NRNP 6560 Midterm exam Updated 2022-2023, Exams of Nursing

Download NRNP 6560 Midterm exam Updated 2022-2023 and more Exams Nursing in PDF only on Docsity! NRNP 6560 Midterm exam Surgery risk classes Correct answer- 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 Correct answer- 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 Correct answer- - 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 Correct 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 - immune competence - determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) Low risk surgeries Correct answer- catarcts breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk surgeries Correct answer- Head/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystecto my nephrectomy non majot intrathoracic High risk surgeries Correct answer- aortic/ cabg transplants spinal reconstruction peripheral vascular surgery Lee's revised cardiac risk index Correct answer- 6 points: High risk surgery = 1 CAD = 1 CHF = 1 Cerebrovascular disease = 1 DM 1 on insulin = 1 Creat greater than 2 = 1 1 = low risk 2 = moderate risk 3 = high risk SCIP pre-operative infection measures Correct answer- - Prophylactic antibiotics should be received within 1 h prior to surgical incision - be selected for activity against the most probable antimicrobial contaminants - be discontinued within 24 h after the surgery end-time Postoperative infection reduction methods Correct answer- - pre-op hair removal (clippers) - wash hands - normothermia - maintain euglycemia - urinary catheters are to be removed within the first two postoperative days Osteoarthritis: what, incidence Correct answer- Slow destruction of bones/ joint followed by production of replacement collagen which causes inflammatory changes Correct 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 Correct answer- - acute painful joint, often great toe (warm, swollen) - pain at night - flank pain because of renal calculi - fever - leukocytosis - elevated erythrocyte sedimentation rate - tophi (bump under skin) on ear - limited joint motion - elevated serum uric acid (greater than 7mg/dl) - urate crystals seen with joint aspiration - xr: joint erosion and renal stones Gout treatment Correct answer- - NSAIDS: naproxen, ondomethacin, sulindac - Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis - Corticosteroids, if NSAIDS and colchicine not tolerated - 24hr urine for uric acid - Allopurinol after flare is over (100mg PO daily) - Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid ANA. Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- Antinuclear antibody (ANA). Normal: Titer 1.32 POsitive with: Sjogren's (SS), SLE (lupus), C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- Determines hemolytic activity which speaks to level of inflammatory response Normal: men: 12-72. Women: 13-75 mg/dl Increased with: inflammatory disease Decreased with: RA, lupus, SS The radioallergosorbent test (RAST). Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- measures presence/ increase antigen IgE normal: 0.01 - 0.04 mg/dl Increased with allergic reaction Erythrocyte sedimentation rate (ESR). Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- rate at which RBC settle out of unclotted blood in 1 hr Normal: men: 0-7mm/hr, women: 0 - 25 mm/hr Increased with inflammation CRP. Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- C-reactive protein, a non- specific antigen antibody Normal: trace to 6mg/ml Increased with infection and inflammation, RA. Decreased with succesfull RA treatment RF. Tests in rheumatic disease: what, normal level, abnormal with. Correct answer- Rheumatoid factor. antibody against IgG. Positive RF in most people with RA Corticosteroids and arthritis: what does it do and adverse effects Correct answer- Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections NSAIDS and arthritis: what and adverse effects Correct answer- analgesic and anti-inflammatory give PPI concurrently to prevent GI complication Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency Celebrex and Arthritis Correct 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 Correct 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 McMurray test, Lachman Test, straight leg test Correct 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 Correct 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 Correct answer- Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, cartilage, skin Classification: - Closed injury: contusion, hematoma, crush, strain (muscle), sprain (ligament, first to third degree), rupture (muscle and ligaments: instability, inability to move) - Open injury: laceration, abrasion, penetrating/ puncture, amputations trauma exercise/ overuse autoimmune (RA, SLE) obesity age (skin tear elderly) Findings and diagnostics soft tissue injury Correct answer- pain swelling feeling of instability of joint Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding Bursa: swelling with boggy feeling, erythema over bursa, decreased ROM Skin: abrasion, laceration, puncture Soft tissue injury findings and diagnostics Correct answer- WBC increased, especially with bursitis Hgb decreased with massive hematoma Synovial fluid aspiration: WBC with inflammation, RBC with bleeding into joint, crystals with gout Xr will reveal swelling MRI (knee/ shoulder) location and degree of injury Soft tissue injury management Correct answer- PRICE (protection, rest, ice, compression, elevation) possible immobilization surgery, if rupture, grade III ligaments sprain, septic bursa, wound closure PT NSAIDS Muscle relaxant Opioids - short term Broad spectrum ab's (cephalexin, cefazolin) Fracture Classification - Gustillo Correct answer- - Closed - Open: Type 1: wound smaller than 1cm Type 2: wound larger than 1cm, moderate contamination Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury - Incomplete or complete - stress - traumatic/ pathologic - displaced/ non-displaced Type of fracture lines Correct answer- Transverse Spiral Oblique Comminut ed Logtitudina l butterfly segmental impacted - amputation if septic from necrotic tissue Restorative: - functional splinting - ROM - early prostethic fitting post amputation Low back pain - four major syndromes Correct answer- 1. Back strain 2. Disk herniation 3. Osteoarthritis/ disk degenration; osteophyte (bone spur) 4. Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment Specific findings for back pain Correct answer- - numbness - saddle anesthesia (CA, mass) - bowel, bladder dysfunction (emergency surgery) - pain worse at rest (CA, tumor, infection) - Discitis, epidural abcess (IV drug use) - Decreased rom - Radiculopathy (pain down leg), not with OA - Crossover straight leg test: herniated disk - back, buttock, leg pain when ambulating (neurogenic claudication with spinal stenosis). Also positive straight leg raise test with spinal stenosis xr anteroposterior, to rule out scoliosis, bone spur MRI for soft tissue structure, bulging disk CT for bony imaging Cauda Equina Syndrome Correct answer- Spinal cord compression from metastatic lesion to spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/ bladder incontinence, diminished sensation in legs: saddle. Surgical emergency! Low back pain management Correct answer- Nonsurgical: - rest - ice/ heat (alternate) - NSAIDS - antispasmodics (diazepam, flexeril) - opioid short-term, to promote mobility - anticonvulsants and antidepressants for neuropathic pain - PT - weight loss - epidural steroid injection Surgical: - Foraminotomy or diskectomy - spinal fusion Herniated disk: what, who Correct answer- Bulging or protrusion of nucleus through a defect in the annulus of spine, may cause nerve entrapment - Trauma - Obesity/ sedentary lifestyle - Age 35 - 45 - Often located at L4- L5, L5 - S1 Herniated disk findings and diagnostics Correct answer- - Decreased/ absent reflexes - Atrophy of muscles - limp - 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) Correct 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) Correct 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) Correct 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 Correct answer- Non surgical: - functional bracing - rest - PT for muscle strengthening - heat/ ice alternate - weight loss - transcutaneous electrical nerve stimulator - NSAIDS - antispasmodic - Narcotics for short-term use - epidural steroid injection Surgical: - Laparoscopic diskectomy - Pneumocystis jiroveci (sudden rapid decline CD4): Trimethoprim- sulfamethoxazole neb. Stop if CD4 above 300 - Toxoplasmosis: when CD4 less than 100. Trimethoprim- sulfamethoxazole plus pyrimethamine. Dc if CD4 above 200. - Mycobacterium avium. Cd4 below 50. Zithromax or clarithromycin Recommended vaccines for HIV Correct answer- - Hep B, if Hep B antigen neg - Inactivated flu vaccine (assess viral load and do not give live vaccine) - Hep A, liver disease risk, iv drug use, MSM - Pneumococcal vaccine - Tdap (instead of Td) - Varcella Zoster for elderly Test for HIV with following infections Correct answer- - candidiasis of esophagus/ trachea/ bronchi/ lungs - extrapulm cryptococcus - invasive cervical ca - cryptosporidiosis with diarrhea - CMV - Herpes simplex lasting longer than 1mo - Lymphoma brain, in younger than 60 - Kaposi sarcoma, younger than 60 - Mycobacterium TB - Pneumocystis jiroveci pneumonia - CD4 less than 200 Giant cell arteritis, definition and etiology Correct 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 Correct 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 Correct answer- - headache - jaw pain - visual impairment - throat pain - arm claudication - difficulty talking - fever - enlarged and tender temporal artery - blindness CT: arterial narrowing WBC normal ESR elevated CRP elevated Gold standard: biopsy of affected artery Giant Cell arteritis treatment Correct answer- Prednisone, do not wait for biopsy IV for 3 days when vision loss Oral for 6 wks to 2mo systemic lupus erythematosus (SLE) Correct 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 Correct answer- - drug- induced; 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 Correct 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 - 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 Correct 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 Correct answer- Deceased: brain dead or non- heart beating Living: related (family), unrelated (friend), paired exchange, altruistic Contraindications to receive organs Correct answer- - malignancy - infection - smoker, drugs - noncompliance - acquired immune deficiency syndrome - HIV - morbid obesity Immune response Correct answer- - from B cells or T cells, that react and form antibodies - Human leukocyte antigens (HLA) recognize self and non-self. Panel reactive antibody (PRA) measures preformed HLA and indicates a good match when elevated. Crossmatching required before kidney, but post heart, lung, liver, pancreas transplant Organ rejection, types, Correct answer- Allograft rejection: recipient's immune system recognizes graft as non-self and causes local and systemic immune response Hyperacute: within minutes, rapid tissue necrosis Accelerated acute: 1-5 days post op, difficult to treat Acute: within first few months, can be treated mostly chronic: occurs slowly and leads to eventual graft loss, no treatment Organ rejection diagnosis, treatment Correct answer- Diagnosis gold standard: biopsy of graft. Symptoms mostly failure of the organ (renal failure, liver failure, pulm effusions/ infiltrate, etc. Also, graft tenderness) Treatment: high dose corticosteroids, optimizing immunosuppressant regimen, antilymphocytic therapy immunosuppression: what and general considerations Correct answer- Pharmacological manipulation of immune system to prevent/ suppress E: htn, edema, rash, hld, thrombicytopenia, hyperglycemia, elevated LFT's, fatigue, fever Corticosteroids: which, indication, adverse effects Correct 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 Correct answer- - infections are leading cause of death - Increased risk 6 mo post transplant - fever and wbc count not as pronounced because of immunosuppressive meds 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 Trimethroprim-sulfamethoxazole (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 Correct 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 Correct 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: 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 Correct 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 Biliary leaks treat with perc or surgical drainage Graft dysfunction Primary: within first week Elevated LFT, acidosis, encephalopathy. Poor prognosis Rejection Infection Biliary cast syndrome (bile duct strictyure and clogging) Recurrence of disease Lung transplantation, incidence and complications Correct answer- Pulm HTN, CF, COPD, sarcoidosis. When life expectancy is 24-36mo. Surgical: Bronchial anastomotic complications: ischemia and necrosis of anastomosis. Place stent with bronch. Bleeding Ischemia/ reperfusion therapy 72 hrs post op. Major cause of death. Causes alveolar damage, pulm edema, hypoexemia. Place on vent. Sepsis Bronchiolitis obliterans syndrome From chronic rejection causing exertional dysonea and cough with decreased FEV1. Treat with high-dose corticosteroid. Rejection. Heart transplantation, incidence and complications Correct answer- cardiomyopathy, cardiac tumor, congenital heart defect, valvular disease Bleeding Rejection Cardiac allograft vasculopathy Leading cause of death. Accelerated form of CAD causing HF, ventricular arrythmia's, death. Denervation altered response to drugs, little response to digoxin and atropine Pancreas transplantation, incidence and complications Correct answer- Diabetes Mellitus 1 Surgical: Anastomotic leaks. Within first few mo. Abd pain and increased amylase. Surgical correction. Bleeding Causing hematuria, cystitis, urethritis, urine leak, metabolic acidosis, intra- abd abscess Pancreatitis 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 - 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 Correct answer- Oral transmission Increased ALT over AST IgM (IgM anti HAV) Diagnose Hep B Correct 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 Correct answer- Intravenous transmission, tattoo's, razors, sex partners Increased ALT over AST Anti HCV Antibody HCV RNA Diagnose alcoholic liver failure Correct answer- Alcohol use AST higher than ALT Diagnosis of exclusion Ischemic liver failure Correct answer- AST and ALT very high (in the 1000) shock state Hepatitis C: what, etiology, findings, management Correct answer- Viral Hepatitis Blood-borne. Small risk for sexual or perinatal transmission. Common, but often asymptomatic. May develop cirrhosis, which can lead to liver transplant. - Pos Anti HCV antibody. Very sensitive.If neg, then unlikely. - Pos Recombinant immunoblot assay: gold standard to confirm HCV infection. Detects virus not antibodies. - Chronic infection: Peginterferon and ribavirin. Give for 48wks. 28 wks for genotype 2 and 3. Add Boceprevir for genotype 1. Vaccination: no vaccination. Screen one time based on age, born between '45 and '65 Hepatitis D Correct answer- RNA virus that can only cause infection with Hep B Prevented with Hep B vaccin Hepatitis E: what, etiology, findings, management Correct answer- acute infection, no chronic ingestion from fecal matter, poor sanitation Like HAV Mortality higher in pregnant women No vaccin Hepatitis G Correct answer- Common in drug users, transmitted percutanously Viral hepatitis risk factors Correct answer- Health care providers hemodialysis blood products IV drug use sex men with men underdeveloped countries piercing/ tattoo Viral Hepatitis Symptoms/ diagnostics Correct answer- - Prodromal phase: malaise, arthralgia, upper resp symptoms, anorexia, n/v, diarrhea/ constipation, skin rashes, aversion to smoking (HBV), mild upper quadrant abd pain - Icteric phase: jaundice, no icterus, dark urine Physical: tender hepatomegaly, splenomegaly, cervical lymphadenopathy, rash (HBV), arthritis Diagnostics: WBC wnl or low Hereditary Hemochromatosis: what, etiology, findings, management Correct 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 Correct 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 Correct answer- Young, movement disorder and psychiatric disease. Kayser-Fleisher rings in eyes Increased ALT and AST Low cerumplasmin (copper sucked up) Diagnose alpha1 -antitrypsin deficiency Correct answer- COPD (later in life, while early smoker), asthma Pas + granules in liver alpha1 antitrypsin level pos Alcoholic liver disease: etiology, findings, management Correct answer- Most common cause of cirrhosis Women twice as sensitive to alcohol toxicity then men Binge drinking High mortality rate Diagnosis on report of alcohol intake, evidence of liver disease, lab abnormalities AST and ALT often high than 2 Score for mortality: Maddreys' score - Abstinence - MDF score greater than 32: prednisone for 4 wks - May require liver transplant Wilson's: what, etiology, findings, management Correct answer- Familial autosomal recessive disease with neurological symptoms, by chronic liver disease, leading to cirrhosis. can be lethal. Caused by a lack of a certain gene that causes diminished excretion of copper into bile. Thus copper injury. Any pt between 3 and 55 with liver disease without clear cause. Abnormal aminotransferase Ceruloplasmin low (less than 50) 24-hr uriary copper: copper greater than 40. Liver biopsy to measure copper high bilirubin to alkaline phosphatase ratio greater than 2 D-penicillamine, initial ansd maintenance Zinc, blocks absorption of copper Avoid food and water with copper May need liver transplant when cirrhosis is present Family screening Fulminant liver failure/ acute liver failure: what, etiology Correct answer- - sudden impairment of liver cell function - Hep A, B, C, D, E - CMV, Epstein-Barr - drug-induced (Tylenol) - Toxins (mushrooms) - Vascular (heat stroke) - other liver disorders Acute liver failure: findings, management Correct answer- Weakness, fatigue weightloss, n/v, abd pain Change in bowel pattern - Check BMP, ABG, lactate, toxicology screen, acetaminophen screen, Hep panel, PT/ INR - Treat specific etiology: charcoal for acetaminophen and N- acetylcysteine) Supportive for Hep A and E Antiviral for Hep B Test for Wilson - ICU management: watch for cerebral edema, hyperventilate if present, mannitol. CT head for encephalopathy HELLP syndrome: what, signs, treatment Correct 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 Correct 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 Correct 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. 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 Correct 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 - Bili elevated - Hypocalcemia if severe disease - Low albumin - xr abdomen: ileus, pancreatic calcifications, gallstones - CT abdomen preferred over US, and MRI over CT Acute pancreatitis management Correct answer- - IV hydration - Fluid therapy to prevent hypovolemia and shock: LR or NS with 20 K at 75- 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 Correct 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 Correct 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 Correct answer- - periumbilical cramping - 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 Correct 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 Correct 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 Large bowel obstruction: findings/ diagnostics Correct 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 Correct answer- Fluid resuscitation AB's NG for vomiting Surgery. Surgical emergency for closed loop obstruction, bowel ischemia, volvulus Mesenteric ischemia: what, etiology Correct 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 Correct answer- - severe cramping and abd pain - possible rectal bleeding - Hypotension/ abd distention with infarction Prevention of re-bleeding: - Follow up endoscopy (screening endoscopy when cirrhosis) - TIPS (stent) Upper GI bleed: what, etiology Correct answer- Bleed between upper esophagus and duodenum Peptic ulcer disease esophageal varices Cancer Upper GI bleed: findings/ diagnostics Correct answer- - Abd pain - Hematemesis - melena - Hypovolemic shock - pale - bloody NG aspirate - 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 Correct answer- Bleeding in small intestine or colon - divericulosis - cancer - IBD - anorectal blood loss - ischemic colitis Lower GI bleed: findings/ diagnostics Correct answer- - Hematochezia (blood from anus) - melena - pallor - shock - hypotension - NG - rules out UGI - anemia - fecal occult blood test - sigmoidscopy/ colonoscopy Lower GI bleed: management Correct answer- -Resuscitate hemodynamically unstable: blood transfusion - dc aspirin and NSAIDS - IV cont PPI (Protonix) Peptic ulcer disease: what, types, etiology, risk factors Correct 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 Correct answer- Duodenal ulcers: 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 Correct 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 Correct answer- - GI bleeding Symptoms: hematesis, melena, coffee ground hematesis, pallor, tachy, hypotension, low Hct, BUN up Perform endoscopy Treat: IV fluids, blood transfusion, H2 blockers (pepcid), no vasopressin or octreotide - Perforation Symptoms: severe abd pain, epigastric pain radiating to back, boardlike abd, absent bowel sounds, knee to chest, fever, leukocytosis, free air on xr, barium studies Treat: surgery, watch poor candidates on ab's, iv fluids, and NG. - Gastric Outlet obstruction Symptoms: early satiety, n/v, epigastric pain unrelieved by food/antacids, succussion splash, NG foulsmelling large amount Perform upper GI endoscopy and saline test at 72hrs (check residual) Treat: Treat hypokalemia, if present because of N/V, Start H2 blocker (pepcid), surgery Meds used for PUD Correct answer- - H2 blocker (Famotidine, Ranitidine), decreases acid secretion, symptom relief in 2 wks, healing in 6wks for duodenal and 8 wks for gastric (Cimetidine raises theophylline and warfarin levels) - PPIs (Omeprazole (gastric), Pantoprazole (duodenal), Esomeprazole (gastric), suppresses gastric acid secretion. For duodenal ulcers, esophagitis, GERD. Check gastrin after 6mo and may cause low Vit B12, Ca, low iron and C Diff, hip #, pneumonia - Sucralfate. Mucosal defense enhancer. Can cause constipation. Needs acidic environment, so do not combine with H2 blocker or PPI and binds with meds, so 2hrs apart. - Cytotec. Used for ulcer prevention when on NSAID. Can cause diarrhea. Can cause contractions/ abortion. Bowel rest NG for ileus Surgery if failure to respons to tx or free air, abscess, obstruction, peritonitis Ulcerative colitis: what Correct answer- Idioptahic inflammatory disease causing bleeding and erosions of colonic mucosa An IBD Ulcerative colitis: findings and diagnostics Correct answer- hallmark sign: bloody diarrhea fecal urgency abd cramping Leukocytos is anemia hypokalemi a transaminit is stool cult to rule out infectious colitis sigmoidoscopy/ colonoscopy to determine extent of disease abd xr No colonoscopy and barium enema during acute attack (may cause perforation) Grading of Ulcerative colitis Correct answer- Mild: normal albumin normal ESR HR less than 90 Hct normal stool #: <4/ day temp: normal weight loss: none Moderate: albumin 3 - 3.5 ESR 20- 30 HR 90 - 100 Hct 30 - 40 stool #: 4 - 6/ day temp: 99 - 100F weight loss: 1 - 10% Severe: albumin less than 3 ESR more than 3 HR higher than 100 Hct less than 30 stool #: more than 6/ day temp: above 100F weight loss: greater than 10% Ulcerative Colitis treatment Correct answer- Mild/ moderate: Firstline: oral or topical (enema) sulfasalazine or corticosteroids Oral prednisone if not responsive to tx or systemically ill Mild/ moderate extensive: Cornerstone: Sulfasalazine First line: oral sulfasalazine. Start at 500mg/ day then increase to 4-6gm/ day. Give Folate with it. Give corticosteroid if no improvement in 2-3 wks (hydrocortisone enema) If that fails: give oral prednisone/ methylprednisone. INfliximab for pt's refractory to that Severe: hospitaliz e NPO no opioids/ anticholinergics nlood transfusion if needed 7-10 days corticosteroid IV (methylprednisolone) Infliximab Immunomodulators: purinethol, imuran, cyclosporine (maintenance of remission) If refractory: colectomy Toxic megacolon: surgical decompression, ab's, colectomy Surgery for: toxic megacolon refractory disease perforation hemorrhage carcinoma Toxic megacolon: symptoms and treatment Correct answer- Symptoms: rapid UC progression fever anemi a xr abd to detect megacolon ab's (cover gram - and aneorobes) NG surgery within 72hrs if failing to respond to tx Immunomodulators: 6-mercaptopurine, Azathioprine, Methotrexate, Cyclosporine, Tacromilus For maintenance, steroid sparing effect May cause pancreatitis, bone marrow suppression, hepatotoxicity 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 Correct 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 Correct answer- Primary: fever and abd pain with mental status change due to hepatic encephalopathy Secondary: acute abd pain fever n/v constipati on abd distention, rebound tenderness, rigidity, decreased bowel sounds, hyper resonance on percussion ascites dyspnea/ tachypnea dehydration Primary diagnostics: ascitic fluid: protein less than 1 Polymorphonuclear cell count greater than 250. Most sensitive test. bacteria on gram stain elevated lactic (> 32) glucose greater than 50 Secondary: Ascotic fluid: Leukocyte count elevated Protein greater than 1 Glucose less than 50 multiorganisms on gram stain