NR511 Final Exam Study Guide LATEST, Exams of Nursing

Download NR511 Final Exam Study Guide LATEST and more Exams Nursing in PDF only on Docsity! 1 1 NR511 Final Exam Study Guide Week 1 1. Define diagnostic reasoning -To solve problems, to promote health, and to screen for disease or illness all require a sensitivity to complex stories, to contextual factors, and to a sense of probability and uncertainty. -Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. 2. Discuss and identify subjective & objective data -Subjective: -reports -complains of -tells you in response to your questions. -Includes ROS, CC, and HPI -Objective: -what you can see, hear, or feel as part of your clinical exam. -It also includes laboratory data and test results. 3. Discuss and identify the components of the HPI -O: Onset of CC -L: Location of CC -D: Duration of CC 2 2 -C: Characteristics of CC -A: Aggravating factors for CC -R: Relieving factors for CC -T: Treatments tried for CC -S: Severity of CC 4. Describe the differences between medical billing and medical coding Medical coding: is the use of codes to communicate with payers about which procedures were performed and why. -Medical billing: is the process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider. 5 5 99212 - 99214 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation -It is an important reference document that gives concise information about a patient's history and exam findings. -It outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. -It is a means of communicating information to all providers who are involved in the care of a particular patient. -It is an important medical-legal document -It is essential in order to accurately code and bill for services. 11. Accurately document why every procedure code must have a corresponding diagnosis code -Every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit. 12. Correctly identify a patient as new or established given the historical information • Patient status -New patient: one who has not received professional service from a provider from the same group practice within the past 3 years. 6 6 -Established patient of your practice: has received professional service from a provider of your office within the last 3 years 13. Identify the 3 components required in determining an outpatient, office visit E&M code -Place of service -Type of service -Inpatient -Consultation’s -Outpatient -Office visit -Hospital admission -Patient status -New patient: one who has not received professional service from a provider from the same group practice within the past 3 years. -Established patient of your practice: has received professional 7 7 14. Describe the components of Medical Decision Making in E&M coding - There are three key components that determine risk-based E&M codes. -History -Physical -Medical Decision Making (MDM) E&M coding requires a medical decision maker -Medical decision-making is another way of quantifying the complexity of the thinking that is required for the visit. -Complexity of a visit is based on three criteria: -Risk -Data -Diagnosis -Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient. 15. Explain what a “well rounded” clinical experience means -Includes both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits 16. State the maximum number of hours that time can be spent “rounding” in a facility <25% 17. State 9 things that must be documented when inputting data into clinical encounter -date of service -visit E&M code (e.g., 99203) -age -gender and ethnicity -chief concern -procedures 10 10 5. Discuss the diagnosis of diverticulitis, risk factors, and treatments Symptoms: LLQ pain/ tenderness, fever, N/V/D Need imaging especially if perforation or peritonitis is suspected; free air = perforation; patient may have ileus, small or large bowel obstruction Can use plain x-ray CT or barium enema are preferred CT with contrast is more sensitive and accurate 6. Identify the significance of Barrett’s esophagus After repeated exposure to gastric contents, inflammation of the esophageal mucosa becomes chronic. · Blood flow increases, erosion occurs 11 11 · As erosion heals, normal squamous epithelium replaced with metaplastic columnar epithelium containing goblet and columnar cells · More resistant to acid and supports esophageal healing · Premalignant tissue · 40-fold risk for development of esophageal adenocarcinoma · Fibrosis and scarring during healing of erosions; leads to strictures 7. Discuss the diagnosis of GERD, risk factors, and treatments - Diagnosis made on history alone; sensitivity of 80% - If symptoms are unclear/patient doesn’t respond to 4 weeks of empiric treatment - Dx made by ambulatory esophageal pH monitoring - pH < 4 above the lower esophageal sphincter and correlates with symptoms = GERD - EGD with biopsy – Barrett’s esophagus - Normal results in 50% of symptomatic patients - Risks o Obesity o Increases after age 50 o Equal across gender, ethnic, and cultural groups - Treatment o Small, frequent meals – main meal at midday o Avoid trigger foods o No bedtime snacks; no eating < 4 hours prior to bed o Eliminate caffeine o Stop smoking o Avoid tight fitting clothing o Sleep with head elevated - Medication: o Step 1: antacids or OTC H2 (Tagamet, zantac, axid) o Step 2: Rx-strength H2 (ranitidine 150mg BID, famotidine 20mg BID) or PPI (pantoprazole 40mg daily, omeprazole 20mg daily) o Step 3: PPI (omeprazole 40mg daily) o Step 4: surgery (fundoplication) 8. Discuss the differential diagnosis of acute abdominal pain, work-up and testing, treatments Diff Diagnosis Acute appendicitis: 12 12 ▪ Inflammation of the vermiform appendix; due to obstruction or infection ▪ Most common surgical emergency of the abdomen ▪ Hollow tube – most common cause is obstruction of appendix 15 15 1. I Get Smashed ▪ I – idoipathic ▪ G- gallstones ▪ E- ETOH abuse ▪ T – trauma ▪ S – steroids ▪ M – mumps virus ▪ A – autoimmune diseases ▪ S – scorpion stings ▪ H – hypertriglyceridemia & hypercalcemia ▪ E – ERCP ▪ D – drugs Symptoms Nausea ▪ Vomiting ▪ Hypocalcemia ▪ Cullen’s sign – bruising around umbilicus ▪ Grey-Turner’s Sign - Bruising along flank ▪ Necrosis induced hemorrhaging spreads 16 16 Acute cholecystitis: Inflammation of gallbladder (GB) Usually due to gallstone in cystic duct 1. Cystic duct – leaves gall bladder & connects to common bile duct Symptoms: Patient will have mid-epigastric pain ▪ Because GB is still squeezing, increasing pressure w/ nowhere for bile to go ▪ Can lead to nausea/vomting 17 17 ▪ Stone can get more stuck w/ more squeezing Bile starts to irritate mucosa Mucosa starts to produce mucous and inflamm enzymes ▪ Leads to inflammation, distention, pressure build up ▪ Bacterial growth (E. coli, enterococci, bacteroides fragilis, colstriduim) As GB “balloons”, pain shifts to RUQ, R scapula/shoulder Bacteria invades in & through GB wall, into peritoneum, causing peritonitis ▪ Rebound tenderness Murphy’s Sign = Put pressure on right side under ribs. This will hold GB in place. Have patient take a deep breath. The diaphragm will push on the GB & a painful response = Cholecystitis Immune response ▪ Neutrophilic leukocytosis ▪ Fever Workup and testing: All patients with abdominal pain should undergo rectal, gential, and pelvic exam. It is important to isolate the location of the pain. Acute appendicitis: ▪ Diagnosis is made clinically and based on history and physical ▪ Elevated WBC 20 20 ▪ Radiolabeled marker used to visualize the biliary system ▪ Acute cholecys – ducts are blocked, GB can’t be seen ▪ Endoscopic Retrograde Cholangiopancreatography (ERCP) ▪ Endoscope down to pancreas ▪ Dye injected & viewed via fluoro ▪ Magnetic Resonance Cholangiopancreatography (MRCP) ▪ Visualizes bili system with MRI Treatment: 21 21 Acute appendicitis: • Appendectomy • Antibiotic • Drain abscesses • Can be removed prophylactically Acute pancreatitis: o pain management o hydration o electrolytes o rest bowels ▪ NPO ▪ IV nourishment o Treat complications ▪ O2 ▪ ATB 22 22 Acute cholecystitis: o Supportive measures ▪ IV ▪ Pain management ▪ ATB o Surgical Removal ▪ Cholecystectomy 1. Laparoscopic 25 25 15. Discuss colon cancer screening recommendations relative to certain populations -Anyone over age 50 should have a routine c-scope -African American’s should start screenings at age 40 -Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age ≥60 years can be screened like average-risk persons. **Red flag symptoms should be sent to GI – unintentional weight loss, rectal bleeding, diffuse lower abdomen pain, new onset diarrhea/constipation, early satiety, loss of appetite 16. Identify at least two disorders that are considered to be disorders related to conductive hearing loss -Chronic Otitis Media (OM) -middle ear effusion -mass -vascular anomaly -cholesteatoma – abnormal noncancerous skin growth in ear canal 17. Identify the most common bacterial cause of pharyngitis -Group A Beta Hemolytic Streptococcus (GABHS) -Absence of cough -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy 26 26 18. Identify the clinical findings associated with mononucleosis -Fever -Malaise -Severe sore throat -Exudative tonsillitis (50% of cases) -Palatal petchiae -Rash -Anterior/posterior cervical lymphadenopathy -Splenic enlargement -POC Monospot test: (+) 19. Identify common characteristics in a rash caused be Group A Strep Sandpaper rash Fine, red, sparing hands & soles 20. Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria -Absence of cough 27 27 -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy 21. Describe an intervention for a patient with gastroenteritis -Supportive care: fluid and nutrients -Low residue diet (BRAT) – no evidence that this helps, but may be more tolerable for pt -Viral cause = NO antibiotics -Education surrounding not prescribing antibiotics/not spreading germs/eating safe foods -Imodium/Zofran/Phenergan 22. Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea -empirical antimicrobial therapy: Trimethoprim-sulfamethoxazole (Bactrim) 1 PO BID ×3d -ciprofloxacin (Cipro) 500 mg -norfloxacin (Noroxin) 400 mg -ofloxacin (Floxin) 300 mg 23. Identify at least one effective treatment for Irritable Bowel Syndrome (IBS) - For IBS - C o Psyllium (fiber) o docusate (softner) o bisacodyl/senna (stimulant/irritant) o loperamide (antidiarrheal) - For IBS – D o dicyclomine (bentyl), hycosamine sulfate (Levsin) phenobarb/hycosamine (donnatal) ▪ anticholenergics – decrease motility of smooth muscle tone/decrease cramping, relaxes muscles in stomach/intestines 30 30 3. Identify at least three examples of flow and volume disorders (intra and/or extra thorax) -Intrathorax flow disorders: originate from obstruction of distal/smaller airways -asthma -bronchiolitis -vascular ring -solid foreign body aspiration -lymph node enlargement pressure -These types of disorders cause expiratory effort in infants and also in children less than 5 years of age (bronchiolitis) 31 31 -Extrathorax flow disorders: originate from obstruction of the larger airways -rhinitis with nasal obstruction, nasal polyp -cranio-facial malformation -obstructive sleep apnea -tonsil-adenoid hypertrophy -laryngo-tracheo-malacia -larynx papilloma -Diphtheria -croup, epiglottitis -thymus hypertrophy -Infants or children ages 5 and younger are affected, and they have clinical findings of inspiratory stridor -Intrathorax volume disorders include lung parenchyma disorders -pneumonia (infection, aspiration) -atelectasis -pulmonary edema -near drowning -These disorders affect inspiratory effort -Extrapulmonary volume disorders -pneumothorax, pneumomediastinum -cardiomegaly, heart failure (perfusion) -pleural effusion (including empyema, hematothorax) -hernia diaphragmatica -diaphragmatica eventration -intra-thorax mass (nonpulmonary) -chest trauma (rib fracture, lung contusion) -thorax deformity (pectus excavatum, scoliosis) -These disorders also affect inspiratory effort 32 32 -Extrathorax volume disorders due to lung compliance issues -neuromuscular disorders (CP, GBS, MG) -gastritis, peptic ulcer -extreme obesity -peritonitis, appendicitis, acute abdomen -aerophagia, meteorismus -ascites -hepato-splenomegaly -abdominal solid tumor -These disorders cause inspiratory constraint -Extrathorax volume disorders that are due to respiratory center disorders -anemia -metabolic acidosis -CNS infections: meningitis, encephalitis -encephalopathy (typhoid, DHF, metabolic) 35 35 Severe Persistent Short acting bronchodilator + High dose inhaled corticosteroids AND Long acting inhaled bronchodilator AND If needed, oral corticosteroids (2mg/kg/day, 60mg/day max) 5. Describe appropriate tests in the work up for dyspnea -CXR: rule out tumors, TB, pneumonia, and other major pulmonary disorders -CBC with differential: rule out anemia and infection -Peak expiratory flow test (in office): to determine the degree of expiratory airflow obstruction in patients with asthma and COPD -EKG, Echo -Spirometry: to determine obstructive, restrictive and mixed lung disease 6. Discuss clinical findings and PFTs for asthma, chronic bronchitis, emphysema, and COPD - Asthma o Subjective: c/o breathlessness, unable to talk, short sentences, profuse sweating, c/o air hunger. In patients who are severely obstructed, there may be no wheezing and only cough may be present. Wheezing, persistent and recurrent cough, difficulty breathing, tightness in chest, endurance problems during exercise. Symptoms are usually worse at night. o Objective: Nasal discharge, mucosal swelling, frontal tenderness, nasal polyps, and allergic “shiners” (dark discoloration beneath both eyes). Allergic rhinitis and eczema often accompany the dx of asthma. - Asthma PFTs o Mild intermittent asthma- FEV1: >80%, PFT >20% o Mild persistent asthma- FEV1: >80%, PFT 20%-30% 36 36 o Moderate persistent asthma- FEV1: 60%-80%, PFT >30% o Severe persistent asthma- <60%, PFT >30% - Chronic Bronchitis/Emphysema/COPD o Subjective: frequent colds, persistent morning cough, upper respiratory infections, dyspnea, fatigue, SOB. Hemoptysis, loss of appetite, nausea, dizziness. Sleep sitting up on >3 pillows to relieve dyspnea. Paroxysmal nocturnal dyspnea. o Objective: In emphysema, hyperinflation of chest, flattening of diaphragm, tachypnea, use of accessory muscles of respiration, end expiratory wheezes may be heard on forced expiration. Coarse crackles during acute exacerbation. - Chronic Bronchitis (chronic productive cough) o more common form of COPD o Airflow obstruction in chronic bronchitis is caused by bronchiole edema, hyperplasia of mucus-producing goblet cells, and bronchiole smooth muscle hypertrophy. Presents as long-term cough or recurrent sputum production, mainly upon awakening, extending over 3 months for a period of at least 2 years o Hallmark of episode-increased purulent sputum production and worsened SOB - Emphysema (increasing shortness of breath) o destruction of alveolar walls due to an imbalance of proteinase- antiproteinase enzymatic activity o Overdistended, hyperinflated, less elastic alveoli over time o Weak elastic recoil of alveoli leads to air trapping, increased residual lung volume, reduced expiratory flow, and retained CO2 - COPD PFTs o Mild COPD (Stage 1)- FEV1/FVC <0.7; FEV1 >80% predicted o Moderate COPD (Stage 2)- FEV1/FVC <0.7; FEV1 50%-79% predicted o Severe COPD (Stage 3)- FEV1/FVC <0.7; FEV1 30%-49% predicted o Very severe COPD (Stage 4)- FEV1/FVC <0.7; FEV1 <30% predicted or 50% predicted w/chronic respiratory failure 7. Differentiate between the following common rashes: rubeola, rubella, varicella, roseola, 5ths disease, pityriasis rosea, hand, foot and mouth disease and molluscum contagiosum. 37 37 Rubeola: Measles: skin is a reddish purple generalized macular and papular rash. o Lesions start out on the head, particularly on the face or behind the ears, and spread down the body within 1–2 days - Rubella: German measles: skin rash will appear with “rose-pink” macules and papules 40 40 -Contact Dermatitis: allergic reaction to a substance that produces an immune reaction in your skin resulting in a very pruritic and erythemic rash -Example: Poison Ivy -Atopic dermatitis: a disorder that is the result of a gene variation that affects the skin’s ability to retain moisture and protection from irritants -Example: Eczema 11. Identify common characteristics associated with blepharitis, chalzion and hordeolum -Blepharitis: an inflammation around the eyelid margins that is caused by staphylococcal infection at the lash bases and dysfunctional Meibomian glands -Chalazion: a chronic internal granulomatous reaction of the Meibomian gland that produces a mass in the lid -Hordeolum: Stye: an abscess of the lid margin caused from a staph infection 12. Differentiate between viral, allergic, bacterial, toxic and HSV conjunctivitis Bacterial: Pink eye: purulent discharge -Viral: Adenovirus: watery or mucousy drainage: NOT purulent -Allergic: environmental: uniquely identifying “bumps” on the conjunctiva: follicles -Toxic: Overuse of eye drops: clear/watery discharge/red conjunctiva -HSV: Corneal infection with the hallmark “dendrite” appearance 41 41 13. Discuss which chemical injury is associated with the most damage and highest risk to vision loss -Alkali injuries (moderate or severe) cause permanent scarring and vision loss 14. Recognize common eye emergency conditions that require emergency room evaluation -Orbital cellulitis -Chemical exposure -Ruptured globe -Hyphema -Foreign bodies -Moderate to severe subconjunctival hemorrhage -Lid laceration 15. Discuss glaucoma, diagnosis and treatment Progressive damage to the optic nerve leading to atrophy and blindness. Due to elevated intraoccular pressure 42 42 Open angle More commonly seen chronic form Good prognosis with treatment S.sx Typically asymptomatic until optic nerve damage Slow gradual onset with slow painless bilateral peripheral vision loss Poor night vision Late s/sx Halos around lights Hardened eyeball Marcus Gunn Pupil Closed angle Acute onset S.sx Rapid onset Significant unilateral eye pain or pressure Redness Visual loss Blurred vision Photophobia Halos around lights Loss of peripheral vision followed by central vision loss Headache n/v "Steamy" appearance to cornea Pale optic disk with excavated cupping If left untreated can lead to permanent vision loss. PCP should closely monitor a family hx of glaucoma or hyperopia with eye ache, headache, dry eye Dx Screening is the most important for PCP's PCP should closely monitor a family hx of glaucoma or hyperopia with eye ache, headache, dry eye 45 45 Tx first goal is prevention R i s k i n c reases with BS >200 Keep HgbA1C <7% Only medication shown to slow progression- ACE inhibitor - lisinopril Laser surgery if in proliferative stage 3 or significant macular edema Week 5 1. Identify the population most commonly affected by bacterial prostatitis 46 46 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 2. Discuss the physical exam characteristics of acute bacterial prostatitis Abdominal exam to detect distended bladder, costovertebral angle tenderness, genital exam, and digital rectal exam Acute bacterial prostatitis- warm, tense, swollen , boggy and very tender prostate. Most common pathogen Strep faecalis and staph aureus 3. Discuss how the Phren sign can differentiate between testicular torsion and epididymitis 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). 4. Discuss common symptoms reported from a patient with BPH Affects men age 40 years and older. Obstructive symptoms include • Decreased stream • Hesitancy 47 47 • 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 50 50 Subjective - Radicular complaints in calves, buttocks, upper thighs - Pain w/ walking or prolonged standing o Vascular claudication – pain stops w/ rest o Psuedoclaudication – pain doesn’t stop immediately at rest - Short term relief by leaning forward/stooping - Sometimes relief w/ sitting - Pain in back/leg when sleeping on back at night - Pain w/ walking/standing Objective - Muscle weakness - Impaired proprioception - Diminished reflexes - Sensory changes (numbness/tingling) - Bowel or bladder symptoms o Sphincter tone decreased o Don’t confuse w/ prostate problems in older men 9. Identify the red flags associated with back and neck complaints which warrant further investigation “TUNA FISH” T- Trauma F- Fever U- Unexplained weight loss I – IV Drug User N- Neurologic symptoms S – Steroid Use A- Age>50 H – History of cancer (prostate, renal, breast, lung) 10. Define chronic pain • 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 11. Identify the number of joints involved in a poly-articular disorder 51 51 Monoarticular: One joint Periarticular: Two to four joints Polyarticular: Four or more joints 12. Describe the four cardinal signs of joint inflammation 1. Erythema 52 52 2. Warmth 3. Pain 4. Swelling 13. Differentiate between DeQuervain’s Tenosynovitis and Carpal Tunnel Syndrome Carpal Tunnel Syndrome: - 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 o Burning, tingling, or itching numbness of the hand and fingers, especially the thumb, middle, and index fingers - Most often dominant hand – may be bilateral - Pain increases with wrist flexion or extension - Paresthesia and numbness along thumb, index, long and radial half of ring fingers - Nighttime wakening of N/T in affected limb - Positive Phalen’s test, Positive Tinel’s sign - - - Diagnostics o Median nerve conduction velocity study most useful o xray if limited wrist movement only - Treatment o Rest, splinting o NSAIDS, NO CORTICOSTEROIDS o Vitamin B6, and management of concurrent diseases o Often resolves after pregnancy if symptoms related DeQuervain’s Tenosynovitis - Inflammation involving the synovial sheaths and tendons of the abductor pollicis longus and extensor pollicis longus, and brevis tendons (snuff box) 55 55 15. Discuss at least 3 vital body functions which thyroid hormones regulate 56 56 Body Function Hyperthyroidism Hypothyroidism 57 57 Metabolic Increased appetite (Polyphagia), Weight Loss, hypercalcemia, K wasting, increased alkaline phosphatase Decreased appetite, Weight Gain General Fatigue, Muscle Atrophy, Tremors Fatigue, decreased libido, hypersomnia, periorbital puffiness Integumentary Diaphoresis, Heat Intolerance, thinning hair, pruritus, onycholysis Hair loss, ankle swelling, cold intolerance, dry cool rough skin, alopecia, dry course thick hair GI 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 N/A Neurological Tremors in hands, hyperactive reflexes Memory deficits, personality changes, hyporeflexia, bradykinesia Cardiopulmonary Palpitations, SOBOE, tachycardia, HTN, CHF, A-Fib Exercise intolerance, bradycardia, cardiac enlargement, pleural effusion GU Decreased menstrual flow, gynecomastia Irregular menses, decreased fertility Head & Neck Increased neck size, enlarged thyroid gland Enlarged neck, enlarged tongue (late), hoarseness Psychosocial Anxiety, nervousness, insomnia, irritability, restlessness, emotional lability, Increase in HR, RR, and BP Depression, slowing of mental processes Musculoskeletal Weakness, loss of muscle tone, Osteoporosis in women Muscle weakness and cramping 60 60 Disease states—hypothyroidism, insulin resistance, PCOS, Cushing’s 21. Discuss one primary prevention for obesity 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 61 61 • 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. 22. Identify the categories of obesity based on the BMI Overweight BMI is 25-29.9; relative weight is 100%-120% Obesity BMI is 30-40 140%-200% Severe (morbid) obesity BMI is greater than 40 greater than 200% 23. Discuss how acute low back pain without neurological dysfunction does not warrant radiological imaging Acute back pain may have several differential diagnoses. If pain isn’t found to be related to any neurological complaints, radiological imaging is not warranted. 24. Identify the roles of TSH, FT4, TT3, and TPO Abs in determining thyroid function Thyroid Stimulating Hormone (TSH)—Pituitary “messenger” to thyroid to increase or decrease thyroid hormone production. used to diagnose hypothyroidism. TSH and FT4 should be used to follow treatment. If the TSH is low or insufficiently elevated in the presence of low T4, central hypothyroidism caused by hypothalamic or pituitary disease should be excluded before starting replacement therapy. Free T4 (FT4)—Circulating unbound thyroid hormone produced by the thyroid, replaced by levothyroxine medication, useful for the diagnosis of hypothyroidism both overt and subclinical *Primary hypothyroidism is associated with a low FT4 and elevated TSH *Subclinical hypothyroidism is a mildly increased TSH with a normal FT4 62 62 Total T3 (TT3)—Circulating unbound thyroid hormone that has been converted from T4. T3 is not routinely used as a diagnostic tool because it isn’t sensitive or specific to the hypothyroidism. T3 levels may be normal in early disease, and may not fall until late in the disease. 65 65 Doxycycline 100 mg Q 12 hours; and TMP-SMX [160 mg/800 mg] (Bactrim DS) one tab Q 12 hours 28. Identify at least one treatment for BPH -Medication (conservative): -Alpha Blockers (Terazosin, Tamsulosin) -5-alpha Reductase Inhibitors (finasteride, dutasteride) -Surgical -TURP (transurethral resection of the prostate) 29. Identify treatment options for obesity based on BMI and comorbid conditions Overweight BMI: 25-29.9kg/m2 Obesity BMI: 30-40 kg/m2 Severe (morbid) obesity BMI: >40kg/m2 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; 500– 750 calorie deficit per day; low CHO diet, increased fiber, and decreased saturated fats; and less than 800 calories per day in certain circumstances under medical supervision. 66 66 30. Describe the Spurling test and what condition it is used to diagnose Spurling’s maneuver assesses nerve root compression (i.e. radiculopathy) in the neck resulting in pain. - Spurling’s maneuver: o With patient’s neck in extension, rotate the neck to the affected side 67 67 o Apply downward pressure on the head o Assess for patient complaint of or accentuation of limb pain or paresthesia (THIS IS A POSITIVE SIGN). Also, observe for neck atrophy. 31. Describe how to perform a Phalen and Tinnel test A. Phalen test: Purpose: Assess for median nerve compression Procedure: Have the patient maintain forced flexion of the wrist for 1 minute or more, with the dorsal surface of each hand pressed together. If the patient complains of numbness and paresthesia in the fingers =TEST IS POSTIVE B. Tinel test: Purpose: Assess for compression neuropathy Procedure: Percuss the median nerve at the wrist. If the patient complains of tingling in the digits (POSITIVE TINEL SIGN), compression at the site of percussion is likely. 32. Identify at least 3 physical exam maneuvers to assess the knee 1. Diagnosing ACL injury: Lachman’s, anterior drawer test, 70 70 Week 6 71 71 1. Differentiate between resting, postural and intention tremors and describe each Resting tremor-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 tremor-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 (Kinetic) tremor-Characterized by an increase in amplitude when the patient attempts movement. Can be checked by having the patient perform finger to nose coordination. 2. Describe one disease with resting tremor as a clinical finding 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. 3. Describe a medication commonly associated with tremors 72 72 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 75 75 7. Describe an appropriate empiric antibiotic treatment plan for cellulitis Cellulitis = bacterial infection most commonly group A beta-hemolytic streptococcus or staphylococcus aureus (gram positive) tx = dicloxacillin or cephalexin for 10-14 days if PCN allergy, erythromycin If caused by animal or human bite: amoxicillin-clavulanic acid (augmentin) for 2 weeks 8. Discuss an intervention to prevent HIV and HIV-associated behaviors *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 9. Identify physical exam findings in the patient with HIV 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 76 76 10. Describe symptoms, DDx, pathogens, testing, and treatment for the following conditions: Cellulitis, impetigo, MRSA, Bites (dogs, cats, humans), Erysipelas - Cellulitis o Pathogens ▪ Strep (A,B,C,G,F) ▪ Staph 77 77 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) Patients with cellulitis should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) with: 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 insufficiency o Treatment ▪ I&D if abscess is involved - Erysipelas 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) ▪ Clear demarcation ▪ Butterfly involvement on face or ear o Milian’s Ear Sign ▪ Involvement of ear, classic for erysipelas o Treatment ▪ I&D if abscess is involved 80 80 • Begins as papules – vesicles – pustules – thick, adherent golden crusts ▪ Bullous impetigo • Seen primarily in young children • Vesicles – flaccid bullae with clear yellow fluid – darker – thin brown crust o Treatment ▪ Topical choices • Mupirocin 3xday for 5 days • Retapamulin 2x day for 5 days ▪ Oral Treatment • Extensive impetigo and Ecthyma should be treated with an ATB effective for BOTH S. aureus and strep infections • Dicloxacillin and cephalexin for 7 days are appropriate treatments • PCN is the preferred agent if only strep are detected • MRSA impetigo can be treated with doxycycline, clindamycin, or Bactrim - Human Bites o Pathogens ▪ Staph aureus ▪ Strep o Agent of choice: Amoxicillin/clavulanate 875/125 2xday - Cat & Dog Bites o Pathogens ▪ Pasturella multocida & capnocytophaga canimorsis o Alternative ATB w/ activity against Pasturella ▪ Doxycycline 100mg 2xday ▪ Bactrim DS 2xday ▪ PCN VK 500mg 4xday ▪ Ciprofloxacin 500mg 2xday • PLUS o Metronidazole 500mg 3xday o Clindamycin 450mg 3xday - ALL bites treatment considerations o Treatment ▪ Copiously irrigate with sterile saline ▪ Remove grossly visible debris ▪ Prophylactic ATB are given if • Deep puncture wounds • Wounds requiring surgical repair • Moderate to severe wounds w/ associated crush injury • Wounds in areas of underlying venous and/or lymphatic compromise • Wounds on the hands or in close proximity to a bone or joint 81 81 • Wounds on the face or in the genital area • Immunocompromised hosts