Differential Diagnosis and Management of Common Medical Conditions, Exams of Nursing

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Primary Care Two Exam One

A 65 year old woman presents complaining of left sided, throbbing headache along with mild fatigue. On examination, the client has a very tender, tortuous temporal artery. A diagnosis of temporal arteritis is suspected. What test will help the NP confirm diagnosis? - Answer-Serum ESR Maria is a 24 year old female who presents with a chief complaint of fatugue that she has had for a few months. Serum laboratory tests are ordered and her CBC results are as follow: WBC 9.6 (4.5-11) RBC 3.6 (4.5-11) HGB 10.9 (12-16) HCT 33.1 (35-45) MVC 79 (82-100) MCH 27.2 (26-34) PLT 285 (150-450) Iron 42 (200-400) Ferritin 7.8 (10-150) What type of anemia does Maria have? - Answer-Microcytic Anemia

Rita, a 22 year old college student, presents to the office complaining of frequent abdominal pain with bloating that is "relieved by defecation." She states that ofter flare-ups of this problem seem to begin with an increased number of loose stools. It is reported that she also struggles with anxiety disorder. What gastrointestinal disorder is most likely? - Answer-Irritable bowel syndrome Christopher, age 48, presents to the practice complaining of reflux and abdominal symptoms. What symptom warrants immediate referral to gastroenterology? - Answer-Unintentional weight loss (always suspect malignancy) A 44 year old male presents complaining of epigastric pain which occurs two hours after eating and is somewhat relieved with antacids. A urea breath test detects the presence of H.pylori. Which of the following is the preferred treatment regimen? - Answer-Non-bismuth-based quadruple therapy for 10 days (PPI, amoxicillin, clarithromycin, metronidazole, plus probiotics) Which type of leukemia is characterized by the presence of "smudge" cells, usual onset after the age of 50 years, and is often asymptomatic? - Answer-Chronic lymphocytic leukemia What is the least expensive and most appropriate test to evaluate for brain neoplasm? - Answer-CT of head plain A 65 year old male presents to his primary care office. He is an active hiker and spends a lot of time in the mountains hiking. The last time he went hiking was two weeks ago. He complains of fatigue and on exam the NP finds a rash on his elbow. Serologic tests are positive for B. burgdorferi. The patient does not have any neurological or arthritic symptoms. What is the appropriate plan of care? - Answer- Doxycycline 100mg PO BID for 2-4 weeks Lyme ELISA

• Western blot Igg = previous

IgM = current Which of the following symptoms are "red flags" for a secondary headache that warrant either a referral to a neurologist or to the ER? (select all) - Answer-Sudden onset of headache during sexual intercourse Sudden severe headache accompanied by a high fever Unlike platelet disorders, factor disorders commonly present: - Answer-Earlier in life as significant bleeding into the joints or prolonged bleeding after circumcision. A 16 year old girl presents to the office complaining of very heavy menses. Laboratory values reveal a normal platelet count, increased bleeding time and an abnormal Restocetin platelet test. The primary care NP suspects Von Willebrand's disease. What treatment should be initiated while awaiting evaluation by hematologist? - Answer-Avoid ASA and NSAIDs Initiate iron replacement therapy *Von Willebrands is factor deficient = can result in heavy bleeding and should not go untreated A 32 year old male presents to the office with complaints of fatigue, bleeding gums, and night sweats. On exam he is tachycardic and has petechiae on his trunk. The nurse practitioner suspects which diagnosis? - Answer-leukemia The nurse practitioner orders a Hepatits B screening panel on a patient. The results are: HBsAg (Hepatitis B surface antigen) NEGATIVE Anti-HBc (Hepatitis B Core antibody) POSITIVE Anti-HBs (Hepatitis B surface antibody) POSITIVE What is the correct interpretation of the results? Rationale? - Answer-Immunity due to natural infection

*HBsAg is the antigen used to make Hepatitis B vaccine. It is positive in individuals who has been successfully vaccinated against hepatitis B. *Total hepatitis B core antibody (anti-HBc) appears at the onset of symptoms in acute hepatitis B and then persists for life. *Antibodies = immunity *Surface antigen = vaccine A 40 year old male presents to the family practice office with a severe headache. He states the headache woke him from sleep, is unilateral, and that he has had this type of headache twice previously. The nurse practitioner notes lacrimation and rhinorrhea on exam. What would be the treatment of choice? - Answer-Oxygen therapy in the office List one (a) preventative therapy and one (b) alternative treatment option for migraine headache. - Answer-Preventative: Inderal CCB-Verapamil TCA's-amitriptyline AED's-topamax Alternative: B12 Supplement CoQ Butterbur

Abortive Therapy: Tylenol NSAIDs Opioids Triptans: Imitrex

• Triptans, propranolol, and promethazine The NP is caring for a 26 year old female patient who has a history of seizure disorders and is being treated with anticonvulsant phenytoin (Dilantin). During a routine office visit, the patient asks about changing her birth control method. She reports that she is getting married soon and expresses that she and her longtime boyfriend no longer wish to use condoms. She also states that she is unsure if they plan to have children in the future. Which of the following are appropriate contraceptive methods for this patient at this time? - Answer-Diaphragm An intrauterine device NO ORAL BIRTH CONTROL George presents complaining of chronic constipation. What is the best advice the nurse practitioner could give? - Answer-Encourage adequate hydration, frequent exercise, and a high fiber diet. A 38 year old female presents to the office complaining of muscle weakness, muscle spasms, and fatigue. Today she began to experience ataxia. She tells the nurse practitioner the symptoms happened once before approximately one year ago for a few weeks but resolved. The NP is concerned and refers her to neurology for evaluation of what suspected diagnosis? - Answer-Multiple sclerosis relapsing - remitting MS

A 30 year old female with systemic lupus erythematosus presents to the office complaining of ptosis that seems to get worse later in the day? The NP suspects what diagnosis? - Answer-Myasthenia gravis A 66 year old male presents with one week history of low grade fever, nausea, mild left lower quadrant pain, and constipation alternanting with diarrhea. Serum lab values reveal leukocytosis and on exam a mass is palpated in the left lower quadrant. Which of the following is the best treatment option. - Answer-Begin oral antibiotics and limit diet to clear liquids until symptoms improve. Refer to GI for evaluation. Consider diverticulitis and only give PO antibiotic is patient is tolerating PO and not vomiting Jessica, a 50 year old female, presents to the office complaining of severe, sharp, intermittent pain on the right side of her face lasting only a few seconds at a time. She explains that talking and applying makeup seem to trigger the pain. On exam gentle palpation of her right cheek induces a grimace and pain response. The NP suspects trigeminal neuralgia. List two secondary causes that are important to rule out - Answer-MS (always consider MS on young patients with trigeminal neuralgia Giant cell arteritis Which of the following symptoms can be seen in patients who have dementia? (Select all that apply) - Answer-Aggression Overtly sexual behavior Cognitive decline Robert, age 67, presents with symptoms suggestive of parkinsons & #39's disease. What two symptoms must be present to make this diagnosis? - Answer-A resting tremor and bradykinesia

A patient presents with flaccid paralysis of his face. The NP diagnoses Bell's Palsy. The NP knows that the cranial nerve affected is - Answer-VII (seven) A 69 year old female presents to the office complaining of a swollen and painful right lower extremity. A stat venous doppler reveals a deep vein thrombosis. The patient is started on anticoagulation and the NP carefully questions her. The patient does report a recent car trip that lasted several hours but denies any trauma to the leg. She has no previous history of DVT or of spontaneous abortions. What is an important clinical consideration? - Answer-The possibility of an underlying malignancy An older woman complains of having difficulty doing her needlework which is her favorite hobby because of a hand tremor. She has no difficulty walking and no rigidity in her movement is noted. When she places her hands in her lab, the shaking in her hands stops. The woman appears sad and distressed by the tremor. What treatment, if any, is appropriate for this patient? - Answer-Propranolol daily The nurse practitioner is evaluating a group of geriatric clients for risk factors of embolic stroke. Which of the conditions would be least likely to precipitate this type of stroke? - Answer-Diabetes mellitius A clot A-fib valvular disease Endocarditis Which of the following patient presentations most likely represents confusion caused by delirium? - Answer-Nore, diagnosed last week with herpes zoster, and now presents with a one day history of confusion. A high risk sexually active female presents to your office with a history of many partners and no use of barrier protection. She asks to be screened for HIV infection but is not symptomatic. What should the NP do? - Answer-Oreder a HIV rapid antibody test or an HIV ELISA test

Fred is a 70 year old male who presents to the office for his routine exam and labwork. His wife reports he naps daily and seems forgetful. With the following lab results, what type of anemia would the NP diagnose? WBC 7.2 (4.5-11) RBC 3.5 (4.5-11) HGB 11.7 (12-16) HCT 35 (35-45) MVC 110 (82-100) MCH 37.1 (26-34) PLT 210 (150-450) Iron 201 (200-400) Ferritin 10.8 (10-150) - Answer-B12 deficient anemia Nancy has celiac disease. Which diet should the NP prescribe? - Answer-Gluten free diet A 50 year old male has bee diagnosed with GERD. On his last visit 12 weeks ago the NP encouraged him to make appropriate lifestyle changes and ordered a low-dose PPI daily. Today at his follow-up appointment, he presents complaining of continued heartburn. What is the next step in treatment? - Answer-Increase the PPI dose and refer to GI for EGD In addition to a low , what lab test suggests that an iron deficiency anemia is present? - Answer-A decreased ferritin level The NP role in prevention of sickle cell crisis includes: - Answer-Ordering a folic acid supplement and encouraging the patient to get proper amount of sleep

Which areas of Ed's gastrointestinal tract may be affected by crohn's disease? - Answer-All areas from the mouth to the anus. Which of the following statements is true about Bell's Palsy? (select all) - Answer-The onset is usually preceded by a viral illness Difficulty making facial expression (such as smiling) are common A patient is being treated for iron deficiency anemia. The best, mot appropirate way to take her iron supplement is? - Answer-On an empty stomach A patient is found to have anemia. The patient's MCH and MCHC is normal. The patient's anemia can be described as? - Answer-Normochromic Which diagnostic studies are used in the differential diagnosis of systemic lupus erythematosus? - Answer-ANA ESR CRP "Classic" or congenital pernicious anemia results from a deficiency of what substance? - Answer- Intrinsic factor A 26 year old woman presents to the office with hives and severe shortness of breath. She reports being stung by a bee 15 minutes ago. What is the most appropriate initial management? - Answer-Immediate administration of epinephrine SQ and call for EMS to transport her to the closest ER. A middle aged woman presents to the office with pallor, fatigue, and palpitations. She was recently treated for a urinary infection with nitrofurantoin (Macrodantin). On assessment, she has a weak, rapid pulse and pale conjunctiva. Her only significant medical history is G6PD. The NP suspects? - Answer- Hemolytic anemia

*G6PD causes red blood cells to break down in response to medications, infections, and stressors A 58 year old male patient presents to the primary care office with his long term male partner. This is his first visit. After introducing you to his husband, he reports he has been very fatigued. What is the most appropriate to include in the initial exam? - Answer-A careful, detailed history and physical exam A female presents with erythematous confluent eruptions on her face that resembles a butterfly shape. This is characteristic of what disorder? - Answer-SLE (Systemic lupus erythematous) Although the cause of autoimmune disorders is not thoroughly understood, autoimmune disorders have been linked to combination of (select all that apply)? - Answer-Genetic mutation Environmental factors Poor gut microbia Low vitamin D levels What is an appropriate medication to treat moderate allergic response that has not responded to oral antihistamines (example: hives over most of the body with no airway involvement)? - Answer-Medrol Dose Pak After initiating Vitamin B 12 therapy, the nurse practitioner would expect with of the following serum sample at a 6 week follow up visit? - Answer-Increased hemoglobin and reticulocyte count A patient has experienced nausea, vomiting, low grade fever, and diarrhea for 72 hours. His white count is elevated with a shift to the left. What is the most appropriate management? - Answer-Prescribe broad spectrum antibiotic and manage symptoms *Shift to left indicates infection

What serum laboratory test is most helpful in differentiating between iron deficiency anemia versus anemia of chronic disease? - Answer-Ferritin level You suspect Patricia has appendicitis because she has significant abdominal pain when her flexed right thigh is internally rotated? What is this maneuver called? - Answer-The obturator sign Which of the four states of alpha thalassemia is not compatible with life? - Answer-Alpha thalassemia major Jim presents to the clinic complaining of upper abdominal pain. Which lab findings most likely suggests pancreatitis? - Answer-Elevated WBC's Elevated amylase and lipase Normal RBC's Mary, a 46 year old overweight female, presents with a complaint of right upper quadrant pain for several hours. The pain radiates to her right shoulder and she has a low grade fever. She reports she has had similar episodes like this in the past but not as severe. On exam, her RUQ is tender. Which of the following maneuvers, if positive would suggest cholecystitis? - Answer-Murphy's sign test List two risk factors for developing colon cancer. - Answer-Cigarette smoking Family history of colon cancer Steve, age 46, presents complaining of epigastric pain which radiates to his back. He reports the has had the pain for a few weeks and it seems to improve if he sits up straight and leans forward. Steve also has unintentional weight loss and past medical history of smoking. The nurse practitioner suspects? - Answer-Pancreatic cancer

An 18 year old, normal weight female presents to the office complaining of frequent headaches, dizziness, and tinnitus. She also mentions she experiences pruritus after taking a hot shower. On exam the NP notes the skin is red on the face, hands, and feet. Her vitals signs are 154/92, 88, and 12. Initial serum test results suggest a diagnosis of polycythemia vera. What important prevention therapy should be ordered while the patient awaits evaluation by a hematologist? - Answer-Low dose aspirin therapy (to prevent clotting) What presenting symptoms help the NP distinguish anemia caused by Vitamin B12 deficiency versus folate deficiency? - Answer-Vitamin B12 = peripheral paresthesia Folate = focal neurological changes with NO paresthesia