in close contact with the anterior rectal wall and is accessible by digital examination

Front 109

Prostate Gland: Median Sulcus

Back 109

divides the right and lateral lobes

A third or median lobe not palpable on examination, is composed of glandular tissue and lies between the ejaculatory duct and the urethra

Front 110

Prostate Gland: Lobes

Back 110

3 lobes

it is convex and is divided by a shallow median sulcus into the right in lateral lobes. A third or median lobe not palpable on examination, is composed of glandular tissue and lies between the ejaculatory duct and the urethra

Front 111

Prostate Gland: Aveoli

Back 111

it contains active secretory alveoli that contribute to ejaculatory fluid.

The seminal vesicles extend outward from the prostate

Front 112

PSA

Back 112

present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer and in other prostate disorders.

While frequently used for prostate cancer screening, the United States Preventive Services Task Force (USPSTF) does not recommend its use in healthy men. This USPSTF recommendation, released in October 2011, is based on "review of evidence" studies concluding that "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary." In those with prostate cancer, rising levels of PSA over time are associated with both localized and metastatic prostate cancer (CaP). Prostate test screening is controversial and may lead to unnecessary, even harmful, consequences in some patients.

Front 113

prostate cancer risk factors

Back 113

older than 50 years

race: black (two times the risk compared with that of white men)

nationality: common in North America and northwestern Europe; less common in Asia, Africa, Central America, and South America

family history (twice the risk with one first-degree relative; risk increases with more than one first-degree relative)

diet high in animal fat

hormones: cumulative exposure of the prostate to high levels of androgens

physical activity

Front 114

Exam & Findings: Inspection/Palpation: prostate

Back 114

Size
1. diameter of 4 cm, with less than 1 cm protrusion into the rectum
2. greater protrusion denotes enlargement, which should be noted with the amount of protrusion recorded

Contour
1. lobes should feel symmetric

Consistency
1. should feel like a pencil eraser-firm, smooth, and slightly movable-and it should be nontender
2. a boggy or rubbery consistency is indicative of benign hypertrophy, whereas stony hard nodular rarity may indicate carcinoma, prostatic calculi, or chronic fibrosis

Mobility
1. slightly movable

Secretions
1. palpation of the prostate can for secretions do the urethral orifice.
2. Any secretions that appear at the meatus should be cultured and examined microscopically

Front 115

Prostatitis

Back 115

Pathophysiology
1. inflammation of the the organ
2. acute: bacterial infection including E. coli, Klebsiella, and Proteus
3. may be acquired as a sexually transmitted disease or from infection of a adjacent organ, or as a complication a biopsy
4. chronic bacterial
5. chronic: May bacterial or nonbacterial (chronic pelvic pain syndrome)

subjective data
1. acute
a. pain
b. urinary problems
c. sexual dysfunction
d. fever, chills, shakes
2. chronic
a. asymptomatic
b. frequent bladder infections
c. frequent urination
d. persistent pain in the lower abdomen or back

objective data
1. acute
a. gentle exam imperative; the size of the prostate can cause bacteremia
b. enlarged organ, acutely tender, and often asymmetric
c. abscess may develop, felt as a fluctuant mass in the organ
d. seminal vesicles are often involved in may be dilated and tender on palpation; however, the prostate may feel boggy, and large, tender out palpable areas of fibrosis that simulate neoplasm
e. bacteria in the urine
2. chronic
a. may be normal sizing consistency
b. maybe enlarged boggy
iv. Swollen, tender and boggy prostate
v. Milk, culture discharge
vi. Long course of antibiotics (6-8 weeks)
vii. Not all is sexually transmitted

Front 116

Prostate Cancer

Back 116

Pathophysiology
1. over 99% are adenocarcinomas, developing from the gland cells within the prostate
2. in most cases, is a relatively slow-growing cancer; a small percentage is rapidly growing, aggressive form
3. incidence increases with age and is less frequent in men younger than 50 years of age

subjective data
1. early carcinoma asymptomatic
2. as the symptoms advances symptoms of urinary obstruction occur

objective data
1. a hard, a regular nodule may be palpable on examination
2. feels asymmetric, and the median sulcus may be obliterated
3. biopsy required for diagnosis

Front 117

Benign Prostatic Hypertrophy

Back 117

Pathophysiology
1. Common in men older than 50 years
2. gland begins to grow adolescents, continuing to enlarge the dancing age
3. growth of the organ parallels the increased incidence of disease process

subjective data
1. symptoms of urinary obstruction: hesitancy, decreased forests and caliber of stream, dribbling, incomplete emptying the bladder, frequency, urgency, nocturia, and dysuria

objective data
1. prostate feel smooth, rubbery, symmetric, an enlarged
2. median sulcus may or may not be obliterated

Front 118

The prostatic sulcus

Back 118

divides the prostate into right and left lateral lobes

Front 119

In males, which surface of the prostate gland is accessible by digital examination

Back 119

posterior

Front 120

Burns: EPIDEMIOLOGY

Back 120

a. 2 million patients/year
i. 80% minor
ii. 12,000 die from burns
b. 3rd leading cause of death in children
c. 18-35 yrs old peak incidence

d. ** IMPORTANT QUESTION TO ASK***
i. Did burn happen in an enclosed space?
1. Worried about inhalation burns to respiratory mucosa.

Front 121

Burns: Depth: SUPERFICIAL

Back 121

Red, painful, blanchable

1st

Front 122

Burns: Depth: Partial Thickness

Back 122

Moist, blisters, painful

MOST PAINFUL

2nd

Front 123

Burns: Depth:Full Thickness

Back 123

Dry, leathery, painless

BURN ITSELF IF PAINLESS

Can go as far as the bone.

3rd

Front 124

Burns: Zones of Damage

Back 124

Zones of Damage

Hyperemia
1. Bad sunburn
Stasis
1. Redness, starts to get pale
Coagulation
1. Thick and leathery

Front 125

Burns: Size

Back 125

Total Body Surface Area (TBSA)
1. Total Body Surface Area (TBSA)
Rule of 9s
Size of palm is 1%
Circumferential burns are most dangerous-swells and cuts of circulation (extremities and chest most problematic)

Front 126

Burns: Electrical

Back 126

Alternating Current (AC)
Voltage/Amps
2. Voltage is the measure of potential difference between 2 locations
3. Amps: Current in electricity. Usually not know so is associated with the voltage number.

10-20mA: if through hand will cause contraction, does not allow the hands to open. 30-50mA: respiratory arrest because of tetany of the diaphragm and chest muscles. 50-100mA: V fib. 2-5 A: cutaneous burn. 5-10A: asystole.

AC: household-current will go in both directions. The frequency of normal house current is similar frequency response then skeletal muscle, that is what causes the muscle contractions.

High: >600V
a. Almost aways death

Household: 110V
a. Low voltage injury

Direct Current (DC)
1. DC: battery-current is going in one direction

Arrythmias
Entrance/Exit Wound
Entrance wound
Small red spot
Exit wound
a. Can blow off hand/bottom of feet
3. Always follows path-can go through vital organs.
Vertical course worse
1. heart
Delayed injury presentation

Pregnancy
High voltage
ii. Fetal demise probable
Low voltage
iv. Fetal demise unlikely
v. Recommend fetal monitoring if viable

Front 127

Burns: Minor: Treatment

Back 127

i. Cooling
ii. Tetanus
iii. Pain Control
iv. Debridement
v. Dressing
1. Silvadene
vi. Follow Up

Front 128

Burns: Major Treatment

Back 128

Airway Management
1. Airway: early prophilatic intubation.

Fluid Resuscitation
1. IV fluids: 2-4 ml/kg/ % BSA burned. ½ over 8 hours then ½ over 16 hours.
2. Burns lose a lot of fluids quickly

Pain Control
1. NSAIDs
2. Narcotics
c. TRANSFER
i. To burn unit

Associated Injuries
i. Burns associated when getting the burn
1. Falling down stairs, being thrown
2. Look for other things (breaks, sprains, etc)
e. Tetanus- Burns are tetanus prone
f. EKG- Especially if electrical burn
g. Labs- Labs: CPK, UA myoglobin, Lytes, EKG
ii. Look for rhabdomylosis- muscle breakdown of myoglobin-clogs up kidneys. Treatment is lots of fluids

Front 129

Burns: CHEMICAL: acid

Back 129

i. Coagulating protein limits penetration
1. burns, painful, draino.
2. PAINFUL

Front 130

Burns: CHEMICAL: alkali

Back 130

Liquification of tissue more damage and systemic absorption
1. not as painful, liquifies tissue, rust removers, pool chemicals.
2. PAINLESS

Airbag
a. Airbag eye injuries caused from sodium azide: copious irrigation
b. Powder causes eye irritation after airbag deployment-

Front 131

Burns: CHEMICAL: organic

Back 131

iii. Fat dissolving corrosive injury
1. petroleium products. Gas, phenols.

Front 132

Heat related problems: Heat Cramps

Back 132

a. Ask about medications they are taking, may contribute.
b. Thermoregulation occurs in the anterior hypothalamus
c. Monitor EKG for problems, specifically ventricular arrythmias.
d. Bodies cooling methods: convection, radiation and evaporation
e. Sweating is the primary method of dissipating heat.
f. Avoid chills/shivering


i. Depleted fluid and electrolytes
ii. Rest
iii. PO fluids

Front 133

Heat related problems: Heat Exhaustion

Back 133

a. Ask about medications they are taking, may contribute.
b. Thermoregulation occurs in the anterior hypothalamus
c. Monitor EKG for problems, specifically ventricular arrythmias.
d. Bodies cooling methods: convection, radiation and evaporation
e. Sweating is the primary method of dissipating heat.
f. Avoid chills/shivering

i. Diaphoresis
ii. Temp: 99-104 degrees
1. 104/105-start loose brain cells
iii. Passive/Active Cooling
iv. Fluids (PO versus IV)
v. Monitor for Rhabdomyolysis
1. Rhabdo: get CPK, lytes (high K), UA dip look for protein. Show hemoconcentration

Front 134

Heat related problems: Heat Stroke

Back 134

i. Change in LOC
ii. No diaphoresis
iii. Hyperthermia >106 degrees
iv. Active Cooling
v. IV fluids
vi. Labs
vii. Consider Rhabdomyolysis and DIC
1. Rhabdo: get CPK, lytes (high K), UA dip look for protein. Show hemoconcentration

Front 135

Difference between heat stoke and heat exhaustion

Back 135

j. DIFFERENCE BETWEEN HEAT EXHAUSTION AND HEAT STROKE IS THAT IN STROKE YOU ARE NO LONGER SWEATING

Front 136

Cold Related Injuries: Frost Bite

Back 136

i. Tissue freezing
ii. 1st, 2nd and 3rd degree
1. Similar to heat burns
2. 1st: pale, edema, decreased sensation
3. 2nd: (superficial) cyanotic, edema, blisters, decreased sensation / (deep) anesthesia, non pliable skin
4. 3rd: Cyanosis, necrosis, gangrene, edema, anesthesia, skin is hard.
5. TAKES 8-24 HOURS FOR SKIN TO SHOW YOU HOW BAD IT IS.
iii. Consider Hypothermia
iv. NSAIDs
1. Helps with inhibiting tissue destruction
v. Rapid rewarming
vi. Warm water (104-108 degrees)
1. Will hurt to someone with frost bite
vii. Debride, Pain control, NSAIDs
viii. Subsequent Injury
1. Body conserves heat: vasocontriction, shivering
2. Initially body vasocontriction leads to vascular stasis and sludgin and thrombosis. This leads to capillary permeability causing edema.
3. Risk: medications (phenothiazines), alcohol/drug intox, homeless, mental retardation, extremes of age.
4. Counsel about smoking (vasoconstriction), caffiene (vasocontriction), alcohol

Front 137

Cold Related Injuries: Hypothermia

Back 137

ii. Risk: extremes of age, decreased body fat, peripheral vascular disease
iii. Paradoxical Undressing: removing clothes even though cold. Thought to be related to vaso dilitation in severe cases.
iv. In field: body to body rewarming, remove wet clothing, shelter.
v. Degree
1. Mild 93-95 degrees
2. Moderate: 86-93 degrees
3. Severe: <86 degrees
a. Looks dead
vi. Monitor: Apnea, V fib and acidosis
vii. Change in LOC, Decreased reflexes, Dysrythmia, No shivering, Hypoventilation, Bradycardia
viii. Rapid Rewarming
1. Trunk first
2. After drop
a. Afterdrop: when cold blood from extremities reaches the core circulation. Less chance if warm trunk first then extremities
b. Leads to arrythmias

Front 138

Cold Related Injuries: Submersion/Drowning

Back 138

a. 8000 death per year. 40% under 4 years. Peaks under 5 and males 15-19
b. Aspiration and swallowing of fluid is response of drowning. Be cautious about emesis and aspiration.
c. Look for trauma-protect Cspine
d. Consider Mechanism
e. Protect from aspiration
i. NG tube
1. Prophylactic
f. Consider Hypothermia
g. CXR

Front 139

Insects: Hymenoptera Bites/Stings

Back 139

i. Most reactions from Yellow Jackets
ii. BODY CAN GET ANY DOSE AND YOU WILL GET SAME REACTION (REACTION IS NOT DOSE DEPENDENT)

Front 140

Insects: Reaction

Back 140

b. IgE-Mediated systemic reaction
i. Histamine causes vasodilation, urticaria, angioedema, change in respiratory rate, hypotension, vomiting, tenesmus

Front 141

Insect Bite: Treatment: LOCALIZED REACTION

Back 141

i. Ice
ii. Antihistamine
iii. Caution Oral/Pharygeal Sting
1. Happens most often because insect is in drink
iv. Cellulitis
v. Rare usually takes >2 days

Front 142

Insect Bite: Treatment: ANAPHYLACTIC REACTION

Back 142

i. History of Past Sting
ii. Immediate Epinephrine
1. Lasts 30 minutes
2. Adult dose 0.5 mg
3. Children dose 0.2 mg
iii. Antihistamine
iv. H1 & H2
1. H1-benadryl
2. H2-zantac, pepcid
v. Steroids
1. BID
vi. Disposition
1. Caution Early Discharge

Front 143

Spider Bites: Brown Recluse

Back 143

1. Lives in gardens, old garages.
2. Doesn’t realize you got bit, doesn’t hurt
3. Enzyme
4. delayed symptoms, usually 24 hours. Is shy in wood piles or storage areas. Localized eccymosis, progresses to necrosis.

Front 144

Spider Bites: Black Widow

Back 144

1. Neurotoxin
a. Burns
b. Metallic taste in mouth
2. live in the ground in secluded/dark areas. Garages, barns, sheds and outhouses. Venom is a neurotoxin. Pin prick sensation goes to a dull ache and hypertension, N/V and tachycardia

Front 145

Snake Bite

Back 145

a. 10-15 deaths per year
b. Pit Vipers (most common)
i. Have a pit between their eyes, elliptical pupils, triangular head, two fangs.
c. Rattlers, Copperheads, Cottonmouths, Watermoccasins (most toxic)

Front 146

Snake Bite: Venom

Back 146

i. Enzymes and Proteins
ii. Local tissue damage, edema, hypotension, coagulopathy and shock.
iii. Dry Bite
iv. Burning at bite site
v. Paresthesias to the face, metallic taste, ecchymosis, diaphoresis, nausea/vomiting, dyspnea, seizure, flaccid paralysis, euphoria

Front 147

Snake Bite: Treatment

Back 147

a. IV fluids
b. O2 Sat monitoring
c. Monitor edema progression
i. Mark on skin
d. Compartment Syndrome
e. Labs
i. Labs: CBC, PT/PTT, CPK, LFTs, Lytes
f. Antivenin
g. Progressive Symptoms
i. Clinical or Laboratory
1. Clinical: progressing edema, eccymosis Lab: decreasing platelet count, elevated coags.
h. Intradermal skin test
i. Intradermal test: can help predict reactions during infusion. If a wheal develops is positive.
ii. 10-20 vials of Antivenom
1. Antivenin: derived from horse serum. Refined and concentrated polyclonal equine immunoglobulin. Neutralizes the venom.
iii. CroFab
iv. Allergic reaction

Front 148

2. Alpha blocker for acute treatment in the ED

Back 148

Catapress

Front 149

EMERGENCY SITUATIONS: PEARLS

Back 149

a. People DON’T Consider Their Emergency Minor
b. Evaluate Each Patient ASAP
c. Stabilize
i. Stabilize: Stop bleeding, assess breathing and tx if needed - treatment, O2, splint (lessen disability, fx, c-spines)
d. Remain Calm No Matter What
i. Remain Calm: Pt needs to see that you can handle what they have, if you are unsure of yourself, assess the situation - stabilize, then leave the room - consult, look at a book.
e. Education/Reassurance
i. Education/reassurance: Great time to educate, assess the education level of the patient - speak at that level. Write down the important points, pt may not remember.
f. Good Discharge Instructions
i. D/C instructions: Best defense against litigation, cover yourself. Prepare patients for possible problems (FB, infection). Make sure patient has good FU.

Front 150

Trauma/Critical Ill Exam: PRIMARY SURVEY

Back 150

i. A-Airway
1. Patent
2. Able to Protect
ii. Breathing
1. Work of Breathing
2. Rate
a. Rate: fast slow or no
iii. Circulation
1. Palpable (Radial)
a. Radial for adults: greater the 80 systolic
b. Pediatric
i. Pediatric: compare central versus peripheral
2. Blanche
3. Color
iv. Disability
1. Immobilization
a. Neck/spine

Front 151

Trauma/Critical Ill Exam: SECONDARY SURVEY

Back 151

i. Vital signs
1. O2 saturation
2. EKG/Monitor
3. Head to Toe Exam
4. IV, O2 and Monitor
a. “IV, O2 monitor” is one word, should be ordered on all critically ill patients.
ii. Interrupt Surveys
1. To intervene in life threatening situation

Front 152

DVT risk factors

Back 152

Sitting for long periods of time, such as when driving or flying. When your legs remain still for long periods, your calf muscles don't contract, which normally helps blood circulate. Blood clots can form in the calves of your legs if your calf muscles aren't moving. Although sitting for long periods is a risk factor, your chance of developing deep vein thrombosis while flying or driving is relatively low.

Inheriting a blood-clotting disorder. Some people inherit a disorder that makes their blood clot more easily. This inherited condition may not cause problems unless combined with one or more other risk factors.

Prolonged bed rest, such as during a long hospital stay, or paralysis. When your legs remain still for long periods, your calf muscles don't contract to help blood circulate, which can make blood clots develop.

Injury or surgery. Injury to your veins or surgery can slow blood flow, increasing the risk of blood clots. General anesthetics used during surgery can make your veins wider (dilate), which can increase the risk of blood pooling and then clotting.

Pregnancy. Pregnancy increases the pressure in the veins in your pelvis and legs. Women with an inherited clotting disorder are especially at risk. The risk of blood clots from pregnancy can continue for up to six weeks after you have your baby.

Cancer. Some forms of cancer increase the amount of substances in your blood that cause your blood to clot. Some forms of cancer treatment also increase the risk of blood clots.

Inflammatory bowel disease. Bowel disease, such as ulcerative colitis, increases your risk of DVT.

Heart failure. People with heart failure are at risk of DVT because a damaged heart doesn't pump blood as effectively as a normal heart does. This increases the chance that blood will pool and clot.

Birth control pills or hormone replacement therapy. Birth control pills (oral contraceptives) and hormone replacement therapy both can increase your blood's ability to clot.

A pacemaker or a thin, flexible tube (catheter) in a vein. These medical treatments can irritate the blood vessel wall and decrease blood flow.

A history of deep vein thrombosis or pulmonary embolism. If you've had DVT before, you're more likely to have DVT in the future.

A family history of deep vein thrombosis or pulmonary embolism. If someone in your family has had DVT or a pulmonary embolism, your risk of developing DVT is increased.

Being overweight or obese. Being overweight increases the pressure in the veins in your pelvis and legs.

Smoking. Smoking affects blood clotting and circulation, which can increase your risk of DVT.

Age. Being over age 60 increases your risk of DVT, though it can occur at any age.

Being tall. Taller men may be more likely to have blood clots. Taller women do not appear to have an increased risk, perhaps because most women do not typically get as tall.

Front 153

Clinical Laboratory Improvement Amendments (CLIA)

Back 153

Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed.
A laboratory is any facility that does laboratory testing on specimens derived from humans to give information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health.
CLIA is user fee funded; therefore, regulated facilities cover all the costs of administering the program.
Centers for Medicare & Medicaid Services (CMS) assumes primary responsibility for financial management operations of the CLIA program.
The categorization of commercially marketed in vitro diagnostic tests under CLIA is the responsibility of the FDA. This categorization includes the process of assigning commercially marketed in vitro diagnostic test systems to one of three CLIA regulatory categories based on their potential for risk to public health:
waived tests
tests of moderate complexity
tests of high complexity
CLIA categorizations will also be announced in Federal Register Notices, which will provide opportunity for comment on the decision. FDA may reevaluate and recategorize these tests based upon the comments received in response to the Federal Register Notices.
FDA will revise as necessary criteria for waivers, moderate and high complexities.

Front 154

CBC

Back 154

A complete blood count (CBC) test measures the following:

The number of red blood cells (RBC count)
The number of white blood cells (WBC count)
The total amount of hemoglobin in the blood
The fraction of the blood composed of red blood cells (hematocrit)
The CBC test also provides information about the following measurements:

Average red blood cell size (MCV)
Hemoglobin amount per red blood cell (MCH)
The amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC)
The platelet count is also usually included in the CBC.