NR511 Midterm and Final Exam Guide, Study Guides, Projects, Research of Nursing

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NR511 Consolidated Midterm and Final Exam

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. 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 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. -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

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 -tests performed or ordered -diagnoses -level of involvement 18. Identify and explain each part of the acronym SNAPPS -S: Summarize -N: Narrow -A: Analyze -P: Probe -P: Plan -S: Self-directed learning Week 2 1. Identify the most common type of pathogen responsible for acute gastroenteritis -Viral: Norovirus (Leading cause for adults) -Rotovirus (Leading cause for peds up to 2 years old) Gastroenteritis, also known as enteritis or gastroenterocolitis, is defined as an inflammation of the stomach and intestine that manifests as anorexia, nausea, vomiting, and diarrhea. Acute gastroenteritis results most often from an infectious agent. The most common mode of transmission for acute infectious gastroenteritis is the fecal–oral route from contaminated food or water. Person-to-person transfer of the disease is more common within the hospital setting and within day-care centers where there are larger groups of people capable of transmitting the disease. Bacterial pathogens account for 30% to 80% of acute gastroenteritis cases and are an important cause of morbidity in tropical areas and in travelers to areas of high risk for the pathogens (traveler’s diarrhea). Page 526 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 Some medications, such as antibiotics, can induce diarrhea by disrupting the normal balance of bacteria. Probiotics have been studied in the treatment of diarrhea. A systematic review of 63 probiotic studies of adults and children revealed that the duration of antibiotic-associated diarrhea was shortened by a mean of 25 hours with probiotics and hydration therapy. Page 512-513. 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 Normal bowel function is regulated by segmental contractions that limit the movement of bowel contents through the colon. An increase in these contractions causes constipation, and a decrease in the contractions results in frequent stooling or diarrhea. Studies have confirmed alterations in colonic activity during periods of emotional stress, in which motility is decreased or inhibited with depression and increased with feelings of hostility and anger. Up to one-third of patients with IBS develop the disorder after bacterial gastroenteritis. It appears that patients with increased life stressors are more prone to developing IBS post infection. See #4. Page 577-578. 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 LLQ
• 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 RLQ Inflammatory bowel disease (IBD) is the term used to describe a chronic immunological disease that manifests in intestinal inflammation. The two most common IBDs are ulcerative colitis (UC) and Crohn’s disease (CD). UC involves only the mucosal surface of the colon, which ultimately results in friability, erosions, and bleeding. It occurs most often in the rectosigmoid area but can involve the entire colon. CD is also known as regional enteritis because of the characteristic segmental presentation of the diseased bowel, which is clearly separated by areas of normal mucosa, often referred to as “skipped lesions.” CD can involve all or any layer of the bowel wall and any portion of the gastrointestinal (GI) tract from the mouth to the anus. UC is more common in males, and CD is more common in females. Page 570-571. 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 Diverticular disease is the term used to describe the inflammatory changes that occur within the diverticular mucosa of the intestine (diverticulitis), as well as the asymptomatic, uninflamed outpouchings called diverticulosis. Although there is no known cause for diverticular disease, a low-fiber diet has been implicated because it causes increased intraluminal pressures within the colon, which lead to mucosal herniation through the weaker areas in the bowel wall. Other factors believed to contribute to the formation of diverticula include hypertrophy of the segments of the circular muscle of the colon, chronic constipation and straining, irregular and uncoordinated bowel contractions, obesity, and weakness of the bowel muscle brought on by aging. Risk factors are directly related to the suspected causes of the disease: older than age 40, low-fiber diet, previous diverticulitis, and the number of diverticula present within the colon. Diverticula occur most often in the left lower quadrant (LLQ); a right lower quadrant presentation is a rare condition, with a higher incidence in Asian populations. Patients with diverticulosis characteristically present with pain in the LLQ of the abdomen. When

the diverticula have become inflamed, there are the usual signs and symptoms of infection—fever, chills, and tachycardia. A physical exam reveals tenderness in the LLQ of the abdomen, and—if the patient can tolerate more vigorous examination —a firm, fixed mass may be identified in the area of the diverticuli. Initial laboratory testing can show mild to moderate leukocytosis, depending on whether the patient presents with diverticulitis or with a more advanced inflammatory process such as peritoneal abscess. The white blood cell (WBC) count is usually normal in patients with diverticulosis. Hemoglobin and hematocrit may be low if there is associated rectal bleeding. Patients with signs suggestive of peritonitis should have a blood culture to assess for bacteremia. An incidental finding of uncomplicated diverticulosis requires no further intervention and can be managed with a high-fiber diet or daily fiber supplementation with psyllium. Treatment of a patient presenting with mild symptoms can often be managed on an outpatient basis with rest, oral antibiotics, and a clear liquid diet. Initial antibiotic therapy varies with the extent of the inflammatory process and can include metronidazole (Flagyl) 500 mg by mouth three times daily with ciprofloxacin (Cipro) 500 mg by mouth twice daily, or trimethoprim/sulfamethoxazole (Bactrim DS) 160/800 mg by mouth twice daily for 7 to 10 days. The symptoms usually

subside quickly; then the diet can be advanced to soft, low roughage and next to high fiber as tolerated. Pain due to spasms can be managed with antispasmodics such as hyoscyamine (Levsin) 0.125 mg every 4 hours, dicyclomine (Bentyl) 20 to 40 mg four times daily, buspirone (BuSpar) 15 to 30 mg/day, and/or meperidine (Demerol) 100 to 150 mg/day in divided doses. To evaluate or diagnose diverticular disease, all patients will require colonoscopy at some point during their disease process; therefore, referral to a gastroenterologist is indicated for symptoms that do not respond to treatment after 6 months. Patients diagnosed with diverticular disease will need to make modifications in their diets with an emphasis on increasing the amount of dietary fiber. The goal of diet therapy is to avoid constipation and straining during bowel movements, which can further increase intraluminal pressures and cause complications. Patients should also be instructed to drink at least ten 8-ounce glasses of water a day to have regular, soft bowel movements. Pages 584- 586

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 · 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 As the erosion heals, the body replaces the normal squamous epithelium with metaplastic columnar epithelium (Barrett’s epithelium) containing goblet and columnar cells. This new epithelium is more resistant to acid and, therefore, supports esophageal healing. Barrett’s epithelium is a premalignant tissue, however, and presents a 40-fold increased risk for the development of esophageal adenocarcinoma. Fibrosis and scarring also accompany the healing process, leading to esophageal strictures. Page 523. 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) Esophageal reflux is the backward flow of stomach or duodenal contents into the esophagus without associated retching or vomiting. Gastroesophageal reflux disease (GERD) is a syndrome that results from esophageal reflux; the characteristic symptoms are caused by repeated exposure of the esophageal mucosa to the deleterious effects of gastrointestinal contents and the gradual breakdown of the mucosal barrier. The primary cause of GERD is the inappropriate, spontaneous, transient relaxation of the lower esophageal sphincter (LES) to an unknown stimulus. Obesity is also a risk factor for GERD. A number of foods and pharmacological agents are known to lower LES pressure. Table 11.5 lists the common substances that reduce LES pressure or cause direct gastric mucosal irritation. It is usually associated with other symptoms, including regurgitation, water brash (reflex salivation), dysphagia, sour taste in the mouth in the morning, odynophagia, belching, coughing, hoarseness, or wheezing, usually at night. Factors that precipitate or make the symptoms worse, such as reclining after eating; eating a large meal; ingesting alcohol, chocolate, caffeine, fatty or spicy foods, or nicotine; wearing constrictive clothing; or working in an occupation in which heavy lifting, straining, or working in a bent-over position is involved also help establish the diagnosis of GERD. Patients with chronic GERD may present with dysphagia as their chief complaint. One pattern that can help differentiate GERD from PUD is that heartburn from PUD is usually relieved by food. This is not the case in GERD; instead, the symptoms are worse shortly after eating. The guidelines for treatment from the Agency for Healthcare Research and Quality include a “step-up” and a “step-down” approach. For all patients with GERD, lifestyle modifications are the first line of treatment. These include elevating the head of the bed 6 to 8 inches; smoking cessation; and avoiding high-fat meals, large meals, and certain foods such as chocolate, alcohol, peppermint, caffeine, onions, garlic, citrus, and tomatoes. The patient should be instructed to avoid recumbency or sleeping for 3 to 4 hours after a meal and avoid bedtime snacks. Weight loss should be encouraged in those patients who are overweight or obese. See Guidelines 11.1 page 525. Pages 523-525.

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 ▪ 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
   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 Acute cholecystitis: Inflammation of gallbladder (GB) Usually due to gallstone in cystic duct
4. 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 ▪ 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 ▪ Mild Fever, 99- ▪ RLQ pain/McBurneys point ▪ CT abd may help rule out other diagnostic possibilities ▪ ABD ultrasound helps to visualize the inflamed appendix Acute pancreatitis: ▪ 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:

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 ▪ O ▪ ATB Acute cholecystitis: o Supportive measures ▪ IV ▪ Pain management ▪ ATB o Surgical Removal ▪ Cholecystectomy

1. Laparoscopic 2. First, the nature of the pain should be elicited in order to provide clues to the mechanism of the pain. Location of the pain is valuable information, but it is important to remember that abdominal pain can be referred from areas outside of the abdomen. Timing of the pain (onset, duration, frequency, and relationship to associated symptoms) can help eliminate some causes. The palliative and provocative aspects of the pain can give clues about the cause of the pain. Any time the pain is very severe and associated with a rigid abdomen, referral to a physician is essential. A complete blood count, serum chemistries, liver function tests, urinalysis, pregnancy test, and abdominal films will help determine the acuity of the problem. Differential Diagnosis Flowchart 11.1 presents selected causes of abdominal pain and their characteristics. Page 504-508. 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 Sensorineural hearing loss is defined as a lesion in the organ of Corti or in the central pathways, including the eighth cranial nerve (CN VIII) and auditory cortex. Age-related hearing loss, termed presbycusis, is a form of sensorineural hearing loss. This first affects perception of high-frequency sounds and then progresses to affect hearing of lower- frequency tones. Conductive hearing loss is a lesion involving the outer and middle ear to the level of the oval window that may result from a variety of structural abnormalities. Cerumen impaction, a reversible form of hearing loss, is a

common cause in all age groups. Perforation of the tympanic membrane, middle ear fluid, damage to the ossicles from trauma or infection, otosclerosis, tympanosclerosis, cholesteatoma, middle ear tumors, temporal bone fractures and injuries related to trauma, or congenital problems may all cause conductive hearing loss. Sensorineural (which is usually irreversible) or conductive (which is often reversible). Ménière’s disease causes fluctuating hearing loss, usually unilateral, associated with tinnitus and vertigo. Page 283.

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 Ménière’s disease (Ménière’s syndrome, endolymphatic hydrops) is a peripheral sensory disorder of both the labyrinth (semicircular canal system) and cochlea of the inner ear. Endolymphatic volume and, in turn, pressure are increased due to unknown etiology, resulting in both vestibular (proprioceptive, balance-related) and auditory dysfunction, characterized by recurrent attacks of tinnitus (ringing or buzzing in the ears), vertigo (a sense of whirling or spinning in space), and progressive hearing loss. Diagnosis of Ménière’s disease is based on a careful history, neurological assessment, and response to empiric therapy, because no specific diagnostic testing exists. A low-salt diet (less than 1,000 mg/day) is considered first-line therapy to reduce endolymphatic pressure and volume, along with a mild diuretic such as chlorothiazide (Diuril) 500 mg/day orally (PO) and potassium supplements to counter diuretic-induced hypokalemia. Caffeine avoidance and tobacco cessation are also suggested to avoid vasoconstriction of the labyrinthine system. Acute attacks are managed with a combination of antimuscarinics or anticholinergics and vestibulosuppressive histamine (H 1 ) blockers from various classes. If conventional treatment fails, intratympanic perfusion with dexamethasone may prove effective, especially if an underlying autoimmune disorder is present. As a last resort, if Ménière’s disease progresses bilaterally, streptomycin or gentamicin ablation therapy may be appropriate to reduce unbearable vestibular symptoms. Pages 287-290. 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 Acutely, it is most often caused by group A Streptococcus infection, and a chronic form may also result from repeated Streptococcus infections. Streptococcal tonsillar infection always has the potential for progressing to peritonsillar or tonsillar abscess requiring aggressive management (incision and drainage followed by antibiotic therapy). Symptoms include gradual onset of severe unilateral sore throat, odynophagia, fever, otalgia, and asymmetric cervical adenopathy. Trismus, similar to lock jaw or "hot potato" voice (speaking as if a hot object was in the mouth), is common. A toxic appearance (e.g., poor or absent eye contact, failure to recognize parents, irritability, inability to be consoled or distracted, drooling, severe halitosis, tonsillar erythema, and exudates can also be observed. Abscess and cellulitis both have swelling above the affected tonsil, but with abscess, there is more of a discrete bulge, with deviation of the soft palate and uvula and more pronounced trismus. Patients should be referred to the emergency room immediately as maintaining airway patency and preventing sepsis is of concern. Page 325 and lesson power point. 12. Identify the most common cause of viral pharyngitis

• Adenovirus: MOST common -RSV -Influenza A&B -Epstein-Barr -coxsackie -enteroviruses -herpes simplex the current literature suggests that in adults, upper respiratory tract viruses are the most common cause of infectious

pharyngitis, accounting for 30% to 50% of all cases: rhinovirus, coronavirus, adenovirus, influenza viruses A and B,

parainfluenza virus, coxsackievirus (herpangina and hand-foot-and-mouth disease), enterovirus, and respiratory syncytial virus (RSV). Page 324

13. Identify the most common cause of acute nausea & vomiting Gastroenteritis Gastroenteritis is the most common cause of nausea and vomiting in adults and children. Contaminated food should be considered in cases of acute nausea and vomiting, especially when more than one person is affected. Gastritis, usually associated with alcohol consumption or drugs (aspirin, NSAIDs, antibiotics, and illicit drugs), is also a very common cause of acute nausea and vomiting in adults. See Table 11.4 Pages 518-519. 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. 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 Age is the most important risk factor for developing colorectal cancer in the United States. The risk increases steadily with age, especially after age 45, and is rare in individuals younger than age 35 unless they are predisposed to rare genetic diseases. Other risk factors for colorectal cancer include a family history and a personal history of adenomatous polyps (multiple polyps or individual polyps greater than 1 cm in size) or colon cancer. Diets high in fat, red meat, and refined carbohydrates and low in plant fiber have been correlated with the areas of highest incidence of colorectal cancer, whereas areas with the lowest incidence of colorectal cancer have diets high in fiber and rich in vegetables and fruits. See Guidelines 11.1 page 591. Pages 587 and 591. 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 Exposure to loud noises, either occupationally or recreationally, is a risk factor for hearing loss, as are ototoxic drugs (e.g., aminoglycoside antibiotics, aspirin, and quinine). Allergies and other causes of eustachian-tube obstruction may also contribute to hearing loss. Conductive hearing loss is a result of obstruction between the middle ear and outer ear. This can occur with cerumen accumulation or impaction, a foreign body in the ear canal, otitis externa, chronic otitis media, middle ear effusion, otosclerosis (scarring of the TM), a vascular anomaly or a cholesteatoma. To treat conductive hearing loss appropriately, an etiology must be accurately identified. Most types of conductive hearing loss are reversible. Page 283 and Lesson PP. 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 Bacterial agents typically cause an exudative pharyngitis, which represents roughly 20% of all cases of sore throat. Group A beta-hemolytic Streptococcus pyogenes, which accounts for 10% to 20% of adult pharyngitis cases, invades and multiplies within the pharyngeal mucosa, causing an intense inflammatory response known as “strep throat.” Group A is the most important cause of pharyngitis because it may lead to the most serious complications, including heart valve damage that may occur many years after systemic infection known as acute rheumatic fever. The most common bacterial cause is from Group A Beta Hemolytic Streptococcus (GABHS). Identification of GABHS is essential as this can cause complications such as rheumatic fever, peritonsillar abscess, scarlet fever or glomerulonephritis. Page 324 and lesson PP.

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: (+) Infectious mononucleosis is famous for its gradual onset of low-grade fever and marked fatigue and severe sore throat. Anorexia and nausea may also be present. EBV-related infectious mononucleosis, however, may present with an exudative tonsillitis (in about 50% of cases), in addition to palatal petechiae and exanthem. Page 325. 19. Identify common characteristics in a rash caused be Group A Strep Sandpaper rash Fine, red, sparing hands & soles Streptococcal infection produces a characteristic white to yellow exudate and may be accompanied by a sandpaper-like, scarletiniform rash. Page 325. 20. Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria -Absence of cough -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy Rapid Strep Tests are highly specific (90%) and sensitive (80–90%) when used judiciously. A Rapid Strep Test to guide antibiotic therapy is considered appropriate for any patient with two or three of the following criteria: fever above 100.5°F (38.1°C), tonsillar exudate, tender anterior cervical lymphadenopathy, and the absence of cough. Patients meeting three or four of these criteria may be empirically diagnosed with group A Streptococcus and treated immediately. Throat swab cultures of the posterior pharynx and tonsils—the current “gold standard” test for the diagnosis of Streptococcal infection—are sent rather than the Rapid Strep Test for patients meeting fewer criteria and considered to have a low pretest likelihood of infection (less than 20%). The clinical features most suggestive of bacterial pharyngitis include fever over 38 degrees C (100.5F), tender anterior cervical adenopathy, lack of a cough, and a pharyngotonsillar exudate. The presence of these four features (known as the Centor criteria), strongly suggest a GABHS infection. Patients with >3 of Centor criteria may be empirically diagnosed with GAS and treated without further testing. Page 326 and lesson PP. 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

Patients who are dehydrated and able to tolerate oral fluid replacement should be instructed to drink fluids with a sodium content of 45 to 75 mEq/L (Pedialyte or Gatorade) or be provided with oral rehydration salts. In patients who are severely dehydrated or those who have chronic diseases and are hypotensive, hospitalization for IV hydration may be indicated. Patients with diarrhea require a diet that includes calories that come from boiled starches and cereals (potatoes, pasta, rice, wheat, and oats), which will facilitate enterocyte renewal, with the addition of salt for the duration of illness. Nonspecific symptomatic treatment of acute diarrhea can decrease the occurrence by 50% and is most effective against secretory diarrhea. Antimotility drugs are the most frequently prescribed and most effective drugs for the treatment of symptomatic gastroenteritis. Teaching includes good hand washing and safe disposal of waste products. Any infant or child with infectious diarrhea should not attend day care until the diarrhea has stopped or the child has completed the prescribed course of antibiotics. Patients traveling in high-risk areas should be instructed to consume only safe foods and beverages there and on the airplane leaving the area. “Safe” foods include acidic foods such as unpeeled citrus fruits; dry foods such as breads and cereals; steamed foods and beverages such as coffee, tea, and cooked vegetables; foods containing high amounts of sugar such as syrups, jellies, and jams; and bottled carbonated drinks such as soda and beer. Pages 535-536.

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 Traveler’s diarrhea is treated empirically with trimethoprim-sulfamethoxazole (Bactrim DS), one double-strength tablet twice daily for 3 days. Other antibiotics that are effective for milder forms of illness include a single dose of ciprofloxacin (Cipro) 500 mg, norfloxacin (Noroxin) 400 mg, or ofloxacin (Floxin) 300 mg. Antibiotic prophylaxis, which has a 90% effectiveness rate, for people traveling in high-risk areas includes the antibiotics mentioned above in daily doses continuing for 2 days after returning home. Nonantibiotic preventive therapy includes bismuth subsalicylate (Pepto- Bismol), two tablets before each meal and at bedtime for a total of eight tablets/day for the entire trip. This remedy has an approximately 60% effectiveness rate. Page 536. 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 o Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): drugs work by acting locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit - Antidepressants for depression/anxiety component The initial step to successful management of IBS is making the diagnosis and then identifying the symptom pattern for each individual patient. A careful diet history is important in identifying foods that may precipitate symptoms. IBS is often confused with lactose intolerance and can be evaluated by removing lactose from the diet for 2 weeks and monitoring the symptoms. Other foods that are frequently identified in producing IBS syndromes include caffeine, legumes (and other fermentable carbohydrates), and artificial sweeteners. Diets high in fiber are beneficial regardless of predominant bowel habit. Patients are encouraged to increase their fiber intake to 20 to 30 grams per day. Foods high in fiber include whole grains, cereals, fruits, and vegetables; however, they must be introduced slowly for IBS patients in order to avoid the sensation of bloating. Antidiarrheal medications are used only as a temporary measure. When the diarrhea is severe,

episodic use of loperamide (Imodium) 2 mg or diphenoxylate (Lomotil) 2.5 to 5.0 mg every 6 hours can be used as

needed. Patients who anticipate stressful situations can use antidiarrheals prophylactically. Patients with constipation who have not responded to a high-fiber diet, hydration, exercise, and bulking agents may benefit from intermittent use of stimulant laxatives such as lactulose or magnesium hydroxide. Long-term use of laxatives is discouraged. Tricyclic antidepressants and selective serotonin re-uptake inhibitors have been shown to relieve symptoms in some individuals. Individuals with IBS need reassurance and understanding that their disease is chronic. They often benefit from support groups and counseling. Psychiatric interventions that teach behavior modification and biofeedback or that can provide psychotherapy or hypnosis are helpful alternative measures for patients with refractory IBS. Pages 579-580.

24. Identify at least one prescription medication for the treatment of chronic constipation -Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): drugs work by acting locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit

• Movtantik (naloxegol) and Relistor (methylnaltrexone) for Opioid induced Miralax is a gentle but effective laxative that is safe for long- term use - OTC Laxatives and stool softeners are sometimes needed if changes in diet are insufficient. Miralax is a gentle but effective laxative that is safe for long-term use. Bulking agents, such as psyllium and methylcellulose, are laxatives that help hold water in the stool and add bulk to it. The increased bulk stimulates the natural contractions of the large intestine. Bulkier stools are softer and easier to pass. Bulking agents act slowly and gently. These agents generally are taken in small amounts at first. The dose is increased gradually until regularity is achieved. There are some relatively new medications in existence that are able to treat opioid-induced constipation. One of the most common medications for OIC is Movantik (naloxegol). This is usually started at 25 mg tablet once daily in the morning or on an empty stomach. Relistor (methylnaltrexone) is another medication that is available in a subcutaneous and oral formulation. Oral dosing starts at 450 mg tablet once daily. 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:

Week

-Vertigo -Hearing loss -Tinnitus

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: Like pain, dyspnea is a perceived sensation that may vary among patients, which is why using a scale from 0 to 10 is recommended. In an older patient, dyspnea is the major atypical presentation for ischemic heart disease and myocardial infarction and is considered a frequent anginal equivalent. In the majority of cases, dyspnea is a result of cardiac or pulmonary decompensation. There are several symptoms associated with dyspnea, such as tachypnea (rapid breathing), orthopnea (dyspnea relieved in the sitting or upright position), and paroxysmal nocturnal dyspnea (sudden episodes of acute dyspnea at night). Pulmonary: COPD, asthma, pulmonary parenchymal disease, ILD, pulmonary hypertension, severe kyphoscoliosis, exogenous mechanical factors (ascites, massive obesity, extensive pleural effusion) Cardiac: Congestive heart failure (CHF), pulmonary venous congestion (mitral stenosis, mitral regurgitation) Hematological: Severe chronic anemia Psychogenic: Anxiety and panic disorders Dyspnea may be acute or chronic, and patients with COPD may have both acute and chronic dyspnea. Onset of dyspnea at rest, accompanied by a sense of chest tightness, a feeling of suffocation, and an inability to “get air in,” is a common presentation of anxiety-related dyspnea. In the absence of heart and lung disease, a history of multiple somatic complaints, emotional difficulties, no activity limitations (exercise intolerance), and dyspnea unrelated to activities provides evidence for psychogenic-related dyspnea. About 75% of cases of dyspnea are caused by respiratory conditions that may be acute or chronic. The majority of other causes of dyspnea are cardiac in origin. Exploring when the dyspnea first occurred and what the patient was

doing at the time is essential. Page 342-343.

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 Flow Disorders: Intrathorax: Obstruction of distal/smaller airway. Intrathorax flow disorders originate from obstruction of distal/smaller airways and include asthma; bronchiolitis; vascular ring; solid foreign body aspiration; and lymph node enlargement pressure. These types of disorders cause expiratory effort in infants and also in children less than 5 years of age (bronchiolitis). Extrathorax: Obstruction of proximal/larger airway. Examples of the extrathorax flow disorders, which originate from obstruction of the larger airways, include rhinitis with nasal obstruction, nasal polyp; cranio-facial malformation; obstructive sleep apnea; tonsil-adenoid hypertrophy; laryngo-tracheo-malacia; larynx papilloma; Diphtheria; croup, epiglottitis; and thymus hypertrophy. Infants or children ages 5 and younger are affected, and they have clinical findings of inspiratory stridor. Volume Disorders: Intrathorax: Lung parenchyma disorders and Extrapulmonary disorders. Extrathorax: Lung compliance disorders and Respiratory center disorders Examples of intrathorax volume disorders include lung parenchyma disorders such as pneumonia (infection, aspiration); atelectasis; pulmonary edema; near drowning *These disorders affect inspiratory effort. Examples of extrapulmonary volume disorders include 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); and thorax deformity (pectus excavatum, scoliosis). *These disorders also affect inspiratory effort. Extrathorax volume disorders due to lung compliance issues include neuromuscular disorders (CP, GBS, MG); gastritis, peptic ulcer; extreme obesity; peritonitis, appendicitis, acute abdomen; aerophagia, meteorismus; ascites; hepato- splenomegaly; and abdominal solid tumor. *These disorders cause inspiratory constraint. Extrathorax volume disorders that are due to respiratory center disorders include anemia; metabolic acidosis; CNS infections: meningitis, encephalitis; encephalopathy (typhoid, DHF, metabolic); psychologic (anxiety, usually adolescent); poisoning (salycylate, alcohol); trauma capitis; and CNS disease sequelae. *These disorders cause deep rapid breathing.

3. Identify at least three examples of flow and volume disorders (intra and/or extra thorax) (see #2 above) -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) -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) -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 Persistent Daily symptoms OR >1 night per week but not nightly Severe persistent Symptoms throughout the day; often 7 nights per week Pharmacological Management *Short acting bronchodilator (albuterol) is a mainstay of treatment for ALL asthma patients

Intermittent Short-acting bronchodilator (albuterol): for exacerbations (inhaled or nebulized) Mild Persistent Short acting bronchodilator +

Preferred tx- Low-dose inhaled corticosteroids (fluticasone/Flovent, budesonide/Pulmicort, mometasone/asmanex Moderate Persistent Short acting bronchodilator + Preferred tx- low to medium dose inhaled corticosteroid AND Long acting inhaled bronchodilator (salmeterol/serevent, formoterol/Foradil) Alternative tx-low to med dose inh. Corticosteroid AND Either leukotriene blocker (Montelukast/singulair) OR theophylline 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) Asthma is a chronic, inflammatory, obstructive disease of the airways. It may occur at any age and may be characterized by wheezing (airway spasms), tightness in the chest, breathlessness (dyspnea), and cough. Although the exact cause is unknown, three principal triggers for exacerbations of asthma have been identified: Allergens and environmental factors: Allergens may include inhaled substances, such as molds, pollens, dust, animal dander, cosmetics, and tobacco smoke; food additives with sulfite preservative agents; and medications, especially beta blockers and aspirin or aspirin- containing drugs. Infections: Upper respiratory infections are common precursors to an asthma attack. Viral infections commonly precede an asthma episode. Psychological factors: Stressful events at work or home or a series of crises may precipitate an asthma attack. Many times, stressors may be overlooked or dismissed. Genetic predisposition, allergy, environmental factors, stress, and infectious agents are factors that play a role in the etiology of asthma. Therefore, prevention of acute episodes, which minimizes the amount of remodeling, is key to the proper treatment of asthma. Expiratory airflow measurements are essential to the differential diagnosis of asthma. Differentiating asthma from other diseases is usually not difficult, particularly with the aid of pulmonary function tests (PFTs), a complete history, and laboratory test results. Spirometry is recommended for the diagnosis of asthma. A common feature of asthma is nocturnal awakening with one or more of the following symptoms: dyspnea, cough, and wheezing. Allergic rhinitis and eczema often accompany a diagnosis of asthma. To establish the diagnosis of asthma, episodic symptoms of airflow obstruction must be present, airflow obstruction must be at least partially reversible, and the provider must have ruled out any alternative diagnoses. A CBC with differential, with special attention to the sedimentation rate and eosinophil count, is done. One key feature to making the diagnosis of asthma is the reversibility of the obstructive phenomenon. The principles of management include the following:Identification of factors that exacerbate the condition. Daily monitoring of PEF with a symptom record (see Asthma Attack Trigger Diary at http://davisplus.fadavis.com). Written instructions on managing an acute asthma attack. Intensive education and follow-up, emphasizing joint decision making. Initial and subsequent management of asthma is aimed at first removing all identified triggers or precipitant. The clinician should always review the patient’s medication technique, adherence, and control of triggers at each visit. Asthma management can require daily pharmacotherapeutics with inhaled corticosteroids, long-acting beta-2 agonists, and/or leukotriene antagonists. In the management of chronic asthma, ABG analysis (in hospital) and PFTs (in primary care) are done periodically to measure how well the patient is responding to treatment. The patient can be taught to use a handheld peak flow meter to measure the peak expiratory flow rate (PEFR) and gauge response to treatment. If the PEFR reading is less than 80% of the patient’s personal best, adjustments in medications or lifestyle may be necessary. Inhaled corticosteroids are the treatment of choice as anti- inflammatory controller therapies, above other classes of inhaled medications and theophylline. See Treatment Flow Chart 9.1. Pages 348-353.

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