Summary NR667 / NR 667 VISE STUDY GUIDE (LATEST UPDATE), Exams of Nursing

Download Summary NR667 / NR 667 VISE STUDY GUIDE (LATEST UPDATE) and more Exams Nursing in PDF only on Docsity! NR 667 VISE STUDY GUIDE  1. Hypertension Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry vision. Look for these clinical findings to rule out organ damage: Microvascular • Eyes (HTN retinopathy): AV nicking (causes when arteriole crosses on top of vein), papilledema • Kidneys: microalbuminuria and proteinuria, elevated serum creatinine and abnormal eGFR, peripheral or generalized edema Macrovascular • Heart: S3 (CHF), S4 (LVH), carotid bruits, decreased or absent peripheral pulses • Brain: TIA or hemorrhagic stroke Assessment/Exam: • Asymptomatic • Occipital headache • Blurry vision • Headache upon wakening • Exam of optic fundi: Look for AV nicking, hemorrhage, papilledema • LVH (long standing HTN) • Perform exam of symmetrical pulses • Auscultate for Carotid bruits, abdominal bruits, and kidney bruits Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O cardiomegaly. CBC, CMP, and urinalysis. Measure BP 5 minutes apart. Assess the patients 10- year risk for heart disease (ASCVD) Diagnosis: > 140/90 mm Hg start on B/P medication. Pharmacologic Management: • FIRST LINE DIURETIC: Hydrochlorothiazide (HCTZ) 25 mg/day (max 50mg/day) *May worsen gout and elevate lipids and glucose • ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower extremity edema) • ACE: lisinopril 10mg/day complicated HTN first line • Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED IN PREGNANCY • If stage 2, initiate 2 drug classes (Diuretic & CCB most effective in African American) Follow up: • 2-4weeks Referral: • Cardiology if EKG is abnormal Secondary HTN causes to consider: • CKD, renal artery stenosis, hyperthyroidism, phenochromocytoma, OSA, coartication of the heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID, decongestants Differential: • Secondary hypertension • White coat syndrome • Pregnant • Pregnancy induced hypertension Education: NR 667 VISE STUDY GUIDE  • First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per week. • Weight loss (BMI 25 and up) • Limit alcohol (men:2 drinks or less per day; women: one drink or less per day) • Stop smoking • Stress management • Eat fatty cold water fish (salmon, anchovy) 3x a week • DASH • Medication compliance • Reduce sodium intake <1,500 mg/day) • Measure BP daily, bring log to next visit, bring home cuff to compare to office • Liek: 1 Hollier: 17, 1 2. Hyperlipidemia Presentation: Most patients are asymptomatic until they develop ASCVD. • Xanthomata (lipid deposits around the eyes) • Corneal Arcus prior to age 50 years (white iris), normal • Angina • Bruits • MI • Stroke Diagnostics: • Fasting/non-fasting lipid profile • Glucose, • UA and creatinine (for detection of nephrotic syndrome which can induce dyslipidemia), • TSH (for detection of hypothyroidism) • CMP Diagnosis: Optimal goal is <100 mg/dL Pt with LDL >= 190mg/dL (without ASCVD or DM is a candidate for high-intensity statin) Non-pharmacologic Management/Education: • FIRST LINE: Lifestyle Modification; diet and exercise. • Diet to improve serum lipids: Mediterranean diet, DASH, vegetarian, low-carb, and low-trans fat. • Decrease sugar and simple carbs • Avoid alcohol • Increase fish diet with Omega-3 (salmon and sardines) twice a week • Weight loss • Aerobic type exercise Pharmacologic Management: • First Line: Atorvastatin 10mg once a day at bedtime (perform liver function tests before initiation therapy and then 4-6 and 12 weeks and after dose increase). a) Low Intensity (lowers LDL on average by <30%): Simvastatin 10mg, Pravastatin 10- 20mg, Lovastatin 20mg b) Moderate Intenstiy (lowers LDL on average by 30-49%): Atorvastatin 10-20mg daily, Rosuvastatin 5-10mg, Simvastatin 20-40mg, Pravastatin 40-80mg. NR 667 VISE STUDY GUIDE  • First Line: Begin Metformin (Biguanide) 500mg twice a day (Max: 2000 mg a day in 2 doses). • Additional 1st line or combo therapy: (Sulfonylureas, thiazolidinediones, GLP-1, DDP-4 • Second Line: Insulin, SGLT2, meglitinides, diphenylamine derivatives, bile sequestrants, alpha-glucosidase inhibitors • Actos 15 mg daily • Levemir 10 units once a day Follow up: • 2-4 weeks Referral: • Ophthalmologist at time of diagnosis and then yearly or bi-annualy if no problems • Fundoscopic exam • Diabetic educator/ specialist • Nutritionist • Podiatry Education: • Carbs 50% • Protein 30% • Fat 20% • Good glycemic control – no low sugars • 10-15 years develop complications • Foot care: a. Avoid going barefoot, test water temperature before stepping into a bath. b. Trim toenails to shape of the toe; remove sharp edges. Do not cut cuticles. c. Wash and check feet daily. d. Shoes should be snug but not tight. e. Socks should fit and be changed daily. • Immunization: Once a year influenza vaccine. Pneumococcal vaccine, revaccination for individuals >64 years of age previously immunized. • Increase awareness and screen for social determinant of health: a. Financial ability to afford medications b. Access to healthy foods c. Community support d. Food insecurity Complications: • Peripheral Neuropathy • Nephropathy • CKD • Glaucoma = blindness • Cataracts • Delayed wound healing • CAD/PVD Differentials: • Gestational diabetes • Cushing’s syndrome • Corticosteroid use Liek: 1 Hollier: pg 231 - 1 NR 667 VISE STUDY GUIDE  4. Back pain – Low back pain is generally mechanical in nature and attributed to degenerative changes. Most commonly seen in L4-L5 and L5-S1 Classified into 3 categories: i. Acute-less than 6 weeks ii. Subacute-6 weeks to 3 months iii. Chronic- symptoms for more than 3 months or on more than half the days in the prior 6 months Presentation: back pain complaint. Maybe localized, referred, or radiating. Determine OLDCARTS, any pre-existing conditions, past surgeries or trauma which may be contributing. Diagnostics: X-ray to r/o fracture/disc degeneration (with injury only). MRI and CT (the study of choice for evaluation of disc disease). Labs: CBC, CMP, Urinalysis, CRP Considerations for Imaging: • Current or recent cancer: especially breast, prostate, lung, thyroid, kidney, MM (consult patient's oncologist) • Significant neuro deficits, progressive motor symptoms (MRI) • History/strong suspicion for cancer (plain X-ray plus ESR) • Symptoms of a spinal infection (MRI, CRP or both) • Compression fracture (X-ray) Rule out cauda equina – loss of bladder control, saddle anesthesia, incontinence – refer to ED Physical Assessment: • Motor, sensory, and reflex exams are imperative • Observe gait • Assess lower extremity strength and bulk of muscles and pulses • DTR: i. Patellar: tests nerves at roots L2-L4 ii. Achilles: tests S1-S2 • Straight Leg Raise Test: elevation of affected leg in supine position will elicit pain at 20- 30 degrees for severe disease, 30-60 degrees for moderate disease • Cross leg raised test: elevating unaffected leg produces pain in the affected leg Non-pharmacologic Management: • Restrict activities that aggravate symptoms and avoid heavy lifting. • Gradually resume activities as tolerated, • Core strengthening workouts – abs/rectus muscles • Apply heat for 20-30 min several times a day. • Manage weight. Pharmacologic Management: • Naproxen 250-twice a day. • Flexeril 5 mg as needed 3 times a day (no driving). Follow up: • Severe pain 24-48 hours • 7-10 days moderate pain • Every 2-4 weeks until able to resume lifestyle Referral: • Physical Therapy Imaging: • If not resolved or improving in 4-6 weeks NR 667 VISE STUDY GUIDE  • X-ray/ct after 4 weeks unresolved Differentials: • Muscle strain • Herniated disc • Compression fracture • Cauda equina • Osteoarthritis • Spinal stenosis Liek: 301-302 Hollier: 502, 1 5. Anxiety Presentation: complaints of apprehension, restlessness, edginess, distractibility insomnia; Somatic complaints like fatigue, paresthesia, near syncope, dizziness, palpitation, tachycardia chest pain/tightness, dyspnea, hyperventilation, nausea vomiting diarrhea. Etc Diagnostic: TSH, CBC, CMP, UA, Urine drug screen, Glucose, EKG (rule out cardia issues), Hamilton Anxiety scale Diagnosis: Assess tools like i. Hamilton Anxiety scale : Positive Greater than 18 The GAD-7 (Table 27) has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity (Total score for the 7 items ranges from 0 to 21. Scores of 5, 10, and 15 represent cutoffs for mild, moderate, and severe anxiety) Non-pharmacological: • Psychotherapy/Counseling (CBT) • healthy diet • Avoid stressors as much as possible. • Relaxation • Regular exercise • Avoid caffeine intake • Avoid alcohol (rebound anxiety) Pharmacological: SSRI may not achieve therapeutic response for 2-4 weeks with full response might take 12 weeks or more. ***Use of Benzodiazepines until therapeutic response reached is a short term strategy-up to 1-3 months with planned taper. (ADDICTIVE) • Buspar 7.5mg twice a day and • SSRI – Escitalopram (Lexapro) 10mg PO once daily. May increase in 1-2 weeks. Or Zoloft 50 mg • Klonopin 0.25mg PO PRN twice a day for short-term use and titrate down because benzodiazepines have abuse potential. (Use in caution during the 2-4 weeks that the SSRI will take to meet partial therapeutic response) Only to be used PRN not daily Follow up: • 2-4 weeks Referral: • Psychologist/Psychiatrist Differentials: NR 667 VISE STUDY GUIDE  Differentials: NR 667 VISE STUDY GUIDE  • Bipolar • substance abuse • medication abuse • medication withdrawal • hypothyroidism • B12/Folate deficiency • Dementia Hollier 628; Leik 363 7. Obesity Presentation: Chronic disease due to abnormal/excessive fats accumulate which impairs health Increased morbidity and morality Defined as 20% more than ideal body mass index Parental obesity, hypothyroidism, cushing syndrome, diabetes, Diagnostics: TSH, Lipid panel, glucose/A1c, CBC, CMP, Lipase, EKG, associated with PCOS Diagnosis: BMI >30 Non-Pharmacological: • Lifestyle modification: exercise and diet • Dietary intake and eating habits • Modify times of eating • Less calories consistently Pharmacological: • Adipex-P 37.5mg daily x12weeks Follow up: 2-4 weeks Referral: Nutritionist/dietitian Liek:196-197,1 Hollier:319, 8.GERD: movement of GI contents into esophogaus d/t decreased LES tone. Subjective findings: Heartburn, burning beneath the sternum, postprandial and nocturnal, regurgitation, chest pain, neck pain, chronic cough. Dysphagia, sour taste in mouth, lump in throat, post nasal drip, erosion of teeth by acid Diagnosis: Based on symptoms of heartburn and regurgitation. Empiric PPI treatment should be started for 8 weeks. Diagnostic: Endoscopy after 8 week trial of PPI and unresolved. Non-pharmacological: • First line treatment! Removing or modifying risk factors like coffee, spicy food, chocolate • small more frequent meals • sit up for 2 hours after meals • don’t eat 3-4 hours before going to bed. • Smoking cessation • Avoid alcohol Pharmacological: Omeprazole 20mg daily before breakfast/ PPI NR 667 VISE STUDY GUIDE  Follow up: 4-8 weeks for re-evaluation, if no relief high risk for Barrets Esophagus. NR 667 VISE STUDY GUIDE  Objective findings: • nasal turbinates (swollen with clear mucus) • anterior pharynx (reddened) • cervical nodes: smoothe, mobile, and small • Lungs: clear Nonpharmaceutical: • Increase fluid and rest. • Humidifier. • Lozenges for scratchy throat • Saline nose drops. Education: • Frequent HAND washing • Wash bedding • Change toothbrush Pharmaceutical: Symptoms relieve that can be taken are • Tylenol/ibuprofen for fever and aching body pain OTC • saline nasal spray, • throat lozenges • antibiotics not necessary unless illness lasts greater than 10 days. (secondary sinusitis) Follow up: usually not needed unless symptoms persist over 10 days. Referrals: NONE Leik: 231 11. Acute laryngopharyngitis - Presentation: Sore throat, tonsillar exudate, malaise, cervical adenopathy, fever, nausea, absence of cough, petechiae on soft palate, beefy red tonsils, sandpaper rash (strep), conjunctivitis, nasal congestion, hoarseness, cough, diarrhea, viral rash (virus) Diagnostic: Rapid strep test with a throat culture Nonpharmacological: • Gargling with warm saltwater, • increase fluids, • change toothbrush after treatment, Pharmacological. • Pen V K 500 mg twice a day for 10 days • Cephalexin 500 mg twice a day for 10 days Follow up: • not generally needed unless not getting better Referral • not needed Liek:?? Hollier:215,1 12. Acute maxillary sinusitis Presentation: Congestion, purulent nasal discharge, headache, sore throat, pressure over sinuses, cough, halitosis, postnasal discharge, periorbital edema Symptoms > 10 days is a bacterial infection Diagnostics: NR 667 VISE STUDY GUIDE  • CBC (elevated WBC), • sinus x-rays for recurrent disease • CT scan for recurrent disease Nonpharmacological: • Avoid environmental irritants, • treat otitis media, • sleep with HOB elevated to aid with drainage, • Good hand hygiene • blowing nose. Pharmacological • Augmentin 875 mg/125 mg PO twice a day for 5 days, • Allergic to Penicillin then Doxycycline 100mg twice a day for 5days. • Azithromycin – Zpack - Follow up: • 1 week Referral: • None Liek: Hollier:202-203,1 13. Acute bronchitis Presentation: inflammation of the bronchioles bronchi and trachea usually follows an upper respiratory infection or exposure to chemical irritants. The cause is usually by adenovirus/rhinovirus – viral in etiology Signs and symptoms: Cough, NON-productive, then productive may be purulent. URI symptoms, fatigue, fever (usually COPD pt), crackles/wheezes, chest wall pain. Diagnostics: • Chest x-ray (hypoxia, tachypnea, fever, abnormal lung exam, o high risk pneumonia) Nonpharmacological: • increase fluid intake, • use humidifier, • rest, • Smoking cessation Pharmacological: • Antibiotics not recommended • Cough suppressants - nighttime • Z-Pack 500mg day one and 250 mg for 4 days (positive Pneumonia) • Tessalon pearls 200mg TID PRN • Albuterol inhaler 2 inhalations every 4-6 hours as needed, Follow up • 1 week Referral • None now • pulmonologist if not improved in 4 weeks. Complications: • chronic cough NR 667 VISE STUDY GUIDE  • secondary infection NR 667 VISE STUDY GUIDE  • Foreign body Liek:235 Hollier:662 15. Hypothyroidism (everything slows down): reduction in circulating free thyroid hormone Subjective complaints: Lethargic, mild weight gain, swelling of hands and feet, Intolerance to cold, constipation, menstrual irregularities, decreased libido, infertility, memory loss, depression, muscle cramps, hair loss, brittle cracking nails, parasthesia Objective findings: coarse hair, dry skin, hair loss, brittle nails, bradycardia. Age greater than 40 Hyperlipidemia (common), at risk of osteopenia, decreased TDRs, macroglossia, dull facial expressions, anemia, hyponatremia, hoarseness, reduced SBP and increased DBP, enlarged thyroid Diagnostic testing: TSH, T4, T3, CBC, CMP, Lipid panel, EKG Confirming Diagnosis: TSH (increased), T4(decreased), T3(maybe decreased) **Subclinical Hypothyroidism: slightly elevated TSH with nonspecific complaints. Monitor TSH Q3 months Nonpharmacological: • High fiber diet to prevent constipation • diet for weight loss • Educate regarding the need for lifelong compliance with thyroid replacement medication • need to report signs of toxicity, infection or cardiac symptoms • Annual lipid level assessment Pharmacological: • Levothyroxine Synthroid 12.5-25mcg (if older), 50mcg daily (empty stomach) • Levo helps prevent mental retardation • Reassess every 6-8 weeks, once stable reassess every 6-12 months • Pregnant monitor monthly and adjust accordingly • See improvement within 2 weeks; symptoms resolve in 3-6 months Follow up: • 6 Weeks, recheck and then q 6-8 until goal • GOAL: <5.0 mU; range 0.5-5.0 Referral: • None at this time Education: • Increase vegetables and fruits, • Increase exercise, • Lipid assessment annually, • Compliance need lifetime treatment • Report s/s: palpitations, nervousness, tremors (means Synthroid dose is too high) Differentials: • Depression • Dementia • CHF • Kidney failure Liek: 249 Hollier: 230 16. Osteoarthritis – NR 667 VISE STUDY GUIDE  Presentation: Generalized disease with no known cause. Most common joint disease (destruction). Progressive destruction of the articular cartilage and bone due to osteophyte formation. Subjective Complaints: Joint pain, usually asymmetrical, develops insidiously and accompanies or follows physical activity. Assess for Morning stiffness lasting <1 hour. Stiffness resumes towards the day end and after periods of activity. Physical exam: Assess for crepitus and limited range of motion. Assess for bunions (MTP joints) Assess for site warm and redness (rheumatoid) (Bouchards nodes @PIP) Heberden’s nodes @DIP (B before H) or D for DIP Not symmetrical No constitutional symptoms – only related to the joints Cool joints – not warm like RA Based on physical and history Diagnostic: x-ray findings (joint space narrowing,osteophytes, subchrondal sclerosis), CBC, CMP, ESR, Rheumatoid factors, ANA-NEGATIVE Nonpharmacological: • Weight loss • Rest • Orthotic shoes or insoles • Topical creams • Weight bearing exercises (walking, lifting weights, resistant band exercises) • braces to stabilize joints while exercising, • apply heat/cold to affected joints Pharmacological: ONLY when symptoms are present! • Exercise first line treatment • Age older than 75 TOPICAL only • Acetaminophen 325-650mg q6-4 hours (MAX dose 4g q 24 hours) • No relief with Acetaminophen switch to short acting NSAID Naproxen (250-500 mg Q12) or Ibuprofen 400-600mg TID or QID • Voltaren cream on the affected area as needed for pain. • Cytotec for GI protection from NSAIDs • Toradol is limited to 5 days, first dose given IM • LOWEST RISK OF GI COMPLICATIONS IS IBUPROFEN AND CELEBREX • LOWEST RISK OF CV EVENT IS NAPROXEN Follow up: • 2-4 weeks. Referral: Physical therapy and nutritionist for weight loss. Orthopedic if complete joint destruction/ bone on bone. Education: • Exercise 3 days week • Lose weight • Strengthen quadriceps • Report black tarry stools Differentials: • Gout • Infective arthritis • Inflammatory arthritis: RA; psoriatic, SLE • Joint injury NR 667 VISE STUDY GUIDE  • Soft tissue injury NR 667 VISE STUDY GUIDE  • 1 week after RICE protocol Referral: • physical therapy • Orthopedics (ACL) Differentials: • Osteoarthritis • Rheumatoid arthritis • Patellofemoral pain syndrome • Meniscus tear • Tendonitis Liek:?? Hollier:?? 18. Shoulder pain: Differential diagnosis based on location of pain Presentation: Rotator cuff syndrome: Rotator cuff tears, advanced age, repetitive use, occupation- related, a higher risk with obesity and diabetes Pain often at night, deltoid pain, weakness with abduction/ forward flexion, positive impingement signs, limited range of motion. **Anterior Lateral Shoulder Pain: 2 Most Common Orthopedic Etiologies 1. Impingement syndrome (IS): compression of rotator cuff tendons and the subacromial bursa 2. Rotator cuff tendinopathy (RCT): strain, uncomplicated tendinopathy, chronic calcific tendinopathy, tendinopathy with tear • IS, RCT complaint: Shoulder pain with overhead activity Osteoarthritis: pretty common too! NR 667 VISE STUDY GUIDE  17 Extrinsic Shoulder Pain • Extrinsic (outside the shoulder and often poorly localized): o Cervical nerve root compression o Myocardial ischemia o Splenic injury o Ectopic pregnancy o Others Posterior shoulder pain: • Cervical strain • Cervical radiculopathy • Other less common Diagnostics: X-ray results typically normal, MRI to diagnose, empty gas can, apley test, stratch test, positive arm drop test, Nonpharmacological: Acute Shoulder Pain after minor trauma/injury • General: o Ice x 48-72 hours o Heat o Rest from aggravating activity o NSAIDs o Maintain ROM! Pharmacological: • Tylenol 650 Po as needed for pain every 6 hours, • Naproxen 250 mg twice a day. • Pain over 5/10 Tramadol 50 mg once a day Follow up: • 2-4weeks Referral: • Refer to PT, ortho if not better in 2-6 weeks Education: • Avoid overhead lifting or reaching Differentials: • Adhesive capsulitis (frozen shoulder) • Degenerative arthritis • Cervical radiculopathy • Suprascapular nerve impingement/entrapment Liek:?? Hollier:516,1 19. Hip pain (info retrieved from UpToDate) Presentation: Young adults: Hip joint labral injuries or synovitis NR 667 VISE STUDY GUIDE  Middle age & older adults: trochanteric pain syndrome, osteoarthritis NR 667 VISE STUDY GUIDE  20 • Lower abdominal pain or flank pain • Dribbling of urine in men • foul-smelling urine • Small volume and/of frequent voiding Child and pregnant women progress to pyelonephritis/ nephron death Diagnostics: • Urinalysis: WBC presents, positive leukocyte esterase, positive nitrites, urine culture with sensitivity • STI panel. • C&S after 2-3 days if symptoms persist to rule out pyelonephritis • WBS >100,000 • Temperature (fever) Nonpharmacological: • Emptying bladder immediately after sexual intercourse • Practice good hygiene • wipe from front to back • cotton underwear • Loose fitting clothing • Good hydration • Changing into dry clothes when wet or soiled (i.e. bathing suits) • Emptying bladder when needed • Avoid seltzer and carbonated drinks (bladder irritants) Pharmacological: • Macrobid 100mg twice a day for 5-7 days with food (NOT USED FROM 38-42 WEEKS GESTATION) • Bactrim DS, 180/160 twice a day for 3 day for uncomplicated cystitis • Pyridium (analgesic for pain relief due to symptoms) 100-200mg PO BID for 3 days – turn urine and contact lenses orange (Use in caution in pregnant patients) MAX OF 6 DOSES PER UTI Follow up: Post treatment culture if patient has frequent or recurrent UTIs Differentials: • Vaginitis • STD • Pregnancy • Pelvic inflammatory disease • Prostatitis, epididymitis • enuresis Liek:254-255,1 Hollier:688,1 23. BPH – benign enlargement of the prostate gland creating a narrowing of the urethral lumen and leading to increased prostatic smooth muscle tone. NR 667 VISE STUDY GUIDE  21 Subjective findings: Weak urinary stream, hesitancy, post-void dribbling, incomplete emptying of the bladder, frequency/urgency, incontinence, retention, hematuria, firm/smooth symmetrical prostate Objective findings: • Prostate is symmetrical in texture and size (rubbery texture) is enlarged • PSA (normal 0-4 ng/mL)- will be elevated Diagnostics: -American Urological Association questionnaire • score >8 on the questionnaire start pharmacological management o mild symptoms 0-7 o moderate symptoms 8-19 o severe symptoms 20-35 -Can also use- International Prostate Symptoms Score (IPSS) -UA-pyuria if residual urine presents, Creatine (assess kidney function), PSA, Post-void residual >100, US (not necessary for routine evaluation) Assessment: • Weak stream • Hesitancy • Post void dribbling • Incomplete emptying of bladder • Frequency and urgency • Nocturia (is very common) • Incontinence • Urinary retention • Hematuria • Firm, smooth, symmetrically enlarged Nonpharmacological/Education • Limit fluids at bedtime • Frequent voiding • Avoid caffeine and alcohol, avoid antihistamines • Sit to urinate instead of standing to have better emptying • May experience dizziness due to low BP • Take medications at bedtime Pharmacological: • AUA score >8 start pharmacological management • Alpha 1 blocker (Alpha-adrenergic Antagonist) improve 50% of symptoms within 4 weeks o For those with mild to moderate symptoms as monotherapy o Flomax 0.4 mg PO daily at bedtime o Can cause orthostatic hypotension • 5-alpha-reductase inhibitors: Finasteride (Proscar) 5mg PO daily takes 12 months to take effect to shrink tissue • Combination therapy for men with severe symptoms Follow up: • 2-4 weeks o Annual digital rectal exam NR 667 VISE STUDY GUIDE  22 o PSA annually Referral: • Urology- if refractory to treatment, evidence of renal complications, or surgery is indicated Differentials: • Prostatitis • Prostate cancer • Urethral stricture • Neurogenic bladder • Medication side effects • Urinary tract infection • Bladder cancer Liek:384 Hollier:398 24. Eczema (atopic dermatitis) – part of atopic triad (allergies, asthma, allergic rhinitis) Presentation: atopic dermatitis is an inflammatory skin condition and chronic pruritic skin eruption. Dry skin, erythema Eczema is the acute stage of the pruritic irritation Diagnostics: none needed typically. Although, may do a skin biopsy to r/o other causes, CBC to check for eosinophilia, serum allergy testing Located: knees, hands, neck, antecubital and popliteal space, arms, legs, face Assessment: • Pruritus • Erythema • Dry skin • Facial erythema • Infraorbital folds Nonpharmacological: • Prevent dry skin by using ointment/petroleum based • manage stress • avoid wool clothing, • fragrance-free detergents, • keep the environment free of dust as possible • oatmeal bath • products without scents/for sensitive skin. • Avoid sun trauma. • Moisturize. Pharmacological: • Topical Corticosteroids (NOT ON FACE) low potency steroids • Hydrocortisone butyrate 0.1% 15g apply thin film 2-4 times daily. No more than 3 weeks. • Antihistamines (oral and topical) for itching • Oral corticosteroids may be used for severe cases • Eucerin, Lubriderm, cetaphil Education: NR 667 VISE STUDY GUIDE  25 Sinusitis DD: Migraine headache; URI; Allergic Rhinitis; Rhinovirus (RV) Infection (Common Cold); Chemical rhinitis; Nasal foreign body Tracheomalacia DD Adults: laryngomalacia, subglottic stenosis, cysts, vocal cord paralysis, and hypocalcemic tetany Tracheomalacia DD Infants: Asthma; Bronchiolitis; GERD; Bronchogenic Cyst; Double Aortic Arc; Bronchopulmonary Dysplasia; Pulmonary Artery Sling; Right Aortic Arch in Vascular Ring Defects; Sinonasal Manifestations of Cystic Fibrosis Otalgia Differential Diagnosis: AOM AEM AME; temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis Nonotogenic otalgia: referred or reflex pain, neuralgia, or to a psychogenic problem, referred also from primary carcinoma of the head and neck Cardiovascular DD: CHF DD: Pneumonia (CAP, bacterial, viral); COPD; Noncardiac pulmonary edema; Emphysema; Acute Kidney Injury; Idiopathic/ interstitial Pulmonary Fibrosis; MI; Respiratory failure Gastrointestinal DD: Acute Abdomen DD: BAD GUT PAINS= Bowel obstruction; Appendicitis, Adenitis (mesenteric); Diverticulitis; DKA; Dysentery/Diarrhea Drug withdrawal; Gastroenteritis; Gall bladder disease/stones/obstruction/infection; Urinary obstruction (stone) infection (pyelonephritis/cystitis); Testicular Torsion; Toxin - Lead, black widow spider bite; Pneumonia/Pleurisy; Pancreatitis; Perforated bowel/ulcer; Porphyria; Abdominal aneurysm; IN - Infarcted bowel; Infarcted myocardium (AMI); Incarcerated hernia; Inflammatory bowel disease; Splenic rupture/infarction; Sickle cell pain crisis; sequestration crisis Gastritis DD: GERD; GE/Viral GE; PUD; Cholelithiasis/Cholecystitis; Crohn Disease; Gastric Cancer Gastroenteritis DD: High fever, bloody diarrhea, or severe diarrhea suggests bacterial GE. Protozoal infections (endemic protozoal areas - Mexico, India, South America, parts of the US), C dif, IBS, food poisoning. GERD: Acute/chronic gastritis; H Pylori; Hiatal hernia; PUD: IBS; Esophagitis; CAD; Esophageal Spasm; Cholelithiasis; Achalasia; Esophageal Cancer. IBS DD: IBS criteria: Bloating, Minimum 1 Manning criteria (pain onset correlates with BM frequency increase, onset of pain associated with looser bowel movements, Pain relieved by BM, NR 667 VISE STUDY GUIDE  26 Visible abdominal bloating, Subjective incomplete evacuation sense >25% time, Mucorrhea > 25% of time); IBS-C= types 1-3 Bristol Stool Scale; IBS-D types 5-7 stools BSS. DD: Bacterial/ Viral GE; Food allergies/ lactose intolerance; Anxiety Disorders; C Diff; Biliary Colic/ disease; Pancreatitis; Celiac Disease (Sprue); Ulcerative Colitis; Colon Cancer; Hypo/Hyperthyroidism and Thyrotoxicosis; Giardiasis; Acute Intermittent Porphyria. Protozoal infections DD: Travel to endemic protozoal areas - Mexico, India, South America, parts of the US. Amebic dysentery- bloody diarrhea with excessive mucus and abdominal pain. Giardiasis- bloating and prolonged diarrhea. R/O Parasitic infections in immunocompromised patients. DD- IBS, CDif, GE, food intolerance, anxiety. Genitourinary DD: UTI DD: Overactive bladder; Noninfectious urethritis; Asymptomatic bacteriuria; Interstitial cystitis; Vaginitis/ vaginosis; Urethral diverticulum; Infected Skene gland cyst; Radiation cystitis. Pelvic Pain (female) DD: See above acute abdomen plus “ECTOPIC” Ectopic; Endometriosis; Cyst rupture (corpus lutetium cyst rupture); Torsion of ovary or cyst; Ovulation: Mittelschmerz; PID; salpingitis, tubo - ovarian abscess; Incomplete abortion; Cystitis/pyelonephritis Musculoskeletal/ Ortho DD: Back Pain/ lumbago DD: Spinal stenosis (Numbness, BLE weakness, radiculopathy to buttock/ leg); Radiculopathy/sciatica (Numbness, weakness in lower extremities, pain radiating to buttock and leg, often unilateral); Cauda equina syndrome (GI/GU incontinence or retention, saddle anesthesia, and sudden unexplained BLE weakness); Spinal compression fracture; AAA; Nephrolithiasis; Pyelonephritis; back Abscess/ osteomyelitis/ or septic diskitis; Spinal neoplasia ( nocturnal pain, weight loss); Ankylosing or psoriatic spondylitis, or reactive arthritis; Sprain/ Strain DD: sprain = stretch/tearing ligaments (bone-bone), may have bruises; strain = stretch/tearing muscles or tendons (muscle-bone) may have muscle spasm; Fracture (difficult to differentiate from grade 3 injuries); Cartilage injury (Difficult to differentiate from sprain); Nerve Impingement; Achilles tendinopathy; Tibialis posterior tendinitis (posteromedial ankle pain and swelling; flatter than the other foot; tip-toe = difficult); fifth metatarsal fractures, navicular fractures, talar dome lesions, and peroneal tendon injuries Ottawa ankle X-ray rules : Required only if the patient has pain near the malleolus and one or more of the following: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus Inability to bear weight for 4 steps, both immediately after the injury and in the ED NR 667 VISE STUDY GUIDE  Ottawa foot X-ray rules :