final exam
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
kcorkinsnctc
Popular Nursing sets