NR 667 Vise call focused Possibilities questions and answers

1. BPH AUA Questions "Over the past month have you..."

1. Sensation of incomplete emptying

2. Urinate less than 2 hours after you finished (Frequency)

3. How often have you found that you start and stop several times when urinating

4. found it difficult to postpose urination

5. Weak urinary stream

6. push or strain when urinating

7. how many times do you typically get up to urinate

Mild= 0-7

moderate= 8-19

Severe 20-35

BPH Labs

U/A

PSA

High PSA and free PSA (cancerous is high PSA and normal to low free PSA)

Renal panel

post void residual

BPH Differentials

Prostatitis

Prostate cancer

UTI

Bladder cancer

BPH Assessment

DRE

Firm, smooth symmetrically enlarged prostate

BPH Non-pharm education

Limit bedtime fluids

Limit caffeine, alcohol, antihistamine/anticholinergics

Limit salt intake

BPH Pharm education

Alpha 1 Blocker

Flomax 0.4mg daily at bedtime

May cause dizziness

Follow up in 2-4 weeks

Urology if patient is not responding to treatment

Annual PSA and DRE if initial PSA >2.5

2. Sinusitis (Maxillary) Assessment findings

Viral <10 days- treat symptomatically with NSAIDs, Acetaminophen

Bacterial >10 days- <4 weeks

HEENT Exam- facial tenderness, post nasal drip, middle ear effusion, halitosis, periorbital edema

Sinusitis differentials

Allergic Rhinitis

dental abscess

migraine

Sinusitis labs

CBC, Sinus X-ray/CT if chronic

Diagnosis based on history and PE unless complications

Sinusitis non-pharm

Rest, hydration, warm compress to sinuses

Use humidifier/ saline nose spray

Sinusitis pharm

Watchful waiting for viral vs bacterial

Start prior to bacterial timeframe for immunocompromised or severe illness such as fever, moderate-severe pain, unilateral tenderness, worsening symptoms

Adults- Augmentin 875/125mg BID x 10 days

PCN allergy Doxy 100mg BID x 7 days

Peds- Amoxiciilin 80-90mg/kg BID 5-7 days

PCN allergy cefpodoxime 5 mg/kg q12h for 10 days (2 mo-12 yrs) or 200 mg q12h for 10 days (>12 yrs)

Sinusitis follow-up

f/u 1 week for effectiveness or if symptoms worsen 3-5 days

ENT if recurrent infections

ER if meningitiis

Immediate referral for periorbital edema

3. Low back pain assessment

Referred, radiating, localized?

OLDCARTs (Onset, location, duration, characteristics, aggravating, relieving, treatment, severity)

Urinary issues

Neuro issues

Low back pain diagnostics

x-ray with injury or 4 weeks without resolution

MRI and CT for disc disease

CBC, CMP, CRP, UA

Low back pain PE

Motor, sensory, and reflex

observe gait

assess lower extremity strength, and bulk of muscle and pulses

DTR-

Patellar nerve roots L2-L4

Achilles nerve roots S1-S2

Straight leg raise- herniated disc

cross leg raise test

Low back pain non pharm

PT

core strenghtening

gradually resume activities

RICE

Low back pain pharm

non pharm is first line

NSAIDs first line for pharm

Naproxen 250mg BID

Flexiril 5mg PRN 3x/day

Low back pain differentials

Herniated disc

Kidney stone

Cauda equina

Pyelnephritis

Degenerative disc disease

Spinal stenosis

Low back pain follow-up

Severe- 24-48hours

Moderate 7-10 days

ER referral for neuro compromise

4. Reflux esophagitis assessment findings

heartburn, burning beneath sternum, postprandial and nocturnal regurgitation, chest/neck pain, chronic cough, lump in throat, post nasal drip, erosion of teeth from acid

Reflux PE assessment

Heart, lungs

GI

Epigastric tenderness

HEENT- mouth/oropharynx

Reflux diagnosis

based on history (primary) and PE

Empiric PPI for 8 weeks

Endoscopy after 8 week trial and unresolved

Reflux non-pharm

Removing or modifying risk factors like coffee, spicy food, chocolate, and citrus.

Small, frequent meals

Sit up 2 hours after meals

Elevate head of bed, lay on left side

Reflux pharm

Omeprazole 20mg daily before breakfast for 8 weeks

Reflux f/u

Return 4-8 weeks for effectiveness

GI referral after 8 weeks without resolution

Reflux differentials

H. Pylori infection

PUD

Asthma

5. Acute laryngopharyngitis presentation (Strep)

sore throat, tonsillar exudate, cervical adenopathy, fever, no cough, petechiae on soft palate, beefy red tonsils, sandpaper rash

Acute laryngopharyngitis presentation (Virus)

fever, cough, nasal congestion, hoarseness, diarrhea, viral rash

Acute laryngopharyngitis diagnosis

rapid strep test

Acute laryngopharyngitis non pharm

gargle with warm salt water, increase fluids, change toothbrush 48-72 hours after abx

Acute laryngopharyngitis pharm

Pen V K 500 mg PO BID x 10 days

Cephalexin 500mg PO BID x 10 days if PCN allergy

No f/u unless worsening symptoms

Allergic Rhinitis Presentation

clear nasal discharge, pale nasal mucosa, red and watery eyes along with nasal congestion, rhinorrhea, itching of nose, eyes, palate, sneezing, cough

6. Allergic Rhinitis PE Assessmnet

Assess for conditions such as asthma, atopic dermatitis, sleep disordered breathing, conjunctivitis, otitis media

Dark discolored area beneath lower eyelids

transverse crease on tip of nose

enlarged tonsils and adenoids

Allergic Rhinitis testing

Specific IgE testing (blood or skin) should be performed for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when diagnosis is uncertain, or when determination of specific target allergen is needed. (allergy panel)

Allergic Rhinitis non pharm

avoid triggers such as allergens or environmental

Allergic Rhinitis pharm

Intranasal steroids (Budesonide or Fluticasone) should be prescribed for patients whose symptoms affect quality of life

or

Oral second-generation/less sedating antihistamines (Cetirizine or Loratadine) should be prescribed for patients with AR and primary complaints of sneezing and itching

or

Intranasal antihistamines may be prescribed for patients with seasonal, perennial, or episodic AR.

Allergic Rhinitis follow-up

F/U 5-7 days after mono therapy, switch to another first line monotherapy if first failed

Referral to ENT needed if symptoms persist or worsen

7. UTI Presentation

Urgency, dysuria, increased frequency, incomplete bladder emptying, fever, chills, hematuria, lower abdominal pain/flank pain, dribbling of urine in men, foul smelling urine, small volume/ frequent voiding

UTI diagnosis

UA- WBC positive, Nitrate positive, urine culture

Pyridium can cause false positive

May also collect STI test, C&S After 2-3 days, WBC >100,000

UTI older adult symptoms

New onset of confusion

fatigue

UTI differentials

Overactive bladder, Vaginitis, STI, PID, prostatitis, BPH

UTI pharm

E.Coli most common cause

Macrobid 100mg BID x 5-7 days

Keflex 500mg PO BID-TID 3-5 days

UTI non pharm/preventative

voiding after sexual intercourse, practice genital hygiene, loose fitting clothing, improve glucose levels in diabetic

8. Asthma PE findings

exp wheezing, SOB, non productive cough, tachypnea, tachycardia, accessory muscle use, sudden nocturnal dyspnea, decreased exercise tolerance, chest tightness

Asthma diagnostics

PFT spirometry, peak flow monitoring

Asthma Non pharm

avoid allergens and irritants, educate S/S of exacerbation, asthma action plan, immunizations UTD

Asthma Pharm reliever

All need PRN reliever-

ICS- Formoterol (Symbicort)

ICS-SABA

SABA (albuterol)

Asthma Pharm step 1-2

low-dose ICS plus formoterol (ICS-formoterol) and a SABA as needed.

Example: Budesonide/Formoterol — MDI† 80 mcg/4.5 mcg or 160 mcg/4.5 mcg2 puffs 2x/day; dose depends on the level of severity or control.

Asthma Pharm step 3

low-dose ICS + either LABA, LTRA, or theophylline(b) OR medium-dose ICS

Example: budesonide/formoterol inhaled, Singulair (LTRA)

Asthma pharm step 4

Severely uncontrolled asthma or with an acute exacerbation

medium-dose ICS + LABA

Asthma Education

Use of inhalers

Avoid triggers

smoking cessation

Children- avoid ASA (Reyes syndrome)

Asthma F/U

Every 2-6 weeks while gaining control

Every 1-6 months to monitor control

Every 3 months, if step down in therapy is anticipated

Refer to pulmonologist for severe asthma received over 2 rounds of oral steroids/ year

Asthma differentials

URI

COPD

CHF

GERD

CF

PE

9. HTN presentation

Typically asymptomatic

Some patients may present with occipital headaches, headache on awakening in AM, blurry vision, posterior neck pain, and dizziness

HTN Findings for organ damage

rule out organ damage:

Microvascular

Eyes- AV nicking, flame shaped hemorrhage, silver/copper wire arterioles.

Kidneys- microalbumin and proteinuria, elevated serum cr, abnormal eGFR, peripheral/generalized edema

Macrovascular

Heart- S3 (CHF), S4 (LVH), carotid bruits, CAD, acute MI, decreased/absent pedal pulse

Brain- TIAs, hemorrhagic stroke

HTN Assessment PE

treat for BP >140/90

HEENT- blurry vision, optic fundi look for AV nicking, hemorrhage, papilledema

Cardio- heart sounds, perform symmetrical pulses

Lungs- SOB, pulmonary edema

Neuro- occipital headache, headache upon awakening, dizziness

Auscultate for carotid bruits bilaterally, abdominal bruits, and kidney bruits

HTN Diagnostics

CBC, CMP, UA

TSH, Lipid, fasting glucose

EKG, CXR

HTN non pharm

Lifestyle modification: weight loss, smoking/alcohol cessation, healthy diet, and sodium reduction

Maintain BP log 2x/ daily and bring to next f/u

HTN pharm

Diuretics: Hydrochlorothiazide (HCTZ) 25mg/day max 50mg/day) *May worsen gout and elevate lipids and glucose. Preferred in patient with osteoporosis and African Americans.

o Ace inhibitors (-PRIL): Complicated HTN, renal/cardio protective for DM patients. (Lisinopril 10mg/day) *Hyperkalemia risk. If patient develops angioedema transition to ARBs

o ARB's (-SARTAN): Renal/cardio protective for DM patients. (Losartan 25mg/day) *Hyperkalemia risk.

o CCB's (-PINE): Preferred in African American and patient >65 years old with (with stiff artery). (Amlodipine besylate 5mg/day) *Watch for lower extremity edema and avoid in GERD patients (weakens gastric sphincter).

o Consider ACE/ARB in patients with DM, proteinuria, HF. (ACE/ARB contraindicated in pregnancy).

o If stage 2 HTN, initiate 2 drug classes (Diuretics and CCB).

o BP meds safe for pregnancy: Nifedipine, Labetalol, and Methyldopa

HTN F/U

Reassess in 1 month for effectiveness of BP-lowering medication therapy.

If goal is met at 1 month, reassess in 3 to 6 months.

If goal is not met after 1 month, consider different medication or titration

10. Hyperlipidemia history

familial hypercholesterolemia, diet, exercise habits, tobacco, alcohol, or drug use, symptoms of peripheral arterial disease, angina, stroke, or presence of coronary artery disease

Hyperlipidemia PE

BP, carotid/abdominal bruits, assess skin for xanthomas, listen for S4 sound, palpate all 4 extremities for intact peripheral pulses.

Hyperlipidemia differentials

DMII, hypothyroid, metabolic syndrome

Hyperlipidemia labs

A1C/ fasting glucose

TSH

Lipid panel

UA

Liver function

Hyperlipidemia non pharm

Lifestyle changes (diet and exercise), weight loss, smoking cessation, avoid alcohol, eat food with high omega 3 (fish)

Hyperlipidemia pharm

high intensity if LDL >190

Moderate risk- statin + lifestyle changes

Intitiate statin therapy as secondary prevention for patients with risk factors such as history of stroke