N5541/6541 Exam 1 Blueprint (Modules 1 & 2)
50 Multiple Choice Questions in a 75 minute time frame
Dermatology (Module 1A)
12 Questions
 Screening and
 Management of various dermatologic conditions of children, adolescents, and adults.
While there are many dermatologic conditions, focus will be on the dermatologic
conditions covered within the module.
CHILDREN
Impetigo
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Screening
o Common in 2-5 year olds
o Highly contagious
Treatment
o Prevention: handwashing
o Warm compresses to soften crusts
o Bactroban oint TID x7 days; Altabax oint BID x5 days—apply with qtip or gloves
o Oral abx when lesions are vesicular or widespread (more than 25% of body)
 Dicloxacillin
 Cephalexin
 Clindamycin—all x7 days
Symptoms
o Red papuleshoney colored crusted pustules—usually around mouth and
nose
Diagnostics
o C&S
o Recurrence: check for nasal carrier of MRSA and treat with Bactroban if
positive
Atopic Dermatitis (Eczema)
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Screening/symptoms
o Allergic (atopic)and genetic tendency
 Often Hx of asthma, allergic rhinitis
 Usually affects cheeks, face, trunk and extremities
 Spares diaper area
o Due to itching, children are at increased risk of impetigo
o Erythematous papules to scaly plaques
Treatment
o elimination of exacerbating factors (if known);
o skin well hydrated with creams/lotions;
o diphenhydramine seems to be most effective oral antihistamine for pruritis
(but should be used sparingly in children younger than 6 years old), non-
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sedating: fexofanadoine (allegra), desloratadine (clarinex) can be prescribed to
children over 6 months, loratadine (Claritin) not indicated until age 6 years;
o Topical corticosteroids: low potency (OTC) because it is an ongoing problem.
 Rx one should be medium potency (triamcinolone 0.1%) not used for
more than 7 days at a time
 Elidel or protopic can be Rx and they do not cause skin atrophy—useful
on face, neck and skin folds: are approved for children over 2 years old
and used sparingly BID** EXPENSIVE and BLACK BOX WARNING: MAY
INCREASE RISK OF SKIN CANCERS AND NON HODGKINS LYMPHOMA
DUE TO IMMUNOSUPPRESSIVE EFFECT (SHOULD NOT BE PRESCRIBED
TO CHILD WITH WEAKENED IMMUNE SYSTEM)
Diagnostics
Hand-foot-mouth (viral)
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Screening/symptoms
o Commonly affects children under 10 years old
o 12-24 hrs of prodrome of:
 Fever, malaise, joint aches and sore throat
 Followed by papular/vesicular lesions on mouth, tongue and hands and
feet
o Moderately contagious; spready by direct contact with nasal discharge, saliva,
blister fluid or stool
 Most contagious during first week of virus, however can persist for
weeks in stool (BE CAREFUL WITH DIAPER CHANGES)
Treatment
o Exclusion from group setting (daycare) for first few days
o Supportive
 Orajel or anbesol for oral ulcers
Causes
o Caused by coxsackie virus A16 and enterovirus 17
Erythema infectiosum—Fifth’s disease(viral)
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Screening/symptoms
o Common in late winter and early spring
o Common in school aged children
o Prodromal:
 Fever, malaise, h/a, sore throat, coryza (common cold), nausea,
diarrhea >>> slapped cheek rash appears after 48 hrs >>> diffuse, lacy
pink rash on body X 1-2 wks
o Once kid has rash, not contagious anymore
o KEEP CHILDREN WITH THIS AWAY FROM PREGNANT WOMEN, CAN BE FATAL
TO FETUS
Treatment
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o Supportive (fever and hydration)
o Good handwashing
Causes
o Caused by parvovirus B19
Pityriasis rosea (viral)
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Screening/symptoms
o Diffuse Rash = first lesion is herald patch on chest,neck or back (2-5 cm in
diameter); becomes scaly and clears centrally
o Several days to a week later: smaller oval lesions (similar to first lesion) occur
primarily on trunk and proximal areas of extremities in lines of skin cleavage”Christmas tree pattern”
Treatment
o Control pruritis
 Calamine
 OTC topical steroids
 Oral antihistamines
o Rash subsides without treatment
Causes
o Recently associated with herpes virus type 6
Varicella (viral)
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Screening/symptoms
o Highly contagious through droplets from nasopharyngeal secretions or direct
contact with skin lesions
o Fever (101-102), malaise, pharyngitis X 2 D >>> rash starts on face or trunk and
spreads downward
o Rash progresses from red macules >> papules >> vesicles >> umbilicated
pustules >>> crusty
Treatment
o Cool compresses, calamine oatmeal baths;
o RX. diphenhydramine, hydroxyzine, fexofenadrine, loratadine
o Watch for secondary impetigo due to scratching
o Varicella vaccination
o Acyclovir only recommended for those that are at risk for complications (those
older than 12, pulmonary or cutaneous disorders or individuals on long term
steroid therapy)
Causes
o Varicella virus
Verruca(viral—warts)
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Screening/symptoms
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o Lesions are raised, pink and rough
o If child has verruca in the anal or genital area, immediately think/suspect
sexual abuse and investigate
Treatment
o No routinely effective treatment; depends on extent and location of warts
o Cryotherapy q wk X3
o Podofilox (Condylox) topical txment cycles
o Aldara topical
o Laser ablation
Causes
o HPV
Molluscum contagiousum (viral)
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Screening/symptoms
o Lesions are 3-5 mm flesh colored papules with umbilicated center; usually < 30
lesions
o No other associated symptoms
o If seen in genital region, suspect sexual abuse, investigate

Treatment
o May treat to prevent spread to others:
o Cryotherapy
o Aldara
o Laser ablation
o Resolved spontaneously in months to years
Causes
o Caused by pox virus, considered contagious
o Spread by direct skin to skin contact (sports)
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Herpes Simplex type 1-labialis/fever blister (viral)
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Screening/symptoms
o Lesions may appear on lips, oral mucosa, genitalia
o Outbreak may be preceded by tingling in area
o If you see this in genital area, suspect sexual abuse
Treatment
o Abreva (OTC) 5X daily;
o Zovirax can be used in children greater than 2 years
Causes
Seborrheic dermatitis/cradle cap (Sebaceous)
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Screening/symptoms
o Chronic - common on face & scalp – flaking, dandruff
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o Occurs in scalp, face, upper chest and back (where there are a lot of sebaceous
glands)
o “Cradle cap” usually resolves by 8-12 months of age; resolves spontaneously
Treatment
o baby shampoo/oil + soft brush
o no meds required
Causes
o Inflammatory condition; skin overproduces skin cells and sebum.
Pediculosis-- LICE(parasitic)
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Screening/symptoms
o Very common in children
o Above ears and base of scalp
o Intense itching
Treatment
o OTC pyrethrin (RID) and permethrin (Nix) – usually 2 txments 7-10 days apart;
RX malathion lotion; benzyl alcohol; ivermectin
o Fine tooth comb
o Wash clothing/bedding in very hot water; place nonwashable items in a sealed
plastic bag for 2 weeks or in a bag and place in freezer
Causes
o Nit (egg) adheres to hair >>> develops into louse(visibly moving on scalp) in 34 D >>> able to reproduce in 12 D >>> single fertilization needed to lay 10
eggs/day for 30 day life span
o Louse pierce the skin and secrete saliva which causes intense itching
o Spread by shared hats, clothing, towels, combs, etc.
Scabies (parasitic)
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Screening/symptoms
o Papular linear rash primarily on hands, feet, & body folds (interdigital, axilla,
genital),
o usually spares scalp and face; pruritus; spreading rash
Treatment
o Wash clothing/bedding in very hot water and dried on high heat
o Isolate non washables in a plastic bag for at least 3 days,
o Permethrin (Elimite) 5% cream applied from neck to feet (even if no rash
present in area) – wash off after 8-14 hrs; may retreat after 10 days (not on
face and scalp)
o Itching can persist 2-4 weeks after treatment but usually less intense
o Antihistamine for pruritus
Causes

o Female mites burrow under skin and lay eggs
o Can survive off human host up to 4 days
Diagnosis
o Skin scrapings – microscope to see mite and confirm diagnosis
Keratosis Pilaris (dryness)
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Screening/symptoms
o Rough bumps on the skin
o Considered a normal skin variant
o Pre-pubertal children
o Upper arm, cheeks, thighs or buttocks
Treatment
o Emollients (Lubriderm, Cetaphil) and mild exfoliation
Causes
o Excess keratin forms plugs in the hair follicles
ADULTS
Impetigo (Bacterial)
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Screening/symptoms
o Thin vesicles with honey colored crust
o Spread via contact from hands, towels, clothing
Treatment
o Topical tx appropriate for limited number of lesions in an isolated area
 Apply warm compress to lesion prior to Bactroban to maximize
absorption.
 Bactroban oint TID x 7 days.
o Oral when it is more widespread x7-10 days
 Dicloxacillin
 Bactrim
 Cephalexin
 Clindamycin
o Recurrence
 Check for nasal carrier of MRSA with C&S swab—if positive: Bactroban
intranasally BID x 5 days
Causes
o Principle cause of staph aureus
Folliculitis (Bacterial)
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Screening/symptoms
o Small, dome shaped yellow pustule surrounding a hair shaft with erythema
o Superficial or deep
o Usually less than 5 mm in diameter
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Treatment
o Usually resolve spontaneously; superficial—antibacterial scrub and topical
mupirocin
o If known pseudomonas or a deep—start oral abx
 Fluoroquinolone (cipro, Levaquin)
 Aminoglycoside (gentamicin, tobramycin)
Causes
o Usually by staph aureus or pseudomonas (hot tub that are inadequately
chlorinated)
Furuncle (Bacterial)
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Screening/symptoms
o 1-5 cm red and tender nodule which often contains pus
o Deep extension of superficial of folliculitis into the dermis and subcutaneous
(hypodermis) layer
Treatment
o Simple lesions respond to warm compresses
o Severe infections: drainage and abx
 Oral abx: cephalexin and clindamycin for larger and deeper infections
 Pseudomonas: quinolones
 MRSA: Bactrim and doxycycline
o C&S of purulent material
Causes
o Caused by staph or pseudomonas
Carbuncle (Bacterial)
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Screening/symptoms
o Large deep abscess that is a progression of furuncle
o Usually 3-10 cm
o Can present with fever and chills
Treatment
o Require drainage of wound AND abx
o Often followed by wound therapy
Causes
o Caused by staph or pseudomonas
Cellulitis (Bacterial)
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Screening/symptoms
o Erisypelas:

more distinctive anatomic features than cellulitis. Raised above level of
surrounding skin, clear demarcation between involved and uninvolved tissue,
acute onset of fever and chills
o Cellulitis:

localized deep erythema over a few days, erythema streaking

Many pts with cellulitis have chronic medical underlying conditions
such as chronic venous insufficiency, lymphedema: treat both-- eg.
compression stockings
Erythema, edema, warmth, taut shiny skin, tender, indurated
Borders are well defined and change rapidly
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Treatment
o Immediate attention
o C&S if draining, CBC, IV or oral antibiotics
o Elevate and heat
Causes
o Usually caused by staph or strep or complication of wound or trauma (dog/cat
bite)
Trauma (Bacterial)
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Screening/symptoms
o Pain, swelling, purulent
Treatment
o Cat/dog bite: Pasteurella most common pathogen
 Wound care
 Tetanus shot
 Abx
 Augmentin, levofloxacin (pts greater than 18 years), doxycycline
(greater than 8 years)
 Rabies (quarantine dog to know rabies status)
o Cat scratch
 Bartonella most common pathogen
 Azithromycin and clarithromycin most effect
Tinea Pedis (Fungal)
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Screening/symptoms
o Athlete’s foot
o Lesions are pruritic, scaly with raised border; may become fissured
Treatment
o Skin scraping with KOH
o Keep feet dry
o Antifungal cream/powder OTC are effective
 miconazole
o Topical steroids not appropriate and can exacerbate condition and contribute
to tx failure
Tinea Cruris (Fungal)
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Screening/symptoms
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o Jock itch
o Red scaly rash in inner thighs/inguinal creases
o Common with increased heat and humidity, obesity
Treatment
o Topical antifungal creams are effective
 miconazole
o keep skin dry
Tinea Versicolor (Fungal)
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Screening/symptoms
o Multiple patchy lesions with fine scales
o Typically occurs on back, neck, chest and shoulders
o More noticeable in summer when affected areas do not tan
Treatment
o Topical antifungal creams are effective
 Miconazole
o Oral antifungals can be used for more extensive disease
 Ketoconazole 400 mg x 1 dose
 Fluconazole and itraconazole are also effective
o Selsum blue on skin as a lotion and leave on for 20 min then wash off
o Do microscopic exam of skin
Tinea Corporis (Fungal)
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Screening/symptoms
o ringworm
o well defined circular patches with scaly borders with central clearing
o occurs after contact with person/animal that has fungus
Treatment
o Topical antifungal creams are effective
 Miconazole and ketoconazole
 NO NYSTATIN
Onychomycosis (Fungal)
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Screening/symptoms
o Toenail fungus
o Yellow, thickened nails which may become painful and brittle
o More common in toenails than in fingernails,
Treatment
o Topical only if less than ½ distal nail plate involved or if oral is contraindicated
 Rx: Penlac nail lacquer—safe for patients with liver disease
o Oral

Use if no liver disease; baseline LFTs needed before tx and at 4-6 week
intervals during tx
 Itraconazole:
 Pulse dose (fingernails); 200 mg qday x12 weeks (toenails)
 Terbinafine (Lamisil): 250 mg qday x 6 weeks (fingernails) or 12 weeks
(toenails)
o If no response, consider removal of nail or Refer to podiatrist or dermatologist
Herpes Simplex (Viral)
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Screening/symptoms
o Type 1 (used to be oral), Type 2 (used to be genital)
o Clear papules with superficial ulcerations/erosions
o Often preceding by burning pain, tingling, itching sensation
o Sudden onset with appearance of multiple vesicular lesions on erythematous base
o Can have fever or malaise
Treatment
o Lesions crust over and heal usually within 7-14 days
o Oral antiviral
 Acyclovir, famvir, zovirax
 Shortens symptoms and hastens healing of lesions
o Chronic antiviral therapy recommended for those that experience more than 4
outbreaks per year: daily meds
Herpes Zoster (Viral)
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Screening/symptoms
o Reactivation of varicella zoster (chicken pox) virus
o Vesicles on an erythematous base on a one-sided nerve distribution (limited to
dermatomes)
o Prodome of fever, malaise and headache or painful sensation on dermatome prior to
rash
o Herpes zoster Opthamicus: lesion on eye or on nose (Hutchinson’s sign), optic nerve
hits tip of nose.
Treatment
o Nerve pain: NSAIDs, gabapentin (post herpetic neuralgia: pain that continues along
dermatome more than 4 month after rash has healed
o Oral antiviral
 Acyclovir, famciclovir, valacyclovir
 Start within 72 hrs of rash
o Zostavax recommended for everyone over 55-60 years of age.
Verruca (Viral)
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Screening/symptoms
o Warts
o Round flesh color progresses to yellow-tan
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Treatment
o 65% will slowly resolve spontaneously
o Cryotherapy (liquid nitro)
o Least painful method for tx should be used initially
o Easier to treat smaller warts early.
o Genital warts: aldara or condylocks?
o Resistent warts: cryo every 2-3 weeks; if spreading, refer to derm.
Causes
o Caused by HPV
o HPV-1 plantar warts
o HPV-6,11 genital wars
Acne (Sebaceous Gland/Bacterial)
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Screening/symptoms
o Open comedones or closed comedones; pustules, nodules, cysts
o Most prevalent in adolescents; psychological impact can be significant.
Treatment
o Avoid oil based cosmetics
o Use gentle cleansers
o Mild (comedonal): topical clindamycin and erythromycin in AM & benzoyl
peroxide 2.5-5% @ hs or topical retinoid (Differin, Retin-A) .025-.05% @ hs
 Initial mgmt. of majority of patients
 Retinoids used daily can cause increased dryness.
o Moderate (pustular): above regimen + minocycline or doxycycline 50-100 mg
bid, tapering to 50 mg/d as acne improves; OCP (progestin & estrogen)
o Severe (cystic): Accutane – refer to dermatologist (labs & pregnancy test,
contraception, informed consent)
Causes
o Obstruction of oil glands
Rosacea (Sebaceous Gland)
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Screening/symptoms
o Stage I: episodic >>> persistent central facial erythema
o Stage II: erythema plus telangiectasias, papules, pustules
o Stage III: above + bulbous nose (rhinophyma)- phymatous rosacea: refer for
laser tx and accutane
Treatment
o Gentle skin care and avoid triggers (sun, cold weather, emotions, alcohol, spicy
foods)
o Depends on stage:
o I: Brimonidine 0.33% gel pea size qday
o II: metronidazole cream; minocycline or doxycycline 50-100 mg bid >> qday
o III: Laser txment; Accutane – refer to dermatologist
Seborrheic Dermatitis (Sebaceous Gland)
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Screening/symptoms
o Chronic
o Common on face and scalp: flaking, dandruff
Treatment
o OTC selenium sulfide shampoo or 2% ketoconazole shampoo (leave on for 520 min then rinse)
Contact Dermatitis (allergic)
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Screening/symptoms
o Papular pruritic rash resulting from allergen
o Strong antigen: such as poison ivy may take one contact, then later just be in
the area and get a reaction.
Treatment
 Avoid exposure
 Mainstay of tx is topical steroids
 OTC skin scrub; moderate to intermediate potency Hydrocortisone cream; cool
compress; antihistamines
 Oral steroids if > 10% skin surface involved: Prednisone 40-60 mg daily, 5-7 days
Urticaria (allergic)
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
Screening/symptoms: Hives
o Inflammatory reaction of epidermis and dermis
o Raised wheals, erythema, transient, migratory, pruritic
o Intensely pruritic erythematous plaque; sometime accompanied by
angioedema or swelling deeper in the skin
o Acute (mainly seen in clinic): periodic outbreaks that resolves within 6 weeks
(2/3 cases)
o Chronic: greater than 2 episodes per week for more than 6 weeks—send for
allergy testing if you cannot figure out cause
Treatment
 Eliminate trigger (drugs, food, insect stings, infection)
 Aimed at relief of pruritis
 LA 2nd generation antihistamines (in am); 1st generation (at hs); oral steroids for a
week or less (prednisone 40-60 mg/day with tapering over 5-7 days)—do not
repeat steroids
 Assess respiratory status – stridor (epi) and admit for observation (anaphylaxis
Eczema (Irritation)
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
Screening/Symptoms
o Extreme dryness of epidermis
o Usually on extremities & trunk; worse in winter
o Pruritic scaly with cracked appearance
Treatment
o Creams to hydrate
o Topical corticosteroids (low potency) for pruritis
o Moderate steroid not to use more than 2-3 weeks at a time. Watch out for
staph infection and need for oral abx
Psoriasis (Irritation)
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Screening/Symptoms
o Inherited disorder (genetic) of increased epidermal cell turnover & thickening
o Thick silvery scales
o Common on elbows, knees, & feet
o Plaque psoriasis: 80% of cases; range from <1 cm to more than 10 cm in
diameter; plaques are usually asymptomatic (sometimes pruritic),
pitting/dystrophy of nails
o Severe plaque psoriasis involves >20% of body—referred to dermatologist for
Remicade
o Guttate psoriasis: abrupt appearance of multiple small red scaly lesions; no
previous hx of plaque psoriasis—usually less than 1 cm in diameter; primarily
in trunk and extremities. Strong association between recent strep pharyngitis
or URI, resolves on its own as infection subsides.
Treatment
o UV light
o Intermediate to High potency topical corticosteroids for acute flares
o Low potency corticosteroids for maintenance
o Topical dovonex (vit D3 derivative) BID
o Topical retinoids
o Emollients
o Methotrexate
Causes
o Normal skin cells turnover every 23 days, however, in psoriasis skin cells
turnover every 3-5 days in area: thickening of skin
o Prevalance of metabolic syndrome, CVD, IBD and arthritis
Actinic Keratosis (Premalignant)

Screening/Symptoms
o Pinkish white papules with scaling, feel gritty like sandpaper.
o Lesions are tan with surrounding erythema, raised, irregular surface


o Most common on sun exposed areas – face, neck, ears, arms, hands in fair skin
or exposure
o Preventive: use sunscreen with min SPF 30 and limit exposure between 10 and
4
o Ongoing monitoring for patients with a hx of actinic keratosis
Treatment
o Cryotherapy for few lesions (10 or fewer lesions)
o For multiple lesions:
 RX. Efudex crm (fluorouracil) bid for 2-4 wks (lesions ulcerate and crust
over – takes 2 wks to heal);
 Aldara twice weekly – wash off after 8 hours for max of 16 weeks
Cause/risks
o Precancerous lesion (may develop into squamous cell cancer)
o Risk of malignant transformation to squamous carcinoma is relatively low,
however, overtime, 60% of squamous cell carcinoma is believed to arise from
actinic keratosis—tx to prevent
Infectious Disease (Module 1B)
12 Questions
CA-MRSA
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
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Screening
o Stable-can live on inanimate objects
o Common in sports settings, prisons
 Towels, gym equipment, razors
o Persons that are immunocompromised
o Report incidence to health department
Treatment guidelines
o Empiric treatment with Bactrim DS or Doxycycline until culture and sensitivity
are back for patients with fever, malaise, elevated WBC and significant
redness, tenderness or induration
o Mark area and educate patient that if induration, redness or tenderness
spreads past markings to come back for further eval.
 Keep wounds clean and covered
 May use heat for comfort and to promote drainage
 Clothing/linen should be kept clean and free of wound drainage
o Follow up in 24-48 hrs to monitor progression after starting abx and follow up
on sensitivity for abx
o I&D
o Good handwashing/hygiene
o Good environmental hygiene
Pertinent symptoms
o Generally presents as a “bite”
o Area of infection usually begins as a red, raised, tender area

 Often in areas where there is hair
o Firmness of skin surrounding lesion (induration)
o Fever
o Generalized malaise
o If untreated can lead to pneumonia or sepsis
Diagnostic criteria
o GOLD STANDARD: culture of suspicious area
o Abx sensitivity
o If suspicious area is not skin, culture appropriate fluid (i.e. blood or urine)
o CBC
CMV




Screening
o 2nd most common cause of infectious mono
o Commonly seen in patients with HIV
o Virus remains latent once infected and can re-activate
 Re-activation typically occurs in immunocompromised
o Congenital CMV is a common cause of birth defects
 Mental retardation, hearing deficits
o Common in daycare and assisted living places due to high contact with bodily
fluid (saliva, breast milk, urine, blood)
Treatment guidelines
o In immunocompromised, may need to refer to GI, pulmonologist,
ophthalmologist due to complications such as GI ulcerations, CMV retinitis
(immediate referral), pneumonitis, neuro symptoms like dementia
o No preventative vaccine
o Tx is supportive unless person is immunocompromised
 Eyes, neuro, GI, HIV (infectious disease), lung involvement: REFER
o Few antivirals can be used to treat HIV pt with CMV: should be done under
care of ID.
o Good handwashing and hygiene
Pertinent symptoms
o Often indistinguishable from EBV infectious mono
o Fever
o Sore throat (not exudative—characteristic difference from EBV infectious
mono)
o Cervical lymphadenopathy
o Fatigue
o Skin rash
Diagnostic criteria
o CMV antibodies are very expensive and should only be ran if EBV antibodies
are found to be negative.
o Tissue biopsy: “owls eye” inclusion body seen on skin biopsy is diagnostic of
CMV infection
o IgG (previous infection, older infection)
o IgM (positive during symptomatic phase)
o LFTs (may be elevated during acute phase)
EBV
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


Screening
o EBV Chronic
 If person that has the antibodies that show a chronic disease (EA, IgG)
and they present with fatigue, fevers, etc... Refer to an immunologist
for further workup
 may be associated with African burkitts lymphoma
 may be associated with nasopharyngeal carcinoma
Treatment guidelines
o Supportive
 Rest
 Hydration
 Avoid contact sports (splenomegaly)
o Oral steroids for severe pharyngitis
o Antivirals not useful
Pertinent symptoms
o Typical triad of symptoms:
 Fever
 Sore throat (can be exudative)
 Posterior cervical lymphadenopathy
o Other symptoms
 Petechiae on palate
 Fatigue
 Abdominal tenderness/fullness (splenomegaly)
 Headache
 myalgias
Diagnostic criteria
o Often made clinically
o Mono-spot
 But only 50% sensitive in children under 14 years old
o CBC with diff (you will see enlarged lymphocytes with EBV) and LFTs
o IgM: acute (active) infection
o IgG: old infection
o EBV antibodies/titers
 Viral capside antibodies (VCA)
 IgM: appears early and fades in 4-6 weeks
 IgG: peaks at 2-4 weeks and is ALWAYS PRESENT after exposure
 Early antigens (EA)
 Generally associated with reactivation or chronic disease

 Disappears weeks to months after onset
EBV nuclear antigens (EBNA)
 Occurs 2-4 months after exposure then remains for life
Hepatitis


Screening
o Hep A:
 Fecal-oral route: commonly spread via contaminated food or water,
daycare workers, food industry workers, prison inmates and assisted
living facilities
 Can become infected after eating raw shellfish (not primary
route of transmission)
 Highly contagious: 30 day incubation period
o Hep B:
 Spread through blood/body fluid exchange, sexual contact
 Blood and serum: highest concentration
 Risk factors
 IV drug use
 High risk sexual behaviors
 Frequent blood transfusions
 Acute/Chronic forms
 Rarely progresses to chronic form in adults
 OFTEN progresses to chronic form in children
o Hep C
 IV drug use most common mode of transmission
 IV needle sticks from infected patients by healthcare workers
 Most common cause of chronic viral hepatitis
 Acute/chronic forms
 Acute: almost always subclinical
 Typically patients seek care in chronic form
Treatment guidelines
o Hep A
 All cases MUST be reported to state health department
 Supportive
 Avoid contact sports for 2-4 weeks
 Avoid alcohol
 Avoid hepatotoxic meds
 Vaccine available for persons over 12 months old. Some formulations
recommend that child be over 24 months old
 If going to a place where Hep A is endemic, person should get vaccine
and they are generally protected after 4 weeks of the vaccination
o Hep B
 Vaccine:
 Given at birth, then at 1 month, then at 6 months




 Recommended for high risk adults
Acute
 Supportive
o Adequate hydration
o Avoid hepatotoxic meds
Chronic:
 Refer to specialist
 Treated with antivirals
 Interferon alpha
 Vaccine is effective against chronic EBV
o Hep C
 Less responsive to antiviral meds
 Avoid hepatotoxic drugs
 Dose adjustments for meds metabolized by liver
 Referral to specialist for possible interferon therapy
 Avoid alcohol
Pertinent symptoms
o Hep A
 Major cause for traveler’s diarrhea
 Fever and jaundice in eyes, oral mucosa and skin
o Hep B
 Acute: fever, arthralgias, jaundice
 Chronic: can lead to cirrhosis and hepatocellular carcinoma
o Hep C:
 Generally results in chronic hepatitis
 Jaundice
 Predisposes to cirrhosis and hepatocellular carcinoma
Diagnostic criteria
o Hep A
 IgM antibodies for HAV
 Sed rate (ESR): systemic inflammation
 CBC: WBC
 CMP: electrolytes and AST, ALT (LFTs)
o Hep B
 Hep B serology
 CMP/LFTs
 CBC: anemias and WBCs
o Hep C
 Hep C antibody panel
 CMP/LFTs
 CBC
 Liver biopsy is useful in staging (specialist?)
Meningitis (most of the following is with bacterial, what is viral will be denoted)




Screening
o Be suspicious of viral meningitis for those with symptoms that attend daycare
or are in adult living facility
o Bacterial is a reportable condition. Must be reported to health department
Treatment guidelines
o Viral: mainly supportive; self-limiting
 Hydration
 Anti-emetic
 Fever control
 Rest: avoid physical activity
o Bacterial: IV abx, followed by ID/neuro
 Infants/children
 IV Ampicillin or 3rd gen cephalosporin
 Adults (up to age 50)
 IV 3rd generation cephalosporin
 Older adults (over 50)
 IV ampicillin or 3rd generation cephalosporins
Pertinent symptoms
o Headache
o Fever (usually low grade)
o Neck stiffness
o Photophobia
o n/v
o bodyaches
o Viral: similar to bacterial just less aggressive; diarrhea and rash with viral due
to causative agents usually being enteroviruses that are transmitted via fecaloral route
Diagnostic criteria
o GOLD STANDARD: lumbar puncture
o Blood cultures
o CBC
o CT head (if etiology is in question; possible tumor?)
o Physical exam
 Complete neuro exam
 Ear/sinus
 Papilledema
 Inspection for skin rash (viral meningitis)
Lymes
 Screening
o Occurs following a bite from an infected tick
o Most common time of infection: between May and November
o Most common in the Northeastern, mid-Atlantic, and upper north-central
United States as well as northwestern California


o REPORTABLE CONDITION
o Causative organism is the spirochete bacterium Borrelia burgdorferi
Treatment guidelines
o Wear long sleeves and pants in an area with high risk
o Use insect repellent containing DEET
o Preventative: Doxycycline 200 mg as a one time dose as long as it is within 72
hrs of exposure
o Doxycycline 100 mg BID for 14-21 days
 NOT recommended for children under 8 years of age
 NOT recommended for pregnant women
o Amoxicillin 500mg TID for 14-21 days
o Can use EES or Cefuroxime in persons allergic to PCN or intolerant to
tetracyclines
o For late disease may need to increase treatment time to 28 days
 IV antibiotics will be necessary if disease progresses to late stage and
results in neurologic and//or cardiac involvement
o
Pertinent symptoms
o Stage 1: early localized
 Erythema migrans lesion is pathognomic to lyme’s disease; ASSESS
LYMPH NODE CHANGE CLOSEST TO BITE SITE.
 Headache
 Fever
 Fatigue
 Arthralgias
 Stiff neck
o Stage 2: early disseminated
 Multiple EM lesions (3-5 weeks after bite), secondary lesions are
generally smaller than initial lesion (because organism is disseminating
through body)
 Facial palsy
 Meningitis
 Conjunctivitis
 Arthralgias
 Headache
 Fatigue
 Different degrees of heart block (rare)
o Stage 3: late disease
 Symptoms present months or years after initial bite
 Arthritis (usually large joints)
 Encephalopathy/personality changes
 Rarely occurs in children if they have been treated at initial bite
 Some thought that chronic Lyme disease exists
o when people present with symptoms, you usually see stage 2 or 3 (not stage
1). More advanced disease when symptoms present months or years after
 Diagnostic criteria
o Generally based on clinical findings because testing is expensive
o Can be diagnosed based on known exposure
o Serologic testing
 If serologic testing performed at time of bite antibodies may not have
had time to have appear so perform with discretion
 Western Blot IgM, IgG
o Skin biopsy
Salmonella
 Screening
o More common in summer months than winter
o Children under 5 and adults over 65 years old most likely to get severely
infected
o From infected foods, animals.
 Treatment
o Fluids (oral or IV in more severe cases)
o Abx for HIV patients, immunocompromised, greater than 50 years old with
cardiac or valvular issues, any older than 65, severe disease
 Fluoroquinolones
 Azithromycin
 Third gen cephalosporin
 Symptoms: start within 6 hrs-6 days after infection and last 4-7 days.
o Diarrhea
o Fever
o Stomach cramps
o n/v
o headache
 Diagnostic criteria
o Stool or blood culture
E.Coli
 Screening
o Illness can start anywhere from 1-10 days after exposure
o Passed from oral-fecal route
 Treatment
o Supportive therapy
 Hydration
o Abx therapy and anti-diarrheals may increase risk of HUS (hemolytic uremic
syndrome)
 Symptoms
o Severe stomach cramps
o Diarrhea (often bloody)

o Vomiting
o Mild fever
Diagnostic criteria
o Stool culture
Immunology (Module 2A)
13 Questions
Osteoarthritis
 Screening
 treatment guidelines
 pertinent symptoms
 diagnostic criteria
Rheumatoid arthritis
 Screening
 treatment guidelines
 pertinent symptoms
 diagnostic criteria
Sjogren’s
 Screening
o Affects women more than men 40-60 years old
 Treatment guidelines
o Supportive care
 Saline drops
 Hard candies (sugar free)
 Pertinent symptoms/signs
o Fatigue
o RA symptoms
o Presents as dryness in all areas of the body where there are exocrine glands
associated with mucous membranes, most notably the salivary and lacrimal
glands
o Dryness of eye, particulates in them
o Dryness of mouth, loss of taste/smell, recurrent dental caries, dysphagia
o Vaginismus
o Rectal bleeding
 diagnostic criteria
o initially: CBC, RF, ANA, y-globulin profile
o 6 defining criteria

SLE
 Screening
 treatment guidelines
 pertinent symptoms
 diagnostic criteria
Fibromyalgia
 Screening
 treatment guidelines
 pertinent symptoms
 diagnostic criteria
MS
 Screening
 treatment guidelines
 pertinent symptoms
 diagnostic criteria
Hematology (Module 2B)
13 Questions
various anemias, including
Iron deficiency anemia
 Screening
o CBC
 Hgb
 Hct
 MCV
 MCHC
o Serum ferritin

 Treatment guidelines
o Determine cause; if blood loss, determine the site and nature of lesion
 Colonoscopy, EGD, GI/GU eval, bronchoscopy
 Fecal occult blood not always reliable
o Ferrous salts PO TID for 6-9 months
 Can cause constipation, upset stomach, therefore, a lot of noncompliance
 Avoid enteric coated and slow release preparations.
o Patient education:
 Take 1-2 hrs before meals on empty stomach or with meals if GI upset
occurs
 Do not take with antacids, dairy products or tetracycline
 BM will be dark in color
 Place iron drops in the back of the mouth to reduce staining of teeth in
infants and young children
 Vitamin C enhances absorption
 Slowly increase amount of iron if GI upset occurs.
 Pertinent symptoms
o Fatigue, palpitations, headache, tinnitus, pallor, “innocent” systolic murmur,
tachycardia, pica, glossitis, sore tongue
 Diagnostic criteria
o H/H: decreased
o Serum ferritin: decreased
o Serum iron: decreased
o TIBC: increased (wants more iron to bind)
o Transferrin/transferrin saturation: decreased
o Reticulocyte count: decreased
o Peripheral smear microcytic/hypochromic
 Follow-up
o Check Response to therapy: hgb should be half corrected in about 3 weeks and
fully corrected in 8 weeks.
o Has patient been taking iron?
Sickle cell
 Screening
o autosommal recessive disease
o mostly in blacks
o Pain in adults is the rule rather than the exception
o Screening of all newborns regardless of racial background (Sickledex test)
o Rule out sequestration syndromes or possibility of acute conditions
(appendicitis, pancreatitis, cholecystitis, PID, UTI, malignancy)
 Treatment guidelines
o Hydration
o Avoid precipitants for crisis: hypoxia, infections, dehydration, acidosis
o Immunize
o Avoid unnecessary transfusions
o Genetic counseling
o Well-balanced diet with folic acid supplementation
 Pertinent symptoms
o PAIN when in crisis
o “Autosplenectomy” prone to infection
 Diagnostic criteria
o Hgb electrophoresis confirms dx and distinguishes between hgb variants
o Labs:
 ↓ Hgb, Hct, ↑ reticulocytes, leukocytes, thrombocytes common
 ↑ bilirubin and LDH common
 Peripheral smear: sickle cells, target cells, poikilocytosis, hypohromia
 ↑BUN/creat possible with progressive renal insuff
 UA: hematuria, proteinura
Anemia of Chronic disease
 Screening
 Treatment guidelines
o Treat underlying inflammatory or infectious process.
o Erythropoietin (EPO) is successful in patients with chronic kidney disease
whom are not producing EPO

Be careful to make sure that EPO is the problem, because it is very
expensive.
 Pertinent symptoms
o Many times symptoms are from the chronic disease
o Weight loss, anorexia, fever, chills, myalgias, arthralgias
 Diagnostic criteria
o Serum ferritin: normal or increased
o Serum iron: decreased
o TIBC: decreased
o Transferrin/transferrin saturation: decreased
o Peripheral smear: normocytic/normochromic
o Reticulocyte count: decreased
Megaloblastic (vit b12/folate anemia)
 Screening
o Premature infants
o Elderly
o Hyperalimentation
o Alcoholism
o Malabsorption (sprue, celiac disease)
o Pts taking anticovulsant drugs
o hyperalimentation
 Treatment guidelines
o Refer to dietician
o For B12 def:
 Increased dietary intake of meat, peas, beans and other protein rich
foods
 Teach pt to give self b12 shots
 1000mcg once a week for 4-6 weeks then monthy for life
 High doses of oral b12
 Avoid folate supplementation without b12 supplementation
o For folate def
 Increased folic acid in diet (in folate def)
 1-2 mg po daily for 4-5 weeks
 If underlying cause is reversed no maintenance therapy needed,
otherwise, 1mg PO daily indefinitely.
 F/U in 2 weeks to check for response to therapy, HCT should rise in 1
weeks of starting tx
 Pertinent symptoms
o
 Diagnostic criteria
o MMA (methylmalonic acid) and total homocysteine: both increased with b12
deficiency; with folate deficiency: total homocysteine elevated and MMA is
normal
o MCV>110 usually
o Serum b12 levels decreased in b12 def (60% of pts with b12 def will have low
folate levels); serum folic acid decreased in folate def
o Ferritin: normal or increased
o TIBC: normal
o Reticulocyte count: low to normal




Screening
o Family hx
o Autoimmune conditions
o Hx of DMI
o Hx of hashimoto thyroiditis
o Hx of Addison disease
o Hypoparathyroidism
o Graves disease
o Myasthenia gravis
o Intestinal disorders
 elderly
o Diet low in b12 (vegetarians)
o Black females
o Alcohol abuse
Treatment guidelines
o Treat underlying cause
o Treatment of true pernicious anemia is lifelong
o Referral to GI
 Endoscopy every 5 years due to increased risk for gastric carcinoma
o Increased dietary intake of meat, peas, beans and other protein rich foods
o Teach pt to give self b12 shots
 1000mcg once a week for 4-6 weeks then monthy for life
 High doses of oral b12
o Avoid folate supplementation without b12 supplementation
Pertinent symptoms
o Mental changes
 Depression, memory issues confusion. Changes in vision-taste-smell
o Fatigue, pallor, weakness, dizziness, loss of balance, SOB,
o don’t assume the little old 85 yo grandma you see is “kinda” anemic, kinda
weak, kinda forgetting things, kinda clumsy cause she’s “just getting old”…
 failure to treat can result in irreversible neurologic changes
Diagnostic criteria
o Shilling test:
 4 stage test though usually first 2 stages are enough to dx pernicious
anemia.

Stage 1: pt given radioactive Vit B12 PO with IM injection of unlabeled
B12. Purpose of injection is to temporarily saturate all B12 receptors in
liver with enough nml B12 to prevent the radioactive B12 from binding
to body tissues so that it will be absorbed into GI tract and pass into
urine. 24-hr urine collection done. If pt has normal GI absorption,
there will be sufficient levels of radioactive B12 in urine (>5%). If pt has
dysfunctional GI absorption (pernicious anemia, atrophic gastritis, etc.),
less than 5% of radioactive B12 will be detected (in urine).
 If Stage 1 is normal, pt does not have true pernicious anemia or
absorption problems, likely Vit B12 deficiency or something else. If
Stage abnormal, go on to Stage 2: repeat Stage 1 with additional oral
intrinsic factor…if second 24 hr urine shows sufficient radioactive B12,
this means pt lacks intrinsic factor…can dx with pernicious anemia
o MMA (methylmalonic acid) and total homocysteine: both increased with b12
deficiency
o MCV>110 usually
o Serum b12 levels <100
o Folate levels (60% of pts will have low folate levels)
o Ferritin: normal or increased
o TIBC: normal
o Reticulocyte count: low to normal
Myelodysplastic
 Screening
 Treatment guidelines
 Pertinent symptoms
 Diagnostic criteria