NRNP 6550 Final Exam-with 100% verified solutions-2023-2024, Exams of Health sciences

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NRNP 6550 Final Exam-with 100% verified solutions-2023-2024 Urine culture with UTI Correct answer- 100.000 colonies in asymptomatic: bacteruria 10 - 10.000 colonies in symptomatic patients but also pyuria pyuria: more than 10 leukocytes elevated erythrocytes with pyelonephritis WBC in urine false positive with tumor, urethritis and poor collection technique Repeat in pregnant women Lower urinary tract UTI and upper urinary tract UTI Correct answer- bladder and urethra: cystitis/ urethritis/ prostatitis kidney and ureters: pyelonephritis/ renal abcess Uncomplicated and complicated uti Correct answer- Uncomplicated: in normal working urinary tract Complicated: defects in urinary tract or with other health problems Common pathogens for UTI Correct answer- E.coli (elderly women) Staphylococcus proteus mirabilis (elderly men) Klebsiella enterecoccus pseudomonas Providencia (institutionalized) Fungus: candida Risk factors for UTI Correct answer- Female critically ill elderly catheter (caused by biofilm) DM calculi, tumor, stricture neurogenic bladder Women: sexual intercourse or new sex partner pregnancy previous UTI Men: prostate enlargement prostatitis lack of circumcision gay HIV Findings UTI Correct answer- Lower: Dysuria/ urgency/ frequency/ incontinence suprapubic pain hematuria fever/ chills uncommon No flank pain Upper: flank pain fever and chills hematuria n/v ams (in elderly) malaise tachycardia/ tachypnea Testing and results for UTI Correct answer- Gold standard: urine culture and sensitivity: detection of bacteria. Start with POC: urine analysis. UA: pos for nitrite or leukocyte or blood CBC: leukocyte with left shift in pyelonephritis For recurrent UTI in women or UTI in men rule out obstruction, calculi, or necrosis with: xr voiding CT abdomen US pelvis MRI pelvis Management acute cystitis Correct answer- First line: - Single dose Fosfomycin (monurol) - 3 day: sulfa: trimethoprim/ sulfa (bactrim) (do not give near delivery of baby, give cephalexin instead) or sulfa - 5 days: nitrofurantoin, caution in elderly Second line: - qiunolones: ciprofloxain or levofloxacin for 3 days (not for pregnant women!) - B-lactams: amoxi-clav, cefdinir for 3 - 7 days Management uncomplicated upper UTI Correct answer- Outpt: quinolone: ciprofloxacin for 7 days or levofloxacin for 5 days Sulfa: trimethoprim/ sulfa (bactrim) for 14 days Inpt: Ceftriaxone or cefotaxime High H2O Low osmolality (350 and less) Specific gravity: 1,010 Urinary sodium: greater than 20 Sediment: + BUN/ creat ratio: less than 20/1 FEna: greater than 2% Treat: stop offending drug. Contrast: fluid administration, pre- and post. Hold metformin before contrast, for 48hrs. Postrenal Correct answer- Cause: Urinary flow obstruction: Enlarged prostate Cervical cancer Tumors Kidney stones Neurogenic bladder, diabetic neuropathy, spinal cord disease - urine creatinine decreased - no proteinuria - no sediment or hematuria with stones - BUN increased - serum creatinine increased - serum phos increased - serum calcium decreased Anuria/ polyuria Urine osmolality less than 350 Fixed urine specific gravity (1.0008- 1.012) Urine Na greater than 40 BUN to creatinine ratio: greater than 20:1 Treat with catheter drainage, urethral stents, percutaneous nephrostomy treatment of ARF/AKI Correct answer- -· Therapy for ARF: o Treat underlying cause o Correct fluid, electrolyte, uremic abnormalities o Prevent complications o Lasix can be given for volume overload (due to oliguria) o Patient can become nutritionally deficient as ARF is a catabolic state. Total caloric intake: 30 - 45 kcal/kg/day. Protein restricted when not on dialysis: 0.6g/ kg/day. If on dialysis protein should be 1-1.5g/kg/day. Diet should be low protein/ Na/ K o Dialysis, often needed. Especially when BUN greater than 100 and serum creatinine greater than 5 - 10, acidosis/ alkalosis, hyperkalemia o Metabolic acidosis: treat with IV (or oral) bicarb when serum HCO3 is less than 15, or PH less than 7.2 o Renal transplant Treat renal failure complications: which and how Correct answer- Hyperkalemia: - Kayelxalate 15-30 g with 100 ml sorbitol: enema - IV calcium: cardioprotective - Insulin (10units) with 25 g glucose - IV sodium Bicarb (150 mEq in 1 lt) - dialysis in significantly elevated K (greater than 7) Hyperphosphatemia: - Keep below 4.6 - Restrict phos (cola, eggs, dairy, meat) - Give calcium carbonate (650mg TID) - Renvela (Sevelamir) - Calcium acetate - Dialysis Hypocalcemia (ion Ca less than 1.12): - Calcium carbonate supplements - maintain phos at 6 Hypermagnesemia Avoid mag. laxatives Fluid overload: - Decrease Na and fluid intake and give lasix HTN: Goal: 140/80 unless proteinuria than 125/75 ACE-inhib, calcium blockers if proteinuria present, hydralazine, B-blocker Protein catabolism: - Limit protein intake: less than 8gr/kg.day, avoid stress and not too much physical activity Acidosis Give sodium citrate when HCO3 below 20 Anemia - give iron - give erythropoietin injection RRT option in AKI and CKD Correct answer- - Hemodialysis (intermittent (MAP of at least 60mmHg), continuously venous or arterial) - Peritoneal dialysis - for long term use. Does not achieve adequate creatinine clearance (may be switched to hemodialysis in acute care situations) and high risk for infection chronic kidney disease Correct answer- · Chronic kidney disease: GFR 60ml/ min or less for longer than 3mo. o HTN common o US with show bilat small kidneys o Cause: § HTN nephropathy § Diabetic nephropathy § Renal artery stenosis § Glomerular disease o When GFR between 5 - 10: dialysis o Creatinine clearance: age and gender-dependent. Males: 97-137, Females: 88-128 o Signs/ Symptoms: - Fatigue/ weakness - Pruritis - bruising - dyspnea on exertion - HTN - Metallic taste - SOB/ pleural effusion - n/v with anorexia - impotence/ nocturia - peripheral neuropathy - anemia (due to erythropoietin deficiency) Stages of CKD Correct answer- o Stages - 5 stages 80 - 120 ml/min § 1: GFR greater than 90 § 2: GFR 60 - 89 § 3: GFR 30 - 59 § 4: GFR 15 - 29 § 5: ESRD GFR less than 15, uremia, cardiovascular disease. Modification of drug dosages based on kidney function Correct answer- serum creat greater than 10mg/ml: major modification serum creat 3-10 mg/ml: modest changes Types of drugs and kidney function Correct answer- Type A: eliminated by kidney entirely Type B: eliminated by extrarenal entirely Type C: eliminated by renal and extrarenal - Gold standard: noncontrast helical CT - renal us, less sensitive - ua: blood - wbc increased - 24/hr urine collection - cmp: calcium, electrolytes, phosphate, uric acid Management of nephrolithiasis Correct answer- - relieve pain and n/v with NSAIDS (not with renal dysfunction!), dilaudid, norco, zofran - increase oral fluid intake to speed up passing of stone - antispasmodics (such as flomax) can hasten stone passage - lithotripsy and ureteroscopy for stones greater than 10mm - promote healthy diet and exercise Onset and duration of regular and basal insulin Correct answer- · Short acting: Onset: 10-30min Duration: 3-5 hrs. lispro, aspart (Glulisine 1.5hrs) · Regular: Onset: 30-60min Duration: 6-8 hrs. · Intermediate acting: Onset 2-4 hrs. NPH (Humulin): Duration: 12 - 15 hrs. · Long-acting: 1-2hrs Levemir/ Lantus. Duration: 24 hrs · Pre-mixed: NPH/ regular Onset: 30min. Duration: 18 - 24 hrs Adjustment of insulin based on glucose levels Correct answer- · 0.5units/ kg/ day, 2/3 in the morning and remaining 1/3 in evening (lower for thinner and higher for obese) · Glucose above 140 mg/ dl before evening meal: add 2 - 5 units every 3 days until regulated · Afternoon regulated, then fasting glucose: elevated? Then 2/3 insulin before breakfast and 1/3 before dinner. Goal fasting: 120 - 140 mg/dl Insulin intake with n/v or poor intake Correct answer- - Don't stop insulin administration. - Check glucose q2-4hrs, plus ketones in urine (also night). - continue oral meds and insulin even if not eating normally - stop taking metformin if dehydrated - if npo drink 8oz sugar containing fld per hr - check BG q 2-4 hrs - Call MD for persistent vomiting/diarrhea, BG consistently >300, temp >101, ketonuria Diagnostic criteria for DM Correct answer- o Random glucose greater than 200mg/ dl o Two hour post glucose test greater than 200 mg/dl o HgbA1C greater than 6.5% (measure every 6mo post diagnosis; less than 6% is goal. Measure q3 - 4mo when using sliding scale) o Fasting glucose greater than 126 mg/dl on two occasions o Urine will show glycosuria and ketonuria Standard insulin dose for new diabetic type 1 Correct answer- - 0.5units/ kg/ day, 2/3 in the morning and remaining 1/3 in evening (regular) - Physiologic: basal long-acting once daily at same time: 1/3 of insulin requirement for dm1. For dm2: kg x 0.2 = basal - non physiologic/ split-dose: morning 2/3 NPH and 1/3 regular. Evening: 1/2 NPH and 1/2 regular - bolus fast-acting before meal: 0.5-1 unit/kg (novolog) DKA vs HHS Correct answer- DKA: PH less than 7.3, HCO3 less than 15, PCO2. Normal in HHS DKA: Ketones in urine/ serum, none in HHS HHS: blood sugar usually elevated 600 mg/dl and higher HHS: hypernatremia, DKA: hyponatremia Metformin side effects and interactions Correct answer- Side effects: o n/v o diarrhea o B12 and folic acid deficiency o Metabolic acidosis in pt's with renal impairment. So do not use! Also contraindicated in HF (predisposed to lactic acidosis) Interactions: o Alcohol: avoid alcohol o Cimetidine (Tagamet) can increase lactic acidosis o Contrast dye: can cayse RF and thus induce lactic acidosis. Dc metformin for 48hrs pre-procedure, start 48 hrs after Treatment of DKA Correct answer- · Critical care · Hydration: NS at 1000ml/hr for 1-2 hrs, then 300-500ml/hr for 4 hrs to correct deficit of 4-8ltr. Then 250ml/ hr. First isotonic, then hypotonic. Change to D5 0.45NS once glucose lower than 250 mg/dl. Add K if potassium smaller than 5 to first bags of fluid. · Monitor K, phos, mag · Loading dose insulin: 0.1 units/ kg regular insulin followed by continuous drip of 0.1units/kg/hr. Decrease to 0.05units/kg/hr once glucose less than 200mg/ dl · If PH less than 7.0. give Bicarb (50 -100 mEq in 1 ltr fluid). DC bicarb when PH 7.1 Management DM Correct answer- - Diet: carb 60% of total intake, fats 25% of total, protein 15% of total. Artificial sweetener better than sugar. Balance and individualized. DM1: 3 meals/ day + 3 snacks. DM2: meals 5 hours apart, no snacks. - Exercise (insulin in non exercised body part) - Foot care - test blood glucose 4/day - For DM2: oral meds when not controlled with diet and exercise. Insulin if oral fails or HgbA1C greater than 8. Complications of DM Correct answer- Diabetes- related retinopathy (blindness) Cardiovascular disease Cataracts and glaucoma Neuropathy (most common complication) Nephropathy (more in DM1 than DM2) Infections Gangrene feet DKA and HHS DM 1 Correct answer- Autoimmune pancreatic Beta-Cell destruction Somogyi effect: definition and treatment Correct answer- nocturnal hypoglycemia followed by rebound hyperglycemia in the morning Reduce bedtime dose of insulin. Give Levemir instead of lantus (is shorter acting) Dawn phenomenon Correct answer- Early morning glucose elevation because of growth hormone which decreases sensitivity to insulin. Add/ increase bedtime dose of insulin Oral Antidiabetic Drugs Correct answer- 1. Biguanides (Metformin) 2. Sulfonylureas 3. Meglitinides 4. Thiazolidinediones (glitazones) 5. Alpha-glucosidase inhibitors 6. DPP-4 inhibitors 7. SGLT-2 inhibitors Biguanides Correct answer- Metformin § Drug of choice for initial treatment for T2DM. § Action: inhibits glucose production, reduces glucose absorption, sensitizes tissues to insulin. Does NOT stimulate insulin release. § Excreted by kidneys so may be toxic in renal failure. § Use: glycemic control. Safe for people who skip meals because it does not actively lower blood sugar. § Side-effects: GI disturbances. Does not cause weight gain. Can cause metabolic acidosis in pt's with renal failure. Alcohol can cause acidosis as well. Sulfonylureas: Correct answer- Glimepiride, Glipizide, Glyburide § Action: promote insulin release § Use: T2DM § Side effects: weight gain and hypoglycemia (especially with renal or liver failure and alcohol use), small and questionable risk for sudden cardiac death. Not in pregnancy! May cause severe hypoglycemia in newborn. Meglitinides Correct answer- Repaglinides, Nateglinide § Action: same as sulfonylureas but act shorter thus taken with meal. Adverse effects: hypoglycemia. NOt for DM1 Hypothyroidism (Myxedema coma): definition, cause, findings, management Correct answer- greatly decreased metabolism caused by deficient amount of thyroid hormone Iodine deficiency (most common) Hashimoto's: autoimmune thyroiditis Deficiency of pituitary TSH Thyroidectomy High dose Amio Fatigue, hypoventilation, bradycardia, hypothermia, hypoglycemia, weight gain, constipation, cold intolerance, parasthesias, Periorbital edema, enlarged tongue, horaseness Elevated TSH, low or normal T4 hyponatrenia anemia hypercholesterolemia Levothyroxine (T4). Younger than 60 without CAD: 50 - 100mcg daily, older than 60 with CAD: 25 - 50mcg daily. Check TSH after 8 wks. Myxedema coma treatment Correct answer- Give O2 Fluid restriction and NS 3% for severe hyponatremia D50W for hypoglycemia IV thyroid replacement: levothyroxine. Give hydrocortisone of adrenal insufficiency is suspected. Rewarming with blankets (no warming blankets: rapid vasodilation may cause hypotension) Cushing's syndrome: definition, cause, findings, management Correct answer- condition caused by prolonged exposure to high levels of cortisol, commonly because of ACTH secretion Benign pituitary adenoma Adrenal neoplasm Nonpituitary neoplasm, such as small cell lung ca Excessive glucocorticoid administration (syndrome) Central obesity with muscle wasting, moon face, emotional lability, bruising, htn, polyuria, hyperglycemia, osteoporosis Hypokalemia Hypernatremia Leukocytosis Elevated serum cortisol (give dexa at 11pm, check cortisol at 8am, greater than 1.8 is CS) Elevated free urinary cortisol (24hr urine, greater than 50mcg/24hr is CS) Metabolic alkalosis Hyperglycemia Hypertension Secondary male characteristics Treat underlying cause (tumor resection, dc glucocorticoids) manage fluid and electrolyte imbalance Addison's disease: definition, cause, findings, management Correct answer- Condition caused by deficiency of cortisol, androgens, and alsdosterone (adrenal gland is not working) Sudden withdrawal of glucocorticoids sepsis autoimmune destruction of adrenal gland metastatic ca pituitary failure causing decreased levels of ACTH weakness, n/v, abd pain, diarrhea, hyperpigmentation, hypotension Hyponatremia Hyperkalemia Hypoglycemia Neutropenia Plasma cortisol less than 5mg/dl at 8am metabolic acidosis Glucocorticoid and mineralcorticoid replacement therapy: Hydrocortisone and potentially fludrocortisone (decrease dose with htn, edema, hypokalemia) Adrenal crisis: definition, findings, management Correct answer- acute adrenocortical insufficiency, often caused by infection Sever weakness, n/v, abd pain, hypotension, fever, tachycardia, ams/ lethargy Hyponatremia Hyperkalemia Hypoglycemia Neutropenia Plasma cortisol less than 5mg/dl at 8am Metabolic acidosis Obtain cortisol level Give hydrocortisone (Solu-Cortef) 100- 300mg IV, then 50-100mcg q6h, taper after 4 days K replacement Broad spectrum ab's Treat underlying cause Pheochromocytoma: definition, findings, management Correct answer- a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine and norepinephrine resulting in sustained HTN Classic triad: palpitations, severe headache, profuse diaphoresis tachycardia, nausea, weakness, HTN, tachy, chest pain, dyspnea Hyperglycemia Leukocytosis urinary catecholamine greater than 135 metanephrine greater than 2.2 (most sensitive) Treat HTN with alpha-blockers (phentolamine) then beta-blocker (propranolol), or nicardipine for HTN crisis SIADH: definition, cause, findings, management Correct answer- Condition resulting from secretion of antidiuretic hormone (ADH) resulting in water retention Malignancies CNS disorders Chronic lung diseases certain drugs: antidepressants, NSAIDS Hyponatremia with symptoms (headache, seizures, somnolence), Hypothermia, concentrated urine and decreased uo, vomiting/ abd cramping, decreased deep tendon reflexes Hyponatremia (less than 120) Decreased serum osmolality increased urine osmolality increased urine Na Decreased BUN Treat underlying cause Restrict water intake If symptomatic: Increase Na by 1-2mEq/hr, but not more than 10-12mEq per 24hr to reach Na 125-130mEq Not symptomatic: Increase Na with NS 0.9% 0.5mEq/L/hrwith 0.5-1mg/kg of lasix for Na lower than 120. Hypertonic 3%NS with or without lasix Na level every 2-4 hrs diabetes insipidus: definition and types Correct answer- Polyuric syndrome because antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect Central - deficiency of ADH production, caused by CNS patients, trauma, pituitary tumor, syphilis Blind loop syndrome Alcohol Hemodialysis Roux-en-Y VitB12 deficiemcy takes 2-7 yrs to develop due to malbsorption Babinski and Romberg positive, Paraesthesia, Ataxia, headache, Splenomegaly/ Hepatomegaly, Depression, sore, smooth tongue, tachycardia, chestpain, SOB MCV 110 - 140 Hct 10 - 15 or lower Reduced reticulocyte count Decreased Vit B12: less than 200 Increased serum ferritin Anti-IF and anti-parietal cell antibodies are specific for pernious anemia and not vitB12 deficiency Schilling test (only if cause for deficiency is unclear - radioactive!) Parenteral VitB12, or subc (1mg daily for 7 days, then 1mg/ week for 1mo, then 1mg/ month for life) Hypokalemia seen with VitB12 replacement Do not give Folic acid without VitB12 (Folic acid can exacerbate neuro symptoms otherwise) Treat underlying cause For blind loop syndrome: Rifaximin/ Augmentin/ Metronidazole/ Norfloxacin iron deficiency anemia: definitions, risks/ causes, findings, treatment Correct answer- Microcytic anemia with iron deficiency. Most common! Impaired Hgb production: small concentrated RBC are created causing hypoxia Decreased intake (infants, vegeteraian) Increased loss: Blood loss, Long-term aspirin use, abnormal uterine bleeding, colonca, helicobacter pylori infection Decrease iron absorption; celiac Gastric/ bowel surgery (decreased absorption) Blood donation Increased demand: pregnancy, children, adolescents Pallor, sob, spoon-shaped/ brittle nails, hair loss, cracking corners of mouth, tachycardia/ palpitations, fatigue, pica, glossitis Peripheral smear: stage 1: Hgb normal stage 2: hgb normal, but iron deficiency stage 3: iron depletion, anemia, normal MCV stage 4: iron deficiency, hypochromic RBC, low MCV Elevated RDW Reticulocyte count decreased (less than 3%) serum iron less than 50mg/dl, low ferritin Platelet elevated If inconclusive then bone marrow biopsy treatment of iron deficiency anemia Correct answer- Treat underlying cause Therapeutic iron trial: Ferrous sulfate for 6mo. Extended-release and enteric coated not well absorbed, thus avoid. Take with orange juice. May cause nausea, diarrhea, constipation Follow up in 3wks with CBC count: Hgb should be normal at 2mo. Takes 6mo to rebuild iron stores. For symptomatic: give RBC's (1ml RBC is 1 mg iron) Sodium ferric gluconate complex injection (10ml for 8 doses with dialysis to reach goal of 1.5-2grams) may cause anaphylaxis so have epi and resuscitation equipment ready. No rapid infusion (may cause hypotension and flushing). Give diluted test dose first. IV iron or IM iron for intolerance or noncompliance with oral iron. Anaphylaxis may occur. Give 0.5ml test dose and have Benadryl and epi ready. IM may stain skin. IV may cause phlebitis. A reticulocyte and Hct response/ increase should be expected in 7-10 days Failure to respond may be misdiagnosis, malabsorption, non compliance, blood loss Folic acid deficiency anemia: definitions, risks/ causes, findings, treatment Correct answer- Megaloblastic anemia caused by impaired production of RBCs and Hgb due to serum folate deficiency inadequate dietary intake/ lack of absorption nutritional lack of folate due to anorexia, alcoholism, old age, celiac disease increased utilization of folic acid due to pregnancy contraceptives/ alcohol/ methotrexate fatigue, pallor, malnutrition, glossitis/ stomatitis, infertility Folate less than 2ng/ml (greater than 4 is rule out) RBC folate less than 150 ng/ml MCV greater than 115 Folate 1-5mg/ day for 3-4mo Anemia of chronic disease: definitions, risks/ causes, findings, treatment Correct answer- Normochromic and normocytic, gradual in onset, with chronic infection/ immune activation/ kidney disease/ cancer due to the reduction of RBC production and lifespan by the bone marrow. Resolves when underlying disorder resolved. Common. CKD, liver disease without alcoholism, endocrine disorders Often no symptoms but mild fatigue, allow, sob Mild anemia, Hgb rarely lower than 10 RBC normochromic and normocytic Reticulocyte count less than 1% Ferritin high, but low iron RDW normal Leukocytosis and thrombocytosis Treat underlying disease Premenopausal women: give oral iron and reevaluate CBC to rule out iron deficiency Recombinant human erythropoietin (Epogen) for chronic renal disease or RA. Give 3/week. Adjust dose to target range of Hct 30-33 ml/dl Thalassemia: definitions, risks/ causes, findings, treatment Correct answer- Inherited disorders that are result of defective globin production (portion of hemoglobin). Hypochromic and microcytic. Often caused by malignant malaria People with Mediterrean, African, or Asian decent Hepatosplenomegaly, jaundice HF Growth retardation Hallmark: microcytic and hypochromic anemia Decrease in Hgb, Hct, MCV, MCH Increased bili Blood transfusion Iron treatment (Remove iron): goal Hgb 6-9gr/dl Bone marrow transplantation sickle cell disease: definition and incidence/ predisposing factors Correct answer- Inherited disorder that causes a defect in hemoglobin molecule causing a sickle hemoglobin instead of normal which leads to hemolytic anemia and vaso-occlusion (because of sickle shape) Hospitalizations for pain Eosinophils elevated in allergy and parasites and cocci (fungus) Infection, steroid, cancer, catastrophic events left shift leukocytosis Correct answer- Increased bands with elevated wbc means infection High wbc with lymphocyes Correct answer- lymphocytic leukemia Correct answer- Microcytic (MCV <80 femtoliters [fL]). image Normocytic (MCV 80-100 femtoliters [fL]); further subclassified according to the reticulocyte count as: Hyperproliferative (reticulocyte count >2%): the proportion of circulating reticulocytes increases as part of a compensatory response to increased destruction or loss of RBCs. The cause is usually acute blood loss or hemolysis. Hypoproliferative (reticulocyte count <2%): these are primarily disorders of decreased RBC production, and the proportion of circulating reticulocytes remains unchanged. Macrocytic (MCV >100 femtoliters [fL]); further subclassified as: Megaloblastic: a deficiency of DNA production or maturation resulting in the appearance of large immature RBCs (megaloblasts) and hypersegmented neutrophils in the circulation. Nonmegaloblastic: encompasses all other causes of macrocytic anemia in which DNA synthesis is normal. Megaloblasts and hypersegmented neutrophils are absent. Acute Lymphocytic Leukemia (ALL); definition and incidence Correct answer- immature lymphocytes (T and B cells) proliferate in uncontrolled fashion replacing bone marrow and thus RBC, WBC, and platelets (more than 30% blasts present) Most common cancer in children and causes risk for brain tumor later on Associated with Down Syndrome ALL findings and required testing Correct answer- sudden onset acute illness fever anorexia fatigue gum hypertropgy and bleeding angina generalized lymphadenopathy stomatitis hepatosplenomegaly bone tenderness on sternum and tibia Pancytopenia (low WBC, RBC, platelets) Blasts present in smear anemia hyperuricemia and azotemia requires bone marrow biopsy: (lot of lymphoblasts (cell with tdt) present Immunophenotyping by FACS with monoclonal antibodies (to define other phenotypes of ALL) Cytogenic studies for prognostic value (hyperdiploid state more favorable) Bone marrow stains: periodic acid schiff positive for ALL) Management of ALL Correct answer- Chemo: in 3 phases: 1.) remission induction: chemo plus TKI (tyrosine kinase inhibitors for Ph positive pts) 2.) postremission therapy consolidation: short course of chemo 3.) CNS prophylaxis: intrathecal methotrexate with/ without radiation Stem cell transplant Supportive treatment: transfuse RBC/ platelets hydration AB for infection Allopurinol to prevent hyperuricemia. Dialysis if still uremic Consider bone marrow transplantation for first relapse or second remission Low survival rate adults, better for children Acute Myeloid Leukemia (AML): definition, classification, incidence Correct answer- malignancy of hematopoietic progenitor cell (immature cell), similar to ALL but myeloblasts present (instead of lymphoblasts) (more than 20% blasts present) Classification: 1. AML with recurrent genetic abnormalities 2. AML with multilineage dysplasia 3. therapy related AML (consequence of prior cancer treatment) 4. no category AML risk increases with age People with chromosomal abnormalities/ Down syndrome AML findings and required testing Correct answer- Bleeding/ easy bruising SOB fever anorexia fatigue bone/ joint pain (sternum/ tibia) associated DIC hepatosplenomegaly stomatitis infection Pancytopenia with blasts (at least 20%) Anemia Mild to moderate thrombicytopenia Many myeloblasts (immature WBC) granules in blasts DIC: elevation of PT, PTT, D-dimer, fibrin degradation products and decreased fibrinogen Immunophenotyping by FACS Bone marrow stain: Sudan black positive and myeloperoxidase positive for AML Management of AML Correct answer- chemo, radiation, stem cell transplants, targeted immune therapy supportive care: Supportive treatment: transfuse RBC/ platelets hydration AB for infection Acetazolamide for alkalinization of urine Allopurinol to prevent hyperuricemia with dialysis if remains uremic Chemo stages: 1. Remission induction. combination therapy 2. Consolidative and maintenance therapy Bone marrow transplantation for first relapse or second remission Chronic Lymphocytic Leukemia (CLL): definition and incidence Correct answer- abnormal more mature lymphocytes with lymphadenopathy. mainly with blood and bone marrow involvement (if many lymph nodes are involved it is lymphocytic lymphoma). B cell leukemia. Will go to lymph nodes, liver, spleen Most common leukemia in adults, primarily in elderly first degree relatives with CLL more men than women farmers russiand and eastern European Jewish decent median survival 6 yrs CLL findings and testing Correct answer- often asymptomatic fatigue/ malaise/ lethargy anorexia infection with notable lymph node enlargement pain or fullness below ribs Lymphoma Staging - Ann Arbor staging classification Correct answer- I = 1 node or single origin II = 2 node groups, same side of diaphragm III = both sides of diaphragm IV = diffuse involvement of more than one organ with or without lymph node involvement. Bone marrow involvement. Costwold modification to Ann Arbor classification Correct answer- X: bulky disease (greater than 33% of diameter) number the regions involved (roman numeral) revised european-american lymphoma classification (REAL) Correct answer- B Cell Neoplasms: precursor B cell neoplasms and peripheral B cell neoplasms, classified by grade (smal, mixed or large cell). Example: Burkitt lymphoma, follicular lymphoma T Cell and putative natural killer (NK) neoplasms: Precursor T cell neoplasms and precursor T-lymphoblastic lymphoma/ leukemia. Peripheral T-cell and NK-cell neoplasms. Hodgkin disease International Prognostic Index Correct answer- One point for each: older than 60 perforamce status greater than 2 elevated LDH more than 2 extranodal sites stage II or IV low risk: 1 low-intermediate: 2 high intermediate: 3 high: 4 or 5 Eastern Cooperative Oncology Group Performance Status Correct answer- Grade 0: fully active as predisease Grade 1: restricted in strenuous activity Grade 2: ambulatory but unable to perform work Grade 3: able of only self-care Grade 4: disabled, unable to perform ADL Grade 5: dead Non-Hodgkin lymphoma (NHL): definition, incidence/ risks, prognosis Correct answer- Group of lymphocytic cancers, mostly B-cell origin lacking Reed-Sternberg cells that produce diverse malignancies. Results from B and T NK cells. 66 years more males than females Risk increased with Epstein-Barr virus, hepatitis, H.Pylori 5 yr survival rate: 60% NHL findings and testing Correct answer- Lymphadenopathy - painless Asymptomatic Fever/ nightsweats weight loss Abdominal fullness (bowel obstruction with Burkitt) Skin ulcer. Splenomegaly and hepatomegaly Often not found till stage IV Biopsy of largest node (excisional not aspirational!) Peripheral blood Molecular profiling required for gene expression determination May order: CBC, hep. panel, HIV, LDH (marker for tumor bulk), CT chest/ abdomen, bone marrow biopsy, lumbar puncture (if high grade lymphoma then present in spinal fluid) Classification of NHL Correct answer- Indolent lymphoma: small, well-differentiated Aggressive lymphoma: larger, more mature Highly aggressive lymphoma: larger, immature NHL treatment Correct answer- Varied, based on tumor, staging, and patient specifics Chemo - often combined with immunotherapy Will cause remission, but not cure Rituximab and CHOP Radiation/ surgical resection Targeted treatment (Rituximab) Immunotherapy: lenalidomide (often with rituximab) Stem cell transplants in recurrent or refractory disease Observe for complications: sepsis, cardiomyopathy, neuropathy Hodgkin Lymphoma (HL): definition, incidence/ risks, prognosis Correct answer- Cancer with present Reed-Sternberg giant cells (T or B cells that didn't undergo hypermutation - looks like owl-eyes). Failure of T cell function (main problem). Only 15% of all lymphomas. Unclear cause 68 yrs, rarely before 30 Hx of Eppstein barr caucasian 95% complete remission. Tumor bulk and staging most prognostic factors. Low Hct and high LDH increase risk for relapse. As the age gets older the cure rate goes down. The more RS cells, the less the cure rate. HL management Correct answer- Most cases can be cured with chemo and radiation but treatment can cause secondary malignancies. Radiation for nonbulky stage IA/ IIA Chemo for advanced (stage II, III, IV): CHOP, CVP, ABVD (may cause pulm fibrosis) Observe for complications: sepsis HL classification Correct answer- WHO classification (looks at number of lymphocytes on slide). 1. Nodular sclerosis. Most common. Age: young females. Varying amount of RS cells, but collagen (clear space) around it. Cervical, mediastinal. 85% cure rate. 2. Lymphocyte-rich HL Age: young. Few RS cells. Cervical and inguinal. 90% cure rate. 3. Mixed cellularity HL Age: middle. Moderate RS cells. Cervical, chest, abdominal. 75% cure rate. 4. Lymphocyte depletion HL Age: old. Many RS cells. Abdominal. 45% cure rate. HL findings and diagnostics Correct answer- Painless mass in neck (cervical lymphadenopathy) no symptoms (group A) Fever, nightsweats, weight loss (group B) Weakness, malaise Pruritis Hallmark: Reed Sternberg cells in biopsy (excisional, not aspirational) Molecular profiling for gene expression determination May order CT chest, abdomen, pelvis, xr chest, CBC, bone scan for staging purposes Stage disease with Ann Arbor staging and HL classification. Lymphoma Correct answer- Collection of white blood cells that are not dying or replicating uncontrollably Divided into: B (CD-19) T (CD-4, CD-8) Dendritic Langehans cells (S100) Lung cancer diagnostics Correct answer- Definitive test: biopsy xr-chest varies with each type, compare with old ones Central lesions: squamous cell ca, small cell ca Peripheral lesions: adenocarcinoma, large cell ca, bronchoalveolar cell ca Cavitation: squamous cell ca or large cell ca Sputum cytology in centrally located lesions Bronchoscopy can provide tissue Pleural fluid small cell lung cancer: staging, findings and treatment Correct answer- Limited stage: one lung and same side lymph nodes Extensive stage: both lungs, bilateral lymph nodes and organs Central location No cavitation Early metastases (to brain) can cause paraneoplastic syndrome (cushing syndrome and siadh/ hyponatremia) Chemotherapy for extensive stage Surgery for limited-stage then chemo Adenocarcinoma of the lung Correct answer- cancerous tumor of lung glandular tissue Peripheral location Early metastasis May cause thrombophlebitis, clubbing squamous cell carcinoma Correct answer- malignant tumor of the squamous epithelial cells in the epidermis of lung Central location Will have cavitation on xr chest May cause hypercalcemia Late metastases Large cell carcinoma (non small cell lung ca NSCLC): what, staging, findings, treatment Correct answer- Most common lung ca. NSCLC originating in the lining of the smaller bronchi. Includes squamous cell and adenocarcinoma staged with TNM system (tumor, nodules, metastases) Peripheral location Might have cavitation Late metastases May cause superior vena cava syndrome and hoarseness Stage 0: surgical resection Stage I: lobectomy Stage II: lobectomy Stage III: IIIA: surgery and chemo (cisplatin)/ radiation, IIIB: chemo/ radiation Stage IV: no cure, palliative (chemo) TNM staging system Correct answer- Tumor, Nodules, Metastasis Stage 0: lining of air passages Stage I: invaded lung tissue Stage II: invasion of expanded lung tissue Stage III: spread to lymph nodes Stage IV: spread to organs colorectal cancer: definition and incidence Correct answer- adenocarcinoma of the colon or rectum, or both older than 50 personal history of colorectal ca, IBD, other ca's, high fat/ low fiber diet Colorectal ca findings and diagnostics Correct answer- Asymptomatic until advanced disease Changed bowel habits/ bloody stool/ straining/ abd pain Fatigue/ weight loss/ nausea/ loss of appetite Digital rectal exam with stool guaiac (occult blood) important Screen starting at age 50 with fecal occult blood, digitalrectal exam, sigmoidoscopy, colonoscvopy potential CT consider xr chest CEA (carcinoembryonic antigen) for monitoring effectiveness of treatment Check for metastasis: CT biopsy, MRI, angio, bone scan Colon ca treatment Correct answer- Surgical resection (potentially with liver) Before surgery: CEA, liver function test, colonoscopy, xr chest Chemo Radiation; not primary but inhibits metastasis Breast ca: definition and incidence Correct answer- Most common in females. Older than 50 Hx of ca, personal or family nulliparity, low parity, late first pregnancy Breast ca findings and diagnostics Correct answer- palpable, painless lump nipple discharge breast pain erosion/ retraction/ itching of nipple Mammographic abnormalities Hard mass Dimpled/ retracted skin around nipple inverted nipple Requires cytologic/ histologic finding with fine needle aspiration/ biopsy Serum alkaline phosphatase with liver and bone metastasis CEA and CA 27 29 as tumor markers to determine process US breast to distinguish cysts from tumor Breast CA treatment Correct answer- Based on type and personal factors Curative or palliative lumpectomy; breast conserving surgery Radical mastectomy If axillary nodes involved: chemo (doxurubicin/ cyclophosphamide) or tamoxifen radiation for more intensive treatment Cervical ca definition and incidence Correct answer- Squamous cell ca of cervix Linked to HPV virus Early age first intercourse multiple sex partners immunosuppression smoking Cervical ca findings Correct answer- Postcoital spotting bloody or purulent discharge bladder/ rectal dysfunction Positive pap smear (epithelial cell abnormalities, may be benign with infection or inflammation). Colposcopy to obtain biopsy Genes associated with breast cancer Correct answer- BRCA 1 BRCA2 Cervical ca treatment Correct answer- Refer to specialist and colposcopy with positive Pap Cryotherapy Laser ablation Hysterectomy (for stage 0, I, II, no childbearing) Radiation (stage III, IV) enlarged uterus endometrial biopsy dilatation and curettage transvaginal uterine us serial CA125 for disease process Endometrial treatment Correct answer- abdominal hysterectomy Radiation for higher grade (III and up) Advanced and recurrent: radiation Hyperthyroidism Correct answer- Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE will show hyperreflexia, goiter, exophthalmos, pretibial edema Labs will show low TSH and high freeT4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments:Propylthiouracil (PTU) if Pregnant Primary adrenal insufficiency: what, clinical, management Correct answer- Adrenal gland does not produce cortisol and aldosterone. So it does not produce sodium and glucose. Will have increased potassium. Hypotension/ shock n/v , diarrhea fever abdominal pain hyponatremia, hypoglycemia, hyperkalemia Hydrocortisone supportive Hypothyroidism Correct answer- · Patient will be complaining of generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain, delayed relaxation of deep tendon reflexes · PE will show periorbital edema, dry skin and coarse brittle hair · Labs will show high TSH and low free T4, antithyroid peroxidase and antithyroglobulin autoantibodies · Most commonly caused by Hashimoto's thyroiditis · Treatment is levothyroxine · Comments: Takes about 6 weeks to see treatment effects. Monitor TSH · Hashimoto's: Risk factor for non-Hodgkin lymphoma Hypoparathyroidism: What, cause, signs, treatment Correct answer- Hypoparathyroidism causes hypocalcemia (lower than 9) Low PTH causes low calcium Cause: H Hypomagnesemia A Autoimmune T Thyroidectomy R radiation Signs: Troussea sign (arm twerk with bp cuff) and Cvosteck sign (smile on check stroke), diarrhea, tingling/ numbness/ paresthesia, muscle spasm/ convulsion Treatment: Give calcium IV and then oral Give Vit D Thyroid nodule: definition, incidence Correct answer- Goiter. Majority are benign. Benign: hashimoto thyroiditis, thyroid adenoma, follicular adenoma, thyroid cyst Malignant. Risk for ca: radiation hx, hx of ca Women Older age Thyroid nodule workup Correct answer- TSH, T3, T4 Thyroid US Radionuclear thyroid scan Fine needle aspiration Diagnostic steps: - TSH high or normal, then ultrasound - Suspicious nodule on US (greater than 1 cm, rapidly growing, taller than wide) then fine needle aspiration - Bethseda staging after fna: stage 3-6: malignant and cause for thyroidectomy - Non-suspicious nodule: High TSH- think Hashimoto's (hypothyroidism) - THS low, think hyperthyroidism - perform thyroid radio nuclear scan: cold nodule (no uptake of iodine) could be thyroid ca. Hot nodule: no suspicion for thyroid ca. - if cold nodule then ultrasound and potential fna - TSH low, with high T3 and T4 then hyperthyroidism thus thyroidectomy or radioactive idodine Packed red blood cells, when and effect Correct answer- Anemia, symptomatic and Hgb below 7. For hemorrhage, not for hypovolemic shock Raises Hgb by 1g/dl transfusion reaction symptoms and treatment Correct answer- Symptoms: Fever (stop transfusion, and give tylenol or nsaid) Chills Tachycardia Abdominal pain hypotension impending doom ARF Hemoglobinuria is diagnostic Transfusion related acute lung injury (TRALI) (resp distress, pulm edema, hypoxia) Treatment: Stop transfusion Alert Blood bank Monitor lab values (renal function and electrolytes) Rehydration with NS (not LR) For TRALI: supportive care Platelets - transfusion: when and effect Correct answer- one unit raises count by 5000 - 10.000/mm3 Give triple dose in ITP Avoid in TTP Fresh frozen plasma Correct answer- For depleted clotting factors (cirrhosis, DIC) Increases clotting factors by 2 - 3% Chemotherapy side effects: what, which, treatment Correct answer- What: Targets cells with high turn over: skin cells, mucosa, bone marrow/ blood cells Which: Nausea and vomiting Mood changes (chemo brain): Treatment: Thoracotomy Fluid resuscitation PRBC Nitroprusside to lower bp till surgery Massive transfusion protocol: when, what, monitor, side-effects Correct answer- Indication: Pulse greater than 120 BP smaller than 90 (syst) penetrating torso injury FAST positive 2/4 then massive transfusion Stop when bleeding controlled and values improved Give universally compatible RBC (O Rhnegative and O Rh-positive) and thawed plasma Transfuse plasma & PRBCs in 1:1. 1 unit of platelets for 6 RBC's Monitor: INR, PTT, fubrinogen, Hgb/ Hct, platelet, ABG (base deficit) Use blood warmer, frequent monitoring of electrolytes and pH Side effects: hypothermia hyperkalemia hyopcalcemia fluid overload/ ARDS Lacerated liver: what, findings, and treatment Correct answer- From blunt trauma or stab woundsresulting in profuse bleeding Grade I - IV (I smaller than 1cm, IVnot compatible with life) Findings: right upper quadrant pain guarding hypovolemic shock FAST us: peritoneal lavage Decreased Hct and Hgb Elevated liver enzymes Treatment: do not remove impaled objects, but wrap and stabilize Fluid resuscitation NG Foley Surgery for unstable Ab's Ruptured spleen: what, findings, treatment Correct answer- Spleen tear from blunt or penetrating injury Grade: I - IV (I is smaller than 1cm, IV is shattered) From MCV, gun- and stab wounds Findings: Pain Kehr's sign (pain in shoulder when lying with legs up) hypovolemic shock guarding FAST us: peritoneal lavage Decreased Hct and Hgb Treatment: do not remove impaled objects, but wrap and stabilize Fluid resuscitation (LR) NG Foley Surgery for unstable with pelvic packing Renal injuries: what, findings, treatment Correct answer- fragmentation of kidneys due to blunt or penetrating trauma (or rib #) Findings: Pain Grey Turner's (flank bruising) Hematuria CT scan Renal xr Treatment: possible nephrectomy watch for RF Pelvic trauma: what, findings, treatment Correct answer- # of pelvis, from auto/ pedestrian or fall Findings: pain numbness/ tingling groin and legs bleeding from urethra/ vagina/ rectum Pelvic xr: widened pelvic ring and joints CT Treatment: Foley, unless blood present. Consult uro Pelvic binder (stabilization) Surgery for hemodynamically unstable patients FAST scan Correct answer- Ultrasound to detect intra abdominal bleeding (liver, renal, spleen) or cardiac tamponade, looking for free fluid (bleeding). Used as a fast assessment tool/ triage. Categories of Burns Correct answer- First: dry, red, no blisters, limited to epidermis Second: moist blisters, beyond epidermis Third: not painful (through nerves), dry/ leathery/ white, from epidermis to dermis to underlying tissues burn treatment Correct answer- Fluid resuscitation! 2-4ml/kg x TBSA in first 24hrs (arm 9%, leg 18%, thorax 18%, back 18%, head 9%, genitals 1%) watch for hyperkalemia first, then hypokalemia Rinse chemical injuries with clean water asap Maintain normal temp with warming blankets control pain (morphine) topical antibiotic Intubate for laryngeal edema (burns to face, hoarse, drooling)