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TWU FHN 2 Final

final exam

QuestionAnswer
If a patient experiences a hypoglycemic reaction when taking glucosidase inhibitors in conjunction with glucose-lowering medications they must treat the hypoglycemia with milk or glucose tabs because all other carb sources will be blocked.
Avandia should never be given in conjunction with insulin
Actos may be given in conjunction with insulin
with less risk of CHF Actos
potential for pancreatitis with Januvia and Victoza
Know potential for thyroid cancers associated with Victoza
basal insulin, Levemir (detemir) Comparable to Lantus but possibly less weight gain.Does not last a full 24 hours in SOME patients. Stable at room temperature for 6 wks, as opposed to all other insulins at 4 weeks.
Avandia (Pioglitazone) and Avandia containing drugs (Avandamet, Avandaryl) restricted in their use by the FDA due to concerns about increased risk for heart attacks
Impaired Glucose Tolerance (IGT) 75 gm oral glucose tolerance test: 140-199 mg/dl.
Impaired Fasting Glucose (IFG) WHO criteria: fasting plasma glucose level from 110 -125 mg/dL ADA criteria: fasting plasma glucose level from 100 - 125 mg/dL)
IGT and IFG linked to insulin resistance and signal increased likelihood of progression to Type 2 diabetes Both are risk factors for CVD
Early in Type 2 Diabetes the skeletal cells become resistant to insulin resulting in an increase in plasma glucose
Elevated serum glucose stimulates the beta cells to increase insulin secretion
The liver and pancreas are the primary organs of glucose regulation
When blood glucose rises, the B cells are stimulated to release insulin
Insulin allows the muscle and liver to use glucose and to store it as glycogen in the liver
Insulin also facilitates fat storage in adipose tissue and conversion of amino acids into protein
Glycogenolysis: the conversion of glycogen into glucose
Gluconeogenesis: the production of glucose from lactate and amino acids, results in increased serum glucose level.
Insulin promotes the transport and storage of glucose as triglycerides in fat cells. (Most Type 2 Diabetics have elevated triglycerides)
Visceral abdominal fat/obesity, due to the accumulation of fat in omental and mesenteric regions, seems to cause release of inflammatory markers resulting cellular insulin resistance-
Adipose tissue secretes bioactive peptides termed adipokines Tumor necrosis factor Interlukin 6 Angiotensinogen Plasminogen activating Inhibitor-1 (PAI-1)
Metabolic Syndrome Dyslipidemia, Insulin Resistance, Central Obesity
Diagnostic criteria for Diabetes AIC >6.5% OR Fasting plasma glucose > 126 mg/dl OR 2-hr plasma glucose > 200 mg/dl during an oral glucose tolerance test (WHO criteria using 75 g glucose) OR Classic symptoms of hyperglycemia and RBS > 200 mg/dl
Impaired Fasting Glucose (IFG) ADA criteria: Fasting plasma glucose test FPG 100 mg/dl to 125 mg/dl (WHO criteria is 110-125)
Impaired Glucose Tolerance (IGT): Oral glucose tolerance test 2-h plasma glucose 140 mg/dl to 199 mg/dl
Pre-diabetes (classified according to test used) Impaired Fasting Glucose (IFG) OR Impaired Glucose Tolerance (IGT): OR A1C 5.7-6.4%
Goals of Glycemic Control Fasting: Normal= <110; goal 80-120; additional action suggested for <80 or > 140. Bedtime Glucose: Normal <120; goal 100-140: Additional action <100 or > 160. HbA1c: Normal <6%; goal <7%; Additional action > 6.5-7%
Diabetes in Children Type 1 Diabetes polyuria, polydipsia, and WEIGHT LOSS Type 2 Diabetes Due to increasing rates of obesity now screening for Type 2 Diabetes
Diabetic Standards of Care HbA1c Every 3 months if not at goal to Q 6 if at goal. Dilated eye exam Yearly Podiatry (foot) exam At least yearly Lipid profile At least yearly Microalbumin At least yearly Blood pressure At each office visit
Diabetes Treatment Goals HbA1c < 7% Fasting blood sugar 90-120 Blood pressure: <130/80 Lipids: Total Cholesterol: <200 Triglycerides: <150 LDL: <100 (<70 with CVD and DM) HDL: men > 40-45 women >50-55
Medical Nutrition Therapy: emphasis should be placed on achieving glucose, lipid, and blood pressure goals.
Obese patients’ major focus is weight reduction and REDUCTION OF TOTAL CALORIC INTAKE. Best achieved by moderate decrease in calorie intake, coupled with increase in caloric expenditure.
Exercise: improves insulin sensitivity and facilitates insulin action increases energy expenditure, improves cardiovascular conditioning and dyslipidemia and facilitates control of hypertension.
consider evaluation exercise-stress ECG in all persons > 35 to detect silent ischemic heart disease.
Diabetes Pharmacological Management - Step 1 Lifestyle modifications and metformin
Diabetes Pharmacological Management - Step 2 Lifestyle modifications, metformin, and basal insulin OR Lifestyle Modifications,Metformin, SU's
Diabetes Pharmacological Management - Step 3 Lifestyle modifications, metformin, intensive insulin.
Sulfonylureas and meglitinides act to stimulate insulin secretion. Improve beta cell function by binding to a receptor unit on the B-cell. Ineffective in Type 1 and advanced Type 2 Diabetes due to decreased number of beta cells Used for mild mod Type 2
Sulfonylureas-Widely used for 50 years Mechanism of action is direct stimulation of beta cells to release insulin. Works at the ATP/K channel on the beta cell Most common side effect is hypoglycemia and can cause weight gain. May have cross sensitivity to sulfa-containing antibiotics
When clinically diagnosed with Type 2DM only 50% of the beta cell function remains.
First Generation Sulfonylureas: Chlorpropamide (Diabinese) Tolazamide (Tolinase) Tolbutamide (Orinase) Not frequently used due to their low specificity of action, delay in onset, occasional long duration of action and a variety of side effects
Second generation sulfonylurea glyburide (DiaBeta, Micronase, Glynase) half life 24 hrs. glipizide ( Glucotrol XL) 24 hrs glimepiride (Amaryl) half life 5-9 hrs Higher specificity/affinity for the sulfonylurea receptor May have mild diuretic effect
Meglitinides -Though structurally unrelated to sulfonylurea, the meglitinide class binds to the same ATP/K channel. Ultrashort in duration, stimulating insulin to coincide with meals; taken with any meal consumed. Decreased risk of hypoglycemia. Repaglinide (Prandin) Nateglinide (Starlix)
Biguanides Metformin (Glucophage).
Metformin Appear to directly effect glucose metabolism, which improves insulin sensitivity, particularly at the liver, while increasing peripheral glucose uptake and utilization.
Biguanides-Metformin (Glucophage). **Cleared by kidneys--contraindicated with serum creatinine of 1.5 or higher **Stop before and not restarted for 2 days after injection of radio-contrast agent to prevent lactic acidosis
Metformin Dosing May be used as initial monotherapy in type 2. Not associated with weight gain. Most common side effects: anorexia, nausea, vomiting, diarrhea-tend to be dose related Start with 500mg bid and increase to maximum of 2500mg/day.
Combination Oral Therapy Glyburide-metformin (Glucovance) Glipizide-metformin (Metaglip) Rosiglitazone-metformin (Avandamet) Success with combination with secretagogues since they have complementary mechanisms of action.
Alpha Glucosidase Inhibitors: Acarbose (Precose) and miglitol (Glyset).
Acarbose (Precose) and miglitol (Glyset). “Starch blockers” Competitively bind to carbohydrate-binding region of the GI enzymes thus slowing digestion of complex carbohydrates, oligosaccharides, and disaccharides. Result in slowing of gut glucose absorption. GI side effects.
Thiazolidinediones (glitazones) Insulin Sensitizers The two TZDs approved for use in the US are rosiglitazone (Avandia) and pioglitazone (Actos)
The two TZDs approved for use in the US are rosiglitazone (Avandia) and pioglitazone (Actos) Adverse effects include edema and weight gain, usually due to fluid retention patients with New York class II-IV heart failure should not use TZDs. Because of recent concern linking these agents - black box warnings have been added.
Incretin mimetics: GLP-1 (Glucagon-like peptides) Peptides (hormones) secreted throughout the day from the enteroendocrine cells in the GI tract Increase insulin synthesis and decrease glucagon production Slow gastric emptying time-may promote weight loss.
Byetta (exenatide) Injectable 5-10mcg SC bid 1 hr. before AM & PM meal increases glucose-dependent insulin secretion decrease postprandial plasma glucose rise hypoglycemia is rare decrease appetite, delays gastric emptying-promotes weight loss-nausea is the s effect may help with insulin resistance risk of pancreatitis
Victoza (liraglutide) 18 + Adjunct to lifestyle Contraindicated in patients with prior medullary thyroid cancer or multiple endocrine neoplasia (MEN) Increased incidence of pancreatitis in users Not been studied in combination with insulin Hypoglycemia with secretagogues
Incretins: Dipeptidyl peptidase -IV (DPP-4) inhibitors Sitagliptin (Januvia) DPP-4 inhibitor Oral Incretin: New class of drugs-works to inhibit DPP-4 and promote GLP DDP-4 is the enzyme which inhibits GLP-1 Can be used with metformin and TZD -1 The effect of the DPP-4 inhibitors is on postprandial glucose Nausea is the most common s/e
Basal insulin therapy: Glargine (Lantus) Can cover the amount of insulin that is necessary to utilize glucose as a fuel long after the meal. Cannot be mixed with other insulins Patients new to insulin Initiate at 10 IU QD >180 mg/dl Increase by 8 IU per day 140-179mg/dL 6 IU per day 120-139 mg/dL 4 IU per day 100-119 mg/dL 2 IU per day
TSH PITUITARY HORMONE NOT A THYROID HORMONE FUNCTION OF TSH IS TO PRODUCE MORE THYROID HORMONE
TSH secretion increased when serum thyroid hormone concentrations fall and decrease when they rise Negative Feedback System.
TSH level: gold standard for thyroid screening TSH influences thyroid gland to synthesize and release thyroid hormone (thyradine-T4) which comprises 90% of secreted hormone and is most abundant thyroid hormone in serum.
Total T4: Bound and unbound Free T4 is a direct measurement of the free unbound thyroxine. Free T4 represents only 0.025% of total-most is protein bound Free T4 is the only metabolically active fraction of T4 that freely enters the cell to produce effects
T3 is metabolically active thyroid hormone. 10% of circulatory T3 is secreted directly by thyroid gland 90% is derived from conversion of T4 in peripheral tissues T4 & T3 circulate in serum bound to several proteins that are synthesized in liver.
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? Partial-thickness superficial
burn patients that require hospitalization Second-degree to third-degree burns with a serious possibility of functional or cosmetic impairment, face, hands, feet, genitalia, perineum, major joint.
In the initial assessment of treating a snake bite at least two locations (more proximal) she be marked along with the circumference of the bitten limb. The bitten limb should be measured every ___ until swelling stops. q 15 min
Most common anaerobic pathogens in human bites are the ______and ________species. Prevotella & Fusobacterium
Recurrent or persistent otitis media with effusion for at least 3 months. Grandma smokes inside the home. The child had a low birth weight (about 3 lbs at birth). pertinent to ear trouble
Lead is a naturally occurring heavy metal. How does it enter our bodies? A. exposure from living in areas near old/active lead smeltering plant or mine. B water, pipes before 1986 C. occupational exposure such as in welding, pottery making, automotive repair. D. from paint/dust in home built before 1977.
Signs of Carbon Monoxide poisoning include: headache, nausea, vomiting, chest pain, and confusion.
refer a patient with a traumatic wound A laceration that occurred the previous day. B) A 4-5cm linear laceration on the right foot with exposed tendon. C) A wound with a positive culture for MRSA.
A 28-year-old male client in good general health arrives at your clinic with a laceration to the left forearm. Your plan will include: Administering lidocaine 1-2% to anesthetize the wound prior to suturing.
a type 2 diabetic who has a history of poor management. A PRIMARY concern for diabetics with foot ulcers is? osteomyelitis
What is the first line antibiotic therapy to treat a typical Erysipelas infection? Penicillin
30 y/o male states he was at work grinding metal and a small piece of debris flew up and hit him in the eye. He states, “it feels like there is something still in there. What is the most likely diagnosis for this patient? Corneal abrasion
presentation of Corneal Abrasion Photophobia Tearing (watery eye) Onset of irritation and/ or pain to the eye with a history of trauma.
Nurse Practitioners should attempt to remove only foreign bodies that are Superficial
Prolonged use of eye patch greater than 48 hours increases the risk for? Amblyopia
Bee stings will present with Redness Itching Wheal
Which antibiotic is appropriate to treat Lyme Disease if caught early? Doxycycline 10mg PO BID x 14-21 days
What is the gold standard for confirming the diagnosis of an acute gout attack? Arthrocentesis & visualizing monosodium urate crystals under a polarized microscope
What do urate crystals look like under a polarized microscope? Yellow, bright and needle like
What is the sensitivity and specificity of viewing negatively birefringent monosodium urate crystals in patients with an acute gout attack? Sensitivity 85%, specificity 100%
Hospitalization and I.V antibiotics maybe required for complicated abscesses these include: systemic symptoms Immunocompromised patients. Abscesses located in the neck, upper lip, central area of the face or scalp.
symptoms of an abscess? Redness, pain, warm to touch, edema.
contraindications to nail removal Diabetes Mellitus Peripheral Vascular Disease Anticoagulant Therapy Bleeding Abnormalities Immunocompromised Patients Pregnancy (Phenol use) Allergy to local anesthetics
What is the average time it will take for the toenail to regrow from the root to the edge? 12-18 months
change in bowel habits, abdominal pain, weight loss, blood in stool, family history of colon cancer. All will warrant further assessment and diagnostics.
When a patient presents with a subungual hematoma it is most important to remember X-ray the hematoma if it is greater than 25% of the nail No drainage is needed if the hematoma is not causing pain or discomfort Always check to be sure that there is no extensor tendon injury
Contraindications to performing nail trephination include The nail edges are disrupted The patient is wearing acrylic nails There is a high risk of infection post-procedure
Silver duct tape therapy might be suggested as first-line treatment for common warts
Contraindications to soft tissue aspiration Severe coagulation problems Swelling on the face Cellulitis or broken skin at the site Joint prosthesis
The pressure dressing applied to site needs to stay in place for: 24 hours
Which organism is most associated with septic bursitis? Staphylococcus aureus
Abnormal TSH values require additional biochemical and clinical evaluation before diagnosis of thyroid dysfunction can be made today most feel TSH is gold standard for thyroid disorders PT ASSMT- GOITER, THYROID SCAN, FULL THYROID PANEL
Because TSH is a pituitary hormone sometimes it does not give the full picture of what the thyroid is doing, which is why testing T4 & T3 are important. MAIN PROBLEM WITH TSH IS REFERENCE RANGE IS TOO WIDE 0.3-5.5
T3 (or T4) Resin Uptake Inverse measurement of thyroid-binding proteins
A high level indicates low level of thyroid binding hormones and high thyroxin levels. Seen with hyperthyroidism, chronic liver disease, renal disease, steroid use
A low resin uptake with low TBP estrogen therapy, pregnancy, acute hepatitis, hypothyroidism
Thyroid Antibodies Thyroid autoantibody, primarily IgG directed against the epithelium of the thyroid gland. Found in 5-10% of normal subjects May be present with inflammation of the thyroid gland. Hashimoto’s Thyroiditis and Graves’s Disease MAY ALSO BE BROUGHT ON DURING PREGNANCY OR IMMEDIATELY FOLLOWING DELIVERY
Thyroid Ultrasound Used to evaluate size, texture of the thyroid gland. Differentiation between cyst and tumor Used for guidance for aspiration of thyroid cyst Monitoring thyroid cysts
Radioiodine Scan/Uptake Radioactive tracer to evaluate the size Used to differentiate between hyperfunctioning nodule, thyroid hyperplasia, thyroid cancer. Cold nodules do not take up the iodine-tissue not functioning normally-more likely to be cancerous.
Thyroiditis A variety of inflammatory thyroid disorders that can cause thyroid enlargement and thyroid atrophy. May lead to hypothyroidism or hyperthyroidism. Complete resolution can occur
Hashimoto’s thyroiditis ( chronic lymphocytic thyroiditis) Most common form Autoimmune disease-often presents as asymptomatic, diffuse goiter. Often first detected after thyroid atrophy and hypothyroidism and occasionally as hyperthyroidism(Hashimoto’s)
Cortisol is subject to negative feedback regulation via hypothalamic-pituitary axis. Majority of cortisol produced (15-25 mg) between 5 and 9 am.
Pheochromocytoma Characterized by paroxysmal or sustained hypertension due to tumor located in either or both adrenals or anywhere along sympathetic nervous chain-rarely in aberrant locations as thorax, bladder, or brain.
Pheochromocytoma Characterized by a rough “rule of tens” 10% of cases not associated with hypertension 10% are extra-adrenal 10% are extra-abdominal 10% occur in children-most tumors are sporadic with only 10-15% familial about 10% tumor involves both adrenal glands and about 10% tumors are malignant
Pheochromocytoma Signs and Symptoms: Severe headache (85%) Palpitations (65%) Profuse sweating (65%) Absence of all three symptoms excluded DX with 99% certainty in one study Vasomotor changes may occur with tachycardia, precordial or abd. pain
Acute Adrenal Insufficiency (Adrenal Crisis) Emergency caused by insufficient cortisol.
Adrenal crisis Signs & Symptoms Headache, lassitude, N/V, abd. pain and often diarrhea Confusion or coma may be present fever, low blood pressure
Addison’s Disease(Chronic Adrenocortical Insufficiency) Uncommon disorder caused by destruction or dysfunction of adrenal cortices.
Addison’s Disease Type 1 caused by defect in T-cell mediated immunity inherited as autosomal recessive trait. presents early childhood with mucocutaneous candidiasis, hypoparaphyroidism, dystrophy of teeth and nails. Addison’s disease usually appears by age 15. Partial or late expression of the syndrome is common
Addison’s Disease Type 2 presents in adulthood with autoimmune adrenal insufficiency(no hypoparathyroidism) associated with autoimmune thyroid disease, vitiligo, type 1 diabetes, alopecia areata, or celiac sprue. Signs and Symptoms may include weakness and fatigability weight loss myalgias and arthralgias fever, anorexia nausea and vomiting anxiety and mental irritability
Cushing’s Syndrome (Hypercortisolism) Refers to manifestations of excessive corticosteroids commonly due to supraphysiologic doses of glucocorticoid drugs.
Cushings syndrome s/s Central obesity with plethoric “moon face”, buffalo hump, supraclavicular fat pads, protuberant abdomen and thin extremities Oligomenorrhea or amenorrhea (impotence in male) Weakness, backache, headache Hypertension, thirst and polyuria renal calculi
Cushing’s syndrome Mental symptoms range from increased lability of mood to frank psychosis
Cushing’s Syndrome Tests for Hypercortisolism Easiest: dexamethasone 1mg at 11 pm and collect serum for cortisol determination at 8am next morning; cortisol level under 5ug/dL excludes Cushings’s syndrome with 98% certainty
Benign Prostatic Hyperplasia Definition: Benign adenomatous hyperplasia of prostate gland Pathogenesis: Enlarged prostate pressing on urethra causes urinary flow changes incomplete bladder emptying increased frequency of urination
Benign Prostatic Hyperplasia Symptoms OBSTRUCTIVE Weak stream Hesitancy Terminal dribbling Sensation of incomplete emptying Sensation of urinary retention
Benign Prostatic Hyperplasia Symptoms IRRITATIVE Nocturia (> 1 X nite) Frequency (> 8 X day) Urgency Dysuria
Benign Prostatic Hyperplasia Guidelines for Symptom Evaluation American Urological Association Symptom Index Also termed International Prostate Symptom Score
Smaller prostates Alpha-adrenergic blockers Hypotension !! Take at bedtime Increase slowly Titrate to response Terazosin (Hytrin, 1993) Best studied drug Doxazosin (Cardura, 1995) Lower risk hypotension Increase ejac. dysfunction.
Tamsulosin (Flomax, 1997) Newer, more specific alph-adrenergic Less hypotension No BP lowering advantage Titrate to response
Alfuzosin (Uroxatral, 2003) Long acting Does not require titration 10 mg daily with meal Contraindicated with potent CyP3A4 inhibitors ketoconazole, etc.
Larger prostates 5alpha-reductase inhibitors Finasteride (Proscar) Dutasteride (Avodart No titration needed 6-12 months for full response Inhibits conversion of testosterone to dihydrotestosterone causing shrinkage of prostate May not decrease sx. Useful in men with prostate volumes > 40 ml
Combination pill therapy Jalyn (Approved June 2010) Combination 5 alpha-reductase inhibitor PLUS alpha blocker Dutasteride 0.5mg/tamsulosin 0.4mg 1 tab taken 30 min prior to same meal daily Dual mechanism of action may improve patient symptoms
Prostatitis Definition: Inflammation or infection of the prostate gland Four common forms Acute bacterial--young and elderly Chronic bacterial—elderly Nonbacterial--most common Prostatodynia--age 22-56
Prostatitis All forms can have dangerous sequelae urinary retention renal infection bacteremia acute prostatitis--no vigorous massage of prostate during exam can disseminate bacteria and lead to septicemia!
Prostatitis: Acute bacterial symptoms chills, high fever urinary frequency, urgency, burning perineal and low back pain obstructed voiding hematuria arthralgia, myalgia
Prostatodynia symptoms no systemic symptoms perineal or low back pain unilateral testicular pain dysuria, hesitancy decreased flow; dribbling postvoid
Sudden appearance of a varicocele in an older man may be caused by a renal or retroperitoneal tumor that has obstructed blood flow through the spermatic vein.
Hydrocele Noncommunicating Most common Sac full, tense, vaginalis closed off Fluid absorbs by 12mos No danger of hernia
Hydrocele Communicating Rarely resolve Flat scrotum in AM, fluid increase during day Patent processus vaginalis Inguinal hernias can accompany
Varicocele Presentation Infertility Testicular atrophy Sense of heaviness in scrotum Tortuous veins in scrotal sac; “bag of worms” More common on the left side Increase with Valsalva Decrease with recumbency
Spermatocele also known as a sperm cyst typically painless benign cyst grows near the top of testicle
Cryptorchidism Failure of testes to descend into scrotum Mechanical factors Hormonal factors Higher incidence in premature infants Spontaneous descent after age 6mos is unlikely
Sequelae of undescended Testicle will deteriorate after age 1 Possible infertility Increased risk of malignancy Testicular torsion Increased risk of hernia
Epididymitis Inflammation of the epididymis Pathogenesis: Pathogens enter epididymis via infected urine posterior urethra seminal vesicles
Epididymitis Clinical presentation Common cause of scrotal pain postpubertal males Urethritis, dysuria Urethral discharge Unilateral testicular pain Fever in 50% N/V is rare
Epididymitis Clinical presentation Physical exam Hydrocele Palpable swelling of epididymis Tender but normal testes Passive elevation relieves (Prehn’s sign) Perform rectal * Prostate tender Urethral discharge
Testicular Torsion May occur spontaneously after activity or trauma Commonly occurs in newborns and at puberty; again after age 21 Must intervene rapidly with surgical treatment to salvage testis Surgical emergency!
Transient Incontinence: Definable sudden onset. DIAPERS mnemonic Drugs: diuretics, adrenergic, or anticholonergic agents Delirium altered mental status.Infection.Atrophy of vagina or urethra. Psychological disorder: functional depression.Endocrine: Hyperglycemia or hypercalcemia.Restricted mobility. Stool impaction.
Medications Which Cause Incontinence Sedative/hypnotics reduce mobility/cognitive awareness Narcotics reduce mobility/awareness/detrusor contraction Diuretics increase urine production Calcium Channel Blockers reduce detrusor contraction strength
Chronic Urinary Incontinence Stress Urine loss with physical exertion without urge to urinate (cough, sneeze, lift, exercise) More common in women May coexist with a cystocele, commonly seen in multiparous women or previous pelvic surgery.
Chronic Urinary Incontinence Urge- hyperactive bladder contractions produce precipitous urge to urinate followed by uncontrolled loss of urine. Elderly population. Parkinson’s, Alzheimer’s, CVA, brain tumor. Outlet obstruction, carcinoma in situ, UTI.
Total or Continuous Incontinence Total loss of urine at all times and in all positions. Fistula of urinary tract is present.
Reflex Precipitous loss of urine with no sense of urgency. Suprasacral spinal cord lesion, MS, Parkinson’s, Diabetes.
Urinary retention/Overflow Incontinence incomplete bladder evacuation or chronic bladder retention caused by obstruction versus deficient detrusor contraction strength: overflow incontinence common symptom BPH, urethral stenosis, bladder stones, tumors
Predisposing Factors for stress incontinence Obesity Parity Vaginal birth Smoking-increases cough, risk for malignancy Aging and menopause- ? Estrogen previous surgery/trauma-hysterectomy, previous bladder suspension, prostatectomy, pelvic fracture
Treatment Nonpharmacological:for stress incontinence Pelvic floor muscle exercises/strengthening Biofeedback Surgical-Pubovaginal sling and retropubic suspensions. 83-84% success rate
Pharmacotherapy Treatment Nonpharmacological:for stress incontinence Exogenous estrogens if hypoestrogen. Alpha agonists-Sudafed (for mild dz) Caution in elderly and hypertensive. Tricyclic Antidepressant (for mild dz and mixed incontinence) Imipramine (Toframil) 10-25 mg bid-tid. Caution in elderly
Urge Incontinence Treatment Often combines with stress incontinence Suppression of urgency-stop and contract pelvic muscles-bladder training Pelvic floor exercise Electrical stimulation-50% cure, 70% cure Fluid restriction 30-40 oz/day. Avoid caffeine and alcohol.
Urge Incontinence Treatment Pharmacotherapy: Antispasmodics/anticholinergic Antispasmodics/anticholinergic Warnings: glaucoma, decreased gastric emptying, myathnia gravis oxybutnin 3.9mg transdermal patch daily tolerodine tartrate (Detrol) 1-2mg po bid Detrol LA 2-4 mg QD oxybutynin 2-5-5 mg bid Ditropan XL day dosing
Urinary Retention Reverse training-void more frequently Prevention Avoid med that increase urethral sphincter tone-decongestants/antihistamines/tricyclics Avoid excess alcohol
Pharmacotherapy Urinary Retention alpha blocking agents (antagonists) doxazosin/Cardura or terazosin/Hytrin, tamsulosin (Flomax) for BPH. Tamsulosin-more specific for alpha receptors found in prostate
Enuresis Urinary incontinence in a child age 5 years or older Primary: most common, wet only at night most commonly caused by parasomnia, a deep-sleep (stage 3 or 4) usually considered a developmental lag that children will outgrow Diurnal: daytime wetting often the results of stress/anxiety
Evaluation:Enuresis R/O UTI, diabetes, seizure disorders, neurologic diseases, and structural abnormalities. Most common complication is low self-esteem
Enuresis Treatment Restricted fluids past dinner Bladder training start and starting stream with urination holding urine for longer periods during the daytime
Enuresis Treatment pharmacological Desmopressin acetate (DDAVP) Affects antidiuretic hormone to decrease urine production nasal spray used at hs can result in complete remission of nocturnal enuresis in 50% of children ? some current concerns with FDA
Primary Amenorrhea Adrenal tumors Pituitary tumors Hypothalamic tumors -may have visual disturbances Congenital absence of the ovarian/uterus or uterine hypoplasia Vaginal introitus blockage Hypothryroidism Uterine malformation Pregnancy
By age 14 95% of females have reached menarche The most common cause of primary amenorrhea is failure of the ovarian failure-Turner’s, or other genetic abnormalities, also think about chemo or radiation Mosaicism-genetic disorders Anorexia Nervosa. Polycystic ovarian syndrome
Testicular feminization outwardly female-genetically male + breast external genital development but decrease in pubic hair, no uterus, + intra-abdominal testes.
Adrenalcortical hyperplasia Cushings Syndrome-truncal obesity, moon face, buffalo hump, purple striae, acne, thinning hair
Turner’s syndrome short stature/ neck webbing broad spaced chest-wide nipple line failure to develop secondary sex characteristics
Hypogonadotropic hyogonadism- inability of the ovaries to respond Low FSH Hypothalmic or pituitary tumors Delayed puberty based on hereditary
Hypergonadotrophic hypogonadism agenesis or absence of the gonads High FSH
Lab Evaluation of Primary Amenorrhea FSH, LH, Testosterone, Prolactin TSH HcG Consider imaging MRI - hypothalamus/pituitary tumor Ultrasound – uterine and ovarian structure and presence.
Secondary Amenorrhea Pregnancy (Most common) Polycystic ovarian syndrome Anorexia nervosa Metabolic disorders Thyroid dysfunction Pituitary Tumors Uterine infection Menopause (average age around 50)
Lab Evaluation of Primary Amenorrhea FSH, LH, Testosterone, Prolactin TSH HcG Consider imaging MRI - hypothalamus/pituitary tumor Ultrasound – uterine and ovarian structure and presence.
Secondary Amenorrhea Pregnancy (Most common) Polycystic ovarian syndrome Anorexia nervosa Metabolic disorders Thyroid dysfunction Pituitary Tumors Uterine infection Menopause (average age around 50)
Polycystic Ovary Syndrome 5-10% of the female population Dysfunction of the hypothalamic pituitary axis by changes in the production and utilization of insulin and hyperandrogenism Ovaries contain multiple inactive follicular cysts
Polycystic Ovary Syndrome Characteristics Anovulation/infertility 75% Amenorrhea or oligomenorrhea 90% Hirsutism 90% Obesity
Polycystic Ovary Syndrome Associated with Insulin Resistance Impaired action of insulin with increase insulin levels limit synthesis on insulin-like growth factor leading to an increase in free testosterone High FSH, androgen, leads to small nonmaturing follicles on the ovary-hence polycystic ovaries
Presentation of polycystic ovary syndrome ovulatory dysfunction characterized by cycle lengths exceeding 35 days or by fewer than 8 cycles per year evidence of androgen excess either clinically or by lab testing exclusion of other sources of anovulation/androgen excess
Indications of androgen excess Hirsutism excess growth of sex steroid dependent hair abnormal facial hair, arms chest, abdomen Acne Obesity Enlarged ovaries Infertility Other derm conditions-alopecia, acanthosis nigrican
No single test provides a definite diagnosis of PCOS Free testosterone levels seem to correlate with androgen excess Elevation of LH, low FSH Low LH to FSH ration Lipids Impaired fasting glucose 33% of normal women have polycystic ovaries on ultrasound, not helpful diagnostically
Polycystic Ovary Syndrome Management Hormone Therapy Oral contraceptives (low androgenic progestin [desogestrel or norgestimate]) decrease androgen production and increase in SHBG Antiandrogens to decrease testosterone Spironolactone, finasteride (Propecia)
Insulin-Sensitizing Agents frequently used first line Polycystic Ovary Syndrome Management Metformin (Glucophage) shown to reduce hyperandrogenism and hyperinsulinemia dosages 1500 to 2000 mg per day + risk for pregnancy + menstrual regularities in adolescents.
PID includes- endometritis, salpingitis, oophoritis, and adnexitis. Most common organisms are Neisseria gonorrhoeae and Chlamydia trachomatis other anaerobes and aerobic agents also occur. Ascending infection that colonized in endocervix.
Presentation PID Acute lower abdominal pain w/ fever and purulent vaginal discharge are classic PID symptoms. Pain may not be severe May c/o spotting between menses Nausea and vomiting-may be sign of peritonitis
Diagnosis of PID is based on clinical findings Empiric tx administered on minimum bases of criteria due to PID’s severe effect on fertility. Cultures for Gonorrhea and Chlamydia. Should also be screened for HIV and Syphilis. Tubal edema and fluid suggestive of PID.
Management Guidelines PID Broad spectrum coverage for N. gonorrhea, Chlamydia, anaerobes, gram-negative bacteria, and streptococci.
Broad spectrum coverage for N. gonorrhea, Chlamydia, anaerobes, gram-negative bacteria, and streptococci. Single dose of cefoxitin 2 grams with probenecid, or Ceftriaxone 250 mg IM x 1 PLUS Doxycycline 100 mg bid for 14 days With or without metronidazole, 500mg bid for 14 days
NSAIDs are used in the treatment of dysfunctional uterine bleeding based on the assumption that higher levels of menstrual prostaglandins stimulate uterine contractions and vaginal bleeding
Tolerodine Tartrate (Detrol), which has both antispasmodic and anticholingeric effects, is most effective with which type of incontinence? urge
Dysfunctional uterine bleeding is usually secondary to? an-ovulation
A 65 year old man with a history of BPH would like to use OTC meds for his URI. Which medications would you instruct him to avoid? Sudafed
Signs and symptoms of acute prostatitis would most likely include: temp 102, dysuria, hematuria
Epididymitis in men less than 35 years of age is most commonly caused by: gonorrhea or chlamydia infection
Which fasting glucose range is now considered pre-diabetic? 100-110
Which oral drug class used to treat Type 2 Diabetes is most likely to cause hypoglycemia? Sulfonylureas
insulin resistance in Type 2 Diabetes Decreased sensitivity at the cellular level to respond to the presence of insulin and allow glucose to enter the cell.
weight neutral, improves insulin sensitivity, and increases peripheral glucose uptake and utilization? Biguanides
tests evaluates the inverse measurement of thyroid-binding proteins? T3 Resin Uptake
Thyrotoxicosis is most frequently caused by Graves Disease.
Dysfunctional uterine bleeding found in adolescents and at the perimenopausal period is often associated with Decrease in progesterone related to level of estrogen
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