NR511 Final Exam Study Guide(Question & Answers), Exams of Nursing

Download NR511 Final Exam Study Guide(Question & Answers) and more Exams Nursing in PDF only on Docsity! NR511 Final Exam Study Guide Week 1 1. Define diagnostic reasoning a. Involves critical thinking in a way that evaluates new data to support the hypothesis and reduce alternative hypothesis. This is done by evaluating all the avenues to reach a conclusion that gives the best evidence to support the main theory or hypothesis. b. Examples of diagnostic reasoning are problem solving, health promotion, and screening for disease or illness. All of these will require sensitivity, complexity, contest, and a sense of probability and uncertainty. 2. Discuss and identify subjective & objective data a. Subjective- what the patient reports as the CC and the responses to the questions in the interview. Includes ROS, CC, and HPI b. Objective – Information gained through exam, labs, imaging and other diagnostic tests. 3. Discuss and identify the components of the HPI a. Describes the reason the patient came in and include information using the acronym OLDCARTS i. Onset ii. Location iii. Duration iv. Characteristics v. Aggravating factors vi. Relieving Factors vii. Treatments tried viii. Severity of the level of pain 4. Describe the differences between medical billing and medical coding a. 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. b. Medical coding is the use of code to communicate with payers about the procedures performed and why. 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system – The two systems need to be in line i.e. the CPT code for the activity performed should be followed with a relevant Diagnosis for the procedure performed. a. ICD 10- the newest version of shorthand for the patients diagnosis. It is necessary for all diagnosis and procedures performed. b. CPT- common procedural terminology represented by a 5 digit code that provides a uniform language to describe medical, surgical, and diagnostic services. Allows for tracking of treatments, trend and outcomes. Therer is 3 levels of CPT codes: Category I- used in contemporary medical practice, Category II -tracking codes used for new or performance measurement, and Category III- Temporary coding used for new procedures, technology and services. i. Catergory I has six sections b. Established patient: 99211 least complex - 99215 most complex 16.Explain what a “well rounded” clinical experience means a. Experience in a varied amount of paitnets across the lifespan i. 15% pediatrics ii. 15 % women’s health 17.State the maximum number of hours that time can be spent “rounding” in a facility a. 25% of total practicum hours for that course i. Rounding is permitted under the following circumstance 1. Your course instructor must be made aware that you’ll be rounding 2. The preceptor has facility privileges where the rounding will occur 3. Patients seen in a facility are patients of the provider’s outpatient practice 4. The student actively participated in the patients care (no observing) 18.State 9 things that must be documented when inputting data into clinical encounter a. Date of service b. Age c. Gender and ethnicity d. Visit E&M code e. Chief concern f. Procedures g. Test performed or ordered h. Diagnoses i. Level of involvement 19.Identify and explain each part of the acronym SNAPPS a. S = summarize - present the pt’s hx and physical exam findings b. N = narrow - narrow your differential down - find the top 2-3 diagnosis c. A = analyze - analyze the differential - compare and contrast the H&P + physical exam findings for each of the dif that you have, coming down to 1 diagn. d. P = probe - ask the preceptor questions about what you are not sure e. P = plan - management plan, as specific as possible f. S = self-directed learning - opportunity to investigate more about the topics you are not sure Week 2 1. Identify the most common type of pathogen responsible for acute gastroenteritis a. Viral most common for adults b. Rotavirus leading cause for children c. Bacterial (30-80%)- i. Campylobacter jejuni- most common in kids ii. Salmenella- most common cause of food borne illness in US 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea a. C-diff is common after use of fluoroquinolones and clindamycin 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD) a. Irritable Bowel Syndrome (IBS)- A functional gastrointestinal disorder that is characterized by abdominal pain and discomfort. i. S&S: abdominal pain, discomfort that is relieved by defecation, change in stool frequency, change in stool appearance, frequent stools (more than 3 a day) or fewer stools (less than 3 per week), passing mucus, feelings of straining, urgency or incomplete evacuation, flatulence, and abdominal distention. b. Inflammatory Bowel Disease (IBD)- Chronic immunological disease that manifests in intestinal inflammation. i. Causes 1. Ulcerative Colitis 2. Crohn’s Disease ii. S&S- exacerbations and remissions that are experiences throughout and individuals lifetime and therefore results in significant disruption in the quality of life. 4. Discuss two common Inflammatory Bowel Diseases a. Ulcerative Colitis i. Involved only the mucosal surface of the colon. Occur in the rectosigmoid area but can be in the entire colon. More common in males. ii. S&S: Bleeding and friability, erosions b. Crohn’s Disease i. Also known as regional enteritis. Has areas of normal mucosa followed by areas of lesions. Can involve all or any layers of the bowel wall and any portion or the gastrointestinal tract from the mouth to the anus. Onset between age 15-30 years old, although it may occur at any age. More common in females. 5. Discuss the diagnosis of diverticulitis, risk factors, and treatments a. Inflammatory changes to the diverticular mucosa of the intestine. b. Risk factors- Older than age 40, low- fiber diet, previous diverticulitis and number of diverticula present in the colon. c. Treatments- High fiber diet, addition of fiber supplement with psyllium, rest, oral antibiotics, and a clear liquid diet. i. Antibiotic will depend on the extent of the inflammatory process 1. Metronidazole (Flagyl) 500mg TID and Ciprofloxacin (Cipro) 500 mg BID 2. Trimethoprim/sulfamethoxale (Bactrim DS) 160/800 mg BID x 7-10 days ii. Pain treatment is due to spasms and can be managed by antispasmodics 1. Hyoscyamine (Levsin) 0.125mg q4hrs 2. Dicyclomine (Bentyl) 20-40 mg 4 time a day 3. Buspirone (BuSpar) 15-30mg/day and or meperidine (Demerol) 100-150 mg per day in divided doses 6. Identify the significance of Barrett’s esophagus a. The effect of repeated exposer to gastric contents and inflammation of the esophageal mucosa. Blood floe increases and erosion occurs causing the normal glucagon that are secreted into the blood stream. Functions as Endocrine and Exocrine i. Common causes- ETOH abuse, Gallstones, Trauma, steroids, idiopathic, mumps, autoimmune diseases, scorpion stings, hypertiglycerdemia, hypercalcemia, drugs, ERCP ii. Symptoms-Nausea, vomiting, hypocalcemia, Cullen’s sign (bruising around umbilicus), grey-turner’s sign (bruising along flank), Necrosis induced hemorrhaging spreads iii. Work up- All patients with abdominal pain should undergo rectal, genital, and pelvic exam. It is important to isolate the location of the pain. iv. Testing-Ct scan, US to look for gallstomnes, Labs will show increase in amylase up to 3x the normal level v. Treatment- Pain management, hydration, electrolytes. c. Acute cholecystitis- Inflammation of gallbladder, usually due to gallstone in cystic duct. i. Common causes- stones ii. Symptoms-Mid-epigastric pain, Fever, nausea, vomiting, 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) iii. Work up- All patients with abdominal pain should undergo rectal, genital, and pelvic exam. It is important to isolate the location of the pain. iv. Testing- 1. Ultrasound -to confirm that stones are detected. Sonographic murphy sign there will be tenderness when the sonogram is over the gallbladder. Thickening of the GB wall. Sludge present in the GB. Distention of the GB or the common bile duct. 2. Cholescintigraphy (HIDA scan)- will visualize the biliary system. This can show if the ducts are blocked. 3. Endoscopic retrograde cholangiopancreatography (ERCP)-dye injected to view the flow and view via fluoro 4. Magnetic resonance Cholangiopancreatography (MRCP)- visualizes the biliary system using MRI v. Treatment- Antibiotics, Pain management, Cholecystectomy 9. Discuss the difference between sensorineural and conductive hearing loss a. Sensorineural- result of deterioration of cochlea, loss of hair cell from the organ of corti, gradual and grogressive, and it is not correctable but it is preventable b. Conductive- obstruction between the middle and outer ear, most types are reversible. 10.Identify the triad of symptoms associated with Meniere's disease a. A sensory disorder of the labyrinth (semi-circular canal system) and cochlea. i. Triad of symptoms- Vertigo, hearing loss and tinnitus 11.Identify the symptoms associated with peritonsilar abcess a. Increasing unilateral ear and throat pain ipsilateral to the affected tonsil, dysphagia, drooling, trismus, erythema, edema of the soft palate with fluctuance on palpation. 12.Identify the most common cause of viral pharyngitis a. Adenovirus, Influenza A&B, coxsackie, herpes simplex, RSV, Epstein-barr, enteroviruses 13.Identify the most common cause of acute nausea & vomiting a. Gastroenteritis 14.Discuss the importance of obtaining an abdominal xray to rule out perforation or obstruction even though the diagnosis of diverticulitis can be made clinically a. Abdominal x-ray films should be obtained on all patients with suspected diverticulitis to look for free air (Indicating perforation), ileus, or obstruction. 15.Discuss colon cancer screening recommendations relative to certain populations a. Should be done on anyone over the age of 50. African Americans should start screenings at age 40. Those with a first-degree relative with colorectal cancer or advanced adenomas diagnosed at age ≥60 years can be screened like those of an average-risk. b. Red flag symptoms should be sent to the 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 a. Mass, middle ear effusion, OM, vascular anomaly, cholesteatoma 17.Identify the most common bacterial cause of pharyngitis a. Group A, B and Hemolytic strep 18.Identify the clinical findings associated with mononucleosis a. Malaise, sore throat, exudative tonsillitis, fever, anterior and posterior cervical lymphadenopathy, palatal petechia, splenic enlargement 19.Identify common characteristics in a rash caused be Group A Strep a. Sandpaperp rash- red and fine, not on the hands or soles of the feet 20.Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria a. No cough, tonsillar exudate, fever, tender anterior cervical lymphadenopathy 21.Describe an intervention for a patient with gastroenteritis a. Supportive measures- Fluid repletion i. Mild to moderate- use Pedialyte ii. Sever- IV fluid and ER reffereal b. Nutrition- there is no evidence that a BRAT or low residue diet shortens the duration, however it is easier for the patient to tolerate. c. Medication- NO abx recommended due to the fact that this is almost always viral in nature. 22.Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea a. Trimethoprim-sulfamethoxazole (Bactrim) 1 PO BOD x 3days b. Ciprofloxacin (Cipro) 500mg c. Norofloxacin (Noroxin) 400 mg d. Ofloxacin (Floxin) 300 mg hypertrophy, laryngo-tracheo- malacia, larynx papilloma, diptheria, croup, epiglottitis, thymus hypertrophy. ii. Infants or children ages 5 and younger are affected and they have clinical findings of inspiratory stridor. c. Intrathorax volume disorders- these disorders affect inspiratory effort i. Lung parenchyma disorders 1. Pneumonia, atelectasis, pulmonary edema, near drowning d. Extrapulmonary volume disorders- affect inspiratory effort i. Pneumothorax, pneumomediastinum, cardiomegaly, heart failure, pleural effusion, hernia diaphragmatica, diaphragmatica eventration, intra-thorax mass, chest trauma, thorax deformity, pectus excavatum, scoliosis. e. Extrathorax volume disorders- i. due to lung compliance issues-these disorders cause inspiratory constraint. These disorders cause deep rapid breathing 1. neuromuscular disorders (CP, GBS, MG), gastritis, peptic ulcer, extreme obesity, peritonitis, appendicitis, acute abdomen, aerophagia, meteorismus, ascites, hepato-splenomegaly, abdominal solid tumor ii. due to respiratory center disorders 1. anemia, metabolic acidosis, CNS infections:meningitis, encephalitis, encephalopathy (typhoid, DHF, metabolic), psychologic: anxiety (usually adolescent), poisoning (salicylate, alcohol), trauma capitis, CNS disease sequelae 4. Discuss diagnosis, risk factors and treatments for asthma a. Risk factor- Aferican American have higher asthma-related mortality than Caucasians.Genetic predisporsition, allergies, environmental factors, stress. b. Diagnosis: Expiratory flow measures essential for DX. Consider asthma in pt’s w/chronic cough. Spirometry used for dx. i. Common: Nocturnal wheezing w 1 or more 1. Dyspnea 2. Cough 3. Wheezing ii. Recurrent episodic dyspnea iii. Recurrent chest tightness iv. Symptoms worsen in relation to: 1. Airborne chemicals/dust 2. Animals w/fur or feathers 3. Weather change 4. Exercise 5. GERD 6. Stress/emotion 7. Pollen 8. Smoke 9. URI v. Episodic symptoms of airflow obstruction must be present vi. Airflow must be at least partially obstructed vii. Must rule out alternative dx viii. ABG ix. CBC x. Mild intermittent 1. Symptoms <once weekly, brief exacerbations i. Also known as the measles. This is highly contagious and is spread through resp. drops. There is no cure. Is From the morbillivirus. Vaccine was created in 1963. A positive case must be reported to the CDC. Is infectious for 4 days before onset or rash and up to 4 days after onset. They can return to work after rash has cleared. ii. S/s: High fever, red mucosal membranes, conjunctivitis, nasal congestion, reddish/purple generalized macular and popular rash. Lesisons start on head and spread down the body within 1- 2 days iii. Blood work: IgG, IgM, reverse-transcriptase polymerase chain reaction (RT-PCR) iv. Complications 1. If pregnant can cause miscarriage 2. Pneumonia, bronchitis, mycarditis, encephalitis v. TX: symptomatic, pain relievers, monitor for a few weeks and watch for complications. b. Rubella i. AKA, German measles or 3 day measles. Caused by the rubella virus. Rash may start 2 wks after exposure and can spread from resp drops. It is infectious for 4-7 days before rash and the patient can return to work/school after the rash is gone. ii. S/S: Low-grade fever, HA, sore throat, Rhinorrhea, Malaise, Eye pain, Myalgia 2-5 days before rash and can last for weeks after the outbreak. Rash is rose-pink macules and papules that start on head and travel down the body. They may fade in 1-2 days in the same order they appeared in. iii. TX: symptomatic NSAIDS and rest c. Varicella i. AKA chicken pox. Highly contagious. Caused by varicella zoster virus. Contagious 2-3 days before rash and can return to work or school after the lesions are scabbed over. Prevention with varicella vaccination ii. S/S: Malaise, fever, chills, HA, Arthralgia. Urticarial erythematous macules/papules that quickly turn into vesicles and pustules. It starts on the face/chest and spreads quickly over the entire body. Blisters can be in the ear canal or mouth and will dry up in about a week. iii. TX: symptomatic: oral antihistamines, NSAIDs, Cool compresses, and oatmeal baths. d. Roseola i. 6th Disease. Caused by human herpes virus types 6 and 7. The virus is usually mild and is common in kids <2 yrs. It is spread through saliva and lasts for 3-5 days. They are contagious 1-2 days before fever and can return to work or school when fever, fatigue, cough and diarrhea are gone. Diagnosis is made by clinical presentation and HX ii. TX: symptomatic e. 5ths disease i. Erythema infection with human parvovirus. It is spread through resp drop and blood products. Patient is contagious a few days before rash and they can return to work or school after the initial s/s of HA, fever, and chills are gone even if rash is still present. ii. Presents in 3 stages 1. HA, fever, chills, possible cough, classic slapped check rash, bright red bilateral checks but not on the forehead, nasal bridge, or perioral area. 2. Pink lacy (reticulated) erythematous macules on all extremities and trunk but not in the palms or sole surfaces, this may itch 3. 2-3 wks of body rash iii. Diagnosis is made via blood test,but result are not detectable for 3 wks after the rash, so not valuable iv. TX: symptomatic and the patient should avoid heat as it exacerbates the rash. f. Pityriasis rosea i. Viral in nature more common in females than males and is common in 10-35 years old. Common in the spring time. Patient is contagious 7-14 days prior to rash and can return to activities depending on symptoms but by the time the rash appears the patient is not contagious. ii. S/S: Solitary 2-4 patch/plaque on trunk (heeald patch) starts 2-3 wks before general rash. Rash is pink, erythematous, round to oval plaques/papules with possible scaly boarders. It may resemble a Christmas tree on the trunk. Usually not on the face, palms or soles. It can be itchy. Can last 1-2 months or longer. iii. TX: antihistamines, sun can help the rash. Acyclovir x 1 wk can help reduce severity. g. hand, foot and mouth disease i. mostly occurs in young children and is caused by coxsackievirus A16 and enterovirus 71. Patient is contagious for 4-6 days prior to outbreak and can return to activates when lesions are scabbed. Diagnosis is through H&P ii. S/S: Low grade fever, fatigue, sore throat x 1-2 days. Then rash: vesicles on hands and feet with mouth sores that is useally the first sign. Hand vesicles appear with erythematous halos and appear mostly on soles and palms. May appear on the legs butt and face and usually resolve in 7 days. iii. TX: symptomatic: reassurance that there will be no scarring h. molluscum contagiosum. i. From the family of Proxviridae. The virus is encased in a protective sac that prevents immune system from being triggered. Spread by contact, scratching, autoinoculation and shaving. Often misdiagnosed as genital warts ii. S/S: Tiny 2-5 mm pustules some may have slight depression in the center of flesh colored dome, single or multiple lesions. Most common in kids on thighs and arms. Common in adults in the genital. NEVER on the soles or palms. Can be erythematous, papules and scaling can be from itching and can last 8 months or longer. iii. TX: OTC Zymaderm, Topical retinoids, PO cimetidine (Tagamet) 40 mg/kg/day x 2mo. Cryosurgery w/liquid nitrogen although this can cause scarring or hypopigmentation 8. Differentiate between the following tineas: pedis, cruris, corporis and unguium and describe an appropriate treatment a. Tinea pedis: i. Athlete’s foot i. Mass in mid-portion of upper lid away from margin ii. Usually not painful or tender iii. Slightly red, swollen c. Hordeolum: i. Usually on outside of lid ii. Abscess on lid margin iii. Redness, swelling, painful 12. Differentiate between viral, allergic, bacterial, toxic and HSV conjunctivitis a. Viral i. Usually caused from adenovirus, but can be HSV, HZV, molluscum contagiosum ii. S/S: 1. Irritation 2. Mild light sensitivity 3. Swollen lids 4. Mild FB sensation 5. Mild conjunctival hyperemia to intense hyperemia 6. Watery/mucousy drainage, not purulent 7. Enlarged, tender preauricular lymph nodes on affected side 8. Red throat 9. Nasal drainage 10. Ear infection iii. Self-limiting, resolve on its own from few days to few wks iv. Highly contagious v. Current recommendation is stay home until redness/tearing resolved b. Allergic i. Usually caused by environmental allergen (pollen, grass, trees, etc.) ii. Can be seasonal and can be isolated to eyes or include upper resp allergy symptoms such as rhinitis iii. S/S: 1. Hallmark characteristic: itching 2. Diffuse, milky, conjunctival hyperemia 3. Swollen conjunctiva 4. Tearing 5. Almost always bilat 6. Uniquely identifying bumps on conjunctiva (“follicles”) iv. Tx : c. Bacterial 1. Symptomatic 2. Artificial tears 3. Anti-allergy drops i. AKA “pink eye” ii. Direct hand-to-eye contact w/infected person iii. Spread of one’s own nasal/sinus bacteria during illness iv. S/S: 1. HALLMARK: purulent discharge 2. Reddened conjunctiva 3. Eyelid swelling 4. Can start unilat, but can spread bilat v. May resolve without treatment, but abx drops can shorten duration vi. Very contagious (stay home until 24hrs of abx treatment or when clinical improvement noted) d. Toxic i. Due to overuse of topical ocular meds (Visine), but abx drops most common (usually from using abx drops for longer than prescribed or for viral infections) ii. Clear, watery discharge iii. Red conjunctiva iv. Dx usually from Hx v. Tx: stop the drops e. HSV i. Spread by contact w/persons who have visible, infected lesions and w/persons symptomatically shedding the virus ii. Pt may experience prodrome of ill-related symptoms: 1. Malaise 2. Low grade fever 3. Pain/tingling near site of lesions but lesions not yet visible 4. Skin vesicles 5. Conjunctivitis (same as viral) 6. Corneal infection with hallmark dendrite appearance 13. Discuss which chemical injury is associated with the most damage and highest risk to vision loss a. Moderate to severe alkali (contain lye, lime, sodium, mag hydroxide) i. Ammonia ii. Drain cleaners iii. Cement iv. Plaster/mortar v. Airbag rupture vi. Fireworks 14. Recognize common eye emergency conditions that require emergency room evaluation a. Gonococcal conjunctivitis (sight-threatening because it can affect cornea) b. Eyelid lac c. Moderate to severe subconjunctival hemorrhage with concern for more extensive injury d. FB e. Hyphema f. Open or ruptured globe g. Chemical injuries h. Orbital cellulitis (because can cause meningitis) h. Further differentiated as primary or secondary i. Congenital form (seen in infants) j. Diagnosis: i. Guidelines not firmly established ii. Dx should be made by optho iii. Tonometry used to diagnose 1. Pneumotonometry (puff of air) 2. Applanation tonometry (pressure against cornea, directly observed) iv. In chronic forms, IOP may not be elevated v. In acute exacerbations of angle-closure, symptomatic pressure can be as high as 40-80mm Hg (normal 8-21mm Hg or 12-22mm Hg) vi. Increased IOP not diagnostic alone vii. Dx made on: 1. Findings of characteristic degenerative changes in optic disc 2. Defects in visual fields 3. Tonometry viii. Differentials 1. Conjunctivitis 2. Uveitis 3. Vascular dz 4. Meds k. Management: i. Once nerve damage present, irreversible ii. Goal: prevent progression, protect optic nerve from pressure iii. Managed pharmacologically as long as possible iv. Laser/surgery when pharm not working anymore v. First-line: 1. Beta blockers a. Timolol (Timoptic) b. betaxolol (Betoptic) c. levobunolol (Betagan) d. carteolol (Cartrol) e. metipranolol (Betanol) 2. Prostaglandin analogs a. bimatoprost (Lumigan) b. latanoprost (Xalatan) c. travoprost (Travata) 16. Discuss diabetic retinopathy a. Its a non inflammatory disorder of the retina. Pt must be referred to opthalmology after dx of DM. High blood sugars cause dysregulation in retinal blood flow. b. 3 stages: 1. background diabetic retinopathy 2. Preproliferative diabetic retinopathy 3. Proliferative diabetic retinopathy Signs and symptoms: Asymptomatic in early stages with gradual complaints of vision changes. 1. Background diabetic retinopathy microaneurysms Intraretinal hemorrhage Macular edema Lipid deposits Dx progresses to 2. preproliferative diabetic retinopathy “cotton wool” spots Venous beading and dilation edema 3. Proliferative diabetic retinopathy New blood vessel proliferation Dx: Diagnosed by hx of DM greater than 10 years and fundoscopic examination changes TX First goal is prevention Risk increases with BS greater than 200 Keep HgbA1C less than 7% Only medication shown to slow progression-ACE inhibitor- lisinopril Maser surgery if in proliferative stage 3 or significant macular edema Week 5 1. Identify the population most commonly affected by bacterial prostatitis Prostatitis occurs predominantly in sexually active men aged 30 to 50 years. Chronic bacterial prostatitis is more common in patients older than 50 years old. 2. Discuss the physical exam characteristics of acute bacterial prostatitis Physical exam: Warm, tense, boggy, very tender prostate 3. Discuss how the Phren sign can differentiate between testicular torsion and epididymitis In epididymitis, the pain often improves when the scrotum is elevated above the level of the pubic symphysis (Prehn's sign).Elevation of the testis in testicular torsion does not relieve testicular pain, as is sometimes observed in epididymitis (Prehn's sign). 4. Discuss common symptoms reported from a patient with BPH Symptoms of obstructive BPH include decreased force of stream, hesitancy, postvoid dribbling, sensation of incomplete bladder emptying, overflow incontinence, inability to voluntarily stop the urinary stream, urinary retention, double-voiding (voiding a second time within 2 hours), and Lateral-- tennis elbow- pain in lateral elbow, down outer forearm, weakness in forearm, weak grip 15.Discuss at least 3 vital body functions which thyroid hormones regulate. Breathing, heart rate, Central and peripheral nervous systems, Body weight, Muscle strength, Menstrual cycles, Body temperature, Cholesterol levels All types of hyperthyroidism are a result of overproduction and/or secretion of thyroid hormones, and the clinical manifestations of hyperthyroidism are a direct result of the effect of excessive thyroid hormones on essentially all organ systems and bodily tissues. Although thyroid hormones are required to regulate normal growth and development, excessive release of T4 and T3 from the thyroid into the circulation upregulates metabolism, leading to an increase in total body heat production, heart rate and contractility, and vasodilation. This explains the clinical manifestations of thyrotoxicosis, which include palpitations, diaphoresis, heat intolerance, and anxiety. T3 is normally 20 to 100 times more biologically active than T4, which is converted to T3 in peripheral tissues. Interestingly, the degree of symptomatology does not consistently correlate with the extent of thyroid hormone overproduction. In general, younger patients tend to have symptoms more reflective of sympathetic activation (tremors, anxiety, and hyperactivity), whereas older patients manifest more cardiovascular symptoms, including atrial fibrillation and dyspnea, as well as weight loss. 16. Describe a goiter and the type of thyroid dysfunction that can be associated with it -A goiter is the hypertrophy and hyperplasia of the thyroid gland in response to TSH levels. Most commonly seen with Hashimoto’s thyroiditis (hypothyroidism) in the United States. Toxic multinodular goiter (hyperthyroidism) in iodine deficiency. Grave’s Disease (hyperthyroidism) has a firm goiter 17.Differentiate between overt hypothyroidism and subclinical hypothyroidism- Overt hypothyroidism 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 o TSH levels are increased, but the FT4 is within range o Some have symptoms, others do not 18. Differentiate between Hashimoto’s thyroiditis and Grave’s disease.Both are autoimmune, attacking thyroid cells. Graves – overproduction of thyroid leading to hyperthyroidism - 90% of hyperthyroidism cases Hashimoto’s – underproduction of thyroid leading to hypothyroidism -Identified via TPO and TBG Abs in blood 19. Identify at least 3 risks associated with obesity Diabetes, CVD, Afib, HTN, NSTEMI, varicosities, cancer, skin infections, arthritis Gallbladder disease, GERD, acute pancreatitis, NAFLD Stress incontinence, infertility, OSA 20. Identify at least 3 causes of obesity 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 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 • 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% -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 26. Discuss one physical characteristic seen in a hyperthyroid patient-- Smooth, velvety skin -Soft, thin hair -Skin with increased pigmentation, spider angiomas, and vitiligo -Onycholysis (splitting and spooning of the nails) -Exophthalmos (bulging eyes) Muscle atrophy, tremors, hyperpigmentation, warm flushed moist skin, fine silky hair, thin hair, increased LFT, lid lag and edema, corneal ulceration, sinus tach, elevated BP, A.Fib, symptoms of CHF, gynecomastia, osteoporosis, hypercalcemia, potassium wasting 27. Identify the CDC recommended antibiotic class for treatment of acute bacterial prostatitis a. Fluoroquinolone x14-28 days i. Cipro 500mg q12h ii. Levoflox 500mg daily iii. Ofloxin 400mg q12h iv. Norfloxin 400mg q12h b. Alternatives i. Doxy 100mg q12h ii. Bactrim DS 800/160mg 1tab q12h c. STD coverage i. Co-treatment for chlamydia essential because often co-exist ii. Single dose IM ceftriaxone 250mg PLUS iii. Single dose PO azithro 1gm or doxy 100mg BID x7 days 28. Identify at least one treatment for BPH a. Mild to moderate symptoms and minimal PVR i. Monitor as long as more serious conditions ruled out b. Avoid caffeine & ETOH (bladder irritants) c. Once prostate ca ruled out, meds can be tried: i. Taken when no strong indication for surgical resection ii. If pt is not surgical candidate iii. Alpha 1 blockers (relaxes smooth muscle around bladder neck): 1. tamsulosin (Flomax) 0.4-0.8mg daily 2. doxazosin (Cardura) 4-8mg daily 3. silodosin (Rapaflo) 4-8mg daily iv. 5-alpha reductase inhibitors 1. finasteride (Proscar) 5mg daily alone or in combo w/doxazosin 2. dustasteride (Avodart) 0.5mg daily d. Surgery i. When there is urinary retention or when other symptoms unmanageable ii. Transurethral resection of prostate (TURP) 29. Identify treatment options for obesity based on BMI and comorbid conditions a. Adults i. Comorbidities = HTN, dyslipidemia, T2DM, OSA ii. BMI >25 1. Diet a. Structured wt loss diet b. Encourage formal programs/wt loss groups c. Avoid fad diets d. Encourage lifestyle change e. 1200-1500 cals/day for women f. 1500-1800 cals/day for men g. 500-750 cal deficit/day h. Low carb, increased fiber, decreased sat fat i. <800cals/day in certain circumstances under medical supervision 2. Exercise 3. Behavior modification iii. BMI >27 w/comorbidity or >30 w/or w/out comorbidity 1. Meds a. Stimulants: a. Decrease appetite but also may have CV effects b. Not for pt’s with coexisting CVD c. Other meds can reduce fat/sugar absorption as well d. 3mo trial is recommended length e. Success = >5% wt loss, so pt can continue med f. If success not achieved, d/c med g. Clinician must be familiar w/med to initiate iv. BMI >35 w/comorbidity or BMI >40 w/or w/out comorbidity 1. Surgery a. Proven to promote greater wt loss than other interventions b. Highly effective to resolve other comorb (like T2DM) c. Before surgery pt must pass blood tests/psych eval d. Most centers require pt to have comprehensive diet counseling and to have failed at least 2 other wt loss methods b. Kids e. Not eligible: cardiopulm issues, psych issues, substance abuse f. Types: i. Most are restrictive, malabsorptive, or both ii. Lap band iii. Vertical sleeve gastrectomy iv. Roux-en-Y gastric bypass v. Duodenal switch vi. Postop ed: 1. Protein first, low carb diet w/numerous vitamin supplements for life (b/c vit malabsorption) 2. Carbonated drinks, NSAIDs, ETOH, pregnancy: avoid in 1st yr postop 3. Checkup q90days postop: blood tests to check for nutritional deficiencies 4. Maintenance: a. Active lifestyle b. Monitor wt weekly c. Daily low cal diet d. Accountability visits w/health professional i. Diet & exercise are mainstay 1. Avoid sugary foods/drinks (no high fructose corn syrup) 2. Avoid fruit juice (eat fruits in whole form) 3. Avoid fast food/high sat fat/Na foods 4. Portion control 5. Exercise 20min x5 days ii. Good sleep patterns iii. Decrease screen time to <1-2hrs/day iv. Approach change as family (address stressors) v. Infant breast feeding as prevention vi. School-based suppot system vii. Treatment options for kids not responding to above: 1. Meds: a. Not recommended for kids <16yo who are overweight b. Can be considered in obese kids; only peds specialists prescribe c. 90-day trials should yield >4% reduction in BMI; if not, d/c med 2. Surgery: a. For peds pt’s who are near-adult ht Week 6 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 standing 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 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. 4. Identify at least 3 laboratory tests to rule out systemic causes of tremor Electrolyte/ABGs (metabolic imbalances, drugs, caffeine, physiological fatigue) Serum glucose (hypoglycemia) Toxicology screen/drug levels (toxic conditions, antipsychotic drugs, caffeine) 5. Describe at least one at-risk population that is recommended to have HIV screening Anyone who had unprotected sex should be screened for HIV Men who have sex with men Those who exchange sex for drugs/money Those who have other STIs IV drug users Healthcare workers 6. Describe at least one pharmacologic treatment option for tremor Primidone (Mysoline) - beta blocker benzodiazepine (lorazepam) If monotherapy is ineffective, REFER TO NEURO If the tremor is medication induced, that agent may be reduced or eliminated. Parkinson’s disease - Dopamine agonist o Carbidopa/levodopa (Sinemet) o Pramipexole (Mirapex) o Ropinirole (Requip) - Anticholinergics 9. Identify physical exam findings in the patient with HIV Infection should be considered in patients who present with the more typical signs and symptoms, including an ill-defined febrile illness, heterophile-negative mononucleosis-like syndrome, heterophile positive mononucleosis in an unusual host (for example, an older adult patient), and/or aseptic meningitis. *Early HIV infection should also be considered in patients who have had a recent high- risk exposure or those who have had a recent sexually transmitted infection (particularly syphilis), regardless of the presence of symptoms or signs. 10.Describe symptoms, DDx, pathogens, testing, and treatment for the following conditions: Cellulitis, impetigo, MRSA, Bites (dogs, cats, humans), Erysipelas Cellulitis · acute infection as a result of bacterial entry via breaches in the skin barrier. · As the bacteria enter the subcutaneous tissues, their toxins are released which causes an inflammatory response. · Cellulitis involves the deeper dermis and subcutaneous fat. · Cellulitis is observed most frequently among middle-aged individuals and older adults. · The vast majority of pathogens associated with cellulitis are from either Streptococcus or Staphlococcus bacteria. · The most common are beta-hemolytic streptococci (groups A, B, C, G, and F), and S. aureus. Symptoms: · Cellulitis may present with or without purulence · Both erysipelas and cellulitis manifest with areas of skin erythema, edema, warmth and pain. · Fever may be present. · Additional manifestations of cellulitis and erysipelas include lymphangitis and inflammation of regional lymph nodes. · Edema surrounding the hair follicles may lead to dimpling in the skin, creating an appearance reminiscent of an orange peel texture called "peau d'orange". · indolent course with development of localized symptoms over a few days. Treatment · Many patients with cellulitis have underlying such as tinea pedis, lymphedema, and chronic venous insufficiency · should be directed at both the infection and the predisposing condition if modifiable. · 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) · Patients with cellulitis typically have symptomatic improvement within 24 to 48 hours of beginning antimicrobial therapy. Impetigo · a superficial bacterial infection of the skin. · primary impetigo when there is a direct bacterial invasion of previously normal skin · secondary impetigo when the infection arises at sites of minor skin trauma. o impetiginization. · most frequently observed in children ages 2–5 years of age, although older children of any age and adults may also be affected. · The infection usually occurs in warm, humid conditions and is easily spread among individuals in close contact. · Risk factors include poverty, crowding, poor hygiene, and underlying scabies. Source · S. aureus. · Group A Streptococcus (GAS) causes a minority of cases, either alone or in combination with S. aureus. · Occasionally, MRSA is detected in some cases of impetigo. Variants of impetigo ● Nonbullous impetigo—Nonbullous impetigo is the most common form of impetigo and begins as papules that progress to vesicles surrounded by erythema. Within a week, the papules eventually become pustules that enlarge, break down, and form thick, adherent crusts with a characteristic golden appearance. Lesions usually involve the face and extremities. Regional lymphadenitis may occur, although systemic symptoms are usually absent. ● Bullous impetigo—Bullous impetigo is seen primarily in young children in which the vesicles enlarge to form flaccid bullae with clear yellow fluid, which later becomes darker and ruptures, leaving a thin brown crust. The trunk is more frequently affected. Bullous impetigo in an adult with appropriate demographic risk factors should prompt an investigation for previously undiagnosed human immunodeficiency virus (HIV) infection. ● Ecthyma—This form of impetigo, caused by group A, beta-hemolytic Streptococcus (Streptococcus pyogenes), consists of an ulcerative form in which the lesions extend through the epidermis and deep into the dermis. Ecthyma resembles "punched-out" ulcers covered with yellow crust surrounded by raised violaceous margins. Complication · Poststreptococcal glomerulonephritis is a serious complication of impetigo (ecthyma). o This condition develops within 1–2 weeks following infection. Poststreptococcal glomerulonephritis manifests with edema, hypertension, fever, and hematuria. diagnosis · Made on the basis of clinical manifestations · A Gram stain and culture of pus or exudate is recommended to identify whether S. aureus and/or a beta-hemolytic Streptococcus is the cause. · Infections with methicillin resistant Staphylococcus aureus (MRSA), as the name indicates, are those caused by strains of Staphylococcus aureus that developed a resistant to methicillin shortly after the introduction of this medication in England in 1961. · Methicillin resistance is mediated by a penicillin-binding protein that permits the organism to grow and divide in the presence of methicillin and other beta-lactam antibiotics. Risk factors for community-associated methicillin- resistant S. aureus (CA-MRSA) · Antibiotic use secondary to antibiotic selective pressure. o Use of cephalosporins and fluoroquinolones strongly correlates with the risk for MRSA colonization and infection. ● HIV infection ● Hemodialysis ● Long-term care facilities CA-MRSA transmission · direct contact with a colonized or infected individual. · contact with contaminated fomites used by an affected individual. · Individuals colonized with MRSA serve as a reservoir for transmission. · MRSA can colonize the skin and nares of hospitalized patients, healthcare workers, and healthy individuals. · Colonization can occur from inhalation of aerosolized droplets from chronic nasal carriers. CA-MRSA isolates · most often associated with skin and soft tissue infections (SSTIs). Signs and symptoms · skin abscess-collection of pus within the dermis or subcutaneous space. · painful, fluctuant, erythematous nodule, with or without surrounding cellulitis. · Spontaneous drainage of purulent material may occur. · Regional adenopathy may be observed. · Fever, · chills, · systemic toxicity are unusual. · furuncles (abscessed hair follicles or "boils") · carbuncles (coalesced masses of furuncles). The diagnosis of a skin abscess is usually based upon clinical manifestations. Laboratory testing is not required for patients with uncomplicated infection in the absence of comorbidities or complications. ~Blood cultures should be obtained prior to the initiation of antibiotic therapy when the lesion is secondary to animal bites or water-associated injuries. ~ Differential should include the following. ● Epidermoid cyst—A skin-colored cutaneous nodule, often with a central punctum, that is freely movable on palpation. Epidermoid cysts may become secondarily infected. ● Folliculitis—Defined as inflammation of one or more hair follicles. ● Hidradenitis suppurativa—A chronic suppurative process involving the skin and subcutaneous tissue of intertriginous skin. ● Recluse spider bites. However, CA-MRSA SSTIs are far more prevalent than spider bites. ~Patients with drainable abscess should undergo incision and drainage with C&S. ~For patients undergoing incision and drainage of a skin abscess, some experts suggest antibiotic treatment under some conditions. ● Single abscess ≥2 cm ● Multiple lesions ● Extensive surrounding cellulitis ● Associated immunosuppression or other comorbidities ● Systemic signs of toxicity (fever >100.5° F/38° C) ● Presence of an indwelling medical device (such as prosthetic joint, vascular graft, or pacemaker) ● High risk for transmission of aureus to others (such as in athletes or military personnel) Antibiotics with coverage for CA-MRSA include the following. ● Bactrim DS twice daily ● Doxycycline 100 mg twice daily ● Minocycline 200 mg orally once, then 100 mg orally every 12 hours ● Clindamycin 300 mg to 450 mg four times daily Treatment should be offered for at least 5 days. **A beta-lactam drug should be added if the abscess is perioral or perirectal. Dog Bites · Soft tissue trauma caused by animal and human bites have serious clinical implications because of the potential for complications. · Animal bites are more common among children than among adults. · Dog bites can cause a range of injuries from minor to major complicated wounds. · The extremities, particularly the dominant hand, are the most frequent site of injury in older children or adults. The predominant pathogens in animal bite wounds are the oral flora of the biting animal and human skin flora. Therefore, infection usually results from a mixture of organisms. Common pathogens include of dog bites ● Pasteurella; ● Staphylococcus; ● Streptococcus species; and ● Capnocytophaga canimorsus, clinically significant in asplenic patients, chronic alcohol abusers, and those with underlying hepatic disease. Cat Bites · About two thirds of cat bites involve the upper extremities. · Deep puncture wounds are of particular concern because cats have long, slender, sharp teeth. · Cat bites can transmit Pasteurella and Bartonella henselae. Human bites · a semicircular or oval area of erythema or bruising is usually visible; · the skin itself may or may not be intact. · Bites by humans occur in two basic categories. · Occlusive wounds, more common in females, with teeth closing over and ~Amoxicillin/clavulanate 875 mg/125 mg twice daily is the agent of choice. ~Alternative antibiotics include one of the following agents with activity against Pasteurella. ● Doxycycline 100 mg twice daily ● Bactrim DS twice daily ● Penicillin VK 500 mg four times daily ● Ciprofloxacin 500 mg twice daily PLUS one of the following agents with anaerobic activity. ● Metronidazole 500 mg three times daily ● Clindamycin 450 mg three times daily ~First-generation cephalosporins and macrolides should be avoided. ~The duration of prophylactic oral antibiotics is 3–5 days, with close follow-up. ~Tetanus toxoid should be given to those who have completed a primary immunization series but who received the most recent booster 5 or more years ago. ~Patients with mild infection can be treated initially with the same prophylactic antibiotics for 5 to 14 days of therapy. Erysipelas ● involves the upper dermis, and there is clear demarcation between involved and uninvolved tissue. ● Erysipelas occurs in young children and older adults ● Erysipelas results almost always results from a group A strep infection Symptoms • Both erysipelas and cellulitis manifest with areas of skin erythema, edema, warmth and pain. • Fever may be present. • Additional manifestations of cellulitis and erysipelas include lymphangitis and inflammation of regional lymph nodes. • Edema surrounding the hair follicles may lead to dimpling in the skin, creating an appearance reminiscent of an orange peel texture called "peau d'orange". • erysipelas is non-purulent. • acute onset of symptoms with systemic manifestations including fever and chills, • Erysipelas lesions are raised above the level of surrounding skin with clear demarcation between involved and uninvolved tissue. • Classic descriptions of erysipelas note "butterfly" involvement of the face. • Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas, since this region does not contain deeper dermis tissue. Treatment • Patients with erysipelas should be managed with empiric therapy for infection due to beta- hemolytic streptococci with: • Penicillin V potassium 500 mg orally every 6 hours • Amoxicillin 875 mg twice daily • 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)