NSG 6420 Midterm Exam (pH, Gerontology, Genetic disorder) | 100% Correct Answers with instructor explanations | South University

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Gerontology Class…. Week 1: 1. Question : The major impact of the physiological changes that occur with aging is: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunol... ogical response CORRECT All of the above Instructor Explanation: The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. (Kennedy-Malone 3) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 2. Question : Men have faster and more efficient biotransformation of drugs and this is thought to be due to: Less obesity rates than women Prostate enlargement CORRECT Less estrogen than women Instructor Explanation: Men have faster and more efficient biotransformation, presumably because of serum testosterone. Conditions of increased or decreased liver perfusion alter the overall level of the drug that is absorbed and how it is metabolized. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : The cytochrome p system involves enzymes that are generally: Inhibited by drugs Induced by drugs CORRECT Inhibited or induced by drugs Associated with decreased liver perfusion Instructor Explanation: Biotransformation occurs in all body tissues but primarily in the liver, where enzymatic activity (cytochrome P [CYP] system) alters and detoxifies the drug and prepares it for excretion. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 4. Question : Functional abilities are best assessed by: Self-report of function CORRECT Observed assessment of function A comprehensive head-to-toe examination Family report of function Instructor Explanation: Two well-established tools used to evaluate function in older adults are the Katz Activities of Daily Living Scale (Katz et al., 1963) and the Lawton and Brody scale for Instrumental Activities of Daily Living (Lawton & Brody, 1969). It is important to be cautious about self- report of function (rather than direct observation of function) and to ask, “Do you …?” instead of “Can you …?” in order to determine if patients actually perform the activity. (Kennedy-Malone 40) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 5. Question : Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data? Hemoglobin and Hematocrit CORRECT Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and serum iron Total iron binding capacity and transferrin saturation Instructor Explanation: RBC indices reveal an MCV (mean corpuscular volume/RBC size) that will be decreased to <80 fL in adults; MCH (mean corpuscular hemoglobin/RBC color) will show hypochromia or pale cells; RBC distribution width (RDW)/volume variation will be increased. (Kennedy-Malone page 519) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 6. Question : When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD): Hemoglobin <12 g/dl, MCV decreased, MCH decreased Hemoglobin >12 g/dl, MCV increased, MCH increased CORRECT Hemoglobin <12 g/dl, MCV normal, MCH normal Hemoglobin >12 g/dl, MCV decreased, MCH increased Instructor Explanation: Hemoglobin (Hgb): <12 g/dL (120 g/L) women <13 g/dL (130 g/L) men Rarely <10 g/dL (100 g/L) Mean corpuscular volume: 80–96 mcm3 (normocytic) Mean corpuscular hemoglobin Normochromic (normal color) RBC distribution width: normal (Kennedy-Malone page 517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 7. Question : The pathophysiological hallmark of ACD is: Depleted iron stores CORRECT Impaired ability to use iron stores Chronic uncorrectable bleeding Reduced intestinal absorption of iron Instructor Explanation: The pathophysiological hallmark of ACD is a disregulation of iron homeostasis, characterized by an increased uptake and retention of iron within the cells of the reticuloendothelial system (liver/spleen), resulting in decreased RBC production. Essentially, iron is present but inaccessible for use in the production of Hgb with the erythrocytes (Bross et al., 2010). A shortened RBC survival is also a contributing factor to ACD. (Kennedy-Malone page 516-517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 8. Question : The main focus of treatment of patients with ACD is: Replenishing iron stores Providing for adequate nutrition high in iron CORRECT Management of the underlying disorder Administration of monthly vitamin B12 injections Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 9. Question : In addition to the complete blood count (CBC) with differential, which of the following laboratory tests is considered to be most useful in diagnosing ACD and IDA? Student Answer: Serum iron Total iron binding capacity Transferrin saturation CORRECT Serum ferritin Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file Question 10. Question : Symptoms in the initial human immunodeficiency virus (HIV) infection include all of the following except: Sore throat Fever CORRECT Weight loss Headache Instructor Explanation: Signal symptoms: The initial HIV infection is characterized by mononucleosis-like illness with fever, sore throat, lymphadenopathy, headache, and fatigue. A roseola- like rash may also develop. These initial symptoms are followed by an asymptomatic phase, which may last 10 years or more. Later, if untreated, lymphadenopathy, weight loss, myalgias, and diarrhea may develop (Cohen, Kuritzkes, & Sax, 2011). In advanced disease, malignancies and opportunistic infections occur. Co-infection with hepatitis B or C is common (25% to 30%) in IV drug users, so hepatitis symptoms may also appear (Centers for Disease Control and Prevention [CDC], 2010a). (Kennedy-Malone page 521) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 11. Question : Essential parts of a health history include all of the following except: Chief complaint History of the present illness CORRECT Current vital signs All of the above are essential history components Instructor Explanation: Vital signs are part of the physical examination portion of patient assessment, not part of the health history. Question 12. Question : Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? Clinical practice guideline CORRECT Clinical decision rule Clinical algorithm Clinical recommendation Instructor Explanation: Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. Goolsby page 7 Question 13. Question : The first step in the genomic assessment of a patient is obtaining information regarding: CORRECT Family history Environmental exposures Lifestyle and behaviors Current medications Instructor Explanation: A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). Goolsby page 18 Question 14. Question : In autosomal recessive (AR) disorders, individuals need: Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease CORRECT Two mutated genes to acquire the disease Two mutated genes to become carriers Instructor Explanation: In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. Goolsby page 28 Question 15. Question : In AR disorders, carriers have: Two mutated genes; two from one parent that cause disease A mutation on a sex chromosome that causes a disease A single gene mutation that causes the disease CORRECT One copy of a gene mutation but not the disease Instructor Explanation: Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. Goolsby page 28 Question 16. Question : A woman with an X-linked dominant disorder will: Not be affected by the disorder herself CORRECT Transmit the disorder to 50% of her offspring (male or female) Not transmit the disorder to her daughters Transmit the disorder to only her daughters Instructor Explanation: Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). Goolsby page 29 Question 17. Question : According to the Genetic Information Nondiscrimination Act (GINA): Nurse Practitioners (NPs) should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information CORRECT All of the above Instructor Explanation: On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). Goolsby page 43 Question 18. Question : Which of the following would be considered a “red flag” that requires more investigation in a patient assessment? Colon cancer in family member at age 70 Breast cancer in family member at age 75 CORRECT Myocardial infarction in family member at age 35 All of the above Instructor Explanation: Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders. Goolsby page 36 Question 19. Question : Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: Variable expressivity related to inherited disease CORRECT Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease Instructor Explanation: Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302). Goolsby page 37 Question 20. Question : In order to provide a comprehensive genetic history of a patient, the NP should: Ask patients to complete a family history worksheet Seek out pathology reports related to the patient’s disorder Interview family members regarding genetic disorders CORRECT All of the above Instructor Explanation: Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted. Week 2: 1. Question : An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: Acoustic neuroma CORRECT Cerumen impaction Otitis media Ménière’s disease Instructor Explanation: Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear. (Goolsby 137-138) Conductive hearing loss is caused by a lesion involving the outer and middle ear to the level of the oval window. Various structural abnormalities, cerumen impaction, perforation of the tympanic membrane, middle ear fluid, damage to the ossicles from trauma or infection, otosclerosis, tympanosclerosis, cholesteatoma, middle ear tumors, temporal bone fractures, injuries related to trauma, and congenital problems are some of the causes. (Kennedy-Malone 170-171) Question 2. Question : In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: Bacterial sinusitis CORRECT Allergic rhinitis Drug abuse Skull fracture Instructor Explanation: When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies. (Goolsby 128-129) Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Question 3. Question : A 45 year old patient presents with ‘sore throat’ and fever for one week. After a quick strep screen you determine the patient has Strep throat. You know that streptococcal pharyngitis should be treated with antibiotics to prevent complications and to shorten the course of disease. Which of the following antibiotics should be considered when a patient is allergic to Penicillin? Amoxicillin CORRECT EES (erythromycin) Bicillin L-A Dicloxacillin Instructor Explanation: MedU Card #1 Question 4. Question : Presbycusis is the hearing impairment that is associated with: CORRECT Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster Instructor Explanation: Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea as well as decreased elasticity of the TM. Although the changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65. (Goolsby 138) Because presbycusis is gradual and insidious, hearing loss may go unnoticed until it has progressed significantly. (Kennedy-Malone 170) Question 5. Question : Epistaxis can be a symptom of: Over-anticoagulation Hematologic malignancy Cocaine abuse CORRECT All of the above Instructor Explanation: Cocaine abuse, which is more common than might be expected, frequently causes epistaxis. Hematologic disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and bleeding from the gums. (Goolsby 142) Epistaxis results from a spontaneous rupture of a blood vessel in the nose, usually in the anterior septum in Kiesselbach's plexus (Nguyen, 2012). The bleeding may be secondary to local infections, systemic infections, drying of the nasal mucous membrane, trauma, arteriosclerosis, hypertension, or bleeding disorders. Trauma is usually the primary mechanism of disruption of the nasal mucosa. Posterior epistaxis can result in nausea and respiratory compromise. In older adults, nasal and paranasal tumors may be involved (Mäkitie, 2010). (Kennedy-Malone 168-169) Question 6. Question : Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by erythematous base on the side of his tongue. The clinician should recognize that very often this is: Malignant melanoma CORRECT Squamous cell carcinoma Aphthous ulceration Behcet’s syndrome Instructor Explanation: Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds. Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation. Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers. The number of lesions ranges from one to several; the size of the ulcers varies from less than to greater than 1 cm. Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes. (Goolsby 153) Tobacco use and heavy alcohol consumption, alone or synergistically, are strongly related to the development of oral cancer. Pipe smoking and sun exposure have been implicated in lip cancer. Leukoplakia and erythroplasia are often precursors to oral cancer. Relationships between oral cancer and Epstein-Barr virus, HPV, herpes simplex virus, and immunodeficiency states also have been found (Stenson, 2011). (Kennedy-Malone 177). Question 7. Question : A 26 year old patient presents with cough and general malaise for 3 days. They note that their eyes have been watering clear fluid and a ‘runny nose’ since yesterday. They note they ‘feel miserable’ and demand something to make them feel better. What would be the best first plan of treatment? CORRECT Saline nasal spray for congestion and acetaminophen as needed for pain. Z-pack (azithromycin) for infection and Cromolyn nasal for congestion Hydrococone/acetaminophen as needed for pain and Guaifensin for congestion Cephalexin for infection and Cromolyn ophthalmic for congestion Instructor Explanation: MedU Card #4 Question 8. Question : Which of the following findings should trigger an urgent referral to a cardiologist or neurologist? History of bright flash of light followed by significantly blurred vision CORRECT History of transient and painless monocular loss of vision History of monocular severe eye pain, blurred vision, and ciliary flush All of the above Instructor Explanation: Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. (Goolsby 108) Question 9. Question : Dizziness that is described as "lightheaded" or, "like I'm going to faint," is usually caused by inadequate cerebral perfusion and is classified as? CORRECT Presyncope Disequilibrium Vertigo Syncope Instructor Explanation: MedU Card #5 Question 10. Question : It is important to not dilate the eye if is suspected. Cataract Macular degeneration CORRECT Acute closed-angle glaucoma Chronic open-angle glaucoma Instructor Explanation: If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure. (Goolsby 108) Acute glaucoma, also known as angle-closure or narrow-angle glaucoma, is an obstruction to the outflow of aqueous humor from the posterior to the anterior chamber through the trabecular meshwork, canal of Schlemm, and associated structures. It results in an elevation of intraocular pressure, damaging the optic nerve and causing loss of peripheral vision, eye pain, and redness. This type of glaucoma is uncommon but may occur as a primary disease or secondary to other conditions and constitutes an ophthalmic emergency (Kennedy-Malone 161) Question 11. Question : Mr. GC presents to the clinic with nausea and vomiting for 2 days, prior to that time he reports occasional ‘dizziness’ that got better with change in position. He denies a recent history of URI or any history of headaches or migraines. What would the most likely diagnosis be? Vestibular neruitis CORRECT Benign paroxysmal positional vertigo Vestibular migraine Benign hypertensive central vertigo Instructor Explanation: MedU Card #9 Question 12. Question : Which of the following patients with vertigo would require neurologic imaging? CORRECT A 68-year-old woman with a history of hypertension and sudden acute onset constant vertigo. She has right nystagmus that changes direction with gaze and that does not disappear when she focuses. A 45-year-old man with recurrent episodes of brief intense vertigo every time he turns his head rapidly. He has no other neurologic signs or symptoms. He has a positive Dix-Hallpike maneuver. A 66-year-old man with recurrent episodes of vertigo associated with tinnitus and hearing loss. His head thrust test is positive. A 28-year-old otherwise well woman with new onset constant vertigo with no other neurologic symptoms. On physical exam, she has unidirectional nystagmus that disappears when her gaze is fixed. Instructor Explanation: MedU Card #11. There are multiple reasons to be concerned about a central lesion and possible infarct in this patient. Her age puts her at risk as does her hypertension. Her physical exam shows nystagmus that changes direction and that does not inhibit with focus. Both of these findings are consistent with a central lesion. She needs an urgent MRI. Question 13. Question : A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: Bacterial conjunctivitis Allergic conjunctivitis Chemical conjunctivitis CORRECT Viral conjunctivitis Instructor Explanation: Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis. (Goolsby 112) Question 14. Question : In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness? History of prior red-eye episodes CORRECT Grossly visible corneal defect Exophthalmos Photophobia Instructor Explanation: Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible. (Goolsby 112) Question 15. Question : A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation? Bacterium CORRECT Allergen Virus Fungi Instructor Explanation: Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Question 16. Question : Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following? Sinus pain, increased vascular permeability, and bronchodilation CORRECT Bronchospasm, vascular permeability, and vasodilatation Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability Instructor Explanation: Rhinitis may be either allergic or nonallergic. Allergic rhinitis results as a response of the nasal mucosa to airborne allergens in atopic genetically prone individuals. This response is mediated by the production of immunoglobulin E (IgE). IgE antibodies produced in response to the initial and subsequent exposure to allergens bind to the nasal mucosa. With repeated exposure, immediate type 1 hypersensitivity reactions may occur (Simoens & Laekeman, 2009). Antigen-specific T cells are activated through the lymphatic system in response to the antigen. The activated antigen- specific T cells activate B cells, and IgE is created in lymphoid tissue and at local tissue sites (Adelman, Casale, & Corren, 2002; Novak, 2009). The newly created antigen-specific IgE is released by plasma cells and binds to high-affinity IgE receptors located on the basophils and mast cells. This leads to the sensitization of the cells in the tissues of the nose, lung, or skin (Adelman et al., 2002; Cirillo, Pistorio, Tosca, & Ciprandi, 2009). IgE also binds with the antigen protein, beginning degranulation of the mast cells and basophils. These actions start the allergic cascade. Mediators are released as a result of the degranulation and include histamine, proteoglycans, enzymes, leukotrienes, cytokines, and many others. The chain in the release of mediators is responsible for the immediate and late phase responses of the cells. Histamine may be fully released within 30 minutes of degranulation, whereas cytokines may be released over many hours (Adelman et al., 2002; Derendorf & Meltzer, 2008). (Kennedy-Malone 181- 182) Question 17. Question : You have a patient complaining of vertigo and want to know what could be the cause. Knowing there are many causes for vertigo, you question the length of time the sensation lasts. She tells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions? CORRECT Ménière’s disease Benign paroxysmal positional vertigo Transient ischemic attack (TIA) Migraine Instructor Explanation: Ménière's disease commonly involves a triad of symptoms—severe vertigo, tinnitus, and hearing loss (Goolsby 140) Question 18. Question : In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion? Fictional keratosis Keratoacanthoma Lichen planus CORRECT Leukoplakia Instructor Explanation: The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol. (Goolsby 152) Question 19. Question : Rheumatic heart disease is a complication that can arise from which type of infection? Epstein-Barr virus Diphtheria CORRECT Group A beta hemolytic streptococcus Streptococcus pneumoniae Instructor Explanation: Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. (Goolsby 156) Question 20. Question : A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered? Mono spot Strep test Throat culture CORRECT All of the above Instructor Explanation: The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A CBC with differential count is helpful in determining the cause of sore throat. (Goolsby 156) Week3: 1. Question : Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? Seasonal allergies Acute bronchitis Bronchial asthma CORRECT Chronic bronchitis Instructor Explanation: The pulmonary component includes an abnormal inflammatory response to noxious stimuli, principally tobacco, but also occupational and environmental pollutants. The hallmark of chronic bronchitis is a daily chronic cough with increased sputum production lasting for at least 3 consecutive months in at least 2 consecutive years, usually worse on awakening; this may or may not be associated with COPD (GOLD, 2011). Emphysema is characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) &Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Question 2. Question : A patient presents complaining of a 5 day history of upper respiratory symptoms including nasal congestion and drainage. On the day the symptoms began he had a low-grade fever that has now resolved. His nasal congestion persisted and he has had yellow nasal drainage for three days associated with mild headaches. On exam he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinus. What would your treatment plan for this patient be? CORRECT Observation and reassurance Treatment with an antibiotic such as amoxicillin Treatment with an antibiotic such as a fluoroquinoline or amoxicillin-clavulanate Combination of a low dose inhaled corticosteroid and a long acting beta2 agonist inhaler. Instructor Explanation: MedU Card #4. According to the American Academy of Ortolaryngology —Head and Neck Surgery Foundation guidelines (2007) on sinusitis, making the distinction between a lingering viral upper respiratory infection that affects the nose and sinuses (viral rhinosinusitis) or early acute bacterial sinusitis can be difficult. It is more likely to be a viral rhinosinusitis if the duration of symptoms is less than ten days and they are not worsening. In this case, you can continue to observe the patient and reassure him that antibiotics are not necessary at this time. Question 3. Question : Emphysematous changes in the lungs produce the following characteristic in COPD patients? Asymmetric chest expansion Increased lateral diameter CORRECT Increased anterior-posterior diameter Pectus excavatum Instructor Explanation: In COPD, patients commonly develop a barrel-shaped chest due to emphysematous changes in the lungs. A barrel shape is due to an increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally the AP diameter is twice the lateral diameter. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file( page 213-214)&Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Question 4. Question : When palpating the posterior chest, the clinician notes increased tactile fremitus over the lef t lower lobe. This can be indicative of pneumonia. Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. In the instance of an extensive bronchial obstruction: CORRECT No palpable vibration is felt Decreased fremitus is felt Increased fremitus is felt Vibration is referred to the non-obstructed lobe Instructor Explanation: Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 209)&Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 193) Question 5. Question : Your patient presents with complaint of persistent cough. After you have finished obtaining the History of Present Illness, you realize that the patient may be having episodes of wheezing, in addition to his cough. The most common cause of cough with wheezing is asthma. What of the following physical exam findings will support your tentative diagnosis of asthma? CORRECT Clear, watery nasal drainage with nasal turbinate swelling Pharyngeal exudate and lymphadenopathy Clubbing, cyanosis and edema. Diminished lung sounds with rales in both bases Instructor Explanation: MedU Card #9 Question 6. Question : Which of the following imaging studies should be considered if a pulmonary malignancy is suspected? CORRECT Computed tomography (CT) scan Chest X-ray with PA, lateral, and lordotic views Ultrasound Positron emission tomography (PET) scan Instructor Explanation: For pulmonary malignancy, chest films are often nondiagnostic, although they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically diagnostic. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 251) Question 7. Question : A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Exercise-induced cough Bronchiectasis CORRECT Alpha-1 deficiency Pericarditis Instructor Explanation: When younger patients or nonsmokers develop findings consistent with COPD, alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Question 8. Question : Upon assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to: CORRECT Pneumothorax Pleural effusion Pneumonia Pulmonary embolism Instructor Explanation: The respiratory excursion, or expansion, is determined by placing hands around the patient’s posterior rib cage with the thumbs approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced COPD and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 208-209) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (pages 193 & 227) Question 9. Question : A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely? Pulmonary edema Heart failure CORRECT Pulmonary embolism Pneumonia Instructor Explanation: The problem may occur when these symptoms are attributed to aging or existing comorbidities. Dyspnea (acute onset), anxiety or apprehension, pleuritic chest pain, cough, tachypnea, and accentuation of the pul-monic component of S2 are frequently present and may be accompanied by diaphoresis, syncope, tachycardia, S3 or S4 gallop, hypoxemia, or hemoptysis . Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 246) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 202) Question 10. Question : A cough is described as chronic if it has been present for: 2 weeks or more CORRECT 8 weeks or more 3 months or more 6 months or more Instructor Explanation: Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 211) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. ((page 206) Question 11. Question : Testing is necessary for the diagnosis of asthma because history and physical are not reliable means of excluding other diagnoses or determining the extent of lung impairment. What is the study that is used to evaluate upper respiratory symptoms with new onset wheeze? Chest X-ray Methacholine challenge test CORRECT Spirometry, both with and without bronchodilation Ventilation/perfusion scan Instructor Explanation: MedU Card #10 Question 12. Question : In classifying the severity of your patient presenting with an acute exacerbation of asthma. You determine that they have moderate persistent symptoms based on the report of symptoms and spirometry readings of the last 3 weeks. The findings that support moderate persistent symptoms include: CORRECT Symptoms daily with nighttime awakening more than 1 time a week. FEV1 >60%, but predicted <80%. FEV1/FVC reduced 5% Symptoms less than twice a week and less than twice a week nighttime awakening. FEV1 >80% predicted. FEV1/FVC normal Symptoms more than 2 days a week, but not daily. Nighttime awakenings 3-4 times a month. FEV1 >80% predicted. FEV1/FVC normal Symptoms throughout the day with nighttime awakenings every night. FEV1< 60% predicted. FEV1/FVC reduced >5% Instructor Explanation: MedU Card #15 Question 13. Question : The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home: Age over 40 Fever greater than 101 CORRECT Tachypnea greater than 30 breaths/minute Productive cough Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN greater than 20mg/dL Respiratory rate of ≥ 30 breaths/minute Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.( page 241) Question 14. Question : Medications are chosen based on the severity of asthma. Considering the patient that is diagnosed with moderate persistent asthma, the preferred option for maintenance medication is: High-dose inhaled corticosteroid and leukotriene receptor antagonist Oral corticosteroid—high and low dose as appropriate Short acting beta2 agonist inhaler and theophylline CORRECT Low dose inhaled corticosteroid and long acting beta2 agonist inhaler Instructor Explanation: MedU Card #16 Question 15. Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: Can be treated as an outpatient CORRECT Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN is greater than 20mg/dl Respiratory rate of ≥ 30 breaths/minute Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) Question 16. Question : Which of the following is considered a “red flag” when diagnosing a patient with pneumonia? Fever of 102 Infiltrates on chest X-ray CORRECT Pleural effusion on chest X-ray Elevated white blood cell count Instructor Explanation: With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 214) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 240) Question 17. Question : A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following: Barrel-shaped chest CORRECT Clubbing Pectus excavatum Prolonged capillary refill Instructor Explanation: In bronchiectasis, there is usually a history of chronic, productive cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 216) Question 18. Question : Your patient has just returned from a 6-month missionary trip to Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect: Legionnaires' disease Malaria CORRECT Tuberculosis Pneumonia Instructor Explanation: Many times, patients with active tuberculosis are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive complaints. When respiratory symptoms occur with tuberculosis, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect tuberculosis when the patient has travelled to a country where TB is endemic, such as Asia. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 249) Question 19. Question : A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the lef t lower lung field. The chest X-ray demonstrates shif t of the mediastinum and trachea to the left. These are classic signs of: CORRECT Lung cancer Tuberculosis Pneumonia COPD Instructor Explanation: Dyspnea is the most common symptom associated with pleural effusion, but effusion may be accompanied by cough, pain, and systemic symptoms, such as malaise and fever. Abnormal physical findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.(page 232) Question 20. Question : A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. Upon examination, you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the lef t lower lobe. It is most important to suspect: Pulmonary embolism Pleural effusion CORRECT Pneumothorax Fracture of ribs Instructor Explanation: Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest. There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 221) Week 4: 1. Question : Which of the following is the most important question to ask during cardiovascular health history? Number of offspring Last physical exam CORRECT Sudden death of a family member Use of caffeine Instructor Explanation: The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke. Family history is particularly important for cardiac assessment because CVD, HTN, hyperlipidemia, and other vascular diseases often have a familial association that is not easily ameliorated by lifestyle changes. If there are deaths in the family related to CVD, determine the age and exact cause of death, because CVD at a young age in the immediate family carries an increased risk compared with CVD in an elderly family member. Ask about sudden death, which might indicate a congenital disease such as Marfan's syndrome. This is especially important to ask during pre-sports physicals because sudden death in athletes is often related to congenital or familial heart disease. Familial hyperlipidemia is autosomal dominant and often leads to CAD and MI at a young age. Family history of obesity and type 2 diabetes are also secondary risk factors for heart disease because the familial tendency for these is strong. Ask about smoking in the house, as secondhand smoke is a risk factor for respiratory and cardiac disease. (Goolsby 167-168) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 2. Question : A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: a. Women with ischemic heart disease many times do not present with chest pain b. Some patients may have no symptoms or atypical symptoms; diagnosis may only be made at the time of an actual myocardial infarction c. Elderly patients have the most severe symptoms CORRECT A & B only Instructor Explanation: The key symptom of IHD is chest pain, but other common symptoms include arm pain, lower jaw pain, shortness of breath, and diaphoresis. These symptoms are referred to as angina equivalents and can also include fatigue or breathlessness. Some patients may have no symptoms or atypical ones so that CAD may not be diagnosed until they experience a myocardial infarction. (Kennedy-Malone 227) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: Echocardiogram CORRECT Exercise stress test Cardiac catheterization Myocardial perfusion imaging Instructor Explanation: Once all the results of the initial laboratory and ECG testing are reviewed, a pretest probability of disease can be generated and additional tests can be ordered.2 The probability of CAD can be calculated by considering the chosen noninvasive test's sensitivity and specificity.2 Selection of the proper cardiac test (see Table 115-1) for an individual depends on the person's risk stratification, age, and tolerable level of activity. The most common and least invasive test for diagnosis of CAD is the stress test, also called the exercise tolerance test (ETT) or treadmill exercise. (Buttaro 488) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. Question 4. Question : Jenny is a 24 year old graduate student that presents to the clinic today with complaints of fever, midsternal chest pain and generalized fatigue for the past two days. She denies any cough or sputum production. She states that when she takes Ibuprofen and rest that the chest pain does seem to ease off. Upon examination the patient presents looking very ill. She is leaning forward and states that this is the most comfortable position for her. Temp is 102. BP= 100/70. Heart rate is 120/min and regular. Upon auscultation a friction rub is audible. Her lung sounds are clear. With these presenting symptoms your initial diagnosis would be: Mitral Valve Prolapse Referred Pain from Cholecystitis CORRECT Pericarditis Pulmonary Embolus Instructor Explanation: Pericarditis, inflammation of the pericardium, is usually not a solo disease process but is seen in conjunction with other diseases or conditions. Pericarditis may occur as a complication of MI (Dressler's syndrome) or coronary artery bypass surgery. It is also more commonly seen in patients with connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosus (SLE), scleroderma, and sarcoidosis. Bacterial, viral, or fungal infections, including HIV, are risk factors for pericarditis. Pericarditis can occur with kidney failure or metastatic neoplasias or as a reaction to medication, particularly phenytoin, hydralazine, and procainamide. Rarely, it is idiopathic and the cause unknown, although a common viral infection is suspected. Cardiac tamponade can occur as a serious complication, and it is an emergency requiring immediate pericardiocentesis. Constrictive pericarditis can occur over time due to scarring of the pericardial sac. Signs and Symptoms Unlike the symptoms associated with ACS, the pain accompanying pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise. (Goolsby 179) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 5. Question : Which symptom is more characteristic of Non-Cardiac chest pain? Pain often radiates to the neck, jaw, epigastrium, shoulder, or arm CORRECT Pain tends to occur with movement, stretching or palpation Pain usually lasts less than 10 minutes and is relieved by nitroglycerine Pain is aggravated by exertion or stress Instructor Explanation: Palpate chest wall for tenderness and swelling. Chest pain present in only one body position is usually not cardiac in origin. (MSN 194) MSN, Jill C. C., FNP-BC. Family Practice Guidelines: Third Edition, 3rd Edition. Springer Publishing Company, 2014-02-01. VitalBook file. Question 6. Question : What is the most common valvular heart disease in the older adult? Aortic regurgitation CORRECT Aortic stenosis Mitral regurgitation Mitral stenosis Instructor Explanation: Age: Present in 2% to 9% of persons over age 65, aortic stenosis is the most clinically significant cardiac valve lesion (Faggiano, 2006). Isolated aortic regurgitation is rarely seen and is usually accompanied by some degree of mitral valve involvement. Mitral regurgitation is more common than mitral stenosis in elderly individuals. Mitral valve disease, commonly caused by rheumatic heart disease, is usually acquired by younger patients; however, the effects may not be seen until they are in their forties or fifties. Mitral valve stenosis has a progressively slow course with latent symptoms over 20 to 40 years followed by rapid acceleration in later life. (Kennedy-Malone 259) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 7. Question : Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, and shortness of breath. The pain comes and goes and is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the lef t nipple. Jeff is concerned because his father has cardiac disease and underwent a CABG at age 65. The ANP examines Jeff and hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of: Angina Pericarditis CORRECT Mitral valve prolapse Congestive heart failure Instructor Explanation: Mitral valve prolapse Sharp left anterior chest pain, generally occurring in response to stress or emotional events Chest discomfort lasting seconds to days Palpitations and dyspnea Mitral valve click may be noted in systole at left lower sternal border (Buttaro 529) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. MVP, also termed click-murmur syndrome, is a variant of mitral regurgitation and occurs in approximately 10% of young women. MVP generally is hemodynamically insignificant and characterized by normal heart size and dynamics, although the process can progress to hemodynamically significant mitral regurgitation. Characteristically, a portion of the mitral valve balloons into the left atrium, giving rise to a midsystolic click followed by a soft grade I murmur that crescendos up to S2. It is high-pitched and is heard best at the apex or left sternal border. Some patients with MVP have only a murmur and no click, and others have only a click and no murmur. (Goolsby 185) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 8. Question : The aging process causes what normal physiological changes in the heart? CORRECT The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis Cardiology occurs along with prolapse of the mitral valve and regurgitation Dilation of the right ventricle occurs with sclerosis of pulmonic and tricuspid valves Hypertrophy of the right ventricle Instructor Explanation: The aging process can also have an adverse effect on the cardiac valves. The valves tend to become thick and stiff secondary to arteriosclerosis and atherosclerotic plaques. (Kennedy-Malone 201) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. During the past three decades, with the successful treatment of streptococcal pharyngitis, the etiology has shifted away from rheumatic to calcific. All such cases share a history of 20 to 30years of repetitive mechanical trauma of the blood against the valve, resulting in fibrosis, calcification, and eventually stenosis. This progress of calcification within the valve cusps is usually seen during the latter decades of life. An inflammatory process similar to that affecting the development of atherosclerotic plaques in coronaries may be a possible cause of the progression of AS. It has been noted that early lesions and calcification in AS are comparable to those found in coronary plaques.4 (Buttaro 602) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. Question 9. Question : Dan G., a 65-year-old man, presents to your primary care office for the evaluation of chest pain and left- sided shoulder pain. Pain begins after strenuous activity, including walking. Pain is characterized as dull, aching; 8/10 during activity, otherwise 0/10. Began a few months ago, intermittent, aggravated by exercise, and relieved by rest. Has occasional nausea. Pain is retrosternal, radiating to lef t shoulder, definitely affects quality of life by limiting activity. Pain is worse today; did not go away after he stopped walking. BP 120/80. Pulse 72 and regular. Normal heart sounds, S1 and S2, no murmurs. Which of the following differential diagnoses would be most likely? Musculoskeletal chest wall syndrome with radiation Esophageal motor disorder with radiation Acute cholecystitis with cholelithiasis CORRECT Coronary artery disease with angina pectoris Instructor Explanation: With a complaint of chest pain, the most life-threatening diagnosis should be ruled out first. A thorough history identifying the quality and quantity of the pain, alleviating and aggravating factors, and associated symptoms assists in raising or lowering your index of suspicion for a myocardial origin of the pain. Age, gender, weight, vital signs, family history, and medical history also assist in diagnosis. Signs and symptoms that are suspicious for myocardial ischemia include substernal chest pain or discomfort that may radiate into the neck or left arm, diaphoresis, nausea, shortness of breath, and perhaps weakness. Chest discomfort that increases with exertion and resolves with rest or nitroglycerin can indicate myocardial ischemia. Chest discomfort that occurs in the early morning or wakes a patient at night can also be cardiac in origin. Chest discomfort or pain at rest is worrisome because it may signify ACS (unstable angina or an acute MI). Atypical symptoms such as jaw pain, fatigue, indigestion, and upper back pain are more common in women, the elderly, and patients with diabetes. (Goolsby 178-179) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file Question 10. Question : A common auscultatory finding in advanced CHF is: Systolic ejection murmur CORRECT S3 gallop rhythm Friction rub Bradycardia Instructor Explanation: Pathological S3, also called a ventricular gallop, is heard in adults and is associated with decreased myocardial contractility, HF, and volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiological S3 and is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft and can be difficult to hear. (Goolsby 165) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 11. Question : Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: Anemia Anxiety Hyperthyroidism CORRECT All of the above Instructor Explanation: Occasional palpitations occur physiologically in the majority of the population or as a result of other noncardiac conditions, such as anxiety, exercise, hyperthyroidism, and anemia. They can also occur with VHD, increased or decreased stroke volume, and arrhythmias. The patient may complain of palpitations or skipped beats, or an arrhythmia may be seen on EKG. Patients are often aware if their heart rate is slower or faster than normal or if it is irregular. With some arrhythmias, patients may complain only of fatigue, shortness of breath, weakness, or syncopal episodes. These are common symptoms in patients who have atrial fibrillation, and, if the ventricular response is slow, the patient may be unaware of the arrhythmia. Ask the patient about the frequency and duration of the palpitations and the presence of associated symptoms, such as loss of consciousness, lightheadedness, chest pain, shortness of breath, nausea, or vomiting. (Goolsby 173) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 12. Question : The best way to diagnose structural heart disease/dysfunction non-invasively is: Chest X-ray EKG CORRECT Echocardiogram Heart catheterization Instructor Explanation: Echocardiography is recommended in patients with ventricular arrhythmias who are suspected of having structural heart disease (Zipes et al., 2006). An echocardiogram is used more commonly than magnetic resonance imaging (MRI) or cardiac computed tomography (CT) because it is inexpensive in comparison. The echocardiogram is a useful tool in assessing for valvular disorders, left ventricular function and wall motion, and the ejection fraction. (Kennedy-Malone 203) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 13. Question : During auscultation of the chest, your exam reveals a loud grating sound at the lower anterolateral lung fields, at full inspiration and early expiration. This finding is consistent with: Pneumonia Pleuritis Pneumothorax CORRECT A and B Instructor Explanation: Adventitious Sounds Description Significance Crackles Coarse, medium, or fine; early, mid-, or late inspiratory Atelectasis, bronchiectasis, congestive heart failure, pulmonary fibrosis Rhonchi, Wheezes Low- or high-pitched; inspiratory or expiratory COPD, acute and chronic bronchitis, asthma, bronchiectasis, pneumonia Friction Rub Loud, grating; late inspiratory–early expiratory Inflamed pleura; pneumonia, pleuritis, malignancy (Goolsby 211) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 14. Question : A 75-year-old patient complains of pain and paresthesias in the right foot that worsens with exercise and is relieved by rest. On physical examination you note pallor of the right foot, capillary refill of 4 seconds in the right foot, +1 dorsalis pedis pulse in the right foot, and +2 pulse in lef t foot. Which of the following is a likely cause of the signs and symptoms? CORRECT Arterial insufficiency Femoral vein thrombus Venous insufficiency Peripheral neuropathy Instructor Explanation: Intermittent claudication is pain in the leg or foot that becomes worse with exercise and is relieved by rest. The classic signs of peripheral arterial disease include pain, pallor, weak pulse, paresthesias, and palpable coolness. The signs of venous thrombosis are erythema, ropiness, as well as warmth and tenderness along the course of the vein. Edema of the leg and Homan’s sign of the foot are also common. Note any symptoms of intermittent claudication, such as complaints of cramping, aching, or pain in the ankle, calf, or thigh that occur with exercise and are promptly relieved with rest. (Goolsby 200) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 15. Question : Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms? Femoral vein thrombosis Femoral artery thrombus CORRECT Venous insufficiency Musculoskeletal injury Instructor Explanation: Chronic venous insufficiency can be a long-term complication of venous thrombosis owing to the destruction of valves in the deep veins. The calf muscle pump that returns blood from the lower legs is damaged, increasing ambulatory pressure in the calf veins. A constellation of symptoms is set up: aching or pain in the lower legs, edema, thinning and hyperpigmentation of the skin, superficial varicosities, venous stasis, and ulceration. Ankle edema is often the earliest sign. Other causes of chronic venous insufficiency include trauma, pelvic neoplasm, and occasionally secondary to superficial venous disease. Prompt treatment of DVT with anticoagulants decreases the risk for chronic venous insufficiency. General measures for symptom management include the following: elevation of the legs intermittently during the day and at night, avoidance of prolonged sitting or standing, and support or compression stockings. Wearing an Unna boot is valuable and successful in the treatment of stasis ulcers. (Goolsby 203-204) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 16. Question : Your 54 year old patient, Mr. A, presents to your clinic with a 2 day history of severe shoulder pain. On initial assessment you note that in addition to shoulder findings his blood pressure on the ‘good’ arm is 162/100. You review his history and on his last visit his blood pressure was 120/70. He has a medical history of sleep apnea and has used anabolic steroids when body building as a younger adult. In addition to caring for Mr. A’s chief complaint of shoulder pain, you also: Start a thiazide diuretic, discussing the importance of adherence Discuss with him his new diagnosis of hypertension and the importance of taking medication. Schedule a follow up appointment after pain has subsided to take additional blood pressure readings Start an ACE inhibitor because with his history he may also be diabetic. Question 17. Question : You decide to order labs today to help with the diagnosis and management of hypertension in Mr. A. Which of the following labs are indicated to assist in the medical management of Mr. A if he meets the diagnostic criteria for hypertension? Serum Sodium Thyroid function tests CORRECT Fasting serum cholesterol panel Complete liver function enzyme panel Question 18. Question : Lifestyle modifications reduce blood pressure, enhance antihypertensive medication efficacy, and decrease cardiovascular risks. Which lifestyle change will decrease blood pressure the most? Physical activity Dietary sodium reduction DASH diet CORRECT Weight reduction Question 19. Question : Mr. A returns to your clinic and a diagnosis of hypertension is made. He is started on a diuretic and counseled on lifestyle modifications including increasing activity and smoking cessation. On his next visit you note that his blood pressure remains elevated. Before referring to a specialist you should do all of the following except: Assure medications are at appropriate dose Identify any underlying medical condition that requires treatment Review diet with Mr. A and refer to dietician if it is diet problematic Determine he has ‘white coat’ hypertension because his home readings are also elevated Question 20. Question : Mr. A has many issues that seem to be interfering with his health outcomes. In order to negotiate and formulate a patient-centered management plan you take the time to gather more information. This can be started by asking the following question: CORRECT What do you think caused your hypertension and how has it affected your life? I see that you are 20 pounds overweight -- do you exercise? Does you wife help you to manage your diet and medication? Taking your blood pressure everyday is important so that I can see what happens each day. Do you do this? Midterm Week 5: 1. Question : A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Exercise-induced cough Bronchiectasis CORRECT Alpha-1 deficiency Pericarditis Question 2. Question : A 74-year-old obese female presents complaining of persistent right upper quadrant pain. She reports that she has not had any prior abdominal surgeries. Which of the following laboratory studies would be most indicative of acute cholecystitis? C-reactive protein level of 3 mg White blood cell count of 11,000 Direct serum bilirubin level of 0.3 mg/dl CORRECT Serum amylase level of 145 U/L Question 3. Question : What is the most common valvular heart disease in the older adult? Aortic regurgitation CORRECT Aortic stenosis Mitral regurgitation Mitral stenosis Question 4. Question : Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? Clinical practice guideline CORRECT Clinical decision rule Clinical algorithm Clinical recommendation Question 5. Question : A nurse practitioner reports that your patient’s abdominal X-ray demonstrates multiple air-fluid levels in the bowel. This is a diagnostic finding found in: Appendicitis Cholecystitis CORRECT Bowel Obstruction Diverticulitis Question 6. Question : During physical examination of a patient, you note resonance on percussion in the upper lung fields. This is consistent with: COPD Pneumothorax CORRECT A normal finding Pleural effusion Question 7. Question : Essential parts of a health history include all of the following except: Chief complaint History of the present illness CORRECT Current vital signs INCORRECT All of the above are essential history components Question 8. Question : Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms? Femoral vein thrombosis Femoral artery thrombus CORRECT Venous insufficiency Musculoskeletal injury Question 9. Question : A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: Women with ischemic heart disease many times do not present with chest pain Some patients may have no symptoms or atypical symptoms; diagnosis may only be made at the time of an actual myocardial infarction Elderly patients have the most severe symptoms CORRECT A & B only Question 10. Question : Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? Seasonal allergies Acute bronchitis Bronchial asthma CORRECT Chronic bronchitis Question 11. Question : Your patient is a 78-year-old female with a smoking history of 120-pack years. She complains of hoarseness that has developed over the last few months. It is important to exclude the possibility of: Thrush CORRECT Laryngeal cancer Carotidynia Thyroiditis Question 12. Question : Which of the following is considered a “red flag” when diagnosing a patient with pneumonia? Fever of 102 Infiltrates on chest X-ray CORRECT Pleural effusion on chest X-ray Elevated white blood cell count Question 13. Question : Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following? Sinus pain, increased vascular permeability, and bronchodilation CORRECT Bronchospasm, vascular permeability, and vasodilatation Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability Question 14. Question : Which of the following is not a contributing factor to the development of esophagitis in older adults? CORRECT Increased gastric emptying time Regular ingestion of NSAIDs Decreased salivation Fungal infections such as Candida Question 15. Question : A 66-year-old patient presents to the clinic complaining of dyspnea and wheezing. The patient reports a smoking history of 2 packs of cigarettes per day since age 16. This would be recorded in the chart as: 50 x 2-pack years CORRECT 100-pack years 50-year, 2-pack history 100-pack history Question 16. Question : Epistaxis can be a symptom of: Over-anticoagulation Hematologic malignancy Cocaine abuse CORRECT All of the above Question 17. Question : The most common cause of eye redness is: CORRECT Conjunctivitis Acute glaucoma Head trauma Corneal abrasion Question 18. Question : Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight loss of 10 pounds in last 3 weeks, and you find a positive hemoccult on digital rectal examination. Laboratory tests show iron deficiency anemia. The clinician needs to consider: Diverticulitis CORRECT Colon cancer Appendicitis Peptic ulcer disease Question 19. Question : An 82-year-old female presents to the emergency department with epigastric pain and weakness. She admits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. She self-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she has orthostatic hypotension and pallor. Fecal occult blood test is positive. A likely etiology of the patient’s problem is: Mallory-Weiss tear Esophageal varices CORRECT Gastric ulcer Colon cancer Question 20. Question : A 22-year-old female comes to your office with complaints of right lower quadrant abdominal pain, which has been worsening over the last 24 hours. On examination of the abdomen, there is a palpable mass and rebound tenderness over the right lower quadrant. The clinician should recognize the importance of: Digital rectal examination Endoscopy CORRECT Pelvic examination Urinalysis Question 21. Question : Which of the following is the most common cause of heartburn-type epigastric pain? CORRECT Decreased lower esophageal sphincter tone Helicobacter pylori infection of stomach Esophageal spasm Peptic ulcer disease Question 22. Question : Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: Anemia Anxiety Hyperthyroidism CORRECT All of the above Question 23. Question : Mr. A presents to your office complaining of chest pain, mid-sternal and radiating to his back. He was mowing his lawn. He reports the pain lasting for about 8 minutes and went away after sitting down. What is his most likely diagnosis based on his presenting symptoms? Acute MI GERD Pneumonia CORRECT Angina Question 24. Question : Which disease process typically causes episodic right upper quadrant pain, epigastric pain or chest pain that can last 4-6 hours or less, often radiates to the back (classically under the right shoulder blade) and is often accompanied by nausea or vomiting and often follows a heavy, fatty meal. Acute pancreatitis Duodenal ulcer CORRECT Biliary colic INCORRECT Cholecystitis Instructor Explanation: MedU Card #7. Biliary colic typically causes right upper quadrant pain, epigastric pain or chest pain that is constant (the term "colic" is a misnomer), typically lasts 4-6 hours or less, and often radiates to the back (classically under the right shoulder blade). It is often accompanied by nausea or vomiting and often follows a heavy, fatty meal. These symptoms are a result of a stimulated gallbladder (e.g., from a fatty meal) contracting when a gallstone obstructs the outlet of the cystic duct. The hallmark of biliary colic is that the stone is mobile and eventually moves away from the outlet allowing resumption of normal gallbladder function and resolution of symptoms. Question 25. Question : A specific exam used to evaluate the gall bladder is: Psoas sign Obturator sign Cullens sign CORRECT Murphy’s sign Instructor Explanation: MedU Card #4 Question 26. Question : An older patient reports burning pain after ingestion of many foods and large meals. What assessment would assist the nurse practitioner in making a diagnosis of GERD? Identification of a fluid wave Positive Murphy’s sign Palpable spleen CORRECT Midepigastric pain that is not reproducible with palpation Question 27. Question : Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data? Hemoglobin and Hematocrit CORRECT Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and Serum iron Total iron binding capacity and transferrin saturation Question 28. Question : A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and episodes of diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a “celiac diet” and the episodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities. This is a history and physical consistent with: Inflammatory bowel disease CORRECT Irritable bowel syndrome Giardiasis Norovirus gastroenteritis Question 29. Question : (*There are multiple questions on this exam related to this scenario. Be sure to read the whole way through to the question.) Mr. Keenan is a 42-year-old man with a mild history of GERD and a remote history of an appendectomy, presenting with an acute onset of significant right upper-quadrant abdominal pain and vomiting. His pain began after a large meal, was unrelieved by a proton-pump inhibitor, was unlike his previous episodes of heartburn, but upon questioning, reports milder, prodromal episodes of similar post-prandial pain. His pain seems to radiate to his back. Despite a family history of cardiac disease, he reports no classic anginal signs or chest pain. He furthermore denies respiratory or pleuritic signs and denies fever, night sweats, and unintended weight loss. Finally, there are no dermatologic signs, nor genitourinary symptoms. Of the following lab studies, which would provide little help in determining your differential diagnosis? CORRECT Abdominal plain films Liver function tests Amylase/lipase INCORRECT Urinalysis Instructor Explanation: MedU Card # 8. Abdominal plain films have little role in Mr. Keenan's specific situation. His symptoms suggest neither an acute intestinal obstruction nor free air from a perforated hollow viscus, the primary two conditions where plain abdominal imaging are useful. If the urinalysis showed hematuria, that would increase the likelihood (currently low) of renal colic, and a simple KUB (kidney, ureter, bladder) film would indeed be helpful in ruling in or ruling out a kidney or ureteral stone. Question 30. Question : In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion? Fictional keratosis Keratoacanthoma Lichen planus CORRECT Leukoplakia Question 31. Question : A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and unintentional weight loss. At times he is constipated and other times he has episodes of diarrhea. His physical examination is unremarkable. It is important for the clinician to recognize the importance of: CBC with differential Stool culture and sensitivity Abdominal X-ray CORRECT Colonoscopy Question 32. Question : According to the Genetic Information Nondiscrimination Act (GINA): Nurse Practitioners (NPs) should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information CORRECT All of the above Question 33. Question : What test is used to confirm the diagnosis of appendicitis? CBC Flat plate of abdomen Rectal exam CORRECT CT of abdomen with attention to appendix Question 34. Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: INCORRECT Can be treated as an outpatient CORRECT Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN is greater than 20mg/dl Respiratory rate of ≥ 30 breaths/minute Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) Question 35. Question : A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation? Bacterium CORRECT Allergen Virus Fungi Question 36. Question : An obese middle-aged client presents with a month of nonproductive irritating cough without fever. He also reports occasional morning hoarseness. What should the differential include? Atypical pneumonia Peptic ulcer disease CORRECT Gastroesophageal reflux Mononucleosis (Epstein-Barr) Question 37. Question : A 59-year-old patient with history of alcohol abuse comes to your office because of ‘throwing up blood”. On physical examination, you note ascites and caput medusa. A likely cause for the hematemesis is: Peptic ulcer disease Barrett’s esophagus CORRECT Esophageal varices Pancreatitis Question 38. Question : Which of the following medications are commonly associated with the side effect of cough? Beta blocker Diuretic CORRECT ACE inhibitor Calcium antagonist Question 39. Question : When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD): Hemoglobin <12 g/dl, MCV decreased, MCH decreased Hemoglobin >12 g/dl, MCV increased, MCH increased CORRECT Hemoglobin <12 g/dl, MCV normal, MCH normal Hemoglobin >12 g/dl, MCV decreased, MCH increased Question 40. Question : If it has been determined a patient has esophageal reflux, you should tell them: They probably have a hiatal hernia causing reflux They probably need surgery They should avoid all fruit juices CORRECT Smoking, alcohol, and caffeine can aggravate their problem Week 6: 1. Question : Which ethnic group has the highest incidence of prostate cancer? Asians Hispanics CORRECT African Americans American Indians Instructor Explanation: Ethnicity: African Americans have the highest incidence of prostate cancer in the world, with Asian and Hispanic men at lower risk than white men (Wilbur, 2008). Diagnosis in African Americans tends to be at a more advanced stage, and disease- specific survival is lower in this group (Prostate cancer, 2012). (Kennedy-Malone 378) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 2. Question : Men with an initial PSA level below 2.5 ng/ml can reduce their screening frequency to what intervals? Every 6 months Yearly CORRECT Every 2 years Every 2 to 4 years Instructor Explanation: Education: Review risk factors and significance of reporting family history. Encourage screening per health-care providers' recommendations and current guidelines. CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES Screening, when completed, is recommended with PSA with or without digital rectal examination. A Wolf et al. (2010) Screening should be conducted yearly for men whose PSA levels are ≥2.5 ng/mL. A Wolf et al. (2010) For men whose PSA is <2.5 ng/mL, screening intervals can be extended to every 2 years. A Wolf et al. (2010) A PSA level of ≥4.0 ng/mL historically has been used to recommend referral for further evaluation or biopsy. A Wolf et al. (2010) The USPSTF recommends against PSA screening for prostate cancer. CUSPSTF (2012) A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient- oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to www.aafp.org/afpsort.xml. (Kennedy-Malone 380) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : Your 55-year-old male patient presents to your office with complaints of sudden development of severe right-sided, colicky lower abdominal pain. He cannot sit still on the examining table. The patient has previously been in good health. On physical examination, there are no signs of peritoneal inflammation. A urine sample reveals hematuria and crystalluria. Which is the next diagnostic test that should be done immediately? Ultrasound of the abdomen Abdominal X-ray Digital rectal examination CORRECT Spiral CT scan Instructor Explanation: The initial study can be a KUB or IVP; however, many facilities can perform a stone protocol spiral CT, a much more definitive test for the evaluation of kidney stones. CT can demonstrate filling defects. CT scan is a highly specific and sensitive test for urinary tract calculi. After the initial evaluation with CT scan, pain reliever can be administered. An IVP can be done at another time when the patient can better prepare for the test. Goolsby. Question 4. Question : The most common complication of an untreated urinary obstruction due to a ureteral calculus is: Ureteral rupture CORRECT Hydronephrosis Kidney mass Renal artery stenosis Instructor Explanation: Hydronephrosis is swelling of the renal pelvis caused by an obstructing stone, ureteral stricture, prostatic hyperplasia, or renal or abdominal tumor that prevents the kidney from draining. The obstruction can be unilateral or bilateral, symptoms can be sudden or gradual in onset, and progressive renal damage will occur with time. Goolsby Question 5. Question : A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Lower urinary tract infection Nephrolithiasis Hydronephrosis CORRECT Pyelonephritis Instructor Explanation: Pyelonephritis is a bacterial infection of the renal pelvis and parenchyma, typically caused by Escherichia coli ascending from the lower urinary tract. The patient will have bilateral or unilateral flank pain, fever, chills, nausea, and vomiting, and LUTS, such as dysuria, may also be present. The patient will appear ill on presentation, with fever and tachycardia commonly noted. Palpation and/or percussion over the infected side is painful. There may be accompanying abdominal discomfort or abdominal distension. Goolsby Question 6. Question : On a physical examination for employment, a 45-year-old male shows no significant findings and takes no medications. Past medical history and surgery are unremarkable. On urinalysis, hematuria is present. The urinalysis is repeated on another day and still reveals microscopic hematuria. It is important to recognize that painless hematuria can be diagnostic of: Urinary tract infection CORRECT Bladder cancer Nephrolithiasis Pyelonephritis Instructor Explanation: Approximately 80% to 90% of patients with bladder cancer present with painless gross hematuria. All patients with this classic presentation should be considered to have bladder cancer until proof to the contrary. Patients should be referred to a urologist. They usually undergo cystoscopy to rule out bladder tumor. The majority of patients with bladder cancer present with no urinary tract symptoms or palpable masses. Goolsby Question 7. Question : On DRE, you note that a 45-year-old patient has a firm, smooth, non-tender but asymmetrically shaped prostate. The patient has no symptoms and has a normal urinalysis. The patient’s PSA is within normal limits for the patient’s age. The clinician should: Refer the patient for transrectal ultrasound guided prostate biopsy Obtain an abdominal X-ray of kidneys, ureter, and bladder CORRECT Recognize this as a normal finding that requires periodic follow up Obtain urine culture and sensitivity for prostatitis Instructor Explanation: An asymmetric prostate is typically asymptomatic and not necessarily diagnostic of prostate cancer; asymmetry can be a normal finding on DRE but should be followed periodically to monitor for changes. Age-specific reference ranges for PSA (see Table 11.4) should be used as a guide when there is no previous PSA for comparison. A prostatic nodule found on DRE necessitates a referral to a urologist or radiologist for transrectal ultrasound-guided prostate biopsy and may well be the first indication of the presence of a cancer. Goolsby Question 8. Question : Age-related changes in the bladder, urethra, and ureters include all of the following in older women except: CORRECT Increased estrogen production’s influence on the bladder and ureter Decline in bladder outlet function Decline in ureteral resistance pressure Laxity of the pelvic muscle Instructor Explanation: Contributing factors: Estrogen-deficient states accompanying metabolic disorders and changes of normal aging create the risk of atrophic vaginitis. Changes in vaginal epithelium and pH caused by estrogen deficiency provide an environment in which pathogenic bacteria and fungi can flourish. Drugs also may alter vaginal secretions and clinical findings (Bachmann & Santen, 2011b). Signs and symptoms: Itching, discomfort, burning, dyspareunia, and, at times, a thin blood-tinged vaginal discharge or bleeding after intercourse as the epithelium thins characterize atrophic vaginitis. As vaginal secretions decrease, vaginal dryness can be another bothersome symptom. Complaints of urinary frequency, urgency, and stress incontinence are common. On physical examination, signs include pale, dry, nonrugated vaginal walls with patches of erythema or petechiae or both. The vaginal canal is short and narrow. A watery white vaginal discharge without foul odor may be found. Estrogen deficiency can lead to loss of uterine support and subsequent uterine descensus (Tan, Bradshaw, & Carr, 2012). (Kennedy-Malone 362) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 9. Question : Mr. Jones is a 68-year-old retired Air Force pilot that has been diagnosed with prostate cancer in the past week. He has never had a surgical procedure in his life and seeks clarification on the availability of treatments for prostate cancer. He asks the nurse practitioner to tell him the side effects of a radical prostatectomy. Which of the following is not a potential side effect of this procedure? Urinary incontinence Impotence Dribbling urine CORRECT Selected low back pain Instructor Explanation: Sequelae: Complications of treatment may include incontinence, ED, mild colitis, and radiation cystitis. After nerve-sparing prostatectomy, urinary continence returns in under 6 months in about 50% of men. The rate of ED after external beam radiation ranges from 10% to 80%, and with brachytherapy approximately 15% to 60% (Ali & Walsh, 2011). (Kennedy-Malone 379) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 10. Question : Your 77-year-old patient complains of frequent urination, hesitation in getting the stream started, and nocturnal frequency of urination that is bothersome. On DRE, there is an enlarged, firm, non-tender, smooth prostate. The clinician should recognize these as symptoms of: Urethritis CORRECT Benign prostatic hyperplasia Prostatitis Prostate cancer Instructor Explanation: BPH is an enlargement of the transition zone of the prostate gland which occurs as men age. An enlarged prostate causes symptoms that include urinary urgency, frequency, hesitation in getting the stream started, decreased caliber and force of stream, and nocturnal frequency of urination that is bothersome. This collection of symptoms has also been termed prostatism. A patient with BPH shows symmetric or asymmetric enlargement and a firm, smooth, non-tender gland.Goolsby Question 11. Question : Your 24-year-old female patient complains of dysuria as well as frequency and urgency of urination that develops the day after she uses her diaphragm. Urine culture reveals a bacterial count of 100 CFU/mL. These signs and symptoms indicate: Upper urinary tract infection Normal bacteriuria CORRECT Lower urinary tract infection Urethritis Instructor Explanation: In women whose symptoms suggest uncomplicated UTI, a culture of greater than 102 CFU/mL of a specific bacterium is indicative of cystitis. However, this CFU number is controversial. Infectious disease specialists recommend use of 103 CFU / mL as diagnostic of UTI. In the past, a bacterial count of 105 CFU/mL was regarded as significant for UTI. UTI diagnosis relies on the patient’s subjective report of symptoms of UTI, not only the number of bacteria. Patients with asymptomatic bacteriuria can have bacterial counts as high as 10 5 CFU/mL. Asymptomatic bacteriuria is not treated. Risk factors for the development of a UTI include increasing age, recent sexual intercourse, a history of UTI, use of a diaphragm or cervical cap, and anatomic abnormalities.Goolsby Question 12. Question : A 79-year-old man is being evaluated for frequent urinary dribbling without burning. Physical examination reveals a smooth but slightly enlarged prostate gland. His PSA level is 3.3 ng/ml. The patient undergoes formal urodynamic studies, and findings are as follows: a decreased bladder capacity of 370 ml; a few involuntary detrusor contractions at a low bladder volume of 246 mL; an increased postvoid residual urine volume of 225 ml; and a slightly decreased urinary flow rate. Which of the following is not consistent with a normal age-associated change? PSA level of 3.3 ng/ml Decreased bladder capacity Involuntary detrusor contradictions CORRECT Increased postvoid residual urine volume Instructor Explanation: Signs and symptoms: Symptoms are lower urinary tract symptoms (LUTS), occur on a continuum, and do not necessarily reflect the degree of prostatic enlargement. The onset of symptoms is gradual and includes increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. These symptoms are not specific for BPH and progress gradually over a period of years. (Kennedy-Malone 373) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 13. Question : Mrs. L. Billings is a 77-year-old Caucasian female who has a history of breast cancer. She has been in remission for 6 years. As her primary care provider, you are seeing her for follow-up of her recent complaint of intermittent abdominal pain of a 3-month duration and some general malaise. Given the brief history above, what will you direct your assessment at during physical examination? Examination of her thyroid to rule out thyroid nodules that may contribute to her feeling fatigued. Auscultation of her abdomen for abnormal bowel sounds to rule out peritonitis. CORRECT Thorough abdominal and gynecological exam to rule out masses and identify any tenderness. A rectal examination to rule out colon cancer as a secondary site for breast cancer. Instructor Explanation: Signs and symptoms: Ovarian cancer may be totally asymptomatic. The woman may experience pelvic or abdominal pain or pressure, bloating, early satiety, or urinary symptoms (frequency/urgency). Because many of these symptoms are nonspecific and occur with other health conditions, they are frequently overlooked by patient and health-care professional alike (Vaughan et al., 2011). Diagnostic tests: Pelvic examination is recommended in all sexually active women on the schedule determined by the American College of Obstetricians and Gynecologists. Rectovaginal examination may be necessary to detect ovarian enlargement. Ovarian enlargement cannot always be palpated, making pelvic examination a limited diagnostic test. (Kennedy-Malone 371) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 14. Question : A 27-year-old male comes in to the clinic for symptoms of dysuria, urinary frequency, as well as urgency and perineal pain. Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate. The clinician should recognize these as signs of: CORRECT Prostatitis Prostate cancer Urethritis Benign prostatic hyperplasia Instructor Explanation: Prostatitis is an acute or chronic infection of the prostate gland. Acute bacterial prostatitis is usually the result of infection by aerobic gram-negative rods (coliform bacteria or Pseudomonas). Enterococcus faecalis, an aerobic gram-positive bacteria, can also cause prostatitis. Routes of infection are ascent from the urethra, reflux of infected urine into the prostatic ducts, direct extension of bacteria, and migration via the lymphatic and vascular system. Acute symptoms commonly include fever, low back and perineal pain, possible penis pain, urinary urgency and frequency, nocturia, dysuria, and muscle and joint aches. Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate. Goolsby Question 15. Question : Which of the following males would be at greatest risk for testicular cancer? John, a 52-year-old, married African American Attorney who lives in Detroit, MI CORRECT Jacob, a 22-year-old, homosexual male, who works as an accountant, resides in Cumming GA, and has a history of cryptorchidism Andy, a 27-year-old, Caucasian, single male who resides in Waukesha, WI and works as a maintenance mechanic Ryan, a 34-year-old healthy, married man from Sweden, who works as a Registered Nurse in Boston, MA Instructor Explanation: Malignant tumors of the testes are uncommon, usually present between the ages of 15 and 35, are slightly more common on the right side, and arise from germ cells. The greatest risk factor for the development of a testicular tumor is cryptorchidism, with an overall incidence of 7% to 10% in the patient with a history of unilateral or bilateral undescended testes. Increased screening and early detection have significantly decreased the mortality from this malignancy, but up to 10% of patients present with pain and/or constitutional or pulmonary complaints that indicate metastasis. (Goolsby 337) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 16. Question : A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Lower urinary tract infection CORRECT Pyelonephritis Nephrolithiasis Hydonephrosis Question 17. Question : Which of the following disorders can cause urinary incontinence? Cystocele Overactive bladder Uterine prolapse CORRECT All of the above Instructor Explanation: Cystocele and prolapse of the uterus can affect pelvic floor anatomy and cause urinary changes, including incontinence and changes to the quality of the urinary stream. Overactive bladder is a cause of incontinence due to atrophic changes of the pelvic floor muscles. Goolsby Question 18. Question : Your 18 year old sexually active patient presents with sudden right sided groin pain that is sharp and constant. Inspection of his genitals reveals a swollen and erythematous right scrotum. His right testicle is exquisitely tender, swollen and has no palpable masses. Elevation of the testis results in no reduction in pain. The lef t scrotum and the testicle are normal. Epididymis and other scrotal contents were within normal limits. The scrotum does not transilluminate. Cremasteric reflex is present on the lef t side but absent on the right. There is no penile discharge, inguinal lymphadenopathy, or hernias. Based on the history and physical exam your immediate concern is for: CORRECT Torsion Infection Cancer Rupture Instructor Explanation: MedU Card #11 Question 19. Question : The Prehn sign is utilized to distinguish epididymitis from testicular torsion. Epididymitis is considered when the Prehn sign is positive. When is the Prehn sign determined to be positive? CORRECT Pain is relieved by lifting of the testicle. Tenderness is limited to the upper pole of the testis. Lightly stroking or pinching the superior medial aspect of the thigh causes testicular retraction. A small bluish discoloration is visible through the skin in the upper pole. Instructor Explanation: MedU Card # 6. Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion. Question 20. Question : Which of the following exam findings makes the diagnosis of testicular tumor more likely? A scrotal mass that is accompanied by exquisite tenderness. Testicular swelling is mostly fluid and transilluminates easily CORRECT A testicular mass that is non-tender to palpation Dilated and tortuous veins in the pampiniform plexus Instructor Explanation: MedU Card #9. Testicular tumor presents as scrotal mass that is rarely accompanied by tenderness. The swelling is solid so should not transilluminate. A testicular tumor is usually non-tender to palpation. Week 7: 1. Question : When a patient presents with a skin-related complaint, it is important to first: Fully inspect all skin lesions before asking the patient how the lesion in question developed CORRECT Obtain a full history about the development of the skin lesion prior to the physical examination Complete a full physical examination of the body prior to inspecting the skin lesion Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis Instructor Explanation: When a patient presents with a skin-related complaint, there is an inclination to immediately examine the skin, as the lesion or change is often readily observable. However, it is crucial to obtain a history before proceeding to the examination in order to understand the background of the problem. A thorough symptom analysis is essential. Goolsby Question 2. Question : Which of the following dermatological conditions results from reactivation of the dormant varicella virus? Tinea versicolor Seborrheic keratosis Verruca CORRECT Herpes zoster Instructor Explanation: Description: Herpes zoster is an acute vesicular eruption caused by a virus histologically identical to the varicella (chickenpox) virus. Herpes zoster is human (alpha) herpes virus 3 (varicella-zoster virus [VZV]), a member of the herpes virus group. Etiology: Recurrent VZV infection causes herpes zoster. The patient has initial contact with VZV in the form of chickenpox. The DNA virus resides within the neurons. During reactivation, the virus spreads across the sensory ganglion to other neurons, which causes a cutaneous eruption of a dermatome distribution (Fashner & Bell, 2011). Older adults have a decrease in cell-mediated immunity, which contributes to the risk of developing herpes zoster and postherpetic neuralgia (Barakzai & Fraser, 2008). (Kennedy-Malone 132-133) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : An older adult male presents with pain in his right chest wall for the past 48 hours. Upon examination, the nurse practitioner notices a vesicular eruption along the dermatome and identifies this as herpes zoster. The NP informs the gentleman that: All symptoms should disappear within three days CORRECT Oral medications can dramatically reduce the duration and intensity of his symptoms He has chickenpox and can be contagious to his grandchildren He has a sexually transmitted disease Instructor Explanation: Treatment: Antiviral agents are recommended in the presence of significant pain, serious herpes zoster, or involvement near the eye. Postherpetic neuralgia is not reduced by antiviral therapy, but these agents may help with healing in the acute phase by reducing viral shredding (Cadogan, 2010). Give acyclovir, 800 mg 5 times a day for 7 to 10 days; famciclovir, 500 mg orally every 8 hours for 7 days; or valacyclovir, 1000 mg orally every 8 hours for 7 days (Fashner & Bell, 2011). These drugs must be given within 72 hours after onset of rash to be effective, and their use must be monitored in patients with reduced renal function (Tyring, Beutner, Tucker, Anderson, & Crooks, 2000). Patients should be encouraged to stay hydrated and to avoid scratching (Cadogan, 2010). Patients with disseminated disease and those who are immunocompromised may need IV antiviral medications (Cadogan, 2010). Topical agents are also effective in treating herpes zoster. The use of cool compresses with 1:20 Burow's solution, calamine lotion, and topical lidocaine (Xylocaine) is recommended for the soothing local effect. Analgesics may be necessary for the initial prodromal pain associated with herpes zoster. Acetaminophen is recommended initially. Tramadol, NSAIDs, and opiates can be used as recommended for severe pain. Gabapentin is recommended for the treatment of PHN. Initial dose is 300 mg on the first day and is titrated up gradually until pain relief is safely reached. The maximum does of gabapentin is 3600 mg/day. Pregabalin is also recommended for the treatment of postherpetic neuralgia and can be administered 50 mg 3 times a day or 75 mg twice a day. The dosage can be increased to 300 mg daily after 3 to 7 days as tolerated, followed by 150 mg every 3 to 7 days. The maximum recommended dose is 600 mg/day. Caution is advised when prescribing gabapentin and pregabalin to older adults given the side effects of dizziness and ataxia (Christo, Hobelmann, & Maine, 2007). The secondary amine tricyclic antidepressants, nortriptyline 10 mg orally or desipramine 10 to 25 mg orally both given at bedtime, may be helpful, and it may be necessary to gradually increase the dosage until reduction of pain occurs; however, because of the anticholinergic side effects, caution is warranted (Ahmad & Goucke,2002). The use of opioids in the treatment of PHN alone or in combination with other therapies has also been studied; greater pain relief was experienced by patients when a combined regimen was prescribed over a single agent (Gilron et al., 2005). The 5% lidocaine patch has been shown to be effective in treating the pain of PHN; 1 to 3 patches are applied in a 24-hour period. For PHN pain, capsaicin (Zostrix cream) can be applied topically. The capsaicin 8% patch can be applied by a health-care professional to the most painful skin areas (Christo et al., 2007). In cases of severe pain, a transcutaneous electrical nerve stimulator unit may be tried (Christo et al., 2007). (Kennedy-Malone 134) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 4. Question : A 70-year-old white male comes to the clinic with a slightly raised, scaly, pink, and irregular lesion on his scalp. He is a farmer and works outside all day. You suspect actinic keratosis, but cannot rule out other lesions. What recommendation would you give him? Ignore the lesion, as it is associated with aging. Instruct him to use a nonprescription hydrocortisone cream to dry up the lesion. CORRECT Perform a biopsy or refer to a dermatologist. Advise him to use a dandruff shampoo and return in one month if the lesion has not gone away. Instructor Explanation: Patients may be concerned about a new, pigmented lesion or a change in an already existing one. Patients may report associated itching, burning, or pain in a mole. Superficial spreading melanoma is a flat to slightly raised pigmented lesion with irregular borders, commonly found on the backs of men and the lower legs of women. Lentigo maligna melanoma, an irregularly pigmented macula with notched borders, occurs on sun-exposed areas, especially on the faces of older adults. Nodular melanoma, brown or black papules usually located on the trunk, head, and neck, is characterized by rapid growth. Acral lentiginous melanomas, a rare melanoma subtype, is found proportionally higher in people of color. Acral lentiginous melanoma occurs on the palms, soles, fingers, and toes; a pigmented streak of the cuticle is diagnostic (Hutchinson's sign) (Bradford, Goldstein, McMaster, & Tucker, 2009; Bristow, de Berker, Acland, Turner, & Bowling, 2010). Clinical evaluation for skin cancer also includes a total body skin examination and palpation of regional lymph nodes, liver, and spleen (Rubin, 2010a). Diagnostic tests: Skin cancer is diagnosed through biopsy. Biopsy of the suspected lesion is necessary to confirm the diagnosis via histological examination of the tissue; an adequate tissue sample should be excised, and an elliptical excision generally is necessary for larger lesions. Excisional biopsy is recommended for any pigmented lesion (Nolen et al., 2011). (Kennedy-Malone 145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 5. Question : The appearance of a 2-10 cm. herald patch with subsequent development of parallel oval lesions on the trunk in a christmas tree distribution involving the upper arms and upper legs are common in: CORRECT Pityriasis Rosea Shingles Psoriasis Lymes Disease Instructor Explanation: The patient is usually asymptomatic, although some complain of a prodromal period of malaise preceding the emergence of the rash. The rash is often pruritic. The first sign is typically a “herald patch,” which is a 2- to 10-cm annular pink patch that, similar to tinea, has an area of central clearing with a fine scale. The herald patch is most commonly located on the trunk. The herald patch is followed several days later by a more diffuse set of smaller pink, salmon, or fawn-colored lesions, which, at 0.5 to 1.5 cm, are much smaller than the herald patch. The distribution of the smaller lesions is described as “Christmas tree distribution” because the lesions have a slightly diagonal axis and are distributed along the skin tension lines. (Goolsby 73) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 6. Question : Mr. Fitzgerald is a 68-year-old previously healthy man with a history of significant sun exposure who presents with a progressively enlarging 18 x 16 mm erythematous pruritic oval patch on his lef t forearm that has been present for three to four years. Your differential would include all of the following EXCEPT: INCORRECT Fungal skin infection Eczema CORRECT Seborrheic Keratosis Squamous cell carcinoma of the skin Instructor Explanation: MedU Card #7 Question 7. Question : What kind of lesions are caused by the herpes simplex virus? Scales CORRECT Vesicles Plaques Urticaria Instructor Explanation: The skin lesions of herpes consist of multiple vesicles, which cluster and are usually preceded by an area of tender erythema. The vesicles erode, forming ulcerations. Goolsby Question 8. Question : Among the following conditions, which needs to be treated with systemic antifungal agents? Tinea pedis/tinea magnum Tinea corporis/tinea cruris CORRECT Tinea capitis/Tinea unguium (onychomycosis) Tinea pedis /tinea faciale Instructor Explanation: MedU Card #9 Question 9. Question : Which lesions are typically located along the distribution of dermatome? Scabies CORRECT Herpes zoster Tinea Dyshidrosis Instructor Explanation: Signal symptoms: Cutaneous eruption of a dermatome distribution, burning or tingling skin sensation. Description: Herpes zoster is an acute vesicular eruption caused by a virus histologically identical to the varicella (chickenpox) virus. Herpes zoster is human (alpha) herpes virus 3 (varicella-zoster virus [VZV]), a member of the herpes virus group. Etiology: Recurrent VZV infection causes herpes zoster. The patient has initial contact with VZV in the form of chickenpox. The DNA virus resides within the neurons. During reactivation, the virus spreads across the sensory ganglion to other neurons, which causes a cutaneous eruption of a dermatome distribution (Fashner & Bell, 2011). Older adults have a decrease in cell-mediated immunity, which contributes to the risk of developing herpes zoster and postherpetic neuralgia (Barakzai & Fraser, 2008). (Kennedy-Malone 132-133) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 10. Question : A smooth round nodule with a pearly gray border and central induration best describes which skin lesion? Seborrheic keratosis Malignant melanoma Herpes zoster CORRECT Basal cell carcinoma Instructor Explanation: There are three specific types of basal cell carcinoma: nodular, morpheaform, and superficial. Nodular BCC generally presents first as a dome-shaped, white-to-pink papule or nodule having a raised pearly border with prominent telangiectasia. BCC tumors can also have a brown to glossy black appearance (Gloster & Neal, 2006). Patients may describe this lesion as a pimple that did not heal. As the nodule enlarges, scaling, crusting, or central ulceration may become noticeable. It is important to note that the ulcerated areas can heal over with new scar tissue; however, the tumor grows deeper and the cycle of ulceration and healing begins again (Habif, 2004). Superficial BCC often appears on the trunk and extremities. Characteristic of the superficial BCC is the presence of a well- circumscribed translucent or bright pink to red patch of skin surrounded often by telangiectasia. This type of BCC resembles other chronic skin conditions such as psoriasis, eczema, discoid lupus erythematous, and Bowen's disease. The least common type of BCC is the sclerosing or morpheaform tumor. Found on the head and neck and occasionally the trunk of the body, the lesion appears to be a hypopigmented tumor that eventually is surrounded by irregular telangiectasia with atrophic scarlike appearance (Nolen et al., 2011). (Kennedy-Malone 144-145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 11. Question : Cellulitis is a deep skin infection involving the dermis and subcutaneous tissues. The nurse practitioner suspects cellulitis in a 70-year-old Asian diabetic male presenting with reddened edematous skin around his nares. Which statement below will the nurse practitioner use in her decision-making process for the differential diagnosis pertaining to reddened edematous skin? Cellulitis is two times more common in women CORRECT Facial cellulitis is more common in people >55 There is low incidence of cellulitis in patients with diabetes Cellulitis is only a disease of the lower extremities of patients with known arterial insufficiency Instructor Explanation: Age: Cellulitis can occur at any age. Facial cellulitis is most common in people 50 years and older. (Kennedy-Malone 128) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 12. Question : Folliculitis is most commonly due to: Contact dermatitis Varicella zoster Dermatophytes CORRECT Staphylococcal infection Instructor Explanation: Folliculitis is an inflammation of the hair follicles and is typically associated with staphylococci. Other microorganisms and causes include pseudomonas (associated with hot tubs), Candida, tinea barbae, and herpes. Goolsby Question 13. Question : The anti-inflammatory properties of topical corticosteroids result in part from their ability to induce vasoconstriction to the small blood vessels in the upper dermis. Of the following, which is the most potent topical corticosteroid? Hydrocortisone 2.5% Triamcinolone acetonide 0.1% CORRECT Betamethasone dipropionate 0.05% Alclometasone dipropionate 0.05% Instructor Explanation: MedU Card #8 Question 14. Question : Which of the following descriptions accurately documents cellulitis? Cool, erythematous, shiny hairless extremity with decreased pulse Scattered, erythematous ring-like lesions with clear centers Clearly demarcated, raised erythematous area of face CORRECT Diffusely inflamed skin that is warm and tender to palpation Instructor Explanation: Signs and symptoms: Patients may complain of localized pain, fever, chills, rigors, malaise, anorexia, nausea, or headache, and, in severe cases, patients may have tachycardia, hypotension, and delirium (Nazarko, 2008b). Cellulitis most often appears on the lower extremities after a skin aberration, such as dermatitis, ulceration, trauma, or tinea pedis. Cellulitis can develop on the arms and the face as well. Scars from previous cardiovascular surgery are common sites for recurrent cellulitis (Price, 2009). Examine for skin temperature, note any breaks in the skin and ulcerations, and determine presence of pulses and sensation. Local erythema with edema and tenderness elicited by palpation are presenting signs of cellulitis. The skin can appear to look stretched, later taking on the appearance of an orange peel when the surface is infiltrated (Price, 2009). Depending on the organism of origin, large hemorrhagic bullae may be present. (Kennedy-Malone 128-129) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 15. Question : Asymmetrical bi-color lesion with irregular border measuring 8 mm is found on the right lower arm of an adult patient. This assessment finding is consistent with: CORRECT Melanoma Basal cell carcinoma Leukoplakia Senile lentigines Instructor Explanation: For patients with suspected melanoma, the mnemonic ABCDE guides the clinician in determining if the clinical characteristics of a suspicious lesion warrant close surveillance and/or biopsy for histological evaluation: Asymmetry Border irregularity Color variation Diameter >6 mm Elevation of a previously flat lesion, evolving and enlarging (Halpern, Marghoob, & Sober, 2009; Rubin, 2010b). It is important to note, however, than only one-third of melanoma cases follow the classic ABCDE pattern of development, and many forms of melanoma mimic benign lesions (Rubin, 2009). (Kennedy-Malone 145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 16. Question : Which of the following descriptions best illustrates assessment findings consistent with tinea capitis? Circular erythematous patches with papular, scaly annular borders and clear discharge CORRECT Inflamed scaly dry patches with broken hairs Web lesions with erythema and scaling borders Scaly pruritic erythematous lesions on inguinal creases Instructor Explanation: Signs and symptoms: Dry scaling is a hallmark of each of the superficial fungal infections. Tinea capitis presents as hair loss (alopecia). Grey patch tinea capitis often is circular in shape with the presence of many broken-off hairs and the scalp assumes a dull grey color due to the arthrospores that are formed by the fungi. Black dot tinea capitis occurs when hairs break off near the surface and give the appearance of dots. The dots may be scattered over the scalp and not form a classic round patch. A kerion is an inflammatory mass on the scalp that is painful and may include pustules and result in cervical or occipital adenopathy. (Kennedy-Malone 150) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 17. Question : A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely a: Bacterial folliculitis Basal cell carcinoma Bullous impetigo CORRECT Epidermoid cyst Instructor Explanation: With an epidermoid cyst, the patient complains of a cystic lesion that produces cheesy discharge with foul odor. The lesion is sometimes tender or painful. The lesion is nodular, round and firm, and subcutaneous; thus, it is flesh colored. The most common sites include the face, scalp, neck, upper trunk, and extremities. Goolsby Question 18. Question : Patient presents with complaint of a “swollen node” under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis? Hidradenitis suppurativa Epidermoid cyst INCORRECT Furuncle CORRECT Both A and C Instructor Explanation: Hidradenitis suppurativa involves occlusions of hair follicles, which causes a red, fluctuant tender lesion. The site is commonly under the breast or in the axillae or groin. The clinician must differentiate this skin condition from an enlarged lymph node, which can appear similar. An enlarged lymph node is usually painless, whereas hidradenitis is usually tender. Furuncles are staphylococcal infections of hair follicles or sebaceous glands. Patients complain of pain, redness, and swelling at the affected site, commonly the axillae and groin. Goolsby Question 19. Question : A patient suffered a laceration of the shin three days ago, and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: Contact dermatitis Folliculitis Hidradenitis suppurativa CORRECT Cellulitis Instructor Explanation: In cellulitis, a patient often describes a history of a break in the skin from an injury, insect bite or sting, or previous procedure preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. Streptococcus or staphylococcal commonly causes the infection. The lower leg is a common site, usually unilateral. Goolsby Question 20. Question : A woman complains of malaise and arthralgias. You note a butterfly-shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in: Psoriasis Lichen planus CORRECT Systemic lupus erythematosus Erythema nodosum Instructor Explanation: In systemic lupus erythematosus, the patient will have a range of symptoms relevantto the diagnosis, depending on the affected organs. There is often coexisting arthralgiaand malaise. The rash is macular and erythematous. It is described as a “butterfly rash”because the distribution resembles a butterfly’s wings overlying the forehead and cheeks.Goolsby Week 8: 1. Question : Which of the following best describes the pain associated with osteoarthritis? Constant, burning, and throbbing with an acute onset Dull and primarily affected by exposure to cold and barometric pressure CORRECT Begins upon arising and after prolonged weight bearing and/or use of the joint Begins in the morning and limits continued ambulation Instructor Explanation: Signs and symptoms: Complaints of morning stiffness lasting <30 minutes or stiffness that improves with activity and accompanying muscle spasms may indicate OA. Persistent pain and limitation of motion in the affected joint may be reported. (Kennedy-Malone 402) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 2. Question : Your 63-year-old Caucasian woman with polymyalgia rheumatica (PMR) will begin treatment with corticosteroids until the condition has resolved. You look over her records and it has been 2 years since her last physical examination and any laboratory or diagnostic tests as she relocated and had not yet identified a health-care provider. In prioritizing your management plan, your first orders should include: Recommending she increase her dietary intake of Calcium and Vitamin D Ordering once a year bisphosphonate and a proton pump inhibitor Participate in a fall prevention program CORRECT Dual-energy X-ray (DEXA) scan and updating immunizations Instructor Explanation: Follow-up: Assess the patient for proximal pain, morning stiffness, resolution of constitutional symptoms, and adverse reaction to corticosteroids (Dasgupta et al., 2010). For patients with PMR, the ESR and/or C-reactive protein need monitoring until the levels decrease and previously reported symptoms are alleviated. The CBC can be repeated to determine if the anemia has resolved. Initially, the patients will need to return every couple of weeks to evaluate the clinical response to therapy; this is followed by approximately an every-3-month surveillance to determine response to treatment and any adverse reactions to the long-term corticosteroids. Additional monitoring of urea and electrolytes and glucose should continue every 3 months while on corticosteroids (Dasgupta et al., 2010). Follow up on the results of the dual-energy x-ray absorptiometry scan. Consider prophylactic therapy to prevent osteoporosis with bisphosphonates with calcium and vitamin D supplementation. Patients also presenting with GCA need to be monitored in the same way, with repeated eye examinations as warranted, including examination for cataracts resulting from corticosteroid therapy (Paget & Spiera, 2006). Because patients with GCA are at risk for developing aortic aneurysm, follow-up abdominal examination for aortic aneurysm is needed. This complication is of great concern especially with patients who are at high risk for developing aortic aneurysms such as patients who smoke, are hypertensive, and have arteriosclerotic heart disease (Unwin et al., 2006). (Kennedy-Malone 407) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : In providing health teaching related to dietary restrictions, the nurse practitioner should advise a patient with gout to avoid which of the following dietary items: Green leafy vegetables CORRECT Beer, sausage, fried seafood Sugar Gluten and bread items Instructor Explanation: Contributing factors: Factors associated with primary gout in men include positive family history, obesity, trauma, hypertension, hyperlipidemia, hypertriglyceridemia, diets high in purine (especially organ meats, anchovies, sardines, scallops, oatmeal), alcohol consumption (especially beer and moonshine whiskey), dietary intake of high-fructose corn syrup products, lead intoxication, dehydration, fasting (which causes ketosis), binge eating, analgesic nephropathy, nephrolithiasis, urolithiasis, and polycystic kidney disease (Choi & Curhan, 2008; Neogi, 2011) (Kennedy- Malone 394) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 4. Question : A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body. There is no history of systemic disease and no history of trauma. On physical examination, the patient has no swelling or decreased range of motion in any of the joints. She indicates specific points on the neck and shoulders that are particularly affected. She complains of tenderness upon palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses: Osteoarthritis Rheumatoid arthritis CORRECT Fibromyalgia Polymyalgia rheumatica Instructor Explanation: In fibromyalgia, the most common symptoms are generalized pain, stiffness, and decreased ROM, with multiple-point tenderness. The diagnostic criteria currently rest on a patient reporting point tenderness in at least 11 of 18 specified sites (Fig. 14.1) in addition to the presence of widespread pain for at least 3 months. The most common tender sites are in the neck, shoulders, spine, and hips. Other common symptoms include morning stiffness, anxiety, depression, sleep disturbances, “brain fog,” and irritable bowel syndrome.Goolsby Question 5. Question : A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical examination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of: Osteoarthritis CORRECT Rheumatoid arthritis Scleroderma Sarcoidosis Instructor Explanation: RA typically affects the joints symmetrically. Symptoms may wax and wane, but the effects are cumulative and progressive. Although RA can affect any joint, it commonly affects the small joints of the hands and feet, and this is often helpful in diagnosis. There is often history of prolonged morning stiffness and fatigue. Affected joints are often tender, swollen with effusions, warm, and inflamed. The disease most commonly affects metacarpophalangeal and proximal interphalangeal joints. Goolsby Question 6. Question : Which of the following statements about osteoarthritis is true? CORRECT It affects primarily weight-bearing joints It is a systemic inflammatory illness The metacarpal phalangeal joints are commonly involved Prolonged morning stiffness is common Instructor Explanation: Osteoarthritis (OA), still also referred to as degenerative joint disease, is a degenerative disease of the joint cartilage. It is the leading cause of disability in older adults in the United States (Lawrence et al., 2008). OA most commonly affects the hips, knees, and cervical and lumbar spine. Joint deformity with minimal pain is found in the DIP and PIP joints of the hand, the first carpometacarpal joint, and the first metatarsophalangeal joint (Shelton, 2013). OA is a complex active disease process involving the wearing away (degradation) and, to a lesser extent, the repair of the cartilage surface. It is now understood that there is both a mechanical (wearing away) and a biological (abnormal joint biology) part of the osteoarthritis (Ling & Rudolph, 2006). Besides the cartilage degeneration, patients often experience neurological and mechanical dysfunction (Chao & Kalunian, 2010). (Kennedy-Malone 402) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 7. Question : The most appropriate first-line treatment for an acute gout flare is (assuming no kidney disease or elevated bleeding risk): CORRECT Indomethacin 50 mg thrice daily for 2 days; then 25 mg thrice daily for 3 days Doxycycline 100 mg twice daily for 5 days Prednisolone 35 mg four times a day for 5 days Ice therapy Instructor Explanation: Treatment: NSAIDs, corticosteroids, and oral colchicine are acceptable first-line options for treatment of acute gout with treatment started within 24 hours of attack onset. Management of the older adult with gout requires careful monitoring. Older adults are susceptible to renal insufficiency, may have other concomitant diseases, and experience hypersensitivity to some of the medications used to treat younger patients with gout. NSAIDs should be used cautiously in the treatment of gout in older adults who have a history of heart failure, renal failure, and gastrointestinal conditions (Fravel & Ernst, 2011). As with any NSAID, renal function must be monitored. NSAIDs can endanger existing renal function, especially when the creatinine clearance is ≤30 mL/min. Additional concern with NSAID use in older adults is the potential for gastrointestinal bleeding due to NSAID- induced peptic ulcers. An exacerbation of hypertension can occur with excessive use of NSAIDs in older adults. Extensive use of NSAIDs can lead to fluid retention and antagonism of diuretic therapy, which may precipitate heart failure (Fravel & Ernst, 2011). Indomethacin is effective in the treatment of acute gout; the usual dose is 25 to 50 mg orally 2 to 3 times daily until the symptoms cease, then begin to taper the dose for 5 to 7 days. Liquid indomethacin is available for patient use. Although indomethacin has been traditionally favored in the treatment of gout, there has been no research documenting the advantage to its use over other NSAIDs such as naproxen (Zychowicz et. al, 2010). As with any NSAID, renal function must be monitored. NSAIDs can endanger existing renal function, especially when the creatinine clearance is ≤30 mL/min. Cyclooxygenase-2 inhibitors may be better tolerated in older adults with history of peptic ulcer. Colchicine can be given for acute gout attacks orally. It is most effective if given within 24 hours of an attack. The oral colchicine dose is 1.2 mg followed by a single 0.6 mg dose 1 hour later. Dose should not exceed 1.8 mg a day for an acute flare. Consensus guidelines indicate that colchicine is not to be used in patients with a creatinine clearance of <10 mL/min. (Hanlon et al., 2009). (Kennedy-Malone 395-396) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 8. Question : A 34-year-old female presents with fever, general malaise, fatigue, arthralgias and rash for the last 2 weeks. On physical examination, you note facial erythema across the nose and cheeks. Serum diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems: Fibromyalgia Sarcoidosis CORRECT Systemic lupus erythematosus Rheumatoid arthritis Instructor Explanation: SLE has many potential symptoms. The classic findings include a malar rash. Patients often have arthralgias, myalgias, fever, fatigue, Raynaud’s syndrome, and neuropathy. SLE effects depend on the organs involved and diagnosis can be difficult. A positive ANA occurs at some point in the condition in the majority of patients but is neither consistent nor specific for SLE. Positive anti- DNA and lupus erythematosus prep are also common to SLE. Goolsby Question 9. Question : Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking the following medications: an ACE inhibitor and beta blocker for treatment of hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2 diabetes. The patient complains of myalgias of the legs bilaterally and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect? Beta blocker ACE inhibitor CORRECT Statin medication Metformin Instructor Explanation: Myalgias are a side effect of lipid-lowering medications called “statins.” If the myalgia is related to rhabdomyolysis, the urine is often reddish-brown. When drug- induced myalgia is present, there is often eosinophilia. For rhabdomyolysis myalgia, the serum creatine kinase is significantly elevated. Goolsby Question 10. Question : A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis? Joint infection Chondromalacia patella Prepatellar bursitis CORRECT All of the above Instructor Explanation: Prepatellar bursitis is also called housemaid’s knee, which is common to persons whose occupation requires extended periods of kneeling, such as plumbers and carpet layers. This bursitis can also be caused by an infection. The patient complains of pain in the area inferior to and over the patella, and there is swelling and inflammation of the bursa. Chondromalacia patella is seen in young active persons of either gender. The condition is also commonly called patella-femoral syndrome and runner’s knee. The pain involves the anterior knee, often develops gradually, and is moderate in intensity. Pain can be reproduced by pressing the patella against the femoral condyles, and there is tenderness around the patella. Other maneuvers that reproduce the pain include applying pressure against the patella as the patient extends the lower leg, flexing the quadriceps, and moving the patella from side to side. Crepitus and effusion are often present. Decision Rule in Chondromalacia Patella: Two or more of the following symptoms (pain reported on muscle contraction, squatting, or kneeling) is associated with 60% sensitivity and 85% specificity for patellofemoral pain syndrome. Of these, the one maneuver with greatest diagnostic strength is pain on resisted contraction (Cook et al., 2010).Goolsby Question 11. Question : A 17-year-old male complains of severe right knee pain. He was playing football when he heard a “pop” at the moment of being tackled and his knee “gave away” from under him. On physical examination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate: CORRECT Knee ligament injury Osgood-Schlatter disease Prepatellar bursitis Chondromalacia patella Instructor Explanation: The anterior, medial, and lateral knee ligaments are vulnerable to injury in athletic activities. The mechanism through which the anterior cruciate ligament (ACL) is typically injured involves deceleration combined with sudden turning or pivoting. The medial collateral ligament (MCL) is most prone to injury through motions that place valgus stress on the knee. Compared with ACL and MCL injury, damage to the lateral collateral ligament (LCL) is much rarer but typically occurs when sudden varus stress is placed on the knee. The patient often relates history of an acute trauma followed by the onset of pain, swelling, and limited mobility. Often patients recall hearing or feeling a “pop” at the moment of injury and/or “give-away” sense. ACL injury is identified through a positive drawer (Fig. 14.9) and/or Lachman’s test (Fig. 14.10). Laxity of the LCL is assessed by placing varus stress on the knee with the leg both extended and flexed. Goolsby Question 12. Question : A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the lef t leg and paresthesias in the lef t foot. On physical examination, the patient has diminished ability to dorsiflex the lef t ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon? Straight leg raising sign Lumbar herniated disc on X-ray Loss of left sided patellar reflex CORRECT Urinary incontinence Instructor Explanation: With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient’s posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, ROM, and any obvious signs of discomfort are noted. Observe the patient walking on heels and on toes, noting any signs of weakness. Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended, the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated. Goolsby Question 13. Question : Your patient is a 43-year-old female golfer who complains of arm pain. On physical examination, there is point tenderness on the elbow and pain when the patient is asked to flex the wrist against the clinician’s resistance. These are typical signs of: Carpal tunnel syndrome Osteoarthritis of the wrist CORRECT Epicondylitis Cervical osteoarthritis Instructor Explanation: Carpal tunnel syndrome causes a range of neurological symptoms, including pain, paresthesia, and weakness. Frequently, nighttime pain is an early symptom. There may be a swelling at the wrist related to inactivity or flexion at night. The pain and/or paresthesias typically involve the anterior aspects of wrist, medial palm, and first three digits on the affected hand. However, pain may radiate up the forearm to the shoulder with numbness and tingling along the median nerve. Over time, hand weakness often develops. Pain and paresthesia are often relieved by the patient “shaking” the affected hand in a downward fashion; this is called the flicking sign. A positive Tinel’s sign is elicited by tapping on the median nerve at the carpal tunnel, causing pain and tingling along the median nerve. Phalen’s maneuver reproduces the pain after 1 minute of wrist flexion against resistance. Goolsby Question 14. Question : Which of the following describes the pathology of De Quervain’s tenosynovitis? CORRECT Irritation of a tendon located on the radial side of the wrist, near the thumb Impingement of the median nerve, causing pain in the palm and fingers Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist Ulnar nerve compression at the olecranon process Instructor Explanation: De Quervain’s tenosynovitis involves irritation of a tendon located on the radial side of the wrist, near the thumb. With overuse, the tissues surrounding the tendon sheath hypertrophy, causing pressure on the tendon and making it difficult to move. The pain is usually limited to the radial aspect of the wrist and area immediately around the base of the thumb. Pain increases with use of the hand, such as with gripping maneuvers. Other symptoms include swelling, decreased sensation, and limited ROM with a locking sensation with thumb motion. The Finkelstein maneuver (Fig. 14.7) is used to diagnose De Quervain’s disease. A positive test results in pain, which is often severe. Patients who can repeatedly open and close the fist with smooth thumb motion are unlikely to have De Quervain’s. Goolsby Question 15. Question : What is the most common cause of hip pain in older adults? Osteoporosis CORRECT Osteoarthritis Trauma due to fall Trochanteric bursitis Instructor Explanation: There are many potential causes of hip pain. Among adults, the most common cause is OA with degenerative changes. In younger patients, the cause is often strain of the muscles or tendons. In comparison to other joints, the hip is often difficult to assess, in part because much of the joint and its periarticular structures lie deeper than those of other joints. Goolsby Question 16. Question : A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical examination, there is no point tenderness over the medial or lateral ankle malleolus. There is no foot tenderness except at the base of the fifth metatarsal bone. According to the Ottawa foot rules, should an X-ray of the feet be ordered? Yes, there is tenderness over the fifth metatarsal No, there is not tenderness over the navicular bone Yes, the patient cannot bear weight on the foot CORRECT A and C Instructor Explanation: Foot Rule: Order film if one of the following is met: Inability to bear weight for four steps (both immediately and in emergency department) Bone tenderness at navicular or base of fifth metatarsal. Sensitivity = 100%.Specificity = 79%. Goolsby.And FYI:The following Ottawa rules recommend x-ray of the ankle if either one of the following conditions exist:Inability to bear weight for four steps (both immediately and in emergency department) Bone tenderness at posterior edge or tip of either malleolus Question 17. Question : 38-year-old Asian male, Mr. Chen, with past medical history significant for prehypertension who has recently taken up softball presents with three to five weeks of shoulder pain when throwing overhead. Ice minimally alleviates pain. Medications: Naproxen minimally alleviates shoulder pain. Allergies: Penicillin-associated rash. Family history: Brother has rheumatoid arthritis. Which of the following musculoskeletal causes of shoulder pain would merit urgent diagnosis and management? Adhesive capsulitis CORRECT Septic subacromial bursitis Impingement of the supraspinatus tendon Calcific tendinopathy Instructor Explanation: MedU Card #3 Delay in recognition and treatment of a septic subacromial bursitis may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone (osteomyelitis) or more distant sites by way of bacteremia and that may progress to sepsis. Question 18. Question : If Mr. Chen had restricted passive as well as active ROM of the shoulder, what problems involving the shoulder might you consider? CORRECT Adhesive capsulitis Rotator cuff tear Tendinopathy of the long head of the biceps INCORRECT Rotator cuff impingment Instructor Explanation: MedU Card #7 A patient with loss of active and passive ROM is more likely to have joint disease; whereas a patient with loss of only active ROM is more likely to have an issue with muscle tissue. The following joint diseases will produce restricted active and passive ROM of the shoulder: Adhesive capsulitis, a condition common in patients with metabolic diseases such as diabetes and hypothyroidism in which there is contracture of the joint capsule Glenohumeral arthritis, a much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity Question 19. Question : What is the essential dynamic stabilizer of the shoulder joint? Labrum CORRECT Rotator muscle group Glenohumeral ligaments Teres major muscle Instructor Explanation: MedU Card #10 Question 20. Question : Given Mr. Chen’s repetitive overhead activities, some injury to his rotator cuff muscle group is most likely. Of the following exam findings, which one would not support the diagnosis of rotator cuff tendinopathy? Positive Apley’s Scratch test Weakness and pain with empty can testing Limited active ROM CORRECT Inability to raise arm above his head Instructor Explanation: MedU Card #15 Limited ROM with significant pain is a hallmark of the physical exam in the patient with a partial or complete rotator cuff tear. In a complete tear, the patient will likely not be able to raise his arm above his head. Week 9: 1. Question : When assessing a patient who complains of a tremor, the nurse practitioner must differentiate essential tremor from the tremor of Parkinson’s disease. Which of the following findings are consistent with essential tremor? The handwriting is not affected by the tremor CORRECT The tremor occurs with purposeful movements The tremor occurs at rest The tremor gets worse with alcohol ingestion Instructor Explanation: Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. The bradykinesia of PD affects gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal. Although Alzheimer's disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer's. Nonspecific secondary manifestations include cognitive dysfunction, sleep disturbances, constipation, dysphagia, blurred or double vision, nocturia, frequency, urgency, autonomic dysfunction (e.g., erectile dysfunction), dizziness, and drooling. (Goolsby 463) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 2. Question : An older adult client with a history of a seizure disorder comes into the clinic for a routine check-up. Although seizure free, the client continues on long-term phenytoin treatment. The nurse practitioner would assess for which of the following long-term effects? Lid lag and nystagmus CORRECT Gingival hyperplasia and nystagmus Nystagmus and microcytic anemia Gingival hyperplasia and iron deficiency anemia Instructor Explanation: Swallowing certain medications such as aspirin, antibiotics, ferrous sulfate, certain chemotherapeutic agents, NSAIDs, quinidine, steroids, alendronate, alprenolol, vitamin C, phenytoin, calcium preparations, theophylline, and potassium chloride contributes to pill esophagitis due to chemical irritation of the esophageal mucosa. (Kennedy-Malone 323) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : An elderly patient is maintained on phenytoin therapy for a history of a seizure disorder. In addition to periodic serum drug concentrations, which of the following are needed for annual evaluation? Complete blood count, liver function tests, and renal function tests CORRECT Complete blood count, liver function tests, and platelet count Renal function and calculated creatinine clearance Serum albumin, liver function tests, and renal function tests Instructor Explanation: Goolsby Question 4. Question : An elderly patient has had a CVA in the anterior cerebral circulatory system (frontal lobe). What symptoms are most likely expressed? Neglect of body and difficulty organizing space Wernicke’s aphasia (difficulty understanding speech) CORRECT Disorders of behavior and cognition Bilateral motor and sensory problem Instructor Explanation: Focal neurological changes are related to the area of the brain invaded by tumor. Frontal and parietal lobe tumors may cause changes in memory, behavior, and cognitive function. Memory, hearing, vision, and emotions are affected most often by temporal lobe tumors. Symptoms of temporal lobe tumors may mimic symptoms of affective or psychotic thought disorders. Visual changes can occur with occipital lobe tumors, in addition to speech, motor, and sensory changes for left-sided occipital masses and an inability to grasp abstract concepts for right-sided occipital masses. Lesions in the cerebellum affect balance and coordination. Pituitary tumors may present with the symptoms of hypothyroidism, hypercortisolism, diabetes insipidus, or visual changes (Chandana et al., 2008; Wong & Wu, 2010). (Kennedy-Malone 421) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 5. Question : The most common neurological cause of seizures in an older adult is: INCORRECT Alzheimer’s disease Multiple sclerosis CORRECT Stroke Peripheral neuropathy Instructor Explanation: A common cause of epilepsy in the elderly is stroke, which accounts for up to 50% of cases in whom a cause can be identified. The risk of epilepsy increases up to 20-fold in the first year after a stroke. Individuals with a brain tumor, bacterial meningitis, or Alzheimer's disease are up to 10 times more likely to develop epilepsy than those without the diseases. (Kennedy-Malone 438) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 6. Question : Mr. Andrews experienced a brief onset of right-sided weakness, slurred speech, and confusion yesterday. The symptoms have resolved. What should the nurse practitioner do? Assure the patient that he will not experience the symptoms again CORRECT Identify modifiable cardiovascular risk factors INCORRECT Do a thorough medication review and a CT scan Order a stat EEG and administer O2 by mask Instructor Explanation: Stroke is one of the leading causes of death in the United States. Patients with stroke often have a history of hypertension, diabetes, cardiac disease, hyperlipidemia, smoking, drug or alcohol abuse, and family history of stroke. Strokes are divided into two main categories: thrombotic and hemorrhagic; however, the two can be difficult to differentiate using clinical signs and symptoms. (Goolsby 462) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 7. Question : An older male patient is experiencing acute onset of right-sided weakness, slurred speech, and confusion. What should the nurse practitioner do promptly? Administer an aspirin by mouth CORRECT Evaluate for stroke and arrange transport to the hospital right away Do a thorough medication review and stat blood sugar Order an EKG and administer O2 by cannula immediately Instructor Explanation: Stroke Stroke is one of the leading causes of death in the United States. Patients with stroke often have a history of hypertension, diabetes, cardiac disease, hyperlipidemia, smoking, drug or alcohol abuse, and family history of stroke. Strokes are divided into two main categories: thrombotic and hemorrhagic; however, the two can be difficult to differentiate using clinical signs and symptoms. Signs and Symptoms The onset is usually an abrupt altered level of consciousness accompanied by hemiparesis or hemiplegia. Patients may experience confusion, memory impairment, and aphasia. Signs and symptoms vary with the location and severity of the stroke. Mentation and cognitive changes may be temporary or permanent, depending on the extent of injury. Communication alterations stemming from fluent or receptive aphasia may be mistaken as dementia. Diagnostic Studies A CT scan, without contrast, is the preferred imaging study in early stroke because hemorrhage may be difficult to determine on an MRI in the first 48 hours. In studies of ischemic stroke patients, researchers have shown the reversibility of abnormalities on CT or MRI through the use of thrombolytic therapy within a 3-hour window. Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 8. Question : When assessing an elderly client who reports a tremor, which assessment findings would be most reliable in identifying Parkinson’s disease? Any presence of tremor Symptoms of slowed movement, unstable angina, and tremor CORRECT Resting tremor, slow unsteady gait, and cogwheel resistance Cogwheel rigidity, bradykinesia, and amnesia Instructor Explanation: Description: Parkinson's disease (PD) is a chronic progressive neurodegenerative disorder resulting in the loss of dopamine-producing cells in the substantia nigra, located in the basal ganglia. The loss of the inhibitory neurotransmitter dopamine results in an imbalance with the neurotransmitter acetylcholine, which is primarily responsible for worsening symptoms leading to immobility. Symptoms of PD include resting tremor, rigidity, akinesia, bradykinesia, and impaired postural reflexes (resulting in postural instability) (Vernon, 2009). Subtle motor impairments may precede the development of overt clinical signs and symptoms by many years. The Braak hypothesis (Burke, Dauer, & Vonsattel, 2008) indicates six pathological stages of PD, but clinical symptoms do not appear until stage 4 to 6. This stage correlates with 60% to 80% loss of substantia nigra neurons and striatal dopamine. It is the second most common neurodegenerative disease. It affects motor and autonomic function, mood, and cognition. (Kennedy-Malone 423-424) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 9. Question : A middle-aged patient has been diagnosed with Parkinson’s disease. What influences the nurse practitioner’s decision to begin pharmacological treatment for this patient? Intentional tremors Gait instability requiring use of a cane CORRECT Symptoms interfering with functional ability Medications initiated at first sign of unilateral involvement Instructor Explanation: Treatment: Drug therapy focuses on correcting the imbalance of dopamine and acetylcholine. Patients with mild disease and no interference with ADLs may not require treatment. With tremors and rigidity causing impairment of the patient's ability to perform ADLs and a disability level that is mild-to-moderate, treatment may include amantadine, which is thought to augment dopamine release from presynaptic nerve terminals or to inhibit dopamine reuptake. Initial dose is usually 100 mg with breakfast. In 5 to 7 days, add amantadine 100 mg with lunch, then increase daily dose to 300 mg. (Kennedy-Malone 425-426) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 10. Question : A female patient presents to the clinic with complaints of a severe, throbbing, unilateral headache. She complains of seeing flashes of light prior to the headache. She complains of sound and light sensitivity as well as nausea. The clinician should recognize these as symptoms of: Epilepsy with aura Cluster headache CORRECT Migraine headache Normal pressure hydrocephalus Instructor Explanation: Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia. There may be tenderness to palpation of the temporal arteries. Auras, if experienced, may include blurred vision and scotoma and/or other prodromal symptoms, such as anorexia, irritability, restlessness, or paresthesias lasting from 30 minutes to 3 hours before the onset of migraine pain. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 11. Question : Which of the following is a common trigger of migraine headache? Missed meals Menses Alcohol CORRECT All of the above Instructor Explanation: Common Migraine Triggers:• Stress• Caffeine• Altered sleep• Specific foods, missed meals • Menses• Alcohol• Hormone supplements Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 12. Question : A 65-year-old woman is accompanied by her daughter for a physical examination. She has mild heart failure and takes digitalis and an ACE inhibitor. As you examine the patient, you note flat affect, hand tremor, and slowed movements. The tremor is worsened at rest. There are no neurologic deficits. Hand grip, sensation of face and extremities, and lower extremity muscle strength are within normal limits and bilaterally equal. DTRs are equal bilaterally. CN II to XII are intact. The mental status exam is normal. These are key signs of: Chiari malformation Normal pressure hydrocephalus CORRECT Parkinson’s disease Drug toxicity Instructor Explanation: Parkinson’s disease occurs with approximately equal sex distribution, and usually begins between 45 and 65 years of age. Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. There is a flattened affect and blank stare. There is bradykinesia of gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal. Although Alzheimer’s disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer’s. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 13. Question : A 65-year-old male complains of a headache that feels “like a knife is cutting into his head.” He also reports feeling right-sided scalp and facial pain and “seeing double” at times. He has a history of hypertension and hyperlipidemia. His medications include beta blocker, statin drug, and an ACE inhibitor. On physical examination, you note palpable tenderness over the right side of the forehead. There are no neurological deficits. Vision is 20/20 with lenses. No weakness of extremities. CN II to XII are intact. The history corresponds to which of the following disorders? Drug toxicity CORRECT Giant cell arteritis Cluster headache Migraine headache Instructor Explanation: Temporal arteritis is also referred to as giant cell arteritis or cranial arteritis. It is characterized by chronic inflammation and the presence of giant cells in large arteries, usually the temporal artery, but can occur in the cranial arteries, the aorta, and coronary and peripheral arteries. It affects the arteries containing elastic tissue, resulting in narrowing and eventual occlusion of the lumen. It occurs more among persons over 50 years of age and is slightly more common in females than in males. The cause is unknown, but there seems to be a genetic predisposition. If left untreated, arteritis can rapidly lead to blindness that is often irreversible. The most common chief complaint is head pain that is lancinating, sharp, or “ice pick” in nature. Patients often complain of visual changes, including amaurosis, diplopia, blurred vision, visual field cuts, eye pain, periorbital edema, and intermittent unilateral blindness. Other common presenting symptoms include scalp and/or jaw tenderness, facial pain, and tenderness to palpation over the affected artery. The pain is generally hemicranial but can be bilateral or diffuse. There may be eye pain, which is usually bilateral; periorbital edema may be present. Other potential associated symptoms include an intermittent fever (generally low grade), nausea, and/or weight loss. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 14. Question : Which type of seizure is involved following a head injury or febrile event? Epileptic CORRECT Isolated Atonic Clonic-tonic Instructor Explanation: Subdural hematomas can be either acute or chronic. Acute subdural hematomas are usually associated with an acute head injury and can cause a range of symptoms, including headache and loss of consciousness. A chronic subdural hematoma in the elderly population may enlarge significantly before the patient begins to notice head pain. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The physical findings vary depending on the severity of the trauma but may include progressive neurological deterioration, which may advance to include coma. The elderly patient with head trauma and anticoagulants should raise suspicion of subdural hematoma. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 15. Question : M. L. is a 40-year-old female that has been recently diagnosed with Multiple Sclerosis (MS). As you provide primary care for your patient you inform her that: MS presents with a classis triad of symptoms, which are blurred vision, vertigo, and tinnitus MS has a predictable course and can easily be managed MS has a predictable course and can easily be managed CORRECT Often MS has a varying pattern of exacerbation and remissions Instructor Explanation: Multiple sclerosis (MS) is a degenerative, demyelinating disease that is usually diagnosed in the second to fourth decades of life. It occurs more often in women than in men. The presentation of MS is often vague and transient, with episodic remission and exacerbation. Patients may have relapsing-remitting or primary/ secondary progressive MS. The etiology is unknown, but it is thought to be autoimmune. A genetic susceptibility is suspected since it is seen more in those of western European lineage who live in temperate zones. (Goolsby 481) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 16. Question : Ms. Smith, 37-year-old, comes to the clinic today complaining of dull, throbbing bilateral headaches almost every evening. You suspect she is experiencing: cluster headaches migraine headaches CORRECT tension headaches benign intracranial hypertension Instructor Explanation: Tension Headache Tension headaches are quite common. Whereas many people with episodic tension headaches do not seek treatment, those who suffer from frequent or chronic tension headaches may enlist the help of their provider. Other terms to describe tension headache include stress headache, essential headache, idiopathic headache, and muscle contraction headache. Tension headaches can occur with equal frequency among men and women, in any age group, and within any socioeconomic group. Signs and Symptoms Typical symptoms of tension headache include mild to moderate, nonthrobbing pressure or squeezing pain that can occur anywhere in the head or neck. The pain often starts slowly as a dull and aching discomfort that progresses to holocranial pain and pressure. The pain can recur intermittently, lasting from minutes to hours and usually remitting with rest or removal of the stressful trigger. There is usually no associated nausea and vomiting. Although patients may report photophobia and phonophobia, it is less severe than those associated with migraines. Tension headaches are not aggravated by movement or activity. The neck muscles are often tight to palpation. Tension headache triggers are listed in Table 15.2. (Goolsby 453) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 17. Question : The FNP is seeing Mr. Smith a 78-year-old gentleman accompanied by his wife to the health clinic. His wife reports that he has been falling down, tripping and stumbling. The FNP suspects a problem in: Peripheral nervous system Brainstem Cerebrum CORRECT Cerebellum Instructor Explanation: Focal neurological changes are related to the area of the brain invaded by tumor. Frontal and parietal lobe tumors may cause changes in memory, behavior, and cognitive function. Memory, hearing, vision, and emotions are affected most often by temporal lobe tumors. Symptoms of temporal lobe tumors may mimic symptoms of affective or psychotic thought disorders. Visual changes can occur with occipital lobe tumors, in addition to speech, motor, and sensory changes for left-sided occipital masses and an inability to grasp abstract concepts for right-sided occipital masses. Lesions in the cerebellum affect balance and coordination. Pituitary tumors may present with the symptoms of hypothyroidism, hypercortisolism, diabetes insipidus, or visual changes (Chandana et al., 2008; Wong & Wu, 2010). (Kennedy-Malone 421) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 18. Question : Educating your patient about headache management should include information about all but: Headache diary Rebound headaches Trigger identification CORRECT Common laboratory testing for diagnosis Instructor Explanation: For recurrent headaches, a headache diary is helpful in arriving at a definitive diagnosis. Although details can be simply recorded on a calendar, a number of headache diaries are available and downloadable via the Internet. Regardless of the format used, the diary should provide a space for the patient to identify daily whether a headache was experienced. When headache is experienced, the form should allow the patient to identify the type, severity, and duration of pain experienced; accompanying symptoms; treatment and response; and any suspected triggers. (Goolsby 450) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. A careful history of symptoms is invaluable. Complete physical examination should include skin survey for stigmata of neurocutaneous syndromes or melanoma, lymph node examination, abdominal examination for hepatomegaly or splenomegaly, and rectal examination with guaiac stool testing. Breast and pelvic examinations in women and cardiopulmonary examination are recommended. The neurological evaluation should include a mental status evaluation, testing for cognitive deficits or memory loss, and assessment for personality changes. Family members may be able to provide clues about subtle personality changes. Ophthalmic examination is essential to assess for papilledema, although this may not be present in patients 55 years old and older. Test also for asymmetry of strength, sensation, visual fields, reflex activity, cranial nerve function, and radicular signs. (Kennedy-Malone 422) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 19. Question : Mr. Marshall is a 72-year-old man, with a history of hypertension, COPD and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today. Mr. Marshall's presentation is most consistent with an acute delirium (acute change in cognition, perceptual derangement, waxing and waning consciousness, and inattention). What is the most likely diagnosis to frequently cause acute delirium in patients with dementia? Adverse drug effects CORRECT Urinary tract infection Depression Acute cerebrovascular event Instructor Explanation: MedU Card #10 Question 20. Question : Mr. Marshall was administered the Mini-Mental State Exam (MMSE). Which of the following statements pertaining to this tool is a true statement? Mr. Marshall’s baseline score of 18 on the MMSE demonstrates severe impairment. The test takes 45 minutes to administer and will detect subtle memory losses, particularly in well-educated patients CORRECT Because Mr. Marshall has symptoms of change of mental status you are not screening; you are doing the MMSE for diagnosis. In interpreting MMSE test scores, allowance does not have to be made for education and ethnicity Instructor Explanation: MedU Card #8 Week 5 Mid­term Return to deck 1. A 22-year-old female comes to your office with complaints of right lower quadrant abdominal pain, which has been worsening over the last 24 hours. On examination of the abdomen, there is a palpable mass and rebound tenderness over the right lower quadrant. The clinician should recognize the importance of Digital rectal examination Endoscopy Pelvic examination UrinalysisDefinition 2. Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? Clinical practice guideline Clinical decision rule Clinical algorithm Clinical recommendation 3. A common auscultatory finding in advanced CHF is S3 gallop rhythm 4. Mr. Keenan is a 42-year-old man with a mild history of GERD and a remote history of an appendectomy, presenting with an acute onset of significant right upper-quadrant abdominal pain and vomiting. His pain began after a large meal, was unrelieved by a proton-pump inhibitor, was unlike his previous episodes of heartburn, but upon questioning, reports milder, prodromal episodes of similar post-prandial pain. His pain seems to radiate to his back. Despite a family history of cardiac disease, he reports no classic anginal signs or chest pain. He furthermore denies respiratory or pleuritic signs and denies fever, night sweats, and unintended weight loss. Finally, there are no dermatologic signs, nor genitourinary symptoms. The chosen imaging study reveals: “GB normal in size without wall-thickening, but with 5-6 stones with shadowing. Common bile duct not dilated. Liver is homogenous and normal in size. Pancreas and kidneys are normal.” What is the most effective therapeutic/management option at this point? chole 5. A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered? Mono spot Strep test Throat culture All of the above 6. Which of the following is not a contributing factor to the development of esophagitis in older adults? 7. Essential parts of a health history include all of the following except: 8. What test is used to confirm the diagnosis of appendicitis? 9. The first assessment to complete related to the eyes is Eye lids Visual acuity Extraocular movements Peripheral vision 10. The best way to diagnose structural heart disease/dysfunction non-invasively is Chest X-ray EKG CORRECT Echocardiogram Heart catheterization 11. Which of the following is considered a “red flag” when diagnosing a patient with pneumonia Fever of 102 Infiltrates on chest X-ray Pleural effusion on chest X-ray Elevated white blood cell count 12. In a patient presenting with suspected recurrence of diverticulitis, abdominal pain usually presents where in the abdomen? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant 13. Mr. A presents to your office complaining of chest pain, mid-sternal and radiating to his back. He was mowing his lawn. He reports the pain lasting for about 8 minutes and went away after sitting down. What is his most likely diagnosis based on his presenting symptoms Acute MI GERD Pneumonia Angina 14. In autosomal recessive (AR) disorders, individuals need Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease Two mutated genes to acquire the disease Two mutated genes to become carriers 15. Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? chronic bronichitis 16. The best evidence rating drugs to consider in a post myocardial infarction patient include: ASA, ACE/ARB, beta-blocker, aldosterone blockade ACE, ARB, Calcium channel blocker, ASA Long-acting nitrates, warfarin, ACE, and ARB ASA, clopidogrel, nitrates 17. A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest X-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of: Lung cancer Tuberculosis Pneumonia COPD 18. Upon assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to Pneumothorax Pleural effusion Pneumonia Pulmonary embolism 19. A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: Bacterial conjunctivitis B. Allergic conjunctivitis C. Chemical conjunctivitis D. Viral conjunctivitis 20. Emphysematous changes in the lungs produce the following characteristic in COPD patients? Asymmetric chest expansion Increased lateral diameter Increased anterior-posterior diameter Pectus excavatum 21. An older patient reports burning pain after ingestion of many foods and large meals. What assessment would assist the nurse practitioner in making a diagnosis of GERD? A. Identification of a fluid wave B. Positive Murphy’s sign C. Palpable spleen D. Midepigastric pain that is not reproducible with palpation 22. Which of the following details are NOT considered while staging asthma? A. Nighttime awakenings B. Long-acting beta agonist usage C. Frequency of symptoms D. Spirometry findings 23. The cytochrome p system involves enzymes that are generally Inhibited by drugs : • Inhibited by drugs • Induced by drugs • Inhibited or induced by drugs • Associated with decreased liver perfusion 24. Mr. Keenan is a 42-year-old man with a mild history of GERD and a remote history of an appendectomy, presenting with an acute onset of significant right upper-quadrant abdominal pain and vomiting. His pain began after a large meal, was unrelieved by a proton-pump inhibitor, was unlike his previous episodes of heartburn, but upon questioning, reports milder, prodromal episodes of similar post-prandial pain. His pain seems to radiate to his back. Despite a family history of cardiac disease, he reports no classic anginal signs or chest pain. He furthermore denies respiratory or pleuritic signs and denies fever, night sweats, and unintended weight loss. Finally, there are no dermatologic signs, nor genitourinary symptoms. Of the following lab studies, which would provide little help in determining your differential diagnosis? Abdominal plain films Liver function tests Amylase/lipase Urinalysis 25. Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, and shortness of breath. The pain comes and goes and is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the left nipple. Jeff is concerned because his father has cardiac disease and underwent a CABG at age 65. The ANP examines Jeff and hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of: Angina Pericarditis Mitral valve prolapse Congestive heart failur 26. Men have faster and more efficient biotransformation of drugs and this is thought to be due to: • Less obesity rates than women • Prostate enlargement • Testosterone • Less estrogen than women 27. An 82-year-old female presents to the emergency department with epigastric pain and weakness. She admits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. She self- medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she has orthostatic hypotension and pallor. Fecal occult blood test is positive. A likely etiology of the patient’s problem is: Mallory-Weiss tear B. Esophageal varices C. Gastric ulcer D. Colon cancer 28. You have a patient complaining of vertigo and want to know what could be the cause. Knowing there are many causes for vertigo, you question the length of time the sensation lasts. She tells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions? Ménière’s disease Benign paroxysmal positional vertigo Transient ischemic attack (TIA) MigraineDefinition 29. . Your patient has been treated for glaucoma for 5 years. Which of the following will provide indication of the level of progression during the funduscopic examination for this patient? Checking the macula Estimating cup-to-disk ratio Verifying a red reflex Extraocular movements 30. If it has been determined a patient has esophageal reflux, you should tell them: They probably have a hiatal hernia causing reflux They probably need surgery They should avoid all fruit juices Smoking, alcohol, and caffeine can aggravate their problem 31. The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home: Age over 40 Fever greater than 101 Tachypnea greater than 30 breaths/minute Productive cough 32. Jenny is a 24 year old graduate student that presents to the clinic today with complaints of fever, midsternal chest pain and generalized fatigue for the past two days. She denies any cough or sputum production. She states that when she takes Ibuprofen and rest that the chest pain does seem to ease off. Upon examination the patient presents looking very ill. She is leaning forward and states that this is the most comfortable position for her. Temp is 102. BP= 100/70. Heart rate is 120/min and regular. Upon auscultation a friction rub is audible. Her lung sounds are clear. With these presenting symptoms your initial diagnosis would be Mitral Valve Prolapse Referred Pain from Cholecystitis Pericarditis Pulmonary Embolus 33. During auscultation of the chest, your exam reveals a loud grating sound at the lower anterolateral lung fields, at full inspiration and early expiration. This finding is consistent with: Pneumonia Pleuritis Pneumothorax CORRECT A and B 34. Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of Anemia Anxiety Hyperthyroidism CORRECT All of the above 35. Presbycusis is the hearing impairment that is associated with: Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster 36. Functional abilities are best assessed by : 37. • Self-report of function • Observed assessment of function • A comprehensive head-to-toe examination • Family report of function In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion? Fictional keratosis Keratoacanthoma Lichen planus Leukoplakia 38. The aging process causes what normal physiological changes in the heart? The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis Cardiology occurs along with prolapse of the mitral valve and regurgitation Dilation of the right ventricle occurs with sclerosis of pulmonic and tricuspid valves Hypertrophy of the right ventricle 39. In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness? History of prior red-eye episodes Grossly visible corneal defect Exophthalmos Photophobia 40. Helicobacter pylori is implicated as a causative agent in the development of duodenal or gastric ulcers. What teaching should the nurse practitioner plan for a patient who has a positive Helicobacter pylori test? A. It is highly contagious and a mask should be worn at home. B. Treatment regimen is multiple lifetime medications. C. Treatment regimen is multiple medications taken daily for a few weeks. D. Treatment regimen is complicated and is not indicated unless the patient is symptomatic. COPD Stage I MILD FEV1/FVC <70% FEV1</80% *Chronic cough/sputum production *Pt unaware lung function is abnormal COPD Stage II MODERATE FEV1/FVC <70% FEV1 50-80% SOB with exertion Cough and sputum production present COPD Stage III SEVERE FEV1/FVC < 70% FEV1 30-50% Greater SOB Reduced exercise capacity Fatigue Repeated exacerbations with impact on QOL COPD Stage IV VERY SEVERE FEV1/FVC<70% FEV1<30% Resp. Failure Cor Pulmonale (elevation of JVP and pitting ankle edema) QOL very impaired Exacerbations may be life threatening How does FEV1 decrease? Inflammation Narrowing of peripheral airways Airway collapse in severe emphysema COPD diagnosis? SPIROMETRY is key Primarily Inflammatory with superimposed bronchospasm Asthma Most common chronic respiratory disorder among all age groups Asthma Atophy exaggerated IgE mediated immune response; all atophic disorders are type I hypersensitivity disorders Type I hypersensitivity reaction Immediate hypersensitivity IgE-mediated Antigen binds to IgE that is bound to tissue mast cells and blood basophils, triggering release of preformed mediators (histamine, proteases, chemotactic factors) and synthesis of other mediators (prostaglandins, leukotrienes, platelet-activating factor, cytokines) -causes vasodilation, increased cap. permeability, mucus hypersecretion **atopic disorders (allergic asthma, rhinitis, conjunctivitis), anaphylaxis, some cases of angioedema, urticarial, and latex and some food allergies **Develop <1h after exposure to antigen Allergic triad of symptoms allergies, eczema, and asthma Samter's Triad Nasal polyps, asthma, and ASA allergy Most common symptom of asthma wheezing Common only symptom of asthma? Cough -can often delay dx of asthma AKA cough variant asthma Best way to confirm asthma dx? bronchial provocation Intermittent asthma sx </2days/week PM awakenings </2/month SABA use </2 days/week No interference with norm. activity 0-1 exacerbations requiring oral steroids / yr Tx for intermittent asthma step 1 Mild asthma Sx >/2days/week but not daily pm awakenings 3-4x/month SABA use >2 days/week but not daily minor limitation Intermittent asthma lung function normal FEV1 bt exacerbations FEV1>80% predicted FEV1/FVC normal Mild asthma lung function FEV1>80% pred. FEV1/FVC normal Mild asthma tx Step 2 Moderate asthma Sx: daily PM awakenings: >1x/week but not nightly SABA use: daily some limiation mod. asthma lung function 60<FEV1<80 predicted FEV1/FVC reduced 5% Mod. asthma tx step 3 and consider shot course of oral steroid Severe asthma Sx: thruout day pm awakenings: often 7x/week extremely limited severe asthma lung function FEV1<60% predicted FEV1/FVC reduced >5% severe asthma lung function tx step 4 or 5 and consider short course of steroids Asthma step 1 SABA prn Asthma Step 2 low dose ICS ALT- cromolyn, LTRA, nedocromil or theophylline Asthma step 3 low dose ICS + LABA or- medium dose ICS Asthma step 4 medium dose ICS + LABA Asthma step 5 high dose ICS + LABA AND consider omalizumab for patients with allergies Asthma step 6 High dose ICS + LABA + oral corticosteroid AND consider omalizumab for pts with allergies Asthma monitoring for acute episode f/u in 1-2 hours or next day until pt is stable then q3-5 days, then weekly until sx are controlled and peak flow consistently 80% of predicted, then monthly until under control for at least 3 months IDA MCH<23 MCV<80 Serum Iron dec TIBC inc RDW>15% MICROCYTIC HYPOCHROMIC Findings on blood test for IDA pencil cells on smear IDA tx 1st line- oral iron 150-200mg elemental iron foods high in iron green leafy veggies, dried peas and beans, red meat, fortified foods ACD normocytic normochromic hgb >10 30% microcytic hypochromic Most common type of anemia in hospitalized pts? ACD ACD labs norm or dec iron norm ferritin norm TIBC norm RDW Thalassemia Microcytic hyopchromic Norm TIBC norm Iron norm ferritin Norm RDW Findings on blood test for thalassemia TEAR DROP CELLS (dacrocytes) and acanthocytes Blood test for thalassemia? hgb electrophoresis Macrocytic anemia? megaloblastic, vit b12 and folate deficiency, pernicious anemia s/sx of vit b12 deficiency? beefy-red shiny tongue (glossitis), abd tenderness, hepatosplenomegaly, tachycardia, tachypnea, pallor, loss of fine motor control, pos rhomberg and babinski s/sx of folate deficiency? fatigue, DOE, pallor, tachy, anorexia, glossitis, HA, neural tube disorders; NO NEURO SIGNS Foods rich in folic acid? bananas, PB, green leafy veggies, fortified bread and cereal foods rich in vB12? shellfish, liver, fish, fortified cereals and breads, low fat dairy, red meat, poultry,eggs, soy Diseases of primarily bronchospasm with superimposed inflammation COPD Inflammation of cells lining bronchial walls, hyperplasia of mucous glands and narrowing of small airways Chronic bronchitis enlargement and destruction of inter alveolar septa within the terminal bronchiole with wall destruction in absence of fibrosis emphysema Most common complaint of COPD dyspnea on exertion COPD dx test? spirometry confirms diagnosis COPD stage I tx SABA prn COPD stage II tx SABA plus 1 or more long acting bronchodilators COPD stage III tx SABA plus 2 or more LABAs; inhaled glucocorticoids COPD stage IV tx SABA plus one or more LABAs; inhaled glucocorticoids; tx of complications sx of COPD exacerbations? cough increases in frequency and/or severity; increased production of sputum/changes in color or viscosity; SOB increases; VS changes Theophylline Bronchodilitation *Therapeutic window- seizures, cardiac if too high *watch drug interactions with antibiotics and statins Anticholinergics precautions narrow-angle glaucoma Beta adrenergic agonists precautions caution with cardiac dx, hyperthyroidism, DM, seizures Otitis externa s/sx usually unilateral *Tragus tenderness is hallmark* pruritis, pain, hearing loss, ear d/c *pt usually well What is chronic otitis externa? Usually PSEUDOMONAS External otitis topical antimicrobial x7days *non-aminoglycoside + corticosteroid *aminoglycoside + corticosteroid (not in perf. TM) *topical preps containing only antibiotic *antifungal (usually yeast) or something containing all three Malignant otitis externa facial nerve palsy in 50% of patients *severe infection d/t pseudomonas and anaerobes causing OM of skull base *Otalgis, otorrhea, hoarseness, swelling, trismus AOM s/sx unwell, pyrexia, otalgia/discharge, loss of outline of drum and landmarks *Red, bulging edematous TM AOM causes MOSTLY VIRAL (15-44%) Strep pneumo (20-35%) H.flu (20-30%) M.cat (15%) Bullous AOM cover mycoplasma pneumo and strep pneumo TX for AOM amox 1st line tx augmentin if severe or previous AOM in last month clarithromycin for PCN allergy BPPV benign paroxysmal positional vertigo *believed to be caused by free floating calcium debris in the semicircular canal; pt changes position, debris settles and signals brainstem, stimulating vertigo and nausea sx of BPPV? severe vertigo seconds after changing position, lasts seconds to minutes Tx for BPPV? Epley maneuvers Habituating exercises Vestibular rehab **self-limiting Vestibular neuritis Labyrinthitis *Infection of inner ear (most likely viral) often following URI *Affects vestibular portion of CN VIII Ages BPPV and vestibular neuritis? BPPV: most common over 60 VN: any age, usually after a URI s/sx of vestibular neuritis? Disabling vertigo with N/V, gait impairment, possible hearing loss *NO TINNITUS *lasts hrs to days Tx for vestibular neuritis vestibular rehab usually resolves in several days *steroid acutely (pred taper), antihistamines, anti emetics, anticholinergic 1st 24-48 hrs Meniere's dx Peripheral vestibular disorder resulting from excess endolymphatic pressure; tears in membrane separating endolymph and perilymph allow mixing and distention, causing vertigo Meniere's dx ages bt 40-70 s/sx of Meniere's sudden episodes of vertigo associated with TINNITUS AND DIMINISHED HEARING *lasts minutes to hours; asymptomatic bt episodes POSITIVE NYSTAGMUS Tx for Meneire's dx? Limit salt, caffeine, ETOH Rest, fluids if necessary Hearing aids, vestibular rehab, surgery *vestibular suppressant + amtiemetics; diuretic ACG? Acute closure glaucoma *hard red eye, ciliary flush, steamy cornea, dilated pupil Halos around eyes Onset of ACG? ACUTE severe pain, HA, nausea ACG more common in what ethnicity? Asian- Americans and Inuits Gold standard for ACG? Gonioscopy TX for ACG? bed rest, laser peripheral iridotomy What to do if >1 hour before pt can see opth with ACG? if suspicion is high, consider pressure lowering drops and systemic meds to control IOP OAG? Open angle glaucoma 90% of glaucoma cases? OAG OAG more common in who? 6x more common in blacks (leading cause of blindness) IOP in OAG? up to 22mmHG S/sx of OAG? Insidious onset, no early sxs, PAINLESS Progressive loss of peripheral vision Optic nerve head pale with increased cup to disc ratio OAG tx? Laser- trabeculoplasty Surgery- possible shunt if advanced dx Meds for OAG? prostaglandin analogs and B-adrenergic antagonists most used- decrease aqueous production and increase outflow s/sx of influenza? high fever (100-102) lasts 3-4 days HA, general aches and pains, fatigue and weakness (up to 2-3 weeks), extreme exhaustion Contraindications to flu vax severe allergic reaction (anaphylaxis) after previous dose or to a vaccine component, including egg protein Flu vax precautions mod or severe acute illness w/or w/o fever h/o guillain barre syndrome w/in 6 weeks of previous flu vax Who should get the nasal flu vax? healthy* children 2 years through 8 years of age when it is immediately available and if the child has no contraindications or precautions to that vaccine. *approved 2-49 Contraindications to nasal flu vax under 2 over 50 long term aspirin use (age 2-17) pregnant women Children 2 years through 4 years who have asthma or who have had a history of wheezing in the past 12 months. Influenza antivirals taken in last 48 hours Ppl who care for severely immunocompromised ppl (or avoid contact for 7 days) CAP typical organisms strep pneumo (60-70% of all bacterial CAP) CAP atypical organisms influenza, mycoplasma, chlamydia, legionella, adenovirus Most common outpatient CAP organisms strep pneumo, mycoplasma pneumo (m.pneumoaniae), h.flu, chlamydophila pneumo (c.pneumoniae), and resp. viruses CAP organisms in ETOH abuse moraxella catarrhalis and klebsiella pneumo CAP organisms in COPD m. catarrhalis gram positive bacteria organisms in CAP s.pneumoniae- leading cause of PNA in any adult age group Gram neg bacteria in CAP h.flu, m.catarrhalis Most common organism in majority of cases of PNA in those younger than 40 yrs m.pnuemoniae Leading cause of PNA in any adult age group? s.pneumoniae s/sx of atypical CAP? fever, HA, myalgias, dry cough *appear less ill than those with bacterial PNA sx may last up to 6 wks and include dry hacking cough CAP dx? chest xray sputum analysis (not routine for outpt) CAP tx for previously healthy pts with no antimicrobial therapy in last 3 months? MACROLIDE CAP tx for pts with comorbids? resp fluoroquinolone -or- B-lactam PLUS a macrolide Most common cause of pharyngitis? virus (90%) rhino, adeno, parainflu s/sx of pharyngitis sore throat, cough, hoarse, fever, odynophagia, malaise, HA, chills, anorexia, enlarged tonsills, erythema, exudates, soft palate petechiae, cervical adenopathy, high fever What not to give in viral pharyngitis? aspirin Tx for pharyngitis? Pen V K 500 BID or TID x10 days *E-mycin or cephalexin in PCN allergy Cause of epiglottitis? h.flu or s.pneumo s/sx of epiglottitis? SUDDEN ONSET, severe odynophagia, dysphagia, fever, SOB inability to swallow secretions, neck tenderness, drooling, stridor, resp distress *Tripod position to breathe *THUMB SIGN- no c xray Mono acute viral pharyngitis caused by EBV peak ages for mono 15-24 yrs; incubation period 4-6 weeks s/sx of mono pharyngitis, fever, lymphadenopathy, malaise, splenomegaly, tonsillar exudates, H/a, rash Labs for mono CBC with diff- absolute neutropenia *Lymphocytosis with atypical lymphocytes *mono spot (if neg repeat in 7-10 days) How often to f/u with mono pt? q 1-2 weeks; no contact sports or blunt trauma until re-evaluated (x1month+) allergic rhinitis statistics (American adults) 45-64 age group 65-75 age group 10-30% of American adults 10.7% 45-64 7.8% 65-75 years PE findings for allergic rhinitis? tip of nose for droop, assess nasal patency, turbinates, septum for polyps, inflammation, watery mucus, cobblestoning, edema and erythema of nasal mucosa Allergic rhinitis labs/smears? nasal smears for eosinophils, CBC(eosinophils, infectious process), serum IgE levels, skin testing for allergies Allergic rhinitis management 1. avoidance of exposure 2 pharmacotherapy 3. immunotherapy 1st line for moderate to severe allergic rhinitis? Other meds intranasal steroids topical and systemic decongestants, leukotriene receptor antagonist Type I hypersensitivity reactions atopic disorders (allergic asthma, rhinitis, conjunctivitis), anaphylaxis, angioedema, uticaria, latex and some food allergies When do type I hypersensitivity reactions occur <1 hour after exposure PPD induration >/5mm HIV pos or persons at high risk for TB Fibrotic changes on xray suggestive of old TB Pts with organ transplants or other immunosuppressed (>15mg/day of pred>1 month) Close contacts of ppl with active TB PPD induration >/10mm Recent immigrants (>5yrs) from high prevalent countries (asia, africa, latin america) IVDA NH Jail HCF homeless shelters pre-exisiting conditions (wt loss >10%, gastrectomy, CRF, malignancy) Recent converters Any child under 4 PPD induration >/15mm ALL PERSONS First line tx for TB rifampin, ethambutol, rifapentin PZA Initial phase for TB 3-4 drugs for 8 weeks, then 2 drug regimen for 18 weeks Adverse effects to INH hepatotoxicity, peripheral neuropathy (vit b6 daily) and drug interactions *liver enzymes at baseline and monthly while on- if sx and 3x limit halt therapy, if 5x norm level halt therapy) Adverse effects of ethambutol? vision changes/optic neuritis, liver tox, peripheral neuropathy, rash, confusion, arthralgia, hyperuricemia Adverse effects to rifampin? Hepatotox, reduced contraceptive effectiveness, rashes, BODY FLUIDS BECOME ORANGE/RED What TB meds to give during pregnancy? PZA and INH Streptomycin CONTRAINDICATED Stats regarding small cell lung ca and non small cell lung ca SCLC= 15% of all lung ca's - early mets, aggressive NSCLC= 85% of all lung cancers Types of non small cell lung ca and stats adenocarcinoma- MOST COMMON 40% squamous cell <25% Large cell approx 10% Leading cause of cancer death for both men and women? lung Where does lung ca metastasize? lymph nodes (pulm, mediastinal), then liver, adrenal, bone, kidney, brain New cases of lung ca in US/yr? 222,520 How many ppl will die of lung ca / year? 160,000 S/sx of lung ca? malaise, bone pain, fatigue, wt loss, anorexia, anemia, clubbing of digits, new or change of cough, wheezing, dyspnea, hemoptysis, chest pain lung ca screening requirements low-dose CT of chest of 55-74 yr old, fairly good health, at least 30 pack year hx of smoking and still smoking or have quit w/in last 5 years- continue yearly thru age 74 as long as remain in good health Common food allergy symptoms skin: hives, uticaria, swelling or flaring of atopic dermatitis resp tract: wheezing, asthma symptoms, allergic rhinitis, trouble breathing GI tract: vomiting, diarrhea, dysphagia, pain What is oral allergy syndrome? triggered by raw fruits and veggies- happens bc pt develops a sensitization to pollen- occurs with apples peaches pears strawberries and carrots sx of oral allergy syndrome? itching mouth, some swelling or itching of lips, itching of throat, 98% of time NOT PROGRESSIVE Food allergies kids grow out of? milk, egg, wheat, soy Persistent allergies from childhood to adulthood? peanuts, tree nuts, fish, shellfish most common food allergy in adults? the most severe reactions- have proteins more resistant to digestion and absorbed in systemic circ more readily In a healthy adult- order of leukocyte diffs? 1. neutrophils 2. lymphocytes 3. monocytes 4. basophils 5. eosinophils Other names for neutrophils? segs or polys What makes you think viral on a cbc with diff? polys (neutrophils) and lymphs CLOSE TOGETHER What leukocytes are the first responders? POLYS AND LYMPHS When do monos become elevated? after pt has been sick over 24 hours When do eosinophils increase? allergic reactions and parasites When do you suspect bacterial on cbc with diff? POLYS AND LYMPHS FAR APART What are bands? immature WBCs 3 most common organisms in CAP? 1. Strep pneumo (14%)- most common cause of death most likely from age extremes 2. M. pneumoniae (16%)- ATYPICAL (walking PNA) 3 Chlamydophila pneumo (12%) ATYPICAL Most common cause of death in CAP? STREP PNEUMO How to treat PNA- healthy pt and no antibiotics in last 90 days most likely ATYPICAL 1. macrolides (azith, clarith) 2. Doxy How to treat PNA in pt with comorbidities or antibiotics in last 90 days? suspect DRSP --respiratory quinolone (gemiflox, levoflox, moxiflox) OR beta lactam PLUS macrolide or doxy What antibiotics can prolong QT intervals? quinolines and macrolides How long to treat CAP 5-10 DAYS fever resolves by day 3 Hospital admission criteria for CAP? C confusion R RR >30 B BP <90 or <60 65 age great or equal to 65 High frequency hearing loss due to non-pathological aging Presbicusis Dry degenerative maculation s/sx drusen, macular pigment changes, progressive, usually B/L, preserved peripheral vision What does hgb electrophoresis test for? identifies different types of hemoglobin Cholesterol deposits around the eye xanthelasma Maneuver to dx vertigo Dix-Hallpike Maneuver sudden episodes of vertigo, associated with tinnitus and diminished hearing Meniere's How long does Meniere's last? minutes to hours Severe vertigo seconds after changing position BPPV BPPV length seconds to minutes Disabling vertigo with N/V, gait impairment, no tinnitus Vestibular neuritis Vestibular neuritis length hours to days S/sx of subconjunctival hemorrhage asymptomatic, sudden onset, vision is NORMAL, no precipitating event identified trauma, cough, valsalva, HTN, anticoag R/O HYPHEMA what does RDW measure? the variation of size of RBCs What does Itropium do? Improves sx of COPD pts -decreases cholinergic nerve stimulation of smooth muscle to lessen bronchoconstriction/decreases sputum PNA and rust colored sputum S. pneumoniae Test for corneal abrasion? Slit lamp exam with fluorescein First line drugs in TB INH- NEEDS VIT B6 DAILY Rifampin, ethambutol, rifapentin, PZA Condition associated with iritis IBD, Reiters, ankylosing spondylitis, psoriatic arthritis, bechet's, ANA, ESR Trismus spasms of masticator muscles- cannot open mouth d/t spasm from infection/swelling Atopic march eczema, food allergy, allergic rhinitis, asthma Which is a modifiable risk factor for melanoma Considerable sun exposure and sunburn A 19 year old female comes to your clinic for a routine visit to obtain birth control pills. You notice a red sunburn over her body. She states that she stayed a little too long in the sunbed. She denies pain and appears happy. What is your most appropriate course of action for skin health promotion and disease prevention? Ask how often she uses the sun bed and explore why it is important to her Large, flaccid bullae with honey-colored crusts around the mouth and nose are characteristic of Impetigo You examine a patient with a well demarcated erythematous rash with silvery scale. You diagnose ? Psoriasis A teenage male comes to your clinic with the chief complaint of foot odor. He notes "extra" white skin between his toes. He denies pain at this time. On history you find that he plays on the local high school football team and is sexually active. What will you include in your plan of care? Miconazole nitrate 2% cream or Clotrimazole 1% solution twice a day x 4 weeks A 60 year old male comes to your office with a history of urticaria. He is staying at home more due to his "rash". The lesions are papular and scabbed on extremities and trunk. What will you include in your treatment plan? Assess medication list for ACE inhibitors and NSAIDs A teenager comes to your clinic with the chief complaint of warts located on her hands. Which treatment is NOT an evidence-based option? Shaving the warts Mr. Jackson, age 64, is active and continues to farm as he has all of his adult life. He is asymptomatic for skin lesions. What should you discuss with him for skin health promotion and disease prevention course of action in this patient encounter? Show Mr. Jackson how to inspect his skin using the ABCDE model and encourage him to do self-skin- inspections A 40 y/o man comes to the office with a rash of 4-5 months duration. He had bumps on his shoulders, back and arms. He reports that the bumps are larger, he has nighttime pruritis and oral and topical corticosteroids have not helped. He has no pets, lives alone, and recalls no insect bites or contacts with anyone with a rash. On eaxm there is a symetric eruption with erythematous papules and excorations on his back, shoulders, axillae, wrists, scrotum, and upper legs. There are a few pustles in the axillae. Which of the following is the most appropriate next step? Examine a skin scraping in mineral oil under a light microscope A 75 y/o man in a nursing facility has developed a Stage 3 pressure ulcer. He weighs 160 lbs with a 10 lb weight loss in the last month. BMI=20.5, Albumin 3.2, Pre-albumin 14. Which of the following is most likely to aid healing? Protein 100 GM qd A 70 y/o patient has a large sacral ulcer measuring 11 by 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed muscle, undermining of the edges and a tunneling tract that extends another 2 cm. Within the ulcer, there is necrotic material and a significant amount of exudate with a foul odor. Which of the following is the next step to reduce odor? Perform surgical debridement A 60 y/o woman is evaluated because she has erythematous lesions. Initially, the lesions were on her arms and legs. By the end of week 1, the lesions spread to her trunk and several large blisters appeared. The lesions are pruritic and cause her to scratch. On exam, there are areas of erythema with tense blisters and serous exudate. Some blisters have opened into oval erosions with serous exudate. Some blisters are covered in scabs. What is the most likely diagnosis? Bullous pemphigoid A 32 y/o woman comes to the office c/o a bad taste in her mouth. She takes Metformin and Valsartan. Three weeks ago she took Nitrofuratonin for a UTI. On exam, there are white plaques on the surface of her cheeks, hard palate, and tongue. Wiping off some of the plaques reveals an erythematous mucosal surface. Which of the following is the most likely diagnosis? Acute psuedomembranous candidiasis All of the following are true about renal dosing EXCEPT Reducing each dose while maintaining the dose interval presents no risks When following up on response to treatment for a bite injury which diagnostic test can be used to evaluate the response to the treatment? C reactive protein Which of the following factors contributes to the potential for antibiotic resistance? Environment, Patient, Drug The best description of logical antibiotic prescribing involves which of the following Answering the 10 questions of logical prescribing An example of a disease caused by vector transmission is Malaria An example of a disease caused by indirect transmission is Salmonella An example of a disease caused by direct transmission is Herpes Type 1 Infections are defined as a harmful invasion and spread of a foreign species or pathogen. Which of the following are sources of infection? All of the above: Prions, Fungus & Protists Epidemiology is defined as The science of discovering the causes of illnesses and injury in populations Which of the following statements is true regarding the first pass metabolism process? After a drug is taken by the oral route, it is absorbed in the small intestines and enters the liver through the portal circulation before being released into general circulation. You would recommend the pneumococcal vaccine to patients with all of the following conditions EXCEPT G6PD deficiency anemia Erythromycin inhibits the cytochrome P450 system. The following drugs should be avoided because of drug interaction EXCEPT Lasix All of the following are included in the criteria used to diagnose patients with AIDS EXCEPT profound fatigue Which of the following is the confirmatory test for the HIV screening test? Western blot Cat and human bites have higher rates of infection than dog bites. A patient comes to your office with a bite. It does not require sutures or appear infected. You want to prescribe antibiotic prophylaxsis. The patient has no history of allergies. You presctibe: Amoxicillin-clavulanate (Augmentin) 74 y/o with a 4 month history of severe stiffness and aching in her neck and both shoulders and hips that is worsened by movement. She reports having difficulty getting OOB and dressing. She also has a low grade fever, fatigue, loss of appetite and weight loss. Yesterday the vision in her right eye has progressively worsened. Which of the following is the most likely? Polymyalgia rheumatica Multiple myeloma is a malignancy of the Plasma cells Which of the following exam findings is most specific for lupus? Malar rash Which of the following lab tests is positive in a large number of patients with lupus? Antinuclear antibody Which of the following is recommended treatment for early Lyme disease? Doxycycline 100 mg bid x 30 days Which of the following viral infections is associated with occasional abnormal forms of lymphocytes during an acute infection? Epstein-Barr Lyme disease is caused by the bite of a Tick Sue has sickle cell anemia. What is the optimum range for her hemoglobin and hematocrit levels? Slightly below normal. You have ordered a CBC for your patient you suspect has polymyalgia rheumatica (PMR). Which two clinical findings are common in patients with PMR? normochromic, normocytic, anemia with thrombocytosis In terms of immune response, a mantoux skin reaction is an example of: T cell immunity Frank, a 66-year-old white male who is on diuretic therapy, presents with an elevated hematocrit. He also has splenomegaly on examination, as well as subjective complaints of blurred vision, fatigue, headache, and tinnitus. You suspect: polycythemia vera You begin ferrous sulfate 325mg daily for your patient who was recently diagnosed with iron deficiency anemia with corrected source of iron loss. Based on the life span of RBCs, when would you expect to see a maximum response to your treatment plan? 3 - 4 months The total iron for a 56 year old female patient is 40 mcg/dl, TIBC 401 mcg/dl, Transferrin Saturation 8%, Ferritin 150 ng/ml, MCV is 82, Hgb is 10.6, Hct 30.3 and WBC is 8.5. These lab results indicate: anemia of chronic disease Anemia of chronic disease is most commonly associated with which of the following conditions: Inflammation, infection, neoplasms IgG responsible for immunity obtained from vaccinations IgM eliminates pathogens in the early stages of B cell mediated (humoral) immunity IgA Found in mucosal areas; prevents colonization of pathogens IgE Binds to allergens and triggers release from histamine receptors, basophils, and mast cells Pernicious anemia is due to a(n): Intrinsic factor deficiency. Amy, a 34-year-old patient receives an influenza vaccination in your office today. Understanding how humoral immunity develops, you expect which of the following: She will have immediate immunity due to an increase in IgM antibodies. The following clinical signs are seen in Parkinson's disease EXCEPT Increased facial movements due to tics A 56 y/o complains of episodes of lacinating pain that shoots up to his right cheek when he eats or drinks, He has stopped drinking cold drinks because of the pain. Most likely this is trigeminal neuralgia When assessing a patient suspected of having vertigo, which description provided by the patient is most consistent with the diagnosis? A sensation of spinning or rotating During the eye exam of a 50 y/o patient with HTN complaining of an onset of a severe headache, you find that the borders of the disc margins in both eyes are blurred. What is the name of this clinical finding? Papilledema Carol, a 73 y/o, complains of episodic vertigo, slight confusion, and weakness that last nearly an hour each time. Movement does not worsen the symptoms. She rests and her symptoms subside but is puzzled because the weakness "jumps from side to side", sometimes on the right and sometimes on the left of her body. Her symptoms suggest: TIA (transient ischemic attack) Jean, a 68 y/o, is suspected of having Alzheimer's disease. Which of the following is the best initial method for assessing the condition? MMSE or MOCA A 60 year old female patient in your clinic reports the recent onset of lancinating, cutting pain (pain scale: 8) on the right side of her face that lasts for approximately 5-10 seconds. The pain commenced after brushing her teeth and there has been no pain between the two recent episodes. You suspect trigeminal neuralgia (tic douloureux). Which of the following best describes your plan of care today? Schedule MRI and start Carbamazepine (Tegretol) at 100 mg. BID. Plan to monitor Tegretol blood levels and liver function. Your patient comes for an annual visit and notes his legs have started "twitching" at night. Sometimes they feel like they shake. What do you know about restless leg syndrome? May be seen in iron deficiency anemia, peripheral neuropathy (especially diabetic); there may be a genetic component A patient comes to your clinic with the chief complaint of hand tremor and some balance problems. You want to differentiate between a benign essential tremor and Parkinsonism since he has neither diagnosis on record. What information do you need to collect? Family history, evidence of rigidity, bradykinesia & postural instability A 21 year old female patient comes to your clinic with complaints of headache. The headache is described as unilateral; throbbing or pulsatile. There was no preceding aura but she states mild dizziness with the headache. She denies acute visual changes, nausea, vomiting & photophobia. She states noises bothered her most.On a scale of 1 - 10 she states the headache was 7 but it disrupted her daily activities enough to make an appointment with you. The headache lasted several hours. When asked about her current medications, she states that she recently began taking birth control pills. You forget to ask about a family history so you do not have this information at the current time. You are developing your differential diagnoses. Of the differential diagnoses below, which one do you most suspect? Classic migraine headache All of the following drugs commonly cause confusion in older adults except Amoxicillin Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the differential is: Rapid change and fluctuating course of cognitive function A 25 year old female comes to your clinic with the chief complaint of new onset headache. What will you include in your history of present illness? Location of pain, duration of pain, description of pain, triggers, past treatments Which form of headache is bilateral? Tension A 32-year-old patient with the right half of her face is paralyzed. She is unable to wrinkle her forehead or close the eye completely. The corner of her mouth droops. She cannot whistle or show her teeth. She has no pain. These findings are consistent with which of the following? Bell's Palsy Choose all of the following cranial nerves that innervate the ear. V, VII, VIII, IX & X Dignity and respect includes all of the following EXCEPT Justice Justice is described as The lack of bias, right to fair and equitable treatment and distribution of societal resources Utilitarianism is described as Presenting information in an honest and truthful way Nonmalficence is described as Obligation to avoid harm Beneficence is described as Obligation to help the patient, remove harm, prevent harm, promote good Autonomy is defined as Personal liberty of action and self determination with respect to all persons as individuals An adult patient is being evaluated for TB and has a positive 2 step PPD. The patient denies symptoms and has a negative chest xray. The patient reports he is in the country illegally and is fearful of discovery. What is the most appropriate acition for the NP? NPs have the ethical duty to provide quality health care to patients, so do not report and treat him accordingly A coworker calls the NP and wants to know about a patient's progress. She tells the NP that they are neighbors and she is worried about the patient's health status. The coworker works in the same facility but is not directly involved in this patient's case. Which of the following is the most appropriate action? Inform the coworker that you cannot release information about the patient because she is not directly involved in her neighbor's care A patient with amenorrhea is tested for pregnancy and it is positive. She tells the NP that she is seriously considering terminating the pregnancy. She tells the NP she wants to be referred to Planned Parenthood. The NP's personal beliefs and religious beliefs are pro-life. Which of the following is the best action for the NP? The NP should tell the patient that an NP peer who is working with her can help to answer her questions more thoroughly The NP calls a patient to discuss the results of routine lab tests, which are all normal. She calls the patient twice and each time the answering machine is on. Which of the following is the most appropriate action for the NP? When the NP is unable to speak to the patient directly, leave a message with her name and telephone number and instruct the patient to call back The HIPPA Act was passed in 2003. All of the following statements are true EXCEPT Patients have the right to review mental health and psychotherapy health information Sources of legal risk for the nurse practitioner would include all of the following EXCEPT inservice training of staff Patients who are considered mentally competent have a right to consent or refuse medical treatment. What is the medical term for this right? Informed consent Laws governing NP authority are determined by Board of Nursing Nurse practitioners and clinical nurse specialists derive legal right to practice from The Nurse Practice Act of the state where they practice Personal liberty of action and self-determination, along with respect for all persons as individuals is the ethical principle of Autonomy In Healthy People 2020, one of the goals is to identify nationwide health improvement priorities. What ethical principle below will help achieve this goal? Justice A 56 year old patient is seen in your office for follow-up of results of routine lab work. You decide, based on his lipid profile that a statin medication is indicated and believe that atorvastatin is the best option for this patient. You note that the patient's estimated glomerular filtration rate is 56ml/min/1.732 . According to the 2012 KDOQI Clinical Practice Guideline, which of the following would be the appropriate rationale in deciding the appropriate dosage of atorvastatin based on his current kidney function? The patient has Stage III CKD, no dosage adjustment is indicated for atorvastatin Ms. Smith is a 30 year old nonpregnant, healthy patient with a first-time diagnosis of acute uncomplicated cystitis. Which one of the following medication regimens below is your first choice for treating Ms. Smith? Trimethoprim-sulfamethoxazole (DS) one tablet q 12 hours for 3 days The major factor to preventing urinary tract infections is: Maintaining sterility of the urinary tract Over the past decade, several studies have shown that proteinuria predicts faster progression of kidney disease to ESRD. Studies have shown that drugs that reduce proteinuria can also slow the progression of established kidney disease. These drugs include which of the following: Angiotensin-Converting Enzyme (ACE) Inhibitors Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) are significant public health problems in the US and a major source of suffering and poor quality of life for those affected. Which of the following ethnic group is least likely to develop CKD? European Causasians Risk factors for glomerulonephritis include all of the following except: Nephrolithiasis Which of the following statements about fluid balance in the elderly is false? Assessment of skin turgor at the sternum is a reliable indicator of dehydration in the elderly You are reviewing a patient's labwork from a clinic visit. You note that serum creatinine is elevated for the second lab draw in a row. What are you thinking about the patient's glomerular filtration rate (GFR)? The patient's GFR is probably going down. A geriatric patient comes to your clinic with a family member who notes an acute onset of confusion. You suspect delirium. Which office urinalysis result are you most interested in today? Nitrites Maria, a 45 year old patient, is seen today for routine office visit. She has no specific complaints. Her medical history is pertinent for hypercholesterolemia. Her urine dipstick shows 1+ nitrites, 10 RBCs, specific gravity 1.022, and 2+ protein. Your plan of care includes which of the following? Repeat urinalysis in 1 week. Nephritic syndrome is synonymous with: Acute glomerulonephritis A 72 y/o patient comes to the clinic for treatment for recurrent cystitis. In addition to antibiotic treatment for the current symptoms, she asks what can see use to prevent further episodes. What would you advise? Cranberry juice > 10 oz per day Your patient with a history of glaucoma is noted to have a new onset of bilateral wheezes and your differential diagnosis includes asthma. In reviewing the medication list what category of medications would give you concern? timolol A patient comes to clinic with an acute eye complaint. Your initial focus is on the history and you include all of the following in your history of present illness except Presence of muscle paresis A 50 year old male is seen in your clinic for a history of hoarseness lasting greater than 3 weeks. His voice has a harsh quality with a low pitch. He denies a recent history of upper respiratory infection. To assist you in defining the differential diagnoses, the pertinent review of systems would include all of the following except : Current use of ACE inhibitor A 35 year old female is seen in your clinic with the following findings on right ear exam: erythematous tympanic membrane with altered bony landmarks and diminished cone of light. A small amount of fluid is noted directly behind the membrane. She gives a history of feeling fatigued and she had sinusitis two weeks ago that has resolved. What is your diagnosis today? Otitis media A 66 year old White male is seen in your clinic for continued tinnitus. His past occupational exposure history is positive for excessive loud noises. His history is negative for head trauma, allergies, hypertension and thyroid disease. His cholesterol is borderline high and he has chronic knee pain from years of jogging. You review his medication list and want to discontinue any medications that may contribute to tinnitus. Which medication below are you most likely to discontinue today? NSAIDs The definitive test for sleep apnea is an overnight polysomnogram Hordeolum and chalazia are commonly seen in the primary care setting. Knowing the etiology and common organisms associated with the disorders assists the provider in selecting appropriate therapies. What common gram-positive bacteria is oftern associated with hordeolum and chalazia? Staphylococcus aureus Papilledema is caused by? Increased intracranial pressure Obtaining an occupational and environmental history in patients is important for the assessment of many upper and lower respiratory diseases. It is not sufficient to ask a patient, "Have you been exposed to anything?" The NP must be directed and specific in questioning a patient when an environmental exposure assessment is done. Consider the following and mark all that would be included in an occupational and environmental history. cigarette use, type of industry and specific work, pets, military service, location of military service, loud noise exposure A 74 y/o woman comes to the office for a routine exam, when asked about her hearing she indicates she cannot always understand what people are saying because they mumble. She appears to struggle to hear questions and seems more withdrawn and confused than in the past. Which of the following is the most appropriate next step? screen for hearing impariment and handicap A 58 y/o woman comes to the office c/o considerable frustration understanding clients in her law office. She has worn hearing aids since age 40 when severe to profound sensorineural hearing impairment developed in both ears. She recently had a hearing test that showed no changes and reaffirmed the diagnosis. She has read about bone-anchored heading aids and cochlear implants and wonders if these may be appropriate in her case. Which of the following is the best recommendation? Cochlear implant in one ear and a new hearing aid in the other A 85 y/o man comes to the office because he has severe pain and blurring in the right eye that improves with blinking or rubbing. Which of the following is most likely cause of his symptoms? dry eye A 30 y/o comes to the office because he has a loss of taste, painful ulcerations on the lips and tongues, and soreness in his mouth that hinders chewing. He started chemo and radiation 2 weeks go for laryngeal cancer. On exam, his oral mucosa is red, raw, and tender with sloughing tissues. Which of the following is the most appropriate management? initiate supportive treatment for oral mucositis You are seeing a 54 year old Asian-american patient with Type II DM. In review of his lab work, his HgbA1c is 10.6. His calculated eGFR is 52ml/min/1.732 . He is 68 inches tall and weighs 210 pounds (95.45 kg) today. You determine he needs to begin insulin therapy. You calculate his total daily dosage of insulin to be (round to the nearest whole number): 48 units The diagnosis of hypothyroidism is made by measuring TSH and T4 Blood sugar is considered well controlled in an older adult with comorbid conditions when Hemoglobin A1C is: Between 7-8% Your patient has no past history of diabetes, heart disease, or endocrine disorders. Today your patient presents with a recent onset of polyuria, polydipsia, weight loss, and fatigue. What will your plan of care include today? urinalysis and glycosylated hemoglobin (A1C) A 86-year old woman presents to the geriatrics clinic with lower back pain. She has a history of vertebral-crush fractures secondary to osteoporosis. She took hormone replacement for five years after menopause (from age 50 to 55), but she discontinued it due to the intolerable side effects. Her only other significant medical condition is gastroesophageal reflux disease (GERD). In addition to calcium and vitamin D, which of the following is the most appropriate treatment for this patient's osteoporosis? Alendronate All of the following are considerations in treating a patient with hypothyroidism EXCEPT Practitioners are encouraged to write prescriptions that allow substitution so the patient may obtain a less expensive generic form of the medication Your patient had a vitamin D [25(OH)D] level below 20 ng/ml. You prescribed Cholecalciferol 50,000 iu weekly for 8 weeks. The patient assures you that she has been compliant with her regimen but her levels have not responded to treatment as expected. What laboratory test would you now consider in your plan of care to further evaluate the poor response? Parathyroid hormone (PTH) The diagnosis of autoimmune thyroid disease is made by adding which of the following to a standard thyroid panel? Antimicrosomal antibody (anti-TPO antibody) According to the American Association of Clinical Endocrinologists (AACE), in a patient with type 1 diabetes mellitus with a HgbA1c > 8, which of the following is not an appropriate treatment plan option? Begin insulin therapy and metformin concurrently to assist with insulin resistance. You have a 33-year-old patient with diabetes type 2. Your patient has a fasting plasma glucose of 280 mg/dl and a HbA1c of 10%. What is the first step in assessing her for diabetic nephropathy? random urine for protein A 75 y/o woman receives a new diagnosis of DM Type II. History includes DVT 5 years ago, HTN, depression, and generalized anxiety. Meds include HCTZ 12.5 mg qd, Lisinopril 10 ng qd, Citalopram 40 mg qd, and ASA 81 mg qd. Physical exam: Height 5 ft., Weight 86 lbs., BP 130/80, P 82. Labs: Glucose 147, Creatinine 1.0, BUN 16, HgbA1C 9. Which of the following is the best initial approach to this patient? Glargine (Lantus) 7units qd An 84 y/o diabetic is taking Metformin 1000 mg bid and Glipizide 10 mg q 12 hours. He performs fingersticks bid with ranges between 100 and the low 200s. His HgbA1C is 8.3. Which of the following is the most appropriate next step? D/C fingersticks A 52 y/o woman comes to the office c/o severe burning in her feet which is worse at night. She recently tried Gabapentin but dc'ed it because it caused a gait disturbance. She takes Glargine 20 units qhs and Metformin 1000 mg q12 hours. Her fingersticks have been between 180-200 in the morning and mid 200s in the evening. Which of the following is the next step for her symptoms? Start pregbalin (Lyrica) Stewart, age 58, has just been diagnosed with hypertension. His medical history is pertinent for DM. His social history is pertinent for a 30 pack year history of smoking. The NP should take which of the following potential pharmacological effects into consideration when choosing a treatment plan for Stewart's choosing a treatment plan for Stewart's hypertension. B-Blocker may cause fatality during respiratory distress d/t pharmacologic action James, an 88 year old patient is seen in the clinic today. His exam is suggestive of atrial fibrillation. In addition, you hear a low grade II rumbling murmur over the aortic area. His EKG shows the absence of P waves and prominent R wave in V1. These findings are suggestive of mitral stenosis Dan, a 65 year old man, presents to your primary care office for the evaluation of chest pain and left-sided shoulder pain. Pain begins after strenuous activity, including walking. It is characterized as dull and aching, 8/10 during activity, otherwise 0/10. It began a few months ago and has been intermittant, aggravated by exercise and relieved by rest. Has occasional nausea. Pain is retrosternal radiating to the left shoulder, definitely affects quality of life by limiting activity. Pain is worse today, did not go away after he stopped walking. BP 120/80, Pulse 72 and regular. Normal heart sounds, S1, S2, no murmurs. Which of the following differential diagnoses would be the most likely? CAD with angina Sarah, who is postmenopausal, has well-controlled asthma and hypertension comes to the office for a routine visit. She is a current smoker with a 10 year pack history. Her LDL cholesterol is 170 mg/dl and her HDL cholesterol is 40 mg/dl. To maxmize Sarah's risk reduction for a cardiovascular event, the primary focus of her treatment plan would be stop smoking Jamie, age 49, who has a history of hyperlipidemia, has symptoms that lead you to suspect unstable angina. Your next action would be? hospitalize in monitored bed with meds Martin, age 56, has hypertension and has been taking anti-hypertensive medication for about 10 years. He has been very stable. You have not seen him in 6 months. His exam today should specifically include fundoscopic exam Pharmacologic therapy should be started in any patient who is diagnosed with hypertension and has end organ disease. In most cases it should begin with ACE I The best evidence rating drugs to consider in a post MI patient include ASA, statin, ACEI/ARB, Beta Blocker Sheila, age 78, presents with a chief complaint of waking up during the night coughing. You examine her and find a S3 heart sound, pulmonary crackles (rales) that do not clear with coughing, and peripheral edema. What do you suspect? pulmonary edema In the person with hypertension, which of the following yields the greatest potential reduction in blood pressure in a patient with a BMI of 35 10kg weight loss Jose is a 68 year old man who presents to your primary care practice for a physical. He has had Type 2 diabetes for 5 years, diet controlled. His BMI is 32. Smokes a pack a day for the last 25 years. He denies other medical problems. Family history includes CAD, CABG x4 for father, now deceased, CHF, DM, hypertension for mother. According to the AHA/ACC guidelines, which heart failure stage would you grade Jose? Stage A: at high risk for heart failure but without structural heart disease or symptoms of heart failure The classic change seen on a 12 lead EKG during an acute MI is ST segment elevation Which of the following statements is true regarding grading systolic heart murmurs V/VI heard with stethoscope off chest Which of the following symptoms might a client with congestive heart failure resulting from pulmonary hypertension exhibit oliguria An 81 year old man comes to the office for a routine appointment. History includes moderate aortic stenosis for the past 8 years, managed with beta blockers, chronic CAD, prostate cancer Stage 2, and mild COPD. He received a left anterior descending artery stent in 2001. At this appointment, his daughter notes that her father is much less active than in the past. An echocardiogram last month showed a 3m/sec increase in peak aortic velocity.Which of the following is true regarding the management of this patient? valve replacement considered A 74 year old woman comes to the office for preoperative evaluation before cataract surgery. History included MI 10 years ago, and her record states that her ejection fraction is 30%. Medications include extended release metoprolol, lisinopril, and spironolactone. Dyspnea on exertion is consistent with NYHA functional class II. She has never been hospitalized for heart failure and has no palpitations or syncope. EKG shows a 4 beat run of sustained ventricular tachycardia. Which of the following is the most appropriate next step? Recommend placement of an ICD A 92 year old comes to the office for follow up. History includes osteoarthritis, well-controlled hypertension, GERD, and a recent cold. Prescribed medication include chlorthalidone and lisinopril. On exam, BP 162/70 and pulse is 76. On further questioning, the patient states her daughter has been giving her OTC Ibuprofen because she has knee pain which is now resolved. She has also been taking an OTC pseudophedrine 30 mg for several days of congestion. Which of the following is the most likely cause of her high blood pressure? NSAIDs A 70 year old woman comes to the office for routine follow up. History includes diabetes, hypertension, and hypercholesterolemia. Medications include ASA, glipizide, lisinopril, simvastatin, and a multi-vitamin. Total cholesterol is 180, LDL is 120, and HDL is 40. She is interested in using therapies other than a statin to improve her cholesterol profile. Which of the following has the strongest evidence to support the effectiveness in lowering cholesterol? viscous fibers (oats, barley, psyllium) A 21 year old woman is seen in the clinic with a 3 month history of watery diarrhea. She had similar episodes on three prior occasions with negative stool cultures. Past medical history is notable for knee surgery 2 years ago. Her medications include oral contraceptives. She has not traveled out of the state in the recent past and is a nonsmoker. Examination reveals a slender woman in no distress. Rectal exam shows black mucosa and a negative Heme test. Which of the following statements is correct? Suspect surrepitious laxative abuse An 75 year old man comes to the office to discuss whether he should undergo colorectal cancer screening. He has well controlled HTN and walks 2 miles per day. Which of the following is the most accurate statement about colorectal screening for this patient? UPSTF guidelines say no screening or benefits outweigh burdens An 80 year old patient comes to the office because she has epigastric discomfort and heartburn. The symptoms occur daily and are not associated with SOB, diaphoresis or dizzyness. She has been taking aluminum and magnesium hydroxide tablets to relieve the symptoms but they provide only temporary relief. A month ago, the patient underwent cardiac catheterization with drug-eluting stents for coronary lesions; history also includes DM and HTN. Medications include Plavix, ASA, Metoprolol, Lisinopril, Pravastatin and Glipizide. She lives with her husband and is independent in all ADLs. Which of the following is the most appropriate pharmacologic intervention for her symptoms? Ranitidine An overweight middle-aged woman has right upper quadrant pain that radiates to her right subscapular area and is severe and persistent. She is also experiencing anorexia, nausea and a fever. Her most recent meal was a double quarter-pound hamburger with cheese, french fries and a vanilla milkshake. Based on this information, the NP examines the abdomen and percusses for costovertebral angle tenderness. The abdomen is tender in the right upper quadrant. Which of the following signs, if positive, corresponds to the correct diagnosis? Murphys sign; patient has choleycystitis A patient with a history of arthritis and gastric ulcers comes to the clinic complaining of severe GI distress. The patient has been taking Ranitidine (Zantac) 150 mg bid. Although the NP would ask all of the following questions, which would be the most important? "What medications are you using for arthritis?" A patient has a history of colon polyps. The NP knows Colon polyps sessile are more likley malignant. Factors that promote the progression of HCV to liver fibrosis Include Increased alcohol intake, age greater than 40 years at time of infection, male gender The NP's patient has early alcoholic chirrhosis diagnosed by liver biopsy. In teaching the patient about her disease, it is important for the NP to inform her that the disease is most likely irreversible at this point, but that the following will generally halt the progression of the disease Abstinence from alcohol The NP is performing the initial physical exam on a 51 year old man. The history reveals that the client's father died of colon cancer but the client is asymptomatic. What priority diagnostic tests are used to screen this patient? stool for O&P and colonoscopy An elderly patient presents with fever, leukocytosis, colicky lower left quadrant pain and diarrhea alternating with constipation. The NP would make the diagnosis of Diverticulitis A diagnostic tool for assessing chronic constipation is ROME criteria Clostridium difficile is Gram positive, spore forming Folate deficiencies, as seen in alchoholics, is most likely related to poor dietary intake A patient with peptic ulcer disease is being treated with a regimen of bismuth subsalicylate (Pepto-Bismol), tetracycline and Flagyl. The patient calls the NP to report his stools are unusually dark. He is not experiencing any gastric discomfort, orthostatic hypertension or increased lethargy. How would the NP interpret this information? His stools are dark secondary to Pepto-Bismol use Marcie just returned from Central America with severe nausea and diarrhea. You suspect traveler's diarrhea. Which antibiotic did you order? Cipro John, 42, has changed his diet and lifestyle to treat GERD without success. Your next treatment should include which medication(s)? Calcium carbonate 500 mg qd and Omeprazole 20 mg qd L5-S1 nerve compression Straight leg lift ACL Tear Lachman's Test De Quervain's tenosynovitis Finkelstein test Meniscal Tear McMurray Test During a pre-participation sports examination, you hear a grade II/VI early midsystolic ejection murmur heard best at the second intercostal space of the left sternal border in an asymptomatic young adult. The most likely represents: innocent flow murmur When evaluating a patient with low back pain, bowel incontinence and overflow urinary incontinence most likely indicate which of the following? Cauda Equina Syndrome Patients with a grade III ankle sprain should be advised that full recovery will likely take a: number of months A grade II ankle sprain is best described as: Moderate swelling, mild to moderate ecchymosis, moderate joint instability Risk factors for gout include Thiazide diuretic use A 25 year old male presents with complaints of daily back pain localized to his lower back after lifting a heavy box at work 3 days ago. The symptoms interfere with his ability to participate in his bowling league. He denies incontinence, gait instability or radicular symptoms. On examination, you note normal musculature, FROM of the spine with moderate paravertibral tenderness throughout the lubrosacaral spine without spasm. The client complains of posterior thigh pain when his right leg is elevated 75 degrees. His remaining examination is unremarkable. Your diagnosis is: Lumbar Strain A 55 year old female presents as a new patient with complaints of a several year history of worsening joint pain that is worse in the morning. On examination, the NP notices Heberden's nodes and understands that this is a sign of: Osteoarthritis A 28 year old female presents with complaints of chronic aching pain and stiffness, frequently involving the entire body but with prominence of pain around the neck, shoulders, low back, and hips. She reports frequent headaches and trouble sleeping at least three nights per week and reports that even minor exertion aggravates pain and increases fatigue. Physical examination is normal except for "trigger points" of pain produced by palpation of various areas such as the trapezius, the medial fat pad of the knee, and the lateral epicondyle of the elbow. Your most likely diagnosis would be: Fibromyalgia In accurately assessing a client who reports back injury, it is critical to first question: Mechanism of injury You've conservatively treated a client for carpel tunnel syndrome for six weeks with cock-up splints, avoidance of repetitive activities, and NSAIDS without significant improvement. Your patient education should include which of the following: Carpel Tunnel Syndrome patients should be referred to a specialist for injection of corticosteroid into the carpal tunnel or for operation when they do not improve. A 45 year old female complains of a several week history of pain, burning, and tingling in palmar surfaces of the thumb, the index and long fingers, and the radial half of the ring finger. The pain radiates into the forearm and is exacerbated by her work as a transcriptionist. It is most bothersome at night. On examination she has a positive Tinel's sign and Phalen's maneuver. Your most likely diagnosis is: Carpal Tunnel Syndrome A 22 year old presents with significant effusion of the knee resulting from a football injury. You perform a knee aspiration and collect 50 ml of bloody synovial fluid. Choose all components applicable to your plan of care: Plan to immobilize, MRI and refer due to chance of ACL rupture. A 36 year old male presents with complaints of pain and swelling in his left knee with associated knee instability and occasional "locking" when walking. He reports playing tennis last week and felt a tearing, popping sensation that caused him to fall to the ground. He denies any bruising. He has self treated with Ibuprofen and wearing a knee brace with partial resolution. Based on this history your differentials should include all of the following except: Could not be trochanteric bursitis due to locking. A 36 year old male presents with acute onset of unilateral inflammation, pain, and erythema of the first metatarsophanlangeal (MTP) joint. Differential diagnoses that should be considered include: [Show More]

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