Exam 3

Question 1

What is acute sinusitis? What is the difference between acute and chronic? What are some signs and symptoms? How would you assess for sinusitis? What are some interventions?

Answer 1

– acute sinusitis: infection of the sinuses

– acute = often due to upper respiratory infection or allergy

• viral = 5 - 7 days
• bacterial = up to 4 weeks

– chronic = more than 12 weeks

– s/s

• h/a
• pain over sinus areas
• fatigue
• nasal obstruction
• purulent nasal discharge

– assess using transillumination of sinuses with penlight

– interventions

• drugs
  
  • antimicrobial agents
  • decongestants
  • saline sprays
• heated mists

Question 2

What is acute rhinitis? What are some caues of acute rhinitis? What are the signs and symptoms and serum labs that might indicate acute rhinitis?

Answer 2

– acute rhinitis: inflammation and irritation of nasal mucosa

– causes

• viral (rhinoviruses and other viruses)
  
  • s/s
    
    • red nasal mucosa
    • red turbinates
    • yellow/green nasal discharge
  • labs
    
    • high lymphocyte levels
• allergies
  
  • s/s
    
    • grey nasal mucosa
    • grey turbinates
    • clear nasal discharge
  • labs
    
    • high eosinophil levels

Question 3

What is the indication for topical nasal decongestants? What is their action? What are some examples of topical nasal decongestants?

Answer 3

– indications

• relief of nasal congestion discomfort that accompanies the common cold, sinusitis, and allergic rhinitis

– actions

• decrease overproduction of secretions by vasoconstricting BVs in the upper respiratory tract
• sympathomimetic causing vasoconstriction
• results in less inflammation and edema of nasal membrane

– examples

• oxymetazoline (Afrin)
• phenylephrine (Coricidin)
• tetrahydrozoline (Tyzine)
• xylometazoline (Otrivin)

Question 4

What is asthma? What is significant about each asthma attack? What are some causes for asthma?

Answer 4

– asthma: hyperreactive airway disease of bronchioles; reversible airway constriction

– each attack leads to inflammatory changes, resulting in bronchial remodeling

• bronchial remodeling is the thickening of the bronchial walls as a result of chronic inflammation

– causes

• allergies
• occupational exopsure
• viral infections
• GERD (especially noctural asthma)
• exercise-induced

Question 5

What are the 4 classifications of asthma, and how do pts present for each?

Answer 5

1. mild intermittent
   
   • symptoms occurs < 2x/week
   • attacks are brief
   • FEV1 > 80% of normal during attacks
2. mild persistent
   
   • symptoms occur > 2x/week but not daily
   • FEV1 = greater than or equal to 80% of normal during attacks
3. moderate persistent
   
   • daily symptoms
   • daily quick-relief inhaler
   • attacks 2+x/week
   • 60% < FEV1 < 80% of normal
   • FEV1/FVC ratio reduced by 5%
4. severe persistent
   
   • continuous symptoms
   • FEV1 < 60% of normal
   • FEV1/FVC ratio reduced by > 5%

Question 6

What are the 2 categories of asthma medications?

Answer 6

1. maintenance:
   
   • long-acting bronchodilators
   • anti-inflammatory corticosteroids
2. rescue:
   
   • short-acting bronchodilators

Question 7

What is a pulmonary embolism? Where do these originate from? How do pts with PE present? Why is it dangerous? What are some interventions?

Answer 7

– pulmonary embolism: clot that has travelled and lodged into pulmonary arterial circulation, obstructing blood flow to the lung

– can originate from DVTs or arterial thrombi

– presentation is vague and can occur without warning

– dangerous because can be fatal

– interventions

• anticoagulants
• antithrombolytics (clot busters)
• inferior vena cava filter

Question 8

What is obstructive sleep apnea? What are some signs and symptoms? What are some risk factors? What are some things that could exacerbate symptoms?

Answer 8

– obstructive sleep apnea: when the muscles in the back of your throat relax too much during sleep and interfere with normal breathing

– s/s

• loud snoring
• choking/gasping during sleep
• unrestful sleep
• daytime sleepiness

– risk factors

• obesity
• nasal blockage
• airway anatomy

– exacerbating factors

• alcohol
• sedative-hypnotic medications

Question 9

What is sleep disordered breathing? What are some signs and symptoms? How is it diagnosed? What are some interventions?

Answer 9

– sleep disordered breathing: syndrome of upper airway dysfunction during sleep due to upper airway resistance and pharyngeal collapsibility

– s/s

• snoring
• increased respiratory effort

– diagnosed with a polysomnography (sleep study)

– interventions

• behavioral changes
• CPAP (continuous positive airway pressure)
  
  • prevents airway closing
• oral appliance
  
  • pulls tongue forward to prevent obstruction
• surgery
  
  • opens airway structures

Question 10

What is acute bronchitis? What are some signs and symptoms?

Answer 10

– acute bronchitis: inflammation of the bronchial tubes caused by viral infection

– s/s

• usually begins with a common cold
• sore throat
• nasal discharge
• muscle aches
• fever
• persistent cough
  
  • becomes prominent as the disease progresses
  • can last 10 - 20 days
• sputum production
  
  • clear/yellow/green/blood-tinged
  • color not indicative of bacterial/viral infection
• rhonchi and wheezes

Question 11

How is acute bronchitis diagnosed? What are some interventions?

Answer 11

– diagnosed with

• symptomatology
• sputum culture

– interventions

• broad spectrum antibiotics
• expectorant medications
  
  • cough meds that help relieve phlegm from the airways
• mucolytic agents
• bronchodilators
• cough suppressants at night

Question 12

What is rickets, and what causes it? What population typically gets rickets?

Answer 12

– rickets: a disease of the softening and weakening of the bones

– caused by lack of vitamin D, calcium, phosphorus, and sunlight

• reduced vitamin D decreases calcium absorption
• when serum calcium levels fall, PTH is secreted which pulls calcium from the bones, stimulating bone breakdown

– population = children, mostly infants 4 - 12 months old

• especially children with malabsorption symptoms or ESRD

Question 13

What are some risk factors of rickets? What are some signs and symptoms?

Answer 13

– risk factors:

• lactose intolerance
• exclusive breastfeeding
• malabsorption
• malnutrition

– s/s:

• malformation of bones
• protrusion of sternum
• varus deformity of the legs (bowing)
• costochondral swelling (swelling of intercostal cartilage)
• delay in fontanelle closure
• delay in tooth development

Question 14

What are the 2 kinds of osteoporosis, and how do they differ? How do hormones play a role in osteoporosis?

Answer 14

– primary: weak and brittle bones caused by natural aging, pathological processes such as

• prolonged negative calcium balance
• poor dietary habits
• lack of weight-bearing exercises
• lack of daily exposure to sunlight

– secondary: weak and brittle bones caused by underlying medical conditions or use of certain medications such as

• hyperparathyroidism
• corticosteroids

– hormones play a role in bone mineral density (BMD)

• estrogen slows osteoclast activity (responsible for degrading bone to start bone remodeling)
  
  • postmenopausal women
  • female triad (menstrual dysfunction, low energy availability, and decreased BMD)
    
    • amenorrhea
    • decreased body weight
    • excessive exercise

Question 15

How is osteoporosis diagnosed?

Answer 15

• dual energy x-ray absorptiometry (DEXA) = gold standard
  
  • measures BMD
  • compares BMD with reference population of healthy adults (30 years of age)
  • reported as a T score
• X-rays
  
  • do not show osteoporosis until bone loss is 40+%
• blood tests
  
  • PTH
  • estradiol
  • osteocalcin
    
    • protein in bone
    • high levels indicate bone breakdown

Question 16

What is degenerative disc disease (DDD)? What are some signs and symptoms? Which regions are most commonly affected?

Answer 16

– degenerative disc disease: condition where a damaged spinal disc causes pain; vertebral disc distortions compromise spinal nerves

–s/s:

• pain in lower back that radiates down back of leg (sciatica)
• pain on buttocks or thighs
• pain that worsens when sitting, bending, lifting, or twisting
• pain that is minimized when walking, changing positions, or lying down
• numbness, tingling, or weakness in legs
• foot drop
  
  • difficulty lifting the front part of the foot
  • top of the foot might drag on the ground when you walk
• motor weakness
• neuropathy

– regions:

• cervical
• lumbar
• L4, L5, and S1 are the most commonly affected

Question 17

What is lyme disease? What is the characteristic sign of lyme disease? How do pts with lyme disease often present?

Answer 17

– lyme disease: a disease caused by Borrelia burgdorferi

– characteristic sign = erythema migrans (bull’s-eye rash)

– presentations:

• bacteria disseminates throughout the body infecting
  
  • skin
  • heart
  • joints
  • eyes
  • CNS
  • peripheral nerves
• arthralgia (joint pain)
• myalgia (muscle pain)
• fatigue
• h/a

Question 18

What are the 3 stages of lyme disease?

Answer 18

1. early localized – 3 - 30 days post-bite
   
   • most common stage of presentation
   • fever
   • myalgia
   • arthralgia
   • erythema migrans
   • lymphadenopathy (swollen lymph nodes)
2. early disseminated – 3 - 12 weeks post-bite
   
   • vague, generalized symptoms
     
     • h/a
   • lymphocytic meningitis
     
     • neck pain
   • cranial neuritis (inflammation of cranial nerve)
     
     • paralysis of nervous system
   • carditis ocular involvement (endocarditis – bacteria enters bloodstream and heart; causing ocular complications)
     
     • unilateral blindness
3. late disseminated – months - years post-bite
   
   • severe joint pain and swelling
   • CNS involvement
   • polyradiculopathy symptoms (damage to multiple nerves)
     
     • nerve pain

Question 19

What are some interventions for lyme disease?

Answer 19

• doxycycline
  
  • for those with a tick bite living in an endemic lyme disease area = single prophylactic dose
  • for those presenting with early localized or early disseminated stages of lyme disease = 21-day course

Question 20

What is post-lyme disease syndrome?

Answer 20

syndrome that results after a pt has completed antibiotic therapy and they continue to display symptoms of lyme disease

Question 21

What is gout? Which joints are most affected? What is the difference between primary and secondary forms?

Answer 21

– gout: a type of inflammatory arthritis that usually affects one joint at a time; deposits of uric acid and urate salts in tissues and on articular surfaces

• hyperuricemia causes inflammation
• tophi: uric acid crystals deposited in subcutaneous tissue

– joints typically affected = first metatarsal

• podagra: acute inflammation of metatarsophalangeal joint of the great toe

– primary gout: gout caused by a metabolic disorder that impacts excretion of uric acid

– secondary gout: gout caused by another disorder

• obesity
• lead exposure
• medications

Question 22

What are some signs and symptoms of gout? What are some risk factors?

Answer 22

– s/s:

• redness
• warmth
• swelling of joint
• discomfort in the early morning or at night

– risk factors:

• high-meat diet
  
  • uric acid is found in purines
• high alcohol consumption
• obesity
• yo-yo dieting
• family hx of gout
• chemotherapy that causes cellular distruction
• medication

Question 23

What is chalazion? What are some signs and symptoms? What are some interventions?

Answer 23

– chalazion: blockage of meibomian gland (glands where the eyelashes are found)

– s/s:

• eyelid tenderness
• painful swelling of eyelid
• sensitivity to light

– interventions:

• warm compress
• steroid injection
• surgical excision

Question 24

What is conjunctivitis? What are some causes? What are some signs and symptoms?

Answer 24

– conjunctivitis: pink eye; easily transmitted inflammation of the bulbar conjunctiva (covers the sclera) and palpebral conjunctiva (lines eyelids)

– causes:

• viruses
  
  • Herpes zoster – can also cause keratitis
  • watery drainage
• bacteria
  
  • mucopurulent exudate (fluid with mucus and pus)
• fungi
• allergies
• chemicals

– s/s:

• itchy eyes
• red and swollen eyes
• discharge may be present

Question 25

What are cataracts? What causes cataracts? What is the difference between senile cataracts and congenital cataracts?

Answer 25

-- **cataracts:** clouding of the lens -- caused by excessive growth of epithelial layer of the lens -- **senile cataracts:** due to * advancing age * smoking * obesity * diabetes * exposure to UV light -- **congenital cataracts:** develop in fetus due to infection such as * rubella * syphilis * cytomegalovirus (CMV) * toxoplasmosis

Question 26

What is a corneal abrasion? How long do they take to heal? Which population is more likely to get corneal abrasions?

Answer 26

-- **corneal abrasion:** damage of epithelial surface of the cornea * most common type of eye injury -- usually heal within 24 hours -- population = contact lens wearers

Question 27

What are some signs and symptoms of corneal abrasion? What are some diagnostic tests? What are some interventions?

Answer 27

-- s/s: * sense of foreign body in eye * gritty eye * photophobia -- diagnostic tests: * slit lamp examination can visualize defect in cornea -- interventions: * antibiotic ointments prevent infection

Question 28

What is the difference between myopia, hyperopia, and presbyopia?

Answer 28

-- **myopia:** nearsightedness * eyeball becomes elongated and images become focused in front of the retina * can see closer objects better -- **hyperopia:** farsightedness * eyeball becomes shortened and images become focused behind retina * can see objects further away better -- **presbyopia:** poor eyesight due to aging * the lens becomes less elastic * begins around age 40

Question 29

What is an astigmatism? What kind of corrective lenses are used for myopia, hyperopia, and astigmatism?

Answer 29

-- **astigmatism:** poor vision due to irregularly shaped lens or cornea * causes light to be improperly focused -- corrective lenses: * myopia = concave lenses * hyperopia = convex lenses * astigmatism = cylindrically curved lenses

Question 30

What is glaucoma? What causes it? What are the 2 types of glaucoma?

Answer 30

-- **glaucoma:** an eye condition that results from increased pressure on the optic nerve that may result in blindness * "silent thief of sight" -- progression is gradual -- caused by elevated intraocular pressure -- 2 types: * primary open-angle glaucoma (POAG) * 90% of glaucoma pts * silent, slow progression * acute angle-closure glaucoma (AACG) * 10% of glaucoma pts * occurs suddenly * emergency

Question 31

Describe the pathophysiology of POAG.

Answer 31

* drainage of aqueous fluid from the anterior chamber is compromised due to changes in * ciliary muscle * trabecular meshwork * canal of Schlemm * increased pressure on the retina and optic nerve due to inability of ocular fluid to drain * optic cup enlarges -- elevated IOP not the only factor that causes glaucoma -- pathophysiology not completely understood

Question 32

What are some risk factors for glaucoma?

Answer 32

* age 40+ * ethnicity * hx of migraine h/a * cardiovascular disease

Question 33

How is glaucoma diagnosed? What are some interventions?

Answer 33

-- diagnosis: * fundoscopic exam (visualization of the retina) * increase optic cup to optic disc -- interventions: * reduce IOP * decrease aqueous fluid production * increase aqueous fluid outflow * drugs * topical eye medications * oral medications * surgeries * laser procedures * incisional surgery

Question 34

What is otitis media? What causes it? Which population experiences it more frequently? How is it diagnosed?

Answer 34

-- **otitis media:** infection of the middle ear -- caused by upper respiratory infections * *Strep. pneumoniae* * *H. influenzae* -- population = children * due to shorter, wider, more horizontal eustachian tubes -- diagnosed: * pneumatic otoscope * decreased movement of tympanic membrane * reddened tympanic membrane

Question 35

What are some signs and symptoms of otitis media? What are some interventions?

Answer 35

-- s/s: * ear tugging * poor feeding * irritability * tympanic membrane rupture -- interventions: * tympanotomy * incision in tympanic membrane to promote drainage

Question 36

How common is hypertension? What are some risk factors?

Answer 36

-- hypertension occurs in 1/3 adults in the US -- risk factors: * age * African American ethnicity * obesity * family hx * DM * tobacco use * stress * high salt diet * excessive alcohol intake * hypersensitivity to angiotensin II * high renin secretor

Question 37

What is an aneurysm? How do aneurysms present?

Answer 37

-- **aneurysm:** a bulge in a blood vessel due to weakness in the vessel wall -- presentation depends on size, location, and integrity * may be missed until it ruptures * **AAA:** * abdominal or back pain * N/V due to compressed organs * may see pulsatile mass * may hear bruit * abrupt onset of severe constant back, flank, or abdominal pain if rupture occurs * do NOT deep palpate the abdomen * **cerebral aneurysm:** * usually silent * subarachnoid hemorrhage if rupture occurs

Question 38

What is peripheral arterial disease? How do you assess for PAD?

Answer 38

-- **peripheral arterial disease (PAD):** narrowing or blockage of arteries that carry blood from the heart to the legs -- assessments: * examine for signs of arteriosclerosis and atherosclerosis * HTN * hyperlipidemia * DM * CAD * MI * assess for symptoms: * pain and numbness with exertion * alleviation of pain and numbness with rest * examine for: * diminished/absent pulses * palpable coolness * paresthesia (pins and needles) * pallor * sensation * moving distal to proximal

Question 39

Describe the effect of glucose on arteries.

Answer 39

* glucose injures endothelial cells * glycosylation (AKA glycation) due to glucose binding to lipids and proteins, changing their structure * advanced glycosylation end products (AGEs) are formed * inflammation and plaque formation may result * AGE's increase endothelin release, leading to vasoconstriction -- this is why DM is a risk factor for CAD

Question 40

Other than glucose, what factors affect arteries?

Answer 40

* free radicals * damage cell membrane of endothelial cells, causing inflammation * nicotine * potent vasoconstrictor, especially in coronary arteries * increase BP * activates SNS * homocysteine * damages endothelial linings * vitamin B12 and folic acid breakdown homocysteine * deficiencies in these vitamins can cause a build up of homocysteine

Question 41

What is Kawasaki's disease? Which population experiences Kawasaki's disease more frequently? Which part of the body does it predominantly affect? What are the signs and symptoms? What are the 4 stages?

Answer 41

-- **Kawasaki's disease:** inflammation in the walls of some blood vessels of the body -- population = children * usually associated with infections -- predominantly affects coronary arteries which may lead to MI and possibly death -- s/s: * persistent fever -- 4 stages: 1. acute 2. subacute 3. convalescent 4. recovering

Question 42

How is Kawasaki's disease diagnosed? What are some interventions?

Answer 42

-- diagnosed: * echocardiogram = gold standard * lab tests -- not specific * elevated CRP * elevated ESR * elevated alpha-1 trypsin -- interventions: * drugs: * IV immunoglobulin * aspirin

Question 43

Describe the pathophysiology of heart failure.

Answer 43

* increased preload fills the heart * weakened heart cannot adequately pump excess blood * excessive filling overtaxes ventricular fibers, leading to decreased contractability * stroke volume and cardiac output decrease

Question 44

What causes heart failure?

Answer 44

* ischemic heart disease * heart tissue becomes compromised * unable to generate adequate pressure * chronic hypertension leading to left ventricular hypertrophy * coronary circulation is unable to meet demand * **restrictive cardiomyopathy:** less filling space due to enlarged left ventricle * cor pulmonale * right sided heart failure due to pulmonary issues * COPD-hypoxia-pulmonary vasoconstriction results in increased workload on right side of heart * pulmonary hypertension causes increased resistance and increased workload on the right ventricle

Question 45

What is deep venous thromboemoblism (DVT)? Why are DVTs important? What is Virchow's triad?

Answer 45

-- **deep venous thromboembolism (DVT):** encompasses both DVT and pulmonary embolism (PE) -- important because hospital admissions for DVT are increasing, likely due to greater sensitivity to tests -- easier to detect -- **Virchow's triad:** 3 broad categories of factors that contribute to thrombosis * venous stasis * vascular damage * hypercoagulability

Question 46

What are the signs and symptoms of DVT?

Answer 46

* unilateral leg pain * redness * ropiness * tenderness * warmth over vein * edema * positive Homan's sign * pain with dorsiflexion of foot * look for Virchow's triad

Question 47

What is chronic venous insufficiency (CVI)? What is the most common cause of CVI? What are some risk factors?

Answer 47

-- **chronic venous insufficiency (CVI):** inability of blood in veins to return to the heart from the legs -- most common cause = damage to valves in deep leg veins -- risk factors: * hx of trauma * obesity * pregnancy * prolonged standing

Question 48

What are the signs and symptoms of CVI?

Answer 48

* shiny skin * dusky discoloration * edema * poor healing * reduced/absent hair distribution * stasis dermatitis * circumferential dusky discoloration noted on lower extremity * caused by build up of hemosiderin

Question 49

What are some interventions for CVI?

Answer 49

* gradient compression stockings * pneumatic compression devices * drugs * anticoagulants * antiplatelets * catheter-delivered thrombolytic agents * elevation of legs throughout the day * surgeries -- venoablation to remove major reflux pathways * sclerotherapy * radio frequency ablation (RFA) * endovenous laser therapy (EVLT)

Question 50

What are varicose veins? Where are these most likely to appear? What causes varicose veins? What are some risk factors?

Answer 50

-- **varicose veins:** twisted, enlarged veins -- most likely to appear in superficial veins -- caused by high pressure within superficial veins that weaken valves * pressure is increased by prolonged standing or sitting, pregnancy, and obesity -- risk factors: * increased age * women

Question 51

What are ACE inhibitors? What is their mechanism of action? What are some indications? What are some examples of ACE inhibitors?

Answer 51

-- **ACE inhibitors:** angiotensin-converting-enzyme inhibitor; vasodilator -- mechanism of action: * prevents conversion of angiotensin I into angiotensin II (which stimulates vasoconstriction) * decreases BP * decreases aldosterone production * increases serum potassium * promotes sodium and water excretion -- indications: * treatment of * HTN * CHF * diabetic neuropathy * left ventricular dysfunction after an MI -- -pril medications: * benazepril (Lotensin) * captopril (Capoten) * enalapril (Vasotec) * lisinopril (Prinivil, Zestril) * **enalaprilat** (generic)