Medication Management and Diagnosis in Older Adults: A Comprehensive Guide, Exams of Nursing

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NSG 6420 : FNP I Family Health - Adult and

Gerontology Final Review Study Guide + Week

10 Final Exam

1. General Concepts in Geriatrics Impact of physiological changes with aging: Kennedy Chapter 1. The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. Reduced renal function, particularly the glomerular filtration rate (GFR), affects the clearance of many drugs, and creatinine clearance provides an index of renal function for use in choosing doses of renally eliminated or nephrotoxic drugs (such as digoxin, H2 blockers, lithium, and water-soluble antibiotics). Normal age related changes: Changes in kidney function begin in the fourth decade of life and continue to decline with each subsequent decade. by age 70, an individual might reasonably have a 40% to 50% decrease in renal function, even in the absence of disease. With advancing age, the ability of the liver to metabolize drugs does not decline. Although liver size and blood flow do decline with age, routine liver function test results are typically normal when no disease exists. Decreased liver size and blood flow can result in decreased first-pass metabolism. Older adults often experience more sedation from central nervous system drugs than younger persons at the same concentration. Signs and symptoms of depression: Altered presentation is another common feature in older adults. The patient with depression may not present with a dysphoric mood but rather agitation and psychotic features.

Questions

The major impact of the physiological changes that occur with aging is: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response All of the above All of the following statements are true about laboratory values in older adults except Reference ranges are preferable Abnormal findings are often due to physiological aging Normal ranges may not be applicable for older adults Reference values are not necessarily acceptable values

Mini Mental Status: Buttaro Chapter 13 Geriatric specialists have multiple assessment tools, such as the Folstein Mini-Mental State Examination, the Mini-Cog screen for dementia, the Short Portable Mental Status Questionnaire, the AD8 Dementia Screening Interview, and the Montreal Cognitive Assessment (MoCa), to differentiate short-term memory loss from dementia and to observe the progression of cognitive impairment. Questions When prescribing medications to an 80 - year-old patient, the provider will a. begin with higher doses and decrease according to the patient’s response. b. consult the Beers list to help identify potentially problematic drugs. c. ensure that the patient does not take more than five concurrent medications. d. review all patient medications at the annual health maintenance visit. The Beers list provides a list of potentially inappropriate medications in all patients age 65 and older and helps minimize drug-related problems in this age group. Older patients should be started on lower doses with gradual increase of doses depending on response and side effects. Patients who take five or more drugs are at increased risk for problems of polypharmacy, but many will need to take more than five drugs; providers must monitor their response more closely. Medications should be reviewed at all visits, not just annually. REF: Polypharmacy/Consequences of Polypharmacy/Management An 80-year-old woman who lives alone is noted to have a recent weight loss of 5 pounds. She appears somewhat confused, according to her daughter, who is concerned that she is developing dementia. The provider learns that the woman still drives, volunteers at the local hospital, and attends a book club with several friends once a month. What is the initial step in evaluating this patient? a. Obtain a CBC, serum electrolytes, BUN, and glucose b. Ordering a CBC, serum ferritin, and TIBC c. Referring the patient to a dietician for nutritional evaluation d. Referring the patient to a neurologist for evaluation for AD Patients with weight loss, confusion, and lethargy are often dehydrated and this should be evaluated by looking at Hgb and Hct, electrolytes, and BUN. This patient is currently leading an active life, so the likelihood that recent symptoms are related to AD, although this may be evaluated if dehydration is ruled out. Anemia would be a consideration when dehydration is ruled out. Referrals are not necessary unless initial evaluations suggest that malnutrition or AD is present. REF: Dehydration/Pathophysiology/Clinical Presentation/Physical Examination

The practitioner is establishing a plan for routine health maintenance for a new female client who is 80 years old. The client has never smoked and has been in good health. What will the practitioner include in routine care for this patient? Select all that apply. a. Annual hypertension screening b. Baseline abdominal aorta ultrasound c. Colonoscopy every 10 years d. One-time hepatitis B vaccine e. Pneumovax vaccine if not previously given f. Yearly influenza vaccine For older clients a one-time pneumovax is given after age 65. Influenza vaccine should be given every year. Hypertension screening should be performed at each office visit, not just annually. An abdominal aorta US is performed once for every smoking male. Colonoscopy is performed every 10 years after age 50, but not after age 74. REF: Table 13-1: Recommended Screening and Immunizations

2. HEENT Pharyngitis Buttaro Chapter 101 In noninfectious pharyngitis the patient reports a sore throat and dryness; if environmental allergens are the cause, symptoms often include rhinorrhea, watery eyes, and postnasal drip. Viral causes are more common (rhinorivus) In viral pharyngitis, findings include fever, cough, nasal symptoms, and mild erythema with little or no pharyngeal exudate. Treatment of viral pharyngitis includes rest, fluids, humidification, voice rest, and warm saline gargles to ease discomfort. 7 Acetaminophen or ibuprofen should be used for fever and general discomfort. Bacterial pharyngitis is more common in children younger than 15. Streptococcus pyogenes is the etiologic agent for acute pharyngitis. Group A β-hemolytic Streptococcus (GAS) is the most important to identify because it is responsible for acute rheumatic fever (ARF) and poststreptococcal glomerulonephritis. Patients may report a sudden onset of sore throat, painful swallowing, fever (temperature higher than 38.5° C [101.3° F]), chills, headache, nausea, vomiting, and abdominal pain. With bacterial pharyngitis, rhinitis, cough, conjunctivitis, and myalgias are not typically present. Diagnostic studies used to detect GAS infection include a throat culture, a rapid antigen detection test (RADT). Penicillin V, 500 mg 2 - 3 times daily for 10 days) is indicated in GAS pharyngitis primarily to prevent complications, such as suppurative tonsillitis, glomerulonephritis, and rheumatic fever. Clarithromycin, 2 50 mg twice daily for 10 days, is indicated for patients with penicillin allergy. questions A patient has sore throat, a temperature of 38.5° C, tonsillar exudates, and cervical lymphadenopathy. What will the provider do next to manage this patient’s symptoms?

a. Order an antistreptolysin O titer b. Perform a rapid antigen detection test c. Prescribe empiric penicillin d. Refer to an otolaryngologist The RADT is performed initially to determine whether GAS is present. The ASO titer is not used during initial diagnostic screening. Penicillin should not be given empirically. A referral to a specialist is not required for GAS infection. A patient reports a sudden onset of sore throat, fever, malaise, and cough. The provider notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms? a. Allergic pharyngitis b. Group A streptococcus c. Infectious mononucleosis d. Viral pharyngitis Viral pharyngitis will cause sore throat, fever, and malaise and is often accompanied by URI symptoms of cough and runny nose. Allergic pharyngitis usually also causes dryness. GAS causes high fever, cervical adenopathy, and marked erythema with exudate. Infectious mononucleosis will cause an exudate along with cervical adenopathy A school-age child has had 5 episodes of tonsillitis in the past year and 2 episodes the previous year. The child’s parent asks the provider if the child needs a tonsillectomy. What will the provider tell this parent? a. Current recommendations do not support tonsillectomy for this child. b. If there is one more episode in the next 6 months, a tonsillectomy is necessary. c. The child should have radiographic studies to evaluate the need for tonsillectomy. d. Tonsillectomy is recommended based on this child’s history. Recommendations suggest 6 to 7 documented episodes of GAS within 1 year, 5/year for 2 consecutive years, or 3/year for 3 years. Radiographic studies are not indicated Mononucleosis (Buttaro Chapter 233) EBV-IM (Epstein-Bar Virus infectious mononucleosis) occurs most often in adolescents and young adults, with the highest incident at ages 15 to 19. Transmission of EBV-IM occurs through exposure to oropharyngeal secretions. The classic triad of symptoms of acute IM includes fever, pharyngitis, and lymphadenopathy. The typical adolescent with EBV-IM is seen with sore throat, fever, and lymph node and tonsillar enlargement. Additional common presenting symptoms include pharyngeal inflammation and transient palatal petechiae. Reports indicate that splenic enlargement occurs in 40% to 100% of cases and can be confirmed with ultrasound. An

abdominal examination identifies splenomegaly and hepatomegaly. Rash and jaundice should be noted because they are associated with EBV-IM. he most useful laboratory test is the serologic test for heterophil antibodies. Treatment of uncomplicated EBV-IM is primarily supportive, including adequate hydration, nonsteroidal anti-inflammatory drugs or acetaminophen for fever reduction and myalgias. Individuals with splenomegaly should be encouraged to refrain from strenuous physical activity for 3 to 4 weeks to avoid the risk of splenic rupture Questions A patient with EBV-IM also has group A beta-hemolytic streptococcal pharyngitis and is being treated with amoxicillin. On the third day of treatment, the patient develops a rash. A urinalysis is normal. What does this indicate? a. A reaction to the amoxicillin b. A streptococcal rash c. Hematologic complications d. Hemolytic-uremic syndrome 80% to 100% of patients with IM who are taking amoxicillin will develop a rash. A streptococcal rash appears at the onset of symptoms, not 3 days after initiation of antibiotics. This rash does not indicate hematologic complications or hemolytic-uremic syndrome. An adolescent patient who plays football in high school is diagnosed with EBV infectious mononucleosis and is noted to have splenomegaly. What will the provider recommend to this patient about returning to sports? a. Abdominal ultrasounds are recommended to determine safety. b. Corticosteroid therapy may help shorten the course of the disease. c. He may return to minimal contact practice in 2 to 3 weeks. d. It will be safe to play football in 3 to 4 weeks. Patients with splenomegaly should be encouraged to refrain from strenuous activity for 3 to 4 weeks to avoid the risk of splenic rupture. Serial US studies beginning at week 2 to 3 may be helpful in determining the risk of rupture. Corticosteroids have not been shown to reduce the severity or duration of symptoms. Strenuous activity is not recommended until 3 to 4 weeks; without an US, it is not possible to ensure absolute safety for sports. An adolescent patient has fever, pharyngitis, and cervical lymphadenopathy and has a negative group A beta-hemolytic throat culture. A complete blood count shows absolute lymphocytosis, but a heterophil antibody test is negative for Epstein-Barr virus (EBV). What will the provider tell the patient about the likelihood of infectious mononucleosis (IM)? a. It will be necessary to repeat the heterophil antibody test in a few weeks. b. Liver function tests will help to confirm a diagnosis of EBV-IM.

c. The likelihood of EBV infectious mononucleosis is still high. d. This IM is most likely caused by a virus other than Epstein-Barr virus. Because heterophil antibodies may not reach detectable levels early in the disease, it is possible to have a negative result. This patient has symptoms and the suspicion for disease remains high. Repeat testing in 7 to 10 days will help confirm the diagnosis. A positive heterophil antibody test with absolute lymphocytosis is diagnostic of acute IM. Epstein-Barr nuclear antigen is measured 6 to 8 weeks after onset of symptoms to distinguish between acute and previous infection. LFTs may be elevated in patients with IM, but this is not diagnostic. Symptoms associated with allergies (buttaro chapter 73) allergic conjunctivitis, a condition seen most frequently in the spring and summer. Unlike conjunctivitis from infectious causes, allergic conjunctivitis typically occurs simultaneously in both eyes. Its predominant feature is itching. If discharge is present, it will be clear or stringy and white. The conjunctiva has a boggy appearance. Because allergic conjunctivitis is typically associated with systemic allergies, an oral antihistamine can be helpful in controlling ocular symptoms. Agents to consider include fexofenadine and loratadine. Conjunctivitis Bacterial conjunctivitis is typically accompanied by thick, purulent discharge. Patients will report that both eyes are sticky or glued shut. Gonococcal conjunctivitis is typically seen in sexually active adults but can also occur in neonates via maternal-neonate transmission. trimethoprim–polymyxin B or fluoroquinolone drops, four times a day for 1 week. The following types of bacterial conjunctivitis require systemic treatment:

• H. influenzae: treat with oral amoxicillin-clavulanate
• Gonococcal: ceftriaxone, 1 g intramuscularly, one dose or ciprofloxacin, 500 mg orally if the patient has a penicillin allergy and one dose of azithromycin, 1g orally—requires same-day referral to an ophthalmologist.
• Chlamydial: azithromycin, 1 g orally, one dose or doxycycline, 100 mg twice daily for 7 days Viral conjunctivitis is self-limited and typically lasts 5 to 14 days. A recent upper respiratory infection or exposure to sick individuals can point to a diagnosis of adenoviral conjunctivitis. Treatment is supportive with artificial tears and cool compresses. In addition, topical corticosteroids should be avoided because they can prolong viral shedding and increase infectivity. Adenoviral conjunctivitis can occur in three different forms. Adenoviral conjunctivitis pharyngoconjunctival fever: systemic symptoms Epidemic keratoconjunctivitis: bilateral conjunctival hyperemia and chemosis, petechial and larger subconjunctival hemorrhages. have corneal involvement, and it is appropriate to refer these patients to an ophthalmologist. questions A patient who has a cold develops conjunctivitis. The provider notes erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes, along with a fever. Which treatment is indicated?

a. Antihistamine-vasoconstrictor drops b. Artificial tears and cool compresses c. Topical antibiotic eye drops d. Topical corticosteroid drops Viral conjunctivitis accompanies URI and is generally self-limited, lasting 5 to 14 days. Symptomatic treatment is recommended. Antihistamine-vasoconstrictor drops are used for allergic conjunctivitis. Topical antibiotic drops are sometimes used for bacterial conjunctivitis. Topical corticosteroid drops are used for severe inflammation. A patient reports bilateral reports burning and itching eyes for several days. The provider notes a boggy appearance to the conjunctivae, along with clear, watery discharge. The patient’s eyelids are thickened and discolored. There are no other symptoms. Which type of conjunctivitis is most likely? a. Allergic b. Bacterial c. Chemical d. Viral Allergic conjunctivitis generally presents simultaneously in both eyes with itching as a predominant feature. Discharge is generally clear or stringy and white and the patient will have lid discoloration, thickening, and erythema. Bacterial conjunctivitis is characterized by acute inflammation of the conjunctivae along with purulent discharge. Chemical conjunctivitis will not have purulent discharge. Viral conjunctivitis is usually in association with a URI. A patient with allergic conjunctivitis who has been using a topical antihistamine-vasoconstrictor medication reports worsening symptoms. What is the provider’s next step in managing this patient’s symptoms? a. Consider prescribing a topical mast cell stabilizer b. Determine the duration of treatment with this medication c. Prescribe a non-sedating oral antihistamine d. Refer the patient to an ophthalmologist for further care Antibiotic-vasoconstrictor agents can have a rebound effect with worsening symptoms if used longer than 3 to 7 days, so the provider should determine whether this is the cause. Topical mast cell stabilizers are useful as prophylaxis for recurrent or persistent allergic conjunctivitis and results do not occur for several weeks. Oral antihistamines may be the next step if it is determined that the cause of worsening symptoms is related to the allergy. It is not necessary to refer to ophthalmology at this time. REF: Management Corneal abrasion (Buttaro chapter 74) The most common symptom of a corneal abrasion or foreign body is sudden onset of severe eye pain in the affected eye. This pain typically resolves after application of a topical anesthetic eye drop. Other symptoms include blurred vision, redness, tearing, light sensitivity, eyelid

swelling, and blepharospasm. Use of topical fluorescein dye can assist in the diagnosis. One drop of fluorescein can be applied and viewed under a cobalt blue light or Wood lamp. A corneal abrasion should appear as a bright green area. Topical anesthetics such as proparacaine should never be used or prescribed for pain control; their prolonged use may lead to corneal melting. A healthy corneal epithelium will repopulate rapidly, from just a few hours for a small, uncomplicated defect to 3 to 5 days with larger defects. Questions A patient who works in a furniture manufacturing shop reports a sudden onset of severe eye pain while sanding a piece of wood and now has copious tearing, redness, and light sensitivity in the affected eye. On examination, the conjunctiva appears injected, but no foreign body is visualized. What is the practitioner’s next step? a. Administration of antibiotic eye drops b. Application of topical fluorescein dye c. Instillation of cyclopegic eye drops d. Irrigation of the eye with normal saline The practitioner must determine if there is a corneal abrasion and will instill fluorescein dye in order to examine the cornea under a Wood’s lamp. Antibiotic eye drops are not indicated as initial treatment. Cyclopegic drops are used occasionally for pain control, but should be used with caution. Irrigation of the eye is indicated for chemical burns. Glaucoma (Kennedy Chapter 7) Acute glaucoma, also known as angle-closure or narrow-angle glaucoma , is an obstruction to the outflow of aqueous humor from the posterior to the anterior chamber. The predominant age range is 60 to 70 years old. The history reveals severe, unilateral eye pain, blurred vision, lacrimation, reports of seeing colored halos around lights, and a red eye. Headache, nausea, and vomiting frequently accompany eye pain, causing eye pain to be overlooked. Immediately refer patients for a complete ophthalmic examination. permanent visual loss occurs within 2 to 5 days if this condition is untreated. Surgical treatment includes peripheral iridectomy or laser iridotomy Chronic Glaucoma: initially; tunnel vision, night blindness, halos around lights. gradual visual field loss, chronic glaucoma is called the silent blinder. Medical treatment with eye drops is usually first-line therapy Prostaglandin analogs are the most effective drugs at lowering IOP and can be considered as initial medical therapy. Ttimolol is frequently prescribed for glaucoma and can exacerbate bradycardia and asthma in susceptible patients. Questions During an eye examination, the provider notes a red light reflex in one eye but not the other. What is the significance of this finding? a. Normal physiologic variant b. Ocular disease requiring referral

c. Potential infection in the “red” eye d. Potential vision loss in one eye The red reflex should be elicited in normal eyes. Any asymmetry or opacity suggests ocular disease, potentially retinoblastoma, and should be evaluated immediately Sinusitis (Buttaro Chapter 92) The most common cause of acute sinusitis is a bacterial infection caused by Streptococcus pneumoniae. The presenting signs and symptoms include nasal congestion, purulent nasal discharge, and a headache that becomes more intense when the patient bends forward. Fever, fatigue, and other constitutional symptoms are common. The onset is abrupt, with infection in one or more paranasal sinuses. There is an association between sinusitis and asthma. Chronic sinusitis occurs with episodes of prolonged sinus infection (more than 12 weeks). Nasal congestion, discharge, and a cough that lasts for more than 30 days are common. Severe pain and headache are not usually present in chronic sinusitis CT scanning without contrast enhancement may be indicated for patient with recalcitrant symptoms that have not responded to two or more courses of antibiotic therapy. Questions A patient is concerned about frequent nasal stuffiness and congestion that begins shortly after getting out of bed in the morning. The patient denies itching and sneezing. A physical examination reveals erythematous nasal mucosa with scant watery discharge. What treatment will the provider recommend for this patient? a. Consultation for immunotherapy b. Daily intranasal steroids c. Oral antihistamines each morning d. Oral decongestants as needed Intranasal steroids should be considered for symptomatic relief for patients with sinusitis, especially those with allergic rhinitis. Oral mucolytics have little support in efficacy. Saline solution rinses may provide some relief, but there is no evidence to support their usefulness. Topical decongestants do decrease nasal congestion and edema, but the potential harm of rebound congestion requires recommendation with caution. Which are potential complications of chronic or recurrent sinusitis? Select all that apply. a. Allergic rhinitis b. Asthma c. Meningitis d. Orbital infection e. Osteomyelitis

Complications of chronic or recurrent sinusitis include spread of infection to other tissues and may cause meningitis, orbital cellulitis, and osteomyelitis. Allergic rhinitis and asthma are associated with chronic sinusitis, but not complications of this condition. A patient has nasal congestion, fever, purulent nasal discharge, headache, and facial pain and begins treatment with amoxicillin-clavulanate. At a follow-up visit 10 days after initiation of treatment, the patient continues to have purulent discharge, congestion, and facial pain without fever. What is the next course of action for this patient? a. A CT scan of the paranasal sinuses b. A referral to an otolaryngologist c. A second course of amoxicillin-clavulanate d. A trial of azithromycin This patient may have subacute sinusitis and may benefit from a second course of the antibiotic. The lack of fever shows improvement, so this antibiotic may be used. CT scan is usually not performed in adults unless other complications are present or suspected. Referral to an otolaryngologist is necessary if no improvement after the second course of antibiotics. Azithromycin is not used in adults unless pregnant, due to resistance patterns. REF: Clinical Presentation/Diagnostics/Management Acute otitis media in adults (Buttaro chapter 86) Otitis media, characterized by fluid in the middle ear. most often associated with upper respiratory tract infections or allergies. The most common bacterial causative agents are Streptococcus pneumoniae and Haemophilus influenzae. otoscopic examination is key to accurate diagnosis of otitis. Cerumen removal may be necessary to obtain a clear view of the TM. AOM usually is characterized by a throbbing, painful earache with impaired hearing. In OME, fluid is present in the middle ear without signs or symptoms of acute infection. The TM often is dull gray, although it may appear injected. Amoxicillin is the recommended first-line antibiotic for children who are not allergic and have not received it in the last 30 days Questions Which symptoms in children are evaluated using a parent-reported scoring system to determine the severity of pain in children with otitis media? Select all that apply. a. Appetite b. Difficulty sleeping c. Level of cooperation d. Poor hearing e. Tugging on ears

Decreased appetite, difficulty sleeping, and tugging on ears are part of the Acute Otitis Media Severity of Symptom Scale used to evaluate pediatric pain. Children may refuse to cooperate for reasons other than pain. Poor hearing is not part of the pain assessment. Which patient may be given symptomatic treatment with 24 hours follow-up assessment without initial antibiotic therapy? a. A 36 month old with fever of 38 .5° C, mild otalgia, and red, non-bulging TM b. A 4 year old, afebrile child with bilateral otorrhea c. A 5 year old with fever of 38.0° C, severe otalgia, and red, bulging TM d. A 6 month old with fever of 39.2° C, poor sleep and appetite and bulging TM Children older than 24 months with fever less than 39° C and non-severe symptoms may be watched for 24 hours with symptomatic treatment. Children with otorrhea, those with severe AOM, and any children with fever greater than 39° C should be given antibiotics. A pediatric patient has otalgia, fever of 38.8° C, and a recent history of upper respiratory examination. The examiner is unable to visualize the tympanic membranes in the right ear because of the presence of cerumen in the ear canal. The left tympanic membrane is dull gray with fluid levels present. What is the correct action? a. Perform a tympanogram on the right ear b. Recommend symptomatic treatment for fever and pain c. Remove the cerumen and visualize the tympanic membrane d. Treat empirically with amoxicillin 80 to 90 mg/kg/day The AAP 2013 guidelines strongly recommend visualization of the tympanic membrane to accurately diagnose otitis media and not to treat based on symptoms alone. The practitioner should attempt to remove the cerumen in order to visualize the tympanic membrane. A tympanogram cannot be performed when cerumen is blocking the canal. Because the child may have an acute ear infection, antibiotics may be necessary.

3. Skin Herpes Zoster Buttaro Chapter 55, Kennedy chapter 6 Herpes zoster is an acute vesicular eruption caused by a virus histologically identical to the varicella (chickenpox) virus. the virus spreads across the sensory ganglion to other neurons, which causes a cutaneous eruption of a dermatome distribution. If herpes zoster affects bilateral dermatomes, it is considered to be disseminated herpes zoster. atients usually experience hyperesthesia with a burning or tingling pain at the site 4 to 5 days before the eruption appears. Pain in a dermatomal pattern may precede the appearance of the vesicles. The direct immunofluorescence with fluorescein-tagged antibody (DFA) or polymerase chain reaction (PCR) (if available) is preferred over the old standard Tzanck smear. A Tzanck test is a rapid way to confirm the diagnosis of zoster in the provider's office but does not distinguish between VZV and herpes simplex virus. Postherpetic neuralgia is not reduced by antiviral therapy, but these agents may help with healing in the acute phase. Give acyclovir, 800 mg 5 times a day for 7 to 10 days; famciclovir, 500 mg orally every 8 hours for 7 days; or valacyclovir, 1000 mg orally

every 8 hours for 7 days/ he vaccine for herpes zoster (Zostavax) is available and is recommended for patients age 60 and older. Questions Which of the following dermatological conditions results from reactivation of the dormant varicella virus? A Tinea versicolor . B. Seborrheic keratosis C. Verruca D Herpes zoster . An older adult male presents with pain in his right chest wall for the past 48 hours. Upon examination, the nurse practitioner notices a vesicular eruption along the dermatome and identifies this as herpes zoster. The NP informs the gentleman that: A. All symptoms should disappear within three days B. Oral medications can dramatically reduce the duration and intensity of his symptoms C. He has chickenpox and can be contagious to his grandchildren D. He has a sexually transmitted disease The immunofluorescent antibody (IFA) is a laboratory test used to diagnose which of the following disorders? A. Tinea versicolor B. Herpes zoster C. Squamous cell carcinoma D. Human papilloma virus `Which of the following is generally not a first-line treatment for post herpetic neuralgia? A. Intrathecal methylprednisolone B. Gabapentin C. 5% lidocaine patch D. Topical capsaicin A patient who has had a previous herpes zoster outbreak experiences a second outbreak and asks the provider about treatment to reduce the duration and severity of symptoms. What will the provider recommend? a. Acyclovir b. Lidocaine patch c. Oral corticosteroids d. Topical corticosteroids Acyclovir, given within 72 hours of onset of rash, has been shown to reduce the duration and severity of the rash and pain and to reduce the risk for PHN and disseminated disease. Lidocaine patches help with pain, but do not reduce the duration of the symptoms. Corticosteroids have not been shown to prevent development of PHN, but have shown modest reduction in duration and severity.

An older patient experiences a herpes zoster outbreak and asks the provider if she is contagious because she is going to be around her grandchild who is too young to be immunized for varicella. What will the provider tell her? a. An antiviral medication will prevent transmission to others. b. As long as her lesions are covered, there is no risk of transmission. c. Contagion is possible until all of her lesions are crusted. d. Varicella zoster and herpes zoster are different infections. Herpes zoster lesions contain high concentrations of virus that can be spread by contact and by air; although they are less contagious than primary infections, contagion is possible until all lesions are crusted. Antiviral medications shorten the course, but do not reduce transmission. Covering the lesions does not prevent transmission. Herpes zoster and varicella zoster are the same. A patient has a unilateral vesicular eruption which is described as burning and stabbing in intensity. To differentiate between herpes simplex and herpes zoster, which test will the provider order? a. Polymerase chain reaction analysis b. Serum immunoglobulins c. Tzanck test d. Viral culture The PCR is a rapid and sensitive test that can differentiate between the two. Serum Ig levels are not diagnostic. The Tzanck test identifies the presence of a herpes virus, but does not differentiate between the two types. Viral culture will differentiate, but is not rapid. 60 - year-old patient with a previous history of shingles asks about the herpes zoster vaccine. What will the provider recommend? a. A series of two herpes zoster vaccinations b. A single dose of herpes zoster vaccine c. No herpes zoster vaccine is necessary d. Prophylactic vaccination if exposed to chicken pox All patients 50 years and older should have a single dose of herpes zoster vaccine regardless of previous herpes zoster infection. Dermatitis Buttaro chapter 48 Contact dermatitis is further classified as irritant or allergic type. A well-demarcated area of erythema, scaling, or crusting will occur at the site of the exposure. The hands are the most

common area affected. A potassium hydroxide (KOH) slide can rule out dermatophyte infection; bacterial. The mainstay of treatment is topical application of medium- to high-potency corticosteroids. Questions A child has irritant contact dermatitis with lesions on the extremities and face. Which treatment is recommended for this patient? a. Antihistamines b. Medium- to high-potency topical corticosteroids c. Oral corticosteroids d. Topical calcineurin inhibitors When periorbital regions or more than 20% of the body surface area is involved, the use of an oral steroid is appropriate. Antihistamines produce relaxation and improve sleep, but do not reduce the pruritus associated with contact dermatitis. Topical calcineurin inhibitors may be used in place of topical steroids, but oral steroids are indicated in this instance. A patient who has been exposed to poison ivy presents with inflammation and a vesicular rash on one arm. The provider recommends a topical steroid, but the next day the patient calls to report similar lesions appearing on the face. What will the provider tell this patient? a. The rash is spreading through self-inoculation. b. The vesicles may continue to develop for up to 2 weeks. c. The rash may spread over the next 8 weeks. d. The patient must have been re-exposed to the irritant. Exposure to poison ivy resin results in vesicles and bullae that develop for up to 2 weeks. Once the resin is washed off, no further spread occurs. With insufficient treatment, the rash may persist, but not spread, for up to 8 weeks. Impetigo (buttaro chapter 47 The common initial presentation of impetigo is vesiculopustular or even bullous lesions. When the lesions rupture and exude their contents, they create the classic honey-colored crusts. Questions A child has vesiculopustular lesions around the nose and mouth with areas of honey-colored crusts. The provider notes a few similar lesions on the child’s hands and legs. Which treatment is appropriate for this child? a. Amoxicillin-clavulanate b. Culture and sensitivity of the lesions

c. Sulfamethoxazole-trimethoprim d. Topical antiseptic ointment This child has symptoms of impetigo which has spread to the hands and legs. A systemic penicillinase-resistant penicillin is recommended. It is not necessary to obtain a culture since this can be treated empirically in most cases. MRSA is unlikely, so sulfamethoxazole-trimethoprim is not indicated. Oral antibiotics, not topical antiseptics, are the treatment of choice. Psoriasis Buttaro Chapter 62 Psoriasis is an inflammatory, autoimmune disease, papulosquamous eruption characterized by well-circumscribed erythematous macular and papular lesions with loosely adherent silvery white scale. The dermis is highly vascular, and tiny bleeding points are revealed if the scales are removed (Auspitz sign). High-potency topical glucocorticosteroids applied BID produce maximum benefit in 2 to 3 weeks. Ointments are the preferred vehicle because of better medicine penetration and support of the skin moisture barrier; however, ointments are not easily tolerated by the patient. Methotrexate, a folic acid antagonist, is highly effective in treating severe, recalcitrant psoriasis involving a large body area, acute pustular psoriasis, and psoriatic arthritis Questions A child has plaques on the extensor surfaces of both elbows and on the face with minimal scaling and pruritis. What is the likely cause of these lesions? a. Atopic dermatitis b. Guttate psoriasis c. Psoriasis d. Seborrhea Children with psoriasis often have lesions on the face and have less scaling than adults. Psoriasis tends to present on extensor surfaces, while atopic dermatitis occurs on flexor surfaces. Guttate psoriasis appears as teardrop-shaped lesions that appear on the trunk and spread to the extremities and are occasionally seen after streptococcal infections in adolescents. Seborrhea usually occurs on the scalp. A patient with psoriasis develops lesions on the intertriginous areas of the skin. Which treatment is recommended? a. High-potency topical steroids b. Oral corticosteroid injections c. Topical steroids with vitamin D d. Topical, low-potency steroids Patients with intertriginous psoriasis should be treated with low-potency topical steroids. High- potency steroids usually produce maximum benefit in 2 to 3 weeks and research suggests

combining high-potency steroids with vitamin D analog is best. Oral corticosteroids are used for recalcitrant symptoms. A patient with severe, recalcitrant psoriasis has tried topical medications, intralesional steroid injections, and phototherapy with ultraviolet B light without consistent improvement in symptoms. What is the next step in treating this patient? a. Cyclosporine b. Etanercept c. Methotrexate d. Oral retinoids Methotrexate has shown good efficacy in treating recalcitrant psoriasis. Cyclosporine and oral retinoids are effective, but have serious side effects. Etanercept and other biologic agents are effective but expensive and should be tried after all other treatments have failed. REF: Management/Systemic Medications/Biologic Agents Tinea Capitis Questions Patients who have an underlying tinea infection to the cellulitis should also be treated with which one of the following? A. An anti-fungal medication B. Topical steroids C. Oral steroids D. Zinc oxide Which of the following descriptions best illustrates assessment findings consistent with tinea capitis? A. Circular erythematous patches with papular, scaly annular borders and clear centers B. Inflamed scaly dry patches with broken hairs C. Web lesions with erythema and scaling borders D. Scaly pruritic erythematous lesions on inguinal creases Skin cancer: Basal Cell Carcinoma Questions A 70 - year-old white male comes to the clinic with a slightly raised, scaly, pink, and irregular lesion on his scalp. He is a farmer and works outside all day. You suspect actinic keratosis, but cannot rule out other lesions. What recommendation would you give him? A. Ignore the lesion, as it is associated with aging. B. Instruct him to use a nonprescription hydrocortisone cream to dry up the lesion. C. Perform a biopsy or refer to a dermatologist. D. Advise him to use a dandruff shampoo and return in one month if the lesion has not gone away. A smooth round nodule with a pearly gray border and central induration best describes which skin lesion?

A. Seborrheic keratosis B. Malignant melanoma C. Herpes zoster DBasal cell carcinoma . An 82-yeAnan 82 years old female has a “pimple” on his nose that occasionally bleeds and may have increased in size in the past year. The lesion is a 0.7-cm, dome-shaped, umbilicated papule with pearly translucence. There is also a hemorrhagic crust covering the central portion. Which of the following is the most likely diagnosis? A. Squamous cell carcinoma B. Basal cell carcinoma C. Keratocanthoma D. Sebaceous hyperplasia AsymmetA Asymmetrical bi-color lesion with irregular border measuring 8 mm is found on the right lower arm of an adult patient. This assessment finding is consistent with: A. Melanoma B. Basal cell carcinoma C. Leukoplakia D. Senile lentigines

4. Cardiovascular Hypertension (Buttaro Chapter 114, Kennedy chapter 8) Hypertension is diagnosed on the basis of a persistently high BP identified on 3 measurements at least 1 week apart Questions A patient who has had mild pulmonary hypertension with a previous symptom of a loud second heart sound on exam now has edema and jugular vein distension. This indicates which complication? a. Left ventricular dysfunction b. Right ventricular dysfunction c. Tricuspid valve involvement d. Mitral valve involvement Right ventricular dysfunction occurs as the disease worsens with manifestations that include jugular vein distension, edema, and increased liver size. These symptoms do not indicate left ventricular dysfunction or valvular involvement.REF: Physical Examination In mitral stenosis, p waves may suggest: Left atrial enlargement Aortic regurgitation requires medical treatment for early signs of CHF with: ACE inhibitors

A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: Women with ischemic heart disease many times do not present with chest pain Some patients may have no symptoms or atypical symptoms. Diagnosis may only be made at the time of an actual myocardial infarction A & B only The best evidence rating drugs to consider in a post myocardial infarction patient include: ASA, ACE/ARB, beta-blocker, aldosterone blockade A 55 - year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: Exercise stress test Preceding a stress test, the following lab work might include: CBC and differential to differentiate ischemic heart disease from anemia Which test is the clinical standard for the assessment of aortic stenosis: Echocardiography What is the most common valvular heart disease in the older adult? Aortic stenosis Ischemic heart disease is: Defined as imbalance between oxygen supply and demand. Frequently is manifested as angina Leading cause of death in the elderly. All of the above. The aging process causes what normal physiological changes in the heart? The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis An older adult may present with atypical clinical signs of pneumonia. The nurse practitioner needs to be aware that the clustering of all of the following signs and symptoms may be indicative of pneumonia in an older person except: Bradycardia Which of the following statements is true concerning anti-arrhythmic drugs? Most anti-arrhythmics have a low toxic/therapeutic ratio and some are exceedingly toxic. Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? Chronic bronchitis

The best way to diagnose structural heart disease/dysfunction non-invasively is: Echocardiogram A common auscultatory finding in advanced CHF is: S3 gallop rhythm The organism most commonly responsible for community-acquired pneumonia in older adults is: Streptococcus pneumonia A 72 - year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely? Pulmonary embolism Hyperlipidemia (kennedy chapter 14 Reductions in lipid levels have been shown to be effective in primary and secondary prevention of cardiovascular disease. The primary target of therapy, in general, is lowering low-density lipoprotein (LDL) cholesterol. econdary causes of hyperlipidemia include hypothyroidism, poorly controlled diabetes mellitus, nephrotic syndrome, certain drug therapy such as glucocorticoids, and liver disease Total cholesterol ≥240 mg/dL is considered high. HDL level of ≤40 mg/dL is considered low TG levels of 200 to 499 mg/dL are considered high, Diet therapy with exercise and stress reduction should be initiated first for a 3 - to 6 - month trial before starting medications. Questions During a routine physical examination of a 62 - year-old female patient, the nurse practitioner identifies xanthelasma around both his eyes. What is the significance of this finding? A. High potential for future blindness and requires immediate referral B. None, normal variant of aging process C. Abnormal lipid metabolism requiring medical management D. Hereditary variant that is of no consequence but requires watchful waiting Mr. White is 62 years old and has chronic kidney disease that has been relatively stable. He also has a history of hyperlipidemia, osteoarthritis, and hypertension. He is compliant with his medications, and his BP has been well controlled on a calcium channel blocker. His last lipid panel showed: TC = 201, HDL = 40, TG = 180, LDL = 98. He currently takes Crestor 20 mg daily. In the office today, his BP is 188/90, and his urine dip now shows significant proteinuria. He denies any changes in his dietary habits or medication regimen. What would be the best medication change for Mr. White at this point? A. No change—have him return in 4 weeks for a re-check of his blood pressure and urine

B. Increase the dose of the calcium channel blocker for his hypertension C. Change the calcium channel blocker to an ACE-I D. Increase the dose of his Crestor and have him return in 3 months for a re-check of his BP Acute myocardial infarction Typical symptom is prolonged chest pain (more than 20 minutes’ duration); atypical symptoms include shortness of breath, neurological symptoms (confusion, weakness), and worsening of heart failure. Elderly persons may not recognize that throat, shoulder, arm, jaw, or abdominal pain may be referred cardiac pain or angina equivalent. Dyspnea is the second most common symptom of MI in both younger and older populations. Chest pain should be treated with sublingual nitroglycerin, repeated 3 times, 5 minutes apart, unless the patient is hypotensive, has right ventricular infarction, or has aortic stenosis. Thrombolytic agents include tissue-type plasminogen (tPA) and streptokinase (SK). Indications for thrombolysis are based on the existence of chest pain and specific ECG changes. Aspirin therapy should be initiated at 162 to 325 mg daily fro 1 motnh to 1 year ACE inhibitors reduce mortality in post-MI patients Questions

1. An asymptomatic 63 - year-old female has a low-density lipoprotein level of 135 mg/dL. Which test is beneficial to assess this patient’s coronary artery disease risk? a. Coronary artery calcium score b. C-reactive protein c. Exercise echocardiography d. Myocardial perfusion imaging The CRP is useful in asymptomatic women >60 years who have LDL <160 mg/dL to predict CAD risk. Although the CACS has shown some benefit in patients with moderate risk, the role for this diagnostic test is unclear. Exercise echocardiography and myocardial perfusion imaging are not performed initially.REF: Overview of Cardiac Diagnostic Testing Which risk assessment for coronary artery disease is recommended for all female patients? a. Coronary artery calcium score b. Electrocardiogram c. Exercise stress test d. Framingham risk score

The Framingham risk score is a quick method for identifying potential risk for CAD and can guide providers in choosing subsequent tests based on risk level. The ECG is performed on women with risk factors. The exercise stress test is useful in symptomatic women who have a normal ECG. The CACS may be used if moderate risk is present. A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: A. + B. Some patients may have no symptoms or atypical symptoms. Diagnosis may only be made at the time of an actual myocardial infarction C. Elderly patients have the most severe symptoms D. A & B only The best evidence rating drugs to consider in a post myocardial infarction patient include: A. ASA, ACE/ARB, beta-blocker, aldosterone blockade B. Ace, ARB, Calcium channel blocker, ASA C. Long-acting nitrates, warfarin, ACE, and ARB D. ASA, clopidogrel, nitrates A 55 - year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: A. Echocardiogram B. Exercise stress test C. Cardiac catheterization D. Myocardial perfusion imaging Syncope (Buttaro chapter 36, kennedy chapter 5) sudden and transient loss of consciousness and postural tone resulting from a reduction in oxygen to the brain. The most common cause of syncope is vasovagal. Orthostatic hypotension is rare in patients younger than 40 years, yet is one of the most common causes of syncope in

patients older than 70 years. he ECG is the most important diagnostic test with a focus on the rate and rhythm. Questions A form of syncope that is more common in the elderly than younger adults is: A. Vasovagal B. Carotid sinus sensitivity C. Orthostatic hypotension D. Arrhythmias Which tests are indicated as part of the initial evaluation for women of childbearing age who report syncope? Select all that apply. a. 12 - lead electrocardiogram b. Cardiac enzyme levels c. Complete blood count d. Electroencephalogram e. Serum glucose testing Initial evaluation for all patients reporting syncope should include a standard 12-lead ECG. Women of childbearing age should have a CBC, serum pregnancy test, and serum glucose testing. Cardiac enzyme levels are obtained if the patient has cardiac risk factors. EEG is performed only if there is a concern for seizure disorder. REF: Syncope/Diagnostics A healthy 20-year-old patient reports having had 1 or 2 episodes of syncope without loss of consciousness. Which is the most likely type of syncope in this patient? a. Cardiac b. Neurogenic c. Orthostatic hypotensive d. Reflex syncope Neurally mediated or reflex syncope is the most common cause of syncope and is primarily seen in young adults. Cardiac, neurogenic, and orthostatic syncope are generally seen in older adults. REF: Syncope/Pathophysiology An elderly patient reports experiencing syncope each morning when getting out of bed. Which assessment will the health care provider perform first to evaluate this patient’s symptoms? a. Cardiac enzyme levels b. Electroencephalogram

c. Fasting blood glucose d. Orthostatic blood pressures Orthostatic blood pressures should be measured first since this patient reports problems associated with rising from a supine position. The other tests are performed as part of the diagnostic workup only if indicated by associated symptoms or suspected causes. REF: Syncope/Physical Examination

5. Pulmonary Community acquired pneumonia (Buttaro chapter 111, kennedy chapter 8) A patient has a cough and fever and the provider auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient’s pneumonia? a. A virus b. Mycoplasma c. S. pneumoniae d. Tuberculosis Atypical pneumonias, such as those caused by mycoplasma often present with headache and sore throat and will have larger areas of infiltrate on chest radiograph. Viral pneumonias show more diffuse radiographic findings. S. pneumonia will have high fever and cough and distinct areas of infiltration.REF: Pathophysiology/Clinical Presentation A young adult, previously healthy clinic patient has symptoms of pneumonia including high fever and cough. Auscultation reveals rales in the left lower lobe. A chest radiograph is normal. The patient is unable to expectorate sputum. Which treatment is recommended for this patient? a. A B-lactam antibiotic plus a fluoroquinolone b. A respiratory fluoroquinolone antibiotic c. Empiric treatment with a macrolide antibiotic d. Hospitalization for intravenous antibiotics This patient likely has community-acquired pneumonia. The patient has typical symptoms and, even though the chest radiograph is normal, will require outpatient treatment. For community- acquired pneumonia in a previously healthy individual, treatment with a macrolide antibiotic is the recommended first-line therapy. B-lactam plus fluoroquinolone therapy is used for patients in the ICU. Respiratory fluoroquinolones are used for patients with underlying disorders who develop pneumonia. Hospitalization is not necessary.REF: Management

A patient who was initially treated as an outpatient for pneumonia and then hospitalized for two weeks after no improvement continues to show no improvement after several antibiotic regimens have been attempted. What is the next step in managing this patient? a. Administration of the pneumonia vaccine b. Increasing the dose of the antibiotics c. Open lung biopsy d. Performing diagnostic bronchoscopy Patients who do not respond to antibiotic therapy may have opportunistic fungal or other infections, bronchogenic carcinoma, or other diseases. Bronchoscopy can exclude or confirm these. The pneumonia vaccine is preventative for pneumococcal causes and will not help this patient. Increasing the dose of the antibiotics is not recommended. Open lung biopsy may be performed if a bronchoscopy is inconclusive.REF: Complications An older adult may present with atypical clinical signs of pneumonia. The nurse practitioner needs to be aware that the clustering of all of the following signs and symptoms may be indicative of pneumonia in an older person except: A. Bradycardia B. Malaise C. Anorexia D. Confusion The organism most commonly responsible for community-acquired pneumonia in older adults is: A. Pseudomonas aeruginosa B. Staphylococcus aureus C. Proteus mirabilis D. Streptococcus pneumonia Asthma (kennedy chapter 8, buttaro 103) A patient who has asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? a. Administering two more doses of albuterol b. Coming to the clinic for evaluation

c. Going to the emergency department d. Taking an oral corticosteroid ANS: A The patient is experiencing an asthma exacerbation and should follow the asthma action plan (AAP) which recommends three doses of albuterol before reassessing. The peak flow is above 70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for oxygen saturation and spirometry evaluation after administering the albuterol. An oral corticosteroid may be prescribed if the patient will be treated as an outpatient after following the AAP. REF: Management An adult develops chronic cough with episodes of wheezing and shortness of breath. The provider performs chest radiography and other tests and rules out infection, upper respiratory, and gastroesophageal causes. Which test will the provider order initially to evaluate the possibility of asthma as the cause of these symptoms? a. Allergy testing b. Methacholine challenge test c. Peak expiratory flow rate d. Spirometry Spirometry is recommended at the time of initial assessment to confirm the diagnosis of asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor asthma symptoms. REF: Diagnostics A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? a. Administer three more nebulizer treatments and reassess b. Admit to the hospital with specialist consultation c. Give epinephrine injections and monitor response d. Prescribe an oral corticosteroid medication Patients having an asthma exacerbation should be referred if they fail to improve after three nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or administering epinephrine are not indicated. The patient will most likely be given IV corticosteroids; oral corticosteroids would be given if the patient is managed as an outpatient. REF: Definition and Epidemiology T.B. (immunization) (kennedy chapter 8 / Buttarp chapter 235)