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Maryville FNP Adult 2 > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

What is the most common psychiatric disorder in the US?

A

Anxiety

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2
Q

Anxiety definition

A

Unpleasant state of physical & psychological arousal that interferes with effective psychosocial functioning

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3
Q

Most common presents at age _____; most commonly affects _____

A

Most commonly presents aged 20-45 years
Mostly women

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4
Q

What are the 3 types of anxiety and describe what you would see in those people

A

Affective—dread, foreboding, or panic, apprehension, fear, irritability, intolerance, frustration, overreaction; accompanied by autonomic hyperactivity

Behavioral—apathy, compulsion, rigidity, overreactions, preoccupation, repetitive actions

Somatic—loss of appetite, dry mouth, fatigue, diarrhea, sweating, chest pain, hyperventilation, vomiting, paresthesias

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5
Q

Depressed mood is what disorder?

A

Mood affective disorder

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6
Q

With depressed mood you can see:

A

Sadness and apathy

Fatigue, loss of appetite, change in sleep, insomnia, irritability, anger, anxiety, hyperactivity

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7
Q

Grief is triggered by:

It is a _____ and ____ response

A

Triggered by loss of things/persons of value to an individual

Emotional and Physiological response

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8
Q

What are the 5 stages of grief?

A

Denial
Anger
Bargaining
Depression
Acceptance

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9
Q

What are the 3 phases of grief?

A

Avoidance
Confrontation
Accommodation

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10
Q

Substance use disorder can cause?

A

SUBSTANCE USE DISORDER Can cause tolerance, habituation, & physical dependence

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11
Q

Intimate partner violence definition

A

Pattern of assaultive & coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, threats

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12
Q

Intimate partner violence victims are typically:
Intimate partner violence perpetrators are typically:

A

Victim is typically a child, woman or elderly person

Perpetrator is typically a man, parent or other trusted adult or caregiver

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13
Q

Psychiatric Assessment pneumonic

A

Always (Appearance)
Send (speech)
Mail (Memory/mood)
Through (thoughts)
the Post (Perception)
Office (Orientation)

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14
Q

Substance use disorder should be a ____ screening

A

Substance use disorder should be a routine screening

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15
Q

2 possible Clinical Presentation of SUBSTANCE USE DISORDER

A

Patients who ask questions about their personal substance use

Recent negative consequences from long-standing substance use

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16
Q

Opioid Use Disorders can be from _____ or _____ drugs

A

Prescription or Illicit
Most common—hydrocodone, fentanyl, oxycodone, oxymorphone, morphine, methadone

Substances sold on street are most likely to be laced with other substances and effects on body can be more unpredictable

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17
Q

Complication of Opioid Use Disorders

A

HIV/AIDS, hepatitis B/C, tuberculosis, social/judicial issues, low birth weights

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18
Q

Opioid Use Disorders intoxication symptoms

A

Sudden change in behavior
Euphoria, Drowsiness, Confusion, Nausea, Slowed breathing, Constipation

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19
Q

Opioid Use Disorders withdrawal symptoms

A

Muscle & Bone pain, Sleep disturbances, Nausea, Diarrhea, Intense cravings

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20
Q

Nicotine dependence can come from

A

Cigarettes, cigars, chewing tobacco, pipes, snuff, Vaping

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21
Q

Nicotine dependence intoxication characteristics

A

Intoxication—no characteristics

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22
Q

Nicotine dependence withdrawal symptoms

A

Withdrawal—intense cravings, depressed mood, sleep problems, impaired concentration, anxiety, increased appetite, irritability

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23
Q

Alcohol-related disorder risk factors

A

Risk Factors—concurrent depression, anxiety, personality disorder, family hx of alcohol disorder, early age at drinking onset

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24
Q

Biochemical effect of Alcohol

A

CNS depressant

readily absorbed from stomach and small intestine → bloodstream → liver

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25
Q

Alcohol intoxication is greatest when:
Alcohol intoxication is manifest at:

A

greatest when BALs are increasing

manifested at the rate of which it is consumed

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26
Q

Alcohol withdrawal symptoms

A

irritability, tremulousness, insomnia; seizures, delirium tremens, death

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27
Q

BAL
0.05
0.1
0.2
0.3
>0.4

A

BAL 0.05
Disruption in:
Thinking
Judgment
Inhibition

BAL 0.1
Obvious intoxication

BAL 0.2
Depression of motor functioning & emotional/behavioral dysfunction

BAL 0.3
Stupor
Confusion

BAL >0.4
Coma

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28
Q

Alcohol treatment can be _____ or _____ setting

A

inpatient or outpatient setting

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29
Q

Pharmacologic treatment for alcohol withdrawal

A

Long-acting benzos—lorazepam, oxazepam, diazepam, chlordiazepoxide, carbamazepine

Antipsychotics—haloperidol (hallucinations, agitation)

Beta blockers, Clonidine, Phenytoin

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30
Q

Cannabis Disorders:

Euphoric effects of THC:
THC can create a mellow mood by:
impairs short term memory by:

A

Euphoric effects of THC can last for hours—distortions of time, sound, color, & taste; changes in ability to concentrate; dreamlike states

THC can create a mellow mood by increasing GABA activity

Impairs short-term memory by decreasing brain acetylcholine activity

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31
Q

High doses of THC can cause:

Smoked marijuana can improve:

A

High doses—red eye, mild tachycardia, orthostatic hypotension, increased appetite, dry mouth, disruptions in recall/memory/sensory-input

Smoked marijuana can improve appetite in persons with HIV/AIDS and reduce N/V in chemotherapy patients

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32
Q

Health risks of THC

A

50-70% more carcinogens than tobacco

Increased cough, asthma, respiratory infections

Increased incidence head and neck cancers

Circulatory changes—BP, arrhythmias, cerebellar infarction

Immune system dysfunction and fertility issues (erratic ovulation, decreased sperm count)

Exacerbation of panic attacks, anxiety, and depression

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33
Q

Hallucinogen-related disorders can be consumed:
examples of drugs include:
can cause:

A

Dissociative agents can be smokes, consumed orally, snorted, or injected

Examples include- PCP, angel dust, ketamine, salvia divinorum, LSD, mescaline, MDMA, ecstasy, psilocybin

Can cause - Falls & accidents, memory loss, cognitive deficits, hallucinations, nausea, altered perception

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34
Q

Inhalant - related disorders occur when -

can cause

A

Exposure to volatile hydrocarbons, gases, nitrities—laughing gas, poppers, snappers, whippets

Can cause neurocognitive problems, pulmonary/cardiac issues, sudden death, respiratory depression, aspiration

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35
Q

Sedative-Hypnotic/Anxiolytic-Related Disorders drugs

Can cause

A

Barbiturates
carbamates —muscle relaxers
benzodiazepine (Xanax, Ativan—short-acting: Klonopin, Valium—longer-acting)

Can cause CNS depressants—neurologic deficits in memory, coordination, autonomic depression & cognition, alcohol-like side effects

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36
Q

Stimulate - related disorders drugs

A

cocaine and amphetamine

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37
Q

Cocaine is a ____ ____
it works by:

A

CNS stimulant—blocks reuptake of dopamine thus increasing dopamine activity in several areas of the brain

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38
Q

Cocaine intoxication symptoms
Cocaine tolerance
Cocaine withdrawal

A

Fast onset of intoxication - increased self-esteem & perception, agitation, irritability, impaired judgement, impulsive sexual behavior, aggression, hyperactivity, mania, paranoid psychosis

Tolerance and need for increased dosages lead to convulsions, respiratory arrest, cardiac arrest; hypertension, angina, MI, CVA, pulmonary edema, respiratory depression, placental abruption, uterine rupture, PIH

Withdrawal - Irritability, depression, anxiety, insomnia, attention deficit

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39
Q

Amphetamines (Adderall and Meth)
Intoxication symptoms -

Side effects -

A

Intoxication - Elation, increased self-esteem, increased physical endurance, insensitivity to fatigue/feelings of invulnerability

Methamphetamine—half-life 11 hours

Side effects—hyperthermia, dehydration, anxiety, insomnia, disturbed mood, violent behavior, psychosis; dermatologic issues (skin sores, tooth decay, tooth loss)

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40
Q

Caffeine related disorders -
low doses -
high doses -
lethal doses -

A

Low Doses—300mg/day—insomnia, restlessness

High Doses–1000mg/—arrhythmias, psychomotor agitation

lethal doses - 5-10g/day—can cause death

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41
Q

Gambling disorder definition

A

Frequent, compulsive, uncontrolled or addictive gambling occurring habitually, intermittently, or in isolated episodes

Behavior not a substance—creates same brain stimulation as substances

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42
Q

Management for patients with substance or addictive behavior disorders

A

Motivational interviewing

Formal treatment, support recovery

Discuss various strategies

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43
Q

Follow-up/Referral for patients with substance or addictive behavior disorders

A

Access to information and support resources (education, treatment, support)

Monitor self-reported use, laboratory markers, & consequences; closely follow those in active treatment

Referral to specialist immediately when patient’s behavior represents a danger to self or others

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44
Q

Patient education for patients with substance or addictive behavior disorders

A

Education on effects of drugs, substances, behaviors, etc.

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45
Q

`DSM 5 criteria for diagnosis of substance use disorder

A

Substances taken in greater amount than intended

There is persistent desire or unsuccessful effort to cut down or control use

There is a craving for the substance

Repeated use leads to inability to perform role in the workplace or at school or home

Use continues despite negative consequences in social and interpersonal situations

Valued social or work-related roles are stopped because of use

Repeated substance use occurs in potentially dangerous situations

Substance use not deterred by medical or psychiatric complication

Tolerance develops: increasing amount is needed to obtain effects

Withdrawal syndrome occurs or patient takes substances to prevent withdrawal

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46
Q

Schizophrenia has a _____ onset
They typically hear:

behavioral symptoms :

A

acute or insidious onset

Hear internally generated voices not heard by others or believe other people are reading their minds, controlling their thoughts, or plotting to harm them

Fearful, withdrawn, reluctant to engage in treatment or nonadherent to treatment

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47
Q

To be diagnosed with Schizophrenia symptoms must:

A

Symptoms present for at least 6 months with 2+ positive or negative sx present for at least 1 month.

and cause social, employment, or self-care impairment

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48
Q

Schizophrenia clinical presentation:
first frank episode:
______ symptoms are common
____ symptom cluster

A

First frank episode usually 15-25yoa (men) and 25-35 (women)

Depressive symptoms are common

4 Symptom Clusters -
Positive-exaggeration of normal
Negative-absence or diminution of normal
Cognitive Impairments
Affective Disturbances

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49
Q

Positive symptoms

A

Hallucinations
Delusions
Disorganization
Movement disorders

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50
Q

Negative symptoms

A

Flat/blunted affect

Alogia (poverty of speech)

Asociality/anhedonia (lack of pleasure)

Apathy (lack of self-motivation)

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51
Q

Cognitive impairment

A

Poor executive function
Difficulty focusing
Verbal/visual learning/memory deficits
Verbal comprehension
Social cognition

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52
Q

Affective disorders

A

Blunted/flat affect
Poor self-esteem
Depression & anxiety
Increased risk of suicide

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53
Q

Management for patients with schizophrenia
tx for positive symptoms
tx for negative symptoms

A

Reduce or eliminate symptoms, maximize quality of life, improve function, promote/maintain recovery

Pharmacologic is mainstay of treatment for positive symptoms

Negative symptoms—cognitive behavior therapy, cognitive remediation therapy

Many patients have increased tendency to be non-compliant due to medication side effects

Clozapine—lowest risk of causing extrapyramidal symptoms—can cause low neutrophils (frequent CBC). Myocarditis potential adverse reaction and clozapine must be stopped at that point

Cognitive behavioral therapy

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54
Q

typical antipsychotic

Atypical antipsychotics

A

Typical Antipsychotics - Perphenazine, fluphenazine, trifluoperazine, haloperidol, thiothixene, loxapine, chlorpromazine

Atypical Antipsychotics - Clozapine, olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, paliperidone, iloperidone

Initiate medications at lower doses and gradually titrate; remission can be achieved in 3-4 months

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55
Q

Follow up/referral for patient with schizophrenia

A

Frequent evaluation of CBC, CMP, presence of cataracts when taking antipsychotics

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56
Q

4 side effects antipsychotic drugs can cause

A

Pseudo-parkinsonism - stopped posture, shuffling gait, tremors at rest

Akathisia - restless, trouble standing still

Acute dystonia - facial grimacing, involuntary upward eye movement, muscle spasms of tongue, face neck, and back (back muscle spasms cause trunk to arch forward)

Tardive dyskinesia - protrusion and rolling the tongue, involuntary movements of the body and extremities

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57
Q

Major depressive disorder definition

A

Substantial negative changes in mood, thinking and behavior.
Intense feelings of sadness, irritability, or apathy

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58
Q

Major depressive disorder risk factors

A

Age—adolescent or adult

Gender—female

Family History—hx of depression, suicide or suicide attempts, alcohol abuse, substance abuse

History—migraine headache, back pain, recent MI, PUD

Current Medical Condition—chronic disease, insomnia

Lifestyle—stress, poverty, <high school education, recent traumatic event, parent/caregiver of child with behavioral disorder, retired

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59
Q

How to diagnosis major depressive disorder

A

DSM-5—five (or more) symptoms have been present during the same 2-week period & represent a change from previous functioning; symptoms must be present nearly every day; at least one symptom must be:
Depressed mood
Anhedonia (loss of interest or pleasure)

DSM-5 Symptom Criteria
1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in activities
3. Significant weight changes
4. Insomnia or Hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or inappropriate guilt
8. Diminished ability to think or concentrate, indecisiveness
9. Recurrent thoughts of death

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60
Q

Pharmacologic management to MDD
front-line tx
Moderate to severe tx with

A

Front-line Tx.—SSRIs, SNRIs, TCAs, bupropion
SEs: decreased sexual desire, decreased sexual response, headache, stomach upset, sedation, fatigue, nervousness

Medication limitations: seizure disorder, renal disease, liver disease
Contraindicated in bulimia—paroxetine, fluoxetine, fluvoxamine (liver)

Moderate to Severe Depression—Sertraline or Escitalopram

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61
Q

Non-pharmacologic tx for MDD

A

Nonpharmacologic
Interpersonal and cognitive behavior therapy
Support groups, Professional counseling
Establish a routine, increase activities, relaxation, massage, exercise, good nutrition

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62
Q

Follow up and referral for MDD

A

Regular monitoring of effectiveness of medications

Titrate every 1-2 weeks with in the first month of initiating therapy; satisfactory relief typically achieved in 4-6 weeks

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63
Q

Patient education for MDD

A

Report signs of increased agitation, irritability & suicidality

Danger symptoms—hallucination/delusions, severe urinary retention, fluctuation of BP, seizure, cardiac complications, suicidal thoughts, extreme self-care deficits

Clear understanding of side effects

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64
Q

Bipolar 1 definition
Bipolar 2 definition
cyclothymic disorder

A

Bipolar I—mania; at least one episode of mania, an episode of depression is not required for dx

Bipolar II—recurrent moods of hypomania & depression; both

Cyclothymic disorder—alternating cycles of hypomania & depressive episodes less severe than manic or MDDs

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65
Q

Management of bipolar

Pharmacological

non-pharm

A

Pharmacological
Mood-stabilizing medications, 2nd-generation antipsychotics, 1st-generation antipsychotics, adjunctive anxiolytics/antidepressants

Antidepressants can precipitate mania so should always be given in conjunction with a mood-stabilizer

BD 1—lithium, valproic acid, carbamazepine, oxcarbazepine
Acute mania—divalproex/valproic acid

Non-Pharm
Referral to psychiatrist, psychotherapy, cognitive behavioral therapy
Follow-Up/Referral:

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66
Q

Patient education for bipolar

A

Limit everyday stimulants (coffee, alcohol, OTC meds that contain)

Maintain regular sleep patterns and work schedules

Avoid unnecessary or illegal drugs

67
Q

Mnemonic for diagnostic criteria for manic episodes

A

D - distractibility
I - indiscretions (excessive pleasure activities)
G - Grandiosity
F - Flight of ideas
A - Activity increase
S - Sleep deficits
T - Talkativeness

68
Q

Definition of
Completed suicide:
Attempted suicide:
Aborted Suicide:
Suicidal ideation:
Parasiticidal behavior:

A

Completed Suicide—self-inflicted death

Attempted Suicide—potentially lethal acts that did not result in death

Aborted Suicide—potential suicidal behavior that was stopped before the action was completed

Suicidal Ideation—thoughts of causing self-demise

Parasuicidal Behavior—patients who injure themselves in nonlethal gestures but do not wish to die

69
Q

If a patient presents with suicidal ideation make sure to ask them about -

Red flag presenting signs

A

plan
intent
availability of means

Hopelessness about the future, helplessness, lack of future-orientation

70
Q

Management of suicidal patient

A

Assess level of risk (more specific & detailed the plan and the more available & lethal the method)

Reduce/eliminate imminent danger

Never leave a patient alone who is actively suicidal

Involve family members or SOs

71
Q

What scoring system can you use to determine a persons degree of suicide risk?

A

S - sex
A - age
D - depression
P - previous attempt
E - ethanol consumption
R - rational thinking loss
S - social support loss
O - organization of a plan
N - no spouse
S - sickness

0-4 low risk
5-6 medium risk
7-10 high risk

72
Q

Follow up and referral for suicidal patients

A

For non-acutely suicidal patients, follow-up within 24 hours of assessment. Acutely suicidal send to hospital.

24-hour crisis line

Do not exceed 1-week supply (no refills) of medications

73
Q

Generalized anxiety disorder definition

Use screening questionnaire such as

A

excessive worry, over 6 months, about multiple concerns that are difficult to control

Cause by inadequate Norepinephrine, Serotonin, and/or GABAs

Use screening questionnaires—i.e. GAD-7, Beck Anxiety Inventory

74
Q

3 primary symptoms of GAD

A

Motor Tension—shakiness, restlessness, insomnia, headaches

Autonomic hyperactivity—excessive sweating, various GI sx., palpitations, concentration problems, tachycardia, headaches, SOB

Cognitive Vigilance—irritability, quick-to-startle response

75
Q

Criteria for diagnosing GAD

A

Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities

76
Q

Management for GAD
pharmacological -

non-pharm -

A

Pharmacological
SSRIs—first-line treatment (Escitalopram, Paroxetine, Sertraline)

SNRIs—acute treatment (Venlafaxine, Buspirone)

TCAs—when needing sedation (Imipramine)

Antipsychotic—trifluoperazine

Antihistamine—Hydroxyzine

Anti-seizure—Pregabalin

Nonpharmacological - Cognitive-behavioral therapy

77
Q

Follow up/Referral for GAD

A

monthly appts may be necessary until patient establishes appropriate support

Develop plan with patient to include criteria for seeking emergency services when needed

78
Q

Patient Education for GAD

A

Medication can take 4-6 or even 8 weeks to reach effectiveness
Do not mix medications with alcohol

GAD cannot be managed with medication alone, CBT and lifestyle modification, counseling

Education—symptom recognition, effective interpretation of physical symptoms, treatment modalities, decrease of stimulants, medication & counseling (together)

79
Q

Panic disorder definition

A

recurrent, intense, short episodes of panic-level psychological & physical symptoms of anxiety

80
Q

clinical presentation of panic disorder

A

Recurrent and unpredictable panic attacks—develop suddenly within 10 minutes; resolve within the hour

Fear of the next attack

81
Q

Pharm

non-pharm

management of panic disorder

A

Pharmacological
SSRIs & SNRIs—first line treatment
TCAs, benzos, valproic acid, gabapentin; avoid extensive use of benzos

Nonpharmacological
Cognitive behavioral therapy, hypnosis, alternative (yoga, meditation)

82
Q

DSM 5 criteria for diagnosing panic disorder

A

Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following are present:
1 - palpitations
2 - sweating
3 - trembling
4 - sense of SOB
5 - feeling of choking
6 - chest pain or discomfort
7 - nausea or abdominal discomfort
8 - feeling dizzy or light headed
9 - chills or heat sensation
10 - paresthesia (numbness or tingling sensation)
11) derealization (feeling of unreality) or depersonalization (being detached from oneself)
12 - fear of loosing control or going crazy
13 - fear of dying

83
Q

Follow up/Referral for panic disorder

A

F/U on pharmacologic management every 1-2 weeks, then every 2-4 until therapeutic dosage is achieved

F/U with psychiatrist if fail to respond after 6-8 weeks of standard treatment

84
Q

Patient education for panic disorder

A

Thorough understanding of disease process
Exercise, healthy nutrition, relaxation techniques

85
Q

PTSD definition

A

Syndrome that develops after a person witnesses, participates in, or experiences direct exposure to actual or threatened trauma (death, threatened death, serious injury, sexual violence)

Experiences are overwhelming; persons re-experience the trauma in dreams and daily thoughts

86
Q

Clinical presentation of PTSD

A

Reexperiencing the traumatic event or having intrusive thoughts/nightmares about the event—nightmares, flashbacks, sudden vivid memories

Avoidance symptoms

Negative thoughts/feelings that began/worsened after the trauma

Hyperarousal symptoms—unprovoked anger, jumpiness, “on guard”

87
Q

pharm

non-pharm

management for PTSD

A

Pharmacological
SSRIs—paroxetine, sertraline

TCAs may be effective; anxiolytics for acute or short=term sx—Buspirone may reduce intrusive sx

Nonpharmacological
Safety assessment, history established, trauma-focused psychotherapy, cognitive behavioral therapies, narrative exposure therapy, written narrative exposure

88
Q

DSM 5 algorithm for diagnosing PTSD

A

Traumatic event -

Trauma exposure -

Meets symptom criteria (new/worse afterward: intrusion, avoidance, hyperarousal

duration >1 month

distress/impairment

PTSD diagnosis

89
Q

Sexual assault definition

A

Intentional touching of the victim’s genitals, anus, groin, or breasts
Voyeurism
Exposure to exhibitionism
Undesired exposure to pornography
Public display of images that were taken in a private context or when victim is unaware

90
Q

pharmacological treatment for sexual assault

A

STI treatment tetanus booster, HIV counseling/testing/prophylaxis, Hep B, emergency contraception

91
Q

OCD diagnostic criteria

A

Presence of obsessions, compulsions, or both—one category required for diagnosis

92
Q

Obsessions vs compulsions

common examples

A

Obsessions—recurrent & persistent thoughts, urges, or images experienced as intrusive & unwanted

Compulsions—repetitive behaviors or mental acts an individual feels forced to perform due to either an obsession or strict rules of conduct—decrease anxiety from obsessions

common obsession - Aggressive impulses
Contamination (shaking hands with someone)
Need for order (distress w/disorder or asymmetry)
Religious (blasphemous thoughts, concerns)
Repeated doubts
Sexual imagery (recurrent pornographic images)

common compulsion
Checking (locks, alarms, appliances)
Cleaning (handwashing)
Hoarding (saving trash)
Mental acts (praying, counting, repeating words)
Ordering (reordering objects to achieve symmetry)
Reassurance-seeking
Repetitive actions

93
Q

OCD

pharm

non-pharm

management

A

Pharmacological
SSRIs—generally, higher dosages and longer duration trials are necessary to treat OCD—escitalopram & citalopram are not recommended

Nonpharmacological
Cognitive behavioral therapy, group sessions,

94
Q

body dysmorphia disorder definition

A

Pre-occupation with one or more perceived physical defects or flaws, often not visible or only slightly so to others

95
Q

Body dysmorphic disorder clinical presentation

A

Rarely report symptoms due to feeling ashamed about themselves & their bodies
Depression, anxiety, request referral to dermatologists, plastic surgeons, orthodontists, maxillofacial surgeons
Frequently check mirrors, pick skin, or camouflage bodies; comorbid eating or substance use disorder

96
Q

pharm and

non-pharm

management for body dysmorphic disorder

A

Management:
SSRIs—first line treatment—fluoxetine, citalopram, escitalopram, fluvoxamine, clomipramine—12-16 weeks trial

Cognitive behavioral therapy, cognitive restructuring, perceptual retraining

Educate patient and family about the disorder

97
Q

Hoarding DSM 5 diagnostic criteria

A

Persistent difficulty disregarding or parting with items regardless of actual value

Results in accumulation of stuff that clutter that living areas and substantially compromise their intended use

98
Q

Management for hoarding disorders

A

SSRIs—venlafaxine, paroxetine, cognitive behavioral therapy

99
Q

Anorexia definition -

A

refusal to maintain a minimally normal body weight and an intense fear of gaining weight d/t to body image disturbance

Symptoms: amenorrhea, Constipation, Abdominal pain, Hypothermia, Lethargy, Anxious energy, Headaches

100
Q

Bulimia definition

A

recurrent episodes of binge eating, followed by compensatory methods to prevent weight gain—self-induced vomiting, misuse of diuretics/laxatives/enemas, excessive exercising or fasting

Symptoms: irregular menses, abdominal pain, fatigue, peripheral edema, bloating, depression, acid reflux, sore throat

101
Q

Binge-eating disorders

A

recurrent episodes of binge eating without the compensatory use of vomiting, laxatives, emetics or diuretics

102
Q

Management of eating disorders

A

Inpatient—supervised meals, gradual increase in calories, activity; daily weight

Outpatient—Weekly weigh-ins progressing to monthly; gradual weight gain, cognitive behavioral therapy, family therapy

SSRIs—fluoxetine (only drug approved for BN), Vyvanse (BEN)

103
Q

insomnia disorders are defined as

A

o Difficulty sleeping

104
Q

Management of insomnia disorders

A

Cognitive behavioral therapy, sleep hygiene habits

Benzodiazepines—estazolam, flurazepam, quazepam, temazepam, triazolam; eszopiclone, zaleplon, zolpidem

Antihistamines—diphenhydramine

Antidepressants—trazodone, mirtazapine, doxepin

Antipsychotics—quetiapine, olanzapine

105
Q

Patient education for insomnia

A

Discuss good sleep hygiene practices, possible sleep study is suspect sleep apnea

106
Q

DSM 5 criteria for insomnia

A

dissatisfaction with sleep quality

clinically significant distress
minimum 3nights/ week
minimum 3 months
have adequate sleep opportunity`

107
Q

Restless leg syndrome definition

symptoms

A

Neurologic, sensorimotor—uncomfortable sensations in legs—burning, tingling, crawling, itching

Uncontrolled desire to move legs, associated with sleep disturbance

Clinical Presentation
Symptoms at rest, often worse at night, uncontrollable urge to move legs, excessive daytime sleepiness, bed partner notices excessive movement during sleep, family history

108
Q

Restless leg syndrome management
pharm

non-pharm

A

Sleep hygiene, baths, whirlpool, massage, exercise

Pramipexole, Ropinirole

109
Q

types of abdominal pain

Visceral pain
parietal pain
colicky
burning pain

A

Most common abdominal complaint cause by mechanical, inflammatory and ischemic factors

Visceral pain—caused by distention or spasm of hollow viscus—generalized and dull

Parietal pain—sharp & well localized—caused by irritation of peritoneum

Colicky—comes and goes

Burning pain—caused by irritation of gastric mucosa by gastric contents

110
Q

constipation def

most common cause

A

Difficult or infrequent defecation

Most common cause is lack of dietary fiber

111
Q

Functional constipation

disordered motility

secondary constipation

A

Functional—diet low in fiber, sedentary lifestyle

Disordered motility—slowed transit time, megacolon or megarectum, IBS, diverticular disease, common in elderly

Secondary constipation—medications—opioids, analgesics, CCBs, antidepressants, antiparkinsonians, cough medicines, aluminum antacids; chronic laxative use, prolonged immobilization, colorectal cancer

112
Q

Diarrhea definition

What do you want to focus on during exam?

A

Increase in frequency, volume, or fluid content of bowel movements over what is normal for the individual

Focus on patient history:
Frequency
Amount & fluidity
Color & characteristics—bloody, tarry, black, steatorrheic, mucus
Diet, Recent Travel, source of drinking water, medication use, med/surg history, sexual practices, social/family hx.

113
Q

Where can people experience heartburn pain?

Dyspepsia definition: - associated symptoms

A

Heartburn—extreme pain, often radiating to the back, arms, or jaw

Dyspepsia—epigastric discomfit, postprandial fullness, early satiety, anorexia, belching, nausea, heartburn, vomiting, bloating, borborygmi, dysphagia, abdominal burning.

114
Q

Jaundice definition

Will see what labs?

A

Yellow coloration of the skin, mucous membranes & sclera from accumulation of bilirubin in the blood

Elevated AST, ALT, bilirubin

115
Q

Melena definition

A

Black, tarry stools that test positive for occult blood—most common cause is upper GI bleed

116
Q

Dysphagia definition

A

Difficulty swallowing caused by mechanical obstruction or a functional problem that impairs motility

117
Q

Gastroenteritis definition

A

Inflammation of the stomach and intestine that manifests as anorexia, nausea, vomiting, and diarrhea

Bacterial, Viral, Parasitic most common causes

118
Q

Management of gastroenteritis

antimotility drugs such as:
Antimicrobials if:

A

Fluid and electrolyte management for patients presenting with diarrhea

Calories from boiled starches (potatoes, pasta, rice, wheat, oats) with salt during illness

Anti-motility drugs—pepto-bismol, Imodium, Lomotil—contraindicated in febrile dysentery

Antimicrobials if severe diarrhea with fever and leukocytes in stool—azithromycin (traveler’s diarrhea)

119
Q

Patient education for gastroenteritis

A

Prevent spread of disease—good hand washing, safe disposal of waste, avoid daycare while sick

When traveling to high-risk area, only consume safe foods & beverages

120
Q

Types of hepatitis and how they are typically contracted

A

Hepatitis A—contaminated food or water—fecal-oral route of transmission

Hepatitis B—transmission via direct contact with infected blood/blood products or by sexual contact

Hepatitis C—percutaneous exposure to blood & blood products

Hepatitis D—only persons with HepB are at risk for HepD—injection drug use—parenteral route

Hepatitis E—fecal-oral route, not as easily transmitted as A—fecally contaminated water

121
Q

Hepatitis definition

chronic hepatitis

A

Acute viral—systemic infection predominantly affecting the liver

Chronic Hepatitis—elevated AST/ALT for more than 6 months; typically B & C

122
Q

Prodromal phase presentation

Icteric phase presentation

Convalescent phase

A

Prodromal Phase Presentation - Anorexia, nausea, vomiting, malaise, URI, flu-like sx., myalgia, arthralgia, easy fatigability, fever

Icteric Phase - Jaundice, dark urine 5-10 days after initial sx.

Convalescent Phase - Increased sense of well-being, other symptoms subside and appetite returns

123
Q

Management and referral of hepatitis

A

HepA & B vaccines

Supportive treatment—balanced nutrition with adequate calories and fluids

HCV—referral to hepatologist
HAV—usually do not require f/u
HBV—f/u 1 month and blood draw in 6 months
Referral to hepatologist for chronic hepatitis

124
Q

Appendicitis definition

How is it diagnosed

A

Inflammation of the vermiform appendix caused by an obstruction and/or infection

Dx - CT abdomen

Most common cause of acute RLQ pain requiring surgical intervention

125
Q

3 signs of acute appendicitis and how to test for them

A

Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadrant.

Psoas sign -Pain on passive extension of the right thigh. It is present when the inflamed appendix is retrocecal and overlying the right psoas muscle.

Obturator sign - is a clinical sign of acute appendicitis, it is defined as discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed. It indicates an inflamed pelvic appendix that is in contact with the obturator internus muscle

126
Q

Appendicitis symptoms

A

pain in RLQ vague at first than localizing
low grade fever
constipation or diarrhea
n/v

127
Q

Management of appendicitis

Follow up

Patient education

A

Surgery - Preop—correct fluid & electrolyte imbalances, bedrest, NPO, NG if indicated, stool softener if constipated
Give a 3rd gen cephalosporins (cefitraxone)

Follow-Up/Referral:
F/U with surgeon 5-7 days post-op

Patient Education:
Post-op instructions from surgeon; no heavy lifting for 2 weeks

128
Q

what is GERD?
Primarily caused by?

A

Backward flow of stomach or duodenal contents into esophagus without retching or vomiting

Primary cause—inappropriate, spontaneous transient relaxation of lower esophageal sphincter (LES)

Precipitating Factors -
Reclining after eating
Eating a large meal
Restrictive clothing
Heavy lifting
Ingesting alcohol, chocolate, caffeine, fatty/spicy foods, nicotine

129
Q

How is GERD diagnostic made?

If a patient fails therapy then?

A

Usually made from history

EGD after failed treatment

130
Q

Initial management to GERD

Unresponsive management

A

Initial:
Weight loss, elevate head of bed 6-8 inches, avoid meals 2-3 hours before bedtime, avoid irritating foods

8 week trial PPI once daily—step-up to twice daily if only partial response

Unresponsive to 8 weeks of PPI:
If EGD shows erosion or Barrett’s esophagus—chronic PPI may be necessary

131
Q

Follow up and referral for GERD

A

8 weeks after initiation of either PPI (omeprazole) or H2 (famotidine) therapy

Evaluate chronic PPIs every 6 months

Possible adverse effects of PPI—pneumonia, c-diff, osteoporosis, vit B12 deficiency

132
Q

What is peptic ulcer disease?

Usually caused by?

A

Break in the surface mucosa of the stomach or duodenum

Occur when there is an imbalance between the protective factors o the mucosa and aggressive factors as acid & pepsin

Usually result of H. Pylori infection, medications (NSAIDs)

Gastric ulcers and Duodenal ulcers

133
Q

Major difference between peptic ulcer disease and GERD

A

PUD has pain (dyspepsia) in epigastrium relieved by food or antacids

134
Q

Management of PUD

how to treat H pylori

A

PPIs—omeprazole, rabeprazole, lansoprazole, esomeprazole, dexlansoprazole, pantoprazole

Duodenal ulcers—4 weeks; Gastric ulcers—8 weeks

H2RAs—avoid cimetidine due to affect on other medications (warfarin, theophylline, phenytoin)

Daily at bedtime or half regular dose twice daily for 8 weeks

H. Pylori infection
riple therapy: clarithromycin w/ amoxicillin or metronidazole and PPI BID x14 days

135
Q

FU and PE for PUD

A

F/U in 4 weeks if treating H. Pylori
If non-HP, f/u unnecessary unless symptoms recur

PE
Stool can turn black if taking bismuth preps
Sucralfate cannot be taken with other medications as it will bind to them

136
Q

What is a hemorrhoid

External

vs

internal

A

Mass of dilated and tortuous veins either internal or external
Primary cause believed to be straining during defecation, complicated by constipation, prolonged sitting, pregnancy, and anal infection

Objective
External: usually protrude on standing or with Valsalva

Internal: rectal bleeding (bright red streaks)

137
Q

Abdominal hernia def

A

Protrusion of peritoneally lined sac through defect or weakened area in abdominal wall

138
Q

Management and PE of hernias

A

Surgical referral

FU 3-7 days post op

Avoid heavy lifting for at least 4-6 weeks.

139
Q

what is Irritable bowel syndrome and how is it diagnosed

A

Abdominal pain/discomfort and change in bowel habits

Two must be present:
Abdominal pain relieved by defecation
Change in frequency in stool
Change in the appearance of the stool

Women more than men, 3:1
Common dietary triggers—lactose, fructose, sorbitol, glutens

140
Q

IBS symptoms

A

Abdominal pain
Altered bowel habits
Diarrhea & Constipation
Painless diarrhea
LLQ pain
Sharp/burning/cramping/
diffuse/dull
incomplete evacuation

141
Q

Management of IBS

what type of diet

2 classes of meds

PE includes

A

First make accurate diagnosis and identify symptom pattern specific to each patient

Therapy is symptomatic
Slowly eliminate IBS triggering foods to attempt to isolate a food trigger

High fiber diet, at least eight 8-oz glasses of water/day, probiotics

Anti-diarrheal—loperamide, diphenoxylate
Antispasmodics—dicyclomine, hyoscyamine

Diet, stress management, good bowel habits

142
Q

What is celiac disease and how is it diagnosed?

A

Gluten-sensitive enteropathy; celiac sprue; autoimmune disorder affecting small intestinal villous epithelium
Wheat, rye, barley
T-cell mediated

Serum testing anti-tTG IgA antibodies

Management is a strict gluten free diet

143
Q

How does a bowel obstruction occur?

Classified based on _____ or ____ and _____ of _____

Early obstruction is:
Late obstruction is _____

A

Mechanical blockage or functional (paralytic ileus) disrupting motility

Acute onset causes—torsion, herniation, intussusception

Chronic causes—slow process, tumor growth, strictures

Classified partial or complete and location of lesion
Early obstruction—alkalosis due to non-absorbed hydrogen ions
Later obstruction—acidosis occurs due to alkaline pancreatic secretions & bile not being absorbed

144
Q

Subjective and objective symptoms

Management

A

Sudden onset colicky pain with N/V
Pain with peristaltic waves
Initial diarrhea followed by constipation
BS high pitched & hyperactive

Management -
Immediate hospitalization with surgical referral
Most will require NG tube insertion
IV fluid rehydration, accurate I/O
Surgical repair if complete obstruction

145
Q

What is diverticulitis vs diverticulosis

A

Diverticulitis - Inflammatory changes within the diverticular mucosa of the intestine

Diverticulosis - Asymptomatic, uninflamed outpouchings

146
Q

Possible causes and

how it is diagnosed

A

Low fiber diet, high fat, high red meat, obesity, chronic constipation

Abdominal X-ray
CT abdomen
Colonoscopy

147
Q

How is diverticular disease treated?

FU will require:

Patient education

A

Rest, clear liquid diet during acute phase; high fiber diet after

Abscess drain if necessary

Augmentin BID, Flagyl TID, Bactrim DS BID all for 7-10 days or until patient is afebrile for 3-5 days

Hyoscyamine, Dicyclomine, Buspirone—for pain

Possible hospitalization for acute presentation requiring hydration, analgesia, & bowel rest (NG)

Possible surgical management with resection

Follow-Up/Referral:
Will require follow up colonoscopy

Patient Education:
High fiber diet, avoid irritating foods (seeds, popcorn, hulls), constipation prevention, increase water intake

148
Q

Inflammatory bowel disease 2 common conditions

A

Chronic immunological disease that manifests in intestinal inflammation
Exacerbations and remissions throughout a patient’s lifetime

Ulcerative Colitis—involves only mucosal surface of the colon—friability, erosions, bleeding

Crohn’s Disease—segmental or patchy transmural inflammation of the bowel wall of any portion of GI tract

149
Q

Management of UC

A

Nutrition counseling: Avoid caffeine, raw fruits/vegetables and other foods high in fiber; can try lactose free

Avoid anti-diarrheals in the acute phase; mild to moderate diarrhea—lomotil, Imodium

Topical mesalamine, steroid enemas, oral 5-ASAs, typically require systemic flucocorticoids

Severe disease unresponsive to treatment will require surgical referral

Correct fluid/electrolyte imbalances (hypokalemia)

150
Q

Management of Crohn’s disease

A

Sulfasalazine, glucocorticoids; treatment aimed at suppressing inflammatory process and symptom relief

Sulfasalazine interferes with folic acid absorption—must take supplement

Metronidazole, ciprofloxacin, ampicillin, tetracycline

Avoid anticholinergics and anti-diarrheals to decrease risk of toxic megacolon or ileus

151
Q

Colorectal cancers
most important risk factor in developing
typically presents as

A

Majority of cases are both curable and preventable if detected early

Age is most important risk factor for developing colorectal cancer in US

Typically present as polyps

Cancer typically found incidentally during abdominal surgery or screening colonoscopy

152
Q

First step in disease process -
average risk should begin coloscopy at
high risk

A

First step is staging of the disease—tissue of origin, origin of specimen, degree of tissue differentiation

Average Risk—Begin age 50 thru 75 (45 for African Americans)

high risk - Colonoscopy every 5 starting age 40 or 10 years younger than age at dx of youngest affected relative

153
Q

what is cholecystitis - impacted ___ within _____

Subjective complaints

A

Acute inflammation of gallbladder was
Impacted calculus within cystic duct

Indigestion, N/V esp after consuming meal high in fat
Begins as colicky pain
Pain localized to RUQ

154
Q

Objective sign of cholecystitis

A

murphy sign take a deep breath push on RUQ pain will be elicited

155
Q

Management of cholecystitis

A

Avoid foods high in fat

Nonsurgical—oral dissolution solutions, lithotripsy
If remain symptomatic after non-surgical attempts and diet management, surgical intervention

156
Q

What is acute pancreatitis
80% of the time it is caused by

A

Acute inflammation of the pancreas and surround tissues from release of pancreatic enzymes

80% caused by biliary tract disease or alcoholism

157
Q

How to treat mild acute pancreatitis

How to treat severe acute pancreatitis

A

Mild—resolves spontaneously in a few days; fasting is necessary
Parenteral fluids, consider NG tube, Morphine for opioid pain relief; introduce clear liquids when patient is pain free, amylase/lipase have returned to normal and bowel sounds returned

Severe—typically require ICU for aggressive fluid resuscitation (up to 6-8L/day)
Daily labs (CBC, CMP, amylase/lipase, blood cx if fever, ABG); prolonged fasting—TPN may be necessary

158
Q

What is chronic pancreatitis

What typically causes it?

A

Slow, progressive inflammation; irreversible fibrosis of the pancreas; destruction of exocrine & endocrine tissue

Alcoholism with high protein and high/low fat daily diet

159
Q

Management and patient education for chronic pancreatitis

A

Prevent further pancreatic damage, manage pain, supplement exocrine & endocrine function

Abstinence from alcohol is imperative

Narcotics are usually necessary for pain control

Low-fat diet, oral pancreatic enzyme supplement, fat-soluble vitamins (A,D,E,K); Insulin (maintain glucose at higher than normal level to avoid hypoglycemia due to deficiency of glucagon secretion)

Goal of treatment is to control diarrhea and gain body weight

Caution against long-term narcotic use and risk for drug dependence

160
Q

What is cirrhosis

A

Hepatocellular injury of entire liver from fibrosis, nodular regeneration, & distorted hepatic architecture.

Cirrhosis is permanent and irreversible

Many causes—chronic alcohol abuse & viral hepatitis leading causes

161
Q

Objective findings of cirrhosis

A

enlarged firm liver palpable below R costal margin

jaundice

muscle wasting

spider angioma

encephalopathy

asterixis (liver flap)

162
Q

Management of alcohol induced cirrhosis

Management of irreversible chronic cirrhosis

A

Alcohol-induced -
Absiinence is most effective treatment
Patients presenting with ascites who continue to drink drop 2 year survival rate to <25%
Increase protein intake to 1-1.5 g/kg per day (unless encephalopathy); vitamin/mineral supplementation (B12, folate, thiamine, magnesium, zinc)

irreversible
Liver transplant is treatment of choice

163
Q

Patient education for cirrhosis

A

Daily weight, psychological well-being, educate on medications that cause hepatotoxicity (i.e. acetaminophen)

Avoid CNS depressants with encephalopathy

S/Sx of infection with ascites and risk for bacterial peritonitis

Maryville FNP Adult 2 (2 decks)

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