Exam 4
Diabetes Mellitus (DM)
1. Look (Observation & Initial Assessment)
Prediabetes: No symptoms, but elevated fasting glucose (100-125 mg/dL).
Type 1 DM: Sudden weight loss, polydipsia (excessive thirst), polyuria (frequent urination), polyphagia (increased hunger).
Type 2 DM: Gradual onset, fatigue, recurrent infections, slow wound healing, blurred vision.
2. Assess (Vitals, Labs, Symptoms)
Labs & Diagnostics:
A1C ≥ 6.5% (Reflects 2-3 months of glucose control)
Fasting Plasma Glucose (FPG) > 126 mg/dL
Symptoms + Random glucose > 200 mg/dL
Complications:
Hypoglycemia: Shakiness, confusion, tachycardia, sweating.
Hyperglycemia: Fatigue, polyuria, nausea, headache.
Chronic: Neuropathy, nephropathy, retinopathy, cardiovascular disease.
3. Test (Diagnostics & Confirmation)
Blood Tests: FPG, Random Glucose, A1C
Urinalysis: Ketones (Type 1)
Oral Glucose Tolerance Test (OGTT): Used in pregnancy and prediabetes screening.
4. Treat (Medications & Interventions)
Oral Medications (Type 2):
Metformin (Biguanide): ↓ Liver glucose production (hold if contrast dye is used).
Sulfonylureas (Glipizide, Glyburide): ↑ Insulin production, risk of hypoglycemia.
Insulin Therapy (Type 1 and Severe Type 2):
Rapid-acting (Lispro, Aspart): Onset 15 min, peak 1 hr.
Long-acting (Glargine, Detemir): No peak, 24-hour duration.
Lifestyle Changes:
Diet: Carbohydrate counting, low-fat diet, adequate protein.
Exercise: 150 min/week, resistance training.
Weight management.
5. Educate (Patient Teaching)
Insulin Storage: Refrigerate unopened vials; opened vials at room temp for 28 days.
Complication Prevention:
Foot Care: Daily inspection, avoid barefoot walking, proper footwear.
Blood Glucose Monitoring: Frequency based on insulin use.
Sick Day Management: Continue medications, monitor glucose more frequently, stay hydrated.
Metabolic Syndrome: Risk factor for DM2; includes obesity, HTN, hyperlipidemia.
Multiple Sclerosis (MS)
1. Look (Observation & Initial Assessment)
Onset 20-50 years old, more common in women.
Progressive, degenerative demyelination of CNS.
Symptoms: Fatigue, weakness, numbness, vision problems (blurred vision, diplopia), muscle spasticity.
Relapsing-remitting course common.
2. Assess (Vitals, Labs, Symptoms)
MRI: Brain/spinal cord lesions (plaques).
CSF: Increased IgG, oligoclonal bands.
Evoked potential tests: Slowed nerve conduction.
3. Test (Diagnostics & Confirmation)
No single diagnostic test.
Criteria for diagnosis:
At least two inflammatory lesions in different CNS locations.
Symptoms at least one month apart.
Rule out other diseases.
4. Treat (Medications & Interventions)
No cure; treatment is symptomatic.
Disease-Modifying Therapies:
Beta-interferons: Reduce exacerbations, but watch for flu-like symptoms, depression.
Corticosteroids (methylprednisolone, prednisone): Acute attacks.
Plasma exchange (plasmapheresis): Severe attacks.
Muscle Spasticity: Baclofen (muscle relaxer).
Lifestyle: Avoid heat, fatigue, stress, infection.
5. Educate (Patient Teaching)
Energy conservation, balance of rest & activity.
Diet: High fiber to prevent constipation.
Exercise: Swimming, stretching.
Fall precautions due to muscle weakness.
Parkinson’s Disease (PD)
1. Look (Observation & Initial Assessment)
Progressive neurodegenerative disorder.
Classic symptoms (TRAP):
Tremor (resting tremor, pill-rolling).
Rigidity (muscle stiffness, jerky movements).
Akinesia (loss of voluntary movement, “freezing” episodes).
Postural instability (frequent falls).
2. Assess (Vitals, Labs, Symptoms)
Gradual onset, asymmetric symptoms.
No specific lab test.
Confirmed by positive response to antiparkinsonian drugs (Levodopa).
3. Test (Diagnostics & Confirmation)
Diagnosis based on history & symptoms.
TRAP criteria + response to Levodopa/Carbidopa (Sinemet).
4. Treat (Medications & Interventions)
Levodopa-Carbidopa (Sinemet): Gold standard.
Levodopa: Converts to dopamine.
Carbidopa: Prevents breakdown before reaching brain.
Avoid high-protein meals (affects absorption).
Dopamine agonists (Pramipexole, Ropinirole).
Anticholinergics (Benztropine): Controls tremors.
Deep Brain Stimulation (DBS) for severe cases.
5. Educate (Patient Teaching)
Exercise: Encourage walking, stretching.
Fall precautions:
Walk to a beat.
Remove rugs.
Use chairs with arms.
Nutritional: Soft foods for dysphagia.
Myasthenia Gravis (MG)
1. Look (Observation & Initial Assessment)
Autoimmune disease affecting neuromuscular junction.
Muscle weakness worsens with activity.
Symptoms:
Ptosis (drooping eyelids).
Diplopia (double vision).
Difficulty chewing, swallowing, speaking.
Respiratory muscle weakness (life-threatening in crisis).
2. Assess (Vitals, Labs, Symptoms)
Edrophonium (Tensilon) Test:
Improvement = MG (positive test).
Worsening = Cholinergic crisis (need Atropine).
EMG: Decreased response with repetitive nerve stimulation.
ACh receptor antibodies.
3. Test (Diagnostics & Confirmation)
Tensilon test to differentiate MG vs. cholinergic crisis.
Electromyography (EMG).
CT/MRI to check for thymoma.
4. Treat (Medications & Interventions)
First-line: Pyridostigmine (Mestinon) (Anticholinesterase).
Corticosteroids (Prednisone): Suppress immune response.
Plasmapheresis or IV Immunoglobulin (IVIG): For crisis.
Thymectomy if thymoma present.
5. Educate (Patient Teaching)
Take meds before meals (to improve swallowing).
Plan activities in the morning (energy conservation).
Soft foods to prevent aspiration.
Emergency care: Recognize myasthenic crisis (severe weakness, respiratory distress).
Seizures & Epilepsy
1. Look (Observation & Initial Assessment)
Uncontrolled electrical discharges in the brain.
Types:
Tonic-Clonic (Grand Mal): Stiffening + jerking.
Absence Seizures: Brief staring spells.
Focal Seizures: Localized symptoms.
Status Epilepticus: Seizure >5 minutes, life-threatening.
2. Assess (Vitals, Labs, Symptoms)
Prodromal phase (warning signs).
Aural phase (sensory warning).
Ictal phase (seizure activity).
Postictal phase (recovery, confusion, fatigue).
3. Test (Diagnostics & Confirmation)
EEG: Abnormal brain activity.
CT/MRI: Check for structural abnormalities.
Lab tests: Rule out metabolic causes.
4. Treat (Medications & Interventions)
Antiepileptics (AEDs):
Phenytoin (Dilantin): Gum hyperplasia risk.
Carbamazepine (Tegretol).
Valproic Acid (Depakote).
For Status Epilepticus: IV Lorazepam or Diazepam.
5. Educate (Patient Teaching)
Avoid alcohol, fatigue, and sleep deprivation.
Wear a medical alert bracelet.
Safety precautions: No driving until seizure-free.
Alzheimer’s Disease (AD)
1. Look (Observation & Initial Assessment)
Chronic, progressive neurodegenerative disorder.
Symptoms:
Memory loss.
Difficulty with familiar tasks.
Personality changes.
Sundowning (worse confusion at night).
2. Assess (Vitals, Labs, Symptoms)
10 Warning Signs: Forgetfulness, confusion, mood changes, etc.
CT/MRI: Brain atrophy.
Cognitive tests (MMSE).
3. Test (Diagnostics & Confirmation)
Diagnosis is clinical (rule out other causes).
4. Treat (Medications & Interventions)
Cholinesterase inhibitors (Donepezil, Rivastigmine).
Memantine (NMDA receptor antagonist).
Supportive care.
5. Educate (Patient Teaching)
Safety: Prevent falls, wandering.
Routine & structure: Reduce anxiety.
Caregiver support.
Urinary Tract Infection (UTI)
1. Look (Observation & Initial Assessment)
Common bacterial infection, especially in women.
Types:
Lower UTI (cystitis, urethritis) – localized symptoms.
Upper UTI (pyelonephritis) – systemic symptoms.
Complicated UTI – structural/functional problems.
Urosepsis – life-threatening.
2. Assess (Vitals, Labs, Symptoms)
Classic Symptoms:
Dysuria (burning), frequency, urgency, hematuria.
Cloudy, foul-smelling urine.
Flank pain, fever, chills (suggests pyelonephritis).
Older Adults: Atypical presentation (confusion, fatigue, no fever).
3. Test (Diagnostics & Confirmation)
Urinalysis (UA): +Leukocyte esterase, +Nitrites, WBCs, bacteria.
Urine culture: Identify pathogen.
Imaging (CT, ultrasound): If recurrent or severe.
4. Treat (Medications & Interventions)
Antibiotics:
Uncomplicated UTI: Trimethoprim/Sulfamethoxazole (Bactrim), Nitrofurantoin, Fosfomycin.
Complicated UTI: Fluoroquinolones (Ciprofloxacin).
Fungal UTI: Fluconazole.
Phenazopyridine (Pyridium): Urinary analgesic (orange urine).
5. Educate (Patient Teaching)
Hydration: Increase fluid intake.
Urinate frequently & after intercourse.
Avoid bladder irritants (caffeine, alcohol, spicy foods).
Prevention: Front-to-back wiping, no douching, avoid bubble baths.
Catheter care: Prevent CAUTI (early removal, aseptic technique).
Kidney Cancer
1. Look (Observation & Initial Assessment)
More common in men, peak age ~64 years.
Risk factors: Smoking, obesity, HTN, exposure to toxins (asbestos, cadmium).
Symptoms:
Hematuria (most common).
Flank pain, palpable mass.
Weight loss, fever, anemia.
2. Assess (Vitals, Labs, Symptoms)
25% have metastasis at diagnosis.
Lab findings: Anemia, high calcium, abnormal liver function.
3. Test (Diagnostics & Confirmation)
CT scan (gold standard).
MRI, ultrasound, renal biopsy.
4. Treat (Medications & Interventions)
Surgical removal (Nephrectomy) – primary treatment.
Targeted therapy (for metastasis) – VEGF inhibitors, immunotherapy.
Radiation or chemotherapy (palliative care).
5. Educate (Patient Teaching)
Smoking cessation.
Post-surgery care (hydration, infection prevention).
Routine follow-ups for recurrence.
Bladder Cancer
1. Look (Observation & Initial Assessment)
Most common urinary tract cancer.
Risk factors: Smoking, industrial chemicals, recurrent UTIs, prolonged catheter use.
Symptoms:
Painless hematuria (most common).
Dysuria, frequency, urgency.
2. Assess (Vitals, Labs, Symptoms)
Evaluate for urinary obstruction.
Monitor for metastasis symptoms.
3. Test (Diagnostics & Confirmation)
Urine cytology (bladder tumor markers).
Cystoscopy with biopsy (gold standard).
CT/MRI to assess spread.
4. Treat (Medications & Interventions)
Surgical:
Transurethral resection of bladder tumor (TURBT) for early-stage.
Radical cystectomy for invasive cancer (requires urinary diversion).
Intravesical therapy:
BCG (Bacillus Calmette-Guérin) therapy to stimulate immune response.
Chemotherapy or radiation for advanced cases.
5. Educate (Patient Teaching)
Monitor for recurrence (frequent follow-ups).
Ostomy care for urinary diversion (if cystectomy performed).
Avoid smoking & carcinogens.
Chronic Kidney Disease (CKD)
1. Look (Observation & Initial Assessment)
Progressive, irreversible loss of kidney function.
Main causes: Diabetes (50%), HTN (25%).
Symptoms:
Early: Asymptomatic or mild fatigue, edema, polyuria/nocturia.
Late (Uremia): N/V, confusion, pruritus, fluid overload, hyperkalemia, metabolic acidosis.
2. Assess (Vitals, Labs, Symptoms)
Labs:
GFR < 60 mL/min for >3 months = CKD.
GFR < 15 mL/min = End-Stage Renal Disease (ESRD).
↑ BUN/Creatinine.
Electrolyte imbalances:
Hyperkalemia (K+ > 7mEq/L can cause fatal dysrhythmias).
Hyponatremia (fluid retention).
Hyperphosphatemia & hypocalcemia (bone disease risk).
3. Test (Diagnostics & Confirmation)
Urinalysis: Proteinuria, RBCs, WBCs.
Renal ultrasound, CT, or biopsy to evaluate kidney damage.
4. Treat (Medications & Interventions)
Dietary management:
Limit protein, sodium, potassium, phosphorus.
Calcium & vitamin D supplements.
Medications:
ACE inhibitors or ARBs (slow progression, control BP).
Kayexalate or Patiromer (for hyperkalemia).
Erythropoietin therapy (for anemia).
Phosphate binders (for bone protection).
Dialysis (GFR < 15 mL/min) or Kidney Transplant for ESRD.
5. Educate (Patient Teaching)
Daily weight monitoring (fluid retention).
Avoid NSAIDs (worsen kidney function).
Limit potassium-rich foods (bananas, oranges, potatoes, tomatoes).
Prepare for dialysis or transplant evaluation if needed.
Dialysis (Peritoneal vs. Hemodialysis)
1. Look (Observation & Initial Assessment)
Indicated for ESRD (GFR < 15 mL/min).
Peritoneal Dialysis (PD):
Abdominal catheter, can be done at home.
Slower, gentler than HD.
Hemodialysis (HD):
Blood is filtered through a machine.
Requires AV fistula or graft.
2. Assess (Vitals, Labs, Symptoms)
Hypotension, muscle cramps, electrolyte imbalances.
AV fistula complications:
Infection, clotting, steal syndrome (cold fingers, poor capillary refill).
3. Test (Diagnostics & Confirmation)
Monitor labs pre- & post-dialysis (BUN, creatinine, electrolytes).
Assess AV fistula (bruit/thrill).
4. Treat (Medications & Interventions)
IV fluids for hypotension.
Adjust medications around dialysis schedule (some drugs removed by dialysis).
5. Educate (Patient Teaching)
No BP or IV in fistula arm.
Report infection signs at dialysis access site.
Monitor fluid & sodium intake.
-Regular Insulin- 30-1hr to make sure they have food
-carbs for low blood sugar: 4-6 oz orange juice, PB, honey, syrup, gram crackers
-prevent UTI- hydration, Pee before intercourse, wipe front to back
-good peri care
-risk factor for bladder or kidney cancer- smoking
-clean catch- collect mid stream for urine culture
-retaining fluid: daily weights
-triptins- vasoconstriction (rebound headache)
-somyogi effect- blood sugar drops in middle of night and is high in the morning
-dementia and CKD—> progressive and irreversible
-after insulin is open → leave it room temp
-determine effectiveness of calcium carbonate for CKD→ check phosphate
-peritoneal dialysis → clear and yellow effluent
-expectation of carbodopa/levodopa → tremors (parkinsons)
-expected findings parkinsons - shuffling, bradykinseia, flat affect, rigity,
-Mysthenia Gravitas- check to see if they can swallow
-type 1 Diabetes→ first symptom anorexia, unintended weight loss
-common cause of tension and cluster headaches→ stress
-A1C of 8→ not controlled diabetes
-CKD progressing blood work increasing → albumin creatine, BUN increasing (GFR decreasing)
-risk factor for kidney cancer- Hypertension, diabetes, genetics
-diet recommendation: what do you like to eat?
-