6550 Final Exam Study Guide Latest Update 2024 Download To Pass Guaranteed Success ., Exams of Nursing

Download 6550 Final Exam Study Guide Latest Update 2024 Download To Pass Guaranteed Success . and more Exams Nursing in PDF only on Docsity! 1 6550 Final Exam Study Guide Latest Update 2024 Download To Pass Guaranteed Success . Genitourinary, gynecologic, renal and acid/base conditions O Carcinoma of the Cervix Increased risk in women who smoke and those with HIV or high-risk HPV types. Considered a sexually transmitted disease as both squamous cell and adenocarcinoma of the cervix are secondary to infection with HPV; squamous cell accounts for 80 percent of cervical cancers, 15 % adenocarcinoma, and 3-5 % neuroendocrine. Prevention through vaccination- recombinant 4 or 9-valent HPV vaccination which target HPV types that poses the greatest risk. Prognosis- overall 5- year relative survival rate is 68 % for white women and 55 % in black women- survival rates are inversely proportionate to the stage of cancer. Signs/Symptoms- Metrorrhagia, postcoital spoting, and cervical ulceration. Gross edema of the legs may be indicative of vacular and lymphatic stasis due to tumor. Pain in the back (lumbosacral plexus region) indicates neurologic involvement. Bladder and rectal dysfunction or fistulas are severe late symptoms. Two to 10 years are required for carcinomas to penetrate the basement layer of the membrane and become invasive- screening has decreased mortality. Diagnostic Tools- Cervical Biopsy- After a positive papnicolaou smear biopsy or endocervical curettage is necessary to determine the extent and depth of the cancer cells. Surgery and radiation should be delayed until biopsy results. Imaging- CT, MRI, lymphangiography, fine-needle aspiration, ultrasound, and laparoscopy are utilized for staging of invasive cancer. Allows for more specific treatment planning. Complications- Metastases to regional lymph nodes occurs with increasing frequency 1 from Stage I to Stage IV. Extension occurs in all directions from the cervix. Hydronephrosis (urine-filled dilation of the renal pelvis due to obstruction) and hydroureters (dilation of the ureter), is a result of the ureters becoming obstructed lateral to the cervix which can lead to impaired kidney function. Treatment/Management- Refer all patients to Gynecologic Oncologist Carcinoma in situ (Stage 0)- women whom child-bearing is not a consideration, total hysterectomy is definitive treatment. 1 Emergency Surgery- indicated for acute torsion of the pedunculated myoma. Marked anemia, heavy menstrual period post-operative treatment includes DMPA IM q3 months. Only indication for emergency surgery during pregnancy is torsion of a pedunculated fibroid. Prognosis- Surgery is curative, however, women should be counseled regarding future fertility- reoccurrence is common, and post-operative pelvic adhesions can impact fertility and may require a cesarean delivery. o Pelvic inflammatory disease- PID is a polymicrobial infection of the upper genital tract associated the sexually transmitted organism Neisseria gonorrhoeae and chlamydia trachomatis, as well as endogenous organisms, including anaerobes, H. influenza, enteric gram- negative rods, and streptococci. Most common in young, nulliparous, sexually active women with multiple partners. Signs/Symptoms Lower abdominal pain, chills, fever, menstrual disturbances, purulent cervical discharge and cervical and adnexal tenderness. Right upper quadrant pain (Fitz-Hugh & Curtis sign) may indicate associated peri-hepatitis. Most women present with subtle or mild symptoms, such as urinary frequency, low back pain, or postcoital bleeding. Diagnostic Criteria Women with cervical motion, urterine or adnexal tenderness should be treated as if they have PID with antibiotics unless there is a competing diagnosis. Symptoms including temp >38.3, abnormal cervical or vaginal discharge with white cells on saline microscopy, elevated ESR, elevated CRP, and laboratory documentation of infection by N. gonorrhea or C trachomatis, should prompt treatment with antibiotics while endocervical cultures are processing. Differential Diagnosis Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or unrupture ovarian cyst. PID is more likely to occur if there is a history of recent sexual contact, history of sexually transmitted disease, recent onset of menses, sexual contact with someone with a sexually transmitted disease. Acute PID is unlikely if sexual intercourse has not occurred within the last 60 days. 1 Obtain a pregnancy test to rule out ectopic pregnancy, septic abortion, Pelvic ultrasound can rule out ovarian cyst and ectopic pregnancy 1 Laparoscopy is often utilized to diagnose PID and imperative if symptoms do not respond to antibiotic therapy within 48 hours of imitating Treatment/Management Antibiotic coverage Mild to moderate infection- treat outpatient 1. Single dose of cefoxitin, 2g IM, with probenecid 1g orally, plus doxycycline 100mg orally twice a day for 14 days OR 2. Ceftriaxone 250mg IM plus doxycycline 100 mg orally twice daily for 14 days. 3. Metronidazole 500 mg orally twice daily for 14 days can be added to either regimen. Severe disease- meet criteria for hospitalization 1. Cefotetan 2g IV every 12 hours OR 2. Cefoxitin 2g IV every 6 hours, plus doxycycline 100mg orally or intravenously every 12 hours. OR alternative regiment is 3. Clindamycin 900 mg intravenously every 8 hours, plus gentamicin loading dose of 2mg/kg intravenously or IM followed by maintenance dose every 8 hours. Either regiment should be continued for at least 24 hours after patient shows symptom improvement and then transitioned to oral regimen for a total of 14 days Surgical Management- Tubo-ovarian abscess is a complication of PID and may require surgical intervention, unless rupture is suspected high dose antibiotics can be initiated. Monitor therapy response with ultrasound. 70 percent of cases respond to ABX, 30 percent require surgical intervention. Admission criteria- Tubo-ovarian abscess, pregnancy, patient is unable to follow outpatient regimen, 1 Signs/Symptoms 1. History of duration and amount of flow, associated pain, and relationship to the LMP, with presence of blood clots and degree of inconvenience caused by the bleeding 2. History of pertinent illness, such as recent systemic infection, physical or emotional stressors. 3. History of medication such as warfarin or heparin, herbal remedies (ginko, ginseng) that may cause AUB 4. History of coagulation disorders in patient or family members 5. Evaluate for excessive weight and signs of PCOS, thyroid disease, insulin resistance, or bleeding disorder 6. Pelvic examination, rule out vulvar, vaginal, or cervical lesions or pregnancy 1 Laboratory Studies 1. CBC, pregnancy test and thyroid test 2. History of coagulopathy or history- coagulation study 3. Vaginal or urine sample to rule out chlamydia 4. Transvaginal ultrasound- rule out ectopic pregnancy, adnexal or uterine masses 5. Cervical biopsy- myomas or polps Treatment- AUB depends on etiology of the bleeding. AUB ovulatory dysfuction 1. Treated hormonally with progestin a. Irregular or light bleeding- medroxyprogesterone acetate 10mg/day orally or norethindrone acetate 5 mg/day for 10 days. If successful, treatment can be repeated for several cycles 2. NSAIDS- Naproxen will often reduce blood loss in menorrhagia 3. Oral contraceptives- taper of oral contraceptives to control bleeding. 4. GnRH (depo) can be used for up to 6 months to temporarily stop menstruation. If bleeding in is not controlled by hormonal treatment, hysteroscopy with tissue sampling to evaluate for structure lesions- In absence of pathology bleeding unresponsive to medical treatment treated with endometrial ablation, IUD, or hysterectomy. o Sexual violence- - Sexual violence is considered penetration vaginally, anally, or orally and may be by the penis, hand, or a foreign object. The absence of genital injury does not imply consent by the victim. Rape Trauma Syndrome is comprised of two principles 1- Immediate or acute, shaking, sobbing, restless activity that may last from a few days to a few weeks. The patient may experience anger, guilt, shame, or repress these emotions. Every patient responds differently 2- Late or chronic- problems related to the attack may develop weeks or months later, lifestyle and work patterns may change, sleep disorders or phobias often develop. Loss-self-esteem can lead to suicide. Treatment- initial presentation 1. Tetanus Toxoid if deep lacerations contain soil or dirt. 1 2. Consider analgesics or sedatives if needed 1 Surgery- Diagnostic Laparoscopy followed by a salpingectomy with removal of the ectopic pregnancy or a partial/complete salpingectomy. Iron therapy for anemia may necessary- Rh immune globulin should be given to Rh- patients Fluid/Electrolyte Imbalance 2/3 body weight intracellular, 1/3 extracellular. Effective circulating volume may be assessing by physical examination, blood pressure, pulse, jugular venous distention. Urine- urine concentration of an electrolyte is helpful to determine whether the kidney is appropriately excreting or retaining an electrolyte in response to high or low serum levels. 24 hour urine- most appropriate to assess electrolyte excretion, however, time consuming. Fractional excretion- FE %= (urine X/serum X)/urine CR/Serum CR x 100. Low fraction excretion indicates renal reabsorption (electrolyte retention or high avidity) High fraction- renal wasting (electrolyte excretion or low avidity) Serum Osmolality- solute concentration- normal 285-295 moll/kg. Differences in osmolyte concentration across cell membranes lead to osmosis and fluid shifts, stimulation of thirst, and secretion of ADH Osmolality = 2 (Na+ mEq/L) + glucose/ 18 + BUN/2.8 o Hypernatremia- volume status and serum osmolality are essential to determine etiology- usually reflects excess water retention relative to sodium. HYPOTONIC fluids commonly cause hypernatremia in hospitalized patients. Serum sodium > 135mEg/L Evaluation of the patient should include 1. Urine sodium (normal 10-20 mEq/L) 2. Serum osmolality (usually 2 x NA) 3. Clinical status 1 Measuring urine sodium helps distinguish renal from non-renal causes. Example Urine sodium >20 suggests renal salt wasting (problem with kidneys) Urine sodium <10 suggests renal retention of sodium to compensate for extra- renal fluid loss (problem outside of the kidney) Isotonic Hypernatremia (Pseudohyponatremia) Serum Osmolality 284-295 1 Occurs with extreme hyperlipidemia or hyperproteinemia Body water is normal and the patient is asymptomatic Treatment- cut down fat (no fluid restriction) Hypotonic Hypernatremia (serum osmolality <280)- state of body water excess diluting all body fluids, clinical signs arise from water excess 1. Assess if patient is hypovolemic or hypervolemia 2. If hypovolemic, assess whether hypernatremia is due to extra renal salt losses or renal salt wasting Hypovolemic/urine NA+ <10 1. Dehydration 2. Diarrhea (codify) 3. Vomiting (NG tube suctioning) Hypovolemic w/urine NA+ >20: low volume and kidneys cannot conserve NA 1. Diuretics 2. ACE inhibitors 3. Mineralocorticoid deficiency. Hypervolemia, hypotonic hypernatremia (need to restrict water) 1. Edematous state 2. CHD 3. Liver disease 4. Advanced renal failure Hypertonic Hypernatremia- (serum osmolality >290) 1. Hyperglycemia- usually from HHNK (DM2) 2. Osmolality is high and NA is low Management of Hypernatremia Replacement has to be slow and calculated- risk for cerebral osmotic demyelination. o Hypernatremia 1 Signs/Symptoms 1. Weakness, flaccid paralysis 2. Abdominal distension 3. Diarrhea 1 Laboratory Findings/Diagnosis 1. ECG not particularly sensitive- 50% of patient with K+ >6.5 will not have ECG changes, however, tall pealed T waves are classic finding Management 1. Exchange resins (Kayexalate) 2. If >6.5 or cardiac toxicity or muscle paralysis is present, consider a. Insulin 10 U with one amp D50 (pushes K into cells) Calcium Major cellular ion and important as a mediator of neuromuscular and cardiac function. Normal total calcium of 2.2-2.6 mmol/L (8.5-10.5 mg/dL) and normal ionized calcium of 1.1-1.4mmol/L (4.5-5.5 m/dL). 1. Ionized calcium does not vary with albumin level (useful to measure the ionized calcium level with the serum albumin is not within normal range) 2. Calcium is maintained by Vitamin D, parathyroid hormone, and calcitonin. 3. Academia increase ionized calcium and alkalemia decrease 4. The total amount of total calcium varies with the level of serum albumin (since 50 % of calcium is bound to albumin, a normal calcium level in the presence of low albumin level suggests that the patient in hyperkalemia. 5. Corrected calcium (mg/dl) = measured total Ca (mg/dl) +0.8 or [4.0- serum albumin (gold)], where 4.0 represents the average albumin level o Hypocalcemia Causes include hyperparathyroidism, hypomagnesaemia, pancreatitis, renal failure, severe trauma, and multiple blood transfusions. Signs/Symptoms 1. Increase deep tendon reflexes, muscle/abdominal cramps 2. Carp pedal spams (Trousseaus sign) or Chvostek sign (sustained cheek) 3. Convulsions, prolonged OT interval Management 1 1. Check blood pH- look for alkalosis 2. If acute, IV calcium glucometer 3. If chronic, oral supplements, vitamin D, albumin hydroxide o Hyperkalemia 1 4. Acute hemolytic anemia from erythrocyte fragility, platelet dysfunction 5. Impaired chemo taxis of leukocytes (increased susceptibility to gram – sepsis) Laboratory Findings Urine phosphate excretion- normal renal response to hypophosphatemia is decreased urinary phosphate excretion to less than 100mg/day Treatment/Management 1. Can be prevented with phosphate repletion in maintenance fluids- rapid decline of calcium can occur with parenteral administration. 2. Oral replacement is preferred 3. IV replacement, consider the potassium and sodium level- IV K- Phis versus IV Na- Phis replacement. Check Na, K, Phis levels q6h 4. Magnesium deficiency often coexists and should be corrected. Contraindications to treatment Hyperparathyroidism, advanced CKD, tissue damage and necrosis, and hypocalcemia. When an associated hyperglycemia is treated, phosphate accompanies glucose into the cells and hypophosphatemia may ensue. o Hyperphosphatemia Causes include CKD, decreased excretion into the urine, laxatives or enemas containing phosphate, metabolic acidosis, respiratory acidosis, IV phosphate supplement. Phosphate concentration greater than 4.5 mg/dL Most patients are asymptomatic however others may develop calcium deposits into the soft tissue (chronic hyperphosphatemia). Similar to hypocalcemia symptoms, muscle cramps, titan, numbness/tingling Treatment/Management Treat the cause 1. Caused by tumor lies, responds to forced saline diuresis to enhance urinary loss 2. Limit phosphate intake- renal failure is the clinical condition most often requiring curtailment of phosphate ingestion- advanced renal insufficiency require phosphate binders to inhibit gastrointestinal absorption of phosphate 3. Enhance renal excretion- use volume repletion with saline coupled with forced diuresis with loop diuretics 1 Magnesium Normal plasma magnesium level is 1.83.0 mg/dL, with about 1/3 bound to protein and 2/3 existing as free action. Excreted via the kidney, physiologic effects on the nervous system resembles those of calcium. Altered magnesium concentration usually provokes an associated alteration of Ca. Both hypo/hyper can decrease PTH secretion or action o Hypomagnesaemia Causes include malabsorption, laxative abuse, PPT, prolonged gastrointestinal suction, malnutrition, alcoholism, increased renal loss Signs/Symptoms - Weakness and muscle cramps, CNS hyperirritability may produce tremors, athetiod movements, jerking, nystagmus, Babinski response, confusion, disorientation. - EKG may show prolonged QT interval, due to lengthening of the ST segment. - PTH secretion is suppressed Management/Treatment - 250-500mg orally once or twice a day for chronic hypomagnesaemia - IV 1-2 g over 5-60 minutes for symptomatic hypomagnesaemia - Cautious replacement in patients with CKD to avoid hypomagnesaemia- reduced doses o Hypomagnesaemia Almost always the result of advanced CKD and impaired magnesium excretion. Antacids and laxatives. Pregnant patients may have severe hyper-magnesia from IV magnesium for preeclampsia and eclampsia. Signs/Symptoms - Muscle weakness, decreased deep tendon reflexes, mental obtundation, confusion. Weakness, flaccid paralysis, ileus, urinary retention, and hypotension. - EKG may show broadened QRS complex and peaked T-waves (related to hyperkalemia) Treatment -Sources of magnesium should be discontinued 1 - Calcium antagonizes Mg+ and can be given intravenously as calcium chloride - Hemodialysis or peritoneal dialysis may be required for CKD patients \ Acid-Base Disorders Metabolic (decreased or increased HCO3-) 1 Endo: Cushings/Bartters 1 Vomiting, NG suction Excess Alkali Refeeding Syndrome Post- Hypercapnia Diuresis Treatment for Saline Responsive Metabolic Alkalosis - Correction of the extracellular volume deficit with isotonic saline. Diueretics should be discontinued. H2 blockers or PPIs may be helpful in patients with M.A. from NG suctioning. Pulmonary or cardiovascular status limits resuscitation; acetazolamide will increase renal bicarb excretion. Treatment for Saline Unresponsive Metabolic Alkalosis - Surgical removal of the mineralcorticoid-producing tumor and blockage of aldosterone effect with an ACE inhibitor or spironolactone. Caused by primary aldosteronism, can be treated by potassium repletion o Respiratory acidosis (Hypercapnia) Results from hypoventilation and subsequent hypercapnia. Arterial pH is low and PCO2 increased. Serum HCO3 is elevated but does not full correct the pH. 1 1 o Autoimmune disorders – Hashimoto thyroiditis, DM1 o CNS infections – late complication of meningitis or encephalitis o Cerebrovascular accident – subarachnoid hemorrhage o Medications - phenytoin 1 o Recognized causes- temozolomide, IgG4 • Nephrogenic Diabetes Insipidus – due to renal insensitivity or resistance to AVP, with a resultant lack of permeability of the collecting duct to water. o Risk factors include lithium therapy, chronic renal disease, and chronic hypercalcemia or hypokalemia ▪ DDx • Psychogenic polydipsia, DM, hyperosmolar hyperglycemic state, hyperaldosteronism, diuretic use, hypercalcemia ▪ Diagnostic studies • Urine osmolality, serum osmolality, serum sodium, serum calcium serum potassium, urine dipstick, 24-hour urine collection for volume, serum BUN, serum glucose ▪ Treatment options • Treatment goals are correction of any pre-existing water deficits and reduction in ongoing excessive urinary water losses. • Central DI , desmopressin is the treatment of choice. • Nephrogenic DI is treated with adequate fluid intake; salt restriction and diuretics may help reduce polyuria • o Acromegaly ▪ Evaluation • Rare, chronic disease caused by excessive secretion of growth hormone (GH), usually die to a pituitary somatotroph adenoma. • Must be screened for in the presences of pituitary adenoma, profuse sweating, acral growth, coarsening of facial features, and when suspected in conjunction with commonly associated conditions such as carpal tunnel syndrome, arthralgia,, glucose intolerance or diabetes, amenorrhea, hypertension, and sleep apnea. ▪ DDx • Acromegaloidism • Pseudoacromegaly ▪ Diagnostic studies • Serum insulin-like growth factor (IGF-1), oral glucose tolerance test, random serum growth hormone (GH) • Consider MRI or CT of pituitary ▪ Treatment options • Goals of treatment are to: o Restore life expectancy to normal o Relieve symptoms of the condition o Completely remove the causative tumor, if 1 possible; if not possible, control its growth and related mass effects o Preserve normal pituitary functioning o Hyperprolactinemia ▪ Evaluation 1 • 4-, 6-, or 24-hour radioiodine uptake • T3/T4 ratio ▪ Treatment options • Treatment primarily is directed at symptomatic relief of thyroid pain and tenderness, if present, and restoration of euthyroidism. • Acute thyroiditis requires abx treatment, PCN or ampicillin 10-14 days • Subacute thyroiditis goal is to relieve discomfort and control abnormal thyroid function. Low dose ASA and if this does not help prednisone for 1 week then taper. o Hypothyroid/myxedema ▪ Evaluation • Present with nonspecific symptoms of weakness, lethargy, depression and mild weight gain. Physical exam may show dry skin, thick tongue, eyelid edema, and bradycardia • Elevated TSH and low T4 • ▪ DDx • Central or secondary hypothyroidism, depression, alzheimers dementia, anemia ▪ Diagnostic studies • Serum TSH, free T4, serum cholesterol, CBC, fasting blood glucose, serum CK, serum sodium, antithyroid peroxidase antibodies ▪ Treatment options • Levothyroxine at starting dose of 1.6mcg/kg daily or 25mcg daily in older patients or those with CAD • TSH should be measured 4-6 weeks after initiation of therapy or dosage changes o Hyperthyroid ▪ Evaluation • Overactive thyroid when thyroid gland produces too much thyroxine. Accelerates body’s metabolism, causing unintentional weight loss and a rapid or irregular heartbeat. • Heart palpitations, increased appetite, nervousness, anxiety and irritability, tremor, sweating, changes in menstrual patterns, increased sensitivity to heat, changes in bowel patterns, goiter, fatigue, muscle weakness, difficulty sleeping, skin thinning, fine brittle hair. • Can be caused by Graves disease, Plummer’s disease and thyroiditis ▪ DDx • Graves disease, euthyroid hyperthyroxinemia, goiter, struma ovarii, thyrotoxicosis ▪ Diagnostic studies 1 • TSH, radioiodine uptake test, thyroid scan, thyroid US 1 ▪ Treatment options • Radioactive iodine – causes gland to shrink • Anti-thyroid medications – tapazole and propylithiouracil • Beta blockers – ease the symptoms of hyperthyroidism • Thyroidectomy o Thyroid nodules ▪ Evaluation • Most do not cause symptoms and are typically discovered during routine physical exam or on imaging tests like CT or US. • Thyroid tests are typically normal, even when cancer is present in a nodule • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879398/ ▪ DDx • Thyroid cancer ▪ Diagnostic studies • Thyroid US, fine needle biopsy, nuclear thyroid scan ▪ Treatment options • Surgical removal if cancerous • Monitor if small and benign o Thyroid cancer ▪ Evaluation • Most commonly presents as an asymptomatic thyroid nodule ▪ DDx – benign thyroid nodule ▪ Diagnostic studies • Fine needle aspiration ▪ Treatment options 1 percussion, pseudofractures, and skeletal deformities are found commonly ▪ DDx • Osteoporosis, Paget disease 1 ▪ Diagnostic studies • Diagnosis is made via laboratory results with a low vitamin D level in the setting of low or normal calcium and an elevated intact PTH level • Serum Ca, serum 25-hydroxyvitamin D, serum Phos, serum Bun & Cr, Intact PTH, serum ALKP, 24-hour urine calcium ▪ Treatment options • Once underlying cause is addressed, a successful treatment regimen is possible: increased sunlight exposure, oral vitamin D, and calcium replacement. o Paget’s disease ▪ Evaluation • Chronic localized bone remodeling disorder characterized by increased bone resorption, bone formation, and remodeling, which may lead to major long bone and skull deformities • Majority are asymptomatic. Symptomatic patients experience pain localized to the bone or join, either from pagetic lesion, secondary osteoarthritis, deformity, or pathological fracture. ▪ DDx • Osteomalacia, fibrous dysplasia ▪ Diagnostic studies • Diagnosis is incidental, with elevated ALKP raising suscpicion for disease. • Bone biopsy is the only confirmatory diagnostic test but is rarely indicated • Plain XR, bone scan, total serum ALKP, bone specific ALKP, serum Ca, serum precollagen 1 N-terminal peptide, serum C- terminal propeptide of type 1 collagen (CTX), LFT’s, serum 25- hydroxyvitamin D ▪ Treatment options • Bisphosphonates are first-line therapy to retard excessive osteoclastic activity. • Adjunctive therapy includes physical therapy, orthoses, and walking and hearing aids • Analgesics are indicated for pain and inflammatory symptoms o Addison’s disease ▪ Evaluation • Presentation may be acute or insidious, with substantial fatigue and weakness associated with mucocutaneous hyperpigmentation, hypotension and/or postural hypotension, and salt craving. 1 ▪ DDx • Adrenal suppression due to corticosteroid therapy, secondary or tertiary adrenal insufficiency, hemochromatosis, hyperthyroidism, occult malignancy, anorexia nervosa 1 hyperplasia, primary glucocorticoid resistance, Ectopic ACTH syndrome ▪ Diagnostic studies • Optimal detection involves screening all hypertensive patients using the plasma aldosterone/renin ratio • Plasma potassium, aldosterone/renin ratio ▪ Treatment options • Unilateral PA o Unilateral adrenalectomy ▪ Immediately before sx, potassium supplementation should be withdrawn, aldosterone antagonists discontinued and other antihypertensive therapy reduced, if appropriate. Post-operative IV fluids should be given, generous sodium diet recommended ▪ Spironolactone 12.5-50mg PO daily ▪ Amiloride 2.5-10mg daily o Non-surgical candidates ▪ Amiloride 2.5-10mg daily • Bilateral PA o No adrenal lesion> or equal to 2.5cm ▪ Amiloride 2.5-10mg daily ▪ Unilateral adrenalectomy if bilateral cannot be removed with post and preop meds as above o Adrenal lesion > or equal to 2.5cm ▪ Unilateral adrenalectomy ▪ Post and preop meds as above o Pheochromocytoma ▪ Evaluation • Presents with palpations, diaphoresis, pallor, and paroxysmal hypertension • Risk factors include multiple endocrine neoplasia type 2, Von Hipple-Lindau syndrome, and neurofibromatosis type 1 • Complications include hypertensive crisis, myocardial infarction, and hypotension ▪ DDx • Anxiety and panic attacks, essential or intractably hypertension, hyperthyroidism, consumption of illicit substances, carcinoid syndrome, cardiac arrhythmias, menopause, preeclampsia ▪ Diagnostic studies • Diagnosed by increased levels of urine and serum catecholamines, metanephrines and normetanephrines • Serum free metanephrines and normetanephrines, plasma catecholamines, genetic testing 1 ▪ Treatment options • Hypertensive crisis 1 o Phentolamine 5-20mg IV as single dose • Without hypertensive crisis o Surgical candidate with benign tumor ▪ Phenoxybenzamine 10mg PO BID, increase by 10mg/day every other day, max 240mg/day ▪ Atenolol 25-100mg PO daily after alpha blockade ▪ Hydration with isotonic saline and high salt diet ▪ Nifedipine 10-20mg PO TID ▪ Surgical excision of tumor o Surgical candidate with malignant tumor ▪ Phenoxybenzamine 10mg PO BID, increase by 10mg/day every other day, max 240mg/day ▪ Atenolol 25-100mg PO daily after alpha blockade ▪ Hydration with isotonic saline and high salt diet ▪ Nifedipine 10-20mg PO TID ▪ Surgical excision of tumor ▪ Post-surgical chemo and radiation o Non-surgical candidate with benign tumor ▪ Phenoxybenzamine 10mg PO BID, increase by 10mg/day every other day, max 240mg/day ▪ Atenolol 25-100mg PO daily after alpha blockade ▪ Hydration with isotonic saline and high salt diet ▪ Nifedipine 10-20mg PO TID o Non-surgical candidate with malignant tumor ▪ Phenoxybenzamine 10mg PO BID, increase by 10mg/day every other day, max 240mg/day ▪ Atenolol 25-100mg PO daily after alpha blockade ▪ Hydration with isotonic saline and high salt diet ▪ Nifedipine 10-20mg PO TID ▪ Post-surgical chemo and radiation o Diabetes Mellitus Type 2 ▪ Evaluation • Chronic syndrome of impaired carbohydrate, protein, and fat metabolism, owing to insufficient secretion of insulin and/or target-tissue insulin resistance. • Complications include both macrovascular and microvascular sequelae. ▪ DDx • Prediabetes, DM1, latent autoimmune diabetes, monogenic diabetes, ketosis-prone diabetes, gestational diabetes ▪ Diagnostic studies • HbA1c, fasting plasma glucose, random plasma glucose, 2-hour post-load glucose after 75g oral glucose, fasting lipid profile, urine 1 • Reduction of plasma glucose • Replenishment of electrolyte and volume losses • Identify underlying cause • Insulin therapy should not be started until serum K+ reaches 3.3 1 • Dopamine 5-10 mcg/kg/min IV, adjust according to BP and other hemodynamic parameters • Sodium bicarbonate for serum pH 6.9-7.0: 50mmol IV over 1 hr at a rate of 200ml/hr for 2hrs or until pH>7.0 o Hyperglycemia hyperosmolar state ▪ Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis ▪ Physical findings of hyperosmolar hyperglycemic state include those associated with profound dehydration and various neurologic symptoms such as coma. The first step of treatment involves careful monitoring of the patient and laboratory values ▪ Precipitating factors may be divided into six categories: infections, medications, non-compliance, undiagnosed diabetes, substance abuse, and coexisting diseases. Myocardial infarction, cerebrovascular accident, pulmonary embolus, and mesenteric thrombosis have been identified as causes of hyperosmolar hyperglycemic state. ▪ DDx • DKA, lactic acidosis, alcohol ketoacidosis, ingestion of toxic substances, acetaminophen overdose, salicylate overdose, seizures, stroke ▪ Diagnostic studies • Plasma glucose level, serum or urinary ketone level, serum BUN, serum Cr, serum Na, K, Cl, Mg, Ca, Phos, serum osmolality anion gap, serum lactate, blood gas, UA, LFT, CBC, EKG, CXR, cardiac panel ▪ Treatment options 1 o Lactic acidosis ▪ Evaluation • Severe lactic acidosis is often associated with poor prognosis. Recognition and correction of the underlying process is the major step in the treatment of this serious condition. Intravenous administration of sodium bicarbonate has been the mainstay in the treatment of lactic acidosis. • S/s – fruity-smelling breath, jaundice, confusion, difficulty breathing, exhaustion, muscle cramps, body weakness, abdominal pain, diarrhea, decrease in appetite, headache, rapid heart rate • Causes: heart disease, sepsis, HIV, cancer, short bowel syndrome, acetaminophen use, chronic alcoholism, intense exercise or physical activity, common in diabetics 1 o Fever of unknown origin ▪ https://emedicine.medscape.com/article/217675-treatment ▪ https://www.aci.health.nsw.gov.au/networks/eci/clinical/ clinical- resources/clinical-tools/infectious-diseases/fever- of-unknown-origin o Infections in immunocompromised patient ▪ https://emedicine.medscape.com/article/973120-overview ▪ http://www.pidsphil.org/home/wp-content/uploads/ 2017/02/08Lec- PREVENTION-OF-INFECTIONS-IN- THE- IMMUNOCOMPROMISED.pdf o Infections in the CNS Diagnosis ‘Symptoms ‘Signs Bacterial meningitis Viral meningitis Fungal meningitis Crcephalitis Cerebral ebscess Spinal abscess Headache, stiff nock, photophobia, phonophobio, aousca, chills, AMS Headache, AMS, nausea, diplopia Headache, AMS, nausea, stift neck, chilis AMS, neurologic complaints, headache, fever AMS, heedache, letharay Back pain, chills, radicular pain, paresthesias, numbness, tingling Cavernous sinus thrombosis Headache, diplopia, AMS Popilledema, higher fevers, vomiting, nuchal rigidity, petechiae (meningococcus) Papilleama (less eammon than in harterial meningitis), low grade to no fever, vomiting Papilledema, low-grade tever, vomiting, nuchal rigidity Focal neurologic deficits, seizures (IISV) Focal neurologic deficits, nuchal rigidity, new-onset seizures Fever, focal tendemess, focal sensory and motor deficits Fever, crenial nerve deficits, ptosis, proptesis, papilledema AMS, altered mental status Pathogen Risk factors “Transmission ‘Symptams Diagnosis Treatment Notes Cryptococcus Immune Respiratory, Fever, headache, India ink stain AmphoteresinB + Found in pigeon nenfnrmans suppressed, esp serandary MS, faral mirinsenpie — flurytnsine, folinwed — drappings; AIDS- HIV or cancer hematogenous neurologic cxaminotion by fluconazole defining illness spreac deficits, seizures prevalent at CD4 Candida albicans st Histoplasmosis Immune suppressed Respiratory, Culture of CSF, capsulatum secondary serologies hematogenous spread Blastomycoses Immune suppressed Respiratory, Culture of CSF, secondary serologies Coccidiodes immitis Immune suppressed Immune uppressed, esp HIV or cancer Hematogsnous from other body sources, ®9. vagine, oral cavity serologies: hematogenous spread Respiratory, secondary hematogenous spread serologies Culture of CSF, Culture of CSF, under 100 Normal ‘lora, requires neutropenia or can arise as superinfection to bevume patluyeniv Found in caves, primarily located in Ohio and Mississippi river valleys Primarily located in Ohio and Mississippi river valleys Primarily located in southwestern United States, arid climates Amphoterecin 8 = flucytosine; alternative azoles or echinocandins Liposomal amphoterecin; alternetive azoles Liposomal amphoterecin; alternative azoles Liposomal amphoterecin; alternative azoles AMS, altered ‘netital stetus, CSF, verebruspinial fluid Pathogen Neisseria meningitides ‘Streptococcus pneu- moniee Haemophilus influenzae Streptococcus aga- lactiae, aka Group B Streptococcus Escherichia coli Listeria monocytogenes Age yroup most Risk factors TH Treatment commonly attected Young adult Living in close quar Respiratory spread Ceftriaxone 80-100 Yes ters, eg. dormitory mg/kg students or military 10-14 days with reu'uils maximum 3 y Children to elderly Respiratory soread Ceftriaxone 7 days Yes Children Unvacsinated Respiratory soread Ceftriaxone 7 days Yes Neonates Preterm, prolonged —Pessage through colonized Penicillin G 50 mg/kg Pending rupture of membranes birth canal 14-21 days Neonates Transplacentally Ceftriaxone 21 days No Neonates, e'derly Immuno suppressed —Transplacentally, food Ampicillin 100 mg/kg No products 14-21 days Age ‘Most common organisms Empiric therapy ‘Additional medication considerations Neonate (0-30 days) Babies (1 24 months) Child (2-18 years) Adult (18-65 years} Elderly (> G5 years] Group B Streptococcus, Escherichia enli, listeria manneytngenes Group B Streptococcus, Streptococcus pneumonia, Neisseria meningitines, Haemaphiitis influenzae, Cscherichia coli Neisseria menmgitdes, Streptococcus pneumoniae Cefotaxime + ampicillin Streptococcus pneumoniae, Neisseria meningitides Streptococcus pneumoniae, Listeria monocytogenes, Escherichia cali, + other gram-negative enterics Cofotaxime 1 vancomycin Cettnaxone + vancomycin Ceftriaxone ~ vancomycin ~ ampicillin ‘Add gentamycin if Listeria suspected Vancomycin added for resistant S. pneumoniae species Consider veceination tor those at increased risk for meningococcal infections Cettnaxone + vancomycin Ampiciliin adced for Listeria coverage 1 o Animal and human bites Skin and Musculoskeletal System • Evaluation, differential diagnosis, diagnostic studies, and treatment options o Cellulitis : Evaluation: Usually caused by gram-positive cocci/A beta-hemolytic streptococci and S aureus, diffuse infection usually in lower legs, infection of the dermis and subcutaneous tissues. Pain, chills and fever present and possible septicemia can develop. Swelling erythema and pain, lymphangitis and lymphadenopathy can be present. Differentials: DVT and necrotizing fasciitis, sclerosing panniculitis and acute severe contact dermatitis. Diagnostic studies: leukocytosis or neutrophilia left shift, positive blood cultures, aspiration of the advancing edge (not common) and full thickness skin biopsy. Treatment: IV antibiotics (the first 2-5 days) to cover strep/staph, MSSA can be treated with nafcillin, cefazolin, clindamycin, dicloxacillin, cephalexin, doxycycline, or TMP-SMZ. MRSA: vancomycin, linezolid, clindamycin, daptomycin, doxycycline, or TMP-SMZ. Mild cases or following IV treatment, dicloxacillin or cephalexin, 250-500 mg four times a day for 5-10 days. Recurrent cellulitis: PO PCN 250 BID daily or erythromycin can delay reoccurrence. 1 wounds need packing with gauze. Heel injury, do not remove eschar to help promote healing. Unstageable, debridement. Deep tissue injury , avoid pressure to the area. o Dermatitis : Evaluation: Atopic dermatitis: diagnostic criteria for atopic dermatitis includes: pruritus, typical morphology and 1 distribution, onset in childhood and chronicity, personal or family HX of atopy, xerosisichthyosis, facial pallor with infraorbital darkening, elevated serum IgE, and repeated skin infections. Pruritic, xerotic, exudative or lichenified eruption on face/neck/upper trunk/wrists and hands/antecubital and popliteal folds. Differentials: seborrheic dermatitis, psoriasis, secondary staphylococcal or herpetic infections-infra-auricular fissure. Dermatologist consult for atypical dermatitis after the age of 30. Diagnostics: itching, and clinicals findings, discrete plaques with weeping, Eosinophilia and increased serum IgE levels may be present. TREATMENT: determined by the pattern and stage of the dermatitis-acute/weepy, subacute/scaly, or chronic/lichenified. Mainly emollient and corticosteroids/topical. Acute weeping lesions: r/o infection, water/aluminum subacetate solution or colloidal oatmeal for soaks, wet dressing for 10-30 minutes 2-4 times daily, high-potency corticosteroids after soaking, Tacrolimus ointment, or systemic corticosteroids-only indicated for severe acute exacerbation, PO prednisone over 2-4 weeks taper off. Systemic corticosteroids are not indicated for maintenance therapy. Subacute or scaly lesions: Mid- to-High potency corticosteroids in ointment form, 2-4- week taper from twice a day to daily dosing with topical corticosteroids to reliance on emollients, then switch to low-potency. Chronic dry/lichenified lesions: high- potency to ultra-high potency corticosteroid ointments, nightly occlusion for 2-6 weeks may enhance the initial response, add tar preparation such as liquor carbonis detergents 10% in Aquaphor or 2% crude coal tar. Maintenance: effective moisturizers to prevent flairs, use of topical anti-inflammatories only on weekend or three times a week. VITAL to taper off corticosteroids and substitute emollients to avoid steroid side effects. Also/other types of dermatitis: Seborrheic dermatitis (dry scales with underlying erythema/body folds), Exfoliative dermatitis (scaling/erythema over most of the body, itching fever/chills, and contact dermatitis (erythema and edema, often followed by vesicle’s, 1 bullae, weeping or crusting in area of contact with suspected agent). o Malignant melanoma : Evaluation: leading cause of death due to skin disease. ABCDE rule: asymmetry, border irregularity, color variegation, diameter greater than 6 mm and evolution-change in mole is the single most important historical reason for close evaluation and possible referral. Different types of melanomas: lentigo maligna melanoma, superficial spreading malignant melanoma, nodular malignant melanoma, acral-lentiginous 1 0.5-0.75 mg/kg/day, check liver enzymes and serum lipids, teratogen agent. Cyclosporine for severe cases; tumor necrosis factor inhibitors etanercept (Enbrel), infliximab (remicaid), and adalimmab (Humira) are effective in pustular and chronic plaque psoriasis and for associated arthritis. Oral phosphodiesterase 4 inhibitors apremilast approved option for plaque-type psoriasis with minimal immunosuppressive effects. o Rosea: Pityriasis Rosea: Evaluation : common mild acute inflammatory disease that is 50% more common in females. Itching, oval fawn-colored, scaly eruption following cleavage lines of trunk, herald patch precedes eruption by 1-2 weeks. Eruption lasts 6-8 weeks. Diagnostic: finding one or more classic lesions: oval, fawn-colored plaques up to 2 cm in diameter, centers have a crinkled or cigarette paper appearance and collarette scale, lesions follow cleavage lines on the trunk/Christmas tree pattern, and proximal portions of the extremities are often involved. Inverse pityriasis rosea affects the flexures, papular variant can occur especially in black patients. Herald patch-often larger lesion, initial lesion that precedes eruption by 1-2 weeks. **check for serologic testing for syphilis. Differentials: Tinea corporis, seborrheic dermatitis, tinea verisicolor, certain medications (ACEi and metronidazole) and immunizations can mimic this disease. TREATMENT: often requires no treatment unless symptomatic. UVB treatments, short course of prednisone, topical corticosteroids of medium strength, triamcinolone 0.1%, and oral antihistamines. Macrolide antibiotic are controversial. o Tinea Corporis or Tinea Circinata (ringworm): Evaluation: Trichophyton rubrum is most common pathogen, ring-shaped lesions with scaly boarder, central clearing or scaly patches with a distinct boarder. Exposure to pets/microsporum infections, face arms, trunk. Diagnostics: diagnosis confirmation by KOH preparation or culture. Positive fungal studies distinguish tinea corporis from other skin lesions. Differentials: annular lesions of psoriasis, lupus erythematosus, syphilis, granuloma annulare, and pityriasis rosea. 1 TREATMENT: topical antifungals like econazole, miconazole, clotrimazole, butenafine, and terbinafine. Treatment for 1-2 weeks after clinical clearing. Betamethasone diporpionate with clotrimazole (Lotrisone) is not recommended. Systemic measures: Itraconazole 200 mg daily for one week or Terbinafine 250 mg daily for one month. Also/Other Tinea: Tinea cruris (jock itch), tinea manuum and tinea pedis (interdigital tinea pedis is the most common 1 predisposing cause of lower extremity cellulitis in health individuals), and tinea versicolor (malassezia infection of the skin-usually upper trunk). o Impetigo : Evaluation: contagious and autoinoculable infection of the skin/epidermis caused by staphylococci or streptococci. Superficial blisters filled with purulent material that rupture easily, crusted superficial erosions, and positive gram stain and bacterial culture. Often in face, ecthyma is a deeper form of impetigo with ulceration and scarring that happens on extremities. Diagnostics: gram stain and cultures confirm diagnosis. Differentials: acute allergic contact dermatitis and herpes simplex. TREATMENT: first line treatment: topical agents like bacitracin, mupirocin, and retapamulin for small areas. Systemic antibiotics for wide-spread cases. Cephalexin 250 mg four times a day or Doxycycline 100 mg BID. CA-MRSA coverage with doxycycline or TMP-SMZ, 50% of CA-MRSA are quinolone resistant. Recurrent impetigo/S Aureus treated with rifampin 600 mg daily for 5 days intranasal mupirocin ointment twice daily for 5 days clears the nasal carriage of MRSA strains. Bleach baths 3-4 times weekly ¼ to ½ cup per 20 liters of bathwater for 15 minutes. Household bleach to clean surfaces and reduce spread. o Acne Vulgaris : Evaluation: most common skin condition, polymorphic, open/closed comedones, papules, pustules, and cysts, more common in younger adults and males. Comedones are the hallmark of acne, affects face and upper trunk, and can cause scarring. Hyperandrogenism may be a cause of acne in women. Differential diagnosis: Rosacea, gram-negative folliculitis, tinea infections, staphylococcal folliculitis, miliaria/heat rash, or malassezia folliculitis or eosinophilic folliculitis. TREATMENT: education on use of medications and cosmetics, Diet-low glycemic diet/hyperinsulinemia has been associated. Comedonal acne: Proper hygiene, topical retinoids 0.25% cream use first twice weekly at night and then to nightly. Benzoyl peroxide/different concentrations, water-based gels, other 1 o Rheumatoid arthritis (RA): Evaluation : Morning stiffness and joint pain, symmetric polyarthritis, ulnar deviation, rheumatoid nodules, insidious onset, symmetrical swelling of multiple joints/tenderness, and pain. Chronic systemic inflammatory disease whose major manifestation is synovitis of multiple joints. More common in women than men, cause is unknown, genetic determinant, chronic synovitis with formation of a pannus which erodes cartilage bone ligaments and tendons, effusion are common 1 signs of inflammation. Symptoms include dryness of mouth, eyes, and other mucous membranes, and scleritis. Other symptoms include interstitial lung disease, pericarditis, pleural disease, palmar erythema, vessel vasculitis, narcotizing arteritis, and Felty syndrome. Diagnostics: Anti-CCP antibodies and rheumatoid factor are present in 70-80 percent of cases, ESR/C-reactive protein are typically elevated and antinuclear antibodies are found in about 20% of RA patients. Arthrocentesis is needed to diagnose superimposed septic arthritis- common complication. Imaging: radiographic changes are the most specific to RA. Differentials: osteoarthritis, CPPD disease, gouty tophi, spondyloarthropathies, Chronic Lyme arthritis, acute viral infections like chikungunya virus and parvovirus B19, chronic infection with hepatitis C, SLE, polymyalgia rheumatica, granulomatosis with polyangiitis, rheumatic fever, carditis and erythema marginatum, variety of cancers, hypertrophic pulmonary osteoarthropathy. TREATMENT: (corticosteroids, synthetic disease- modifying antirheumatic drugs (DMARDs), biologic DMARDs, and DMARD combinations) Low-dose corticosteroids like oral prednisone 5-10 mg daily, intra-articular corticosteroids may be helpful, triamcinolone 10-40 mg intra-articular. Methotrexate/synthetic DMARDs, 7.5 mg initially orally once weekly, increase by 15 mg once per week if initial does is not therapeutic, max dos is 20-25 mg/wk. Sulfasalazine, second line agent 0.5 BID, increase by 0.5 up to 3 g. Leflunomide/pyrimidine synthesis inhibitor, FDA approved for RA treatment, daily dose of 20 mg. Antimalarials, hydroxychloroquine sulfate 200-400 mg/day orally and tofacitinib/inhibitor of janus kinase 3 for refractory RA to methotrexate and dose includes tofacitinib 5-10mg twice daily. Biologic DMARDs: Tumor necrosis factor inhibitors, abatacept, rituximab, tocilizumab. DMARD combinations: methotrexate and TNF, methotrexate, sulfasalazine, and hydroxychloroquine, methotrexate plus etanercept. o Osteoarthritis (OA): Evaluation : Degenerative disorder with minimal articular inflammation, no systemic 1 symptoms, pain relieved by rest, most common form of joint disease, disease of aging. Age, obesity, and sex (more females than males) are risk factors, degeneration of cartilage and by hypertrophy of bone at the articular margins. Hereditary and mechanical factors for pathogenesis. Causes Heberden nodes and Bouchard nodes. Primary (most commonly affects DIP and proximal interphalangeal joints in fingers, hip, knee MTP joint and cervical/lumbar spine) vs secondary (occurs in any joints). Onset insidious. Diagnostics: 1 are most common features. Precipitated by antecedent gastrointestinal and genitourinary infection (1-4 weeks) and manifests as an asymmetric sterile oligarthritis typically lower extremities. Diagnostics: HLA-B27-positive in 50-80% of patients, radiographic sings of permanent or progressive joint disease seen in sacroiliac as well as peripheral joints. Differentials: Gonococcal arthritis, RA, ankylosing spondylitis, and psoriatic arthritis, Behcet disease and HIV common with reactive arthritis. Treatment: NSAIDs or individuals who do not response to NSAIDs can use sulfasalazine 1000 mg PO BID or methotrexate 7.5-20 mg PO per week, or if that is ineffective than anti-TNF agents. o Poisonings – symptoms / antidotes: Symptoms: Coma/airway protection, Hypothermia, hypotension, hypertension, arrhythmias, seizures, hyperthermia. Antidotes: Naloxone-opioid antagonists, and Flumazenil-for benzodiazepine overdose. TABLE 38-3 page 1594; Chapter 38; page 1591-1619 o Acetaminophen overdose : Specific antidote: N- Acetylcysteine (based on serum level). Overdose- greater than 150-200 mg/kg, or 8-10 g in an average adult. Causes hepatotoxicity, recommended maximum dose of 4g/day for several days. Causes nausea or vomiting, signs of toxicity may not show until 24-48 hours after ingestion. Fulminant hepatic necrosis can occur, jaundice, hepatic encephalopathy, AKI and death. Could cause acute comma, seizures, hypotension and metabolic acidosis. Diagnosis: Based on measurement of the serum acetaminophen level. TREATMENT: activated charcoal if it can be given 1-2 hours of ingestion; if serum or plasma acetaminophen level falls above the line on monogram/Figure 38-1 page 1599, treatment with N- acetylcysteine is indicated. PO or IV, PO 140 mg/kg followed by 70 mg/kg Q4H, 72-hour treatment. IV 150 mg/kg over 60 minutes, then 4-hour infusion 50 mg/kg and then 16-hour IV infusion of 100 1 mg/kg. Call poison control center. o Amphetamine/Cocaine overdose : euphorigenic and stimulant properties, causes anxiety, tremulousness, tachycardia, HTN, diaphoresis, dilated pupils, agitation, muscular hyperactivity and psychosis. TREATMENT: maintain patent airway, assist if 1 necessary, treat for seizures, lower body temperature, give IVF to prevent myoglobinuric kidney injury in patient with rhabdomyolysis. Treat symptoms with benzodiazepines such as diazepam 5-10 mg or lorazepam 2-3 mg IV. Phenobarbital 15 mg/kg IV for persistent seizures. Phentolamine 1-5 mg IV for HTN or nitroprusside, treat arrhythmias with short-acting BB such as esmolol. o Shoulder impingement syndrome: EVAULATION : subacromial impingement syndrome-shoulder pain with overhead motion, night pain while sleeping on shoulder; a collection of diagnosis that cause mechanical inflammation in the subacromial space, can be caused due to muscle strength imbalances, poor scapula control, rotator cuff tears, and subacromial bursitis/bone spurs. Clinically presents with one or more of the following: pain with overhead activities, nocturnal pain with sleeping on the shoulder or pain on internal rotation (putting on a jacket or bra). Atrophy in the supraspinatus or infraspinatus fossa, dyskinesis, rolled-forward shoulder posture of head forward posture, tenderness over anterolateral shoulder, lack full active range of motion but should have preserved passive ROM, + NEER and +HAWKINS impingement signs. Diagnostics: AP scapula, AP acromioclavicular joint, lateral scapula, and axillary lateral radiographs. MRI/US show tears or tendinosis, US can also show thickening of rotator cuff tendons and tendinosis. TREATMENT: conservative: first-line treatment: Education and PT, activity modification. No evidence for ICE/NSAIDS, some relief with corticosteroid injections. o Rotator cuff tear: Evaluation : common cause of shoulder impingement syndrome after age 40 (partial tears), difficulty lifting the arm with limited active ROM, weakness with resisted strength testing, caused by trauma or can be degenerative. Common with falls, outstretched arm or pulling on the shoulder, overhead movement or lifting. Full thickness rotator cuff tears may require 1 treatment: NSAIDs and analgesics, PT, McKenzie exercises, and oral Prednisone 1mg/kg daily and tapering over 10-15 days, neuropathic pain-calcium channel alfph-2-delta ligands like gabapentin, and tricyclic antidepressants. Other treatments include Epidural and transforaminal corticosteroids injections. Microdiscectomy, percutaneous endoscopic discectomy, disk replacement surgery, spine fusion surgery. 1 o Hip fractures: Evaluation : increased mortality in elders, osteoporosis, female sex, height greater than 5’8” and over 50 y/o are risk factors. Secondary to fall, internal rotation of hip, require surgical repair, patient may not be able to bear weight, Pain with internal rotation of the hip is the most sensitive test to identify intra-articular hip pathology. + Trendelenburg test can examine weakness or instability of the hip abductors. Diagnostics: AP views of the pelvis and bilateral hips, and frog-leg-lateral views of the painful hip. MRI/CT for hip fracture pattern. TREAMENT: most hip FX need surgery, surgery is recommended with the first 24 hours. Stress FX- protected weight bearing immobilizer and gradual return to activities. Femoral neck FX, hemiarthroplasty or total hip replacement. Peritrochanteric hip FX treatment with ORIF, plate and screw construct or intramedullary devices o Knee injuries : ACL injury (+Lackman test, anterior drawer test, and Pivot tests), MCL injuries (+valgus stress test, and varus stress test), and PCL injuries (+safe sign and posterior drawer test). Meniscus injuries (+McMurray test, Modified McMurray test, and Thessaly test). Patellofemoral pain, AKA runner’s knee (+apprehension sign and patellar grind test). TREATMENT: ACL Most people with need surgery, MCL injuries can be treated with protected weight bearing and PT, Isolated PCL injuries can be treated nonoperatively, immobilization with knee brace and knee extension, crutches, PT, however, PCL associated with other injuries that require operative reconstruction. Conservative treatment with Meniscus injuries, analgesics and PT. Conservative treatment ice/anti- inflammatory medication for runner’s knee and surgical treatment is last resort. o Ankle injuries: Both Inversion (localized 1 pain/swelling, majority of ankle injuries/lateral ligaments) and Eversion-high ankle sprains (severe and prolonged pain, limited ROM, mild swelling, difficulty with weight bearing). Inversion +anterior drawer test, subtaler tilt test . Imaging: Ottawa ankle rules. Eversion +external rotation stress test, affects anterior tibiofibular ligament, more painful than typical ankle sprain. TREATMENT: Inversion-MICE: modified activities, ice, compression, and elevation. PT and early motion. Eversion: Conservative with a 1 o Nail removal : for ingrown toenails and paronychia, education-cut nails straight across, notch center of nail with a V, absorbent socks. TWO methods: cotton wick insertion or partial avulsion with phenolization. Cotton wick insertion procedure: supine, feet flat, sanitize with antiseptic cleanser, file middle third of nail on the affected side with a nail file or emery board, roll cotton to forma. Wick, gently push cotton wick under the distal portion of the lateral nail groove on the affected side using splinter forceps, identify the offending spicule and remove it, continue to insert cotton wick to separate the nail for the groove, apply tincture of iodine to the cotton wick, cauterize granulomatous tissue with silver nitrate stick, bandage the toe. Check toe circulation, pain medication, oral antibiotics for 5 days, like cephalexin, and return to office in two days. o Skin closure: using Dermabond (tissue adhesive), only about 1/3 of wounds meet criteria for tissue adhesive closure, 5-0 or smaller diameter sutures. Procedure: Access wound, irrigate with saline, apply povidone- iodine to the wound beginning at the wound edges and expanding out in a circular pattern, let dry, remove with alcohol prep pad, put on gloves, topical anesthetic if needed, oppose the wound edges with good approximation, crush the dermabond vial and invert, apply to the approximated would edges with a gently brush motion to the edges-avoids oozing into the wound. Hold wound edges in place for 30 seconds, 10 seconds to make any corrects, apple a total of three layers of adhesive, and optional-steri-strips may be applied. Education: can shower within 6 hours after application, no topical antibiotics s/s of infection, return within 48 hours for follow up o Skin lesion: (removal) two methods, cautery and cryosurgery (superficial lesions-seborrheic keratoses). Indications for removing skin tags, BCC, actinic keratosis, lentigo, and warts. Contraindications-face or melanomas. Cautery: Position 1 patient, cleanse area, inject under lesion with 1% lidocaine or perform a field block, drap lesion, gloves, cauterize the lesion with the disposable cautery pen, wipe off the burned area, apple topical antibiotic and gauze. For Keloids either cryotherapy, corticosteroid injection or surgical excision. Skin tag/Acrochordon removal: either Snip or cryogenic techniques. 1 o Suture placement and management : repairs lacerations of the skin. Lidocaine or Bupivacaine used. Complications include infection with gram-positive bacteria (staph aureus or strep) or Gram-negative bacteria (proteus/kelbsiella/pseudomonas). Procedure: Position, apply povidone-iodine, gloves, infiltrate wound with 1% lidocaine-insert needle parallel along each side of the edge of the laceration to the farthest point, carefully explore wound, irrigate with sterile normal saline, trim with iris scissors if wound edges are ragged, place suture needle in needle holder, with opposite hand use forceps with teeth to grasp wound edge and evert the edges, penetrate the wound edge with the suture needing, tie suture off as determined by chosen technique, trim leftover suture to a length suitable for grasping with forceps for easy removal. Once completed, cleanse area with 0.9% sodium chloride, pate dry apply dressing. Keep clean/dry for 24 hours, then dressing can be removed. Bathing after 48 hours, pain management, s/s of infection, clean off crusts, wound check by 48 hours. o Immobilizations: Clavicle immobilization for clavicle FX. Three methods: clavicle strap technique, figure eight technique or sling and swath technique. Procedure: Clavicle strap technique: Place the straps over the client’s shoulder, one strap over each shoulder, pull straps gently toward the middle of the back and fasten, palpate the fractured clavicle checking that the displaced clavicle is pulled into alignment and obtain x-ray of the chest. o Bursa injection: Bursa Corticosteroid injection: decrease pain, promote joint function. Procedure: draw up lidocaine and corticosteroid into the syringe, mix by rolling/rocking syringe, mark the injection site with thumbnail, position patient-joint slightly flexed, gloves, clean site with povidone-iodine, insert needle 45-90 degree angle, aspirate-if blood remove needle, should be cloudy bursal fluid, inject corticosteroid, remove needle, apply pressure and cover with band aide. 1 A P P R OX I M AT E T IM E T O T Y P E N A M E A N D S O U R C E A D M I N I S T E R S T R E N GT H S W E A K N E SS E S Level-of- Glasgow Coma Scale 2 minutes Simple, valid, None observed. 1 conscious ness scale [a] reliable. Brief, reliable, can be administered by non- NIH Stroke Scale [b] 2 minutes neurologists. Low sensitivity. Some useful Stroke deficit Canadian Brief, valid, measures scales Neurological Scale [c] 5 minutes reliable. omitted. Walking is the only explicit Good for overall assessment Global disability assessment of criterion. Low scale Rankin Scale [d, e] 5 minutes disability. sensitivity. Widely used for stroke. Excellent Low sensitivity 5-10 validity and for high-level Barthel Index [f] minutes reliability. functioning. Widely used for stroke. Measures Measures of Functional mobility, ADL, disability/ activit Independence cognition, “Ceiling” and ies of daily Measure functional “floor” living (ADL) (FIM) [g] 40 minutes communication . effects. Several functions with summed score. May misclassify Folstein Mini- Mental Widely used for patients with State Examination [h] 10 minutes screening. aphasia. Does not distinguish right from left hemisphere. No reliability studies in stroke. No studies of Predicts gain factorial Neurobehavioral in Barthel Index structure. Mental Cognition Status scores. Correlates 1 status Unrelated with screening Exam (NCSE) [i] 10 minutes to age. education. Assessment of Fugl-Meyer [j] 30-40 Extensively Considered too motor function minutes evaluated complex and measure. Good time- consuming validity and by many. reliability