NURS 660 / NURS660 Exam 1 V2 | 2026/2027 Latest Update | Psychopharmacology & Advanced Mental Health | Verified Questions & Answers | 100% Correct | Maryville University

NURS 660 / NURS660 Exam 1 V2 | 2026/2027 Latest Update | Psychopharmacology & Advanced Mental Health | Verified Questions & Answers | 100% Correct | Maryville University Q: What is the most important differential to rule out in postmenopausal bleeding? Answer Cancer (especially endometrial) Q: An average cycle is how many days? Answer 28 days Range 21-35 days/3-5 weeks Q: How long does an average cycle last and how much blood is typically lost? Answer 4-6 days 30 mL (not typically measured, upper limit of normal 6-80) Q: Amenorrhea is defined as Answer Absence of menses 6 months If 6 months, this is just irregular menstrual bleeding and not actual amenorrhea Q: Define oligomenorrhea Answer Bleeding at an interval 35 days Q: Define menorrhagia Answer Excessive or prolonged menstural bleeding occurring at regular intervals 80 cc or 7 days Q: Define polymenorrhea Answer Bleeding at an interval 21 days Q: Differentiate between ovulatory and anovulatory bleeding. Answer Ovulatory bleeding is cyclic bleeding accompanied by cyclic signs of ovulation (tender breasts, cramping, pain) aka typical menstrual bleeding Anovulatory bleeding is unpredictable, non-cyclic bleeding that is variable in flow and duration. There are no signs of ovulation. Q: What age groups are anovulatory bleeding not uncommon in? Answer Perimenopausal Pre-teen Q: What are some differentials to consider with pregnancy related AUB? Answer Spontaneous abortion, ectopic pregnancy, placental previa (not attached to the fundus), placenta abruptio (detaching, emergency), trophoblastic disease, childbirth complications Q: What are some medications that can cause irregular bleeding? Herbals? Answer Anticoagulants, SSRIs/antipsychotics (especially Lexapro), corticosteroids, hormonal medications, IUD, tamoxifen Also some herbals like ginseng, gingko, soy, black cohosh Q: Tamoxifen has what effects on estrogen? Answer Blocks estrogen at the breast but has a positive effect on uterus which can increase endometrial cancer risk and therefore create AUB Q: Name some systemic diseases that can cause AUB. Answer thyroid disease (both hypo and hyper) PCOS Coagulopathies Hepatic disease Pituitary adenoma Hypothalamic suppression (common in athletes due to low adipose) Q: In a woman who is not menopausal, what needs to be ruled out before investigating other causes of AUB? Answer pregnancy always Q: Why is it important to assess the size, contour, and tenderness of the uterus when doing a physical exam for someone with AUB? Answer rule out ectopic pregnancy, fibroids that you may be able to palpate Q: What lab are you going to make sure to add for a woman who reports she is reporting she is changing her pad or tampon multiple times in an hour? Answer Bleeding studies: H/H, platelet count, PT, PTT May want to consider factor VIII, von Willebrand factor antigen (referral) Q: A patient with AUB is also reporting nipple discharge. What is your top differential and what lab do you want to order? Answer Prolactinoma Order prolactin level Q: Who requires an endometrial biopsy if experiencing AUB? Answer All women over age 35 or with risk factors of endometrial cancer Q: What is the initial pharmacologic management of SEVERE AUB in reproductive-age women? Answer High dose of estrogen during severe acute bleeding Oral: 35 mcg 1-4x/day for 7 days and then daily IV prn Q: What is something to consider when a patient is interested in endometrial ablation as treatment for their AUB? Answer Fertility Will not be able to have children after this procedure so it is not recommended in the case that she wants to reproduce Q: For a patient who is having chronic or less severe ANOVULATORY AUB, what would the pharmacologic management be? Answer OCPs can help by increasing the predictability of cycles as well as decreasing blood loss per cycle Provera is cyclic progesterone which can help manage flow or jump start cycles to get back on track Q: What is the use for the medication Provera? Answer By taking 5-10 mg daily for 5-10 days you can manage your flow OR jump start your cycle to get back on track (bleeding should start within a week after taking) Synthetic progesterone Q: For a patient who is having chronic or less severe OVULATORY AUB, what would the pharmacologic management be? Answer Basically what you would think of to treat a bad period: NSAIDs before/during cycle to decrease prostaglandins and hopefully reduce cycle If patient wants to try a progesterone IUD like Mirena to decrease cycles/stop cycles Q: A woman with postmenopausal bleeding comes to your office. She has been taking hormone therapy. What is something you want to know to help determine cancer risk? Answer How long she has been on the therapy AUB cannot be diagnosed until the bleeding has been present for 6 months to 1 year IF she's been on it 6 months (or if she were to not be on hormonal therapy) -- r/o endometrial cancer Q: What is the initial workup for postmenopausal bleeding? Answer Transvaginal US can be done BUT Endometrial biopsy is more specific/sensitive so should probably just go straight to that Q: What endometrial stripe would be concerning in a postmenopausal woman? Why? What is the next step? Answer 5mm is concerning for potential endometrial cancer and requires biopsy Postmenopausal women should not have estrogen production which therefore means they should have a thin stripe Biopsy is next step to evaluate for endometrial cancer Q: Your postmenopausal patient's transvaginal US was normal but their AUB persists with no explanation. What is the next step? Answer Continue the workup and do not rule out endometrial cancer. May need D&C, hyersteroscopy w/ biopsy Q: What is the gold standard for endometrial cancer diagnosis? Answer D&C Q: Describe the differences between a D&C and biopsy for endometrial cancer diagnosis. Answer D&C is gold standard BUT requires anesthesia/sedation and is a scheduled procedure. Biopsy can be performed in the office with no sedation BUT is not the gold standard because you can biopsy the wrong spot or miss the cancer and have a false reassuring result. Q: How many months does pelvic pain need to be present to be considered chronic? Answer 6 months Q: What is the most common missed contributor to pelvic pain? Answer IBS Q: What is some important education for an endometriosis patient who is interested in pre sacral neuroectomy? Answer This procedure only works well for midline pain, not pain over the ovaries which is where many endometriosis patients have pain Q: What is a potential side effect from adhesiolysis surgery? Answer may increase scar tissue and therefore worsen adhesions, having opposite effect 3 key symptoms of endometriosis Answer Pain with sex Pain with defecation Pain with menses What is the pathophysiology of endometriosis? Answer unknown etiology but it occurs when there is endometrial tissue outside of the uterus that acts the same as the tissue inside the uterus, so it sheds and creates pain during cycles What is required for a true endometriosis diagnosis? Answer visualization of tissue via laproscopy What is the number 1 theory of what causes endometriosis? Retrograde menstruation -- shed uterine tissue exits through os but some backflows via tubes into pelvic cavity What is the rating system for endometriosis like? Rated from stage 1 which is minimal to stage IV which is severe What is adenomyosis? Endometriosis tissue inside of the uterine wall Can change the shape of uterus, causes pain with palpation What is the only definitive treatment for endometriosis? Removal of all reproductive organs What is a goal of pharmacologic treatment for endometriosis? decrease cycles less cycles -- less pain for woman Danazol is used for what? What are some side effects? Suppresses LH and FSH which can in turn stop periods Essentially a weak androgen Can have side effects like weight gain, masculinizations, vocal changes (can be permanent) When choosing an OCP for a patient with endometriosis, what do you want to consider regarding estrogen content? Choose OCPs with the least estrogenic effects with maximum endrogenic effects This will minimize the building of the lining Describes the uses and side effects of progestins for endometriosis. Can be taken long term for pain control unlike GnRH-A and are relatively inexpensive BUT can cause AUB, weight gain, amenorrhea (Which is not always the goal) How do GNRH-A work for endometriosis? How long can you use? What is "add back therapy"? GnRH-A initially stimulate FSH/LH release and down-regulates GnRH receptors to cause a pseudomenopause (so much stimulation that the anterior pituitary 'ignores' GnRH) Add back therapy is taking estrogen with it as well which can lengthen the amount of time patients can be on it. Should be a low dose estrogen Without add back: 6 months With add back: 1 year What is the main factor to consider when deciding how long someone can be on Orlissa? Pain with sex: 6 months max No pain with sex: 24 months Reason: if pain with sex, higher dosage (BID) A patient with endometriosis is having new, sharp pain over her RLQ. What might you suspect? Appendicitis Very common as tissue often lands on appendix and causes inflammation The core cause of PCOS is what body system? endocrine, not gynecological Stein-Leventhal syndrome includes what triad of symptoms Amenorrhea, obesity, hirsutism Name the 4 requirements for PCOS diagnosis 1. Ovarian/menstrual dysfunction 2. Clinical/biochemical evidence of increased androgens 3. Ultrasound showing polycystic ovaries 4. Insulin resistance/metabolic syndrome What assessments in a teen with delayed onset or irregular menses would make you suspicious for PCOS? This as well as significant acne, hirsutism, other signs of masculinity Which hormone is more of the issue with PCOS? FSH or LH? LH They typically do not have issues with folicles being stimulated (will see several developed on US) but do not have a strong enough LH surge to trigger ovulation however, their LH will be high because it's trying to get something to happen What number of periods per year would be suspicious for PCOS? 8/year Describe the lab work you would see in a PCOS patient most likely for these values Testosterone, glucose, insulin, FSH, LH Increased T Increased glu (can also be low, really anything altered would be expected) Increased insulin normal FSH Increased LH In regards to PCOS, does BMI/obesity matter regarding insulin resistance? No Both obese and non-obese will have hyper-insulinemic insulin resistance Obese just are at risk for type 2 as well which could be causing this as well What is more accurate in assessing a PCOS patient's glucose? Oral glucose tolerance test Finger sticks are often normal What does decreased SHBG production mean for PCOS patients? Less binding of testosterone/inactivation--more testosterone circulating and higher androgen What are the diagnostic requirements for metabolic syndrome? 3/5 of the following Waist circumference 36 TGs 150 Decreased HDL 50 Elevated BP fasting glu 100 The risk of a PCOS patient taking oral ovulation meds is what? Hyperstimulation -- multiple gestation pregnancy What is the reason for why PCOS women have high incidence of pregnancy loss? Insulin resistance suppresses glycodelin which is required for maintaining pregnancy What medication should be prescribed to PCOS women to take during the 1st trimester of pregnancy? Metformin Reduces risk of pregnancy loss when taken in the 1st trimester only What are some skin manifestations you may see in a PCOS patient? acanthosis nigricans due to hyperinsulinemia acne, hirsutism, and alopecia due to hyperandrogenism In order to assess a patient with PCOS's risk for heart disease, what are some labs/values that need to be monitored? OGTT for glucose (DM?) BP (hypertension?) Lipid profile (dyslipidemia?) Describe the benefit of spironolactone in treating PCOS. It is a diuretic that can decrease BP but also has the extra benefit of decreasing testosterone so they may see a benefit in features like acne Why would Yaz be a good option for a PCOS patient? What is the medication's benefit? Yaz is a birth control that contains spironolactone. BC: controls estrogen and progestin and controls uterine lining, gives ovaries a rest Spironolactone: diuretic with anti-testosterone effects Name two medications that are typically used to treat males but have offlabel use for PCOS. Antiandrogen: flutamide (usually used for prostate cancer) Alpha reductase inhibitors: finasteride (usually used for BPH) When is surgical therapy an option for PCOS patients? What are some of the surgeries available? Surgery is last resort after all other options have been exhausted: nutrition referral, weight management, medications Can do a wedge resection (not favored d/t scar tissue), ovarian drilling (cauterization of portion of ovaries, mixed reviews, better results in younger patients with a normal BMI), or bariatric surgery to decrease adipose tissue and therefore decrease insulin What is the underlying pathophysiological reason for basically all of PCOS's manifestations? hyperinsulinemia!!! endocrine problem Hyperinsulinemia -- low SHGB, high androgens, disordered LH/FSH -- hyperandrogenism and anovulation -- PCOS What is the largest non-pharmacological treatment that a PCOS patient can do that will help restore ovulation/ovarian function? lose weight (even a little) How long should baby blues last to be truly considered baby blues? 2 weeks if prolonged beyond 2 weeks, more likely PPD When is the onset for PPD? variable can be within 24 hours or months postpartum, cannot rule it out Name some symptoms of PPD. Hopelessness, helplessness, persistent sadness, irritability, low self-esteem, loss of pleasure in activities, mood changes, inability to adjust to role of motherhood, inability to concentrate, sleep/appetite disturbance some of these feelings are normal in the initial 2 week PP period to a degree as moms adjust, but should be able to adjust. Name some risk factors that predispose someone to getting PPD. Family or personal history of mood disorder Anxiety/depression during pregnancy Previous PPD Baby blues Child-care difficulties (for example, child with colic or other health issues) Marital conflict Stress life events Poor social support Lower educational status Lower socioeconomic status Assessing a woman's psychosocial health is key during their pregnancy, make sure you can anticipate risk When should you screen women for PPD? basically every time you see them preconception visit, prenatal intake and subsequent visits, postpartum exams, f/u visits, sick care or in ER, early intervention home visits, family planning visits, mother's visits for episodic care Describe the screening tool for PPD most commonly used and what score means what. Edinburgh Postnatal Depression Scale 0-8: low risk 9-11: additional f/u required (every 1-2 weeks until stable) 12+: immediate intervention, disregard reason for visit and focus on PPD A patient sitting in front of you is concerning to you for PPD. When you give her the Edinburgh Postnatal Depression scale, she only scores a 2. What should your next step be? These tools are just screening and should not be substituted for professional judgment. Investigate further, follow up frequently (or intervene now depending on how concerned you are). Do not use the screening tool as the end all be all. What is Zulresso? Black box warning? The only FDA approved medication for treatment of PPD However, is given scheduled IV and is restricted to only certain centers BBW: excessive sedation and sudden loss of consciousness What symptoms shown by a woman suffering from PPD is out of the FNP's scope of practice and should be referred immediately to psych? Psychosis-hallucinations, delusions Suicidal/homicidal ideations Differentiate between an unintended and intended pregnancy. Intended: desired at the time they occurred or were wanted sooner than they occurred Unintended: either one that occurred when a woman wanted to become pregnant in the future but not currently OR occurred when she did not ever want to be pregnant Name the 3 options currently available for emergency contraception. 1. Copper IUD 2. Ella 3. Plan b Name the window of use for the 3 types of emergency contraception After unprotected or inadequately protected intercourse: 1. Copper IUD: 5 days 2. Ella: 5 days 3: Plan B is technically 5 days but efficacy decreases after 3 Describe the BMI restrictions for emergency contraceptions. If using Ella, less effective if BMI 35 If using Plan B, less effective if BMI 25 and likely ineffective if BMI 30 Describe the MOA of Ella and Plan B. These pills essentially are just progestin (ella is a progestin agonist while plan b is straight up progestin) and therefore delay or inhibit ovulation. They do NOT harm an existing pregnancy (because progestin is actually beneficial for pregnancy) but will stop the sperm and egg from meeting by not allowing release of egg due to hormonal changes (shutting off GnRH feedback loop) Ella can also alter endometrial thickness if taken after to ovulation Name some common side effects of emergency contraception pills. Many similar to those of hormonal contraception: headache, abdominal pain, nausea, dysmenorrhea (heavier, more irregular, may be delayed), fatigue, dizziness Make sure to do patient teaching so they aren't concerned or anxious How does the Copper IUD act as emergency contraception? the same way it acts as long term birth control: creates an inflammatory reaction in the endometrium and prevents fertilization and implantation (NOT ovulation, sperm and egg still can meet but won't implant, decreased chance of meeting) Name the two most important factors in deciding a patient's prognosis with vulvar cancer. 1. Lymph node involvement 2. Primary lesion size Describe the etiology of vulvar cancer. NOT genetic 1. HPV-related (more common in young women) 2. Related to vulvar non-neoplastic epithelial disorders like Lichen's sclerosis, Paget's, squamous cell hyperplasia (typically 65+) Describe the symptoms of vulvar cancer. 50% = asymptomatic Other symptoms: vulvar lump/mass with a history of pruritus, vulvar bleeding/discharge/dysuria/pain, lesion (typically wart-like, can be raised or ulcerated and typically standalone) What is the definitive diagnosis for vulvar cancer? biopsy typically a punch biopsy is performed with local numbing agent What is the best prevention for vulvar cancer? to not get HPV so avoiding exposure (vaccine, smaller amounts of partners), not smoking (prolongs HPV) Your patient was treated for vulvar cancer 2 years ago and is here for her annual exam. You notice a lesion on her labia. What is the most likely cause? Reoccurrence Very common for reoccurrence of vulvar cancer w/i first 2 years, need to refer back to gyn onc patient needs to make sure she is having regular follow up during the initial 3 years post diagnosis Are condoms 100% effective in prevention of HPV? No spread by skin to skin genital contact (so could be the area not covered by penis) What is the most significant risk factor for development of invasive cervical cancer? Persistent infection with a high risk (esp. 16 and 18) HPV strain NOT the transient infections that clear up (patients will have a lot of anxiety) What is the latency period between HPV exposure and the development of cervical cancer? around 10-12 years coincides well with pap schedule What does SIL and CIN stand for and what (in general) are these terms describing? SIL: squamous intraepithelial lesions CIN: cervical intraepithelial lesions these are terms on a pap smear that refer to premalignant changes (can regress, progress, or persist) Your pap smear comes back with an ASCUS reading. What does this mean? What are some reasons it could say this? ASC-US: atypical squamous cells of undetermined significance Basically, they appear abnormal but unsure why. This could be for many reasons: HPV infection, symptom of benign growth, low hormonal levels. Requires more testing to definitively decide. Per the guidelines, how do you manage treatment for a woman whose pap smear comes back ASC-US? If 24 years, it is recommended to do HPV reflex testing. If that's positive, proceed with a colposcopy. Technically the guidelines say you can also wait 1 year but this is not preferred. If 24 years, it's recommended to not do any further testing and repeat pap in 1 year and go from there. If negative again, repeat again in 1 year from there and then can go back to routine if still negative. If positive at either the 1st 1 year f/u or the 2nd 1st year f/u, colpo. How should you manage an "unsatisfactory" cytology per the guidelines? Repeat cytology in 2-4 months If already known HPV positive, can progress to colpo immediately. What does LSIL mean on a cytology report? What could cause this? Low-grade squamous intraepithelial lesion (often CIN 1 or 2) Could be an HPV transient infection Per the guidelines, how do you manage a cytology report of LSIL? If 24, repeat cytology in 12 months. If negative/ASC-US/LSIL (so basically if the same or better), repeat again in 12 months. If worse (HSIL) -- colpo. If better the 1st check and worse the 2nd check, colpo. If pregnant, colpo. If 24, colpo is often immediately performed. The only exception is for the 30+ age group who get cotesting with HPV DNA, can defer 1 year and retest if LSIL with HPV negative. What does HSIL mean on a cytology report? What could be the cause? High-grade squamous intraepithelial lesion Typically means an HPV persistent infection Usually CIN 3 Management of HSIL per guidelines If 24: immediate colpo, will need frequent colpo and cytology every 6 months for up to 2 years If 24: immediate colpo or immediate loop electrosurgical excision Symptoms of cervical cancer Usually asymptomatic 80-90% do experience some sort of irregular bleeding (could be vaginal, postmenopausal, post coitus, irregular menses) When late: bladder obstruction, constipation, back pain, leg swelling What is the most common site for cervical cancer? around the os What does ASC-H mean on cytology? Atypical squamous cells Cannot rule out HSIL (worse than ASC-US) May be precursor to cancer if not treated Describe the three types of endometrial cancer. 1. Estrogen dependent (80%), due to exogenous or endogenous excess estrogen 2. Spontaneous neoplasm development (10%), often seen in multiparous normal weight women 3. Familial endometrial cancer, hereditary and often seen with Lynch syndrome Risk factors for endometrial cancer Estrogen therapy (esp unbalanced), Tamoxifen, early menarche, late menopause, inferility, nulliparity, obesity, chronic anovulation, diabetes, high fat diet, ovarian cancer, PCOS essentially anything that increases estrogen exposure What is the #1 symptom of endometrial cancer? Abnormal uterine bleeding ESPECIALLY in postmenopausal women Your patient is concerned they have endometrial cancer because they have had some irregular bleeding. On exam, you find an irregularly shaped uterus. What is your top differential? More likely fibroids as cancer rarely changes the size or contour of the uterus A pap smear comes back with AGUS. What are you worried about? AGUS (atypical glandular cells) is a concern that the patient may have endometrial cancer. They need referral and biopsy. What other cancers or syndromes require close monitoring for endometrial cancer? breast, ovarian, or Lynch syndrome Name a significant risk factor for ovarian cancer. advanced age (average age of diagnosis is 63) Name the early symptoms of ovarian cancer and why these contribute to the high mortality rate. Vague symptoms early in the disease process: abdominal bloating, discomfort, difficulty eating, early satiety So vague they are often missed A woman 50 is having bloating, abdominal discomfort. Per the text, what is the number of days per month of having these symptoms that would most concern you for ovarian cancer? 12 days a month for 12 months very concerning for ovarian cancer Describe some of the late symptoms of ovarian cancer. Anorexia, N/V, ascites, ABD or back pain, abd mass, pleural effusion Describe the use of CA-125 in ovarian cancer. Not helpful for initial diagnosis, not sensitive enough Can be helpful in monitoring their status though once ovarian cancer has been CONFIRMED NOT screening What can help reduce risk of ovarian cancer? Inhibiting ovulation (OCP usage, pregnancy, breast feeding) What might the treatment for ovarian cancer include? Bilateral salpingo-oopherectomy Paired with chemo if stage II or higher May also require debulking surgery When do majority of ovarian cancer reoccurrences occur? How can you monitor for this? within 1 year of initial treatment trend CA-125 and monitor for symptom of cramping abdominal pain Define infertility. A couple who has attempted to conceive (meaning usual amount of intercourse and no BC) for 1 year OR 6 months if female is 35 Who are some candidates for assisted reproductive technology? tubal factor (blockage in tubes that prevents egg and sperm from joining, often from a past infection or injury), endometriosis (inflammation can lead to ovarian or tubal damage), anovulation (PCOS or hypothalmic amenorrhea?), premature ovarian failure (decreased ovarian function at a young age), male factor (no sperm, low sperm count, or poor quality sperm), immunologic (common w/ lupus), unexplained infertility A patient with endometriosis is going to get a lap done to clean out some endometrial tissue. When should she plan on having her IVF done? immediately following the lap, much better chance of success since endometriosis will worsen again Those with PCOS undergoing infertility treatment will need a medication that has what hormone? Only FSH they usually have high levels of LH so they do not need a combination FSH/LH while other women would Name some medications that stimulate ovulation. Clomid Gonadotropins Describe the two main risks/complications of IVF/ART Ovarian hyperstimulation syndrome: can be dangerous but is not super common in IVF patients, rather those who are not being monitored with injection therapy. S/S: soreness, bloating, respiratory distress, may require paracentesis Multiple gestations-usually prevented by only transferring up to 2 embryos instead of many When would you expect a pregnant woman to start producing colostrum? around 16 weeks What hormone stimulates the mammary secretory epithelial cells to produce milk? prolactin When does breast milk supply switch from endocrine to autocrine? What does this mean? sometime during lactogenesis 2 (day 3-8 PP) This switches it to a supply and demand control rather than automatic What is a very important thing to consider may have occurred in a mom with a reduced milk supply? Retained placental fragments When should the first feed occur post partum? Vaginal: within the first 1-2 hours C/S: whenever mom is in recovery and able to do skin to skin ideally hold off on other interventions for about 1 hour until first feed has occurred (bath, vaccines, etc) Name some populations that may experience some issues with breast feeding. Diabetes may have hypoglycemia secondary to breastfeeding. Those who gave birth via C section may have a delay in their milk of about 24 hours. Those who had breast surgery should be okay unless it was cut in a certain way. PCOS/endometriosis can decrease supply. Those who experienced blood loss during birth will have a decreased supply. Describe what you would expect a baby to eat in the first 1-3 days of life as well as their output. Typically 8-12 times/24 hours (feeds increase from 2-10mL/feeding to 30-60mL/feeding by the end of the 3 days). Should pass meconium within first 24-48 hours Anticipate 1 wet, 1 dirty diaper day 1 2 wet, 2 dirty day 2 3 wet, 3 dirty day 3 (these are minimums) How much weight loss is normal in day 1-3 of life? 5-7% 8% is concerning Your patient is going back to work and will need to pump. What is the recommended pumping schedule? Pump as many times as you would feed to keep your supply the same. If you pump too little, supply will go down. Pump too much, oversupply and can lead to risks of clogged ducts or mastitis. Do not go 5 hours without pumping Wait until 3 weeks PP to start pumping (unless NICU baby or other unique circumstances) When is weaning recommended? at 6 months, can start baby led weaning and feeding baby what you eat, but milk is still main source of nutrition AAP recommends not weaning until 1 year, WHO 2 years How should you start to incorporate solid into baby's diet? build slowly to assess for allergies, consider mom and dad's allergies and be weary when baby tries always breast feed before offering solids or they may not want the solids and your supply can decrease What is the most common causative bacteria of UTIs? E. coli Describe the symptoms of cystitis as well as the pertinent negatives. Dysuria, frequency, urgency Pertinent negatives: no fever or CVA tenderness What is the difference between complicated and uncomplicated cystitis? Uncomplicated: patient is not pregnant, no recent antibiotic use (for any reason), no UTI within last 6 months, not immunocompromised, no signs of upper urinary tract infection Complicated is the opposite What is asymptomatic bacteriuria? What is the treatment recommendations? Bacteria is in the urine on UA but the patient has no s/s Book: only treat if preg Dr L: treat What are the s/s of pyelonephritis? Fever, chills, back pain, CVA tenderness, flank pain, as well as cystitis symptoms Can progress to hypotension and even shock Who should be hospitalized for pyelonephritis treatment? pregnant, vomiting, hypotensive, immunocompromised How many days of antibiotics will an uncomplicated pyelonephritis patient require? 10-14 days treat before culture returns What void is the most reliable for UTI evaluation? first AM void, more concentrated A woman is symptomatic but has a negative dipstick. What is the next step? Send the urine out for culture and/or microscopic urinalysis Also test for chlamydia/gonorrhea on the urine Still treat as if it's a UTI while the culture pends Why might a patient have a negative urinalysis but still have symptoms? Not all bacteria creates nitrates or it's too soon for them to be present What is the gold reference standard for diagnosis of a UTI? urine culture An untreated case of pyelonephritis can lead to CKD, HTN, AKI Describe the 3 antibiotics (and length of prescription) used for UTIs. Bactrim BID x 3-5 days Cipro BID x 3 days (no need for 7d) Macrobid/macrodantin BID x 7 days (higher resistance) Patient education for phenazopyridine Not a cure for the UTI so if they get Azo OTC they still need to get antibiotics Turns urine orange, may stain Describe some contributing factors to urinary incontinence. Fluid intake (lots of caffeine, alcohol, artificial sweeteners?) Constipation (pressure on abdomen) Habitual preventative emptying Race/family (increased in caucasian/european) Age 30 (also if 70, increased fall risk) pregnancy/childbirth BMI 35 Comorbidities (childhood enuresis, cig smoking, diuretics, DM, strokes, HTN) What muscle contracts to release urine? detrusor What population would you suspect the cause of their urinary incontinence is a weak urethra? Those who have leaking while coughing, bending, or reaching, especially if over 60 years old Name some behavioral interventions for urinary incontinence. Knack manuever (contract pelvic muscles just before and after an identified trigger) Kegal exercises (repetitive contractions of pelvic floor muscles, expect results in 1-3 months) Bladder training (contract pelvic floor muscles as urge suppression and distract to ignore urge) Reverse bladder retraining (pee on a schedule of every 3-4 hours until normalized urge sensations can be relied upon) Pharmacologic treatment for urinary incontinence Urge: anticholinergics (avoid in 70-lowest, shortest dose possible for others, due to side effects and potential cognitive issues) Stress: none specifically designated but some will prescribe pseudoephedrine or ephedrine to increase outlet resistance What is interstitial cystitis? What are the symptoms? Chronic condition involving bladder pressure, bladder pain, and sometimes pelvic pain Symptoms: vary person to person and may flare based on triggers like menstruation, sitting, exercise, sexual activity. Symptoms include: urinating more often and with smaller volumes, pain in the perineum, chronic pelvic pain, pain or discomfort while the bladder fills and relief after urinating, pain during sexual intercourse A patient with interstitial cystitis will show what on their urine culture? nothing typically clean Treatment of interstitial cystitis Includes PT, NSAIDS, TCAS, Elmiron, antihistamines, Uribel, Myrbetriq, nerve stimulation, surgery, etc Patient should avoid citric acid, spicy foods, coffee Describe the typical symptoms of renal calculi. Renal colic (severe, sudden flank pain over CVA that can radiate to the groin or testicles), n/v, hematuria, fever, chills, dysuria, vague abdominal pain (can be severe), restlessness What populations are at high risk for complications with kidney stones? pregnant, pediatric, renal pathologies, h/o kidney stones What pertinent negatives would help you rule out life threatening conditions in a patient who you suspect kidney stones? lack of peritoneal signs, nontender, nondistended abdomen What is the gold standard for diagnosis of renal calculi? Non-contrast CT What are some diagnostic labs you would want to order for kidney stones? CBC, CMP, uric acid, GFR, BUN Uric acid can help determine what type of stone UA w. culture In populations like pregnancy, pediatrics, or those who cannot have radiation, what may be the imaging preferred for renal calculi? US What is the treatment for most kidney stones? Typically 2-4L daily of hydration and watching for stone passage is sufficient, many will pass on their own If stone is 7-9mm or greater will probably refer Medications: NSAIDs or narcotics, possibly CCBs (nifedipine), alpha blockers-tamsulosin (may aid in relaxation of smooth muscle to allow stone to pass) What is the most common make up of a renal stone? Calcium When would you want to immediately refer or hospitalize a renal calculi patient? if they may require surgery (stones 7-9mm, esp once 10mm) Infection and nonobstructing stone or multiple Fever, chills, n/v Obstruction/hydronephrosis Anuria Intractable pain Serious bleeding, gross hematuria stone 5mm that does not pass History of stones Pregnancy CKD is a progressive decline of what? functioning nephrons (cell of the kidney responsible for filtration of blood, removal of waste, releasing hormones to regulate BP, balancing fluid, controlling RBC development) What are the two most common underlying diseases for CKD? HTN, DM Name some RFs for CKD age, heart disease, obesity, family history, NSAID abuse, cigarette smoking, collagen vascular disease like RA or SLE, AIDs, cirrhosis, multiple myeloma, PKD, alport syndrome Describe why frequent monitoring of kidney labs is important. Symptoms do not occur until function decline of 10-15%, need to catch before symptoms. Describe the early symptoms of CKD anorexia, lassitude/lack of energy, fatigability, weakness Describe the derm symptoms of CKD Pruritus, dry skin, uremic frost (2/2 uremic crystals developing on skin, causes pts to be pale), hyperpigmentation Describe the GI symptoms of CKD N/V, anorexia, hiccups, metallic taste at risk for electrolyte or acid base imbalances due to n/v Describe the neurological symptoms of CKD Confusion, muscle cramps/twitching/spasm, headaches, seizures, peripheral neuropathy or retinopathy, altered mental status, asterixis (tremor when hands are extended), coma Describe the psych symptoms of CKD Insomnia, fatigue, irritability, sexual dysfunction, depression, lability, suicidal ideation may have issues with holding down a job Describe the metabolic symptoms of CKD urine odor breath/sweat gout peripheral edema/ascites Describe the hematologic symptoms of CKD infection, bleeding, bruising Describe the CV symptoms of CKD SOA, crackles, pericardial rub, HTN, bounding pulse, tachycardia What is an important assessment for those with CKD regarding the renal arteries? listen for a bruit (+) bruit -- renal artery stenosis? How many months does someone need to have kidney damage or decreased function to be considered in CRF? /= 3 months What GFR corresponds with the following GFR stages? G1 G2 G3a G3b G4 G5 G1=/=90 (normal or high kidney function) G2=60-89 (mildly decreased) G3a=45-59 (mildly to moderately decreased) G3b=30-44 (moderately to severely decreased) G4=15-29 (severely decreased) G5=15 (kidney failure) What is the lab follow up for a patient who was just diagnosed with CKD? Get another set of labs 6 weeks after initial lab, then every 3-6 months If your first follow up lab on a CKD patient is rapidly decreased, what is your next step? if that 6 week f/u lab is rapidly decreasing, need to refer. need a nephrologist to weigh in due to rapid decline What is the lab(s) you want to monitor to track progression and stability of CKD? BMP with serum creatinine and eGFR What is a normal eGFR? 120 in women, 130 in men What is the creatinine clearance measuring and what are normal values? essentially how much of kidney is still working M: 1.13 W: 0.93 Describe what you would expect to see on a patient's blood chemistry with CKD for the following values. Vit D Ammonia Uric Acid Sulfate Potassium Phosphate Parathyroid hormone (PTH) Glucose Vit D: LOW Ammonia: HIGH Uric Acid: HIGH Sulfate: HIGH Potassium: HIGH Phosphate: HIGH Parathyroid hormone (PTH): HIGH Glucose: HIGH Describe what you would expect to see on a CKD patient's CBC. RBC HCT Platelets Immune response Bleeding Capillary fragility RBC: LOW (normocytic, normochromic anemia--nothing wrong with the RBCs, just less 2/2 decreased erythropoeitin) HCT: LOW PLTS: LOW Immune response: LOW Bleeding: INCREASED Capillary fragility: INCREASED If you wanted to r/o multiple myeloma as a cause for your patient's CKD, what lab would you want to order? serum protein electrophoresis What labs would help you r/o an autoimmune cause for your patient's CKD? ANA, complement What electrolyte would you expect to be high in an ESRD patient's urine? Sodium Describe the initial workup for ALL CRF patients. Renal ultrasound w/ Duplex doppler What do you do if the renal US is abnormal in your CKD patient? Further evaluation with a low dose contrasted renal CT What is the gold standard for diagnosing renal artery stenosis? renal angiography If contrast is contraindicated in your CKD patient, what imaging would you do instead? MRI/MRA What is your systolic BP goal for your renal patients? between 110-130 too low -- decreased kidney perfusion too high -- more work for kidneys, damage Describe what values of the following labs are very concerning and would warrant a referral. Creatinine BUN eGFR Cr around 12 BUN 100 eGFR 10 Diuretics are an important medication for CKD patients. What kind would be avoided? potassium sparing (aldactone/spironolactone) Describe the recommended protein intake for CKD patients. 0.6-0.8mg/kg/day no less, no more What is the caloric intake recommended for CKD patients? around 35-50 cal/kg/day Why might a CKD patient require hospitalization? Fluid volume excess/overload, hyperkalemia, infection, retractable HTN What are some findings that indicate your CKD patient needs to start dialysis? Pericarditis, diuretic-refractory fluid overload, medication resistant or worsening HTN, uremic syndrome w/ bleeding, neurological s/s, persistent n/v Describe some reasons for why you would refer your CKD patients. eGFR 30 autoimmune disease PKD (large) multiple myeloma evidence of rapid loss of kidney function single kidney with eGFR 60 young patients with no identifiable cause hyperkalemia, metabolic acidosis, erythropietin therapy required, etc resistant hypertension, recurrent/extensive stones pregnancy hereditary kidney disease difficult to manage 2/2 stuff like chemo When should you educate your CKD patients to immediately seek care? decreased UOP n/v/d, anything that can throw off electrolytes more Transient vs persistent hematuria Transient: one occasion Persistent: two or more consecutive occasions (if not consecutive, just transient) When is exercise induced hematuria a concern? if it persists 24 hours have them come back outside of that window and recheck UA What is the most concerning type of hematuria? gross (you can visibly see the blood in the urine, the urine is discolored vs just registering as positive for blood on a UA or microscopic) What is the most common cause of hematuria in adults? UTI What is asymptomatic microscopic hematuria? urine does not appear to be bloody but blood is present on UA Name some risk factors for asymptomatic microscopic hematuria? smoking, occupational exposures (dyes rubber), analgesic abuse, chronic infection esp with stones, recent URI men w/ prostate issues have issues too Your patient has painless hematuria. What other symptom would make you highly suspicious of a malignancy? unexpected or unexplained weight loss What patient with gross hematuria would be especially concerning? The patient who was a male 50 and a smoker low threshold for referral If a patient is having microsopic hematuria, what are important things to look for on your physical exam? make sure to look at the external genitalia like the vaginal or the head of the penis and make sure that is not the source of the blood rather than the GU tract Your patient presenting with hematuria also has HTN, weight gain, and edema. What do you suspect? a glomerular disease Your patient had hematuria and was treated for a UTI. On follow up, they are still having hematuria. Should you be concerned or wait? be concerned and continue to evaluate if not treated like a UTI, may not be a UTI What patient population is expected to have intermittent microscopic hematuria? history of bladder cancer Your patient is on warfarin due to their a fib. Their UA shows microscopic blood. Is this an expected finding? no, work up anticoags should not cause hematuria Hypospadias means the urethral meatus is where on the penis? Ventral (underside) and proximal Hypospadias is occasionally hand in hand with what two conditions? cryptorchidism (ensure to do a scrotal exam in these patients) intersex Epispadias means the meatus is where on the penis? Dorsal The more ___ the urethral meatus is on the penis, the more concerning. Proximal the closer to the pubic bone, the higher the incidence of bladder issues or incontinence What procedure should not be performed in unrepaired hypospadias or epispadias patients? circumcision will likely need that tissue for repair The majority of undescended testicles will resolve when? within 3 months refer after this point as referrals are recommended to occur before 6 months What is a major risk factor for cryptorchidism? prematurity/low birth weight When does surgical intervention of cryptorchidism occur? what is the goal? between 9-15 months goal: reduce malignancy risk and improve fertility What is the non-surgical treatment of cryptorchidism? IM HcG Differentiate between direct and indirect inguinal hernias. Direct are often a result of straining or pressure and are not something you are born with. Indirect are congenital and consist of herniation through internal inguinal ring. They can be complete (into the scrotum) or incomplete (remaining in the canal). Describe reducible vs strangulated when discussing hernias. Which is an emergency? Reducible means you are able to push it back into the right spot when applying pressure strangulated aka non-reducible means it does not return to its spot when pressure is applied. this can lead to ischemia and tissue death When are inguinal hernias most common in the lifespan? 1 year (d/t an open process vaginalis which should have closed in utero) 55 year old (d/t weakness of muscles) How do you diagnosis an inguinal hernia? usually by observing or palpating the protrusion (finger in inguinal canal, can have patient cough to valsalva) females may have labia swelling imaging typically not warranted What is the treatment of an inguinal hernia? depends on severity if strangulated, emergent (have patient alternate ice pack on and off en route to ER, may help with becoming reducible) otherwise, watchful waiting because surgeries are risky, just make sure they know how to monitor for strangulation Describe s/s of testicular torsion. Sudden, acute pain (often brought on after trauma, sleeping) N/V Scrotal erythema, swelling, tenderness Higher than normal teste Teste may be rotated horizontally Loss of cremasteric reflex Pain unrelieved by any intervention such as elevation of testes When you suspect testicular torsion, do you begin your exam on the affected or unaffected side? start on the unaffected side to establish a baseline What findings on MRI or US would be indicative of ovarian torsion? MRI: whirlpool US: "string of pearls" When would you expect a child to develop continence? Daytime: age 4 Nocturnal: age 6 What is the difference between primary and secondary enuresis? primary: child has NEVER achieved continence/dryness secondary: child had achieved for 6 months and is now incontinent Which is more common, nocturnal or daytime enuresis? nocturnal by far Name some causes for primary enuresis. Genetic component (strong) polyuria at night exceeds bladder capacity overactive bladder hard to arouse from sleep (sleep disorder?) anatomic abnormalities (urethral obstructuion, strictures, spina bifida) Name some causes for secondary enuresis. UTIs, neurologic disorders, GU tract abnormalities, constipation, endocrine disorders, hypercalciuria, drugs, OSA, psychosocial stress What is some important questions to ask during a workup of a child with enuresis? how frequently are they going during the day? what is the discipline regarding this? how much are they drinking, esp after dinner, and what kind of fluids? PMH? history of the enuresis/ever achieving continence? Describe how to treat enuresis (non-pharmacologic and pharmacologic). Non pharm: positive reinforcement (child should not be criticized, should not have to launder their own sheets, etc) Limit fluid intake at night (last fluids /=2 hours before bedtime) Set alarms to wake up and void during night Void before bed, often during night Pharm: DDAVP, oxybutynin, TCAs Note: DDAVP cannot be intranasal 2/2 hyponatremia and seizure risk, and oxybutynin should not be monotherapy Regarding pediatric UTIs, what age group has a higher incidence in males than females? 0-3 months Highest incidence: uncircumcised males What symptoms would you see in a patient 2-24 months who has a UTI? typically very nonspecific so hard to differentiate between cystitis, pyelo fever, frequency, dysuria (cries when voiding?), enuresis, flank pain/CVA tenderness (hard to assess until school age), suprapubic tenderness, distention, fecal impaction, genital erythema/edema/irritation/discharge/adhesions may have BP issues if kidneys are affected Describe a positive urine culture in a child. Clean catch: 100,000 Cath: 50,000 Symptomatic: 10,000 In a febrile child with no apparent source for a fever, what needs to be done before starting antibiotics? UA sent off for culture not form a urine bag, but catheterization or suprapubic Why will only about 50% of UAs from a person with a UTI show positive urine nitrites? urine has to be in the bladder for 4 hours for this (why first morning void is good) AND not all bacteria produce these not gold standard for diagnosing UTI A patient with a UTI will have what type of urine pH on UA? alkaline Describe imaging guidelines for a patient 2-24 months presenting with a UTI. 1st UTI: renal ultrasound if abnormal OR patient presents with 2 UTIs, get a VCUG (voiding cystourethrogram) and refer What antibiotic is first line for pediatric UTIs? cephalosporins How many days of antibiotics should an uncomplicated cystitis patient aged 2-24 months have? 10 days What pediatric UTi patients should be hospitalized? 2 months urosepsis immunocompromised vomiting, unable to tolerate PO lack of adequate outpatient f/u (no telephone, live far from hospital) failure to respond to outpatient therapy Describe vesicoureteral reflux Backward flow of urine from bladder into ureters and kidneys Can be as non severe as grade 1 where it does not reach the renal pelvis or as severe as grade V where there is hydronephrosis and distention of the ureters/renal pelvis Does VUR typically require surgery? no, a lot of the time it resolves spontaneously Is nephritis infectious? No When would you expect glomerulonephritis to present after strep? 10 days after strep pharyngitis, but could be 4-6 weeks after strep impetigo general rule of thumb: 2-3 weeks S/S of acute glomerulonephritis hematuria (urine may be tea colored) edema (esp periorbital) HTN in 60-70% of cases oliguria When would you want to run ASO or antiDNAse on a patient with glomerulonephritis? if unable to confirm strep infection if you know they had strep, no need What are some lab findings you can expect in PSGN? low serum C3 or C4 elevated ESR What are two non-strep infections or disease processes that can cause glomerulonephritis? Hep B Lupus Are steroids indicated for the treatment of glomerulonephritis? no Tea color urine often indicates what? glomerular disease How long will it take for labs and UA to be normal in glomerulonephritis? gross hematuria should resolve within 1-2 weeks UA will be abnormal for up to 12 weeks C3/C4 return to normal in 6-8 weeks Treatment of glomerulonephritis focuses on managing what two symptoms? hypertension edema If your patient presents with glomerulonephritis with no evidence of strep infection, what is your next step? autoimmune w/u What is the most common UA finding for a patient with nephrotic syndrome? massive proteinuria 90% of nephrotic syndrome cases are idiopathic and are called what? Minimal change nephrotic syndrome other causes: lupus, Hep B, HIV, drugs, DM Describe the s/s of nephrotic syndrome. Proteinuria /= +1 Sudden dependent pitting edema or ascites Oliguria N/V/D BP abnormalities Ill appearing anorexia malaise What values on your CMP would you expect to be abnormal in nephrotic syndrome? hypoalbuminemia and hyponatremia Are C3/C4 affected in nephrotic syndrome? no, if they are abnormal, this is likely not MCNS and could indicate a lesion When is a kidney biopsy required for nephrotic syndrome? only when you do not suspect MCNS for any reason if you're confident it's MCNS, can defer What is the dose of prednisone indicated for MCNS? 2mg/kg/day up to 60 mg max for 12 weeks and then wean over several months Your patient with nephrotic syndrome is severely edematous so you start a loop diuretic like Lasix on them. What follow up is required? CMP or BMP within 7-10 days What patient education regarding MCNS is required? May have periods of remission or flares, monitor for symptoms Your 10 year old patient was diagnosed with MCNS and has been on steroids for a month with no relief. What is your next step? A biopsy is required very unusual to not have a response especially for this age group, likely not actually MCNS due to this finding Other than steroids and diuretics, what is another medication that a patient with nephrotic syndrome may require? antibiotics high risk for infections What nephrotic syndrome patients require hospital admission? 1st episode: required teaching and monitoring malnutrition, dehydration severe edema (could compromise ventilation?) pleural effusions signs of volume overload (CHF) severe infection significant hypertension or electrolyte abnormalities compromised renal function Identify three major hypotheses of psychosis and their neurotransmitter netwrokds 1. Dopamine hypothesis (overactivity of dopamine pathways) 2. Serotonin Hypothesis (abnormal serotonin neurotransmission) 3. Glutamate hypothesis (disruption of glutamate-mediated signaling) Identify the different dopamine pathways and what role each pathway plays in relation to schizophrenia/psychosis symptoms and treatment. The four main dopamine pathways are: 1.Mesolimbic: Linked to positive psychotic symptoms due to hyperdopaminergia. 2.Mesocortical: Linked to negative symptoms due to hypodopaminergia. 3.Nigrostriatal: Traditionally uninvolved in symptoms but can be affected by medications, impacting movement and possibly emotional regulation. 4.Tuberoinfundibular: Not impacted by schizophrenia but affected by drugs, influencing prolactin.Thalamic pathway's role in schizophrenia is unclear. Neuroleptic Malignant syndrome (NMS) a rare, potentially life threatening reaction to antipsychotic medications often developing withing the first 7 days of starting or increasing a dopamine blocking medication. NMS symptoms Parkinsonism (lead pipe muscle rigidity) Elevated HR High BP Hyperthermia NMS management Management of Neuroleptic Malignant Syndrome (NMS) includes: immediate discontinuation of antipsychotics, supportive care (cooling for fever, IV fluids for dehydration, correcting electrolyte imbalances, maintaining cardiorespiratory stability), IV benzodiazepines (lorazepam/diazepam), IV dantrolene for severe hyperthermia, and dopamine agonists (bromocriptine or amantadine). Electroconvulsive therapy may be considered in refractory cases. Serotonin Syndrome A potentially serious toxic effect resulting from excess serotonin. Serotonin risk factors Polypharmacy and use of substances like St. Johns wort or ecstasy Serotonin syndrome symptoms Altered mental status autonomic dysfunction Hyperactive neuromuscular clonus, hyperreflexias, tremor Serotonin syndrome management Serotonin syndrome is managed primarily with supportive care by discontinuing the offending agent. Additional measures include use of benzodiazepines, IV fluids, oxygen, and other supportive interventions as needed. There is no one-size-fits-all approach; most cases rely on stopping serotonergic medications and managing symptoms. The "Pip" Family 5HT1a partial agonism, D2 partial agonism, 5HT2a antagonism, and 5HT7 antagonism. Aripiprazole, Brexpiprazole Aripiprazole (Abilify) Atypical antipsychotic"3rd generation". D2 partial agonism Management of schizophrenia, and acute manic or mixed episodes in bipolar disorder. Adjunct to treat depression or irritability associated with autism (ages 6-18) SE: dizziness, insomnia, akasthisia, n/v, weight gain (less likely to cause), suppresses prolactin levels Interactions- ketoconazole and other 3a4 inhibitors increase aripiprazole levels.May increase effects of antihypertensives Brexpiprazole (Rexulti) Greater affinity for d2 blockade Indications: schizophrenia and treatment resistant depression SE: dizziness, sedation, hypotension, restlessness. hyperglycemia and DKA. Metabolic labs before, monitor BMI and lipids Chlorpromazine (Thorazine) Indications: schizophrenia, psychoses, manic-depression, and severe behavioral problems in children ages 1-12. Chlorpromazine is also used to treat nausea and vomiting, anxiety before surgery, chronic hiccups, acute intermittent porphyria, and symptoms of tetanus. SE: photophobia, lightheadedness, dizziness, drowsiness, blurred vision, weight gain, trouble sleeping Interactions: Food, alcohol, and benztropine can reduce absorption. Antacids can slow absorption. Lithium and barbituates can lead to increased clearance. TCAs decrease clearance Serious adverse effects: postural hypotension, EKG changes, respiratory depression Perphenzaine (Trilafon) Potent D2 antagonist SE: neuroleptic induced deficit syndrome, akathisia, EPS, parkonsonism, TD, galactorrhea, urinary retention, sexual dysfunction Interactions: Fluoxetine, paroxetine, and bupropion can increase levels. Antihypertensives have synergistic interaction, increasing risk for hypotension. Serious adverse events: NMS, jaundice, seizures, CV death in elderly Haloperidol More selective for D2 receptor, less anticholinergic effects, less antihistamine, and anti adrenergic effect SE: EPS, neuroleptic induced syndrome, akathisia, TD with high doses, amenorrhea, galactorrhea Interactions: decreases effects of levodopa, dopamine agonists. Serious adverse events: If given IV, pt needs to be on cardiac monitor. Can prolong qtc interval and lead to torsades and cause sudden cardiac death. Indications: acute agitation, Tourette's, delirium The "Done" family Bind more potently to 5HT2A than D2, have less affinity to 5HT1A than the pines, lower 5HT2C potency than pines. Risperidone, Lurasidone, paliperidone Second generation antipsychotics Lurasidone (Latuda) Treats schizophrenia and depression. SE: must be taken with 350 calories of solid food for max absorption. Low risk of weight gain Paliperidone (Invega) If patient has a lot of SE from risperidone, will most likely have a lot of SE with this med. Interactions: Can enhance risk of QT prolongation in other medications with SE. Increases effects of antihypertensivies. Serious adverse effects: hyperglycemia/ DKA, NMS, increased risk of death in elderly pts with dementia indications: oral or LAI (monthly and every 3 month doses) The "-pine" family Have 5-HT2A and D2 antagonism. Strong potency for H1 and muscarinic receptors Clozapine, Olanzapine, Quetiapine, Clozapine Atypical Antipsychotic SE: AGRANULOCYTOSIS- ANC blood testing prior, during. Can be very sedating, excessive salivation, Increased risk of myocarditis, Greatest degree of weight gain and possibly greatest cardiometabolic risk Indications- treatment resistant schizophrenia, reducing suicidal behavior Drug interactions with Clozapine Potential to increase levels: SSRIS, cipro, cimetidine, macrolides, caffeine Potential to decrease levels: Carbamazepine, rifampicin, SJW, Omeprazole, Phenytoin, Phenobarbital Olanzapine (Zyprexa) class: Antipsychotic, mood stabilizers Indication: schizophrenia, mania, depression, anorexia nervosa, Action: Strongest of the pines at the H1 and 5HT2a receptors SE: Obesity, dyslipidemia, insulin resistance Baseline labs: BMI, fasting glucose, lipid panel Quetiapine Prominent H1 potency, more sedating SE: constipation, sedation-strong, dizziness, drowsiness, dry mouth, gen weakness, headache, indigestion, low energy, orthostatic hypotension, weight gain Warnings- Coadministered with keotconazole results in increased seroquel exposure. Coadministered with phenytoin increases the oral clearance up to 5 fold. Suicidal thoughts/behaviors in YA/adolescents Risperidone (Risperdal) Indications: schizophrenia (13+), acute/mixed mania, bipolar maintenance. Interactions: increase hypertensive agents, antagonize levodopa and dopamine agonists, coadministeration decrease risperidone. Serious adverse events: hyperprolacinemia SE: diabetes, dyslipidemia, dose dependent EPS, insomnia, anxiety, sedation, nausea, dose dependent sexual dysfunction, TD (rare) Signs and symptoms of potentially severe adverse effects associated with clozapine Seizures severe constipation paralytic ileus agranulocytosis myocarditis cardiomyopathy what tests and/or physical exam components to monitor before and after starting clozapine Before and after starting clozapine, monitor white blood cell count, specifically absolute neutrophil count, as clozapine can lower your white blood cells and increase risk of agranulocytosis. Regular blood tests are necessary to detect neutropenia early. Physical exam focus should include signs of infection related to lowered immunity. Acute dystonia symptoms abrupt spasmodic muscle contractions (face, neck, eyes) within 4 hours of exposure. Treated with IM anticholinergics (benztropine or diphenhydramine) Akathisia symptoms inner restlessness within 4 days of treatment; managed with beta-blockers or 5h2a antagonists, Drug induced parkinsonism symptoms tremor rigidity bradykinesia within 4 weeks of treatment treat with anticholinergics Tardive dyskinesia symptoms manifests 4 months or later after involuntary facial, tongue, or limb movements treatment with VMAT2 inhibitors Explain upregulation of dopamine 2 receptors and how this is related to long-term side effects, such as tardive dyskinesia, with antipsychotic medications. Chronic blockad