Joy NP 3

  1. Ulcerative Colitis

    What is it
    Signs and symptoms
    • Diffuse mucosal inflammation of the colon, involves the rectum and may extend upward involving the whole colon with symptomatic episodes and remission
    • Bloody diarrhea is the hallmark symptom
    • Stool studies are negative, sigmoidoscopy establishes diagnosis
    • Management
    •     Mesalamine (Canasa) sup or enema for 3-12 wks
    •     Hydrocortisone sup and enema
    •     iV abx cipro and flagyl
  2. Mesenteric Infarct

    What is it
    • result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of the bowel
    • arterial or venous, coagulopathy following recent surgery
    • sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
    •     N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
    • Lab/diagnostics
    •     Elevated amylase, leukocytosis, abd films, CT
    • Emergent surgical intervention
  3. Appendicitis
    Signs and symptoms
    Physical findings
    • Colicky umbilical pain-pain shifts to RLQ after several hrs
    • RLQ guarding with rebound tenderness,
    •     Psoas sign-pain with rt thigh extension
    •     Obturator sign- pain with internal rotation of flexed right thigh
    •     Positive Rovsing’s sign- RLQ pain when pressure is applied to the LLQ
    • CT or U/S is diagnostic, WBC 10 to 20
    • Management
    •     Surgical treatment, IV broad spectrum abx, IV fluids, Pain management
  4. Gerontology consideration with GI disorders
    • Physiologic changes
    •     Decreased thirst and taste perception
    •     Decreased gastric motility with delayed emptying
    •     Impaired defecation signal, decreased liver size
    • Possible findings and/or results- risk of
    •     Poor nutrition
    •     Altered drug absorption
    •     Decreased or impaired metabolism of drugs
    •     Dysphagia, NSAID induced ulcer
    •     Constipation
  5. Which of the following displays a current or recent Hepatitis A infection?
    Antibody-specific to IgG
    Anitbody-specific to IgM
    Hepatitis A core Antibody
    Hepatitis A Surface antigen
    Anitbody-specific to IgM


    Anti-HAV and IgM implies recent infection

    IgG implies previous exposure and advises immunity
  6. Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓BS. What is the diagnosis?
    Mesenteric Infarct


    • sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
    •     N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
  7. Crohns
    What is it
    • Mucosal inflammation and ulceration, structuring fistula development, and abscess formation
    • Pt may present with a combo of the following:
    •     Chronic inflammation, intestinal obstruction, fistula formation, abscess formation
    • Meds
    •     Aminosalicylates- mesalamine
    •     Corticosteroids
    •     Immunomodulatory- Tacrolimus
    •     Anti-TNF Monoclonal Antibodies – flagyl, Cipro
  8. Who is at the risk for both toxic and megacolon
    Crohns and Ulcerative Colitis
  9. Lower UTI

    Signs and symptoms
    • Signs and symptoms
    •     Dysuria, frequency, urgency, nocturia
    • Laboratory/diagnostics
    •     U/A>10 WBC, nitrates, esterase detection
    • Management
    •     3 day abx therapy
    •     Bactrim, Cipro, augmentin
    •     Preganancy= amoxicillin, macrobid, Keflex
  10. Upper UTI

    Signs and symptoms
    • Signs and symptoms
    •     Flank, low back, abd pain, fever/chills, N/V AMS
    • Laboratory/diagnostics
    •     U/A=WBC cast, elevated ESR with pyelonephritis
    • Management
    •     14 day vs 6 week course of abx
    •       TMP/SMX; Bactrim, Cipro, augmentin, gentamicin
    •       Pts with suspected pyelo with N/V or more severe illness should be hospitalized
  11. Renal insufficiency

    Symptoms/general concepts
    Stages of renal failure
    • Symptoms/general concepts
    • Pts are often asymptomatic until the late stages of disease
    • There is a direct relationship btw nephron loss and renal fx
    • Systemic changes not evident until overall renal fx is <20%-25% of normal
    • Stages of renal reserve
    • Diminished Renal reserve: 50% nephron loss, Cr doubles
    • Renal insufficiency: 75% nephron loss, mild azotemia present
    • End-Stage Renal disease: 90% nephron damage, azotemia, metabolic alterations
  12. Renal insufficiency

    Types – acute and chronic
    • Types
    • Acute: Sudden impairment
    • BUN increases out of proportion to cr
    • Due to obstruction, ATN, or contrast media
    • Reversible with proper therapy
    • Chronic: progressive impairment over months to yrs
    • Steady increase in BUN and cr (10:1 ratio)
    • Intrinsic kidney damage which is irreversible but progression can be slowed
  13. Management for Renal insufficiency
    • Acute renal insufficiency
    • Determine cause and intervene to prevent permanent kidney damage
    • Chronic renal failure
    • Institute mechanism to slow the progression of the renal failure
    •     Controlling HTN and DM
    •     Reducing dietary protein intake to 40g/day
    •     Modifying the dosage of medication
  14. Causes of Acute renal failure
    • Pre renal (outside kidney)
    • Caused by conditions that impair renal perfusion-
    •     Shock, dehydration, cardiac failure, burns, diarrhea, vasodilation/sepsis

    • No damage to renal tubules
    • Intrarenal (renal or intrinsic)
    • Disorders that directly affect the renal cortex or medulla
    •     Allergic disorders, obstruction of renal vessels, nephrotoxic agents, mismatched blood transfusions
    • Post renal
    • Results from urine flow obstruction
    •     Mechanical- calculi, tumors, urethral strictures, BPH
    •     Functional- neurogenic bladder, diabetic neuropathy
  15. What is the criteria for Dialysis?
    A- acidosis

    E- electrolyte disarray

    I- Intoxicants

    O- Fluid overload

    U- uremic symptoms (Nausea, seizure, pericarditis, bleeding)


    Do dialysis early – Keep BUN <100 Cr <10
  16. What is the management for acute renal failure?
    • Prerenal:
    • Expand intravascular volume, consider dopamine
    • Intrarenal:
    • Maintain renal perfusion, stop nephrotoxic drugs, renal replacement therapies as indicated
    • Postrenal:
    • Remove source of obstruction, check Foley, CT, renal ultrasound
  17. Renal Calculi: Nephrolithiasis

    Signs and symptoms
    • Signs and symptoms
    • Frequency/urgency, Pain, bleeding, colic like flank pain, radiating pain to groin indicates the the stone has passed to the lower third of the ureter
    • Lab/diagnostics
    • Serum urine= elevated minerals responsible for stone formation (calcium, uric acid, creatinine, oxalate)
    • Abd X-ray, CT should be performed
    • Management
    • Depends on stone type, location, extent of obstruction, fx of kidneys
    • Analgesia and hydration – morphine, toradol, reglan
    • If stone is obstructing outflow or accompanied by infection, removal is indicated
  18. Benign Prostatic Hypertrophy

    Signs and symptoms
    • Signs and symptoms
    • Frequency, dysuria, urgency, nocturia, incontinence, hesitancy dribbling retention
    • Laboratory/diagnostic
    • U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
    • Management
    • Consult urologist, Alpha blocker-flomax,
    • 5-alpha reductase inhibitor- proscar to shrink prostate
    • TURP if urinary symptoms persist
    • Avoid meds the worsen signs/symptoms of BPH
    •     Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
  19. Gonorrhea
    Signs and symptoms
    • Signs/symptoms
    • Females often asymptomatic (80%), dysuria, urinary frequency, green vaginal discharge, White/yellow-green penile discharge
    • Lab
    • Fram stain of discharge smear shows gram negative dipliococci and WBC
    • Treatment-
    • Rocephin 250 IM X1 dose to tx gonorrhea +
    • Zithromax 1 g orally X1 to cover chlamydia
    • Report to health department
  20. Syphilis

    Clinical stages
    • Stages
    • Primary- painless ulcer, located at site of exposure
    • Secondary- flu-like symptoms, arthralgia, lymphadenopathy
    • Latent- seropositive, but asymptomatic
    • Tertiary- cardiac insufficiency, meningitis, aortic aneurysm, hemiplegia, hemiparesis

  21. Management of syphilis 
    • Treatment
    • Primary, secondary or early syphilis less than 1 yr
    •     PCN G 2.4 IM
    • Late, latent and inderminate length; tertiary stage
    •     PCN G 2.4 IM weekly X3
    • PCN allergy
    •     Doxycycline 100mg PO twice a day
    •     Erythromycin 500mg PO 4 Xday
    • Report to health department
  22. What is the confirmatory test for diagnosing syphilis?
    Fluorescent treponemal antibody absorption (FTA-ABS)

    Syphillis: STD caused by multiple organs and by treponema pallidum, a spirochete. Third most common reported infectious disease in the US.
  23. When treating a pt diagnosed with syphilis, what drug allergy is most important to consider before initiating Tx?
    PCN allergy, syphilis is treated with PCN G
  24. Chlamydia

    Signs and symptoms
    • Signs/symptoms
    • Often asymptomatic, dysuria, thick cloudy penile discharge, painful intercourse
    • Lab/diagnostic
    • Chlamydia culture is most definitive test
    • Treatment
    • Azithromycin 1 g PO X1 dose or
    • Doxycycline 100 PO twice a day X7 days
    • Report to health department
  25. Vulvovginitis


    Signs/ symptoms of trich, BV, candidiasis and treatment
    • Trichomonas- frothy yellowish-green discharge, pruritus, strawberry patches on cervix and vagina
    •     Flagyl 2 g PO single dose; 500mg PO bid x7 days
    • Bacterial vaginosis- fishy smelling discharge, vaginal spotting
    •     Flagyl 2g PO single dose; 500mg PO Bid x7days; gel 0.75%, 5g intravaginally BID X5 days
    •     Clindamycin vaginal cream 2% 5g intravaginally at bedtime X7days; 300mg PO BID X7days
    • Candidiasis-thick white, crud like discharge
    •     Monostate 1% 5g intravaginally at bedtime X7days
    •     Terconazole 80mg suppositoru at bedtime X3days
  26. What are the lab/diagnostics for prerenal disease, Inrarenal disease and post renal disease?

    Serum BUN
    Urine Sodium
    Specific Gravity
    Urinary sediment
    Fractional excretion of Sodium (FEna)
    Image Upload 1
  27. What is the normal value of?

    Serum Iron
    • Hgb = 14-18 (males) 12-16 (female)
    • Hct = 40-54% (males) 37-47% (females)
    • TIBC = 250-450
    • Serum Iron = 50-150
    • MCV = volume/size – 80-100
    • MCH = amt/wt – 26-36%
    • MCHC = consentration/color – 32-36%
  28. What are the characteristics and values of MCV?



    What are the characteristics and values of MCHC?
    • Microcytic= <80
    • Normocytic= 80-100
    • Macrocytic= >100

    • Hypochromic <32%
    • Normochromic 32-36%
    • Hyperchromic >36%
  29. What are the differential diagnosis for Low MCV?

    What are the differential diagnosis for high MCV?

    What are the differential diagnosis for normocytic?
    Microcytic- Iron deficiency anemia and thalassemia

    • Macrocytic- B12 or folate deficiency, alcoholism, liver failure, and drug effects

    • Anemia or chronic disease, sickle cell disease, renal failure, blood loss, and hemolysis
  30. Iron deficiency Anemia

    Signs and symptoms
    • Symptoms
    • As the Hct falls- Pica, dyspnea and mild fatigue with exercise, spoon shaped nails
    • Lab
    • Low hgb, hct, MCV, MCHC, RBC, serum iron, serum fr
    • High TIBC, RDW
    • Management
    • Oral ferrous sulfate 300-325mg 1-2hrs after meals
  31. Thalassemia

    What is it
    • Genetically inherited disorders resulting in abnormal Hgb production and microcytic, hypochromic anemia
    • Lab/diagnostic
    • Low hgb, MCV, MCHC,
    • Normal TIBC and ferritin
    • Management
    • No tx for mild to moderate, transfusion or splenectomy for severe
    • Iron is contraindicated as iron overload can result
  32. Folic Acid Deficiency

    Signs and symptoms
    • Signs and symptoms
    • Fatigue, dyspnea on exertion, HA, Glossitis,
    • Laboratory/diagnostics
    • Low Hct, RBC, serum folate
    • Elevated MCV
    • Normal MCHC
    • Management
    • Folate 1mg PO Q day
  33. Pernicious Anemia

    Signs and symptoms
    • Signs and symptoms
    • Neuro like symptoms
    • Lab/diagnostics
    • Low Hgb, Hct, RBC, serum B12
    • Increased MCV
    • Management
    • B12 (cyanocobalamin) 100mcg IM daily X1week
  34. Anemia of chronic disease

    • Signs/symptoms
    • Fatigue, weakness, dyspnea on exertion, anorexia
    • Lab/diagnostics
    • Low Hgb, serum iron, TIBC
    • High serum ferritin
    • Normal MCV and MCHC
    • Management
    • Treat associated disease, provide nutritional support
  35. Leukemia 

    • Signs and symptoms
    • May be asymptomatic, weight loss, fatigue
    • Lab/diagnostics
    • Elevated ESR, bone marrow aspiration is required to confirm the diagnosis
    • Management
    • Chemo, bone marrow transplant, control symptoms
  36. Classifications of leukemia
    • Acute Nonlymphocytic Leukemia/Acute Myelogenous Leukemia
    • Constitutes 80% of acute leukemia in adults
    • Acute Lymphocytic Leukemia (ALL)
    • 90% remission in children, pancytopenia with circulating blast (hallmark of disease)
    • Chronic Lymphocytic Leukemia (CLL)
    • Most common in adults
    • Lymphocytosis (hallmark disease)
    • Chronic Myelogenous (CML)
    • Philadelphia chromosome seen in leukemic cells (hallmark of disease)
  37. Lymphoma


    • Stage 1
    • Disease localized to single lymph node or group
    • Stage 2
    • More than 1 lymph node group involved; confined to one side of the diaphragm
    • Stage 3
    • Lymph nodes or spleen involved; occurs on both sides of the diaphragm
    • Stage 4
    • Liver or bone marrow involvement
  38. What are the types of Lymphoma?
    • Non hodgkins lymphoma
    • Cause is unknown, may have viral etiology
    • Often presents with lymphadenopathy
    • Most common neoplasm btw 20-40 yrs
    • Hodgkins disease
    • Cause is unknown
    • More common in males; avg age is 32 yrs
    • Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
  39. Idiopathic thrombocytopenia Purpura

    Other consideration
    • Lab/diagnostic
    • Bone marrow analysis
    • Management
    • <20,000
    • high dose corticosteroids may elevate within 2-3 days
    • IV gamma globin 2-3 days, plt transfusion
    • Other consideration
    • Thrombocytopenic precaution
    • Heparin induced thrombocytopenia purpura HIT
    •     Argatroban, Lepirudin
  40. Disseminated Intravascular Coagulation (DIC)

    Associated conditions
    Signs and symptoms
    • Associated conditions
    • Infection/sepsis, liver disease, massive trauma, extensive burns, shock, obstetrical complications, leukemia
    • Signs and symptoms
    • Bleeding vs thrombosis
  41. Lab/diagnostics for DIC
    • Increase PT/PTT/FDP and low fibrinogen/plt
    • Thrombocytopenia (pls <150,000)
    • Hyperfibrinogenemia (fibrinogen <170)
    • Increased fibrin degradation product FDP (>45 or >present at >1:100)
    • Prolonged PT >19sec
    • Prolonged PTT >42sec
    • increased FDPs give a predictive accuracy of 96% for diagnosing DIC
  42. Management of DIC
    • Goal- treat underlying condition and control bleeding
    • transfusion for severe bleeding
    •     Platelets (for thrombocytopenia),
    •     FFP (to replace clotting factors) and
    •     cryo (to maintain fibrinogen levels)
    • overall therapy is aimed at cessation of bleeding, increasing plasma fibrinogen and the platelet count, and decreasing FDRs
  43. Which of the following is not an indicator of prerenal failure?
    BUN/Cr ratio > 10:1
    FeNa < 1
    Specific Gravity > 1.015
    Urine Na > 40
    Urine Na > 40 (this is postrenal)
  44. 53 yo M c/o dribbling and nocturia. You suspect BPH. PSA is 3.2. What confirms the dx?
    • Transrectal ultrasound
    • Laboratory/diagnostic
    • U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
    • Management
    • Consult urologist, Alpha blocker-flomax,
    • 5-alpha reductase inhibitor- proscar to shrink prostate
    • TURP if urinary symptoms persist
    • Avoid meds the worsen signs/symptoms of BPH

    Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
  45. Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure?
    Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen)
  46. What is azotemia?
    Azotemia – an excess of nitrogenous waste products in the blood- high levels of uria


    BUN>100= tx dialysis
  47. What should the dietary protein requirement be with chronic renal insufficiency?
  48. Which lab value is expected in iron deficiency anemia?
    Elevated MCHC
    Elevated TIBC (>450)
    Elevated MCV
    None of the above
    Elevated TIBC (>450)
  49. Iron def table
    Image Upload 2
  50. Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not expected in her anemia?
    Low serum ferritin (<15)
    Low Hgb
    TIBC 300
    MCHC < 32%
    Low serum ferritin (<15)
Card Set
Joy NP 3
starting with UC