Unit 4 Week 13

Telogen effluvium

, a poorly understood condition, affects the growing or resting cycle of hair follicles. In telogen effluvium, the number of resting follicles increases and the number of growing follicles decreases. The result is a generalized thinning of hair over the entire scalp. This reversible type of hair loss is often associated with chronic stress and nutritional deficiencies.

latent period of radiation burn

, which is characterized by a lack of symptoms, although cutaneous and systemic damage is still evolving.

myringotomy tubes

. These tubes are inserted into the tympanic membrane to allow drainage of discharge from the middle-ear space. If otitis results in the destruction or fixation of the ossicles, surgery on the ossicles may improve hearing function. Hearing aids can be used to increase the sound that is transmitted to the affected ear.

Comprehensive visual assessment Comparison Lesions ◦Description Patient and Family history Rash Charting ◦Color, texture, turgor, tenderness, temperature, moisture, and secretions

Assessment of skin disorders

Bedbugs,

Cimex lectularius, are insects associated with a lack of clean mattresses or bedding. They bite children and adults who sleep in unsanitary conditions. Homeless persons are at particular risk of bedbug bites. Although the bite itself is painless, the person awakens to find itchy skin. More careful examination of the skin reveals red wheals arranged in linear patterns (see Fig. 41-6). Because the saliva of bedbugs contains a protein substance, purpuric reactions are not uncommon. Diagnosis of the cause of the skin irritation is made by finding bedbugs in linen or mattresses. Vigorous sanitation of bedding and specific pesticide use are required to kill bedbug

Emergent phase of electrical burns

For electrical burns, first ensure the source of electrical current has been disconnected. Assess the patient for responsiveness and initiate cardiopulmonary resuscitation (CPR) if indicated. All patients injured with an electrical burn, including those injured by lightning, have an increased risk for trauma and fractures caused by intense muscle contraction from the electrical current, from a fall, or from the hazardous flash of the electricity. The major concern is the increased risk for cervical spine injury. So, it is imperative that the patient not be moved until the cervical spine has been immobilized with the application of a semirigid collar. This places the cervical spine in a neutral position and reduces the risk of spinal cord compression

Emergent phase of radiation burns

For radiation burns resulting from an industrial accident, trained personnel will render the contaminated areas safe for entry. Interventions are focused on shielding, distance, and limiting the time of exposure. Specific conditions exist for a patient to be transferred to a specialized burn center

Gastrointestinal Responses to Burn Injury

Patients with burns greater than 35% of TBSA have decreased circulating blood flow to the GI tract due to hypovolemia and the stimulation of the SNS. Hypovolemia and the extensive catecholamine release of the SNS cause both decreased GI circulation and activity. This can impair GI motility, interfere with absorption of nutrients, and lead to paralytic ileus. Hypovolemia and reduced cardiac output can promote ischemia and sloughing of the gastric mucosa. Interventions to increase perfusion to the GI tract include adequate fluid resuscitation and the use of positive inotropic medications such as dopamine to support blood pressure. Additionally, the combination of early enteral feedings and the use of proton pump inhibitors (PPIs) or H2 blockers is needed to prevent damage to the gastric mucosa. PPIs are recommended for prophylactic acid suppression. This has virtually eliminated the development of Curling's ulcer, a gastric stress ulcer that occurred in severely burned patients years ago, before the availability of PPIs.

verrucae,

Warts, are benign lesions of the skin caused by certain strains of the human papilloma virus (HPV). Transmitted by touch, they are round, rough, gray lesions that can occur anywhere on the body.

Emergent phase of chemical burns

When the injury is related to chemical exposure, brush off the dry chemical agent, remove all clothing, and irrigate with copious amounts of water immediately for approximately 20 minutes to interrupt the chemical's contact with the skin.

paronychia.

When the paronychial fold, a seal between the nail plate and the surrounding tissue, is broken, bacteria and fungi can invade the tissue, producing pain, redness, and swelling An acute paronychia is most often caused by Staphylococcus aureus, and an abscess is commonly present. Chronic paronychias are commonly caused by Candida (yeast) infection.

Chemical overprocessing,

a common cause of hair loss, follows efforts to change the color, quality, texture, and style of hair by curling, straightening, braiding, rinsing, dying, and tinting. Treatment is aimed at discontinuing the processes that stimulated the hair loss.

Presbyopia,

a common disorder in aging adults caused by the decreased elasticity of the lens with age, is a vision defect exhibited as a gradually diminished ability to focus on close objects. This begins around the age of 40 years, which is why some individuals start to require reading glasses at this age. As with hyperopia, individuals need to have objects held at a distance to see clearly. Individuals may first notice that the ability to read small print is more difficult. Treatment for presbyopia includes corrective lenses such as contacts and glasses with bifocals.

Acne vulgaris,

a common multifactored inflammatory disorder of the sebaceous glands, affects 85% of the population between the ages of 12 and 25 years. Its lesions are inflammatory papules, pustules, nodules, noninflammatory open or closed comedones, and cysts. Propionibacterium acnes colonize the lesions of acne. Topical agents and oral antibiotics are often required to counteract acne. Tretinoin (Retin-AR) and isotretinoin (AccutaneR), synthetic forms of vitamin A, have been very effective in treating severe acne. However, isotretinoin should be used with caution in patients, as it can lead to depression and suicidal ideation. It is also contraindicated in pregnancy due to the teratogenic potential.

Albinism,

a genetic disorder, deprives skin, hair, and eyes of pigment. It leaves a person with diminished vision and extreme sensitivity to light and UV rays. Individuals with any of the 10 types of albinism have pale or pink skin, yellow hair, and very light or pink eyes. Patients lack the pigment melanin; they should use protection from solar radiation and undergo frequent screening for skin malignancies.

Thermal burns

result after exposure to fire, hot objects, scalding liquids, hot grease, or steam. They comprise over 90% of all burn traumas and produce damage to the skin and underlying tissues after exposure to temperatures greater than 111.2°F (40°C). Thermal burn injuries can range from superficial, affecting only the epidermis, to full thickness, which injure subdermal tissues. Exposure to Flames, grease, steam, etc. Temperatures greater than 111 degrees Fahrenheit Top layer to full thickness Varies based on time of exposure and temperature Inhalation injury potential

Excoriation:

scratch that breaks the skin's surface

Fissure:

crack in the skin that breaks through keratin

Over-the-counter Based on etiology & symptoms ◦Steroid creams ◦Oral steroid therapy ◦Topical antibiotics ◦Oral, IV antibiotics ◦Biopsy ◦Laser surgery Prevention

Treatments for skin disorders

elastosis,

This process of skin aging, is more pronounced in sun-damaged skin.

Manifest illness stage of radiation burn

As the basal cell layer attempts to repair itself, the body enters the manifest illness stage, and severe skin blistering and erythema are observed. If a significant dose of radiation (exposures greater than 1,000 rads) is encountered, then a third phase of cutaneous symptoms known as the third wave of erythema

Erythema

: reddened skin; area blanches with pressure

Effects of Burn Injury on Immunity

A thermal injury causes massive impairment of the immune system; therefore, any prior immunological abnormality has a profound impact on morbidity and mortality. Serum levels of immunoglobulins and complement activation are reduced, and the production and function of white blood cells, such as neutrophils, monocytes, and macrophages, are suppressed. Decreased interleukins-1 and interleukins-2, decreased T-helper cells, and overstimulation of suppressor T cells impair the cellular immune response. An increased risk of infection is promoted by loss of the skin barrier, by excessive nutritional needs induced by the hypermetabolic state, and by increased release of mediators at the wound site that causes suppression of the immune response. Additionally, an open burn wound provides excellent conditions to support bacterial growth: dead cell debris provides nutrients for the bacteria, and burns reduce blood flow and inflammatory response to invasion of organisms. Thus, aggressive early surgical débridement is advocated to improve blood flow to the burned area. This stimulates tissue regeneration and restores phagocytic activity to fight invading organisms while decreasing the risk of opportunistic infection. Opportunistic infections can lead to rejection of skin grafts and delayed wound closure; despite improvement in antimicrobial therapy, sepsis continues to be a leading cause of death in burn patients.

Renal Responses to Burn Injury

After the initial burn injury, reduced blood flow to the kidneys is proportional to the degree of hypovolemia. There is also vasoconstriction of the renal arterial circulation due to the stimulation of the SNS. Diminished renal blood flow activates the rennin-angiotensin-aldosterone system and stimulates the release of antidiuretic hormone, which causes retention of sodium and water, as well as major loss of potassium, calcium, and magnesium. If fluid resuscitation is inadequate to restore intravascular volume, renal ischemia can develop and lead to acute kidney injury. Laboratory findings include elevated serum creatinine and decreased creatinine clearance. Intervention is aimed at restoring intravascular volume and avoidance of nephrotoxic medications such as aminoglycoside antibiotics and vancomycin. Need increased urine output until myoglobin levels subside (50-100 mL of urine/hour)

molluscum contagiosum,

Another viral disease, causes small bumps to appear on the skin. The bumps are smooth, waxy, and small, about the size of a pin, and their central core is filled with a white cheeselike substance. The virus that causes this illness can live in warm water and can be transmitted in spas, baths, and heated swimming pools. In persons with HIV, regardless of their age, the lesions of molluscum contagiosum are more numerous and larger.

Subconjunctival Hemorrhage

Blood vessels can become apparent in the sclera in a subconjunctival hemorrhage A subconjunctival hemorrhage occurs when a small blood vessel breaks open and bleeds near the surface of the white of the eye. Alternatively, pinpoint subconjunctival hemorrhage is exhibited by red blood vessels in the sclera; sometimes this is referred to as "injected sclera" or "bloodshot eyes." Sudden increases in pressure, such as violent sneezing or coughing, can cause a subconjunctival hemorrhage. The hemorrhage may also occur in persons with high blood pressure or those who take blood thinners. A bright red patch appears on the white of the eye, but it does not cause pain or discharge. Vision does not change. No treatment is needed; eventually, the body absorbs the blood

1. Emergent phase 2. Acute phase 3. Rehabilitation phase

Burn care occurs in three phases:

Radiation burn:

Close proximity to an explosion involving ionizing radioactive material can induce significant harm and produce both thermal burns from the explosion and internal or external radioactive contamination. External contamination from radioactive material is usually limited to the skin or underlying tissue damage by a layer of clothing, although cutaneous burns might not be immediately visible. It is important to obtain the patient's history to determine the degree of exposure. Some patients may report exposure to radiation or contact with an unknown metal object from industrial exposure, although the onset of visible symptoms can appear weeks after exposure. Radioactive exposure is measured in terms of "rads." Skin irritation Bioterrorism Level of burn depends on closeness of radiation (can be internal and external) Cutaneous Radiation Injury Based on visual damage, dose of radiation, and depth Injury to the external and underlying tissues from acute radiation exposure is known as cutaneous radiation injury (CRI). Diagnosis of CRI is based on the scope of visible damage, dose of radiation, and depth of penetration. There are four stages: 1. Prodromal stage 2. Latent period 3. Manifest illness stage 4. Third wave of erythema

organ of Corti

Contained within the cochlear duct is the , the spiral-shaped receptor organ of hearing. The organ of Corti is made up of supporting cells and many long rows of cochlear hair cells: one row of inner hair cells and three outer rows, all resting on the basilar membrane in the scala media. Afferent sensory nerve fibers from the cochlear nerve are wrapped at the base of the cochlear hair cells. The stapes delivers sound waves to the oval window, which are then transmitted to the scala vestibuli and the scala tympani where the perilymph is located. The transmission of sound occurs when the trapped cilia of the hair cells in the organ of Corti are bent by the movement of the basilar membrane.

Contractures

Deep dermal and full-thickness burns heal with formation of fibrotic tissue that causes scarring. Epithelial replacement is not possible if skin is burned below a certain level called the stratum reticulare. In areas of deep skin loss, healing occurs by a concentric reduction in the size of the wound with proliferation of fibroblasts, myoblasts, and collagen. This process pulls edges of wounds together, forming constricted regions of tissue called contractures. Contractures often form around joints, which pull the two bones close together so the joint cannot fully open. After healing is complete, surgical reduction of the fibrous tissue and surgical reconstruction using skin grafts can reverse some contractures. Some contractures require several surgeries to achieve a gradual release. Orthopedic surgery and physical therapy may also be needed.

1. Male and female pattern baldness 2. Telogen effluvium 3. Chemical overprocessing 4. Alopecia areata

Four types of hair loss account for 95% of visits to dermatologists:

Compartment Syndrome

Full-thickness circumferential and near-circumferential skin burns result in the formation of tough, inelastic, dead, burned tissue called eschar. Eschar can cause burn-induced compartment syndrome, which is a buildup of pressure within an area of the body so restrictive that it suppresses circulation to the region. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or other parts of the body. The excessive fluid causes collapse of blood vessels within the region, which can lead to ischemia and infarction of tissue. Eschar around the torso can cause chest wall restriction and hinder ventilation. Abdominal compartment syndrome can cause hypoperfusion of organs within the abdomen and torso. Circumferential burns involving the neck may cause airway obstruction and restricted venous return. Treatment consists of surgical escharotomy or fasciotomy, which is the excision of the restrictive eschar tissue. This releases tissue restriction and allows for circulation.

Functions of the skin: • Temperature control and regulation • Barrier protection • Secretion and absorption • Vitamin D production • Immunological surveillance Mirror of Internal Disease Processes Indicator of General Health

Functions of the skin: - - - - - - -

Pulmonary Responses to Burn Injury

In response to the injury, respiratory rate increases secondary to anxiety or pain, and minute ventilation can increase 2 to 2.5 times the normal rate. Increased lung capillary permeability and increased pulmonary vascular resistance can affect adequate tissue oxygenation. The pulmonary complications that develop after a major burn are airway edema of the upper respiratory tract and inhalational injury to the lungs. Systemic toxicity can occur from inhalation of toxins such as carbon monoxide. Acute respiratory distress syndrome (ARDS) can also be a life-threatening sequela due to capillary permeability after a pulmonary burn injury. Airway edema ◦Mucosal damage related to heat exposure ◦Rapid progression of edema; presence of stridor ◦Intubate

keratitis

Inflammation of the cornea, is commonly caused by herpes simplex virus type 1. The virus infects the ophthalmic division of the trigeminal nerve (CN V). Other viruses that cause keratitis include varicella zoster and the adenoviruses. Keratitis can also be caused by misuse of contact lenses, trauma to the eye, occupational toxin exposures, tanning booths, and hypersensitivity reactions. More rarely, keratitis is caused by other infections such as bacteria, parasites, and fungi

acute radiation syndrome (ARS)

Ingestion, inhalation, or entry of radioactive materials via open wounds can induce internal contamination and produce this if exposure to an excessive dose of penetration radiation occurs over a short period. Initially, the patient may be asymptomatic, but systemic contamination ensues until treatment is initiated to promote elimination of the radioactive material. Doses of 25 rads produce systemic effects such as bone marrow suppression and the consequent deficient synthesis of blood cells. High doses of radiation can produce aplastic bone marrow, which requires blood transfusion to replace the low blood cell production. Patients exposed to the highest levels of radiation experience gastrointestinal (GI) symptoms such as nausea, vomiting, and diarrhea, as well as damage to the central nervous system.

Anhidrosis

It is not uncommon for newborn and premature infants to exhibit anhidrosis for several weeks after birth. In adults, the causes of diminished sweat production include head injuries, tumors, occlusion of the sweat ducts, degeneration of peripheral sympathetic fibers as seen in peripheral neuritis, atrophy caused by burns and radiotherapy, and the use of anticholinergic (antiparasympathetic) drugs.

lentigos,

Large pigmented spots, called age spots or appear on fair, sun-damaged areas of the skin, usually on the hands, forearms, and face. As in other disorders of melanin production, preventive measures include limiting sun exposure through the use of sun-screening agents. Skin bleaching agents applied to darkened areas of the skin can be used for cosmetic purposes.

decibels (dB),

Level of hearing is measured in this, a logarithmic unit that describes loudness of sound, with 0 being the threshold for sound perception of people with normal hearing. A soft whisper is approximately 0 to 20 dB. Normal conversation is approximately 60 dB. Sounds louder than 85 dB can cause hearing loss.

Stage III

Melanoma that has spread to a nearby lymph node and is found in increasing amounts in one or more lymph nodes

Stage IV

Melanoma that has spread to internal organs, beyond the closest lymph nodes to other lymph nodes, or to areas of the skin far from the original tumor

Stage 0; in situ

Melanoma that is confined to the epidermis

Stage I-II

Melanoma that is confined to the skin but has increasing thickness; skin may be intact or ulcerated (top layer of skin is absent)

- ringworm of the body -ringworm of the groin - ringworm of the face -ringworm of the scalp - ringworm of the foot, also called athlete's foot -ringworm of the hand -ringworm of the nail -ringworm of the upper chest, back, or arms

Tinea infections are named for the part of the body they infect: • Tinea corpora: • Tinea cruris: • Tinea faciale: • Tinea capitis: • Tinea pedis: • Tinea manus: • Tinea unguium: • Tinea versicolor:

dermatophytes,

Superficial fungi, such as tinea (ringworm), live on the keratinized tissues of skin, hair, and nails and secrete digestive enzymes that cause skin scaling, nail disintegration, and broken hair. Diagnosis of superficial fungal infections is made clinically by a microscopic examination of scrapings from the lesions or by visualizing the lesions with a Wood's light. When viewed under a Wood's light, fungi take on a fluorescent yellow-green appearance. When fungal infections penetrate the keratinized tissue and invade the skin layers, vesicles, redness, and signs of inflammation appear in the affected areas. Invasive fungi can cause septicemia (bloodstream infection) in an immunocompromised individual.Treatment of superficial fungal infections is simple and involves the use of topical, and in difficult cases, systemic (oral or IV) antifungal agents.

American Burn Association Classification of Burn Injury

The ABA Classification of Burn Injury uses both the extent and the depth of burns to classify burns as minor, moderate, or major. The ABA uses the rule of nines to determine TBSA as a basis for their classification.

vitreous humor.

The body of the eyeball behind the lens is a clear, gel-like substance called

zone of coagulation.

The deepest point of injury occurs here. This is the core of the wound with the greatest degree of irreversible tissue necrosis that occurs from protein coagulation and cellular death. T

Mild hearing loss:

The individual cannot hear sounds softer than 26 to 40 dB. Symptoms of mild hearing loss include difficulty following conversations if people are not close to the patient or in a noisy environment and complaints that others are whispering or mumbling.

•Severe hearing loss:

The individual cannot hear sounds softer than 60 to 90 dB. This type of hearing loss will generally cause the patient to be unable to hear normal conversational speech. Without the significant assistance of hearing aids, someone with severe hearing loss may not be able to follow even loud conversations.

Moderate hearing loss:

The individual cannot hear sounds that are softer than 41 to 55 dB. A patient experiencing moderate hearing loss would experience difficulty hearing clearly with background noise and will generally need to wear hearing aids to hear normal conversation clearly.

Profound hearing loss:

The individual cannot hear sounds that are softer than 90 dB. This type of patient typically can only hear extremely loud sounds and has difficulty hearing or following conversations. New types of digital hearing aids for profound losses can help. Additional assistance, such as lip reading or sign language training, would also be indicated for patients with profound hearing loss.

lens,

The light waves are focused by this which is suspended by zonule fibers attached to the ciliary body. The lens can change shape by the ciliary muscle actions, which cause contraction or relaxation of the zonule fibers. The lens changes shape in order to form a sharp image on the retina—a process called accommodation.

papilledema.

The optic nerve can be visualized on the retina as a yellow, circular, clearly defined disc. When there is increased intracranial pressure, the optic disc becomes swollen with irregular borders, a condition termed

zone of hyperemia,

The outer zone, is reddened from vasodilation and increased blood flow but has minimal tissue damage and heals quickly

perilymph

The periotic fluid, separates the two labyrinths from each other.

Actinic keratosis,

a premalignant lesion found on skin that has been damaged by the sun's UV rays, is common in fair-skinned persons. The lesions present as patches of rough, scaly, red plaques. The surrounding tissues are red and may show telangiectasia (branches of delicate capillaries). Lentigos, premalignant skin lesions, usually appear as brown spots on sun-exposed areas. Commonly called solar lentigos, liver spots, or age spots, these lesions are benign, but they bear watching because there is also a lentigo maligna that appears as a freckle on sun-exposed areas. Lentigo maligna are pigmented macules with well-defined borders. Slow-growing, they can reach a size of 5 cm. Over time, the lesions may become raised and wartlike in appearance. Persons with a high number of actinic keratoses or lentigos on the body should consult a dermatologist periodically for a whole-body skin assessment.

labyrinth.

a system of communication channels. There are two parts to the labyrinth: an outer bony wall called a bony labyrinth that encases a thin-walled membranous labyrinth that floats inside. Within the labyrinth are the semicircular canals, which sense head movement, and the utricle and saccule, which sense head position

stye,

also known as a hordeolum, is a bacterial infection that develops near the root of an eyelash and appears on the outside of the eye . Pain, swelling, and redness of the conjunctiva and eyelid are symptoms. Staphylococcus aureus is the most common pathogenic etiology. Physical examination of a stye reveals swelling, erythema, and tenderness to touch. Treatment includes antibiotics and warm compresses with diluted boric acid solution.

Chemical burns

account for less than 10% of all burn injuries and generally occur after an industrial accident or ingestion of harsh household chemicals, including strong acids, alkalis, and corrosive materials. Chemical burns induce protein coagulation of tissues (protein breakdown) as chemical energy is converted into thermal energy. This produces a characteristic gray coloring of the skin.The severity of the response, which can be localized or systemic, is proportional to the type, quantity, and concentration of the chemical; duration of contact; and degree of penetration of the tissues. Chemical agents that are common offenders include sulfuric acid, ammonia, lye, and chemical warfare agents. Exposure to the agent must be halted by removing the clothes and vigorously irrigating the area to decontaminate the patient or neutralizing the chemical agent to limit injury. Working with chemicals, acids, corrosive materials Household chemicals Coagulates proteins in skin resulting in graying color of skin Decontamination: Remove clothes and irrigate area

Electrical burns

account for less than 10% of all burn trauma and range from mild injury after an electrical shock from a low-voltage household current (110 to 220 volts) to death after exposure to high voltage that exceeds 1,000 volts of energy. The electrical current generates heat when it meets resistance in body tissues and produces damage as the current passes through the body, possibly leaving entrance and exit wounds. The path of electrical energy commonly causes internal organ injury. The degree of injury depends on the amount of voltage, length of contact, and pathway of current. Most low-voltage household current produces deep burns at the exit and entrance wounds. High-voltage injury is divided into true high tension and flash injuries produced by a bolt of lightning. Voltage greater than 1,000 produces a high-tension injury that causes extensive tissue, muscle, and bone damage and frequently results in loss of limbs. When lightning strikes—a characteristic flash injury lasting only a few milliseconds—it traumatizes the victim. Electricity tends to flow along the path of least resistance toward a natural ground. Nerves and muscles produce less resistance and therefore suffer greater damage than tendons, fat, and bones. The pathway of current across the heart is associated with the highest mortality, as the alternating current of the electrical shock disrupts normal cardiac conduction, which can produce cardiac arrest. Household or as extreme as lightening Depends on degree of voltage and length High voltage (greater than 1000 volts) Extensive tissue damage; potential to break bones Travels along path of least resistance Potential for cardiac arrest Watch for metabolic acidosis

Melasma,

also called chloasma, by contrast, is characterized by the appearance of dark macules on the face. More common in brown-skinned women, melasma commonly occurs during pregnancy and in women who use oral contraceptives. Sun damage can also cause this skin discoloration. Blue-eyed and fair-skinned people reveal sun damage more dramatically than dark-skinned people.

Hypertrophic Scarring

also called keloids, can occur as burns heal in some patients. This hyperplastic growth of skin forms hyperemic, raised areas of firm skin. Compression dressings and garments can be worn to prevent development of hypertrophic scars. Silicone gel sheets worn over the wound 24 hours a day have been effective. Pressure therapy diminishes the number of myofibroblasts, erythema, thickness, and firmness of hypertrophic scarring and accelerates its maturation. Pressure and silicone gel dressings may exert effects by increasing the temperature of the scar, thereby enhancing the activity of collagenase, which breaks down fibrous tissue. Cosmetic surgery can also reduce hypertrophic scars.

Lice infestation,

also called pediculosis, is associated with lack of cleanliness. Lice obtain nourishment by attaching themselves to the skin, biting, and sucking blood. They can live on clothing for up to a month. Lice bites produce reddened macules, inflammation, hyperpigmentation, and parallel scratch marks. Although lice bites can cause significant illness—including typhus, relapsing fever, and trench fever—usually they produce itchy skin and social embarrassment.Lice bites are more common in children, and lice have an affinity for skin that is covered with hair. When lice penetrate the scalp, the hair becomes dry and lacks luster. Scalp itching is a common symptom. Body lice are associated with poverty, overcrowding, and poor hygiene. Some lice infections, called pediculosis pubis, are sexually transmitted. If patients have evidence of pubic lice, they should be screened for other sexually transmitted diseases, and their sexual contacts should be advised and treated.Diagnosis of lice is made by finding the lice or lice eggs, called nits, in the clothing, bed linen, or the hair of the person who has been bitten (see Fig. 41-7).Washing the person, his or her clothing, and the environment is the first step in eradication. Definitive treatment requires the destruction of lice with special soaps, shampoos, and rinses. Fine combs are used to determine if there are nits in hairy parts of the body. Usually, this process requires repeated applications of soap, shampoo, or rinse. The eradication process may also require shaving the hair.

Pressure ulcers,

also called pressure injury, decubitus ulcers, and bedsores, are the most common of the skin ulcers. Pressure causes diminished blood flow to the skin, especially skin covering bony prominences, which are particularly vulnerable to pressure. If pressure on the skin is released after several hours, the skin is reddened but not damaged. Sustained pressure produces blisters, followed by reddish-blue discoloration, and finally skin breakdown and tissue ulceration, which create opportunities for infection.Pressure ulcers affect older adults and persons who are immobilized for long periods; they are costly, burdensome illnesses. Persons with diabetes are at special risk for all types of skin ulcers because peripheral nerve damage and lack of circulation accompany the disease.

Exophthalmos,

also called proptosis, is a bulging of the eye out of the orbit; hyperthyroidism or ocular tumor are the most common causes. Dryness and irritation of the eyes can occur. The cornea becomes inflamed because of the friction that occurs when the patient blinks. Some patients may experience compression of the optic nerve or ophthalmic artery, which can eventually affect the patient's vision, leading to blindness. The cause of the exophthalmos needs to be treated. Corticosteroid drops, artificial tears, and ophthalmic lubricants can be used to relieve symptoms.

Vesicle (blister):

blister smaller than 0.5 cm in diameter

Eczema,

also known as atopic dermatitis, is the most common dermatitis, occurring in two clinical forms: infantile and adult. Vesicle formation, oozing, and crusting with excoriation that begins on the cheeks and spreads to the scalp, arms, trunk, and legs characterize the infantile manifestation of eczema (see Fig. 41-9). This form may become milder as the child ages, sometimes disappearing by age 15 years. However, some persons continue to have eczematous lesions and rhinitis throughout their lives. Adolescents and adults with eczema have dry, lichenified lesions that are either hypopigmented or hyperpigmented; these lesions are usually seen in the antecubital and popliteal areas, spreading to the neck, hands, feet, eyelids, and behind the ears. Because these lesions are itchy, inflammation and infection occur. Eczema also has a range of clinical presentations: acute, subacute, and chronic. In eczema, there is a recognized interaction among genetic and environmental factors, skin barrier, immune factors, and stress. Persons with eczema often have family histories of asthma or hay fever. The individual has elevated immunoglobulin IgE levels, as it is associated with allergy or type I hypersensitivity reactions. The goal of treatment, usually sought in the acute phase, addresses symptoms such as pruritus, dryness, inflammation, and infection. However, the ultimate therapeutic goal is to keep the eczema in remission. Treatment involves allergen control; good skin care; and avoidance of stress, foods, drinks, and temperature changes that exacerbate the eczema or its symptoms. Topical and occasionally systemic corticosteroids are used. Immune modulators are showing positive results without side effects.

Amblyopia,

also known as lazy eye, affects just 2% to 3% of the population. In this condition, central vision fails to develop properly, usually in one eye, which is called amblyopic. These symptoms include eyestrain, poor visual acuity, squinting, or completely closing one eye to see.

Scleroderma,

an autoimmune disease that occurs more often in women than in men, affects the skin's connective tissue and blood vessels. Beginning as a mild inflammation, the lesions of scleroderma develop into patches of yellow, hardened skin. The disease, which may be localized or generalized, alters the skin's appearance and flexibility and restricts movement. As a systemic disease, scleroderma affects internal organs and can cause cardiac problems (for more information,

Dacryocystitis,

an inflammation of the lacrimal sac, is often caused by an obstruction of the nasolacrimal duct. Incomplete canalization of the nasolacrimal duct or infection is the cause. The most common organisms include Staphylococcus aureus, Haemophilus influenzae, beta-hemolytic streptococci, and pneumococci. Newborns frequently have dacryocystitis caused by obstruction of the nasolacrimal duct. When dacryocystitis infection is present, the area around the lacrimal sac is painful, red, and swollen. The eye becomes red and watery and oozes purulent exudate. Slight pressure applied to the lacrimal sac may push exudate through the opening at the inner corner of the eye, near the nose. Fever is also common. Dacryocystitis is typically diagnosed by physical examination. Additionally, blood cultures may be necessary. Standard treatment consists of antibiotics and warm compresses. However, if conservative measures are ineffective, this condition is treated surgically.

Stasis ulcers

are also related to diminished circulation and are usually found in the lower extremities. Venous insufficiency, obesity, pregnancy, family history, old age, and blood clotting disorders are factors associated with the development of stasis ulcers.The process of developing stasis ulcers is subtle; as the valves in the legs become blocked or incompetent, blood flow back to the heart is compromised. As pressure rises in the veins, fluid seeps from the veins into the surrounding tissues. As a consequence of venous blood pooling and accumulation of wastes, the skin in the area becomes darker, thicker, dryer, and itchy. If untreated, these darkened areas of skin become ulcerated and infected.Loss of sensation, poor circulation, and itching contribute to the development of these easily infected ulcers. Because blood supply is restricted, infected stasis ulcers are difficult to heal.

Pattern injuries

are bruises, wounds, or those injuries whose shape suggests the instrument that inflicted them, such as belt buckles, irons, or burning cigarettes. These injuries indicate physical abuse. Usually, the history of the injury is inconsistent with its appearance and severity. Clinicians are required to report evidence that a patient has been abused.

Pruritus and purpural (bruising) syndromes

are common manifestations of psychogenic skin disease. Often, excoriation of the skin from picking, rubbing, scratching, or self-mutilation leads to secondary infections and scarring.

Spider bites

are common occurrences. They cause pain, redness, itching, swelling, and small puncture wounds. Although most spider bites are benign, the black widow spider and brown recluse spider inject toxic substances into the skin. These spider bites present as target marks, pale areas surrounded by red rings. The person who is bitten experiences local itching, rash, and burning, as well as systemic symptoms, including cramping pain, weakness, fever, sweating, nausea, and vomiting. Severe symptoms include difficulty breathing and increased blood pressure. Children and older adults have more severe symptoms.

Strawberry hemangiomas,

by contrast, are enlarged blood vessels that grow rapidly after birth and resolve by 6 years of age. Spider veins are enlarged blood vessels that grow with age. A

Assessment History Physical examination Whisper test Romberg test Pneumatic otoscope Diagnosis •Genetic testing •Connexin-26 •MRI, CT, Otoacoustic emissions (OAE's), Audiometry Treatment •Removal of obstruction •Myringotomy tubes •Hearing aids •Surgery •Cochlear implantation

care for ear disorders

Mosquito bites

are commonly encountered during warm months. The mosquito bite produces a localized, itchy wheal. Sweat attracts mosquitoes, which need protein to produce eggs. Mosquitoes bite horses, cattle, small mammals, birds, and people because of their large skin surface and abundant underlying blood supply. In tropical countries, mosquitoes can carry malaria, yellow fever, dengue fever, and encephalitis. Within the past decade, there have been serious outbreaks of mosquito-borne West Nile viral infections in the United States.Because mosquitoes can cause serious illness, there are public health initiatives related to their eradication: destruction of breeding grounds, emptying of pools of stagnant water, screening of windows and porches, and spraying of wetlands and grassy breeding areas. In areas where mosquitoes are abundant, mosquito netting, protective clothing, insect repellents, and avoidance of tall grassy areas and stagnant water decrease the incidence of exposure and the number of mosquito bites.

Ticks bites

are insects that live in grasses and bushes, as well as on forest animals, humans, dogs, and cattle. A female tick punctures the skin, sucks blood, and falls to the ground when engorged. Tick bites produce local damage to the skin, which resembles new moles. In some persons, urticarial wheals appear at the site of puncture. A characteristic "bull's-eye" type of red rash called erythema migrans often develops in bites from ticks carrying the microorganism Borrelia burgdorferi. Ticks carrying the bacteria can cause Lyme disease after puncturing human skin. Tick bites can produce systemic reactions such as fever, chills, headache, abdominal pain, and vomiting. It is important to recognize that these symptoms can occur as late as 2 weeks after the original bite. In addition to Lyme disease, tick bites can cause Rocky Mountain spotted fever, tularemia, and encephalitis (see Chapter 39 for more information on Lyme disease).

Port-wine stains

are permanent blood vessel abnormalities affecting 0.5% of the population. At birth, these lesions look like pink patches; as the child ages, the birthmark darkens and becomes larger.

Scald burns

are specific types of thermal burns. They occur after exposure to hot liquids, grease, or steam and cause tissue necrosis and cellular death within seconds after exposure to temperatures of 158°F (70°C). Because water has a higher specific gravity and is a better conductor of heat than air, a deeper burn can be produced by hot liquids with lower temperatures of 120°F to 130°F. This has prompted many states to mandate that hot water heaters be set below 140°F, which has decreased the incidence of scald burns from hot bath water. The high heat-carrying capacity of steam can also produce significant inhalational injury. Hot liquids, grease Result in tissue necrosis and cellular death within seconds Inhalation Greater than 158 degrees Fahrenheit Impetus to change laws regarding how water heaters (140 degrees F) Observe pattern of burn.....was it deliberate?

Lesions

are traumatic or pathological loss of normal skin continuity, structure, or function.

Acute Phase of burns

begins 48 to 72 hours after the burn injury; it includes the start of diuresis (loss of water from the body) and ends with closure of the burn wound. Continued assessment of respiratory and circulatory status related to edema and fluid shifts, nutritional support, infection prevention, and burn wound care are priorities during this phase. During this time frame, there is a shift of fluids from the interstitial to the intravascular space, and diuresis begins as capillaries regain integrity. There must be continued caution with fluid administration because of the fluid loss from large burn wounds. In older adult patients and in patients with inadequate cardiac or renal function, fluid overload occurs with the resulting signs and symptoms of congestive heart failure (CHF). Early detection and intervention with vasoactive medications, diuretics, and fluid restriction may prevent CHF and pulmonary edema.The burn patient is at high risk for sepsis related to the immunosuppression that accompanies extensive burn injuries. Monitoring of the patient's temperature is important for early detection of bacteremia or septicemia. •Begins with diuresis and ends with wound closure •Respiratory assessment •Hydrotherapy •Excision •Grafting •Infection monitoring •Debridement

emergent phase of burns

begins with the onset of the injury and continues until completion of fluid resuscitation. During this phase, the estimation of the extent of the burn, first aid measures, and fluid resuscitation are accomplished. The goal is to prevent shock and respiratory distress and to assess and treat additional injuries. The initial focus of care addresses the ABCDEF (airway, breathing, circulation, disability, exposure, and fluid resuscitation) of trauma care because the systemic injuries, if present, pose a threat to life.

Hemangiomas,

benign tumors of blood vessels, are apparent in 30% of newborns, with females more likely to be affected.

prodromal stage

can begin within minutes after intense radiation exposure or can emerge over 2 days with exposure to smaller doses of radiation. Radiation doses as low as 200 rads can damage the hair follicles and basal layer of skin and produce early cutaneous symptoms of pruritus, inflammation, and transient erythema, which might not be evident for days to weeks after initial exposure.

third wave of erythema of radiaiton burn

can occur over months or years postexposure. Exposures greater than 1,000 rads produce late effects with permanent damage to hair follicles, sebaceous and sweat glands, and pigment-producing cells. Skin tissue may become fibrotic, then necrotic, and develop ulcers. Usually pain and pigment changes will occur.

Assessment Determination of size and depth ◦Information regarding severity ◦Guides fluid resuscitation ◦Guides surgical intervention ◦Predicts mortality Classification of Burns ◦Superficial (first degree) ◦Partial-thickness (second degree) ◦Superficial Partial thickness or Deep partial thickness ◦Full-thickness (third degree) Diagnosis Rule of Nines Lund and Browder Method American Burn Association Classification of Burn Injury Minor Moderate Major Laboratory Testing ◦CBC, electrolytes (Na+, K+, CPK, BUN, creatine), urinalysis, ABG's, carboxyhemoglobin ◦Myoglobinuria Treatment Phases of Care ◦Emergent phase ◦Acute ◦Rehabilitation

care for burn injuries

Strabismus,

commonly called crossed eyes, is a related condition where the visual axes of the eyes are not parallel and the eyes appear to be looking in different direction

Macule:

defined, flat area of altered pigmentation

Crust:

dried yellowish or yellow-brown exudate on the skin

Emergent phase of thermal burns

eliminating the heat source, stabilizing the patient's condition, identifying the type of burn, preventing heat loss, and preparing to transport. At the scene of thermal burn injury, the flames must be extinguished so the rescuers can assure both their own and the victim's safety. The burn wound is then irrigated with cool water to halt the burning process; this gives immediate relief from the pain and limits edema and tissue damage. Restrictive clothing and items such as rings or belts should be removed if in the burned area. The next step is to quickly assess the airway and initiate oxygen therapy based on the type and location of injury. Maintain a patent airway, or intubate if the patient is demonstrating signs and symptoms of respiratory compromise. If no respiratory distress is present, 100% oxygen should be administered by face mask and the patient's head elevated 30 degrees. Fluid resuscitation is initiated using crystalloid and colloid solutions, which are similar to the composition of blood. The goal is to provide adequate fluid volume that supports perfusion of organs and maintains acid-base balance

• Burn depth • Percentage of the body surface area injured • Age of the patient • Extent of associated systemic involvement

factors determine the magnitude and severity of the burn: - - - -

Telangiectasia:

fine, irregular, red lines produced by dilation of the capillaries

Scale:

fragment of dry skin

condyloma acuminata,

genital warts, caused by certain strains of HPV that target the mucous membranes of the external genitalia and anus. Eighty percent of sexually active persons become infected with HPV at some point in their lifetime. Spread by vaginal, oral, or anal sexual activity, HPV infection can cause genital warts; cervical, anal, or oropharyngeal cancer; or resolve without consequences. High-risk HPV strains include HPV 16 and 18, which cause about 70% of cervical cancers. Low-risk HPV strains, such as HPV 6 and 11, cause about 90% of genital warts, which rarely develop into cancer. Warts can be removed by freezing, laser treatments, or the application of keratolytics or irritants. Imiquimod (AldaraR), podophyllin and podofilox (CondyloxR), trichloroacetic acid (TCA), or sinecatechins (VeregenR) are agents used to treat genital warts.

Induration:

hardening or thickening of the skin

Lichenification:

hardening or thickening of the skin with markings; lichenification develops from repeated trauma such as scratching

Vertigo

have the sensation that the room is spinning around them, when in fact there is no movement. Additionally, patients report an exaggerated sense of motion with any self-initiated movement. Episodes of vertigo usually last minutes to hours and are often associated with severe nausea and vomiting. This may be because of Ménière's disease or alterations in the labyrinth of the inner ear. It is important to distinguish vertigo from dizziness. A dizzy patient reports incoordination and a feeling that he or she is going to "black out" or fall. Nausea and vomiting do not necessarily accompany dizziness as they do with vertigo.

Papulosquamous dermatoses

include psoriasis, pityriasis rosea, and lichen planus. They are distinguished by scaling papules and plaques.

Contact dermatitis

represents delayed hypersensitivity to materials such as metals, chemicals, drugs, and poison ivy. The condition affects the head, neck, trunk, arms, hands, abdomen, groin, and lower extremities. This allergic skin reaction usually occurs days after the skin contact with the allergen. Emollients and topical anti-inflammatory medication are standard therapy.

Mite bites

injure the skin and render it susceptible to other infections. Scabies, the disease transmitted by mites, is associated with poverty, malnutrition, and sexual promiscuity. Usually scabies is spread by skin-to-skin contact, but it can also be spread via objects, clothing, and bedding because mites can survive for several days without contact with the skin's blood supply.Activated by warmth, the female mite finds her way to the bottom of the stratum corneum layer of the skin by creating a tunnel or burrow—a narrow, raised, irregular channel. Scabies are often suspected when small papules and visible wavy or linear burrows are present on the interdigital webs of the fingers and toes, folds of the skin, nipples, or genitalia. Because the lesions are itchy, the skin around the burrows is usually excoriated

major burn

injury is described as: • A partial-thickness burn exceeding 25% TBSA in adults or 20% in children • All full-thickness burns exceeding 10% TBSA • All burns involving the eyes, ears, face, hands, feet, perineum, and/or joints • All burns involving inhalation injury, electrical injury, concurrent trauma, and poor-risk patients

minor burn

injury is described as: • A partial-thickness burn of less than 15% TBSA in adults and less than 10% TBSA in children • A full-thickness burn of less than 2% TBSA not involving special care areas, such as the eyes, ears, face, hands, feet, perineum, or joints

moderate burn

injury, or uncomplicated burn, is described as: • A partial-thickness burn of 15% to 25% TBSA in adults or 10% to 20% in children • A full-thickness burn of less than 10% TBSA not involving special care areas

Keloid:

irregular, elevated scar tissue formed by excessive collagen growth during wound healing

Mongolian spot

is a benign darkened area of skin commonly on the back or buttocks.

Chalazion

is a blockage in one of the small meibomian oil glands at the margin of the eyelid . Symptoms include eyelid tenderness, increased tearing, painful swelling on the eyelid, and sensitivity to light. Warm compresses, steroid injection, and surgical excision are the treatments.

xerosis,

is a common dermatological complaint. Dry skin appears to be rough, scaly, and wrinkled. Skin dryness can be caused by dehydration of the stratum corneum, changes in sebaceous gland secretions, decreased sweat, and a flattening of the epidermal ridges, which reduce the ability of fluids to move between the skin's layers.Dry skin is more easily bruised and irritated. Because pruritus is the major symptom of dry skin, excoriation of the extremities, abdomen, back, and waist are found on examination. Liberal use of moisturizing agents such as emollients, humectants, and occlusives is the major treatment for dry skin. Each of these substances acts differently by replenishing oil on the skin, drawing water from deeper layers of the skin up to the skin's surface, or preventing water loss from the skin. Lotions or creams that contain camphor, menthol, or benzocaine are widely used to decrease pruritus. Temperature control and use of room humidifiers are also helpful.

Pruritus (itching)

is a common patient complaint. Sometimes the cause of the itching is localized and associated with a rash or an insect bite. Often persons with severe itching suffer sleep disturbances. At times there are no objective data to explain the itching. This manifestation of itching, which is more difficult to diagnose and treat, may be a sign of a systemic illness, such as liver failure, or it may be psychogenic in origin. Discontinuing drugs known to cause itchy skin or removal of offending agents is usually the first remedy. Treatment addresses the underlying cause of the itching if it can be identified. Local treatment relies on creams, lotions, and antihistamines. Excoriated skin can become infected, so it is important to address pruritus.

Color blindness

is a condition that impairs an individual's ability to distinguish certain colors. It occurs in about 8% to 12% of males and in about 0.5% of females. Red/green color blindness, in which the individual has problems distinguishing between reds and greens, is the most common type. The red and green objects in the environment appear gray in color. The disorder is a dysfunction of the rods and cones within the retina. Rods and cones are photoreceptor cells in the retina; rods allow us to see clearly in low light, and cones allow us to make color distinctions. Color blindness is normally diagnosed through clinical testing using the Ishihara color chart. There is no treatment for color blindness, and most persons compensate well for their defect. The gene for color blindness is carried on the X chromosome and is inherited from the mother. Since color blindness is an X chromosome trait, males have a higher incidence than females. X chromosome traits are dominant over Y chromosome traits in the male.

Hidradenitis suppurativa

is a disorder of the apocrine sweat glands, which are present in the axilla and groin areas. In this disorder, there is plugging or clogging of the gland openings onto the skin. The glands become obstructed and inflamed, and tender areas of swelling develop under the arm or in the groin. Bacterial infection is common, causing a purulent exudate that drains from the swollen, erythematous, tender glands onto the skin surface. Hidradenitis suppurativa is often a chronic disorder that occurs as remissions and exacerbations. Obesity, stress, and poor hygiene will make the glandular swellings worse. Chronic exacerbations can cause glandular swellings to develop fibrotic scar tissue. Medical treatment consists of oral antibiotics as well as topical or intralesional injections of antibiotics. Tretinoin (Retin-AR) and isotretinoin (AccutaneR), which are synthetic forms of vitamin A, have also been effective. If medical treatment is ineffective, surgical incision and drainage of the swollen glandular regions is common.

Autografting

is a procedure performed in the operating room to provide early wound coverage. In this procedure, healthy skin is removed from nonburned areas of the patient, known as donor sites, and transferred to burned areas. Deceased donor skin grafts (allografts) can be used on a patient's burned regions; however, tissue matching is necessary with this procedure. Alternatively, artificial skin can be synthesized in the laboratory using fibroblasts and bovine collagen scaffolds that induce the regeneration of human skin. Artificial skin does not contain immunogenic cells and therefore is not rejected.

rad

is a radiation dose of energy absorbed by the tissues, similar to a joule of energy. However, the radiation dose of energy does not indicate the biological risk of the exposure, which is measured in "rems." For example, one dental x-ray or chest x-ray causes a biological risk of 4 to 15 millirems, which is considered minor.

rule of nines

is a rapid method used during the prehospital and emergent phase of care. The body is divided into regions that present 9%, or multiples of nine, with the exception of the perineum, which is 1% of BSA. The face and back of the head are 4.5% each, so the entire head is 9%. The anterior and posterior portion of the arm is 9%, and the total for each leg is 18%. The rule of nines is fairly accurate for adults; however, for children it must be modified because of the differences in BSA between an adult and child. For example, a child's head comprises 18% of his or her TBSA, because a child's head is large in proportion to the child's body, whereas in the mature adult, the head comprises only 9% of the TBSA. The patient's total area of burn is estimated by adding the percentages of surface area burned

ciliary muscle

is a smooth muscle controlled by the autonomic nervous system that changes the shape of the lens for accommodation—near versus far vision. Sympathetic nervous system stimulation causes relaxation of the ciliary muscle, which places high stress on the zonule fibers attached to the lens that flattens its shape. Conversely, parasympathetic nervous system stimulation causes ciliary muscle contraction, which allows the zonule fibers to relax; in response, the lens bulges. The change of the lens's shape changes how light converges on the retina. The ciliary muscle also regulates the flow of aqueous fluid through the canal of Schlemm—

cochlea

is a snail-shaped bony tubule; the center of this tubule contains the cochlear duct. The cochlea is divided into three parts by the cochlear duct and the spiral lamina, which is a thin, shelflike extension. The three chambers of the cochlea are the scala vestibuli, scala tympani, and scala media.

Escharotomy

is a surgical procedure to prevent circumferential constriction of a limb or the chest. Surgical débridement is an operative procedure as opposed to natural débridement. It consists of removing tissue to the level of the viable tissue at the fascia level, also called fasciotomy. This procedure is reserved for patients with full-thickness burns because it removes potentially viable fat and lymph tissues.

rash

is a temporary eruption of the skin associated with systemic disease, heat, irritation, allergy, or a response to drug therapy.

Blepharitis

is also referred to as granulated eyelids. Symptoms of blepharitis include red, watery eyes; dry, gritty sensation of the eyes; burning sensation in the eye; itchy eyelids; erythematous, swollen eyelids; flaking of the skin around the eyes; crusted eyelashes upon awakening; photophobia; excessive tearing; abnormal eyelash growth; and loss of eyelashes. The eyelids may also appear greasy and crusted with scales that cling to the lashes. Acne rosacea and seborrheic dermatitis are skin disorders associated with blepharitis of the eyelids. Blepharitis can be difficult to treat. Good eye hygiene is key to effectively treating this eye infection.

Vitiligo

is an acquired skin condition characterized by abnormalities in the production of melanin. It presents as a series of discolored patches on the skin. Appearing suddenly, these patches present as macules of varying sizes with smooth borders. They commonly appear on the face, neck, axillae, and extremities. The lesions are depigmented, itchy, and easily burned by exposure to the sun or UV rays. The exact cause of vitiligo is unknown, and no treatment has yet been effective. Vitiligo often occurs with hypothyroidism or other autoimmune diseases.

Seborrheic dermatitis

is an inflammation of the skin caused by excessive secretions of the sebaceous glands. Its lesions are red, usually on the face and scalp, and yield yellow to yellow-brown scales known as dandruff. The lesions appear to be greasy, inflamed, and itchy. Removal of scales by frequent washing of the skin and shampooing of the hair provides some relief from this condition.

pupil

is an opening in the center of the iris. The pupil can dilate; referred to as mydriasis, and it can constrict, referred to as miosis.

posterior chamber

is between the iris and lens. The vitreous chamber is between the lens and the retina. The eye has three main layers: sclera, choroid, and retina.

Conductive hearing loss (CHL)

is caused by a problem with any of the structures of the outer and middle ear. One of the most common causes of CHL is impacted cerumen (earwax). Other possible causes include impaction of foreign bodies, trauma, otitis media (OM), and otosclerosis, which is the hardening of the ossicles

Sensorineural hearing loss (SNHL)

is caused by any disorder that damages the inner ear or auditory nerve. Tinnitus is a ringing or humming heard in the ear in the absence of outside sound. SNHL occurs because of disorders of the inner ear, auditory nerve, or auditory pathways within the brain (see Box 44-1). It is commonly caused by loss of hair cells from the organ of Corti within the inner ear, but it can also occur because of damage to CN VIII or, more rarely, the auditory cortex of the brain, which is located within the temporal lobe. When there is damage to this area of the brain, sounds may be heard but not understood. This type of SNHL is referred to as central hearing impairment. SNHL may also be caused by genetic disorders or infections while the fetus is in utero. Trauma, tumors, vascular disorders, infection, Ménière's disease, acoustic neuroma, and multiple sclerosis also can cause SNHL. Viral infections that can cause SNHL in the fetus during pregnancy include rubella and cytomegalovirus. Measles, mumps, and meningitis are childhood infections that can also cause it. Genetic disorders that cause SNHL include Waardenburg syndrome, Branchio-oto-renal syndrome, Stickler syndrome, neurofibromatosis type II, Alport syndrome, Treacher Collins syndrome. Usher's syndrome, Down's syndrome, and Pendred syndrome. Hearing loss can occur because of exposure to excessively loud noises for a prolonged period. Noise exposure can diminish the individual's ability to hear high-frequency sounds. Eventually, this loss can progress to more severe loss, including the inability to hear the sound frequencies of normal speech. Noise injury commonly occurs in the workplace but may also occur with recreational and social exposure to loud noises (see Box 44-3). This includes the use of personal music devices and attendance at concerts with excessively loud sound systems.

. Trichotillomania

is hair loss from repeated urges to pull or twist the hair until it breaks off. Anxiety often reveals itself in obsessive-compulsive behavior, such as pulling, twisting, or removing clumps of hair or biting the fingernails.

Uveitis

is inflammation of the uveal tract, which includes the iris, choroid, and ciliary body. Common causes include infection or autoimmune disorders, such as rheumatoid arthritis or ankylosing spondylitis; inflammatory disorders, such as Crohn's disease or ulcerative colitis; infections, such as syphilis, toxoplasmosis, and tuberculosis; and eye injury. Symptoms, which can develop quickly, include eye redness and irritation, blurred vision, eye pain, photophobia, and floaters. Uveitis is diagnosed with a thorough examination of the eye with a slit lamp microscope and ophthalmoscopy. Treatment of active inflammation usually involves topical cycloplegic agents (e.g., atropine or cyclopentolate) and topical corticosteroids (e.g., prednisolone ophthalmic). Immunomodulator (e.g., adalimumab) or immunosuppressive agents (e.g., azathioprine) may be necessary for patients with autoimmune uveitis. An intravitreal dexamethasone or fluocinolone implant has been effective for some patients. Some patients may require surgery.

Vision acuity

is measured using an eye chart, and results are recorded as a pair of numbers. Normal sight is scored as a ratio of 20/20; the numerator indicates that the object to be visualized is at a distance of 20 feet, whereas the denominator indicates how far away the object seems to the patient. Someone with a visual acuity of 20/20 can see letters at a distance of 20 feet away as if he or she is 20 feet away. Someone with a visual acuity of 20/60 sees letters at 20 feet as if he or she is 60 feet away. The higher the denominator of visual acuity, the worse the individual's vision. According to U.S. law, if a person's best eye has an acuity of 20/200 or worse and/or if their peripheral vision is less than 20 degrees, then that person is legally blind.

Alopecia areata

is sudden loss of hair in one area of the scalp. The cause is unknown, and usually the hair grows back in several months. A diagnostic tool for hair loss, the hair pull test, provides clues to the amount of hair that is being shed. Often clinicians biopsy the skin in the thin or bald areas or check for fungal or bacterial infections because some hair loss is caused by scalp ringworm. Although hair loss secondary to radiation or chemotherapy is not identified as a major type of hair loss, it is common in patients undergoing these treatments. After cessation of treatment, the hair usually returns.

middle ear

is the air-filled space between the tympanic membrane and the inner ear. The middle ear contains three tiny bones called the auditory ossicles. These ossicles, which hang from the roof of the middle ear, are the connection between the tympanic membrane and the oval window, which is an opening into the vestibule of the inner ear. The first of the three bones is called the malleus, or the "hammer." The handle of the malleus is called the umbo. It connects to the upper portion of the tympanic membrane and can be seen through the membrane. The head of the malleus attaches to the incus, also known as the "anvil," which attaches to the stapes, a stirrup-shaped bone. The stapes, in turn, attaches and is sealed into the oval window by the annular ligament. Sound waves cause vibrations of the tympanic membrane, which moves the ossicles and, in turn, vibrates the oval window and fluid in the inner ear. The two tissue-covered openings—the oval and the round windows—located in the medial wall of the middle ear are responsible for transmission of sound from the middle ear to the inner ear. Vibrations are amplified as they travel from the ossicles in the middle ear to the membrane of the oval window in the inner ear The middle ear is connected to the nasopharynx by means of the eustachian tube. The eustachian tube usually remains closed except during yawning or swallowing, which allows equalization of the air pressure between the middle ear and the outside atmosphere. This mechanism of equalizing pressure prevents rupture of the tympanic membrane when there is a sudden pressure change, such as during airplane travel.

inner ear

is the most complex portion of the ear, containing structures important for both balance and hearing. These structures include the labyrinth, cochlea, and spiral organ of Corti. Balance depends upon vision, vestibular function from the ear, and proprioception (neurological position sense).

Tinnitus

is the perception of abnormal sounds in the head or the ear, often described as ringing in the ears. Some patients describe the noise they hear as buzzing, ringing, humming, or hissing in nature. Tinnitus can be continuous or intermittent; unilateral or bilateral; and high, medium, or low pitch. It can occur because of CN VIII disorders, injury from prolonged noise exposure, infection, or medications such as aminoglycosides and aspirin (see Box 44-2). Tinnitus due to excessive aspirin use is termed salicylism.To resolve tinnitus, it is first necessary to find its cause. Sometimes there are triggers such as red wine, caffeine, or the food additive monosodium glutamate (MSG). Ménière's disease is a common cause of tinnitus that can be treated with medication or surgery.

Enophthalmos

is the recession of the eyeball within the orbit. It may be a congenital anomaly or occur as a result of trauma, collapse of the facial sinuses, Horner's syndrome, or other disorders. Treatment is aimed at the disorder's etiology; surgery may be necessary.

retina

is the sensory portion of the eye that changes light waves into neuroimpulses that travel via the optic nerve to the brain for interpretation . On funduscopic examination, the optic nerve is visualized as a bright, yellow, round structure located medially on the retina. It consists of a lighter-colored optic cup in the center, surrounded by the darker yellow optic disc. Blood vessels, both arterial and venous, lead out of the optic disc and perfuse the retina. Approximately two-and-a-half disc diameters to the left of the optic disc is the macula, a slightly oval-shaped, blood vessel-free, dark-red area. The central region of the macula is called the fovea, which is responsible for sharp central vision.

Onychomycosis

is the term for a fungal or yeast infection that involves the proximal and lateral nailfolds. Pseudomonas bacteria can also infect the space between the nail plate and the nailbed. Like other organisms that invade the paronychial fold, Pseudomonas thrive on moisture. Most infectious agents discolor the nails, causing them to darken; the degree of discoloration indicates the depth of the infection (see Fig. 41-2). A bacterial or fungal invasion may be deep enough to cause the nail plate to separate from the nailbed, a process called onycholysis.

choroid

is the thin vascular layer between the sclera and the retina.

sclera

is the white outermost layer of the eye. Within the sclera is the cornea

Flea bites,

known as pulicosis, occur when the flea bites its host, most commonly either a human, cat, or dog. Flea bites appear as small brown lesions and hemorrhagic punctures surrounded by a red, urticarial patch. These bites, which exhibit a zigzag pattern, are usually found around the waist and on the legs. The lesions from the bites are often seen in sets of three .Some persons have hypersensitivity responses to flea bites. When disturbed, fleas can jump from one host to another or to rugs, furniture, or bedding and remain in the environment. Pets that go outdoors can transfer fleas to humans. Unsanitary environments are often associated with flea infestation and an increase in bites. Pest control, window screens, removal of garbage and stagnant water, and environmental cleanliness are important modes of preventing flea bites.

Bulla:

large blister (larger than 0.5 cm in diameter)

Ulcer:

loss of epidermal and dermal tissue

Hyperhidrosis

may be related to physiological, pathological, or endocrine factors; brain trauma; or drug therapy. Often excessive sweat production is localized to the palms, soles, and axilla. Physiologically, sweat is produced in response to emotions; pain; fear and stress; hot, humid environments; work; and exercise. Pathologically, it is associated with febrile diseases, hyperthyroidism, and diabetes. Trauma to the hypothalamus or its tracts can interfere with heat regulation mechanisms and produce excessive sweating. Sympathomimetic (sympathetic stimulant) drugs and drugs that affect the hypothalamus also lead to sweating.

rehabilitation phase

may extend for years after the injury and actually begins during the emergent phase with the application of splints and the initiation of physical therapy. Active and passive range-of-motion exercises are initiated as soon as possible to prevent the development of contractures (inflexible contracted musculature). Scar tissue formation can be modified with pressure dressings, such as AceR wraps over the burn dressings, especially when the patients are ambulating. As the burn wounds are grafted, specialized tubular support bandages are applied to supply an equal amount of pressure to the wounds to prevent or decrease the amount of scar formation. Begins during emergent phase with physical therapy •Long-term •Active ROM •Pre-medicate

keratoconjunctivitis,

meaning corneal and conjunctiva inflammation, is often used. The patient has eye pain, redness, photophobia, and a feeling that a foreign body is irritating the eye. Infectious or inflammatory keratitis can leave a scarred cornea than can interfere with vision. Fluorescein staining of the cornea is necessary to diagnose keratitis. Antibiotics may be needed with bacterial keratoconjunctivitis. Acyclovir is the treatment for herpes simplex or varicella zoster. Corticosteroids should not be used for viral keratitis, as they will worsen the disease. Corneal transplant can be done in severe cases.

Refraction

occurs as rays travel from the pupil through the aqueous and vitreous humors to the retina, the innermost layer of the eye.

Conjunctivitis

occurs when the conjunctiva of the eye becomes infected or inflamed. The conjunctiva becomes red and swollen, and the eye feels itchy to the affected individual. There may be a purulent or watery discharge from the eye. There are viral, bacterial, and allergic causes of conjunctivitis. Bacterial or viral conjunctivitis, commonly called pinkeye, is highly contagious. Persons can spread the bacteria or virus by touching the eye and then touching the hands of another individual. Contaminated objects or bedding can transmit the microorganism as well. Patients should avoid touching their eyes and wash hands thoroughly, as infectious conjunctivitis is easily spread.

Entropion

occurs when the eyelid turns inward and irritates the eye, can cause eye irritation, excessive tearing, and corneal dryness. Artificial tears and surgery are the treatments.

ectropion

occurs when the eyelid turns outward, revealing the pink, conjunctival membrane. can cause eye irritation, excessive tearing, and corneal dryness. Artificial tears and surgery are the treatments.

Lund and Browder method

of assessing burns is a more accurate estimation of affected body surface. It divides the body into smaller sections of TBSA and evaluates the percentages of these areas. Again, the patient's total area of burn is estimated by adding the percentages of surface area burned

Acne rosacea,

often seen in middle-aged adults, appears as erythematous papules and pustules. Usually these lesions, which are associated with inappropriate vasodilation, appear in the middle third of the face but may extend to the forehead and chin. When the inflammatory process of rosacea affects the nose, it produces an unsightly, irreversible swelling and inflammation called rhinophyma. Heat exposure and alcohol consumption accentuate the vasodilation and inflammation of this disease. Although the exact cause of acne rosacea is unknown, it is thought that this inflammation of the sebaceous glands results from infection or from an immune-related response. Sunscreen lotions and protective coverings are recommended. In severe cases, oral antibiotic therapy is used.

Hyperopia,

or farsightedness, occurs when visual objects are focused behind the retina because of a shorter anteroposterior width of the eyeball. The lens cannot focus the light rays on to the retina. Individuals with hyperopia see better when objects are farther away. The closer an object moves, the blurrier it becomes. Treatment includes corrective lenses or surgery. If untreated, hyperopia tends to worsen with age. Hyperopic individuals cannot see objects in close range, such as reading material. The eyeball is shortened and visual images fall behind the retina. Convex lenses used in hyperopia focus the light on the lens of the eye, causing the image to land directly on the retina

Urticaria,

or hives, are elevated, pink or red, itchy blotches or plaques of varying size. These lesions, also called wheals, appear suddenly on the skin or mucous membranes and blanch with pressure (see Fig. 41-11). In about 40% of patients, the appearance of urticaria is accompanied by angioedema, the swelling of the eyes, face, lips, and the mucous membranes (see Fig. 41-12). Urticaria may occasionally be associated with acute anaphylactic reactions and laryngeal edema. The release of histamine from the granules of mast cells is the cause of urticaria. Immunological, nonimmunological, physical, and chemical stimuli can cause mast cell degranulation and release histamine into the skin and the circulating blood. The disease classification of either acute or chronic urticaria depends on the duration of symptoms. If a person has urticaria for longer than 6 weeks, he or she is considered to have a chronic form of the disease. Chronic urticaria affects adults and is twice as common in women as in men. It appears to be an autoimmune disorder, but extensive laboratory work-ups usually fail to identify a causal agent; avoidance of suspect antigens is not helpful. Approximately half of the persons with chronic urticaria have circulating immunoglobulin G antibodies to a subunit of the immunoglobulin E receptor. These antibodies activate the release of histamine from basophils and mast cells. It may manifest an underlying disease, certain cancers, collagen diseases, or hepatitis B. Physical urticaria is considered a chronic form of the disease. These intermittent, short-acting manifestations can be induced by rubbing the skin or by exercise, cold, pressure, sunlight, water, vibration, and heat.

Scleritis,

or inflammation of the sclera, causes severe eye pain that may radiate to the eyebrow, temple, or jaw. Other symptoms include photophobia; tearing without discharge; eye tenderness; and purplish-red, edematous, and engorged blood vessels. Inflammation of the sclera is usually associated with autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. Sometimes the cause is unknown. Treatment involves corticosteroid drops and oral NSAIDs.

Nevi,

or moles, are probably the most common benign skin tumors. These lesions, which can be pigmented or depigmented, develop from melanocytes during childhood, usually between 3 and 5 years of age. They present as papules and nodules and vary in size. Atypical or dysplastic nevi are those that are irregular in shape, variegated in color, and have a high susceptibility to cancerous change. These lesions require clinical examination to rule out skin cancer. Persons with a high number of nevi on the body should consult a dermatologist periodically for a whole-body skin assessment.

Myopia,

or nearsightedness, occurs when the eyeball is elongated and visual images are focused in front of the retina. Individuals with myopia see better when objects are close, which allows the lens to focus light waves on to the retina. Hence, in myopia the farther away an object moves, the blurrier it becomes. Symptoms include blurry distal vision, headache, squinting, and eyestrain. Visual acuity examinations are used to diagnosis myopia. Treatment includes corrective lenses via eyeglasses or contact lenses, or corrective surgery such as laser-assisted in situ keratomileusis (LASIK) surgery. If left untreated, myopia may worsen with age. Myopic individuals have impaired distance vision. In myopia, the eyeball is elongated and visual images fall in front of the retina. Concave lenses used in myopia spread the light out before it reaches the lens of the eye, allowing the image to fall directly on the retina

endolymph

otic fluid, which fills the membranous labyrinth. Perilymph has a composition similar to cerebrospinal fluid, whereas endolymph is comparable to intracellular fluid because of its potassium content.During physical movement of the head, the flow of the endolymph fluctuates. This movement is sensed by the vestibulocochlear nerve, also called cranial nerve (CN) VIII. Coordinated responses of this nerve provide a sense of balance and stability of movement.

Pustule:

papule filled with pus

Scar:

permanent replacement of normal skin with connective tissue

Purpura:

purplish lesion caused by free red blood cells in the skin; does not blanch on pressure and may be nodular

Plaque:

raised, flat-topped lesion, usually larger than 2 cm in diameter

Papule:

raised, well-defined lesion, usually smaller than 0.5 cm in diameter

Inhalational injury

should be suspected in people trapped in an enclosed space and exposed to smoke, noxious fumes, and steam inhalation. It should also be suspected in individuals who lose consciousness because the protective reflex of the vocal cords that limits injury to the lungs is lost, resulting in damage to the lower airway. Depending on the type of burning material, injury of the respiratory tract mucosa from the oropharynx to the alveoli can occur. Damage includes loss of bronchial cilia, decreased alveolar surfactant, interstitial edema, and release of inflammatory substances that increase pulmonary vascular resistance and narrow small airways. CO is contained in the smoke and fumes of a fire. In the body, CO binds to hemoglobin and pushes oxygen off, which leads to hypoxia. The initial chest x-ray may be normal, and the patient may be asymptomatic for up to 24 hours before respiratory distress develops. If the patient is demonstrating signs or symptoms indicative of respiratory distress such as stridor, hoarseness, use of accessory muscles, and increased work of breathing, the patient should be intubated immediately to prevent total airway obstruction.

anterior chamber

sits between the cornea and the iris. The watery fluid that circulates within the anterior chamber of the eye is the aqueous humor.

Nodule:

solid lump larger than 0.5 cm in diameter

iris,

the colored part of the eye, is located in the choroid layer.

Vertigo,

the feeling of spinning and imbalance, is the result of labyrinthitis.

Corneal abrasion,

the most common type of structural eye trauma, is damage to the epithelial surface of the cornea, usually caused by a foreign body that comes into contact with the eye. It can also be caused by either physical or chemical trauma. Contact lens wearers are more vulnerable to corneal abrasions because foreign bodies may become trapped between the cornea and the contact lens, causing scratching of the corneal membrane. Also, persons who play sports are more prone to corneal abrasions because of the increased risk of foreign bodies entering the eyes. Often, persons with a corneal abrasion present with the following: foreign body sensation of the eye, gritty eye sensation, unilateral eye watering pain, photophobia, and mild erythema of the conjunctiva. Minor corneal abrasions may be asymptomatic. In cases of a significant abrasion, slit lamp examination reveals a defect in the corneal epithelium. This defect can be confirmed by placing a drop of fluorescein dye in the eye. The fluorescein dye flows into the defect and glows under the light of a Wood's lamp (see Fig. 43-12). Treatment includes topical antibiotic ointments to prevent bacterial growth. Untreated corneal abrasions are susceptible to infections that may cause corneal ulcerations and blindness.

comedone,

the prototypical lesion in acne, is a plug of sebaceous and necrotic cellular material within the opening of a hair follicle. The follicle may be open (blackhead) or almost closed (whitehead). The lesions most commonly appear on exposed areas of the face, chest, and back. (plugged hair follicle with sebaceous and necrotic cell material)

astigmatism,

the rays are diffusely spread about the retinal area, resulting in blurred vision.The cause of astigmatism is the shape of either the lens or the cornea. The eyeball is often referred to as having a football shape rather than its normal spherical shape. These changes in shape distort the light rays entering the eye so that the rays do not center on the retina.Although some individuals may be asymptomatic, people with astigmatism may experience blurred vision, headaches, and eyestrain. Keratoscope and videokeratoscope are ophthalmic devices to measure and assess the curvature of the cornea to diagnose astigmatism. Treatment for astigmatism includes use of corrective lenses or refractive surgery such as LASIK. The eye's shape in astigmatism makes the light rays focus on two spots instead of one on the retina. The cornea has a steep, flat curve that can be corrected with lenses. A cylindrical curve in the corrective lens compensates for the eye's abnormal shape

cornea,

the transparent section through which light enters the eye.

Atrophy:

thinning and loss of skin layers

Wheals/urticaria:

transient pink, itchy, elevated papules that evolve into irregular red maculopapular patches

Male pattern baldness,

which can begin at any age, is usually genetic and influenced by male hormones. Typically, the hair loss is on the front, sides, and crown of the head. Female pattern baldness is less common and involves a thinning of hair over the entire head. Conversely, hirsutism, a type of male pattern hair growth, is often seen in women because of increased androgenic hormones.

Hymenoptera bites,

which include bites from bees, wasps, and fleas, are another common source of skin injury. These bites cause local inflammation, irritation, swelling, and itching. Some Hymenoptera bites trigger the severe allergic reaction termed anaphylaxis. Other reactions result from toxins injected by Hymenoptera that penetrate the skin and cause vesicles and bullae formation. Toxins can produce hematological symptoms in addition to skin lesions. Bee and wasp stings are immediately painful, and swelling and itching persist for about a week. A sting can inject poisonous venom into the skin that can reach the blood supply and cause systemic reactions. Serious, even fatal, allergic or anaphylactic reactions can occur immediately or within 1 hour of the sting.Treatment requires immediate removal of the stinger if it remains because it is a source of venom, followed by the application of ice to the area. Persons who continue to have symptoms or show any signs of an anaphylactic reaction, such as hives, should receive prompt medical care.

external ear,

which is shaped like a funnel, conducts sound waves through the ear canal to the tympanic membrane, commonly known as the eardrum. The lining of the ear canal consists of a thin layer of epidermis with fine hairs, sebaceous glands, and glands that produce cerumen, or earwax. The function of the external ear is altered when there is blockage, inflammation, or drainage within the canal or disruption of the tympanic membrane.

The zone of stasis,

which surrounds the zone of coagulation, is characterized by decreased tissue perfusion with some vascular damage. However, if intervention is aimed at increasing blood flow to this area, minimizing edema, and preventing infection, tissue damage is potentially reversible.

C. trachomatis

| A bacterial infection that causes mucopurulent keratoconjunctivitis. There is intense conjunctival inflammation, which leads to conjunctival fibrosis, scarring, corneal abrasions, corneal scarring, and opacification. Ultimately, these conditions lead to blindness. Signs and symptoms Symptoms include discharge from the eye, swelling of preauricular lymph nodes, and swollen eyelids. The eye appears "glued shut." The patient endures eye discomfort and tends to rub the eyes, which allows secretions to spread to others from the hand. Physical assessment Patient's eyes demonstrate cloudy corneas, discharge from the eyes, swelling of preauricular lymph nodes, swollen eyelids, and entropion formation. Diagnostic tests Nucleic acid amplification test, referred to as the polymerase chain reaction. This test amplifies the DNA of the pathogen, which in turn, identifies the specific organism. treatment The key to treating trachoma is the SAFE strategy developed by the WHO: S - surgery A - antibiotics F - facial cleanliness E - environmental improvement Two antibiotics: oral azithromycin and tetracycline eye ointment.

Retinoblastoma

| A cancerous development of the optic nerve. The tumor arises in the retina and can invade the brain. The cells of the tumor have an immature appearance and are referred to as retinoblasts. •Genetic mutation •Malignant tumor of the retina •Presentation: white spots in pupil, strabismus, redness, pain, poor vision absent red reflex •Prognosis and treatments based upon stage at diagnosis Signs and symptoms Strabismus, redness of the eye, pain, and poor vision. Physical assessment White spots are seen in the pupil; strabismus of eye and redness of the eye are apparent. Absence of "red reflex" of the pupil during the examination with the ophthalmoscope. Diagnostic tests An examination of the retina under general anesthesia leads to diagnosis of the eye tumor. Treatment If the cancer is in one eye and it is expected that vision can be saved, treatment may include radiation therapy, cryotherapy, and chemotherapy. If the cancer is in both eyes, treatment may include the enucleation of the eye with the most cancer and radiation therapy to the other eye, or chemotherapy followed by local treatment. Combination chemotherapy is demonstrating suppression of the cancer. Enucleation surgery of both eyes is done when vision cannot be saved.

Squamous Cell Carcinoma (SCC)

| A more serious epidermal cancer that is aggressive, invasive, and often develops from actinic keratosis. Signs and symptoms Lesion often appears on face or lips, or can be an oral lesion inside the mouth or on the tongue. Sun-exposed areas are the most common regions of SCC. Physical assessment Presents as red, scaly, slightly elevated lesions with irregular borders. Diagnostic tests Biopsy. treatment Surgery to remove lesion. Radiation or chemotherapy may be necessary.

Malignant Melanoma

| Arises from the melanocytes. Differ in size and shape and may arise from dysplastic nevi or new molelike growths. Slightly raised and brown or black in color. Can appear anywhere on the body and may be slowly or rapidly growing. ◦Etiology - Genetic link; Link to UV exposure ◦Pathophysiology - Radical growth; Signs and symptoms Patient presents with a lesion that has changed in size, shape, and appearance. Lesion is usually asymptomatic, but occasionally pruritus is observed. Cosmetic concerns about appearance of the lesion are frequent. Skin cancers may appear suddenly or develop over time. Physical assessment Description and comprehensive skin history reveal sun exposure and change of the lesion's appearance in its symmetry, diameter, color, or border. Melanoma ABCDE rules: A: Asymmetry B: Irregular border C: Variable color D: Diameter E: Evolving The general skin examination shows evidence of sun exposure. Diagnostic tests Biopsy, with assessment of spread of disease if the biopsy is positive. Insepction CT MRI treatment Surgery with a wide excision. Cryosurgery, radiation, and chemotherapy. Yearly skin checkup by a dermatologist. Monthly skin self-assessment by patient. Advice about protection from sun rays.

Basal Cell Carcinoma

| Arises from the nonkeratinizing cells of the basal layer of the epidermis. It is nonmetastasizing. Signs and symptoms Lesion often appears on the face, particularly the nose. Sun-exposed areas are the most common regions of basal cell carcinoma. Physical assessment Begins as a nodular-cystic, small, pearly, flesh-colored, smooth nodule that enlarges over time. Diagnostic tests Biopsy. treatment Surgery to remove lesion—often needs a very deep excision.

Cerumen Impaction

| Earwax within the ear canal that impairs sound conduction from the external ear to the inner ear. Signs and symptoms Hearing difficulty. Sense of "fullness" or itching in the ear. Physical assessment Hearing impairment. Yellow-brown colored earwax buildup in the ear canal seen with otoscope. Diagnostic tests None. treatment Removal of impacted cerumen using irrigation technique or curette. It is best to use warm water as an irrigant to avoid disruption of equilibrium that may occur with cold water because of stimulation of the vestibular caloric reflex. The vestibular caloric reflex occurs when the ear's vestibular system is disrupted by cold water placed in the ear canal. Nystagmus, a horizontal movement of the eyes, is a sign of the vestibular caloric reflex.

Cataract

| Excess protein layers and irregular clumping of proteinaceous substances within the lens. May be a change of physiological aging. •Excessive growth of epithelial layers of the lens (opacity) •Lens becomes thick and looses flexibility with age •Congenital cataracts result from fetal infection •Gradual vision loss •Difficulty seeing at night •Surgical removal of cataract; replacement of lens Signs and symptoms Blurry vision and cloudiness in lens of eye. Halos at night around bright objects such as light sources. Sensitivity to glare. Physical assessment Cloudy lens of the eye. Red reflex duller than normal. Diagnostic tests Visual acuity test. Slit lamp and tonometry; an instrument within the slit lamp measures IOP (pressure inside the eye). treatment Antiglare sunglasses. Surgical removal of cataract.

Ménière's Disease

| Increased volume of endolymph in inner ear. ◦Changes in fluid volume of both the bony and membranous labyrinth ◦Can be related to head trauma but frequently etiology is unknown ◦Brain will compensate balance over several weeks if one inner ear is surgically destructed Signs and symptoms Tinnitus, hearing loss, and vertigo. Increased ear pressure Physical assessment Hearing loss. Romberg test: may be positive. Diagnostic tests None. treatment Low-salt diet, diuretics, and steroids. Aminoglycosides may relieve symptoms. Meniett device or destructive surgery may be necessary.

Otitis Externa

| Infection of the auricle and ear canal. Common microorganisms include Pseudomonas, Staphylococcus, and Candida. Signs and symptoms Pain and tenderness of the auricle, fullness and itching of the ear canal. Discharge from ear canal common. Hearing difficulty. Physical assessmnet Tenderness, erythema, and edema of the auricle and ear canal. Purulent or serous discharge from the ear canal. Diagnostic tests None. treatment Antibiotic and steroid treatment. Ear plugs when in water.

Otitis Media

| Infection of the middle ear region. Discharge accumulation in middle ear. Common microorganisms include S. pneumonia and H. influenza. Signs and symptoms Earache. Hearing difficulty, sense of fullness. Fever, nausea, and vomiting possible. Children are extremely irritable, tug at ear, do not feed, and may have vomiting. Physical assessment Bulging, red tympanic membrane. Erythema and edema of the ear canal. Hearing impairment. Often pharyngeal erythema, edema, and rhinorrhea present. Diagnostic tests Pneumatic otoscope will demonstrate decreased movement of the tympanic membrane. Throat culture may be needed. treatment Antibiotic treatment. Antipyretics and analgesic may be needed. Tympanostomy may be necessary in chronic OM.

Bacterial and Viral Conjunctivitis

| Infection or allergy that causes inflammation of the palpebral portion of the conjunctiva. Exudative discharge may be present in bacterial infection. Pinkeye" •Viral is most common AdenovirusSelf-limitingWatery discharge •Bacterial: Strep, Staph, Haemophilus Mucopurulent exudate Ocular antibiotic prescribed Signs and symptoms Mild foreign body in the eye and photophobia. Visual acuity slightly affected. Physical assessment Red, swollen conjunctiva. Bacterial conjunctivitis yields mucopurulent exudates, whereas viral infection and allergy cause a watery discharge. Diagnostic tests Culture of exudate if present. treatment Topical antibiotic. Anti-inflammatory topical drops prevent contagion with bacterial infection.

Allergic Conjunctivitis

| Inflammation of both the palpebral and bulbar conjunctiva inflammation because of an allergen irritant such as pollen or animal dander. Signs and symptoms The patient has a sensation that a foreign body is in the eye; a red, teary eye; and photophobia. The eye is usually itchy and edematous. Visual acuity is slightly affected. Physical assessment Redness and tearing of the eye, swelling of the eyelid and surrounding tissue. Watery, nonpurulent discharge from the eye. Pinpoint subconjunctival hemorrhages. Diagnostic tests The diagnosis of conjunctivitis is usually based on the clinical symptoms. Culture of exudate is done with severe infections. Slit lamp examination is necessary if corneal involvement is present. treatment Avoidance of allergen. Antihistamine eye drops.

Labyrinthitis

| Inflammation of the membranous labyrinth of the inner ear. Signs ans symptoms Dizziness. Loss of balance. Hearing difficulty and tinnitus possible. Physical assessment Hearing loss. Romberg test may be positive. Diagnostic tests None. treatment Antibiotic and meclizine.

Full-Thickness Burns

| Injury involves the entire epidermis, dermis, and underlying subcutaneous tissues. Common causes are direct contact with flames, hot liquids, or steam. Fluid and heat loss are related to the loss of the protective layer. Signs and symptoms Acutely, the layers beneath the epidermis and dermis are totally exposed. Red, raw-appearing wound. No pain sensed. Physical assessment Skin exhibits a dry, leathery, and white or yellow color that does not blanch with pressure, which indicates it is avascular. Nontender because nerves are destroyed. Diagnostic tests CBC, electrolytes, urinalysis, BUN, serum creatinine, arterial blood gas, CPK, and carboxyhemoglobin level. There is an increased risk for infection. Culture of exudate may be needed. treatment Tetanus booster. Topical agents and wound dressing. Burns heal within weeks to months. Wounds usually require surgical intervention. Débridement and skin grafting. Depending on percentage of body surface involved, IV fluids or enteral feedings may be needed. Antibiotic agents may be needed. Pain control.

Deep Partial-Thickness Burns

| Injury involves the epidermis and most of the dermis. Wound is not painful, as the nerve endings are destroyed. Signs and symptoms Deep area of exposed tissue. The area appears dry, pale, or whitish-yellow in color. May be nontender if nerves are destroyed. Physical assessment Deep area of exposed tissue. The area appears dry, pale, or whitish-yellow in color. May be nontender if nerves are destroyed. Diagnositc tests Depending on how much surface area is involved, CBC, electrolytes, urinalysis, BUN, serum creatinine, arterial blood gas, CPK, and carboxyhemoglobin level may be needed. Increased risk for infection. If infection occurs, may need to culture the exudate. treatment Topical agents on wound area. Healing occurs within 3 to 5 weeks. Débridement. Skin grafting may be necessary for injuries within the deeper layers of the dermis. Pain control. Tetanus booster. IV fluids or enteral feedings may be needed, depending on surface area involved. Antibiotic treatment may be needed.

Superficial Burns

| Injury is limited to the outermost layer of the skin (epidermis). Tissue damage is minimal; the protective barrier is not impaired. Overexposure to the sun is the most common cause of injury. Signs and symptoms Painful erythema of the skin. Extremely tender to the touch. Physical assessment Skin is tender and appears pink, red, and dry. Blisters common. Peeling skin. No break in the epidermal layer of the skin. Diagnostic tests None. treatment Treatment limited to analgesics and moisturizers. The area heals within 3 to 5 days, with no scarring.

Diabetic Retinopathy

| Proliferation of new blood vessels in the retina. Blood vessels are fragile; can cause blindness. •Changes in the retina for patients with Type I and II •Vascular changes before DM diagnosis •Changes related to high glucose levels •Nonproliferative Early on Cotton Wool Spots •Proliferative Later Neovascularization Aneurysms and hemorrhages Signs and symptoms Floaters, blurred vision, poor night vision, and vision loss. Usually affects both eyes. Physical assessment Visualization of the retina through funduscopic examination shows lesions such as hemorrhages, microaneurysms, hard exudates, dilatation and beading of retinal veins, cotton wool spots, and proliferation of fragile, new blood vessels. Diagnostic tests Funduscopic examination and diagnostic tests related to diabetes such as fasting serum glucose or HgbA1c. treatment Blood glucose control to slow progression of retinal changes. Laser photocoagulation of blood vessels. Drug therapy includes intravitreal injections of ovine hyaluronidase (e.g., VitraseR), anti-VEGF inhibitors (e.g., aflibercept and ranibizumab), and intravitreal corticosteroids.

Age-Related Macular Degeneration

| RPE cells of the macula region of the retina age and become less able to process accumulated cellular debris. The RPE cells normally transport cellular debris to choroid blood vessels, which remove the debris from area. Changes in the permeability of the choroid membrane lead to deposition of cell debris between the RPE and choroid. The deposited material is called drusen. •Deterioration of the macula and loss of central vision Nonexudative (AKA "dry") Majority of cases Drusen accumulates between retina and the choroid layers; leads to retinal detachment Exudative (AKA "wet") More severe Blood vessels grow from choroid layer to behind the retina; leads to separation/detachment Signs and symptoms Patients with AMD report fluctuations in vision, with some poor vision days and other days when it appears improved. Patients also report difficulty with reading and seeing faces. Central vision is affected with peripheral vision intact. Physical assessment Areas of yellow-white drusen in the macula region are visible upon funduscopic examination. Diagnostic tests Amsler grid to measure central vision; individuals notice black spots in their central vision when looking through the Amsler grid. Slit lamp examination is necessary. Fluorescein angiography is a procedure that can highlight the retinal epithelium. treatment Consumption of antioxidants, including vitamins A, C, D, and E; zinc; and lutein, is recommended, as is a supplement consisting of folic acid, pyridoxine, and vitamin B12. A low-fat diet and smoking cessation are preventive strategies. Wraparound sunglasses are recommended to diminish glare. Intravitreous injection of VEGF inhibitors. Photodynamic therapy, which involves injection of photosensitizing dye, followed by laser therapy.

Retinal Detachment

| Retina peels away from its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment, entire retina may detach, leading to vision loss and blindness. Signs and symptoms Symptoms include a sudden or gradual increase in either the number of floaters or light flashes. Appearance of a curtain over field of vision. Physical assessment Abnormal retina; holes or peeling away of retina from vitreous apparent on ophthalmoscopic examination. Diagnostic tests Slit lamp ophthalmoscopic examination. treatment Emergency laser photocoagulation.

Papilledema

| Swelling of the optic disc, which is a sign of pressure on the optic nerve and a sign of increased intracranial pressure. Signs and symptoms Headaches, which are worse upon awakening and exacerbated by coughing, holding breath, or other maneuvers that increase intracranial pressure. Nausea and vomiting. Changes in vision, such as temporary and transient blurring, graying, flickering of light, and double vision. Physical assessment Swelling of optic disc; has become blurred with nondiscrete borders. Diagnostic tests Dilated visual examination of eye with ophthalmoscope. treatment Treatment of underlying condition causing high intracranial pressure.

Superficial Partial-Thickness Burns

| The injury involves the epidermis and limited dermis. The protective barrier is impaired, causing heat and fluid loss. Scalds or brief contact with hot objects is the usual cause of injury. Signs and symptoms Painful redness of the skin and exposure of dermal tissue beneath the epidermis. Blisters. Physical assessment Skin is bright red, pearl-pink, painful, wet, or blistered. Dermis is exposed. Extremely tender. Diagnostic tests Depending on how much BSA is involved, CBC, electrolytes, urinalysis, arterial blood gas, CPK, and carboxyhemoglobin level may be needed. If infection occurs, one may need to culture the exudate. treatment Topical agents used on the wound area. Débridement. Skin grafting may be needed. Burn heals in 10 days to 2 weeks. Monitor for infection. Tetanus booster. Depending on how much of the body is involved, IV fluids may be needed. Antibiotic treatment may be needed. Pain control.

Vestibular Schwannoma

| Tumor of the auditory nerve that compresses the nerve and causes hearing impairment. Signs and symptoms Hearing loss, tinnitus, and loss of balance. Physical assessment Hearing loss. Romberg test may be positive. Diagnostic tests MRI. treatment Surgery.

Glaucoma

| Two kinds of disease: POAG and PCAG. POAG has gradual onset; PCAG has sudden onset and is an emergency. Both are caused by an obstructed canal of Schlemm, which normally drains aqueous humor. Obstruction causes accumulation of aqueous humor leading to high IOP and optic nerve damage. •Unknown etiology •Death of retinal and optic nerve cells •Irreversible vision loss •Assess patient medication history •Goal to reduce IOP Signs and symptoms Painful, red eye; blurry vision. Halos around lights. Vision loss. Physical assessment Optic cup-to-disc ratio greater than 0.3 due to high IOP. Diagnostic tests Ophthalmoscopic slit lamp examination Tonometry. treatment Treatments available for glaucoma include topical eye medication, oral medications, laser procedures, and incisional surgery. Major drug classes for medical treatment include alpha-2 agonists, beta blockers, carbonic anhydrase inhibitors, cholinergic agents, and prostaglandin analogs.

Psoriasis

—a genetic, chronic thickening of the epidermis that presents as overlying silver-white scales covering red, circumscribed, thickened plaques—is a disease of unknown cause found throughout the world. More common in colder climates, the disease affects less than 5% of the American population, although its prevalence increases with age. Psoriasis can be associated with disabling arthritis of the hands and fingers. Psoriasis is a T-cell-mediated autoimmune response to an unknown antigen. Histories of adults with psoriasis reveal that skin trauma, stress, infection, and the use of medications such as hydroxychloroquine (PlaquenilR), angiotensin-converting enzyme inhibitors, and lithium often precede the appearance of psoriasis. Although the lesions of psoriasis can appear anywhere on the body, they are frequently seen on the extensor surfaces of elbows and knees, as well as on the scalp (see Fig. 41-10). Topical agents and emollients can soften and hydrate the skin. Exposure to sunlight and saltwater baths are known to be helpful. Topical corticosteroids are used with varying results but cannot be used long term. Immunomodulator drugs, also called biological agents or monoclonal antibodies, are a novel category of drugs found to be effective in psoriasis and other autoimmune disorders. These agents act systemically to inhibit inflammatory mediators, tumor necrosis factor alpha (TNF-alpha), and/or interleukins (ILs). There is a growing number of available systemic immunomodulators used to treat autoimmune disorders. Patients using these drugs have an increased risk of infection and need close monitoring during treatment. Testing for tuberculosis is often necessary before initiation of immunomodulators. Treatment varies with the severity of the disease, the age of the patient, and the person's ability to tolerate side effects of systemic drug therapy.

canal of Schlemm

—an important structure that regulates intraocular pressure (IOP). Sympathetic stimulation causes relaxation of the ciliary muscle, which blocks drainage of the canal of Schlemm. Consequently, aqueous fluid can accumulate within the eye. Parasympathetic stimulation causes contraction of the ciliary muscle, which opens the way for the canal of Schlemm to drain.