Final

Question 1

Values

Answer 1

BUN= 7-18 mg/dL (waste product of protein metabolism)
GRF=125-200 ml/min
Proteinuria= 150 mg/day
Serum Creatinine=0.7-1.4 mg/dL

Question 2

Terms

Answer 2

Anuria=less than 50ml/ day
ADH= vasopressin
Amblyopia= lazy eye (decrease vision acuity)
Astigmatism= blurred vision caused by irregularity of the cornea
Arthereotomy=remove plaque from artery
Aphakia= absence of lens after cataract surgery
Advera= nutritional supplement that has been developed specifically for people with HIV and AIDS
Blindness= 20/400 to no light perception
Belching= burp
Borborygmi= stomach growling soun
CLABSI= central line associated bloodstream infection
Commissure=where the heart leaflet meet
Detumescence= subsiding of erection
EIA= enzyme immunoassay
Enuresis=urinary incontinence at night
Ectropion= your eyelid turns outward. This leaves the inner eyelid surface exposed and prone to irritation. generally effecting only the lower eyelid
Entropion= your lower eyelid is turned inward so that your eyelashes rub against your eyeball, causing discomfort
Epitaxis= nose bleed
Epididymitis= secondary to prostatitis, UTI, gonorrhea
Emmetropia= normal vision
Flatulence= fart
Fulminant= severe or sudden onset
Gonad= reproductive organ
GFR= Perfusion pressure in the glomerular capillaries
Hyperopia= farsighted
Hydrocele= Collection of fluid in the tunica vaginalis of the testes
Intermittent=irregular interval, not continuos. Stopping and beginning again, sporadic
Legal blindness= vision acuity doesn’t exceed 20/200 or whose widest vision field diameter is 20 degrees or less
Low vision= a person who needs a device to perform a visual task
Myopia= nearsighted
Myosis= pupil contraction (small pupil)
Mydriasis= pupil dilation
Middle age adult= 40-65 (auditory acuity decrease especially for high frequency sounds. so use low pitch voice when speaking)
Nystagmus=involuntary oscillation of the eyeball. (neuro issue)
Oliguria=less than 0.5ml/kg/hr
Oscillation =movement back and forth
OS= left eye
OD= right eye
Overactive bladder=constant urge to pee
Ptosis= drooping eyelid
Papilledema= swelling of the optic disc from increased IOP
Prolapse= Stretching of AV valve into the atrium during systole
Specific gravaity= ability or kidney to concentrate salute in urine
Strangury= slow and painful discharge of urine
Strabismus= crossed eye (yelena) condition in which there is deviation from perfect ocular alignment.
Scotomas= blind spot
Smegma= thicken secretion (phimosis)
Scaphoid= sunken or hallow
Trichiasis= Eyelashes grow inwards toward the eye
Tympani= Sound results from presence of air in the stomach or small intestine
Vision impairment= 20/40 or worse vision acuity
Viral set point= amount of HIV in the body after the initial immune response subside (equilibrium between HIV level and the immune response)
Varicocele= abnormal dilation of the pampiniform venous plexus and the internal spermatic vein in the scrotum
Warp= bent or twisted

Question 3

function of kidney

Answer 3

primary
-Regulate acid base balance by regulating hydrogen ion excretion.
Too much hydrogen ion cause acidity, two little cause alkalosis [hydrogen ion is acidic]
-water reabsorption

secondary
-secrete enzyme renin and activate vitamin d

Question 4

UTI

Answer 4

Risk factor

• diabetes
• gout
• neurological disorders
• obstructed urinary flow caused by congenital abnormalities, urethral stricture’s, bladder tumor, kidney stone, compression of ureter
• reflux/backward flow when coughing, sneezing, or straining

s/s
urinary frequency, urgency, nocturia, dysuria, incontinence, supra public or pelvic pain, hematuria, back pain

teaching

• avoid spicy food, sugary food
• lactobacillus helps

Question 5

Phenazopyridine (Pyridium)

Answer 5

Urinary Tract Analgesic

give with meal. can cause gi upset

Question 6

think uric acid stone think

Answer 6

purine

Question 7

Pyelonephritis

Answer 7

TB can be the cause

assess temp every 4 hour

Chronic Pyelonephritis s/s: symptomless or poor appetite
can lead to chronic kidney disease

Question 8

iatrogenic incontinenece: what medication

Answer 8

alpha adrenergic agent and steroid

Question 9

urinary incontinence

Answer 9

risk factor
-menopause

tx
1. behavioral treatment (kegal, voiding diary, biofeedback, PT)

2. medication
tricyclic antidepressant (amitriptyline/ elavil)
Pseudoephedrine sulfate (Sudafed)

teaching
avoid bladder irritant such as aspartame/ nutrasweet

Question 10

urinary retention

Answer 10

int:
Apply heat to lower abdomen 
pour warm water 
sits bath 
crede's maneuver (apply pressure to the bladder)

fexofenadine (antihistamine) can cause urinary retention

Question 11

about suprapubic bladder drainage

Answer 11

• a tracer cannula is used to puncture the abdominal and bladder wall. The catheter is then threaded through it
• when the patient’s ability to urinate on their own is being tested, the catheter will be clamp for four hours. After the patient void, the catheter is unclamped to measure the residual. If residual is less than 100 ML on 2 occasion suprapubic bladder drainage can be discontinue. Sterile dressing is hen placed over the site

Question 12

neurogenic bladder cause

Answer 12

Spinal cord injury 
spinal tumor 
herniated vertebral disc 
multiple sclerosis 
congenital disorder (spina bifida or myelomeningocele) infection 
diabetes

Question 13

about urinary catheter

Answer 13

• wash perineal area twice daily
• clean perineum before removing Foley
• always check for latex, Teflon, and iodine allergies before performing catheterization
• position of female catheterization: dorsal recumbent (feet flat on bed 2 feet apart)

Question 14

3 factor that favor the formation of kidney stone

Answer 14

infection, urinary stasis, immobility

Question 15

cause of calcium phosphate stone

Answer 15

Renal tubular acidosis 
cancer [leukemia, multiple myeloma) 
granulomatous (sarcoidosis, TB) 
increase vitamin D intake 
excessive protein intake

Question 16

tx for calcium phosphate stone: give thiazide if

Answer 16

cause is hyperparathyroism

Question 17

example of acidic food

Answer 17

Grains, cereal, prunes, plum

Question 18

uric acid kidney stones

Answer 18

cause
-myeloproliferative disorders

tx

• avoid shellfish, anchovies, asparagus, mushroom, organ meat
• medication: allopurinol (zyloprim)

Question 19

two type of stone that tx include increase acidic food

Answer 19

calcium phosphate and struvite

Question 20

tx of cystine stone

Answer 20

base forming food and low protein diet

Question 21

kidney stone

Answer 21

Patient compares up to 1 cm in diameter of stone on their own
CT scan is a gold standard for a diagnostic test
s/s
-n/v is s/s of severe pain

Medication that can cause kidney stone
-acetazolamide (dimox), high dose of aspirin, and laxative

int

• hot bath or moist heat, increase will take, increase ambulation, lost weight
• ESWL extracorporeal shockwave lithotripsy [passage of stone fragment may occur in six weeks to several months after the procedure. Informed patient to expect hematuria. It should disappear within 4-5 days]

prevention

• limit protein to 60 g per day or a boy altogether.
• Avoid oxalate containing food (spinach, strawberry, rhubarb, tea/coffee/beer/cocoa/chocolate, peanut, wheat brain, vit c)

Question 22

BPH

Answer 22

• occurs when prostate become more sensitive to estrogen and less responsive to dihydrotesterone (DHT)
• risk factor: being unhealthy similar to HTN risk factor. smoking and heavy alcohol consumption
• s/s: abdominal straining with urination, dribbling, fatigue, anorexia, and/V, they are a review large, robbery, and on tender prostate
• medication: 1.) alpha adrenergic blocker (alfuzosin/ uroxatral, tamsulosin/ flomax, terazosin/ hytrin) It relax smooth muscle SE: HA, dizziness, fatigue, hypotension, sexual dysfunction
  2. ) 5-alpha reductase inhibitor (finasteride/ proscar) It reduce prostate size SE: decrease libido, gynecomastia, flushing (some herbal supplements are contraindicated with Proscar. As the patient about the use of dietary supplement)

-surgical tx: 1.) TUMI transurethral microwave thermotherpy 2.) TUNA transurethral needle ablation 3.) TUIP transurethral electrovaporization (cuts are made in prostate to reduce construction. No tissue is removed)

Question 23

oxalate containing food think

Answer 23

in plant based food

no meat

Question 24

early sign of kidney disease

Answer 24

Diluted urine with a fixed specific gravity (1.010) or affects osmolarity (300)
inability to concentrate urine

Question 25

bruit (low pitch murmur) at costoverterbral angle can indicate

Answer 25

renal arteries stenosis or aortic aneurysms

Question 26

specific gravity

Answer 26

increase=CHF, SIADH

decrease=renal failure, nephritis

Question 27

GU diagnostic test

Answer 27

MRI

• Avoid stimulant 2 hour prior and food 1 hour prior
• patient can take their usual medication except iron supplement

IV pyelogram
-contraindication for pregnant/ breastfeeding

renal angiography
-pre op a laxative may be prescribed to evacuate the colon so that unobstructed x-ray can be obtained

kidney biopsy

• npo 6-8 hour prior
• if needle biopsy is being performed, pt is instructed to breath in and hold their breath to prevent kidney from moving
• is for AKI, persistant proteinuria or hematuria, transplant rejection, glomerulopathies
• contraindicated in pt with sepsis, large polycystic kidney, UTI, kidney neoplasm

cystoscopy
-Common complication after is Urinary retention from edema caused by the instruments

pelvic/ urincary tract ultrasound
- need a full bladder. increase fluid intake

Question 28

bladder cancer

Answer 28

cause
smoking, genetic, exposure to arsenic

s/s
visible, painless, hematuria

tx
transuretral resection (fulguration) followed by BCG treatment for 1 year (BCG treatment is an intravesicle procedure. Patient is allowed to eat and drink before the procedure. Once the bladder is full, patient must retain BCG solution for two hours)

Question 29

Urinary diversion

Answer 29

1. Cutaneous
   - Vesicostomy (from bladder)
   - Nephrostomy (from kidney)

expect hematuria for 2 days

2. Continent
   - ureterosigmoidostomy
   - kock pouch (only for men)

Introduction of urine into the bowel because diarrhea and electrolyte in balance. Fluid and electrolyte is monitored closely. Encourage potassium rich food (citrus fruits)

teaching

• avoid moisturizing soap and body wash when cleaning the area because it interfere with the adhesion of the pouch
• for odor: avoid asparagus, cheese, air, garlic, and onion. Diluted white vinegar may be introduced through the drain spout into the bottom of the pouch with syringe or eyedropper. Vitamin C also helps
• drain when 1/3 full
• use three to one solution of water and White vinegar to clean the appliance (soak for 30 minutes) after drying, the appliance maybe powdered with cornstarch
• should be 1/8 inches larger than the stoma
• the size of stoma is measured every 3 to 6 weeks for the first few months post operative

Question 30

Mode for sexual assessment

Answer 30

PLISSIT
Permission
Limited information
Specific suggestion
Intensive therapy

Question 31

Prostate cancer

Answer 31

screening
>50 or >40 African American should screen annually

PSA

• increased PSA may indicate acute urinary retention and acute prostatitis
• less than 4 ng/ml is normal
• help detect non-palpable prostate cancer and SS with staging it
• increase with age
• if PSA or DRE are abnormal, do transrectal ultrasound (TRUS) TRUS is also use when doing needle biopsy of the prostate

Question 32

Erectile dysfunction

Answer 32

cause

• medication: anti-adrenergic, antihypertensive, anti-cholinergics, antidepressant
• HTN, heart disease, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hypothyroidism, hypothyroidism), cirrhosis, chronic renal failure, Parkinsonism, anxiety, depression

tx:
1. phosphodiesterase type 5 (PDE 5) inhibitor PO (ex: viagra/ sildenafil, levity/ vardenafil)
take before intercourse. erection can last 1 hour
SE: HA, flushing, dyspepsis, diarrhea
caution with retinopathy
contraindicated with nitrate use, pt with HTN, heart, kidney, or liver dysfunction

2. injection of alprostdil, papaverine
3. Penile implant (healing takes up to 3 weeks
   4 Negative pressure device

Question 33

Premature ejaculation

Answer 33

• In men age 18 to 25, factor associated with premature ejaculation are smoking, use of illegal drugs, poor physical and mental health
• retrograde premature ejaculation occur with prostate surgery, diabetes, an anti-hypertensive meds
• medication
  1. Selective seretonin reuptake inhibitor (dapoxetine/ priligy)
  2. Alpha 1 antagonist
  3. tricyclic antidepressant (clomipramine/ anafranil)

Question 34

Prostate cancer

Answer 34

risk
diet high in red meat or diary product that are high in fat

s/s
blood in urine and semen, painful ejaculation, DRE will find nodule or hardening gland
(metastasized in lymph node and bone: backache, hip pain, anemia, weight loss, weakness, spontaneous pathologic fracture)

diagnosis

• tumor grading system Gleason score. A score of 8 to 10 = high-grade cancer. Lower scores is better
• antibody capromab pendetide with indium III (prostascint) can detect recurrent prostate cancer or metastatic disease

tx

1. therapeutic vaccine, sipuleucel-T (proving) for use in men with metastatic prostate cancer that do not response to hormone therapy
2. if prostate cancer not response to #1, medication such as abiraterone acetate (Zytiga) and cabazitazel (jevtana) help
3. radiation (1. teletherapy or external (EBRT) 2. Brachytherapy or internal seeds- avoid close contact with pregnant women and infants for up to two months. Strain urine for seeds for two weeks after the procedure
4. hormonal therapy or androgen deprivation therapy ADT: suppressed testosterone ( leuptolide/ lupron, flutamide/ eulexin)

Question 35

Prostate surgery

Answer 35

May be indicated for BPH and prostate cancer

1 TURP transurethral resection of the prostate
-doesn’t cause erectile dysfunction

2. perineal prostatectomy
   - may cause incontinence, sexual dysfunction, rectal injury
3. retropublc prostatectomy
   - risk for infection
4. Suprapubic prostatectomy
   - risk for bleeding

Pre-op prostatectomy

• anti-embolism stocking are applied to prevent DVT, PE. Pt will be in lithotomy position
• Enema is given the evening before to prevent post op straining/ Valsalva maneuver which can induce bleeding
• teach the patient that are prostatectomy carry a risk of importance because of potential damage to the pudendal nerves. If this damage occurs, the effects are permanent

Post-op

• warm compress to the publs or sitz bath may relieve bladder spasm (urgency, feeling of pressure or fullness in the bladder) coffee and spicy food can induce bladder spasm
• avoid sitting for a long period of time
• avoid straining, heavy lifting, long car ride 6 to 8 weeks postop
• continuous bladder irrigation for TURP: a change in color from Pink to Amber indicate reduced bleeding. irrigate 50 ML at a time

Question 36

Testicular cancer

Answer 36

1. Germinal tumor
   - This type of cancer grow from germs cell that produce sperm
2. Nongermina tumor/stromal

-secondary testicular cancer are those that have metastasized to the testicle the most common is lymphoma

risk
Genetic, white men, 15-35, HIV, cryptorchidism (testicle fail to move to the scrotum before birth)

s/s
elevated alpha-fetoprotein (AFP) and beta-hCG

diagnostic
inguinal orchiectomy (discussed the option to bank sperm prior)

teaching

• Self examination should be performed once a month
• patient with a history of one testicular tumor has a greater chance for a developing subsequent tumor usually within two years after the treatment of first one

Question 37

Disorders affecting the penis

Answer 37

1. Phimosis
   A condition in which the foreskin/prepuce cannot be retracted over the glans penis in uncircumcised male because if the foreskin wasn’t retracted during cleaning, secretion accumulates and cause inflammation of the glans penis (balanitis)

-tx: steroidal cream

2. Paraphimosis
   When the foreskin is retracted and cannot return to its usual position
   -tx: firmly compress the glans for five minutes and move the foreskin forward
3. Peyronie’s disease
   - plagues/fibrous scar tissue forming inside the penis causing it to curve during erection and makes sex impossible because of the shape. It is painful.
   - Typically begin 45 to 65 years old
4. Prostatitis
   - s/s perineal discomfort, burning, urgency, frequency with urination, and pain with ejaculation

Question 38

about eye

Answer 38

• Pupil 3-5 mm. small pinpoint pupil= opioid. dilated fixed pupil= death
• Production of aqueous humor (fluid in the eye) is related to IOP (normal is less than 21MMHG)
• The eyeball, or globe, sit in the bony protective orbit
• Eyeballs moved by extraocular muscle
• The room should be dark when assessing pupil with penlight
• Snellen chart: 20/20 means patient can read the “20” line at a distance of 20 feet
• Cranial nerves responsible for the eye is optic nerve (two), oculomotor nerve (three)[job is to contrict the pupil) , four, six
• Atropine is a medication that is administered for glaucoma, uveitis, or after surgery
• Cyclopentolate, phenylephrine, and tropicamide are administered for pupillary dilation for ophthalmoscopy and surgical procedures
• diabetic retinopathy cause dark spots.
• apply 0.25-0.5 inch ribbon of ointment

Question 39

Eye diagnostic test

Answer 39

1. Tonometry
   - Measure IOP
   - Because the probe touch the cornea, a topical anesthetic is given prior
   - Advise patient not to squeeze the eyelid, hold their breath, or perform Valsalva maneuver
2. Laser scanning
   - Shows image of optic and other nerves and is an important indicator of glaucoma and papilledema (swelling of the portico disc from increased IOP)
3. Polychromatic plates
   - For detection of color blind
   - Color vision deficit can be inherited. Acquired color vision loss may be caused by medication (digoxin) or cataract
4. Amsler grid
   - For detection of macular degeneration.
   - Test each eye separately
5. Angiography
   - Injected dye into an antecubital vein. Within 10-15 seconds die can be seen through the retina vessels
   - Pre-op: check BUN and creatinine for kidney function, tell patient to expect metallic taste, Urine may turn deep yellow or orange after and usually disappear in 24 hours
   - Contraindicated in patient with history of iodine reaction
6. Perimetry testing
   - Evaluate the field of vision
7. Gonioscopy
   Visualizes the angle of the anterior chamber/ drainage angle (between cornea and iris)

Question 40

Common ocular medication

Answer 40

1. topical anesthetic agent
   - proparacaine hydrochloride (ophthain 0.5%), tetracaine hydrochloride (pontocaine 0.5%)
   - teaching: don’t rub eye
2. Mydriatics (dilate) and cycloplegics (paralyze)
   - Contraindicated with narrow angles or shallow anterior chambers and inpatients on monoamine oxidase inhibitors or tricyclic antidepressant
   - May cause CNS symptoms and increased BP, dizziness, ataxia, especially in children or older adults
   - teaching: may cause glare, inability to focus, difficulty reading. Effect can last up to three hours to several days. Advise patient to wear sunglasses
3. Antifungal
   - amphotericin B (SE: anaphylaxis, severe pain, conjunctival necrosis, Iritis, retinal and hepatic toxicity)
4. Anti-inflammatory/ allergy drugs
   - Side effects of long-term topical steroids include glaucoma, cataracts, impaired wound healing, mydriasis, ptosis, increased IOP, and increased risk of infection. To avoid these effects, oral NSAID therapy may be used as an alternate to steroid use

Question 41

Glaucoma

Answer 41

-increase IOP caused by congestion of the aqueous humor that can lead to damage of the optic nerve (pallor and cupping- cup appear more basin like) and eventually blindness. In glaucoma, aqueous production and drainage are not in balance
When aqueous outflow is blocked, pressure builds up in the eye

• risk: thin cornea, >40 yo, African American, heart disease, diabetes, family history, migraine, myopia, previous eye trauma, prolonged use of corticosteroid
• surgery: laser trabeculoplasty, peripheral iridotomy, Filtering procedures, Trabeculectomy, Drainage implants or shunts

-tx: start with beta blocker (timolol- contraindicate in 2 and 3 heart block, Bradycardia. Assess HR first. it decrease aqueous production). Medication decrease IOP by increase aqueous outflow or decrease aqueous production.
Other meds are alpha adrenergic agonist (brimonide)
cholinergic agonist /miotic (pilocarpine- can cause eye and eyebrow pain, increase sensitivity to light.. problem with dim light, increase salivation, sweating, bronchospasm, and increase myopia)antidote is atropine
Carbonic anhydrase inhibitor (CAIs) zolamide/ acetazolamide… assess for sulfonamide allergies
Prostaglandin analog: bimatopost (can lead to longer, thicker eyelashes and brown iris)
Manitol

• diagnostic test: Tonometry, Gonioscopy
• initial target/ goal= IOP 30% lower than the current pressure

-types
1. Open angle
Chronic
Normal-tension glaucoma
Ocular hypertension
No pain, tunnel/ halos vision (loss of peripheral vision)
2. Angle closure (pupillary block) /narrow/ close angle glaucoma
Acute
Subacute angle closure
Chronic angle closure
s/s severe eye pain, blurred vision, halos, n/v, red eye, edema cornea

Question 42

cataract

Answer 42

risk
-age >80, can also congenital/ new born, smoking, sun light

s/s
Sensitivity to glare, light scattering, myopic shift, astigmatism, monocular diplopia (double vision); and color changes including brunescens (color value shift to yellow-brown)

surgery
takes20-30 min
-Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens, reducing potential postoperative complications
-Phacoemulsification: an ECCE that uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE
-Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL). This eliminates the need for aphakic lenses; however, the patient may still require glasses

[pre-op: dilating drops will be given. ask about history of taking alpha-antagonist tamsulosin climax bc it can cause intra-operative floppy iris syndrome.]
[post-op: avoid lying on the side of the affected eye the night after surgery, avoid lifting objects heavier than 15 pounds, avoid bending or stooping, an eye shield is worn at night for the first week, because cataract surgery increase the risk of retina detachment patient must notify new floaters/dots, flashing light]

Question 43

Corneal surgery

Answer 43

1. Phototherapeutic keratectomy (PTK)
   - SE: induced hyperopia and stroll haze
   - followed up are required for up to 2 years
2. Penetrating Keratoplasty (PKP)
   - Use of donor tissue for transplant/ grafting
   - post-op pt receive mydriatic for 2 weeks and topical corticosteroid for 12 months (all are preservative free)

Question 44

Retina detachment

Answer 44

s/s
sensation of a shade or curtain/ shade coming across the vision of one eye, bright flashing lights, floaters, black dot, cobwebs

diagnostic
dilated fundus examination using an indirect ophthalmoscope as well as slit lamp biomicroscope, stereo fundus photography and fluorescein angiography

surgical
(post op avoid reading, sewing, writing or any other close work)
1. Scleral buckle
2. Vitrectomy
Removal of vitreous locating the incisions at the pars plana
Frequently used in combination with other procedures
3. Pneumatic retinopexy
Injected gas bubble, liquid, or oil is used is used to flatten the sensory retina against the RPE
Postoperative positioning is critical if gas bubble is used, pt must be in prone position

Question 45

Age related macular degeneration (AMD)

Answer 45

-characterized by druse (tiny, yellowish spots)
-risk: >60 years old, smoking history, overweight, HTN, hyperopia, genetic, arthritis
-effect central vision
-Types
Dry or nonexudative type; most common, 85% to 90%
Slow breakdown of the layers of the retinal with the appearance of drusen
Wet type
May have abrupt onset
Proliferation of abnormal blood vessels growing under the retina—choroidal revascularization

-Photodynamic Therapy for Slowing Progression of AMD (Light-sensitive verteporfin dye is injected into vessels. A laser then activates the dye, shutting down the vessels without damaging the retina
The result is to slow or stabilize vision loss. Patient must avoid exposure to sunlight or bright light for 5 days after treatment to avoid activation of dye in vessels near the surface of the skin)

Question 46

Hypoglycemia

Answer 46

s/s: weakness, HA (early) loss of consciousness, disorientation (late)

unconscious: if give glucagon 1 mg (place pt in a lateral position bc glycogen can cause vomiting) and wait 10 minutes and still unconscious give another one milligrams of glucagon and call ambulance
conscious: after give 15g of fast acting CARB (4-6 oz of juice or regular soda, 3-4 glucose tablet) And re-test blood glucose in 15 min. Retreat if BL is >70 mg/dL or if the symptoms persist more than 10-15 min and testing is not available

Question 47

DM

Answer 47

risk
BMI >24, HTN, History of gestational diabetes , Have baby over 9 pounds

-what cause polyuria in DM= osmotic diuresis
-don’t exercise when ketone are present
-regular insulin peak 2-3 hour, duration 4-6
-intermediate insulin duration 16-20. discarded if there’s frosted, white coating inside the bottle (flocculation)
-example of long acting insulin: detemir/ Levemir
-Biguanide/ metformin: pt should take B12. s/s of lactic acidosis which is SE is sluggishness, hyperventilation
-second generation sulfonylureas: avoid alcohol due to disulfiram effect, avoid NSAID. SE is weight gain
-Thiazolidinedines/ Glitazone: ex Pioglitazone, Rosiglitazone. SE anemia, decrease effectiveness of oral contraceptive
-When hanging insulin drip, nurse should discard the first 50 ml
-foot care: Don’t soak your feet
don’t check water temperature with your feet, use thermometer or elbow
-example of first generation sulfonylurea: acetohexamide (Dymelor) chlorpropamide (Diabinese) tolazamide (Tolinase) tolbutamide (Orinase)

• Hyperglycemia hyperosmolar syndrome: risk is diuretic, weight loss, and avoid consuming liquid DEHYDRATION! s/s= serum osmolarity >350. Bicarb normal, increase BUN and creatinine bc dehydration
• diagnosis of DM: 1.) symptoms+random/ casual plasma glucose >200 2.) fasting plasma glucose >126 3.)A1C >6.5%
• normal a1C=4-5.6, increased risk= 5.7-6.4
• people with diabetes should maintain A1C below 7
• somogyi effect= hypoglycemia at 2-3am followed by hyperglycemia can be treated by either decreasing the evening dose of NPH or increase bedtime snack
• insulin pump: don’t remove at bedtime because it will deliver a basal dose 24 hour
• glucose level increase when pt is taking corticosteroid
• DKS: s/s GI symptoms, decrease PCO2
• sick days rules: check BGL every 3-4 hour. test for ketone if BGL >240

Question 48

GI

Answer 48

• esophagus is posterior to trachea and heart
• pepsin (protein digestion) enzyme and secretion in the stomach
• vitamin B12 to be absorbed in the ileum or small intestine
• enzyme and secretion of small intestine: amylase (breakdown carb, also is in saliva, Lipase, bile, Trypsin (digest protein)
• absorption begin in jejunum
• turn stool red: carrots, beets, red gelatin
• turn stool dark red: cocoa
• turn stool yellow: Senna (laxative)
• turn stool black: iron, licorice, charcoal
• bismuth: is an antacid, can turn stool black, need to stop 1 month prior to urea breath test
• normal bowel sound=5-30 BS/ min
• hyperactive BS= 5-6 BS/ <30 sec
• hypoactive BS= 1-2 BS/ 2 min
• FOBT:help screen for colon cancer. Blue is positive. 3 repeats of positive is needed to confirm GI bleed
• Hydrogen breath test: evaluate carb absorption, also help detect lactose intolerance (lactose is sugar)
• Urea breath test: detect H.pylori. Patient ingest a capsule of Carbon label urea. A breath sample is obtain 10 to 20 minutes later. stop antibiotic and bismuth 1 month before urea breath test
• Abdominal ultrasonography: fast 8 to 12 hour prior. If the gallbladder study are being performed, patient should eat a fat free meal the evening before the test
• Barium enema: need bowel prep. stop anticoagulant, aspirin, anti platelet prior. Must be done before upper GI studies
• CT: concern with radiation. Administration of intravenous sodium bicarb one hour before and six hour after contrast is a kidney protective measure
• MRI: Takes 60 to 90 minutes. remove jewelry, pacemaker , dental implants , paper clips , pen, key
• PET (positron emission tomography) scan: Produce image by detecting the radiation emitted from radioactive substances. the radioactive substances are injected into the body intravenously
• Colonoscopy: complication- Consent is required. Cardiac dysrhythmia, respiratory depression from the medication given, vasovagal reaction, hypotension. Pt with prosthetic heart valves or history of endocarditis requires prophylactic antibiotic prior to the procedure. Medication that maybe used during the procedure is opioid analgesic, sedative, glucagon. If it’s done on an out pt basis, someone must transport pt home
• sigmoidoscopy: dietary restriction or not necessary like colonoscopy. No sedation is use

-dumping syndrome: s/s diarrhea, bloating, cramping, dizziness
-2 lumen gastric tube: is called salemsump
-when enteral tube is not being use, flush once a day
-

Question 49

heart

Answer 49

Mitral valve prolapse

• heridetary
• most people never have a symptoms. If you have a tea, shortness of breath, lightheadedness, dizziness, syncope, papa Tatian, chest pain, anxiety
• s/s: extra heart sound (mitral click)
• eliminate stimulant: coffee, alcohol (month wash), and smoking, OTC drugs

mitral valve regurgitation

• s/s: dyspnea, fatigue, and weakness, high pitch blowing sound at Apex of the heart. S3 is expected
• Int: medication that will decrease afterload and dilate atria like ACE and ARB

mitral stenosis

• can lead to afib (weak pulse)
• cause: rheumatic endocarditis which progressively thicken mitral valves (20 years later)
• dry cough, wheezing, repeated respiratory infection, A fib (weak pulse)
• s/s: dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, dry cough, wheezing, hemoptysis

aortic valve stenosis

• cause: degenerative calcification (with age over 60 years-old), cause similar to atherosclerosis (inflammation), rheumatic endocarditis
• s/s: dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, pulmonary edema, syncope, angina, loud, harsh systolic murmur heard at a aortic area and may radiate to the carotid arteries. The murmur is low pitch, crescendo - decrescendo, rough, rasping, vibrating. Best heard when patient lean forward. S4 may be heard

balloon valvuloplasty
-contraindicated in pt with thrombus, severe aortic root dilation, mitral valve regurgitation, valvular calcification, thoracolumbar scoliosis, rotation of the great vessel

commissurotomy
-separate fuse. The side where the leaflet meet is called commission

annuloplasty
repair of a cardiac valve's outer ring
open heart surgery
general anesthesia
anticoagulant for 3 month after the procedure

Cardiomyopathy

• genetic
• early sign are tachycardia

1. dilated (DCM)
   - no hypertropies
   - cause: pregnancy, heavy alcohol intake, viral infection/flu, chemo medication, thyrotoxicosis, myxedema, persistent tachycardia, Chagas disease
   - diffuse necrosis of myocardial cell resulting in poor systolic function
2. Restrictive (RCM)
   - diastolic dysfunction caused by Richard ventricular walls that impair diastolic filling and stretch. Systolic function is normal
   - associated with amyloidosis and other infiltrative disease
   - s/s- dyspnea, non-productive cough, chest pain
3. Hypertropies (HCM)
   - Heart attack/ mi maybe the first sign in young people an athlete who appear healthy
   - nonsurgical treatment for obstructive HCM is alcohol septal ablation. it is done in cardiac catheter lab.
   - EKG of left ventricular hypertrophy will show left axis deviation, wide QRS, ST changes, inverted T-wave
   - myectomy or morrow procedure (cut off septum tissue) is a surgical procedure for HCM who have differences in pressure of 50 MMHG or more between the left ventricle and aorta

Question 50

HIV

Answer 50

risk

• having blood transfusion before 1986
• injection drug (not marijuana)
• have STD (ex: syphillis)

HIV1 is more common
HIV2 is common in Western Africa. The course of illness are slower

stage
0/window period/ primary/ acute/ recent infection
- period from infection with HIV to the development of HIV antibodies

1/ Asymptomatic/ category A
>500 CD4
equilibrium (Viral set point)
can last for years

2/ Symptomatic/ category B
200-499 CD4
candidiasis, cervical dysplasia (abnormal cell during pap smear), lymphdenopathy, fever, PID

3/ AIDs/ category C
<200 CD4 or a presence of opportunistic infection
Herpes (painful skin vesicle) - treat with Acyclovir

• we have more CD4 and CD8 receptor cell
• PREP contain tenofovir disoproxil fumarate 300 mg and emtricilabine 200 mg (Truvada). Take it daily and check HIV status every 3 month. Prescribed for 90 days at a time and used continuously
• PEP start no more than 3 days after possible HIV exposure. take for 28 days [Zidovudine (ZDV) and lamivudine (3TC) or emtricitabine (FTC)]
• first phase is attachment (HIV glycoprotein GP120& 41 binds to host CD4 and chemokine (CC5) receptor) then it will emptied 2 single stands of viral RNA and 3 viral enzyme: reverse transcriptase, integrase, protease
• need consent for HIV testing
• people who are planning to get married should be tested for HIV
• IRIS immune reconstitution inflammatory syndrome: is characterized by fever, abdominal symptoms, worsening of clinical manifestation. Treated with anti- inflammatory medication such as cortisone. Look out over at the first three months after taking ART medication
• Genvoya: a new form of tenofovir (tenofovir alafenamide) Was developed particularly for people with HIV who have experienced side effects like bone loss and kidney problems on other HIV meds, or people who had those issues prior to starting HIV treatment.
• Toxic effect of zidovudine is neutropenia . can lead to anemia and muscle disorder

Diagnostic test

three types of HIV tests are available:

1. Nucleic acid tests (NATs) — detects HIV ribonucleic acid (RNA)
2. Antigen/antibody combination tests — detects HIV p24 antigen as well as HIV immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies
3. Antibody tests — detects HIV IgM and/or IgG antibodiesCD4 count measure the number of T4 cell lymphocytes (normal 700-1,200 cell/mm

-RT-PCR measure viral load

• Test for resistance (mutations may occur when not suppressed)
  a. genotype (identified specific viral mutation)
  b. phenotype (concentration of an antiretroviral drug)

Treatment

• facial wasting- treat by injectable filer
  1. Nucleoside reverse transcriptase inhibitor (NRTIs)
• ziagen, trizivir (SE: hypersensitivity that can be fatal; symptoms include fever, rash, N/V/D)
• didanosine/ video (don’t take with meal. SE: pancreatitis, peripheral neuropathy, retina change)

2. Non Nucleoside reverse transcriptase inhibitor (SE: rash, Numbness, tingling in toes)
   - efavirenz (take on empty stomach)
   - etravirine (take after meal)
3. Protease inhibitor (can cause fat redistribution)
   - atazanazir (take with snacks SE: EKG changes)
   - durunavir (take with snacks SE: rash, Stevens Johnson syndrome)
4. Fusion inhibitor
   - enfuvirtide/ fuzeon (subs injection)
5. Integrase inhibitor (INSTIs)
   - dolutegravir/ tivicay (SE: rash)
   - elvitegravir/ evg ( take with snack. SE: N/D, decrease bone density)
6. CCR5 antagonist
   - maraviroc/ mvc (SE: cough, fever, dizziness)

Adverse effect of all HIV treatment regimen include hepatotoxicity, nephrotoxicity, osteopenia, increase heart disease, insulin resistance

Question 51

HIV opportunistic infection

Answer 51

1. Pneumocystis jiroveci pneumonia (PCP)
   -Most common infection
   -treatment can be given prophylaxis
   -Initial symptoms nonspecific and may include: nonproductive cough, fever, chills, dyspnea, and chest pain. pulmonary examination is usually normal at rest
   If untreated, progresses to pulmonary impairment and respiratory failure
   -diagnosis: histopathologic, cytopathologic, bronchoalveolar lavage fluid, sputum sample
   -Treatment: Sulfamethoxazole-trimethoprim or pentamidine TMP-SMZ(Bactrim) SE: rash, Steven johnson, fever
2. Mycobacterium avium complex (MAC)
   - occur when CD4 <50
   - treatment can be given prophylaxis
   - leading acid fast bacilli, high mortality rate, s/s similar to TB
   - treatment: clarithromycin/Biaxin, azithromycin/Zithromax, Mycobutin.
3. TB
   -tx: 4 drug combination: isoniazid, rifampin, pyrazinamide, ethambutol
   for lantana TB treat with isoniazid and pyridoxine for 9 month
4. Oral candidiasis (fungal infection) – seen early in progression HIV
   - S/S: painless creamy white patches, painful swallowing
   - Treatment with Mycelex troches or nystatin (take last) and ketoconazole
5. Diarrhea
   -Tx: Octreotide acetate (sandostatin) for severe chronic diarrhea
   Send stool for culture
6. Wasting syndrome
   - involuntary loss of more than 10% of body weight while having experienced diarrhea, weakness, and fever for more than 30 days
   - Anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute
   - TX: Megestrol/ megace help with weight gain by increasing body fat storage
7. Kaposi’s sarcoma
   - cause by HHV-8, more common in men
   - bilaterally Deep purple to brownish pink
   - vessel damage.
   - TX: Radiation therapy, Alpha- interferon
8. B cell lymphomas
   - s/s weight loss, night sweat, fever
   - Tx Aggressive chemo, but may be short lived
9. Encelopathy/ dementia complex
   - Progressive cognitive, behavioral, and motor decline
   - s/s: early (HA, memory deficit, difficulty concentrating, progressive confusion) late ( global cognitive impairment, delay in verbal response, a vacant stare)
10. Cryptococcus neoformans
    - fungal infection that cause neurological s/s
    - S/S fever, ha, stiff neck N/V, mental changes
    - diagnosis: CSF analysis.
    - Tx: Amphotericin B or Diflucan
11. Depression
    - Tx: psychotherapy with antidepressants Tofranil, Norpramin, Prozac or stimulant (Ritalin).
12. progressive multifocal leukoencephalopathy (PML)
    - a demyelinating CNS disorders that effect the oligodendroglia
    - s/s begin with mental confusion and rapidly progress to blindness, aphasia, muscle weakness
13. Cryptococcal meningitis
    - s/s: fever, malaise, HA
    - tx: amphoterican B and fluconazole (diflucan)

Question 52

Ear

Answer 52

Scopolamine is a motion sickness medication