NRNP 6560 Midterm Exam Graded A+
Acute Fractures Management - ANSWER-- ABC care (Airway, breathing, circulation),
musculoskeletal second survey
- fluid resuscitation
- early reduction of fracture
- cover open wounds
- surgical irrigation and debridement for open fracture
- Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
- pain: opioids
- tetanus shot of unknown
- calcium upon discharge for osteoporosis
- cement injection in bone with vertrebroplasty
Acute liver failure: findings, management - ANSWER-Weakness, fatigue
weightloss, n/v, abd pain
Change in bowel pattern
- Check BMP, ABG, lactate, toxicology screen, acetaminophen screen, Hep panel, PT/
INR
- Treat specific etiology:
charcoal for acetaminophen and N-acetylcysteine)
Supportive for Hep A and E
Antiviral for Hep B
Test for Wilson
- ICU management: watch for cerebral edema, hyperventilate if present, mannitol. CT
head for encephalopathy
Acute pancreatitis findings/ diagnostics - ANSWER-- Epigastric abd pain, abrupt, worse
with walking or supine, better with knee to chest, leaning forward
- N/V
- hypoactive bowelsounds
- tachycardia, hypotension
- jaundice
- ascites
- Elevated lipase and amylase
- elevated urine amylase
- elevated trypsin levels
- leukocytosis
- Bili elevated
- Hypocalcemia if severe disease
- Low albumin
- xr abdomen: ileus, pancreatic calcifications, gallstones
- CT abdomen preferred over US, and MRI over CT
,Acute pancreatitis management - ANSWER-- IV hydration - Fluid therapy to prevent
hypovolemia and shock: LR or NS with 20 K at 75- 100 ml/hr
- May need plasma, RBC, albumin
- Pain control - Morphine, Fentanyl
- AB's, not prophylactically, only when septic or biliary stones.
- NPO, then supplements, small frequent meals
- NG for ileus or vomiting
- replace electrolytes
- enteral feeding
acute pancreatitis: what and etiology - ANSWER-inflammation of pancreas
Alcoholism
Gallstones
Smoking
Traumatic or hereditary
Infectious (CMV)
Meds: Sulfa drugs, thiazide diuretics, Lasix, Corticosteroids, Depakote, Opioids
Advanced HIV infection: definition, symptoms, prognosis - ANSWER-CD4 below 50
Wasting, fevers, fatigue
Poor
AIDS, definition and diagnosis - ANSWER-acquired immune deficiency syndrome
CD4 low, below 500 and infection with opportunistic organism
Or:
CD4 below 200
Alcoholic liver disease: etiology, findings, management - ANSWER-Most common
cause of cirrhosis
Women twice as sensitive to alcohol toxicity then men
Binge drinking
High mortality rate
Diagnosis on report of alcohol intake, evidence of liver disease, lab abnormalities
AST and ALT often high than 2
Score for mortality: Maddreys' score
- Abstinence
- MDF score greater than 32: prednisone for 4 wks
- May require liver transplant
,ANA. Tests in rheumatic disease: what, normal level, abnormal with. - ANSWER-
Antinuclear antibody (ANA).
Normal: Titer 1.32
POsitive with: Sjogren's (SS), SLE (lupus),
Antiretroviral therapy (ART) - ANSWER-- Combination therapy, 3 or more from different
drug classes
- Follow up with HIV viral load determination at 4 - 6 wks after initiation and then every 3
- 6 mo.
- Adherence is vital
- always assess drug- drug interactions/ medication reconciliation
- May make changes when CD4 exceeds evidence level
- check GFR/ creat/ BUN monthly for elderly on Tenofovir
- If deteriorating on ART (decline in CD4) then perform drug resistance testing and
revision of ART
Appendicitis findings and diagnostics - ANSWER-Abd pain: periumbilical first, then right
lower quadrant pain (McBurney's point)
Rovsing's sign: pain rlq when touched llq
Psoas sign: pain with extension of right hip
Obturator sign: pain with internal rotation right hip
Anorexia
n/v
constipation
low grade fever
motionless, right thigh up
guarding rlq
Moderate leukocytosis
UA: elevated spec gravity, hematuria, pyuria, albuminuria
Ultra sound: very sensitive
CT to detect: perforation, periappendiceal abscess
Appendicitis Treatment - ANSWER-Mainstay treatment: surgery
IV fluids/ correct electrolytes
AB: Cefoxitin 1 - 2 gr
Tx for gangrenous/ perforated appendicitis:
- mild/ moderate severity: one AB or Cefazolin/ Ceftraixone/ Cipro/ Levaquin with Flagyl
- high risk/ severity (immunocompromised, old): Meropenem, Zosyn or Cefepime/ Cipro/
Levaquin with Flagyl.
Narrow AB once culture results available
Pain tx:
Dilaudid
Morphine
, Appendicitis: what and etiology - ANSWER-Acute inflammation of the appendix.
Caused by: fecalith (fecal stone), inflammation, intestinal worms, strictures, tumors.
Gangrene and perforation if not treated within 36hrs.
Assessment of surgical risk - ANSWER-- Unstable cardiac condition (recent MI, active
angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF.
arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more than 10 METs
makes low risk)
Autoimmune hepatitis: what, etiology, findings, management - ANSWER-unresolving
inflammation of liver with unknown cause
More women than men
- Abnormal serum globulins and presence of autoantibodies
- Abnormal serum aminotransferases
Prednisone monotherapy, induction and maintenance
Prednisone with azathioprine, induction and maintenance
May need liver transplant
C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. -
ANSWER-Determines hemolytic activity which speaks to level of inflammatory response
Normal: men: 12-72. Women: 13-75 mg/dl
Increased with: inflammatory disease
Decreased with: RA, lupus, SS
Calcineurin inhibitors: which, indication, adverse effects - ANSWER-Tacrolimus
Cyclosporine
Prophylaxis of rejection
T: tremor, renal dysfunction, hyperglycemia
C: tremor, renal dysfunction, htn, hirsutism, gingival hyperplasia
Cauda Equina Syndrome - ANSWER-Spinal cord compression from metastatic lesion to
spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/
bladder incontinence, diminished sensation in legs: saddle. Surgical emergency!
Acute Fractures Management - ANSWER-- ABC care (Airway, breathing, circulation),
musculoskeletal second survey
- fluid resuscitation
- early reduction of fracture
- cover open wounds
- surgical irrigation and debridement for open fracture
- Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
- pain: opioids
- tetanus shot of unknown
- calcium upon discharge for osteoporosis
- cement injection in bone with vertrebroplasty
Acute liver failure: findings, management - ANSWER-Weakness, fatigue
weightloss, n/v, abd pain
Change in bowel pattern
- Check BMP, ABG, lactate, toxicology screen, acetaminophen screen, Hep panel, PT/
INR
- Treat specific etiology:
charcoal for acetaminophen and N-acetylcysteine)
Supportive for Hep A and E
Antiviral for Hep B
Test for Wilson
- ICU management: watch for cerebral edema, hyperventilate if present, mannitol. CT
head for encephalopathy
Acute pancreatitis findings/ diagnostics - ANSWER-- Epigastric abd pain, abrupt, worse
with walking or supine, better with knee to chest, leaning forward
- N/V
- hypoactive bowelsounds
- tachycardia, hypotension
- jaundice
- ascites
- Elevated lipase and amylase
- elevated urine amylase
- elevated trypsin levels
- leukocytosis
- Bili elevated
- Hypocalcemia if severe disease
- Low albumin
- xr abdomen: ileus, pancreatic calcifications, gallstones
- CT abdomen preferred over US, and MRI over CT
,Acute pancreatitis management - ANSWER-- IV hydration - Fluid therapy to prevent
hypovolemia and shock: LR or NS with 20 K at 75- 100 ml/hr
- May need plasma, RBC, albumin
- Pain control - Morphine, Fentanyl
- AB's, not prophylactically, only when septic or biliary stones.
- NPO, then supplements, small frequent meals
- NG for ileus or vomiting
- replace electrolytes
- enteral feeding
acute pancreatitis: what and etiology - ANSWER-inflammation of pancreas
Alcoholism
Gallstones
Smoking
Traumatic or hereditary
Infectious (CMV)
Meds: Sulfa drugs, thiazide diuretics, Lasix, Corticosteroids, Depakote, Opioids
Advanced HIV infection: definition, symptoms, prognosis - ANSWER-CD4 below 50
Wasting, fevers, fatigue
Poor
AIDS, definition and diagnosis - ANSWER-acquired immune deficiency syndrome
CD4 low, below 500 and infection with opportunistic organism
Or:
CD4 below 200
Alcoholic liver disease: etiology, findings, management - ANSWER-Most common
cause of cirrhosis
Women twice as sensitive to alcohol toxicity then men
Binge drinking
High mortality rate
Diagnosis on report of alcohol intake, evidence of liver disease, lab abnormalities
AST and ALT often high than 2
Score for mortality: Maddreys' score
- Abstinence
- MDF score greater than 32: prednisone for 4 wks
- May require liver transplant
,ANA. Tests in rheumatic disease: what, normal level, abnormal with. - ANSWER-
Antinuclear antibody (ANA).
Normal: Titer 1.32
POsitive with: Sjogren's (SS), SLE (lupus),
Antiretroviral therapy (ART) - ANSWER-- Combination therapy, 3 or more from different
drug classes
- Follow up with HIV viral load determination at 4 - 6 wks after initiation and then every 3
- 6 mo.
- Adherence is vital
- always assess drug- drug interactions/ medication reconciliation
- May make changes when CD4 exceeds evidence level
- check GFR/ creat/ BUN monthly for elderly on Tenofovir
- If deteriorating on ART (decline in CD4) then perform drug resistance testing and
revision of ART
Appendicitis findings and diagnostics - ANSWER-Abd pain: periumbilical first, then right
lower quadrant pain (McBurney's point)
Rovsing's sign: pain rlq when touched llq
Psoas sign: pain with extension of right hip
Obturator sign: pain with internal rotation right hip
Anorexia
n/v
constipation
low grade fever
motionless, right thigh up
guarding rlq
Moderate leukocytosis
UA: elevated spec gravity, hematuria, pyuria, albuminuria
Ultra sound: very sensitive
CT to detect: perforation, periappendiceal abscess
Appendicitis Treatment - ANSWER-Mainstay treatment: surgery
IV fluids/ correct electrolytes
AB: Cefoxitin 1 - 2 gr
Tx for gangrenous/ perforated appendicitis:
- mild/ moderate severity: one AB or Cefazolin/ Ceftraixone/ Cipro/ Levaquin with Flagyl
- high risk/ severity (immunocompromised, old): Meropenem, Zosyn or Cefepime/ Cipro/
Levaquin with Flagyl.
Narrow AB once culture results available
Pain tx:
Dilaudid
Morphine
, Appendicitis: what and etiology - ANSWER-Acute inflammation of the appendix.
Caused by: fecalith (fecal stone), inflammation, intestinal worms, strictures, tumors.
Gangrene and perforation if not treated within 36hrs.
Assessment of surgical risk - ANSWER-- Unstable cardiac condition (recent MI, active
angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF.
arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more than 10 METs
makes low risk)
Autoimmune hepatitis: what, etiology, findings, management - ANSWER-unresolving
inflammation of liver with unknown cause
More women than men
- Abnormal serum globulins and presence of autoantibodies
- Abnormal serum aminotransferases
Prednisone monotherapy, induction and maintenance
Prednisone with azathioprine, induction and maintenance
May need liver transplant
C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. -
ANSWER-Determines hemolytic activity which speaks to level of inflammatory response
Normal: men: 12-72. Women: 13-75 mg/dl
Increased with: inflammatory disease
Decreased with: RA, lupus, SS
Calcineurin inhibitors: which, indication, adverse effects - ANSWER-Tacrolimus
Cyclosporine
Prophylaxis of rejection
T: tremor, renal dysfunction, hyperglycemia
C: tremor, renal dysfunction, htn, hirsutism, gingival hyperplasia
Cauda Equina Syndrome - ANSWER-Spinal cord compression from metastatic lesion to
spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/
bladder incontinence, diminished sensation in legs: saddle. Surgical emergency!
