D118 Unit 4 Study Guide

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Western Governors University

D118 Adult Primary Care for the Advanced Practice Nurse

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Unit 4: Acute Illnesses: Urinary, Renal, Dermatologic, Musculoskeletal & Infectious Diseases

Module Vocabulary Key Questions

You should be able to answer these questions upon completing the unit. Add your own notes as necessary.

Managing Acute Urinary Tract and Renal Disorders

Glomerulonephritis is an acute kidney infection that affects both children and adults, most commonly caused by Streptococcus bacteria. Symptoms typically manifest 7 to 10 days after the initial infection.

Nephrolithiasis refers to the formation of kidney stones, which can cause significant pain and obstruction.

Urinary Tract Infection (UTI) can involve any part of the urinary tract—kidneys, ureters, bladder, or urethra.

Urethritis is the inflammation of the urethra, which can be mechanical, chemical, viral, or bacterial in origin. The most frequent type is nongonococcal urethritis (NGU), often caused by Chlamydia.

1. What are the clinical manifestations, diagnostic criteria, and treatment for urinary tract infections?

Condition	Clinical Manifestations	Diagnostic Criteria	Treatment
UTI	Uncomplicated: frequency, urgency, dysuria, suprapubic pain, foul-smelling urine, hematuria. Complicated: fever, chills, flank pain, costovertebral angle (CVA) tenderness, nausea/vomiting (N/V).	Uncomplicated: Urinalysis and urine culture. Sterile pyuria: Negative culture but positive urinalysis. Complicated: Renal ultrasound to check for abnormalities, stones, masses, or hydronephrosis. Persistent cases require urologic referral.	Increase fluid intake. Uncomplicated UTIs in nonpregnant women >16 years: nitrofurantoin or trimethoprim-sulfamethoxazole if resistance is low; alternatives include fosfomycin, ciprofloxacin, levofloxacin, cephalosporins. Pregnant women (first trimester): cephalexin, amoxicillin, amoxicillin-clavulanate, ampicillin. Men: trimethoprim-sulfamethoxazole, nitrofurantoin, amoxicillin-clavulanate.
Urethritis	Men: dysuria, urinary frequency, urethral discharge, pruritus. Women: frequency, nocturia, dysuria, pruritus, fever, hematuria, discharge, pelvic discomfort, back or flank pain.	Urinalysis, gram stain, cultures (especially in young men), wet mount, tests for gonorrhea and chlamydia.	Azithromycin 1g orally in a single dose or doxycycline 100 mg twice daily for 7 days.Second-line: erythromycin, ofloxacin, levofloxacin.
Pyelonephritis	Chills, high fever (>100°F), frequent and painful urination, flank and groin pain, nausea, vomiting, dysuria, urgency.	Urinalysis, urine and blood cultures, CBC, CT scan, kidney ultrasound.	Antibiotics for at least 2 weeks; surgery if urinary tract obstruction occurs.
Nephrolithiasis	Sudden onset of severe pain due to obstruction; intermittent pain suggests partial blockage, constant pain suggests complete obstruction. Pain localized to flank, lower abdomen, genitalia, or groin. Associated symptoms: nausea, vomiting, hematuria, fever, CVA tenderness.	Urinalysis and urine culture to assess pH, presence of bacteria, crystals, and red blood cells. CBC, comprehensive metabolic panel (CMP), parathyroid hormone, vitamin D levels. 24-hour urine analysis for calcium, oxalate, citrate, magnesium, sodium, sulfate. Complete stone analysis.	Hydration, pain management, and expectant stone passage. Specific treatments by stone type: – Calcium stones: thiazide diuretics. – Uric acid stones: urine alkalinization with potassium citrate. – Struvite stones: magnesium ammonium phosphate management. – Cystine stones: urine alkalization plus thiol-binding drugs. Urgent referral to emergency or urologist if severe symptoms occur.

Managing Acute Skin and Nail Disorders

Intertrigo is a superficial bacterial or fungal inflammatory skin disorder caused by persistent skin-to-skin contact with friction, moisture, warmth, and poor ventilation.

Impetigo is a common bacterial skin infection, mostly affecting infants and young children. It has two forms: nonbullous (small vesicles) and bullous (usually caused by Staphylococcus aureus).

Cellulitis is characterized by localized swelling, redness, pain, and warmth. It can be purulent or nonpurulent and sometimes produces pus.

2. What are the clinical manifestations, diagnostic criteria, and treatments for bacterial skin infections?

Infection	Clinical Manifestations	Diagnostic Criteria	Treatment
Impetigo	Lesions with honey-colored crusts, translucent vesicles, or pustules on a moist, erythematous base.	Usually diagnosed by history and physical exam; cultures and gram stain for MRSA in complicated cases. Urinalysis in children 2-4 years to check for acute nephritis.	Topical antibiotics (mupirocin 2% ointment), oral antibiotics (dicloxacillin, cephalexin, azithromycin, amoxicillin/clavulanate), daily washing with antimicrobial cleansers (chlorhexidine gluconate).
Cellulitis	Erythema, induration, warmth, pain, systemic symptoms such as fever and chills; possible bullae, abscess, necrosis.	CBC with differential, renal function tests, gram stain, culture of purulent lesions, blood cultures, imaging if needed.	Oral antibiotics, NSAIDs; severe cases may require IV antibiotics targeting MRSA (vancomycin, daptomycin, linezolid, telavancin, ceftaroline). Incision and drainage if abscess present.
Intertrigo	Erythema, peripheral scaling, macerated erythematous plaques; itching, burning, stinging; odor and discharge if secondary infection present.	Clinical diagnosis; scrapings for KOH wet mount, gram stain; Wood lamp for erythrasma identification.	Antifungal or antibacterial topical agents depending on causative organism.
Furuncle/Carbuncle	Red, hot, tender nodules often evolving from folliculitis, accompanied by fever and malaise.	Clinical examination.	Incision and drainage; antibiotics if systemic symptoms are present.

Viral Skin Infections

3. What are the clinical features, diagnosis, and treatments for viral skin infections such as warts?

Warts caused by human papillomavirus (HPV) present as firm, small, skin-colored papules, often on hands and feet. Plantar warts are thicker, rough plaques on the soles.
Diagnosis is typically clinical, confirmed by observing pinpoint capillaries during debridement.
Treatments include topical agents, cryotherapy, laser ablation, or surgical removal.
Tinea corporis (ringworm) manifests as erythematous plaques with raised borders and central clearing.
Tinea versicolor causes cosmetic hypopigmented or hyperpigmented patches, mostly asymptomatic.

Fungal Infections

4. What are the clinical presentations and management of superficial fungal infections?

Fungal Infection	Clinical Presentation	Diagnostic Criteria	Treatment
Dermatophyte tinea	Annular, arcuate lesions with or without scale and central clearing; possible pustules and itching or burning.	KOH microscopy, Wood lamp examination for specific species.	Topical antifungal creams and medicated shampoos; oral antifungals for nails/scalp involvement.
Tinea versicolor	Hypopigmented or hyperpigmented scaly papules and plaques, commonly on trunk, neck, and arms.	KOH prep, Wood lamp, skin culture, liver function tests.	Topical antifungal agents first line; systemic antifungals for extensive or resistant cases.
Candidiasis	Thrush with white or gray plaques on mucous membranes; vaginal candidiasis with itching, discharge, maceration.	KOH prep, skin culture, biopsy if needed.	Oral nystatin, clotrimazole troches, fluconazole for oral thrush; topical or oral antifungals for other sites.

Dermatological Office Procedures

5. What are the indications, contraindications, precautions, and preparation involved in dermatological procedures?

Cryosurgery uses liquid nitrogen to freeze and destroy skin lesions; contraindicated in cold intolerance and certain blood disorders. Patients with darker skin are at risk for pigment changes. Protective measures are essential near sensitive areas.
Electrocautery employs electric current for cutting or cauterizing tissue, useful in treating vascular lesions and some skin cancers.
Curettage involves scraping lesions with a curet and is used for seborrheic keratoses, warts, molluscum, and some skin cancers. Local anesthesia is usually required.

Parasitic Infestations

6. What are the clinical signs and treatment options for common parasitic skin infestations?

Scabies presents as small papules and serpiginous burrows in characteristic locations, often with intense itching. Crusted scabies is highly contagious and occurs in immunocompromised individuals. Treatment involves topical permethrin 5% cream or oral ivermectin.
Pediculosis capitis (lice) causes itching with visible nits and lice on hair shafts, especially near the neck and behind ears. Treatment is with permethrin or prescription agents for young children.
Bed bugs cause itching, wheals, and blood stains on bedding; eradication of infestation and symptomatic relief are primary treatments.

Adnexal Diseases (Hair, Sweat Glands, Nails)

7. What are the presentations and treatments for common adnexal disorders such as acne, rosacea, and hyperhidrosis?

Acne vulgaris: Characterized by comedones, papules, pustules, or nodules primarily on the face, neck, and upper trunk. Treatment aims at normalizing follicular keratinization, reducing sebum, and inflammation with topical retinoids, antibiotics, or hormonal therapies.
Rosacea: Presents with facial flushing, erythema, papules, pustules, telangiectasia, and ocular irritation. Management includes topical metronidazole, oral antibiotics, and lifestyle modifications.
Hyperhidrosis: Excessive focal sweating impacting daily life, diagnosed clinically. Treatments include topical aluminum chloride, oral anticholinergics, and botulinum toxin injections.
Hidradenitis suppurativa: Chronic, painful abscess formation in apocrine gland–rich areas, managed with antibiotics, anti-inflammatories, and sometimes surgery.

Minor Burns

8. What are the clinical features, examination steps, and management for minor burns?

Burns are classified by depth:

First-degree burns affect only the epidermis, appearing red, glossy, and painful (e.g., sunburn).
Second-degree burns involve the dermis, with blistering and severe pain.
Third-degree burns extend into subcutaneous tissue, with a dry, white or charred appearance and insensitivity due to nerve destruction.

Examination must assess airway, breathing, circulation, burn depth, total body surface area (TBSA), and associated injuries. Circumferential burns can impair limb perfusion.

Management includes applying topical antimicrobial creams (e.g., silver sulfadiazine), using non-adherent dressings, analgesics, and tetanus prophylaxis as needed.

Dermatitis and Other Skin Conditions

9. What are the clinical presentations and management strategies for different types of dermatitis?

Dermatitis Type	Clinical Features	Physical Exam Findings	Management
Eczematous (Atopic)	Pruritic, erythematous, dry patches often with scaling; chronic scratching leads to lichenification.	Poorly defined lesions with crusting, oozing; thickened skin with marked scratching lines.	Patient education, avoidance of triggers, antihistamines, topical steroids, emollients.
Contact Dermatitis	Itching, burning, redness, swelling with well-demarcated scaly, vesicular, or maculopapular lesions.	Inflammation localized to contact areas, sometimes linear patterns (e.g., poison ivy “rhus lines”).	Avoid irritants/allergens; topical corticosteroids; symptomatic care.
Seborrheic Dermatitis	Mild to severe red, flaky, scaly patches on scalp, face, ears, trunk.	Yellow or white greasy scales, commonly called cradle cap in infants.	Antifungal shampoos, topical corticosteroids, keratolytic agents.
Cutaneous Drug Reactions	Variable skin eruptions ranging from mild rashes to severe reactions like Stevens-Johnson Syndrome.	Erythema, pustules, bullae, systemic symptoms depending on severity.	Drug discontinuation, supportive care, steroids, hospitalization for severe cases.

Exam

Patches presenting as poorly defined, greasy-appearing areas over inflamed skin are commonly observed, accompanied by mild itching or a burning sensation. These lesions frequently appear in specific regions such as the nasolabial folds, ears, eyebrows, and hairline. However, they may also manifest in intertriginous areas like the groin, axilla, and mid-chest. This condition is typically chronic, causing cosmetic discomfort, but in some cases, it can progress to infection, especially in moist skin folds and eyelids.

Management

Treatment usually involves topical corticosteroids, antifungal shampoos such as ketoconazole or sulfide shampoos, antifungal agents like ciclopirox, zinc paste, and tacrolimus ointment. Consistent management can alleviate symptoms and reduce recurrence.

Stasis Dermatitis

Clinical Manifestation

Stasis dermatitis arises due to impaired circulation, particularly affecting the lower extremities, which results in fluid accumulation and skin inflammation.

Examination

The skin often shows discoloration and itching; in advanced cases, ulcers may develop, especially in patients with peripheral arterial disease (PAD) or peripheral vascular disease (PVD).

Management

Treatment focuses on symptom relief and prevention of complications. Key interventions include elevating the legs, wearing compression stockings to improve venous return, and applying topical corticosteroids to control inflammation. In some instances, surgical procedures are necessary to correct underlying venous insufficiency.

Urticaria (Hives)

Clinical Manifestation

Urticaria is characterized by transient outbreaks of raised, itchy papules or wheals appearing anywhere on the body, often with intense pruritus.

Examination

Lesions typically resolve within hours to days but may recur with varying severity.

Management

Avoidance of known triggers is essential. Pharmacological treatment may include epinephrine in severe cases, antihistamines such as diphenhydramine (Benadryl), and over-the-counter topical creams to relieve itching.

Clinical Presentation, Physical Examination, and Management of Corns and Calluses

Aspect	Details
Clinical Manifestation	Corns are painful lesions typically located between toes or on the dorsal surfaces, whereas calluses are often asymptomatic thickened skin areas.
Examination	Corns appear as erythematous, tender lesions often associated with deformities like hammertoes. Calluses show as thickened, hardened epidermal layers that may protect underlying plantar warts or foreign bodies.
Management	Prevention through avoiding tight footwear and using pressure-relieving corn pads is critical. Regular debridement with a file or scalpel helps reduce lesion size. Applying powders or cotton (like lamb’s wool) between toes prevents moisture buildup. Orthotic devices may be necessary for structural foot deformities, and surgical correction is considered for hammertoes. Diabetic or PVD patients require close monitoring to prevent infection or ulceration. Daily use of moisturizers and pumice stones aids in maintenance.

Nail Disorders

Herpetic Whitlow

Clinical Manifestation: Painful herpetiform vesicles or blisters occur on the distal phalanx, accompanied by throbbing, tingling, numbness, or itching.
Examination: Inspection should focus on nail shape, texture, and presence of vesicles. Lymph nodes (axillary and epitrochlear) need assessment for lymphadenopathy. Examination for genital herpes is advisable if symptoms are present.
Management: Incision and drainage (I&D) are sometimes required; cool compresses and dry dressings are recommended. Patients should avoid touching their mouth and eyes to prevent viral spread. Persistent symptoms beyond three weeks warrant medical review.

Paronychial Infections

Clinical Manifestation: Localized pain, erythema, swelling, and sometimes purulent discharge around the nail fold; possible nail changes such as onycholysis and discoloration.
Examination: Tenderness and possible pus release upon pressure. Greenish nail discoloration may suggest Pseudomonas infection.
Management: Warm soaks or compresses several times daily and keeping the area dry. I&D may be necessary if an abscess forms. Topical antibiotics are commonly used.

Onychomycosis

Clinical Manifestation and Examination: Thickened, discolored, and brittle nails.
Management: Oral antifungals are the primary treatment, with topical agents reserved as adjunct therapy.

Musculoskeletal Injuries and Illnesses

Condition	Clinical Manifestation	Examination Findings	Management
Sprains and Strains	Pain, swelling, muscle spasm (strain); edema, bruising (sprain)	Inspection for deformity, ROM limitation; guarding and grimacing	Rest, Ice, Compression, Elevation (RICE), splinting, physical therapy, NSAIDs
Fractures	Pain, swelling, skin discoloration, deformity	Palpation for neurovascular status; visible deformity	Immobilization, possible surgery, pain management
Bursitis	Swelling, warmth, erythema, pain in elbow, hip, knee, or heel	Localized swelling, fluctuance; tenderness	Aspiration if septic; NSAIDs, antibiotics, local corticosteroid injections, activity modification
Carpal Tunnel / De Quervain’s Tenosynovitis	Pain at base of thumb, radiating along tendon	Tenderness, limited ROM	Splinting, NSAIDs, physical therapy, corticosteroid injections
Sciatica	Radiating leg pain with limited ROM	Neurological deficits on exam	NSAIDs, physical therapy, rest
Hand/Wrist/Elbow/Shoulder Pain	Localized pain, numbness, weakness	Inspection, palpation, ROM, grip strength, neurological testing	NSAIDs, physical therapy, splinting, injections, surgery if indicated
Neck and Low Back Pain	Pain, limited movement, possible neurological signs	Observation of posture, gait, ROM, neurological exam	NSAIDs, physical therapy, rest, possibly imaging

Infectious Diseases: Clinical Presentation, Examination, and Management

Disease	Clinical Manifestation	Examination Features	Management
Lymphadenopathy	Swollen, painful, or firm lymph nodes	Location, size, firmness, tenderness, symmetry	Treat underlying cause; possible biopsy if malignant
Fever (Pyrexia)	Elevated body temperature as part of immune response	Physical exam varies with underlying infection	Supportive care, antipyretics, treat underlying cause
Infectious Mononucleosis	Fever, sore throat, lymphadenopathy	Diffuse cervical lymphadenopathy, splenomegaly	Supportive care; steroids if severe; avoid antibiotics to prevent rash
Tuberculosis	Chronic cough, weight loss, night sweats, fever	Rales, pleural effusion, lymphadenopathy	Multi-drug therapy tailored to clinical classification
Lyme Disease	Erythema migrans rash, flu-like symptoms, joint pain	Expanding circular rash, regional lymphadenopathy	Early oral antibiotics; supportive care
Rocky Mountain Spotted Fever	Fever, rash, headache	Petechial rash, systemic signs	Prompt antibiotic therapy
Zika Virus	Fever, rash, conjunctivitis	Neurological symptoms possible	Supportive care, mosquito control
Influenza	Fever, chills, malaise, cough	Usually normal chest exam	Symptomatic treatment; antiviral agents within 48 hours
Mosquito-Borne Illnesses	Weakness, paralysis, rash, conjunctivitis	Rash, jaundice, lymphadenopathy	Supportive care, mosquito control, public health notification

Summary Table: Infectious Disease Management

Disease	Treatment Highlights
Bacterial infections	Antibiotics tailored to pathogen
Viral infections	Supportive care, symptomatic relief
Tick-borne diseases	Early antibiotic intervention (e.g., doxycycline for Lyme)
Mosquito-borne illnesses	Vector control, symptomatic management
Tuberculosis	Prolonged multi-drug therapy

References

Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (2017). Dermatology (4th ed.). Elsevier.
James, W. D., Berger, T. G., & Elston, D. M. (2015). Andrews’ Diseases of the Skin: Clinical Dermatology (12th ed.). Elsevier.
Longo, D. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Jameson, J. L., & Loscalzo, J. (2018). Harrison’s Principles of Internal Medicine (20th ed.). McGraw-Hill Education.
Habif, T. P. (2015). Clinical Dermatology (6th ed.). Elsevier.
UpToDate. (2023). Management of common skin infections and inflammatory skin disorders. Retrieved from https://www.uptodate.com
Centers for Disease Control and Prevention. (2023). Lyme Disease. Retrieved from https://www.cdc.gov/lyme/index.html