FNP NR 506 LEIK EXAM TIPS TEST PREP (NR506)

Exam (elaborations) FNP NR 506 LEIK EXAM TIPS TEST PREP (NR506) LEIK EXAM TIPS Health Screening and Health Promotion US Health Statistics/Mortality Statistics Leading cause of death (all ages/genders): 1. Heart disease (or diseases of the heart) 2. Cancer (or malignant neoplasms) 3. Chronic lower respiratory diseases (i.e., chronic obstructive pulmonary disease [COPD]) Leading Cause of Cancer Death 1. Lung Cancer for both men and woman 2. Men – prostate & Woman- Breast 3. Colorectal Cancer for both men and woman Leading Cause of Death in Adolescents (^ in males than females) 1. Accidents /Unintentional Injuries 2. Suicide 3. Homicide Leading Cause of Death by Age Group  Birth to 12 months:  Congenital malformations (20.3%)  Ages 1 to 44 years:  Unintentional injuries  Ages 45 to 64 years:  Cancer (30.9%)  Ages 65 and older:  Heart disease (25.6%) Average Life Expectancy: 78.8 years of life Cancer Statistics Most Common Cancer: skin cancer Most Common type of skin Cancer: Basal Cell Carcinoma and Melanoma causes the majority of skin cancer related deaths. Most Common Cancer by Gender  Men – Prostate cancer (there are more cases of prostate cancer, however lung cancer is still the highest mortality cancer associated to males).  Females- Breast Cancer (there are more cases of breast cancer, however lung cancer is still the highest mortality cancer associated to females). Most Common Cancer among all children: Acute Lymphoblastic Leukemia (34% of all cancers in children). FNP NR 506 LEIK EXAM TIPS TEST PREP Sensitivity vs. Specificity  Sensitivity: is a good way of detecting those people who have the disease (i.e. true positive).  Specificity: is a good way of detecting those people without the disease (i.e. true negative). Top Three Cancers in Children  Leukemia (34%)  Brain and nervous system tumors (27%)  Neuroblastoma (7%) Health Promotion Aspirin Use to prevent Cardiovascular Disease or Colorectal Cancer  Begin at age 50-59 with =/ 10 % risk for cardiovascular disease (ASCVD score) Breast Cancer  Risk factors o age 50 or greater, o previous hx of breast CA, o two or more first * relatives o nulliparity, early menarche, late menopause (longer exposure to estrogen) o Obesity (adipose cells can synthesize small amounts of estrogen)  Baseline mammogram starts at 50 years of age  Repeat every 2 years from ages 50-74 years of age NOTE: Does NOT apply to those individuals with known genetic mutations (BRCA1 or 2), familial breast cancer history, history of chest radiation at a young age or previously diagnosed with high risk breast lesions, who may benefit from starting screenings at age 40. So, essentially if at high risk start screenings at age 40-49. Cervical Cancer  Risk factors o Multiple sexual partners o Younger age onset of sex o Immunosuppressed and/ or smoking individuals. Age Group Recommendations for Pap/Liquid Cytology Age 20 years or younger Do not screen (even if sexually active with multiple partners). Age 21 to 65 years Baseline at age 21 years. Screen every 3 years. Age 30 to 65 years Another option starting at age 30 years is to screen with combination of cytology plus human papillomavirus (HPV) testing every 5 years. Had hysterectomy with removal of cervix If hysterectomy with cervical removal was not due to cervical neoplasia (CIN grade 2) or cervical cancer, then can stop screening. Age Group Recommendations for Pap/Liquid Cytology Women older than 65 years who had adequate prior screening Do not screen if history of adequate prior screening and is otherwise not at high risk for cervical cancer. Colorectal Cancer  Risk factors o Familial history of polyposis (multiple polyps on colon) o 1st * relative with colon cancer o Chron’s disease (ulcerative colitis)  Start at age 50-74 years of age is routine screenings  Age 76-85 years of age: against routine screening, but may have individual considerations for screening.  Screening Modalities for Colorectal Cancer o High-sensitivity fecal occult blood test (gFOBT) for three consecutive stool samples annually o Flexible sigmoidoscopy or CT colonography every 5 years o Colonoscopy every 10 years Lipid Disorders  Must be fasting for a minimum of 9 hours.  40-74 years of age  Must have 1 or more risk factors i.e.- dyslipidemia, DM, HTN, and/ or smoking.  ASCVD of 10 % or greater Lung Cancer  Screening for individuals who smoke 30 pack-years or have quit in the past 15 years.  Age 55-80 years of life – low dose CT Prostate Cancer  Risk Factors o 50 years or older o African Ancestry o 1st * relative with prostate cancer.  Does not recommend PSA screening for prostate CA.  The benefits do NOT outweigh the disadvantages. Ovarian Cancer  Very high-risk women with BRCA1/BRCA2 mutations: Refer to specialists. If ovarian cancer screening is done, transvaginal ultrasound with serum cancer antigen (CA-125) is ordered.  Screening starts at age 30  Some recommend BSO between age 35-40 years of life.  Who is at high risk? o Look for family history of having two or more first- to second-degree relatives with a history of ovarian cancer or a combination of ovarian cancer; women of Ashkenazi Jewish ethnicity with first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer. Skin Cancer Counseling  Should occur starting at age 10-24 with fair skin.  Should avoid sunlight from 10am-to- 4 pm and use of 15 spf sunblock or higher, protective clothing, wide brim hats. No Routine Screening for the following  Ovarian cancer  Oral cancer  Prostate cancer  Testicular cancer General Recap of Screening Recommendations Vaccination Facts Hepatitis B Vaccine  Total of 3 doses with one given at birth and 4 weeks given between 1st and 2nd dose.  If patient only one dose of hep B vaccine? o Do not restart the series, just give the second dose. Then given 3rd when time permits. Influenza Vaccination  6 months is the youngest age at which it can be given.  Most flu vaccinations are manufactures using egg-based technology. o Note: only 1.3% of children and only 0.02 % of adults have egg allergies.  Use caution with pt’s with previous reactions, history of Guillain-Barre syndrome within 6 weeks prior to previous immunization.  Live vaccine contraindications o Pregnancy o Chronic disease (i.e. COPD, Renal failure, DM, and immunosuppression). o In children on aspirin therapy ages 2-64 years of age. Tetanus Vaccines (Tdap and/ or Td)  Given every 10 years with boosters (i.e. contaminated wounds) every 5 years.  Age Implications o Infancy and younger than 7 years of age : use DTap form. o 7 years of age and older: only use Td or Tdap forms of the vaccine o All forms are given IM  Tdap can be used as a booster and substitute for Td (but only once in a lifetime) in adolescent and adults starting at 11-12 years of age.  What do you do for someone with a tetanus prone wound that has no tetanus history? o Give Td/Tdap vaccine and the tetanus immunoglobin (TIG) injection ASAP.  High risk wounds for Tetanus exposure o Puncture wounds o Wounds with devitalized tissue o Soil contaminated wounds o Crush injuries o Other injuries that are high risk for tetanus infection.  Use in caution with hx of Guillian-Barre Syndrome within 6 weeks of previous dose as well as pertussis component in individuals with progressive or unstable neurological disorder and or uncontrolled seizures. Pneumococcal Vaccinations  Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax (50% effective): 65 years of age or older.  Pneumococcal conjugate vaccine (PCV13 or Prevnar) (85% effective) o All children less than 5 years of age o Those who are at high risk for pneumococcal disease  Chronic Disease (alcoholism, DM, CSF leaks, asthma, chronic hepatitis).  Anatomical or functional asplenia (including sickle cell disease)  Immunocompromised or on medications that are immune-compromising.  Malignancy or cancers of the blood.  Renal Disorders  History of organ or bone marrow transplant.  65 years or older – CDC recommends giving PCV 13 first (if they never had PPSV23) then 12 months later give PPSV23 (better immunologic response is seen with this order)  In Adults less than 65 years of age who were previously vaccinated with Pneuovax 23 a booster should be given every 5 years after the initial dose. Shingles Vaccination  Risk factors for shingles o Older age (60 or ) o Immunocompromised – HIV, steroids, chemotherapy o Leukemia or lymphoma  Zoster Vaccine (Zostavax) is a LIVE vaccination.  Give at age 60 with a one time-SC even with a past history of shingles or chicken pox.  Certain anti-viral medications (acyclovir, famciclovir, valacylovir decrease the effectiveness if taken within 24 hours prior and 14 days after vaccination.  Can cause an exacerbation of asthma and polymyalgia rhematica (PMR)  Youngest age Zostavax can be given is 50 years of age.  Shingles is contagious until the lesions are dry and crusted (follow contact precautions)  NOTE: Shingles vaccine has 14 more times VZV then the varicella vaccine (Varivax) Varicella Vaccination  Varivax is a LIVE vaccine  1st Dose: given at 12-15 months (no younger) and ADVISE woman not to get pregnant for 1 month after getting vaccination.  Reactions: Mild rash or several small chickenpox rashes can occur after vaccination (contagious, avoid immunocompromised people).  DO NOT administer to someone born in the United States before 1980 Immunizations for Health Care Workers  Td or Tdap: Give one-time dose of Tdap for all health care personnel who have not received the Tdap when due for a tetanus booster. Continue giving Td boosters every 10 years for a lifetime.  MMR: Proof of immunity is necessary (born before 1957, laboratory confirmation such as positive titers). If not vaccinated for MMR, two doses are needed (at least 28 days apart).  Varicella: Proof of immunity is necessary (positive varicella titer, documentation of two doses of varicella vaccine or diagnosis of varicella by physician/health care provider).  Hepatitis B: If incomplete hepatitis B series (fewer than three doses), complete the series (do not restart). If job involves blood or body fluids, obtain anti-HBsserological testing 1 to 2 months after dose 3. If anti-HBs is less than 10 mIU/mL, three additional doses should be administered on the regular hepatitis B schedule followed by anti-HBs testing in 1 to 2 months.  Influenza: All health care personnel should have an annual influenza shot during the fall/winter. Vaccination Clinical Pearls  TB blood tests (IGRA) are preferred method of testing of TB for people who have received BCG vaccine.  During flu season around 80-90% of all flu related deaths occur in people aged 65 years or older. Start immunizations in October. Systems Review Eye Emergency Review Herpes Keratitis  Clinical Manifestations: o Severe ACUTE onset of eye pain o Photophobia o Tearing o Blurred vision in one eye  Diagnosed: Fluorescein dye with black lamp in a dark room. (fern like lines in the corneal surface).  Can effect Cranial Nerve V –ophthalmic branch if due to shingles infection  Can cause permanent damages of the corneal epithelium. Acute Angle-Closure Glaucoma  SUDDEN blockage of aqueous humor caused by ^ IOP, resulting in ischemia and damage to CN II) Optic nerve.  Clinical Manifestations: o Acute onset of severe eye pain o Headache o Nausea and/or Vomiting o Halos around lights o Decreased vision.  Exam o Mid-dilated pupil that is OVAL shape o Fundoscopic exam shows cupping of the optic nerve.  Management: Immediate ED referral. Primary Open-Angle Glaucoma  GRADUAL onset of ^ IOP 22mmHg due to blockage of drainage inside the eye.  Clinical Manifestations: o Usually asymptomatic in early stages. o Changes in peripheral vision first then central vision. o C/O of missing portions of words when reading  Exam: If shows cupping (IOP is to high and warrants immediate ophthalmologist referral). Retinal Detachment  Clinical Manifestations: o Sudden onset of floaters associated with looking through a curtain o Sensations of sudden flashes of light (Photopsia)  Management: Refer to ED Ear, Nose, and Sinuses Review Cholesteatoma  Clinical Manifestations: o Cauliflower like growth (non-cancerous) can erode into the bones and cause nerve damage. (Cranial Nerve Vii). o Foul smelling ear discharge o Hearing loss on affected side  Exam o TM or ossicles are no longer visible o Hx of chronic otitis media infection.  Management: o Antibiotics and surgical debridement and refer to otolaryngologist. Battle Signs  Clinical Manifestations: o Bruising occurs behind the ear (mastoid area) 2-3 days after trauma occurs  Exam: o Physical exam does not show the clinical signs right away o Look for clear, golden, serous discharge from ear or nose (essentially a CSF leak through the fracture. You can test the fluid with a urine dipstick and if it is positive for glucose than its CSF fluid. Normal drainage should be negative for glucose.  Management: o R/O basilar and/ or temporal bone skull fracture b/c it can lead to intracranial hemorrhage. (Refer to ED) Pharynx Emergency’s Peritonsillar Abscess  Clinical Manifestations: o Sore throat, difficulty swallowing and/ or painful swallowing (odynophagia) o Jaw muscle spasm making it difficult to open mouth (Trismus) o “Hot Potato Voice” o malaise o Fever/chills  Exam o Unilateral swelling of the Peritonsillar area and soft palate o Markedly swollen o Bulging red mass with uvula displacement away from mass  Management: Refer to ED Diphtheria  Clinical Manifestations: o Sore Throat o Hoarseness with dysphagia o Low grade fever o Markedly swollen neck (Bull neck) o Posterior pharynx, tonsils, uvula, and soft palate are coated with gray-to yellow colored pseudomembrane  Management: o Contact Isolation: VERY contagious. o Refer to ED Head, Near, Eyes, Nose, and Throat Review (EXAM TIPS ONLY) Seasonal Allergic Rhinitis  Topical steroid nasal spray (Flonase is the 1st line defense). Uticaria  New onset is treated with Benadryl (sedating and last a few hours) or Zyrtec (last 24 hours) Mononucleosis (Acute or Reactivated)  Clinical Manifestations o Generalized maculopapular rash o Enlarged tonsils o Cryptic Exudate (white or darker color) o Sore throat o Enlarged Cervical nodes that are tender to touch. Otitis Externa  Common Pathogen – Psudomonas  Treatment for Otitis external is Cortisporin Otic Drops. Ruptured Spleen  Avoid contact sport for 4 weeks until US show resolution. Beta Blocker eye drops (Timolol)  Used to decrease intraocular pressure  Has the same contraindications as PO beta blockers. Cholesteatoma  Peri-orbital sinusitis complication that results in a cauliflower like growth accompanied by foul-smelling ear discharge.  Clinical Manifestations o No visualization of TM or ossicles  Treatment: Abx, surgical debridement and refer to EENT Penicillin allergic patients  Use Macrolides and quinolones that have gram + coverage (usually 4th generation abx)  Avoid Cephalosporin’s if patient has had a class I reaction or anaphylaxis to PCN. Learn to recognize Eye descriptions Chalazion:  Chronic inflammation of the melbomian gland (specialized sweat gland) of the eye lid  Painless and can resolves spontaneously in 2-8 weeks and/ or enlarge over time.  Often times pt’s c/o of gradual onset of small superficial nodule on the upper eyelid that feels like “bread” Pinguecula:  Yellowish to white small white growth of the bulbar conjunctiva located next to the cornea  Due to UV light damage to collagen. Pteygium:  Yellowish triangular “WEB SHAPED” thickening of the conjunctiva that extends to the CORNEA on the nasal side.  Can be red and inflamed at times and Pt’s often c/o of foreign body sensation on the eye. Treatment for BOTH pinguecula and Pteygium  If inflamed – use weak steroid eye drops during exacerbations  Recommend good quality sunglasses  Remove surgically if encroaches cornea and affects vision. Cerumenosis  Impacted wax blocking auditory canal  Txt: OTC is carbonate peroxide (similar to hydrogen peroxide) Vision  What someone sees at 20/40 vision means that they can see at 20 feet can see what the normal person at 40 ft can see. Herpes Keratitis  Two Types o Herpes Simplex Keratitis – infection due to herpes simplex virus. (self inoculation “cold sores: or herpes whitlow) o Herpes Zoster Ophthalmicus- acute eruption of crusty rash that follows the ophthalmic branch (CN V1) of the trigeminal nerve on only one side of the forehead, eyelids, and/ or tip of nose. (ED REFFERRAL)  Clinical Manifestations: o Severe onset of eye pain o Photophobia o Tearing o Blurred vision in one eye  Diagnosed: Fluorescein dye with black lamp in a dark room. (fern like lines in the corneal surface).  Management: o Shingles form send to ED ASAP. Corneal Abrasions or Keratitis  Use fluorescein strips to diagnosis/check Papilledema- swollen optic nerve RT to ^ ICP secondary to bleeding, tumor & etc. Hypertensive Retinopathy  Copper and silver wire arterioles (caused by arteriosclerosis)  AV nicking (when arteriosclerotic arteriole crosses the retinal vein and thus causes and indentation. Retinal hemorrhages occur as well. Diabetic Retinopathy  Micro-aneurysms are caused by neovascularization (new fragile arteries in the retina that rupture and bleed).  Cotton wool spots- look like fluffy yellow-white patches on the retina. Cataracts  Opacity of the lens of the eye (central or on the sides (cortical)).  Difficulty with glare (with headlights when driving at night or sunlight) , halos around lights, blurred vision. Koplik’s Spots  Cluster of small red papules with white centers inside the checks by the lower molars that is usually indicative of Measles. Hairy Leukopenia  Elongated papilla of the tongue that is usually indicative of HIV infection that is caused by the Epstein-Barr Virus. Cheilosis  Painful skin fissure at the corners of the mouth due to excessive moisture (most common in elderly with dentures).