NURS 6531 Final Exam Study Guide, Adult Primary Care

NURS 6531 Final Exam Study Guide, Adult Primary Care 1.) Hydrocele (member did not use template, no review questions received-this is all I got) Definition: an accumulation of fluid within the tunica vaginalis surrounding the testicle; it may also result from a patent processus vaginalis at birth and sometimes closes spontaneously within the first 1 to 2 years of life. Hydroceles are the most common cause of painless scrotal swelling.; in adults they are often the result of trauma, a hernia, testicular tumor, or torsion or a complication of epididymitis. Presenting Symptoms: Usually painless and may be present for long periods, partially resolve, and recur before the patient seeks medical attention. Gradual enlargement of the scrotum occurs with marked edema, which may be uncomfortable because of the added weight. A hydrocele may occur secondary to a tumor when excess serous fluid accumulates in the scrotal sac. It will transluminate but may make testicular palpation difficult. Leik Review: Hydrocele more common in infants. Serous fluid collects inside the tunica vaginalis. During scrotal exam, hydroceles are located superiorly and anterior to the testes Most hydroceles are asymptomatic. Will glow with transillumination. If new-onset hydrocele in an adult or enlarging hydrocele, order scrotal ultrasound and refer to urologist. Differential Diagnoses: Epididymitis, Testicular torsion, epididymal cyst Review questions: 1. A patient who has had a swollen, nontender scrotum for one week is found to have a mass within the tunica vaginalis that transilluminates readily. The family nurse practitioner suspects: a.) a hydrocele. b.) a varicocele. c.) an indirect inguinal hernia. d.) carcinoma of the testis. 2.) Chronic Kidney failure: (member did not use template, no review questions received-this is all I got) Definition: The absence of kidney function. Kidney failure is also known as End Stage Kidney Disease. It is characterized by anuria and the need for renal replacement therapy or kidney transplant. The kidneys and urinary tract system no longer filter blood, create filtrate. Or excrete urine in amounts sufficient to clear waste and balance fluid intake with output. Key highlights: Proteinuria or hematuria, and /or a reduction in the glomerular filtration rate, for more than 3 months duration. The most common causes are diabetes mellitus and hypertension. Most people are asymptomatic and the diagnosis is determined only by laboratory studies. Differential diagnosis: obstructive uropathy, nephrotic syndrome, glomerulonephritis 3.) Acute tubular necrosis (member did not use template, no review questions received-this is all I got) Definition: reversible or irreversible type of renal failure caused by ischemic or toxic injury to renal tubular epithelial cells. The injury results in cell death or detachment from the basement membrane causing tubular dysfunction. A history of hypotension, fluid depletion, or exposure to nephrotic agents is usually present. In otherwise healthy individuals, when the underlying insult is corrected, the patient frequently has a good outcome with complete renal recovery. There is no specific therapy for acute tubular necrosis apart from supportive care. Differential diagnosis -Prerenal azotemia, intrinsic renal azotemia Treatment Options: There is no specific treatment apart from supportive care in maintaining volume status and controlling electrolyte and acid-base abnormalities. Nephrotoxins should be ceased or if this is not possible, dose should be decreased. Review questions: A client had excessive blood loss and prolonged hypotension during surgery. His postoperative urine output is sharply decreased, and his blood urea nitrogen (BUN) is elevated. The most likely cause for the change is acute: A) Prerenal inflammation Bladder outlet obstruction C) Tubular necrosis D) Intrarenal nephrotoxicity Which of the following is a sign or symptom of acute tubular necrosis (acute kidney injury)? answer-Thirst and increased rapid pulse symptoms of ATN can vary depending on severity. and one may have- problems waking up, feeling drowsy even during day time , feeling lethargic or physically drained, being excessively thirsty or experiencing dehydration, urinating very little or even not at all, retaining fluid or experiencing swelling in body, having episodes of confusion and experiencing nausea and vomit 4. Indirect inguinal hernia Definition: Indirect inguinal hernia – Indirect inguinal hernia is caused by a birth defect in the abdominal wall that is present at birth. A scrotal-inguinal hernia results when a segment of the bowel slips through the internal inguinal ring, where it may remain in the inguinal canal or pass into the scrotal sac. An inguinal hernia may occur as a result of a defect in the anterior abdominal wall or because of a patent process vaginalis. Inguinal hernias predominantly affect men (9:1) and have the highest incidence in men aged 40 to 59. A hernia may move freely between the abdomen and the scrotum or can be spontaneously reduced by digital manipulation. When a hernia becomes strangulated or is unreducible, this compromises the blood supply and requires emergent surgical reduction. Strangulation should be suspected when a tender mass is palpated in the scrotum in addition to redness, nausea, and vomiting Presenting Symptoms: Scrotal swelling, mild to moderate pain on straining, scrotal heaviness, and the possible presence of a bulge are common complaints. Increased edema after standing in an erect position but decreases when the patient is recumbent. 3 Differential Diagnoses: undescended testis, lymphadenopathy, femoral hernia Pattern Recognition: Enlarged hemiscrotum or a bulge in the groin area that may spontaneously reduce when the patient is supine or with manual reduction. The provider will not be able to move the fingers above the mass, which should be soft and mushy but painless unless it is incarcerated and ischemic. Scrotal hernias do not transilluminate. Auscultation of bowel sounds over the mass is significant for the diagnosis of bowel in the scrotal sac. Treatment options: If the herniated bowel is reducible, surgical referral for possible future repair is indicated. Difficulty in reducing a hernia is cause for urgent surgical intervention. However, pain may indicate incarceration of the bowel or complete inability to reduce the hernia, which is cause for immediate emergency department referral and surgical exploration. Review questions: 1. Mr. S. comes to you with scrotal pain. The examinations of his scrotum, penis, and rectum are normal. Which of the following conditions outside of the scrotum may present as scrotal pain? A. Inguinal herniation and peritonitis ** B. Renal colic and cardiac ischemia C. Pancreatitis and Crohn ’ s disease D. Polyarteritis nodosa and ulcerative colitis Rationale: Conditions outside of the scrotum that may present with scrotal pain are abdominal aortic aneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially in the age groups of the neonate and adolescents. 2. The most common type of hernia is a(n): A. indirect inguinal hernia. ** B. direct inguinal hernia. C. femoral hernia. D. umbilical hernia. Rationale: An indirect inguinal hernia is the most common type of hernia affecting all ages and both genders and accounts for 50% of hernias treated. The point of origin is above the inguinal ligament and often travels into the scrotum. A direct inguinal hernia is less common (accounts for about 25% of hernias seen) and usually occurs in men older than age 40. The point of origin is above the inguinal ligament and rarely travels into the scrotum. The femoral hernia is the least common (about 10% of hernias seen) and occurs more often in women than in men. The point of origin is below the inguinal ligament and never travels into the scrotum in men. An umbilical hernia occurs more frequently in infants and is a protrusion of part of the intestine at the umbilicus. 3. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that it is not painful, but it is annoying. You note that the origin of swelling is above the inguinal ligament directly behind and through the external ring. You diagnose this as a(n): A. indirect inguinal hernia. B. direct inguinal hernia. ** C. femoral hernia. D. strangulated hernia. Rationale: A direct inguinal hernia usually occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or chronic obstructive pulmonary disease (COPD). The origin of swelling is above the inguinal ligament directly behind and through the external ring. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 year of age and in men ages 16 – 25. The origin of swelling is above the inguinal ligament. The hernia sac enters the canal at the internal ring and exits at the external ring. A femoral hernia, which occurs more frequently in women, is acquired and results from an increase in abdominal pressure, as well as muscle weakness. The origin of swelling is below the inguinal ligament. Because Max is not having any pain and the condition has been this way for months, you know that the hernia is not strangulated. A strangulated hernia, which requires immediate referral to a surgeon, results in no blood supply to the affected bowel and causes nausea, vomiting, and tenderness. 5. Orchitis Definition: Orchitis is a systemic, blood-borne infection that results in an acute inflammation of one or both testicles. It may coexist with infections of the prostate and epididymis; causes – viral infection (ex. Mumps), C. trachomatis and N. gonorrhoeae in adolescents, E. coli – men, complication of syphilis, mycobacterial, fungal; hydrocele and scrotal wall thickening may be seen as a complication of mumps Presenting Symptoms: Gradual onset of acute or moderate pain, testicular swelling, and fever 3 Differential Diagnoses: epididymitis, testicular tumor, hernia, testicular torsion Pattern Recognition: Testicular edema may be so pronounced that it is difficult to distinguish the testes from the epididymis. Palpation may reveal swollen, very tense testes that are painful, and the patient may be febrile. Inflammation of the testis usually involves systemic viral infections (commonly mumps) and includes unilateral or bilateral erythema, edema, and scrotal tenderness, which occurs 4 to 7 days after initial fever. Treatment options: Anti-infective therapy is recommended, with guidance by local sensitivity reports. The following antibiotic regimens are effective against the most common causes of epididymitis: singledose ceftriaxone given intramuscularly (IM), 250 to 500 mg, and doxycycline, 100 mg twice daily for 10 days for men younger than 35 years; in men older than 35 years, levofloxacin (given intravenously [IV] or orally [PO]), 500 to 750 mg/day, or ciprofloxacin, 500 mg (IV or PO), for 10 to 14 days. Antipyretics should be used to reduce discomfort and fever, and an anti-inflammatory agent should be prescribed. An antiemetic can also be prescribed for nausea and vomiting. Bed rest and scrotal elevation are also recommended for epididymitis. Hot or cold compresses may be helpful for orchitis. Review questions: A 35 year old sexually active man presents with a 1 week history of fever and pain over the left scrotum. It is accompanied by frequency and dysuria. The scrotum is edematous and tender to touch. He denies flank pain, nausea, and vomiting. He reports that eh pain is lessend when he uses scrotal-support briefs. The urinalysis shows 2 + blood and a large number of leukocytes. What is the most likely diagnosis? A. Acute urinary tract infection B. Acute pyelonephritis C. Acute orthitis D. Acute epididymitis ** Orchitis is caused by which of the following? A. Mumps virus ** B. Measles virus C. Chlamydia trachomatis D. Chronic urinary tract infections that are not treated adequately A 10 year old boy complains of sudden onset of scrotal pain upon awakening that morning. He is also complaining of severe nausea and vomiting. During the physical examination, the nurse practitioner finds a tender, warm, and swollen left scrotum. The cremastic reflex is negative and the urine dipstick is negative for leukocytes, nitrites, and blood. The most likely diagnosis is: A. Acute epididymitis B. Severe salmonella infection C. Testicular torsion ** D. Acute orchitis What type of follow up should this patient receive? A. Refer to a urologist within 48 hours B. Refer him to the emergency department as soon as possible ** C. Prescribe ibuprofen (advil) 600 mg QID for pain D. Order a testicular ultrasound for further evaluation 6. Testicular torsion Definition: Testicular torsion - obstruction of blood flow to the testes because of a twisting of the arteries and veins in the spermatic cord resulting in occlusion of blood flow. Occurs in 12-18 year olds. Usually unilateral, effecting the left testis. Two types: extravaginal and intravaginal. Extravaginal (rare, seen in neonates)- twisting of the spermatic cord, testis, and process vaginalis; intravaginal (seen in adolescents)- failure of the testis to adhere to the scrotal wall, creating a “bell clapper deformity.” Different from torsion of the appendix testis. Presenting Symptoms: sudden in onset, extremely painful, and may awaken the patient from sleep or be trauma induced. Testicular pain, experience abdominal pain, nausea, and vomiting; 25% of patients have a fever. Clinical manifestations-testicle that rides high in the scrotum and an absent cremasteric reflex on examination 3 Differential Diagnoses: testicular appendix torsion, epididymitis, epididymo-orchitis, hydrocele Pattern Recognition: Most common in the left hemiscrotum. Scrotal edema and erythema may be seen. The affected side may have a higher position as a result of rotation. The spermatic cord is swollen and extremely tender, the epididymis may be felt anteriorly, and the majority of patients will have an absent cremasteric reflex. In some instances a small area of cyanosis (blue dot sign) may be present on the scrotal skin and indicates torsion of the appendix testis. Treatment options: Surgical consultation with surgical exploration – needs to occur in 6 hours. Review questions: 1. A 24-year-old man presents with sudden onset of left-sided scrotal pain. He reports having intermittent unilateral testicular pain in the past but not as severe as this current episode. Confirmation of testicular torsion would include all of the following findings except: A. unilateral loss of the cremasteric reflex. B. the affected testicle held higher in the scrotum. C.testicular swelling. D.relief of pain with scrotal elevation. ** 2. In assessing a man with testicular torsion, the NP is most likely to note: A.elevated PSA level. B. white blood cells reported in urinalysis. C. left testicle most often affected. ** D. increased testicular blood flow by color-flow Doppler ultrasound. 3. Anticipated organ survival exceeds 85% with testicular decompression within how many hours of torsion? A.1 B.6 ** C.16 D.24 4. To prevent a recurrence of testicular torsion, which of the following is recommended? A.use of a scrotal support B.avoidance of testicular trauma C.orchiopexy ** D.limiting the number of sexual partners 7. Epididymitis 1 Definition: Inflammation or infection of the epididymis. Commonly occurs in men younger than 35 yrs. of age with chlamydia as the cause. Men older than 35 yrs. is likely as a result of bacterial ascension from bladder or bacteria introduced during cauterization/surgery. Diagnostic test STD testing, urine culture and scrotal ultrasound R/O testicular torsion. 2 Presenting Symptoms: pain, dysuria, urgency/frequency, low back pain/perineal pain, fever/chills/malaise, scrotal edema 3 Differential Diagnoses: testicular torsion, inguinal hernia, hydrocele, testicular tumor, 4 Pattern Recognition: Enlarged, tender epididymis, Urethral discharge may be evident, Positive prehns sign, Normal cremasteric reflex R/O testicular torsion. 5 Treatment options: A Adult under 35yrs ceftriaxone 250mg IMx 1 PLUS Doxy 100mg BID a day or Azithromycin 1gm once. B Adult over 35 yrs Bactrim DS 1 tab BID a day x 10 days or cipro 250 mg BID x 10 days. C support/elevate scrotum D Analgesic NSIADs,ice(early),heat (late),bed rest. 6 Review questions: 1. Jordan appears with a rapid onset of unilateral scrotal pain radiating up to the groin and flank. You are trying to differentiate between epididymitis and testicular torsion. Which test to determine whether swelling is in the testis or the epididymis should be your first choice? A. X-ray B. Ultrasound C. Technetium scan D. Physical examination Answer B If your client has a rapid onset of unilateral scrotal pain radiating up to the groin and flank and you are trying to differentiate between epididymitis and testicular torsion, an ultrasound test is useful to determine whether the swelling is in the testis or the epididymis and should be your first choice. Initially, before the swelling has reached its peak, a physical examination will probably differentiate, but within a few hours, when the testis also swells, it may not be possible to differentiate between epididymis and testis by palpation. A reactive hydrocele may also develop. A technetium scan will show an increased uptake in the case of epididymitis and decreased uptake in the case of torsion, but the least invasive and most inexpensive test is an ultrasound. 2. The nurse practitioner recognizes that the most common cause of epididymitis in a young man is: A chlamydia B E. coli C mycoplasma D Proteus species Answer A Chlamydia is a sexually transmitted infection which is the leading cause for epididymitis and nongonococcal urethritis in men less than 35 years old. Symptoms of epididymitis include unilateral testicular pain and tenderness, hydrocele and palpable swelling of the epididymis 3. Your 25-year-old male patient has had a fever, dysuria, low back pain, and scrotal edema. Which of the following is likely the diagnosis? A acute bacteria prostatitis B acute pyelonephritis C epididymitis D urinary tract infection Answer C The combination of urinary tract infection symptoms and scrotal edema is often the case in epididymitis. Treatment for those aged < 35 years is ceftriaxone (Rocephin) or doxycycline because the most common causative agent is chlamydia. For those aged over 35 years, (Bactrim) Trimethoprim/sulfamethoxazole is the common treatment. The proper treatment for urinary tract infection, acute pyelonephritis, and acute bacterial prostatitis is trimethoprim/sulfamethoxazole (Bactrim); however, scrotal edema is not present in these differential diagnoses 8. Benign prostatic hyperplasia Definition: a non-cancerous enlargement of the prostate gland. Seen in 50% of men older than 50 and 90% alder than 80. BPH is related to elevations of androgen and estrogen that stimulate prostatic growth. Presenting Symptoms: Symptoms are develop gradually. Obstructive BPH: urinary hesitancy, decreased caliber and force of the stream, and post void dribbling related to bladder outlet obstruction. Irritative symptoms include frequency, urgency, and nocturia and occur as a result of decreased functional bladder capacity and instability of infection. Hematuria may be present. 3 Differential Diagnoses: Bladder Calculi, Uretheral Stricture, Cancer of the Prostate, Bladder neck contracture, and UTI, and Bladder cancer Pattern Recognition: UA should be ordered to exclude UTI. PSA is appropriate for men with a lifeexpectancy of more than 10 years in the presence of physical finding on DRE and if 5a-reductase inhibitor therapy (Proscar) is planned. DRE: Prostate that is enlarged but is symmetrical in texture and size (rubbery texture). Treatment options: Lifestyle changes may decrease symptoms such as reduction of caffeine and alcohol intact, avoiding fluids before bedtime, and avoidance of diuretic medications. Meds: 1. Alpha-adrenergic antagonist: (Terazosin, Tamsulosin, Doxazosin) relax smooth muscle in the bladder neck, prostate capsule, and prostatic urethra. Take at night. Watch for orthostatic hypotension. Tamsulosin may have less effect on BP than other alpha blockers. 2. 5-alpha-reductase inhibitors (blocks testosterone): Finasteride (Proscar): shrink the prostatic glandular hyperplasia by decreased tissue DHT levels, but it may take up to 6-12 months to see improvement in symptoms. 3. Phosphodiesterase-5 (PDE%): Sildenafil or Tadalafil: used for men with mild to moderate symptoms and erectile dysfunction 4. Saw Palmetto: herbal, may increase bleeding Balloon dilation: reduces symptoms in the short term TURP: effective for severe BPH, Gold standard treatment for bladder outlet obstruction, limited to prostates weighing less than 100g Review questions: 1. Which statement is true about the use of alpha blockers in the treatment of symptomatic BPH? They do not lower blood pressure in normotensive clients. 2. Milton, a 72 year old unmarried, sexually active white man presents to your clinic with complaints of hesitancy, urgency, and occasional uncontrolled dribbling. Although you suspect benign prostatic hypertrophy, what else should your differential diagnosis include? Urethral stricture (may develop as a result of sexually transmitted diseases and should be considered in a sexually active individual no matter what the age) 3. The action of a 5 alpha-reductace inhibitor in the treatment of BPH is to: reduce action of androgens in the prostate. 4. Harry has BPH and complains of some incontinence. Your first step in diagnosing overflow incontinence would be to order a: Post void residual urine measurement 5. Lower urinary tract symptoms in males can present as a constellation of storage or voiding symptoms. Storage symptoms include: urgency and nocturia 6. A 63-year-old man presents to you with hematuria, hesitancy, and dribbling. DRE reveals a moderately enlarged prostate that is smooth. The client’s PSA is 1.2. What is the most appropriate management strategy for you to follow at this time? Prescribe an alpha adrenergic blocker, which will relax bladder and prostate smooth muscle to improve flow and relieve symptoms. 7. In deciding whether to treat Morrison, who has BPH, you use the American Urological Association scale. No treatment is indicated if the AUA score is 7 or lower. 8. According to the AUA guideline on the management of BPH, when is referral for invasive surgery automatically warranted? With the presence of refractory retention and bladder stones. 9. What differentiates prostate cancer symptoms from BPH? Symptoms of prostate cancer in general tend to progress more rapidly than those of BPH. 9. Chronic prostatitis- Definition : Inflammatory infection of the prostate. Usually caused by gram negative bacteria like E. coli. nonbacterial prostatitis mostly in young men caused by chlamydia, mycoplasma, Gardnerella. Diagnostic test is urine culture. Presenting Symptoms: fever /chills, low back pain, dysuria, urgency /frequency, nocturia Differential Diagnoses: cystitis, BPH, Kidney stones, bladder ca, prostatic abscess, enterovesical fistula. Pattern Recognition: Edematous prostate, may be warm and tender/boggy in palpitation, pain. Treatment options: Antibiotic choices : Bactrim,Levaquin,noroxin,ofloxacin B sitz bath 3 times a day for 30mins C no sexual intercourse until acute phase resolves Review questions: 1 The most common gram-negative bacteria that causes both acute and chronic bacterial prostatitis is A. Staphylococcus aureus . B. Klebsiella . C. Escherichia coli . D. Enterobacteriaceae . Answer C The most common gram-negative bacterium that causes both acute and chronic bacterial prostatitis is Escherichia coli. The other aerobic gram-negative bacteria include Klebsiella, Pseudomonas, Enterobacteriaceae, Proteus mirabilis, and Neisseria gonorrhoeae. Occasionally other bacteria (Staphylococcus aureus and Streptococcus faecalis) are causes. 2 A history of urinary tract infections in males is often seen in men with chronic bacterial prostatitis. Other signs and symptoms of chronic bacterial prostatitis includes A. irritative voiding symptoms, low back pain, and perineal pain. B. nausea and vomiting, as well as fever. C. loss of appetite and weight loss. D. irritative voiding symptoms, inability to ambulate, and fever. Answer A Chronic bacterial prostatitis may have a variety of clinical presentations, but nausea and vomiting, loss of appetite and weight loss, as well as an inability to ambulate are rarely among the presenting symptoms of this disorder. Even fever is typically not present in chronic cases. Typically, there are irritative voiding symptoms that have persisted over time, low back pain, and perineal pain, although any one, or all, may be present. Sometimes clients are completely asymptomatic, although bacteria might be present on urinalysis, and expressed prostatic secretions usually demonstrate increased numbers of leukocytes. Physical examination may be unremarkable as well, although in some cases the prostate will feel boggy or indurated. There is often history of repeated urinary tract infections. Cystitis and/or chronic urethritis may be secondary or mimic prostatitis; however, cultures of the fractionated urine may localize the source of infection. Anal disease may share some of the symptoms of prostatitis, but physical examination should permit a distinction between the two. 3 When performing a prostate examination, you note a tender, warm prostate. What do you suspect? A. Benign prostatic hypertrophy B. Prostatic abscess C. Prostate cancer D. Bacterial prostatitis Answer D Bacterial prostatitis, in which the prostate feels very tender and warm, is usually caused by Escherichia coli. Clients with bacterial prostatitis usually also have a sudden onset of high fever, chills, malaise, myalgias, and arthralgias. In benign prostatic hypertrophy, the prostate gland would feel soft and nontender and would be enlarged. With prostatic abscess, the prostate feels like a firm, tender, or fluctuant mass. With prostate cancer, the prostate may have single or multiple nodules that are firm, hard, or indurated and are usually nontender. 10. Inguinal hernia Definition: An inguinal hernia happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall. Inguinal hernias occur at the inguinal canal in the groin region. In males, the spermatic cords pass through the inguinal canals and connect to the testicles in the scrotum—the sac around the testicles. The spermatic cords contain blood vessels, nerves, and a duct, called the spermatic duct, that carries sperm from the testicles to the penis. In females, the round ligaments, which support the uterus, pass through the inguinal canals. Presenting Symptoms: The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of the groin—the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down. Other signs and symptoms can include • discomfort or pain in the groin—especially when straining, lifting, coughing, or exercising—that improves when resting • feelings such as weakness, heaviness, burning, or aching in the groin • a swollen or an enlarged scrotum in men or boys • Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and cannot go back into the abdomen. A health care provider is unable to massage the hernia back into the abdomen. • Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing “strangulation” of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die. 3 Differential Diagnoses: Ectopic testis, Femoral or inguinal adenitits, femoral hernia, sports hernia Pattern Recognition: Physical exam: Feel for a bulge in the inguinal area when a patient strains or coughs. If the hernia is causing problems and it is not reducible then x-ray, CT scan or Ultrasound may be needed to see if it is incarcerated or strangulated. Treatment options: Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and can prevent incarceration and strangulation. Health care providers recommend surgery for most people with inguinal hernias and especially for people with hernias that cause symptoms. Research suggests that men with hernias that cause few or no symptoms may be able to safely delay surgery until their symptoms increase.3, 6 Men who delay surgery should watch for symptoms and see a health care provider regularly. Health care providers usually recommend surgery for infants and children to prevent incarceration.1 Emergent, or immediate, surgery is necessary for incarcerated or strangulated hernias. Review questions: 1. Gerard is complaining of a scrotal mass; however, the scrotum is so edematous that it is difficult to assess. How do you determine if it is a hernia or a hydrocele? Bowel sounds may be heard over a hernia. 2. Mr. S comes to you with scrotal pain. The examinations of his scrotum, penis, and rectum are normal. Which of the following conditions outside of the scrotum may present as scrotal pain? Inguinal hernia and peritonitis. Conditions outside of the scrotum that may present with scrotal pain are abdominal aortic aneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially In the age groups of the neonate and adolescents. 3. The most common type of hernia is an: indirect inguinal hernia 4. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that is not painful, but it is annoying. You note that the origin of swelling is above the inguinal ligament directly behind and through the external ring. You diagnose this as a: direct inguinal hernia: which occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or COPD. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 and in men ages 16-25. 11. Varicocele Definition: Enlarged pampiniform plexus veins within the scrotum. They form during puberty and can grow larger over time. More common on the left side. Presenting Symptoms: Often asymptomatic. When there are symptoms they are: pain, infertility, and they may cause one testicle to grow slower or shrink. 3 Differential Diagnoses: testicular tumor, inguinal hernia, hermatocele or spermatocele Pattern Recognition: Described as a “bag of worms” because of how they look and feel. Mass disappears when the patient lies down and reappears when the patient stands. Often found using the “Valsalva maneuver.” Scrotal Ultrasound can definitively diagnose. New onset varicocele can signal testicular tumor or mass that impedes venous drainage. Treatment options: asymptomatic varicoceles do not need treatment. Surgical treatment is offered to those with fertility problems, pain, or asymmetrical growth of one testicle. Ibuprofen and Tylenol can help with pain. Least invasive, Percutaneous embolization, is done under general anesthetic and involves blocking blood flow to the pampiniform plexus veins and the varicocele shrink. If necessary, open or laparoscopic surgery is done. Review questions: 1. A 17 year old boy reports feeling something on his left scrotum. On palpation, soft and movable blood vessels that feel like a “bag of worms” are noted underneath the scrotal skin. It is not swollen or reddened. The most likely diagnosis is (D) A. Chronic orchitis B. Chronic epididymitis C. Testicular torsion D. Varicocele ** Rationale: Varicose veins in the scrotal sac feels like “a bag of worms” 2. What risk factors contribute to varicocele? (D) A. Younger age B. Current cigarette smoker C. Multiple sex partners D. None of the above ** Rationale: There are no apparent significant risk factors for varicocele, but being overweight may slightly increase risk. 3. Treatment options for varicocele repair include all of the following except: (C) A. Open surgery B. Laparoscopic surgery C. Treatment with a thrombolytic agent ** D. Percutaneous embolization Rationale: Treatment for varicocele might not be necessary unless it causes pain, testicular atrophy, or infertility. Repair can involve open surgery, laparoscopic surgery or percutaneous embolization. A scrotal support may also provide relief of discomfort associated with this condition. 12. Balanitis Definition: Inflammation of the glans penis. Presenting Symptoms: Erythema, tenderness, edema, foul smelling discharge, ulceration, plaque. 3 Differential Diagnoses: psoriasis, Reiter syndrome, Lichen planus Pattern Recognition: Most common in uncircumcised men, diabetics, and/or immunocompromised. Treatment options: Local hygiene, warm compresses or sitz baths. Consider circumcision for prevention of recurrent balanitis. Most common pathogen is candida. Treat with antifungals (Clotrimazole, Nystatin, Fluconazole) or Abx (Bacitracin, Neosporin). If cellulitis present use po or IV cephalosporin or sulfa drug. Osmotic agents like granulated sugar placed on edematous tissue for several hours can reduce swelling. The puncture technique involves puncturing the edematous foreskin with 21 g needles allowing fluid to drain. Review questions: There is a higher risk of balanitis in which of the following conditions? A. Renal Insufficiency B. Diabetes Mellitus ** C. Graves’ disease D. Asthma Rationale: Balanitis is more common in uncircumcised, diabetic, and/or immunocompromised males. 2. Balanitis is caused by: A. Staphylococcus aureus B. Streptococcus pyogenes C. Candida albicans ** D. Trichomonads Rationale: Balanitis is most often caused by a Candidal infection of the glans penis. 3. Balanitis is a symptom of which one of the following diseases A. Psoriatic arthritis B. Reactive arthritis ** C. Alkylosing Spondylitis D. Rheumatoid arthritis Rationale: Circinate balanitis occurs in reactive arthritis (formerly known as Reiter Syndrome) presents as painless, asymptomatic, shallow, ulcerative lesions on the glans of the penis. 13. Prostate cancer screening Prostate specific antigen (PSA) & Digital rectal exam (DRE) Controversial and conflicting depending on your source. Latest info from epocrates says: Screening for prostate cancer using the PSA may prevent mortality from prostate CA in a very small number of men. Prostate screening put many men in danger of long-term harms such as urinary incontinence and erectile dysfunction. If men desire prostate screening, it should only be done after risks vs benefit is explained. Routine screening for prostate cancer should not be done. Men age 55-69 should be given the risks vs benefit information and then they decide if they want to be screened. Men age 70 and older should not be screened. African Americans, obese, and those with a family history are more at risk. These groups should be informed of their increased risks of PC and also risks of testing and then make an informed decision. DRE does not improve detection of prostate CA and should not be performed as part of a screening. Review Questions: The average American man has an approximately % lifetime risk of prostate cancer and an approximately % likelihood of clinical disease. A. 15, 5 B. 25, 8 C. 40, 10 ** D. 60, 15 Rationale: The average American male has a 40% lifetime risk of latent prostate cancer, an approximate 10% risk of clinically significant disease, and an approximate 3% risk of dying of prostate cancer. All of the following can cause an elevated PSA level except: A. Current prostate infection B. Recent cystoscopy C. BPH D. Prostatectomy ** Rationale: PSA levels can be transiently elevated in conditions other than prostate cancer, including prostatitis, or immediately after prostatic instrumentation such as cystoscopy. Levels often remain chronically elevated in patients with BPH. Serial increases even in the presence of a normal prostate examination should be evaluated further. According to recent epidemiologic studies, prostate cancer is the number cause of cancer death in men residing within the US. (B) A. 1 B. 2 ** C. 3 D. 4 Rationale: Prostate cancer is the second leading cause of male cancer death in the US. 14. PSA and DRE PSA (prostate-specific antigen) and DRE (Digital rectal exam) Definition: The DRE can reveal a discrete, painless lesion or area of induration in the POSTERIOR lobe of the prostate. PSA is a blood test that test for presence of glycoprotein which is produced in benign and malignant prostate cells, while DRE can be uncomfortable due to examiner having to complete the exam for the patient. The benefits of PSA screening for cancer does not outweigh the harms. Presenting Symptoms: Theses are exams done to look for prostate cancer, No presenting symptoms present for PSA and DRE. 3 Differential Diagnoses: BPH, prostate calculi, UTIs Pattern Recognition: DRE is used to detect physical abnormalities of the prostate gland, a firm nodule on rectal exam, induration (deep thickening of the skin). Elevated PSA, evaluate for underlying cause. Treatment options: Depends on the stage at diagnosis, patient’s age, tumor features, comorbidities. Options include radical prostatectomy, cryotherapy, Hormonal therapy, androgen deprivation therapy (ADT). Pallative treatment with chem. And radiation therapy for pain. Review questions: 1. You perform a DRE on a 72-year old man and find a lesion suspicious for prostate cancer. The findings are described as: A. a rubbery, enlarged prostatic lobe. B. an area of prostatic induration** C. a boggy gland. D. prostatic tenderness Lesions are usually asymptomatic with DRE only done when suspicion is evident. 2. All of the following can cause a elevated PSA level except: A. current prostate infection B. recent cystoscopy C. BPH D. prostatectomy** PSA level can be elevated in prostatitis, and immediately after prostatic instrumentation like cystoscopy. PSA level are chronically elevated in patients with BPH. Prostatectomy is removal of the prostate gland. 3. A 54 year old white man with no obvious risk for prostate cancer opted to undergo PSA screening and DRE testing. The DRE findings are normal and his PSA is 3..7ng/ml. You recommend: A. Repeating the PSA test immediately. B. Repeat screening in 1 yr. ** C. Repeat screening in 2 yrs. D. Repeat screening in 5 yrs. The American Cancer Society recommends conversation between the provider an the male patient 50 yr or older starts for men at average risk of prostate cancer and expect to live at least 10 more years. PSA level < 2.5ng/ml = testing every 2 years; PSA > 2.5ng/ml = testing every year. 15. Erectile Dysfunction Definition: also known as impotence. Can be caused from reduced blood flow to the penis or nerve damage. Also, low self-esteem, anxiety, depression, stress and be associated with coronary artery disease. Presenting Symptoms: The inability to achieve or maintain penile erection enough for satisfactory sexual performance 3 Differential Diagnoses: Decreased libido, anorgasmia and ejaculatory dysfunction Pattern Recognition: Treatment options: First line – phosphodiesterase (Viagra, Levitra, Cialis) use caution with nitrates Review questions: 1. Which of the following mediations is associated with the highest incidence of erectile dysfunction? a.Lamotrigine (Lamictal) b.Clonazepam (Klonopin) c. Paroxetine (Paxil) ** d.Doxepin (Sinequan) Rationale: SSRI cause sexual adverse effects in up to 50% of men who take them. Paxil seems to have the highest risk of ED. It can also affect women achieving orgasm. 2. Which of the following is not a common risk factor for erectile dysfunction (ED)? A. diabetes mellitus B. hypertension C. cigarette smoking D. testosterone deficiency ** Rationale: Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED 3. When taking a phosphodiesterase-5 (PDE-5) inhibitor, concomitant use of which medication must be avoided? A. statins B. sulfonylurea C. angiotensin-converting enzyme (ACE) inhibitors D. nitrates ** Rationale: The concomitant use of an ED medication with a nitrate is contraindicated because of the risk of profound hypotension ******THERE ARE MAY MORE QUESTIONS FOR REVIEW IN THE FITZGERALD FILE***** 16. HPV (Human PapillomaVirus) Definition: most common STI in the US. Small percentage of women who have HPV develop cervical cancer with most lesions resolving spontaneously. Over 100 different types of HPV, 30-40 are genital subtypes. 13 are high risk types; especially types 17 and 18 which causes 70% of all cervical cancers. HPV-6 and 11 are associated with genital warts Presenting Symptoms: Normally lesions are not visible on cervix during pelvic examination. HPV is detected through Pap test. 3 Differential Diagnoses: molluscum contagiosum, Marked cervicitis and erosion, Cervical polyp Pattern Recognition: Found with Pap Smear and HPV testing during pelvic examines. Usually cannot visually see changes in cervical tissue. High grade lesions may appear as dark, brownish lesions around the cervix. In severe cases, patient make present with abnormal irregular vaginal bleeding. Can appear as genital warts in genitalia area. Treatment options: HPV Vaccine (Gardasil) recommended for young girls and boys before becoming sexually active to prevent HPV strains 6, 11, 18, 31, 33, 45, 52, & 58, which are the strains that cause genital warts and cervical cancer. Cervarix is another vaccine only approved for girls. If HPV is detected, then biopsy has to be done as a definitive diagnostic test. CIN=no cervical dysplasia detected through biopsy. CIN 1= patient can manage conservatively with surveillance by Pap, or Pap and HPV test at particular intervals. CIN 2 and CIN 3 refer to OB/GYN Genital Warts treatment- podophyllotoxin and podophyllum resin, trichloroacetic acid and bichloroacetic acid, Fluorouracil, Imiquimod, Sinecatechins, Interferons. ALL TOPICAL AGENTS Surgeries include: Cryoblation with liquid nitrogen or nitrous oxide, Laser ablation, electrocautery, Ultrasonic aspiration, and excision biopsy Review questions: 1. What percent of patients with genital warts have spontaneous regression of the lesions? a. 10% B. 50% ** C. 25% D. 75% About 50% of patients have spontaneous regression of genital warts without intervention. 2. Which HPV types are the most likely to cause genital warts or condyloma acuminatum? A. 1,2, &3 B. 16 & 18 C. 6 & 11 ** D. 22 & 24 HPV types 6, 10, 40, 42, 43, 44, 54, 61, 70, 72, & 81 have low malignancy risks, however, types 6 & 11 most often cause genital warts. HPV 16 & 18 are most often associated with genital malignancies (cervical cancer). 3. Treatment for patients with condyloma acuminatum include all of the following except: A. Topical acyclovir ** C. Podofilox B. cryotherapy D. trichloroacetic acid Topical Acyclovir is a antiviral medication used to slow the growth and spread of herpes infections. This cream is typically used for cold sore treatment whereas the ointment is used for genital herpes lesions. 17. UTI Definition: UTI (cystitis) – Infection and inflammation of the kidney, bladder or urethra. Bacterial infection of the bladder mucosa is the most common type of urinary tract infection. Presenting Symptoms: burning, frequency, and/or urgency during urination, pain during or after urination, sensation of incomplete bladder emptying, fever, chills, hematuria (gross or microscopic), lower abdominal and/or back pain, costovertebral angle tenderness, dribbling of urine in men, small volume and/or frequent voiding, foul-smelling urine 3 Differential Diagnoses: vaginitis, STD, PID, pregnancy, overactive bladder, enuresis, prostatitis, epididymitis Pattern Recognition: E-coli 75-95% of cases, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter, Staphylococcus saprophyticus Treatment options: Consider Bactrim DS 1 tab PO daily fo 10-14 days; others to consider Macrobid (Nitrofurantoin) and Monurol (Fosfomycin Alternate Treatment Options: Cipro, Levaquin, Beta-Lactams Review questions: 1. What antibiotic would you expect NOT to give to a pregnant woman with a UTI? Bactrim – TMP avoid use during pregnancy secondary to possible risk of teratogenicity 2. What is the most common symptom of upper UTI in young children? Fever 3. What lab result will be altered if a patient has taken an antibiotic? Urine culture 4. What is the preferred method to collect a urine specimen in children who are not toilet-trained? catheterization 18. Pyelonephritis Definition: Acute Pyelonephritis – Infection of the upper urinary tract and renal parenchyma. Usually uncomplicated, but when unmanaged can lead to bacteremia, scarring, and death. Presenting Symptoms: Adolescents and adults: fever (could exceed 103), chills, costovertebral angle tenderness, flank pain (usually unilateral), abdominal tenderness malaise, myalgia, hematuria (occurs in 30-40% of women), nausea, vomiting, headache, dysuria, frequency, and urgency. Infants and children: fever (can progress to sepsis), failure to thrive, irritability, enuresis, nausea, and vomiting. Older adults: fever, mental status change, decompensation in another organ system, general deterioration 3 Differential Diagnoses: renal calculi, prostatitis, appendicitis, cholecystitis, urinary stones Pattern Recognition: E-Coli responsible for 75% of cases; most common route of infection is movement of bacteria from the bladder to the upper urinary tract; in neonates, the most common route is hematogenous spread to the kidneys. Treatment options: First line: Cipro 500mg PO BID for 7 days, Cipro XR 1000mg PO daily x 7 days, Levaquin 750mg PO daily for 5 days, Bactrim DS (160/800) 1 tab PO BID x 14 days Review questions: 1. When would you consider a CT scan or renal ultrasound for patients with acute pyelonephritis? If the patient has not improved after 48-72 hours on an appropriate antibiotic. 2. What four reasons would you consider the infection complicated until proven otherwise? If the patient is a man, an older adult, or child, or has symptoms lasting more than 7 days 3. What medication would you expect not to use in acute pyelonephritis? Do not use nitrofurantoin because poor tissue concentrations are achieved in the renal parenchyma 19. Urinary calculi (Renal Calculi--Nephrolithiasis) Definition: Commonly known as kidney stones. Renal, urologic, endocrine, and metabolic disorders can lead to the crystallization of material within the urinary system Typically classified by composition: Calcium Stones (most common approx 80%) Calcium Oxalate (most common of calcium type stones) Calcium Phosphate Uric acid (common in warm dry climates-40% incidence) Struvite Stones (result of infection-magnesium ammonium phosphate) Cystine (caused by genetic disorder) Mixed Risk Factors: Influenced by urine composition, Increased incidence in men vs women (4:1) Family History of Stones, Dehydration, Gout, Bariatric Surgery (increased oxalate excretion), Dietary High Protein Diet, High Vitamin C Diet (for men) Medications Topiramate, Indinavir (HIV) Presenting Symptoms: Hematuria, Dysuria, Abdominal, flank, or groin pain. Sudden onset, typically severe back and flank pain that waxes and wanes. Pain may radiate to groin, testes, suprapubic area, and labia. CVA tenderness Differential Diagnoses: Acute peritonitis, pyelonephritis: flank pain, fever, and pyuria (Fever is unlikely in uncomplicated stone), Acute Appendicitis, Pancreatitis Females Only: Salpingitis, Ectopic Pregnancy: occasionally mistaken (Clarified with renal/pelvic ultrasound) Pattern Recognition: Classic Presentation: acute onset of unilateral severe colicky flank pain that waxes and wanes in waves where patient may become restless and unable to remain still at height of pain. Extreme pain is associated with N/V. Typically presenting with gross or microscopic hematura. 50% of patients pass stone within 48 hours. Diagnosis: Urinalysis, Imaging (Xray or CT), Analysis of collected stone to assist in future prevention Treatment options: Treatment varies based on size of stone as well as pain or obstruction. Analgesics, Alpha blocker, IV hydration in presence of nausea and vomiting, Strain Urine for Stone Retrieval, Shock wave lithotripsy (SWL), Ureteroscopy, Percutaneous nephrolithotomy and nephrostomy tube Special Considerations: Urology referral for larger stones, inability to pass, or acute renal failure. Refer to ED for high fever (r/o urosepsis), extreme pain, acute renal failure Pregnant women: rule out ectopic, abruptio placentae, preterm labor, and kidney stones Prevention: Maintain adequate hydration, Calcium (general) stones: Reduce sodium and animal protein, Adequate calcium intake. Calcium Oxalatereduce oxalate rich foods (ie beets, swiss chard, sweet potatoes, nuts, tea, chocolate, soy). Uric Acid Stones- limit animal protein Review questions 1. To decrease the production of uric acid stones, the family nurse practitioner orders which medication? A. allopurinol (zyloprim) B. indomethacin (indocin) C. bethanechol (urecholine) D. phenazopyridine (pyridium) Rationale: To decrease the formation of uric acid stones, a urinary alkylating agent, such as allopurinol is frequently used. As standard practice, the family nurse practitioner should check the patient’s serum uric acid level monthly for three months to ensure the levels are decreasing to normal ranges and then annually once serum uric acid levels are normalized. 2. You see a 58-year-old man diagnosed with a kidney stone who reports pain primarily during urination. You consider all of the following except: A. improved hydration. B. alpha blocker use. C. prescribing a diuretic. D. analgesia use Rationale: Diuretics would deplete fluid volume and therefore contribute to stones. 3. Your 35-year-old patient is being worked up for microscopic hematuria. All of the following are differential diagnoses of microscopic hematuria except: A) Kidney stones B) Bladder cancer 527 C) Acute pyelonephritis D) Renal artery stenosis Rationale: Renal artery stenosis Renal artery stenosis refers to narrowing of the kidney arteries. It is commonly noted in individuals older than 50 years of age and is associated with atherosclerosis and hypertension. Hematuria is not associated with renal artery stenosis. Evidence of blood in the urine can be seen with kidney stones, bladder cancer, and acute pyelonephritis. 20. Chlamydia (member did not follow template, this is all I got) Definition: Sexually Transmitted Infection caused by atypical bacterium; it is the most common bacterial cause of STI. Site of Infection: Urethritis Pharyngitis Proctitis Females: Cervicitis Endometritis Salpingitis; can lead to Cervicitis, Dysuria-pyuria due to urethritis, PID, Perihepatitis (Fitzhugh-Curtis Syndrome) Males: Epididymitis Prostatitis, can lead to Urethritis, epididymitis, prostatitis Presenting Symptoms: Most often asymptomatic with highest prevalence among people age 25 years or younger 3 Differential Diagnoses: urogenital infection, Proctitis, Coinfection with N.Gonorrhoeae Pattern Recognition: if left untreated in females can lead to PID that can lead to infertility, ectopic pregnancy, and chronic pelvic pain Treatment options: Uncomplicated: Azithromycin 1 g PO x 1 dose Doxycycline 100 mg PO BID x 7days No repeat test for cure necessary unless pregnant Review questions: 1. what is the most common bacterial STI? 2. List one of the drugs of choice for Chlamydia 3. Cervical chlamydial infection can lead to PID if untreated, which can lead to (infertility, ectopic, or chronic pelvic pain: all are correct) 21. Osteoarthritis: Definition: Progressive destruction of the articular cartilage and subchondral bone accompanied by osteophyte formation and sclerosis. OA is confined to the joints & constitutional symptoms are absent. Presenting Symptoms: Joint pain, usually asymmetrically, develops insidiously and accompanies or follows physical activity. 3 Differential Diagnoses: RA, Gout, Infective arthritis Pattern Recognition: Morning stiffness lasting less than one hour; Joints are cool with possible crepitus and limited ROM; Overgrowth of osteocytes causes bony enlargement, especially bunions (MPT joint) Heberden’s nodules (DIP joints), and Bouchard’s nodes (PIP joints) Commonly affected joints: DIP, PIP, CMC, MTP, hips, knees, cervical and lumbar spine Treatment options: Weight loss, knee or elbow braces to stabilize joints during exercise; NSAIDS: Ibuprofen, Naproxen, Meloxicam, Celebrex, Diclofenac PO or topical Review questions: 1. A 65-year-old carpenter complains of stiffness and pain in both hands and right knee shortly after waking and worsens in the afternoon. He feels some relief with rest. On, exam the nurse practitioner notices the presence of Heberden’s nodes. Which of the following is most likely? a. Osteoporosis b. Rheumatoid Arthritis c. Osteoarthritis d. Reiter’s syndrome Answer C Rationale- Heberden’s nodes are classic sign of OA. They are bony overgrowths located at the distal interphalangeal joints. 2. Mary, age 72, has severe osteoarthritis of her right knee. She obtains much relief from corticosteroid injections. When she asks you how often she can have them, how do you respond? A. Only once a year in the same joint B. No more than twice a year in the same joint C. No more than three to four times a year in the same joint D. No more than five to six times a year in the same joint Answer C. Rationale: Intra-articular corticosteroid injections provide much needed pain relief in weightbearing joints of clients with osteoarthritis; however, they should be limited to no more than three to four in the same joint per year because of potential damage to the cartilage if given more frequently 3. Your 75-year-old client with osteoarthritis of the knee will be starting on a course of NSAIDs for pain management. The most important teaching point for your patient currently is: A. You should start with a high dose first and taper down the dose as needed. B. You should continue to take your Coumadin as you have been. C. Report any excessive stomach upset or if you notice that your stools become dark or bloody. D. At this point, it will not be helpful to lose weight. Answer C When clients are taking NSAIDs, there is always a risk of gastrointestinal tract bleeding, so the clients should be advised to look for signs of this complication. The American Academy of Family Physicians (AAFP) recommends that the smallest possible doses of NSAIDs for the shortest possible duration are best to minimize the incidence of side effects. The AAFP cautions to avoid using NSAIDs in clients taking anticoagulant such as Coumadin, as there may be an additive effect and increased risk of bleeding. Obesity is one of the major contributors to the development of osteoarthritis of the knee. Any weight loss that can occur will remove stress from the client’ s joints and may improve overall cardiovascular health. 22. Rheumatoid Arthritis Definition: chronic systemic autoimmune disease that primarily affects the lining of the synovial joints Presenting Symptoms: Symmetric involvement; Morning stiffness and gelling; Hand and wrist (esp. MCP joints) involvement; Shaking hands is painful (withdraws hand on squeeze); Characteristics of onset Onset over weeks to months; Prodromal symptoms of Anorexia, weakness, Fatigue. Usually starts in one joint 3 Differential Diagnoses: Osteoarthritis, Fibromyalgia, Systemic Lupus Erythematous Pattern Recognition: ACR Rheumatoid Arthritis Diagnostic Criteria: Score of 6 or more is definitive for RA diagnosis Joint Involvement Large joints: Shoulders, elbows, hips, knees and ankles Small joints: MTP, PIP, DIP and wrists Points 0: One large joint involved Points 1: Two to ten large joints involved Points 2: One to three small joints involved (with or without large joint involvement) Points 3: Four to ten small joints involved (with or without large joint involvement) Points 5: More than 10 joints involved (with at least one small joint involved) Serology (Rheumatoid Factor, Anti-Citrullinated Protein Antibody) Points 0: RF negative and ACPA negative Points 2: Low positive RF or ACPA Points 3: High positive RF or ACPA Acute Phase Reactants (C-Reactive Protein, Erythrocyte Sedimentation Rate) Points 0: Normal C-RP and ESR Points 1: Abnormal C-RP or ESR Duration of symptoms Points 0: Less than 6 weeks Points 1: Six weeks or more Treatment Options: DMARDS (Methotrexate first line Tx) and can use along with NSAIDs Review Questions: 1. A 45-year-old woman in complaining of generalized stiffness, especially in both her wrist and hands. It is much worse in the morning and last a few hours. She also complains of fatigue and generalized body aches that have been present for the past few months. Which of the following is most likely? a. Osteoporosis b. Rheumatoid arthritis c. Osteoarthritis d. Gout Answer B Rationale: When RA is active symptoms can include fatigue. Loss of energy, depression, low grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. 2. Ginny, age 48, has rheumatoid arthritis and gets achy and stiff after sitting through a long movie. This is referred to as A. longevity stiffness B. gelling C. intermittent arthritis D. molding Answer B. Rationale Gelling refers to the achiness and stiffness that occur in clients with rheumatoid arthritis after a period of inactivity. 3. Mrs. Matthews has rheumatoid arthritis. On reviewing an x-ray of her hip, you notice that there is a marked absence of articular cartilage. What mechanism is responsible for this? A. Antigen-antibody formation B. Lymphocyte response C. Immune complex formation D. Lysosomal degradation Answer D. Rationale Lysosomal degradation results when leukocytes produce lysosomal enzymes that destroy articular cartilage in rheumatoid arthritis. The collagen fibers and the protein polysaccharides of articular cartilage are broken down by the enzymes. Immune complexes initiate the inflammatory process that brings leukocytes to the cartilage. Immune complexes are formed by the combination of immunoglobulin G with rheumatoid factors that are the result of antigen-antibody formation. 23. Myasthenia gravis Definition: Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles of the body, which are responsble for breathing and moving parts of the body. In myasthenia gravis, the immune system--which normally protects the body from foreign organisms--mistakenly attacks itself. Presenting Symptoms: Symptoms vary in type and intensity. The hallmark of myasthenia gravis is muscle weakness that increases during periods of activity and improves after periods of rest. Certain muscles that control eye and eyelid movements, facial expression, chewing, talking, and swallowing are often, but not always, involved. The muscles that control breathing and neck and limb movements may also be affected. Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles. Normally when impulses travel down the nerve, the nerve endings release a neurotransmitter substance called acetylcholine. In myasthenia gravis, antibodies produced by the body's own immune system block, alter, or destroy the receptors for acetylcholine. The first noticeable symptoms include weakness in muscles, difficulty in swallowing, or slurred speech. Other symptoms may include blurred or double vision, drooping eyelid(s), and weakness in the arms, hands, fingers, legs, and neck. Myasthenia gravis is not directly inherited nor is it contagious. 3 Differential Diagnosis: Botulism, Motor Neuron Disease, Generalized Fatigue Pattern Recognition: Myasthenia Gravis has the ability to affect ocular, bulbar, limb, and respiratory muscles. Transient worsening of myasthenic symptoms can be precipitated by concurrent infection, surgery, pregnancy, childbirth, certain medications. When severe, patients are at risk for life-threatening neuromuscular respiratory failure referred to as myasthenic crisis. Severe bulbar weakness that produces dysphagia and aspiration often complicates the respiratory failure. Patients in myasthenic crisis typically experience increasing generalized weakness as a warning, although occasionally a patient will present with respiratory insufficiency out of proportion to their limb or bulbar weakness. Treatment Options: Symptomatic treatment (acetylcholinesterase inhibition) to increase the amount of acetylcholine (ACh) available at the neuromuscular junction; Oral pyridostigmine is the most widely used choice. Pyridostigmine provides marked improvement in some patients and little or none in others Chronic immunosuppressive therapies (glucocorticoids and nonsteroidal immunosuppressive agents) to target the underlying immune dysregulation. Rapid but short-acting immunomodulating treatments (therapeutic plasma exchange and intravenous IVIG Immune Globulin), Surgical treatment (thymectomy) Review Questions: 1. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it: A. Stimulates the production of acetylcholine at the neuromuscular junction. B. Promotes the removal of antibodies that impair the transmission of impulses C. Inhibits the breakdown of acetylcholine at the neuromuscular junction. D. Decreases the production of autoantibodies that attack the acetylcholine receptors. ** 2. Treatment for Myasthenia Gravis Includes: A. IVIG or Plasmapheresis ** B. Antibiotics C. Analgesic’s D. Sedation 3. What specific treatment is given patients diagnosed with Myasthenia Gravis that will focus on improving conduction? A. Surgery B. Physical Therapy C. Mestinon (pyridostigmine) Neostigmine ** D. Fluroquinolones 24. Juvenile Rheumatoid arthritis Definition: fever lasting at least 2 weeks and arthritis lasting at least 6 weeks. Presenting Symptoms: high spiking fever (>101.3 – daily), rashes, markedly elevated WBC, anemia, lymphadenopathy diffuse joint pain. Patients younger than 16 years old, both sexes and can present as young as 1 year. 3 Differential Diagnoses: Infection (bacterial bone and joint), Viral and postinfectious arthritis, Inflammatory bowel disease, Kawasaki disease, Systemic lupus erythematosus **The list can go on and on – UP TO DATE (systemic juvenile idiopathic arthritis: clinical manifestations and diagnosis – Author Yukiko Kimura MD** Pattern Recognition: wrists, knees and ankles more typically. But hand, hips, cervical spine and temporomandibular joints are sometimes also affected. Salmon-pink colored rash (multiple round/oval macules, slightly raised, differing in size) Treatment options: moderate – sever disease should be referred to pediatric rheumatologist for management. NSAIDS (mild-moderate acute disease) Anakinra, canakinumab or tocilizumab (moderate – severe acute disease) Methotrexate Glucocorticoids (DMARD) **more information on UP TO DATE (systemic juvenile idiopathic arthritis: Treatment) – Author Yukiko Kimura MD Review questions: 1. First-line treatment of SLE in a patient with mild symptoms is: A. systemic corticosteroids. B. hydroxychloroquine plus NSAIDs. ** C. anakinra. D. methotrexate. 2. Common physical findings of SLE include all the following except: A. weight gain. ** B. joint pain and swelling. C. fatigue. D. facial rash. 3. Which of the following is not characteristic of rheumatoid arthritis (RA)? A. It is more common in women than in men at a 3:1 ratio. B. Family history of autoimmune conditions often is reported. C. Peak age for disease onset in individuals is age 50 t