Pharmacy Practice Winter 2020

Fungal Skin Infections (Dermatomycoses)

-Tinea capitis= scalp; think "cap"= skull cap -tinea unguium= nails; think "n"= nails -tinea cruris= groin -tinea corporis= body b/c corpus -tinea pedis= feet -symptoms= itchiness, burning/stinging pain, inflammation, redness, macerated skin, foul odor (sweating/gram-neg bacterial infection), weeping/oozing pus, scaling, fissures, small vesicular lesions, nail changes (brittle/discolored) -happens in stratum corneum (horny layer of epidermis= outer layer w/ keratinized, non0nucleated cells, "orn" -stages: 1. Inoculation (establishment)= dermatophyte infects skin, 2. Incubation: fungal growth in stratum corneum, 3. Refractory (enlargement)= fungal growth>>epidural turnover= symptomatic at 3rd stage now= itching/inflammation, 4. Involution= immune response, resolution of symptoms -skin=largests organ in body= for protection (skin flora vs invasion by bacteria, also skin pH=acidic, ~pH 5), sensation, thermoregulation, immunomodulation, vitamin D synthesis -risk factors: trauma to skin (blisters from ill-proper footwear), diabetes mellitus, obesity, immunosuppression (drugs, disease), impaired circulation, poor nutrition/hygiene, occulsion (blocking of blood vessels) of skin, climate=warm/humid, some infections spread via direct contact like combs/clothing -DO NOT TREAT OTC scalp/nails (tinea capitis/tinea unguium)> can treat tinea corpus, tinea cruris, tinea pedis (body, groin, feet=ok OTC) -Exclusions from self-tx: causative factor unclear, initial treatment unsuccessful/worsening, involves Face, mucus membrane, genitals, nails or scalp, signs of 2ndary infection, pus/oozing, extensive/extreme inflammation, diabetes, systemic infection or immune deficiency, fever or malaise 1. Tinea pedis= "Athlete's Foot"= avoid communal areas (public pools/gyms, home bath), atheletes b/c sports=feet trauma plus sweating/occulsive (blocking) footwear)> need to rule out contact dermatitis (eczema, i.e. wear watch>red rash there) in kids -symptoms= chronic intertriginous= between the toes, can spread to sole, fissure, scaling, maceration, malodor, itching/stinging -chronic papulosquamous pattern= bilateral on both feet> mild inflammation, diffuse scaling on soles, often seen with tinea unguium> so refer cause nails -vesicular= small vesicles near feet surface, skin scaling, symptoms in summer not winter= REFER -acute ulcerative= white, wrinkly, oozy, ulcers, bad odor= b/c complication of overgrowth of gram-negative bacteria> REFER -tinea cruris (groin)= "jock itch" -rare in children, common in males, warm weather, sweating, occlusive clothes> in medial and upper thighs, pubic area -symptoms= bilateral lesions w/ well-defined margins (margins slightly elevated, erythematous (red), often w/ small vesicles)> acute= bright red, chronic= hyperpigmented w/ scaling> super itchy, if spread to penis=refer -tinea corporis= "ringworm of the body"= common in pre-pubescent children> risks: day care, hot/humid, contact spots like wrestling, stress/obesity -located on glaborous (smooth/bare) skin -symptoms: small, circular erythematous, scaly areas spread peripherally, borders w/ pustules (blisters, pimple, w/ pus) or vesicles, itchiness, infect occluded areas, or exposed neck/face/arms -tinea unguium = "ringworm of the nails", onychomycosis= REFER -risks: older age, swimming, tinea pedis, infected family members, immunodeficiency/diabetes> nails become thick, yellow, rough, opaque, friable (crumbles easily)> nail can become separated from nail bed, subungual hyperkeratosis (skin under nails= hard) -tinea capitis= ringworm of the scalp= REFER -common in children, black females, risk: direct contact w/ infected individuals/infected fomites (clothes, etc) -symptoms: 4 variants: 1. noninflammatory= small papules surrounding hair shaft, 2. inflammatory: pustules> kerion formation (weeping lesions that form thick crust) formation, 3. black dot= hairs break off at scalp and leave black dots> hair loss, inflammation, 4. favus= patchy hairy loss, scutula (yellowish crusts/scales)> atrophy, scars, perm hair loss -OTC Treatment babyyyy: -think about dosage forms/convenience -non-pharm therapies: 1. GOOD HYGIENE= cleanse skin daily w/ soap/water and PAT DRY -2. stay dry= allow shoes to dry before wearing, use drying powder, change insoles every 3-4 months, LIMIT use of occlusive or wet clothing (wool/synthetic fabrics limit air circulation) -3. Prevent spread of infection= launder towels/clothing in HOT water/dryer, don't share towels/clothing/personal articles, use separate towels or dry affected area last -4. prevent acquisition of infection= avoid close contact w/ ppl w/ fungal infection, wear protective footwear in shaded areas OTC Antifungals: 1. Creams (most common)= penetrate stratum corneum well, good for DRY/CRACKED skin, adhere and doesn't rub off easily 2. Solutions= good for MOIST/OOZING areas, easy application, but has to Air dry :/ 3. Ointments= Oil-based, occulsive, greasy> don't use on wet, macerated tissue= dry areas only 4. Sprays= convenient, no touch, spray 6-10 inches away from affected area, avoid contact w/ eyes, caution: aerosols may have menthol 5. Powder/Spray powder= use for LARGE areas, tolnaftate= cornstarch+talc (absorb moisture) -basically: creams and solutions= most efficient in delivering drug to epidermis -sprays and powders= less effective (b/c not rubbed in) but easy to apply (adherence) -MOA= How to make bacteria: biosynthesis of ergosterol for the cytoplasmic membrane of bacteria: Squalene> Squalene 2,3 epoxide> lanosterol>>> ergosterol -Squalene epoxidase inhibitors (Terbinafine hydrochloride, Butenafine hydrochloride; think "-afine"=squalene epoxidase inhibitor) obviously stop the first step of that of squalene> squalene 2,3 epoxide -Azole Antifungals= Miconazole nitrate 2%, Clotrimazole 1% (-Azole= azole antifungal)= inhibits lanosterol>>> ergosterol -these inhibitations result w/ damaged fungal cell wall membrane -other antifungals= tolnaftate HCl 1%= stunts fungal growth, undecylenic acid 10-25%, haloprogin 1%, clioquinol 1% (not available) -drying agents= salts of aluminum -DW about dosing= see dosing list: 1. Terbinafine (12+ only)= squalene-epoxidase inhibitor= depletes egosterol to prevent fungal growth (fungistatic) and causes accumulation of intracellular squalene> kills fungus (fungicidal) -dosing= between toes=twice a day for 2 weeks for spray/soln; gel formulation= once a day for 1 week, cream= twice a day for 1 week, for bottom/side of feet= cream= twice a day for 2 weeks -for groin/body= once a day for 1 week -terbinafine= the shortest acting treatment for tinea pedis (may require longer duration of therapy) -2. Butenafine (12+ only)= squalene-epoxidase inhibitor= depletes egosterol+accumulates squalene= stops fungal growth/kills them -only has 1% OTC cream= once daily for 4 weeks (preferred) or twice daily for 7 days for between toes -for groin/body= once daily for 2 weeks -Azoles= prevent de-methylation of lanosterol> stop cell wall synthesis (fungistatic=growth): 1. Clotrimazole (2+ y.o.): (soln/cream/ointment) body and feet= twice a day for 4 weeks, groin= twice a day for 2 weeks -2. Miconazole Nitrate (2+ y.o.)= all formulations= body and feet, twice a day for 4 weeks, groin= twice a day for 2 weeks -Tolnaftate (2+ y.o.)= reversible non0competitive inhibition of squalene epoxidase, fungistatic/fungicidal dep on conc, LESS EFFECTIVE vs terbinafine -tolnaftate POWDER may not be effect on its own -use twice a day for 2-4 weeks for everything, side fx=stinging Undecylenic acid and undecylenate salts (2+ y.o.)= unsaturated FAs that impact fungal growth (fungalstatic)> similar efficacy to tolnaftate -feet and body= twice a day for 4 weeks, groin= twice a day for 2 weeks -Salts of Aluminum= useful for wet, soggy, tinea pedis -MOA= Astringent (aluminum sulfate + calcium acetate (domeboro)= decreases edema, exudation (oozing) and inflammation= drying -antibacterial too at HIGH concs tho (>= 20% solns) -uses: COMBINATION THERAPY (drying agent) for tinea pedis= not monotherapy -relief of inflammatory conditions of skin (athlete's foot) -instructions=foot soak= dissolve 1-3 packets in 16 oz of cool/warm water= inc conc= inc drying but also inc irritation -soak feet for 15-30mins (>30 mins= irritation)> then discard soln> can repeat 3x daily for up to 1 week> after= refer -compress/dressing instructions= soak a clean cloth in the mixture, apply cloth for 15-30mins directly to affected area> discard soln after use -side effects= skin dryness, burning, stinging, irritation esp if fissures (use diluted concs), tissue necrosis -warnings= External use only, no eye contact, accidental child poisoning, prolonged use= tissue necrosis (no more than 1 week), D/C if lesions appear/worsen Counseling pts: -clean and pat dry affected area (don't share towels) -apply antifungal sparingly twice daily (AM and PM) -massage medication into affect area -avoid touching eyes -wash hands thoroughly w/ soap/water -expect improvement w/in 1 week> if not, see PCP -continue therapy for entire directed course (up to 6 weeks)

Random stuff from conference (don't need to know)

Mouth stuff: diffs of mouthwash= alcohol content, some ppl can't have alcohol= dries out the gums= no listerine> not much diff between them even if whitening/etc -biotiene= for dry mouth, 1st choice, for elderly ppl -whitening strips= not for everyone too b/c can make gums very sensitive, expensive, 30mins vs 1 hr kind= try to do 30mins to dec gum irritation -there's also dry mouth lozenges -cold sores= herpes, contagious, abreva= docosanol vs canker sores=inside mouth from biting, benzocaine= numbing agents; cause for either= like stye, just variety of reasons dep per person -samilasan= homeopathic for swimmers ear -debrox= carmabide peroxide 6.5%> 5-10 drops, leave it there, then it comes out after washing out for earwax -swim ear (no glycerin) or aurodry (better b/c has glycerin if use multiple times)= isopropyl alcohol (drying) and glycerin (prevents overdrying) -acetic acid w/ isopropyl alcohol= another txt w/ swimmers ear -itchy eyes, red eyes, irritation in eyes, dry eyes -ketotifen (zatidor, alloway)= antihistamine for itchy eyes, twice a day, can use oral antihistamine too -red eyes= visine, Clear eyes=naphazoline, tetrahydrozoline, rebound red eyes= can use temp, but doesn't really txt underlying cause -refresh for dry eyes, blink, sustain, ointment at bedtime b/c oily, can use wet cloth to clean eyes in morning, mineral oil, white petrolatum, glycerine, carboxymethyl sodium -Do you wear contacts or not?> barrier -eye washes= for foreign objects= use an eye cup, need to open eyes and blink to get irritant out -contact solutions= biotrue, optifreez, bostum, w/e, just be aware they're out there -clearcare= contact soln, can burn your eyes b/c has hydrogen peroxide=has to be neutralized w/ own container left for 6 hrs= will burn if not left for 6 hrs, used as a rinse, etc. -optomologist= the surgery, optometrist= day to day, can diagnosis too > eye pain, etc= tell patient to go to optometrist not urgent b/c usually won't treat underlying cause -diff colors on eye caps for diff classes for prescription eye stuff

Healthy Literacy and Communication

PAR strategy= Prepare, Assess, and Respond -reflect back understanding of content and feelings -"Sounds like you're..." -"What I hear you saying is.." -"It seems like you.." -"You appear to be feeling.." -"Let me see if I understand.."

Diabetes Workshop

-Lipohypertrophy is a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin> switch injections sites (SQ injection=abdomen, thighs, outer pt of upper arms, buttocks) -if lipohypertrophy= can feel it and injection into these areas= dec abs of insulin (nonpredictable > fluctuation of BG -1 method: select an injection site for 1 week and in that site, rotate around, 1 finger width apart from last injection site> next week choose diff injection site -2nd method: crisscross method, stay away from navel/scare tissue/lipohypertrophy sites by 2 inches -use smallest insulin syringe for doses of insulin -6mm or 8mm needle length= normal -4 or 5mm= shorter for thinner/normal weight patients/children -inc guage= dec thickness (so thinner) -inc guage= dec volume b/c thinner -sometimes want thick needle and smaller guage to inject faster -1CC=1mL=100U -0.5mL=50U -3/10mL=30U -ex: 80U=100U syringe b/c less shots -only talk to patients in units to not confuse them cause syringes only come in units -only use insulin syringes b/c not calibrated -BG Log Book Management: -1. Assess hypoglycemia= <70mg/dL or symptoms of hypoglycemia like shaky, sweaty, hungry, dizzy 2. Assess fasting BG (FBG) =if high=due to hepatic gluconeogenesis or high bedtime BG= inc dose of LA insulin 3. Assess hyperglycemia= long-term complications= b/c of food/missing dose of insulin Nutrition: -40-65gm of carbs using the available food models -15g of fruit, 3-4oz protein -calories=ind but 400-500 calories= normal adult meal -fat=avoid trans fats, aka "partially hydrogenated", saturated fats= limited to 5-6% of daily calories ex: 2000 calories=16gm saturated fat/day -sodium= 2300mg/day (1tsp) -total carbohydrate= men: 60-75gm carbs/meal; women=45-60gm carbs/meal -fiber= higher=better, adults= 20-30gm fiber/day -sugar= low, no more than 24gm/day (6 tsp) -protein= 0.8g protein/kg/day (ex: 75kg person= 60gm protein/day or 20 gm/meal) -1oz protein= 7gm -snacks= 100-150calories or 15g carbs -How to Check Blood Glucose: 1. wash hands, use alcohol swab to clean 1 fingertip, wait 1 min for alcohol to dry 2. prepare lancet= adjust needle depth 3. Insert test strip into glucose monitor 4. Select finger to puncture, hold lancet, twist and pinch to remove safety pin> press lancet to side of finger and press down (alternate sites/fingers for other readings b/c inc chance of scar tissue/pain) 5. apply blood to test strip and you'll get a reading 6. throw away lancet in sharps container and test strip in trash 7. interpret glucose reading Insulin Injection: 1. Inspect insulin vial (color, expiration, right insulin) 2. clean top of vial with an alcohol wipe 3. draw air into insulin syringe for how much you're going to put in 4. Insert needle into insulin vial at 90 deg angle, turn vial upside down and plunge in 10U air 5. draw up the dose of 10U insulin, flick syringe to remove air bubbles, take out needle and recap needle 6. clean skin with alcohol wipe and allow to dry 7. inject insulin via pinching abdomen to create skin fold using dart-like action, 90 deg angle into skin, release pinch, inject insulin then take out and put needle/syringe into sharps Insulin Pen Administration: 1. Inspect the insulin pen for color, right insulin, expiration 2. attach the needle by screwing it on, remove the needle cap 3. Prime it: dial a test dose of 2 U, push plunger, you need to prime it every time 4. Dial the right dose like 10U 5. inject insulin at 90 deg angle, depress plunger and hold for 10 secs to make sure the full dose has been administered 6. put cap back on, remove the needle from the pen, discard into sharps -How to treat hypoglycemia: -hypoglycemia= BG<70mg/dL (depends on person tho, txt when have symptoms: sweating, fainting, dizziness, shaking, headache, irritated, blurry vision, hunger, nausea, weakness, anxiety, tachycardia, heart palpitations, confusion -BG <50mg/dl= unconscious, coma, seizures or even death -15/15/15 rule= 15g carbs (fast acting), wait 15mins, check blood sugar levels and if still low, eat another 15g -if not low, eat complex carbs and protein= meal i.e. peanut butter and meal -4 tablets of glucose, 1/2 cup of fruit juice or soda, whole box of raisins,etc. -severe hypoglycemia= glucagon emergency kit> if unconscious, move them to their side> put in thigh, butt, deltoid -remove flip off seal from bottle of glucagon, remove needle protector from syringe, and inject entire contents of syringe into bottle of glucagon -remove syringe from bottle, swirl bottle gently til glucagon dissolves completely> it should be clear/colorless -w/ same syringe, put it back in, hold bottle upside down, making sure needle tip still in soln, gently withdraw ALL the soln (1mg mark on syringe for adult) from bottle -inject syringe contents into butt, thigh, back of arm -as soon as patient regains consciousness and can swallow, give them 15g fast acting carb then a complex carb+protein -glucagon dosing: adults/children >5-6 y.o and >20kg= 1mg (1CC or 1mL) SQ -children <20kg, give 0.5mg (1/2CC or 1/2 mL) SQ -can also be given IM (thigh, arm, butt)= good blood flow b/c want fast acting> response= 5-20mins, call 911 Insulin Self-Lecture: fastest to slowest= IV>IM>SQ (Preferred) tho b/c dec variability b/c SQ= low amt of blood vessels -insulin suspensions are never administered IM or IV -abdomen (Preferred)>deltoid (upper arm)>thighs> hips -inc abs= warmth and inc blood flow= massage, exercise, fever, sauna, jacuzzi -dec abs= cold packs, extremities -erratic abs= large insulin doses (>800U) or improper mixing -1/2inc= 12.7mm needle, 5/16in=8mm, 3/16inch=5mm -use smallest barrel size (syringe measurement) for that dose for accuracy= 0.3mL=1/3CC, holds 30U (1U increments) b/c 1mL=1CC=100U (2 unit increments) -you can reuse insulin needles/syringes in SAME patient til needle becomes dull, bent or in contact w/ any surface other than skin -risks= infection esp if poor hygiene, open wounds, or dec immunity= don't use in these ppl -benefits= cheaper, but only rec if patient can safely recap syringe and is not at inc risk of developing infections/no children, safe -store needles/syringes at rm temp, DO NOT CLEAN W/ ALCOHOL (B/c needle is coated to slip in skin easily) -caution: long term insulins can't be mixed w/ other insulins so don't mix needles -gently roll vial to re-suspend NPH and mixes (suspensions) -if mixing insulins, need enough air for both vials= draw up rapid/regular insulin first, then NPH -air bubbles don't hurt the patient but they displace insulin and can result in incorrect doses -thin patients/children= inject at 45 deg angle -preventing painful injections: remove air bubbles, relax muscles, inject quickly (dart-like), only use insulins that's stored at rm temp, don't reuse dull needles -try to avoid high fat foods like chocolate, chips, donuts, etc for hypoglycemia b/c delays abs of carbs= takes longer to treat

Nutritional Deficiencies: Vitamins

-Vitamins=essential, organic, made endogenously vs minerals=essential but inorganic -Vitamin Deficiency: -inadequate nutrient intake=malnutrition from poverty, diets/eating disorders, alcoholism, substance abuse -increased metabolic needs=pregnancy/breastfeeding, infants, children for growing, severe trauma/injury or systemic infection=need vitamins to heal -Malabsorption=advanced age, celiac disease, CF, GI disorders: malignancy, prolonged diarrhea, bariatric or other GI surgery -Drug-nutrients interactions -other=social isolation, depression, poor appetite, fatigue or arthritis pain affecting food prep, inadequate exposure to sunlight (vitamin D) -OTC vitamin supplements=to prevent deficiences and replenish stores -OTC Vitamin supplements are NOT intended for self-txt of deficiencies unless prescribed via PCP -doesn't benefit if take >DRI (dietary reference intake) -once daily multivitamin <100% of DRI sufficient for most -refer to PCP for suspected vitamin deficiencies -eat a variability/balanced diet to prevent vitamin deficiency -Fat soluble vitamins= ADEK -ADEK can be toxic in excess -deficiencies d/t limited fat intake/abs like certain meds, celiac disease, CF, short bowel syndrome -Water soluble vitamins: -vitamins B and C complex=not stored extensively in tissues=mostly peed out=seldom toxic -Vitamin A= forms: 1. Retinoids (retinol)=animal sources, 2. Carotenoids (alpha and beta carotene)=plant sources, liver converts it to retinoids -functions: essential for normal growth and reproduction -skeletal and tooth development -proper function of eyes -maintain epithelial cell barrier (protect vs infection)=skin -dietary sources= dark green veggies, red, orange, or dark yellow fruits/veggies, egg yolk, liver, milk fat -deficiency=rare (most likely in children/malabsorption) -symptoms= night blindness (can't see well at night but reversible), zerophthalmia (dryness of cornea/conjunctiva), dry skin, follicular hyperkeratosis (like pimples) -Vitamin A DRI=2330-3000IU/day for adults, so max=3microgram/day (see dosing list) -Vitamin A toxicity= risk factors: doses>DRI, or retinol>beta-carotene -symptoms: "He Doesn't Need Vitamin Dosing Very Frequently"= Headache, diplopia (double vision), nausea, vomiting, drowsiness, vertigo, fatigue -carotenemia=yellow skin -teratogenic=harmful to fetus -fractures -inc risk of lung cancer? -Vitamin A drug interactions= ingestion of mineral oil (for constipation, not abs thru GI), orlistat, cholestyramine (dec cholesterol, inhibits bile acids), colestipol (same)= dec vitamin A abs -take multivitamin tablet w/ vitamin A -separate dose by 2 hrs before or after dosing -Warfarin= large vitamin A doses inc warfarin effect> but not an issue if vitamin A taken at <= DRI -Vitamin D= calciferol= synthesized in skin on exposure to UV radiation -Forms: -Vitamin D3= CholeCalciferol (fish, meat or from sun> liver>kidney>active form) -Vitamin D2=ErgoCalciferol (supplements) -1,25-DihydroxyCholecalciferol (active form after liver/kidney processing) -Functions= proper bone formation, calcium/phosphate homeostasis, prevents tooth loss and disease -Vitamin D= from sunlight, fortified milk/milk pdts (100IU/cup), fortified cereals, egg yolk, salmon, tuna, sardines, liver -Vitamin D deficiency: -symptoms: hypocalcemia, secondary hyperparathyroidism, muscle weakness, rickets, osteoporosis -at risk?: elderly, vegetarians, liver/kidney disease, childern/infants, inadequate milk/sun -Vitamin D dosing: -1mcg=40IU -age 1-70y.o.: DRI= 15mcg=600IU or 4000 UL (IU) (100mcg=daily LIMIT) -age >70 y.o.: DRI= 20mcg=800 IU or 4000 UL (IU, upper limit=100mcg) -cholecalciferol (D3)= 3x more potent than ergocalciferol (D2) -Vitamin D toxicity: -AEs (dose>UL): hypercalcemia (INCREASED Ca2+ lvls), anorexia, soft-tissue calcification, kidney stones, RENAL FAILURE -Drug Interactions: Mineral oil, orlistat, cholestyramine: dec vita D abs -anti-seizure meds (Phenytoin) or prednisone (glucocorticoid): increase vitamin D metabolism= so need HIGHER doses of vitamin D=Rx from PCP -Vitamin E: -forms= tocopherol, tocotrienol -function: antioxidant -common dietary sources: vegetable oils, whole grain cereals, wheat germ, green leafy veggies, egg yolk, nuts -Vitamin E deficiency is super rare but at risk: premature, very-low birth weight infants, or those w/ fat malabs: CF, biliary disease -symptoms: peripheral neuropathy= numbness, nerve dmg, muscle weakness, intermittent claudication= painful legs if walking, hemolytic anemia -Vitamin E toxicity: AEs (dose>DRI): bleeding (may dec vitamin K lvls), GI problems: diarrhea, ab pain -Drug Interactions: orlistat, mineral oil, cholestyramine -Warfarin= inc bleeding (inc INR lvl)=inc effect of warfarin b/c too much vitamin E -Iron= vitamin E may inc iron bioavailability -Vitamin K= think clotting factors -forms= phytonadione (K1, dietary), menaquinone (K2, bacterial metabolism), Menadione (K3, synthetic) -functions: clotting factor synthesis and activation in liver (II, VII, IX, X) -activates anticoagulant factors (protein C and S) -actives osteocalcin -dietary sources= green leafy veggies: spinach, kale, cabbage, cauliflower, vegetable oil, liver -Vitamin K deficiency: symptoms: unusual bleeding, prolonged prothrombin time (PT, Inc INR), inc risk of oseteoporotic fractures -at risk?: neonates, malabsorption, intestinal disease/resection, impaired bile production, liver disease, chronic broad-spectrum antibiotics (kill gut microbiomes= dec abs) -Vitamin K Dosing/ADEs (also antidote for too much warfarin): -indications= vitamin K deficiency, treatment of bleeding: adults/neonates, prolonged PT/INR -adult dose for deficiency: 90-120mcg/day, typically intake 90mcg/day in most diets, no UL established -AEs: changes in dietary vitamin K intake can alter PT/INR=keep consistent amt vitamin K -no toxic effects even at large doses -Vitamin K Drug interactions: -orlistat, mineral oil, cholestyramine -warfarin= rec consistent amt of vitamin K in diet when on warfarin, excessive amts may dec anticoagulant effect -broad spectrum antibiotics -vitamin E= large doses of vitamin E may antagonize vitamin K function, avoid high dose vitamin E -vitamin A= large doses may interfere w/ vitamin K abs, avoid w/ high-dose vitamin A -Water soluble Vitamins: -B-vitamins= involved in cellular pathways and metabolism: "The Rhythm Nearly Proved Contagious For Pigs" -B1=Thiamine= meat, legumes, whole grains, DRI=1.2-1.3mg/day -B2=Riboflavin=meat, fish, dairy, green leafy, DRI=1.1-1.3mg/day -B3=Niacin= meat, fish, milk, grains, nuts, legumes, DRI=14-16mg/day -B6=Pyridoxine= meat, milk, cereal, legumes, nuts, DRI= 1.3-1.7mg/day -B12=Cyano-cobalamin= meat, fish, dairy, DRI=4.2 mcg/day -B9=Folic Acid=meat, fish, dairy, grains, fruit, veggies, DRI=400mcg/day -B5=Pantothenic Acid=most foods, eggs, DRI= 5mg/day -All B vitamins need to be supplemented in: -inadequate intake -malabs - alcoholics (esp Thiamine (vitamin B1)>Beriberi=bilateral peripheral paraesthesias aka numbness on hands/feet, weakness, Wernicke encephalopathy -Pregnancy/lactation=esp folic acid (Vitamin B9)= fetal neural tube defects -Vitamin B3 Niacin=for niacin deficiency, no longer used for hypercholesterolemia -adverse effects= flushing, itching, GI upset, liver toxicity, hyperglycemia -Vitamin B6 Pyridoxine= enzyme cofactor and involved in heme pdtion -deficiency: peripheral neuropathy, 2D's: dermatitis, dulled mentation, concussions, risk factors: alcoholics, malabs, isoniazid -toxic at doses >100mg/day (UL)= severe sensory neuropathy, dec prolactin lvls, may inc risk of hip fracture in post-menopausal women -Vitamin B12=Cyanocobalamin -functions: active in all cells, esp bone marrow, CNS and GI tract -involved in synthesis of DNA, metabolism of folates, myelin formation -Dietary sources= animal protein -storage= large amt stored in liver, takes 3 years to become deficient so causes of deficiency: -poor abs/utilization: -illeal diseases, intestinal resection, gastrectomy -metformin=reduces abs of B12 in gut (check serum B12 lvl every 2-3 yrs if on long term metformin) -dec gastric motility, achlorhydria (geriatrics, acid suppressant txt)= bacterial overgrowth in small intestine, resulting in more microorganisms in gut using B12 -atrophic gastritis (geriatrics)=can lead to pernicious anemia d/t inadequate pdtion of gastric intrinsic factor -symptoms of B12 defiency= anemia, neurologic symptoms= paresthesias, peripheral neuropathy, unsteady gait -B12 deficiency can also cause folate deficiency which can cause anemia= if anemic= should obtain serum B12 lvl as well as folate lvl -drug interactions: metformin=may dec serum B12 lvls (b/c dec gut abs of B12) w/ long term use -B12 Supplements for: vegetarians, >50 y.o., pregnancy, malabs, long term metformin users -toxicity= high intake may inc risk of hip fracture in post menopausal women -Vitamin C (ascorbic acid): -functions: precursor for collagen, osteoid, and dentin biosynthesis -assists in the abs of iron from food by reducing ferric iron in stomach to ferrous -diet sources: fresh fruits/veggies, green and red bell peppers, broccoli, spinach, tomatoes, strawberries, citrus fruit -Vitamin C deficiency symptoms: malaise, weakness, capillary hemorrhages and petechiae (tiny red,purple, brown spots under skin d/t blood clotting), swollen hermorrhagic gums, bone changes, impaired wound healing, if huge deficiency=scurvy -at risk?= chronic low intake, infants fed formula w/o vitamin supplementation -Vitamin C dosing= doesn't prevent common cold, tiny amt= shortens duration of cold tho= helps a bit -indications= vitamin C deficiency, antioxidant, immune function, wound healing -dosing/DRI: -adults: 75-90mg/day, UL=2000mg/day -smokers: 100-125mg/day -infants on formula w/o vitamin C= 40-50mg/day -scurvy: need 100-300mg for at least 2 weeks to replenish stores -Vitamin C toxicity= adverse effects (dose >2mg/day): GI: nausea, diarrhea, bloating, cramping, kidney stones, hemolysis in certain patients, fetal loss/perinatal death (>1gm/day) -avoid prolonged high dose supplementation in diabetes, recurrent kidney stones and renal dysfunction -drug interactions: -Iron= vitamin C inc iron abs= may be useful to combine if low gastric acidity (ex: on PPI/H2RA or if elderly) -orlistat, mineral oil, cholestyramine -warfarin: Decrease anticoagulant effect w/ high doses -estrogens: dec clearance by vitamin C (inc estrogen effects/AEs)

Insulin Therapy

-there are OTC insulins -T1D = insulin only= symlin (pramlintide)= rx only -T2D= oral agents (rx only, don't worry about): sulfonylureas, non-sulfonylurea secretagogues, biguanide, thiazolidinediones, alpha-glucosidsase inhibitors, DPP-4 inhibitors, SGLT-2 inhibitors -Injectables= Insulin, Pramlintide (rx only), exenatide (rx only), or inhaled insulin -types of insulin= human, human analogs (rx only, includes mixtures= change in AA structure to make it last longer/shorter to mimic physiological release of insulin), single agents, conc insulins, combo preps -Insulin generic (brand): -Lispro (Humalog, Admelog) i.e. lysine and proline -Aspart (Novolog, Fiasp)= Asparagine and Proline -Glulisine (Apidra) -Regular (Humulin R or Novolin R -NPH (Humulin N, Novolin N)= think "lin" s -Detemir (Levemir) -Glargine (Lantus, Toujeo, Basaglar) -Degludec (Tresiba) -Insulin Type: 1. Rapid-acting (RA)= Lispro (humalog, ademelog), aspart (novolog, fiasp), glulisine (apidra)= clear, colorless, lasts 3-5 hrs, peaks in 1/2-2 hrs -think "log"s= RA insulin -rx only, vials, pens> dosing= 2x-4x/day, 15mins before meals -Pros: closely mimics endogenous postprandial insulin, works very fast, flexible w/ mealtimes (don't eat, don't take), improves postprandial hyperglycemia, usually less hypoglycemia than regular insulin -cons: caution w/ CHO (carbohydrate) intake (if <expected, then hypoglycemia), cost, insurance coverage, MDI (b/c counted as biologics), rx only 2. Short-Acting= Regular (Humulin R and Novolin R), clear, colorless= lasts 4-8 hours, peaks at 2-4 hrs (so 2x it); (think: shortie's a regular) -dosing: 2x-4x/day, 30mins before meals -pros: cheap (but it's per vial vs insurance= large doses of insulin/month= depends), available OTC, IV available -cons: takes longer to work and can cause delayed hypoglycemia -less flexibility w/ mealtimes 3. Intermediate-Acting= NPH (Humulin N, Novolin N)= CLOUDY, white= peaks at 4-10hrs, lasts 10-18 hours so do 2x/day for IM (10hrs matches); (think: No Intermediate=NPH intermediate) -just think Q12hrs/2x/day, and dec when sleeping b/c don't want peak at sleep -IM insulin (NPH)= insulin of choice for mixing, protamine suspension slows dissolution/abs from site) -dosing= daily at bedtime or BID -pros: provides basal insulin coverage, cheap, OTC too -cons: protamine and zinc may cause immunologic rxns like urticaria (hives) at the injection site, action can be unpredictable>hypoglycemia> need to monitor more -NPH (aka IM insulin) can be mixed w/ short (regular) and RA insulin but long-acting shouldn't be mixed w/ other insulins ever if you mix it yourself 4. Long-acting aka basal insulins so no peak= glargine (lantus, basaglar, toujeo), detemir (levemir), degludec (tresiba=100mg&200mg, all other insulins=100U), clear, colorless -detemir=lasts 6-24 hrs= dose dep, hard to manage b/c kinetics change w/ normal dose usage= tend not to use -degludec= lasts 42 hrs -glargine= lasts 20-26 hrs -Glargine (lantus, basaglar, toujeo)= 28 days stable at RT, dosing= 1x/day, only SQ injection, pros: more predictable, steady, long acting, peakless basal insulin for 24 hrs, dec noctural hypoglycemia/less weight gain vs NPH, cons: expensive, injection site stinging, no mix, rx only -glargine MOA= injection of an acidic soln (pH 4)> ppt of glargine in SQ tissue (pH 7.4)> slow dissolution of hexamers from ppt glargine> action -Detemir (Levemir) (6-24hrs, think 4x): 42 days stable at RT= longer shelf life (most only 28 days, unused insulin=fridge, then used= RT and dec injection site rxns b/c not cold and won't extend shelf life if cold) -detemir dosing=1x-2x/day, only SQ, pros: more predictable, steady, long acting, peakless basal insulin for 24hrs at higher doses, no stinging (b/c neutral pH), dec noctural hypoglycemia and less weight gain compared w/ NPH (same advs w/ glargine), cons: expensive, can't be mixed, rx only -detemir MOA= proteins bind and dissociate in both SQ tissue and Bloodstream -Degludec (tresiba)= newest insulin, ULTRA long acting insulin (42 hrs!), available as 100U, 200U (specified on rx), 8 weeks stable at RT= longest lasting -dosing: 1x/day only, pros: predictable, steady, long acting, peakless basal insulin for 42 hrs, no stinging (neutral pH), also consistent insulin regardless of disease state cons: rx only, expensive, MOA= huge protein added that has to be broken down 5. Combos: Regular, Novolog, Humalog (short acting and rapid acting)= cloudy/white -cloudy=has protein that makes it last longer= for IM and combos -MOA= the insulin is in hexamers= microcrystals need to dissolve first to get into bloodstream -Concentrated Insulins: -Humalog (lispro) U200 -Tresiba (degludec) U200 -Toujeo (glargine) U300 -available in insulin pens (Preferred), similar PK to U100 -Regular U500 (vial and pen) -pros: less volume for injection but cons: dosing error, access b/c insurance -most pens= 3mL> ex: U200= 200 units/mL -inhaled insulin= Afrezza= RA insulin= faster/shorter duration -dosing: 2x-4x/day, 5 MINUTES before/during meal -pros: closely mimics endogenous postprandial insulin, very fast (peak in 15mins), more flexibility w/ mealtimes, improves postprandial hyperglycemia, less hypoglycemia than rapid insulin, less weight gain -cons: multiple inhalations for large doses, cost/insurance coverage, rx only, lung disease -available at cartridges w/ 4U or 8U insulin> must use w/ inhalation device called dreamboat, both should be kept at RT 10mins before use (fridge otherwise) -Valeritas V-Go (basal + bolus)= response to rapid clicks for bolus, vs basal= constant, waste if you don't use both -24 hr disposable wearable delivery device, holds 56,66,76 units, offers basal rates of 20/30/40U/day and bolus at 2U> 36U/day Insulin Mixtures: (rapid and short only w/ NPH): -just know that the 1st number is always the LONGER ACTING pt (IM, basal)> 2nd pt= RA (bolus) and always in percentages -ex: Humalog Mix 75/25= 75% insulin lispro protamine suspension (IM), 25% insulin lispro -Novolin, Humalin 70/30: 70% NPH, 30% regular -Ryzodeg 70/30= 70% degludec/30% aspart= only exception to long acting mix -Type 1 Diabetes Txt: -initially start dosing total daily insulin at about 0.2-0.5U/kg/day> divide half daily dose as basal (NPH, glargine or detemir) and other half as bolus (regular insulin or RA) -doses vary up to 1U/kg/day -T2D: -add single dose of basal insulin (glargine, detemir or NPH usually at bedtime) then add diff things like RA insulin one at a time -use conservative starting dose= 10U, 0.1-0.2U/kg, 0.3-0.4U/kg if severe hyperglycemia -usually in combo w/ oral meds + lifestyle changes 1:1 ratio for following: -Glargine>detemir>degludec -regular>lispro>aspart>glulisine (short acting and rapid acting basically) -U100, U200, U300 (all same dose if you switch these, exception= 2x NPH (acts like bolus w/ peaks)> Long acting insulin (no peaks so give less insulin= want basal like only -Converting NPH> LA insulin: 1. add up the total daily dose of NPH> dec dose by 20%= LA insulin dose> ex: 30U/day> 24U LA -risks of insulin= weight gain and hypoglycemia> benefits= improved glycemic control, delays worsening/progression of diabetes complications -1 vial= 10mL usually, 1 pen=3mL -so U100= 100units/mL= 1000U -U500=5000U per vial -all have pH 7.4 except glargine=pH 4

Dermatitis, Dry skin, and Secondary Skin Infections

Epidermis> Dermis> Subcutaneous Tissue -Epidermis: Stratum basale at the bottom=regeneration here> up to stratum corneum w/ the dead keratinocytes -regular keratinocytes=absorbs water -28-45 days is the skin life cycle -when the water content of the stratum corneum is <10%=dry, brittle skin= loses elasticity and permeation charcs -Skin Functions: -Physically protective barrier -pH= 4.5-5.5= slightly acidic to protect vs pathogenic microbes -skin flora -sensory, temperature control -pigment development -vitamin D synthesis -hydroregulation= controls moisture loss and permeation -Percutaneous absorption of drugs: -drug factors -oily hydrocarbon bases= easily abs into skin; transiently occulsive, promotes hydration of skin -hydrous emulsion bases= less occlusive, promotes hydration of skin -skin factors= inc temp or inc BF= inc abs of drug -if stratum corneum= well-hydrated= inc diffusion into skin; occulsion= inc hydration and damage to stratum corneum like wounds, burns, etc= inc abs=bad b/c toxicity -Types of dermatitis: 1. Atopic Dermatitis (Eczema) 2. Contact dermatitis= irritant vs allergic -acute, subacute, and chronic dematitis= all treated diff -Atopic dermatitis: chronic, relapsing skin disorder that typically begins during infancy/early childhood and continues to adulthood -characterized by itchiness, eczematous lesions, dry skin, and thickening of skin (Licenification) -most common skin disorder in children, persists in 60% ppl w/ inc pervalence, mostly mild tho -genetic predisposition to exaggerated skin sensitivity: atopic triad: allergic rhinitis, asthma, and atopic dermatitis -worsening factors: soaps, detergents, chemicals, fragrances, clothing fabrics (wool, synthetics), sudden temp changes, low humidity, pollens, dust, dust-mites, animal hair/dander, stress -not well defined pathophysiology but primary immune dysfunction resulting in IgE sensitization and 2ndary epithelial-barrier disturbance -primary defect in the epithelial barrier leading to secondary immunologic dysregulation, resulting in inflammation -70% family history -no est. lab test to det diagnosis= elevated blood IgE lvls, elevated peripheral blood eosinophilia -itchiness d/t neuropeptides, proteases, kinins, cytokines, and Maybe histamine (antihistamines=limited role in this condition) -Diagnostic criteria: -itchy skin disorder plus 3 or more of: -onset <2 y.o. -history of skin crease involvement (including cheeks in children younger than 10 y.o.) -history of generally dry skin -personal history of other atopic disease (asthma) -visible flexural dermatitist (or dermatitis of cheeks/forehead and other outer limbs in children younger than 4 y.o.) -symptoms: -infancy and early childhood: redness and chapping of cheeks> progression to face, neck, trunk, may become generalized: crusting (dried exudate w/ protein/cell debris) on forehead and cheeks, extensor surfaces of forearms and legs=for children=more common, remission: between 2-4 y.o. -adolescents and adults: flexor surfaces of elbows and legs, hands -Atopic Dermatitis: Acute: symptoms: -Mild: redness, itching, papules, vesicles, progressing to weeping (clear exudate aka pus), localized to a few areas of skin -moderate: bullae, edematous swelling of various body areas, in addition to above mild symptoms -severe: extensive involvement or edema of extremities and/or face -eyelids may be swollen shut -extreme itching, irritation, and formation of severe vesicles, blisters, and bullae= REFER -Atopic dermatitis: subacute: symptoms: -redness, itching, excoriated (removing pts of skin/dmg) scaling papules -atopic dermatitis: chronic: symptoms: -thickened plaques of skin, skin markings -acute, subacute, and chronic AD can coexist in same individual -AD Complications: secondary cutaneous infections= from scratching b/c itchy> AD is known as the "itch that rashes" -bacterial= yellow crusting lesions or eczematous lesions= REFER -poor sleep/insomnia= waking up at night b/c itching -REFER: -moderate-severe condition w/ intense pruritis -involvement of large BSA (>20%) - < 1y.o. -secondary infection -involvement of face -involvement of intertriginous areas like armpits, groin= thin, sensitive areas -if symptoms worsen during treatment -it's not curable: want to stop itching, keep skin hydration, avoid triggers, prevent secondary infections -identify/seek triggers and minimize: allergens, chemicals, cosmetics, dyes, laxtex, laundry detergent (use hypoallergenic, unscented), animal dander, cigarette smoke, exposure to extreme temps, food, irritating fabric (wool, synthetics), electric blankets -use cotton sheets> launder all new clothes before wearing them> gentle detergent and 2 cycle rinse -skin hydration=moisturization w/ emollients 2x/day -only treat AD if already have diagnosis: -Non-pharm: -limit bath/shower time (3-5mins)> first 5mins hydrates the skin, but >5 mins dehydrates the skin when water is hot -use lukewarm water (not hot) -daily or every other day baths -avoid soaps: soaps w/ long chain FAs can dry skin, use non-soap cleansers that don't lather like cetaphil restoraderm -after pathing, pat skin dry (don't rub)> apply moisture immediately after bathing b/c opens pores -keep fingernails short, smooth, and clean> wear cotton gloves/socks on hands to bed at night if itching at night= avoid scratching esp in children -keep room humidity high> humidifier in bedroom at night -Pharm for Acute AD: -if it's wet, dry it; for weeping -1. astringents: MOA: stops oozing, discharge, bleeding from dermatitis: protein ppt that forms may act as a protective coat, allowing new tissue to grow underneath, cools and drys skin thru evaporation, causes vasoconstriction and dec BF in inflammed tissue, softens and removes skin of exudates, crust and debris -Aluminum acetate 5% (Burow's soln) solution -available as tablets or powder> dilute in 1:40 water before use (ex: 1 tablet/package to 1 pint/16 oz of cool tap water) -soak affected area for 15-30mins 2x-4x/day or loosely apply a compress of washcloth, cheesecloth, or small towels> wring so that they're wet but not dripping>rewet and apply every few mins to affected area for 20-30mins, 4x-6x/day -discard remaining soln and prepare fresh soln for each application -can also provide mild anti-itch effect -Side fx: stinging -Witch Hazel= same application as burow's soln -less expensive: isotonic saline soln, tap water (cools down/cleans the area, not as effective), diluted white vinegar (1/4 cup per 1 pint water)=same application as burow's soln -Refer: if lesions continue to weep after 2 days of treatment -topical corticosteroid like OTC hydrocortisone 0.5-1% cream= can apply liberally b/c their rx med=stronger= dec itching, inflammation, apply to any pt of skin (except eyes/eyelids) -apply 2x-4x/day prn to AA for up to 7 days -minimal ADRs if short time -avoid use over large surface areas, or prolonged use (>7 days), use w/ occulsive dressing -do not use over an infected site (may delay healing) -use cream, not ointment, for acute AD -if itching/poor sleep d/t scratching= use oral, sedating antihistamine like diphenhydramine, cetirizine, chlorpheniramine> may relieve itching/enhance sedation at night -AVOID topical anesthetics (benzocaine), topical antihistamines (diphenhydramine), topical antibiotics (w/ neomycin)> may cause sensitization (inc flare ups) leading to drug-induced acute contact dermatitis -pharm txt Chronic AD: "it it's dry, wet it" -moisturization: bath pdts: -bath oils: MOA: provide lubrication to skin, mineral or vegetable oil w/ a surfactant, may also contain colloidal oatmeal= dec itching -can add to bath water at end of bath or applied as a wet compress (1tsp in 1/4 cup warm water), can make tub slipper=safety hazard for children/old ppl -cleansers= avoid typical soaps that contain long chain FAs (oleic, palmitic, stearic acid) and alkali metals (sodium, potassium) b.c they remove natural lipids that keep skin soft/pilable and inc skin pH -use glycerin soaps= transparent, higher oil content b/c addition of castor oil -use mild cleansers like cetaphil resoraderm=contain shea butter, glycerin, maintains skin pH -use emollients and moisturizers= MOA: temp fills space between desquamating skin scales w/ oil droplets, puts moisture to skin, inc skin flexibility, acts by leaving an oily film on skin surface where moisture can't readily escape -makes skin feel soft and flexible> for hands, need to re-apply after each hand washing -occlusives: 1. petrolatum like vasoline (petroleum jelly=ointment) 100%= effective and inexpensive as moisturizer when applied at bedtime and covered w/ wet wraps/clothing -best tolerated if applied after bathing/ at bedtime -apply thin layer and massage into area gently but thoroughly -but greasy=bad -do not apply over puncture wounds/laceration> high occlusive ability can lead to maceration and further inflammation -minimize application to intertriginous areas like arm pits, groin, perianal areas, mucous membranes, acne-prone regions -mineral oil -dimethicone -lanolin=natural pdt derived from sheep's wool= possible allergic reaction from wool tho> refined lanolin= less likely to be sensitizing> ex: ingredient in Aquaphor -2. Humectants= helps skin retain water, like lip balms= dep on climate, can make more dry -MOA: hygroscopic= draws water into stratum corneum to hydrate skin> water may come from dermis (if low humidity or atmosphere >80% humidity) -usually combined w/ occlusive agent to prevent water loss -ex: glycerin, propylene glycol, alpha hydroxy acids (lactic acid, glycolic acid), urea -ammonium lactate (ex: AmLactin) -Allantoin -Children can mostly or forever outgrow it if take care of skin but can still have flare ups -3. Ceramides (ex: Curel, CeraVe)= natural lipid component of epidermis; deficient in AD patients -MOA: helps to repair moisture-barrier of skin -combo pdts= (dec ingredients better tho b/c potential allergies)= usually have water, mineral oil, propylene glycol, petrolatum, lanolin, etc, may include other oils like avocado, peanut, safflower, sesame -4. Topical Hydrocortisone 0.5-1%= same as acute AD -5. antipruritics like oral diphenhydramine, cetirizine, chlorpheniramine -6. topical antibiotics= for open sores, bactracin/polymyxin B (polysporin)= AVOIDtriple antibiotic (neomycin) d/t sensitization risk, max 7 days use -ointments= use in burns/INTACT skin= protective film, impede evaporation, prevent drying but bad: excessive moisture can promote bacterial growth, skin maceration -cream=emulsions= good for BROKEN skin, allow fluid to pass, easier to apply -lotion= spread easily, bad: powdery cover, can dry wound -aerosol/pump spray= hold container 6 inches from wound, spray for 1-3 secs= good: sanitary, don't need to touch wound, bad: expensive -Dry Skin (xerosis): most common cause of itchiness -winter months, low humidity, windy, cold, dry climates, long, hot showers w/ excessive soap, 2ndary to prolonged detergent use, malnutrition, dehydration, hypothyroidism, advanced age: hormonal changes, thinning of epidermis, reduced sebum output -pathphys: dec water content of skin= abnormal loss of cells from stratum corneum> disruption of keratinization and impairment of water binding props -symptoms: roughness, scaling, loss of flexibility, fissures, inflammation, itchiness, cracked appearance esp on arms/legs i.e. mom's crocodile skin -treatment: similar to Chronic dermatitis: -limit baths/showers to 3-5mins 2x-3x/week> can add bath oil to baths -lukewarm water -avoid soap, use non-soap cleansers> pat body dry and moisturize after -care w/ slippery tubs if using oils in baths esp old ppl -moisturize at least 3x/day -if itching= add more moisturizers or use hydrocortisone 0.5-1% ointment 2x-4x/day up to 7 days> refer if no resolution after 1-2weeks -stay well-hydrated, increase room humidity w/ humidifier -Contact Dermatitis: -Irritant Contact Dermatitis (ICD)= inflammatory rxn of skin d/t irritant -Allergic Contact Dermatitis (ACD)= immunologic rxn of skin caused by antigen -ICD= usually related to your job esp if related to water/exposure to irritant substances (acids, alkalis, wood dust, oils, fiberglass, etc.)= forestry, agriculture, fishing, education, health services, personal services (hair stylists), food handlers -usually on exposed skin esp face/dorsal surfaces of hands/forearms -pathophys: direct dmg to epidermal cells by direct abs thru cell membrane> magnitude of response= affected by existing skin conditions, quantity and conc of substance exposure (chemicals vs soap), occlusive clothing (diapers) -symptoms: -accute: inflammation, redness, swelling, itching, burning, stinging, crusting may occur w/in days -if remove irritant= resolves in several days -if chronically exposed to irritant, inflammation can persist and lead to fissures, scales, hyper/hypo pigmentation -chronic=licenification=plaque like skin -treatment= remove offending agent, prevent future exposure, relieve inflammation/irritation, educate ppl on prevention/txt -prevention: use protective clothing/gloves/other equipment, freq changes in coverings -non-pharm: immediate washing of area if exposed to irritant -pharm: liberal app of emollients= assists in restoring moisture/protects skin from further dmg -itching= collodial oatmeal baths, hydrocortisone -AVOID: caine-type anesthetics, salicylic acid, lactic acid, urea, propylene glycol=inc irritation -ACD: usually from poison ivy/oak/sumac, metal (nickel), latex, fragrances, cosmetics, skin care pdts -pathophys: inflammatory dermal rxn related to exposure to an allergen that activates sensitized T-cells> t cells migrate to site of contact and release inflammatory mediators -doesn't usually occur on 1st contact= sensitization must occur> on 2nd exposure, antigen induced a type IV delayed hypersensitivity rxn> can take 24hrs-21 days to develop>on subsequent exposure, rash occurs between 2hrs-24hrs after exposure -Urushiol induced ACD= poison ivy/oak/sumac -"leaves of three, leave them be" -when plant is dmged=urushiol is released (antigenic oleoresin)> goes to skin/clothing/breathed in via smoke particles -symptoms: distribution and presentation of rash> if u touch it, can transfer to other pts of body/ppl/clothing -acute: linear or occur over a broad area b/c can transfer -rash=papules, small vesicles, sometimes large bullae over inflammed, swollen skin, super itchy -chronic: licenification -Refer: (just see if it makes sense to u) - <2 y.o. -dermatitis present for >2 weeks -involvement of >20% BSA -presence of numberous bullae -extreme itching, irritation, or severe vesicle/bullae formation -swelling of body or extremities -swollen eyes/eyelids shut -genitalia discomfort from itching, redness, swelling/irritation -involvement and/or itching of mucus membranes of mouth, eyes, nose, anus=fase=refer basically -signs of infection (yellow pus) -failure of self-txt after 7 days -low tolerance for pain, itching/symptom discomfort -impairment of daily activities -Non-pharm: remove antigen= immediately wash exposed area (even under fingernails) w/ soap/water to avoid/reduce severity of rash esp if w/in 10mins of exposure -can also use urushiol cleanser (Tecnu outdoor skin cleanser, zanfel, tencu extreme medicated poison ivy scrub)= contains mineral spirits, water, soap and surface active agent> rub into AA asap, aims to limit exposure to other areas of body -cleanse area for min 2 mins -water isn't initially req, but can wipe cleanser away w/ cloth/rinsed w/ cool water -equal effiacy to dishwashing soap/grease remover -avoid cleaning w/ alcohol b/c inc dmg -pharm txt: -albuminum acetate, aluminum sulfat 1347mg (domeboro astringent soln), calcium acetate 952mg (astringent powder packers), isotonic saline soln, diluted white vinegar, or tap water -itch relief: calamine lotion (calamine 8% and zinc oxide)= skin protectant, relieves itch, pain, discomfort and dries weeping/oozing -caladryl lotion (calamine 8% w/ pramoxine, other combos)= shake well, AAA w/ cotton ball and rub in gently, allow to dry, use 3x-4x/day for up to 7 days, leaves pink/white residue on skin -hydrocortisone cream 3x-4x/day> don't use ointment if weeping/oozing lesions. cream is preferred b/c wet -colloidal oatmeal baths -AVOID: caine-type anesthetics, topical diphenhydramine/other topical antihistamines, topical antibiotics w/ neomycin (sensitizers) -prevention: know which plants/irritants to avoid, remove plants near home by removing plants by roots/herbicide -wear protective clothing to cover exposed areas when outdoors> clean pet's fur as well b/c can transfer -wash all clothing worn during exposure/place clothing directly into wash and separately from other clothes -wash/clean w/ soap/water all shoes, gloves, jackets, sports equipment,etc that was exposed and wear vinyl gloves when cleaning -clip fingernails and keep nails clean Wound Infections: -all wounds are colonized w/ bacteria= delay collagen synthesis and epitheliaization, prolong inflammatory phase, and result in more tissue dmg -infections develop w: immunocompromised, systemic conditions, high bacterial burden -signs of LOCAL infection: redness, edema, pain, crepitation (feeling of air into wound), presence of purulent/odorous exudate in AA -signs of SYSTEMIC infection (REFER): fever, flu-like symptoms, leukocytosis (inc white BC count) Acute wounds: -Abrasions= rubbing/friction injury to epidermic through the uppermost portion of dermal layer -punctures=sharp objects through the epidermal layer and lodged in dermal layer -lacerations: sharp object through many layers -Chronic wounds: pressure ulcers (bed bound, immobile patients> area breaks down, needs to be shifted every 30mins) -arterial and venous ulcers -Self-care= stage 1: no loss of skin (warmth/redness), stage 2: superficial lesions (partial-thickness skin loss, dmg to epidermis/dermis) -REFER: stage 3: full-thickness skin loss (dmg to entire epidermis, may include SQ tissue), stage 4: deep-full thickness skin loss= extensive tissue necrosis (dmg to muscle, tendon, bone) -Diabetes= delayed wound healing b/c microvascular dysfunction=poor oxygen perfusion, dec collagen synthesis, imparired wound contraction, reduced immune cell function> diabetes foot ulcers/infections= REFER -pharm txt: -1. Antiseptics: chemical substances used to disinfect intact SURROUNDING AREA of wound (DO NOT ever put inside wound b/c inc intensity/duration of inflammation, tissue necrosis, leukocyte action) -2. normal saline or water- good to remove dirt/debris from wound= 1st thing= WASH wound> don't use antibacterial soap b/c inc bacterial resistance, no better efficacy that soap and water -OTC antiseptic pdts: keep wet w/ antibiotic, not dry: -ethyl alcohol 48-95%= bactericidal, but causes irritation if directly in contact w/ wound -isopropyl alcohol 50-91.3%= stronger bactericidal activity, less surface tension, but cytotoxic in open wound beds, causes dry skin, flammable -hydrogen peroxide topical soln 3%= contact w/ skin causes enzymatic release of O2, mechanically cleans, but limited bactericidal activity and don't use in abscess -iodine tincture or iodine topical soln= for superficial wounds, but irritation (don't use lugol's soln for antiseptic) and can't use if have chlorhexidine allergy -phenol and camphor 0.5-1.5%= apply to dry, intact skin only, but do not bandage, moisture will result in tissue dmg -quaternary ammonium compd 0.13% -chlorhexidine gluconate 2-4%, brand name Hibiclens -3. first aid topical antibiotics= prevents infection, esp useful if wound has debris -apply TO wound bed 1-3x/day AFTER cleansing and BEFORE sterile dressing -refer if no healing w/in 7 days -triple antibiotic formulation: bacitracin, neomycin, polymyxin B -Bacitracin topical antibiotic= bactericidal for GRAM POSITIVE bacteria (most of your skin bacteria=gram pos), min systemic abs, ADR: ACD -Neomycin topical antibiotic= for GRAM NEG bacteria/some staphylococcus sp, resistance may develop, apply to SMALL areas (large=inc risk of systemic toxicity), ADR: hypersensitivity rxns=high -combos preferred (triple antibiotic), combos dec resistance to neomycin -Polymyxin B sulfate topical antibiotic: for GRAM NEG bacteria, polymyxin-bacitracin preferred over neomycin-bacitracin combo, ADR= hypersensitivity=rare -see dermatitis WS

OSCE Cheatsheet

OTC insulins: 2. Short-Acting= Regular (Humulin R and Novolin R), clear, colorless= lasts 4-8 hours, peaks at 2-4 hrs (so 2x it); (think: shortie's a regular) -dosing: 2x-4x/day, 30mins before meals -pros: cheap (but it's per vial vs insurance= large doses of insulin/month= depends), available OTC, IV available -cons: takes longer to work and can cause delayed hypoglycemia -less flexibility w/ mealtimes 3. Intermediate-Acting= NPH (Humulin N, Novolin N)= CLOUDY, white= peaks at 4-10hrs, lasts 10-18 hours so do 2x/day for IM (10hrs matches); (think: No Intermediate=NPH intermediate) -just think Q12hrs/2x/day, and dec when sleeping b/c don't want peak at sleep -IM insulin (NPH)= insulin of choice for mixing, protamine suspension slows dissolution/abs from site) -dosing= daily at bedtime or BID -pros: provides basal insulin coverage, cheap, OTC too -cons: protamine and zinc may cause immunologic rxns like urticaria (hives) at the injection site, action can be unpredictable>hypoglycemia> need to monitor more -NPH (aka IM insulin) can be mixed w/ short (regular) and RA insulin but long-acting shouldn't be mixed w/ other insulins ever if you mix it yourself -Type 1 Diabetes Txt: -initially start dosing total daily insulin at about 0.2-0.5U/kg/day> divide half daily dose as basal (NPH, glargine or detemir) and other half as bolus (regular insulin or RA) -doses vary up to 1U/kg/day -T2D: -add single dose of basal insulin (glargine, detemir or NPH usually at bedtime) then add diff things like RA insulin one at a time -use conservative starting dose= 10U, 0.1-0.2U/kg, 0.3-0.4U/kg if severe hyperglycemia -usually in combo w/ oral meds + lifestyle changes -risks of insulin= weight gain and hypoglycemia> benefits= improved glycemic control, delays worsening/progression of diabetes complications -1 vial= 10mL usually, 1 pen=3mL -so U100= 100units/mL= 1000U -U500=5000U per vial -switch injections sites (SQ injection=abdomen, thighs, outer pt of upper arms, buttocks) -if same injection site=fatty deposits in same spot= can feel it more and injection into these areas= dec abs of insulin (nonpredictable > fluctuation of BG -1 method: select an injection site for 1 week and in that site, rotate around, 1 finger width apart from last injection site> next week choose diff injection site -2nd method: crisscross method, stay away from navel/scare tissue/lipohypertrophy sites by 2 inches -use smallest insulin syringe for doses of insulin -6mm or 8mm needle length= normal -4 or 5mm= shorter for thinner/normal weight patients/children -inc guage= dec thickness (so thinner) -inc guage= dec volume b/c thinner -sometimes want thick needle and smaller guage to inject faster -1CC=1mL=100U -0.5mL=50U -3/10mL=30U -ex: 80U=100U syringe b/c less shots -only talk to patients in units to not confuse them cause syringes only come in units -only use insulin syringes b/c not calibrated Nutrition: -40-65gm of carbs using the available food models -15g of fruit, 3-4oz protein -calories=ind but 400-500 calories= normal adult meal -fat=avoid trans fats, aka "partially hydrogenated", saturated fats= limited to 5-6% of daily calories ex: 2000 calories=16gm saturated fat/day -sodium= 2300mg/day (1tsp) -total carbohydrate= men: 60-75gm carbs/meal; women=45-60gm carbs/meal -fiber= higher=better, adults= 20-30gm fiber/day -sugar= low, no more than 24gm/day (6 tsp) -protein= 0.8g protein/kg/day (ex: 75kg person= 60gm protein/day or 20 gm/meal) -1oz protein= 7gm -snacks= 100-150calories or 15g carbs Insulin Injection: 1. Inspect insulin vial (color, expiration, right insulin) 2. clean top of vial with an alcohol wipe 3. draw air into insulin syringe for how much you're going to put in 4. Insert needle into insulin vial at 90 deg angle, turn vial upside down and plunge in 10U air 5. draw up the dose of 10U insulin, flick syringe to remove air bubbles, take out needle and recap needle 6. clean skin with alcohol wipe and allow to dry 7. inject insulin via pinching abdomen to create skin fold using dart-like action, 90 deg angle into skin, release pinch, inject insulin then take out and put needle/syringe into sharps -How to treat hypoglycemia: -hypoglycemia= BG<70mg/dL (depends on person tho, txt when have symptoms: sweating, fainting, dizziness, shaking, headache, irritated, blurry vision, hunger, nausea, weakness, anxiety, tachycardia, heart palpitations, confusion -BG <50mg/dl= unconscious, coma, seizures or even death -15/15/15 rule= 15g carbs (fast acting), wait 15mins, check blood sugar levels and if still low, eat another 15g -if not low, eat complex carbs and protein= meal i.e. peanut butter and meal -4 tablets of glucose, 1/2 cup of fruit juice or soda, whole box of raisins,etc. -preventing painful injections: remove air bubbles, relax muscles, inject quickly (dart-like), only use insulins that's stored at rm temp, don't reuse dull needles -try to avoid high fat foods like chocolate, chips, donuts, etc for hypoglycemia b/c delays abs of carbs= takes longer to treat -PEFR= Peak Expiratory Flow Rate via Peak Flow Meters= hand-held device used to monitor a person's ability to breath out air= home monitoring, Rx/OTC, cheap, PEF= peak expiratory flow= max flow at the outset of forced expiration> compare within themselves Asthma Action Plan= uses PEF monitoring for patients to monitor asthma at home= written doc w/ specific instructions based on objective findings="zone scheme"=red,greeb,yellow= ids if txt is working/potential deterioration -green=80-100% of normal peak flow, can do all usual activities -yellow=50-79%= getting worse= cough, wheeze, chest tightness or SOB> add quick relief medication -red= less than 50%= quick relief meds don't help, can't do usual activities, symptoms no better after 24 hrs in yellow zone> get medical help NOW OTC Treatment: (limited) -Current symptoms= mild, intermittent (less than 2x/week) and of short duration (<24hrs) OR a prior diagnosis of intermittent asthma by PCP AND person knows warning symptoms inidicating need for urgent medical care AND they don't have other serious concurrent diseases that impair breathing (COPD/CAD) AND the person is >= 4 yrs for nebulize txt or >12 y.o. for oral and not pregnant AND current asthma symptoms=consistent w/ previous symptoms AND the nonrx meds are for SHORT-term (<24hrs) txt of mild symptoms until they can see a PCP -Exclusions for Self-txt: -no previous dignosis of asthma, concurrent condition whose symptoms can be similar to asthma (COPD, Heart failure, vocal cord dysfunction_, history of asthma episodes severe enough to require systemic corticosteroids or urgent medical care, use of (or non adherent to) other long therm rx meds for asthma, no asthma care provider/no visit in last year, pregnant or <4 y.o. for neb, <12 y.o. for oral, rx meds preceived as ineffective, symptoms of moderate/great severity or >2x/week, >24 hrs symptoms or unresponsive to OTC meds, symptoms of diff quality/severity than previous episodes, signs of respiratory/sinus infection -Nonpharm txt: identify triggers, reduce exposure/eliminate triggers, reduce/eliminate tobacco smoke, ensure vaccinations are up to date (influenza, pneumococcal) -OTC pdts: racepinephrine nebulizer soln, ephedrine/guaifenesin, epinephrine metered-dose inhaler 1. Racepinephrine=for ppl >4y.o., pour 0.5mL (1 vial) into nebulizer reservoir> give 1-3 inhalations from nebulizer, no more than every 3 hrs, NTE 12 inhalations/24hrs -seek medical advice if breathing doesn't improve w/in 20 mins/worsens, patient uses >9 inhalation in 24 hrs or >3 days/week or has >2 asthma attacks w/in 1 week -side fx= tachycardia, arrhythmia, nervousness -do not use w/ MOAi or 2 weeks after stopping MAOi s -contraindications= pregnancy, cardiac arrhythmias, coronary insufficiency, poorly controlled HTN, seizures, hypokalemia, angina, hyperglycemia, and uncontrolled hyperthyroidism -do not use if brown/cloudy 1. Ephedrine/Guafenesin combo pdt= broncodilator and expectorant -look at dosing list: all >12 y.o. 1. Bronkaid= 25mg ephedrine, guaifenesin, 1T PO Q4hrs prn, NTE 6tabs/day 2. Primatene Tablets= 12.5 ephedrine/ 200mg guaifenesin> 1-2 tabs Q4hrs pwn, NTE 12 tabs/day 3. Mini-two way action tablets= same dosing/qty (12.5/200mg) as primatene or 25mg/200mg= 1/2-1 tablet Q4hrs prn, NTE 6 tabs/24 hrs -Ephedrine Side effects= palpitations, tachycardia, arrthymias, (inc HR) seizures, hypokalemia (dec potassium), angina, hyperglycemia (inc sugar), hypotension, hypertension (both inc/dec BP) -Guaifeneside side fx= nephrolithiasis (kidney stones) -Epinephrine Inhaler aka Primatene Mist= MDI (metered dose inhaler), no <12 y.o., mild, intermittent asthma only (not replacement for rx meds)= 1Puff PO, may repeat x1 after 1min (do not repeat for 3-4 hrs) -see PCP if never been diagnosed w/ asthma, not better in 20mins/gets worse, need >8 inhalations/24 hrs, >2 asthma attacks in a week -adverse rxns= hyperactivity, restlessness, exitability, palpitations, headache, upper resp irritation, pharyngeal dryness 8. Peak Flow Meter= won't tell you if have asthma= that's the spirometer at the dr's office -before using peak flow meter, slide down the marker or arrow on the meter to zeo -take a deep breath, put the peak flow meter mouth piece in your mouth and close the lips around the mouth piece and blow quickly and as FORCEFULLY as you can -remove the peakflow meter from your mouth -repeat these steps 2-3 times and record the highest number on your provided sheet -use peak flow meter every day at the same time for accurate results for about 2 weeks to get a good avg of where you are> below 50%=red=bad= immediately get medical attention, 50-79%=yellow=caution in activities and refer to txt plan for actions to be taken, green= >80%= meds=working, do normal activities

Lect. 17 Obesity and Weight Loss

-BMI Calculation: BMI= kg/m^2 -1kg=2.2lbs and 1in=2.54 cm -BMI: <18.5 kg/m^2 underweight 18.5-24.9 normal 25 to 29.9 overweight 30-39.9 obese >40.0 morbidly obese -asians have a higher percentage of body fat than white ppl so their BMI: <18.5= risk of developing nutritional deficiency, osteoporosis 18.5-22.9 low risk (healthy range) 23-24.9 moderate risk for developing comorbidities >27.5 high risk for developing comordbidities -increase risk of diabetes in asians -Know how to calculate Ideal Body weight (IBW): -Men: IBW= 50kg +2.3 kg (every inch over 5ft) -Women: IBW= 45.5 + 2.3kg (every inch over 5 feet) -ex: 5'9 male weighs 170 lbs, BMI=25.1, ideal body weight= 156lbs -BMI= 69 inch b/c 5ftx 12inch+9inch=69inch -inchx2.54cm= cm then divide by 100 to covert to m then square it -then kg/m^2 -ex problems associated with obesity: hypertension, hyperlipidemia, T2DM, osteoarthritis, stroke, gallbladder, liver, renal disease, coronary artery disease, sleep apnea, myocardial infarction, reproductive complications, congestive heart failure, cancer, atrial fibrillation, gout -metabolic syndrome (just know these risk factors): -waist circumference (waist=at level of belly button) -HDL-cholesterol -serum triglyceride -serum glucose -blood pressure -note: being treated for high BP or having diabetes= also counted as positive risk factors -1lb of adipose tissue= 3,500 calories> ex: 10calories/day for 1 year=1 lb weight gain -risk factors: -lifestyle: increased portion sizes/calories -increased work hours -decrease exercise -decreased sleep -genetics: increased storage of body fat -hormones -leptin -ghrelin -medication causing weight gain: -atypical and typical antipsychotics= clozapine, olanzapine, haloperidol -antidepressants= tricyclics, MAO inhibitors, mirtazapine -insulin -corticosteroids (hormonal contraceptives) -anticonvulsants -treatment goals for self-care weight loss: -weight loss: 10% over 6 months= initial 10%=easiest and most beneficial to health -maintenance of weight loss -prevent weight gain -may help with comorbidities -REFER: -severe obesity (BMI >= 40) -pregenancy or breastfeeding -age <18 y.o. or >65 y.o. -cardiovascular disease -hypertension, diabetes, dyslipidemia (b/c want PCP to monitor these disease states) -eating disorders -Non-pharm txt: -dietary change: caloric restriction -avg caloric intake for 30 yr old: -men=2,200-3,000kcal/day -women=1,800-2,800kcal/day -restriction: decrease 300-1000kcal/day -Low Calorie Diet (LCD): dec 1-2lbs/week so want to eat 800-1,500kcal/day for LCD -Very Low Calorie Diet (VLCD)= <800kcal/day, but at least 1g/kg of protein so no muscle wasting> NEEDS SUPERVISION -need multivitamin for diets <1,200-kcal/day -starvation= depletes body of lean tissue (protein), electrolytes, and fat -adverse effects= fatigue, hair loss, dizziness, diarrhea, constipation, dry skin, irregular menses, gallstones Calories: -1 Calorie= 1kcal= 1000 calories -protein- 4kcal/g -carbs=4kcal/g -fat=9kcal/g -just know that fat= more kcals/g=bad Vegetarianism= best diet every ito health -pros: reduce fat intake, inc fiber, helps reduce coronary artery disease -cons: miss essential fatty acids, vegans= miss vitamin B12 -High Protein, High Fat, Low Carb: mixed results: -Ketogenic diets= dec insulin release, simplified food choices, promote body fat storage -Fat Diets: Atkin's Diet= 5-15% of calories from carbs -Zone Diet= 35-50% of calories from carbs -Cons: high protein> ketone bodies> ketoacidosis= for anybody with diabetes= dangerous= need to be monitored -inc cholesterol> cardiovascular disease -electrolyte imbalance and vitamin insufficiencies -Dietary Change: Altered Food Groups: -they rec fat </=30% and 8-10% comes from saturated fat -protein=15% -carbs= >=55% -glycemic index= inc blood glucose after eating= inc complex carbs, slower absorption -Paleolithic Diet= if can't find in nature, don't eat it, including wheat -eat hunter-gatherer style w/ no agriculture= no grains, legumes, dairy, refined salt/sugar/oils -pros: relatively nutritious/healthy (choose lean meats), carbs consumed w/ lower glycemic index -cons: calcium/vitamin D deficiency and expensive -Intermittent Fasting= no limits on foods -the 16/8 method aka Leangains protocol: skip breakfast and restrict daily eating period to 8 hours, then fast for 16 hours in between -Eat-Stop-Eat= fast for 24 hrs, 1x/2x a week -the 5:2 diet= consume only 500-600 calories on 2 non-consecutive days of the week> eat normally on other 5 days -Commericial weight loss programs= pros: social support, cons= no supportive concluding data, expensive -Meal Replacement Therapy= slim fast, shakeology, etc: swap 1-2 meals/day for a shake, bar, measure meal -pros: portion control, low-fat, low-carb, early weight loss (physiological boost to adherence) -cons: short-term efficacy, weight maintence hard, expensive -sugar alcohols (sorbitol, xyitol, maltitol)= doesn't contribute to tooth cavities, raises blood sugar but less than regular sugar, bad=bloating/diarrhea= sugar free stuff 2. Increased physical activity: -want 150 mins (2hrs, 30min) of moderate aerobic activity OR 75 mins (1hr, 15min) of vigorous aerobic activity per week -PLUS do muscle-strengthing exercises 2+ days/week -start low and go slow -Moderate aerobic= fast walking, water aerobics, biking on flat ground, double tennis, mowing the lawn -vigorous aerobic= jogging/running, swimming laps, biking fast/on hills, singles tennis, basketball -muscle strengthening= lifting weights, resistance bands, body weight exercises, heavy gardening, yoga 3. Behavioral Therapy: -individual or group, w/ counselor or alone -environmental= remove access to high-calorie foods= don't buy junk food -modify thinking= set reasonable short-term goals= stay accountable -self-efficacy= optimistic, positive approach -social support= family, friends, healthcare providers 4. Pharm txt= only drug OTC is Orlistat -When to use meds?: -only if BMI >/=30 (obese) -BMI >= 27 if w/ disease/risk factors i.e. diabetes, hypertension, dyslipidemia= but REFER usually, then they come back when rec by PCP -use in conjunction w/ diet and physical activity -used at lowest effective dose= minimize adverse events -there's dangers to weight loss ingredients like inc BP/pulse rate, carcinogenic, anxiety, etc. -Orlistat: -MOA= blocks gastric and pancreatic lipase= prevents breakdown and absorption of dietary fats= fats go out to colon -dec weight of 5-10lbs/6 months, dec LDL, dec BP -Orlistat is called Xenical if prescription: -has to be >=12 y.o. and BMI >=30 or >=27 w/ disease -dose= 120mg PO 3x/day WITH meals -efficacy= dec fat absorption by 30% -Orlistat is called Alli if OTC (think Ally you in weight loss): -has to be >= 18 y.o. for OTC and BMI >= 25 -dose= 60mg PO 3x/day with meals (half the dose of prescription -no published studies on effiacy -side fx: headache, GI problems: farting, oily spotting, loose stools and fecal urgency (diarrhea), fatty stools, severe liver injury -Avoid in: thyroid disease, cholelithiasis, nephrolithiasis, pancreatitis, pregnancy -contraindications= malabsorption syndrome, cholestasis -Counseling: -make sure not to eat without meals or with meals that have no fats= useless -Supplement to lifestyle modification= helpful in initial weight loss and maintence -more carbs, less fat= helps dec GI side effects -recommend taking it with multivitamin b/c it decrease absorption of fat-soluble vitamins ADEK -drug interactions due to dec absorption= dec cyclosporine, dec levothyroxine, inc warfarin effects -Benzocaine= local anesthetic of oral/GI mucosa= alters the taste of food= appetite suppression= not really rec b/c not supported by data for safety/efficacy ito weight loss -Supplements= regulated as food by DSHEA= only innocent until proven guilty=possibility of contamination/adulteration -Supplements- Increased metabolism: -caffeine, bitter orange= stimulants, energy boosters, thermogenic aids= caution: hypertension, tachycardia -green tea, chromium, garcinia= modulate fat/carbs metabolism. dec body fat and inc lean muscle mass, caution: mood/sleep changes, headaches -Supplements- Appetite Suppressants: -guar gum, glucomannin= promote satiety, dec caloric intake, caution: GI distress, farting, N/V -5-Hydroxytryptophan, Hoodia, St. John's Wort= dec appetite, but GI discomfort, mood disturbances, drug-drug interactions w/ antidepressants Supplements- Block Absorption: -Chitosan= block intestinal fat absorption, caution: GI upset, gas, nausea, constipation -Bean pod= block intestinal carbs abs, is a dietary fiber, caution: heartburn, gas, diarrhea, stomach pain -Supplements- Loosen Up: -cascara sagrada, psyllium= laxative= limit use to 102 weeks at a time -dandelion, caffeine= diuretics -DO NOT ABUSE -Overall Counseling pts: -obesity results from numerous environmental and genetic factors -obesity results in many complications including cardiovascular disease, diabetes, and cancer -realistic weight loss goal is 10% in months -diet and exercise= key to success -Orlistat= (Alli) is the only FDA approved OTC weight loss med -dietary supplements haven't been proven to be effective and lots of side effects= don't rec -Goal: achieve healthy weight and maintain it over the long term

Nausea and Vomiting

-Don't need to know: -Nausea=sensation that one's going to vomit (GI/ab sx), can be associated w/ regurgitations/retching -Vomiting= physical expulsion of gastric contents> ab muscles contract and the diaphragm descends resulting in inc intrathoracic pressure, esophagus dilates and reverse peristalsis all contribute to vomiting -retching=dry heaves -regurgitation=food from pharynx/esophagus -Pathopys: -Labyrinths in vestibular apparatus (ear stuff)> histamine antagonists, muscarinic antagonists> vomiting center (medulla)= vomiting reflex -sensory input> higher cortical centers> benzos> vomiting center (medulla)=vomiting reflex -stomach, small intestine> 5HT3 antagonists to chemoreceptor trigger zone> vomiting center OR straight to vomiting center -anaesthetics, opioids> chemoreceptor trigger zone > histamine antagonists, muscarinic antagonists, dopamine antagonists, cannabinoids> vomiting center (medulla) -N/V=self-limiting, will pass but can get severe -Mild sx of N/V can be treated w/ OTC agents but it's easier to prevent N/V than to treat it (ex: motion sickness) -acute complications of N/V: dehydration (dry mouth, excessive thirst, little to no urine output, lightheaded), esophageal tearing (d/t retching), electrolyte imbalance (acid-base disorder), malnutrition, aspiration -Causes: -Motion Sickness: more common in children, easier to prevent than treat -Pregnancy= more common during 1st trimester, 70-80% pregnant women, half will vomit -viral gastroenteritis= acute, transient attack, 2 most common pathogens=rotavirus and norovirus, usually w/ diarrhea but self-limiting -over-eating -food-poisoning -Drug therapy= chemotherapy, NSAIDs, opiates, antibiotics (penicillins, tetracyclines), corticosteroids, estrogen therapy (oral contraceptives, hormone replacement therapy) -disease states: diabetes, CHF, bulimia, IBS, CNS disorders (migraines, CNS infections) -Non-Pharm: 1. environmental changes: -exposure to fresh air in sleeping quarter -rest and relax -avoid odors that elicit N/V (raw fish, tobacco smoke, even "nice" smells like perfumes) -travel where motion is minimal (front of bus, wings of airplane) -avoid reading during travel 2. Diet/meal alterations -small sips of carbonated fluids (ginger ale) or fruit juices -consume crackers/dry toast -avoid overeating and excess alcohol intake -eat smaller meals 4x-5x/day -avoid: greasy, fried foods, spicy or acidic foods 3. acupressure wristband and acustimulation band -MOA: stimulation of the P6 acupuncture pt (believed to be involved in N/V) located bilaterally on the inner forearm -adv: can be used concurrently w/ anti-emetic pharm txt -an alt for pts who don't want drugs -Acupressure wristbands= Sea-Band, Travel aids= for prevention of motion sickness, NVP, ass. w/ chemo. and anesthesia, also for txt of N/V sx: NVP, motion sickness, and overeating -counseling: this device doesn't cause sleepiness, can be used w/ antiemetic therapies, manufacturer states that wristband has been used in children as young as 2 y.o., use before onset/when sx first occur -Acustimulation Wristband=Reliefband NST -MOA= electrical stimulation of nerves -indication: non-rx: txt of N/V: motion sickness, mild-moderate NVP (not severe) -rx use (higher power output): txt of N/V: chemotherapy, in combo w/ antiemetics for post-operative N/V -side fx: mild, self-limiting rash -counseling: contains latex, avoid in latex allergy pts -pdt to be worn on one wrist -doesn't cause sleepiness -can be used w/ antiemetic therapies -use before onset/when sx first occurs -Pharm: (OTC): -1. Antihistamines= prevents/txts N/V d/t motion sickness b/c histamine is a neurotransmitter from inner ear to N/V center (MOA) -side fx: drowsiness, Anticholinergic effects (blurred vision, constipation, urinary retention, dry mouth), CNS rxns (hallucinations and psychosis) -Note: 2nd gen antihistamines don't cross BBB so not effective= use 1st gen like benadryl -caution in: -elderly: falls, BPH, glaucoma, respiratory conditions -more prevalent CNS AEs: confusion, hallucinations, psychosis -lactating women: antihistamines reduce milk supply and they're secreted in milk -pregnancy= falls, goes to placenta?> emphasize non-pharm txt as first line -2nd line= doxylamine 12.5mg + pyridoxine 10mg> refer to PCP before trying other antihistamines -children= hyperactive= age limits d/t risk of CNS effects -NOT rec <2y.o. -even if diphenhydramine and dimenhydrinate FDA approved: caution use and rec -No OTC dose labeled for < 6 y.o. -counseling: most common side fx: sedation or sleepiness=be aware of other agents that also cause sedation (TCAs, BZDs) -avoid combining w/ alcohol (additive sedation) -minimize operating vehicle or hazardous machinery -many other pdts contain an antihistamine (topicals, combo cold therapies)= avoid concurrent use -to prevent N/V d/t motion sickness, take 30-60mins before travel and keep taking them during travel -2. Antacids -Pdts: Magnesium hydroxide (Phillips MOM), Aluminum hydroxide (Alternagel), Calcium carbonate (Tums, Maalox), Magnesium Carbonate -indication: N associated w/ excessive/disagreeable food intake> used to txt symptoms of infreq heartburn, dyspepsia, indigestion, and upset stomach> marginal efficacy for N/V b/c other causes like motion sickness and don't block neurotransmitters -MOA: neutralize gastric acid -Side fx: constipation (aluminum containing pdts) -diarrhea (Mg containing pdts) -chalky taste -caution: pts w/ renal disease (b/c may have elevated blood calcium concs) -Counseling: be aware of diff amts elemental calcium in various antacid pdts (Tums, TumsEX, Tums Ultra) -max dose varies -take 30mins after meals -3. H2RAs -4. PPIs -H2RAs and PPIs Indication: Nausea associated w/ excessive/disagreeable food intake> used to treat symptoms of infreq heartburn, dyspepsia, indigestion, and upset stomach -H2RA =marginal efficacy for N/V -PPI=lack of data to supp use of N/V -MOA: PPIs=block proton pumps and pdtion of acid -H2RA=block histamine from binding to parietal cells in stomach which dec acid secretion -side fx: dizziness and headache, GI (diarrhea and constipation) 5. Bismuth subsalicylate (BSS) -Indication: nausea associated w/ excessive/disagreeable food intake> used to txt sx of infrequent heartburn, dyspepsia, indigestion, upset stomach -MOA: GI mucosal protectant -side fx: bad taste, discoloration of stool and tongue (black tongue) -dosing: original (262mg/15mL): 2 tablespoons PO every hour pwn, NTE 8 doses/day (16 tablespoons) -max strength (525mg/15mL): 2 tablespoons PO every hour prn, NTE 4 doses/day (8 tablespoons) -Cautions: avoid in pts w/ salicylate allergy (aspirin) -avoid in children/teens who are recovering from chicken pox/viral illness (reye's)> don't use in children <18 y.o. -counseling: for liquids: shake well -may refrigerate liquid formulation for better taste -can take w/ or w/o food -may cause stool and tongue discoloration=harmless, transient and may last several days after your last dose 6. Phosphorated carbohydrate solution (PCS) -Indication: nausea associated w/ excessive/disagreeable food intake and by intestinal or stomach flu -MOA: hyperosmolar soln that dec GI SM contraction and delays gastric emptying time -formulation=mix of levulose (fructose), dextrose (glucose), and phosphoric acid= lots of sugars, avoid in diabetic pts/fructose intolerance - 2-12 y.o.: 5-10mL PO every 15mins, NTE 5 doses/hour - >12 y.o. and adults: 15-30mL PO every 15mins, NTE 5 doses/hr -NVP=15-30mL PO on arising and every 3 hrs, NTE 5 doses/hr -side fx: diarrhea -counseling: do not dilute (b/c dec efficacy b/c hyperosmotic soln) -avoid liquid consumption 15mins before and after for max effect (same reason) -Complementary and Herbal Remedies: -1. Ginger= in a variety of pdts (ginger ale, ginger root, extracts) -Pros: doesn't produce CNS depressant fx -effective for postoperative nausea, NVP, and motion sickness -Cons: optimal dose?, not FDA approved for N/V -others: chamomile, lemon balm, peppermint, artichoke 7. Pyridoxine (vitamin B6)= mainly used for NVP -Pregnancy: -1st line: non-pharm (environmental, diet/food changes), prevent dehydration -2nd line: acupressure or acustimulation bands -phosphorated carbohydrate soln (tricky b/c also pregnancy induced diabetes) -doxylamine 12.5mg + pyridoxine 10mg PO 4x prn N/V -Rx: Diclegis= doxylamine 10mg + pyridoxine 10mg=pregnancy category A, FDA approved for NVP -avoid: other antihistamines= none are FDA approved for OTC use in NVP, avoid all anti-HM in lactating women, no PPIs, no BSS, no H2RAs -Children: -1st line: non-pharm therapy: environmental, food/diet changes, prevent dehydration -2nd line: phosphorated carbohydrate soln -acupressure or acustimulation bands -antihistamines for motion sickness -age limits -controversial dosing 2-5 y.o. (dose no longer listed on OTC packages < 6 y.o.)> FDA cautions use -Avoid: BSS <18 y.o. -Elderly: -1st line: non-pharm: environmental, diet/food changes, prevent dehydration -2nd line: acupressure or acustimulation bands, phosphorated carbohydrate soln -3rd line: antacids, H2RAs, PPIs, BSS= limited efficacy, possible DDIs: cimetidine (potent cyp P450 antagonist, BSS (subsalicylates) and anticoagulants) -avoid: antihistamines: fall risk, CNS, anti-Cholinergic AEs, BPH, glaucoma, respiratory conditions, confusion, delirium -REFER: -presence of blood in vomit/stool -N/V w/ severe abdominal pain -N/V w/ head injury -presence of stiff neck w/ or w/o HA (meningitis) -suspected food poisoning longer than 24hrs -severe N/V in pregnancy -REFER children: -signs of severe dehydration (weight loss >9%, difficulty waking up the child) -unable to manage N/V at home - < 6 months y.o. or weight of < 8kg -refusal to drink liquids -no urine output for >8hrs -child appears lethargic and unusually sleepy or is listless -suspected poisoning

Ophthalmic Disorders (Eye Disorders)

-Exclusions for self-txt: eye pain, blurred vision not associated w/ use of ophthalmic ointments, sensitivity to light, history of contact lens wear, blunt trauma/chemical exposure, heat/sun exposure to eye, symptoms >72 hrs -Dry eyes= associated w/ aging, disease, drug or environment -symptoms: white/mildly red eye, sandy/gritty sensation, excess tearing, difficulty wearing contact lens -txt= artificial tears solns or non medicated ophthalmic ointments -Artificial Tear Solns MOA: -1. cellulose ethers (Ex: Refresh) stabilize tear film and inc viscosity= inc viscosity= inc effect, for elderly, drugs that cause dry eyes, etc -2. Polyvinyl Alcohol (PVA)= inc tear film stability (for young, not that serious, cheaper) -3. Povidone promotes wetting of eye surface -Dosage: mild dry eye= low viscosity tears 1-2x/day -moderate dry eye= low viscosity tears 3-4x/day or high viscosity tears -severe: add nighttime use of ointment at bedtime and non preserved tears as needed (eyedrop 1st>10mins>ointment or eyedrop>5min>another eyedrop) -side fx= toxicity from preservatives inc as #drops/day inc -Nonmedicated Ophthalmic Ointments: -MOA= white petrolatum, mineral oil, and lanolin> enhanced retention time helps integrity of tear film, benefits both mucin/aq deficient eyes -dosage: 2x/day usually but can be used every few hrs> bedtime preferred to keep eyes moist during sleep -side fx= blurred vision, hypersensitivity to preserved formulations Counseling: -try to get preservative free/disappearing preservative formulations -avoid situations causing tear evapopration -how to administer eye lubricants -what to expect/when to go to doctor (wait 72 hrs to see if it worked) -Allergic Conjunctivitis (both eyes, vs viral= on one eye, unless spreads if touch): -due to allergies= red eye, watery discharge, itching -treatment: -cold compress/ remove/avoid allergens -1st line= artificial tears as needed; to wash out eyes -2. use ophthalmic antihistamine/mast cell stabilizer if symptoms continue= ketotifen -may consider ophthalmic decongestants/alpha-adrenergic agonist -oral antihistamine -medical referral -Ophthalmic Decongestants= work fast: -phenylephrine 0.12% (1-2 drops up to 4x/day) -naphazoline(1-2 drops up to 4x/day), tetrahydrozoline (1-2drops every 4hrs), oxymetazoline (1-2 drops every 6 hrs) (imidazoles) -MOA: alpha adrenergic receptor activity to constrict BVs in eye to reduce redness> improves symptoms of tearing, itching and burning -MAX 72 hrs> after 72hrs= rebound conjunctivitis= redness will come back (but dr. could put them on these for >72hrs) -side fx: rebound congestion most common> refer to eye care specialist -rebound congestion less likely with naphazoline/tetrahydrozoline -pupil dilation can occur w/ phenylephrine/naphazoline -don't worry about til 3rd year: -drug/disease interactions: enhancer pressor effects w/ TCA's, MAO inhibitors, methyldopa -caution in systemic hypertension, arteriosclerosis, cardiovascular disease, diabetes, or hyperthyroidism (if properly administered (i.e. close tearduct)= unlikely to cause side effects though b/c won't inc BP, etc) -contraindications: avoid in (angle-closure) glaucoma b/c will inc Pressure in eye -use sparingly during pregnancy (just don't) -refer if >72hrs -naphazoline 0.02%= 1st line eye decongestant -less rebound congestion w/ naphazoline or tetrahydrozoline -Naftcon vs Naftcon A= Naphazoline (decongestant) + antihistamine= quicker/stronger fx -Decongestant/Antihistamine: -pheniramine and antazoline, both histamine 1 receptor antagonists -more effective combined w/ topical decongestant naphazoline -indicated for symptomatic relief of seasonal or atopic conjunctivitis -side fx: burning, stinging, discomfort> pheniramine= less stinging but w/e -don't use in glaucoma patients -Ophthalmic Antihistamine/ Mast Cell Stablizer -zaditor/ketotifen= only one u can use forever b/c no decongestant, only antihistamine -MOA= potent H1RA prevents histamine mediated allergy symptoms -inhibits mast cell degranulation, preventing release of inflammatory mediators -dosage: 2x/day dosing, relief w/in minutes and lasts up to 12 hrs -3+ y.o. -best for allergies (safest/most effective), no vasoconstriction activity, and can use for >72 hrs -side fx= burning, stinging, discomfort -no glaucoma -Viral Conjunctivitis: -most common form of conjunctivitis -usually caused by cold, sore throat, exposure to patient w/ this condition -symptoms: pink eye w/ watery discharge -eye discomfort/sensation of foreign body in eye -low grade fever and swollen lymph glands -occasional blurred vision -non-pharm: use hygienic measures, wash hands, dispose tissues, no sharing -pharm txt: symptomatic relief w/ artificial tears and topical decongestants as needed to dec redness/watery -counseling: stress hygienic measures -advise symptoms resolve over 1-3 weeks (how long viruses last) -refer if loss of vision or >3 weeks -Corneal Edema: -symptoms= causes: contact lens overwear, corneal damage (scratched) -fluid accumulation in cornea> halos/starbursts around lights, need diagnosis by practitioner (they'll come w/ rx/note to get pdt from dr) -txt= goal is to draw fluid from cornea relieving symptoms, use topical hyperosmotic formulations (Sodium Chloride aka Muro 128) -MOA NaCl= inc movement of fluid from cornea to tear film> improves comfort/vision -1st line: NaCl 2% (1-2 drops 4x/day) -2nd line: NaCl 2% + NaCl 5% ointment at bedtime -3rd line: NaCl 5% (1-2 drops 4x/day) + NaCl 5% ointment (at bedtime) -counseling= go to dr. if dmged eye, NaCl 2% preferred for long term therapy -Loose Foreign Substances in Eye= flush eye out if reflex tearing doesn't remove it -rinse w/ sterile saline or ocular irrigant (eyewash preparation) -ocular irrigants= cleanse ocular tissues and maintain moisture, use on short term basis, don't use for open wounds/contact lens, avoid using eyecup b/c contamination risk -chemical burn= pain, tearing, irritation, photophobia= txt= lots of irrigation w/ sterile saline/tap water> eye emergency so refer -Macular Degeneration= age related leading cause of blindness= two forms= neovascular (wet) and atrophic (dry) -antioxidants + zinc therapy may help atrophic (dry) form -counsel for possible GI toxicity/hypervitaminosis -Eyelid disorders: -1. Contact Dermatitis of Eyelid= rxn to allergen/irritant, usually involving both eyelids on one eye= swelling, scaling, redness, itching -txt: identify and discontinue use of irritant -cold compress 3-4x/day -oral antihistamine prn -refer if >72hrs 2. Lice Infestation of Eyelid=symptoms= red,scaly,thickened eyelids w/ crab/head louse and prob on other pts of body -REFER then when come back: use nonmedicated ophthalmic ointment for 10 days (vasoline, mineral oil, baby johnson and johnson shampoo) -freq cleaning (4-5x/day) w/ mild soap/water, wash bedding/clothes -Blepharitis= inflammatory condition of eyelid margins, associated w/ staphylococcus/soborrheic dermatitis or both -symptoms= red, scaly, thickened eyelids w/ loss of eyelashes, complaints of itching/burning -REFER then when come back: eyelid hygiene, apply hot compress 15-20mins 2x-4x/day, then use lid scrubs (little towels to scrub eyelids or baby johnson and johnson shampoo) -can use home made or commercial lid scrubs -can use occular lubricant for eye irritation -How to administer eyelid scrubs: 1. wash hands 2. apply 3-4 drops of baby shampoo or eyelid cleanser to cotton tipped applicator or gauze 3. Close one eye. Clean the upper eyelid and eyelashes using side strokes. don't touch eyeball -open eye, look up, clean lower eyelid/eyelashes now -repeat on other eye -rinse eyelids/eyelashes w/ clean, warm water -Hordeolum (infectious) and Chalazion (not infectious): -symptoms= hordeolum=stye= tender palpable nodule, infection of glands -chalazion= sterile granuloma, not infected, not tender nodule= little white bump thing on eye -txt= go away on their own in a week> hot compress 5-10mins 3x/4x/day -periodic use of lid scrubs to dec occurance -refer if >1 week -basically if diagnosed already= can help txt, if unsure, serious/bacterial conjunctivitis= refer

Skin Hyperpigmentation, Photoaging and Hair Loss

-Hyperpigmentation: -causes= melanocytes produce melanosomes (Pigment granules) w/ protein melanin (brown-black pigment)> provides protection from UV raditation= overactive b/c: -endocrine imbalances from hyperthyroidism, pregnancy, estrogen therapy (BC), addison's disease, cushing's disease -skin trauma= inflammatory dermatosis thermal burns -drugs: phenytoin, minocycline, amiodarone, chlorpromazine, hydroxychloroquine, amitriptyline, oral contraceptives -refer for all of these -symptoms= discoloration on face/sun exposed areas usually 1. Ephelides (Freckles)= uneven skin pigmentation 1st appeared in childhood and worsened by sun= self-txt 2. Melasma (Chloasma)= macular hyperpigmentation associated w/ pregnancy or BC use= can txt if rec by PCP b/c most drugs to self-txt=not rec for preg 3. Lentigines= liver spots, appear at any age tho, solar or senile lentigines= age or liver spots -Pharm txt: topical skin-bleaching agents (hydroquinone) w/ or w/o alpha-hydroxy acid (AHA)= inc results w/ both -avoid UV radiation (hrs=10am-3pm) -use sunscreen (30+ SPF) and protective clothing -follow up w/ you in 2 months b/c 4-8 weeks to work, no improvement after 3 months= refer, if works= prn -Exclusions/REFER: - <12 y.o. -large BSA -disease/drug induced -lesions that are changing in size/shape -Hydroquinone= FDA approved for nonrx use= 1.5-2% -MOA= selectively damages melanocyte membrane -administration: 2x/day on clean dry skin (only at affected area, will bleach clothes), or 1x/2x/day for maintenance -apply before moisturizers or other pdts -when get right skin tone use prn -if no improvement w/in 2 months, dc and f/up w/ PCP -side fx= mild tingling/burning -do sensitivity test= small amt on inside wrist and see rxn -watch for hypopigmentation (takes 6-8 weeks for it to resolve) -Skin Type: cream base for dry skin, lotion for normal skin, gel for oily skin -hydroquinone based pdts= has other stuff mixed into it= not reg by FDA -Alternative Agents= not FDA rec but options: 1. Synthetic Oligopeptide 0.01% -MOA: similar to hydroquinone, inhibits tyrosinase -adv= well tolerated, less toxic than hydroquinone -not approved by FDA, available as lumixyl -apply pea-sized amt 2x/day w/ results 8-16 wks 2. Kojic Acid= from fungus -kojic acid 1%-4% is combined w/ AHA's +/- hydroquinone -MOA=inhibits pdt of tyrosinase -side fx= contact dermatitis, erythema= not for sensitive skin -kojic acid 2% + glycolic acid 10%= similar efficacy to hydroquinone 2% + glycolic acid 10% 3. Rucinol=expensive -MOA= a resoreinol derivative that inhibits both tyrosinase and tyrosinase-related protein-1 (TPP-1), an enzyme used in melanin synthesis -application= rucinol 0.3% serum/crea= 2x/day 8-12 wks -tolerated well 4. Tranexamic Acid -MOA= inhibits UV-induced plasmin activity which also dec tyrosinase activity in melanocytes -some studies= improvement in 12 weeks, can cause local irritation 5. Mandelic Acid=not as popular -type of AHA, from almonds, works well w/ hyperpigmentation, combined w/ salicylic acid and used as a peel= less side fx/better results than glycolic acid peel 6. Niacinamide=not as popular -vitamin B3 derv, inhibits transfer of melanin to keratinocytes, similar to niacin w/ mild side fx -Counseling: -results in general are better in patients w/ lighter skin= darker skin patients take a bit longer but will work -lighten only hyperpigmented skin -use sunscreen and protective clothing regularly -results can take up to 3 months, follow up w/ PCP if no improvement after 2 months -Photoaging= prematurely aged facial skin d/t: -genetics, hormonal changes, exposure to wind, chemicals, smoking, UV radiation -symptoms= yellow, discolorations, distended capillaries, loss of smoothness/collagen/elastin, dry course papery skin, sebaceous glands break down, enlarged pores -txt: tretinoin (only one approved but others used by dermatologists,etc), adapalene, tazarotene -cosmeceuticals (no rx, not reg by FDA): AHAs (Biggest benefit= 1st line), BHAs, kinerase, vitamin A,C,B3,E and coenzyme Q10 pdts -alpha-hydroxy acids= 1st choice even after tretinoin= major role in reversing/improving aging skin -lactic acid and glycolic acid pdts, widely available and not FDA approved -MOA= acts as exfoliants removing keratinocytes (dead skin cells)> results in smoother, non scaly skin, improves skin elasticity, inc collagen/elastin w/ long-term use -indications (not approved so can make up indications): melasma, acne, solar lentigos, photoaging -side fx= mild stinging, burning, dryness (use sunscreen/lotion, polyhydroxy acids= new gen of AHA's w/ less irritation/similar results) -Product selection: -creams for dry skins -lotions for combo/normal skin -gels/solns for oily skin -AHAs are safe if <10% conc and final pH= >= 3.5 2. Beta-hydroxy acids (BHAs)= salicylic acid 2%= most common, less water soluble than AHAs -acne= use salicylic acid -3. Kinerase (N-furfuryladenine)= antiwrinkle product= treats wrinkles, blotchiness, and dryness, expensive -4. Retinol and Retinaldehyde (Vit A derv): -Retinol: added to many skin care pdts, MOA: 2 step enzymatic process: retinaldehyde> retinoic acid -Retinaldehyde: well tolerated, similar effects to tretinoin, but very unstable and light exposure degrades to inactive form> he doesn't rec -5. Ascorbic Acid (Vitamin C): -MOA=antioxidant, removes free radicals -has potential to be used topically for prevention/correction of human skin aging -may have photoprotective properties -6. Idebenone: a synthetic derivative of Uniquinone (Coenzyme Q10) w/ potent antioxidant properties -MOA: quenches free radicals in epidermis and prevents/reverses photoaging -found in cosmetic creams/lotions promoted as anti-aging and/or antioxidant props -Counseling: -protect skin by avoiding peak sun exposure and use UVA/UVB suncreen SPF 30+ -preg/lactation= not evaluated -good skin hygiene practice: prevent dry skin, cleanse w/ mild soap/soap-free cleanser -use alpha-hydroxy acid pdt> start at bedtime, every other day for 7 days, then use 2x/day as tolerated -results= seen in 2 months, sometimes as early as 1 month -can use forever -Hair Loss: -non-scarring alopecia= most common type of hair loss -androgenetic alopecia, alopecia areata, and telogen effluvium -scarring alopecia= not common, diagnosis by dermatologist 1. Androgenetic Alopecia (AGA) aka male pattern baldness= most common form of hair loss -anagen to telogen ratio decrease -telogen hairs replaced by vellus hairs (short, unpigmented, fine, loose, like hair on arms) -family history, gradual air loss 2. Alopecia areata= REFER= autoimmune hair loss, rapid onset, patchy hair loss, young ppl, usually pre-existing disease like diabetes 3. Telogen effluvium= REFER=rapid shedding of hair in resting phase cycle, nonhereditary, mostly causes by drugs like beta blockers, ACEi, warfarin, heparin, etc= metabolic/hormonal disturbances -prob don't have to know: -Cycle hair follicle activity: -Anagen (active hair growth, 2-8yrs)> Catagen involution (4-6wks)> telogen (resting=2-3months)> exogen (release of dead hair)> anagen -role of testosterone and dihydrotestosterone -REFER/exclusions: -<18 y.o. -no family history of hair loss -sudden/patchy hair loss -autoimmune disease or skin infections -postpartum women w/ hair loss (preg/breast feeding) -scaling, sunburn, dmg to scalp -evidence of fever/inflammation -skin lesions, broken off hair shafts= infection -loss of eyebrows/eyelashes, changes in nails -basically only treat androgenetic alopecia (male pattern baldness)> Minoxidil -Counseling= -nonpharm: camouflage, hair transplants -minoxidil use w/ expectation: use for at least min rec period =at least 4 months and if you stop using it, hair will go away, you have to use every day for rest of your life -use continuously for best results -Minoxidil works better at earlier ages -MOA: may inc BF directly to hair follicles, may transform telogen phase hair follicles to active anagen hair follicles -indications: -men= minoxidil 2%, 5% solns, and 5% foam pdts -women= minoxidil 2% soln and 5% foam pdt -Admin: apply to clean, dry scalp and hair -apply 1mL 1x/day for women, 2x/day for men -allow 2-4hrs to penetrate scalp -wash/dry hands after use -don't double dose for missed application -do not dry scalp w/ hairdryer after applying drug -at night apply drug 2-4 hrs before bedtime -Minoxidil 5% foam: -wash hands in COLD water before applying -part dry hair into 1/more rows to max foam contact w/ scalp -hold can upside down, apply 1/2 of a capful of foam to fingertips> spread foam over thinning area, massage gently into scalp -let pdt dry and wash hands -side fx= itching, irritation, possible hair growth in other places w/ long term use -precautions: scalp dmg, preg, heart disease -avoid topical corticosteroids, retinoids, petrolatum -minoxidal slows down hair loss, gets some hair regrowth but short, unpigmented, peach fuzz -at least 4 months are needed to stimulate hair growth> if no inc hair density after 4-6months>PCP -soln=cheaper vs foam=better for sensitive scalp

Nutritional Deficiencies: Minerals

-In general: Want to know if diagnosed or if they just feel like they need it= to change how to treat b/c could be getting too much -minerals=essential and inorganic -diff labeling and hard to evaluate safety/efficacy of Multivitamins/supplements -Nutritional supplements: Purpose= to prevent nutritional deficiencies, maintain nutritional status, OTC supplement doses should not be used to self-txt deficiences -should be an adjunct to balanced diet and not a substitute -optimal mineral intake values=imprecise and longer term effects of high doses=unknown -freq interactions dec bioavailability -FDA approval not req but USP (pharmacopeia)= tests pdts meets reqs: verified ingredients, effective dissolution, no harmful contaminants, sanitary manufacturing facility -major minerals (amt >5g in body): calcium, iron, mg, phosphorous -trace element minerals (<5g in body)= zinc, manganese, selenium -Calcium (Ca2+)= most abundant mineral in body (about 1200g)> majority stored in skeleton -other 1% present in extracellular fluid, intracellular structures and cell membranes> if not enough from diet, body will take from body -Function: bones and teeth (99%) -regulates muscle contraction and relaxation -aids in vitamin B12 abs -plasma clotting factor activation -Ca2+ deficiency: -causes: malabsorption, hypoparathyroidism, vitamin D deficiency, renal failure, anticonvulsant therapy, inadequate intake (esp during periods of growth, pregnancy, lactation, and advanced age) -symptoms: bone deformities: rickets (children), osteomalacia or osteoporosis (adults); CNS: convulsions, mental status changes -FDA approved for: treatment and prevention of deficiency, acid indigestion, hyperphosphatemia associated w/ ESRD -intake rec is based on elemental calcium: 2 tables given on exam -Calcium: types of supplements: insoluble calciums (calcium carbonate, calcium phosphates)= take w/ food, optimal absorption at low pH> need to look at med list to see acid suppresant therapies like PPI to check this (inc pH=bad for insoluble)=take WITH food -soluble (calcium citrate, calcium lactate, calcium gluconate)= inc abs regardless of pH (pH ind)=good, can take w or w/o food -note: the serving size for calcium supplements and if just says "Calcium" on label= amt of elemental calcium per serving size vs calcium citrate 500mg= need to calculate using table -Calcium absorption considerations: -small intestine controls abs based on calcium intake -optimal abs occurs w/ doses 500mg or LESS -Inc Abs: food and vitamin D: take calcium w/ food: calcium carbonate, calcium phosphate salt (Calcium citrate can be taken on empty stomach) -ensure pt is not vitamin D deficient b/c affects Ca2+ abs -divided dose interval= max 500mg elemental calcium per dosing int (divide doses if needed) -Dec abs (don't worry about too much ito patients but yes potential reasons): phytic acid foods: unpolished rice, bran, wheat meal -high oxalate foods- raw kale, raw spinach -vitamin D deficiency -achlorhydria (low acid pdtion)= same effect occurs w/ PPIs, H2RAs= avoid calcium carbonate, use citrate salt -side fx: kidney stones (d/t high Ca2+ lvls in urine), constipation -toxicity: doses >3,000mg/day may be harmful -anorexia, N/V, constipation, polyuria, calcium deposition in soft tissue -rec limit supplementation to 1000mg/day b/c already getting Ca2+ in diet -inc cardiovascular risk?> some studies=yes, some evidence, no prospective RCTs tho, theory= Ca2+ could cause vascular calcification, doesn't mean dietary calcium=issue tho, only supplements -DDIs: -Corticosteroids=inhibits calcium abs from gut= to prevent: consider calcium supplementation -aluminum-containing antacids, phosphates, cholestyramine: dec calcium abs> sep by 2 hrs -PPIs, H2RAs: dec abs of insoluble Ca2+ salts> use soluble Ca2+ formulations -Iron, Zinc, Mg: high calcium intake inhibits abs of these minerals> sep by at least 2 hrs -Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin): calcium dec antibiotic abs> sep by at least 2 hrs before or 6 hrs after antibiotics -Iron (Fe) Function: -oxygen and electron transport -iron in body is either functional or stored -functional iron= hemoglobin (RBCs), myoglobin (muscle), heme-containing enzymes and bound to transferrin (iron transport protein) -stored iron: ferritin, hemosiderin in intestinal mucosa, liver, spleen and bone marrow -Iron dietary sources and abs: widely available in U.S. diet; abs controlled by need for iron, intestinal conditions, food source, and other meal comps (like vitamin C) -dietary iron available in 2 forms: (know): 1. Heme Iron: meat, fish, poultry> reasonably well-abs 2. Nonheme iron: dark green vegetables, whole or enriched grains= poorly abs (ferric hydroxide) -roughly 10% of total iron is absorbed (heme+nonheme)> increases to 20% if iron deficient> not a great estimate in absence of heme iron (i.e. vegetarian meal) -Iron Deficiency: -Causes: blood loss (hemorrhagic or menstruation), inadequate diet, malabsorption, pregnancy, diseases (PUD, hemorrhoids) -drugs that cause iron deficiency: NSAIDs, salicylates, corticosteroids, anticoagulants -epoetin alpha txt w/ inadequate iron supplementation -At risk: children <2 y.o.= low iron content from cow's milk -adolescents=rapid growth, blood loss during menses -pregnancy= inc blood vol, demands of fetus/placenta, blood loss of childbirth -advanced age (65+ y.o.)= dec dietary intake, inc risk of GI tract blood loss (malignancy, ulcers, NSAIDs) -symptoms of iron defiency: weakness, fatigue, pallor (face, nail beds), split nails, sore tongue, dyspnea on exertion -REFER: -vomiting blood -stool (red blood or black tarry) -menstruation (abnormally heavy flow) -urine= cloudy or pink/red urine -suspected iron toxicity= V/D, ab pain, electrolyte imbalance -symptoms worsen or inadequate response to iron -Elemental Iron= prevention and txt of iron-deificiency anemia= table in final, same like calcium -d/t GI side fx: UL=45mg/day -Ferrous Sulfate=gold standard -inc abs: vitamin C, empty stomach, fruit juice (b/c vitamin C) -dec abs: phosphates in eggs, carbonates, oxalates (in foods/cereals) -When selecting Iron: look at elemental iron content of pdt -look at absorption: XR pdts (EC or Delayed release) DECREASE overall abs -vitamin C may INCREASE absorption if taken concurrently (OJ, vitamin C tablets) -Iron side fx: INCREASE abs w/o food (EMPTY STOMACH) but also increase GI SIDE EFFECTS=bad -GI mucosal irritation: GI tolerability is linked to the iron DOSE, not the salt form -may need to use an EC pdt> take w/ food if stomach pain (but dec abs up to 50%!) -CONSTIPATION: dose related: highest w/ FeSO4> add Stool Softener such as docusate prn -black, tarry stools -Iron toxicity= medical emergency!! (15 iron tablets= lethal in kids!! and they look like candy!) -sx: initial stage: pain, N/V/D, electrolyte imbalances, shock -later stages: cardiovascular collapse -txt: whole bowl irrigation, iron chelator, gastric lavage -prevention: child-resistant storage -DDIs: -antacids= DECREASE iron solb and abs> to prevent: sep by at least 2 hrs -tetracycline (doxycycline, minocycline) fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)> dec antibiotic abs and iron absorption> separate by at least 2 hrs before or 6 hrs after iron -levothyroxine: dec abs of levothyroxine> sep by at least 4 hrs -BASICALLY, Calcium and Vitamin D absorption are intertwined, inc abs of each other; BUT Calcium/OJ DECREASES Iron absorption.(also pH/antacids affect iron=dec abs)>separate out by 2 hours; empty stomach inc iron abs but also inc GI effects=bad -Not on exam: -Magnesium: Adverse fx: -diarrhea -alt: magnesium protein (expensive) -hypermagnesemia= excessive magnesium sulfat (epsom salts) or magnesium hydroxide (milk of magnesia) use or magnesium antacids in severe renal failure> muscle weakness, dec deep tendon reflexes, CNS depression, cardiac: hypotension, bradycardia=complete heart block -Mg DDI: tetracyclines, fluoroquinolones and levothyroxine= dec drug abs (sep by 2 hrs before or 6 hrs after iron) -Phosphorous: -Function: as calcium phosphate= structural comp of bone matrix, functional comp of phospholipids, carbohydrates, nucleoproteins, and high-energy nucleotides -pH (inorganic phosphate buffers), energy (ATP), phosphorylation -diet sources (nearly all foods): meat, poultry, fish, dairy pdts, legumes, cereal grains -causes of deficiency: rare, usually induced; from aluminum hydroxide use for prolong periods= binds phosphorous, dec abs d/t insolubility of bound complex -symptoms: weakness, pain, anorexia, bone loss -DRI: 700-1250 mg/day (UL=4000mg/day), sodium and potassium phosphates salts -side fx: diarrhea, stomach pain -DDI: sulcralfate, antacids w/ mg, ca2+, or aluminum

Diabetes Stuff

-Normal Plasma Glucose for ppl w/o diabetes: fasting= 70-99 mg/dL, 2 hrs after meal= <140mg/dL Type 1 diabetes (T1D)= autoimmune disease by beta-cell destruction; type 1= like "i"= pencil thin, skinny, patietns= txt= give insulin= 1 cure (no oral meds), young children usually <30 y.o. (acute, rapid), normal weight, rare from family history -Type 2 Diabetes (T2D)= progressive loss of beta-cell insulin secretion w/ background, insulin resistance= majority, usually >40y.o., some adolescents (gradual onset, asymptomatic for like 10 years), usually obese= apple-shaped, genetic from family history -signs/symptoms of diabetes= renal threshold= 180mg/dL -3 P's= polydipsia (thirsty), polyuria (freq peeing), polyphagia (hungry af b/c not absorbing into cells). also dry mouth and dehydration, nocturia (peeing at night), fatigue, unexplained weight loss, blurred vision, poor wound healing, freq. bladder/vaginal/skin infections, numbness/pain in legs/hands, muscle weakness/impotence -MEMORIZE: Diabetes Diagnosis (1 of them): 1. FPG (Fasting, 8hr no food): >=126mg/dL 2. Random Glucose (casual)= >=200mg/dL (only if w/ polyuria, polydipsia, or unexplained weight loss b/c 20% error on machines) 3. A1C= >= 6.5% 4. Oral Glucose Tolerance Test (OGTT): >= 200mg/dL at 2 hrs post 75 gm glucose load Know: -HbA1C= goals: <7% (6-6.5% for younger, healthier ppl tho and 7.5-8% for older, comorbities, hypoglycemia prone ppl and avoid hypoglycemia) -preprandial (before meals) glucose= 80-130 mg/dL -postprandial glucose: <180 mg/dL A1C= the weighted average of blood glucose values over 2-3 months= the sugar sticking to the RBCs -KNOW: <5.7%= normal, 5.7-6.5%= prediabetes, >6.5%= diabetes -FPG: 100-126mg/dL= prediabetes, <100% mg/dl=normal, >=126mg/dl= diabetes -OGTT: 140-200mg/dL= prediabetes, >200mg/dL= diabetes, <140mg/dL= normal -Know: A1C 7%= about 150 average glucose mg/dL, and go by +/- 30mg/dL for the percentages> i.e. 8%= about 180mg/dL -microvascular complications=nerves, eyes, kidneys= most sensitive to blood glucose= blurred vision -blood glucose goal= 80-130mg/dL Diabetes Control: Complications can be prevented/delayed! -BMI 25+ = overweight, 30+ = obese BP goal= <140/90 mmHg -BMI goal= <25 kg/m^2 -follow up every 3-6 months, A1C -annually= eye exam, flu vaccine, tests for microalbuminuria, lipid panel, comprehensive foot exam -pneumoccocal vaccines 2 shots, 12 months apart, up to date on other like tetanus, hep A/B and herpes zoster Medical Nutrition Therapy (MNT): individualized approach> quality vs quantitiy, portion sizes (use smaller plate) -Carbs= high fiber (20-28g/day), veggies, fruits, whole grains, legumes -proteins= 15-20%= low fat meat, poultry, fish, eggs, milk, yogurt, cheese, soy -fat: <30%= beware of light or fat free foods b/c change w/ sugar -minimize intake of trans fats -cholesterol <200mg/day -2 or more fish servings a week (omega-3 FA) -minimize alcohol consumption b/c can cause hypoglycemia esp on empty stomach> eat first and space drinks -include in daily calories calculation (Counted as fat) -men should have 2 drinks/less/day -women 1 drink/less/day -1 drink= 5 ox wine, 1.5 oz distilled beverages or 12 oz beer -sodium= <2,300mg/day Exercise: -exercise increases insulin sensitivity, muscle/tone (More efficient use of energy), strength, endurance, flexibility, self-esteem, feelings of well-being -dec fat, weight, BP, cholesterol, stress and anxiety -BG improves when sitting is interrupted every 30 mins w/ just 3 mins or more of standing/light-intensity activities like leg lifts, stretches, etc.> can dec A1C -want at least 150min/week (2 hrs 30min) of moderate-aerobic exercise -burst exercise= 3 periods of 10 mins at 85% target heart rate> results in greated improvement of A1C, lipids, BMI and cardiopulmonary fitness -resistance training at least 2x/week if no contraindications -reccommend sugar free pdts b/c will inc BG even in cough/cold meds> like nasal decongestant over oral -do dental care (teeth cleaning/oral health evaluation 2x/yr, teeth brushed/flossed 2x/day, check for gum abnormalities like bleeding) -do skin care (daily bathing w/ mild soap, dry skin thouroughly> inspect for potential infections)> cleanse minor cuts/scratches promptly w/ soap/water and avoid topical drying agents (alcohol or salicylic acid pdts) -do eye care= 1x/yr do dilated eye exam, review topical eye preparations for potential contraindication, seek medical attention immediately if vision changes or eye irritation occurs Diabetic Foot Care: -Foot Ulcers> Amputations -diabetes affect the nerves and hyperglycemia impairs phagocytosis -3 main causes: -1. Peripheral Neuropathy (numbness) w/ loss of protective sensation -3 types: sensory, motor, autonomic -1. Sensory Neuropathy= distal symmetrical (furthest away and both sides) polyneuropathy= both common form= glove pattern i.e. start at the tips and pull gloves on is how the neuropathy starts -loss of sensory nerve function resulting in loss of protective sensation -symptoms= numbness, burning, tingling, pin/needles, jabbing, loss of ability to feel pressure, friction, irritation, trauma, heat 2. Motor Neuropathy= loss of motor nerve function causes foot structure and gait changes= inc plantar pressure under metatarsal heads and tips of toes (hammer/claw toes), bunions (b for bony) and callus formation (not bony, overworked skin) 3. Autonomic Neuropathy= changes in nerves that control blood flow, perspiration, and skin hydration> Charcot's foot=microfractures, bone resorption, collapse of arch -diminished sweat gland secretion (dyshidrosis) in foot> dry/cracked skin, infection and ulcers 2. Altered biomechanics (in presence of neuropathy)= evidence of inc pressure (erythema (redness), hemorrhage under callus) -bone deformity or severely thick nails 3. PAD (Perhipheral artery disease)= bad cholesterol in the feet -atherosclerosis of the perhipheral blood vessels> impaired perfusion of extremities> diminished or absent pulse: dorsalis pedis artery or posterior tibial artery> delayed wound healing, inc risk of infections/gangrene -symptoms: possibly asymptomatic, neuropathic pain, dry/cracked skin, infections, calluses, blisters, bunions, ulcers -REFER: all patients w/ diabetes should be followed by a PCP/endocrinologist> any signs of bacterial infection/fungal infection, open wounds/lesions/ulcers/diminished/loss of protective sensation -Non-Drug tx: -proper foot hygiene and care, foot inspections= daily and each visit by healthcare professional if neuropathy exists, annually by PCP if no neuropathy Foot exam: -wash hands before/after, teach how to care for their feet/prevent complications -look at toenails= thickened? super long? how cut? ingrown? infected? (white pts) -in between toes= peeling? flaking? -calluses, corns, pressure pts, bony deformities, erythema, hairlessness? -peeling, flaking, dry, cracked skin? -listen to patients as perform the semmes-weinstein monofilament sensory foot exam : -first test MF on patient's wrist area= feels like fishing wire -ask patients to close eyes and respond yes if they feel the MF on the foot> press the filament vs the skin at 90 degree angle until it bows> on plantar surfaces and top of feet -neuropathy is diagnosed if the 10gm MF can't be felt at any site on either foot> clean with alcohol swab and wash hands -feel the presence/absence of pedal pulses w/ pads of index/middle fingers -check posterior tibial artery (big toe side, behind ankle) -check dorsalis pedis artery (upper surface of foot) (V shape thing) -smell for foul odor -High risk patient= ONE or more: -loss of protective sensation -absent pedal pulses -foot deformity -history of foot ulcer -prior amputation -patient foot care= DAILY and use mirror/family member help if can't see feet> look for cut, blisters, callus, evidence of pressure, scratches, cracks, fissures, color changes, excessive dryness/moisture -Cleaning: use warm (NOT HOT b/c can't feel it) or cool water and mild soap> always test bath/shower water temp w/ hands/arms/elbows before using -avoid prolonged soaking b/c drys out feet -dry feet thoroughly w/ soft towel esp between toes -no pumice stones -to prevent dryness/cracks= avoid pdts w/ irritatnts, use amlactin (good for dry skin) or carmol (softens calluses)> only use 1-2x/day, NOT between toes (b/c moisture) -avoid keratolytic topical agents= burns skin -diabetic patients shouldn't self-tx large stuff on foot that can cause ulcers -prevent moisture= if feet become soft and tender= rub w/ rubbing alcohol 1x/week -if suspect athlete's foot> tell PCP -clotrimazole cream 1% applied sparingly 2x/day to clean, dry feet= ok -low-risk patients should trim toenails straight across w/ slightly rounded edges, not too close> file down sharp edges -high risk patients shouldn't cut own toenails -careful w/ pedicures -avoid barefoot, wear well-fitting, soft cotton, synthetic bled/wool socks and shoes that avoid high heals for calluses> athletic/walking shoes preferred=comfortable/not tight, break new shoes in slowly -inspect shoes daily inside and out= shake out shoes before putting on -may change shoes 2x/day -avoid heating pads/hot water bottles, no tight stockings/knee highs w/ tight bands -can get prescribed diabetic shoes (even medicare has it)= fits shoes exactly to feet= wide opening for foot, leather-like material, secure closure, reinforced toe, light weight -avoid sitting w/ legs crossed b/c constricts circulation/pressure on nerves

Otic Disorders (Ears)

-Self-care for ear disorders= excessive cerumen (earwax) and water-clogged ears and external ear disorders on earlobe -children <7y.o.= more susceptible to develop ear infections b/c shorter/more horizontal eustachian tube -Cerumen Impactation: -usually no symptoms but if impacted can cause: hearing loss, pain, tinnitus, dizziness, chronic cough, and otitis externa -causes: abnormally narrow/misshapen EACs, excessive hair growth in canal (disrupts migration of earwax going out), overactive cerumen glands, hearing aids, ear plugs, sound stuff= prevent migration and cause wax buildup, old age= atrophy of ceruminous glands and drier cerumen= harder to expel -earwax=oily secretions from exocrine gland mixed w/ milky, faty fluid from apocrine glands -earwax lubricates ear canal, traps dust, and foreign material -provides waterproof barrier to the entry of pathogens -has antimicrobial substances like lysozymes and exhibits acidic pH, which inhibits bacterial and fungal growth -Refer: -patients who can't follow instructions (mental disabilities) -bleeding/discharge from ear -presense of otalgia (ear ache, >dull pain) -ruptured tympanic membrane -ear surgery in past 6 weeks -signs of infection/trauma -unexplained dizziness, tinnitus, hearing loss, pruritis -children <12 y.o. -OTC txt ineffective after 4 days -tympanostomy tubes -non-pharm txt: earwax should only be removed if it's migrated to outermost portion of EAC -remove earwax using a wet, wrung out washcloth draped over the finger (not effected once cerumen impacted tho) -Cerumen-Softening Agents: 1. Non-water/non-oil based: Carbamide Peroxide ("Debrox")= softens earwax before irrigation or as an alternative to irrigation -dosing= 5-10 drops into affected ear for 15mins 2x/day for up to 4 days (then can rinse out/professionally cleaned) -side fx= rash, itching/swelling (esp of face,tongue,throat), severe dizziness, trouble breathing= rare -Not on exam (Off-label use): -2. Water-based= Docusate Sodium (soap-like) or 3% hydrogen peroxide or oil-based= olive oil, almond oil, mineral oil: softens earwax before irrigation= fill affected ear canal with 1mL 15min before irrigation for water-based ones -for oil-based= put 3 drops into affected ear at bedtime for 4 days -Candle wax= no b/c can dmg ears -uses hollow candle inserted into ear canal, burned at one end for negative pressure effect> wax can get into ear/burns -Water-Clogged Ears: -causes= shape of ear canals or lots of earwax=swells, traps water -excessive moisture in ears can also be from hot, humid climates, sweating, swimming, bathing, or improper aqueous solns to cleanse ears -simple attempts to remove water by mechanical manipulations may be insufficient -non-pharm: tilting the affected ear down and pulling on auricle can expel excessive water -using a blow dryer on low setting immediately after swimming/bathing can help dry it -pharm txt: (12 y.o.+, ask dr if irritation, burning/pain occurs) 1. AURO-DRI, swim ear drops= isopropyl alcohol (95%, dries it by lowering evaporation temp), anhydrous glycerin) 2. ear dry drops= isopropyl alcohol 95% and boric acid 2.75% (poisonous to kids, but added to inc pdt acidity+weak germicide) 3. Compounded= 50:50 mixture of acetic acid 5% and 95% isopropyl alcohol=bactericidal and antifungal properties -pdt= after shower/swim, apply 4-5 drops into affected ear, tilt head sideways and place drops in ear for several mins by keeping head tilted -side fx: ear pain, itching, irritation, drainage, discharge, warmth/swelling around ear Contact Dermatitis: skin becomes red, sore or inflamed after direct contact w/ substance> 2 types: irritant or allergic -Pharm pdt: 1. Aluminum acetate soln or Domeboro Astrigent Soln: -MOA= aluminum acetate has anti-inflammatory/limited antibacterial properties -useful for treating itchy, weeping, swollen conditions to external ear -astringents ppt proteins and dry affected area by reducing secretory function of skin glands -dilute soln has an acidic pH that inhibits bacterial/fungal growth -Directions= soak affected area for 15-30mins prn or as directed> repeat up to 3x/day, throw away soln after each use -if worsens/symptoms >7 days= stop use and go to dr -mix 1-3 packets in 16 oz soln to get dilutions: 1 packet= 1:40, 2 packets= 1:20, 3 packets= 1:13 -side fx= allergic rxn, rash,itching/swelling (ear,face,tongue,throat), severe dizziness, trouble breathing -Treatment of Boils (infectious): -boil=skin infection involving an entire hair follicle and nearby skin tissue> will usually go away on their own -warm compresses followed by topical antibiotic like bacitracin=rec -antibiotics don't penetrate boils so cut/drainage by PCP might be req if gets fix -REFER: multiple boils, boils that don't respond quickly to topical treatment/boils in EAC -Psoriasis of Ear= common skin condition that causes redness/irritation= thick, red skin w/ flaky, silver-white patches called scales -treating the scalp w/ antiseborrheic shampoos (coal tar)= relieves symptoms -topical hydrocortisone 1%= also useful in txting= 2x/day -moderate/severe cases=refer -How to remove excessive earwax: 1. place 5-10 drops of cerumen-softening soln into ear canal, wait 15mins 2. prepare warm (Not hot) soln of plain water/soln as directed by dr., 8 oz usually 3. to catch returning soln= hold container under ear being cleaned, tilt head down slightly there 4. gently pull earlobe down and back to expose the ear canal 5. place open end of synringe into ear canal w/ tip pted slightly upward towards side of ear canal (don't aim the syringe into back of ear canal and make sure it doesn't block the outflow of soln) 6. squeeze bulb gently- not forcefully) to avoid rupturing eardrum -if pain/dizziness= remove syringe and don't resume til ask dr. -8. make sure all water is drained from ear to avoid infection -rinse syringe thoroughly before/after each use and let it dry -do this 2x/day for no longer than 4 consecutive days

Minor Burns and Sunburns

-by synthesizing melanin, the skin protects underlying tissues from certain forms of irradiation -physiology: vitamin D3 is produced in the skin through exposure to UV radiation -vitamin D deficiency can be avoided in most individuals by 5-20mins of exposure of sunlight 2x-3x/week -sebaceous glands produce oil, which lubricates and prevents excessive drying of the skin -burns are tissue injuries caused by thermal, electrical, chemical or UVR exposure -excluding sunburns, most burns= from flames, hot liquids/objects or inhalation of smoke/hot vapors -Thermal Burns: smoke inhalations produces extensive lung dmg b/c toxic particles -if smoke or heated gas inhalation has occurred> ER -children/elderly=at risk of fire injuries -Chemical Burns: result from skin contact w/ acids/bases in household pdts/workplace> ER -Photoallergy= very rare, usually from topical agents and results in intense eczematous dermatitis that may evolve into thickened leathery changes in the skin -phototoxicity (photosensitivity) includes redness that resembles a sunburn, which desquamates (peeling of skin) w/in several days; edema, vesicles (blisters), and bullae (large blisters) may occure -OTC meds associated w/ phototoxicity: -antihistamines (certirizine, diphenhydramine, etc) -coal tar and dervs: DHS tar gel shampoo -NSAIDS: ibuprogen, naproxen, etc. -sunscreens aminobenzoic acid, benzoic acid esters, benzophenones, cinnamates, homosalate, menthyl anthranilate, oxybenzone -etc (Benzoyl peroxide) -Sunburn= caused by acute overexposure to skin to UV rays -sunburn can be caused from natural sunlight (primarily UVB), tanning beds, UV lamps -Sunburns cause a superficial burn injury, charc. by redness and slight dermal edema -severe sunburn can lead to blistering (partial thickness injury), fever, vomiting, delirium and shock -shock can be caused by heat exposure or hyperpyrexia (extreme fever w/ body temp >= 41.5 deg C or 106.7 deg F) and can lead to death -REFER: -burn to BSA of >2% (palm of your hand) -burns involving eyes, ears, face, hands, feet, or perineum -chemical burns (use first aid measure then seek medical attention) -electrical or inhalation burns -old ppl -pts w/ diabetes or multiple medical disorders (poor healing) -immunocompromised pts -new burn grading system: superficial burns> superficial partial-thickness burn> deep partial-thickness burns> full thickness burns -MEMORIZE: Rule of Nine for BSA: -1 front leg=9%, whole leg= 18% front and back -groin=1% -1 front of arm: 4.5%, whole arm (front+back)=9% -chest/torso=18% -back=18% -face=4.5%, back of head=also 4.5% -baby heads=9% b/c bigger heads -Non-pharm: stop the burning process> cool the burn> provide pain relief and cover the burn -active cooling delays progression of the burn and inc healing if performed w/in 20mins of injury (tap 10-15mins) -oral analgesics and NSAIDS=relieve pain -Product Selection: -Ointments= helps keep skin from drying -but if skin is broken= no ointment b/c impermeability -the presence of excessive moisture may promote bacterial growth or maceration of the skin, thereby delaying healing -Creams= creams are emulsions that allow some fluid to pass through the film and are best for BROKEN skin -Lotions: lotions spread easily and are easier to apply when the burn area is large -but lotions that produce a powdery cover shouldn't be used on a burn b/c they dry the area and are difficult to remove, and provide a medium for bacterial growth under the caked particles -Aerosols= costly but offers adv of not touching injured area -proper app reqs holding it approx 6-12 inches from burn and spraying for 1-3 secs -1. Skin Protectants= First Line, intact skin= protect it to encourage healing=oily based ointment (or cream but ointment better) -skin protectants make wound area less painful and protect wound from mechanical irritation caused by friction -rehydration of stratum corneum helps relieve irritation and permits normal healing to continue -Apply as often as needed, but if no improvement after 7 days/worsens > PCP -open wounds= use triple antibiotic -2. Topical Anesthetics= don't put on broken wounds/skin, lots of pain, intact skin only -relief is short-lived, only 15-45mins -higher concs of topical anesthetic appropriate for burns where skin=intact -lower concs are preferred when skin is not intact b/c enhanced abs -apply to small area only to avoid systemic toxicity -Topical Anesthetics: -benzocaine produces a hypersensitvity rxn in 1% pts> but free of systemic toxicity -systemic abs of lidocaine can lead to a number of side fx, but rare systemic toxicity if used on intact skin, localized area, and short period -3. Topical Hydrocortisone= dec redness/irritation -Hydrocortisone 1% is not FDA approved for txt of minor burns but sometimes used in txt of minor burns covering small area (size of quarter)= but not really rec> use other pdts -hydrocortisone=anti-inflammatory> caution when broken skin b/c infections -4. Antimicrobials= only if skin=broken to prevent infection -for minor burns, non-rx first-aid antibiotic or antiseptic pdts are of limited value esp on burns in which skin is intact -petrolatum based antimicrobials may act as a skin protectant and provide symtomatic relief (i.e. triple antibiotic) -skin cancer=most common type of cancer -2 most common types: 1. Basal Cell Carcinoma (BCC) 2. Squamous Cell Carcinoma (SCC) -UVA Radiation= penetrates deeper into the skin than epidermis (potent af=redness, skin cancer), causing histological and vascular dmg -UVB=causes redness (sunburn radiation, need for Vitamin D3 synthesis) -Risk factors for UVR-induced problems: -fair skin that always burns and never tans -history of one or more serious/blistering sunburns -blonde/red hair, blue,green,gray eyes -freckles -previous growth on skin or lips caused by UV exposure -existence of UV-induced disorder -family history of melanoma -current use of immunosupressive drug -excessive lifetime exposure to UVR, including tanning beds/booths -hx of autoimmune disease -xeroderma pigmentosum (autosomal recessive genetic disorder of DNA repair where ability to repair dmg caused by UV light=deficient) -don't need to know: -SPF 15= 93% UVB radiation> spf 30=96.7%, 40=97%> inc spf to 30 or 40 may req 25% more ingredients= inc side fx, not worth it really -Substantivity= ability to remain effective during prolonged exercising, sweating, or swimming -generally cream based (water in oil) vehicles have more resistance to removal by water than those w/ alcohol bases -Water Resistant: pdt retains SPF for at least 40mins in water -Very water resistant: pdt retains sun protection for at least 80mins in water -KNOW: Types of Sunscreens: -1. Chemical Sunscreens (white sunscreens)= work by absorbing and thus blocking transmission of UVR to the epidermis typically between 290-320nm -2. Physical Sunscreens= black sunscreens, block entire spectrum= generally opaque, and act by reflecting and scattering UVR (not abs it) between 290nm and 777nm -Para-aminobenzoic acid (PABA) and dervs: UVB only, bad= major skin sensitizer= rash -benzophenones like oxybenzone= UVB (extends a bit into UVA range ~350nm), bad: oxybenzone skin sensitizer -Physical sunscreen: Zinc oxide or titanium oxide= UVB and UVA= blocks entire spectrum=good, bad= discolor clothing and they can occlude the skin to produce prickly heat and folliculitis> use on small areas prominently exposed to sun (don't use on entire body, only on face) -Sunscreen Administration: -appy 15-30mins before UV exposure and every 15-30mins thereafter (SPF 30=rec) -face and neck=one half teaspoon -arms and shoulders= one-half teaspoon to each side of body -torso: one half teaspoon to each front and back -legs and top of feet 1 teaspoon to each side of body -stop use if skin rash occurs

Scaly Dermatoses: Dandruff, Seborrheic Dermatitis, Psoriasis

-cause: increased cell turnover> scaling of epidermis -dandruff=2x faster -seborrheic dermatitis= 3x faster -psoriasis=5-6x faster -conditions are chronic (relapsing and remitting)= txt= only symptom control -Dandruff: -often itchy, scalp ONLY, even distribution, spares bald areas -flakes=thin, white or gray, minimal skin inflammation -appears in puberty, peaks in early adulthood and lessens with older age -Seborrheic Dermatitis= often itchy, location= scalp (usually on hairline), face or trunk= patchy distribution -scales=thin, often yellow or oily (like fish scales=dead skin), underlying plaques of red/inflamed skin=chronic -Seborrheic dermatitis in infants= "Cradle Cap" -symptoms= doesn't disturb sleep/feeding, rarely itchy -scalp=most common location hence cradle cap but also possible on face, trunk or diaper areas, patchy -crusts or scales=thin, yellow, oily, w/ underlying plaques of red/inflammed skin= like normal one -usually begins ~3 weeks old and usually resolves before 1 y.o. -Plaque Psoriasis= may be itchy/painful, non-dermatological complications=common like thinning of nails, etc= usually followed by dermatologist -location: scalp, trunk or extremities, extensor surfaces (elbows, knees), symmetrical distribution (usually) -bleeding spots if scales are removed, scales=thick, silvery white w/ red underlying plaque with sharp borders, chronic -don't worry about: -unknown causes for all of them, bacteria for dandruff/seborrheic? dermatitis or immune hyperactivity/inflammation for all of them? -genetics for psoriasis? -Triggers: -dandrugg and seborrheic dermatitis: dry or cold climate, physical/emotional stress -risk factors= HIV/AIDS, parkinson's disease, epilepsy, recent stroke/ HA, depression, eating disorders -psoriasis= dry/cold climate, physicla/emotional stress, skin irritation/injury, infections, alcohol/tobacco use, certain meds (beta blockers, lithium,etc) -risk factor= family history -REFER: -age <2y.o.=see PCP before meds, non-med shampoos=ok tho -worsening/no improvement after 2 weeks of appropriate OTC use -involvement of eyes/inner ear canal -extensive disease (>5% BSA) -BSA=head=10%, 20%=chest/torso, 10% each arm, 20% each leg, and back= 20% -Non-pharm: -Dandruff/seborrheic dermatitis= residue free, non-medicated shampoo/soap, avoid triggers -psoriasis= residue free non med, shampoo/soap, avoid triggers, plus sunlight or UV therapy, emollients, lubricants or warm soaks for dry, cracked skin -OTC txt: 1. Antifungals: kills yeast=1st choice -Pyrithione Zinc -Selenium Sulfide -Ketoconazole 2. Cytostatics=reduce skin cell turnover -Coal Tar= 2nd choice for rebound 3. Keratolytics= soften and break up flakes=rarely used except for patient perference b/c low efficacy -Salicylic acid -Sulfur 4. Corticosteroids=reduce inflammation -Hydrocortisone -Dandruff OTC Txt: -shampoos= preferred pdt form -dose: apply 5 mins 2x-3x/week til symptom control, then decrease to every 1-2 weeks (leave on for 5 mins aka do rest of shower) -1st choice= antifungals (good efficacy, few AEs) -keratolytics= useful in select cases=patient preference -coal tar=useful in rebound cases (significant AEs) Antifungals: -1. Pyrithione Zinc (0.3-2%)=1st choice -good efficacy, but may work slower than selenium sulfide -mild AEs, like skin irritation -there's lots of shampoo formulations like head and shoulders -2. Selenium Sulfide 1%= same good efficacy=FASTER -side fx: may DISCOLOR hair, esp light colors, may cause oily scalp -lots of shampoo formulations -rinse for 5mins to prevent discoloration -do not use w/in 48 hrs of dying/perming -3. Ketoconazole 1%= good efficacy -side fx= HAIR LOSS or abnormal texture, skin irritation or dryness -dose: same as all other shampoos=see dosing list -few shampoo formulations, but has creams/ointments -Coal Tar 0.5-5%=cytostatic -good efficacy -Side fx: skin irritation, photosensitization, dermatitis, may STAIN hair, jewelry or clothes, unpleasant odor and color -available in creams and ointments too -Salicylic Acid 1.8-3%= keratolytic -limited efficacy and SLOW (7-10 days, can take weeks) -high prescription concs=faster but inc AEs -AEs: skin irritation, altered hair appearance -also available in creams/ointments -Sulfur 2-5%= similar to salicylic acid -sometimes combos of sulfur, salicylic acid, and occasionally coal tar -Seborrheic Dermatitis OTC txt: -same options, but dosed more aggressively: -daily for 1st week, then 2-3x/week for 1 month, then weekly -if on scalp/hairy areas= shampoo preferred, if on skin of face and body=ointment/cream -hydrocortisone= preferred for acute exacerbations -Hydrocortisone 0.5-1%= reduces itch, redness, and inflammation -side fx= infection (don't put on broken skin, mucus membranes), skin injury (prolonged use esp on face) -dose= 2x/3x /day until improvement, max 7 days, then PRN only -ointment=more potent than cream -Cradle Cap=emphasize non-pharm txt, refer if severe/no response after 2 weeks -frequent shampooing w/ non-med shampoo -emollients (petrolatum, vegetable oil, mineral oil, baby oil) to soften and loosen scales, may apply and leave overnight -gentle brushing to remove scales -Psoriasis OTC txt: -only mild cases (<5%)=OTC -product selection deps on disease phase: -chronic phase (gray scales)= coal tar, salicylic acid -acute phase (red flares)=hydrocortisone -antifungals=not useful (unless chronic, mild cases of scalp) -Coal Tar for psoriasis= may help dec scale formation -side fx= skin irritation, dermatitis, photosensitization, exacerbates acute psoriasis flares (use hydrocortisone) -dosing: usually applied overnight, washed off in the morning, can stain bedsheets -Salicylic Acid for psoriasis= may help w/ softening and loosening of scales -AEs: skin irritation, Avoid application over very large areas to prevent systemic absorption -dosing= usual onset= 7 days (higher concs= fast onset but inc AEs) -hydrocortisone for psoriasis= may help dec inflammation, redness, itch= most potent form usually req i.e. 1% ointment= can inc potency by using occulsive dressing or covering area with petrolatum 30mins after hydrocortisone -psoriatic arthritis= >30% of patients= joint pain or soreness= refer -nail pitting, ridging or color change=refer -depression/suicidality=refer -Administration Technique: Shampoo: 1. Rinse and wash hair and scalp w/ non-med residue-free shampoo to remove oil and dirt 2. Apply medicated shampoo, massage into scalp 3. leave in for 5-10mins (contact time=key) 4. rinse off thoroughly (prevents staining) 5. Avoid eyes, mucus membranes or broken skin -Skin pdts: 1. gently cleanse area 2. apply product sparingly (only enough to cover) 3. do not wash off afterwards 4. avoid eyes,mucous membranes, or broken skin -dosing= initial therapy=frequent and short term til symptom control or refer -maintence therapy=intermittent and long term to maintain remission

Oral Health

-dental caries=most common pathologic condition in childhood -enamel= hard pt to chew -dentin= right below enamel, when exposed to outside of gum line=hypersensitivity -pulp=nerve endings -Plaque: complex microbial community which adheres to tooth surface, readily removed by brushing/flossing> microbes causes caries/periodontal disease b/c their acids cause tooth breakdown -Calculus (tartar)= hardened deposit d/t calcium salts in saliva; removable only by professional=helps bacteria stick to it -Cause/pathophys: Plaque bacteria generate acid> acid demineralizes tooth enamel and dentin> dental plaque attracts more bacteria, promoting decay -Sx: enamel= no symptoms> Dentin: tooth pain and sensitivity> pulp: pain> systemic: inflammation and pus formation -Risk factors for Caries: -poor oral hygiene -diet -xerostomia (dry mouth) -hereditary -gum tissue recession -limited access to dental care -orthodontic appliances -tobacco -medications and medical disorders (Anticholinergic meds, diabetes) -radiation therapy to head/neck -baby bottle tooth decay= infant/child's bottle is left too long, substances like juices= too long in baby's mouth/teeth= decay -Prevention: key to preventing caries is to control dental plaque -Nonpharm: dietary measures, plaque removal devices: toothbrushes, dental floss, oral irrigators -pharm: fluoride, dentrifrices (toothpastes), mouth rinses -nonpharm: -Dietary measures: -inc foods w/ high water content -inc fibrous foods -inc fluids -inc saliva pdtion (chew sugar-free gum) -dec highly cariogenic foods (contains >15% sugar, clings to teeth, remains in mouth after chewing) -dec acidic foods/beverages -Plaque Removal Devices (prevents plaque/tartar formation) -Toothbrush: no standardization of brush firmness (soft bristles=less likely to cause dmg) -keep dry -choose brush w/ ADA seal of acceptance -replace about every 3 months or when brush shows wear or when sick> worn out toothbrush may actually injure gums -manual vs electric -brush teeth after each meal or at least 2x/day -if using toothpaste, apply a small amt of paste to toothbrush -use gentle scrubbing motion w/ bristle tips at a 45 def angle vs the gum line so that the tips of the brush do the cleaning -do not use excessive force b/c may result in bristle dmg, cervical abrasion, irritation of delicate gingival tissue, and gingival recession associated w/ hypersensitivity -brush for at least 2 mins, cleaning all tooth surface systematically -gently brush the upper surface of the tongue to reduce debris, plaque, and bacteria that can cause oral hygiene problems -rinse month, spit out all the water -Floss: if you fail to floss, 35% of tooth surface remains uncleaned -no pdts proven superior to one another: waxed vs unwaxed, tape vs threaded, w.e. -consider: manual dexterity, old ppl, tightness of teeth -choose ADA seal of acceptance -tongue scraper: cleans tongue papillae to prevent halitosis -oral irrigators: high pressure stream of water, not a subs for toothbrush, floss -How to Floss: pull out approx 18inch of floss and wrap most of it around middle finger -wrap the remaining floss around the same finger of opp hand> approx an inch of floss should be held between thumbs/forefingers -do not "snap" the floss down between the teeth; instead, use a gentle, sawing motion to guide the floss to the gum line -when the gum line is reached, curve the floss into a C shape vs one tooth and gently slide the floss into the space between the gum and the tooth until u feel resistance -hold the floss tightly vs the tooth, and gently scrape the side of the tooth w/ an up and down motion -curve the floss around the adjoining tooth and repeat the procedure -use a new section of floss for each tooth surface to avoid transfer of plaque and bacteria to other teeth -Proper Oral Hygiene: -brush w/ toothpaste (after each meal or at least 2x/day) -floss at least 1x/day -proper selection and timely replacement of toothbrushes -use tongue scrapers -visit dentist at a min 2x/year -Pharm: -Dentirice= toothpaste: enhances removal of dental plaque and stains -dec incidence of dental caries and gum disease -reduces mouth odors -enhances personal appearance -commonly contain: abrasive, surfactant, humectants, binder, sweetener, flavoring, therapeutic ingredient -abrasive (silica, calcium/aluminum salts) essential in cleaning teeth -surfactant (sodium lauryl sulfate) causes foaming -sweetener (saccharin) -available as powders, pastes, and gels -Therapeutic ingredients: -Fluoride: prevents AND treats carious lesions: facilitates remineralization of early caries, may interfere w/ bacterial process (dec plaque adherence and/or inhibit glycolysis) -Triclosan> antigingivitis/antibacterial> still in some toothpastes altho FDA banned them in 2016 in antiseptic hand/body wash -potassium nitrate= sensitive teeth -titanium dioxide, hydrogen peroxide> antistain, whitening: plain baking soda also effective at stain removal -Fluoride: indicated for both prevention and treating carious lesions, maintain overall oral health -topical effects facilitates remineralization of early carious lesions -3 forms effective for anticaries/anticavity effect: sodium fluoride, sodium monofluorophosphate, stannous fluoride> this one may cause slight tooth discoloration, not perm -Mouth Rinses: adjunct to proper flossing and brushing: -Fluoridated mouthwashes (0.05% sodium fluoride daily or 0.2% weekly)> effective anticaries agents> use after brushing and DO NOT SWALLOW, nothing PO for 30mins after use> not rec for kids <6y.o. or those w/ difficulty rinsing -Gels (stannous fluoride 0.4%)> use after brushing, daily at night, brush 1 min, swish before expectorating, do not rinse, available via dental professional -Other Ingredients in Mouth Rinses: -Antigingivitis/Antiplaque effects: -aromatic oils (eucalyptol, menthol, methyl salicylate, thymol> ex: Listerine)> antibacterial, local anesthetic effect -quaternary ammonium compounds (cetylpyridinium> ex: Crest Pro Health)> antimicrobial -Phenol oils, methyl salicyclate and alcohol: sloughing of the oral epithelium may occur, burning sensation, disulfiram rxn/alcool disorders=caution -demulcents (sorbitol, glycerin) -caution: children <12 y.o. b/c don't swallow, poison control center if do - <3 y.o.=begin brushing teeth as soon as they come into mouth w/ fluoride toothpaste: grain of rice toothpaste b/c they're going to swallow it= too much fluoride changes teeth growth - 3-6 y.o.= peasize -do not use high fluoride conc toothpaste in children <6 y.o. -children need supervision brushing til age 8-9 y.o. b/c proper technique/habits -Periodontal Disease: main cause of tooth loss; inflammation of supporting structures of the teeth> associated w/ hygiene status, not w/ age -Types of Periodontal Disease: 1. Gingivitis (mildest form, early stages): common, reversible, inflammation of gingiva w/o loss of epithelial attachment to the tooth 2. Periodontitis (involves bone loss): significant, irreverisble> periodontal ligament attachment and bone support of tooth have been compromised/lost -Risk factors: hereditary, poor hygiene, hormonal changes, immune system disturbances (AIDS), meds, tobacco -sx: red, swollen or puffy gums -gums that bleed easily esp when brushing -unpleasant taste in mouth and halitosis -gum recession -loosening of teeth -drifting of teeth to create spaces or protrusion -TXT REFER if notice any gingivitis: oral hygiene improvement (same measures as prevention of caries) -debridement (removal of foreign stuff from wound) -scaling and root planning by dentist -chlorhexidine gluconate rinse -gum surgery -Gingivitis and Pregnancy= pregnant patients more susceptible to dental caries and gingivitis -local factors + varying hormone lvls that make gingival tissue sensitive to plaque -prevented/resolved w/ adequate plaque control -susceptibility dec postpartum, returns to pre-pregnancy lvls after about 1 year Oral Pain Disorders: 1. Tooth Hypersensitivity: causes: gum recession exposing sensitive portions of teeth (i.e. exposed dentin/dental erosion) -extrinsic acid (acidic foods/drink, fruit juices/soda, wine, sour candy -intrinsic acid= GERD, vomiting (pregnancy, bulimia, alcoholism) -Xerostomia (dry mouth) -incorrect tooth brushing -occupation -teeth clenching (results in referred pain) -dental work (can be temp) -dmg to pulp/tooth -infection (gum, bone) -sx: pain from hot, cold, sweet, or sour solns -ind. pain thresholds vary: mild discomfort> sharp, excruciating pain> self-treatable if d/t abrasion or erosion -REFER: toothache, fracture, faulty restoration, gingival recession -Management of Tooth hypersensitivity: -identify and eliminate predisposing factors: extrinsic/intrinsic acid exposure, improper brushing -brush and floss carefully and completely -do not brush w/in 30-60mins after consuming acidic foods/drinks b/c brushes acid into teeth and takes off further enamel -avoid whitening or stain removal toothpastes -ice may provide temp relief -toothpaste for sensitive teeth= contains Potassium Nitrate 5%= use for 2-4 weeks to relive symptoms, can use long term prn -referral to dentist if no relief after 2-3 weeks -REFER: -toothache -mouth soreness associated w/ poor-fitting dentures -presence of fever or swelling -loose teeth -bleeding gums w/o trauma -broken teeth -severe tooth pain -trauma to mouth -Eruption Cysts: infants primary teeth come in: -bluish, soft, and round swellings over emerging incisors and molars during teething process -not the result of infection> no txt needed> resolves spontaneously -Nonpharm: massaging gum, cold teething rings, AVOID OTC topical meds (i.e. benzocaine) b/c risks outweigh benefits -Recurrent Aphthous Stomatitis (RAS) aka Canker sores or Aphthous ulcers: -onset peaks at 10-19 y.o. -not contagious> can't be cured, self-resolved -causes: unknown, stress, local trauma, infectious, nutritional deficiency, systemic conditions (HIV) -Nonpharm for RAS: -Diet: avoid spicy foods, acidic foods, sharp-textured foods, correct nutritonal defiency -Ice: applied directly to lesions in 10 min increments (DO NOT use heat b.c can spread bacteria if present) -stress removal, relaxation -Pharm txt: systemic analgesics for pain -oral debriding and wound cleansing agents (carbamide peroxide, hydrogen peroxide, sodium perborate monohydrate, sodium bicarbonate)> ex: Cankaid, Orajel Antiseptic Rinse: apply after meals to AA up to 4x/day -topical oral anesthetics (benzocaine, benzyl alcohol,etc)> ex: Orajel, Anbesol> apply up to 4x/day -oral protectants: coat and protect ulcerated area by creating a barrier> apply/use prn -Oral rinses: can hasten healing process> saline rinses, baking soda paste -Refer if no improvement after 7 days of OTC txt or worsens -Herpes Simplex Labialis (HSL) aka cold sores or fever blister: -Primary Herpes: the INITIAL infection by the virus= usually occurs in childhood, virus remains in latent state -Herpes Labialis: RECURRENT herpes simplex: reactivated on exposure to triggering stimulus, mainly occurs on the lips -caused by HSV-1= contagious, w/in 1-2 weeks after contact (direct or indirect) -presentation: lesions (red, fluid containing vesicles 1-3mm in diameter) on lips, nose, intraorally -burning, itching, tingling and numbness -usually resolves in 10-14 days -recurrance: usually milder, unpredicatable: often in same location -triggers: menstruation, sun exposure, illness w/ fever, stress, immunosuppression, fatigue -nonpharm: keep clean, hand washing, keep moist, avoid triggers -Pharm txt: -duration and severity reduction (by about 1 day sooner but expensive): docosanol 10% (Abreva cream)= Dose: AAA 5x/day ASAP sx (ex: tingling), apply til lesion healed, NTE 10 days -relief of discomfort only: systemic analgesics or topical anesthetics (ex: benzocaine 5-20%, benzyl alcohol 10% topical gel (zilactin) -secondary bacterial infections=triple antibiotic -topical steroids are contraindicated -refer if >14 days -REFER: -lesions present >14 days -inc freq of outbreaks -compromised immunity -sx of infection (fever, rash, swollen glands) -no previous diagnosis of cold sore -Halitosis: -pathophys: may be related to systemic and oral conditions - volatile sulfur compounds d/t breakdown food debris, food (garlic, onions, alcohol) -medical: sinus infection, ulcers -dental= gum disease, xerostomia (meds, trauma, radiation), oral cancers, dentures -smoking -prevention: good oral hygeine, txt underlying disorders, zinc salts, chlorine dioxide pdts (Oxyfresh, ClosSys) -Denture Stomatitis: inflammation of the oral tissue in contact w/ removable denture d/t failure of removing dentures at bedtime and not cleaning reg> can lead to chronic candidiasis -denture cleaners: clean thoroughly at least 1x/day -combo regimen=ideal: brushing dentures w/ an abrasive cleaner AND soaking dentures in a chemical cleanser -Denture cleansers: alkaline peroxide, hypochlorite bleaches, dilute acids -Xerostomia (dry mouth): salivary flow is limited/stopped -cause: meds (antidepressants, antihistamines, etc), radiation therapy, nerve dmg, nonpharm causes: alcohol, tobacco, caffeine, etc, breathing through mouth, medical disorders (chron's, diabetes, Sjogren syndrome, etc) -can inc dental caries and gingivitis -cause of halitosis -can predispose oral cavity to candidiasis (thrush), hypersensitivy -can impair speech, swallowing, ability to taste foods -Nonpharm: sip water, sugar free candies, consider change in drug therapy, avoid substance that reduce saliva (tobacco, alcohol) -Pharm: artificial saliva: biotene rinse, salivart spray, entertainer's secret spray, xylitol pdts (ex: Spry), topical fluoride -refer: if conditions worsens/complications

Asthma

-dyspnea= difficulty/labored breathing -atopy= genetic tendency to develop allergic diseases like asthma/eczema/allergies= me :/ -risks= family history, concurrent atopy (inc pdtion of immunoglobulin E (IgE) after allergen exposure -smoking/2nd hand smoke -higher BMI -severe viral respiratory infections during first 3 years of life -Pathophysiology= 1. exposure to allergen> allergen binds to IgE> IgE binds to receptor on Mast cell> mast cell secretes histamine, leukotrienes, chemokines, inflammatory mediators that attract other inflammatory cells> results in broncoconstriction -hyperreactivity=exaggerated response of bronchial smooth muscle to trigger stimuli of airways to physical, chemical, immunologic, and pharmacologic= char. of asthma> basically smooth muscle in airways= broncoconstrict b/c hyperreactive to allergens -if you don't minimize inflammation of airways> airway remodeling where the structural changes obstructing airflow= permanent ish (only partially reversible) -symptoms= intermittent episodes of wheezing, coughing, and dyspnea(hard to breathe)> esp at night/morning -chest tightness/chronic cough -childhood asthma=associated w/ atopy (genetic predisposition for the development of immmunoglobin E (IgE) mediated response to common allergens)= strongest predisposing factor in dev asthma -FEV= measures lung working -PEFR= Peak Expiratory Flow Rate via Peak Flow Meters= hand-held device used to monitor a person's ability to breath out air= home monitoring, Rx/OTC, cheap, PEF= peak expiratory flow= max flow at the outset of forced expiration> compare within themselves -Spirometry= device to measure volume of air INSPIRED and EXPIRED by the lungs (tidal volume)> in dr's office (usually specialized for asthma)> provides FEV1 (forced expiratory volume at 1 sec, expressed as percentage of total vol of air exhaled in 1 sec) and FVC (forced vital capacity= max vol of air exhaled w/ maximal force effort) too> needed to confirm lung function abnormality -FEV1 %= FEV1/FVC -healthy ppl=at least 75%-80% of FVC Asthma Action Plan= uses PEF monitoring for patients to monitor asthma at home= written doc w/ specific instructions based on objective findings="zone scheme"=red,greeb,yellow= ids if txt is working/potential deterioration -green=80-100% of normal peak flow, can do all usual activities -yellow=50-79%= getting worse= cough, wheeze, chest tightness or SOB> add quick relief medication -red= less than 50%= quick relief meds don't help, can't do usual activities, symptoms no better after 24 hrs in yellow zone> get medical help NOW -Asthma exacerbation= acute episode of worsening of symptoms> usual w/ tachypnea (rapid breathing), tachycardia, use of accessory muscles, prolonged expiration, can't talk Controlled Asthma: -symptoms= SOB, wheezing, cough= <=2 days/week, night time awakening= <=2x/month, SABA (short acting beta adrenergic)= <=2x/week, FEV1 or peak flow meter= >80%, exacerbation req oral steroids= 0-1x/year OTC Treatment: (limited) -Current symptoms= mild, intermittent (less than 2x/week) and of short duration (<24hrs) OR a prior diagnosis of intermittent asthma by PCP AND person knows warning symptoms inidicating need for urgent medical care AND they don't have other serious concurrent diseases that impair breathing (COPD/CAD) AND the person is >= 4 yrs for nebulize txt or >12 y.o. for oral and not pregnant AND current asthma symptoms=consistent w/ previous symptoms AND the nonrx meds are for SHORT-term (<24hrs) txt of mild symptoms until they can see a PCP -Exclusions for Self-txt: -no previous dignosis of asthma, concurrent condition whose symptoms can be similar to asthma (COPD, Heart failure, vocal cord dysfunction_, history of asthma episodes severe enough to require systemic corticosteroids or urgent medical care, use of (or non adherent to) other long therm rx meds for asthma, no asthma care provider/no visit in last year, pregnant or <4 y.o. for neb, <12 y.o. for oral, rx meds preceived as ineffective, symptoms of moderate/great severity or >2x/week, >24 hrs symptoms or unresponsive to OTC meds, symptoms of diff quality/severity than previous episodes, signs of respiratory/sinus infection -Nonpharm txt: identify triggers, reduce exposure/eliminate triggers, reduce/eliminate tobacco smoke, ensure vaccinations are up to date (influenza, pneumococcal) -OTC pdts: racepinephrine nebulizer soln, ephedrine/guaifenesin, epinephrine metered-dose inhaler -epinephrine (aka adrenaline)= group of monoamines called catecholamine= binds to beta-2 adrenergic receptors> bronchodilation 1. Racepinephrine=for ppl >4y.o., pour 0.5mL (1 vial) into nebulizer reservoir> give 1-3 inhalations from nebulizer, no more than every 3 hrs, NTE 12 inhalations/24hrs -seek medical advice if breathing doesn't improve w/in 20 mins/worsens, patient uses >9 inhalation in 24 hrs or >3 days/week or has >2 asthma attacks w/in 1 week -side fc= tachycardia, arrhythmia, nervousness -do not use w/ MOAi or 2 weeks after stopping MAOi s -contraindications= pregnancy, cardiac arrhythmias, coronary insufficiency, poorly controlled HTN, seizures, hypokalemia, angina, hyperglycemia, and uncontrolled hyperthyroidism -do not use if brown/cloudy -ephedrine= sympathomimetic amine similar to amphetamine= also B2RA and mimics actions of catecholamines 1. Ephedrine/Guafenesin combo pdt= broncodilator and expectorant -look at dosing list: all no <12 y.o. 1. Bronkaid= 25mg ephedrine, guaifenesin, 1T PO Q4hrs prn, NTE 6tabs/day 2. Primatene Tablets= 12.5 ephedrine/ 200mg guaifenesin> 1-2 tabs Q4hrs pwn, NTE 12 tabs/day 3. Mini-two way action tablets= same dosing/qty (12.5/200mg) as primatene or 25mg/200mg= 1/2-1 tablet Q4hrs prn, NTE 6 tabs/24 hrs -Ephedrine Side effects= palpitations, tachycardia, arrthymias, (inc HR) seizures, hypokalemia (dec potassium), angina, hyperglycemia (inc sugar), hypotension, hypertension (both inc/dec BP) -Guaifeneside side fx= nephrolithiasis (kidney stones) -Epinephrine Inhaler aka Primatene Mist= MDI (metered dose inhaler), no <12 y.o., mild, intermittent asthma only (not replacement for rx meds)= 1Puff PO, may repeat x1 after 1min (do not repeat for 3-4 hrs) -see PCP if never been diagnosed w/ asthma, not better in 20mins/gets worse, need >8 inhalations/24 hrs, >2 asthma attacks in a week -adverse rxns= hyperactivity, restlessness, exitability, palpitations, headache, upper resp irritation, pharyngeal dryness

Acne

-super common; mostly on face; back, best, shoulders, arms, neck -adult onset rising in females >25 y.o. -cause unknown, genetics, inc androgens like puberty, pregnancy -foods like sweets, dairy, high carbs can worsen acne (oily, not really) -Risk/Worsening Factors: -Environmental: high humidity, dirt, oil, chemicals, chlorine -hormonal: puberty, ovulation and pregnancy, oral contraceptives (not on exam: deps on generation: 1st/2nd gen progesterone=inc androgens, inc acne) -acne mechanica (something rubbing on your face) -extreme emotion and stress -drug-induced= KNOW: "PIMPLES" -Phenytoin, Isoniazid (TB med), Moisturizers (acne cosmetica, thick, occlusive), Phenobarbital, Lithium, Ethionamide, Steroids (androgens, OC, corticosteroids) -Pathophys: 1. Sebum (oily mat. that protects/ moisturizers skin) production by sebaceous gland> overgrowth of sebum b/c puberty 2. Propionibacterium acnes (gram pos anaerobic rod) follicular colonization 3. Alteration in the keratinization process 4. Releases inflammatory mediators in skin -hair follicle blocked b/c sebum and bacteria= open comedo (blackhead, melanin exposed to air) or closed comedo (whitehead) -blackheads (open)=pore partially blocked, sebum, bacteria and dead cells slowly drain to surface, often takes long time to clear -whiteheads (closed= pore completely blocked, traps sebum, bacteria, dead cells, normally quicker life cycle than blackheads -papules=inflammed, red, tender bumps -pustules=inflammed red circle w/ pus -Not on exam: -nodules= large, hard bumps under skin, can be quite painful, lasting months, scarring=common and if unresolved can leave an impactation which can flare -cysts= appear similar to nodule but pus-filled> painful, scarring=common -scars -residual hyperpigmentation -Know: Grading and Classification of Acne: -can only treat Mild Acne, rest=refer -Mild: Few erythematous papules and occasional pustules mixed w/ comedones -Moderate=many erythematous papules and pustules and prominent scarring -Severe= extensive pustules, erythematous papules and multiple nodules in an inflammed background -REFER: -moderate-severe acne -exacerbating factors: Comedogenic drugs (PIMPLES), acne mechanica (mechanical irritation) -possible rosacea (huge redness) -Non-pharm therapy: -gently wash AA 2x/day thoroughly, pat try -warm water and non-oily medicated/non-med soap (bar soaps=drying, but ok for oily skin, hot water=inc inflammation and drys out) -no washcloths or abrasive/harsh pdts -use cleansing pads if unable to wash w/ soap/water -wash after a meal to remove oil around mouth -facial toners may dec oily skin and remove makeup and dirt but overuse=inc irritation -consider dietary changes by eliminating/cutting back on high glycemic index foods -stay hydrated -Physical txts: (limited evidence to rec these but use w/ traditional pharm txt): scrubs, cleansing clothes, cosmetic adhesive pads, brushes, heating devices, light therapy (Neutrogena Light Therapy Acne Mask), professional comedo extraction -Pharm txt: Benzoyl Peroxide (BP), adapalene gel (Differin), other= hydroxy acids, sulfur, sulfur/resorcinol -Benzoyl Peroxide=1st line, can use forever, is an oxidizer that will inactivate retenoid -most common topical antibiotic pdt (OTC/Rx) -keratolytic (exfoliant), comedolytic (kills acne), and antibacterial properties -prevents/eliminates txt resistance by P. acnes -use in combo w/ oral or topical antibiotics (rx) -AVOID co-administration w/ retinoids if possible (like adapoline) -2.5-10% strengths in variety of formulations= start w/ 2.5-5% (high concs=inc ADRs) -BP Counseling: -test new pdts x3 days on 2-3 small AAs -gently wash AA thoroughly w/ warm water and non-oily soap -wait 15-20mins after washing to apply -apply thin layer over entire AA (not just lesions) -ADRs: drying, peeling, redness, burning during first days, subsides w/in 1-2 weeks, will get worse before gets better -rare but serious allergic reactions include hypersensitivity and anaphylaxis (FDA) -stops bacterial growth involved in acne, unclogs pores by mild peeling effect -do not use if you have very sensitive skin or are sensitive to BP -avoid eyes, lips, mouth, nose, cuts, scraps and abrasions -continue txt regimen even after lesions have cleared -avoid contact w/ clothes or hair (b/c bleaching) -avoid excessive sun and use sunscreen >15 SPF (wait 10-15mins before applying) -alcohol-based after-shave may worsen stinging -slight improvement in a few days, max effect takes 8-12 weeks (2-3months) -separate if also using retinoid -2. Adapalene (Differin gel 0.1%=OTC)= don't use forever: -1st line topical drug for acne and 1st OTC retinoid= equally effective as BP -MOA: vitamin A derivative that controls cellular change, overgrowth of keratinocytes, and inflammation= no antibacterial props tho - >12 y.o. -apply once daily at bedtime to AA -ADE: redness, scaling, dryness, itching, burning (usually diminish after 1st month of therapy) -acne may WORSEN during first weeks; full effect seen w/ 8-12 weeks of therapy (2-3months) -lack of data in pregnancy -do not use on damaged skin -must apply sunscreen while using -3. Hydroxy Acids: (Alpha hydroxy acids=more water soluble, for exfoliants, beta hydroxy acids=gets into skin better=salicylic acid) -less potent, use when cannot tolerate other pdts -moderately effective for acne -keratolytic agrents -AHAs (4-10%): -natural exfoliating acids in sugar cane, milk, fruits -most common: glycolic acid, lactic acid, citric acids -unable to penetrate pilosebaceous unit (NOT comedolytic/for pus) -light chemical peel once acne is controlled may help w/ scarring and hyperpigmentation -dosed once every 15 days for 4-6 months -polyhydroxy acids= fewer adverse effects such as irritation/stinging -marketed for clinical sensitivity -moisturizing/humectant props -Glycolic Acid (AHA) Contraindications: -active infection or open wounds (herpes simplex, excoriations, open acne cysts) -for medium/deep peels: medium or deep resurfacing procedure in last 3-12 months, recent facial surgery involving extensive undermining -history of abnormal scar formation or delayed wound healing -history of rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis vitiliago, active retinoid dermatitis -history of therapeutic radiation exposure -isotretinoin therapy w/in last 6 months -lack of physchological stability and mental preparedness -poor general health and nutritional status -unrealistic expectations -BHAs: salicylic acid 0.5-2%: -comedolytic d/t lipid solubility (conc-dep) -milder, less effective alt to rx pdts -considered adjunctive treatment in cleansing preps -prevents/potentially reverses wrinkles d/t aging and sun but must wear broad-spectrum sunscreen, spf >15 -phytohormone chemically like Aspirin active ingredient -limit use to AA (toxic on large areas for long periods) -potentially life-threatening hypersensitivity rxns (FDA) -contraindications: diabetic pts, poor blood circulation -Salicylic acid important DDIs: -Anticoagulants (Warfarin): inc anticoagulation/bleeding -anti-diabetic agents: incs activity of glyburide (hypoglycemia) -aspirin: inc anticoagulation and serum K+ -corticosteroids: prednisone may inc renal clearance; inc risk of GI ulceration -diuretics: inc effect of salicylates -methotrexate: inc serum lvl of methotrexate -heparin: dec platelet adhesiveness and interferes w/ hemostasis -Salicylic Acid Counseling: -unclogs pores via slight peeling -less effective than BP -use 1x-3x daily; if excessive peeling occurs, use once daily or every other day -gel formulations should be applied only to AA -may cause sun sensitivity, so use sunscreen -4. Sulfur 3%-10%: rarely use anymore -keratolytic and antibacterial -promotes resolution of existing comedones but.. can also have comedogenic effect w/ continued use (can worsen acne) -usually combined w/ other pdts -apply thin film 3x/day -side effects are rare (b/c not very effective)= noticeable odor, dry skin -sulfur combos: -sulfur 3%-8% + resorcinol 2% or sulfur 3%-8% + resorcinol monoacetate 3% -resorcinol enhances effect of sulfur, ineffective alone -kertatolytic, fosters cell turnover, and desquamation, and antibacterial and antifungal effects w/ sulfur -reversible, dark brown scales on darker-skinned patients Sulfur Counseling: (last line pdt): -believed to work by inhibiting bacterial growth -apply 1x-3x daily but use is limited by chalky yellow color and unpleasant odor -use is mostly adjunctive, not as effective as BP -do not use in patients w/ allergy to sulfa drugs -Selecting a Product: -products available in variety of vehicles and strengths -gels=most effective and remain on skin longest= b/c alcohol based= potent and drying -gels and solutions are drying (cause contact dermatitis) -creams and lotions are less irritating to skin >for dry or sensitive skin and use in dry winter weather -ointments should not be used!! b/c thick, will worsen acne -start w/ lowest conc and gradually inc -special populations: -pregnancy may cause/worsen acne d/t hormonal changes: -if pregnancy occurs during any treatment, d/c and discuss w/ OB/GYN -little if any data exist for topical BP, sulfur, hydroxy acids, and photodynamic therapy during pregnancy -pediatrics: most infantile and neonatal (age 2-4weeks old) acne is self-limited and usually d/t maternal androgens -salicylic acid is contraindicated (risk of Reye's) -Complementar y Therapy: -Tea tree oil: antibacterial, antifungal, anti-inflammatory props, effective at reducing lesion counts, no robust studies -oral zinc= alt to tertracycline antibiotics, bacteriostatic vs P. acnes, inhibits chemotaxis, and effective vs severe acne, NVD tho=poor adherence -Vitamin A = metabolite (retinoic acid) eliminates wrinkles/fine lines -doses up to 300,000 Units/day for women and up to 500,000 Units/day for men may help acne but few studies to validate b/c too much vitamin A=toxic af -xerosis and cheilitis -Nicotinamide= active form of niacin w/ anti-inflammatory propriety to improve texture of photoaged skin and dec sebum pdtion, data=limited -Counseling: -stay well-hydrated -avoid/reduce exposure to environmental factors -do not wear tight-fitting clothes, headbands, or helmets -avoid resting chin on your hand -do not use-oil-based cosmetics and shampoos -practice stress management techniques -do not pick or squeeze pimples -acne cannot be cured, but can be controlled -full efficacy to be assessed after 6 weeks (6 months w/ diet changes) -diligence and adherence is req -if you exp tightness in throat, breathing problems, feeling faint, or swelling of the eyes, face, tongue, lips w/ BP/salicylic acid, seek ER

Foot Disorders and Warts

Corns and Calluses: lesions disappears w/ friction/pressure stopping -Corns "Clavus"= small, raised, sharply demarcated hyperkeratotic lesion with CENTRAL CORE (vs wart=no central core); think: Core for Corns=pain -due to pressure from underlying bony prominences/joints -yellowish-gray and well circumscribed, diameter <=1cm, base is on skin surface, apex pts inward and presses on nerve endings, causing pain -cause= inappropriate, tight-fitting shoes -types of Corns: Heloma durum (think; hard, dry)= polished, shiny, dry hard corns, most common, on bulb of big toe, 4th/5th toe or tips of middle toe -Heloma molle= Soft corns w/ whitish thickenings of skin, super painful, grows BETWEEN TOES d/t sweat -Calluses= broad base w/ skin thickening -on joints/weight-bearing areas on hands/feet (heel, ball of foot, toes, sides of foot) -indefinite borders, raised/yellow w/ normal ridges -causes= friction (loose/tight-fitting), walking barefoot, structural bio-mechanical problems -Exclusions for Self-care: -diabetes, Peripheral vascular disease (PVD, circulatory issue>refer), lesions hemorrhaging or oozing purulent (Pus) material, anatomic defect/fault in body weight distribution, extensive/painful debilitating corns/calluses, proper but unsuccessful self-tx, Rheumatoid arthritis (RA) and complaint of painful metatarsal heads/deviation of great toe -Treatment: -prevention= eliminate pressure/friction, select properly-fitted footwear -Non-pharm: daily soaking for 5 mins in warm water -gentle debridement w/ callus file or pumice stone -use of barriers for footwear= circular goam/gel cushion pads (gel preferred), silicone toe sleeves filled w/ mineral oil for corns, foam spacer/lamb's wool for soft corns, pad or lamb's wool for painful callus -How to Select Properly-fitted footwear= better to be bigger than small -measure feet every 2 yrs -det. shoe length by longest toe of longest foot -distance between shoe tip and longest toe= 1/2 in (1 in in athletic shoes) -for arch length, 1st metatarsal head should fit metatarsal shoe break -for width, should be comfortable at 1st metatarsal joint (not cramped) -once size is determined, choose a shoe shaped to match foot shape -if toe abnormalities= use orthotics/padding, select toe box w/ adequate depths/width to prevent friction -ensure heel fits snugly/holds foot straight -if physically active, ensure midsole provides cushioning/support -try both shoes, wearing socks usually worn, if feet tend to swell, select shoes at end of day -Pharmacologic Txt: salicylic acid for corns/calluses: -12%-17.6% in collodion vehicle (solvent) -12-40% in plaster vehicle (disks/pads) -MOA= dec skin cell adhesion, inc water binding to soften skin -adverse fx: redness, irritation, may be hazardous in pregnancy -no breastfeeding (Reye's syndrome), in ped >2 y.o., limit to 1.8-6% concs -Salisylic acid collodion/collodion-like vehicles= liquid forms that form films that prevent moisture evaporation(keeps dry in there) -super flammable/volatile, may be inhaled/abused -has pyroxylin/various combos of solvents (ether, acetone, alcohol) or plasticizer (castor oil) -some systemic absorption w/ prolonged use on large surface areas of childen/renal/hepatic impairment -directions: apply 1 drop 2x/day on lesion til covered (max 14 days), allow to dry/harden, after use, cap container tightly, store in amber/light-resistant container away from direct sunlight/heat -salicylic acid plaster vehicles= direct, prolonged contact> quicker resolution/more effective -solid/semisolid adhesive on backing material -directions: trim to follow contours of lesion, apply plaster, cover w/ occlusive tape, if using medicated disks w/ pads, apply disk and then cover disk w/ pad -remove plaster/pad and occlusive tape w/in 48 hrs -after removing softened skin reapply every 48 hrs PRN (MAX 14 days) -Counseling pts: -remission can take several days to months -eliminate causes -apply only to corns/calluses -pdts w/ collodions are poisonous when ingested -max 14 days self-care -Common and Plantar Warts (hands and feet) -common warts= caused by human papillomaviruses (HPVs) -7-10% of population has warts, 70%=common, occurances peak at 12-16 y.o., usually self-resolves -risks: previous/existing warts, depressed immune system, biting one's fingernails, barefoot, esp on wet surfaces, using swimming pools/public showers, working in a meat handling occupation -What they look like: -effect skin/mucous membranes anywhere on body (hands/feet=self care> everywhere else=REFER) -common warts= skin-colored/brown, hyperkeratotic, dome-shaped papule w/ rough cauliflower-like appearance, freq on hands, PAINLESS=hands -plantar warts= skin-colored, callous-like lesions on FEET hence plantar -may be PAINFUL=FEET, esp in weight bearing spot -can be confused w/ corns, calluses or malignant growths (the diff= if you take the top of the wart= can see little capillaries vs corn/calluses=no) -treatment of warts: -Exclusions to self-care: -<4 y.o. -pregnancy/breastfeeding -diabetes, PVD, neuropathy (circulatory issues basically) -large/multiple warts located in one area of body -painful plantar warts -anywhere not on hands/feet: on face, breasts, armpits, fingernails, toenails, anus, genitals, mucus membranes -for salicylic acid pdts only: no immunosuppresive meds that contradict salicylic acid, and salicylate allergy -Non-pharm txt: -wait and see if self-resolves -avoid cutting/shaving/picking at warts -wash hands before/after treating/touching warts b/c contagious -use designated towel to dry warts -avoid sharing towels, razors, socks, shoes -keep wart covered -don't walk barefoot esp in bathroom/public areas -use padding (Lamb wool/moleskin) on pressure pts if having pain -1. Salicylic acid for warts: -formulations= 17% liquid and gel (common)- every 12 hrs -40% plaster, pads, strips, and stick (plantar)= every 48 hrs (longer/harder to get rid of so inc strength) -cheap, easy, effective to use, few side fx (stinging, burning) -need CONSISTENT, freq application for warts -may dmg skin surrounding wart -improvement w/in few weeks -removal in 6-12 WEEKS (MAX use=12 weeks i.e. 3 months) -2. Cryotherapy for Warts (compound W) =destroys warts by freezing it (no better than salicylic acid) -agents= liquid nitrogen (rx) or dimethyl ether + propane (DMEP) -place tip on wart x20-40 SECONDS -blisters form under wart and falls off ~10 DAYS, repeat after 10-14days, up to 3x but change application each time u do it b/c can reinfect yourself -adverse fx: blistering, scarring, hypo/hyper pigmentation, tendon or nerve dmg w/ aggressive therapy -MAX duration= 12 weeks (3 months) -counseling pts: warts are contagious and spread to other body pts/ppl -warts can progress to a more serious disorder -see provider if not resolved after 12 weeks (3 months) self-tx -do not use medicines on moles, birthmarks, warts w/ hairs growing from them, irritated/inflamed/infected skin -Tired, Aching Feet: -causes: inc freq of standing/walking, age-related erosion of fat padding on foot bottoms, circulatory/neurologic disorders, poor-fitting/inappropriate footwear -Plantar Fascitis (heel pain b/c inflammation)= causes: high arches, flat feet, repetitive stress during exercise, pronated feet (walk and foot rolls inward), prolonged standing -strain on connective tissue that attaches arch to front of heel -presentation: pain from first moment getting out of bed or standing up after sitting; painful, burning sensation on bottom of heel d/t tissue contraction -Heel Spurs= due to bony calcium growths on underside of heel bone -causes= incorrect walking/running technique, excessive running, poor-fitting shoes, obesity, aging -presentation= inc pain intensity after prolonged periods of rest -detected via x-ray -Tx for aching feet: -Non-Pharm: footwear w/ sufficient padding/cushioning -replace worn shoes or heel pads -shoe inserts, partial insoles, heel cups/cushions -use a night splint, strap or tape the arch -dec weight-bearing activity -enter weight-loss program -compression stockings (8-30mmHg, inc circulation, dec inflammation) -apply ice and/or contrast bath soaks -pharmacologic: short-term OTC NSAIDs, epsom salt baths (not a lot of evidence tho) Exercise-induced foot injuries: shin splints, blisters, ankle sprains 1. Shin Splints= overzealous workout, inappropriate stretching, running/walking on hard/sloped surfaces, ill-fitting footwear, over-striding> pain in 1/3 of shin, worsens w/ exercise, cramping, burning/tightness on shin -rec: PRICE (RICE w/ P for protect); APAP/ibuprofen, shoe orthotic, referral -2. Blisters= repetitive movement, ill-fitting footwear/tight hosiery> fluid accumulation beneath stratum corneum w/w/o pain -rec: do not remove, protect w/ topical bandage, refer for drainage prn -3. Ankle Sprain= ankle rotates outside of range> pain, bruising, tenderness, difficulty walking> PRICE, compression bandage -Exclusions for self-care: achilles tendonitis, intermetatarsal neuritis, stress fractures, toenail loss -prevention= proper footwear, running on proper surfaces w/ correct posture, stretching b4 exercise, moisture-wicking socks to prevent blisters -txt= PRICE,RICE= stop activity, rest, alt exercises, ice bags alternating w/ heat, compression bandages, arch supports/heel cushions, analgesic -consult w/ PCP after 7 days if no relief of pain or if swelling >72 hrs -PRICE for 1st 2/3 days after injury: -P=protect injury i.e. splint/support -R=rest, reintroduce movement gradually -I=Ice= ice w/ ice/frozen peas wrapped in towel for 15-20mins every 2/3 hrs -C=Compress injured area w/ bandage to limit swelling/movement -E=Elevate injury above the heart -Ice Counseling -fill ice bag w/ crushed/shaved ice 1/2-2/3 capacity, squeeze out air, check for leaks -wrap ice bag in thin towel, bind injured area w/ wet elastic wrap then apply ice -apply ice bag for 10mins, remove for 10mins> repeat 3/4x/day til swelling decreases or 12-24 hrs -wetting it a bit also helps transfer cold from ice to skin -Counseling for properly applying compression bandages: -recommend elastic bandages according to are: -2inch wide for foot, wrist, ankle -3 inch wide for elbow, knee, ankle -4inch wide for knee, lower leg, shoulder -6inch wide for shoulder, upper leg, chest -unwind and relax 12-18 inches of bandage at once -if ice is being applied, soak bandage in water -overlap previous layer of bandage by 1/3-1/2 of its width -tightly wrap the point most distal from injury, dec tightness of bandage as wrapping -cold/swollen toes/fingers= too tight -wash in lukewarm, soapy water and air-dry -Counseling for Injured Feet: -shin splints: rest and ice, ASA/NSAID; do not take b4 workout to suppress pain/inc endurance> see PCP if becomes cramping, burning tightness that repeatedly occurs at same distance/time -blisters: wear moisture wicking socks (wool/acrylic), wear 2 pairs of socks w/ talcum sprinkled in between -apply compound tincture of benzoin/flexible colloidion pdt (New Skin) to the blister b4 exercise to dec pain/accelerate healing -apply antiperspirant (20% aluminum chloride) to feet to prevent -if breaks, apply 1st aid antibiotic, cover w/ moleskin to protect -ankle sprain= max swelling occurs at 48 hrs but begin txt ASAP> stay off foot, wrap compression bandage, apply ice, elevate> see PCP if swelling >72 hrs -Ingrown Toenails: occurs when nail curves/embeds into flesh>pain -causes: onychocryptosis (ingrown toenails), hyperhidrosis (hyper sweating), trauma, obesity, excessive pressure on toes, bedridden patients w/ too-tight bedcovers -Non-pharm: warm water soaks 10-20mins several times daily -insert cotton wisps/dental floss under nail edge -ensure shoes fit properly to eliminate toenail pressure -cut nails straight across -pharm: OTC NSAIDs, sodium sulfide gel 1% (Dr. Scholl's Ingrown toenail pain reliever) 2x/day for up to 7 days w/ retainer ring -exclusions: diabetes, PVD, arthritis, patients w/ foot malformations, or if recurrent or oozes discharge, is painful/severely inflamed -evaluate in 3-4 weeks, refer if no relief

Insect Bites, Stings, and Pediculosis

Insect Bites: -Mosquitos: prevalent worldwide, esp in humid, warm climates -inject anticoagulant saliva into victim= welts and itching -can transmit disease as vectors: malaria, west nile virus, dengue fever, chikungunya, zika virus -Zika Virus: -biggest concern in pregnant women (fetal microcephaly and birth defects) -symptoms: fever, rash, joint pain, conjunctivitis (few days-1 week), only 1/5 infected show symptoms -currently no approved vaccine or drug to txt/prevent (self-resolving usually) -APAP can be used for fever -avoid ASA/NSAIDs d/t risk of hemorrhage if dengue -can be sexually transmitted -Zika Virus Prevention: -avoid travel where transmission is ongoing (S America) if pregnant or trying to get pregnant -stay indoors where there are screens on doors and windows -EPA-registered repellant and clothing to cover entire body -DEET 10-30% (OFF! Deep Woods,etc)= gold standard= inc conc= lasts longer, not works better -Picaridin (Natrapel, etc)= if want to avoid DEET's oilyfeel, odor, or dmg to some fabrics/plastics -oil of lemon eucalyptus (Cutter Lemon Eucalyptus) -IR3535= steer away from combos -permethrin ok on clothing but not on skin -Fleas: worldwide, but breed best in humid climates -humans bitten after moving into flea-infested habitat or when living w/ infested pets -bites usually mutiple and grouped: -primarily on legs and ankles -lesions have erythematous region around puncture and intense itching -can transmit diseases like bubonic plague, endemic typhus -Scabies ("The Itch"): -very contagious parasitic infection via physical contact -Mites (Sarcoptes Scabiei) burrow in skin where females lay eggs -commonly infested in: (anywhere warm and cozy): -interdigital spaces of fingers, wrist flexor, surfaces of wrists, external male genitalia, buttocks, anterior axillary folds -char. by inflammation and intense itching -req.s prescription therapy= REFER -Bedbugs: -Prevention is Key: hard af to get rid of -actively feed at night -during day: hide and lay eggs in crevices (nice, dark, deep) in crevices of walls, floors, pic frames, bedding, linen folds, suitcase corners, and furniture -increased traveling has led to US infestations (hotels>look for feces=black dots, blood marks, don't put suitecase on hotel beds/furniture) -increased resistance to pesticides w/ pyrethroids -bites typically occur: on exposed skin (head, neck, arms) -in clusters of 2s and 3s in a straight line -reaction ranges from site irritation to small dermal hemorrhage -Ticks: feed on blood of humans and animals= via tall grass/trees, etc -mouthparts introduced into skin, allows to hold on -if left attached, becomes fully engorged w/ blood and remains for up to 10 days before dropping off -if improperly remove tick but mouthpts remain, intense itching and nodules req surgery may develop -local rxn: itching papule, disappears w/in 1 week -systemic symptoms appear later (lyme disease) -Ticks: Systemic Diseases: -1. Lyme Disease (deer ticks)= bulls-eye rash, flu-like symptoms, later symptoms= neurologic, cardiac, hematologic -2. Rocky Mountain Spotted Fever (wood or dog ticks)= headache, rash, extreme fatigue, fever -Tick Removal: -Remove intact w/ fine tweezers or thread w/in 36 hrs= want as intact as possible and want to keep tick in case get disease to figure out what you get -grasp tick as close to skin surface as possible and pull upward w/ steady, even pressure -do not twist or jerk the tick (mouthparts may detach and remain in the skin) -pull firmly to lift skin for 3-4mins and tick will back out -do NOT squeeze, crush or puncture the body b/c it may contain bacteria -immediately wash hands and AA w/ soap and water/rubbing alcohol -keep tick in sealed container in case of systemic rxn -Chiggers ("Red Bugs"): live in shrubbery, grass, and trees -after attaching, larvae secrete fluid that causes cellular disintegration of skin, a red papule, and intense itching -fluid hardens skin and forms a tiny tube where chigger feeds until engorged, then drops off as an adult -Black Widow Spiders: found throughout US in warmer climates (even in SD) -char.=hourglass on abdomen -bites not initially noticed but symptoms develop quickly -delayed intense pain, stiffness and joint pain, ab disturbances, fever, chills, dyspnea -usually for spiders, fangs can't penetrate=don't know got bit= death from spider bites=rare -Brown Recluse Spiders= found in southern/midwest US -bites initially painless but may cause local and/or systemic rxns later -reactions same as black widow (delayed intense pain, joint stiffness/pain, ab disturbances, fever, chills, dyspnea) PLUS spreading, ulcerated wound at bite site=necrosis -Treatment of Insect Bites: -REFER: - < 2y.o. -hypersensitivity (systemic sx or sx distant from bite) -hx of tick bite and systemic fx indicating infection -suspected spider bite (black widow or brown recluse) -signs of 2ndary infection bite area -scabies -diabetes=not nec refer but also use clinical judgement, esp if ulcer -General txt approach to bites: -apply ice pack to washcloth up to 10min w/ 10 min between applications -apply topical analgesic to the site -avoid scratching -seek med attention if worsens or sx persist after 7 days of txt -prevent future bites: -cover skin w/ clothing/socks, cuff clothes at ankles, wrists and neck -avoid swamps, dense woods, dense brush -keep pets free of pests -remove standing water near home to dec mosquito breeding -limit time spent outside at dawn/dusk -use barriers (window screens/netting) -to prevent scabies, don't share combs/brushes. towels, caps, hats, clothing -use insect repellants -Insect repellents: PREVENT bites (does not txt) from mosquitos, fleas and ticks -select based on ingredients, conc, type, and length of exposure -N, n-diethyl-m-toluamide 4-100%, DEET -in most commercial pdts- BEST all-purpose repellant -releases vapors that discourage insect approach -available in sprays, solns, creams, wipes, etc -duration varies w/ conc (10%=2 hrs, 30%= 5hrs) -Adults: 10-35% conc (>=20% to repel ticks, >50% do not offer additional protection, but may have longer duration and skin rxns) -children= <30% -avoid in < 2 months old -apply no more than every 4-8hrs -skin irritation=most freq problem -apply sunscreen FIRST and wash hands after applying -toxic if ingested -safe for pregnant and breast feeding DEET Safety: -do not allow children <10 y.o. to apply to themselves -do not apply to young children's hands or near eyes/mouth -don't breath in, swallow or get into eyes -do not put on wounds or broken skin -use just enough to cover EXPOSED skin/clothing -do not use under clothing -after returning indoors, wash treated skin (soap and water) -wash treated clothing before wearing again -do not spray in enclosed areas -to apply to face, spray on hands first then rub on -Other insect repellants (less effective than DEET): -citronella -lemon eucalyptus oil -soybean oil -cedar oil -lavendar oil -tea tree oil -garlic -scented moisturizers in mineral oil (Skin-So-Soft) -Picaridin (possibly less odor/less iritating to skin than DEET) -Permethrin 0.5% (for clothing/camping equipment) -Pharm txt: -local anesthetics -topical antihistamines -counterirritants -hydrocortisone -topical skin protectant agents -first-aid antiseptics and antibiotics -not approved for < 2y.o. -1. Local Anestetics= for itching/irritation relief d/t insect bites -MOA: reversible blockade of nerve impulses (Loss of sensation) -formulations: creams, ointments, aerosols, lotions -apply to bite area up to 3x-4x/day, max 7 days -relatively nontoxic (may cause ACD) -avoid phenol in pregnant women/children -Benzocaine= rec pramoxine, benyl alcohol -not rec b/c inc fxs: lidocaine: dibucaine, phenol -2. Topical Antihistamines: -Diphenhydramine 0.5-2% in most pdts -MOA: anesthetic effect by depressing cutaneous receptors -for temp relief of pain/itching d/t minor bites -multiple formulations -apply to bite area up to 3x-4x/day, max 7 days -not absorbed sufficiently to cause systemic side effects -can cause photosensitivity and hypersensisitvity rxns -continued use for 3-4 weeks inc likelihood of contact dermatitis -3. Counterirritants: -MOA: at low concs, depress cutaneous receptors, thereby causing analgesia and anesthesia -Camphor 0.1-3%= very dangerous if ingested (keep away from children) -menthol 0.1-1%= considered safe and effective antipruritic -apply to bite 3x-4x/day, max 7 days -4. Hydrocortisone= 1% topical prep for temp relief=wide variety of dosage forms available -apply to bite area 3x-4x/day for up to 7 days -adverse fx: skin atropy, acneiform eruptions, irritation, folliculitis, skin tightening/cracking -contraindications (b/c immunosuppresion, will make worse): scabies, fungal, bacterial infections -5. Skin Protectants: act as protectants, reduce inflammation and irritation -available as ointments, lotions, creams -zinc oxide and calamine: zinc oxide=mild astringent and weak antiseptic -both absorb fluids from weeping lesions -both safe/effective at concs 1-25% -titanium dioxide= safety/efficacy not det by FDA -apply prn to AA 3x-4x/day, max 7 days -min adverse fx; ok for adults, children, and infants -How to select pdt: sensitization can occur w/ local anesthetics -prolonged use can lead to hypersensitivity -hydrocortisone can worsen or mask infections -camphor-containing pdts dangerous if ingested -consider pt preference and dosage form -Insect stings: -at risk: being outdoors -venomous: bees, wasps, hornets, yellow jackets, fire ants -attack in defense or to kill other insects -venom=allergens and pharmacologic active molecules, venom content varies -most ppl= pain, itching, irritation (no systemic side fx)> allergic: hives, itching, swelling, burning of skin (anaphylaxis=rare) -Wild Honeybees: found in west/midwest, nest in hollow tree trunks; barbed stinger remains in skin injecting venom -wasps, hornets, yellow jackets= found in south, central, and southwest -wasps nest in high places, under house eaves, or branches of high trees -hornets nest in hollow spaces, esp hollow trees -yellow jackets nest in low places (burrows, sidewalk cracks, small shrubs) -stingers not barbed, so can sting repeatedly -fire ants= found in south and west, live in underground colonies, form mounds -some bite while others bite AND sting (but bite causes rxns)> intense itching, burning, vesiculation, tissue necrosis, and anaphylactic rxns in hypersensitive -Txt for stings: labeling for non-rx pdts only mentions insect bites, but accepted that FDA intends it to also include insect stings -pharm txt: same as bites -REFER: - <2 y.o. -hives, excessive swelling, dizziness, weakness, N/V, difficulty breathing -sign. allergic response away from site of sting -previous sting by honeybee, wasp, or hornet (need to evaluate possible development of hypersensitivity) -previous severe rxn to insect bites -personal/family history of sign. allergic rxns -continued symptoms after 7 days of self-txt -General txt approach: -1. Remove stinger ASAP= use tweezers, edge of credit card, fingernail, etc -2. Apply ice pack in 10 min intervals -3. Apply local anesthetic, skin protectant, antiseptic, topical antihistamine or corticosteroid, or counter-irritant -Counseling: -to prevent stings: avoid perfume, scented lotions, bright clothes -control odors in picnic and garbage -wear shoes when outdoors -destroy nests of stinging insects near home -change children's clothing if contaminated w/ fruit -Do not scratch AA; keep fingernails trimmed -if hypersensitive to stings, wear bracelet or carry emergency card -if allergic sx occur, admin. emergency txt (epinephrine and/or oral antihistamine) and seek ER -seek med. attention if sx worsen/persist after 7 days of txt or symptoms of 2ndary infection/fever occur -complementary therapies for stings: meat tenderizer, ammonia, baking soda -don't need to know: -anaphylaxis= antibody (IgE) triggers immune response> BP falls and angioedema develops> airways narrows) -epinephrine=drug of choice (no danger if inject epinephrine if not actually having rxn) -systemic antihistamines and corticosteroids used together -patients who are allergic to stinging insects should ALWAYS carry epinephrine -Pediculosis= lice -lice=wingless parasites w/ well-developed legs= don't jump like fleas and don't fly -types: head lice, body lice, pubic lice -Head Lice: -common pediatric complaint, mostly in day-care and school-age children -infestation via close personal contact or less likely, by sharing personal items (hats, brushes, combs) -outbreaks= peak after school starts (aug-nov) -do not contribute to spread of other diseases -affects everyone (rich or poor) -Head Lice pathophys: -usually infest head and live on scalp -female deposits 10-150 eggs (aka nits, nits can also be empty casing itself, doesn't matter) that become glued to hair and hatch in 5-10days -nit= ~1mm in diameter w/ yellowish or gray-ish white color (typically found w/in 4 mm of scalp)=easier to see than actual lice b/c they resemble human hair -nymph or instar (newly hatched, immature louse) begins feeding w/in 1 min of hatching, resembles adult (2-3mm) and matures w/in 8-9 days -w/o txt, this cycle repeats ~3weeks -hair length and #times shampoo=no diff -once hatch need to feed w/in 24hrs or will die -Body Lice ("Cooties"): mostly occur in ind.s who don't shower/change clothing freq (ex: homeless) -live, hide, and lay eggs in seams, folds of clothing, esp in underclothes -periodically attack the body to feed -can transmit disease (typhus and trench fever) -Pubic Lice ("crabs")= transmitted through high-risk sexual contact, toilet seats, shared undergarments, or bedding -usually found in pubic area but may also infest armpits, eyelashes, mustaches, beards, and eyebrows -symptoms: -louse saliva causes immediate wheal around bite -local papule appears w/in 24 hrs -itching> scratching> 2ndary infection -scalp irritation causes poor sleep and disruption of school/work -inspection should focus on crown, near ears, and base of neck -nits=easier to see, adults=hard to see b/c move, part hair first=usually spotted at base of hair shaft -lice/nit comb is helpful in removing> grayish nits blend into hair but casings=lighter color -diff from dandruff b/c nits are attached to shaft -can also see black, powdery specks (Lice feces) -Lice txt: 1. Non-rx pediculicide agents (do NOT prevent lice infestation) 2. Appropriate hair combing for nit removal 3. home vacuuming and cleaning of personal items (avoid re-infestation -Pharm OTC txt: -1. Synergenized pyrethrins -2. Permethrins -none kill 100% of nits, therefore must follow w/ careful visual inspection for nits and use a nit comb (b/c immune for 1st few days of their life since no nerves) -inc resistance in US= 25% now b/c overuse, pesticides, improper use, etc + genetic mutations (25 states, but CA, texas, florida, maine=most resistant) -REFER: -presence of 2ndary infection in lice-infested area (open scratch) - <2 y.o. for pyrethrins - < 2 months for permethrin (your scabies med!) -lice infestation of eyelids, or eyebrows -preg. or breastfeeding (strong caution for self-txt= benefits MUST outweight risks, don't need to know: permethrin=lower preg risk rating) -presence of active tumors -regional resistance to pediculosis (still rec these pdts even tho in CA tho) -Patient Assessment: -visual inspection adequate but difficult: head: nits, eggs, body: nits and eggs on clothing -best to confirm w/ nit comb -do not rec txt w/o confirmation of lice by pharmacist other HCP -1. Synergized Pyrethrins: (from chrysanthemums): -synergized w/ piperonyl butoxide, a petroleum derv. -MOA: pyrethrins block nerve impulse transmission, causing insect's paralysis and death -piperonyl interferes w/ pyrethrin's breakdown -for head and pubic lice (not body) -several pdts available (shampoos, foams, solns, gels) -admin: apply to DRY hair for 10mins, lather, rinse over SINK (for foam, remove w/ shampoo or soap and water)> not in shower b/c don't want your body to abs -comb w/ lice comb after txt -repeat txt in 7-10 days to kill remaining nits -do not apply more than 2x/day -ADR: low toxicity; skin irritation, redness, itching, swelling -need to be dry hair and apply so much that hair=wet -Permethrin= WET hair -MOA: disrupts sodium channel on lice nerve cell membrane, delays depolarization and causes paralysis and death - 1% cream rinse indicated for HEAD lice only (OTC) -admin: cream rinse to cover shampooed, wet, but towel-dried, hair and scalp -leave on scalp for 10mins before rinsing -comb w/ lice comb -rinse over sink w/ warm (not hot) water rather than bath/shower -re-treatment not req unless active lice detected -leaves hair residue to kill remaining nymphs no initially killed -suggest re-txt (day 9) d/t additives in shampoos/conditioners (avoid silicon based ones) anyway if concerned -side fx: low toxicity, transient itching, burning, stinging, irritation -pdt selection: -Public lice> pyrethrins -Head lice> pyrethrins or permethrin (equally effective), choose preferred dosage form or desire for single app= permethrin -pyrethrins may be used on children >= 2 y.o. (must be prescribed if younger or preg/lactation) vs permethrin= children >= 2 months -avoid pyrethrins for chrysanthemum allergy -Combing after pediculocide: -fine toothed comb designed for nit removal like LiceMeister -metal combs better than plastic -electronic combs available but data unavailable -bobby pins/hair clips for long hair -large towel around shoulders during combing to catch anything that falls -tissue/paper towels -bowl or soapy water -perform combing in well-lit area= seat so that head is just below eye lvl, consider entertainment for children -prepping hair: cover hair w/ oil or conditioner before to make combing easier, remove tangles w/ reg. hair comb -sep mass of hair about width of metal lice comb (small sections so can easily see lice/nits) -hold mass of hair w/ one hand -insert comb as close to scalp as possible and gently pull slowly through hair several times -comb one section at a time -after combing, pin hair in a curl flat against the head -dip comb in soapy water and use paper towel to remove lice and debris -make sure comb is clean before using again -complementary therapy for pediculosis= don't rec b/c inc resistance -lice enzyme shampoos= no data for efficacy -occlusive agents: petroleum jelly, mayonnaise, olive oil, etc.= theorized to impair lice respiration but likely only slow movement -10% tea tree oil + 1% lavender oil= 1 study showed combo applied weekly x3 weeks more effective than pyrethrin x2 doses 1 week apart> must be used w/ caution d/t potential for significant allergic rxns/hepatotoxicity -Natrum muriaticum (sodium chloride), Vamousse Lice Treatment and Licefree Spray= dries out lice and eggs, sodium chloride spray showed superiority to permethrin in 1 trial> apply to dry hair x 15mins, then comb w/ nit comb -dangerous alt: gasoline and kerosene= flammable and toxic -Emerging Therapies: 1. DSP (Dry-on Suffocation-based Pediculicide) Lotion -ex: Nuvo method aka Cetaphil cleanser -apply to wet hair and use hairdryer= shrink-wrap film mover hair and lice suffocates -leave on for 8 hrs then wash -usually repeat 1x/week for 3 weeks> data suggests effective -2. Dimethicone 100% gel= less irritation than traditional therapy= -not abs transdermally -coats lice to irreversibly immobilize them w/in 5mins -2 8-hr txts 1 week apart -resistance not likely b.c not a neurotoxin -3. AirAlle= machines that kill lice and nits using heat x30mins, FDA approved medical device, reqs certified tech to operate> expensive but does work -Supplemental Measures= machine-wash and dry clothing, bed linens, and other items worn/used during 2 days before txt -hot water (130 deg F) laundry cycle> high heat drying cycle> clothing that is not washable can be dry-cleaned -AND/OR> seal in plastic bag and store x2 weeks (a nit can survive up to 1 week) -soak combs/brushes in hot water (130 deg F) for 5-10mins -vacuum floor/furniture, particularly where sat or lay -fumigant sprays are NOT rec -low risk of infestation by a louse that has fallen off scalp -head lice survive < 1-2 days if they cannot feed -nits cannot hatch and usually die w/in 1 week if not at the same rm temp as that close to scalp -spending sign time/money on housecleaning activities=not nec -Patient Counseling: -control reqs pharm + non-pharm -reassure that head lice is not d/t poor hygiene -treat family members if find live lice or nits w/in 1 cm of scalp or if share bed w/ infested person -follow up w/in 10 days> if signs after 2nd app> see PCP -discuss preventive measures: -avoid head to head contact -do not share clothing/hair stuff (but still use protective head gear) -do not share combs, brushes, towels -do not lie on beds, couches, pillows, carpets or stuffed animals that have recently been in contact w/ an infected person

Pulmonary Devices

Pulmonary Devices= 1. Twisthaler Device: -wash/dry hand thoroughly -hold inhaler up w/ pink pt at bottom, remove cap in upright position to make sure right dose dispensed -hold pink base and turn cap counter clockwise direction to remove it (once the cap is removed, the dose will be loaded into chamber, make sure indented arrow is pointing at dose counter) -hold the twisthaler in horizontal positions and exhale away from twisthaler -put mouthpiece in mouth and take DEEP FAST breath, remove mouthpiece from mouth - hold breath for 5-10 seconds, exhale slowly - close cap in clockwise direction til hear click -make sure arrow is aligned w/ inhaler window> RINSE MOUTH WITH WATER, NO SWALLOW 2. Nebulizers= adv= unconscious ppl, children= b/c as long as breathing you get the dose/no force -Always wash your hands before use, put nebulizer on hard surface and connect hose to air compressor and other end to medicine cup -pour the medication/ampule in medication cup -turn on the power switch and put the mouthpiece/mask in mouth/on> breathe through MOUTH not nose -breathe through your mouth the entire time and take SLOW and DEEP breaths= txt ~ 8-15mins> when little/no mist= done -mask/mouthpiece and medicine cup should be cleaned between each txt w/ 1 pt distilled white vinegar and 1pt water> rinse w/ warm water and let sit dry, don't leave in sunlight -the air filter= checked between txt and if necessary replaced b/c dec the life of compressor/efficiency of nebulizer 3. Aerolizer (the one w/ the weird pill stabbing)= chronic med for COPD (loss of elasticity of tissues around alveoli), spiriva= atropine-like=dec secretions, side fx= dry mouth, onset= 15-30mins, peak 3 hrs -remove the cap from the aerolizer and twist open the device -unwrap the aerolizer capsule and place one capsule in device, close device -squeeze the two side handles until you hear a crunch -exhale away from device mouthpiece -now inhale FORCEFULLY and DEEPLY to get all the powder inside the lung. if you feel like you haven't gotten all the powder= repeat inhalation -then discard the pill in the trash -Emphasize that the capsule is for inhalation NOT swallowing 4. Soft Mist Inhaler/Respimat (Combivent)= long acting, maintenance/prevention for asthma -to set up: hold the inhaler upright, press the safety guard to remove the clear base, take the cartridge and place the narrow end into the inhaler> use a hard surface to press the cartridge into the inhaler (a bit of cartridge will be visible), place the clear base back unto the inhaler til hear click -need to prime 1st= open away from face> prime it 4x by spraying the mist, close it, twist, open and spray again> expires 3 months after you put in canister -hold the inhaler upright -open the cap until it snaps in place -set up straight or stand up and tilt head slightly -exhale away from mouthpiece -put mouthpiece to mouth and push dose bottom while breathing in DEEPLY and SLOWLY (don't cover airvent) -hold breath for 8-10 seconds before exhaling away -if haven't used respimat for 30 days, need to prime once, if >90 days, need to do priming of 3x 5. Metered Dose Inhaler (Symbicort (longacting), albuterol, ventolin (shortacting): -take off the cap -look inside the mouthpiece for foreign objects -shake the inhaler well b/c suspension= want to disperse into canister -breath out fully through the mouth, away from the inhaler -put the mouth piece in the mouth and tighten lips around it OR place inhaler 2 finger widths away from lips, w/ mouth open and tongue flat, tilt the mouthpiece towards the upper back of mouth= not as effective -press the canister down while inhaling DEEPLY and SLOWLY through mouth -remove inhaler from mouth, hold breath for 8-10 secs -breath out -if 2nd dose required= wait 30-60 seconds before repeating 6. Diskhaler (MDI=pressurized mist vs this one= dry powder inhaler= need to inhale FORCEFULLY, ex: advair for maintence): -note: pressing the lever= the meter goes down, opening it doesn't affect this -check the dose counter to see how many inhalations remaining -hold the discus and use thumb grip to open the inhaler until you hear a click -hold the diskus horizontal and slide the level downward until you hear the click to load the dose -breath out fully through the mouth, away from the inhaler -put mouth piece in mouth and tighten lips around it/(put teeth on it, close lips) -breath in QUICKLY/FORCEFULLY and DEEPLY like sucking on a straw to get all the powder out -remove the inhaler from mouth and hold breath for 8-10 seconds -breath out slowly -repeat steps in 30 seconds if have to take another puff -rinse mouth out after each use to prevent trush 7. Turbuhaler/Flexhaler= long term, dry powder - twist off the cap and look at the window which shows how much medicine is left in the container -turn the disk to one direction and turn it back to the other until you hear a click= loaded dose -don't turn it upside down b/c the medicine can fall out of it -breath out fully through the mouth, away from the inhaler -put the mouth piece in the mouth and tighten the lips around it -take a SLOW and DEEP breath -remove inhaler from mouth> hold breath for 8-10 seconds -breath out away from inhaler -rinse mouth after and spit out 8. Peak Flow Meter= won't tell you if have asthma= that's the spirometer at the dr's office -before using peak flow meter, slide down the marker or arrow on the meter to zeo -take a deep breath, put the peak flow meter mouth piece in your mouth and close the lips around the mouth piece and blow quickly and as FORCEFULLY as you can -remove the peakflow meter from your mouth -repeat these steps 2-3 times and record the highest number on your provided sheet -use peak flow meter every day at the same time for accurate results for about 2 weeks to get a good avg of where you are> below 50%=red=bad= immediately get medical attention, 50-79%=yellow=caution in activities and refer to txt plan for actions to be taken, green= >80%= meds=working, do normal activities

Prescription Workshops and Health Literacy

Transferring prescriptions: -has to be pharmacist to pharmacist (interns=ok) -Info that TRANSFERRING pharmacist records on ORIGINAL prescription (6): 1. Name and address of receiving pharmacy 2. Full name of receiving pharmacist 3. Name of transferring pharmacist 4. Date of transfer 5. Number of refills transferred -6. if all refills are transferred, the original rx is marked as VOID -Info that a RECEIVING pharmacist records (usually the case) (8): -1. first, they will create a prescription containing the usual prescription info -2. write: TRANSFER on the prescription -3. original date of issue and dispensing (1st fill, if diff) -4. original prescription number -5. number of refills authorized on original prescription -6. number of valid refills remaining and date of last refill -7. name and address of transferring pharmacy -8. name of transferring pharmacist -Controlled substance transfers: -any number of remaining refills can be transferred (after it's been filled once) but the original prescription becomes VOID -can only transfer ONCE -pharmacies w/ real time (online electronic database) can transfer as many times as they want though -transferring pharmacist 1. writes VOID on invalidated prescription, and 2. records DEA number of receiving pharmacy -receiving pharmacist records DEA number of transferring pharmacy -receiving pharmacist MUST record dates/locations of all previous refills -can't get verbals for CIIs (need hard copy), and can't be transferred -controlled substances in california= must be a refill transfer> cannot be a new/on hold prescription -otherwise contact prescriber for CIII-V and get a verbal (and tell original pharmacy to void the other prescription) -F=Findings= indicating the problem that may/does exist -A= Assessment= the pharmacist's evaluation of the current situation -R= Resolution of the problem= reflect the actions proposed/performed to resolve the drug-related problem based on analysis -M= Monitoring for endpoints and outcomes= a plan for follow-up monitoring of the patient has to be documented and adequately implemented