NRNP 6560 MIDTERM EXAM LATEST 2023 2024 190 REAL EXAM QUESTIONS AND ANSWERS NRNP6560 MID, Exams of Nursing

Download NRNP 6560 MIDTERM EXAM LATEST 2023 2024 190 REAL EXAM QUESTIONS AND ANSWERS NRNP6560 MID and more Exams Nursing in PDF only on Docsity! 1 | P a g e NRNP 6560 MIDTERM EXAM LATEST 2023-2024 (190+ REAL EXAM QUESTIONS AND ANSWERS NRNP6560 MIDTERM EXAM / NRNP 6560 WEEK 6 MIDTERM EXAM WALDEN UNIVERSITY – EXPERT FEEDBACK 2 | P a g e Surgery risk classes – ANSWERS - Class 1: benefits outweigh risk, should be done Class 2a: reasonable to perform Class 2b: should be considered Class 3: rarely appropriate General rules for surgery: testing - ANSWERS ECG before surgery only if coronary disease, except when low risk surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization Meds before surgery - ANSWERS- - Diabetic agents: Use insulin therapy to maintain glycemic goals(iii) Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists - Do not start aspirin before surgery - Stop Warfarin 5 days before surgery. May be bridged with Lovenox. - Do not stop statin before surgery - Do not start beta-blocker on day of surgery, but may continue Assessment of surgical risk - ANSWER- - Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD - patient stable or unstable? - urgency of the procedure (oncology will be time sensitive) - risk of procedure - nutritional status 5 | P a g e Osteoarthritis findings and diagnostics - ANSWER- - Pain in weight bearing joints - stiffness after sitting, gets better when arising - feeling of instability on stairs - fine motor skills deficit - larger affected joints - Heberden nodules (bony bumps on the finger joint closest to the fingernail) - Bouchard's nodules (bony bumps on the middle joint of the finger) - limited ROM with crepitus - xr shows narrowing of joint space (need anteroposterior and lateral knee films bilaterally) - synovial fluid is clear and without WBC Osteoarthritis treatment - ANSWER- Goal is to relieve symptoms, maintain/ improve function, and avoid drug toxicity Hand OA: - rest/ joint protection, with splinting - heat/ cold therapy - topical capsaicin - topical NSAID (trolamine salicylate) (especially for older than 75) - Oral NSAIDS, incl COX2 inhibitors such as celecoxib (Celebrex) (may cause cardiac problems) - tramadol - no opioids Hip/ knee OA: - weight reduction, cardiovascular exercises - transcutanous external nerve stimulator - acetaminophen 6 | P a g e - Topical NSAIDS (knee) - intraarticular corticosteroid injections - surgery (joint replacement) Rheumatoid arthritis: what, who - ANSWER- chronic, systemic autoimmune disease that causes inflammation of connective tissue, first that of jionts them other soft tissues (renal, cardiovascular, pulm). TNFalpha plays a big role - more women than men - unknown cause - Epstein Barr virus Rheumatoid arthritis: Findings and diagnostics - ANSWERS- - symmetric joint/ muscle pain, worse in the morning then gets better - weakness, fatigue - anorexia, weight loss - generalized malaise - swollen joints/ boggy feeling of joints with deformity of joints - warm, red skin on affected joints later: - pleural effusions and pulmonary nodules - inflammation of sclerea (scleritis) - pericarditis, myocarditis - splenomegaly (Felty's syndrome) - anemia (hypochromic, microcytic) with low ferritin - possibly: positive rheumatoid factor - XR: joint swelling, later cortical and space thinning - synovial fluid: yellow, thick with elevated WBC up to 100.000 Felty's syndrome - ANSWER- rheumatoid arthritis, splenomegaly, neutropenia 7 | P a g e Rheumatoid arthritis treatment - ANSWER- - early treatment better than stepwise - early referral rheumatologist - disease-modifying anti-rheumatic drugs (DMARDs): - methotrexate ( no alcohol, monitor renal and liver, give with folic acid) - cyclosporine - Gold preparations (can cause thrombocytopenia) - Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor) - sulfasalazine, moderate RA - Leflunomide, moderate to severe RA - Etanercept - monitor liver function with DMARDs - screen for TB (skin test) and Hep B - surgery: joint debridement, joint replacement Gout: what, who - ANSWER- Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean) - impaired renal function which causes excess uric acid - foods high in purine, such as dairy, red meat, shellfish, beer Gout findings, diagnostics - ANSWER- - acute painful joint, often great toe (warm, swollen) - pain at night - flank pain because of renal calculi - fever - leukocytosis - elevated erythrocyte sedimentation rate 10 | P a g e Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency Celebrex and Arthritis - ANSWER- Analgesic and anti-inflammatory Fewer ulcers than with other NSAIDS Not recommended in renal or liver failure Screen for sulfa allergy May cause cardiovascular thrombotic event May cause GI adverse event subluxation: what, cause - ANSWER- partial dislocation of a joint. Common sites: shoulder, elbow, wrist, hip, knee, patella, ankle, spine trauma, blunt force neuromuscular disease inflammatory joint disease, RA Loose ligaments 11 | P a g e Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital) Findings and diagnostics subluxation - ANSWER- Pain over affected area previous subluxation swelling around joints loss of ROM XR, CT, MRI show subluxation Increased WBC (stress response) Management of subluxation - ANSWER- Early reduction, many spontaneously immobilization (splint, sling) PT NSAIDS for pain/ swelling Dislocation: what, cause - ANSWER- Complete displacement of bone end and position in joint. Common sites: shoulder, elbow (nurse maid), wrist, hip, knee (emergency if loss of integrity of ACL and PCL), ankle/ foot high energy blunt force trauma congenital neuromuscular disorder inflammatory joint disease, RA Loose ligaments younger than 35 often, due to sports Often associated with fracture Findings and diagnostics dislocation - ANSWER- severe pain over affected area hx of mechanism of injury numbness/ tingling distal to injury joint deformity shortened limb 12 | P a g e contusion/ laceration over affected joint decreased pulses distal to joint decreased rom decreased sensation distally due to nerve damage WBC elevated due to stress Hgb may be low due to bruising xr: dislocation (should get anteroposterior) CT scan for pelvic trauma to rule out hip/ pelvic fracture Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury McMurray test, Lachman Test, straight leg test - ANSWER- McMurray: turn foot and bend knee. Positive with Meniscus injury Lachman test: Hold upper and lower leg, around knee, stretch. Hyperstretch: ACL injury Straight leg test: Pain when raising leg, while supine. Positive for herniated disk. Dislocation management - ANSWER- Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery. Postreduction immobilization (splint, cast, sling) surgical repair of ligaments PT/ OT NSAIDS Muscle relaxant for muscle spasms Narcotics for short term use Soft tissue injury: definition, classifications, incidence - ANSWER- Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, 15 | P a g e Type of fracture lines - ANSWER- Transverse Spiral Oblique Comminuted Logtitudinal butterfly segmental impacted Salter-Harris Fracture Classification - ANSWER- Concerns growth plate S: straight across growth plate A: Above growth plate L: BeLow growth plate T: Through growth plate R: ERaser of growth plate (Rammed) Cause of fractures - ANSWER- Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders Findings and diagnostics of fractures - ANSWER- Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling xr, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury 16 | P a g e Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle DEXA scan to determine degree of osteoporosis Acute Fractures Management - ANSWER- - ABC care (Airway, breathing, circulation), musculoskeletal second survey - fluid resuscitation - early reduction of fracture - cover open wounds - surgical irrigation and debridement for open fracture - Ab's: Cefazolin for gram pos. Clindamycin for tetani infection - pain: opioids - tetanus shot of unknown - calcium upon discharge for osteoporosis - cement injection in bone with vertrebroplasty Fractures: Reduction - ANSWER- - Orthopedic surgeon referral - buddy-tape toe fracture for immobilization - radius/ ulna: splint with ace-wrap, unless open - post reduction xr - check neurovascular function pre and post reduction - intramedullary rodding for closed femoral and tibial fracture - external fixation for open fracture Compartment syndrome: what, who - ANSWER- Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, nerves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen Men under age 35 stemming from fracture of tibia stemming from splint, cast, scar 17 | P a g e increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite Compartment syndrome finding and diagnostics - ANSWER- pain out of proportion to injury hx of trauma paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb Polar/ poikilothermia (ice cold limb) Elevated WBC Hyperkalemia (tissue necrosis) CPK and LDH elevated Myoglobin in urine Elevated compartment pressure (normal 0-8) Clinical diagnosis, MRI may confirm Acute renal failure (due to myoglobinuria) Compartment syndrome management - ANSWER- Non surgical: - limb at heart level (do not elevate) - remove bandages/ immobilizers - diuretic - neurovascular checks - CRRT/ dialysis to treat ARF - intracompartmental pressure monitoring Surgical: 20 | P a g e - possible straight leg raise test/ radiculopathy - limited rom spine - xr anteroposterior and lateral of spine - CT with and without dye: detects bony defects - MRI: detects soft tissue defects - myelogram - EMG (tests nerve innervation) Herniated disk L4 root finding (disk between L3 and L4) - ANSWER- - quadriceps weak, difficulty extending quadriceps (have pt squat and rise) - pain and numbness radiating into medial malleous - diminished/ absent knee jerk Herniated disk L5 root finding (disk between L4 and L5) - ANSWER- - dorsiflexion of great toe and foot weak (have pt walk on heels of feet) - pain and numbness into lateral calf and between first toe web space Herniated disk S1 root finding (disk between L5 and S1) - ANSWER- - weakness of plantar flexion of great toe and foot (have pt walk on toes) - pain along buttock, lateral leg and lateral aspect of foot and posterior calf - diminished achilles calf Herniated disk management - ANSWER- Non surgical: - functional bracing - rest - PT for muscle strengthening - heat/ ice alternate - weight loss - transcutaneous electrical nerve stimulator - NSAIDS 21 | P a g e - antispasmodic - Narcotics for short-term use - epidural steroid injection Surgical: - Laparoscopic diskectomy - hemilaminectomy - total disk replacement arthroplasty HIV and age - ANSWER- - Can live beyond 50 years, but survival decreases after 45 yrs, unless tested. - Antiretroviral meds are approved for younger than 50yrs, so older pt's need close monitoring HIV etiology - ANSWER- Africa/ Asia: heterosexually acquired Western nations: men who have sex with men, iv drug user, congenital spread Pathophysiology of HIV - ANSWER- - HIV infects cells with CD4 receptor (macrophages, Tcells). Acute infection (high viral load) then latent (lower viral load). When CD4 is less than 200 AIDS and viral load increases again, this immunodeficiency - HIV is chronic and prgressive: HIV - acute retroviral syndrome, symptoms - ANSWER- fever, chills fatigue diffuse erythematous rash HIV test may be negative, based on how long since infection HIV viral load increased, CD4 within normal range HIV - latent phase - ANSWER- - asymptomatic - may have persistent lymphadenopathy 22 | P a g e - HIV load and CD4 load variable (ultimately HIV load high, CD4 low) Symptomatic HIV disease - ANSWER- Symptoms: fever, chills, diarrhea, weight loss - infections: candidiasis/ thrush (oral, mucocutaneous, vaginal), shingles (herpes zoster), frequent bacterial infections AIDS, definition and diagnosis - ANSWER- acquired immune deficiency syndrome CD4 low, below 500 and infection with opportunistic organism Or: CD4 below 200 Common oppertunistic organism in AIDS - ANSWER- Pneumocystis jiroveci Cryptosporidium Candida albicans Advanced HIV infection: definition, symptoms, prognosis - ANSWER- CD4 below 50 Wasting, fevers, fatigue Poor HIV serologic testing - ANSWER- - ELISA: test for antibodies, requires seroconversion (neg to pos) which happens 3wks to 6mo after infection - Rapid test: fast but not as sensitive as ELISA - Confirmatory HIV test: Western blot test (HIV antibody test), used after pos with ELISA 25 | P a g e - Mycobacterium TB - Pneumocystis jiroveci pneumonia - CD4 less than 200 Giant cell arteritis, definition and etiology - ANSWER- Inflammation of the medium and large arteries, often temporal artery or aorta, represents polymyalgia rheumatica - adults older than 50 - more women than men - most will also have polymyalgia rheumatica - at risk for aortic aneurysm polymylagia rheumatica - ANSWER- Medical emergency because temporal arteritis can lead to blindness and aortic arteritis can cause aortic occlusion - pain, stiffness in shoulder and pelvic girdle region - malaise weight loss, fever - headache, jaw claudication, scalp tenderness, throat pain Giant cell arteritis findings - ANSWER- - headache - jaw pain - visual impairment - throat pain - arm claudication - difficulty talking - fever - enlarged and tender temporal artery - blindness CT: arterial narrowing WBC normal 26 | P a g e ESR elevated CRP elevated Gold standard: biopsy of affected artery Giant Cell arteritis treatment - ANSWER- Prednisone, do not wait for biopsy IV for 3 days when vision loss Oral for 6 wks to 2mo systemic lupus erythematosus (SLE) - ANSWER- Chronic, inflammatory, autoimmune disorder that affects multiple body systems, caused by trapping of antibodies in capillary and visceral structures, destructing host cells. Exacerbations/ remissions systemic lupus erythematosus (SLE), incidence - ANSWER- - druginduced; hydralazine, methyldopa, quinidine, chlorpramazine, isoniazid - triggers for malfunctioning of T and B cellsL sex hormones, UV radiation, infection, stress - mostly women - mostly African-American - familial risk systemic lupus erythematosus (SLE), findings - ANSWER- - joint symptoms without synovitis - fever, malaise, weight loss, anorexia - skin lesions - oral and nasal ulcers - ocular changes - HF; myovcarditis, pericarditis, cardiac arrhythmia's, htn - pleural effusions, pneumonia, pleurisy - CKD - abd pain 27 | P a g e - cognitive impairment, depression, stroke, seizures - serum antinuclear antibody present in all pt's but not specific - no specific diagnostic test - may be abnormal: anemia, leukopenia, thrombocytopenia, positive coombs, proteinuria, hematuria, false/ pos for syphilis systemic lupus erythematosus (SLE), treatment - ANSWER- - supportive, not curative - sunscreen (photosensitivity) - corticosteroid cream - NSAIDS for joint symptoms - Hydroxycloroquine, takes 6mo till effect is seen - Prednisone - hospital for worsening RF, or severe infections - Calcium and Vit D when on longterm corticosteroids - Warfarin to achieve INR for 2-3 Cytotoxic drugs for life-threatening manifestations (lupus nephritis) types of donors - ANSWER- Deceased: brain dead or non-heart beating Living: related (family), unrelated (friend), paired exchange, altruistic Contraindications to receive organs - ANSWER- - malignancy - infection - smoker, drugs - noncompliance - acquired immune deficiency syndrome - HIV - morbid obesity Immune response - ANSWER- - from B cells or T cells, that react and form antibodies 30 | P a g e Calcineurin inhibitors: which, indication, adverse effects - ANSWER- Tacrolimus Cyclosporine Prophylaxis of rejection T: tremor, renal dysfunction, hyperglycemia C: tremor, renal dysfunction, htn, hirsutism, gingival hyperplasia mTOR inhibitors: which, indication, adverse effects - ANSWER- Sirolimus Everolimus Prophylaxis of rejection S: edema, rash, hyperlipidemia, abd pain, nausea, diarrrhea, trombocytopenia, fever E: htn, edema, rash, hld, thrombicytopenia, hyperglycemia, elevated LFT's, fatigue, fever Corticosteroids: which, indication, adverse effects - ANSWER- Prednisone Solumedrol P: Prophylaxis of rejection S: Induction, treatment and prophylaxis of rejection Fluid retention, hyperglycemia, impaired wound healing, peptic ulcer Infections in organ recipients: general thoughts and types - ANSWER- - infections are leading cause of death - Increased risk 6 mo post transplant - fever and wbc count not as pronounced because of immunosuppressive meds 31 | P a g e Viral: CMV, cause of morbidity and rejection Requires frequent monitoring Prophylaxis with ganciclovir is recommended Fungal: Candida in post-liver, Aspergillus in post-lung Oral fluconazole for fungal prophylaxis or Trimethroprimsulfamethoxazole (bactrim) for pneumocystis prophylaxis Bacterial: Most common infections Intra-abd infections for liver, pancreas and intestinal transplant Pneumonia for heart and lung transplants UTI for renal and pancreas transplant organ recipient and vaccinations - ANSWER- - Should receive flu vaccine, but not live vaccine - Up to date on vaccines before transplantation - no live vaccines and avoid household members post live vaccine vaccination kidney transplantation, incidence and complications - ANSWER- ESRD, creat clear less than 15ml/min Surgical: Graft thrombosis, 2-3 days post-op. Thrombosis with loss of urine or hematuria. Diagnosis with renal us. Will cause graft loss. Urine leak: 32 | P a g e 2-3 days post-op from surgical technique or necrosis. Diagnosis with fluid aspiration: creatinine in fluid. Take back to surgery or foley/ nephrostomy tube. Lymphocele: lymphfluid around graft, can cause ureteral obstruction and compress iliac vein. Diagnosis with aspiration (protein containing fluid). Treat with perc aspiration. Bleeding Uretral obstruction: decline in graft function from blood clot, surgical technique, rejection, or infection. Diagnosis with renal us. Treat with nephrostomy tube, surgical correction Delayed graft function: May need dialysis and modification of immunosuppressive regimen Rejection Infection: UTI Liver transplantation, incidence and complications - ANSWER- Chronic hepatitis, alcoholic liver disease, hepatocellular carcinoma, ESLD Surgical: Hepatic Artery Thrombosis. Any time post transplant causing bile leaks, graft necrosis, abscess. Diagnosis with US or CT. Treat with thrombectomy, regrafting Portal vein thrombosis Portal htn and esophageal varices 35 | P a g e Will resolve spontaneously Sepsis Leading cause of death. Peritonitis Rejection Intestinal transplantation, incidence and complications - ANSWER- Necrotizing enterocolitis, Chrohn's, stenosis of small bowel Surgical: Bleeding Bowel obstruction Ascites Perforation Biliary leaks Hypermotility In early posttransplant phase. Give antidiarrheals and fiber. Rejection Infection Hepatitis - ANSWER- Inflammation of the liver, caused by Hep A, C, D, E as RNA and B as DNA Hepatitis A: what, etiology, findings, management - ANSWER- Viral Hepatitis Spread by fecal-oral route. Poor sanitation. 36 | P a g e -Pos Immunoglobulin IgM anti-HAV - first week of disease, disappears after 3 - 6 mo. So pos when infected in last 6mo. Neg: no infect in last 12mo - ALT AST elevated - Pos IgG anti-HAV. Means previous exposure and immunity. If neg: no infection. - Bedrest till jaundice resolves, no lifting - High caloric diet, small frequent meals. Low protein, no fatty foods, high carb - no alcohol - hospital for encephalopathy or coagulopathy - antiemetics Vaccine: Hep A for children 1 year and people increased risk Hepatitis B: what, etiology, findings, management - ANSWER- Viral hepatitis Bloodborne, saliva, semen, vaginal secretions, so transmitted through sex, drug use, piercing, tattoo, blood products - Pos Hep B surface antigen or Hep B core antigen, in acute infection - Total Hep core antigen can indicate past exposure - Hep B surface antibody after clearance of Hep B surface antigen or vaccination, which means: recovery, noninfectious, protection from current infection - pos Hep B e-antigen: acute or chronic infection - Hep B e-antibody means success from antiviral therapy (e-antigen has become e-antibody) - Treat if liver-related mortality risk in next 5-10yrs is high and chance of viral suppression high 37 | P a g e - Antiviral therapy: - Peginterferon alpha, weekly/ 48 wks (many side effects) - Entecavir, PO daily, renal adjustment - Tenofovir, PO daily Vaccination: Not live, in 3 doses Diagnose Hep A - ANSWER- Oral transmission Increased ALT over AST IgM (IgM anti HAV) Diagnose Hep B - ANSWER- Intravenous transmission Increased ALT over AST pos for the surface if vaccinated (IgM surface antigen) pos for the core and the surface if infection (Cor IgM antigen and IgM surface antigen) Diagnose Hep C - ANSWER- Intravenous transmission, tattoo's, razors, sex partners Increased ALT over AST Anti HCV Antibody HCV RNA Diagnose alcoholic liver failure - ANSWER- Alcohol use AST higher than ALT Diagnosis of exclusion Ischemic liver failure - ANSWER- AST and ALT very high (in the 1000) shock state Hepatitis C: what, etiology, findings, management - ANSWER- Viral 40 | P a g e Diagnose autoimmune hepatitis - ANSWER- Young women ALT higher than AST Will have anti smooth muscle antibody nonalcoholic steatohepatitis (NASH): what, etiology, findings, management - ANSWER- Nonalcoholic fatty liver disease. Hepatic fat with inflammation without causes such as alcoholism or medication. No fibrosis (scarring of liver which can lead to cirrhosis). Obesity, DM, dyslipidemia risk factors Serum aminotransferase and CT/ MRI for initial screening Liver biopsy: hepatic inflammation or fibrosis? - Lifestyle changes: weight loss, exercises - Medications: Vit E (for non DM) - Bariatric surgery - May require transplant, if liver cirrhosis Diagnose NASH - ANSWER- Obese people! ALT higher than AST Diagnosis of exclusion NAFLD (non-alcoholic fatty liver disease) fibrosis score - ANSWER- less than 1.455: no fibrosis greater than 0.676: advanced fibrosis Primary biliary cirrhosis: what, etiology, findings, management - ANSWER- Autoimmune disease From environment and genetics 41 | P a g e LFT's up Immunoglobulins present Pos Antimitochondrial antibodies Hyperbilirubinemia Ursodiol May require liver transplant Diagnosing primary biliary cirrhosis - ANSWER- Common in middle aged women, causes fatigue and itching. Tired, itching woman Positive anti mitochondrial antibodies (liver biopsy) Alk phos elevated Portal granumolas (intrahepatic biliary ducts destruction) Increased cholesterol Bilirubin up late in disease Diagnosing Primary sclerosing cholangitis - ANSWER- Intra en extra hepatic flow is blocked. Associated with ulcerative colitis Fibrosis of biliary duct seen on cholangiography) Alk Phos elevated Total bili elevated Primary sclerosing cholangitis: what, etiology, findings, management - ANSWER- Chronic cholestatic (bileflow from liver is blocked) liver disease: inflammation and fibrosis of bile ducts in and out of liver, bile strictures. Often leads to cirrhosis. Often asymptomatic 42 | P a g e Often also have Crohn's or ulcerative colitis Gold standard: endoscopic cholangiopancreatography or MRI Open biliary obstruction with endoscopy May need liver transplant Hereditary Hemochromatosis: what, etiology, findings, management - ANSWER- Inappropriate absorption of dietary iron, that can lead to cirrhosis, hepatocellular ca, diabetes, heart disease Caucasian/ Northern European/ Celtic Elevated iron ferritin Hemochromatosis gene detection Iron overload? Then phlebotomy with goal of ferritin 50 - 100 No Vit C and iron No dietary restrictions Family screening Diagnose hemochromatosis - ANSWER- Men (women don't store iron because they have periods) ALT and AST equally elevated Ferritin level will be very high Bronze diabetes: pituitary problems, CHF, diabetes (diabetes with a bronze look) diagnose wilson's disease - ANSWER- Young, movement disorder and psychiatric disease. Kayser-Fleisher rings in eyes Increased ALT and AST Low cerumplasmin (copper sucked up) 45 | P a g e HELLP syndrome: what, signs, treatment - ANSWER- hemolysis, elevated liver enzymes, low platelets Triad: jaundice, coagulopathy, low platelets Steatosis (fatty liver) Intrahepatic hemorrhage Deliver baby Scoring systems for acute liver failure - ANSWER- King's College Criteria: indicator for poor prognosis - Acetaminophen induced considered for transplant if: PH less than 7.3, encephalopatic, INR greater than 6.5, creat greater than 3.4 - Non acetaminophen: liver transplant if INR greater than 6.5, encephalopathy, younger than 10 or older than 40, jaundice, bilirubin high, unfavorable etiology (Wilson's). Model for End-Stage Liver Disease (MELD): to determine severity of liver disease, based on bilirubin, INR, and creat. Complications from liver disease with treatment - ANSWER- - Cardiac: portal HTN, arrythmia's, edema - Dermatologic: jaundice, pruritis. Cholestyramine or Colestipol for pruritis - Fluid/ electrolytes: ascites, hypokalemia, hyponatremia, hypernatremia, hypoglycemia. D10 for hypoglycemia. Water restriction for hyponatremia. Replace K. 46 | P a g e Low sodium diet, fluid restriction, and diuretics, potential paracentesis (give albumin) for ascites. Give Bicarb for severe acidosis. - GI: GI bleeding, abd pain, varices, n/v - Neuro: hepatic encephalopathy. Give lactulose. Limit protein. Rifaximin BID if no lactulose tolerated. - Resp: Hyperventilation, hypoxemia Mech ventilation possible. - Renal: RF, oliguria, hyponatremia, hypotension. May need dialysis. Liver disease labs - ANSWER- - elevated bili - decreased albumin - prolonged PT. Give Vit K subq for PT greater than 14 and INR greater than 2 - ALT and AST elevated - ammonia elevated Liver labs - ANSWER- Cytotoxic: AST (made in liver): marker for hepatic inflammation. Low specificity for the liver. Will go up in recent liver injury. Does not indicate liver function. ALT: marker for hepatic inflammation. High specificity fir the liver. Will go up in recent liver injury. Does not indicate liver function. Albumin (made in liver): low means chronic liver injury 47 | P a g e PT: prothrombin time. Reliable and most sensitive for acute and chronic liver disease. Clotting time. INR will be elevated (PT usually tenfold). Low Vit K and coumadin can also increase prothrombin time. Cholecystitis: what, etiology - ANSWER- Inflammation of galbladder, acute or chronic. Often with gallstones (cholelithiasis). - Gallstones: obstruct cystic duct which causes inflammation behind it. From cholesterol. - Acalculous cholecystitis: rare. With unexplained fever or after multiple trauma and poor oral intake -bacteria - cancer - risk factors: obesity, pregnanvy, sedentary lifestyle, low fiber diet, female, older age, high cholesterol mild: no organ dysfunction moderate: leukocytosis, complaints longer than 72 hours, local inflammation Severe: organ dysfunction Cholecystitis: findings/ diagnostics - ANSWER- - asymptomatic, devloping into bloating/ abd pain - biliary colic: intense epigastric pain radiating to shoulder/ back - N/V - anorexia - elevated temp - pos Murphy's (pain on inspiration with fingers under right rib cage) - palbable galbladder - jaundice - right upper quadrant pain, fever, leukocytosis, guarding with severe inflammation 50 | P a g e 100 ml/hr - May need plasma, RBC, albumin - Pain control - Morphine, Fentanyl - AB's, not prophylactically, only when septic or biliary stones. - NPO, then supplements, small frequent meals - NG for ileus or vomiting - replace electrolytes - enteral feeding Scoring Pancreatitis Prognosis - ANSWER- - Ranson Criteria: fewer than 3 risk factors, low risk for mortality. More thna seven: 100%. (older age, WC, hyperglycemia, LDH, AST, Hct, BUN, Calcium, PaO2) - Apache - BISAP (BUN, mental status, older age, SIRS, pleural effusion) Small bowel obstruction: what, etiology - ANSWER- Blockage of intestine, with fluid losses into gut. Intestine next to obstruction fills with gas and fluid which is not absorbed and causes distention. That causes vomiting and fluid/ electrolyte loss. Which triggers intestine to release even more fluid and cause distention. Ischemia can occur as a result (diminished blood flow to the intestine). - Adhesions - Hernia's - Volvulus - twisting of bowel on itself - strictures: crohn's, radiation, ischemia - Intussusception - impaction - foreign body Small bowel obstruction: findings/ diagnostics - ANSWER- - periumbilical cramping 51 | P a g e - upper abd pain with profuse vomiting: high bowel obstruction - cramping, periumbilical pain with episodic pain: middle bowel obstruction - Constipation - High pitched tinkling bowel sounds, first. Then absent. - Dehydration signs - leukocytosis - Elevated Hgb and Hct - metabolic acidosis - electrolyte imbalances - supine and upright abd xr: air-fluid levels ladderlike, free air reqiures immediate surgery - US abd: dilated loops of bowel filled with fluids. Specific but not often used. - Can use barium but CT better (also better than xr) Small bowel obstruction: management - ANSWER- - NPO - Fluid and electrolyte replacement - NG to LIS - bld. cult, CBC, CMP, ABG, lactate - AB's for suspicion of perforation - surgery for complete obstruction or partial that doesn't improve Large bowel obstruction: what, etiology - ANSWER- Blockage in large bowel that prevents food from passing through which causes blood supply cut off which can cause a leak and bacteria being spread into body or blood - Cancer - Abd surgery - Abd radiation 52 | P a g e Large bowel obstruction: findings/ diagnostics - ANSWER- - Abd distention - N/V - Crampy abd pain - abrupt inset symptoms - chronic constipation - guarding and rigidity on abd exam - xr chest upright: free air means perforation and ileus rather than obstruction - CT abd: test of choice. Can distinguish between complete and partial obstruction, ileus, and small bowel Large bowel obstruction: management - ANSWER- Fluid resuscitation AB's NG for vomiting Surgery. Surgical emergency for closed loop obstruction, bowel ischemia, volvulus Mesenteric ischemia: what, etiology - ANSWER- Not enough O2 and nutrients to intestine, due to thrombus or no physical occlusion - Acute arterial occlusion, from embolism or thrombus (older than 60) - mesenteric venous thrombosis (younger than 50) - Non-occlusiev (CHF, aortic stenosis, shock) Mesenteric ischemia: findings/ diagnostics - ANSWER- - severe cramping and abd pain - possible rectal bleeding - Hypotension/ abd distention with infarction 55 | P a g e - low Hgb, though not clear representation - Blood transfusion: RBC and plasma and vit K for elevated INR. platelets for low platelets. - check ECG to make sure not arrhythmic due to anemia - endoscopy: diagnostic and therapeutic - IV PPI (protonix) - surgery of two endoscopy's have failed - TIPS (stent) - AB prophylaxis Lower GI bleed: what, etiology - ANSWER- Bleeding in small intestine or colon - NG - rules out UGI - anemia - fecal occult blood test - sigmoidscopy/ colonoscopy Lower GI bleed: management - ANSWER- -Resuscitate - diveri culosis - cancer - IBD - loss anorectal blood - ischemic colitis Lower GI bleed: f indings/ diagnostic s - ANSWER - - Hematochezia ) ( blood from anus - mele na - pallor - shock - hypotension 56 | P a g e hemodynamically unstable: blood transfusion - dc aspirin and NSAIDS - IV cont PPI (Protonix) Peptic ulcer disease: what, types, etiology, risk factors - ANSWER- Chronic disorder with lifelong tendency to develop mucosal ulcers at sites exposed to peptic juice (acid and pepsin). Gastric ulcer: loss of surface epithelium. - Duodenal ulcers: most common, Peak incidence: 30-35yrs, in first portion of duodenum - Gastric ulcerss: in lesser curvature of stomach. From NSAID and aspirin use. More likely than duodenal when using NSAID. Peak incidence: 55-70yrs. H. Pylori present in most duodenal ulcers. Imbalance between protective factors (mucosal barrier, blood supply, meds, competent sphincter) and aggressive factor (H.pylori, gastric acid, pepsin, bile, meds (NSAIDS/ aspirin). - smoking - NSAID - CMV - Crohn's - alcohol - corticosteroids - stress - spices - caffeine Findings/ diagnostics for duodenal and gastric ulcers - ANSWER- Duodenal ulcers: 57 | P a g e Epigastric (midline/ right midline) pain 1-3hrs after eating, nocturnal pain. Relieved by food ingestion. Gastric ulcers: Epigastric pain periodic and rhythmic. Not relieved by food. Food may precipitate symptoms. Nausea. Epigastric pain to palpation. Midline or left of midline. Boardlike abdomen and rebound with perforation. Hematesis or melena with bleeding ulcers. - H. Pylori testing - CBC: anemia? - Leukocytosis: perforation or penetration - elevated amylase: penetration into pancreas - Upper GI barium studies: after 8-12wks for established ulcer to distinguish benign from malignant - Endoscopy: Procedure of choice for diagnosis of duodenal and gastric ulcer. Can stop bleeding ulcer, can detect H. Pylori, and inflammatory disorders, and can perform electrocautery H. Pylori testing - ANSWER- Detection of H. Pylori: - Endoscopic biopsy (gold standard) - urea breath test (pos is H. Pylori) - PPI can cause false negative - serum H. Pylori antibody test (can also mean previous infection) - fecal antigen H. Pylori (can assess if treatment was successful) Complications of PUD - ANSWER- - GI bleeding Symptoms: hematesis, melena, coffee ground hematesis, pallor, tachy, hypotension, low Hct, BUN up Perform endoscopy 60 | P a g e Dysphagia Belching Pneumonia, chest pain, cough, hoarse, sore throat -Clinical history -24-hr ambulatory PH monitoring (most specific and sensitive): gold standard. Electrode PH probe aboev LES -Barium swallow test (as screening tool and rule out inflammation, ulcers, and strictures) -Endoscopy (for diagnosis and possible biopsy and dilation of stricture) - Bernstein test (infusion of acid and ns) GERD management - ANSWER- Phase 1: Elevate head No exercise before bed No large meals before bed Avoid chocolate, fats, alcohol, mint, spicy, citrus, coffee, tomato juice Reduce weight Stop smoking Avoid aggravating meds Use antacids PRN (after meals and bedtime) and over the counter H2 blocker (ranitidine/ famotidine) for 8 - 10 wks Phase 2: Continue phase 1. weight loss No supine No eating before bed Phase 3 (start after 2 -4 wks of other phases and no improvement): Increase dose of initial drug Start longterm daily PPI 61 | P a g e If worse: add lifestyle changes then add drug If better: remove drug Phase 4: surgery (reflux related pulm disease, ulcerative esophagitis, esophageal strictures, hiatal herna) Diverticulitis: what and etiology - ANSWER- Perforation of colonic diverticulum (micro or macro with peritonitis) Common in people older than 50yrs (50%) Low fiber diet Diverticulitis findings and diagnostics - ANSWER- Lower left quadrant pain Fever constipation and diarrhea abd pain, guarding, spasms, rebound tenderness, n/v hypoactive bowelsounds dysuria/ frequency Leukocytosis elevated procalcitonin CT abdomen (diagnose and rule out fistula) Barium enema may reveal strictures or fistulas Flexible sigmoidoscopy should be avoided in acute phase Diverticulitis Treatment - ANSWER- Outpt: oral AB (Cipro or amoxicillin) clear liquids for 2-3 days Inpt: IV ab (cipro and flagyl) (ceftriax and flagyl) (zosyn) 62 | P a g e Bowel rest NG for ileus Surgery if failure to respons to tx or free air, abscess, obstruction, peritonitis Ulcerative colitis: what - ANSWER- Idioptahic inflammatory disease causing bleeding and erosions of colonic mucosa An IBD Ulcerative colitis: findings and diagnostics - ANSWER- hallmark sign: bloody diarrhea fecal urgency abd cramping Leukocytosis anemia hypokalemia 65 | P a g e fever anemia xr abd to detect megacolon ab's (cover gram - and aneorobes) NG surgery within 72hrs if failing to respond to tx Crohn's Disease - ANSWER- Inflammation and ulceration, stricturing, fistula, abscess across entire colon. May cause chronic inflammation, intestinal obstruction, fistula, abscess. At greater risk for developing colon ca, lymphoma, and small bowel adenoca. IBD Crohn's treatment - drugs - ANSWER- Drugs: - Mesalamine 2.4 - 4.8gr/ day - Corticosteroids for active disease (prednisone/ methylprednisone, long course and taper - Immunomodulating drugs: azathioprine, methrotrexate if no response to corticosteroid - Anti-tumor necrosis factor therapy: infliximab, certolizumab for refractory Crohn's treatment - ANSWER- Mild/ moderate: First line: oral mesalamine or Pentasa If not responding: Flagyl May give Cipro May give oral budesonide as first line Moderate/ severe: 66 | P a g e Corticosteroid (prednisone 40 - 60mg) until symptoms resolve Anti TNF therapy: infliximab if refractory to corticosteroid Severe/ sudden: Surgery if no response to oral corticosteroid and anti TNF therapy and suspicion for mass, obstruction, abscess. IV corticosteroids IV cyclosporine/ methotrexate (immunomodulator) Maintenance: no corticosteroid Azathioprine (2-3mg/kg/day) or inflixinab (immunomodulator and anti TNF monocloiinal antibody) Diet: well-balanced, may need supplemental enteral therapy during active disease IBD drugs: - ANSWER- Aminosalicylates: Sulfasalazine, non sulfa: mesalamine. For induction and maintenance of remission. May cause N/V and folate malabsorption. Give folate! Corticosteroids: Prednisone, Budesonide, Methylprednisone Suppress acute flares, no maintenance May cause N/V, gastritis, adrenal suppression, osteoporosis Immunomodulators : 6-mercaptopurine, Azathioprine, Methotrexate, Cyclosporine, Tacromilus For maintenance, steroid sparing effect May cause pancreatitis, bone marrow suppression, hepatotoxicity 67 | P a g e Anti TNF Monoclonal antibodies Infliximab, certolizumab Only for Crohn's. May cause infusion related reactions: fever, pruritis, chest pain, hypotension, htn, infections/ sepsis. Expensive! Peritonitis: what and etiology - ANSWER- Acute inflammation of peritoneum Primary: spontaneous bacterial peritonitis of ascitic fluid as complication of cirrhotic ascites. Secondary: peritonitis with cause that can be operated on, such as infection, abdominal trauma, perforation from appendicitis, colitis, PUD, diverticulitis, pancreatitis, cholecystitis. Peritonitis findings and diagnostics - ANSWER- Primary: fever and abd pain with mental status change due to hepatic encephalopathy Secondary: acute abd pain fever n/v constipation abd distention, rebound tenderness, rigidity, decreased bowel sounds, hyper resonance on percussion ascites dyspnea/ tachypnea dehydration Primary diagnostics: