NR569 Midterm Exam (100 out of 100) Questions and Verified Solutions (Latest Update)

  NR569 Midterm Exam (100 out of 100) Questions and Verified Solutions (Latest Update) Evidence based decisions based on four cardinal elements 1-the research evidence 2-the patients clinical state 3-the patient's preference 4-the clinician's judgement and expertise Which study design will provide the most powerful results, and is the gold standard for determining the effect of a therapeutic intervention? Randomized controlled trial (RCT) PICOT format P - Identify the population or problem (age, gender, ethnicity, disease/disorder) I - Intervention, or range of interventions of interest (therapy or diagnostic test in question) C - What will you compare the intervention against? (no disease, absence of risk factors, placebo or no intervention) O - Outcome of interest (risk of disease, rates of occurrence of adverse outcomes, accuracy of diagnosis) T - Time it takes for intervention to achieve the outcome (selected to observe the population or problem/condition) What stimulates the chemoreceptor trigger zone and causes vomiting Chemical stimuli from the circulation that crosses the blood brain barrier, which includes: -Certain drugs -Uremia -DKA -Toxins derived from gram-positive bacteria Causes of acute nausea and vomiting Acute infection (esp GI) Ingestion of toxins G.I. obstruction or ischemia New medication Pregnancy Head trauma/increased ICP Causes of chronic nausea and vomiting Defined as the persistence of symptoms for more than one month Partial mechanical obstruction Intracranial pathology Dysmotility, such as gastroparesis Metabolic or endocrine etiology Psychological disturbance Patients with a pyloric, peptic ulcer or psychogenic vomiting, may present with vomiting when? During or soon after a meal Patience with a gastric outlet obstruction as a diabetic or post vagotomy gastroparesis are more likely to experience... Delayed vomiting of more than one hour after eating Old food in the vomitus may suggest Gastro paresis Gastric outlet Proximal small bowel obstruction Bilious vomit indicates Patency between the stomach and the proximal duodenum ematogenic drugs Opiates Chemo Antibiotics General anesthesia Symptoms of Cardiac etiology in presence of nausea Diaphoresis Dyspnea Changes in HR Changes in BP Hx cardiovascular risk factors If the symptoms I had a fortune to the clinical scenario, or unusually prolonged, like Persistent N/V four days after general anesthesia for a non-abdominal surgery, what is indicated? Diagnostic evaluation beyond just supportive care Treatment goals of N/V -correction of fluid and electrolyte imbalance -identification of treatment of the underlying cause, if one exists -Relief of symptoms, either by suppression or by elimination, if the primary cause cannot be promptly identified and removed. Patients with long-standing, chronic nausea and vomiting, or risk for developing what? Malnutrition If a patient is not able to tolerate adequate oral caloric intake after five days, what should be considered? Enteral or parental feeding Enteral feeding is usually the first option however, dislodgment of enteral tube with acute vomiting is not uncommon and occasionally parental feeding may be required Two categories of anti-emetic agents Central anti-emetic agents Peripheral prokinetic agents Nausea medications for vestibular disease and motion sickness Antihistamines and antimuscarinic agents Abdominal pain without other symptoms or signs Rarely a serious problem Roth spots Round or oval hemmorhagic retinal lesions with small white centers petechiae a small red or purple spot caused by bleeding into the skin. Osler nodes painful erythematous nodules on the pads of the fingers and toes Splinter hemorrhages under nails erosive esophagitis -epigastric pain, difficulty swallowing, reflux, intermittent burning, regurgitation, substernal pain, typically some degree of dysphagia -can lead to esophageal bleeding and commonly associated with heavy alcohol use and NSAIDs. -Pts w/ esophagitis commonly have dysphagia -can be d/t prolonged GERD diagnosing erosive esophagitis definite diagnosis by endoscopy Main difference between gastritis and PUD Gastritis can progress to PUD when the inflammation of the stomach wall causes an irritation in the lining of the stomach. Irritation can lead to formation of an ulcer. Often preceded by H. pylori infection. Both diseases aggravated by NSAIDs and caffeine, and lessened by antacids. Given similarities in diseases, diagnostics needed to confirm if ulcer has formed. Diagnosing PUD Endoscopy Achalasia absence of peristalsis of the lower esophagus resulting in difficulty swallowing, regurgitation, and sometimes pain. Heartburn is a common symptom of this. Non-ulcer dyspepsia (functional dyspepsia) -symptoms of indigestion with no obvious cause Esophageal cancer malignant cells within the esophagus sx: heartburn, dysphagia Hiatal hernia prolapse of a portion of the stomach through the diaphragmatic esophageal hiatus. Most people asymptomatic - may have heartburn GERD treatment Lifestyle modification: -nonrestrictive clothing -weightless -symptom journaling -wait 3 hrs after meal to lay down -raise HOB 8 inches -avoid large fatty meals -dont eat before bed -avoid alcohol, caffeine, mint, chocolate, spicy food, acidic food, carbonated drinks. Pharmacological: -PPIs (front line and most commonly prescribed) Omeprazole, ianoprazole, esomeprazole Red flags for GERD -severe or persistent dyspepsia -dysphagia -unexplained wt loss -GI bleeding -persistent or protracted vomiting -severe coughing spells -palpable abdominal mass Atopic Dermatitis (Eczema) chronic inflammation of the skin; rash occurs in face, neck , elbows, knees, and upper trunk of the body along with itching dry skin scaly, patchy contact dermatitis irritated or allergic response of the skin that can lead to an acute or chronic inflammation Burning, pruritis Found in areas in contact with the irritant Pityriasis Rosea Presents with a herald patch, Christmas-tree pattern. Alarming signs that accompany abdominal pain Weight loss Gastrointestinal bleeding Anemia Fever Frequent nocturnal symptoms Onset of symptoms in patients older than 50 years old Types of lesions pathognomonic of infective endocarditis -Roth spots -Petechiae -Janeway lesions -Osler Nodes -Splinter hemorrhages under nails atopic dermatitis Dry skin Scaly, patchy Elbows, knees contact dermatitis Burning Pruritis Areas in contact with irritant Pityriasis Rosea -Raised truncal patch (Harold patch) -Scaly plaques or papules, Christmas tree shaped -Scattered on trunk and limbs herpes zoster -Painful -Fluid filled vesicles that crust over -Segmentary rash; does not cross midline of body; follows dermatome -often appears during times of low immunity or stress. Can also cause fever, headache, fatigue, and sensitivity to light. Psoriasis chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales Scabies -Pruritus worse at night -Small erythematous papules -Waist, web of fingers, buttocks -prefer warm moist areas such as skin folds Rosacea Chronic skin disorder of the face with red inflamed areas appearing mostly on the nose and cheeks Pityriasis rosea treatment Symptomatic treatment to reduce pruritus, fever, and discomfort associated with this condition: -Second generation antihistamines —Allegra, Zyrtec, Claritin, etc. -Acetaminophen -Natural sunlight exposure or phototherapy -Spontaneous resolution occurs within 6 to 12 weeks, occurrences are uncommon atopic dermatitis treatment Prevention and maintenance: -Reduce triggers if possible -Baseline therapy of dryness w/ emollients Pharmaceutical therapy: -Nonsteroidal or steroid topicals -Oral antihistamines -Avoid the use of systemic corticosteroids Patient education and counseling: -Treatment and prevention of xerosis: — avoid taking long, hot showers, and baths — use soap only in skin body folds (like axilla, buttocks, groin), otherwise avoid soap to other skin surfaces — after bathing, lightly path, a scam with a towel so that it remains damp, but not wet — apply lotion to damp skin Contact dermatitis treatment Treatment: -Identify the causative substance and eliminate exposure Pharmaceutical treatments: -Topical steroids, systemic antihistamines -Wet dressings or cloth soaked in burrows solution for relief of pruritus -systemic therapy with glucocorticoids indicated for severe cases, or for a rash on face or genitals Patient education/counseling: -Wear gloves or protective clothing in environments where exposure is possible -Wash area with soap and water and wash clothes that may be contaminated -Rash is not contagious (you cannot spread it to another area of the body or a person by touching the rash) -avoid scratching to prevent secondary bacterial infections Rhus dermatitis treatment Treatment: -Small topical areas respond well to low to medium potency topical steroids -Larger areas may require topical and systemic steroids tapered over 10 to 14 days Patient teaching: -The rash is not contagious. Touching the rash and touching elsewhere. Does not make it spread. The rash occurs only in areas where the oil of the Rhys plant, urushiol, comes into direct contact with the skin. Scabies treatment -Scabicide lotion or cream -bedding, clothing, and towels need to be treated -Washing hot water and dry and a hot dryer -Dry clean -Seal in a plastic bag for at least 72 hours -Family members may need to re-treatment Herpes labialis treatment Diagnosis can be made clinically through the history and physical, however, a viral culture can be done if needed for confirmation -Antivirals if initiated within 72 hours of the onset of symptoms can be beneficial — acyclovir, valacyclovir, famciclovir — viscous lidocaine may be used to reduce the pain associated with the lesion Can treat recurrent infections with varying strategies: -Chronic suppressive therapy -Topical anti-viral -Oral antiviral Janeway lesions nontender hemorrhagic lesions - fingers, toes, nose, earlobes - associated with endocarditis onychomycosis -fungal infection of the nail -May involve any component of the nail unit -Nail is usually yellow - white, with yellow streaks -Nail is thick and crumbling, and they separate from the nail bed -Rarely painful, but may interfere with standing and walking with disease progression -Long history, possibly in other nails -Assess occupational and environmental risk factors -Common in the elderly and immuno suppressed patients paronychia -Bacterial infection of the finger involving the lateral nail fold -If untreated can form an abscess between the nail plate and the nail folds, lifting the nail plate; infection and extends into the pulp space -acutely tender to touch -No systemic illness -Pain, erythema, and swelling -Inquire about occupational exposures -Inquire about a prior history of paronychia or MRSA risk factors -assess whether the patient bites the finger nails (oral Flora, anaerobes may be the source of infection) -commonly caused by an ingrown nail Treatment for paronychia Warm soaks (multiple throughout the day) -May resolve the condition initially, if no cellulitis or abscess antibiotics (keflex) -needed if cellulitis, but no abscess – need to cover Staph aureus, possibly MRSA I&D -if cellulitis and abscess Partial or full wedge resection -if ingrown nail, also, add antibiotics to cover staph aureus and maybe MRSA Treatment for onychomycosis Fungal culture Systemic treatment -typically required Topical treatment Direct microscopy -20% KOH prep -false negatives do exist Recurrence rate remains high, typically a long treatment process Intertriginous pertaining to a type of dermatitis occurring between folds or juxtaposed surfaces of skin and caused by sweat retention, moisture, warmth and concomitant growth of resident microbes Patient presents in the hospital with fever and rash must be divided into what two categories? Those who are critically ill and those who are not. Critically ill patients with rash often have a fulminant onset of both fever and rash. Causes of critically ill patients with fever and rash Hemorrhagic fever Meningococcemia Rocky mountain spotted fever Toxic shock syndrome Steven Johnson syndrome Toxic epidermal necrolysis Acute vasculitis Obtaining history for someone with a rash -Age of patient -season of the year -Location of onset of rash, and time sequence of progression -Secondary changes to the rash, possibly due to self treatments, such as lotions and over-the-counter ointments, or from excoriation or picking -If there are multiple lesions present, ask the patient to show you an area that looks like how the rash started or where there are any new lesions -systemic symptoms like fever, weight loss, lymphadenopathy, sore throat -Medication changes -Allergies -Personal and family history of rheumatological diseases -Social, travel, and exposure histories -Sexual history Leukopenia and rash Usually indicates viral illnesses including arboviral infections, Chikungunya virus, CMV, measles, dengue Eosinophilia and rash Suggests an allergic reaction or cholesterol emboli syndrome Herpes Zoster Treatment Prevention: -Vaccination for adults over 50 Antiviral therapy: -Oral famciclovir (Famvir) -Oral valacyclovir (Valtrex) -Oral acyclovir (Zovirax) Pain management: -Oral gabapentin -Oral pregabalin -Tricyclic antidepressant (doxepin, amitriptyline) -Topical capsaicin cream Characteristics of chronic vomiting Results in weight loss Sustained vomiting results in water, loss and electrolytes, leading to dehydration and hypokalemic metabolic alkalosis Metabolic and endocrine causes of nausea and vomiting Addison's Diabetes Hypercalcemia Hyperparathyroidism Hyperthyroidism Hyponatremia Hypoparathyroidism Pregnancy Uremia E/M Base on what things Physical exam MDM Patient history Time Leukocytosis with a typical lymphocytes is the hallmark of... Mononucleosis from EBV