NR511 Final Exam Study Guide Week 1, Exams of Nursing

Download NR511 Final Exam Study Guide Week 1 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 -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. 2 2 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system -The CPT system offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non- physician providers. -CPT codes are recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. -ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed. 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data -Specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. -Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. -When a test is very sensitive, we mean it has few false negatives. 7. Discuss the elements that need to be considered when developing a plan Acknowledge the list -Negotiate what to cover -Be Honest -Make a follow-up 8. 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. 9. Correctly order the E&M office visit codes based on complexity from least to most complex 5 5 -Rotovirus (Leading cause for peds up to 2 years old) 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea Due to risk of C Diff infection 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD) -IBS (Irritable bowel syndrome): disorder of bowel function not from anatomic abnormality -constipation, diarrhea, bloating, urgency w/ diarrhea -NOT assoc w/ serious medical consequences, IBD or CA +S/S: result from disordered sensation or abnormal function of the small and large bowel -IBD (Inflammatory bowel disease): chronic immunologic disease that manifests in intestinal inflammation - UC/CD 4. Discuss two common Inflammatory Bowel Diseases -Ulcerative colitis (UC): the mucosal surface of the colon is inflamed and ultimately results in friability, erosions, and bleeding. - Most common in recto-sigmoid colon. Can involve entire colon - Pain in RLQ -Crohns (CD): the inflammation extends deeper into the intestinal wall and can involve all or any layer of the bowel wall and any portion of the GI tract from the mouth to the anus. - Skipped lesions - Pain in LLQ 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 6 6 · 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: ▪ 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 7 7 ▪ Fecaltih – hard lump of fecal matter ▪ Undigested seeds ▪ Pinworm infections ▪ Lymphoid follicle growth/lymphoid hyperplasia Symptoms ▪ Symptoms ▪ Nausea/vomiting ▪ RLQ pain ▪ Guarding Acute pancreatitis: ▪ Sudden inflammation and hemorrhaging of the pancreas due to destruction by its own digestive enzymes 1. Autodigestion ▪ Most of the time mild, but can be severe ▪ Pancreas ▪ Long skinny gland, length of dollar bill ▪ Located in upper abdomen ▪ Behind the stomach ▪ Endocrine ▪ Alpha/beta cells produce insulin & glucagon that are secreted into the blood stream ▪ Exocrine ▪ Leading causes: 1. ETOH abuse 2. Gallstones 3. Other Causes of acute pancreatitis 10 10 ▪ Pain in epigastrium which radiates to back ▪ Labs ▪ Increase in amylase; gold standard in diagnoses (up to 3x the normal level) ▪ Increase in lipase ▪ CT scan ▪ US to look for gallstones Acute cholecystitis: ▪ US confirmed ▪ Detects stones ▪ Sonographic murphy sign ▪ Tenderness when sonogram is over gallbladder ▪ GB wall thickening ▪ Sludge ▪ Distention of GB or common bile duct ▪ Cholescintigraphy (HIDA scan) ▪ 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: 11 11 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 Acute cholecystitis: o Supportive measures ▪ IV ▪ Pain management ▪ ATB o Surgical Removal ▪ Cholecystectomy 1. Laparoscopic 12 12 9. Discuss the difference between sensorineural and conductive hearing loss - Sensorineural: Results from deterioration of cochlea -Loss of hair cells form the organ of Corti -Gradual and progressive -Not correctable but preventable - Conductive: Obstruction between middle and outer ear -Most types are reversible 10. Identify the triad of symptoms associated with Meniere's disease -Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea -S/S: -Vertigo -Hearing loss -Tinnitus 11. Identify the symptoms associated with peritonsilar abscess -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 -Adenovirus: MOST common -RSV -Influenza A&B -Epstein-Barr -coxsackie -enteroviruses -herpes simplex 13. Identify the most common cause of acute nausea & vomiting 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 Abdominal xray films should be obtained on all patients with suspected diverticulitis to look for free air (indicating perforation), ileus, or obstruction 15 15 25. Discuss at least one treatment for Meniere's disease -Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea -S/S: -Vertigo -Hearing loss -Tinnitus Week 3 1. Discuss that the majority of dyspnea complaints are due to cardiac or pulmonary decompensation -2/3 of symptomatic patients the etiology is due to cardiopulmonary disease -1/3 of all cases the cause of dyspnea is multifactorial -Common cardiopulmonary conditions: 2. Explain the differences between intra-thorax and extra-thorax flow disorders -Flow Disorders -Intrathorax -Obstruction of distal/smaller airway -Extrathorax -Obstruction of proximal/larger airway 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) 16 16 -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 -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) 17 17 -psychologic (anxiety, usually adolescent) -poisoning (salycylate, alcohol) -trauma capitis -CNS disease sequelae -These disorders cause deep rapid breathing 4. Discuss diagnosis, risk factors and treatments for asthma Diagnosis- Essential elements to consider- HX- cough (especially nocturnal), recurrent wheeze, recurrent episodic dyspnea, recurrent chest tightness Symptoms worsen in relation to specific factors- changes in weather, exercise, environmental allergens, GERD, Beta blockers, sensitivity to ASA, strong emotional expression To establish the diagnosis of asthma, episodic symptoms of airflow obstruction must be present, airflow obstruction must be at least partially reversible, and must rule out other diagnoses. Spirometry measurements are helpful in diagnosis & in evaluation of management The diagnosis is made by demonstrating the reversibility of the airway obstruction from the pre- and post- PFTs. Reversibility is defined as a 15% or greater increase in the FEV1 after 2 puffs of a beta- adrenergic agonist have been inhaled. When spirometry is non-diagnostic, bronchial provocation testing maybe useful with histamine, methacholine, or exercise. Risk Factors Family or personal history- allergic rhinitis, eczema/atopic diseases Residing in urban area Exposure to smoke or air pollution Cockroaches and dust Viral respiratory infections Cold air intolerance obesity Classifications of Asthma Severity Mild Intermittent Symptoms < 2 days per week OR < 2 nights per month. Exacerbations brief Mild Persistent Symptoms > 2 times per week, but not daily; OR 3-4 times per month at nighttime Moderate Daily symptoms OR >1 night per week but not nightly 20 20 o first present on the head and travel down the body. o fade in 1–2 days in the same order the lesions appeared - Varicella: Chicken pox: arthralgia, then 1–2 days later the urticarial (or itching) erythematous macules & papules appear, quickly turn into vesicles & pustules. o The rash starts on the face and chest then spreads quickly over the entire body. - Roseola: The skin rash presents with light pink, erythematous macules and papules on the face, neck, and extremities. - 5th’s disease: - o 3 Stages: ▪ 1. Classic “slapped cheek” rash bright red bilateral cheeks which spare the forehead, nasal bridge, and perioral area ▪ 2. Pink lacy (or reticulated) erythematous macules on all extremities and trunk spare the palms and sole surfaces. • The rash may be itchy at this stage. ▪ 3. 2–3 weeks of the body rash. ▪ This rash may come and can last for up to 3 weeks. - Pityriasis rosea (PR): solitary 2–4 patch or plaque on the trunk that starts 2–3 weeks prior to the general rash o Herald’s patch o Christmas tree - Hand foot and mouth disease: vesicles on the hands and feet with mouth sores. o Mouth sores are in almost 90% of the cases and are usually the first sign. o There can be more than 10 mouth apthae (sores) anywhere in the oral cavity and frequently are asymptomatic. o The hand vesicles appear with erythematous halos and appear mostly on the soles and palms. o Vesicles might appear on the legs, buttocks, and face. o Molluscum contagiosum: Tiny pustules which are 2–5 mm, and some even have a slight depression in the center of the flesh-colored dome. 8. Differentiate between the following tineas: pedis, cruris, corporis and unguium and describe an appropriate treatment Tinea Pedis: athletes foot -Antifungal cream: -Ketaconozole for at least 4 weeks -Tinea Cruris: Jock itch -Topical antifungal -Tinea corporis: Ring worm -Topical antifungal cream -Tinea unguium: onychomycosis: fungal infection of the fingernails or toenails -topical agent: Ciclopirox nail laquer 8% applied daily for months at the base of the nail 9. Identify the virus that causes warts -HPV (Human papilloma virus) 10. Differentiate between atopic and contact dermatitis and give examples of each 21 21 -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 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 22 22 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 Tonometry reading yearly (measure of intraocular pressure ) Normal is 12-22 Refer to opthamologist Management Once nerve damage has occurred = irreversible If left untreated can lead to permanent vision loss. Goal to prevent progression and protect optic nerve 25 25 Erectile dysfunction should be assessed on patient taking finasteride. 5. Discuss the hallmark characteristic of a varicocele 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 6. Identify the population most affected by testicular cancer Males between the ages of 15 and 35 7. Explain spinal stenosis Narrowing of the spinal canal w/ compression of nerve roots - Congenital or acquired (age) - Most commonly from enlarging osteophytes at the facet joints, hypertrophy of the ligamentum flavum and protrusion/buldging of the intervertebral discs - May produce symptoms by directly pushing on nerve or interrupting the blood supply to nerve Common source of chronic low back pain, seen most with aging. All older people have some degree of this. 8. Discuss common characteristics (subjective and objective findings) of patients with lumbar spinal stenosis 26 26 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 Monoarticular: One joint Periarticular: Two to four joints Polyarticular: Four or more joints 12. Describe the four cardinal signs of joint inflammation 1. Erythema 27 27 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) - 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 - Physical Exam o Allen’s test o Phalen’s test (negative) 30 30 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 Hematological Fatigue, normochromic normocytic anemia 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. 31 31 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 32 32 • 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 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. 35 35 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, 2. Diagnosing meniscal tears: McMurray and Appley 36 36 3. Diagnosing PCL injury: posterior drawer test and Thumb sign 4. Diagnosing collateral (MCL and LCL) injury: Valgus and Varus stress test Week 6 37 37 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 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 40 40 • 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: 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) 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 41 41 - MRSA o Risk factors ▪ ATB use • Cephalosporins • Fluoroquinolones ▪ HIV infection ▪ Hemodialysis ▪ ECFs o Signs and Symptoms ▪ Skin abscess • Painful, fluctuant, erythematous nodule, with or without surrounding cellulitis • Spontaneous drainage may occur • Regional lymphadenopathy may be observed • Fever, chills, and systemic toxicity are unusual • Also manifested as furuncles (abscess of hair follicles) or carbuncles (coalesced masses of furuncles) ▪ Experts recommend oral ATB for patients undergoing I&D of an abscess if • Single abscess is equal or greater than 2cm or multiple lesions • Extensive surrounding cellulitis • Immunosuppression or systemic signs of toxicity (fever>100.5/38) • Presence of an indwelling medical device • High risk of transmission of S aureus to others o Athletes or military personnel ▪ ATB with coverage for CA-MRSA include • Bactrim DS 2x day • Doxycycline 100mg 2x day • Minocycline 200mg PO once, then 100mg Q12 hours • Clindamycin 300-450 mg 4xday ▪ Treatment should be offered for at least 5 days • Beta-lactam drug should be added if the abscess is peri-rectal or peri-oral - Impetigo o Primary ▪ Infection of previously normal skin o Secondary ▪ Infection arises at sites of minor skin trauma o Microbiology ▪ S. aureus ▪ Group A Strep (GAS) causes a minority of cases ▪ Occasionally MRSA o Signs/Symptoms ▪ Non-bullous impetigo • Most common form 42 42 • 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