self care exam 2

HPV transmission

○Person-to-person

○Auto-inoculation

○Contaminated surface

HPV causes warts

Common Warts description

Skin- colored/brown, dome-shaped, rough surface;

typically painless

Flat Warts description , what happens if on face

smooth, flat topped, yellow-brown papules

if on face, exclude self treatment

Plantar Warts vs Mosaic Warts

plantar: callus like, can be painful

mosaic: Multiple, closely grouped plantar warts

Filiform Warts

Flesh-colored, rapidly growing, thread-like projections

Periungual warts

Thickened, fissured, cauliflower- textured skin around the nail plate

bc of nail biting

treatment of warts, goals of treatment

wait and watch

goals: no scarring or recurrence, eliminate signs and symptoms, prevent HPV spread

non pharmacologic HPV warts, symptomatic relief, management points

prevent HPV spread- dont pick at warts, no barefoot, keep it covered, dont share personal stuff

symptom relief—> lamb’s wool or moleskin

vitamin A, zinc, garlic, duct tape

pharmacologic therapy HPV warts, counseling points and which is better

Salicylic Acid → only for common(17%) and plantar(higher concentration) warts

• dont use more than 12 weeks

• if on foot-→ use 40%

cryotherapy→ uses liquid nitrogen OR nitrous oxide or a mix of dimethyl ether and propane

• blister forms under wart and it falls of in 10 days

• 20 seconds for common, 40 for plantar

for both→ wash hands before use to soften it and better penetration

both are effective, if on hand tho cyrotherapy maybe more effective

wart exclusion for self treatment

• preggo/lactating women bc Teratogenic concerns with salicylic acid

• children < 3 for sali and <4 for cryo

• diabetes and poor circulation

• Immunocompromised patients

corns vs calluses

corns→ central core, on foot, can be smooth or hard; prolly caused by tight fitting shoes; painful

calluses→ broad base, even thickening

calluses non-pharm therapy

soak in warm water atleast 5 min,

Circular foam cushioning pads,Well-fitting, non binding footwear, Orthopedic corrections

pharm therapy calluses and application

Salicylic Acid→ Swells, softens, macerates, then desquamates affected epithelium

warm water then sali acid

17% and 40% available

calluses exclusion criteria for self treatment

>14 days→ go doc

diabetes, hemorrhaging/ pus, Extensive or painful, unsuccessful self-medication, hx of rheumatoid arthritis, body weight distribution issues

causes of hair loss

Causes→ Postpartum period, Fever, Infections, Endocrine Disorders (e.g.hypo/hyperthyroidism, diabetes),Anticonvulsants, chemotherapy agents, Rapid weight loss

which alopecia is the self treatable option

Androgenetic alopecia (AGA)

exlcusion for self treatment alopecia

<18 yo, women, hx/concominant of medical treatments, more serious underlying conditions

alopecia pharm therapy, and CIs

Minoxidil (Rogaine)→ Increases hair follicle blood flow and prolongs anagen phase

• dont use in preggo

Annual Deaths Attributable to Smoking

480k+ annually

includes first and second hand smoking

how many cigarettes in each pack

20

smoking is a risk factor for what

oral cancer/disease

The 5 A’s in smoking cessation and STAR method

Ask, Advise, Assess, Assist, Arrange

Assist:

• STAR method:

  • Set a quit date

  • Tell family, friends, coworkers

  • Anticipate challenges

  • Remove tobacco products from environment

Nicotine Patch Dosing and couseling

dependent on # of cigarettes smoked

>10 cigs→ start with 21mg, 14mg, 7mg (4,2,2 wks)

<10 cigs→ 14mg, 7mg (6,8 wks)

• remove before MRI bc has metal in it, don’t cut patches

Nicotine Gum/Lozenge Dosing

dosing dependent on when pt smokes when they wake up

Smoke first cigarette within 30 minutes of waking → 4 mg

Smoke first cigarette after 30 minutes of waking → 2 mg

• 12 weeks, decrease frequency of chewing between weeks

• use atleast 9 pieces;

• dont exceed 24 gums, 20 lozenges

Bupropion(Zyban®) moa, dose, CIs

Bupropion 150mg: Blocks neuronal uptake of dopamine and, to a lesser extent, norepinephrine; reduces craving

• start 1-2 wks before quit day; no tapering rep

• delays weight gain

• CI:

  • Seizure disorder

  • Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic, drugs

  • hx of bulimia or anorexia

  • Use of MAO inhibitor within previous 14 days

  • Initiation in patients receiving linezolid or intravenous methylene blue

Varenicline(Chantix) moa, how to start

Varenicline: Partial nicotinic receptor agonist, Binds selectively to α4-β2-nicotinic acetylcholine receptors with a greater affinity than nicotine

• decreases withdrawl symptoms

Starting:

• 1wk before quit day

• start and establish quit day btw 8-25 days

• start and reduce smoking for 12 wks, then stop smoking and stay on therapy for 12 wks

EAGLES study

bupropion and chantix black box warnings were removed, not statistically significant

heartburn and Dyspepsia symptoms

heartburn: "Burning" sensation rising from the abdomen that can radiate to the neck; acid regurgitation

Dyspepsia: Indigestion with symptoms like bloating, upper ab pain, painful fullness

Heartburn vs Dyspepsia exclusion criteria and alarm symptoms

>45yo, preggo, or <12yo children

• frequent symptoms >3 months, >2wks of OTC

• severe/nocturnal

• difficulty pain, swallowing

• continuous, persistent nausea, vomiting, diarrhea

• unexplained weight loss

Alarm symptoms→ REFER

• Heartburn: vomiting, painful swallowing

• Dyspepsia: anemia, >45yo

• Both: difficulty swallowing, GI bleed, unexplained weight loss

Self-Treatment Heartburn, Dyspepsia

Mild infrequent→ can do normal activities→ Antacids or low dose H2RAs PRN

Mod infrequent→ cant do normal activities→ H2RAs

Frequent→ Symptoms occur ≥ 2 days/week→ PPIs

Moas antacids, H2RAs, PPIs, Bismuth Subsalicylate

Antacid→ Neutralize excess gastric acid, inhibits pepsin activation and Cytoprotective effects(mucus, bicarb secretion)

H2RAs→ Competitively inhibit histamine at H2 receptors on gastric parietal cells; Reduce gastric acid secretion, regardless of food presence

PPIs→ Inhibit H+-K+ ATPase

Bismuth Subsalicylate→ Binds bacterial toxins in GI tract - suppresses growth of H. pylori

Antacids electrolyte ades: Sodium bicarbonate, Calcium carbonate, Aluminum salts, Magnesium salts

Sodium bicarbonate: Sodium overload

Calcium carbonate: Hypercalcemia

Aluminum salts: Hyperaluminemia, Hypophosphatemia

• constipation too

Magnesium salts: Hypermagnesemia

Bismuth Subsalicylate ADE

black tongue and stool

Intestinal Gas treatments(moa), prevention(moa) and non-pharm way

Simethicone: Defoaming agent to relieve it, Reduces surface tension of gas bubbles

Prevention:

Lactase Replacement(Lactaid): Breaks down lactose into glucose and galactose, admin w first bite

α-D-galactosidase(Beano®): Promote digestion and prevent gas formation

Lifestyle:

smoking cessation, eat/drink slowly, dont chew gum, dont lie down after eating immediately

Gas exclusion criteria

persist for several days and occur several times per month, severe debilitating symptoms, Increased symptom severity and/or frequency, >40yo

N&V Impulses received from sensory centers

Chemoreceptor trigger zone (CTZ)

• Neurons stimulated by toxins and drugs

• Cerebral cortex

Sensory inputs (sights, smells, toxins)

Visceral afferents: pharynx, GI tract

Vestibular apparatus

• Detects changes in equilibrium (ear i think)

• Motion sickness

Exclusion for Self-Treatment N&V ADULTS

food poisoning >24hrs, fever, diarrhea, Severe right upper quadrant pain, blood in vomit, dark urine, head injury, jaundice, cancer, ADRs

Severe symptoms in pregnancy or nursing

N&V treatment for Pregnancy, Motion sickness, Overeating, Food poisoning, Medication use

Pregnancy→ refer

Motion sickness→ OTC antihistamines

Overeating→ Antacids, H2RAs, bismuth-containing products, or phosphorylated carbohydrate solution

Food poisoning→ Oral rehydration solutions

Medication use→ consult w prescriber

Exclusion for Self-Treatment N&V CHILDREN

stiff neck, <6 months OR <8kg, refusal to drink fluids, vomitting after eating, dehydration, >8hrs continous vomiting, diarrhea, red/green/blue fluid vomit

N&V treatment approach in children for motion sickness, Gastroenteritis, Episodic or situational nausea or vomiting

Motion sickness→ OTC antihistamines

Gastroenteritis→ Oral rehydration solutions like pedialyte (no antiemetics)

Episodic or situational nausea or vomiting→ Initiate phosphorylated carbohydrate solution

Antihistamines moa

Reduce stimulation of bony labyrinth in temporal lobe

• not meant for preggo vomitting

• Monitor for increased risk of anticholinergic effects

Phosphorylated Carbohydrate Solution moa

Osmotic effect delays gastric emptying and GI motility

• can cause diarrhea

Bulk-Forming Laxatives moa

retain water

Agents:

Psyllium (Metamucil®)

Methylcellulose (Citrucel®)

Calcium polycarbophil (FiberCon®)

Hyperosmotic Laxatives – Saline vs Polymer Type moa and agents

Saline: draw fluid into intestine via osmosis,

• oral sodium Phosphate→ nepropathy BBW

Agents:

Magnesium citrate

Magnesium hydroxide

(Milk of Magnesia®)

Sodium phosphates (Fleet® Enema)

• can cause dehydration and electrolyte changes

Polymer: contain large ions that draw water into colon through osmosis,

Agents

PEG3350 (MiraLAX®)

Glycerin suppositories

• can cause bloating, flatulence

Stimulant Laxatives moa

stimulates peristalsis by local mucosal irritation; increase intestinal secretion of water and electrolytes

more aggressive

Agents

Senna (Ex-Lax®)

Bisacodyl (Dulcolax®)

Castor oil

Stool Softeners – Emollients moa

anionic surfactants that increase wetting efficiency of water in

intestine to soften fecal mass

○ Decreases stool surface tension

Agents

Docusate sodium (Colace®)

Docusate calcium

Stool Softeners – Lubricant moa and ADE

Coats stool to prevent colonic absorption of fecal water

ade: Lipoid pneumonia due to aspiration from oral administration (dont take before lying down)

Agents

Mineral oil

Hemorrhoids: Exclusions for Self-Treatment

<12 yo, comorbidities, hx of colon cancer, unresposive to 7 days of treatment, acute onset w severe pain/ bleeding etc

Hemorrhoids external vs internal application

External: Temporary relief of external anal symptoms (itching, irritation, burning, discomfort, soreness)

• Local anesthetics, Keratolytics Analgesics, anesthetics, antipruritics, Corticosteroids

Internal: Relief of anorectal pain, bleeding, seepage, and prolapse

• Astringents, Protectants, Vasoconstrictors

Diarrhea treatment approach and moa

Correction of fluid and electrolyte loss

• Oral rehydration solutions: Pedialyte®

3. Symptomatic relief with OTC meds

• Antidiarrheal agent: loperamide (Imodium AD®)

  • selective opioid agonist in gut

• Antisecretory agent: bismuth subsalicylate (Pepto Bismol®)

  • increases body's absorption of water from gut

Preparation H moa

constricts blood vessels to relieve swelling and irritation

Bacterial Vaginosis hallmark symptoms and treatment

fishy odor, Thin (watery), white or gray, and/or foamy discharge

NO OTC meds/self treatment; Clindamycin or Metronidazole

Trichomoniasis signs/symptoms and treatment and unique

Frothy, malodorous, yellow-green (or discolored) discharge, strawberry cervix, little polyps in cervix(hallmark)

Treatment: not OTC: Metronidazole or Tinidazole

TREAT PARTNERS

Vulvovaginal Candidiasis signs/symptoms

thick, white cottage cheese, bready no odor→ hallmark

Vulvovaginal Candidiasis self care when and refer when?

mild-to-moderate classic symptoms, infrequent vaginal symptoms, and antibiotic- associated VVC

refer→ 1wk after treatment or reoccurrence in 2 months

Vulvovaginal Candidiasis self care exclusion

preggo, <12yo, First vulvovaginal episode, comorbidities, warfarin pts, >3 in 1 year, or if one <2 months ago

7 vs 3-Day Treatment VVC

same efficay; CDC reccomends 7 day in preggo and diabetes pts

giving: Vaginal antifungal agents (imidazole antifungals)- Minicanazole, Tioconazole

Dysmenorrhea signs and treatment

difficulty/painful menstruation; cramping, pain, N&V, diarrhea, headache

primary(cramp at lower ab) vs secondary(pelvic pain)

no self care for secondary

for primary: NSAIDs, Acetaminophen, Aspirin

Dysmenorrhea exclusion for self treatment

secondary, hx of PID, allergy to asprin or NSAID, bleeding disorder

PMS signs/symptoms and treatment

irritability, bloating, depression, anxiety

treat: Vitamin B6, Tocopherol/Vitamin E, Calcium, Magnesium, NSAIDs, Diuretics, Combination Products

PMS exclusion criteria and CI

severe, atypical timing of symptoms, onset bc of contraception, CI to agents

Xanthines are contraindicated w hx of taking MAOis in PMS

Toxic Shock Syndrome symptoms and treatment

Approximately 5-12 days after onset of TSS, desquamation of the skin on the patient's face, trunk, and extremities

• hallmark

cant treat OTC

TSS counseling points

rare/small risk

change tampons every 6 hours or product instructions; alternate between pads and tampons

Condoms main counseling point

dont use male and female condom at the same time

Vaginal spermicides ade

can increase risk of STIs

contraceptive sponge ade

Increased risk for TSS

Opill counseling point missed dose

If >3 hours late(considered missed dose): Take one tablet immediately, then return to taking a daily tablet at the usual time

Emergency contraception counseling point

doesnt protect pregnancies after treatment or against STIs

Headache Referrals

severe pain, >10 days w/wo treatment, migrane wo diagnosis, basically any extreme

<8yo, preggo

Headaches treatments for sinus, tension and migraine

sinus→ Decongestant +/- OTC analgesics

Tension→ OTC analgesics work well + relaxing techniques

Migraine→ OTC w Rx

OTC→ NSAIDs or acetaminophen

Children’s Acetaminophen dosing

<12yo→ 10-15mg/kg Q4-6h prn; MDD- 5 doses

>12yo→ 325-1000mg q4-6h; MDD= 3000mg

Acetaminophen counseling points

• Dont use if drinking alc, 

• Max 3000mg dose for >=12yo

• NOT for inflammation

Ibuprofen (IBU) / Naproxen (NAP) moa, indications

Reversible peripheral COX-1 and COX-2 inhibition

indications: Analgesic - Mild-moderate, Antipyretic, Anti-inflammatory

Children and Adult Ibuprofen dosing

Children→ 5-10mg/kg q6-8h; MDD→ 4 doses

Adult→ 200-400mg q4-6h→ 1200mg

Tympanic (Aural) thermometer use

• <1yo: Pull ear back

• 1yo+: Pull ear back and up

• Point to back of eyes;

• Not for <6 months

Fever referals

> 3 days with or without treatment, Suspected infection, impaired labs/functions,