CH 23 Supplemental concepts/q's Flashcards
CN 1
olfactory - (1 nose) smell
CN II
optic (2 eyes)
CN III
Oculomotor - eyelid movement
upward, medial, downward eye movements
CN IV
trochlear - innervates superior oblique turns eyes down and laterally
CN V
trigeminal - chewing, face, mouth, touch/pain
touch forehead, cheek, clench teeth
CN VI
Abducens - look side to side
turns eye laterally
CN VII
facial - facial expression
-secretion of tears, saliva, taste
taste of anterior 2/3 of tongue, smile
CN VIII
acoustic
hearing and equilibrium
CN IX
glossopharyngeal - taste, tenses carotid blood pressure, posterior 1/3 of tongue
CN X
vagus - slowed HR, defecation stimulate digestive organs, taste
CN XI
spinal accessory - controls trapezius and sternocleidomastoid, swallowing movements
-shrug shoulder
CN XII
hypoglossal - control tongue movements
which CN is puffing out cheeks?
CN VII Facial nerve
which CN is, w/o moving head follow fingers with your eyes?
CN III Oculomotor
Matthew is a 29-year-old man who presents with a 6-hour history of sudden onset of inability to raise his eyebrow or smile on the right side. He also reports decreased lacrimation in the right eye and difficulty closing the right eyelid. The
rest of his health history and physical examination is otherwise unremarkable.
This likely represents paralysis of cranial nerve (CN):
A. III.
B. VIII.
C. IV.
D. VII
Which of the following is the most appropriate next step in Matthew’s care?
A. Urgent referral for neuroimaging
B. Initiating a course of oral corticosteroids
C. Prescribing a short course of high-dose antiviral therapy
D. Referral to a neurology specialist within the next 24‒48 hours
SUDDEN onset
- and the rest is unremarkable (good bc no headaches, or unilateral body weakness)
CN VII 7 - Facial - bells palsy
- only seen on face only.
Bell’s palsy is a clinical diagnosis (only on hx and exam)
C. Start oral corticosteroids!
Bell’s palsy aka IDIOPATHIC facial paralysis, patho:
acute paralysis of CN VII (facial) in absence of brain dysfunction
-largely unknown, inflamed CN d/t viral infection
Bell’s palsy presentation
think CN 7 not working..
Sudden onset of unilateral facial paralysis including inability to raise the eyebrow
or smile on the affected side
decreased lacrimation/tears of affected eye with inability
to close eyelid
Bell’s palsy Diagnosis
clinical dx (HPI/PE)
-tests to r/o other conditions, lyme disease serology, electromyography
neuro imaging if sx’s don’t improve over time
bell’s palsy treatment
start systemic oral corticosteriods (PO prednisone) asap!
-eye care for eyelid closure/reduced tears
-recover w/in 3 months
-facial PT if not recover
A. Zoster (shingles)
B. Varicella (chickenpox)
C. Both
- Presents with primary and secondary lesions including
vesicles and crusts - Usually unilateral dermatomal pattern
- Mild to moderately systemically ill with fever
- Miserable with pain, itch, usually without fever
5.Risk of disease development significantly reduced by
immunization.
- Treatment to minimize severity of disease or
complications includes oral acyclovir
- C
- A
- B (ppl with shingles are miserable but NOT sick. with varicella, is miserable (ITCHY) AND sick)
- A
- C
- C. high dose acyclovir for shingles and varicella but needs to be EARLY on disease
varicella (chicken pox) presentation
2–3 mm vesicles that start on trunk then
appear on limbs 2–3 days later
- Nonclustered
lesions at a variety of stages, crusts (high rate of complication=bacterial suprainfection of lesions)
myalgia, FEVER, itchy!
zoster (shingles) presentation and complications
Vesicles unilateral dermatomal pattern, slowly resolving with crusting, with pain and/or severe itch (no fever)
postherpetic neuralgia,
ophthalmologic involvement,
superimposed bacterial infection
varicella treatment and prevention
Acyclovir EARLY! w/in 24-48 hours of eruption = reduces severity
NO aspirin (Reyes syndrome)
NO NSAIDS (necrotizing fasciitis risk)
Varivax - 80% lifetime immunity with 1st dose, 99% 2nd dose
herpes zoster treatment and prevention
high dose acyclovir EARLY w/in 72 hrs of onset!
-analgesia
-for itch: ice pack, calamine lotion, avoid clothes rubbing (put emollient over)
-Zostavax, Shringrix
(T/F) Across North America, brown recluse spider bites are the most common reason for
new-onset ulcerating skin lesions
false
brown recluse spider bite presentation
“red, white, and blue”
Central blistering with surrounding gray- to -purple discoloration at bite site surrounded by ring of blanched skin surrounded by large area of redness
Treatment of brown recluse spider bite
Local debridement, elevation, loose immobilization.
-When bitten, use ice to limit venom spread helpful.
- Dapsone (not that effective)
- Check before putting body part into area where
spiders hide (footwear, boxes)
A. Seborrhea
B. Psoriasis
C. Dandruff
- Lesions in scalp, eyelid margins, nasolabial folds
- Usually limited to the scalp only
- Most frequently encountered in teen, adult years
4.First-line treatment includes topical antifungal therapy
5.First-line treatment for milder disease is topical corticosteroid
therapy.
6.Lesions most commonly located over the knees and tips of the
elbows
7.With forced removal of a lesion, pinpoint bleeding, quickly stops
(Auspitz sign)
8.Usually mildly symptomatic with feelings of itch, irritation
- Seb
- dan
- Seb, Psoriasis, dandruff
- Seb (ketoconazole is antifungal) & dan
- Psoriasis (medium potency)
- Psoriasis
- Psoriasis
- seb, ps, dan -MILD SX but NOT systemically ill
auspitz sign
With forced removal of a lesion, pinpoint bleeding, quickly stops
seen in psoriasis plaques
ask pt’s and they’ll tell you
when do you start putting on sunscreen in children?
until they are 6 months or OLDER
(more prone to side effects of sunscreen < 6 mo: clothing, hat, shade)
seborrhea (seborrheic dermatitis) locations
sebum areas: scalp, eyelids, ears, nasolabial folds, upper trunk
seborrhea lesions
itchy, patchy SCALES and crusts over red, inflamed skin
hypopigmentation and
oozing can occur
plaques rare
“I have areas of burning,
itchy and scaly skin around
my nose, eyebrows, and in
my ear canals that gets
worse then gets better.”
psoriasis locations
extensor (elbows, knees, scalp, trunk, limbs)
psoriasis lesions
raised silvery
scales and underlying red
plaque with well-defined
margins
Auspitz sign: pinpoint bleeding common with forcible
removal of plaques
“I have itchy, red areas of
skin on my elbows, knees
and trunk, with scaling,
peeling, and sometimes
bleeding if I pick at them.
seborrhea tx
Topical antifungal (ketoconazole);
low potency
topical corticosteroids
topical immune modulators
(e.g., pimecrolimus,
tacrolimus, sulfonamide) can be helpful
Class IV or lower topical
corticosteroid for acute flares
For severe/unresponsive
cases, systemic fluconazole
psoriasis tx
mild: topical corticosteroids on specific skin areas
if more generalized areas: UV A light therapy, systemic retinoids, cyclosporin, methotrexate
A 63-year-old man who resides at the homeless shelter is brought to urgent
care with a chief complaint of chronic cough and intermittent sharp, localized
chest pain that worsens with cough or deep breath. T=102.3°F (39.1°C), HR=112
bpm, RR=45 bpm, BP=135/85 mm Hg. Which of the following findings would best
support a diagnosis of active tuberculosis infection?
Choose two that apply.
A. Erythematous plaques on the extremities
B. Hemoptysis
C. Dry cough with bronchospasm
D. Macrocytic anemia
E. Chest x-ray demonstrating right upper lobe infiltrate.
Hemoptysis &
chest xray of UPPER lobe infiltrate
Tb tends to affect upper lobes of lung while other bacterial are lower lobes
TB: wet cough
active tuberculosis clinical presentation
Congested, productive/wet, cough with white, yellow, and/or blood streaked sputum
hemoptysis * (only 8% has it; can rule in but absence doesn’t rule out)
chest pain
fever
unexplained weight loss/anorexia
night sweats
fatigue
Tb risk factors
HIV infection
History of positive PPD tuberculin
skin test (TST) result
History of prior TB treatment
Known or suspected active TB
exposure
Travel to or emigration from an
area where TB is endemic
Homelessness, shelter-dwelling,
incarceration
TB diagnostic testing
Mantoux tuberculin skin test or QuantiFERON-TB Gold test (QTF-G) (screening method)
Acid-fast bacilli (AFB) smear or culture from sputum sample
Enzyme-linked immunospot
(ELISpot®) assay for mycobacterial
ribosomal RNA
Chest radiograph or thoracic CT
HIV testing if status unknown
The typical international normalized ratio (INR) goal during warfarin therapy for
a 65-year-old woman with atrial fibrillation is:
A. 1.0‒2.0.
B. 1.5‒2.5.
C. 2.0‒3.0.
D. 2.5‒3.5.
C. 2-3
The use of which of the following potentially increases bleeding risk during warfarin use.
(Y/N) Amoxicillin
(Y/N) St. John’s wort
(Y/N) Naproxen
(Y/N) Gingko biloba
(Y) Amoxicillin - ALL antibiotics bc they alter gut flora. Warfarin works against vitamin K. Vit K comes from gut flora and if it’s altered with antibiotics = INR goes up/bleeding risk
(N) St. John’s wort = cytochrome P 450 inducer. No it reduces INR bc it causes warfarin to be kicked out quicker
(Y) Naproxen - NSAID - yes due to antiplatelet effect but not alter INR
(Y) Gingko biloba = Yes due to antiplatelet effect
Match each tx option with STI diagnosis. can be used more than once.
A. External genital warts in a 25-year-old adult
B. Pelvic inflammatory disease in a 22-year-old adult
C. Syphilis in a 45-year-old adult
D. External genital warts in a 28-year-old pregnant woman
- Injectable penicillin
- Imiquimod cream
- Trichloroacetic acid (TCA)
- Ceftriaxone plus oral 5. doxycycline with oral
metronidazole
- syphilis
- imiquimod (Aldara) for 25 year old adult. DON’T use during pregnancy
- TCA (tricholoracetic acid) - external genital warts for 25 & 28 year old pregnant woman
- ceftriaxone (1 shot) + oral doxy + oral metronidazole = PID
-cef takes care of gonococcal, doxy takes care of chlamydia, metronidazole takes care of anaerobes
A. External genital warts
B. Pelvic inflammatory disease
C. Primary syphilis
- Fever, abdominal pain
- Verruca-form lesions
- Painless genital ulcer with indurated margins
- pelvic inflammatory disease: infection of uterus, endometrium, fallopian tubes. Female version of Epididymitis. Upper repro infection
- external genital warts
- primary syphilis
syphilis:
primary stage
secondary stage
latent stage
primary: chancre (painless ulcer) on genital or anal with clean base, indurated margins, localized lymphadenopathy, ~ 3 weeks, resolves w/o therapy
secondary: non itchy skin rash (palms, soles, mucus membranes, w/o genital lesions).
-systemic sx’s (fever, diffuse lymphadenopathy, sore throat, patchy hairloss, headaches, weight loss, muscle aches, fatigue)
-resolves w/o tx possible
latent: varies, occurs when primary & sec sx’s resolve
syphilis treatment
1st line: penicillin injection
if allergy: PO doxycycline
genital warts (condyloma acuminata) orgs
HPV 6, 11
GU cancer a/s HPV: 16, 18, 31, 33, 45, 52, 58
can be infx w/ multiple
condyloma accuminata clinical findings & tx
verruca form lesions
-trichloracetic acid (TCA; ok in pregnancy), bichloracetic acid, surgical removal, imiquimod (Aldara; only external warts; no pregnancy)
topical podofilox, liquid nitrogen, cryoprobel
pelvic inflammatory disease orgs and tx
*think PID = 3 orgs = 3 drugs
N. gonorrhoeae, C. trachomatis,
bacteroides, Enterobacterales,
streptococci = to cover, 1st line:
1.ceftriaxone IM 1 shot
2. doxycycline x 2 weeks
3. metronidazole x 2 weeks
PID diagnosis and sequeles
bimanual exam
≥ 1 of:
-uterine tenderness
-adnexal tenderness
-cervical motion tenderness (Chandelier sign)
plus
Irritative voiding symptoms, fever, abdominal pain, vaginal discharge, elv CRP, elv WBC
- tubal scarring = increased risk for ectopic pregnancy and/or infertility.
Which of the following is a worrisome finding noted during pelvic examination on a 62-year-old woman?
A. Flattening of the vaginal rugae
B. Vaginal pH=5.6
C. Ovary palpable on bimanual examination
D. Scant white vaginal discharge
-menopause, normal to have flattening and thinning of walls
-estrogen leaves = lacto bacilli leaves = higher pH = more alkaline
C. ovary should NOT be palpable (ESP) post menopausal (except super thin young women)
GET pelvic ultrasound for possible ovarian mass or cyst
Brian is a 14-year-old who presents for a sick visit with 4-hour history of sudden onset of left-sided scrotal pain. He has had mild intermittent unilateral
testicular pain in the past but not as severe as this current episode. He has
vomited once since the onset of the pain and is without fever or history of recent
scrotal trauma. Confirmation of testicular torsion would include all of the following findings except:
A. Unilateral loss of the cremasteric reflex on the affected side.
B. The affected testicle held higher in the scrotum.
C. Testicular swelling.
D. Relief of pain with scrotal elevation.
no fever = no infection
A. Yes, stroke inside of thigh and cremaster retracts
B. Yes.
C. Yes. Tesicle is ischemic
D: NO! elevating doesn’t decrease pain with torsion but with Epididymitis (Prehn sign)
uro emergency! need surgery w/in few hours
For scrotal pain, you want to evaluation for tesicular torsion by using what screening?
TWIST score
1. Testicular swelling = 2pts
2. Testicle HARD = 2 pts
3. Testicle high riding= 1 pt
4absent cremaster reflex = 1 pt
5. nausea or vomiting = 1 pt
5‒7 points= Prompt urology consult, scrotal ultrasound unlikely provide significant additional information, detorting procedure needed.
1‒4 points=Promptly check scrotal ultrasound to determine if urology consult required.
- Linda is a 54-year-old woman who presents with complaints of a disfigured toenail on her right great toe that developed over the past 4 months. She also reports some discomfort that is affecting her gait, and will no longer wear opentoed shoes due to embarrassment. The NP notes nail thickening and a yellowish
color involving the full nail bed. Suspecting onychomycosis, the NP realizes:
A. This is primarily a clinical diagnosis.
B. A KOH prep should be performed.
C. A blood culture is necessary.
D. A Gram stain should be performed. - Appropriate treatment for Linda can include:
A. Topical 8% ciclopirox olamine for 4 weeks.
B. Oral fluconazole for 7–10 days.
C. Oral terbinafine for 12 weeks.
D. Laser therapy
- C: No. Blood culture for blood sepsis.
D: No. Onychoycosis is fungal so no gram stain.
answer: B! best practice is to get KOH prep on toe nail scrapings to verify - 1st line: oral terbinafine QD x 12 weeks (3 months). need antifungal on board until full nail grows out (3 months)
nail fungal infection/onychomycosis patho
-Fungal infection involving the nail plate, matrix, and/or bed.
-Most commonly by dermatophytes (Trichophyton rubrum and Trichophyton
mentagrophytes).
NOT Candida infection
Nail Fungal Infection (Onychomycosis) presentation
-asymptomatic at early stages
- progresses to cause paresthesia, pain, discomfort, and loss of dexterity.
- Disfigurement can impact selfesteem and quality of life.
- Nail shows subungual hyperkeratosis with yellow streaks or yellow-white onycholytic areas; thickening of the nail, separation of nail from the bed.
Nail Fungal Infection (Onychomycosis) diagnosis
-NEED Laboratory studies to confirmation to rule out other disorders & insurance won’t pay for meds
- get KOH prep to visualize hyphae; culture of pulverized nail scraping to identify
pathogen
Nail Fungal Infection (Onychomycosis) treatment
Topical therapy:
-Reserved for MILD cases (<1/2 of nail plate) or cannot tolerate oral meds; generally poor penetration to nail bed (8% ciclopirox olamine, 10% efinaconazole); can be combined with laser therapy
-tea tree oil, vix rub not much evidence
Full nail = Oral therapy:
-Fingernail: Terbinafine 250 mg QD for 6 weeks, or itraconazole 200 mg QD for 3 months or 200 mg BID for 1 week/month for 2 months
-Toenail: Terbinafine 250 mg QD for 3 months or itraconazole 200 mg QD for 3 months or 200 mg BID for 1 week/month for 3–4 months
Sue is a 34-year-old woman who is being evaluated for fibromyalgia consisting
of a 6-month history of widespread pain and tenderness. During the patient
history, which of the following findings would be least expected?
A. Reports of poor sleep
B. Depression
C. Fatigue
D. Unexplained weight loss
Which of the following would be considered a first-line treatment to manage
pain and tenderness for Sue?
A. Naproxen
B. Pregabalin
C. Clonazepam
D. Oxycodone
answer: D.
if generalized aches, differentials are RA, systemic lupus. RA & lupus HAS unexplained weight loss. (always document intended or unintended). Fibro is NOT systemic like RA & Lupus
1st line: Pregabalin (Lyrica), gabapenin (Neurontin) = PREVENTS pain. Naproxen is an adjunct for acute pain. Benzo and opioids avoided with fibromyalgia! not effective
fibromyalgia patho
Not completely understood
- considered a disorder of central pain processing or syndrome of central sensitivity.
- Common in young and middle-aged women, but can be all ages
-1/3 identify a specific event (illness, injury) triggered fibromyalgia symptoms.
fibromyalgia presentation & diagnosis
Chronic (>3 months continuously) widespread pain and tenderness
- fatigue,
-unrefreshed sleep
-cognitive dysfunction, along with somatic symptoms
dx of exclusion, thoro pt hx, PE, lab analysis
-use Widespread Pain Index (WPI) and Symptom Severity (SS) Scale
-get Fibromyalgia Intensity Score (FIS) from scoring pain at 18 tender points
fibromyalgia treatment
-No cure
-patient education and lifestyle mod (physical activity)
- FDA-approved: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). TCAs common to use
-Psychological therapy (depression, anxiety, stress, and sleep disturbance)
-Avoid opioids, hypnotics, anxiolytics, and muscle relaxants due to abuse
potential. NSAIDs and acetaminophen have limited effect on fibromyalgia pain.
You see a 55-year-old woman with type 2 diabetes mellitus, hypertension, and
dyslipidemia. Evaluation today reveals a BMI=36 kg/m2. She states, “I just do not
know where to start in trying to lose some weight.” Which of the following is the
most appropriate response to this statement?
A. “How much weight do you want to lose?”
B. “How do you feel about your weight?”
C. “What barriers do you see to losing weight?”
D. “Your blood sugar control will likely improve if you lose some weight.”
C.
motivational interviewing
motivational interviewing techniques
Express empathy
Develop a discrepancy
Roll with resistance
Support self-efficacy
Reflective listening
Change talk (examples)
* Explore pros and cons of behavior change
* Look back to a previous time—how were things different?
* Explore values
* Explore negative side of ambivalence
Ask open-ended questions
Affirming statements: Recognize patient’s strengths
Summarize: Review of session
Provide information
* Ask-provide-ask
Greg is a 45-year-old man with type 2 diabetes mellitus and a BMI of 29 kg/m2.
He asks about using pharmacotherapy for weight loss. The NP advises:
A. He does not meet the criteria for use of weight-loss pharmacotherapy.
B. Typically, individuals taking weight loss medications lose approximately 10% of
their starting weight.
C. The use of many of weight-loss medications can result in micronutrient deficiency.
D. Weight-loss medication use seldom results in significant BMI reduction.
B. he DOES meet criteria for med weightless med: overweight (BMI >25) with a comorbid condition .
-true, will lose 10% of starting weight
-GLP1 Agonists
C. not true
D. not true
Which of the following would be the best candidates for bariatric surgery?
(Select two correct answers)
A. A 29-year-old woman with BMI 32 kg/m2 and history of bulimia nervosa
B. A 26-year-old man with BMI 36 kg/m2 and who has not attempted any lifestyle
modifications
C. A 43-year-old man with BMI of 38 kg/m2 and with type 2 diabetes mellitus
D. A 39-year-old woman with BMI 42 kg/m2 and has had inadequate response to
lifestyle modifications and pharmacotherapy
answer: C & D
caution with those with eating disorder
-gastric sleeve/bypass is NOT 1st line if no lifestyle mod / med hasn’t tried
obesity management according to BMI? when is bariatric surgery recommended?
BMI 25-29= overweight
BMI 30-39= obesity
BMI 40+ = morbid obese
-BMI > 25: lifestyle, diet, PA, behavior mod
-BMI >27 + comorbidity OR BMI >30: phentermine + topiramate and buproprion plus naltrexone = suppress appetite and cravings, increase energy
GLP 1 agonist (semaglutide, liraglutide): decrease appetite and calorie intake
Orlistat (Xenical) blocks pancreatic lipase action, dec trig absorb
ALL THERAPIES AS ADJUNCT TO CALORIE RESTRICTION, INCREASE EXERCIES, BEHAVIOR MOD
Bariatric surgery: individuals with BMI >35 + comorbidity, or with BMI >40)
bariatric surgeries
for BMI >35 AND comorbidity or with BMI >40
Gastroplasty (gastric sleeve, vertical sleeve)
-reduces 50% excess body weight in 1 year
Gastric bypass (Roux-en-Y gastric bypass)
-reduces 60% excess body weight over 2 years
-Can result in micronutrient deficiencies including calcium, vitamin B12, folate,
and iron