Final ANP3 Flashcards
1
Q
A three dimensional spine deformity characterized by lateral and rotational curvature of the spine is?
A
Scoliosis
2
Q
What is the most common form of Scoliosis?
A
Idiopathic
3
Q
When would you refer a child to an orthopedic physician when evaluating for scoliosis?
A
Based on Scoliometer >7 degrees in patients with BMI < 85th percentile
or radiographic cobb angle 20 degrees
4
Q
What are the 4 characteristic stages of growth?
A
Rapid growth in infancy and early childhood
Slow steady growth in middle childhood
Rapid growth during puberty
Gradual slowing down of growth in adolescence until adult height is reached
5
Q
What is the most common rheumatologic condition in children?
A
Juvenile Idiopathic Arthritis (JIA)
6
Q
How is oligoarthritis defined?
A
4 or less joints affected (this is the most common form)
7
Q
How is polyarthritis defined?
A
5 or more joints affected
8
Q
How is systemic JIA defined?
A
affects the entire body (joints, skin, internal organs)
9
Q
How is Psoriatic Arthritis defined?
A
Joint symptoms with a scaly rash
10
Q
How is Enthesitis-related: also called spondylarthritis defined?
A
Inflammation, pain and stiffness in the spine and pelvic joints and inflammation where ligament or tendon attach to the bone.
11
Q
What is the most common comorbidity related to JIA?
A
Iridocyclitis
12
Q
What are 6 systemic abnormalities in JIA?
A
High fever
Rash
Splenomegaly
Generalized adenopathy
Serositis
Lung disease
13
Q
What are 6 differential diagnosis when diagnosing JIA?
A
Leukemia
Lupus
Acute Rheumatic Fever
Osteomyelitis
Septic Arthritis
Lyme Disease
14
Q
In order to dx JIA how long must arthritis symptoms be present?
A
Longer than 6 weeks with no other known cause
15
Q
What are 3 labs that can be ordered to dx JIA?
A
Rheumatoid factor
Antinuclear antibodies (ANA)
HLA-B27 (Human leukocyte antigens)
16
Q
What are 3 disease modifying antirheumatic drugs (DMARDS) that can be used in the treatment of JIA?
A
Methotrexate
Sulfasalazine
Hydroxychloroquine
17
Q
When can patients receive live vaccines after stopping immunosuppressive therapy?
A
At least 3 months
18
Q
When would you refer to ortho for suspected scoliosis?
A
Cobb angle greater than 20 degrees or
Scoliometer >7% in patients with BMI <85th%
or
when a parent request.
19
Q
What is most important disease that is mistaken for JIA?
A
Leukemia
20
Q
How long is necessary for a reliable calculation of height velocity in children older than 2 years?
A
At least 6 months
21
Q
At what age do you start assessing height when the child is standing?
A
2 years
22
Q
What are 7 differentials for poor growth?
A
Familial short stature
Constitutional delay in growth and puberty
Chronic disease
Malnutrition
Hypothyroidism
Genetic syndromes
Idiopathic short stature
23
Q
How is short stature defined?
A
Height that is 2 standard deviations or more below the mean for age and sex
24
Q
What are the 2 most common non-pathological causes of short stature?
A
Familial short stature
Constitutional delay in growth and puberty
25
How do you determine a females estimated height potential using the MPH (mid parental target height)?
Subtract 5" for the fathers height and average with the mothers height.
26
How do you determine a males estimated height potential using the MPH (mid parental target height)?
Add 5" to the mothers height and average with the fathers height.
27
What is a hallmark sign seen in constitutional delay of growth in puberty?
Delayed skeletal age
28
If a child with severe short stature or growth failure presents to your practice what diagnostic test should be done?
Radiographic to determine bone age
29
How can delayed bone age be defined?
2 standard deviations or more below the mean
30
How can advanced bone age be defined?
2 standard deviations or more above the mean
31
What is the most common pathologic cause of short stature?
Low height velocity
32
Give examples of lab test and imaging done in a patient suspected of short stature or the Childs growth.
CBC
CMP
ESR
CRP
TSH
T4
Phos
PTH
Vit D
Prolactin
Bone Age
Karyotype
33
What is one of the most common causes of recurrent musculoskeletal pain in children?
Growing pains
34
What are some concerning findings when seeing a patient with cc of growing pains?
Fever
Weight loss
Decreased activity
Persistent increasing or unilateral limb pain
Pain during the day
Limp or limitation of activity
Decreased range of motion
Warmth
Tenderness
Swelling
Erythema
Pain isolated to the upper extremity, back, or groin
35
What are some ways to treat growing pains?
Education
Continue with normal activities
Stretch
Massage
Heat
OTC analgesics
Vit d supplementation
PT for hypermobility, genu-valgum, and foot malalignment
36
What would you expect to find on physical exam for a patient with Osgood-Schlatter disease?
Tenderness and soft tissue or bony prominence of the tibial tubercle
37
How would you treat Osgood-Schlatter?
NSAIDS for 3-4 days
Ice after activity
Continuation of activity
PT to strengthen quads and increase hamstring flexibility
Educate on course of disease
38
When would you refer for Osgood-Schlatter?
Persistent pain that alters the ability to play in sports for more than 3 months
39
What is Rheumatoid Arthritis
A chronic, systemic, inflammatory disorder that primarily affects joints with synovial linings.
40
What is Osteoarthritis?
Degenerative disease of the cartilage of joints and subsequent abnormal bone growth.
41
Joint pain and stiffness in the morning that last more than and hour or after periods of inactivity is indicative of?
Rheumatoid Arthritis
42
Deep aching joint pain that is aggravated by motion and weight bearing, morning pain resolves within 30 minutes, can be worse at night after a day of vigorous activity is indicative of?
Osteoarthritis
43
Heberden's nodes are located on what joint?
Joint closest to the fingernail or the distal interphalangeal joint.
44
Bouchard's nodes are located on what joint?
Middle joint of the finger or proximal interphalangeal joint.
45
What are Heberden's nodes and Bouchard's nodes indicative of?
Osteoarthritis
46
What labs or diagnostic test can you do to help dx Rheumatoid arthritis.
RF- Rheumatoid Factor
ESR- Erythrocyte Sedimentation Rate
ACPA- Anticitrullinated protein antibody
CRP- C-reactive Protein
CBC with diff
U/A
Chemistry with LFTs
X-rays of selected joints
Synovial fluid analysis
47
Based on the RA classification criteria scale what score is indicative of a RA DX?
>6 or more
48
What is the length of time for symptoms to be present in working towards a dx of RA?
6 weeks or more
49
Swan neck and boutonniere deformities are indicative of?
Rheumatoid arthritis
50
What are some differential dx for RA?
Lyme disease
Gout
Lupus
OA
Ulcerative Colitis
Acute Rheumatic fever
Polymyalgia Rheumatic
51
What are 3 medication classifications that can be used in the management of RA?
NSAIDS
DMARDS
Oral Glucocorticoids
52
Name some clinical presentations associated with Osteoarthritis.
Joint pain, tenderness and limitation of movement
Morning stiffness or after prolonged inactivity resolves within 30 min
Crepitus
Joint deformity (Heberden nodes in distal interphalangeal joints)
53
Name some differential dx for Osteoarthritis.
Arthritis
Gout
Fibromyalgia
Lyme disease
Lupus
Neuropathy
Tendonitis
Fracture/dislocation
54
Which joints are most affected in Osteoarthritis?
DIP
first metacarpophalangeal
knees
hip
cervical spine
lumbar spine
55
What are some labs/diagnostic test that can be done for diagnosis of Osteoarthritis?
CBC
Sed Rate
Chemistry
Calcium
Phosphorus
Uric Acid
Alkaline phosphatase
U/A
Rheumatoid Factor
Joint aspirate for crystals
X-ray of joints
56
What is the goal in the management of OA?
Minimize disability and maximize function
57
What are 2 criteria for classification of Fibromyalgia?
Widespread pain
Pain in 11 of 18 tender point sites on digital palpation
58
What is the gold standard treatment in Rheumatoid Arthritis?
Methotrexate 7.5 mg a week
59
Most children with severe short stature (height <-2.25 SD) or growth failure should undergo a?
Radiographic determination of bone age
60
What are the 3 features for the subtypes of JIA?
Number of involved joints
Presence of extra articular (systemic) manifestations
Presence of serological markers
61
What are 3 ways to reproduce pain in Osgood-Schlatter?
Extending the knee against resistance
Stressing the quadriceps
Squatting with the knee in full flexion
61
In a patient with Osgood-Schlatter is straight leg raising painful or painless?
Painless
62
What is the most common type of JIA?
Oligoarthritis
63
What test is performed to determine bone age?
X-ray of the left hand and wrist
64
What are 4 examples of Autonomic Disfunctions seen in Post-Concussion Syndrome (PCS)?
Headache
Sleep difficulties
Light/sound sensitivity
Postural Hypotension
65
What are 4 examples of Vestibular Ocular Dysfunction seen in Post-Concussion Syndrome (PCS)?
Dizziness
Nausea
Poor balance
Vision changes
66
What are 3 examples of Cognitive symptom's seen in Post-Concussion Syndrome (PCS)?
Feeling Foggy
easily distracted
memory problems
67
What are 4 examples of emotional symptoms seen in Post-Concussion Syndrome (PCS)?
Irritability
anxiety
moodiness
sadness
68
How long before most Mild traumatic brain injury (mTBI) completely resolve?
Within 4 weeks
69
When evaluating a patient for PCS how long must the symptoms be present?
Greater than 1month or 4-6 weeks
70
What is the most common chronic HA condition in children and adolescents?
Chronic migraine
71
What is the gold standard test for diagnosing Postural Tachycardia Syndrome (POTS)?
Tilt-table testing (Gold standard)
72
What are 5 distinct criteria for diagnosing PANDAS?
Abrupt OCD and/or dramatic, disabling tics.
A relapsing-remitting episodic symptom course.
Pediatric onset (between age three and puberty; average between age 6-7).
Presence of neurologic abnormalities (tics, motor hyperactivity, etc.).
Association between symptom onset and GAS infection.
73
What is PANDAS?
Pediatric Autoimmune Neuro psychiatric disorder associated with Group A-Streptococci
74
What is PANS?
Acute onset neuro psychiatric syndrome caused from other infections such as flu, mycoplasma, and varicella.
75
What are 3 proposed criteria for diagnosing PANS?
Abrupt, dramatic overnight onset of OCD or severely restricted food intake.
Concurrent abrupt onset of additional severe neuropsychiatric symptoms from at least two of the following seven categories.
Anxiety
Emotional lability and/or depression
Irritability, aggression, and/or severe oppositional behaviors
Developmental regression
Deterioration in school performance
Sensory or motor abnormalities (hallucinations, complex motor and/or vocal tics)
Somatic s/s including sleep disturbances, enuresis, urinary frequency
Symptoms are not better explained by a known neurologic or medical disorder
76
What is considered the classic triad of symptoms associated with Parkinson's Disease?
Tremor (first sign usually), pill rolling
Rigidity
Bradykinesias/Postural disturbances
77
What is the most common clinical feature observed in patients with Parkinson's Disease?
Bradykinesia
78
Common clinical presentations associated with Bradykinesia include?
difficulty getting started or initiating movements and a slow, shuffling gait
79
What is the first line medication and what is it’s action in the treatment of Parkinson’s Disease?
Levodopa
Replaces dopamine in the brain
80
What is the most common etiology in children presenting with TICS?
Tourette’s Syndrome
81
What disorder is typically seen in a patient with POTS?
Anxiety
82
In a patient with POTS what happens with the heart rate and blood pressure?
Heart rate increases but Blood pressure does not go down
83
What is the peak age onset of childhood absence epilepsy?
4-7 years old
84
Describe a typical absence seizure.
Brief
Vacant
Blank stare
No post ictal
85
What is the age range of juvenile absence epilepsy?
7-16 years old
86
What is an adverse effect of dopamine agonists in the treatment of Parkinson's?
May reduce impulse control leading to sex and gambling compulsions.
87
When diagnosing Alzheimer's, patients present with memory impairment, and 1 or more of the 4 following classic findings to include?
Aphasia
Apraxia
Agnosia
The inability to plan, organize, sequence and make abstract differences.
88
What is a classification of medications used in Alzheimer's Disease?
Acetylcholinesterase Inhibitors
89
What labs/diagnostic test can be done when working a patient up for Alzheimer?
Thyroid
CBC
Sed rate
B-12
HIV
RPR
CT or MRI of head
90
In young adults what are 5 causes for seizures?
Drugs
ETOH withdrawal
Cancer
Trauma
HIV or other CNS infection
91
In older or elderly adults what are 5 causes of seizures?
Cancer
Trauma
CVD
Hypoglycemia or
other non-epileptic convulsion
92
What is the first choice drug for generalized seizures in adults?
Valporate
AVOID in pregnant women
93
What two classes of medications used to treat migraines should not be given together and why?
SSRI's and Triptans
they can cause Serotonin syndrome
94
What are 6 classic symptoms of Celiac Disease?
Diarrhea
Abdominal Pain
Bloating
Weight loss
Malabsorption
Failure to Thrive
95
Who should be screened for Celiac Disease?
Children older than 3 and adults with symptoms
96
What are 2 lab tests recommended in the screening for Celiac Disease.
Immunoglobulin A (IgA)
Tissue Transglutaminase (tTG)
97
What procedure is preformed to confirm the dx of Celiac disease?
Esophagogastroduodenoscopy (EGD) with a small bowl bx
98
How is Hepatitis A transmitted?
Contaminated food or water
Unsanitary conditions
Fecal-Oral
99
How is Hepatitis B transmitted?
Sexually transmitted
IV drug use
Contact with contaminated blood or body fluids
100
How is Hepatitis C transmitted?
IV drug use
Contact with contaminated blood
Intranasal drug use
101
What are 7 signs and symptoms of Iron Deficiency Anemia?
Irritability
Decreased concentration
Confusion
Agitation
Frequent falls
**Shortness of breath
**Peripheral edema
102
What can you take with iron supplements to enhance their absorption? (5)
Vit C
Citric acid
meat
poultry
fish sources
103
What are 7 substances the inhibit iron absorption?
Soy protein
bran
dairy products
tea
coffee
calcium-rich antacids
vegetable sources
104
MCV <80 is Microcytic Anemia, what are 4 examples of microcytic anemias?
Iron Deficiency Anemia
Thalassemia
Chronic Inflammation (disease)
Rare Causes
*Can remember acronym TAILS (thalassemia, ACD, IDA, lead poisoning, sideroblastic anemia)
105
What are 5 signs and symptoms of severe anemia?
-exercise fatigue
-headache
-dizzness
-pallor (primarily conjunctival)
-irritability
106
What are some things we might see on physical exam of someone who is anemic?
-tachycardia
-tachypnea
-edema
-hepatosplenomegaly
-weight loss
-CHF
-hypotension
-icterus and/or jaundice
107
What are 5 causes of iron deficiency anemia?
-inadequate dietary intake
-improper absorption (ex: celiac disease)
-increased losses (ex: gastric ulcer, parasites, destruction of RBCs/hemolysis)
-increased need (ex: pregnancy)
-blood donation
108
Where is iron absorbed?
Iron is absorbed in the small intestine (duodenum)
109
(T or F) Hypochromic anemia would most appropriately have a low MCHC
True
110
What is aplastic anemia?
When the bone marrow doesn't make enough RBCs
Could be due to;
-an infection like HIV
-toxins
-radiation exposure
-genetic disorders
111
What conditions may you see with an increased MCV and an increased RDW?
-autoimmune hemolytic
-liver disease
-folate or cobalamin deficiencies
112
What type of anemia is it when you see an increased MCV and a normal RDW?
aplastic anemia
113
What is the most common cause of microcytic anemia?
Iron deficiency anemia
114
What 5 labs will you see in iron deficiency anemia?
-low MCV
-low MCH
-high RDW
-low serum iron
-low ferritin
115
What labs do you see with folate and vitamin B12 deficiencies?
elevated MCV and RDW
116
What type of RBC disorder is sickle cell disease?
Sickle cell disease is an intrinsic RBC disorder
117
What is the hgb range typically for those with SCD?
6.5 - 8.5
118
Anemias treatment
-replacement of iron ( 3 - 6 mg/kg/day) for IDA
-dietary regulation
-address underlying cause
-hematology referral
-early intervention/transfusions for SCD and B-Thalassemia major
119
What is the most common childhood cancer?
Acute Lymphoblastic Leukemia (80% of all pediatric leukemia cases)
-Acute Myeloid Leukemia accounts for the rest
-followed by brain tumors, lymphomas, neuro blastoma, wilms tumor, and other solid tumors (osteosarcoma)
120
What are 7 signs and symptoms reflecting leukemia infiltration of the bone marrow and other locations?
-bone pain
-fever
-pallor
-fatigue
-bleeding
-bruising
-infections
121
What is SVC syndrome?
-SVC is an oncologic emergency!
-SVC is an anterior mediastinal mass and symptoms related to compression of the mass on the trachea and blockage of venous return and lymphatic drainage
122
What are 5 presentations of SVC?
-wheezing
-dyspnea
-dysphagia
-cyanosis
-pleural and pericardial effusions
123
What type of cell does myeloma arise from?
Myeloma arises from abnormal plasma cells.
124
What does the treatment for myeloma involve?
Myeloma treatment involves chemotherapy and targeted radiation therapy, and sometimes corticosteroids, targeted therapy, or stem-cell transplant.
125
What type of cells does lymphoma involve and what body system does it involve?
Lymphoma is a solid tumor of the lymphocytes in the patient's lymphatic system.
126
What treatment is involved in treatment of lymphoma?
Treatment of lymphoma involves chemotherapy, radiation, and sometimes immunotherapy.
127
What type of cell is involved in leukemia?
Leukemia is a cancer arising from WBCs that produce blood in the patient's bone marrow.
128
What types of treatment are involved in leukemia?
Treatment for leukemia involves chemotherapy, radiation therapy, or a stem-cell transplant.
129
Describe Hodgkin lymphoma
- 2 - 3 months of painless enlarging of cervical or supraclavicular nodes
-They may be firm, immobile, rubbery, nontender
-Cough or wheezing due to mediastinal adenopathy
-fever, pruritis, anorexia, fever, night sweats, and weight loss of >10% of body weight
130
What are the two types of Non-Hodgkin Lymphoma and what is the difference between the two?
-Lymphoblastic
Superdiaphragmatic nodes similar to Hogkin (nodes, SVC syndrome), but also increased ICP if CNS involved
-Nonlymphoblastic
Intra-abdominal disease such as intussusception, HSM, obstructive jaundice can occur
131
Initial lab work (7) for potential malignancy
-CBC
-CMP
-lactate dehydrogenase (nonspecific marker for increased cell turnover)
-tests for tumor lysis syndrome if you suspect leukemia or lymphoma (uric acid K+ phosphate, CA++)
-alpha-fetoprotein (tumor marker if you suspect cancer)
-ferritin
-ESR
*CXR also needed for inital eval and staging of all childhood cancers (primarily to assess for a mediastinal mass for lymphomas)
132
Pediatric cancers; optimal outcome depends on (6)
-correct pathologic diagnosis
-careful medical management
-administration of chemotherapy and monitoring of side effects
-precise radiation if indicated
-optimal surgical resection if indicated
-post intervention rehabilitation
133
MCV 80-100 is Normocytic (normochromic) Anemia, What are 5 examples of normocytic anemia?
Hemorrhage/Acute Bleed
Hemolysis
Chronic disease/Inflammation
Early iron deficiency
Aplastic anemia
134
MCV >100 is Macrocytic Anemia, what are 3 examples of macrocytic anemias?
B12 deficiencies
Folic acid deficiencies
Antimetabolites
*Can remember acronym FAT RBC for macrocytic differentials (fetus, alcohol, thyroid- hypothyroid, reticulocytosis, B12 & folate deficiency, cirrhosis & chronic liver disease)
135
In diagnosing of anemia by MCV, what would a MCV of < 80 indicate?
microcytic anemia
-iron deficiency
-thalassemia
-chronic inflammation
-rare causes
136
What labs do you want to check in microcytic anemia?
-iron
-TIBC
-ferritin
-transferrin saturation
137
In diagnosing anemia by MCV, what would a MCV of > 95 (or 100) indicate?
macrocytic anemia
138
What special considerations/labs (6) do we need to consider in macrocytic anemia?
labs;
-RDW
-B12
-folate
-TSH
-peripheral smear (cells will be round for liver or thyroid, cells will be oval if B12 or folate deficiency)
-LFTs
*ask about alcohol use
-----------------------------------------------
-if above workup is negative;
-bone marrow biopsy
-suspect MDS (?What is MDS?)
139
What hgb is considered anemia in males and in females?
<13 in men
<12 in women who are not pregnant
140
What will the MCV be in normocytic anemia and what do we want to do next?
80 - 100
Check reticulocyte count
141
If low reticulocyte count, what do we want to do?
-check iron studies, ferritin
-replete iron if low
-check EPO and hemoglobin electrophoresis if normal iron
142
What do we want to check in instance of normal reticulocyte count?
-check EPO (erythropoietin) and hemoglobin electrophoresis
143
What to do in instance of high reticulocyte count?
-check peripheral smear
-evaluate for hemolysis
bilirubin
low haptoglobin
high LDH
144
What labs and conditions typically indicate microcytic anemia?
MCV 50 - 82, MCHC 24 - 32
-iron deficiency anemia
-thalassemia
-chronic disease
145
What labs and conditions typically indicate normochromic/normocytic anemia?
MCV 82 - 92, MCHC 32 - 36
-hemorrhage
-hemolysis
-chronic disease
-iron deficiency
-aplastic anemia
146
What labs and conditions typically indicate macrocytic anemia?
MCV > 100, MCHC >36
-B12 deficiency
-folic acid deficiency
-antimetabolites
*Can remember the acronym "FAB" (folate, antimetabolites, B12)
147
Where is vitamin B12 absorbed?
Vitamin B12 is absorbed in the portion of the small intestine called the ileum.
148
Pernicious anemia Vitamin B12) signs & symptoms (4)
-S/S of marked anemia
-sore mouth, loss of taste
-neurologic deficits (loss of proprioception, ataxia, hyperactive reflexes, positive Romberg's, confusion)
-smooth, red, shiny tongue
149
Pernicious anemia (Vitamin B12) management
-distinguish between primary and secondary causes
-recognize that therapy is lifelong
-therapeutic (initial B12 100ug IM QD x 3 weeks, then 1000 ug IM Q month)
-CBC monthly x 3, then Q 3 - 6 months
150
What do the cells of folic acid deficiency look like and what is the etiology?
-normochromic
-macrocytic
-results from deficiency in folic acid
alcohol abuse
inadequate dietary intake
impaired absorption
prolonged drug therapy
overcooking foods
151
What are the signs and symptoms of folic acid deficiency anemia?
-progressive and severe fatigue
-SOB
-palpitations
-diarrhea
-anorexia
-nausea
-headaches
-irritability
-forgetfulness
-depression
151
Diagnostics for folic acid deficiency
hematocrit- decreased
platelets- decreased
reticulocytes- decreased
MCV > 100
RDW- increased
WBC- decreased
serum folate- decreased (<4 mg/ml)
Shilling test- WNL
152
Management for folic acid deficiency anemia
-eliminate contributing factor
-therapeutic (folate 2 - 4 mg PO QD if alcoholic 5 - 10 mg QD)
-hct and reticulocyte count in 4 - 6 weeks
-*refer for concurrent folate and B12 deficiency
153
What type of cell will you see in anemia of chronic disease and what is the etiology?
*second most common to IDA
-normochromic
-normocytic
-usually mild, persistent, and asymptomatic
-due to chronic infections, inflammations, and illnesses
disruption of iron metabolism
defect in red blood cell production
shortening of erythrocyte lifespan
154
Signs and symptoms of anemia of chronic disease (8)
-decreased activity level
-easily prone to fatigue
-headaches
-dizziness
-tinnitus
-generalized weakness
-DOE
-malaise
155
What are some physical findings in anemia of chronic disease (5)?
-generalized pallor
-lingual surface, buccal surface, conjunctivae, and nail beds pale
-ankle swelling
-visual changes
-dementia
156
What diagnostics will you see in anemia of chronic disease?
serum iron- decreased
TIBC- decreased
serum ferritin- increased
hgb- decreased
hct- increased
MCV- normal
reticulocytes- decreased
157
What is the management for someone with anemia of chronic disease?
-treat underlying/primary cause
-promote rest as needed
-refer and consult w physician for further evaluation and treatment of underlying problem
158
What is the viral load in acute HIV infection stage 1?
large amounts of virus in the blood
159
What is the onset of symptoms in acute HIV infection stage 1?
within 2 - 4 weeks of infection
160
What are the symptoms associated with acute HIV infection stage 1?
flu-like symptoms (fever, body aches, rash, and/or headaches)
161
What is the viral load in Chronic HIV infection stage 2?
low amounts of virus in the blood
162
What are typical symptoms in chronic HIV infection stage 2?
asymptomatic
163
What is the onset of symptoms in chronic HIV infection stage 2?
after 4 weeks post infection, continues as long as patient is being treated
164
What is the viral load in AIDS stage 3?
very large amounts of virus in the blood
165
What is the onset of symptoms in AIDS stage 3?
Within 10 years if HIV is left untreated
166
What are some symptoms of AIDS stage 3?
-chronic diarrhea
-weight loss
-fevers
-lethargy
-lesions of the tongue
-rashes
-loss of appetite
-night sweats
-opportunistic infections (toxoplasmosis, PCP, TB, candidiasis, salmonella)
167
(T or F) PrEP must be taken DAILY to reduce the risk of infection by 99%.
T
*Medication adherence is critical (90%)!!!
168
What meds are most commonly prescribed for PrEP?
-Truvada
-Descovy
-Apertude (subcut injectable) Q 2 months.. this one is good for anyone w serious kidney disease not candidate for the orals
169
What labs do we want to monitor in those taking PrEP?
*review drug interactions
kidney function;
-yearly for those under 50
-every 6 months for those over 50 and/or with other conditions
triglycerides and ttl cholesterol
-yearly
170
What patient population should you prescribe PrEP?
Non HIV positive individuals that engage in risky sexual behavior ie. sex workers, partner HIV positive, no condom use in male with male etc.
171
What labs should be monitored for patients on PrEP?
HIV
Triglycerides
Renal Function
172
What are the 2 most common complications in sickle cell disease?
Aplastic crisis
Splenic sequestration
173
What is a good range for the Hgb in a sickle cell patient?
6.5-8.5
174
What patient population would you see B12 deficiency in?
Gastric bypass
175
What patient population would you see Folic acid deficiency in?
Pregnancy
Alcohol
176
Which type of anemia in the most common in the adult and pediatric population?
Iron Deficiency Anemia which is a Microcytic Anemia
177
What are the 2 types of Inflammatory Bowel Disease?
Ulcerative Colitis
Crohn's Disease
178
How do you manage sickle cell disease?
HOPIA
Hydration
Oxygenation
Pain control
Infection prevention
Avoid high elevations
179
What are some risk factors for GERD?
obesity
age 50 and older
low socioeconomic status
tobacco use
excess alcohol consumption
connective tissue disorder
pregnancy
postprandial supination
drugs (anticholinergic meds, benzos, NSAIDS, nitrates, beta agonists, CCBs, tricyclic antidepressants, glucagon, HRT)
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What is the pathophysiology of GERD?
includes impaired lower esophageal sphincter (LES) function, hiatal hernia, and impaired esophageal mucosal defense
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What is the treatment plan for someone diagnosed with GERD?
-provide education regarding LSM
-provide education on meds
-follow-up (8 weeks if starting on PPI, sooner if no improvement)
D/C PPI after 8 weeks if symptoms resolve (if symptoms reoccur after d/c, the pt may be placed on long term PPI therapy)
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What are some questions to ask a patient when making a GERD diagnosis?
Hx:
-medical hx incl food/drug allergies, atopic dermatitis, asthma, pneumonia
-past sx hx including any GI or esophageal surgeries
-review of all med inc OTC
-social hx; smoking, exposure to secondhand smoke, activity level, drugs, alcohol
-frequency of symtpoms
-dietary triggers
-fam hx of barrett or GI cancers
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ROS when making a GERD diagnosis
const: fatigue, unintentional weight loss
HEENT: nasal congestion, hx of dental erosion
GI: heartburn, regurgitation, dysphagia, odynophagia, globus sensation, nausea, vomiting, diarrhea, constipation, evidence of GI bleeding, change in appetite, early satiety, abd bloating, abd pain
Resp: SOB, wheezing, cough
Cardiac: CP
skin: atropic dermatitis
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Physical examination of a patient when making a GERD diagnosis
Const: general appearance, skin color, vitals
HEENT: dentition, nasal, pharyngeal, and oral mucosa inspection
heart + lungs
abd: assess for tenderness (epigastric), evidence of ascites, hernias, bowel sounds, palpate liver, assess for gallbladder tenderness (Murphy's sign)
extremities: edema, cyanosis, clubing
lymph nodes: cervical, supraclavicular
rectal: if indicated
neuro: strength, reflexes, orientation
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LSM for a patient w GERD
-maintain normal BMI
-avoid late meals
-maintain good sleep hygiene
-avoid dietary triggers
-elevate HOB
-avoid alcohol and tobacco
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Medications commonly used in the treatment of GERD
-antacids (neutralize acids in the stomach, provide relief w/in 5 mins)
-H2 blockers (block histamine- induced gastric acid secretion from the parietal cells of the stomach, reaches peak in 2.5 hours and lasts 4 - 10 hours)
-PPIs (reduces the production of acid by inhibiting the H+/K+ ATPase proton pumps, reaches half life at 1 hour and lasts 48 hours)
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PPI examples
-Esomeprazole (Nexium)
-Pantoprazole (Protonix)
-Lansoprzole (Prevacid)
-Rabeprazole (Aciphex)
-Omeprazole (Prilosec)
-Dexlansoprazole (Dexilant)
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Name some Histamine (H2) Antagonists
-Famotidine (Pepcid)
-Nizatidine
-Cimetidine (Tagamet)
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What are the names of some antacids?
-Magnesium hydroxide (MOM)
-Calcium carbonate (Tums)
-Aluminum hydroxide (Gaviscon)
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What are symptoms of PUD in children?
PUD presents differently in peds than adults!
-better with fasting (in adults symptoms are typically alleviated w food)
-worse w food
-rarely present w acute abd pain
-poorly localized epigastric or right lower quadrant pain; dull, aching, and lasting from mins to hours
-nocturnal pain that wakes the child from sleep
-antacids provide relief in only 33% of children
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What diagnostic tests do we want to order for PUD in children?
-tests for anemia
-upper GI series
-EGD
-H pylori
-stool for occult blood
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What is the management of PUD in peds?
1. pharm agents
2. correction of iron def anemia (if they have it)
3. referral to GI
4. therapeutic measures to prevent complications
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The nurse practitioner uses the irritable bowel syndrome (IBS) Rome III diagnostic criteria in evaluating an adolescent patient who reports recurrent abdominal pain or discomfort and four or more loose, watery stools per day. Which is a criterion of this diagnostic tool?
Onset of symptoms associated with a change in stool frequency
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Treatment for PUD with H. pylori (peds)?
-Amoxicillin (Amoxil) or Metronidazole (Flagyl) for penicillin allergy
-Clarithromycin (Biaxin)
-Omeprazole (Prilosec)
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The nurse practitioner is seeing an adolescent patient recently diagnosed with Crohn disease. Which is a characteristic of inflammatory bowel disease (IBD) in the pediatric population?
Pediatric patients w IBD tend to have more vague symptoms and more extraintestinal symptoms, such as arthralgia and conjunctivitis.
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How do we detect H pylori infection?
1. Gold standard: Histologic examination and biopsies obtained by endoscopy.
Requires anesthesia, not the preferred method in pediatrics.
2. Test of choice: C-urea breath test
Noninvasive, cost-effective, safer, and sensitive in children older than two years.
Avoid false-negative results: The patient should be off acid-suppression medications for four weeks before the test.
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What are some pediatric specific symptoms pf GERD?
-neck contouring
-chest or abdominal pain
-reactive airway disease
-sinus or laryngeal inflammation
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What are some GERD symptoms at any age?
-cough
-halitosis
-hoarseness
-dysphagia
-respiratory changes
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What are some physical exam findings for someone w GERD?
-wheezing
-hoarseness
-stridor
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What are some symptoms of fibromyalgia?
-widespread pain
-increased pain sensitivity
-sleep problems
-fatigue
-emotional and mental distress
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What are some risk factors for developing fibromyalgia?
Proven:
-Age: Middle age and older
-Gender: Women twice as likely to be diagnosed than men
Suspected but unproven:
-Co-existing lupus or rheumatoid arthritis
-Earlier viral infection
-Stressful events
-Repetitive injuries
-Illness
-Family history
-Obesity
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How would we manage fibromyalgia?
Non-Pharmacologic Treatment:
-Complementary therapies (e.g. meditation, acupuncture)
Exercise
-Cognitive behavioral therapy (CBT)
Pharmacologic Treatment:
-FDA-approved drugs:
Duloxetine (Cymbalta)
Milnacipran (Savella)
Pregabalin (Lyrica)
-Older drugs:
Amitriptyline (Elavil)
Cyclobenzaprine (Flexeril)
-Other treatments:
Gabapentin (Neurontin) to block overactive nerve cells
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