NSG 555/ NSG555 Exam 2 V2 – Nurse Practitioners in Primary Care II Review| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

NSG 555/ NSG555 Exam 2 V2 – Nurse Practitioners in Primary Care II Review| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A Pulmonary Function Tests/Spirometry: What can cause it to vary? Age Sex Height Weight Pulmonary Function Tests/Spirometry: Used to evaluate Peop eval of lungs and pulmonary reserve response to bronchodilator therapy differentiate between restrictive and obstructive chronic pulmonary disease Determine capacity of lungs Inhalation allergy tests Pulmonary Function Tests/Spirometry: What tests do they include? Spirometry Airflow measurement Lung volume Lung capacity Forced Vital Capacity (FVC) Amount of air that can be forcefully expelled from a maximally inflated lung position. What does a reduced forced vital capacity suggest? Obstructive and restrictive pulmonary diseases. Forced expiratory volume in 1 second (FEV1) Volume of air expelled during the first second of FVC What are the findings of FEV1 in obstructive pulmonary disease? Airways are narrowed Resistance to flow is high Numbers of FEV1 are less than predicted because not so much air can be expelled in 1 second. FEV1: What are the findings in restrictive lung disease? Decreased because amount of air originally inhaled is low, instead of airway resistance. What is a normal FEV1/FVC ratio in restrictive lung disease? 80%. What is a normal FEV1/FVC ratio in obstructive lung disease? Less than 80% Under what condition will the FEV1 value reliably improve? With bronchodilator therapy with a spastic component to obstructive pulmonary disease exists. Normal results of Spirometry Greater than 80% of expected value Airflow rate: When is it considered diminished? Less than 60% of normal. What helps to increase airflow rate and by how much? 20% by with bronchodilator Diagnosis of COPD requires what? Demonstration of persistent airflow limitation based on spirometry testing. After bronchodilator, FEV1/FVC of less than 70%. Classification of COPD severity is based on what? Assessment of spirometry testing at regular intervals COPD Risk factors Smoking Pollution exposure Genetic predispostion How does COPD compare with asthma? Onset later in life. Slower progression of symptoms. Poorer response to inhaled therapy. Polysomnography Sleep study When is a polysomnography indicated? When any person: snores excessively Experiences narcolepsy Excessive daytime sleepiness Insomnia Motor spasms while sleeping Cardiac rhythm disturbances when sleeping. What does a polysomnography test most commonly diagnose? Sleep apnea 3 multiple choice options What is a actigraphy? A watch that can be worn a few nights at home What is a bronchoscopy used for? Performing diagnostic and therapeutic procedures What can you use a bronchoscopy for? Visualization of a tracheobronchial tree Transbronchial and Endobronchial biopsy Bronchoalveolar lavage Removal of foreign bodies Clots Mucus plugs Deployment of metallic stents. Aspiration of deep sputum Bleeding control What are some indications of bronchoscopy? hemoptysis malignancy interstitial lung disease pulmonary infections Pleural effusion Pleural Tap Thoracentesis and pleural fluid analysis Why would you use a pleural tap? To determine the cause of an unexplained pleural effusion To relieve the intrathoracic pressure that accumulates with a large volume of fluid and inhibits respiration. What are transudates most frequently caused by? Congestive heart failure Cirrhosis Nephrotic syndrome Hypoproteinemia What is the appearance of the transudates? Clear/serous, protein less than 3 What conditions are exudates most often found in? Inflammatory Infectious Neoplastic What is the appearance of exudates? Cloudy/turbid Increased WBC Protein more than 3 Low glucose pleural fluid/serum LCH more than 0.6 What is obtained before thoracentesis? Chest Xray Why is a chest xray obtained before thoracentesis? To ensure that the pleural fluid is mobile and accessible to a needle place in the pleural space. How do you diagnose Influenza? RNA/DNA PCR Antibody testing- front line testing Why is RNA/DNA PCR good to diagnose influenza? Because its very specific. What panel of testing is the RNA/DNA PCR test? Respiratory panel Why is an antibody test not as good as a PCR test for testing influenza? It is non-specific Pulmonary Embolus: Risk Factors: What are the weak risk factors for pulmonary embolus? Best Rest= more than 3 days Extended immobility (air travel of more than 8 hours) Increasing age (40 years) Laparoscopic surgery Obesity Pregnancy/antepartum Varicose Veins 2 multiple choice options Pulmonary Embolus: Risk Factors: How much bed rest is a risk factor? 3 days 3 multiple choice options Pulmonary Embolus: Risk Factors: How much immobility is a risk factor? 8 hours 3 multiple choice options Pulmonary Embolus: Risk Factors: What age is risk factor? 40+ years 3 multiple choice options Pulmonary Embolus: Risk Factors: What category is bed rest? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is extended mobility? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Increasing age? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Laparoscopic surgery? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Obesity? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is pregnancy/ antepartum? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Varicose veins? Weak 2 multiple choice options Pulmonary Embolus: Risk Factors: What are the odds of weak risk factors? Less than 2 3 multiple choice options Pulmonary Embolus: Risk Factors: What are the odds of medium risk factors? Less than 2 3 multiple choice options Pulmonary Embolus: Risk Factors: What are the medium risk factors? Arthroscopic knee surgery Central venous lines Chemotherapy Congestive heart or respiratory failure Hormone replacement therapy Oral contraceptive therapy Malignancy Pregnancy/Postpartum Previous VTE 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Arthroscopic knee surgery? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is central venous lines? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is chemotherapy? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is CHF or Respiratory Failure? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Hormone replacement therapy? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Oral contraceptive therapy? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is Malignancy? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is pregnancy/ postpartum? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What category is previous VTE? Medium 2 multiple choice options Pulmonary Embolus: Risk Factors: What are the odds of strong risk factors? More than 10 3 multiple choice options Pulmonary Embolus: Risk Factors: What are strong risk factors? Fracture hip or leg Hip or knee replacement Major general surgery Major trauma Spinal cord injury 2 multiple choice options Pulmonary Embolus: Signs and Symptoms? Chest pain SOB Feelings of doom Pleurodynia (pain w/ deep inhale) Tachycardia Hypoxemia S4 gallop What is Pleurodynia? Pain w/ deep inhale Pulmonary Embolus: What would the diagnostics show? Increased D-Dimer Decreased Fibrinogen V/P mismatch low PO2 and high/low PCO2 Reduce diffusion capacity Enlarged PA on CXR Increased alveolar dead space R Ventricular dysfunction S1Q3T3 on ECG Pulmonary artery emboli on CT Pulmonary Embolus: What would a D-dimer show? Increase 2 multiple choice options Pulmonary Embolus: What is the relation to fibrinogen? Decrease 2 multiple choice options Pulmonary Embolus: What would is V/P? Ventilation/Perfusion Scan 2 multiple choice options Pulmonary Embolus: Relation to PO2 and PCO2? low PO2 and low/high PCO2 3 multiple choice options Pulmonary Embolus: What is the relation to diffusion capacity? Reduced Pulmonary Embolus: What would the CXR show? Enlarged PA and increased alveolar dead space 3 multiple choice options Pulmonary Embolus: What would be the effect on the ventricles? R ventricular dysfunction 1 multiple choice option Pulmonary Embolus: What would the finding be on an ECG? S1Q3T3 Pulmonary Embolus: What would the CT show? Pulmonary artery emboli What category is a ventilation/perfusion scan? Nuclear medicine What is a ventilation/perfusion scan used for? Often used to detect PE For Pulmonary Embolus: What will the ventilation/perfusion scan show? V/P mismatch What is a CT scan used for Diagnosing and evaluating pathologic conditions What conditions is CT scan used for? Tumors Nodules Hematomas Parenchymal coin lesions Cysts Abscesses Pleural effusion Enlarged lymph nodes that affect the lungs and mediastinum Tumors and cysts of pleura Fractures of ribs When IV contrast is added, what can CT scan diagnose? Vascular structures are identified Aortic abnormality Vascular abnormality When Oral contrast is added, wat can CT scan daignose? Esophagus Upper gastrointestinal structures evaluated for tumor. What is the preferred study for pulmonary embolus? Spiral CT scan (CT pulmonary arteriography) 3 multiple choice options What is a Chest XR used for? ID and monitoring of: Tumors of the lung, heart, chest wall, and bony thorax Inflammation of lung, pleura, and paricardium Fluid accumulation in the pleura, pericardium and lung Air Accumulation in the lung and pleura Fractures of bones of the thorax or vertebrae Diaphragmatic hernia Heart size Calcification Location of centrally placed intravenous access devices Infection in lung CXR: What tumors are detected in the lungs? Primary and metastatic CXR: What tumors are detected in the heart? Myxoma CXR: What tumors are detected in the chest wall? Soft-tissue sarcomas CXR: What tumors are detected in the bony thorax? osteogenic sarcoma CXR: What inflammation are detected in the lung? Pneumonia CXR: What inflammation are detected in the pleura? Pleuritis CXR: What inflammation are detected in the pericardium? Pericarditis CXR: What fluid accumulation are detected in the pleura? Pleural effusion CXR: What fluid accumulation are detected in the pericardium? Pericardial effusion CXR: What fluid accumulation are detected in the lung? Pulmonary edema CXR: What air accumulation are detected in the lung? Chronic Obstructive Pulmonary Disease CXR: What air accumulation are detected in the pleura? Pneumothorax CXR: What can calcifications detected in the chest indicate? Large-vessel deterioration or old lung granulomas Histoplasmosis Fluoroscopy: What does fluoroscopy show? Motion Cytology Looks for malignant cells What replaced cytology? Biopsy When is cytology used? In patients w/ abnormal CXR, productive cough, and nothing visible on bronchoscopy. Culture: When is a culture used? In a patient with persistent cough, fever, hemoptysis, or chest xray picture compatible with pulmonary infection. What is ordered after a CXR shows a pulmonary infection? Culture What is a culture used to diagnose? Penumonia bronchiectasis bronchitis pulmonary abscess What can be cultured? Bacterium Fungus Virus What is normal BP? 120/80 What is elevated BP? Systolic: 120-129 Diastolic: Less than 80 What range is stage 1 hypertension? Systolic: 130-139 Diastolic: 80-89 What range is stage 2 hypertension? Systolic: 140+ Diastolic: 90+ What does a holter monitor do? Records a patient's heart rate and rhythm for 1+ days. Why would you order a holter monitor? For patients that experience syncope, palpitations, atypical chest pains, or unexplained dyspnea. What blood tests are used to assess risk for coronary vascular disease? Total Cholesterol High-Density Cholesterol Low-Density Cholesterol Triglycerides Apolipoprotein B Lipoprotein (a) Apolipoprotein E Genotyping Fibrinogen C-Reactive Protein Homocysteine Insulin, Fasting. Why would a lipid profile be ordered? To assess risk of coronary vascular disease What are predictors of heart disease? Lipoproteins When should blood levels be collected for lipid profile test? After a 12-14 hour fast 3 multiple choice options What is HDL Cholesterol? Good cholesterol What does HDL Cholesterol do? Removes cholesterol from the tissues and transports it to the liver for excretion. 1 multiple choice option What do High levels of HDLs indicate? Decreased risk of Coronary Heart Disease What is LDL cholesterol bad cholesterol What does LDL cholesterol do? Carries cholesterol and deposits it into the peripheral tissues. 1 multiple choice option What do high levels of LDL indicate? Increased risk of CHD Should you repeat Cholesterol tests? Yes Why repeat cholesterol tests? It varies and should be verified by repeat test What happens to triglycerides when levels are high? Transported by LDL/VLDL and are deposited in fatty tissue Total Cholesterol: Normal level Less than 200 2 multiple choice options Total Cholesterol: Borderline High level 200-239 2 multiple choice options Total Cholesterol: High level 240+ 2 multiple choice options LDL Cholesterol: Normal level Less than 130 2 multiple choice options LDL Cholesterol: Borderline High level 130-159 3 multiple choice options LDL Cholesterol: High level 160+ 2 multiple choice options HDL Cholesterol: Normal level 50+ 2 multiple choice options HDL Cholesterol: Borderline High level 40-49 3 multiple choice options HDL Cholesterol: High level 40 3 multiple choice options Triglycerides: Normal level 200 3 multiple choice options Triglycerides: Borderline High level 200-399 3 multiple choice options Triglycerides: High level 400+ 3 multiple choice options What is the Venous Doppler (Duplex) used for? To Detect DVT Why is the Venous Doppler called "duplex"? Combines the benefit of the Doppler with B-mode scanning What is the Venous Doppler (Duplex) not used for? Detection of venous occlusive disease of the lower calf What is better at detecting venous occlusive disease of the lower calf? Venography DVT (deep vein thrombosis) Formation of a blood clot in a deep vein. Where is DVT most common? Lower leg Thigh Pelvis Sometimes, Arm 3 multiple choice options What is the most serious complication of DVT? When part of the clot breaks off, travels through the blood stream to the lungs, causing a blockage What is blood clot in the lung called? Pulmonary embolism DVT: Risk Factors hospitalization recent surgery immobility older age obesity genetics malignancy estrogen-based medications pregnancy injury/trauma DVT: Symptoms Swelling (Usually unilaterally) Pain Tenderness Redness over affected area What is the standard diagnostic test for diagnosing DVT? Venous duplex ultrasound study. What tests can be used for diagnosing DVT, other than venous duplex? D-dimer MRI CT scan DVT: Treatment Anticoagulants Thrombolytics Inferior vena cava filters Eliminate causative factor Compression stockings Arterial Doppler: Single Mode: What is used for? Peripheral arteriosclerotic occlusive disease of the extremities. How can you get an accurate measurement of systolic pressure in the arteries of extremities? By slowly deflating blood pressure cuffs placed in calf and ankle and detecting the first evidence of blood flow with Doppler transducer. What can the Doppler ultrasound detector recognize? The swishing sound of even the most minimal blood flow. Where is systolic bp slightly higher? In arteries of the arms than in the legs. What is the difference in blood pressure exceeds 20mmHg? Occlusive disease is believed to exist immediately proximal to area tested. What can be assessed in the lower extremities with Doppler Ultrasound? Lower extremity arterial bypass graft patency How is Arterial Plethysmography performed? Performed by applying three blood pressure cuffs to proximal, middle, and distal parts of extremity. How does the ankle brachial index work? As the blood pressure cuff deflates, the blood pressure in arteries is recorded. BP in arm is also recorded. An ultrasound doppler device is utilized to amplify the sound of arterial blood flow in the brachial, dorsalis pedis, and posterior tibial pulses. What are the BP readings attached to? plethysmograph Plethysmograph: What does it do? Enables each pulse wave to be displayed. What indicates arterial occlusion? A reduction in amplitude of a pulse wave in any of the three cuffs. Where is the arterial occlusion if there is a reduction in amplitude in a cuff using the ABI? Immediately proximal to the to the area of the decreased amplitude. What difference in pressure indicates a degree of arterial occlusion in the extremity? 20 What does a positive result mean on an ABI? Reliable evidence of arteriosclerotic peripheral vascular occlusion. What does a negative result mean on an ABI? Unreliable. Does not definitely exclude diagnosis of arteriosclerotic peripheral vascular occlusion. ABI: When can an arterial plethysmography be performed in relation to s/sx of claudication? Performed immediately after exercise to determine is sx are caused by peripheral vascular occlusive disease. What are the tests to diagnose myocardial infarction? Creatinine Kinase Troponin Electrocardiography Define MI Damage to the cardiac muscle. Myocardial infarction: lab results Elevated cardiac troponin levels in the setting of acute ischemia. MI: Risk Factors Older age Male Gender Chronic renal disease Diabetes Mellitus Known Atherosclerotic Disease Fam Hx of Coronary Artery Disease Hyperlipidemia HTN MI: S/Sx Retrosternal chest pain Pain can radiate to arms, neck, and jaw Chest pressure Abdominal pain Dyspnea Nausea/Vomiting Sweating Syncope When do you use EKG for suspicion of MI? Within 10 minutes of presentation MI: With an EKG, what is being assessed? ST segment and T wave changes Development of pathologic Q waves New left bundle branch block MI: What is required to make an MI diagnosis? Elevated cardiac troponin MI: Cardiac Troponin: What are you looking for in MI? Elevated troponin level Watch for rise or fall of cardiac troponin One troponin value should be above 99th percentile of normal reference range Natriuretic Peptides: What is it used for? To identify and stratify patient with CHF What is the best marker of CHF? BNP Natriuretic Peptides: Neuroendocrine peptides: What do they do? Oppose the activity of the renin-angiotensin system What are Natriuretic peptides? They are released by the heart muscle to cause vasorelaxation, inhibition of aldosterone secretion from the adrenal gland and renin from the kidney. This increases natriuretic peptides and lowers blood volume. What is the expected finding of natriuretic peptides in CHF? Increased 2 multiple choice options Peripheral Vascular Disease (PAD/PVD): Causes Plaque buildup in the peripheral arteries that results in reduced blood flow to the legs. Where is the most common place for PVD/PAD to develop? The arteries of the lower extremities PAD: Risk Factors Smoking High Cholesterol Hypertension Diabetes Obesity Fam Hx of cardiac disease Poor eating patterns PAD: Symptoms Pale or Discolored extremities Cold extremities Leg weakness/numbness Pins and Needles in legs/feet Sores or wounds on lower extremities Lack of growth of toenails and leg hair What is the hallmark symptom of PAD? Intermittent claudication Intermittent Claudication Pain, aching, heaviness, or cramping in the legs with walking or climbing the stairs. Discomfort resolves with rest. Where does Intermittent Claudication most commonly occur? In the calves What is the first diagnostic test to diagnose PAD? Ankle-brachial index test What does the ankle-brachial index test compare? Compares blood pressure in the ankle with the blood pressure in the arm. In what position is the patient during the ankle branchial index test? Supine 3 multiple choice options What is a normal ABI? 1.00+ Ankle-Branchial Index: At what ABI level should you suspect PAD? 0.90 or less at rest What ABI level indicates severe PAD? 0.40 or less What are the treatments for PAD? Antiplatelet medications Statins Anti-HTN medications Angioplasty Arterial Bypass surgery Modification of risk factors PVD: s/x swelling of the legs or ankles pain that gets worse when you stand and gets better when raising legs. Leg cramps Aching, throbbing, or heaviness in legs Itchy legs Weak legs Thickening of skin on legs or ankles Skin that changes color, especially around ankles Leg ulcers Varicose veins a feeling of tightness in calves Echocardiogram: What is it used for? Evaluate heart wall motion and detect valvular disease. Evaluate the heart during stress testing Identify and quantify pericardial fluid Chest pain (In the ER) Echocardiogram: Why do you need to evaluate the heart wall motion? measure of heart wall function What is the echocardiogram used to diagnose? Pericardial effusion Valvular heart disease Subaortic Stenosis Myocardial wall abnormalities Infarction Aneurysm Cardiac Tumors Atrial and Ventricular septal defects Congenital Heart Disease Post-infarction mural thrombi What is another way to perform an echo? Transesophageal Echo: In what condition would to use a transesophageal echo? COPD Why would you use the transesophageal echo with COPD? Air gets in the way Cardiac Stress Test: What is it used for? Evaluate for: CAD in angina Intermittent claudication Treatment progress Safe exercise limits How can you stress the heart? Exercise Chemical Pacer What equipment is usually used for a cardiac stress test? EKG Heart Rate Blood pressure What can be used for cardiac stress test that isn't usually used? Echo Nuclear scan What is Arteriography/Venography? Injecting dye and taking x-rays to see vasculature What is the CT of abdomen and pelvis used for? Evaluating Abdominal organs and pelvis Guide needles during biopsy of tumor or aspiration of fluid Staging know neoplasms Monitor abdominal disease when serially or repeatedly performed. Diverticulosis small pouches form and push outward through weak spots in the wall of the colon. Which part of the colon is most commonly affected by diverticulosis? Sigmoid colon Diverticulitis When one or few of the pouches become inflamed. Diverticulitis: S/sx Severe pain LLQ Nausea/ Vomiting Constipation/Diarrhea Fever/Chills Diverticulitis: Diagnostic Tests CT scan of abdomen and pelvis Blood tests to rule out infection (CBC) Colonoscopy Lower GI series (Barium enema) Diverticulitis: Treatments High fiber diet/ Fiber supplements Probiotics Colon resection surgery, in severe cases Diverticulitis: What is the treatment if there is infection? Bowel Rest Liquid Diet Antibiotics Acute Pancreatitis Inflammation of the pancreas. Acute Pancreatitis: How does it occur in time and duration? Occurs suddenly and short-term How common is pancreatitis? 275,000 hospital stays a year Pancreatitis: Risk Factors Male gender African American race Fam Hx DM Elevated triglycerides Cystic Fibrosis Gallstones Obesity Alcohol abuse cigarette smoking Pancreatitis: s/sx Severe pain in the epigastric area of the abdomen Fever Nausea/ Vomiting Swollen or tender abdomen on palpation Tachycardia Pancreatitis: Where does the pain most often radiate? Back or LUQ Pancreatitis: Diagnostics: Blood Tests Amylase and Lipase (elevated) Lipid profile (elevated) Blood glucose (elevated due to impaired beta cell function CBC Pancreatitis: Diagnostics: Blood Tests: Why do a CBC? To assess for infectious processes? Pancreatitis: Diagnostics: Imaging Pancreatic and gallbladder ultrasound CT Scan Pancreatitis: Treatments Bowel Rest IV hydration Pain medicine Antibiotics Low fat diet Elimination/Treatment of risk factors or predisposing conditions Stool testing: How do you test for C-diff? PCR test C-Diff: Treatment Metronidazole Vancomycin What conditions would you do a stool culture, O & P? Diarrhea Fever Bloating When does normal stool flora become pathogenic? If bacterial overgrowth occurs as a result of antibiotics, immunosuppression, or excessive catharsis. Stool testing: Occult blood: What would you order this test? Screen for colorectal cancer What needs to be avoided for an occult blood test? Red meat must be avoided for 3 days Amylase + Lipase Testing: Indications? Pancreatic disorders. What is amylase testing most used for? Diagnosing Acute Pancreatitis, but not specific What does lipase show in pancreatitis? 5-10 times the normal limit Amylase Enzyme in saliva that breaks the chemical bonds in starches Lipase pancreatic enzyme necessary to digest fats What is included in the Comprehensive Metabolic Panel Albumin Blood Urea Nitrogen Calcium Carbon Dioxide Chloride Creatinine Glucose Potassium Sodium Total bilirubin and protein liver enzymes CMP: What are the pancreatic enzymes that are tested in CMP? Alanine aminotransferase Alkaline phosphatase Aspartate aminotransferase Endoscopic Retrograde Cholangiopancreatography Endoscopy that looks inside biliary ducts/gallbladder Endoscopic Retrograde Cholangiopancreatography: What is it used for? Evaluate the jaundiced pt Evaluate unexplained upper abdominal pain Pancreatitis Colonoscopy: Why use this test? For patients who had a change in bowel habits Blood in stool Abdominal pain Colonoscopy: When is it used as a surveillance tool? Patients with colorectal cancer Inflammatory bowel disease Polyposis How can you do a virtual colonoscopy? CT scan How much of the colon is examined by flexible sigmoidoscopy? Up to 60cm from anus At what age is it recommended for colorectal cancer? Start at 50 and continue to 75 Should to screen for colorectal cancer in pt's aged 76 to 85? Based on individual decision based on pt's state of health and screening hx. What tests are used to screen for early colorectal cancer? Fecal Occult Blood Testing Colonoscopy Flexible Sigmoidoscopy Fecal Immunochemical Test (FIT) Fecal Immunochemical Test + DNA (FIT-DNA) Colorectal cancer screening: How often?: Fecal Occult Blood Testing Annually Colorectal cancer screening: How often?: Colonoscopy every 10 years Colorectal cancer screening: How often?: Flexible Sigmoidoscopy every 5 years Colorectal cancer screening: How often?: FIT Annually Colorectal cancer screening: How often?: FIT-DNA every 1-3 years Upper endoscopy: What is it used for? To visualize the upper digestive system using a tiny camera attached to the end of a long, flexible tube. Collect biopsy of tissues in GI tract. Upper endoscopy: What conditions is it used to diagnose and/or treat? Conditions of: Esophagus Stomach Duodenum Upper endoscopy: What symptoms should it investigate? N/V Abd. pain dysphagia (Difficult swallowing) GI bleeding What procedures are done by upper endoscopy? Burning a blood vessel Widening a narrow esophagus Removing a polyp or foreign object Barium swallow X-ray Identifies swallowing/esophageal abnormalities Provides visualization of the lumen of the esophagus When is a Barium Swallow X-ray Indicated? For patients with dysphagia, noncardiac chest pain, painful swallowing, Swallowing abnormalities, GERD H. Pylori testing: When is it indicated? Patients that may have: Peptic ulcers Gastric MALT lymphoma Melena Hematemesis Weight loss Persistent vomiting Dysphagia Anemia H. Pylori: Why do a culture? Gives antibiotic sensitivities H. Pylori: How long does a culture take? 1 week H. Pylori: Biopsy Takes time, but identifies infection H. Pylori: Rapid Urease Testing. What is used and how long for results? Piece of gastric mucosa Results in 3 hours? H. Pylori: What is first-line testing for H. Pylori? Breath for urea because its reliable H. Pylori: what is the problem with breath for urea testing? It's expensive H. Pylori: Which test is the least sensitive? IgG or IgM serology H. Pylori: Stool testing: What is ELISA? Enzyme linked immunoassay H. Pylori: Stool testing: What is ELISA used for? To Monitor for eradication after treatments Cholecystitis: s/sx Pain with N/V after heavy meals Scleral icterus RUQ and epigastric tenderness to palpation (Murphy's sign) What is Scleral icterus? Yellowing of the eyes How does pancreatitis usually present? LUQ tenderness with or without epigastric pain How does cholecystitis usually present? RUQ tenderness with or without epigastric pain Differentiate between cholecystitis and pancreatitis as r/t pain? Pancreatitis is pain in LUQ, Cholecystitis is pain in RUQ 3 multiple choice options Which quadrant is the the gallbladder located? RUQ Pt has pain after heavy meals, and scleral icterus, what should you rule out? blockage in the common bile duct or pancreatic duct. How do you evaluate patency of bile and pancreatic duct? Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiopancreatography (ERCP): How does it work? Combines upper gastrointestinal endoscopy with x-rays to visualize and treat problems of the bile and pancreatic ducts. What are the liver enzyme tested for liver function? Alanine transaminase (ALT) Alkaline phosphate (ALP) Aspartate transaminase (AST) Albumin and Total protein Bilirubin Gamma-glutamyltransferase (GGT) L-lactate dehydrogenase (LD) Alanine transferase (ALT): Function helps break down proteins Alanine transferase (ALT): Location Liver Alanine transferase (ALT): What do high levels mean? Liver damage Alkaline Phosphatase (ALP): Location Liver, bile ducts, bone Alkaline Phosphatase (ALP): What do high levels mean? Liver damage/disease, a blocked bile duct, bone disease. Aspartate transaminase (AST): Location Liver Aspartate transaminase (AST): What do high levels mean? Liver damage or disease Albumin and total protein: What proteins does the liver make? Albumin and globulin Albumin and total protein: What level might mean damage or disease? Low What organ or system also makes globulin? Immune system 3 multiple choice options Bilirubin: Function Breaks down red blood cells What cleans bilirubin out of the body? Liver Bilirubin: What do high levels indicate? Liver damage Jaundice Gamma-Glutamyltransferase (GGT): What do high levels mean? Could point to liver or bile duct damage L-lactate dehydrogenase (LD): What do high levels mean? Liver damage. Other conditions. Where is Norepinephrine made in the brain? And what is its' function? Locus Cerulus(Brain stem, responsible for medicating SYMPATHETIC nervous system and stress responses) Hyperactivity of the norepinephrine system/increased locus cerulus system is common in those with anxiety. -Leads to hypervigilance, increased arousal, panic, and exaggerated stress responses. What is the main function of GABA? Primary function is inhibition at post synaptic neuron -Induces calmness, relaxation, big role in anxiety disorders -Acted directly on by BDZ and barbituates -Gaba_A and GABA_B What is agoraphobia and how is it treated? -Fear of public places; where escape or obtaining help may be difficult -Tx via CBT and SSRI GAD Tx? 1st Line - SSRI (Escitalopram, Paroxetine, Duloxetine) 2nd line - Buspar (Partial serotonin agonist at pre and post synapses) and SNRI (Venlafaxine) -Can consider short term course of BDZ Rx Panic attack initial treatment? Benzodiazepines Panic Disorder 1st and 2ndline tx? 1st line - SSRI or SNRI (Fluoxetine, Sertraline, or Venlafaxine) 2nd line - TCAs (Clomipramine, imipramine) Adjunct tx- Benzodiazepines, SHORT term only until other medications reach therapeutic efficacy, Alprazolam SPECIFICALLY is FDA approved) Social Phobia (Ex. performance Anxiety) Fear of scrutiny by others or fear of acting in a humiliating or embarrassing way -CBT 1st line - SSRI or SNRI Betablockers (Atenolol 50-100mg) and Propranolol (20-40mg one hour prior to performance or public speaking) - AVOID in patients with COPD due to bronchospasm risk -Benzodiazepines can be used scheduled or PRN Specific Phobia Rx - Fluvoxamine, Paroxetine, Sertraline, or Venlafaxine. (Hence SSRI or SNRI) CBT (Exposure type specifically) Obsessive compulsive disorder (OCD) Obsessions and/or compulsions that are time consuming, distressing and impairing 1st line - Fluvoxamine (50-300mg this one is FDA approved, with common side effects being N/V). Sertraline, Fluoxetine, 2nd line - SNRI (Venlafaxine), maybe TCA (Clomipramine, this is also approved for OCD treatment) -Can AUGMENT with atypical antipsychotic in severe cases. Panic attack treatment Use Benzodiazepine short term, in ADDITION to long term SSRI until the SSRI kicks in to bridge the gap. *Patients tend to discontinue SSRIs while taking benzodiazepines. Continuous education is REQUIRED to continue BOTH SSRI and Benzodiazepine UNTIL Benzodiazepine is tapered. -Taper Benzodiazepine by reducing ~10% weekly, can also switch to LONG acting Benzodiazepine from short acting to facilitate taper Most commonly prescribed Benzodiazepines? Alprazolam (short acting) Lorazepam (Intermediate acting) Benzodiazepines - MOA? Potentiates effects of GABA, enhances activity of GABA at GABA-A Receptor. -causes drowsiness, cognitive impairment, dampening of fear and anxiety, impaired balance, motor control, decrease muscle tone, impaired coordination, anterograde amnesia ELDERLY - Increases fall risk, hip fracture risk, and increases risk of dementia with chronic use. -Big potential for both abuse and addiction, patient can become physically dependent and build tolerance easily; used to treat akathisia -A known limitation of benzodiazepines are rebound insomnia. How to choose specific Benzodiazepine? Depends on desired time of onset, duration of action, and method of metabolism. Short - TOMA (Temazepam, Oxmazepam, midazolam, alprazolam) Intermediate - CETL "Settle" - Clonazepam, temazepam, estazolam, Lorazepam Long acting - DC^2F - Diazepam, Chlordiazepoxide, Clonazepam, Flurazepam Benzodiazepines, which are metabolized outside the liver? (And hence can be used in EtOH use disorder or liver failure?) LOT Lorazepam, Oxazepam, Temazepam) What are side effects of Benzodiazepines? Anticholinergic effects, such as Dry mouth, constipation, blurry vision, urinary retention, confusion, delirium, odd behaviors, hallucinations, day time somnolence, amnesia -Can also cause REBOUND insomnia What is Benzodiazepine withdrawal most like? Alcohol withdrawal Insomnia anxiety hand tremors irritability anorexia N/V Autonomic hyperactivity (Diaphoresis, tachycardia, HTN) Tonic-clonic seizures -Abrupt cessation after chronic use can be life threatening, requires both a PHYSICAL and behavioral taper. Taper ~10% of total dose per week, with common strategy being converting from short acting to long acting benzodiazepine for more comfortable taper Buspirone MOA? Onset? Partial 5HT_1A (Serotonin) agonist, causes neural adaptations at pre and post synapses resulting in decreased serotonergic activity -Slower onset, takes several weeks -Used in conjunction with SSRIs -LOW potential for abuse/addiction, dosed 2-3x daily. -NO PRN doses Endocrine conditions that mimic or exacerbate anxiety? (Endocrine) Hyper and hypo thyroidism Pheochromocytoma Cushings Dz. Addisons Dz Meno Pause DM Cardiovascular conditions that mimic/exacerbate anxiety? ACS Arrhythmia CHF HTN Mitral Valve Prolapse Neurologic conditions that mimic or exacerbate anxiety? Epilepsy Cerebrovascular Dz Meniere's Dz Multiple Sclerosis Migraine Encephalitis Early Dementia Metabolic Conditions that worsen or mimic anxiety? Porphyria DM Pulmonary conditions that mimic or worsen anxiety? Asthma COPD Pulmonary Embolism PNA PTSD - What is typically heightened? What parts of the brain? Definition? Development of multiple symptoms s/p exposure to one or more traumatic events (With threat of death, injury, violence) -Norepinephrine which is produced in the LC or Locus Cerulus is highly elevated, with these responses contributing to intrusive memories, significant hyperarousal and sleep disturbances that may culminate in night terrors or nightmares. -Hippocampus is embedded in TEMPORAL lobe - which has a major role in both learning and memory; heavily involved in encoding the time and place of a specific traumatic event. -The Amygdala(Fear center of brain) - has increased activity PTSD - How is this treated? 1st Line - SSRIs - Sertraline, Paroxetine, also celexa. (Think the P.S in PTSD, both paroxetine and sertraline are FDA approved) Also SNRI (Venlafaxine). For night terrors, hypervigilance and flashbacks - Use Prazosin which is an Alpha-1 receptor antagonist - Hence it is essential to monitor blood pressure with this medication -Can augment Tx with atypical antipsychotic in severe/treatment resistant cases. -CBC therapy, exposure therapy **AVOID BENZODIAZEPINES - There is a very high rate of substance use disorders and lack of efficacy; this ALSO interferes with psychological processes necessary to benefit from CBT DID - Dissociate Identity Disorder (Multiple personality disorder) Predominantly in victims of significant and chronic childhood trauma, patients with DID often cope with PTSD as well -Have more than one distinct personality state; due to fragmented sense of self -70%+ of patients attempt suicide with high frequency and self mutilate -Psychotherapy is standard treatment, with SSRIs to target comorbid depressive and PTSD symptoms Prazosin - Reduce nightmares (Again watch BP with this as it is Alpha 1 agonist) Naltrexone - Opioid antagonist that REDUCES self injurious behaviors -ECT is NOT contraindicated in DID, can be considered as a viable option in combination with psycho therapy as DID patients have depressive symptoms. Sleep onset medications? TEZ. T^2, E^2, Z. Temazepam, triazolam Eszopiclone Zolpidem Zaleplon Ramelton (MT1 MT2 antagonist, safe for elderly) Sleep Maintenance Rx? SEZTD (SEZ TD) Suvorexant (DORA) Eszopiclone Zolpidem CR Temazepam Doxepin (TCA) Narcolepsy definition? Etiology? Excessive daytime somnolence, falling asleep in inappropriate places -Characterized by cataplexy(Brief episodic loss of muscle tone) -Hallucinations/sleep paralysis at the beginning or end of sleep episodes are common -More common in male vs females -Etiology is loss of hypothalamic neurons that produce hypocretin Narcolepsy management and Pharmacologic tx? Non-Pharmacologic - Sleep hygiene, scheduled daytime naps, avoiding shift work Rx - Modafinil 1st line Tx. (Inhibits dopamine reuptake) -Can use ACTIVATING antidepressants that suppress REM - SSRI and SNRIs (D.A.V.F - Fluoxetine, Duloxetine, Atomoxetine, Venlafaxine) Treating Cataplexy in narcolepsy? Sodium oxybate (AKA GHB) - Avoid use with alcohol and other CNS depressants -Can also use TCAs (Imipramine, desipramine, clomipramine) -Can use ACTIVATING antidepressants that suppress REM - SSRI and SNRIs (D.A.V.F - Fluoxetine, Duloxetine, Atomoxetine, Venlafaxine) -Non-Benzodiazepines do NOT affect REM sleep Tolerance to OTC sedative/hypnotics, how quickly do they develop? They develop quickly, typically 1 week, and change sleep architecture; hence if they are not working quite quickly within a short period of time, it is efficacious and best to discontinue. Ramelteon MOA? Selective MT1 and MT2 (Melatonin Agonist) -Effective and safe sleep aid; there are NO issues with TOLERANCE and DEPENDENCY, so this is the safest sleep aide for the ELDERLY. Does NOT act on Benzodiazepine receptors, acts on melatonin receptors. Sleep apnea Tx Weight Loss Avoid EtOH CPAP Uvulopalatopharyngoplasty RLS - Restless leg syndrome definition and characteristics, risk factors? Urge to move legs with unpleasant sensation in legs; the unpleasant sensation is relieved with movement, aggravated with inactivity. -1.5-2x more likely in males -Occurs or worsens in the evening Risk factors - Age, Iron deficiency, ACTIVATING antidepressants(D.A.V.F, but Venlafaxine in particular), antipsychotics, dopamine blocking antiemetic (Promethazine, prochlorperazine, metoclopramide), antihistamines, strong familial(genetic) component RLS - Restless Leg Syndrome Treatment? Remove offending agent (Which can be activating antidepressants, antipsychotics, antihistamines, dopamine antagonizing antiemetics), Iron rerplacement 1st Line - Dopamine AGONIST - Pramipexole, Ropinirole. (P.R for RLS! Personal record). and Benzodiazepines. -Gabapentin (Careful with substance abuse patients, this has street value), Pregabalin -IF treatment refractory, try low potency opioids. Is Sedative/Hypnotic use SAFE in elderly patients? Use sleep hygiene as first line Tx, always. Sedatives and hypnotics are more likely to cause side effects such as memory impairment, ataxia, paradoxical excitement and rebound insomnia. If sleep medications must be used Trazodone and Ramelteon are safer options in depressed elderly patients. Anorexia Nervosa Characteristics Preoccupation with weight, body image and thinness. -TWO types, restricting type and binge eating/purging type -Intense FEAR of gaining weight or becoming fat -Restriction of calorie intake, low body weight Anorexia Nervosa Tx -CBT, family therapy -Can use SSRIs for COMORBID anxiety and depression -Can Tx preoccupation with and food with Olanzipine -Can use Premeal anxiolytic (Alprazolam) - to encourage eating by decreasing anticipatory anxiety **-Pharmacotherapy overall may NOT be a useful treatment modality for most anorexia nervosa patients Bulimia Nervosa Characteristics -Binge eating with behaviors intended to counteract weight gain (Vomiting, laxative use, enema/diuretics, fasting, excessive exercise) -Essentially, binging with counteracting compensatory behavior -Patients are typically embarrassed by their binge eating, and overly concerned with body weighty -Bodyweight is typically normal, or perhaps overweight Bulimia Nervosa Treatment -Antidepressant + Therapy 1st Line SSRI(Fluoxetine 60-80mg) FDA Approved Tx -Otherwise nutritional counseling and education binge eating disorder characteristics No fixation on body shape, body weight -Recurrent episodes of binge eating -NO COMPENSATORY BEHAVIORS (Such as vomiting, laxatives, excessive exercise) -Usually obese (Think the B in binge as in BIG) Treatment of Binge Eating Disorder 1st line - SSRI - Escitalopram Vyvanse - (FDA APPROVED, stimulant that suppresses appetite) Topamax - Causes weight loss Orlistat - Inhibits Lipase enzyme from pancreas, decreasing amount of fat absorbed from GI tract -Psychotherapy, CBT, IPT Bupropion in eating disorders Avoid use in ALL eating disorders as this lower seizure threshold! What class of medications can help reduce obsessions and fearful preoccupations associated with psychosomatic disorders? SSRIs for the comorbid anxiety and depression. Anything else psychotropic.