Clinical Path exam 3

Cystitis/urethritis (UTI)

Cystitis (inflammation of the bladder), Urethritis (inflammation of the urethra)

• S/S: bacteriuria, cloudy/bloody urine, dysuria

Renal calculi (kidney stones)

Common cause of urinary obstruction; concentration of various mineral salts in the renal pelvis or the calyx

• S/S: excruciating pain in the flank and upper outer quadrant of the abdomen on the affected side, nausea, vomiting, chills and fever, hematuria, abdominal distention

BPH (Benign Prostatic Hyperplasia)

Enlarged prostate

• S/S: urinary obstruction, nocturia, dribbling, urinary frequency, hematuria, weak urine stream, and incontinence

• Tx: “watchful waiting” then alpha blocker medication to shrink the prostate

Prostatitis

Inflammation of the prostate gland (can be acute or chronic)

• S/S: low back pain, pain in pelvic region, perineal fullness or pain, fever, dysuria, hematuria, and urinary frequency and urgency

• Tx: antibiotic

Epididymitis

Inflammation of the epididymis due to infection

• S/S: epididymis enlarged, hard, and causing pain, scrotal and groin tenderness, fever, and malaise

• Tx: antibiotoic

Testicular torsion

a medical emergency occurring when a testicle twists on the spermatic cord, cutting off the blood supply

• S/S: sudden, severe scrotal pain, swelling, and nausea

• Tx: immediate surgery

Ovarian cysts/tumors

Benign cysts of the ovary are derived from ovarian follicles that do not break open to release the egg

• S/S: Some cysts are asymptomatic. Large can have pelvic pain, low back pain, and dyspareunia. Cysts that are mobile can twist, producing spasmodic abdominal pain

• Watchful waiting

Endometriosis

Appearance and growth of endometrial tissue in areas outside of the endometrium, the lining of the uterine cavity

• S/S: Dysmenorrhea with lower back and vaginal pain, Pain at the ectopic site during menses. Clients might have profuse menses, infertility, dyspareunia, dysuria, and even painful defecation

Pelvic inflammatory disease

infection of the uterus, fallopian tubes, or ovaries

• S/S: no symptoms, while serious damage is being done to reproductive organs. acute: sudden pelvic pain, foul-smelling vaginal discharge, fever, sexual dysfunction, metrorrhagia (abnormal uterine bleeding), and rebound pain.

Polycystic ovary syndrome (PCOS)

Numerous cysts in the ovaries disrupt the monthly reproductive cycle

• S/S: irregular menstrual periods, excess hair growth, and obesity, enlarged polycystic ovaries, infertility, pre-diabetes or type 2 diabetes, hypertension, sleep apnea, amenorrhea or irregular menses

Menstrual disorder (amenorrhea, dysmonorrhea and menopause)

Amenorrhea - the absence of menstruation

Dysmenorrhea - painful, crampy menstrual periods, affecting the lower abdomen, back, or thighs.

Menopause - not a disease, but can be a RF for osteoporosis, HTN, high cholesterol, depression

Breast Cancer

Occurs when breast cells mutate and grow uncontrollably, often forming tumors

• S/S: breast thickening/lump, pain/swelling in armpit, breast size change, nipple discharge/irregular shape/crustiness, skin changes (dimpling)

Testicular/prostate cancer

Prostate cancer - S/S: dysuria, nocturia, frequent urination, low back pain, hematuria, bone pain, erectile dysfunction, weakness/numbness in legs and feet, incontinence, weight loss

Testicular cancer - S/S: lump/swelling in the testicle (may be painless), breast growth/soreness; LBP, SOB, abdominal pain in advanced cases

Hyperpituitarism/hypopituitarism

Hyperthyroidism/hypothyroidism

Hyperparathyroidism/hypoparathyroidism

Cushing syndrome - adrenal dysfunction

Too much cortisol

• Enlargement

• weight gain

• waist weight gain

• stretchmarks

Addison syndrome - adrenal dysfunction

• A lot of atrophy

• muscle weakness

• GI issues

• Hyperpigmentation (darkening of skin)

Diabetes mellitus

pancreatic dysfunction (insuffiicnet insulin poduction or inadequate utilization of insulin)

Diabetes mellitus - Type 1

immune-mediated

• Abrupt onset, earlier in life

Diabetes mellitus - Type 2

age related

• gradual onset, later in life

Gestational diabetes

hormonal changes d/t pregnancy

• cut off of supply to the pancreas

Consequences/comorbidities of DM (untreated)

• Chronic kidney disease, renal failure

• Diabetic neuropathy

• Cardiovascular diseases (including hypertension)

• Diabetic retinopathy (and blindness)

  • Build-up of pressure in the eye because of blood glucose

Comorbidities

• PCOS

• thyroid dysfunctions

• hyperlipidemia

• obesity

• psychological disorder

• celiac disease and other GI complications (gluten sensitivity)

Diagnosing DM

• Non-fasting sugar test >200mg/dL (normal before meal is 70-130 mg/dL; post-meal normal is <180 mg/dL)

• Fasting blood glucose test >126mg/dL (normal is 70-100 mg/dL)

• A1C >6.5% (normal is below 5.7%)

(A1C is how much sugar is included in hemoglobin part of RBC)

Diabetes Tx & Management

Medications

• Insulin (for sure for type 1)

• Metformin and others for lowering blood glucose levels (T2DM)

• Cholesterol-lowering medication

Exercise, diet, and other lifestyle/habit modification

Regular assessment of blood glucose and A1C

Preventing hypoglycemia and hyperglycemia

Metabolic acidosis - pH, S/S

• pH<7.35

• Accumulation of ketones and lactic acid, renal failure, drug/toxins, GI issues (diarrhea)

Metabolic alkalosis - pH, S/S

• pH>7.45

• Prolonged vomiting (acid loss), hypovolemia, diuretic use, hypokalemia

(pH is increased bc of vomiting)

GERD (gastroesophageal condition)

Malfunction of the lower esophageal sphincter

• S/S: heartburn, regurgitation, nausea

Peptic ulcers (gastroesophageal condition)

Mucous membrane lesion due to excess acid, H. pylori infection, excess NSAID use

• S/S: bloody stool, lack of appetite

Gastroenteritis (chronic gastroesophageal condition)

No specific cause, but stress, food ant other habits RFs

• S/S: intermittent abdominal pain without bowel issues

Celiac disease (intestinal condition)

gluten-induced enteropathy - an autoimmune disorder affecting the villi (absorption ability is affected)

• S/S: flatulence, bloating, loose bowel, indigestion, nausea/vomiting, anemic osteoporosis, dry/itchy skin, weight loss

IBS

3 types of inflammatory bowel disease: diverticulitis, crohn’s, ulcerative colitis

Diverticulosis, diverticulitis

Bulging pouches (diverticula) cause issues when inflamed or rupture

• S/S: fever, pain (may be relieved by bowel movement), constipation/diarrhea, muscle spasm

Crohn’s disease

Chronic inflammation causing intenstinal wall (all layers) to thicken/toughen

• Mix of healthy and diseased sections

• S/S: RLQ pain, diarrhea, appetite loss

ulcerative colitis

Chronic inflammation of the mucosal lining of the colon

• S/S: bloody diarrhea, abdominal pain, urgency for bowel movement, fever, dehydration

Pancreatitis

Cholecystitis, cholelithiasis

Acute inflammation of the interior wall of the gallbladder

• Lasting URQ pain, nausea/vomit, low-grade fever, lack of appetite

Cirrhosis

Chronic degenerative disease of the liver; build-up of fibrotic scar tissues

• Various causes (alcohol, diet, toxins, CHF, hepatitis)

• S/S: nause/vomiting, lack of appetite, dull abdominal pain, weakness/fatigue, pruitus, edema and ascites, jaundice, neuritis

Hepatitis (A, B, C) liver condition

Necrosis of liver cells

• A: acute infection; fecal-oral route infection; vaccine present

• B: blood/serum transmission; more serious than A; vaccine present

• C: chronic infection; blood transmission; high risk for cirrhosis and liver failure; vaccine not present

Flu like symptoms: dark urine; clay colored stools; pruitis/hives, nausea, vomiting; loss of appetite; pain; jaundice

Appendicitis (acute)

*Perforation is life-threatening

• S/S: Local LRQ pain (McBurney point), rebound tenderness, rigidity, muscle spasms, constipation, fever and malaise (later)

Spleen injury (not in textbook)

• MOI: blunt force trauma

• Rupture is a medical emergency

• Tx: depends on vascular supply; non-surgical preservation to splenectomy

• Monitor for decreased immune function

Kidney functions

• Waste removal

• Body fluid, electrolyte, and pH balance

• Hormone release for regulating blood pressure

• Regulation of RBC production

Chronic kidney disease stages (1-5)

Stage 1 - normal, eGFR>90

Stage 2 - mild decrease, eGFR 60-89

Stage 3 - moderate damage, eGRF 30-59

Stage 4 - moderate/severe damage, eGFR 15-30

Stage 5 - severe damage/failure, eGFR <15, aka end-stage renal disease or ESRD

Typical S/S of kidney disease

• May remain asymptomatic until a more serious failure

• Swelling in the body (face, extremities)

• Foamy and brown urine

• Sharp back pain (and tenderness at CVA)

• Dysuria

• Reduced urine volume

• Itchy skin

Specific assessment (urinary, reproductive system conditions)

• Pain in the CVA (costovertival angle), flank, or abdomen

• Perineal, genital, groin, or low-back pain (common w/ ovary issues)

• Painful intercourse

• enlarged, painful nodes

• abnormal discharge

Specific assessment - urine

• Frequency of urination

• Amount of urine, urgency

• Dysuria - difficulty/pain w/ urination

• Nocturia - having to pee at night

• urinary retention - bladder isn’t empty all the way

• Incontinence - cannot hold pee in the bladder

• Change in color and odor of urine (including blood)

• Stones or sediment in urine

• Systemic issues (fever, chills, excess sweat)

Abnormal colors of urine: Pink/red

kidney disease, tumors, UTI, prostate problems, lead or mercury poisoning, trauma causing internal bleeding (rhabdomyolysis - could be brown)

Abnormal colors of urine: orange/brown

Liver disease, porpuria (genetic disorder), bile duct issues, severe dehydration

Abnormal colors of urine: green/blue

Bacterial infection, bilirubin (too much excreted in body)

Abnormal colors of urine: bright yellow

Excess bilirubin (bile production), vitamin B supplement

USG (hydration status)

Urine specific gravity

measured through a refractometer

• USG <1.010: hydrated

• USG > 1.020: dehydrated

Dipstick analysis

Endocrine dysfunctions

• Lack of hormone production

• Excess of hormone production

• Dysfunctions of the target organs

  • receptor malfunction

• Other diseases and mediation that contribute to above diagnoses

Common issues associated with endocrine dysfunctions

• decreased energy level, increased fatigue

• Intolerance to heat or cold

• Changes in sexual function

• development of 2nd degree sex characterics

• changes in mood and ability concentrate

• changes in memory and sleep patterns

• weight changes

• hypotension or hypertension

• diminished or excessive growth

• Immune system disruption

Thyroid gland (T3 and T4 - triiodothyronine and thyroxine)

• Protein synthesis

• Maintenance of BP, HR, digestion, metabolism, body temp, brain functions and reproductive functions

Thyroid gland (calcitonin)

Ca2+ regulation can cause:

• Over storing - kidney stones

• Over release - osteoporosis

Parathyroid gland (parathyroid hormone - PTH), what does it do? possible tx?

Maintains normal blood calcium level via a negative feedback loop

possible tx: take a gland out… then might need to watch heart and keep an eye out for increased muscle injury…

Adrenal glands (cortex - cortisol, aldosterone, androgen)

Cortisol functions

• Regulating blood sugar level for brain functions

• Convert fat, protein, glucose to energy

• Regulate BP and CV functions

Aldosterone

• Targets the kidneys for maintaining a balanced blood Na+ level

Androgen

• Secondary male sexual characteristics

Adrenal glands (adrenal medulla - Epinephrine and NE)

Fight or flight response

Epinephrine (adrenaline)

• Increased HR, blood flow to muscles + brain

• Increased blood sugar

Norepinephrine

• Increased vasoconstriction - increased BP

Pancreas (insulin vs glucagon jobs)

Insulin (beta cells)

• Reduce blood glucose (signal muscle, blood, and fat cells to absorb glucose)

Glucagon (alpha cells)

• Increased blood glucose (activate the liver to release glucose)

Endocrine-Specific assessment

• Family Hx

• Frequency, hx of infection

• diet + physical activity level

• stress (hormones are regulated by the hypothalamus)

• environmental factors

• medication hx, supplement use

• pregnancy, menopause

Endocrine “inspection” points

• Hair - thinning, growth

• skin - itchiness, darkness/redness, scaling, sweat

• nails

• eyes — deer in headlights (?)

• tremors

• breast development in men

• body shape (fat distribution, atrophy, muscular tone)

• deformity, swellling

General Tx for endocrine dysfunction

• Medications (for treating symptoms)

• Hormone replacement (e.g., insulin shots)

• Surgical removal of affected glands

• Side effects, consequences for above options

• Monitored exercises and diet

• dietary modifications

• Addressing underlying cause or comorbidities

Alimentary canal

• Open tract of major organs through which food travels from mouth → anus

Accessory organs

• Secrete fluids into digestive tract to assist in digestion and absorption in nutrients

Functions of the digestive system

• Food is INGESTED

• Food is DIGESTED

• Water and nutrients in food are ABSORBED

• Undigested food is ELIMINATED

Digestive issue S/S that warrent emergency care

• Vomiting bright red blood, black material (resembling coffee grounds)

• Fever >101, accompanied by severe abdominal pain

• Persistent vomiting (inability to keep any fluid down for 24-36 hours)

• Unstable vital signs, altered mental status

Digestive system inspection

• Typically with patient in supine position

• Scars (hx of appendectomy, cholecystectomy)

• bruising, discoloration

• Swelling, distention, visible mass

• Abdomen movement during regular breathing

• Guarding (protective) position

Abdominal Auscultation (normal vs abnormal)

Normal - some clicking and gurgling (also assess vascular sounds esp. abdominal aorta)

Abnormal - hyperactive, hypoactive, absence

Abdominal percussion

• Tympanic or resonant (high pitch, drum-like)

  • Over air-filled structures

• Dull sounds (thuds)

  • Over solid or fluid-filled structure

Abdominal palpation

• tenderness (rebound tenderness), rigidity

• Superficial (light) vs deep

• Spleen, liver, kidneys (especially CVA), appendix (McBurney’s point)