group 1

Question 1

List the therapeutic order

Answer 1

1. Establish the foundations for optimal health
2. Stimulate the self-healing Mechanism
3. support & restore weakened systems
4. Address physical alignment
5. Natural Symptom control
6. Synthetic symptoms relief
7. High Force Intervention

Question 2

What should be monitored at each visit for a patient with anemia?

Answer 2

signs of hemodynamic instability

Question 3

what are signs of hemodynamic instability

Answer 3

• Altered consciousness / Loss of consciousness
• Tachycardia / Bradycardia
• Arrhythmias
• Tachypnea / Bradypnea
• Agonal respirations
• Low oxygen saturation / high CO2 output
• Hypertension (compensated) / Hypotension (progressive)
• Wide pulse pressure
• Distant / Muffled heart sounds
• Jugular venous distension
• Decreased peripheral pulses
• Signs of fluid accumulation – pulmonary or peripheral edema, pleural or pericardial effusion,
ascites, sacral or genital edema, anasarca
• Decreased urine output
• Pallor
• Cyanosis – peripheral or central
• Skin coolness – especially extremities
• Delayed capillary refill

Question 4

ANEMIA Criteria for initiating referral/hospitalization:

Answer 4

Need based on hemoglobin concentration:
• Hgb <7 g/dL: Refer to ER: RBC transfusion indicated. If the patient is otherwise stable, the
patient should receive 2 units of packed RBC, following which the patient’s clinical status and
circulating HgB should be reassessed.
• Hgb 7 to 10 g/dL: Correct strategy is unclear- treatment based on clinical judgment and patient
status.
• Hgb >10 g/dL: RBC transfusion not indicated
• High risk patients: Patients >65 and/or those with cardiovascular or respiratory disease may
tolerate anemia poorly. Such patients may be transfused when Hgb <8 g/dL.

Question 5

ANEMIA Criteria for initiating pharmacological intervention:

Answer 5

• All presentations of anemia must be evaluated for an underlying cause. Treatment guidelines
will depend on underlying cause.
• Blood transfusion should be reserved for the patient who is hemodynamically unstable
(orthostatic hypotension, unstable because of active bleeding and/or shows evidence for endorgan ischemia).
• While definitive data are lacking at this time, the likelihood of a transfusion being of benefit is
high when the patient’s hemoglobin is less than 6 g/dL (60 g/L) and is low when it is greater than
10 g/dL (100 g/L).

Question 6

For acute exacerbation of asthma ER referral is indicated if?

Answer 6

• Vital Signs: R > 30 rpm, P > 120 bpm
• Pulse Ox - < 91 or if > 91 with a ↓ to < 91 with walking (decompensation)
• Peak Flow – less than 50% of predicted value for patient
• Any other S/Sxs – cyanosis, pulsus parodoxus – pulse amplitude decreases with an inhalation,
altered mental status, inability to speak as a result of dyspnea (strong indicator), use of
accessory muscles

Question 7

for acute exacerbation of Asthma REFER to pulmonologist or allergist under what circumstances

Answer 7

after a life-threatening asthma exacerbation
• after hospitalization was required
• when more than two courses of oral corticosteroids required in a year
• when step 4 care or higher in a person over 5 years of age is indicated
• when step 3 care or higher in a person under 5 years age is indicated
• when not controlled after three to six months of active therapy and monitoring
• when unresponsive to therapy
• if/when diagnosis of asthma is uncertain
• when special testing is indicated
o skin testing for allergies, bronchoscopy, complete pulmonary function tests
• when patient may be a candidate for allergen immunotherapy
• when significant co-morbidities exist:
o nasal polyposis, chronic sinusitis, severe rhinitis, allergic bronchopulmonary
aspergillosis, COPD, vocal cord dysfunction, etc

Question 8

Consider a referral for acute exacerbation of asthma under what circumstances?

Answer 8

when step 3 care or higher in a person over 5 years old is indicated
• when step 2 care or higher care in a person under 5 years old is indicated
• when psychosocial or psychiatric problems are interfering with asthma
• when peak flow measures are 50-60% of predicted (strong consideration)

Question 9

Describe ongoing care for Asthma patients

Answer 9

• Monitor at each visit
• Expiratory peak flow
• Pulse oximetry, resting/ambulatory
• Asthma action plan
• Assess:
o Frequency of symptoms
o How often asthma symptoms require rescue inhaler use
o Loss of function due to asthma (ADL’s)
o Number of night time exacerbations
• The “Asthma Action Plan” should be implemented at the initiation of care.
ohttp://www.cdc.gov/asthma/tools_for_control.htm
The “Stepwise Approach for Asthma Management”
o A clinical tool for monitoring and modification of treatment
o “The stepwise approach is meant to assist, not replace, the clinical decision making
required to meet individual patient needs”

Question 10

Cancer

Answer 10

All patients with a current diagnosis of cancer are strongly encouraged to be seen and co-managed by
an oncologist. Patients refusing consultation with an oncologist must sign a refusal of medical treatment
form. NUNM Health Centers follow standard screening guidelines for cancer detection/prevention
(i.e.mammograms, colonoscopy, PSA, pap smears/HPV, etc

Question 11

Cellulitis Non- antibiotic treatment

Answer 11

• Management of cellulitis and erysipelas should include elevation of the affected area and
treatment of underlying conditions. Elevation facilitates gravity drainage of edema and
inflammatory substances. The skin should be sufficiently hydrated to avoid dryness and cracking
without interdigital maceration.
• Cellulitis that develops into an abscess will most likely require an incision and drainage
procedure along with the above therapies,
• Many patients with cellulitis have underlying conditions that predispose them to developing
recurrent cellulitis (these include tinea pedis, lymphedema, and chronic venous insufficiency). In
such patients, treatment should be directed at both the cellulitis and the predisposing condition.
Patients with edema may benefit from treatment with compressive stockings and diuretic
therapy.

Question 12

cellulitis antibiotic therapy

Answer 12

Most patients develop mild cellulitis and can be treated with oral antibiotics; patients with signs
of systemic toxicity or erythema that has progressed rapidly should be treated initially with
parenteral antibiotics.
• Options for empiric oral therapy for treatment of MRSA include:
o Clindamycin
o Trimethoprim-sulfamethoxazole
o Tetracycline (doxycycline or minocycline)
o Linezolid
• The duration of therapy should be individualized depending on clinical response; 5 to 10 days is
usually appropriate; longer duration of therapy may be warranted in patients with severe
disease

Question 13

Erysipelas

Answer 13

Patients with classic manifestations of erysipelas and systemic manifestations such as fever and
chills should be referred to the ER to be treated with parenteral therapy. Patients with mild
infection or those who have improved following initial treatment with parenteral antibiotic
therapy may be treated with oral penicillin (500 mg orally every six hours), or amoxicillin (500
mg orally every eight hours).
• Macrolides (such as erythromycin 250 mg orally every six hours) have also traditionally been
used but may not be adequate therapy in areas with relatively high resistance rates among betahemolytic streptococci. In the setting of beta-lactam allergy, cephalexin (if the patient can
tolerate cephalosporins), clindamycin, or linezolid may be used.
• The duration of therapy should be individualized depending on clinical response; 5 to 10 days is
usually appropriate.

Question 14

approach to adult patients presenting with chest pain

Answer 14

The patient presenting with recent or ongoing chest pain should be immediately evaluated for
stability based on:
• brief history,
• appearance,
• vital signs
• signs of hemodynamic compromise, including:

Question 15

if an adult patient with chest pain in assessed as unstable what do you do?

Answer 15

• transport immediately to an emergency department by ambulance equipped with a
defibrillator.
• stabilization should begin in the prehospital setting:
o intravenous access
o placement of a cardiac monitor
o supplemental oxygen if breathlessness, hypoxemia, or signs of heart failure or shock are
present.
• if high suspicion for acute coronary syndrome (ACS), give:
o 325 mg aspirin tablet, chewed and swallowed.
o 0.4mg sublingual nitroglycerin should be given, unless:
▪ patient has relatively low blood pressure without IV access
▪ has recently taken a phosphodiesterase inhibitor such as sildenafil (Viagra™).
o A 12-lead electrocardiogram and a blood sample for cardiac enzyme measurement
should be obtained if possible.
o Further assessment should be conducted in the emergency department.

Question 16

If an adult patient with chest pain is assessed as stable what do you do?

Answer 16

• begin with consideration of imminently life-threatening causes:
o acute coronary syndrome (see above), pulmonary embolus, aortic dissection,
pneumothorax, and esophageal rupture.
• if life-threatening etiology has been excluded, identify the specific cause of symptoms and begin
treatment.
based upon the patient’s risk factors, description of the pain, and associated symptoms.
o useful to estimate the pretest probability of organic causes of chest pain prior to
undergoing diagnostic tests (e.g., stress ECG testing to detect CHD or d-dimer, CT angiography or lung perfusion scanning to detect pulmonary embolism).
▪ Pretest probability is an important component of the interpretation of these
test results.

Question 17

Adult with chest pain: required Referral or hospitalization

Answer 17

Patient is unstable:
o Call 911 for transport to Emergency Department (ED)
• Emergent conditions cannot be definitely ruled out
o Myocardial infarct, pulmonary embolism, vascular dissection/ruptured aneurysm,
pneumothorax, other urgent conditions
o Call 911 for transport to ED
• Consciousness or sensorium is or has been impaired
o ASAP referral to appropriate specialist or ED
• Increasing instability of previously stable condition
o ASAP referral to appropriate specialist or ED

Question 18

Adult with chest pain: Requirements for Pharmacological intervention:

Answer 18

• Chronic stable angina – Rx sublingual nitroglycerin
• Increasing instability of previously stable angina – Rx anti-anginals or referral
• Suspected MI – 325mg Aspirin; 0.4mg sublingual nitroglycerin Q5mins to a maximum of 3 doses
over 15 mins, Oxygen as appropriate.
• Pneumonia – see appropriate guidelines in pneumonia section

Question 19

Adult with chest pain: Required Monitoring at each visit:

Answer 19

Hemodynamic stability, oxygen saturation, fluid sequestration;
• Change in pain severity, frequency, duration;
• Dyspnea on exertion, shortness of breath at rest, orthopnea, PND;
• Peripheral edema;
• Changes in degree of limitation caused by the condition;
• Change in frequency or efficacy of previously palliative agents
o E.g.- nitroglycerine

Question 20

Adult with chest pain: Required Follow up and Management:

Answer 20

• Constant until stability is sure.
• Hourly to daily until life-threatening conditions have been ruled out.
• Daily to weekly until the underlying cause of the pain is determined or after a severe
exacerbation, hospital stay or emergency department visit.
• Weekly to monthly for chronic concerns after a change in stability, medication or other
management.
• Monthly to semi-annual for well-managed, controlled, chronic complaints.

Question 21

Review Chronic Substance therapy initiation and managment

Answer 21

check packet

Question 22

Depression: guidelines

for evaluation and diagnostic criteria

Answer 22

Depression should be suspected when any of the following symptoms are present:
• Depressed mood
• Loss of interest or pleasure in most or all activities (anhedonia)
• Insomnia or hypersomnia
• Change in appetite or weight
• Low energy
• Psychomotor retardation or agitation
• Poor concentration
• Thoughts of worthlessness or guilt
• Recurrent thoughts about death or suicide
Major depression is diagnosed when 5 or more the symptoms are present for most of the day nearly
every day for a minimum of 2 consecutive weeks. Either depressed mood or anhedonia must be
present

Question 23

comorbidities for depression

Answer 23

These may include anxiety disorders, dementia,
eating disorders, personality disorders, sleep disorders and substance abuse (dual diagnosis).
Depression is common in chronic diseases including neurologic, cardiovascular, cancer and
rheumatologic diseases. The prognosis for depression is worsened by the presence of significant
medical comorbidity.

Question 24

Evaluation requirements for for depression

Answer 24

Patients with symptoms of depression should be given the patient
health questionnaire-9 item (PHQ-9). A score of 5 or greater
establishes the diagnosis of depression. Validation studies of the
PHQ-9 report a sensitivity of 61% and 94% specificity (Likelihood ratio
positive10.17, Likelihood ratio negative 0 .41). In geriatric population
the 5-item geriatric depression scale is well validated: sensitivity 97%
specificity 85% (likelihood ratio positive 6.47, likelihood ratio Negative
0 .04). When screening indicates depression may be present, the
diagnosis should be confirmed with DSM-4 criteria for depression

Question 25

risk factors for depression

Answer 25

chronic medical illness
stress
chronic pain
family history of depression
female
low income/job less
low self esteem
low social support
prior depression
single/divorced/widowed
traumatic brain injury

Question 26

screening for depression based on USPSTF

Answer 26

patients with risk factors for depression with the PHQ-2. Patient with a positive PHQ-2 should be given
the PHQ-9.

Question 27

medical history retrieved for depression patients

Answer 27

Current and past medical history need be reviewed given the potential for medical conditions and
medications to contribute to depression. Comorbid medical conditions are more likely with new onset
depression, especially in an older adult; depression that has not responded to treatments and
depression with significant cognitive impairment.
Laboratory evaluation should be pursued in patients with higher risk of comorbidity i.e. geriatric
patients. Tests to consider:
• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• RPR
• Serum B12 and folate
• Urinalysis
• EKG the dysrhythmia is suspected

Question 28

treatment for depression

Answer 28

Depression should be treated with a comprehensive naturopathic program including, but not limited to:
diet, exercise, counseling, nutritional, supplementation, botanical and homeopathic prescriptions. There
is high-grade evidence for the use of Hypericum perforatum for the treatment of major depression.
Patients with moderate to severe depression should undergo a PARQ conference on pharmacologic
treatment options. Patients with moderately severe to severe depression should be co-managed with a
mental health professional.

Question 29

Patinets with depression monitor at each visit the following

Answer 29

Response to treatment can be evaluated using the PHQ-9.

Evaluation for suicidality: See Suicidality Screening Protocol (below)
Direct inquiry concerning suicidal ideation should be pursued in patients with depression. Patients with
suicidal ideation should be asked about nature the ideation, intent, plans and any actions they have
taken.
• Risk Factors: Age 20 – 24, or older than 65 years. Male sex.
• Psychological features: anhedonia, history of suicide attempt, hopelessness, insomnia,
irritability, or psychiatric history, severe anxiety, substance abuse/ dependence.
• Environmental/social concerns: Availability of means (access to guns, medications), changes in
future plans i.e. establishing a will, making funeral arrangements. Recent illness, recent suicide
in the community, state or nation. Stressful life events i.e. death of a friend, family member, loss
of employment, and for relationship, legal issues. Unmarried or limited social support.
• No decision-making rules have been widely adopted to predict suicide risk.

For high-risk patients Multnomah County Mental Health can facilitate Emergency Holds at a hospital
until patients can be stabilized. The 24-hour Mental Health Crisis Line is 503-988-4888.
The use of suicide prevention contracts should generally be avoided.

Question 30

Criteria for initial referral/ hospitalization for patients with depression

Answer 30

The decision to refer will vary depending on the clinicians level of expertise and confidence in assessing
and treating depression. Referral should be considered with the following clinical factors:
• Severe depression
• Suicidal ideation or inability to care for self
• Depression failed to respond to initial treatment
• Psychotic depression
• Depression associated with bipolar disorder, schizophrenic disorder or other major psychiatric
illness