NURS 6531 FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS 100%CORRECT/VERIFIED BEST GRADED A+, Exams of Pharmacology

Download NURS 6531 FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS 100%CORRECT/VERIFIED BEST GRADED A+ and more Exams Pharmacology in PDF only on Docsity! NURS 6531 FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS 100%CORRECT/VERIFIED BEST GRADED A+ GUARANTEED SUCCESS LATEST UPDATE 2022 1.) Hydrocele (member did not use template, no review questions received-this is all I got) Definition: an accumulation of fluid within the tunica vaginalis surrounding the testicle; it may also result from a patent processus vaginalis at birth and sometimes closes spontaneously within the first 1 to2 years of life. Hydroceles are the most common cause of painless scrotal swelling.; in adults they are often the result of trauma, a hernia, testicular tumor, or torsion or a complication of epididymitis. Presenting Symptoms: Usually painless and may be present for long periods, partially resolve, and recur before the patient seeks medical attention. Gradual enlargement of the scrotum occurs with marked edema, which may be uncomfortable because of the added weight. A hydrocele may occur secondary toa tumor when excess serous fluid accumulates in the scrotal sac. It will transluminate but may make testicular palpation difficult. Leik Review: Hydrocele more common in infants. Serous fluid collects inside the tunica vaginalis. During scrotal exam,hydroceles are located superiorly and anterior to the testes Most hydroceles are asymptomatic. Will glow with transillumination. If new-onset hydrocele in an adult or enlarging hydrocele, order scrotalultrasound and refer to urologist. Differential Diagnoses: Epididymitis, Testicular torsion, epididymal cyst Review questions: 1. A patient who has had a swollen, nontender scrotum for one week is found to have a mass within thetunica vaginalis that transilluminates readily. The family nurse practitioner suspects: a.) a hydrocele.b.) a varicocele. c.) an indirect inguinal hernia.d.) carcinoma of the testis. 2.) Chronic Kidney failure: (member did not use template, no review questions received-this is allI got) Definition: The absence of kidney function. Kidney failure is also known as End Stage Kidney Disease. Itis characterized by anuria and the need for renal replacement therapy or kidney transplant. The kidneysand urinary tract system no longer filter blood, create filtrate. Or excrete urine in amounts sufficient toclear waste and balance fluid intake with output. Key highlights: Proteinuria or hematuria, and /or a reduction in the glomerular filtration rate, for more than 3 months duration. The most common causes 3 Differential Diagnoses: undescended testis, lymphadenopathy, femoral hernia Pattern Recognition: Enlarged hemiscrotum or a bulge in the groin area that may spontaneously reducewhen the patient is supine or with manual reduction. The provider will not be able to move the fingersabove the mass, which should be soft and mushy but painless unless it is incarcerated and ischemic. Scrotal hernias do not transilluminate. Auscultation of bowel sounds over the mass is significant for thediagnosis of bowel in the scrotal sac. Treatment options: If the herniated bowel is reducible, surgical referral for possible future repair isindicated. Difficulty in reducing a hernia is cause for urgent surgical intervention. However, pain mayindicate incarceration of the bowel or complete inability to reduce the hernia, which is cause for immediate emergency department referral and surgical exploration. Review questions: 1. Mr. S. comes to you with scrotal pain. The examinations of his scrotum, penis, and rectum arenormal. Which of the following conditions outside of the scrotum may present as scrotal pain? A. Inguinal herniation and peritonitis ** B.Renal colic and cardiac ischemia C. Pancreatitis and Crohn ’ s disease D.Polyarteritis nodosa and ulcerative colitis Rationale: Conditions outside of the scrotum that may present with scrotal pain are abdominal aorticaneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially in the age groups of the neonate and adolescents. 2. The most common type of hernia is a(n): A. indirect inguinal hernia. ** B. direct inguinal hernia. C. femoral hernia. D. umbilical hernia. Rationale: An indirect inguinal hernia is the most common type of hernia affecting all ages and both genders and accounts for 50% of hernias treated. The point of origin is above the inguinal ligament andoften travels into the scrotum. A direct inguinal hernia is less common (accounts for about 25% of hernias seen) and usually occurs in men older than age 40. The point of origin is above the inguinal ligament and rarely travels into the scrotum. The femoral hernia is the least common (about 10% of hernias seen) and occurs more often in women than in men. The point of origin is below the inguinal ligament and never travels into the scrotum in men. An umbilical hernia occurs more frequently in infants and is a protrusion of part of the intestine at the umbilicus. 3. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that it is not painful, but it is annoying. You note that the origin of swelling is above the inguinalligament directly behind and through the external ring. You diagnose this as a(n): A. indirect inguinal hernia. B. direct inguinal hernia. ** C. femoral hernia. D. strangulated hernia. Rationale: A direct inguinal hernia usually occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or chronic obstructive pulmonary disease (COPD). The origin of swelling is above the inguinal ligament directly behind and through the external ring. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 year ofage and in men ages 16 – 25. The origin of swelling is above the inguinal ligament. The hernia sac enters the canal at the internal ring and exits at the external ring. A femoral hernia, which occurs more frequently in women, is acquired and results from an increase in abdominal pressure, as well as muscle weakness. The origin of swelling is below the inguinal ligament. Because Max is not having any pain and the condition has been this way for months, you know that the hernia is not strangulated. A strangulatedhernia, which requires immediate referral to a surgeon, results in no blood supply to the affected boweland causes nausea, vomiting, and tenderness. 5.Orchitis Definition: Orchitis is a systemic, blood-borne infection that results in an acute inflammation of one or both testicles. It may coexist with infections of the prostate and epididymis; causes – viral infection (ex.Mumps), C. trachomatis and N. gonorrhoeae in adolescents, E. coli – men, complication of syphilis, mycobacterial, fungal; hydrocele and scrotal wall thickening may be seen as a complication of mumps Presenting Symptoms: Gradual onset of acute or moderate pain, testicular swelling, and fever 3 Differential Diagnoses: epididymitis, testicular tumor, hernia, testicular torsion Pattern Recognition: Testicular edema may be so pronounced that it is difficult to distinguish the testesfrom the epididymis. Palpation may reveal swollen, very tense testes that are painful, and the patient may be febrile. Inflammation of the testis usually involves systemic viral infections (commonly mumps) and includes unilateral or bilateral erythema, edema, and scrotal tenderness, which occurs 4 to 7 days after initial fever. Treatment options: Anti-infective therapy is recommended, with guidance by local sensitivity reports. The following antibiotic regimens are effective against the most common causes of epididymitis: single- dose ceftriaxone given intramuscularly (IM), 250 to 500 mg, and doxycycline, 100 mg twice daily for 10 days for men younger than 35 years; in men older than 35 years, levofloxacin position as a result of rotation. The spermatic cord is swollen and extremely tender, the epididymis may be felt anteriorly, and the majority of patients will have an absent cremasteric reflex. In some instances a small area of cyanosis (blue dot sign) may be present on the scrotal skin and indicates torsion of the appendix testis. Treatment options: Surgical consultation with surgical exploration – needs to occur in 6 hours. Review questions: 1.A 24-year-old man presents with sudden onset of left-sided scrotal pain. He reports having intermittent unilateral testicular pain in the past but not as severe as this current episode. Confirmationof testicular torsion would include all of the following findings except: A.unilateral loss of the cremasteric reflex. B.the affected testicle held higher in the scrotum.C.testicular swelling. D.relief of pain with scrotal elevation. ** 2. In assessing a man with testicular torsion, the NP is most likely to note:A.elevated PSA level. B.white blood cells reported in urinalysis. C. left testicle most often affected. ** D.increased testicular blood flow by color-flow Doppler ultrasound. 3.Anticipated organ survival exceeds 85% with testicular decompression within how many hours oftorsion? A.1 B.6 ** C.16 D.24 4. To prevent a recurrence of testicular torsion, which of the following is recommended?A.use of a scrotal support B.avoidance of testicular traumaC.orchiopexy ** D.limiting the number of sexual partners 7. Epididymitis 1Definition: Inflammation or infection of the epididymis. Commonly occurs in men younger than 35 yrs.of age with chlamydia as the cause. Men older than 35 yrs. is likely as a result of bacterial ascension frombladder or bacteria introduced during cauterization/surgery. Diagnostic test STD testing, urine culture and scrotal ultrasound R/O testicular torsion. 2Presenting Symptoms: pain, dysuria, urgency/frequency, low back pain/perineal pain,fever/chills/malaise, scrotal edema 3Differential Diagnoses: testicular torsion, inguinal hernia, hydrocele, testicular tumor, 4Pattern Recognition: Enlarged, tender epididymis, Urethral discharge may be evident, Positive prehnssign, Normal cremasteric reflex R/O testicular torsion. 5Treatment options: A Adult under 35yrs ceftriaxone 250mg IMx 1 PLUS Doxy 100mg BID a day or Azithromycin 1gm once.B Adult over 35 yrs Bactrim DS 1 tab BID a day x 10 days or cipro 250 mg BID x 10 days. C support/elevate scrotum D Analgesic NSIADs,ice(early),heat (late),bed rest.6 Review questions: 1. Jordan appears with a rapid onset of unilateral scrotal pain radiating up to the groin and flank. You aretrying to differentiate between epididymitis and testicular torsion. Which test to determine whether swelling is in the testis or the epididymis should be your first choice? A.X-ray B.Ultrasound C.Technetium scan D.Physical examination Answer B If your client has a rapid onset of unilateral scrotal pain radiating up to the groin and flank and you aretrying to differentiate between epididymitis and testicular torsion, an ultrasound test is useful to determine whether the swelling is in the testis or the epididymis and should be your first choice. Initially, before the swelling has reached its peak, a physical examination will probably differentiate, butwithin a few hours, when the testis also swells, it may not be possible to differentiate between epididymis and testis by palpation. A reactive hydrocele may also develop. A technetium scan will show an increased uptake in the case of epididymitis and decreased uptake in the case of torsion, but the leastinvasive and most inexpensive test is an ultrasound. 2. The nurse practitioner recognizes that the most common cause of epididymitis in a young man is:A chlamydia 3. Phosphodiesterase-5 (PDE%): Sildenafil or Tadalafil: used for men with mild to moderatesymptoms and erectile dysfunction 4. Saw Palmetto: herbal, may increase bleeding Balloon dilation: reduces symptoms in the short term TURP: effective for severe BPH, Gold standard treatment for bladder outlet obstruction, limited toprostates weighing less than 100g Review questions: 1.Which statement is true about the use of alpha blockers in the treatment of symptomatic BPH?They do not lower blood pressure in normotensive clients. 2.Milton, a 72 year old unmarried, sexually active white man presents to your clinic with complaints of hesitancy, urgency, and occasional uncontrolled dribbling. Although you suspect benign prostatic hypertrophy, what else should your differential diagnosis include? Urethral stricture (may develop as a result of sexually transmitted diseases and should be considered in a sexually active individual no matterwhat the age) 3. The action of a 5 alpha-reductace inhibitor in the treatment of BPH is to:reduce action of androgens in the prostate. 4.Harry has BPH and complains of some incontinence. Your first step in diagnosing overflowincontinence would be to order a: Post void residual urine measurement 5. Lower urinary tract symptoms in males can present as a constellation of storage or voiding symptoms.Storage symptoms include: urgency and nocturia 6.A 63-year-old man presents to you with hematuria, hesitancy, and dribbling. DRE reveals a moderatelyenlarged prostate that is smooth. The client’s PSA is 1.2. What is the most appropriate management strategy for you to follow at this time? Prescribe an alpha adrenergic blocker, which will relax bladder and prostate smooth muscle to improveflow and relieve symptoms. 7. In deciding whether to treat Morrison, who has BPH, you use the American Urological Associationscale. No treatment is indicated if the AUA score is 7 or lower. 8. According to the AUA guideline on the management of BPH, when is referral for invasive surgeryautomatically warranted? With the presence of refractory retention and bladder stones. 9.What differentiates prostate cancer symptoms from BPH? Symptoms of prostate cancer in general tend to progress more rapidly than those of BPH. 9. Chronic prostatitis- Definition : Inflammatory infection of the prostate. Usually caused by gram negative bacteria like E. coli.nonbacterial prostatitis mostly in young men caused by chlamydia, mycoplasma, Gardnerella. Diagnostic test is urine culture. Presenting Symptoms: fever /chills, low back pain, dysuria, urgency /frequency, nocturia Differential Diagnoses: cystitis, BPH, Kidney stones, bladder ca, prostatic abscess, enterovesical fistula. Pattern Recognition: Edematous prostate, may be warm and tender/boggy in palpitation, pain. Treatment options: Antibiotic choices : Bactrim,Levaquin,noroxin,ofloxacinB sitz bath 3 times a day for 30mins C no sexual intercourse until acute phase resolves Review questions: 1The most common gram-negative bacteria that causes both acute and chronic bacterial prostatitis is A. Staphylococcus aureus . B.Klebsiella . C.Escherichia coli . D.Enterobacteriac eae .Answer C The most common gram-negative bacterium that causes both acute and chronic bacterial prostatitis isEscherichia coli. The other aerobic gram-negative bacteria include Klebsiella, Pseudomonas, Enterobacteriaceae, Proteus mirabilis, and Neisseria gonorrhoeae. Occasionally other bacteria (Staphylococcus aureus and Streptococcus faecalis) are causes. Bacterial prostatitis, in which the prostate feels very tender and warm, is usually caused by Escherichiacoli. Clients with bacterial prostatitis usually also have a sudden onset of high fever, chills, malaise, myalgias, and arthralgias. In benign prostatic hypertrophy, the prostate gland would feel soft and nontender and would be enlarged. With prostatic abscess, the prostate feels like a firm, tender, or fluctuant mass. With prostate cancer, the prostate may have single or multiple nodules that are firm, hard, or indurated and are usually nontender. 10. Inguinal hernia Definition: An inguinal hernia happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall. Inguinal hernias occur at the inguinalcanal in the groin region. In males, the spermatic cords pass through the inguinal canals and connect to the testicles in the scrotum—the sac around the testicles. The spermatic cords contain blood vessels, nerves, and a duct, called the spermatic duct, that carries sperm from the testicles to the penis. In females, the round ligaments, which support the uterus, pass through the inguinal canals. Presenting Symptoms: The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sidesof the groin—the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down. Other signs and symptoms can include • discomfort or pain in the groin—especially when straining, lifting, coughing, or exercising—thatimproves when resting • feelings such as weakness, heaviness, burning, or aching in the groin • a swollen or an enlarged scrotum in men or boys • Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and cannot go back into the abdomen. A health care provider is unable to massagethe hernia back into the abdomen. • Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing “strangulation” of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die. 3 Differential Diagnoses: Ectopic testis, Femoral or inguinal adenitits, femoral hernia, sports hernia Pattern Recognition: Physical exam: Feel for a bulge in the inguinal area when a patient strains or coughs. If the hernia is causing problems and it is not reducible then x-ray, CT scan or Ultrasound may beneeded to see if it is incarcerated or strangulated. Treatment options: Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias andcan prevent incarceration and strangulation. Health care providers recommend surgery for most people with inguinal hernias and especially for people with hernias that cause symptoms. Research suggests that men with hernias that cause few or no symptoms may be able to safely delay surgery until their symptoms increase.3, 6 Men who delay surgery should watch for symptoms and see a health care provider regularly. Health care providers usually recommend surgery for infants and children to prevent incarceration.1 Emergent, or immediate, surgery is necessary for incarcerated or strangulated hernias. Review questions: 1.Gerard is complaining of a scrotal mass; however, the scrotum is so edematous that it is difficult to assess. How do you determine if it is a hernia or a hydrocele? Bowel sounds may be heard over a hernia. 2.Mr. S comes to you with scrotal pain. The examinations of his scrotum, penis, and rectum are normal.Which of the following conditions outside of the scrotum may present as scrotal pain? Inguinal hernia and peritonitis. Conditions outside of the scrotum that may present with scrotal pain are abdominal aortic aneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially In the age groups of the neonate and adolescents. 3.The most common type of hernia is an: indirect inguinal hernia 4.Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that is not painful, but it is annoying. You note that the origin of swelling is above the inguinalligament directly behind and through the external ring. You diagnose this as a: direct inguinal hernia: which occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or COPD. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 and in men ages 16-25. 11. Varicocele Definition: Enlarged pampiniform plexus veins within the scrotum. They form during puberty and cangrow larger over time. More common on the left side. Presenting Symptoms: Often asymptomatic. When there are symptoms they are: pain, infertility, andthey may cause one testicle to grow slower or shrink. 3 Differential Diagnoses: testicular tumor, inguinal hernia, hermatocele or spermatocele Pattern Recognition: Described as a “bag of worms” because of how they look and feel. Mass disappearswhen the patient lies down and reappears when the patient There is a higher risk of balanitis in which of the following conditions? A.Renal Insufficiency B.Diabetes Mellitus ** C.Graves’ disease D.Asthma Rationale: Balanitis is more common in uncircumcised, diabetic, and/or immunocompromised males. 2.Balanitis is caused by: A. Staphylococcus aureus B. Streptococcus pyogenes C.Candida albicans ** D.Trichomonads Rationale: Balanitis is most often caused by a Candidal infection of the glans penis. 3.Balanitis is a symptom of which one of the following diseases A. Psoriatic arthritis B.Reactive arthritis ** C.Alkylosing Spondylitis D.Rheumatoid arthritis Rationale: Circinate balanitis occurs in reactive arthritis (formerly known as Reiter Syndrome) presents aspainless, asymptomatic, shallow, ulcerative lesions on the glans of the penis. 13. Prostate cancer screening Prostate specific antigen (PSA) & Digital rectal exam (DRE) Controversial and conflicting depending on your source. Latest info from epocrates says: Screening forprostate cancer using the PSA may prevent mortality from prostate CA in a very small number of men.Prostate screening put many men in danger of long-term harms such as urinary incontinence and erectile dysfunction. If men desire prostate screening, it should only be done after risks vs benefit is explained. Routine screening for prostate cancer should not be done. Men age 55-69 should be given the risks vs benefit information and then they decide if they want to be screened. Men age 70 and older should not be screened. African Americans, obese, and those with a family history are more at risk. These groups should be informed of their increased risks of PC and also risks of testing and then make an informed decision. DRE does not improve detection of prostate CA andshould not be performed as part of a screening. Review Questions: The average American man has an approximately % lifetime risk of prostate cancer and anapproximately % likelihood of clinical disease. A. 15, 5 B. 25, 8 C. 40, 10 ** D. 60, 15 Rationale: The average American male has a 40% lifetime risk of latent prostate cancer, an approximate10% risk of clinically significant disease, and an approximate 3% risk of dying of prostate cancer. All of the following can cause an elevated PSA level except: A. Current prostate infection B. Recent cystoscopy C. BPH D. Prostatectomy ** Rationale: PSA levels can be transiently elevated in conditions other than prostate cancer, including prostatitis, or immediately after prostatic instrumentation such as cystoscopy. Levels often remain chronically elevated in patients with BPH. Serial increases even in the presence of a normal prostateexamination should be evaluated further. According to recent epidemiologic studies, prostate cancer is the number cause of cancer death inmen residing within the US. (B) A. 1 B. 2 ** C. 3 D. 4 Rationale: Prostate cancer is the second leading cause of male cancer death in the US. 14. PSA and DRE PSA (prostate-specific antigen) and DRE (Digital rectal exam) Definition: The DRE can reveal a discrete, painless lesion or area of induration in the POSTERIOR lobe ofthe prostate. PSA is a blood test that test for presence of glycoprotein which is produced in benign and d.Doxepin (Sinequan) Rationale: SSRI cause sexual adverse effects in up to 50% of men who take them. Paxil seems to havethe highest risk of ED. It can also affect women achieving orgasm. 2. Which of the following is not a common risk factor for erectile dysfunction (ED)? A. diabetes mellitus B. hypertension C. cigarette smoking D. testosterone deficiency ** Rationale: Any disorder that causes injury to the nerves or impairs blood flow in the penis has thepotential to cause ED 3.When taking a phosphodiesterase-5 (PDE-5) inhibitor, concomitant use of which medication must beavoided? A. statins B. sulfonylurea C. angiotensin-converting enzyme (ACE) inhibitors D. nitrates ** Rationale: The concomitant use of an ED medication with a nitrate is contraindicated because of the riskof profound hypotension ******THERE AREMAYMORE QUESTIONS FOR REVIEW IN THE FITZGERALD FILE***** 16. HPV (Human PapillomaVirus) Definition: most common STI in the US. Small percentage of women who have HPV develop cervical cancer with most lesions resolving spontaneously. Over 100 different types of HPV, 30-40 are genital subtypes. 13 are high risk types; especially types 17 and 18 which causes 70% of all cervical cancers. HPV-6 and 11 are associated with genital warts Presenting Symptoms: Normally lesions are not visible on cervix during pelvic examination. HPV isdetected through Pap test. 3 Differential Diagnoses: molluscum contagiosum, Marked cervicitis and erosion, Cervical polyp Pattern Recognition: Found with Pap Smear and HPV testing during pelvic examines. Usually cannot visually see changes in cervical tissue. High grade lesions may appear as dark, brownish lesions around the cervix. In severe cases, patient make present with abnormal irregular vaginal bleeding. Can appearas genital warts in genitalia area. Treatment options: HPV Vaccine (Gardasil) recommended for young girls and boys before becoming sexually active to prevent HPV strains 6, 11, 18, 31, 33, 45, 52, & 58, which are the strains that cause genital warts and cervical cancer. Cervarix is another vaccine only approved for girls. If HPV is detected,then biopsy has to be done as a definitive diagnostic test. CIN=no cervical dysplasia detected through biopsy. CIN 1= patient can manage conservatively with surveillance by Pap, or Pap and HPV test at particular intervals. CIN 2 and CIN 3 refer to OB/GYN Genital Warts treatment- podophyllotoxin and podophyllum resin, trichloroacetic acid and bichloroacetic acid, Fluorouracil, Imiquimod, Sinecatechins, Interferons. ALL TOPICAL AGENTS Surgeries include: Cryoblation with liquid nitrogen or nitrous oxide, Laser ablation, electrocautery, Ultrasonic aspiration, and excision biopsy Review questions: 1. What percent of patients with genital warts have spontaneous regression of the lesions? Presenting Symptoms: Adolescents and adults: fever (could exceed 103), chills, costovertebral angle tenderness, flank pain (usually unilateral), abdominal tenderness malaise, myalgia, hematuria (occurs in30-40% of women), nausea, vomiting, headache, dysuria, frequency, and urgency. Infants and children:fever (can progress to sepsis), failure to thrive, irritability, enuresis, nausea, and vomiting. Older adults:fever, mental status change, decompensation in another organ system, general deterioration 3 Differential Diagnoses: renal calculi, prostatitis, appendicitis, cholecystitis, urinary stones Pattern Recognition: E-Coli responsible for 75% of cases; most common route of infection is movementof bacteria from the bladder to the upper urinary tract; in neonates, the most common route is hematogenous spread to the kidneys. Treatment options: First line: Cipro 500mg PO BID for 7 days, Cipro XR 1000mg PO daily x 7 days,Levaquin 750mg PO daily for 5 days, Bactrim DS (160/800) 1 tab PO BID x 14 days Review questions: 1. When would you consider a CT scan or renal ultrasound for patients with acute pyelonephritis? If thepatient has not improved after 48-72 hours on an appropriate antibiotic. 2. What four reasons would you consider the infection complicated until proven otherwise? If thepatient is a man, an older adult, or child, or has symptoms lasting more than 7 days 3. What medication would you expect not to use in acute pyelonephritis? Do not use nitrofurantoinbecause poor tissue concentrations are achieved in the renal parenchyma 19. Urinary calculi (Renal Calculi--Nephrolithiasis) Definition: Commonly known as kidney stones. Renal, urologic, endocrine, and metabolic disorders canlead to the crystallization of material within the urinary system Typically classified by composition: Calcium Stones (most common approx 80%) Calcium Oxalate (most common of calcium type stones)Calcium Phosphate Uric acid (common in warm dry climates-40% incidence) Struvite Stones (result of infection-magnesium ammonium phosphate)Cystine (caused by genetic disorder) Mixed Risk Factors: Influenced by urine composition, Increased incidence in men vs women (4:1) Family History of Stones, Dehydration, Gout, Bariatric Surgery (increased oxalate excretion),Dietary High Protein Diet, High Vitamin C Diet (for men) Medications Topiramate, Indinavir (HIV) Presenting Symptoms: Hematuria, Dysuria, Abdominal, flank, or groin pain. Sudden onset, typically severe back and flank pain that waxes and wanes. Pain may radiate to groin, testes, suprapubic area,and labia. CVA tenderness Differential Diagnoses: Acute peritonitis, pyelonephritis: flank pain, fever, and pyuria (Fever is unlikely inuncomplicated stone), Acute Appendicitis, Pancreatitis Females Only: Salpingitis, Ectopic Pregnancy: occasionally mistaken (Clarified with renal/pelvicultrasound) Pattern Recognition: Classic Presentation: acute onset of unilateral severe colicky flank pain that waxesand wanes in waves where patient may become restless and unable to remain still at height of pain. Extreme pain is associated with N/V. Typically presenting with gross or microscopic hematura. 50% ofpatients pass stone within 48 hours. Diagnosis: Urinalysis, Imaging (Xray or CT), Analysis of collected stone to assist in future prevention Treatment options: Treatment varies based on size of stone as well as pain or obstruction. Analgesics,Alpha blocker, IV hydration in presence of nausea and vomiting, Strain Urine for Stone Retrieval, Shockwave lithotripsy (SWL), Ureteroscopy, Percutaneous nephrolithotomy and nephrostomy tube Special Considerations: Urology referral for larger stones, inability to pass, or acute renal failure. Referto ED for high fever (r/o urosepsis), extreme pain, acute renal failure Pregnant women: rule out ectopic, abruptio placentae, preterm labor, and kidney stones Prevention: Maintain adequate hydration, Calcium (general) stones: Reduce sodium and animal protein, Adequate calcium intake. Calcium Oxalate-reduce oxalate rich foods (ie beets, swiss chard, sweet potatoes, nuts, tea, chocolate, soy). Uric Acid Stones- limit animal protein Review questions 1.To decrease the production of uric acid stones, the family nurse practitioner orders which medication? A. allopurinol (zyloprim) B. indomethacin (indocin) C. bethanechol (urecholine) D. phenazopyridine (pyridium) Rationale: To decrease the formation of uric acid stones, a urinary alkylating agent, such as allopurinol isfrequently used. As standard practice, the family nurse practitioner should check the patient’s serum uricacid level monthly for three months to ensure the levels are decreasing to normal ranges and then annually once serum uric acid levels are normalized. 2. You see a 58-year-old man diagnosed with a kidney stone who reports Bouchard’s nodes (PIP joints) Commonly affected joints: DIP, PIP, CMC, MTP, hips, knees, cervical and lumbar spine Treatment options: Weight loss, knee or elbow braces to stabilize joints during exercise; NSAIDS:Ibuprofen, Naproxen, Meloxicam, Celebrex, Diclofenac PO or topical Review questions: 1.A 65-year-old carpenter complains of stiffness and pain in both hands and right knee shortly after waking and worsens in the afternoon. He feels some relief with rest. On, exam the nurse practitionernotices the presence of Heberden’s nodes. Which of the following is most likely? a. Osteoporosis b. Rheumatoid Arthritis c. Osteoarthritis d. Reiter’s syndrome Answer C Rationale- Heberden’s nodes are classic sign of OA. They are bony overgrowths located at thedistal interphalangeal joints. 2. Mary, age 72, has severe osteoarthritis of her right knee. She obtains much relief from corticosteroidinjections. When she asks you how often she can have them, how do you respond? A.Only once a year in the same joint B.No more than twice a year in the same joint C.No more than three to four times a year in the same joint D.No more than five to six times a year in the same joint Answer C. Rationale: Intra-articular corticosteroid injections provide much needed pain relief in weight-bearing joints of clients with osteoarthritis; however, they should be limited to no more than three to four in the same joint per year because of potential damage to the cartilage if given more frequently 3. Your 75-year-old client with osteoarthritis of the knee will be starting on a course of NSAIDs for painmanagement. The most important teaching point for your patient currently is: A.You should start with a high dose first and taper down the dose as needed. B.You should continue to take your Coumadin as you have been. C.Report any excessive stomach upset or if you notice that your stools become dark or bloody. D.At this point, it will not be helpful to lose weight. Answer CWhen clients are taking NSAIDs, there is always a risk of gastrointestinal tract bleeding, so the clients should be advised to look for signs of this complication. The American Academy of Family Physicians (AAFP) recommends that the smallest possible doses of NSAIDs for the shortest possible duration are best to minimize the incidence of side effects. The AAFP cautions to avoid using NSAIDs in clients taking anticoagulant such as Coumadin, as there may be an additive effect and increased risk of bleeding. Obesity is one of the major contributors to the development of osteoarthritis of the knee. Anyweight loss that can occur will remove stress from the client’ s joints and may improve overall cardiovascular health. 22. Rheumatoid Arthritis Definition: chronic systemic autoimmune disease that primarily affects the lining of the synovial joints Presenting Symptoms: Symmetric involvement; Morning stiffness and gelling; Hand and wrist (esp. MCPjoints) involvement; Shaking hands is painful (withdraws hand on squeeze); Characteristics of onset Onset over weeks to months; Prodromal symptoms of Anorexia, weakness, Fatigue. Usually starts in onejoint 3 Differential Diagnoses: Osteoarthritis, Fibromyalgia, Systemic Lupus Erythematous Pattern Recognition: ACR Rheumatoid Arthritis Diagnostic Criteria: Score of 6 or more is definitive for RAdiagnosis Joint Involvement Large joints: Shoulders, elbows, hips, knees and anklesSmall joints: MTP, PIP, DIP and wrists Points 0: One large joint involved Points 1: Two to ten large joints involved Points 2: One to three small joints involved (with or without large joint involvement)Points 3: Four to ten small joints involved (with or without large joint involvement) Points 5: More than 10 joints involved (with at least one small joint involved) Serology (Rheumatoid Factor, Anti-Citrullinated Protein Antibody) Points 0: RF negative and ACPA negativePoints 2: Low positive RF or ACPA Points 3: High positive RF or ACPA Acute Phase Reactants (C-Reactive Protein, Erythrocyte Sedimentation Rate)Points 0: Normal C-RP and ESR Points 1: Abnormal C-RP or ESR Answer D. Rationale Lysosomal degradation results when leukocytes produce lysosomal enzymes that destroy articular cartilage in rheumatoid arthritis. The collagen fibers and the protein polysaccharides ofarticular cartilage are broken down by the enzymes. Immune complexes initiate the inflammatory process that brings leukocytes to the cartilage. Immune complexes are formed by the combination of immunoglobulin G with rheumatoid factors that are the result of antigen-antibody formation. 23. Myasthenia gravis Definition: Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles of the body, which are responsble for breathing and movingparts of the body. In myasthenia gravis, the immune system--which normally protects the body from foreign organisms--mistakenly attacks itself. Presenting Symptoms: Symptoms vary in type and intensity. The hallmark of myasthenia gravis is muscleweakness that increases during periods of activity and improves after periods of rest. Certain muscles that control eye and eyelid movements, facial expression, chewing, talking, and swallowing are often, but not always, involved. The muscles that control breathing and neck and limb movements may also be affected. Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles. Normally when impulses travel down the nerve, the nerve endings release a neurotransmitter substance called acetylcholine. In myasthenia gravis, antibodies produced by the body's own immune system block,alter, or destroy the receptors for acetylcholine. The first noticeable symptoms include weakness in muscles, difficulty in swallowing, or slurred speech. Other symptoms may include blurred or double vision, drooping eyelid(s), and weakness in the arms, hands, fingers, legs, and neck. Myasthenia gravis isnot directly inherited nor is it contagious. 3 Differential Diagnosis: Botulism, Motor Neuron Disease, Generalized Fatigue Pattern Recognition: Myasthenia Gravis has the ability to affect ocular, bulbar, limb, and respiratory muscles. Transient worsening of myasthenic symptoms can be precipitated by concurrent infection, surgery, pregnancy, childbirth, certain medications. When severe, patients are at risk for life-threatening neuromuscular respiratory failure referred to as myasthenic crisis. Severe bulbar weakness that producesdysphagia and aspiration often complicates the respiratory failure. Patients in myasthenic crisis typicallyexperience increasing generalized weakness as a warning, although occasionally a patient will present with respiratory insufficiency out of proportion to their limb or bulbar weakness. Treatment Options: Symptomatic treatment (acetylcholinesterase inhibition) to increase the amount ofacetylcholine (ACh) available at the neuromuscular junction; Oral pyridostigmine is the most widely usedchoice. Pyridostigmine provides marked improvement in some patients and little or none in others Chronic immunosuppressive therapies (glucocorticoids and nonsteroidal immunosuppressive agents) to target the underlying immune dysregulation. Rapid but short-acting immunomodulating treatments (therapeutic plasma exchange andintravenous IVIG Immune Globulin), Surgical treatment (thymectomy) Review Questions: 1. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurseunderstands that this therapy is effective because it: A. Stimulates the production of acetylcholine at the neuromuscular junction. B. Promotes the removal of antibodies that impair the transmission of impulses C. Inhibits the breakdown of acetylcholine at the neuromuscular junction. D. Decreases the production of autoantibodies that attack the acetylcholine receptors. ** 2. Treatment for Myasthenia Gravis Includes: A. IVIG or Plasmapheresis ** B. Antibiotics C. Analgesic’s D. Sedation 3. What specific treatment is given patients diagnosed with Myasthenia Gravis that will focus onimproving conduction? A. Surgery B. Physical Therapy C. Mestinon (pyridostigmine) Neostigmine ** D. Fluroquinolones 24. Juvenile Rheumatoid arthritis Definition: fever lasting at least 2 weeks and arthritis lasting at least 6 weeks. Presenting Symptoms: high spiking fever (>101.3 – daily), rashes, markedly elevated WBC, anemia, lymphadenopathy diffuse joint pain. Patients younger than 16 years old, both sexes and can present asyoung as 1 year. 3 Differential Diagnoses: Infection (bacterial bone and joint), Viral and postinfectious arthritis,Inflammatory bowel disease, Kawasaki disease, Systemic lupus erythematosus Review questions: 1.The use of all of the following medications can trigger gout except: A. aspirin. B. statins. ** C. diuretics. D. niacin. The use of select medications, including thiazide diuretics, niacin, aspirin, and cyclosporine, canprecipitate gout by causing hyperuricemia; alcohol use is also a possible precipitant. 2.Which of the following dietary supplements is associated with increased risk for gout? A. vitamin A B. gingko biloba C. brewer’s yeast ** D. glucosamine Dietary modification to avoid foods with high purine content is an important and often overlooked intervention to minimize the risk of future gout episodes. Examples of high-purine foods include certain seafood (scallops, mussels), organ and game meats, beans, spinach, asparagus, oatmeal, and baker’s andbrewer’s yeasts when taken as dietary supplements. 26. Plantar fasciitis Definition: Plantar fasciitis is an acute or chronic pain in the inferior heel at the attachment of the medialband of the plantar fascia to the medial calcaneal tubercle. It has been described as a chronic inflammatory process and may be an overuse injury. Pain is worst when taking the first few steps out ofbed in the morning and after periods of rest. Although an aggravating condition, pain is self-limiting and usually resolves between 6 to 18 months without treatment. Presenting symptoms: heel pain (stabbing or knife-like), pain relieved with rest, poststatic dyskinesia Differential diagnosis: Plantar fascia rupture, Inferior calcaneal bursitis, Calcaneal contusion, Abductorhallucis tendonitis Pattern recognition: pain exacerbated by walking barefoot, pain improved with nonsteroidal anti- inflammatory drug (NSAID) use, no hx of acute injury to the heel, self-limiting pain, unilateral heel pain,positive dorsiflexion-eversion test, positive Windlass test, negative Tinel sign Treatment options: all patients rest and management of precipitating factors, stretching, low-Dye tapingor strapping, foot orthotics, night splint, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injection, other physical therapies: cast immobilization, extracorporeal shockwave therapy (ESWT), surgery Review questions: 1. Which of the following conditions places a patient at an increased risk of plantar fasciitis? A. Diabetes** B. Pregnancy C. Alcoholism D. Thyroid disease There is a greater risk of plantar fasciitis with obesity, diabetes, aerobic exercise, flat feet, prolongedstanding. 2. A 48-year old obese female presents to the clinic with complain of pain on the bottom of her feel withthe first few steps in the morning that gets worse with prolonged walking. You would suspect: A. Gout B. Morton’s Neuroma C. Rheumatoid Arthritis D. Plantar fasciitis ** Classic case of plantar fasciitis: middle-aged adult complains of plantar foot pain either on one or both feet that is worsened by walking and weight bearing. Complains that foot pain is worse during the first few steps in the morning and continues to worsen with prolonged walking. 27. Cruciate ligament tear Definition: Injured ligaments (ACL & PCL) are considered "sprains" and are graded on a severity scale. Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but isstill able to help keep the knee joint stable. Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This isoften referred to as a partial tear of the ligament. Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament.The ligament has been split into two pieces, and the knee joint is unstable. Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near completetears. Presenting Symptoms: When you injure your anterior cruciate ligament, you might hear a "popping"noise and you may feel your knee give out from under you. Other typical symptoms include: Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve onits own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee. 1.A 15-year-old high school athlete complains of a painful area below both knees. He tells you they feelbone-like and are tender to palpation. He denies any hot joints, fever, rash, or difficulties with weight- bearing. Which of the following conditions is most likely? a) osteomyelitis b) internal tibial torsion c)Osgood-Schlatter Disease** d)Calve-Perthe's Disease 2.When caring for the child with Osgood-Schlatter Disease, the nurse practitioner would know hertreatment has been effective when: a. The child no longer complains of pain at lower knee at rest b. The child no longer complains of pain at the ankle at rest. c.The child no longer complains of pain at the hip during exercise. d. The child no longer complains of pain at lower knee during exercise.** 3. Common risk factors for Osgood Schlatter Disease include: a.Highly active with open growth plates b. Significant Growth Spurt c.Typically asymmetrical but can occur bilaterally d.Boys> Girls e.All of the above ** 29. Patellar fracture Definition: A patellar fracture is a break in the patella, or kneecap, the small bone that sits at the front ofyour knee. Presenting Symptoms: The most common symptoms of a patellar fracture are pain and swelling in thefront of the knee. Other symptoms may include: Bruising, Inability to straighten the knee or keep it extended in a straight leg raise, Inability to walk 3 Differential Diagnoses: Soft tissue knee injury, ACL injury, Meniscus injury Treatment options: Some simple patellar fractures can be treated by wearing a cast or splint until the bone heals. In most patellar fractures, however, the pieces of bone move out of place when the injury occurs. For these more complicated fractures, surgery is needed to restore and stabilize the kneecap andallow for the return of function. Review questions: 1.What must you you do to diagnose a distal femur, patellar, and proximal tibia fracture?Obtain imaging according to Ottawa knee rules 2.What are the key physical findings of patellar fractures? palpable DEFECT on patella, HEMARTHROSIS, Failure to do STRAIGHT LEG RAISE = failure of EXTENSORMECHANISM (retinaculum displaced) 3.What is the classification of patella fractures?Just based on FRACTURE PATTERN -Nondisplaced -Transverse -Pole/sleeve (upper/lower) -Vertical -Marginal -Osteochondral -Comminuted (Stellate) 30. Acute back pain -- Low Back Pain Definition: Most common musculoskeletal problem worldwide. 2nd most common reason for visits to aphysician’s office in the US. It is commonly classified by symptoms duration as acute, subacute, or chronic. Most people recover within 1 – 6 weeks. Reoccurrence rates are high, with 50% reporting reoccurrence within 6 months. It is usually transient, if it persists and becomes subacute with an increased chance for developing chronic low back pain. Acute back pain lasts less than 6 weeks and is usually mechanical. Subacute lasts 6 weeks to 3 months and can be mechanical or systemic medical (nonmechanical). Chronic is more than 3 months with symptoms more than half the days in the last 6 months. Risk factors are broad. They include jobs involving heavy lifting, pulling, pushing, prolonged standing or walking, and vehicular driving. Age, smoking, obesity, and genetic disposition. on the back muscles. Never bend and twist simultaneously, but rather keep the spine straight tominimize injury 31. Spondylolithiasis- Definition: spinal disorder in which a bone (vertebra) slips forward onto the bone below it Presenting Symptoms: usually asymptomatic, occurs during growth spurt in late childhood/early adolescence, unlikely cause of back pain in adults after 40yo with no history of symptoms prior to age30, if symptoms are present usually low back pain that is exacerbated by motion, especially twisting. Tenderness to deep palpation of the spinous process above slip (typically L4). Positive 1 leg hyperextension test (stork test), however not confirmatory test. Hamstring tightness occurs in 80%, muscle spasm and tenderness present. 3 Differential Diagnoses: osteomyelitis, Scheuermann disease, mechanical low back pain Pattern Recognition: Imaging needed for diagnosis pursued in this specific order: standing lateral xrays,standing extension/flexion xrays, SPECT scan, CT, MRI Treatment options: Rest, PT after pain with ADLs has subsided, OT, bracing. Surgery performed in skeletally immature patients w >30-50% slippage, progressive neurologic deficit, or pain persisting morethan 6-12 months that is not relieved with rest and immobilization Review questions: 1. With the straight-leg–raising test, the NP is evaluating tension on which of the following nerve roots? A. L1 and L2 B. L3 and L4 C. L5 and S1 D.S2 and S3 ANSWE R: C 2. The most common sites for lumbar disk herniation are: A. L1 to L2 and L2 to L3. B. L2 to L3 and L4 to L5. C. L4 to L5 and L5 to S1. D.L5 to S1 and S1 to S2ANSWER: C 3. Immediate diagnostic imaging for low back pain should be reserved for all of the following EXCEPT: A. presence of signs of the cauda equina syndrome. B. presence of severe neurological deficits. C. presence of risk factors for cancer. D. presence of moderate pain lasting at least 2 weeks.ANSWER: D 32. Bursitis Definition: acute or chronic inflammation of bursa (sac containing synovial fluid between tendon and either skin or bone). Thickening and proliferation of synovial lining, bursal adhesions, villus formation, tags and deposition of chalky deposits usually resulting from repetitive stress, infection, autoimmune disease, or trauma Presenting Symptoms: localized pain and tenderness over a bursa and swelling if superficially sited 3 Differential Diagnoses: baker cyst, soft tissue infection, fracture Pattern Recognition: pain, tenderness, decreased active range of motion, swelling, (warmth, erythema,low grade fever in septic bursitis) Treatment options: 1st line rest, ice, modification in activity and lifestyle, NSAIDs. 2nd line corticosteroidinjections. 3rd line surgery to remove bursa (septic bursitis: needle aspiration and antibiotic therapy) Review questions: 1. First-line therapy for prepatellar bursitis should include: A. bursal aspiration. B. intrabursal corticosteroid injection. C. acetaminophen. D. knee splinting. ANSWER: A 2. Clinical conditions with a presentation similar to acute bursitis include which of the following? (Morethan one can apply.) A. rheumatoid arthritis B. septic arthritis C. joint trauma D. pseudogout ANSWER: all of the above 3. Patients with subscapular bursitis typically present with: A. limited shoulder ROM. B. heat over affected area. C. localized tenderness under the superomedial angle of the scapula. D. cervical nerve root the ankle. 34. Olecranon bursitis Definition: The human body contains more than 150 bursae. These fluid filled sacs act as a cushion between tendons and bones. Bursitis develops when the synovial tissue that lines the sac becomes thickened and produces excessive fluid, leading to swelling and resulting pain. The bursae are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures. Themost commonly affected bursae are the subdeltoid, olecranon, ischial, trochanter, and prepatellar. In contrast to most forms of arthritis, bursitis typically presents with an abrupt onset with focal tendernessand swelling. The joint range of motion (ROM) is usually full but is often limited by pain. Risk factors include prolonged pressure or trauma to the elbow (also known as draftsman’s elbow). Presenting Symptoms: Pain, swelling behind the elbow, swelling in the same area, often described asball or sac hanging from elbow. 3 Differential Diagnoses: Rheumatoid arthritis, joint trauma, pseudogout. Pattern Recognition: abrupt onset with focal tenderness and swelling. The joint range of motion (ROM)is usually full but is often limited by pain. Treatment options: first-line therapy includes minimizing or eliminating the offending activity, applying ice to the affected area for 15 minutes at least four times per day, and taking nonsteroidal anti- inflammatory drugs (NSAIDs). If these conservative measures have not worked after approximately 4 to8 weeks, intrabursal corticosteroid injection should be performed. Before injection, patients should be informed of the risks of this procedure, especially the most common problem, soreness at the injectionsite. After corticosteroid injection, infection, tissue atrophy, and inflammatory reaction are possible, butrarely encountered, complications. Review questions: 1. The most common cause of acute bursitis is: A. Inactivity B. Joint overuse C. Fibromyalgia D. Bacterial infectionAnswer: B Rationale: Risk factors for acute bursitis include joint overuse, trauma, infection, or arthritis conditions such as rheumatoid arthritis or osteoarthritis. Because recurrence is common, prevention of further jointoveruse and trauma should be emphasized. 2. First-line treatment options for bursitis usually include: A. corticosteroid bursal injection. B. heat to area. C.weight-bearing exercises. D. nonsteroidal anti-inflammatory drugs (NSAIDs).Answer: D Rationale: first-line therapy includes minimizing or eliminating the offending activity, applying ice to theaffected area for 15 minutes at least four times per day, and taking nonsteroidal anti-inflammatory drugs(NSAIDs). 3.Likely sequelae of intrabursal corticosteroid injection include: A. irreversible skin atrophy. B. infection. C. inflammatory reaction. D. soreness at the site of injection.Answer: D Rationale: If conservative measures have not worked after approximately 4 to 8 weeks, intrabursalcorticosteroid injection should be performed. Before injection, patients should be informed of the risks of this procedure, especially the most common problem, soreness at the injection site. Aftercorticosteroid injection, infection, tissue atrophy, and inflammatory reaction are possible, but rarely encountered, complications. 35. Lateral epicondylitis Definition: also known as "Tennis Elbow", is the most common overuse syndrome in the elbow. It is atendinopathy injury involving the extensor muscles of the forearm. These muscles originate on the lateral epicondylar region of the distal humerus. Presenting Symptoms: Patients complain of pain over lateral epicondyle or outer aspect of lower humerus, which increases with resisted wrist extension, especially with elbow. Hand grip is often weakon affected side. Elbow ROM usually is normal. Often called tennis elbow, results from repetitive activity such as lifting, use of certain tool, playing sports involving a tight grip. Prevent recurrence by avoiding precipitating causes, ensuring proper use of tools, using proper bodymechanics, and developing of flexibility and strength of the involved musculature. 3 Differential Diagnoses: Pattern Recognition: Women ages between 40 and 60 years are at highest risk. The symptoms are typically worse at night and characteristically awaken affected patients from sleep. CTS symptoms are often provoked by activities that involve flexing or extending the wrist or raising the arms. Risk factors for CTS include obesity, coexisting conditions (diabetes, pregnancy, rheumatoid arthritis, osteoarthritis ofthe hand, hypothyroidism, and connective tissue diseases. In addition, occupational biomechanical factors involving the hand and wrist, particularly repetition, forceful exertion, and vibration. Treatment options: a. Limiting the activity that caused the condition and elevating the affected extremity. b. Application of a volar splint in a neutral position to help relieve the increase in intracanalpressure caused by wrist flexion and extension. c. NSAIDS and acetaminophen provide pain relief. d. Corticosteroid injection into the carpal tunnel to help reduce the swelling. e. Surgery to release the transverse carpal ligament provides symptom relief in most patientswhose CTS does not respond to conservative therapy. Review questions: 1.Carpal tunnel syndrome is inflammation of the: A)Ulnar nerve B)Radial nerve C)Brachial nerve D)Median nerve ** Rationale: By compressing the median nerve within the carpal tunnel, characteristic symptoms— burning; tingling; numbness over the thumb, index, middle, and ring fingers—convey a positive test. ThePhalen maneuver is a diagnostic test for carpal tunnel syndrome. The Phalen test is done by pushing the back of the hands together for 1 minute. Symptoms indicate a positive result for carpal tunnel. 2.The Phalen test is used to evaluate for: A) Inflammation of the median nerve ** B)Rheumatoid arthritis C)Degenerative joint changes D)Chronic tenosynovitis Rationale: The Phalen maneuver is a diagnostic test for carpal tunnel syndrome. The Phalen’s test is doneby pushing the back of the hands together for 1 minute. By compressing the median nerve within the carpal tunnel, characteristic symptoms (burning, tingling, numbness over the thumb, index, middle and ring fingers) convey a positive test result. 3. Sandra, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. Yournext step is to A. refer her to a hand surgeon. B. take a more complete history. C. try neutral position wrist splinting and order an oral NSAID. ** D. order a nerve conduction study such as an electromyography (EMG). Rationale: For the client who has just been given a diagnosis of carpal tunnel syndrome, your next stepis to try neutral position wrist splinting and order an oral NSAID. For symptoms of less than 10 months ’ duration, conservative treatment should be tried first. Taking a more complete history is not essential at this point because a diagnosis has already been made. Nerve conduction studies (i.e., electromyography [EMG]) confirm focal median nerve conduction delay within the carpal canal and also provide information about disease severity. For refractory cases, median nerve decompression may beaccomplished by surgery, but complete recovery is not possible if atrophy is pronounced. 37. Ankle Sprain Definition: The ankle joint is the most primitive joint in the body and important for walking, running, andthe performance of sports. There are three major bones of the ankle: tibia, fibula, and talus. Ankle sprains happen at all ages and are a common problem seen by providers. A sprain is a ligamentous injury caused by an abnormal motion, sudden change in direction, or a misstep on an uneven surface. A minor ankle sprain can even jeopardize joint stability. The severity of the physical findings will determine the sprain category, and the sprain category will determine the treatment. Grade 1: stretching or minor tearing of ligament fibers. Minimum pain, mild bruising, full ROM, mild jointtenderness, stable joint, and ability to bear weight. Grade 2: Partial tearing of ligament and fibers. Mild to moderate pain, moderate swelling and bruising, painful, slightly limited motion and stability, tenderness over joint, mild joint laxity with stress, painful tobear weight and may be unable to do so. Grade 3: Complete tearing of ligament fibers. Severe pain, Significant swelling and bruising, loss ofmotion and stability, severe pain, abnormal joint movement, inability to bear weight. Presenting Symptoms: Most common is swollen and painful joint. Bruising and decreased motion usuallypresent. It is important when obtaining history to determine whether the patient heard any audible sounds at the time of the injury. Immediate swelling or bruising causes concern for fracture. 3 Differential Diagnoses: Infection, facture, tendinitis, arthritis. Treatment options: RICE are key first steps. NSAIDs can help with pain management. Grade 1: RICE, active ROM exercises, non-weight bearing activity such as Presenting Symptoms: fever, chills, lethargy, pain, swelling, erythema in infected area. Restriction ofmovement in area involved 3 Differential Diagnoses: systemic infection from another source, neuropathic joint disease (charcotfoot), localized inflammation or infection of overlying skin and soft tissues (gout) Treatment options: direct empiric therapy toward probable organism and tailor according to culture results. 4-6 weeks of therapy is appropriate for acute osteomyelitis. >8 weeks for chronic osteomyelitisor MRSA infection. Additional therapies include: hyperbaric oxygen therapy, negative pressure wound therapy, surgicaldrainage Review questions: 1. Janice is recovering from osteomyelitis of her leg. She asks you for advice as to what she can do topromote healing. You tell her to: A. put weight on the affected leg more frequently to promote increased circulation, oxygenation, andnutrition to the tissues of the wound area. B. eat foods high in vitamins and calcium and increase her calorie and protein intake. C. spend time in the fresh air and expose the wound to fresh air and sunlight. D. be sure to use strict aseptic technique when changing the dressing, which should be kept wet at alltimes to improve wound healing. Answer: B Rationale: To help Janice recover from osteomyelitis and promote healing, advise her to do the following: Do range-of-motion and strengthening exercises; eat foods high in vitamins and calcium; and increase caloric and protein intake, as well as fluid intake, which helps minimize the risks of kidney damage, yeast infections, and adverse gastrointestinal effects. You do not have enough history in the stem of the question to determine if the client should bear weight. Likewise, it is unclear if exposing thewound to open air would be helpful or if wet dressings should be applied. 2.Dan, age 49, developed osteomyelitis of the femur after a motorcycle accident. Which of the followingstatements about the clinical manifestations of osteomyelitis is correct? A. Integumentary effects include swelling, erythema, and warmth at the involved site. B. There is a low-grade fever with intermittent chills C.Musculoskeletal effects include tenderness of the entire leg. D.Cardiovascular effects include bradycardia.Answer: A Rationale: The clinical manifestations of osteomyelitis include the integumentary effects of swelling,erythema, and warmth at the involved site, as well as drainage and ulceration through the skin and lymph node involvement, especially in the involved extremity. The client with osteomyelitis may alsohave tachycardia, localized tenderness, and a high fever with chills. 39. Muscular dystrophy Definition: Group of more than 30 genetic diseases characterized by progressive weakness anddegeneration of the skeletal muscles that control movement. Duchenne MD – most common form affecting boys Some forms appear in childhood and infancy, while others may be seen until middle adulthood or later. Caused by the absence of dystrophin (protein involved in maintaining the integrity of muscles. Onset is between 3-5 years and the disorder progressesrapidly. Most boys are unable to walk by age 12 and later needs a respirator to breath. Girls in these families have 50% of inheriting and passing the defective gene to their child. Becker MD – very similar but less severe than Duchenne md have faulty or not enough dystropin in theirbody Facioscapulohumeral MD – usually begins in teenage years and causes progressive weakness in musclesof the face, arms, shoulders, and chest. It progresses slowly and can vary in symptoms from mild to disabling. Myotonic MD – most common adult form. Typified by prolonged muscle spasms, cataracts, cardiac abnormalities, and endocrine disturbances. Individuals have long thin faces, drooping eyelids, and swanneck. Cause of death from respiratory failure. Muscles are infiltrated by fatty and fibrous tissue causing progression of painless necrosis and degeneration of muscle fibers. X-chromosome gene is responsiblefor miscoding the protein dystrophin. Mental retardation is present in 30% of patients with Duchene muscular dystrophy. Elevated CK is due to the increased permeability of the sarcolemma and skeletal muscle necrosis. CK levels decreases when there are fewer muscles to be broken down. Waddling gait,clumsiness, and frequent falling are seen due to weakness of muscles of the pelvis and shoulders in young children. Gower’s sign when the patients walk up their legs to stand due to weak pelvic girdle. Skeletal muscle atrophy and filled with fat and fibrous tissue infiltration appearing as muscle tissues inthe calf. Calves hypertrophy. Ventilatory impairment is due to restrictive type. Pt presents with ineffective cough, impaired swallowing, and inability to mobilize secretions. The heart is a muscle, Differential diagnoses: Neurofibromatosis, cerebral palsy. Juvenile idiopathic scoliosis, multiplesclerosis, Rett syndrome Pattern recognition: screen girls at 10 and 12 years old, boys only once bet 13-14 years old; unequalshoulder heights; unequal scapular prominences and heights; unequal waist angles; unequal rib prominences with forward flexion(ADAM’s Forward bending test); chest or back symmetry * Functional scoliosis disappears when bending forward, accentuated with structural scoliosis Scoliosis assessment: 0-9 degree convexity 10-19 mild scoliosis 20-29 moderate 30-39 marked scoliosis Treatment Options: Serial casting or bracing for infants with greater than 25- degree curvature. “Growthfriendly” spinal surgery when bracing is not tolerated or is ineffective. Thoracolumbar orthosis (TLSO) for skeletally immature patients with 25-45 degree curve. Spinal fusion - adolescents with 45- degree curvature or adults with greater that 50-60 curvature. Neuromuscular scoliosis – wheelchair, varied bracing options, surgical approach for underlying cause Review Questions: 1. The following are causes of scoliosis except: a. unknown b. spinal congenital deformity c. arthritis d. herniated disc.Ans: D 2. It is defined as a true deformity of the spine a. functional scoliosis b. structural scoliosis c. arthritic scoliosis d. neurofibroma scoliosisans. B 3. Screening for females are recommended at what age? A. 5 and 12 B. 7 and 11 3. 14 and 15 d. 10 and 12.Ans: d 41. Septic Arthritis Definition: infection due to bacterial invasion of the joint space. It affects the musculoskeletal system.Also referred to as infectious arthritis, pyarthrosis, pyogenic arthritis, bacterial arthritis. Risk factors include: age >80, low socioeconomic status, alcoholism, cellulitis and skin ulcers, violation of joint capsule, history of previous joint disease, and systemic illness. Presenting Symptoms: typically presents with combination of joint pain, swelling, warmth, anddecreased range of motion. 3 Differential Diagnoses: crystal arthritis, osteoarthritis, inflammatory arthritis (RA, SLE, sarcoidosis) Pattern Recognition: swollen, tender joints, limited ROM Treatment options: admit patient for parenteral abx and monitoring, drainage of purulent material.Consider referral to infectious disease and orthopedic Review questions: 1. Bouchard’s nodule is found in which of the following? A)Rheumatoid arthritis B)Degenerative joint disease C) Psoriatic arthritis D) Septic arthritis Answer: B) Degenerative joint disease Rationale: Enlargement of the middle joint of a finger is called a Bouchard’s node. Signs of osteoarthritis(OA) include stiffness of joints, especially in the morning and after sitting for long periods. Visible signs ofOA are an element in the diagnosis. (RA and gout often rely more heavily on lab tests.) Heberden nodes (bony overgrowths) are classic signs of OA. They are located at the distal interphalangeal joints. They are felt as hard, nontender nodules usually 2–3 cm in diameter but sometimes encompass the entire joint. 2. Podagra is associated with which of the following? A)Rheumatoid arthritis B)Gout C)Osteoarthritis D) Septic arthritis Answer: B) Gout Rationale: Gout (also known as podagra when it involves the big toe) is history and physical examination in 50-85%of patients. No single laboratory test has greater diagnostic efficacy. A detailed account of the event must be obtained from the patient. The account must include the circumstances surrounding the episode: the precipitant factors, the activity the patient was involved with prior to the event, and the patient's position when it occurred. Precipitating factors can include fatigue, sleep or food deprivation, warm ambient environment, alcohol consumption, pain, and strong emotions such as fear or apprehension. Differential Diagnosis: Drop attacks, Coma, Vertigo, Seizure disorder, Stroke/TIA, Psychiatric Pattern Recognition: Vasomotor/vascular conditions to consider in patients with suspected syncopeinclude the following: Dehydration, Diabetic neuropathy, Diuresis, Drug-induced orthostasis, Dysautonomia, Ectopic pregnancy, Hemorrhage, Hypotension, Hypovolemia, Multisystem atrophy, Peripheral polyneuropathy, Postural hypotension, Subclavian steal, Vasodepressor/vasovagal response,Vasomotor insufficiency, Cardiac conditions to consider in patients with suspected syncope include the ,following: Bradydysrhythmias, Cardiac myxoma, Cardiac outflow obstruction, Dysrhythmias, Hypertrophic subaortic stenosis, Paroxysmal supraventricular tachycardia, Paroxysmal ventricular, tachycardia, Primary pulmonary hypertension, Prolonged QT syndrome, Sick sinus syndrome, Sinoatrialblock, Sinus pause (>3 s), Tachydysrhythmias, Tricuspid stenosis Treatment options: General measures include reassurance, education, behavior modification. Meds arebased on underlying cause, whether cardiac or neurologic. In cases with recurrent NMS, Mineralocorticoids a-adrenergic agonists are used; second line therapy: SSRIS, vagolytics Review questions: 1. Jonas, age 62, experienced a temporary loss of consciousness that was associated with an increasedrate of respiration, tachycardia, pallor, perspiration, and coolness of the skin. How would you describe this? A. Lethargy B.Delirium C. Syncope** D.A fugue state 2. The Hallpike maneuver is performed to elicit A. a seizure. B. vertigo. C. syncope.** D. a headache. 3. Common signs of high-grade aortic stenosis in an individual during exercise include all of the followingexcept: A. dyspnea. B. angina. C. seizure. D. syncope.** 44. Migraine - Migraine Headaches Definition: Migraine headache is a common headache disorder which can be disabling, It can be with or without an aura. Migraine headache with an aura occurs with preceding signs such as blind spots, flashing light or changes in visual fields, tunnel vision, halos preceding the headache. Aggravating factorsinclude: foods high in triptans, teenage to middle age. Migraine without aura occurs with throbbing painbehind one eye, photophobia, phonophobia (noise), nausea/vomiting. Aggravating factors include: Redwine, MSG, aspartame, menstruation, stress Risk factors: Being female, or positive family history, excessive sleep, insomnia, long periods betweeneating, low weather pressure changes Presenting Symptoms: Gradual onset, throbbing headache, sensitivity to light and noise, throbbing painbehind one eye which can be bilateral without treatment 3 Differential Diagnoses: Headache disorders, Secondary headaches, Giant cell arteritis, Mental healthdisorder, TIA, Syncope, Seizure Pattern Recognition: Changes in mental state, aphasia, fatigue, anorexia, n/v, irritability, restlessness,aura, dizziness, tingling, numbness, weakness Treatment options: Nonpharmacological: Rest in a quiet darkened room with an ice pack to forehead; Ginger ale or dry toast or crackers for nausea, relaxation techniques. Avoid fatty foods, MSG, red wines,beer, caffeine, chocolate, nitrates/nitrites in hot dogs, sausage, luncheon meats, Sleep changes, stress, barometric weather changes, Avoid visual triggers (glares, sunlight, strobe lights); Avoid odor triggers, (tobacco smoke, perfumes, strong odors); Pharmacological: Abortive agents (Triptans or Ergotamine) orProphylactic agents (beta-Blockers or Anticonvulsants); Sumatriptan (Imetrix) NSAIDs, analgesics( extra strength Tylenol), Narcotics, ( codeine, hydrocodone), aspirin, Magnesium 600mg po daily or riboflavin 400mg po daily may be beneficial. Metoclopramide, prochlorperazine fornausea/vomiting Review questions: a. Photophobia is seldom reported. b. The pain is typically described as “pressing” in quality ** c. The headache is usually unilateral d. Physical activity usually makes the discomfort worse 2. A first-line prophylactic treatment option for the prevention of tension-type headache is a. Nortriptyline ** b. Verapamil c. Carbamazepine d. valproate 3. Migraine associated with muscle or neck pain, which is NOT an International Headache Societymigraine diagnostic criterion, is often diagnosed as a. Sinus headache b. Cluster headache c. Increased intracranial pressure d. Tension-type headache ** 46. Subarachnoid hemorrhage Definition: Subarachnoid Hemorrhage are usually caused by a ruptured saccular aneurysm in the circle of Willis in the brain. Arteriovenous malformation or inherited bleeding disorders are another cause. A subarachnoid bleed occurs in the subarachnoid space, the area between the tissue that covers the brainand the brain. Risk factors are smoking, HTN, connective tissue disorders, polycystic kidney disease andfamily history of aneurysms. The mortality rate is 50% with 10-15 % of patients dying before they reachthe hospital. Presenting Symptoms: Sudden onset of severe headache described as the “worst headache of my life” accompanied by photophobia, nausea/vomiting, meningeal irritation (stiff neck, positive Brudzinski and Kernig sigh), rapid decline in level of consciousness. Some people experience a small leak called sentinelheadache (sudden onset) resolved headache that then leads to a major hemorrhage. Sentinel headachecan occur a few days before up to 20 days before the event. Seizures occur during the first 24 hours in less than 10% of the patients. SAH account for 5% of the total strokes (CVA 80%, 15% ICH) Kernig’s Sign: Flex patients hips one at a time, then attempt to straighten the leg while keeping the hipflexed at 90 degree. Positive: resistance to leg raise, pain to back or neck pain with raising the leg. Brudzinski Sign: Passively flex/bend the patients neck towards the chest. Positive: Patient reflexivelyflexes the hips and knee to relieve the pressure and pain. Nuchal Rigidity: Neck flexed with the chin touching the chest. Inability to touch the chin to the chest dueto pain is positive finding of nuchal rigidity (meningeal irritation) Diagnostics: First- Non-contrast head CT (better than MRI at determining hemorrhage or ischemic stroke), lumbar puncture immediately if severe headache but CT is neg (LP: elevated opening pressure,RBC elevated in tubes 1-4, centrifugation of CSF can differentiate bleeding in SAH from traumatic LP), cerebral angiography if both are negative but still suspicious for SAH. Xanthochromia represents hemoglobin degradations and is highly suggestive of SAH. CT angiogram or MRA is done for preplanningof surgery. 3 Differential Diagnoses: Reversible cerebral vasoconstriction syndromes (RCVS), Cerebral infection (eg,meningitis, acute complicated sinusitis), Cerebral venous thrombosis, Cervical artery dissection Pattern Recognition: cc sudden onset “worst headache of my life” Treatment options: Prevention of vasospasm with highest risk day 3-8 (Nimitop 60 mg PO q4hr Treatment is continued for 21 days) all patients should receive nimodipine and euvolemia should be maintained , Transcranial Doppler (TCD) sonography is useful for detecting and monitoring vasospasm in SAH and performed daily, delayed cerebral ischemia, and prevention of rebleed (systolic BP < 160), Ventriculostomy to prevent hydrocephalus, prevention of seizure controversial, first-degree relatives of patients with SAH have a two- to five-fold increased risk of SAH compared with the general population, itmay be reasonable to screen some family members for the presence of cerebral aneurysm. Review questions: 1. Acute cerebral hemorrhage is best identified with which of the following imaging techniques? a. transesophageal echocardiogram b. CT Scan c. Cerebral angiogram d. MR angiography Answer: B 47. Glaucoma Definition: Glaucoma is a group of eye diseases traditionally characterized by elevated intraocular pressure. Glaucoma is defined as an optic neuropathy involving a characteristic atrophy of the opticnerve head, often accompanied with typical visual field defects. Open-angle glaucoma is an optic neuropathy characterized by progressive peripheral visual field loss followed by central field loss in a typical pattern. It is usually but not always in the presence of elevatedintraocular pressure (IOP). Increased aqueous production and/or decreased outflow are possible mechanisms for elevated intraocular pressure. The optic nerve or "disc" takes on a hollowed- *Carbonic anhydrase inhibitors – Diamox, 250mg qid or 500mg bid *Alpha 2 agonists and cholinergic agonists *Hyperosmotic agents (mannitol IV) in acute treatmentAngle closure: *Laser iridotomy early in disease process *Acute general trx – IV mannitol, Pilocarpine, Beta blockers, Diamox, Anterior chamber paracentesis (as emergencytreatment) Review questions: 1.A 64-year-old woman presents to your clinic with a sudden right-sided headache that is worse in her right eye. She claims her vision seems blurred, and her right pupil is dilated and slow to react. The rightconjunctiva is markedly injected, and the eyeball is firm. You screen her vision and find that she is 20/30 OS and 20/30 OD. She most likely has A. open-angle glaucoma. B. angle-closure glaucoma. C. herpetic conjunctivitis. D. diabetic retinopathy. Answer B Rationale: In angle closure glaucoma, the patient presents with a sudden onset of symptoms as described in this case. This client has a marked visual deficit and pain as well as a fullness of the eye. Thisis a medical emergency and should be referred immediately because blindness can occur within days without intervention. With open angle type, the onset is more insidious. Herpetic conjunctivitis is generally associated with a herpetic rash, and the pain is dull in character. 2. Sylvia has glaucoma and has started taking a medication that acts as a diuretic to reduce theintraocular pressure. Which medication is she taking? A. A carbonicanhydrase inhibitor B. A beta-adrenergic receptor blocker C. A miotic D. A mydriatic Answer A Rationale: Carbonic anhydrase inhibitors, such as acetazolamide (Diamox), act as diuretics to reduce theintraocular pressure in clients with glaucoma. A miotic causes contraction of the pupil and a mydriatic dilates the pupil. Because of the effect of pupil dilation on aqueous outflow in angle-closure glaucoma, medications such as atropine and other anticholinergics that have a mydriatic effect should be avoided.Miotics such as pilocarpine (Pilocar) may be given to cause contraction of the sphincter of the iris and to contract the ciliary muscle, which promotes accommodation for near vision and facilitates aqueous humor outflow by increasing drainage through the trabecular meshwork in open-angle glaucoma. But the question is asked about diuretics, which pilocarpine is not. It is a cholinergic agent. 3. Signs and symptoms of acute angle-closure glaucoma include A. painless redness of the eyes. B. loss of peripheral vision. C. translucent corneas. D. halos around lights. Answer D Rationale: Signs and symptoms of acute angle-closure glaucoma include seeing halos around lights, severe eye pain and redness, nausea and vomiting, headache, blurred vision, conjunctival injection, cloudy cornea, mid- dilated pupil, and an increased intraocular pressure. Acute angle-closure glaucomais less common than primary open-angle glaucoma, accounting for about 10% of all glaucoma cases in the United States. Emergency treatment is indicated, so a prompt referral is necessary when these signsand symptoms 48. Meningitis Definition: Meningitis is an infection/inflammation of the meninges, CSF, and ventricles. It is caused by bacterial, viral, or fungal. Encephalitis is inflammation of the brain most commonly caused by a virus (Epstein Barr, herpes simplex: most common in the U.S, varicella-zoster, enterovirus, mosquito and tick bites), nuchal rigidity and fever usually absent. Viral is usually less severe and gradual onset of symptoms. EEG will be abnormal. Bacterial Meningitis: In adults usually caused by the bacteria Streptococcus pneumoniae, Neisseria meningitidis, Staphylococcus, and Haemophilus influence type b. Vaccines for pneumococcal (PCV 13 and PPV23) have prevented the infection of meningitis from that strain. Vaccine for meningococcal are MCV4 and MPSV4. MCV4 is recommended for all adolescents ages11-12. A booster dose is given at age 16. Children never vaccinated can receive vaccine at age 13-18, ages 19-21 years of age not recommended but can receive booster dose if missed at age 16. MPSV4 is recommended for people older than 56 years who are at risk. Spread via respiratory tract, sinusitis, mastoiditis, otitis media.