NSG 550 EXAM 1 Flashcards
- Process of clinical reasoning and determining differential diagnoses in the role of an NP
● Clinical reasoning occurs in clinical practice through thinking and decision-making processes.
● Knowledge + cognition= metacognition required for clinical reasoning.
● Knowledge is theory and research, personal, and professional experience.
● Cognition is reflective inquiry.
● Metacognition combines knowledge and cognition
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness
Accuracy
– Does the test measure what it was designed to measure?
– Proportion of all tests (positive and negative) that are correct.
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness
Precision
– Does the test reproduce the same results when repeated on the same patient or a sample? A
– test can be precise but not necessarily accurate if the results differ from reference range.
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Sensitivity
– True positives ÷ (True positive + False negative)
● Measures proportion of true positive (diseased) with a positive test result
● Those with disease
● A high sensitivity test means that it detects the presence of a condition with relatively few indicators (depends on the key point evaluated in the test)
● Among people with disease, how often is the test right?
● Example
● Test A has a sensitivity of 0.8 or 80%
● Test A correctly identifies 80% of the people who have the disease
● But it misses 20%. → 20% have the disease but the test did not detect it
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Specificity
– True negatives ÷ (True negatives + False Positive)
● Measures proportion of true negative (non-diseased) with a negative test result
● Those who are well / disease free
● A highly specific test means that it really rules out a diagnosis if a patient does not have the indicators
● Among people who are well, how often is the test right?
● Example
● Test A has a specificity of 0.8 or 80%
● Test A correctly identifies 80% of the people who do NOT the disease
● But it misidentifies 20%. → 20% do NOT have the disease but the test said they did
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Disease + Positive Test = True Positive
Disease + Negative Test = False Negative
No Disease + Positive Test = False Positive
No Disease + Negative Test = True Negative
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- American College of Radiology Appropriateness Criteria-understand the categories for procedures as they relate to 1) appropriateness rating and 2) radiation level.
● “Why?” → Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition
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○ 1) Appropriateness Rating
■ Appropriateness Category Names and Definitions
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■ 2) Radiation Level
● Relative radiation level designations along with common examples of each classification
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: Usually Appropriate
Appropriateness Rating: 7. 8. or 9
Approp. Category Definition:
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: May Be Appropriate
Appropriateness Rating: 4, 5, or 6
Approp. Category Definition:
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: May Ba Appropriate (Disagreement)
Appropriateness Rating: 5
Approp. Category Definition:
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
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American College of Radiology Appropriateness Criteria
Appropriateness Category Name: Usually Not Appropriate
Appropriateness Rating: 1, 2, or 3
Approp. Category Definition:
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
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- Steps to patient safety in the management of diagnostic studies/follow up to patients with results
timeliness in reporting test results is no less essential. To be clinically useful, results must be reported promptly. Delays in reporting test results can make the data useless. The data must be included in the appropriate medical record and presented in a manner that is clear and easily interpreted.
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
X-Ray:
Beam of X-rays (highly charged electrons) that is passed through the body.
● High Density objects appear white (bone)
● Low Density objects appear black (lung)
● Radiation–★
● Cost – $
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
CT Scan:
A series of cross-sectional X-rays (360 degree view)
● Helps image bone, soft tissue, and vasculature at the same time
● High Density = White
● Low Density = Black
● Radiation– ★★★
● Cost – $$
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
CT (With Contrast):
Contrast helps highlight specific areas of interest - areas with contrast will ‘light up’ on CT
● PO (Oral) Contrast
○ Helps differentiate areas of GI Tract from surrounding soft tissue, blood vessels, etc.
● IV Contrast
○ Helps differentiate between normal and abnormal blood vessels
○ Aid in describing an abnormality such as tumor that might have own vasculature
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
Ultrasound:
High frequency sound waves are bounded off of tissue in our body, and are used to create cross-sectional image of the body
● Quick, easy, portable method of visualizing body cavities, tissues, and blood vessels [[[anywhere w/ fluid ]]]
● Radiation: NONE
● Cost: $
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
US With Doppler:
Doppler effect: Object traveling towards you has a higher frequency
● Can be applied to Ultrasound of blood vessels to assess for blood flow
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
MRI:
Large magnetic fields are used to manipulate hydrogen atoms in our soft tissues, creating 3D maps
● Best for visualization of the brain, spinal cord, and other soft tissue
● Radiation: NONE
● Cost:$$$$
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Patient follow-up with results
o Do not give over the phone, or on answering machine
o Do not give to family/friends unless written consent is given
o Provide education on meaning of results, disease process, home care, next visit,
and treatment options
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Precision:
does the test reproduce the same results when repeated on the same patient or a sample; a test can be precise but not necessarily accurate if the results
differ from reference range
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Specificity:
among people who do not have the disease, how often is the test
right?
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Sensitivity:
among people who have the disease, how often is the test right?
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Accuracy:
does the test measure what it was designed to measure; proportion of
all tests (positive and negative) that are correct.
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Clinical decision making is multifaceted and encompasses the patient, clinical
problem, and the practitioner’s perspectives
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Critical thinking involves application of analysis, evaluation, and inference
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Knowledge + cognition = metacognition
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Collect H&P, complete physical exam, interpret diagnostic studies
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- Blood studies
o Used to establish Dx, r/o clinical problem, monitor therapy, establish prognosis,
screen for disease
o Venous – most common
o Arterial – causes more discomfort, used for blood gasses, higher risk of hematoma
– hold pressure longer
o skin puncture – often used in pediatrics, mix of venous and arterial. Earlobe can
be used for arterial if needed. Do not milk d/t hemolysis
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Electrodiagnostic studies
o Tests electrical impulses
o May cause discomfort from stimulation
o Do not move, have caffeine or sedatives before test
o Few complications
o Not invasive, usually do not need written consent
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- Endoscopy
o Need written consent
o Baseline labs
o Prep depending on type of study
o Like minor surgery (educate re: sedative, have emergency equipment available,
need ride home)
o IV antibiotics for those with prosthetic joints or cardiac valve disease
o Education – may cause gas, discomfort, infection signs
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- Fluid Analysis Studies
o Normal fluids and effusions
o Aspiration must be sterile
o Diagnostic and therapeutic
o Risks: infection, seeding of malignancies, leakage, reflex bradycardia/hypotension
from anxiety
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- Manometric Studies
o Measure and record pressures
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- Microscopic Studies
o Biopsy, culture/smear (STIs, TB, etc.), pathologic conditions (liver, renal,
urological), PAP
o Gram staining and shape (Gram neg rods = e coli)
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- Nuclear Scanning
o Stage cancer, detect sites of GI bleed, diagnose cholecystitis/pulm embolism,
brain scan, eval gastric emptying/thyroid nodules/testicular swelling/cardiac
function
o Technetium-99m (99mTc) is used extensively in nuclear scanning because its
half-life is 6 hours and it emits low levels of gamma rays. Other commonly used
radionuclides include gallium, thallium, and iodine.
o Combined with a transport molecule that takes the radionuclide to the intended
organ
o Superimpose of baseline CT/PET to see hot and cold spots
o Normally uptake is consistent across organ
o SPECT gives 3D images
o Radiation risk but less than x-rays
o Contraindicated in pregnant and nursing
o Use toilet and flush several times after use, clean up spilled urine, wash hand
thoroughly, wash soiled clothes separately
o Assess for allergy
o Oral, inhaled or IV admins of radionuclide
o Encourage water drinking
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- US
o Used to determine if lump is fluid or solid, guide needle biopsy, stage tumor, eval
pregnancy/placenta, detect ectopic pregnancy, determine fetus status/size, eval
arterial or venous disorders
o No radiation and less costly than CT or MRI
o B-scan, M-mode scan (motion), Real time imaging, doppler (amplifies sound
waves), color flow doppler (direction of flow), duplex scanning (real time + color
flow), 3D (pregnancy)
o Air, fat, and movement get in the way of good image
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- Urine
o Used to dx renal, urinary tract, metabolic disease
o 1st morning – void before bed then in AM. Best for protein, nitrates
o Random – convenient
o Timed – after meal (2hpp), urobilinogen (between 2 and 4pm). Discard void then
start timer and collect all until end time
o Double voided – fresh urine
o C&S – sterile container and cleaning of meatus. Midstream
o 24hr. discard 1st of day, then start collection, including next days AM void. Keep
on ice or fridge
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- X-ray
o Used to eval dye excretion in urinary tract/arterial occlusion/GI tract with barium/
bone disorders/ tracheobronchial tree/pulm and cardiac systems/abd pain or
trauma, detect breast cancer, guide needle biopsy, determine patency of fallopian
tubes
o Plain
o Fluoroscopy – can view motion, barium movement, more radiation
o Tomography – CT, xrays make cross sectional 3D image
o Contrast – barium, iodine, etc.
▪ Iodine contraindications – renal disease (check BUN and create 1st), DM
causes renal concerns, allergy to shellfish, dehydration,
pheochromocytoma (htn)
- Can premedicate with Benadryl and prednisone in those with
allergy hx. Use nonionic contrast - Iodine can cause lactic acidosis – must stop oral
antihyperglycemics for 48 hrs before and after
o Digital subtraction angiography – type of fluoroscopy w/ catheterization of vein
or artery. Before/after vascular/tumor surgery
o Barium – interferes with other tests, prep required before and after.
▪ Contraindicated in perforation (can use gastrografin instead) and colitis
o Nephrotoxicity d/t contrast medium – increase in serum create by more than 25%
w/i 3 days. Hydrate, use low osmolar nonionic medium in minimal amount. Do
not give diuretics
o Radiation dose – higher with CT than xray. Depends on length of time and
number of images. Dental and DEXA very low
▪ Minor reaction (n/v, urticaria) Give antihistamine
▪ Intermediate reaction (mouth/throat edema, bronchospasm, chest pain,
chills/fever) Give antihistamines and maybe steroids, fluids,
bronchodilators
▪ Severe reaction (edema, hypotension, MI, arrythmia, seizure, resp failure)
Give antihistamines, steroids, fluids, bronchodilators, intubation/vent,
pressors, antiepileptics
▪ Delayed reactions can occur for 2-6hrs
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- MRI
o No radiation
o Advantage over CT – better contrast image, no obscuring bone, natural blood
vessel contrast, can image multiple angles
o Evals most body systems – brain, GI, muscle, cardiac, breast, spine
o Expensive and labor intensive
o Can use contrast like gandolinium or gasoxetate
▪ Should check renal function, especially in those over age 60
o Contraindicated in extreme obesity, claustrophobia, agitation, metal in body
o Remove patches and any metal, remain still
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Urologic/Renal
* Imaging studies
o KUB – not specific
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Urologic/Renal
* Imaging studies
o Pyelography – mostly replaced with CT.
▪ X-ray that uses contrast injected into renal system or IV.
▪ Indicated for stones, hematuria, trauma, outlet obstruction, tumor, pelvic
surgery
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Urologic/Renal
* Imaging studies
o Renal scan
▪ Nuclear study - Radioisotope and scintillation camera
▪ No iodine, safe to use in renal disease and allergies
▪ Perfusion, structure, function, hypertension, or obstruction
▪ Not to be done w/I 24 hrs of IVP
▪ Evaluate transplant rejection
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Urologic/Renal
* Imaging studies
o Cystoscopy
▪ Camera in bladder
▪ Used for hematuria, recurrent UTI, dysuria, frequency, retention,
inadequate stream, urgency, incontinence
▪ Diagnostic
- Ureter sample collection, visualization, measurement, calculi
▪ Therapeutic
- Resection of tumors, removal of FB, dilation, stent placement,
coag of bleeding, implant radium seeds, TURP
▪ Urethroscope, cystoscope, ureteroscope. Nephroscope
▪ Complications – perforation, sepsis, hematuria, retention
▪ Assess voiding for 24 hrs, note urine color (pink tinge common) avoid
standing immediately after, burning during urination common (should pee sitting), drink fluids, observe for sepsis, may use antibiotics before and
after, avoid constipation
▪ Tumor, stones, prostate hypertrophy/cancer, inflammation, stricture
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- Interpreting a Urinalysis
▪ Appearance: clear
* Cloudy d/t pus or foods (fat, urates, phosphates)
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- Interpreting a Urinalysis
Color: amber yellow
- Kidney bleed- dark red
- Lower bleed – bright red
- Urobilinogen or bilirubin – dark yellow
- Pseudomonas – green
- Beets/rhubarb – red/brown
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- Interpreting a Urinalysis
▪ Odor: aromatic
- DKA – acetone
- UTI – foul
- Enterobladder fistula – fecal
- PKU - musty
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- Interpreting a Urinalysis
▪ pH: 4.6-8.0 (average, 6.0)
- acid base balance, foods
- acidic urine associated with zanthine, cystine, uric acid and
calcium oxalate stones - alkaline urine associated with calcium carb/phos and mag phos
stones. UTI - urine become alkaline on standing
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- Interpreting a Urinalysis
▪ Protein: 0–8 mg/dL; 50–80 mg/24 hr (at rest); <250 mg/24 hr (during
exercise)
- Presence indicates glomerular capsule injury
- During pregnancy - preeclampsia
- Proteinuria and edema – nephrotic syndrome
- If random elevated, do 24 hr
- Usually checked with creatinine
- Orthostatic proteinuria
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- Interpreting a Urinalysis
▪ Specific gravity: Adult: 1.005–1.030 (usually, 1.010–1.025)
- Elderly: values decrease with age
- Newborn: 1.001–1.020
- High means concentrated and low means dilute
- SIADH – elevated SG
- DI – decreased SG
- Renal disease causes dilute
- Easier to check than osmolality
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- Interpreting a Urinalysis
▪ Leukocyte esterase: negative
- Pos (>100,000) = UTI, contamination by vaginal secretions
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- Interpreting a Urinalysis
▪ Nitrites: none
- Pos = UTI
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- Interpreting a Urinalysis
▪ Ketones: none
- Pos = poorly controlled DM and hyperglycemia, infection,
ketoacidosis r/t alcoholism, fasting, aspirin toxicity, anesthesia
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- Interpreting a Urinalysis
▪ Bilirubin: none
- Pos = gallstones
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- Interpreting a Urinalysis
▪ Urobilinogen: 0.01–1
- pH can affect urobilinogen levels. Alkaline urine indicates higher
levels; acidic urine may show lower levels.
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- Interpreting a Urinalysis
▪ Crystals: none
- Uric acid = gout
- Phosphate/calcium = parathyroid abnormality
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- Interpreting a Urinalysis
▪ Casts: none
- Hyaline or granular – exercise
- Fatty – glomerular disease
- Waxy – chronic renal disease
- Epithelia (renal tubular) – tumor, infection, polyp of bladder
o Most suggestive of renal tubular disease or toxicity.
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- Interpreting a Urinalysis
▪ Glucose: Fresh specimen: none
- 24-hour specimen: 50–300 mg/24 hr or 0.3–1.7 mmol/day (SI
units) - Pos = common in pregnancy, hyperglycemia, renal glycosuria,
Fanconi syndrome, nephrotoxic chemicals
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- Interpreting a Urinalysis
▪ White blood cells (WBCs): 0–4 per low-power field
- Pos = UTI
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- Interpreting a Urinalysis
▪ WBC casts: none
- Pos = UTI (usually kidneys)
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- Interpreting a Urinalysis
▪ Red blood cells (RBCs): ≤2
- Pos = something causing bleed, menstruation
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- Interpreting a Urinalysis
▪ RBC casts: none
- Pos = glomerulonephritis (which may be present in patients with
acute bacterial endocarditis, renal infarct, Goodpasture syndrome,
vasculitis, sickle cell disease, or malignant hypertension),
interstitial nephritis, acute tubular necrosis, pyelonephritis, renal
trauma, or renal tumor
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- Culture and Sensitivity
o Negative: <10,000 bacteria/mL urine
o Positive: >100,000 bacteria/mL urine
o Prelim report in 24 hr, final in 48-72
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- PSA
o <2.5 is low, >20 is very high
o Early detection and monitoring of prostate cancer
o 80% false positive
o Bound PSA more indicative of cancer than free PSA
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- Serum Carbon Dioxide Level (23-30)
o Part of electrolyte studies
o Regulated by kidneys
o Increase = alkalosis
o Decrease = acidosis (renal failure)
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- Testing to diagnose and manage CKD
o Urine albumin
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- Testing to diagnose and manage CKD
o Serum Creatinine (0.5-1.2 mg/dl)
▪ >4 mg/dL (indicates serious impairment in renal function)
▪ Normal differs by sex, age: lower in children
▪ Trough at 7am, Peak at 7pm,
▪ Higher after meal
▪ Dehydration and diet high in meat causes elevation
▪ Increased: Diseases affecting renal function, such as glomerulonephritis,
pyelonephritis, acute tubular necrosis, urinary tract obstruction, reduced
renal blood flow (eg, shock, dehydration, congestive heart failure [CHF],
atherosclerosis), diabetic nephropathy, nephritis. Also, rhabdo/increased
muscle mass diseases
▪ Interpreted with BUN: BUN/Create ratio normally 6-25 (15.5 optimal)
▪ Used to estimate GFR
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- Testing to diagnose and manage CKD
o BUN (7-20)
▪ Formed in liver and excreted by kidney
▪ Low in liver disease, high in kidney disease
- Testing to diagnose and manage CKD
o Creatinine Clearance
▪ 90-140, higher in males
▪ Decreases by 6.5 with each decade of age after 20
▪ 24 hr urine and serum creatinine used to calculate
▪ Measure of GFR
▪ Decreased in kidney disease and anything that reduces kidney perfusion
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- Testing to diagnose and manage CKD
o eGFR
▪ Cystatin C might be better to estimate GFR than Create because its more
stable
▪ Calculated by create/CC and age, gender, race
▪ Normal around 120
▪ Below 60 indicates disease
▪ Below 15 is kidney failure
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Endocrine
- Thyroid Nodule Diagnosis and Imaging
o US can identify non palpable nodules and cysts – preferred method
▪ Malignant nodules are mostly solid and hypoechoic with irregular margins ▪ Benign nodules are well defined and hyperechoic
o Scintigraphy reserved for characterizing functioning nodules and for staging
follicular and papillary carcinomas
o Plain radiographs are used to detect retrosternal thyroid extension, thyroid
calcification, bony or mediastinal lymph nodes, and lung metastases. Limited usefulness.
o CT scanning is an effective method for detecting regional and distant metastasis
from thyroid cancer.
o MRI has a limited role in characterizing thyroid nodules, although it appears to be
effective in the diagnosis of cervical lymph node metastasis and staging cancers.
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Endocrine
- Fine Needle Aspiration of Thyroid
o Percutaneous needle aspiration remains the key procedure in the diagnosis of
thyroid lymphoma; however, thyroid lymphoma’s differentiation from thyroiditis
occasionally can be difficult. A tissue-specific diagnosis of a lymphoma can be
achieved by using US-guided FNA.
o Risks – bleeding, infection, injury to vital structures, bruises
o Might need to stop blood thinners
o Results – benign (f/u), cancerous (remove), indeterminate (repeat in few months),
inadequate (repeat in few months)
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Endocrine
- Thyroid function tests
o TSH (0.3-5)
▪ Elevated – hypothyroid ▪ Decreased – hyperthyroid ▪ Trough 10am, peak 10pm
o Thyroxine (T4) – 5-12, free 0.8-1.8 micrograms
o Triiodothyronine (T3) – 100-200 nanograms
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Endocrine
- Diabetes
o C-Peptide - evaluates islet cell function (0.5-2)
▪ Used to evaluate diabetic patients and to identify patients who secretly self-administer insulin. C-peptide is also helpful in monitoring patients with insulinomas ▪ Decreased in DM with insulin admin ▪ Usual correlates with insulin levels but more accurately reflects islet cell function in patients taking insulin
o Fasting plasma glucose, a 75-gram oral glucose tolerance test (also called the 2-
hour glucose tolerance test), and hemoglobin A1C are all valuable in
diagnosing DM
o Microalbumin – first indicator of renal disease, screen annually
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Endocrine
- Cortisol
o Diurnal variation, higher in AM (5-23), decreased after 4pm (3-13)
o Measures adrenal activity
o Cushing – does not go down during day
o Elevated – Cushing, ACTH producing tumor, hyperthyroid, obesity
o Low – Addison disease, hypopituitary/thyroid, adrenal hyperplasia
o Pregnancy, stress increases
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Endocrine
- ACTH (6-58 F, 7-69 M)
o Anterior pituitary function
o Cushing – Low=pituitary cause/High=adrenal cause
o Addison – High because adrenal not working
o Hypopituitary – Low Cortisol and ACTH
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Endocrine
- ACTH stimulation
o Evaluates the ability of the adrenal gland to respond to ACTH administration. It is
useful in evaluating the cause of adrenal insufficiency and also in evaluating
patients with cushingoid symptoms.
o Increase in cortisol after ACTH-drug indicated adrenal gland is normal but
pituitary isn’t functioning correctly
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Endocrine
- Insulin (6-26)
o Used to diagnose insulinoma (tumor of the islets of Langerhans) and to evaluate
abnormal lipid and carbohydrate metabolism. It is used in the evaluation of
patients with fasting hypoglycemia.
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Immunologic/Skeletal
- Rheumatoid Arthritis Diagnoses
o Antinuclear Antibody – tests multiple antibodies, not specific
o Rheumatoid Factor - autoantibody
o Inflammatory Markers
▪ C reactive inflammatory markers
* < 1
* Infection, infarction, autoimmune inflammation
* Rises and falls quickly
▪ Erythrocyte Sedimentation Rate
* Up to 15 M, up to 20 F
* Slower to rise and fall than CRP
* Infection, infarction, autoimmune inflammation
o X-ray – inexpensive and easy
o MRI in c-spine abnormalities
o Joint aspiration and synovial fluid analysis
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Immunologic/Skeletal
- Arthroscopic Knee Surgery
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Immunologic/Skeletal
- Vitamin D
o Total: 25-80 ng/ml
o Below 20 is deficient
o 20-30 is insufficient
o Over 200 could be toxic
o Intake
▪ Under 50 = 200iu
▪ 51-70 = 400iu
▪ 71+ = 600iuo Works with PTH to increase serum calcium
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Immunologic/Skeletal
- Bone Densitometry/Density (DEXA) Scans
o Normal: <1 SD below normal (>–1.0)
o Osteopenia: 1.0–2.5 SD below normal (–1 to –2.5)
o Osteoporosis: >2.5 SD below normal (<–2.5)
o Done on postmenopausal women every 2 years
o Annual for hyper parathyroid or long-term steroids
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Immunologic/Skeletal
- Calcium Levels (9-10.5 mg/dL, ionized 4.5-5.6)
o Used to evaluate parathyroid function and calcium metabolism, to monitor
patients with renal failure, renal transplantation, hyperparathyroidism, and
various malignancies and to monitor calcium levels during and after largevolume blood transfusions.
o When blood levels decrease, PTH is stimulated which stimulates release of
calcium from reservoirs
o Half is free and half is bound to albumin. Ionized measurements do not change
d/t albumin
o Symptoms of hypercalcemia may include anorexia, nausea, vomiting,
somnolence, and coma.
▪ Most common cause is hyperparathyriod
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Immunologic/Skeletal
- HIV Testing
o Viral load - accurate marker for prognosis, disease progression, response to
antiviral treatment, and indication for antiretroviral prophylactic treatment.
o Serology and virology: Standard for testing
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- Process of clinical reasoning and determining differential diagnoses in the role of an NP
What goes into clinical reasoning - understanding of the situation, knowledge of disease process and findings, decision making for testing
Never guessing or “shotgun approach”
Best information is through thorough history and physical
- listen to your patients, don’t always need diagnostic testing to determine a diagnosis, use clinical practice guidelines to develop your plan of care
Coming up with a diagnosis - knowledge, experience, analyzing data (diagnostics), and looking at other differentials to keep an open mind (use these to rule in or rule out your differentials) - Example - differential diagnosis pregnancy
- Negative Hcg rules this out
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Pearl of the Day:
A retroperitoneal ultrasound is a diagnostic test used to examine the area behind the intestine and other abdominal organs. It allows the NP to view the patient’s kidneys and ureters and can help diagnose a number of conditions such as renal cysts or gallstones.
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- Application of sensitivity vs specificity to diagnostic testing and appropriateness.
Specificity - looking for patients without disease (screening test) - low false positive
Sensitivity - looking for patients with disease - low false negatives
Specific - CRP, PSA
Sensitive - Hcg
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- American College of Radiology Appropriateness Criteria - understand the categories for procedures as they relate to appropriateness rating and radiation level.
Guidelines for ordering tests based on what information you are looking for - helps with contrast vs noncontrast (renal stone protocol)
Compares radiation exposure
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- Steps to patient safety in the management of diagnostic studies/follow up to patients with results
You have an obligation for every test you order to read the FINDINGS and IMPRESSION - you are responsible for that information in regards to incidental findings as well as if there are any inconsistencies - what do you do in that situation?
Always relay information to patients as quickly as possible - normal vs abnormal
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- Differences in types of testing as they pertain to the main areas of the textbook -example, ultrasound, MRI, vs microscopy
Ultrasound - looks at vessels (venous arterial duplex) good for ovaries and testicles, can look at soft tissue as well for abscess/cyst, thyroid
MRI - in depth look, bone tissues vessels
Microscopy - culture and sensitivity, blood culture, UA
Xray - bones and bone densitometry
Nuclear med - bone scan, thyroid scan (scintography)
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Serum CO2 - kidneys remove acid and maintain balance of HCO3
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PSA - all prostate secrete; levels by age and is screening tool (specific)
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Creatinine - removed entirely by the kidneys; best way to follow over time. Also GFR and CrCl
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Microalbumin - done by UA most commonly caused by diabetic nephropathy
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Gold Standard for first time kidney stone testing
- a non-contrast CT of the abdomen and pelvis.
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High ACTH High Cortisol - Cushing’s disease
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Low ACTH High Cortisol - Cushing’s Syndrome or adrenal tumor
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High ACTH Low Cortisol - Addison
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Low ACTH Low Cortisol - hypopituitary
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C reactive protein
- one of the proteins that activates the complement above - protein made by the liver, releases more if you have high inflammation. Can look at chronic inflammation/infection but doesn’t distinguish.
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