NR511 Final Exam Study Guide latest

1 NR511 Final Exam Study Guide Week 1 1. Define diagnostic reasoning -To solve problems, to promote health, and to screen for disease or illness all require a sensitivity to complex stories, to contextual factors, ...

1 NR511 Final Exam Study Guide Week 1 1. Define diagnostic reasoning -To solve problems, to promote health, and to screen for disease or illness all require a sensitivity to complex stories, to contextual factors, and to a sense of probability and uncertainty. -Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. 2. Discuss and identify subjective & objective data -Subjective: -reports -complains of -tellscategory. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient. 15. Explain what a “well rounded” clinical experience means -Includes both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits 16. State the maximum number of hours that time can be spent “rounding” in a facility <25% 17. State 9 things that must be documented when inputting data into clinical encounter -date of service -visit E&M code (e.g., 99203) -age -gender and ethnicity -chief concern -procedures -tests performed or ordered -diagnoses -level of involvement 18. Identify and explain each part of the acronym SNAPPS -S: Summarize -N: Narrow -A: Analyze -P: Probe5 -P: Plan -S: Self-directed learning Week 2 1. Identify the most common type of pathogen responsible for acute gastroenteritis -Viral: Norovirus (Leading cause for adults) -Rotovirus (Leading cause for peds up to 2 years old) 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea Due to risk of C Diff infection 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD) -IBS (Irritable bowel syndrome): disorder of bowel function not from anatomic abnormality -constipation, diarrhea, bloating, urgency w/ diarrhea -NOT assoc w/ serious medical consequences, IBD or CA +S/S: result from disordered sensation or abnormal function of the small and large bowel -IBD (Inflammatory bowel disease): chronic immunologic disease that manifests in intestinal inflammation - UC/CD 4. Discuss two common Inflammatory Bowel Diseases -Ulcerative colitis (UC): the mucosal surface of the colon is inflamed and ultimately results in friability, erosions, and bleeding. - Most common in recto-sigmoid colon. Can involve entire colon - Pain in RLQ -Crohns (CD): the inflammation extends deeper into the intestinal wall and can involve all or any layer of the bowel wall and any portion of the GI tract from the mouth to the anus. - Skipped lesions - Pain in LLQ 5. Discuss the diagnosis of diverticulitis, risk factors, and treatments Symptoms: LLQ pain/ tenderness, fever, N/V/D Need imaging especially if perforation or peritonitis is suspected; free air = perforation; patient may have ileus, small or large bowel obstruction Can use plain x-ray6 CT or barium enema are preferred CT with contrast is more sensitive and accurate 6. Identify the significance of Barrett’s esophagus After repeated exposure to gastric contents, inflammation of the esophageal mucosa becomes chronic. · Blood flow increases, erosion occurs · As erosion heals, normal squamous epithelium replaced with metaplastic columnar epithelium containing goblet and columnar cells · More resistant to acid and supports esophageal healing · Premalignant tissue · 40-fold risk for development of esophageal adenocarcinoma · Fibrosis and scarring during healing of erosions; leads to strictures 7. Discuss the diagnosis of GERD, risk factors, and treatments - Diagnosis made on history alone; sensitivity of 80% - If symptoms are unclear/patient doesn’t respond to 4 weeks of empiric treatment - Dx made by ambulatory esophageal pH monitoring - pH < 4 above the lower esophageal sphincter and correlates with symptoms = GERD - EGD with biopsy – Barrett’s esophagus - Normal results in 50% of symptomatic patients - Risks o Obesity o Increases after age 50 o Equal across gender, ethnic, and cultural groups - Treatment o Small, frequent meals – main meal at midday o Avoid trigger foods o No bedtime snacks; no eating < 4 hours prior to bed o Eliminate caffeine o Stop smoking o Avoid tight fitting clothing o Sleep with head elevated - Medication: o Step 1: antacids or OTC H2 (Tagamet, zantac, axid) o Step 2: Rx-strength H2 (ranitidine 150mg BID, famotidine 20mg BID) or PPI (pantoprazole 40mg daily, omeprazole 20mg daily) o Step 3: PPI (omeprazole 40mg daily) o Step 4: surgery (fundoplication) 8. Discuss the differential diagnosis of acute abdominal pain, work-up and testing, treatments Diff Diagnosis Acute appendicitis:7  Inflammation of the vermiform appendix; due to obstruction or infection  Most common surgical emergency of the abdomen  Hollow tube – most common cause is obstruction of appendix  Fecaltih – hard lump of fecal matter  Undigested seeds  Pinworm infections  Lymphoid follicle growth/lymphoid hyperplasia Symptoms 4. Symptoms  Nausea/vomiting  RLQ pain  Guarding Acute pancreatitis:  Sudden inflammation and hemorrhaging of the pancreas due to destruction by its own digestive enzymes 1. Autodigestion  Most of the time mild, but can be severe  Pancreas  Cholescintigraphy (HIDA scan)  Radiolabeled marker used to visualize the biliary system  Acute cholecys – ducts are blocked, GB can’t be seen  Endoscopic Retrograde Cholangiopancreatography (ERCP)  Endoscope down to pancreas  Dye injected & viewed via fluoro  Magnetic Resonance Cholangiopancreatography (MRCP) 1. Visualizes bili system with MRI Treatment: Acute appendicitis:  Appendectomy  Antibiotic  Drain abscesses  Can be removed prophylactically Acute pancreatitis: o pain management o hydration o electrolytes o rest bowels  NPO  IV nourishment o Treat complications  O210  ATB Acute cholecystitis: o Supportive measures  IV  Pain management  ATB o Surgical Removal 1. Cholecystectomy 1. Laparoscopic 9. Discuss the difference between sensorineural and conductive hearing loss - Sensorineural: Results from deterioration of cochlea -Loss of hair cells form the organ of Corti -Gradual and progressive -Not correctable but preventable - Conductive: Obstruction between middle and outer ear -Most types are reversible 10. Identify the triad of symptoms associated with Meniere's disease -Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea -S/S: -Vertigo -Hearing loss -Tinnitus 11. Identify the symptoms associated with peritonsilar abscess -Increasing unilateral ear and throat pain ipsilateral to the affected tonsil -Dysphagia -Drooling -Trismus -Erythema -Edema of the soft palate with fluctuance on palpation 12. Identify the most common cause of viral pharyngitis -Adenovirus: MOST common -RSV -Influenza A&B -Epstein-Barr -coxsackie -enteroviruses -herpes simplex11 13. Identify the most common cause of acute nausea & vomiting Gastroenteritis 14. Discuss the importance of obtaining an abdominal xray to rule out perforation or obstruction even though the diagnosis of diverticulitis can be made clinically Abdominal xray films should be obtained on all patients with suspected diverticulitis to look for free air (indicating perforation), ileus, or obstruction 15. Discuss colon cancer screening recommendations relative to certain populations -Anyone over age 50 should have a routine c-scope -African American’s should start screenings at age 40 -Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age ≥60 years can be screened like average-risk persons. **Red flag symptoms should be sent to GI – unintentional weight loss, rectal bleeding, diffuse lower abdomen pain, new onset diarrhea/constipation, early satiety, loss of appetite 16. Identify at least two disorders that are considered to be disorders related to conductive hearing loss -Chronic Otitis Media (OM) -middle ear effusion -mass -vascular anomaly -cholesteatoma – abnormal noncancerous skin growth in ear canal 17. Identify the most common bacterial cause of pharyngitis -Group A Beta Hemolytic Streptococcus (GABHS) -Absence of cough -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy 18. Identify the clinical findings associated with mononucleosis -Fever -Malaise -Severe sore throat -Exudative tonsillitis (50% of cases) -Palatal petchiae -Rash -Anterior/posterior cervical lymphadenopathy12 -Splenic enlargement -POC Monospot test: (+) 19. Identify common characteristics in a rash caused be Group A Strep Sandpaper rash Fine, red, sparing hands & soles 20. Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria -Absence of cough -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy 21. Describe an intervention for a patient with gastroenteritis -Supportive care: fluid and nutrients -Low residue diet (BRAT) – no evidence that this helps, but may be more tolerable for pt -Viral cause = NO antibiotics -Education surrounding not prescribing antibiotics/not spreading germs/eating safe foods -Imodium/Zofran/Phenergan 22. Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea -empirical antimicrobial therapy: Trimethoprim-sulfamethoxazole (Bactrim) 1 PO BID ×3d -ciprofloxacin (Cipro) 500 mg -norfloxacin (Noroxin) 400 mg -ofloxacin (Floxin) 300 mg 23. Identify at least one effective treatment for Irritable Bowel Syndrome (IBS) - For IBS - C o Psyllium (fiber) o docusate (softner) o bisacodyl/senna (stimulant/irritant) o loperamide (antidiarrheal) - For IBS – D o dicyclomine (bentyl), hycosamine sulfate (Levsin) phenobarb/hycosamine (donnatal)  anticholenergics – decrease motility of smooth muscle tone/decrease cramping, relaxes muscles in stomach/intestines o Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): drugs work by acting locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit13 - Antidepressants for depression/anxiety component 24. Identify at least one prescription medication for the treatment of chronic confic factors- changes in weather, exercise, environmental allergens, GERD, Beta blockers, sensitivity to ASA, strong emotional expression To establish the diagnosis of asthma, episodic symptoms of airflow obstruction must be present, airflow obstruction must be at least partially reversible, and must rule out other diagnoses. Spirometry measurements are helpful in diagnosis & in evaluation of management The diagnosis is made by demonstrating the reversibility of the airway obstruction from the preand post- PFTs. Reversibility is defined as a 15% or greater increase in the FEV1 after 2 puffs of a betaadrenergic agonist have been inhaled. When spirometry is non-diagnostic, bronchial provocation testing maybe useful with histamine, methacholine, or exercise. Risk Factors Family or personal history- allergic rhinitis, eczema/atopic diseases Residing in urban area Exposure to smoke or air pollution Cockroaches and dust Viral respiratory infections Cold air intolerance obesity16 Classifications of Asthma Severity Mild Intermittent Symptoms < 2 days per week OR < 2 nights per month. Exacerbations brief Mild Persistent Symptoms > 2 times per week, but not daily; OR 3-4 times per month at nighttime Moderate Persistent Daily symptoms OR >1 night per week but not nightly Severe persistent Symptoms throughout the day; often 7 nights per week Pharmacological Management *Short acting bronchodilator (albuterol) is a mainstay of treatment for ALL asthma patients Intermittent Short-acting bronchodilator (albuterol): for exacerbations (inhaled or nebulized) Mild Persistent Short acting bronchodilator + Preferred tx- Low-dose inhaled corticosteroids (fluticasone/Flovent, budesonide/Pulmicort, mometasone/asmanex Moderate Persistent Short acting bronchodilator + Preferred tx- low to medium dose inhaled corticosteroid AND Long acting inhaled bronchodilator (salmeterol/serevent, formoterol/Foradil) Alternative tx-low to med dose inh. Corticosteroid AND Either leukotriene blocker (Montelukast/singulair) OR theophylline Severe Persistent Short acting bronchodilator + High dose inhaled corticosteroids AND Long acting inhaled bronchodilator AND If needed, oral corticosteroids (2mg/kg/day, 60mg/day max) 5. Describe appropriate tests in the work up for dyspnea -CXR: rule out tumors, TB, pneumonia, and other major pulmonary disorders -CBC with differential: rule out anemia and infection -Peak expiratory flow test (in office): to determine the degree of expiratory airflow obstruction in patients with asthma and COPD -EKG, Echo -Spirometry: to determine obstructive, restrictive and mixed lung disease 6. Discuss clinical findings and PFTs for asthma, chronic bronchitis, emphysema, and COPD - Asthma o Subjective: c/o breathlessness, unable to talk, short sentences, profuse sweating, c/o air hunger. In patients who are severely obstructed, there may be no wheezing and only cough may be present. Wheezing, persistent and recurrent cough, difficulty breathing, tightness in chest, endurance problems during exercise. Symptoms are usually worse at night.17 o Objective: Nasal discharge, mucosal swelling, frontal tenderness, nasal polyps, and allergic ―shiners‖ (dark discoloration beneath both eyes). Allergic rhinitis and eczema often accompany the dx of asthma. - Asthma PFTs o Mild intermittent asthma- FEV1: >80%, PFT >20% o Mild persistent asthma- FEV1: >80%, PFT 20%-30% o Moderate persistent asthma- FEV1: 60%-80%, PFT >30% o Severe persistent asthma- <60%, PFT >30% - Chronic Bronchitis/Emphysema/COPD o Subjective: frequent colds, persistent morning cough, upper respiratory infectionsllowing tineas: pedis, cruris, corporis and unguium and describe an appropriate treatment Tinea Pedis: athletes foot -Antifungal cream: -Ketaconozole for at least 4 weeks -Tinea Cruris: Jock itch -Topical antifungal -Tinea corporis: Ring worm -Topical antifungal cream -Tinea unguium: onychomycosis: fungal infection of the fingernails or toenails -topical agent: Ciclopirox nail laquer 8% applied daily for months at the base of the nail19 9. Identify the virus that causes warts -HPV (Human papilloma virus) 10. Differentiate between atopic and contact dermatitis and give examples of each -Contact Dermatitis: allergic reaction to a substance that produces an immune reaction in your skin resulting in a very pruritic and erythemic rash -Example: Poison Ivy -Atopic dermatitis: a disorder that is the result of a gene variation that affects the skin’s ability to retain moisture and protection from irritants -Example: Eczema 11. Identify common characteristics associated with blepharitis, chalzion and hordeolum -Blepharitis: an inflammation around the eyelid margins that is caused by staphylococcal infection at the lash bases and dysfunctional Meibomian glands -Chalazion: a chronic internal granulomatous reaction of the Meibomian gland that produces a mass in the lid -Hordeolum: Stye: an abscess of the lid margin caused from a staph infection 12. Differentiate between viral, allergic, bacterial, toxic and HSV conjunctivitis Bacterial: Pink eye: purulent discharge -Viral: Adenovirus: watery or mucousy drainage: NOT purulent -Allergic: environmental: uniquely identifying ―bumps‖ on the conjunctiva: follicles -Toxic: Overuse of eye drops: clear/watery discharge/red conjunctiva -HSV: Corneal infection with the hallmark ―dendrite‖ appearance 13. Discuss which chemical injury is associated with the most damage and highest risk to vision loss -Alkali injuries (moderate or severe) cause permanent scarring and vision loss 14. Recognize common eye emergency conditions that require emergency room evaluation -Orbital cellulitis -Chemical exposure -Ruptured globe -Hyphema -Foreign bodies -Moderate to severe subconjunctival hemorrhage -Lid laceration20 15. Discuss glaucoma, diagnosis and treatment Progressive damage to the optic nerve leading to atrophy and blindness. Due to elevated intraoccular pressure Open angle More commonly seen chronic form Good prognosis with treatment S.sx Typically asymptomatic until optic nerve damage Slow gradual onset with slow painless bilateral peripheral vision loss Poor night vision Late s/sx Halos around lights Hardened eyeball Marcus Gunn Pupil Closed angle Acute onset S.sx Rapid onset Significant unilateral eye pain or pressure Redness Visual loss Blurred vision Photophobia Halos around lights Loss of peripheral vision followed by central vision loss Headache n/v "Steamy" appearance to cornea Pale optic disk with excavated cupping If left untreated can lead to permanent vision loss. PCP should closely monitor a family hx of glaucoma or hyperopia with eye ache, headache, dry eye Dx Screening is the most important for PCP's PCP s new blood vessel proliferation Dx diagnosed by hx of DM >10 years and fundoscopic exam changes Tx first goal is prevention Risk increases with BS >200 Keep HgbA1C <7% Only medication shown to slow progressionACE inhibitor - lisinopril Laser surgery if in proliferative stage 3 or significant macular edema22 Week 5 1. Identify the population most commonly affected by bacterial prostatitis o Acute - Sexually active men 30 to 50 years - Chronic bacterial prostatitis common in men older than 50 years old - Athletes who run long distance are predisposed - Complaints of fever, chills, LBP, malaise, arthralgia, myalgia, frequency, urgency, dysuria, nocturia, and bladder outlet obstruction o Chronic bacterial prostatitis- men over age 50 years of age. Symptoms often absent , perineal pain, lower abdomen pain, scrotal or penile pain, pain with ejaculation, dysuria, irritative voiding 2. Discuss the physical exam characteristics of acute bacterial prostatitis Abdominal exam to detect distended bladder, costovertebral angle tenderness, genital exam, and digital rectal exam Acute bacterial prostatitis- warm, tense, swollen , boggy and very tender prostate. Most common pathogen Strep faecalis and staph aureus 3. Discuss how the Phren sign can differentiate between testicular torsion and epididymitis Epididymis characteristic is relief of discomfort with elevation of testis. Positive Prehn’s sign = pain relief. Testicular torsion elevation of the affected testicle does NOT relieve the pain (Negative Prehn’s sign = pain is NOT relieved) Epididymis Positive Prehn’s sign = pain relief. Neg = no pain relief = testicular torsion). 4. Discuss common symptoms reported from a patient with BPH Affects men age 40 years and older. Obstructive symptoms include • Decreased stream • Hesitancy • Postvoid dribbling • Sensation of incomplete bladder emptying • Overflow incontinence • Inability to voluntarily stop the urine stream • Urinary retention • Straining23 Irritative symptoms include • Nocturia • Urinary frequency • Urinary urgency • Dysuria Urge incontinence Erectile dysfunction should be assessed on patient taking finasteride. 5. Discuss the hallmark characteristic of a varicocele The hallmark characteristic of varicocele is the sensation that the testes feel like a ―bag of worms.‖ Varicocele can be bilateral, but if it is unilateral it is almost always on the left side due to the anatomy of the vasculature drainage in the testes. Tortuous veins posterior and above testes can be seen with patient sitting upright Venous engorgement may increase with Valsalva maneuver; resolves when patient lies down. Grade 1 varicocele is one that is palpable only when the patient performs the Valsalva maneuver. Grade 2 varicocele is palpable when the patient is standing. Grade 3 varicocele may be assessed with light palpation and visual inspection 6. Identify the population most affected by testicular cancer Males between the ages of 15 and 35 7. Explain spinal stenosis Narrowing of the spinal canal w/ compression of nerve roots - Congenital or acquired (age) - Most commonly from enlarging osteophytes at the facet joints, hypertrophy of the ligamentum flavum and protrusion/buldging of the intervertebral discs - May produce symptoms by directly pushing on nerve or interrupting the blood supply to nerve Common source of chronic low back pain, seen most with aging. All older people have some degree of this.24 8. Discuss common characteristics (subjective and objective findings) of patients with lumbar spinal stenosis Subjective - Radicular complaints in calves, buttocks, upper thighs - Pain w/ walking or prolonged standing o Vascular claudication – pain stops w/ rest o Psuedoclaskin, alopecia, dry course thick hair GI Diarrhea, Increase in BM Constipation, nausea, hypoactive bowel sounds, ascites, enlarged tongue Eye Blurred vision, tearing, double vision, decreased visual acuity, photophobia, increased orbital pressure, lid lag, exophthalmos, corneal ulcer N/A Neurological Tremors in hands, hyperactive reflexes Memory deficits, personality changes, hyporeflexia, bradykinesia Cardiopulmonary Palpitations, SOBOE, tachycardia, HTN, CHF, A-Fib Exercise intolerance, bradycardia, cardiac enlargement, pleural effusion GU Decreased menstrual flow, gynecomastia Irregular menses, decreased fertility Head & Neck Increased neck size, enlarged thyroid gland Enlarged neck, enlarged tongue (late), hoarseness Psychosocial Anxiety, nervousness, insomnia, irritability, restlessness, emotional lability, Increase in HR, RR, and BP Depression, slowing of mental processes Musculoskeletal Weakness, loss of muscle tone, Osteoporosis in women Muscle weakness and cramping Hematological Fatigue, normochromic normocytic anemia28 16. Describe a goiter and the type of thyroid dysfunction that can be associated with it A goiter is the hypertrophy and hyperplasia of the thyroid gland in response to TSH levels. Most commonly seen with Hashimoto’s thyroiditis (hypothyroidism) in the United States. Toxic multinodular goiter (hyperthyroidism) in iodine deficiency. Grave’s Disease (hyperthyroidism) has a firm goiter. 17. Differentiate between overt hypothyroidism and subclinical hypothyroidism - Overt hypothyroidism o TSH above 10 and FT4 is decreased o Too little hormone is being produced o Pituitary is attempting to get the thyroid to produce more  Low FT4 and high TSH - Subclinical hypothyroidism o TSH levels are increased, but the FT4 is within range o Some have symptoms, others do not 18. Differentiate between Hashimoto’s thyroiditis and Grave’s disease Both are autoimmune, attacking thyroid cells. Graves – overproduction of thyroid leading to hyperthyroidism - 90% of hyperthyroidism cases Hashimoto’s – underproduction of thyroid leading to hypothyroidism -Identified via TPO and TBG Abs in blood 19. Identify at least 3 risks associated with obesity Diabetes, CVD, Afib, HTN, NSTEMI, varicosities, cancer, skin infections, arthritis Gallbladder disease, GERD, acute pancreatitis, NAFLD Stress incontinence, infertility, OSA 20. Identify at least 3 causes of obesity Calorie excess—either overeating or high intake of carbohydrates Food insecurity—eating from a fear of potential hunger or past experience with poor availability of food on a regular basis Genetic pre -Persons with psychiatric disorders (Dunphy, p. 847 & 859 and ―Thyroid Disorders‖ Lecture) 26. Discuss one physical characteristic seen in a hyperthyroid patient -Smooth, velvety skin -Soft, thin hair -Skin with increased pigmentation, spider angiomas, and vitiligo -Onycholysis (splitting and spooning of the nails) -Exophthalmos (buldging eyes) (Dunphy, p. 851 & Hollier, p. 231) Muscle atrophy, tremors, hyperpigmentation, warm flushed moist skin, fine silky hair, thin hair, increased LFT, Exopthalamos, lid lag and edema, corneal ulceration, sinus tach, elevated BP, A.Fib, symptoms of CHF, gynecomastia, osteoporosis, hypercalcemia, potassium wasting31 27. Identify the CDC recommended antibiotic class for treatment of acute bacterial prostatitis -Flouroquinolones (Ciprofloxacin, levofloxacin, ofloxacin, or norfloxacin) (Dunphy, p. 657 & ―Male GU Problems‖ Lecture) Alternatives to a fluoroquinolone include Doxycycline 100 mg Q 12 hours; and TMP-SMX [160 mg/800 mg] (Bactrim DS) one tab Q 12 hours 28. Identify at least one treatment for BPH -Medication (conservative): -Alpha Blockers (Terazosin, Tamsulosin) -5-alpha Reductase Inhibitors (finasteride, dutasteride) -Surgical -TURP (transurethral resection of the prostate) 29. Identify treatment options for obesity based on BMI and comorbid conditions Overweight BMI: 25-29.9kg/m2 Obesity BMI: 30-40 kg/m2 Severe (morbid) obesity BMI: >40kg/m2 Treatment options: lifestyle changes (diet, exercise- 45-60 minutes/day), managing behavior (i.e. H.A.L.T. – hungry, angry, lonely, tired, behavior modification), reduce caloric intake, drugs (i.e. fenfluramine/Fen Phen, dexfenfluramine/Redux, phentermine, diethylopropion, orlistat). Surgical intervention (vertical-banded (mason) gastroplasty and roux-en-Y bypass) for BMI over 40 OR over 35 with comorbities A structured weight loss diet is most effective. Encourage formal programs or weight loss groups (WW, etc.). Diet goals should include a program with 1200–1500 calories per day for women and 1500–1800 calories per day for men; 500–750 calorie deficit per day; low CHO diet, increased fiber, and decreased saturated fats; and less than 800 calories per day in certain circumstances under medical supervision.32 30. Describe the Spurling test and what condition it is used to diagnose Spurling’s maneuver assesses nerve root compression (i.e. radiculopathy) in the neck resulting in pain. - Spurling’s maneuver: o With patient’s neck in extension, rotate the neck to the affected side o Apply downward pressure on the head o Assess for patient complaint of or accentuation of limb pain or paresthesia (THIS IS A POSITIVE SIGN). Also, observe for neck atrophy. 31. Describe how to perform a Phalen and Tinnel test A. Phalen test: Purpose: Assess for median nerve compression Procedur IV drug users Healthcare workers 6. Describe at least one pharmacologic treatment option for tremor Primidone (Mysoline) - beta blocker benzodiazepine (lorazepam) If monotherapy is ineffective, REFER TO NEURO If the tremor is medication induced, that agent may be reduced or eliminated. Parkinson’s disease - Dopamine agonist o Carbidopa/levodopa (Sinemet) o Pramipexole (Mirapex) o Ropinirole (Requip) - Anticholenergics o Benztropine (Cogentin) o Trihexyphenidyl (Artane) - If pharmacological therapy has been ineffective, localized botox injections may be considered - Deep brain stimulation in severe cases. - If tremor is due to alcohol withdrawal: diazepam, lorazepam (mild symptoms)36 7. Describe an appropriate empiric antibiotic treatment plan for cellulitis Cellulitis = bacterial infection most commonly group A beta-hemolytic streptococcus or staphylococcus aureus (gram positive) tx = dicloxacillin or cephalexin for 10-14 days if PCN allergy, erythromycin If caused by animal or human bite: amoxicillin-clavulanic acid (augmentin) for 2 weeks 8. Discuss an intervention to prevent HIV and HIV-associated behaviors *safe sex practices - latex condoms *needle exchange programs *universal testing of donated blood products *education to HIV positive women of childbearing age about c-sections, arv drugs for mother and baby *voluntary HIV testing a routine part of medical care *new models for HIV diagnosing outside medical setting *prevent new infection by working with HIV infected and their partners to minimize risk 9. Identify physical exam findings in the patient with HIV fever, sore throat, myalgia, headaches, cervical lymphadenopathy, night sweats, majority are asymptomatic flu-like sumptoms 6 days to 6 weeks after viral transmission dark purple colored spots (karposi's sarcoma) non-productive cough, SOB, and fever for several weeks pulmonary symptoms: pcp pneumonia, tb, bacterial pneumonia localized candida infections other STD's weight loss anemia, leukopenia, and/or thrombocytopenia 10. Describe symptoms, DDx, pathogens, testing, and treatment for the following conditions: Cellulitis, impetigo, MRSA, Bites (dogs, cats, humans), Erysipelas - Cellulitis o Pathogens  Strep (A,B,C,G,F)  Staph37 o Symptoms  Skin erythema, edema, warmth, pain, possible fever  Lymphangitis, lymphadenopathy, peau d’orange (orange peel texture)  No fever/chills, localized symptoms only  Underlying infection, lymphedema, venous insufficiency o Treatment  I&D if abscess is involved Patients with cellulitis should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) with:  Cephalexin 500 mg four times daily (alternative for mild penicillin allergy)  Clindamycin 300 mg to 450 mg four times daily (alternative for severe penicillin allergy) - Erysipelas o Pathogens  Group A Strep o Symptoms  Skin erythema, edema, warmth, pain, possible fever  Lymphangitis, lymphadenopathy, peau d’orange (orange peel texture)  Copiously irrigate with sterile saline  Remove grossly visible debris  Prophylactic ATB are given if  Deep puncture wounds  Wounds requiring surgical repair  Moderate to severe wounds w/ associated crush injury  Wounds in areas of underlying venous and/or lymphatic compromise  Wounds on the hands or in close proximity to a bone or joint  Wounds on the face or in the genital area  Immunocompromised hosts