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NR 601 Comprehensive Final exam study guide and practice questions

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NR 601 Comprehensive Final exam study guide and practice questions How to conduct Mini-Cog- Causes of delirium in elderly- Agnosia ADA criteria for diagnosing DM- Differentials as cause for erectile d... ysfunction- Elder abuse o . Differentials as cause for hematuria- Terazosin use(s)- UTIs in men and women UTI treatment guidelines BPH- Acanthosis nigricans Delirium treatment Essential tremor vs. Parkinson’s Disease Seizure causes Hospice & palliative care- Pain- Pain management in elderly Delirium vs. dementia- Steps of the grieving process Alzheimer’s treatment Sexuality sundowning metformin side effects- ACC 2017 Guideline for High Blood Pressure in Adults- Acute prostatitis Beta blocker side effects in diabetics- How to diagnosis HF and COPD via CXR findings- OA HF stages- Causes for insomnia – Prescription for insomnia – GOLD criteria- Malone 207) Arrhythmia evaluation SIG-E-CAPS- DEXA scan results findings- Anxiety treatment- ___________________________________________________________________________________________ Week 1 video & lesson notes (taken directly from videos- refer to lesson videos for sources): Flow loops indicate validity of results, but flow loops WILL NOT be on boards or tests – just included them because they help make sense of the changes in values Spirometry- tech enters age, weight, race, sex & height - when looking at results you don’t need this- it’s pre-calculated in the results Spirometry Results and GOLD classifications: Normal values GOLD classifications post bronchodilator FEV1 (step 2 grade severity) FEV1 80% to 120% GOLD 1 mild FEV1 > = 80% predicted GOLD 2 moderate FEV1 50% to 79% predicted GOLD 3 severe FEV1 30% to 49% predicted GOLD 4 Very severe FEV1 < 30% predicted FVC 80% to 120% FEV1/FVC ratio (step 1 = determine if obstruction) > 70% (no obstruction) Step 3- Reversibility? A. Test spirometry pre and post bronchodilator (SABA or SAMA) B. Post testing is 10-15 minutes after SABA/SAMA C. ATS criteria: “significant response” is > = 12% FEV1 or FVC improvement and an absolute improvement of > = 0.2 L D. : “significant response” indicates asthma (due to reversibility) Interpreting PFT results Step 1: Check the ratio to see if obstruction exists. Is FEV1/FVC low? <70 = Obstructive defect or COPD Step 2: grade severity with FEV1 post bronchodilation to classify by GOLD criteria GOLD 1 mild FEV1 > = 80% predicted GOLD 2 moderate FEV1 50% to 79% predicted GOLD 3 severe FEV1 30% to 49% predicted GOLD 4 Very severe FEV1 < 30% predicted Step 3- Reversibility Is there a 12% FEV1 or FVC increase post bronchodilation? Yes = reversible TYPICAL PNEUMONIA SYNDROME- (see lesson;Hutt & Kramer, 2002; Furman, Rayner, & Tobin, 2004): Fast fever, cough = new/worse; purulent sputum (rusty, green), pleuritic CP; Lobar infiltrate on chest X-ray (day 2 - may become infiltrates) indicating pulm consolidation; Consider Streptococcus pneumoniae & other bacterial pathogens ATYPICAL PNEUMONIA- (see lesson; Hutt & Kramer, 2002; Furman, Rayner, & Tobin, 2004): Gradual fever, dry cough, min secretions, HA, malaise, myalgias, pharyngitis, GI distress. crackles (rales); Abnormal or patchy chest X-ray pattern. Consider mycoplasma or chlamydia, pneumoniae, or oral anerobes. Viral pneumonia may be atypical in presentation. Helpful images below from this video (Thanks to Nicole Popovich-Johnson): youtube spirometry video link FVC essentially same as VC FVC essentially same as VC. In obstructive lung disease, the graph (image above left) shifts to the left due to increased RV (because of air trapping); VC stays same but TLC increases due to increased FRC and increased RV. line R upper image below – Dotted line is the normal lung, solid lines (shifted left) are obstructive lung spirometry. Restrictive lung disease = lungs don’t fully expand; reduced lung volume & TLC (sarcoidosis, pneumoconiosis, Interstitial lung disease i.e. pulmonary fibrosis; Neuromuscular disease, i.e. MD or ALS); graph shifts to right to due to decreased TLC; In restrictive FEV1/FVC is not as affected as in obstructive disorders ******************************************************************************************* Week 2 notes: BPH and BP: Alpha blockers include doxazosin mesylate (Cardura), prazosin hydrochloride (Minipress), and terazosin hydrochloride (Hytrin); If we start on alpha blocker, they should follow up in 4-6 weeks. PROSCAR (finasteride): inhibitor of steroid Type II 5α-reductase, an intracellular enzyme that converts the androgen testosterone into 5α- dihydrotestosterone (DHT). For BPH & male pattern baldness. ______________________________________________________________________________________________ Week 3: SIG E CAPS”, for Sleep, Interest, Guilt, Energy, Concentration, and Appetite, Psychomotor, and Suicidal ideation Asthma and COPD inhalers See 601 shared drive for a clearer chart below. Chronic bronchitis > 3 months x 2 years, s/s R heart failure Gold 1. 80% 2. 50-79% 3. 30-49% 4. < 30% = is WNL/ no change FVC TLC RV FEV1 FEV1 after bronchodilator FEV1/FVC Small airway obstruction COPD = or Chronic Bronchitis = or = = = or or = Asthma (obstr) = or = = Or = Emphysema or = Upper airway obstruction Variable intrathoracic = Variable extrathoracic = = = Fixed = Mild intermittent asthma < 1 per week & < 2 HS/week > 80% PFT >20 prn SABA Cromolyn Mild persistent asthma > 2x/w days; > 80% PFT 20-30 SABA QD ICS Cromolyn, leuk Mod persistent asthma QD but not QHS >1/week (HS); sleep affected; 60-80 >30% QD SABA, combo ICS/LABA Severe persistent asthma QD & freq HS < or = 60% > 30% SABA ICS cromolyn leukotriene Week 4 Osteoporosis: fragility fracture or by a BMD T score of −2.5 or lower in the femoral neck or hip bones; World Health Organization definition of osteoporosis is a bone mineral density less than 2.5 standard deviations or more than the mean of a young adult. physical signs kyphosis, evidence of oral bone loss, restrictive pulmonary problems (decreased thoracic cage volume) Osteopenia: body density t-score is between minus 1 and minus 2.5, the patient has osteopenia. Low bone mineral density (BMD), evaluated by dual-energy x-ray absorptiometry (DXA) can predict fracture risk Bone strength- 70% is bone density (DXA score) & 30% is bone quality (unmeasurable) DEXA results are reported as t and z-scores. The t-score compares the patient's bone mass to the mean bone mass of a young adult. The z-score compares the patient with someone within their own same age group. The QCT is an expensive three-dimensional study. ultrasound at the heel, it's an inexpensive frequent screen and it is approved by the FDA. You've probably seen this performed at health fairs. AACE guidelines= bisphosphonates, or denosumab as first line therapy. Screening recommendations: normal bone density or mild osteopenia = rescreen in 15 years. Moderate osteopenia= rescreen in 5 years. Advanced osteopenia = rescreen yearly. Fragility fractures Defined as >40 years old & standing height fall causes hip, spine, forearm shoulder bone fracture meets criteria for fragility fracture Fragility fractures- vertebral and hip fractures worst morbidity and mortality risk Modifiable risk factors- ETOH, smoking, Vitamin D replete (muscle strength and bone density), calcium fortified foods & leafy greens, strength/ balance- work on weight bearing exercises for muscle strength and balance. Practice standing on 1 leg. Other risk factors: hyperthyroidism, diabetes, rheumatoid arthritis, chronic kidney disease, Cushing syndrome, liver disease, hyperparathyroidism, alcoholism, and a history of gastric bypass surgery or organ transplant. Women who experience early menopause without hormone replacement are at risk as well as people with malabsorption problems and anorexia. Peak bone mass occurs in adolescence and osteoporosis risk originates in adolescence with a failure to achieve a high quality of bone. Screen patients: annual height check & oral cavity check; age 50 FRAX screen (10 year risk for fracture) DXA - > or = 65 years old get bone density. If fragility fracture get DXA sooner. Drugs: antiresorptive agents and anabolic agents- (long acting or shorter acting) bisphosphonates estrogens and parathyroid hormones risks: adverse effects and low adherence receptor activator of NF-κB ligand (RANKL) and sclerostin: Denosumab (Prolia and Xgeva)- monoclonal antibody that binds to RANKL, mimics osteoprotegerin (OPG), thereby inhibiting osteoclastogenesis. Romosozumab (Evenity), a monoclonal antibody that binds to and inhibits sclerostin, has the dual effects of promoting bone formation and inhibiting bone resorption Bisphosphonate drug holidays (per American society for bone and mineral research white paper)- consider after 3-5 years of maintenance for: pts at modest fracture risk. T score. Bisphosphonates slowly have reversal of their effects. DO NOT bisphosphonate holiday: T score in osteoporosis range, prior spine or hip or other osteoporotic fracture in prior 2-3 years; holiday 1-2 year & the re-eval the BMD and their risk factors. If BMD is stable (meeting osteoporosis level) or decreased – restart after 1 or 2 years off. Unproven which to restart at that time. If hip-bone density is quite low then a bisphosphonate isn’t a good choice, but Denosumab is a better choice at that time Monoclonal antibodies: Denosumab (Prolia and Xgeva) – bone remodeling effects go away quickly; fracture risk at pre tx level in few months after missed dose SERM selective estrogen receptor modulators- block estrogen effects at receptors in breast tissue, bones and the uterus Raloxifene (Evista) Drug holidays do NOT apply to SERMs or monoclonal antibodies Chronic pain: Assess for hyperalgesia (extreme, exaggerated reaction to pain stimulus) or allodynia (central pain sensitization-increased response of neurons to normally non-painful, repetitive, stimulation). Ask about OA, RA, previous fractures, and fibromyalgia. All of these contribute in the older adult to chronic pain. Assess the history of or current chemical dependency such as alcohol (CAGE), depression (PHQ-9, HAM-D), and anxiety (GAD7, HAM-A), review sleep and diet patterns. Assess pain location, intensity, quality, onset, duration, variation, rhythm, and manner of expressing pain, pain relief, what are some exacerbating triggers, the effects of the pain, and response to previous treatments. Pain assessment tools. And consider utilizing assessment tools for pain, addiction risk, depression, and functional status ADLs. Poorly managed psychological disorders can interfere with the patient's ability to be a part of their care and decrease the effectiveness of their treatment and increase the risk of suicide. Neuropathic pain (from pathology or damage to the nervous system)- DM neuropathy, post-herpetic neuralgia, or a stroke. Symptoms: numbness, paresthesia, allodynia, tingling, burning, shooting/stabbing pain; follows nerve path Nociceptive pain- caused by tissue damage, muscle pain, inflammatory pain. This includes arthritis infection, tendonitis, tissue injury, post-op pain, and chronic infections. Mechanical/compressive pain increases with activity and decreases with rest. muscle/ligament sprain or strain, degenerative of disks or facets, osteoporosis with compression fractures, fracture, obstruction, dislocation, or compression by a tumor, cyst, or bony structure Biofeedback -assisted relaxation- influence involuntary and voluntary physiological responses. frequently used in the management of pain conditions and has been found to be effective in headache management, temporomandibular disorders, and other pain conditions. Mindfulness Based Stress Reduction- a structured program; teaches self-acceptance, pain acceptance and present moment awareness. acceptance rather than the distraction of the pain and leads to improved coping with the pain. Imagery promotes relaxation. With practice, imagery reduces autonomic arousal and is an effective diversion strategy. And then diaphragmatic breathing teaches patients correct diaphragmatic breathing, which includes slow breathing. Autogenic training: attention of the patient towards desired somatic responses. sensations of warmth or heaviness in the extremities. increase blood flow to the extremities and cause a decrease in sympathetic nervous system arousal. And then progressive muscle relaxation. The patients are taught to distinguish between various forms of muscle tension. with practice, they can achieve a deep relaxation. Hypnosis involves perceptual alteration and muscle relaxation. Neuromodulation activities. TENS unit; systematic evals are inconclusive. Spinal cord stimulation- An implanted device that sends pulsed electrical signals to the spinal cord to control pain; used for chronic neuropathic pain. Deep brain stimulation- Neuromodulation of the brain to help control pain has been effective for central poststroke and facial pain. Large joint or trigger point Injections: Small-bore bore needles are inserted into the affected site, and a glucocorticoid or local anesthetic is injected. Spinal injections, intercostal nerve blockade, occipital and other peripheral nerve injections. These may provide short-term improvements but not long-term. neuropathic pain and topical treatments- topical capsaicin (causes warmth, used TID-QID) for diabetic neuropathy and postherpetic neuralgia. Topical lidocaine (cream or patch) for neuropathic pain. Neuropathic pain- gabapentin (Neurontin) and pregabalin (Lyrica)- reduce with renal insufficiency. Anticonvulsants for peripheral neuropathy, especially DMPN and fibromyalgia as well as partial onset seizures Carbamazepine (Tegratol) is also FDA approved for trigeminal neuralgia. Off label neuropathic pain meds: Oxcarbazepine (Trileptal) potential benefits in trigeminal neuralgia and other neuropathic pain phenytoin, carbamazepine (not off label), and valproic acid- need CBC and baseline liver enzymes prior to initiation and checked for the first 3 weeks and periodically thereafter. Levetiracetam (Keppra) and zonisamide (Zonegran), sodium off label used in clinical trials and anecdotally for pain control. Keppra NOT effective in neuropathic pain. Tricyclic antidepressants have been used off label for neuropathic pain. TCAs used for pain are generally used at lower doses than they would use it for depression. Start at a dose of 10 milligrams and increase to an analgesic dose of 75 milligrams. An adequate trial of a TCA may take up to 6 to 8 weeks, with the highest dose tolerated given for at least 2 weeks. May experience side effects- decrease dose or another TCA with less anticholinergic effects can be considered. Tertiary TCAs, including amitriptyline (Elavi), are included in the Updated Beer's Criteria for potentially inappropriate medication use in the elderly. Adverse effects include the anticholinergic effects (constipation, orthostatic hypotension, dry mouth, urinary retention), antihistaminergic effects (sedation about 3h after taking), cardiac effects (prolonged QT interval, prolonged AV node conduction, and increased interventricular conduction), and alpha 1-adrenergic blockade. May have better results with secondary TCAs like desipramine or the nortriptyline. Doxepin is the least sedating TCA. Use with caution in pts with ischemic cardiac disease. Get a baseline EKG & keep dose < 100 mg/ day in elderly. Desipramine (Norpramine) and nortriptyline (Pamelor) can be used in older patients (start 10 mg po Qhs with typical dose 10-50 mg po qhs). SNRI: serotonin norepinephrine reuptake inhibitors. – Taper when dc to avoid withdrawal Venlafaxine is off label effective for diabetic neuropathy and polyneuropathy but not noted for postherpetic neuralgia. 2-4 weeks before desired dose. Caution with cardiac (r/t increased BP & cardiac conduction abnormalities). Starting 75 mg po (divided BID or TID) to typical dose 150-225 po (divided BID or TID). Duloxetine (Cymbalta)- chronic musculoskeletal pain including pain from arthritis and chronic low back pain, diabetic peripheral neuropathy, and fibromyalgia, as well as for depression and generalized anxiety disorder. Side effects include insomnia, constipation, dizziness, nausea, dry mouth, drowsiness. Start at 30 milligrams daily and then increased to 60 milligrams daily to reduce side effects. And then you want to avoid in patients with liver or severe renal insufficiency. Opioids are not known to work through mechanisms that decrease neuropathic pain, and so they're not the first-line treatment for neuropathic pain. Methadone (can cause QTc interval prolongation and dysrhythmias and hypotension) and tramadol may be more effective than opioids in neuropathic pain. Methadone ½ life 12 to 16 hours but may increase to 90 to 120 hours after 1 week of use. Methadone- need EKG at initiation, 1 month after & periodically. Tramadol (Ultram) weak opioid analgesic- GI upset, risk of seizure (decrease seizure threshold), serotonin reuptake inhibition (good for neuropathic or mixed pain); suicide risk. Reduced dose in older patients or liver impairment. Ultram 50-100 milligrams PO every 4 to 6 hours as needed, or Ultram extended release, 100 to 300 milligrams once a day are the options. Tapentadol (Nucynta, Nucynta ER) NO ETOH with! MOA: dual mode of action as an agonist at the mu-opioid receptor and as a norepinephrine reuptake inhibitor. For neuropathic pain. Contraindicated in those with convulsive disorders and with severe kidney or liver impairment. 50 mg po Q12h, increase dose q3days by 50 mg/12 hours. Max dose= 500 mg/24 hours. muscle pain: Use a biopsychosocial interdisciplinary approach with a cognitive behavioral component encouraging exercise and active participation of the patient in the plan of care. Cyclobenzaprine (Flexeril) FDA approved for muscle spasm Inflammatory pain: managing the inflammation. NSAIDs, corticosteroids, and, opioids are rarely helpful for inflammatory pain. Mechanical/compressive pain treat with splinting, strengthening, surgical decompression or stabilization, or the use of assistive devices nociceptive pain: cardiovascular risk or disease, utilize the lowest effective NSAID dose (use naproxen). Chronic kidney disease and advanced age, you want to avoid NSAIDs and COX-2 inhibitors. Liver disease, avoid APAP, NSAIDs, and COX-2 inhibitors. Use TCAs or duloxetine as first line. Peptic ulcer disease or patients on glucocorticoids, avoid NSAIDs. Mild-to-moderate pain: Approach in the following order. topical agents, APAP, NSAIDs plus PPI, or COX-2 inhibitor (Celebrex and Bextra, Meloxicam) with or without APAP to manage some of the GI irritation. Or TCA or duloxetine. You can do an opioid. Consider adding baclofen (Lioresal) or tizanidine (Zanaflex) if they is a spasmodic component. moderately severe to severe pain: noninflammatory or patient with risk factors for NSAIDs, APAP or NSAIDs plus a PPI or COX-2 inhibitor with or without APAP, if there's no NSAID risk, TCA or duloxetine, opioids. Consider adding baclofen or tizanidine if there is a spasmodic component. If on APAP and heavy ETOH max 2 grams/day dose. More than 4 days of APAP intake at therapeutic doses can lead to increase in serum aminotransferases (AST, GOT, ALT) NSAIDs: for mild-to-moderate somatic pain or non-neuropathic pain; for periodic flare ups rather than long-term. Some newer drugs are for severe pain. headaches, arthritis, strains, sprains, and other soft tissue injury. But you want to use caution when considering NSAIDs in those gastropathy, low creatinine clearance, cardiovascular disease and heart failure. Relative contraindications: high risk for peptic ulcer disease, they're in advanced age, they have a history of peptic ulcer disease or prior NSAID gastroduodenopathy, concurrent glucocorticoid use, advanced illness, and risk of bleeding. interaction with antihypertensive medications, warfarin, and low-dose aspirin. Side effects: platelet inhibition, GI (dyspepsia, abd discomfort/pain, mucosal lesions, NV, hemorrhage, peptic, and esophageal ulcerations), decreased GFR/ renal failure, edema, increased BUN and creatinine, reversible renal insufficiency, inability to concentrate, confusion, hepatic toxicity (reversible with med cessation), increased MI/CVA risk. NSAIDs can interfere with the cardioprotective effects of aspirin. NSAIDs can exacerbate heart failure, may raise blood pressure. It can have prothrombotic effects, relative contraindication is history of DVT. Absolute contraindications: active peptic ulcer disease, chronic kidney disease, and heart failure. Relative contraindications, hypertension, H. pylori, history of peptic ulcer disease, they haven't had active, just history, concurrent use of SSRIs or corticosteroids. Exceptions to adverse effects are a choline magnesium trisalicylate (Trilisate) and COX-2 inhibitors. fewer side effects than NSAIDs but doses > 200 mg/day = increased CV risk. Celecoxib 200 milligrams po qd or 100 milligrams bid per AGS guidelines, older adults should take a PPI or misoprostol for GI protection when taking nonselective NSAIDs or an NSAID and COX-2 inhibitor together. Opioids- ALL patients need pain contract if on narcs. “PEG" pain, energy, general activity: pain intensity over the past week, how it has affected their energy level, and how the pain has affected their general activity. If patients don't improve or PEG scores remain high, the opioids may be ineffective. Consider other pharmacological and nonpharmacological treatments and reconsider diagnosis. Available data does not support the use of doses above morphine 200 milligrams in the treatment of noncancer pain. A slow taper of 10% per week is recommended to decrease withdrawal symptoms. The taper rate for those on very high doses may be as high as 25% to 50% and slowed when the dose reaches morphine 60 to 80 milligrams or equivalent. Week 5: BPH- mild-to-moderate symptoms, alpha-adrener-gic blockers such as terazosin (Hytrin) and tamsulosin (Flomax) relax smooth muscle of the bladder neck and prostate and can increase peak urinary flow rate; all alpha-adrenergic blockers are equally effective (Kennedy-Malone, et al., 2019) 1ST line mgt- helps with stress, mixed, and urge UI, but not NOT functional UI Men Alpha 1 adrenergic antagonists’ better choice with BPH. Not used for women occurs in children; onset 30-70; 10% men Urethritis in men has typically been treated with a 7-day regimen of doxycycline. Some research is showing that a small dose of azithromycin may be just as effective, while causing fewer side effects. A one-dose treatment also improves compliance, so cure rates may be even better than with a long-term regimen. But there is a concern, however, that it's an infection that spreads to the prostate gland, which is harder to treat. It should be noted that azithromycin and similar antibiotics do not cure prostate infection. (Macrolides= Biaxin (Clarithromycin), Zithromax (Azithromycin),Dificid (Fidoximycin), and Erythromycin) And they mask the symptoms of an accompanying sexually transmitted disease, such as gonorrhea. STI tests should be conducted if urethritis is diagnosed. Men always need to be cultured and treated for all STDs on the day of service, as well as for urethritis. Thinning tissues and vaginal flora changes (lower glycogen and lactobacilli) can result in a more alkaline environment and this increases a woman's risk for UTI. The standard treatment is estrogen. Localized treatment is preferred to decrease the risks related to systemic estrogen. Estrogen creme which is less expensive than the estrogen tablets is a good option. Recommendations include just start using the minimum daily dose times two weeks, and then use one to three times per week thereafter. Resolution is about 2-3 months typically. Physical causes for sexual dysfunction can be related to weight, neurologic and vascular symptoms; many medications can cause sexual dysfunction (antidepressants, antihypertensives, pain medications, and some lipid-lowering agents). Alcohol and illicit drugs such as cocaine, marijuana and heroin can exacerbate sexual dysfunction. There's a new medication for our women that has been developed, it's called Addyi. It's for the treatment of hypoactive sexual desire disorder. Low testosterone levels and BPH, as well as prostate cancer, can present with ED. Meds- antihypertensives, psychotropic agents, alcohol, and illicit drugs such as cocaine, marijuana and heroin, can affect male sexual function too. Adjust medications, if possible, prior to prescribing an ED medication. Reviews the PDE5 medications: potential adverse effects, precautions, and contraindications to prescribing PDE5s. ______________________________________________________________________ Week 5 & 6: glucocorticoids, thiazide diuretics, some HIV medications, and atypical antipsychotics increase DM risk. Know the appropriate screening tests- this is based on the ADA guidelines you reviewed for the case study. Interpret screening test results and the appropriate next step. Appropriate diagnoses: prediabetes, diabetes type 2- for all people start screening at 45 if asymptomatic. If normal tests, re-screen at a minimum of 3-year intervals. IFG (impaired fasting glucose) = FPG levels between 100 and 125 mg/dL (between 5.6 and 6.9 mmol/L) IGT (impaired glucose tolerance) = 2-h PG during 75-g OGTT levels between 140 and 199 mg/dL (between 7.8 and 11.0 mmol/L) T1D= classic symptoms, plasma glucose is sufficient to diagnose DM (hyperglycemia or hyperglycemic crisis plus a random plasma glucose ≥200 mg/dL [11.1 mmol/L]) Prediabetes= presence of IGT and/or IFG and/or A1C 5.7–6.4% (39–47 mmol/mol) Type 2 DM criteria: Two tests: A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, OR A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT); A1C A1C level of 6.5 percent or higher Gestational diabetes mellitus (GDM) diagnosis either: “1-step” 75-g OGTT or “2-step” 50-g (nonfasting) screen followed by a 100-g OGTT for those who screen positive DM screening includes FPG, OGTT, and A1C 4 main types of incontinence: Stress incontinence due to poor closure of the bladder. Overflow incontinence due to either poor bladder contraction or blockage of the urethra. Urge incontinence occurs when the bladder contracts involuntarily (detrusor overactivity) or OAB. Functional incontinence due to medications or health problems making it difficult to reach the bathroom UI – Cardura (doxazosin); Hytrin (terazosin) nonselective alpha1 blocker- for BPH UI and HTN BPH- 5 alpha reductase inhibitor finasteride (Proscar), dutasteride (Avodart) decrease prostate size Proscar inhibitors type II 5a-reductase; Avodart inhibitors both type I and II 5a-reductase The most common UTI causing pathogens are Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis and Staphylococcus saprophyticus. Asymptomatic bacteria- we discussed who should be treated and who does not need to be treated (pregnant women must be; young healthy asymptomatic bacteriuria typically don’t need tx) _____________________________________________________________________________________ Week 7 notes: Parkinson’s Disease AKA Paralysis Agitans • progressive incurable neurological disease • 1-2% incidence in > 60 (1 in 100) in US • only 4% of PD occurs in < 50 • Inverse PD risk: Caffeine, elevated plasma urate level*, nicotine – but DO NOT slow disease progression • * urate elevation above is per lecture & book. BUT “men, but not women, with higher urate concentrations had a lower future risk of developing PD doi: 10.1212/WNL. • Conversely, Gout may increase PD risk • Inverse PD risk: outdoor activity and total vitamin D intake esp. outdoor activity for less PD risk doi: 10.1631/jzus.B • nicotine is an inverse risk factor for PD. Likely due to striatal activity via dopaminergic system (balance dopamine transmission, decrease levodopa-induced dyskinesias). A small amount of nicotine can saturate a substantial portion of nicotine receptors in the brain. doi: 10.1186/s40035-017-0090-8 Pathophysiology of PD: • Neuron and glial cells in the substantia nigra (basal ganglia) stop Dopamine (neurotransmitter) production • Once cell loss is > 60% the dopamine deficiency is critical and subsequent motor systems develop. • Brock’s theory: PD initial prodromal symptoms occur (outside the brain) in the olfactory bulb or in the enteric (gut) systems then move upward into the hypothalamus, then the midbrain, and up into the cortex. PD Diagnosis: diagnosis of exclusion • Symptom presentation and progression • There are no specific lab tests • Brans scans (PET and SPECT scans) help monitor disease progression • Diffusion MRI aids in neurosurgery procedures • DaT scan identifies the dopamine loss in Parkinson’s by targeting a specific dopamine transporter protein on the nerve cell; FDA approved for PD dx confirmation & monitoring progression • No one test identifies the disease • Initially tough to discern Parkinson’s from other neurological disorders • Cardinal signs due to dopamine deficiency:  Unilateral arm/hand tremor initially  Postural instability-unstable gait; Parkinsonian gait (AKA festinating gait) NOT a circumducted or Wernicke-Mann gait  Muscle rigidity-cogwheel rigidity in joints, stiffness  Bradykinesia (slow movement)-often handwriting first Early or prodromal symptoms can include:  Prodromal-decrease in sense of smell (i.e. coffee)  Bradykinesias (handwriting, decreased speed of motion)  Muscle fatigue in a limb, requires more strength to move a limb  Decrease of loss of arm swing with walking  Unilateral resting tremor of hand or arm-slow velocity  Cog wheel rigidity passively felt in a limb by examiner • A positive clinical response with levodopa administration i.e. symptom abatement = diagnosis • Myerson sign may be present-forehead tapping elicits an uncontrollable blinking. This is the glabellar reflex and may also be present in dementia or other neurological disorders. • Cognitive changes occur later and over time in the disease PD Differential Diagnoses to rule out: Some/ all of PD cardinal signs present with these as well • Common neuro s/s in neuro disorders AND PD  Stuttering  Hypophonia- low volume voice  Monotonic speech  Drooling, impaired swallowing  Masked facies, decreased blinking • Progressive Supranuclear Palsy-additional cardinal sign is loss of upward gaze • Overlapping disease- Alzheimer’s, Fronto-temporal dementia, Huntington’s chorea • Secondary parkinsonism-toxins, neuroleptic drugs • Brain Tumor or trauma • Hydrocephalus-additional cardinal sign of incontinence • Cerebral arteriosclerosis, Infectious encephalopathy, Creutzfeldt-Jakob disease, Wilson disease, HIV/AIDS PD Staging: International Parkinson & Movement Disorder Society recommends 1 of 3 scales for staging PD: 1. Unified Parkinson’s Disease Rating Scale (UPDRS) - (2001) = most recognized tool 2. MDS-UPDRS (updated 2008) – specialists use because time consuming & complex need licensure to use 3. Hoehn and Yahr 5 stages Scale: shorter & most commonly used no licensure to utilize and easily available i. Stage One  Usually presents with tremor of one limb  Mild Unilateral s/s  Symptoms inconvenient but not disabling  Friends have noticed changes in posture, locomotion and facial expression ii. Stage Two (still mild but progressive)  Medications generally administered towards end of this stage  Bilateral signs and symptoms  Minimal disability  Posture and gait affected iii. Stage Three  Significant slowing of body movements  Early disequilibrium on walking or standing  Generalized dysfunction that is moderately severe iv. Stage Four  Severe symptoms  Can still walk to a limited extent  Marked rigidity and bradykinesia  No longer able to live alone  Tremor may be less than earlier stages v. Stage Five – severe symptoms  Decisions must be made re: swallowing ability and tube feedings. Cachectic stage  Aspiration pneumonia likely and often the cause of death.  Complete invalidism. Cannot stand or walk and requires constant nursing care PD Management: (incurable and progressive) • Treatment is focused on the disabling symptoms • Individualized management; no algorithm • Levodopa/ dopaminergic meds start after 65 R/T long term use association with disabling complications • Dopaminergic replacement provided when: ADL difficulty including walking & compromised employment PD Med management: • Early stages of PD initial meds: 1. Rasagiline (Azilect) Monoamine B Inhibitors (MAO-B) a. MOA: inhibits MAO-B, the major metabolizing enzyme of dopamine for less dopamine breakdown b. Provide symptomatic relief in patients with early PD or adjunctive therapy for moderate PD c. Delays motor disability progression in the first 2 years of the disease d. Can be used adjunctively with carbidopa/levodopa in moderate to advanced disease as well e. Side effects include sleep disturbance, hyper or hypotension f. Contraindicated with meperidine (Demerol), opioids, SSRIs, and MAO inhibitors g. MUST STOP Rasagiline 2 weeks prior to any general anesthesia (see package insert) 2. Selegiline (Eldepryl) (MAO-B) inhibitor a. MOA: inhibits MAO-B, the major metabolizing enzyme of dopamine for less dopamine breakdown b. Some symptomatic benefits in early PD and may elevate mood and decrease fatigue c. Has been shown to delay levodopa use by one year d. Poorly tolerated in confused patients e. Contraindicated with meperidine or SSRIs 3. Amantadine (Symmetrel) Viral m2 channel inhibitor and Dopamine agonist a. MOA: Dopamine promoter, glutamate receptor, and antiviral drug (Anti Flu-A); prevents release of viral nucleic acid by interfering with the function of the transmembrane domain of the viral M2 protein b. Improves tremor in early PD patients c. May used in more advanced PD patients to help reduce dyskinesias d. Side effects- hallucinations and livedo reticularis (mottled and purplish discoloration to the skin) e. Caution in older adults with renal dysfunction • To a lesser degree: Anticholinergic drugs or Neuroprotection options 1. Anticholinergic drugs  Rarely used due to high side effects  Useful for younger patients who present with significant tremor  Side effects-urinary retention, constipation, and can aggravate confusion in older patients 2. Neuroprotection options  Coenzyme Q (CoQ) at 1200 mg/d had some effect on progression of ADL scores. not FDA approved • Dopamine Replacement Therapy  Carbidopa/levodopa combination permits greater entry of levodopa into the central nervous system.  Carbidopa/Levodopa is orally administered and absorbed in the small intestine  Carbidopa/levodopa absorption is inhibited if taken with large protein meals  It is better absorbed on an empty stomach or with reduced dietary protein Dopamine Replacement Drugs: initial monotherapy or adjunctive therapy of PD (with carbidopa/levodopa)  D2 & D3 dopamine agonists are newer drugs approved for treatment of PD  Directly act on dopamine receptors and mimic the endogenous neurotransmitter • Dopamine Agonists: Apokyn (apomorphine hydrochloride); Parlodel (bromocriptine); Neupro (rotigotine transdermal system); Mirapex (pramipexole dihydrochloride) or Mirapex ER; Requip (ropinirole) or Requip XL o Start low and go slow! o Beware! case reports of patients falling asleep while driving- no driving with somnolence o Reports of impulse control problems (compulsive gambling) or hypersexuality 1. Pramipexole (Mirapex) 2. Ropinirole (Requip) 3. Rotigotine (Neupro) • Ergot-derived dopamine agonists: initial therapy and adjunctive therapy of PD o Bromocriptine and Pergolide o Older ergot-derived dopamine agonists rarely used R/T side effect profile and other med efficacy o Side effects: nausea, hypotension, and confusion; reported cardiac valve changes – need annual monitoring with an echo. For this reason, they are not recommended • Newer ergot-derivative dopamine receptor agonists  Cabergoline (Dostinex) - potent dopamine receptor agonist on D2 receptors. o Has a long half-life and taken twice weekly o Side effects: nausea, hypotension, confusion, cardiac valve changes have been reported an annual echocardiogram is advised PD Complications:  Response to therapy wanes over time  Carbidopa/levodopa combination – effect also wears off and produces motor complications.  These changes in medication response often occur within 5-6 years of the initiation of levodopa therapy  Levodopa half-life 90-120 min. “wearing off fluctuations”- med doesn’t last as long; less med bioavailability  Motor fluctuations often become abrupt, erratic, and unpredictable  “On-off fluctuations” which is variable response to the medications.  Dyskinesias (increased involuntary movements) become more problematic  Many report gait freezing and balance disturbances and the risk of falls increase  A general decline in ADLs also occurs as the disease progresses Managing Motor Complications of PD:  Consider: referral to a movement disorder specialist for evaluation.  Have patient use a motor complication diary  Review foods and meal timing with meds  Explore other causes of ineffective medication doses and monitor for side effects with medication changes  Change only 1 med at a time  Allow time to evaluate effects of medication adjustments Non-motor PD Symptom Management  Blood pressure-postural hypotension • Increase fluids, salt & caffeine • TED hose • Decrease PD meds • Add Fludrocortisone (Florinef); midodrine  Bowels-constipation • Increase fluids/fiber and Exercise • Stool softeners(docusate) • Laxatives (polyethylene glycol)  Bladder dysfunction • Limit nighttime liquids • Timed voidings • R/O infection • Bladder meds-watch for side effects  Depression  Psychosocial counseling • Paroxetine • Venlafaxine • Anxiety  Psychosocial counseling/relaxation therapy • Adjust dopaminergic medications/schedules • Consider SSRI, Buspirone, benzodiazepines  Cognitive changes • Rivastigmine (Exelon)-1st choice  Caregiver support and resources • National Parkinson’s Foundation Helpline 800-473-4636 • Caregivers Forum • Parkinson’s Disease Foundation Caring for the Care Partner = 2-page caregiver support letter  Support groups for patients and caregivers • Parkinson’s Disease Foundation • National Parkinson Foundation https://www.P • The Michael J. Fox Foundation for Parkinson’s Research • Parkinson’s & Movement Disorder Institute Meds in advanced PD:  Medication combination treatment more complex- 3 or more medications are needed.  To counteract the med’s motor complications, carbidopa/levodopa is also a combo med with entacapone  Med adjustment by neurologist or movement disorders specialist is recommended for advanced PD  A multidisciplinary approach with PT, OT and a home/environment safety assessment is needed Advanced PD Medications can include: • Carbidopa/Levodopa/Entacapone a. Entacapone or Comtan is a catechol-o-methyltransferase (COMT) inhibitor and slows enzymatic degradation of levodopa and dopamine. Entacapone can be used in this triple combination drug or given separately from the carbidopa/levodopa b. This triple combination provides higher and more sustained plasma levels of levodopa and is useful in moderate to advanced PD c. Side effects include discoloration of urine, diarrhea, and it may also increase dyskinesias 2. Rasagiline (Azilect) MAO-B inhibitor (see also p. 41-42 above) i. Can extend efficacy and prevent “wearing off” when used in combination with carbidopa/levodopa ii. Can be taken orally, with or without food iii. Caution for postural hypotension iv. Avoid use with opioids, meperidine, SSRIs, and MAO inhibitors 3. Entacapone (Comtan) 4. Tolcapone (Tasmar) COMT inhibitor i. Like entacapone; catechol-o-methyltransferase enzyme inhibitor or COMT medication. ii. In clinical trials, tolcapone is more potent than entacapone and longer acting iii. More significant side effect profile than entacapone i.e. serious/fatal hepatotoxicity, and infrequently causes diarrhea iv. Informed consent is required for this drug due to hepatotoxicity. v. LFTs must be monitored every 2 weeks for the first year of therapy & every 4 weeks for the next 6 months and every 8 weeks thereafter Miscellaneous neuro: GREAT video on gaits- _______________________________________________________________________________________ Week 8 video notes: Degenerative diseases have replaced communicable diseases as the leading cause of death in the United States and most economically advanced countries. 80% of all US deaths (2000) are caused by (in order): heart disease, malignant neoplasms, cerebrovascular disease, chronic lower respiratory disease. Accidents with unintentional injuries, diabetes, Alzheimer's disease, influenza and pneumonia, nephritis, nephrotic syndrome, septicemia. Increased life expectancy related to demographics and social trends, reduction in infant and child mortality. Hospice is one type of palliative program, it's outlined by Medicare, and it's restricted to individuals with a disease trajectory or life expectancy of six months or less of life. Hospice is outlined with the requirements and rules from Medicare. With normal disease progression a life expectancy of six months or less of life would qualify someone for hospice services. Hospice is regulated and covered by Medicare, BUT most private insurances also have hospice allowances. Hospice- generally a bundle payment reimbursement system. The hospice agency determines which services, equipment, and medications are covered. Specific hospice guidelines indicate what must be provided. Including a case manager that's a registered nurse, a social worker, a nurse aide, assistant, chaplain, grief counsellor, volunteer services. Admission to hospice: 1. Provider certifies that the patient is terminally ill (< 6 mos. life expectancy if the disease runs its normal course). 2. Patient elects to receive hospice care rather than curative treatments. T 3. Patient then enrolls in the Medicare approved hospice organization. Palliative care (relief): Specific types of palliative care programs. Palliative care may be provided to anyone, regardless of their life expectancy or disease progression. Some facilities offer community based palliative care and some offer inpatient palliative care consults. Primary palliative care should be included by any healthcare provider in any patient encounter. PPC is managing physical symptoms, psychological, social, and existential distress. Secondary, or specialty palliative care, that's the extra layer of support that's initiated in specific patient situations. Palliative care is billed fee-for-service. Consultations take an extended time period and are often more expensive than they are reimbursed. Most palliative care programs are subsidized by another agency or philanthropy. Palliative care services are typically considered cost avoidance entities rather than revenue streams. Palliative programs are nurse practitioner or physician led, some may include a RN, a social worker, or a chaplain. Routine weekly visits or hours are not often provided. 2010 NEJM seminal study found that routine treatment plus palliative care actually exhibited higher quality of life and lived longer than those not receiving palliative care in metastatic non-small-cell lung cancer. PCP role in palliative care? Provide risk factors and health promotion information. Be involved in screening and diagnosis, be involved in discussion of treatment options, especially if the therapeutic window is small. And make that referral to specialty care, especially emotional and spiritual support. Advanced Care Planning (ACP) Living will: specify what a person’s health wishes if unable to participate in healthcare decision-making. California developed a state law which they called the Natural Death Act Patients have Determination to Act (1990) law: all facilities that receive federal funds (e.g. CMS – Medicare and Medicaid) must educate their patients on right for self-determination of care and ask about advanced directives. ACP conversations reimbursed by Medicare (2016) in illness OR wellness visits DPOA- (durable power of attorney for health care) This person acts for patient when they cannot self-determined care and can legally receive HIPAA protected info and make healthcare decisions on behalf of the patient. They need a DPOA document, becomes part of the patient’s record. POLST = physician orders for life-sustaining treatment (Dr’s orders NOT a living will or an advanced directive). Developed for patients with less than a year life expectancy. Order set must be followed by emergency workers. Emergency workers are not bound to follow a living well or DPOA, but they are bound to follow orders outlined a POLST. Review your state’s POLST laws to see if an APRN can develop or sign POLST. Find documents and instructions through an organization called Respecting Choices. Look at the Conversation Project. It's a free online resource to help you start your conversation with your patients. SPIKES approach for difficult conversations. S is for setting (private location for the discussion, but also setting your role in the process.) P is for perception. You want to assess the patient's and family's perception of the situation. I is for invitation to share knowledge. Ask your patient & family for permission to talk about the subject. K is for knowledge or information sharing, listen for themes and hot topics. E: emotions and empathy. S is for summarize and strategize. Summarize what you have heard, and what is the next step, or steps, based on the prognosis and wishes of the patient and family. (in real life meetings= who’s gonna do what, and by when? PRACTICE QUESTIONS: 1.6mo ago an elderly pt was dx'd with subclinical hypothyroidism. Today the pt returns and has a TSH of 11 and c/o fatigue. He has taken Synthroid 25mcg daily as prescribed. What is the best course of action for you?: Double the dose of Synthroid 2.48yo female presents for annual exam. A1C is 6.2%. You interpret this result as: a. Prediabetes b. T2DM c. T1DM d. Normal: 3.52yo Caucasian woman comes in for annual exam. She has mitral valve prolapse, no symptoms. PE reveals clear/equal breath sounds, midsystolic click. You know her stage of HF is: a. A b. B c. D d. C: (Stage B) 4.55yo Caucasian man follows up w/you after referral to cardio. He reports that he thinks the med is causing a cough and sometimes he has dyspnea. Which of the following meds was most likely prescribed? a. Metolazone b. Enalapril c. Amlodipine d. Irbesartan: 5.55yo Caucasian man w/T2DM presents as new pt. Take metformin 500mg BID. Labs reveal albuminuria and A1C was 7%. He's current on eye/foot exams. BP today is 136/84. According to 2017 ACC Guidelines, the most appropriate med for his current status is: a. Furosemide b. Amlodipine c. Lisinopril d. Clonidine: 6.55yo post-menopausal woman with h/o HTN c/o jaw pain on heavy exertion. There were no c/o CP. Her EKG indicates NSR w/out ST segment abnormalities. Your plan may include::Exercise stress test 7.55yo woman presents with somatic complaints. You suspect anxiety. You know that somatic symptoms of anxiety include: a. All answers are appropriate b. Palpitations, CP, tachycardia c. Fatigue, insomnia, diaphoresis d. Diarrhea, nausea, vomiting: ANS:A 8.55yo woman w/BMI of 28, has 20yr h/o primary HTN, has been on HCTZ 25mg for years w/excellent response. During this follow up visit, she reports that for the last 6mo she has felt thirsty all of the time even though she drinks at least 10 glasses of water/day. Previous fasting BGL was 136. No further testing was done at that time. You check random BGL now, is 210. What is the next appropriate step? a. Order 3hr OGTT b. Order another random BGL in 2wks c. Order A1C d. Prescribe metformin XR 500mg PO: 9.59yo female c/o pain when she urinates. She has been seen three times for this in the last 3mo. Each time, dx'd with UTI, given abx. She carefully followed instructions, but has no relief of symptoms. Last UA: WBC: 2-3 RBC: 0-2 Epithelial cells: few Nitrite: neg Leuk: neg Which should be done next? a. Perform pelvic exam b. Reassure the pt that she has asymptomatic bacteriuria and does not need abx c. Obtain clean catch urin for UA and C&S d. Order pelvic ultrasound: 10.59yo woman presents w/following: h/o MI, new onset SOB, especially w/exertion, an occasional rapid fluttering heartbeat and swollen feet. You know this pt's stage of HF is: a. Stage A b. Stage B c. Stage D d. Stage C: ANS:D (stage C) 11.60yo obese male has T2DM and lipid panel of TC 250, HDL 32, LDL 165. You teach the pt about his modifiable cardiac risk factors, which include?: ANS:DM, obesity, hyperlipidemia 12.60yo woman w/30-pack year hx presents for eval of persistent, daily cough w/increased sputum production, worse in the AM, occurring over past 3mo. She says, "I have the same thing year after year." Which of the following choices would you consider strongly in your critical thinking process? a. Acute bronchitis b. Chronic bronchitis c. Seasonal allergies d. Bronchial asthma: 13.62yo female c/o fatigue and lack of energy. Constipation has increased and the pt has gained 10lbs in the past 3mo. Depression is denied although she reports lack of interest in usual hobbies. VS are WNL and her skin is dry and cool. Which of the following must be included in the DD?: Hypothyroidism 14.62yo male has chronic kidney dz that has been relatively stable. He has h/o hyperlipidemia, OA, HTN. He is compliant w/meds, BP has been well-controlled on a CCB. Last lipids showed TC 201, HDL 40, TG 180, LDL 98. He currently takes Crestor 20mg daily. Today his BP is 188/90 and urine dip shows significant proteinuria. He denies any changes in dietary habits or med regimen. What would be the best med change for him at this point?: Change CCB to ACEI 15.65yo Caucasian female presents with h/o mitral valve stenosis, PE unremarkable. You know the stage of HF is: a. D b. A c. B d. C: (stage B) 16.65yo female presents to the clinic for the first time and c/o urinary incontinence and dyspareunia. She went through menopause 10yrs ago w/out any hormone replacement therapy and had hysterectomy for a fibroid. Her mom had hip fx at 82. Pt's most recent mammo was 5yrs ago, no known fam h/o breast ca. She is not taking any meds. Exam is unremarkable except for findings consistent w/atrophic vaginitis. You decide to begin topical hormone replacement therapy. Which of the following evals would be necessary prior to initiating HRT?:Mammo 17.65yo man presents for eval of CP and L-sided shoulder pain, begins after strenuous activity, including walking. Characterized by dull, aching, 8/10 during activity, otherwise 0/10. Began few months ago, intermittent, aggravated by exercise, relieved by rest. Occasional nausea. Pain is retrosternal, radiating to L shoulder, affects QOL by limiting activity. Pain is worse today, did not go away with rest. BP 120/80, HR 72 regular. Normal heart sounds, S1/2, no murmurs. Which of the following diff dx would be most likely? a. Afib b. Coronary artery dz w/angina pectoris c. Esophagitis d. Musculoskeletal chest wall syndrome w/radiation: 18.65yo woman w/BMI 29, 15yr h/o HTN, on HCTZ 25mg for years w/excellent response. Follow up visit: reports that for last 1-2mo, she has been thirsty, increased urination. Last fasting BGL was 118. What action should you take next? a. Plan to recheck BGL as scheduled at yearly physical b. Check POC glucose now, since she has just eaten breakfast c. Educate that the diuretic is causing the increased thirst d. Order fasting BGL: ANS:D 19.66yo dx'd with acute prostatitis, afebrile w/out severe pain, deemed appropriate to be managed outpt. An appropriate initial treatment option for mild case is: a. Septra x6wks b. Cipro x10-14 days c. Bactrim x14 days d. Levaquin x3wks: ANS:B 20.68yo male, retired Air Force pilot, has been dx'd w/prostate ca in the past wk. He's never had surgery and seeks clarification on availability of tx's for prostate ca. He asks you to tell him the SE of radical prostatectomy. Which of the following is NOT a potential SE of this procedure?: Selected low back pain 21.68yo man presents for physical, has had T2DM x5yrs, diet controlled. BMI 32. H/o HTN, smoker 10cigs/day x20yrs. Fam h/o CAD, CABG x4 for father, now deceased; CHF, T2DM, HTN for mother. He is asymptomatic today, exam is normal, EKG NSR. According to AHA/ACC guidelines, he is at risk for what stage of HF? a. Stage C b. Stage D c. Stage B d. Stage A: ANS:D (stage A) 22.72yo female has been dx'd w/gout. She also has a long h/o chronic HF. The most likely contributing factor to development of gout in this pt is:: Thiazide diuretics 23.72yo woman and husband are on cross-country driving vacation. After long day of driving, they stop for dinner. Midway through meal, she gets very SOB, w/CP and a feeling of panic. Which of the following problems is most likely?: Pulm embolism 24.76yo man seen for c/o UI. You should explore which of these causes of UI in men? a. UTI b. Sildenafil c. Urethral polyps d. All of the above: 25.77yo Caucasian female has h/o breast ca. She's been in remission for 6yrs. As her PCP, you are seeing her for follow up of her recent c/o intermittent abd pain x3mo and general malaise. Given the hx above, what will you direct your assessment at during the exam?: Thorough abd and gyn exam to rule out masses and ID any tenderness 26.78yo female presents w/sz that occurred over the weekend. In selecting the most important diagnostics for this presentation, it is important to know that the least common site of sz's in the elderly is:: Temporal lobe 27.78yo man w/PD is being care for in a nursing home. The nurses observe that he coughs at mealtime; he has the ability to feed himself w/adaptive equipment. He has had no aspirations. Oral exam is normal, except during swallow eval you note there is slight delayed elicitation. You assess that he has only mild dysphagia. You recommend which of the following as the next step in his care?: Provide trial of foods differing in consistency 28.79yo man is being eval'd for frequent urinary dribbling w/out burning. Physical exam reveals smooth but slightly enlarged prostate. His PSA is 3.3. He undergoes formal urodynamic studies and findings are as follows: decreased bladder capacity of 370mL, few involuntary detrusor contractions at a low bladder volume of 246mL, increased postvoid residual urine volume of 225mL, and slightly decreased urinary flow rate. Which of the following is not consistent with normal age-associated change?: Increased postvoid residual urine volume 29.87yo female has been taking 100mcg of Synthroid x10yrs. She comes to your office for routine follow-up, feeling well. Her HR is 90. Your first response is to:: Order TSH 30.2017 HTN guidelines categorize a healthy 54yo African American woman with a BMI of 23 and consistent BP readings of 120-128/76-78 as: a. Normal BP b. HTN stage 1 c. Elevated BP d. HTN stage 2: ANS:C 31.You are reviewing a pt chart before the exam. You note that the pt is using topical capsaicin. You know that topical capsaicin is often used for tx of: a. Diabetic neuropathy b. Stress reduction c. All answers are appropriate d. Depression 32.Acanthosis Nigricans is associated with all of the following except: a. Colon cancer b. Tinea versicolor c. Obesity d. DM: ANS:B 33.ACC 2017 guidelines for high BP in adults, adults w/stage 1 HTN and high ASCVD risk should be managed w/both nonpharm and antihypertensive drug therapy. You know the pt should return for a follow up appointment which includes BP check in: a. 3wks b. 1wk c. 1mo d. 2wks: 34.ACC 2017 Guidelines for High BP in adults discusses screening/management of other CVD risk factors for hypertensive pts. According to the guideline, basic testing for primary HTN includes fasting BGL, CBC, lipids, BMP, TSH, UA, EKG w/optional echo, uric acid, and urinary albumin-to-creatinine ratio. a. True b. False: 35.According to 2017 ACC HTN guidelines, normal BP is: a. <130/90 b. <120/80 c. <140/80 d. <140/90: 36.According to 2017 ACC HTN guidelines, the recommended BP goal for 65yo African American woman w/a h/o HTN and DM and no h/o chronic kidney dz is: a. <130/80 b. <120/80 c. <140/80 d. <140/90: 37.According to 2017 Guidelines for HTN in adults, recommended BP goal for 68yo Asian American woman w/no h/o DM and a h/o CKD is: a. <150/90 b. <120/80 c. <140/80 d. <130/80: 38.According to ADA guidelines, which of the following are appropriate screening tests for T2DM? a. Fasting plasma glucose b. 2-hour OGTT c. HgbA1C d. All of the above: 39.According to the GU presentation, #1 risk factor for urinary incontinence is: a. Uncontrolled DM b. Obesity c. Aging d. Smoking and caffeine intake: 40.A drug that can be used to treat two very common symptoms in a dying pt (pain and dyspnea) is:: Morphine 41.A fluoroquinolone (Cipro) is prescribed for a male pt w/a UTI. What should you teach the pt regarding taking this med?: Its effectiveness is decreased by antacids, iron, or caffeine 42.A form of syncope that is more common in elderly than younger adults is:: Orthostatic hypotension 43.Age-related changes in the bladder, urethra, and ureters include all of the following in older women except:: Increased estrogen production's influence on the bladder and ureter 44.Aging process causes what normal physiological changes in the heart? a. Dilation of R ventricle occurs w/sclerosis of pulmonic and tricuspid valves b. Hypertrophy of R ventricle c. Heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis d. Cardiology occurs along w/prolapse of mitral valve and regurgitation: ANS:C 45.A key symptoms of ischemic heart dz is CP. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because:: A & B only (women w/ischemic heart dz many times do not present w/CP, Some pt's may have no symptoms or atypical symptoms so dx may only be made at the time of the actual MI) 46.Ali is 72yo man who recently came to US from Nigeria. He reports having BCG (bacille Calmette-Guerin) vaccinations as a child. Which of the following is correct regarding TB skin test?:Vax hx is irrelevant; read as usual 47.All of the following antimicrobials may be indicated in chronic bacterial prostatitis except:: Azithromycin 48.All of the following are considered as contributors to dysphagia except:: Smooth muscle relaxants 49.All of the following are true about lab values in older adults except: a. Normal ranges may not be applicable for older adults. b. Abnormal findings are often due to physiological aging c. Reference ranges are preferable d. Reference values are not necessarily acceptable values: 50.All of the following may be reasons associated w/an elevated PSA besides prostate ca except:: UTI 51.All of the following pts have a risk of adverse reaction from Metformin except: a. Pts w/alcoholic disorder b. Pts w/BMI >30 c. Pts w/hypoxia d. Pts w/renal dz: 52.All of the following statements about tremor are true except::The most common tremor is the Parkinson tremor 53.All of the following statements are false about drug absorption except: a. Antacids increase bioavailability of digitalis b. Gastric acidity decreases w/age c. Anticholinergics increase colonic motility d. Underlying chronic dz has little impact on drug absorption: 54.All of the following statements are true about drug absorption in the elderly except: a. Drugs distributed in water have lower concentration b. Drugs distributed in fat have less intense, more prolonged effect c. Drugs highly protein bound have greater potential to cause an adverse drug reaction d. The fastest way to deliver a drug to the action site is by inhalation: 55.All of the following statements are true about interventions in working w/the bereaved except:: There is strong evidence behind recommended interventions 56.All of the following statements are true regarding anxiety except: a. Common in older adults b. Often co-occurs w/depression c. Is a normal part of aging d. More common in females: 57.Anal wink reflex is used to test:: Sensation and pudental nerve function 58.An effective exercise therapy for RA is: a. Yoga and/or Pilates b. Walking 20min daily c. Bicycle riding d. Water exercise programs: ANS:D 59.An elderly nursing home pt is maintained on phenytoin tx for h/o sz. In addition to periodic serum drug concentrations, which of the following are needed for annual eval?: CBC, LFT, platelet count 60.An elderly pt has had a CVA in the anterior cerebral circulatory system (frontal lobe). What symptoms are most likely expressed?: Disorders of behavior and cognition 61.An elderly pt presents w/a new onset of feeling heart race and fatigue. EKG reveals afib w/rate >100. Pt also has a newfound tremor in both hands. Which of the following would you suspect?: Hyperthyroidism 62.An example of secondary prevention you could recommend/order for elderly would be to: a. Provide foot care for DM pt b. Check for fecal occult blood c. Administer tetanus shot d. Wear seat belts: 64.An older adult female pt had a stroke. What symptoms are not usually expressed by pt's who have had a vertebrobasilar stroke?: Monocular blindness 65.An older adult w/a h/o sz disorder comes into the clinic for routine checkup. Although sz-free, the pt continues on long-term phenytoin tx. You would assess for which of the following long-term effects?: Gingival hyperplasia and nystagmus 66.An older male pt is experiencing acute onset of R-sided weakness, slurred speech, and confusion. What should you do promptly?: Eval for stroke and arrange for transport to the hospital right away 67.Aortic regurgitation requires medical tx for early s/s of HF with: a. Surgery b. BB c. ACEI d. Hospitalization: 68.A pelvic mass in a post-menopausal woman:: Is highly suspicious for ovarian ca 69.Atypical presentation of acute coronary syndrome is:: More common in females 70.Atypical presentation of dz in elderly is reflected by all of the following except: a. Infection w/out fever b. Depression w/out dysphoric mood c. MI w/CP and diaphoresis d. Cardiac manifestations of thyroid dz: ANS:C 71.Beers criteria are appropriate for use in evaluating use of certain meds in pts: a. >70yo b. >50yo c. >65yo d. >60yo: 72.Best method of verifying a dx of gout in a joint is:: Joint aspiration and polarized-light microscopy 73.Best recommendation for pt who state they have no equipment to exercise would be:: Improvise w/recommended objects at home that can be used. 74.Best way to diagnose structural heart dz non-invasively is: a. CXR b. Heart cath c. Echo d. EKG: 75.Biochemical individuality is best described as:: Each individual's variation is often much smaller than that of a larger group. 76.Bordetella pertussis is best characterized by:: Sub-acute cough lasting >2wks 77.CC, 62yo male, new to your practice. Previously dx'd w/Stage B HF. According to week 2 HF lecture, you'll look for the following med classes to ensure appropriate tx of HF: a. ACE/ARB, statin, BB b. ACE/ARB c. BB: 78.Chronic fatigue syndrome is best described as:: Fatigue lasting longer than 6mo not relieved by rest 79.Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: a. Depression b. Sleep disturbance c. Decreased socialization d. All of the above: 80.Common auscultatory finding in CHF is:: S3 gallop 81.Consistent finding in delirium, regardless of cause, is:: Reduction in regional cerebral perfusion 82.Delirium is typically characterized by all of the following except:: Hyperactive level of psychomotor activity 83.Diabetic pt presents w/the c/o R foot pain but denies recent known injury. He states it has gotten progressively worse over the past few months. On exam, vibratory sense as well as sensation tested w/a monofilament was abnormal. Pt's foot is warm, edematous, misshapen. You suspect Charcot foot. What intervention is indicated?: Refer to podiatry 84.Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the DD is::Rapid change and fluctuating course of cognitive function 85.Drug-induce [Show More]

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