NR511 Final Exam Study Guide: Fully Updated

NR511 Final Exam Study Guide Fully Updated Topics: o Common M/S disorders o Common spine disorders o Metabolic disorders o Endocrine disorders o Wounds, lacerations & bites o Common hematological disorders o Common male GU disorders o Testicular disorders Chapters + lectures: Wk 5: o Chapter 52: Common Musculoskeletal Complaints o Chapter 53: Spinal Disorders o Chapter 54: Soft-Tissue Disorders o Lectures o Hollier o DE Wk6: o Chapter 57: Glandular Disorders (p. 880-897 only) o Chapter 59: Metabolic Disorders o Chapter 73: Common Injuries (p. only) table 73.1 o Review thyroid lecture again o Lectures o Hollier o DE Wk7: 3 o Chapter 46: Nocturia in Men (p. 682) & Testicular Pain (p. 685) o Chapter 49: Prostate Disorders o Chapter 50: Penile & Testicular Disorders o Chapter 61: Hematological Disorders o Lectures o Hollier o DE Completion of study guide: IIII 1. Signs and symptoms and management of musculoskeletal sprains/strains/dislocations Signs and symptoms and management of musculoskeletalsprains/strains/dislocations Sprains: stretching or tearing of ligaments that occurs when a joint isforced beyond its normal anatomical range First degree-stretching of ligamentousfibers Second degree- partial tear of part of the ligament with pain and swelling Third degree- complete ligamentous separation Sprain- sudden injury or fall that caused acute pain and swelling that got worse over a few hours, redness and bruising, active and passive ROM decreased. Radiography to rule out fx. Strain: muscle injury caused by excessive tensile stress placed on a muscle that results in stiffness and decreased function -effects muscle or tendon that connects a muscle to a bone, complain of “pulled muscle,” severe cases cause inflammation,swelling, weakness and loss of function-surgery may be needed Management: PRICE (protect,rest, ice, compression, elevation), limitation of activity, physical 4 therapy, NSAIDS, referral to ortho Dislocation- complete separation of 2 bones that form a joint Very painful and cause immobility, need immediate medical attention Referral to orthopedicsfor possible surgery or reduction with application of cast or splint. four cardinal signs of inflammation (erythema, warmth, pain, or swelling) -SPEW 2. Signs and symptoms and management of spinal disorders (spondylosis, stenosis, etc.) Cervical Spondylosis- neck stiffness, mild aching discomfort with activity. Pain and limited ROM occur with lateral rotation and lateral flexion of the neck toward the affected side. Weakness shoulder abduction- C5. Bicep weakness- C6. Tricep weakness-C7.Myelopathy- leg weakness, gait disturbance, balance problems, difficulty performing fine motor tasks, loss of bowel and bladder. Treatment- cervical traction, PT, pain relievers. Surgery for Myelopathy. Low back pain-Tenderness and decreased range of motion. Positive straight leg test. TreatmentNSAIDS, muscle relaxants, opioids, surgical, self-care, spinal manipulation Stenosis-pseudoclaudication causing radicular pain in the calves, buttocks, and upper thighs of one or both legs. Symptoms progress from a proximal to distal direction. Walking or prolonged standing causes pain and weakness in buttocks and legs. Stooping over helps relieve pain. Positive Romberg. Reflexes diminished. With bowel or bladdersymptoms,sphincter tone may be decreased Management-surgical decompression. NSAIDS, folic acid, vitamin b12. PT-flexing the spine.Bicycling. Intermittent use of NSAIDs may be helpful, as well as folic acid or vitamin B12 supplementation in some cases depending on results of laboratory tests. Management revolves around physical therapy or an exercise program that focuses on flexing the spine. Flexion of the spine increases intraspinal volume. Bicycling is one exercise that is done with the spine in flexion. Improving abdominal muscle tone lifts the pelvis anteriorly and flexesthe lumbar spine. Reduction of intra-abdominal fat is critical to achieving the objective. 5 Thus, weight loss may be pivotal. Lumbar flexion exercises increase spinal canal volume. Examples include exercise on all fours, arching the back, or in the fetal position. Exercises that extend the spine should be avoided (swayback). 3. Recognition and immediate management of cauda equina syndrome Immediate management of cauda equina syndrome. (P. 829) Cauda equina syndrome is a medical EMERGENCY and requires immediate decompression. If Cauda equina is confirmed, surgical lumbar decompression is necessary to halt neurological deterioration unless surgery is contraindicated for other medical reasons. *Rational on Davis Edge question: Low back pain accompanied by acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, loss of sensation in the buttocks and perineum, and motor weakness in the lower extremities is a red flag for cauda equina syndrome or severe neurologic compromise. Perianal numbness. Cauda equina compression is characterized by bilateral lower extremity weakness, anesthesia, or paresthesia of the perineum and buttocks (saddle anesthesia). There may or may not be bowel or bladder incontinence or bladder retention. When there is neurologic deficit affecting the bowel or bladder, these changes may not be reversed with surgical decompression, 4. Maneuvers and expected findings with joint pain (knee,shoulder, wrist, etc.) Neck pain-Spurling’s. Shoulder pain-Apley scratch test(reaching the scapula). Internal and external flexion. Internal and external abduction. Pain with abduction= early supraspinatus tendinitis and subacromial bursitis=early rotator cuff injuries. Wrist and hand-allen’s test= radial and ulnar arteries. Phalens test=median nerve compression. Tinel’s sign assess for compression neuropathy – tapping over nerve. Finkelsteinstest- de Quervains disease. Thumb between finger and point. Knee Pain= Mcmurray, apprehension sign, bulge sign, inspect/palpate to assess effusion. Lachman, drawer sign – ACL, Thumb test - PCL MCL, LCL test are valgus and varus Tennis elbow cup coffee cup sign CTS-NSAIDs not effective 6 Achillies rupture – Thompson test 5. Initial assessment of FOOSH injury in correlation to anatomical location of radial head bone Lisa Callahan FOOSH - Falling On an Out Stretched Hand. After falling on an outstretched hand patients present after trauma with pain and swelling in the distal forearm or wrist. Numbness may be present if the medial nerve is affected. The mechanism of injury will often provide important clues to the diagnosis. The examination begins with gentle palpation to locate the area of point tenderness and includes a thorough neurovascular assessment. A radiograph of the wrist (including an oblique view) may be necessary to rule out fracture. Common fractures are the Colles fracture of the distal radius and the navicular (scaphoid) fracture of the anatomical snuffbox. It is not unusual to have a navicular fracture missed on radiography, so an orthopedic referral should be provided when the presenting complaint is pain and trauma to the soft-tissue area of the anatomical snuffbox. Scaphoid injury. 6. Assessment and management of Myofascial pain Trigger points within a muscle. Common cause of nonarticular rheumatic pain. Injections at the trigger point with saline, an anesthetic, or corticosteroid, dry needling, muscle relaxant tizanidine, NSAIDS, or cyclooxygenases-2 inhibitors. Tricyclic antidepressants. 7. Health promotion activitiesto preventsport related musculoskeletal injuries Protection may refer to preventing the injury from occurring or making it less severe by wearing protective gear, such as helmets, wrist pads, and kneepads. Maintain adequate hydration and proper diet while playing sports. Stretch before the activity. Stop when you are injured, do not “tough it out”. 8. Osteopenia Osteopenia: • Osteopenia Isthe precursor to osteoporosis. Osteopenia is categorized by the level of Tscores in relation to the results of a dual-energy x-ray absorptiometry scan or (DXA Scan), which measures the mineral content of bone. A T-score ranging from -1 to -2.5 would be classified as osteopenia. Pathophysiology: • It occurs secondary to uncoupling of osteoclast-osteoblast activity, resulting in a quantitative decrease in bone mass. Peak bone mass is typically achieved by males and females just prior to, or early-on in the 3rd decade of life. • Beyond age 30, bone resorption gradually becomes favored as dynamic bone remodeling continues into later decades of life. • Histologic specimens demonstrate markedly thinned trabeculae, decreased osteon size, and enlarged haversian and marrow spaces. 7 Osteopenia Prevention: • Certain habits can accelerate the process such as: o Smoking – prevents calcium uptake o Not getting enough calcium and vitamin D o Drinking too much ETOH o Use of certain medications(i.e.: corticosteroids and anticonvulsants) o Not getting enough weight-bearing exercise (at least 30 mins on most days). If your feet touch the ground during an exercise, it’s probably weight bearing. Running and walking are weight bearing. Swimming and biking are not – non-weight bearing o Falls • Women are more likely to have low bone density than men, but it’s no longer viewed as solely a women’s condition. • Approx. a third of white and Asian men over age 50 are affected. • Percentagesfor Hispanics (23%) and blacks (19%) are lower, but stillsizable. Current National Osteoporosis Foundation (NOF) recommendstesting for: • Women 65 and older • Postmenopausal women younger than 65 who have one or more risk factors, which include being thin • Postmenopausal women who have had a fracture • For men: testing is done more on a case-by-case basis. Osteopenia Treatment: Can be treated with exercise and nutrition or with medications. • If T-score is under -2, need to ensure you are doing regular weight-bearing exercise, and getting enough vitamin D and dietary calcium. • If T-score is closer to -2.5, a medication may be considered to keep bones strong. • Bisphosphonates are most commonly prescribed medication classfor treatment to prevent/reduce reabsorption of bone. Prolonged use has been linked with 2 major clinical side effects: osteonecrosis of the jaw (ONJ) 8 and the atypical subtrochanteric femur fracture. DE quiz question. • ONJ is rare and is associated with IV forms and not oral forms of the medication. Tx entails immediately stopping the offending agent. • Atypical femur fractures also are rare but have significant associated morbidity, and clinicians are cautioned against the chronic, uninterrupted bisphosphonate use beyond 3 to 5 years or in situations when pts report mild thigh discomfort while undergoing tx. • The core treatment options for osteopenic patients involve early education on how to achieve and maintain healthy bone mass levels and extensive education and counseling on the relevant social, environmental, and lifestyle risk factors that compromise bone health. General consensus favors pharmacologic treatment in a patient with spine or hip fractures in addition to a documented low BMD. Treatment recommendations vary for other nonvertebral fractures and include the following: • The National Osteoporosis Society (NOS) recommends starting treatment in all postmenopausal women with a history of any fragility fracture • The National Osteoporosis Foundation (NOF) recommends performing DXA scans on patients sustaining nonvertebral fragility fractures, and the decision to treat or not with pharmacotherapy is based on the patient’st-score; patients considered to be osteopenic (tscore between -1 and -2.5) are not started on drugs. Pharmacotherapy agents work through either anti-resorptive or anabolic means. Bisphosphonates are the most commonly prescribed medication class. These drugs are divided into non-nitrogen and nitrogen-containing compounds. The latter are considered first-line therapy. The nitrogen-containing compounds inhibit farnesyl pyrophosphate synthase and ultimately inhibit osteoclast resorption and induce osteocyte apoptosis. Common agents include: • Alendronate may reduce the rate of hip, spine, and wrist fractures by 50% • Risedronate may reduce vertebral and nonvertebral fractures by 40% over three years • IV zoledronic acid reduces the rate of spine fractures by 70% and hip fractures by 40% over three years Other Medication Classes • Conjugated estrogen-progestin hormone replacement (HRT) • Estrogen-only replacement (ERT) 9 • Salmon calcitonin (Miacalcin, Fortical) • Selective estrogen receptor modulators (Raloxifene) - Raloxifene is an agonist to estrogen receptors on bone and reduces osteoclast resorption • Anabolic (Teriparatide) - Teriparatide is a recombinant form of parathyroid hormone (PTH) that stimulates osteoblasts to produce more bone. Teriparatide is now FDA approved for osteoporosis treatment in males and females • RANKL inhibitors (Denosumab) - Denosumab is a monoclonal Ig2 that targets RANKL and inhibits its ability to bind to RANK and results in the inhibition of osteoclast activation • The t-score is measured in standard deviations and reflectsthe difference between the patient's measured BMD and the mean value of BMD in healthy, young, matched controls (30- year-old women). By definition, a normal BMD measurement is within one standard deviation of the young adult mean. The WHO defines t-scores between -1 and -2.5 as osteopenic and scores below -2.5 as osteoporotic. Greater than -2.5 means osteoporosis. The z-score is also measured in standard deviations, but the z-score is compared to a healthy, age-matched control group. The z-score is most clinically relevant when obtaining a DXA scan in younger patients when secondary osteoporosis is being considered. A z-score less than -1.5 warrants a comprehensive secondary osteoporosis workup. • Standard laboratory workup includes checking calcium, phosphorus, albumin, alkaline phosphatase, liver function tests, creatinine (serum and urine), 25 hydroxyvitamin D, TSH and free T4, and intact PTH levels. Males should have a free testosterone level checked to rule out hypogonadism. • The WHO created a fracture risk assessment tool (FRAX score) to predict the 10-year risk of sustaining a hip or other major osteoporotic fracture. These other major fragility fractures include fractures of the spine, wrist, forearm, or humerus. The assessment includes 12 questions weighted by the relative risk associated with a future fragility fracture event. Assessment includes age, sex, personal history of fracture, low BMI, oral steroid use, secondary osteoporosis, parental history of hip fracture, smoking status and alcohol intake. In addition, optional BMD measurement values can be included from a prior DXA scan (if available) to 10 provide a more comprehensive score report. Obesity is a predisposing factor, asis osteoporosis 9. Assessment and management of gout Persons from the United States, the Pacific Islands, and countries with abundant lifestyles have an increased incidence of gout. Gout is more prevalent in African American men. The increased incidence of gout in older adults has been associated with an increased use of diuretics – HCTZ DEQ. Patients with gout may experience an acute attack with rapid fluctuations of serum urate levels. Surgery, dehydration, binge alcohol consumption, emotional stress, infections, diuretics, and uricosuric drugs can all cause rapid fluctuations in serum urate levels. Causes of primary gout include idiopathic inborn errors of purine metabolism, decreased renal clearance of uric acid, and specific enzymatic defects such those resulting in Lesch-Nyhan syndrome and glycogen storage disease. Secondary causes of gout include other disease processes and medications, such as thiazide diuretics, that result in an overproduction or underexcretion of uric acid. The patient will present during an acute attack with pain, tenderness, erythema, and swelling of the affected joints. the joint most frequently affected is the first metatarsophalangeal joint of the great (big) toe; however, the midfoot, knees, fingers, wrists, and elbows may also be affected. The typical presentation is excruciating pain that awakens the patient at night. Patients often describe the pain as throbbing, crushing, and pulsating. The pain is not relieved by rest or positional changes and prevents weight-bearing on the affected limb. Often the patient cannot tolerate anything coming in contact with the affected joint—even bed clothing touching the limb can be extremely painful. The clinical presentation and medical history findings are often sufficient to diagnose gout. A definitive diagnosis is only made with identification of sodium urate crystals in the aspirated fluid from affected joints. The goals of clinical management are to terminate an acute attack, prevent future attacks, normalize hyperuricemia, and prevent potential complications of urate deposits. Management of gout includes pharmacological treatment of acute attacks and longterm medical and pharmacological treatment of hyperuricemia. Acute management of gout includes generalized rest, elevation and immobilization of affected joints, and pharmacological