Midterm AGACNP Questions and Answers

Midterm AGACNP Questions and Answers Signs of Severe Anemia (six, hgb and hct) Hgb less than 7, hct 0.2, pallor tahycardia visible vigorous neck pulsations, soft systolic murmur, wide pulse pressure, proteinuria and weight loss Variations in symptoms between 20%, 30% and 50% blood loss 20% at rest would have minimal to no clinical signs with mild exercise the pt may experience tachycardia, 30% circulatory collapse and shock, 50% with significant mortality Chronic anemia compensatory dependent on many things? Health status of the pt, age of the pt, amount of blood loss The y and x axis of the oxyhemoglobin dissociation curve Yaxis hemoglobin saturation SaO2, Xaxis partial pressure of O2 in arterial blood (PaO2) What occurs at the lungs based on the Oxyhemoglobin diss curve At the lungs, oxygenated blood leave the alveoli and jump on hemoglobin, O2 binds, increasing SaO2 and PaO2 What occurs at the tissue based on the Oxyhemoglobin diss curve? At the tissue, O2 leaves the blood and the Hemoglobin enters cells and O2 dissociates causing a decrease in SaO2 and decrease in PaO2 What happens if the dissociation curve shifts to the right? And why? The Y axis decreases which means there is less O2 on HGB, more O2 in the tissue. This can be caused by acidosis (therefore low pH), increase temperature, increased altitude, increase in 2-3 BPG **R hand symbolizes giving 2 to tissue aka R hand handshake) What happens if the dissociation curve shifts to the left? And why? The y axis increases SaO2 which means more O2 on the hemoglobin, moving O2 away from tissue. This can be caused by alkalosis (increase in pH), decrease temperature, decrease in altitude, decrease in 2-3BPG. **With left shift the tissue is left behind" What is the Schling test? 24 hour urine test of B12 What is the mechanism of erythropoietin production? If hypoxia occurs due to decrease RBC count, decreased HGB or availability of O2, the kidney releases erythropoietin stimulating red bone marrow enhanced erythropoiesis, therefore increasing RBC count and increasing O2 carrying ability of blood creating homeostasis What are reticulocytes and where do they mature? Reticulocytes are immature RBCs, they mature in bone marrow. They compromise of 1% of RBCs. What is the reticulocytes count? Number of reticulocytes as a percentage of RBCs (bone marrow activity), this will be very elevated in anemia therefore need to use Reticulocytes production index (RPOI), a normal % is 0.5-1.5% What are important history taking factors that can contribute to a patients dx of anemia? Fmhx of Thalacemia, Splenectomy, and Gallstones, environmental exposures, diet specifically long term vegetarian (B12deficiency or folate def), ETOH abuse (folate def), travel or sick contacts Physical exam findings of anemia Pallor, smooth tongue, jaundice, scooping of nails, hepatosplenomegaly, cardiac abnormalities Exam findings of Vitamin B12 Signs of malnutrition, NEURO CHANGES, glossitis iron deficiency exam findings Severe pallor, spoon shaped nails and esophageal webs Exam findings of hemolytic anemia Jaundice due to elevated bilirubin from increased RBC destruction, pallor or mild sclera icterus, chronic leg ulcers Exam findings of pernicious anemia LEMON yellow palloor, remastered greying hair, glossitis/burning Exam findings of Severe bone marrow failure Pallor and petechiae Who besides hemolytic anemia can have chronic leg ulcers? Sickle cell patients Exam findings of aplastic anemia or leukemia Painful ulcerative mouth lesions What is the biggest difference between Vitamin B12 and folate deficiency? Neuro changes What helps determine if anemia is hemolytic? Haptoglobin levels What does HCT measure? And what is the difference between males and females? Measures the percentage of whole blood that is occupied by erythrocytes; the amount of plasma to total RBC mass. Males 40% to 54% and females 37 to 47% What does MCV measure? Volume and Size of RBCs, approx 82-98 is normal. (Microcytic vs normocytic or macrocyctic) What is MCH? Amount and weight of HGB contained in a single RBC 26-34 What is MCHC? Average content of hgb of eachRBC occupied by hgb 32-36%. It is more accurate than MCH. (Hyper chronic vs hypochromic) What are the steps in defining anemia based on lab results? Is the Pt anemic- hemoglobin and hct What type is it.- look at MCV and MCHC Then look at reticulocytes If microcyctic hypochromic anemia is investigated, what additional measures need to be done? Serum iron needs to be ordered. If Serum iron is high in microcytic hypochromic anemia, what needs to be done next and what is the dx? Marrow for iron and a possible dx of Sideroblastic Anemia If serum iron is normal to high in microcyctic hypochromic anemia, what needs to be done next and what is the dx? HGB studies and if the hgb is abnormal, the pt has thalassemia If serum iron is low in microcyctic hypochromic anemia, what needs to be done next and what is the dx? Obtain ferritin level, if low the pt has iron deficiency. If normal or high, anemia of chronic disease If the pt has normocytic normochromic anemia, what lab should be obtained next? Reticulocytes If the pt has normocytic normochromic anemia, and reticulocytes are normal, what is the dx? Second anemia due to inflammatory, live disease, renal failure, endocrine failure If the pt has normocytic normochromic anemia, and reticulocytes are low, what is the dx? Can be hypoplastic- aplastic anemia Infiltration- Leukemia, myeofibrosis, metastasis Dysplasia- Myelodysplasia If pt has macrocytic anemia, what blood level should be obtained next? Reticulocytes If pt has macrocytic anemia, and the reticulocytes are high, what does that mean? Acute blood loss or hemolytic anemia to response If pt has macrocytic anemia, and the reticulocytes are normal to low, what does that mean? Obtain bone marrow, can be nonmegalblastic (normalblastic or dysplastic) Or can be Megablastic indicating either folate or B12 deficiency What are the types of mcirocytic hypochromic anemias? Iron deficiency (most common), Thalassemia, Sideroblastic What are the types of Macrocytic normochromic anemias? Folic Acid deficiency or pernicious anemia If pt had gastric bypass, what type of anemia are they at risk for? Pernicious anemia What type of anemia is anemia of chronic disease? Normocytic normochromic What type of anemia is Sickle Cell Disease? Hemolytic Anemia What are two types of ulcers Gastric and duodenal What are the main cause of peptic ulcers? H. Pylori and NSAIDs or rare Zollinger Ellison Sydrome (gastronoma) What kind of bacteria if H.Pylori Gram negative Why do NSAIDs cause peptic ulcers? NSAIDs inhibits cycloxygenase which normally synthesizes inflammatory prostaglandins, however if prostaglandins continue to reduce the stomach is left prone to manage What are two common complication of duodenal ulcers? Perforation and Gastric outlet obstruction What are signs of gastric ulcers? Pain with eating and decreased weight loss (because they want to avoid eating since that causes pain)a What are signs of duodenal ulcers? Pain decreases with eating and therefore have weight gain What things worsen peptic ulcers? Stress spicy foods NSAIDs ETOH smoking and caffeine What diagnostic treatment needs to be done? Upper endoscopy and biopsy What are classic sx of duodenal ulcers? Two to fiver hours after a meal whenacid is secreted in the absence of a food buffer, at night between 11pm and 2am when the circadian stimulation of acid secretion is maximal What are the classic sx of gastric ulcers? food provoked sx, epigastric pain that worsens with a eating, postprandial belching, epigastric fullness, early satiety, fatty food intolerance, nausea and vomiting what is important to do when testing forH. Pylori? Stop PPI therapy one to two weeks prior to testing, testing should performed at least four weeks after completion of tx What are invasive ways to test for. H pylori? Biopsy urea testing and histology What are noninvasive ways to test for h pylori? Urea breath tests (high sensitivity and specificity) Stool antigen assay which would indicate ongoing infection Once confirmed positive for H pylori and tested, what should be done next? Repeat testing 4 weeks after end of tax to confirm eradication Medication tx for H pylori Combination therapy of 2abx + PPI and/or bismuth If a patient is positive for H Pylori and has prior exposure to macrolides and Clarithomycin resistance, which tx will be utilized? Bismuth quadruple therapy for fourteen days, including bismuth, flagyl, tetracycline and a PPI If a patient is positive for H Pylori and has NO prior exposure to macrolides and Clarithomycin resistance, but has a penicillin allergy, and has used flagyl within the last few years, which tx will be utilized? Bismuth quadruple therapy will be used including bismuth, flagyl tetracycline and PPI If a patient is positive for H Pylori and has NO prior exposure to macrolides and Clarithomycin resistance, but has a penicillin allergy, and has NOT used flagyl within the last few years, which tx will be utilized? TX with either Clarithomycin based triple therapy with Flagyl That can be Clarithomycin Amoxicllin and PPO or Clarithomycin FLagyl and PPI If a patient is positive for H Pylori and has NO prior exposure to macrolides and Clarithomycin resistance, but does NOT have a penicillin allergy, which tx will be utilized? Clarithomycin based triple therapy with amoxicillin and PPI If H. Pylori is present with duodenal ulcer, post abx tx, what options should be continued for additional tx? Omeprazole 40mg daily for 7 weeks Lansprazole 30mg daily for 7 weeks H2 blockers or Sulcrafate can be given for 6 to 8 weeks What are signs of bleeding in PUD? Hematemesis or hematocehzia, hemodynamic instability What are signs of perforation in PUD? Sudden severe diffuse abd pain If a patient has an acute upper GIB, what should be done next? Eval, stabilize and upper GI endoscopy performed If pt has an acute upper GIB, with high risk ulcers in endoscopy what should be done? endoscopic therapy + IV PPI If the bleeding reoccurs, angiographic embolisation or surgery should occur If pt has an acute upper GIB, with low risk ulcers in endoscopy what should be done? Oral PPI What are the three phases of perforation in peptic ulcers? Phase one 2 hours acute sudden pain Phase two 2-12 hours pain may lessen generalized abd rigid Phase three 12 hours abd distenson, peritonitis and circulatory collapse If on X-RAY presence of free air on abd imaging is seen on the R hemidiaphragm, what does it indicate? Highly indicate of a perforated viscus What needs to be done in terms of management of perforation? NG tube, Volume replacement, IV PPOO, Abx (combo beta lactam so like Unasyn or Zosyn, or combo third gen cephalosporin like Cetftriaxone or cEftazidime plus Flagyl) Surgery is patient dependent What are symptoms of gastritis? Epigastric discomfort, nausea without vomiting What is essential for tx in gastritis? Recognizing causation What is the most common cause of gastritis ? H. Pylori What causes gastritis? NSAIDS, alcohol abuse, stress, infection chronic = h. pylori Autoimmune responses If patient has chronic gastritis, what else should be considered? Pernicious anemia What is the tx for gastritis? To eliminate the underlying cause, no well defined tx protocol. Can use PPI or H2 receptors but remove what is causing is it. EGD is not necessary What is GERD? Acid exposed to esophageal mucus, high acid decreased peristalsis, relaxation of lower esophageal sphincter (LES) What can cause pt's relaxation of lower esophageal sphincter? Estrogen, progestins, theophylline, calcium channel blockers, bentos, TCA, ETOH, tomatoes, citrus, chocolate, coke, peppermint, overeating, supine 3hours after eating, nicotine and obesity When does GERD symptoms worsen? At night What are some symptoms caused by GERD? Sore throat (morning), cough, dysphonia, persistent clearing of throat, bad taste in mouth, wheeze (which can be difficulty to control in asthma) What assessment can be done for GERD? Clinical symptoms, PPI tests are not great, endoscopy, pH monitoring barium esophagram also not typical in eval of GERD should be performed with coincident dysphasia