SM Flashcards
(246 cards)
1
Q
Which findings would make you refer the patient to a gastroenterologist?
A
Unintentional weight loss is a red flag in this patient that would warrant referral for an EGD. Some other red flags for Barrett’s esophagus or esophageal cancer would be difficulty or painful swallowing, bleeding, or early satiety. Common presentations of GERD including heartburn that may mimic chest pain and a dry cough. Alcohol use can put the patient at higher risk for worsening GERD so this statement would require patient education. The patient is on omeprazole which is a proton pump inhibitor and the most effective class out of our first line options. However, if the patient can no longer afford a PPI, we could trial an H2 blocker instead.
2
Q
Acute pancreatitis
A
Patients experience a sudden onset of acute upper abdomen pain, which they often state radiates to their back. As the pancreatitis progresses, they may have bruising on their flank (Turner’s sign) and/or around their umbilicus (Cullen’s sign). These patients need to go to the emergency room for prompt treatment.
3
Q
Patient presented with several concerns including RUQ pain. He states that he is a daily drinker what would be our priority lab?
A
Aspartate aminotransferase (AST)/ Alanine transaminase (ALT), he states he is having RUQ pain, and is a heavy drinker, so checking liver function would be a priority.
4
Q
Quadruple therapy is used to treat H. pylori infections in areas where there is high antibiotic resistance.
A
Quadruple therapy for treatment of H. pylori includes Metronidazole (Flagyl), Tetracycline, a proton pump inhibitor and bismuth subsalicylate (Pepto-Bismol). Quadruple therapy can be used in those who have failed triple therapy or have persistent H. Pylori. It is also utilized in areas of high antibiotic resistance to the components of triple therapy.
5
Q
Risk factors for cholecystitis
A
The four main risk factors for cholecystitis are being
- female
- being over 40 years of age,
- being overweight,
- being fertile.
6
Q
Triple therapy for treatment of H. pylori may include which of the following drugs
A
Traditional triple therapy for H. pylori consists of a proton pump inhibitor, Amoxicillin and Clarithromycin. Metronidazole can be utilized instead of Amoxicillin if patient allergies are present.Triple therapy is a 14 day treatment of antibiotics followed by 2-4 continuing weeks of the PPI.
7
Q
First-line medications for gastroesophageal reflux disease (GERD)
A
Proton pump inhibitors (PPI). The most common PPIs are pantoprazole (Protonix) and omeprazole (Prilosec).
8
Q
Psoas sign
A
While lying supine and raising her right leg against resistance. A sign that is positive as it elicits abdominal pain is suspicious for appendicitis.
9
Q
Markle test
A
markle test is performed by having the patient jump or drop their heels suddenly if you feel pain suspect appendicitis.
10
Q
Obturator sign
A
elicited by internally rotating the right hip while monitoring for right lower quadrant pain if its positive you should suspect appendicitis.
11
Q
Risk factors for colorectal cancer requiring earlier or more frequent testing
A
- family history of a first degree relative with colorectal cancer
- irritable bowel disease- either Crohn’s disease or ulcerative colitis, and colonic polyps
12
Q
At what age does the The U.S. Preventive Services Task Force (USPSTF) recommends colorectal cancer screening
A
between ages 50-75 years.
13
Q
Treatment of diverticulitis
A
Mild cases of diverticulitis can be treated in the outpatient setting, with close followup. If the patients worsen or do not improve in 48-72 hours on antibiotics and a clear liquid diet, they should be referred to the emergency department. Augmentin (amoxicillin/clavulanic acid), or ciprofloxacin with flagyl (metronidazole) are the antibiotics of choice.
14
Q
Where is the pain in diverticulitis located
A
Pain with diverticulitis is localized to the left lower quadrant, and may be accompanied by a change in bowel habits and nausea or vomiting.
15
Q
Patient eligibility prior to starting Zofran.
A
EKG because it can cause QT
prolongation.
16
Q
Ulcerative colitis (UC)
A
Ulcerative colitis (UC) is an inflammatory bowel disease that affects only the colon. Patients will present with bloody diarrhea, often with mucus. Abdominal pain, weight loss, and fatigue are all common symptoms of UC as well. Another key clue in this question is her history of ankylosing spondylitis - this condition is found in 15-40% of patients with UC.
17
Q
Signs and symptoms of gastroenteritis.
A
Nausea, vomiting, and stomach pain
18
Q
Gastroenteritis treatment
A
Bland diet, increased water intake, and Zofran (Ondanestron). Increased water intake and a bland diet (breads, bananas, applesauce) are recommended in treatment of gastroenteritis to prevent dehydration and promote gut rest in order to allow for recovery of the patient. Zofran can also be prescribed to help with nausea.
19
Q
Magnesium carbonate (Magnesite) side effects
A
Diarrhea and hypotension, but may help with leg cramps and headaches.
20
Q
Crohn’s disease
A
Crohn’s disease is a type of inflammatory bowel disease (IBD)
characterized by “skip lesions” which are throughout the GI tract. It can also be characterized by fistulas and strictures throughout the intestines.
21
Q
Will you need to write down the normal lab values as soon as you see them on AANP
A
YES, THEY ONLY GIVE THE NORMAL ONCE AND ASSUME YOU KNOW IT THERE AFTER.
22
Q
JNC 8 hypertension guidelines,
A
- Patients less than 60 years old do not need treatment with antihypertensives until the blood pressure reaches >140/90.
- In patients 60 years old or greater, we do not need to initiate antihypertensive treatment until their blood pressure is >150/90 according to the JNC 8 guidelines. here are variations in these cutoffs if the patient has either diabetes or chronic kidney disease.
23
Q
What should be check prior to starting this patient on a HMG-CoA Reductase.
A
The nurse practitioner should get a baseline CK level.
24
Q
Which type of murmurs radiate
A
Only systolic murmurs radiate
25
Where does a systolic Mitral regurgitation murmur radiate
Axilla
26
Mitral regurgitation is a systolic murmur that radiates to the axilla where can it be heard best
At the apex of the heart
27
What is the goal blood pressure in this patient according to AHA/ACC guidelines
The goal blood pressure in patients is <130/<80 mmHg.
28
According to AHA/ACC guidelines what would be considered stage I hypertension
Stage 1 hypertension is a blood pressure of 130-139/80-89 mmHg and we would initiate antihypertensives if the patient's ASCVD risk score was 10% or greater.
29
According to AHA/ACC guidelines what would be considered stage II hypertension
Stage 2 hypertension is ≥140/90 mmHg.
30
What ASCVD risk score would we start treatment of hypertension medications
10% or greater
31
When would be a good time to start a patient on high-intensity statins
patients with LDL >190, high risk conditions such as cardiovascular diseases, diabetes, or CKD. Patients over 65 years old should also be considered for high intensity statins.
32
Rhabdomyolysis
muscle proteins start to break down and be released into the bloodstream
33
What is the biggest risk factor with Rhabdomyolysis
Renal failure
34
What is a good blood pressure medication to use in patients with osteoporosis
thiazide diuretics
35
Which of the following drug classes does Aspirin (Bayer) belong to
Antiplatelet
36
Which of the following drug classes does warfarin or heparin belong to
anticoagulant
37
What does over fifty percent of infective endocarditis relate to
IV drug use
38
What valve is affected with IV drug users
IV drug users typically have their Tricuspid messed up
39
What blood pressure medication would you want to avoid in a patient with an heart failure comorbidity
Amlodipine (Norvasc) because of issues with swelling
40
What ABI score indicates PAD
A score of less than 0.9 indicates peripheral arterial disease.
41
Raynaud’s treatment
Typically calcium channel blockers
42
How do we treat a Diastolic murmur in primary care
WE DONT THEY ARE ALWAYS SENT OUT! Refer the patient to a cardiologist for further evaluation
43
Risk factors for peripheral arterial disease
1. BMI of greater than 30
2. Diabetes mellitus
3. Atherosclerosis
4. Cerebrovascular disease
Smoking is the biggest risk factor for PAD, but conditions like hypertension, diabetes, heart disease, and hyperlipidemia can all put this patient at an increased risk.
44
What are symptoms of acute drug-induced hepatitis in a patient that started a statin a few weeks ago
Abdominal pain coupled with the jaundiced sclera are clues that his high intensity statin is causing acute hepatitis, and we would need to draw liver function test on patient to see where they are at.
45
What is the antidote for acetaminophen (Tylenol)
N-acetylcysteine
46
How could we check for heart failure
1: Echocardiogram
2: Brain Natriuretic Peptide (BNP) level
3: Chest x-ray
4: electrocardiogram (EKG)
5: CBC and CMP
47
PAD signs and symptoms
intermittent claudication where there is pain in the lower extremities that is quickly relieved with rest. The lower extremities may also be cool to touch with decreased pedal pulses and non-healing ulcers.
48
Normal hemoglobin level
12-18 with women being on the lower end and men being on the higher end.
49
Hematocrit to hemoglobin ratio
3/1
50
Normal Hematocrit level
36-54% or 3x the hemoglobin
51
Normal MCV level
80-100
52
What is always helpful when deciding between anemias
MCV
53
What is a low MCV known as
Microcytic Anemia and its normally Iron deficiency anemia
54
Most common symptom of any type of anemia
Fatigue
55
What is the biggest risk factor for Iron deficiency anemia in the 1st year of life
Cows milk
56
Macrocytic anemia
MCV greater than 100
57
What are some examples of macrocytic anemia
B12 and folate
58
How are we going to tell the difference between B12 and Folate anemia
Its going to be based off symptoms like B12 will have neurological symptoms such as paresthesias, which is numbness and tingling in the hands and feet, but in B12 neurological symptoms it could be gait or memory that is affected.
59
What surgery typically leads to B12 deficiency anemia
Patients that have had gastric bypass or some stomach altering surgery because of the loss of the intrinsic factor.
60
What diabetes medication if used long term can lead to B12 deficiency
Metformin
61
What are microcytic anemias
Iron and lead anemia
62
Normal lead level
less than 5 an abnormal level will be greater than 5
63
Signs and symptoms of lead intoxication
cognitive delays and behavioral problems
64
Mnemonic to remember our microcytic anemias
L = Lead
I = Iron
T = Thalassemia
65
What is a normal total cholesterol
Less than 200, this is the total cholesterol in the blood, things that impact our total cholesterol is smoking, diet, and physical activity.
66
HDL
40-60 and the higher end is better
67
LDL
less than 100
68
Triglycerides
less than 150
69
How often should we order a standard lipid profile on a patient
Every 5 years unless they are having symptoms, how alot of risk factors, or they are already being trated.
70
Which is our bad cholesterol LDL or HDL
LDL
71
The main culprit for atherosclerosis that clogs up arteries.
LDL
72
Which is our good cholesterol HDL or LDL
HDL, and its cardio protective and helps us remove cholesterol from the body.
73
Mnemonic to remember our macrocytic anemias
F= Folate
A= Macrocytic Anemia
B= B12
74
What does our Triglycerides tell us
Its a really good indicator of insulin resistance and true dietary intake.
75
Triglycerides greater than 500 put us at a increase risk for
Pancreatitis
76
What is always important before starting a Statin
1. Always ask about muscle pain
2. LFTs
77
Rhabdomyolysis
You want to get a CK level, if its rhabdo it will be 5x the normal limit. YOU WILL DC THE STATIN
78
What can Rhabdomyolysis lead to
Acute renal failure.
79
What two organs do we worry about statins messing up
Renal and liver
80
What lab do you monitor for warfarin
INR
81
Therapeutic INR for someone on warfarin
2-3
82
Warfarin antidote
Vit K
83
If a patient was to come in with a INR less than 10 but not bleeding how would we proceed
Hold a dose and adjust the dose
84
If INR is greater than 10 what do we do?
Give them Vit K, PO or IV depends if they are actively bleeding. Even if its only 5 or 6 if they are actually bleeding we are going to give them vit K.
85
What two labs can we use to evaluate the pancreas
Amylase and Lipase
86
What are the two main labs to evaluate the liver
AST and ALT
87
What two labs are inflammatory markers
ESR and CRP
88
What does a D-dimer test for
Blood clot
89
Diabetes diagnosis
6.5 or greater
90
What random plasma glucose level is suggestive of diabetes
Greater than 200 with symptoms
91
What level on the 2 hour glucose tolerance test is suggestive of diabetes
200 or greater
92
When is Fenofibrate used
Fenofibrate is especially effective at protecting the pancreas when triglycerides are >500.
93
Fundoscopic exam findings in patients with HTN
Copper wire arterioles, AV nicking, and flame hemorrhages
94
Fundoscopic exam findings in patients diabetes
In a patient with diabetic retinopathy, we may see cotton wool spots, neovascularization, or microaneurysms.
95
If we had a patient come in with papilledema what would we do?
Papilledema could indicate a number of things like a dangerously, extremely high blood pressure, increased ICP, brain tumor, etc. They would need to go to the ER ASAP.
96
What are Thiazide diuretics known to cause
1. Hyperglycemia
2. Hyperlipidemia
3. Uric acid
97
What sorts of food contain high levels of vitamin K.
Turnip greens, beef liver, and mayonnaise its important to follow these guidelines because This is because vitamin K is the antidote to warfarin, and can reverse the patient’s international normalized ratio (INR.) Foods high in vitamin K,
98
What category is ACE Inhibitors
Category D, this is not safe to give in pregnancy
99
How could we attempt to correct supraventricular tachycardia in a primary care practice
The patient should be instructed to perform a Valsalva maneuver as described in the correct answer. This maneuver stimulates the vagus nerve and slows the conduction through the atrioventricular node, which in turn lowers the patient’s overall heart rate.
100
Differential diagnoses for chest pain
1. Hiatal hernia
2. Pericarditis
3. Peptic ulcer
4.
101
What is pulsus paradoxus
occurs when there is a decrease in blood pressure by greater than 10 mmHg specifically on inhalation. Pulmonary causes include severe COPD exacerbations, pulmonary embolism, obstructive sleep apnea, status asthmaticus, etc. Severe hypovolemia can also create this pressure change due to lack of circulation.
102
Which of the following murmurs would be the most likely for the nurse practitioner to be able to palpate a thrill?
mitral stenosis is a diastolic murmur, and they are normally loud enough to hear a thrill. We do not treat in primary care they are sent to Cardio.
103
Systolic murmurs are considered benign in nature. Do you typically here a thrill with them?
No
104
What are some Systolic murmurs
Mitral regurgitation, aortic stenosis, and mitral valve prolapse are all systolic murmurs
105
JNC 8 guidelines
1. Guidelines for hypertension state that a patient less than 60 years old or those with chronic kidney disease (CKD) or diabetes need treatment with antihypertensives starting at ≥140/90 mmHg.
2. A goal blood pressure in these patients is <140/90 mmHg once they have started treatment.
3. In patients 60 years or older without chronic kidney disease or diabetes, treatment with antihypertensives are initiated at a blood pressure ≥150/90 mmHg. A goal blood pressure for these patients is <150/90 mmHg.
106
What patients is it contraindicated to use Amiodarone (Pacerone) in?
patients with thyroid disorders
107
Symptoms of a second degree AV heart block
fatigue, dyspnea, chest pain, syncope, and even sudden cardiac arrest
108
What heart medications are not to be given in second degree AV heart block
Calcium channel blockers, such as Diltiazem (Cardizem), are contraindicated in patients with second degree, and some other meds are Other medications that should be avoided in these patients include digoxin and beta blockers.
109
The gold standard of diagnosis for an abdominal aortic aneurysm
Abdominal ultrasound
110
Patients who should receive prophylactic antibiotics prior to dental procedures
Past history of infective endocarditis, those with a prosthetic valve, and transplant patients with a valvulopathy. For those patients, it is appropriate to administer amoxicillin (Amoxil) approximately 1 hour before the procedure.
111
Who are at risk for developing a pulmonary embolism
patients who are immobile, taking estrogen therapy, have clotting abnormalities (such as Factor V Leiden thrombophilia)
112
Penicillin uses
1. Pregnancy safe
2. Pneumonia, otitis media, group A strep, sinusitis, animal bites, mastitis
113
Amoxicillin (Amoxil) which is a PCN is good for treating what things?
1. Pneumonia if they meet the criteria
2. Acute otitis media if no ABX in the last month
3. Group A strep
4. Can be used for sinusitis but Amoxicillin/clavulanate potassium (Augmentin) penetrates the bones better so often is the first choice.
114
Amoxicillin/clavulanate potassium (Augmentin) this is also a PCN is good for treating?
1. Sinusitis
2. Dog Bites
3. Acute otitis media if they have HAD ABX in the last month
115
PENICILLIN G (BICILLIN) IM is often given for what
Syphilis
116
Dicloxacillin (Diclocil) which is a PCN, is good for what
Mastitis
117
What are some other ABX that can be given for Mastitis
1. Cephalexin
2. Keflex
3. Clindamycin ( lots of GI side effects)
118
If a patient has a allergy to PCN can they still receive cephalosporins?
Yes, if their reaction is not Ige mediated.
119
Cephalosporins overview
- Pregnancy category B they are safe
1. Most start with Ceph or Cef examples; Cephalexin (Keflex), Cefdinir (Omnicef)
2. Treatment for; Infected post-op wounds, Otitis media ( if the patient has had ABX in the last month, treatment for sinusitis if first line has failed, skin complaints.
- Cephalexin & Keflex is used for above the waist skin complaints.
3. Ceftriaxone (Rocephin) IM is used to treat Gonorrhea.
120
Macrolides Overview
- Pregnancy category B they are safe
All the MYCIN'S (Azithromycin, erythromycin)
* MACROLIDE = Mycin
* Always remember just because one macrolide causes n/v does not mean they are will. These are known for GI side effects. Its not a allergy
- MACROLIDES are 1st line treatment for
1. Pneumonia if they met the correct criteria
2. They can also be used for group A strep, but not first line.
121
Pregnancy category B
1. PCN
2. Cephalosporins
3. Macrolides
122
Pregnancy category C
Sulfonamides
Fluoroquinolones
123
Sulfonamides (Trimethoprim/sulfamethoxazole) AKA Bactrim
* Can be used to treat UTIS
- Bactrim is commonly used for uncomplicated UTI's.
* Also is ok to use in other below the waist skin complaints such as purulent cellulitis
*** They need to be educated BIG BIG BIG WARNING if that develop a rash to let us know, because of Stevens Johnson syndrome. ***
124
Stevens Johnson syndrome
Starts with flu like symptoms and turns into a rash and goes into blisters, the entire top layer is being peeled off and shedded, its very painful and can be dangerous.
125
Sulfa allergy what can you not take
Bactrim
126
Tetracyclines
- Cycline
** Examples: Doxy,
* Not pregnancy safe
* Side effects N/V/D and photosensitivity!!! WEAR SUNSCREEN
* Can be used to treat
1. Pneumonia ( if they meet criteria)
2. Rocky mountain/ Lyme disease
3. Purulent Cellulitis
4. Chlamydia= Doxy
127
Chlamydia & Gonorrhea
*** We do not CO-treat these still according to the CDC we only treat if they tested positive.
1. Chlamydia= doxy is now 1st line
2. If your patients has Chlamydia & Gonorrhea= Doxy for the Chlamydia, and they will need the IM Rocephin for the Gonorrhea.
128
Tetracyclines and children
when they are given to children we need to educate the parents about teeth staining.
129
Fluoroquinolones
- Floxacin's
** Examples: Ciprofloxacin, Levofloxacin (Levaquin)
****HEEL PAIN REPORT ASAP****
*** This is HEAVY duty ABX ( we save this til we really really need it)
* Pregnancy category C
** 1st line in
- UTI's Cipro 1st line
- Pneumonia if they meet the criteria like asthma, copd, heart failure, or other co-morbidities or have been treated in the last
- Travler's diarrhea
- Diverticulitis
- Chronic prostatitis
130
What blood pressures would be considered stage 2 hypertension according to the AHA/ACC guidelines?
According to the AHA/ACC (American Heart Association and American College of Cardiology) guidelines,.a blood pressure of 120-129/<80 mmHg would be considered an elevated blood pressure. Stage 1 hypertension is a blood pressure of 130-139/80-89 mmHg and we would initiate antihypertensives if the patient's ASCVD risk score was 10% or greater. Stage 2 hypertension is a systolic pressure ≥140 or a diastolic pressure >90 mmHg. The goal blood pressure is <130/80 mmHg with the AHA/ACC guidelines.
131
What would the nurse practitioner expect to see on an EKG that reveals atrial fibrillation?
The EKG of patients with atrial fibrillation will reveal absent P waves and will be irregularly irregular, or have variable intervals between QRS complexes. With atrial fibrillation, QRS complexes are narrow rather than wide. If an EKG reveals P waves embedded in the QRS complexes, the likely diagnosis is supraventricular tachycardia (SVT) while inverted T waves usually indicates ischemia.
132
What is the criteria for metabolic syndrome? Select all that apply by choosing two of the following answer choices.
1. Diagnostic criteria for metabolic syndrome includes the following: Waist circumference greater than 35 inches in women and 40 inches in men.
2. Triglycerides greater than 150 mg/dL, HDL less than 50 mg/dL in women and 40 mg/dL in men.
3. Blood pressure greater than 130/85 mmHg and fasting blood sugar greater than 110 mg/dL.
***A patient must meet three or more of the criteria to be diagnosed with metabolic syndrome.
133
signs of diabetic retinopathy on the physical exam
neovascularization and microaneurysms
134
Addison’s disease symptoms
fatigue, weight loss, nausea, vomiting, abdominal pain, myalgia, hypotension, and hyperpigmentation.
135
Addison’s disease overview. Everything is low except K+.
Addison’s disease, is in charge of producing cortisol and aldosterone. Aldosterone then regulates sodium retention and potassium excretion in the body. When this system is impaired in Addison’s disease, it results in electrolyte abnormalities including
** hyperkalemia (normal K+ 3.6- 5.2)
** hyponatremia ( Normal 135-145)
136
Hyperparathyroidism presenting signs
Abdominal pain, nausea, vomiting, fatigue, confusion, muscle weakness, and bone pain
137
Presentations of iron deficiency anemia
138
When assessing peripheral neuropathy in a diabetic patient, which of the following tests would be the most appropriate to perform
Monofilament test
139
The nurse practitioner has elicited a positive Chvostek’s sign by tapping the face near the ear where the facial nerve runs.
A positive sign is when the patient elicits facial twitching and is indicative of hypocalcemia.
140
Systemic lupus erythematosus (SLE)
malar rash, arthritis in two or more joints, photosensitivity, nasal/oral ulcerations, serositis, renal disorders, neurological disorders, immunological disorders (platelet count <100,000/m), cardio-pulmonary involvement and a positive antinuclear antibody test.
141
Flagyl
Used to treat
- Trich
- BV
-Diverticulitis
- Giardia
142
what is the big thing you need to educate with Flagyl
DO NOT DRINK CAN CAUSE A RASH
143
CLINDAMYCIN
USED TO TREAT PURULENT CELLULITIS
*** AT RISK FOR FATAL COLTIS
** CAN CAUSE C DIFF SUPERINFECTION
144
NITROFURANTOIN (MACROBID)
This is first line treatment for UTI ( so is bactrim and Cipro)
145
Vanco
* current 1st line for C-Diff
* treatment in MRSA
146
Vancomycin Side effects
* Ototoxicity
* nephrotoxicity
* RED MAN SYNDROME
147
Rifapin
Turns pee red and all other secretions
liver toxicity monitor LFT
148
What ABX are used to treat purulent cellulitis
B= Bactrim
C= Clindamycin
D= Doxy
149
Mechanism of action for this medication?empagliflozin (Jardiance) f
This class blocks glucose reabsorption by the kidneys and therefore increases glucosuria
150
PCOS increases risk for many complications,
Infertility, type 2 diabetes, ovarian, and endometrial cancer, coronary heart disease,
nonalcoholic fatty liver disease, and central obesity.
151
What can Radioactive iodine lead to
1. swollen salivary glands
2. bone marrow suppression
3. infertility
152
Sulfonylureas
Sulfonylureas such as Glipizide cause weight gain due to the increase in insulin levels throughout the body. In addition, the weight gain associated with thiazolidinediones is largely due to fluid retention.
153
Metformin work by
This medication decreases gluconeogenesis and decreases insulin resistance
154
Left ventricular hypertrophy and uncontrolled hypertension often-times lead to what heart sound
s4
155
Pantoprazole (Protonix) and omeprazole (Prilosec)
Are the most common PPI
156
Ulcerative Colitis
Ulcerative colitis (UC) is an inflammatory bowel disease that affects only the colon. Patients will present with bloody diarrhea, often with mucus. Abdominal pain, weight loss, and fatigue are all common symptoms of UC as well. Another key clue in this question is her history of ankylosing spondylitis - this condition is found in 15-40% of patients with UC.
157
Gastroenteritis signs and symptoms
Nausea, vomiting, and stomach pain
158
Treatment for Gastroenteritis
Bland diet, increased water intake, and Zofran (Ondanestron)
159
Crohn's disease
* Type of inflammatory bowel disease
* *skip lesions** This is a KNOW NAME FOR THIS
* Other common signs can include watery diarrhea with or without blood and mucus, weight loss, fever, and fistulas.
160
AHA/ACC guidelines these are more strict
* Normal l120/80 or less
* Elevated 120-129 greater than 80
- Treatment for them will be life style modifications
Stage 1: 130-139/ 80-89
- Assess ASCVD risk to determine whether to start medications or not.
- stage 1is all about ASCVD risk
Example 118/86 they are stage 1 HTN because the diastolic blood pressure
Stage2: > 140 or > 90
- Start meds no matter what
****GOAL BLOOD PRESSURE ONCE WE ARE TREATING HTN LESS THAN 130/80****
161
Go to meds for HTN
Ace, ARBS, CCBs, and Thiazides
162
Ace-I (Prils)
* Dry, hacking cough
* Possible angioedema
* Risk for hyperkalemia same with ARBS
* May see a slight worsening in kidney function initially.
* Discontinue
- GFR drops > 30% or below 30
- Cr increases > 30%
* This ARE NOT GIVEN TO PREGNANT WOMEN
** These are renal protective
** We need to monitor renal function closely
163
Thiazide diuretics
*** Preferred in Black patients
*** May increase three things
1. Uric acid
2. Triglycerides
3. Glucose
*** Do not use in patients with GFR less than 30
***This med is good for patients with osteoporosis messes with the calcium in the urine.
164
CCB
*** Preferred in black patients
Calcium channel blockers have two classes
1. Dihydropyridines (Pine) endings
- Ex: Amlodipine (Norvasc)
2. Non- dihydropyridines NEVER GIVE TO A PATIENT WITH HEART FAILURE!!!!!
-Verapamil (Verelan)
- Diltiazem (Cardizem)
***Main S/E; Edema/Headache
** Really should avoid in a patient with history of GERD because of vasodilation it can make things worse.
***
165
Complications of HTN
***Microvascular (if diabetes is present)
1. Retinopathy
2. Neuropathy
3. Nephropathy
*** Macrovascular "big things"
1. MI
2. Stroke
3. Heart failure
166
Fundoscopic exam with HTN
***Papilledema send them to out big concern
*** AV nicking
*** Copper wire arteries
these can be reversed with BP control
167
How often should renal function be checked in a patient with HTN
Annually if they have issues more.
168
Hypertension highlights
*** Stage 1 or greater, start meds with ASCVD risk > 10% so if we have a pressure of 131/79 and their risk is 10% or greater you will go ahead and start treatment with lifestyle modifications.
*** HTN is one of the leading causes of CKD
169
Uncomplicated cases of Salmonella
Treatment will be symptomatic as the infection is typically self-limiting and only lasts about four days on average.
170
How long can Proton pump inhibitors (PPIs) be used
short-term treatment for 4-8 weeks.
171
Long term effects of Proton pump inhibitors (PPIs)
PPI’s can lead to osteoporosis, clostridium difficile, and vitamin B12 deficiency when used long term. If problems persist past 8 weeks of PPI use, the patient should be referred to gastroenterology for further evaluation.
172
If a patient has a history of osteoporosis what would be the best treatment in GERD
H2 blocker if they have tried TUMS, because PPI increase the chances of osteoporosis
173
Pain in the left upper quadrant
pancreas, and even the stomach are what is in the LUQ, and this patient is likely experiencing pancreatitis. To help heal the pancreas, eating non-fatty foods, and sometimes even a clear liquid diet, is prescribed.
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Cullen’s sign and Turner’s sign
Cullen’s sign is identified as bluish discoloration around the umbilicus of a patient, while Turner’s sign is bluish discoloration along the flank. Both signs are indicative of possible intra-abdominal bleeding which can be seen with conditions such as necrotizing pancreatitis, ruptured ectopic pregnancy, etc. The patient may be tender to palpation, but it is not a distinguishing factor. If either or both of these signs are noted by the provider, the patient needs to be immediately referred to the ED for further evaluation.
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What is the best way to confirm acute appendicitis
CT scan
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What is considered a “red flag” for colorectal cancer
*** A new onset of ribbon-like stool
** Red or dark blood in the stool, loss of appetite, weight loss, and fatigue. Bright red blood with anal pain upon defecation can be due to anal fissures or hemorrhoids.
***
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Which of the following signs may be present when a patient has acute appendicitis
1. Obturator sign is positive if inward rotation or flexion of the right hip causes RLQ pain.
2. Rovsing’s sign is positive if palpation of the LLQ causes the patient pain in the RLQ.
3. Psoas/iliopsoas sign is positive if there is RLQ pain when the patient is supine and raises their right leg against resistance applied by the provider.
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Where do the majority of colon cancer cases or colon polyps occur
Descending colon
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H. Pylori in a patient who has recently took a PPI would best be done by what means?
Fecal antigen. Given the recent PPI use, the fecal antigen is the best option at this time. The urea breath test may not be accurate if a proton pump inhibitor (PPI) such as omeprazole (Prilosec) has been used within the last couple weeks.
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Ulcerative colitis
Affects only the colon
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What is an early sign of a bowel obstruction
*** High pitched bowel sounds
*** Side note about later stages. In later stages, the bowel sounds dissipate altogether. Severe abdominal pain and bilious vomit are also more likely to be seen in the later stages as the obstruction progresses.
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The nurse practitioner is reviewing the lab results of a patient who has been on famotidine (Pepcid) for eight weeks. Which abnormal lab results are likely caused by daily use of this medication?
1: Decreased liver function tests (LFT)
2: Decreased platelet count
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We suspect our patient has cholecystitis, what sign will sign will we use
Murphy’s sign
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sign used to evaluate a possible appendicitis
COME BACK TO THIS ONE AND ADD THEM ALL IN ON HERE.!!!
Blumberg sign is also used to evaluate a possible appendicitis. This is also known as rebound tenderness and is done by deeply palpating the abdomen and assessing if the patient experiences pain upon releasing your hand.
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McMurray’s test
diagnose a meniscus injury.
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Bacterial vaginosis
** Clue cells are a hallmark sign of BV, or bacterial vaginosis. Along with the milky white discharge, this is a classic presentation. BV is not contagious, and is treated with oral Flagyl twice a day x 7 days. Only the patient will need to be treated, not her partner. She should be educated to not douche as this is a high risk factor for BV.
** grey, thin, “fishy” smelling vaginal discharge
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Trichomoniasis
**** A strawberry cervix,which presents as an erythematous cervix with hemorrhages, is a hallmark finding of trichomoniasis.
*** wet mount that shows mobile trichomonads that move with help of flagella is a positive test for trichomoniasis
*** Partners should also be treated as trichomoniasis is a sexually transmitted infection.
*** Classic symptoms that occur with trichomoniasis include lower abdominal pain, green-yellow, frothy, and malodorous discharge, and pain and itching around the vagina.
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HPV testing age
Routine HPv testing begins at age 21 in the presence of an abnormal pap-smear.
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Chlamydia is left untreated, which of the following may occur
Correct Answer 1: Pelvic Inflammatory Disease (PID)
Correct Answer 2: Ectopic Pregnancy
Correct Answer 3: Urethral strictures
Correct Answer 4: Infertility
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saw palmetto
Saw palmetto is an herbal supplement used by patients who have benign prostatic hyperplasia (BPH)
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Chlamydia.
*** Nucleic acid amplification test (NAAT)
*** Chlamydia is typically treated with 1g oral azithromycin, without co-treatment for gonorrhea. Another treatment option for chlamydia is 100mg doxycycline twice a day for 7 days.
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Report notes that there are atypical squamous cells and can not exclude high-grade squamous intraepithelial cells (ASC-H).
Refer for colposcopy
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Cipro
Fluoroquinolones have a black box warning for achilles tendon rupture.
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A middle aged patient presents to the clinic for a follow up after requiring lithotripsy for several kidney stones. When reviewing the report from the urologist, it is noted that the patient had stones composed of calcium oxalate specifically. Which of the following foods should the patient be educated to avoid to ideally
check_boxChocolate
check_boxSpinach
check_boxRhubarb
check_boxTangerines
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A middle aged patient presents to the clinic for a follow up after requiring lithotripsy for several kidney stones. When reviewing the report from the urologist, it is noted that the patient had stones composed of calcium oxalate specifically. Which of the following foods should the patient be educated to avoid to ideally
check_boxChocolate
check_boxSpinach
check_boxRhubarb
check_boxTangerines
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What lab is not a part of a routine urinalysis with microscopic exam
***Bacteria culture
A complete urinalysis (UA) consists of a gross evaluation, dipstick analysis and a microscopic examination of urine sediment. A UA can be used to screen
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Epididymitis.
The key findings here are the positive Phren’s sign and the unilateral, swollen scrotum. For patients under 35, doxycycline is the drug of choice. For patients over 35, we choose ciprofloxacin.
*** A positive Prehn’s sign is associated with epididymitis.
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vulvovaginal candidiasis infection
Vulvovaginal candidiasis, commonly referred to as a yeast infection, is one of the most common causes of vaginal irritation and discharge. It can be identified by pseudohyphae, spores, and bud cells present on a wet mount. Patients also commonly describe a chunky white vaginal discharge and intense itching.
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Nucleic acid amplification test (NAAT) is the test of choice for what stds.
chlamydia and gonorrhea
200
If a patient has a UTI and its needing ABX, but she is on warfarin what ABX should we not give
Bactrim (Trimethoprim/Sulfamethoxazole). Sulfamethoxazole is a competitive inhibitor of the CYP2C9 enzyme which is responsible for metabolizing warfarin. Therefore, in those taking warfarin, we want to avoid bactrim as it can cause delayed metabolism of the warfarin, increasing the risk of bleeding in the patient.
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testicular cancer
*** males 15-35 years old
*** presents as a singular sided “heaviness.”
*** solid mass
*********** need for referral.******
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Leading bacteria in UTI's
Escherichia coli
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A patient presents with severe colicky flank pain
This patient is suffering from nephrolithiasis, or a renal calculi. This is most commonly caused by a buildup of calcium oxalate, and occurs most frequently in males.
*** Acyclovir (Zovirax) as herpes simplex suppressive treatment puts the patient at a higher risk of this.
**Most stones pass within 48 hours
*** This patient should hydrate well, can take NSAIDs for pain, and should strain his urine to try and catch the stone.
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What finding is consistent with benign prostatic hyperplasia
A prostate with BPH typically feels enlarged, symmetrical, smooth, and rubbery
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In a patient with prostatitis
In a patient with prostatitis, the provider would feel a warm, tender, swollen, and boggy prostate.
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Possible prostate Cancer
If a provider felt an asymmetrical firm, fixed painless nodule, they should suspect possible prostate cancer.
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A complicated UTI at 28 weeks
a complicated urinary tract infection (UTI). At 28 weeks along, she is now in the third trimester making cephalexin (Keflex) the most appropriate and safe choice
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How to diagnosis syphilis
Rapid plasma reagin test
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Important teaching on PAP
The transformation zone is the most common place for abnormal cells to develop in the cervix. The transformation zone consists of both squamous epithelial cells as well as endocervical cells. Obtaining an adequate sample from this zone is critical as otherwise possible precancerous or cancerous cells may be inadvertently missed.
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Normal Vaginal PH
Vaginal pH level is usually between 3.8 and 4.5, which is moderately acidic. The pH level can vary depending on your age and health. In some cases, changes to pH may indicate an underlying health condition, such as a vaginal infection.
***A high vaginal pH level — above 4.5 — provides the perfect environment for unhealthy bacteria to grow. Having a high vaginal pH puts you at risk for these infections:
*** BV and Trich is with a high PH which is acidic
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Alpha blockers
Alpha blockers, like terazosin, cause vasodilation. Because of this, they can cause a massive drop in blood pressure, and dizziness for patients - especially during the first dose. It is important to educate patients on this risk and have them take their medication before bedtime to avoid any complications from dizziness.
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What serologic test is used to initially screen a patient for syphilis
Rapid plasma reagin (RPR)
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what in a patient patient’s past medical history is considered a risk factor for this type of cancer
Cryptorchidism puts you at a high risk for testicular cancer
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Chronic kidney disease (CKD)
1. Stage I has a GFR still >90 mL/min, but there is kidney damage.
2. Stage II is 60-89mL/min
3. Stage III is GFR of 30-59 mL/min
4. Stage IV is 15-29 mL/min
5. Stage V, or end stage, is a GFR < 15mL/min
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The glomerular filtration rate (GFR) as a patient ages
The glomerular filtration rate (GFR) decreases as patients age as well as in kidney disease or failure. The GFR and creatinine usually have an inverse relationship. Therefore, as a patient develops kidney disease, their creatinine will rise.
216
Gonorrhea
Treat with 500 mg intramuscular ceftriaxone (Rocephin) today and bring back in 3 months to retest
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Hordeolum AKA stye
* Rim of the eyelid
* Small
* Acute
* Rim of the eyelid
SYMPTOMS
Painful bump on the eyelid
Swollen eyelid
Redness, swelling, and tenderness of the eyelid
Sensitivity to light
Visible pus at the centre of the lump
A scratchy feeling in the eye
The feeling of something in the eye
Crusting along the affected eyelid
More tears than usual
CAUSES
it develops when Zeis glands (oil glands at the eyelash follicle) become infected.
The infection is usually caused by a bacteria called Staphylococcus aureus.
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Chalazion
* The conjunctival side, where meibomian glands are located
* Large
* Chronic
* A slow-growing lump
SYMPTOMS
Painless bump on the eyelid
Swollen eyelid
Blurry vision
Redness and swelling on the bump
Mild irritation, causing the eyes to water
CAUSES
It develops when the meibomian glands (oil glands in the eyelid) become clogged. These glands keep the eye moist. When blocked, these glands start retaining oil. Eventually, the fluid drains and a hard lump develops on the eyelid.
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Actinic keratosis
Actinic keratosis is considered the most common precancerous lesion of squamous cell carcinoma in older adults. Actinic keratosis is a rough, scaly patch on the skin that develops from years of exposure to the sun. It is most commonly found on the face, lips, ears, back of the hands, forearms, scalp, or neck
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Senile actinic keratosis.
Senile purpura presents as bright, purple-colored patches located on the forearms and hands and are benign. Lentigines, also known as “liver spots,” are brown-colored macules located on the hands and forearms of older adults and are benign.
221
Seborrheic keratoses
Seborrheic keratoses are soft, wartlike benign lesions that frequently appear on the back and trunk of older adults.
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Erysipelas
Erysipelas is a subtype of cellulitis involving the upper dermis and superficial lymphatics. It is distinguished by well-demarcated borders, marked erythema, and warmth. It occurs commonly in the face.
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Rosacea
Rosacea is a common skin condition that causes redness and visible blood vessels on the face. It may also produce small, red, pus-filled bumps.
224
Tinea unguium is also known as
(onychomycosis)
225
Tinea unguium (onychomycosis) is a fungal infection
is a fungal infection of the nails, usually the great toe
226
First line treatment for Tinea unguium (onychomycosis) is
oral terbinafine (Lamisil) for 12 weeks
227
When should a patient diagnosed with a carbuncle return for a follow-up visit
Within 48 hours
228
Treatment for a Carbuncle
The patient should be treated with doxycycline or minocycline PO BID × 10 days or clindamycin TID to QID for 10 days if methicillin-resistant Staphylococcus aureus (MRSA) is suspected. The patient should return within 48 hours, as there is usually improvement within 48 to 72 hours after starting antibiotics.
229
Bowen’s disease is
squamous cell cancer (SCC) of the epidermis that has not invaded the dermis yet
230
Bowen’s disease (squamous cell cancer (SCC) ) best treatment is
Radiation therapy
Curettage and electrodessication
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a chronic inflammatory disease of the cheeks, chin, and nose, with dry, reddened eyes
Acne rosacea
232
Rule of 9s for burn fix this one .
The calculation is based on the rule of nines for the body surface of an adult: 9% for each arm and the head, and 18% for each leg, anterior trunk, or posterior trunk. For children, it is 9% for each arm, 14% for each leg, and 18% for anterior trunk or posterior trunk.
232
Acrochordons
Also known as a skin tag.
232
Cherry angiomas
A cherry angioma is a smooth, cherry-red bump on the skin. Although cherry angiomas usually appear on the trunk of the body, they can occur nearly anywhere. The cause of cherry angiomas is malformed arterioles in the skin, and the growths usually appear on people over the age of 40
232
Tinea cruris
Also known as jock itch, typically in the groin area.
232
Condylomata lata
secondary syphilis with infectious white papules in the vulvar area that look like white warts (condylomata lata). Condylomata lata may be skin-colored, white, pink, or yellowish. Additional data for secondary syphilis diagnosis includes alopecia, lymphadenopathy, maculopapular rash on the soles of the feet, and a rapid plasma reagin result of 1:8 (normal = 1:1).
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Roseola infantum (exanthema subitum)
Roseola infantum is a common viral rash that is caused by the human herpesvirus. The most common ages of onset are between 6 months and 2 years. The rashes are maculopapular (small, round, pink colored) rashes that first appear on the trunk and then spread to the extremities.
232
Lanugo in a older child happens because of why?
The appearance of fine, downy body hair should be documented as lanugo, commonly associated with anorexia nervosa.
232
infection with the eggs of parasites (worms) that are commonly found in the intestines of dogs and cats
Larva migrans
232
Pityriasis versicolor
Used to be known as tinea versicolor, is a fungal infection caused by a type of yeast that is normally present on the skin but has grown out of control. Pityriasis versicolor is diagnosed by clinical appearance and a sample of the skin scrapings placed on a KOH wet mount, which reveal short hyphae and budding cells.
232
Condyloma acuminata
anogenital warts, may present as single lesions or in groups. They range from skin-colored to erythematous to brown and may be flat, dome-shaped, cauliflower-like, or plaque-like. They are typically asymptomatic.
233
Examination reveals lesions that are raised and have a silvery-white appearance. When the nurse practitioner palpates the lesion, a small piece falls off, and some bleeding is noted. What is this finding called?
Auspitz sign
234
In the adult population, which secondary skin lesion is commonly seen in patients with chronic atopic dermatitis?
Lichenification
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Hypertrophic scar
These present as erythematous and glossy areas of induration. They may be painful or pruritic. Hypertrophic scars may develop at sites of recent lacerations, burns, surgical wounds, vaccination sites, or insect bites. They do not grow past the margins of the original injury. Hypertrophic scars can be linear or diffuse in shape. They develop within a few weeks of injury, rapidly grow for 3–6 months, and then plateau and regress in size. Conservative management is recommended, as is first-line treatment for hypertrophic scars, including corticosteroid tape, plasters, and injections. Hypertrophic scar development can be prevented with timely wound healing. Patients should be instructed to avoid activities that stretch a new scar, as this leads to inflammation and scar tissue growth.
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Atrophic scars
often develop secondary to acne vulgaris and appear indented.
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keloid
A keloid (C) has a similar presentation to a hypertrophic scar but invades healthy tissue outside of the original injury site
