NSG555 / NSG 555 Exam 1: Nurse Practitioners in Primary Care I | Complete Guide with Questions and Verified Answers | (Latest 2026/2027 Update) All Modules Covered | 100% Correct | Grade A - Wilkes

NSG555 / NSG 555 Exam 1: Nurse Practitioners in Primary Care I | Complete Guide with Questions and Verified Answers | (Latest 2026/2027 Update) All Modules Covered | 100% Correct | Grade A - Wilkes Specificity Looking for patients without disease. Low false positives. Sensitivity Looking for patients with disease. Low false negatives. Sensitivity: Equation TP —————— (TP+FN) Specificity: Equation TN ————— (TN+FP) American College of Radiology Appropriateness Criteria Guidelines for ordering tests Contrast vs. non-contrast Compares radiation exposure What are NP's obligations for patient safety in testing? Read Findings and Impression Inconsistencies and incidentals. ..... follow up. Deliver results to patients Ultrasound Used for vessels, ovaries, testicles, soft tissue, abscess/cyst, thyroid, guide needle biopsy, stage tumor Vessels: imaging Ultrasound & MRI Ovaries: imaging Ultrasound Testicles: imaging Ultrasound Soft tissue: imaging Ultrasound & MRI Abscess/ cyst/ blood clot: imaging Ultrasound Thyroid: imaging Ultrasound Thyroid: Non-blood test Radioactive Iodine Uptake High RAIU- Hyperthyroid Low RAIU- Hypothyroid Use ultrasound to see where the iodine was absorbed. MRI In depth look at: Bone Tissues Vessels Bone: Imaging MRI & X-ray & Nuclear med Testing bone densitometry X-ray Microscopy Culture and Sensitivity Blood culture Urinalysis Culture and sensitivity: test Microscopy blood culture test Microscopy urinalysis test Microscopy X- ray Bones and bone densitometry Evaluate dye excretion Detect breast cancer Guide needle biopsy Determine patency of fallopian tubes Nuclear med Bone scan Thyroid scan = scintograpy Thyroid scan: name Scintography Thyroid scan: testing Nuclear med Bone scan Nuclear med Renal tests Urinalysis CO2 PSA Creatinine Microalbumin KUB Renal Scan Cystoscopy Gold Standard for first time kidney stone testing? CT Scan Urinalysis: physical exam Volume Color Clarity Odor Specific gravity Urinalysis: Chemical PH Red Blood Cells White Blood Cells Protein Glucose Urobilinogen Bilirubin Ketones Leukocyte esterase Nitrates Microscopic casts Cell crystals Microorganisms Best indicator for UTI Bacteria of 5+ Leukocyte esterase present WBC in urine Serum CO2 kidneys remove acid and maintain balance of HCO3. PSA prostate-specific antigen All prostates secrete levels are by age and is a specific screening tool Creatinine removed entirely by kidneys What is the best way to assess creatinine? Follow it over time Also test GFR and CrCl Microalbumin Done by UA Caused by diabetic neuropathy What are the ACR Practice Guidelines for Communication of Diagnostic Imaging Findings? Effective communication should: 1. promote optimal patient care while supporting the provider 2. be tailored to satisfy need for timeliness 3. Minimize communication errors What are blood studies used for? Establish DX R/O clinical problem Monitor therapy Establish Prognosis Screen for disease What is the most common blood study? Venous What are arterial blood studies used for? Blood gasses 2 multiple choice options What are some disadvantages of arterial blood studies? More Discomfort Risk of Hematoma Hold pressure for longer Skin puncture Often used in pediatrics Mix of venous and arterial What can be used for arterial blood if needed? Earlobe 2 multiple choice options Why should you never milk for blood studies? Hemolysis Electrodiagnostic studies Tests electrical impulses Electrodiagnostic studies: Patient education May cause discomfort from stimulation Do not move Do not have caffeine or sedatives before test Few complications Do you need written consent for electrodiagnostic studies? Why? No. It's not invasive 2 multiple choice options How is ultrasound used in pregnancy? Evaluate pregnancy/placenta Detect ectopic pregnancy Determine fetus status/size 3D imaging Ultrasound: benefits No radiation Less costly than CT or MRI Ultrasound: Types B-mode M-mode (Motion) Real time imaging Doppler Color flow doppler Duplex scanning 3D What is a doppler Ultrasound? amplifies sound waves What is a color flow doppler on ultrasound? detects direction of blood flow What is duplex scanning? Real time + color flow What can get in the way of a clear ultrasound image? Air, Fat, Movement Urine tests: Types 1st morning Random Timed Double voided Culture and Sensitivity 24 hour What is the advantage of a 1st morning urine test? Best for protein and nitrates 1st morning urine test Void before bed, then Void in the AM Advantage of a random urine test Convenient How is a timed urine test done? 2 hours after meal Discard the first void, then start timer and collect until end time. When is a urobilinogen test done? Between 2pm - 4pm. Benefit of a double voided urine test? Fresh Urine How to do take a culture and sensitivity urine test? Sterile container. Clean meatus. Collect midstream after urinating into the toilet a little bit. 24 hour urine collection: directions Discard 1st of the day, then start collection. Ends next day after AM void. Keep on ice/fridge. What kind of dye excretion can be seen on X-ray? urinary tract arterial occlusion GI tract w/ barium Bone disorders Tracheobronchial tree Pulmonary system Cardiac system Abd pain Trauma Fluoroscopy X-ray Tomography CT Fluroscopy View motion Barium Movement More Radiation Tomography X-rays make cross sectional 3D image Iodine contrast: Contraindications Renal Disease Diabetes Allergy to Shellfish Dehydration Pheochromocytoma (HTN) Oral anti-hypertensives (48 hours pre and post) Iodine contrast: What can you do with pts that have allergy? Premedicate with Benadryl and predisone. Use Nonionic contrast. 3 multiple choice options Why must you stop oral anti-hypertensives for 48 hour before and after contrast? Iodine may cause lactic acidosis 3 multiple choice options Digital subtraction angiography: category x-ray Digital subtraction angiography Type of fluoroscopy with catheterization of vein or artery. Used before or after vascular/tumor surgery. Barium contrast: Directions Can interfere with other tests. Prep required before and after Barium contrast: Contraindications Perforation Colitis What can you use instead of barium for perforation and/or colitis? Gastrografin What complications can contrast do to the body? Nephrotoxicity What can you do for nephrotoxicity d/t contrast? Hydrate Use low osmolar nonionic medium in minimal amount DO NOT GIVE DIURETICS Radiation dose with X-rays Lower than CT Depends on length of time, number of images taken. What test give the lowest amount of radiation? Dental and DEXA. Radiation: Mild reaction signs and interventions N/V Urticaria Give antihistamine Radiation: Intermediate reaction signs and interventions Mouth/throat edema Bronchospasm Chest pain Chills/ Fever Give antihistamines (Possibly steroids, fluids, bronchodilators) Radiation: Severe reaction signs and interventions Edema Hypotension MI Arrythmia Seizure Respiratory Failure Give antihistamine, steroids, fluids, bronchodilators, intubation/ventilator, pressors, antiepileptics. When can delayed reactions to contrast occur? 2-6 hours after administration magnetic resonance imaging (MRI) a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain. MRI benefits No radiation Advantage over CT Better contrast image No obscuring bone Natural blood vessel contrast Can image multiple angles Expensive and labor intensive Can use gandolinium or gasoxetate contrast MRI: Uses Most body systems: Brain GI Muscle Cardiac Breast Spine MRI: Considerations with contrast Check renal function, especially age 60 and over. MRI: Directions Remove patches Remove Metal Remain still MRI: Contraindications Extreme obesity Claustrophobia Agitation Metal in body KUB kidney, ureter, bladder xray 2nd line imaging if no CT scan Pyelography x-ray imaging of the renal pelvis and urinary tract Mostly replaced by CT Uses contrast injected into renal system or IV Pyelography: Indications Stones Hematuria Trauma Outlet obstruction Tumor Pelvic surgery Renal Scan: Category Nuclear tests Renal Scan Uses radioisotope and scintillation camera Perfusion, structure, function, hypertension, obstruction Evaluate transplant rejection Do you need contrast for renal scan? Why? No iodine. Safe to use in renal disease and allergies. Renal Scan: Contradindications Not to be done w/in 24 hours of IVP. Cystoscopy Camera in bladder Cystoscopy: Uses Hematuria Recurrent UTI Dysuria Frequency Retention Inadequate stream Urgency Incontinence Cystoscopy: Diagnostic uses Ureter sample collection Visualization Measurement Calculi Cystoscopy: Therapeutic Uses Resection of tumors Removal of FB dilation Stent placement Coagulation of bleeding Implant radium seeds TURP Cystoscopy: Complications Can cause: Perforation Sepsis Hematuria Retention Cystoscopy: Directions Assess voiding for 24 hours, note urine color (Pink is common) avoid standing immediately after, burning during urination is common pee while sitting Drink fluids Observe for sepsis Antibiotics, if needed, before and after Avoid constipation Cystoscopy: Findings Tumor Stones Prostate hypertrophy/cancer Inflammation Stricture Urinanalysis: Appearance - Normal Clear Urinalysis: Appearance - Abnormal Cloudy Urinalysis: Appearance - Cloudy Pus Foods (fat, urates, phosphates) Urinalysis: Color - Normal Amber yellow Urinalysis: Color - Dark Red Kidney bleed Urinalysis: Color - Bright Red Lower bleed Urinalysis: Color - Dark yellow Urobilinogen/ Bilirubin Urinalysis: Color - Green Pseudomonas Urinalysis: Color - Red/Brown Beets/Rhubarb Urinalysis: Odor- Normal Aromatic Urinalysis: Odor- Acetone DKA Urinalysis: Odor- Foul UTI Urinalysis: Odor- Fecal Enterobladder Fistula Urinalysis: Odor- Musty PKU Urinalysis: PH- Normal 4.6-8.0 - average is 6.0 Urinalysis: PH- acid-base balance foods Urinalysis: PH- acidic Zanthine Cystine Uric acid Calcium oxalate stones Urinalysis: PH- alkaline Calcium carb/phos and mag phos stones. UTI. Urinalysis: Protein - Normal 0-8mg/dL 50-80mg/ 24hr (at rest) 250mg/24hr (during exercise) Urinalysis: Protein- Present Presence indicates glomerular capsule injury Pregnancy: Preeclampsia Usually checked with creatinine Orthostatic Proteinuria Urinalysis: Protein and Edema Nephrotic Syndrome Urinalysis: If random elevated Do 24 hour collection Urinalysis: Specific Gravity: Normal 1.005-1.030 (Usually 1.010-1.025) Elderly: Values Decrease with age Newborn: 1.001-1.020 Easier to check than osmolality Urinalysis: Specific Gravity: High Concentrated SIADH Urinalysis: Specific Gravity: Low Dilute DI Renal disease Urinalysis: Leukocyte Esterase: Normal Negative Urinalysis: Leukocyte Esterase: Positive (100,000) UTI Contamination by vaginal secretions Urinalysis: Nitrates: Normal Negative Urinalysis: Nitrates: Positive UTI Urinalysis: Ketones: Normal None Urinalysis: Ketones: Positive Poorly controlled DM and hyperglycemia, infection, ketoacidosis r/t alcoholism, fasting, aspirin toxicity, anesthesia Urinalysis: Bilirubin: Normal None Urinalysis: Bilirubin: Positive Gallstones Urinalysis: Urobilinogen: Normal 0.01-1 pH can affect urobilinogen levels. Urinalysis: Urobilinogen: Alkaline Indicates higher levels of urobilinogen Urinalysis: Urobilinogen: Acidic Indicates lower levels of urobilinogen Urinalysis: Crystals: Normal None Urinalysis: Crystals: Present - Uric Acid Gout Urinalysis: Crystals: Present - Phosphate/calcium Parathyroid abnormality Urinalysis: Casts: Normal None Urinalysis: Casts: Hyaline/ Granular Exercise Urinalysis: Casts: Fatty Glomerular Disease Urinalysis: Casts: Waxy Chronic Renal Disease Urinalysis: Casts: Epithelia (Renal tubular) Most suggestive of renal tubular disease or toxicity Tumor Infection Polyp of bladder Urinalysis: Glucose: Fresh specimen None Urinalysis: Glucose: 24 hour specimen 50-300mg/24 hr or 0.3-1.7mmol/day Urinalysis: Glucose: Fresh specimen: Positive Pregnancy Hyperglycemia Renal glycosuria Fanconi syndrome Nephrotoxic chemicals Urinalysis: WBC: Normal Negative Urinalysis: WBC: Positive UTI (usually kidneys) Casts: UTI Urinalysis: RBC: Normal or equal to 2 Urinalysis: RBC: Positive Bleed Menstruation Casts: Glomerulonephritis Interstitial nephritis Acute tubular necrosis Pyelonephritis Renal Trauma Renal Tumor Urinalysis: Culture and Sensitivity: Normal Negative (10,000 bacteria/mL urine) Urinalysis: Culture and Sensitivity: Positive 100,000 bacterial/mL urine When is the report delivered for a urine cultural and sensitivity? Preliminary: 24 hour Final: 48-72 hour Urine toxicology: Category Microstudies: Amphetamines, marijuana, cocaine, benzodiazepines, barbiturates, ethanol PSA: Category Microstudies Urinalysis: Category Microstudies PSA: Uses prostate-specific antigen Early detection and monitoring of prostate cancer PSA: Low Less than 2.5 PSA: High More than 20 PSA: specificity 80% false positive PSA: Bound vs Free indications Bound PSA is more indicative of cancer than free PSA Serum Carbon Dioxide: Normal 23-30 Serum Carbon Dioxide: Uses Part of electrolyte studies Regulated by kidneys Serum Carbon Dioxide: Abnormal Increase (31+): Alkalosis Decrease (23-): Acidosis: Renal Failure CKD: Diagnose and Manage Urine albumin Serum Creatinine BUN Creatinine Clearance eGFR Serum Creatinine: Normal Level 0.5-1.2; Differs by sex and age. Lower in children Serum Creatinine: Elevated Dehydration Diet high in meat Higher after meal Renal Disease: Glomerulonephritis Pyelonephritis Acute tubular necrosis Urinary Tract Obstruction Reduced renal blood flow Diabetic nephropathy Nephritis Rhabdomyolysis What level of creatinine indicates serious impairment in renal function? 4mg/dL Serum creatinine: Peak 7pm Serum creatinine: Trough 7am Serum creatinine: Uses Used with BUN to estimate GFR Serum creatinine: Normal BUN/Creatinine Ratio 6-25 (15.5 optimal) BUN: Normal 7-20 BUN: High Kidney Disease BUN: Low Liver Disease Where is BUN formed? Liver Where is BUN excreted? Kidney Creatinine Clearance: Normal 90-140 Higher in males Decreases by 6.5 with each decade of age after 20. Creatinine Clearance: Why and How to measure Measure GFR 24 hour urine and serum creatinine used to calculate Creatinine Clearance: Decreased level Kidney disease and anything that reduces kidney perfusion eGFR: Normal Around 120 eGFR: Low Below 60 Signifies kidney disease eGFR: Below 15 Signifies kidney failure Thyroid Nodule: Diagnosing and Imaging Ultrasound Scintigraphy Plain Radiographs CT Scanning MRI Fine Needle Aspiration Thyroid function tests Thyroid disorder: TSH and T4: High TSH and Normal T4 subclinical hypothyroidism Thyroid disorder: TSH and T4: What to do in subclinical hypothyroidism Repeat in 1-3 months to confirm. Thyroid disorder: TSH and T4: What to do in subclinical hypothyroidism if pt is recently hospitalized/ill? Repeat in 2 weeks Thyroid disorder: TSH and T4: What to do in subclinical hypothyroidism, if pregnant Start Levothyroxine and refer to endocrinology Thyroid disorder: TSH and T4: High TSH, Low T4 Primary hypothyroidism Thyroid disorder: TSH and T4: Primary hypothyroidism, if pregnant TSH to confirm Start Levothyroxine and consult with endocrinology. Thyroid disorder: TSH and T4: High TSH, High T4 Needs TSH, T3, T4 repeated. If still abnormal, refer to endocrinology. Thyroid disorder: TSH and T4: High TSH, High T4: DDX Pituitary adenoma non-adherence to tx. Amiodarone Resistance to thyroid hormone. Thyroid disorder: TSH and T4: Low TSH, Normal T4 If taking biotin, discontinue and repeat. Thyroid disorder: TSH and T4: Low TSH, Normal T4, Normal T3. Subclinical hyperthyroidism, likely. Repeat in 1-3 months Thyroid disorder: TSH and T4: Low TSH, Normal T4, High T3. Overt hyperthyroidism due to T3 toxicosis. Additional Testing needed and referral to endocrinology. Thyroid disorder: TSH and T4: Low TSH, High T4. If taking biotin, discontinue and repeat. Overt hyperthyroidism likely. Needs diagnostic testing to determine cause. Referral to endocrinology. Thyroid disorder: TSH and T4: Low TSH and High T4: Tests to consider. Radioactive iodine reuptake. Thyrotropin receptor antibody Thyroid ultrasound Thyroid disorder: TSH and T4: Low TSH, Low T4. Central hypothyroidism. Acute illness Pregnancy Thyroid disorder: TSH and T4: Low TSH, Low T4: Central hypothyroidism Referral to endocrinologist Thyroid disorder: Radioactive iodine uptake: Contraindications Pregnancy and Lactation Thyroid disorder: TSH and T4: Low TSH, Low T4: Central hypothyroidism: Follow up labs Estradiol Gonadotropins Testosterone Prolactin Thyroid Nodules: Preferred Methods Ultrasound Can identify non-palpable nodules and cysts Thyroid Nodules: Malignant Mostly solid and hypoechoic with irregular margins Thyroid Nodules: Benign Defined and Hyperechoic Thyroid Nodules: Scintigraphy Reserved for characterizing functioning nodules staging follicular papillary carcinomas Thyroid Nodules: Plain radiographs Used to detect: Retrosternal thyroid extension, Thyroid calcification Bony or mediastinal lymph nodes Lung metastases **Limited Usefulness Thyroid Nodules: CT Scan Effective method for detecting regional and distant metastasis from thyroid cancer Thyroid Nodules: MRI Limited role Diagnosis of cervical lymph node metastasis and staging cancers. Fine Needle Aspiration of Thyroid Percutaneous needle aspiration remains key procedure for: Diagnosis of Thyroid Lymphoma Tissue-specific diagnosis of a lymphoma by US guided FNA Lymphoma's differentiation from thyroiditis can be difficult. Fine Needle Aspiration of Thyroid: Risks Bleeding Infection Injury to vital structures Bruises *** Stop blood thinners Fine Needle Aspiration of Thyroid: Results: Benign Follow-up Fine Needle Aspiration of Thyroid: Results: Cancerous Remove Fine Needle Aspiration of Thyroid: Results: Indeterminate/Inadequate Repeat in few months Thyroid function tests TSH Thyroxine (T4) Triiodothyronine (T3) TSH: Normal 0.3-5 TSH: Elevated Hypothyroid TSH: Decreased Hyperthyroid TSH: Peak 10pm TSH: Trough 10am Thyroxine (T4): Normal 5-12 free= 0.8-1.8 micrograms Triiodothyronine (T3) 100-200 nanograms Diabetes: Diagnose Fasting Plasma glucose 2-hour glucose tolerance test (75 gram oral glucose) A1C hemoglobin If all three tests are high, diabetes is diagnosed C-Peptide Diabetes: Diagnosis: Fasting plasma glucose 126 or higher on 2 separate occasions. Diabetes: Fasting Plasma Glucose: Normal Less than 100 Diabetes: Fasting Plasma Glucose: Prediabetes 100 to 125 Diabetes: Diagnosis: HbA1c 6.5 or higher on 2 separate occasions Diabetes: Diagnosis: HbA1c: Advantages Measures average blood sugar during the past 3 months. Don't have to fast or drink anything. Diabetes: Diagnosis 2-hour post meal, 200 or higher Diabetes: C-Peptide Evaluates islet cell function (0.5-2) Used to evaluate diabetic patients who secretly self-administer insulin. Reflects islet cell function in patients taking insulin. Monitoring insulinomas Diabetes: Decreased levels DM with insulin administration What is the first indicator of renal disease, and how often should you screen? Microalbumin Screen annually Cortisol: Normal levels Higher in AM: 5-23 Decreased after 4pm: 3-13 Cortisol: Uses Measures adrenal activity Cortisol: Elevated Cushing ACTH producing tumor Hyperthyroid Obesity Cortisol: How do you know its Cushing? Cortisol level does not go down during the day Cortisol: Low Addison disease Hypopituitary/thyroid Adrenal hyperplasia How does pregnancy affect cortisol? Pregnancy increases stress ACTH: Normal level Female: 6-58 Male: 7-69 ACTH: What does it measure? Anterior pituitary function In Cushing's: ACTH level: Low Pituitary cause In Cushing's: ACTH level: High Adrenal cause High Cortisol, High ACTH Cushing's disease High cortisol, Low ACTH Cushing's Syndrome or adrenal tumor Low cortisol, High ACTH Addison's disease Low Cortisol, Low ACTH Hypopituitary ACTH stimulation Evaluates the ability of the adrenal lnd to respond to ACTH administration. Useful in evaluating the cause of adrenal insufficiency and Evaluating patients with Cushingoid symptoms. ACTH stimulation: Increase in cortisol after ACTH-drug Adrenal gland is normal but pituitary isn't functioning correctly. Insulin Test: Normal level 6-26 Insulin Test: Uses To diagnose insulinoma and.... Evaluate abnormal lipid and carbohydrate metabolism. Evaluate patients with fasting hypoglycemia. CMP (Complete Metabolic Panel) -Glucose: 70-110 -Ca: 8.5-11 -Na: 135-145 -K: 3.5-5.0 -CO2: -Cl: 98-107 -BUN: 7-22 -Cr: 0.6-1.5 -GFR: 90-120 -ALT: 7-56 -AST: 10-40 -Alk Ph: -Bili: less than 1.0 -Alb: 3.5-5.0 (3.5 = indication of malnutrition) -Tot Pro: 6.2-8.1 BMP tests Na, K, BUN, Creat, Gluc, HCO3-, Cl- Lipid panel Total cholesterol LDL ("bad") cholesterol HDL ("good") cholesterol Triglycerides, another type of fat that causes hardening of the arteries CBC: Included tests RBC WBC Platelets Hemoglobin Hematocrit Mean corpuscular volume Rheumatoid Arthritis: Diagnosis Tests Antinuclear Antibody Rheumatoid Factor Inflammatory Markers C Reactive Inflammatory markers Erythrocyte Sedimentation Rate X-ray MRI in c-spine abnormalities Joint aspiration with synovial fluid analysis Rheumatoid Arthritis: Rheumatoid Factor Autoantibody Helps to diagnose Rheumatoid Arthritis Rheumatoid Arthritis: Antinuclear Antibodies Tests multiple antibodies that target normal proteins in the nucleus of a cell. SLE Rheumatoid Arthritis Scleroderma Sjogrens syndrome Addison autoimmune hepatitis What inflammatory markers do you test for RA? C-reactive inflammatory markers Erythrocyte Sedimentation Rate C-Reactive Inflammatory Markers 1 Infection, infarction, autoimmune inflammation Rises and falls quickly C-Reactive Inflammatory Markers: How does it show inflammation? One of the proteins that activates the complement Presence suggests a protein made by the liver that releases more during high inflammation. Can look at chronic inflammation or infection, but cannot distinguish between the two. Erythrocyte Sedimentation Rate (ESR) Males: Up to 15 Females: Up to 20 Slower to rise and fall than CRP Erythrocyte Sedimentation Rate (ESR): Uses Measures time it takes for erythrocytes to settle to the bottom of a test tube. RBC clump together and sink faster when there is inflammation. Detects: Infection Infarction Autoimmune inflammation When do you use an MRI in RA? When there are C-spine abnormalities Vitamin D: Normal Level 25-80 Vitamin D: Abnormal level Under 20 is deficient 20-30 is insufficient Over 200 could be toxic Vitamin D: Intake if level under 50 200iu Vitamin D: Intake if level: 51-70 400iu Vitamin D: Intake if 71+ 600iu What is Vitamin D's relationship with PTH Work with PTH to increase serum calcium Bone Densitometry/Density (DEXA) Scans: Normal Normal: 1 SD normal (-1.0) Bone Densitometry/Density (DEXA) Scans: Abnormal 1.0-2.5 SD below normal (-1 to -2.5) This suggests osteopenia 2.5 SD below normal This suggests osteoporosis Bone Densitometry/Density (DEXA) Scans: Who gets routinely monitored? Post menopausal women: Hyperparathyroid Long-term steroid user Bone Densitometry/Density (DEXA) Scans: Frequency: Post menopausal women Every 2 years Bone Densitometry/Density (DEXA) Scans: Frequency: Hyperparathyroid Annually Bone Densitometry/Density (DEXA) Scans: Frequency: Long term Steroid Users Annually Calcium levels: Uses Evaluate Parathyroid Function Evaluate Calcium metabolism Monitor patients with renal failure Renal transplantation Hyperparathyroidism Various malignancies Monitor calcium levels during and after large volume blood transfusions Calcium: Normal level 9-10.5, ionized 4.5-5.6 Why is calcium monitored after large volume blood transfusions? When blood levels decrease, PTH is stimulated which stimulates release of calcium from reservoirs. What is calcium bound to? Half of calcium is free and the other half is bound to albumin. Do ionized calcium measurements have to change r/t albumin? No. Hypercalcemia: Most common cause Hyperparathyroidism Hypercalcemia: Symptoms Anorexia Nausea/Vomiting Somnolence Coma HIV Testing: Diagnosis Viral Load Serology and Virology HIV Testing: Viral Load Accurate marker for prognosis, disease progression, response to antiviral treatment, and indication for antiretroviral prophylactic treatment. HIV Testing: What is the standard? Serology and Virology Endoscopy: Directions Needs written consent Baseline labs Prep-depending on study It's like minor surgery: sedative, emergency equipment on standby, needs ride home. Endoscopy: Patient Education May cause gas, discomfort, infection signs IV antibiotics needed with prosthetic joints or cardiac valve disease Fluid Analysis Studies: Uses Normal fluids Effusions Aspiration: Must be sterile. Diagnostic or therapeutic Fluid Analysis Studies: Risks Infection Seeding of malignancies Leakage Reflex bradycardia/hypotension r/t anxiety. Manometric studies Measure and record pressure. Microscopic Studies Biopsy Culture/Smear Pathologic conditions Gram staining and shape. Microscopic Studies: Culture/smear examples STI, TB, PAP Gram negative rods E. Coli Nuclear scanning: Uses Stage cancer Detect sites of GI bleed Diagnose cholecystitis/ pulmonary embolism Brain scan Evaluate gastric emptying/thyroid nodules/testicular swelling/cardiac function. Nuclear Scanning: What substance is used? Why? Technetium-99m (99mTc) Nuclear Scanning: Why is substance used? Half-life is 6 hours and it emits low levels of gamma rays. Nuclear Scanning: What other substances are used? Gallium Thallium Iodine Nuclear Scanning: How does it work? Combined with transport molecule, it takes radionuclide to intended organ. Superimpose of baseline CT/PET scan to see hot and cold spots. Nuclear Scanning: Normal Organ takes up substance consistently across the organ. Nuclear Scanning: SPECT Gives 3D images Nuclear Scanning: Radiation risk? Yes. But less than X-ray. Nuclear Scanning: Contraindications Pregnant and nursing Nuclear Scanning: Directions When using toilet flush several times after use clean up spilled urine wash hands thoroughly, wash soiled clothes separately Drink plenty of water. Assess for allergy Nuclear Scanning: Routes of radionuclide Oral Inhaled IV in outpatient settings most common malpractice claims are due to what? •diagnosis, medications, medical and surgical treatment. Handoff communication and electronic health records play a role in cases with adverse patient outcomes. What is disclosure of errors in malpractice? •Policy of sharing investigative findings of adverse events with patients and families •A process of apologizing and offering compensation risk management strategies •Patient first, communication issues, patient concerns, patient adherence diagnosis related claims categories 1. failure to id observation findings or change in condition 2. failure to order correct testing to establish a dx 3. delay in establishing a dx 4. failure to dx 5. failure to order or address diagnostic test results disclosure of errors and adverse events appologize and compensate works better than litigation. acknowldege event occured empathis and appologize if appropriate take steps to minimize further harm explain to pt/family what will happen next communicate the investigation process disclose the results of the investigation make changes to prevent the failure from recurring provide emotional support · Common geriatric syndromes polypharmacy cognitive impairment dehydrayion falls FTT elder abuse · What is palliative care-tenets, definition and epidemiology · Advanced directives living will: describes in detail the patient's wishes Health care proxy/DPOA--alternate decision maker polypharmacy pathophysiology: use of 5 medications or any not medically indicated, includes rX and OTC. Drug distribution/clearance affected by dec. lean body mass and kidney/liver blood flow, inc in body fat. alters pharmacokinetics. consequences--adverse drug rx--GI, delirium, dizziness, depression, derm effects management--BEERS list, improved rx in elderly tool, screening tool to alert doctors to the right treatment, screening tool of older persons and potentially inappropriate prescriptions cognitive impairment most common is AD short term memory loss is primary symptom +disorientation; exec. functioning problems, ADLs, neuro (aphasia, apraxia, agnosia), sleep cycles reversed, psychomotor changes, irritability or apathy in early stages delirium: transient waxing/waning of LOC. acute onset. more common in hospitalized patients, may actually be unmasking an undiagnosed dementia dehydration Na imbalance is most common pathophys:decreased thirst response, decreased renal plasma flow, vasopressin release stimulated by low fluid volume diminished clinical presentation: nonspecific: confusion, lethargy, weight loss, functional decline, FTT PE: CV assessment--orthostatic drop in BP and rise in pulse indicates volume depletion, temp elevatied if inflammatory or infectious process. dry mucous memranes (not tile late dehydration) labs: review electrolytes, BUN/Cr ratio, osmolality, h and h (elevated), glucose, Na ( 148) BUN/Cr ratio that indicates dehydration 25:1 or more differential dx dehydration and management fever, iatrogenic meds, GI fluid losses assess fluid deficit (preillness weight-current weight=deficit) then increase oral fluids can replace with subq button (hypodermoclysis) IV replacement is fastest but expensive and more complications (fluid overload, HF, cerebral edema, IV issues) dehydration prevention 6-8 8oz glasses of fluid per day full glass of fluid with meds drink more when hot or fever keep intake record X2 days get dentition taken care of monitor fluid intake if memory problems Falls definition: unintentional loss of balance that results in a position change and contact with the ground Pathophys: LE weakness, poor balance, orthostatic hypotension, CNS disease, unsafe environtment, cognition/sensory abnormality, meds changes in CV system that blunt hemeostatic mechanisms can cause hypotension dx testing after falls rule out anemia, infection: CBC rule out dehydration/electrolyte im balance: electrolytes, BUN, Cr GI: Stool occult blood test rhythm problems: ECG IF ECG abnormal + syncope MUST RUlE OUT MI If neuro exam + get MRI to rule out brain/spinal cord lesions inner ear disase/benign positional vertigo (ENT referal) Fall prevention screen, balance training, Tai Chi, multidisciplinary team Failure to thrive progressive loss of energy, strenght, stamina--decreased function and deterioration cognitive and physically. s/s anorexia, wt loss, skeletal muscle loss (sarcopenia), functional decline pathophys FTT weight loss+sarcopenia--decrease in strength, endurance, weakness, fatigue, low bone density, low metabolic rate (heat/cold intolerance). partially due to decreased in estrogen, Gh and androgen but giving these as supplements increases lean mass but not necessarily functional capacity/strength. (also lower HDL, risk of metabolic syndrome and prostate cancer) presentation FTT weakness, inability to care for self, dizziness, weight loss, memory loss, depression. GI malabosrption, ca risk, infection, thyroid change, depression, change in memory. PE/dX of failure to thrive unplanned weight loss of 10% or more in less than 1 year assess symptoms, organ failure, infection, malignancy, skin testing: continue mammograms, stop pap after age 65. CBC, electrolytes, kdiney/thyroid, fasting glucose, lft, ca, UA, stool for occult blood X3, CXR management of failure to thrive increase protein/calories, MOW, community support. MVI, antidepressant, regular exercise to build strength. . NOT RECOMMENDED: appetite stimulants Elder abuse clinical presentation seven kinds. older adults with disabilities and dementia at higher risk. bruising, pressure/rope marks, broken bones or burns, breast/genital bruising, sudden change in behavior, change in financial situation, unattended medical needs. management of elder abuse call state APS. whistle-blowers cannot be punished. palliative care goal is to improve QOL, appropraite at any age and any stage in serious illness when should advance care planning be introduced initial history for all patients. should be revisited annually new model of palliative care •Replace a dichotomous "either-or" model of cure versus palliation. •Focus on integrating palliative strategies early and concurrently with disease-modifying treatments. DPOA vs health care proxy DPOA can make all decisions related to care. HC proxies cannot override a living will or CPR directive and are not authorized to make decisions other than those directly related to healthcare. pathophysiology of pain nociceptive (somatic/visceral)--most common--normal function of CNS or neuropathic or idiopathic (no disease but may have psych elements and still needs treated) nociceptive pain pathophys nociceptors respond to noxious stimuli transmit message through peripheral nerve to spinal cord to cerebral cortex to interperate message then motor response or other is initiated (pull hand away, etc) somatic (soft tissue/muskuloskeletal) or visceral (internal organs somatic pain s/s vs visceral s/s dull, sharp, ache, crush, heavy vs poorly localized, not attributed to involved organ. dull, crampy, deep neuropathic pain due to injury to peripheral nerve, spinal cord or nervous system or brain. result from injury-- anatomic and neurochemical changes in neurons. can cause chronic pain or reduced function. PQRST of pain provocative/palliative Quality Region Severity Timing 3 step pain ladder from WHO Step 1: use nonopioids and adjuvants ( NSAID, TCS, SSRI, anticonvulsant) Step 2: mixed opiate like codeine apap, tramadol in combo with step 1 or alone step 3: pure opioids pure agonist opiates can be titrated to pain relief without a ceiling effect mixed agonist/antagonist opioids produce analgesia and can reverse analgesia. HIGH INCIDENCE psychotomimetic side effects. this displaces a pure agonist opioid from the receptor which can precipitate withdrawel and reverse analgesia ESSENTIAL diagnostics for oncology pain radiography, CT, MRI, bone scan, EMG, CBC with dif acute pain treatment ex. for post-op pain or accidents short acting opioid, or can use as prevention to prevent breakthrough pain moderate to severe long term pain and opioids around the clock dosing rX for opioids keep at 3 days or less. always start with IR instead of ER. screen for alcohol use, depression/suicide risk, opioid risk tool to screen for substance use. follow up at min q3 mos to assess efficacy. controlled substance agreement. d/c opioids dose decrease by 5-10% every 1-4 weeks. refer to pain management if long term use needed Acute pain 3 months and relieved when underlying injury resolved. due to nociceptors. this increase in activity can alter circuits and lead to chronic pain. dx for acute pain: use appropriate labs and dx studies to determine cause chronic pain may start with an injury but is ongoing often unrelated to initial cause. manage using WHO 3 step method may also refer to inteventional pain specialist for nerve block, trigger point injection, etc. oncology pain ID underlying cause. can be from infection, trauma, tumor growth. often in typical patterns for that cancer. Pancreatic cancer: mid/upperback or shoulder associated swelling--pressure on nerves/tissue surrounding tumor. can also cause pain. management of oncology pain opioids. don't use agonist-antagonist because this can reverse analgesia, cause withdrawal+exacerbation step approach 1. nonopioids (NSAID for pain level 1-3) 2. mild opioid 3. strong opioid. use adjuvants like muscle relaxants, antidepressants, anianxiety, anticonvulsant to help with fear/anxiety end of life pain get comprehensive pain assessment. may need diagnostic/radiographic imaging. assess for constipation, bladder distention, hypoxemia, infections, delirium, decum, mucositis, opioid toxicity still use 3 step approach. do not worry about addiction. opioids are usually best. loss of oral route