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NR 511 FINAL
Identify the population most commonly affected by bacterial prostatitis - CORRECT ANSWER
- o Acute - Sexually active men 30 to 50 years
- Chronic bacterial prostatitis common in men older than 50 years old
- Athletes who run long distance are predisposed
- Complaints of fever, chills, LBP, malaise, arthralgia, myalgia, frequency, urgency, dysuria, nocturia, and bladder outlet obstruction o Chronic bacterial prostatitis- men over age 50 years of age. Symptoms often absent , perineal pain, lower abdomen pain, scrotal or penile pain, pain with ejaculation, dysuria, irritative voiding Discuss the physical exam characteristics of acute bacterial prostatitis - CORRECT ANSWER - Acute bacterial prostatitis- warm, tense, swollen , boggy and very tender prostate. Most common pathogen Strep faecalis and staph aureus Discuss how the Phren sign can differentiate between testicular torsion and epididymitis - CORRECT ANSWER - Epididymis characteristic is relief of discomfort with elevation of testis. Positive Prehn's sign = pain relief. Testicular torsion elevation of the affected testicle does NOT relieve the pain (Negative Prehn's sign = pain is NOT relieved) Epididymis Positive Prehn's sign = pain relief. Neg = no pain relief = testicular torsion). Discuss common symptoms reported from a patient with BPH - CORRECT ANSWER - Affects men age 40 years and older. Obstructive symptoms include
- Decreased stream • Hesitancy
- Postvoid dribbling • Sensation of incomplete bladder emptying
- Overflow incontinence • Inability to voluntarily stop the urine stream
- Urinary retention • Straining Irritative symptoms include
- Nocturia • Urinary frequency
- Urinary urgency • Dysuria Urge incontinence Erectile dysfunction should be assessed on patient taking finasteride. Discuss the hallmark characteristic of a varicocele - CORRECT ANSWER - The hallmark characteristic of varicocele is the sensation that the testes feel like a "bag of worms." Varicocele can be bilateral, but if it is unilateral it is almost always on the left side due to the anatomy of the vasculature drainage in the testes. Tortuous veins posterior and above testes can be seen with patient sitting upright Venous engorgement may increase with Valsalva maneuver; resolves when patient lies down. Grade 1 varicocele is one that is palpable only when the patient performs the Valsalva maneuver. Grade 2 varicocele is palpable when the patient is standing. Grade 3 varicocele may be assessed with light palpation and visual inspection
o Sphincter tone decreased o Don't confuse w/ prostate problems in older men Identify the red flags associated with back and neck complaints which warrant further investigation - CORRECT ANSWER - T-Trauma U-Unexplained weight loss N-Neurologic symptoms A-Age> F-Fever I-Iv Drug user S-steroid use H-Hx of CA (prostate, renal, breat, lung) Define chronic pain - CORRECT ANSWER - • Pain that extends beyond the expected period of healing
- Pain > 3 months in duration
- More generalized, less localized to the site of injury/initial complaint
- Referral patterns can shift in location, intensity, frequency & quality
- Pain does not change with movement, rest or time
- Usually reported as constant/continuous (less likely intermittent)
- Mood or current psychological status tends to affect/worsen c/o pain Identify the number of joints involved in a poly-articular disorder - CORRECT ANSWER - Monoarticular: One joint Periarticular: Two to four joints Polyarticular: Four or more joints Describe the four cardinal signs of joint inflammation - CORRECT ANSWER - 1. Erythema
- Warmth
- Pain
- Swelling DeQuervain's Tenosynovitis - CORRECT ANSWER -- Inflammation involving the synovial sheaths and tendons of the abductor pollicis longus and extensor pollicis longus, and brevis tendons (snuff box)
- Pain at base of thumb or at the radial styloid process on abduction and extension of the thumb or on radial side of wrist with lifting
- Generally seen in patients that perform pinch-grip activities like using hand tools, sewing, assembly
- More often middle-aged women DeQuervain's Tenosynovitis-Exam - CORRECT ANSWER - o Allen's test o Phalen's test (negative) o Tinel's sign (negative) o Confirmed by Finkelstein's test (grasp the thumb in the palm while you deviate the wrist to the ulnar side) o Xray only if history of trauma DeQuervain's Tenosynovitis-treatment - CORRECT ANSWER - o Rest, splinting for 3-6 weeks o NSAIDS o Injected corticosteroids o Tendon release surgery. Carpal Tunnel Syndrome: - CORRECT ANSWER -- Peripheral nerve compression of the medial nerve
- Caused by repetitive flexion and extension of the wrist or direct compression of medial nerve
- Pain and/or numbness are usual presenting symptoms
Treated with rest, ice, NSAIDS, PT, and possible corticosteroid injections and splinting. Medial epicondylitis - CORRECT ANSWER - (AKA golfer's elbow) is less common. Overuse syndrome of wrist flexion. Pain on medial epicondyle worsens with wrist flexion. Treated same as lateral epicondylitis. Imaging: Usually unnecessary, but it may be useful if needed to rule out alternative diagnoses. Discuss at least 3 vital body functions which thyroid hormones regulate - CORRECT ANSWER
- Hyperthyroidism Metabolic--Increased appetite (Polyphagia), Weight Loss, hypercalcemia, K wasting, increased alkaline phosphatase Hypothyroidism Decreased appetite, Weight Gain General Hyperthyroidism: Fatigue, Muscle Atrophy, Tremors Hyperthyroidism: Fatigue, decreased libido, hypersomnia, periorbital puffiness Integumentary Hypothyroidism Diaphoresis, Heat Intolerance, thinning hair, pruritus, onycholysis Hyperthyroidism: Hair loss, ankle swelling, cold intolerance, dry cool rough skin, alopecia, dry course thick hair
GI
Hypothyroidism: Diarrhea, Increase in BM Constipation, nausea, hypoactive bowel sounds, ascites, enlarged tongue Eye Blurred vision, tearing, double vision, decreased visual acuity, photophobia, increased orbital pressure, lid lag, exophthalmos, corneal ulcer Hyperthyoidism N/A Neurological Hypothyroidism Tremors in hands, hyperactive reflexes Hyperthyroidism Memory deficits, personality changes, hyporeflexia, bradykinesia Hypothyroidism Cardiopulmonary Palpitations, SOBOE, tachycardia, HTN, CHF, A-Fib Hyperthyoidism Exercise intolerance, bradycardia, cardiac enlargement, pleural effusion GU Hypothyoridiam Decreased menstrual flow, gynecomastia Hyperthyroidism Irregular menses, decreased fertility
in the United States. Toxic multinodular goiter (hyperthyroidism) in iodine deficiency. Grave's Disease (hyperthyroidism) has a firm goiter. overt hypothyroidism - CORRECT ANSWER - o TSH above 10 and FT4 is decreased o Too little hormone is being produced o Pituitary is attempting to get the thyroid to produce more Low FT4 and high TSH subclinical hypothyroidism - CORRECT ANSWER - o TSH levels are increased, but the FT4 is within range o Some have symptoms, others do not Hashimoto's thyroiditis - CORRECT ANSWER - underproduction of thyroid leading to hypothyroidism
- Identified via TPO and TBG Abs in blood Grave's disease - CORRECT ANSWER - overproduction of thyroid leading to hyperthyroidism
- 90% of hyperthyroidism cases Identify at least 3 risks associated with obesity - CORRECT ANSWER - Diabetes, CVD, Afib, HTN, NSTEMI, varicosities, cancer, skin infections, arthritis Gallbladder disease, GERD, acute pancreatitis, NAFLD Stress incontinence, infertility, OSA Identify at least 3 causes of obesity - CORRECT ANSWER - Calorie excess—either overeating or high intake of carbohydrates
Food insecurity—eating from a fear of potential hunger or past experience with poor availability of food on a regular basis Genetic predisposition with familial history—influences of ghrelin and leptin levels Medication influences—antidepressants, anti-seizure, steroids, insulin, oral contraceptives Psychological factors—self-soothing, large CHO intake = increased serotonin Disease states—hypothyroidism, insulin resistance, PCOS, Cushing's Discuss one primary prevention for obesity - CORRECT ANSWER - Obesity occurs when one's intake of calories exceeds metabolic needs. Primary prevention for obesity includes increasing activity level, and managing caloric intake. Triad—Identify, Food, Activity
- Identify those at risk—both adults and children—calculate BMI at every preventative visit: adult's minimum yearly and children at each preventative visit following routine schedule.
- Provide targeted nutritional advice—low CHO diets with high protein, small frequent meals throughout the day.
- Eliminate sweetened liquid calories including juice.
- Recommend 60 minutes of activity on most days of the week for adults and children.
- Encourage good nutrition and activity at the family level, not just the individual level.
- 24-hour diet recall and use motivational interviewing techniques.
- Promote good sleep hygiene. Identify the categories of obesity based on the BMI - CORRECT ANSWER - Overweight BMI is 25-29.9; relative weight is 100%-120% Obesity BMI is 30-40 140%-200%
o Baseline at 35 o Pregnant women o Women older than 60 o Individuals with autoimmune disease. Identify at least one "at-risk" population who should be considered for thyroid screening - CORRECT ANSWER - Pregnant women
- Women older than 60 years
- Persons with other autoimmune diseases
- Persons with pernicious anemia
- Persons with a family history (1st degree relative) of thyroid disease
- Persons with a history of prior thyroid surgery or dysfunction or neck radiation
- Persons with Abnormal thyroid exam
- Persons with psychiatric disorders Discuss one physical characteristic seen in a hyperthyroid patient - CORRECT ANSWER - Smooth, velvety skin
- Soft, thin hair
- Skin with increased pigmentation, spider angiomas, and vitiligo
- Onycholysis (splitting and spooning of the nails)
- Exophthalmos (buldging eyes) Muscle atrophy, tremors, hyperpigmentation, warm flushed moist skin, fine silky hair, thin hair, increased LFT, Exopthalamos, lid lag and edema, corneal ulceration, sinus tach, elevated BP, A.Fib, symptoms of CHF, gynecomastia, osteoporosis, hypercalcemia, potassium wasting Identify the CDC recommended antibiotic class for treatment of acute bacterial prostatitis - CORRECT ANSWER - Flouroquinolones (Ciprofloxacin, levofloxacin, ofloxacin, or norfloxacin)
Alternatives to a fluoroquinolone include Doxycycline 100 mg Q 12 hours; and TMP-SMX [160 mg/800 mg] (Bactrim DS) one tab Q 12 hours Identify at least one treatment for BPH - CORRECT ANSWER --Medication (conservative):
- Alpha Blockers (Terazosin, Tamsulosin)
- 5 - alpha Reductase Inhibitors (finasteride, dutasteride)
- Surgical
- TURP (transurethral resection of the prostate) Identify treatment options for obesity based on BMI and comorbid conditions - CORRECT ANSWER - Overweight BMI: 25-29.9kg/m Obesity BMI: 30-40 kg/m Severe (morbid) obesity BMI: >40kg/m Treatment options: lifestyle changes (diet, exercise- 45 - 60 minutes/day), managing behavior (i.e. H.A.L.T. - hungry, angry, lonely, tired, behavior modification), reduce caloric intake, drugs (i.e. fenfluramine/Fen Phen, dexfenfluramine/Redux, phentermine, diethylopropion, orlistat). Surgical intervention (vertical-banded (mason) gastroplasty and roux-en-Y bypass) for BMI over 40 OR over 35 with comorbities A structured weight loss diet is most effective. Encourage formal programs or weight loss groups (WW, etc.). Diet goals should include a program with 1200 - 1500 calories per day for women and 1500-1800 calories per day for men;
Identify at least 3 physical exam maneuvers to assess the knee - CORRECT ANSWER - Diagnosing ACL injury: Lachman's, anterior drawer test Diagnosing meniscal tears: McMurray and Appley Diagnosing PCL injury: posterior drawer test and Thumb sign Diagnosing collateral (MCL and LCL) injury: Valgus and Varus stress test Resting Tremors - CORRECT ANSWER - Occurs at rest, against gravity, or sitting still with arms resting in lap. The most common condition that causes resting tremors is Parkinson's Disease and medication tremors. Postural tremors - CORRECT ANSWER - Seen when the patient is asked to extend the arm in front of them. The most common type is an essential tremor. It's bilateral and generally symmetric. There's often a family Hx. Drinking alcohol can reduce the tremor. intention tremors - CORRECT ANSWER --Characterized by an increase in amplitude when the patient attempts movement. Can be checked by having the patient perform finger to nose coordination. Describe one disease with resting tremor as a clinical finding - CORRECT ANSWER - Parkinson's Disease. It is a progressive neurological disease
- 4 hallmark signs: o resting tremor o cogwheel rigidity o bradykinesia, o postural instability
- Other characteristics are facial masking, difficulty staining from sitting in a chair, "freezing", reduced arm swing, festinating (quick, short stride, with head down) and shuffling gait.
Wilson's disease is another condition that is associated with resting tremor. This is a very rare genetic disorder associated with copper toxicity. Patients who are affected may have extrapyramidal symptoms [similar to Parkinson's] with a slow and progressive course. There may be symptoms of incoordination in the hands, dysarthria, and gait disorder, bradykinesia, rigidity, and ophthalmologic changes. The work up for Wilson's includes serum ceruloplasmin and copper. Diagnosis is confirmed with liver biopsy, which identifies the copper toxicity. Treatment is aimed at lowering copper levels. Describe a medication commonly associated with tremors - CORRECT ANSWER - Extrapyramidal side effects similar to Parkinson's disease. Antipsychotics are the most common offending agent. Metoclopramide (Reglan) Phenothiazine - Compazine Steroids Caffeine Anti-epileptics Antidepressants Asthma medications Intention tremor may be associated with medications, alcohol or drug abuse, multiple sclerosis, stroke, or a mass affecting the cerebellum. Identify at least 3 laboratory tests to rule out systemic causes of tremor - CORRECT ANSWER
- Electrolyte/ABGs (metabolic imbalances, drugs, caffeine, physiological fatigue) Serum glucose (hypoglycemia) Toxicology screen/drug levels (toxic conditions, antipsychotic drugs, caffeine) Describe at least one at-risk population that is recommended to have HIV screening - CORRECT ANSWER - Anyone who had unprotected sex should be screened for HIV Men who have sex with men Those who exchange sex for drugs/money
If caused by animal or human bite: amoxicillin-clavulanic acid (augmentin) for 2 weeks Discuss an intervention to prevent HIV and HIV-associated behaviors - CORRECT ANSWER - *safe sex practices - latex condoms *needle exchange programs *universal testing of donated blood products *education to HIV positive women of childbearing age about c-sections, arv drugs for mother and baby *voluntary HIV testing a routine part of medical care *new models for HIV diagnosing outside medical setting *prevent new infection by working with HIV infected and their partners to minimize risk Identify physical exam findings in the patient with HIV - CORRECT ANSWER - fever, sore throat, myalgia, headaches, cervical lymphadenopathy, night sweats, majority are asymptomatic flu-like sumptoms 6 days to 6 weeks after viral transmission dark purple colored spots (karposi's sarcoma) non-productive cough, SOB, and fever for several weeks pulmonary symptoms: pcp pneumonia, tb, bacterial pneumonia localized candida infections other STD's weight loss
anemia, leukopenia, and/or thrombocytopenia Cellulitis - CORRECT ANSWER - o Pathogens Strep (A,B,C,G,F) Staph o Symptoms Skin erythema, edema, warmth, pain, possible fever Lymphangitis, lymphadenopathy, peau d'orange (orange peel texture) No fever/chills, localized symptoms only Underlying infection, lymphedema, venous insufficienc o Treatment I&D if abscess is involved Patients with cellulitis should be managed with empiric therapy for infection due to beta- hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) with:
- Cephalexin 500 mg four times daily (alternative for mild penicillin allergy)
- Clindamycin 300 mg to 450 mg four times daily (alternative for severe penicillin allergy) Erysipelas - CORRECT ANSWER - o Pathogens Group A Strep o Symptoms Skin erythema, edema, warmth, pain, possible fever Lymphangitis, lymphadenopathy, peau d'orange (orange peel texture) Acute onset with systemic symptoms (fever, chills)
