NURS 600 quiz #3 modules 5-6 2023 with verified questions and answers

Mild/Moderate depression Prevalence 5-12% will experience at some point can be as high as 40$ Depression Risk Factors pre-existing mood disorder Signs/Symptoms Depression negative emotional experiences, sadness, disinterest (anhedonia), self-hate, unexplaind fatigue, anger, anxiety, irritability, hyperactivity, altered sleep, appetite or sexual behaviour. Motor slowness, stooped posture, minor cognitive impairment Differential Dx for Depression parkinsons, thyroid disorders, dementia, epilepsy, CVA and tumors Work up for Depression ask 2 questions: Have you felt down or hopeless in the past month? Little interest in doing things for the last month? PHQ-9 checklist of 9 symptoms over 2 week time. Full physical assessment, medical history, neuro exam, UA, routine blood work including THYROID and ADRENAL function. any family HX of depression Medications that can cause Depression BP meds, sedatives, hyponotics, anti seizure, antipsychotics, anti parkinsons, steroids, analgesics, antibacterials, antineoplastics. Pharm management for depression ... Non-pharm management for Depression ... Major Depression Risk Factors female, strong family history or suicide attempt, etoh abuse, hx of migraines, back pain, recent MI, peptic ulcer dx, current chronic disease, insomnia, stress, poverty, high school education, recent trauma, parent or caregiver with behavior disorder, hypersecretion of cortisol and coexisting thyroid disorder. Sign/Symptoms Major Depression severe negative changes in mood, thinking and behavior sadness and apathy slowed thinking emotional numbness substance abuse social withdrawal death and suicidal thoughts that persist regardless of circumstances global thinking is distorted/ circular loss of energy anxious distress difficult thoughts about future melancholy can have psychotic features with catatonic states. Pharmacologic management of Major depression simultaneous use of psycho therapy and medications. SSRI's, SNRI, NRI, TCA's and DA's Non pharmacologic management of Major depression CBT, home and reassurance, Massage, relaxation therapy, exercise, good nutrition, self care. establish a routine, focus on behaviors or activities rather than feelings. PHSQ-9 scores 0-4 : None 5-9: Mild 10-14: Moderate 15-19: Moderately Severe 20-27: Severe General Anxiety Disorder excessive worry over 6 month period of time about multiple concerns that are difficult to control General Anxiety Disorder Prevelance: 50-90% have co-morbid depression Women Men 5-6% of general population have GAD. General Anxiety signs and symptoms occurs more days than not associated with 3 or more symptoms: easy fatigue, difficulty concentrating, muscle tension, sleep disturbance, feelings of restlessness or hyperness. Hyperarousal and insomnia. More disruptive than normal anxiety. motor symptoms: shakiness, restlessness, headache, autonomic hyperactivity: sweating, palpitations, GI distress, tachycardia, HA, SOB, cognitive villegence (irritability and quick to startle). must cause significant impairment or distress. Differential diagnosis for GAD caffeine intoxication stimulant/ etoh abuse sedative anxiolytic and hypotic withdrawal panic disoders phobias OCD Workup for General Anxiety disorder EKG, CBC, thyroid function tests, Beck anxiety interview, hamilton anxiety rating scale, anxiety disorder interview schedule primary care exam of mental disorders ( somatic complaints such as stomach, back, chest pain, dizziness, sweating, depressed feelings and loss of interest. Management of GAD SSRI's SNRI's Benzos ( for short term use or acute issue only) SSRI's zoloft paxil lexapro SNRI effexor buspar Benzo's Valium xanax ativan klonopin other off label meds for GAD stelazine vistaril Lyrica Non pharm management for GAD relaxation training CBT decreased nicotine and caffeine intake Panic Disorder recurrent, intense and short panic levels with psychological and physical sx of anxiety can occur when focus of others attention ( public speaking) Prevalence of panic disorder 1.5-3% of the population peaks at 25 years women men Risk factors for panic disoder family history of panic comorbid psych disorder major depression bipolar substance abuse Signs/Symptoms of Panic disorder sudden panic onset panic symptoms create secondary sx of fear unshakable sense of doom/danger one attack followed by 1 month or more of persistent worry Panic develops quickly (10 mins) and usually resolves in 1 hr. First attack usually outside the home What are the physical symptoms associated with panic disorder Panic disorder must meet these 4 criteria: hx of recurrent, unexpected attacks one attack is followed by 1 month of persistent worry about having additional attacks, and implications of attack with significant change in bahavior r/t attacks not related to substance abuse or general medical condition not better accounted for by another mental disorder: OCD, social phobia, PTSD, separation anxiety. Differential diagnosis for Panic Disorder schizo bipolar depression pheochromocytoma hyperthyroidsim SE cardiac arrhythmia MI abuse or withdrawal of substances steroids theophylline Workup for Panic disorder comprehensive PE CBC, thyroid, chemistry cardiac enzymes consider tox screen Pharm management for Panic Disorder SSRI's SNRI's first line consider Benzo for acute attack/ episodes Non Pharm CBT avoid triggers hypnosis yoga meditation PTSD anxiety disorder triggered by witnessing, participating in or hearing about an extremely traumatic event. reaction is usually fear and helplessness, reliving the events over and over and trying to avoid being reminded of it. Prevalence of PTSD 8-9% of general population women 2x men very young and very old more susceptible Risk Factors for PTSD physical/sexual childhood abuse, sexual or other life threatening assault, combat exposure, Fire, flood, hurricane, witnessing severe bodily injury or death. increased association with anxiety, substance abuse and mood disorders. Signs Symptoms of PTSD may experience traumatic events in dreams and daily thoughts may have numbing responsiveness along with depression, anxiety, cognitive difficulties and often substance abuse. Differential diagnosis PTSD anxiety Bipolar Workup CBC, chem, UA (tox screen) thyroid Non Pharm intervention crisis intervention immediately after trauma debriefing not recommended anymore CBT Pharm management for PTSD SSRI's: Paxil and Zoloft refer to psych Rheumatoid Arthritis Autoimmune disorder characterized by symmetric inflammatory polyarthritis and varying degrees of extra-articular involvement Prevalence Rheumatoid Arthritis Females males almost 3:1 20-40 yrs Signs/Symptoms of Rheumatoid Arthritis insidious onset: general systemic manifestations of inflammation (weakness weight loss, malaise, fatigue, anorexia, aching and stiffness) morning stiffness lasts minimum 1 hr metacarpophalangeal and PIP joints, wirsts, and metatarsophalangeal joints are commonly affected. joint involvement in bilateral and symmetric hips, knees, shoulders and C-spine sub Q nodules extra-articular signs: vasculitis, ocular signs, respiratory and cardiac involvement Work up for Rheumatoid Arthritis based on clinical hx and PE labs: CBC, ESR, CRP, ANA, RF factor, serum creatinine, hepatic panel, UA, anti-CCP antibodies radiographs of affected joints synovial fluid analysis Differential dx for Rheumatoid Arthritis Psoriatic arthritis seronegative spondyloarthritis fibromyalgia tendinitis bursitis viral infections Management for Rheumatoid Arthritis DMARDS (need to have TB test and Hep B titers) NSAIDS: ASA, Tylenol or Motrin. Corticosteroids: Prednisone: 7.5 mg daily or intra-articular injections. Gluccocorticoids Non Pharm for Rheumatoid Arthritis PT, OT, hot or cold applications, exercise, assistive devices (braces) splints, weight loss, psychological interventions, assess cardio risks. Systemic Lupus Erythematosus SLE chronic multisystem inflammatory autoimmune disorder Prevalence of SLE 85% women, higher incidence in women of color in US. Signs/ symptoms of SLE classic Malar (butterfly) rash, alopecia and scalp xanthema discoid lupus rash/skin lesions. fatigue joint pain SE edema chest pain nephritis, serositis, vasculitis malaise weight loss/ anorexia fevers lylmphadenopathy tachycardia Differential DX for SLE rheumatoid arthritis mixed connective tissue disease dermatomyositis primary systemic vasculitides fibromyalgia endocarditis lyme disease MS infections non rheumatic disorders Workup for SLE CRP, ESR, serum gamma globulins, CBC with diff, ANA, RA, Anti-smith and anti-double stranded DNA antibodies, BUN/creat, 24 hr protein, IgG and IgM, anticardiolipin antibodies and anti-beta-2 glycoprotein 1 and lupus anticoagulant. Pharm Management for SLE corticosteroids Statins NSAIDS hydroxychloroquine immunosuppresant agents human monoclonal antibodies Non-Pharm for SLE avoid sun exposure modest physical exercise heart healthy diet low dose Omega-3 fish oil regular PE, gyn exams, annual flu vaccine, osteo and HTN prevention Raynauds Phenomenon reversible vasospastic disorder affects blood flow to digits/hands Primary: no associated autoimmune disorder Secondary: + autoimmune disorder (SLE) or may be associated with CREST constellation. CREST constellation Calcinosis, Raynaud's phenomenon, esophogeal dysmotility, sclerodactlyly and telangiectasia Prevalence of Raynaud's 70-80% women 15-45 Signs and Symptoms of Raynaud's classic tricolor changes white (pallor) blue (cyanosis) and then Red (reperfusion hyperemia) after vasospasm ends parasthesias symmetric infrequent involvement of feet or toes may involve single digits or multiple body parts vasospasm time frame: 20 min-hours physical exam: demarcation where spasm occurs. Differential Diagnosis occupational exposures occlusive vascular disease connective tissue disease hematologic disorders cold agglutinins livedo reticularis atherosclerosis, buergers disease, repetitive motion injury workup for Raynauds phenomenon based on clinical history and classic tricolor changes capillaroscopy ANA Pharm tx for Raynauds phenomenon Non Pharm is initial treatment CCB's first line therapy. slow release nifedipine 30-180, amlodipine: 5-20 mg endothelin-blocking agents oral and inhaled prostaglandin inhibitors Non-Pharm tx for Raynauds clothing/ keep body warm stress management strict avoidance of smoking Polymyalgia Rheumatic connective tissue disease polyarthalgias in pts 50 remain rheumatoid factor- negative and have chiefly proximal muscle pain and stiffness, centered on the shoulder and hip girdles. Common DMARDS in Rheumatoid Arthritis Methotrexate usually the initial synthetic DMARD 7.5 mg orally once weekly, can increase to 15 mg orally once per week if tolerating meds with no response. Max dose: 20-25 mg/week Second line agent for DMARDS? sulfasalazine 0.5 g orally BID increased weekly by 0.5 g until symptoms improvement or 3 g max dose. Biologic DMARDS TNF (tumor necrosis factor) Inhibitors: etanercept infliximab adalimumab golimumab certolizumab pegol Etanercept. Pharm for SLE Antimalarials: hydroxychloroquine 200-400 mg/day corticosteroids.: 40-60 mg When would you use corticosteroids in SLE? glomeruloenphritis hemolytic anemia pericarditis or myocarditis alveolar hemorrhage CNS involvement thrombotic thrombocytopenia purpura. Prevalence for Polymyalgia Rheumatic 50 Signs/symptoms polymyalgia rheumatic pain and stiffness in shoulders and hips lasting for several weeks without other explanations fever, malaise, wt loss, stiffness and pain in the shoulders, hips and lower back. pts have difficulty with ADL's NO muscular weakness Differential diagnosis for polymalgia rheumatic giant cell arteritis. Main difference between giant cell arteritis and polymalgia rheumatic Polymyalgia Rheumatica: does not cause blindness, responds to low dose 10-20 mg daily prednisone. Giant Cell Arteritis: can cause blindness and large artery complications and requires high dose prednisone. (40-60mg) Signs/symptoms of Giant cell arteritis vs Polymyalgia rheumatica: headache, scalp tenderness, jaw claudication, throat pain, diplopia Symptoms of polymyalgia rheumatica: pain of shoulder/pelvis Workup for Polymyalgia Rheumatica: CBC (anemia), ESR's Pharm for Polymyalgia Rheumatica prednisone 10-20 mg daily. should have dramatic improvement in 72 hrs. If not, need to re-evlaluate. usually need 2-4 weeks treatment, then taper dose. Most patients require some dose of prednisone for a min of 1 year. disease flares are common. Weekly doses of Methotrexate can assist in tapering prednisone. Giant Cell Arteritis systemic panarteritis affecting medium sized and large vessles frequently called temporal arteritis headache, jaw claudication, polymyalgia rheumatica, visual abnormalities can cause blindness any unexplained head or neck pain in pt 50 should r/o giant cell arteritis. workup for giant cell arteritis ESR 100 (frequenlty, but not always) initiate prednisone 60 mg daily immediate temporal artery biopsy. Ankylosing Spondylitis chronic inflammatory disease of joints of axial skeleton pain and progressive stiffening of the spine Prevalence of Ankylosing Spondylitis age of onset: late teens early 20's Males females symptoms more prominent in Men Men more likely to have ascending involvement of the spine Signs/symptoms of Ankylosing Spondylitis Chronic low back pain in young adults (worst in am) progressive limited ROM in spine and chest. gradual intermittant bouts of back pain that radiates to buttocks. symptoms progress in cephalad direction pain improves with movement (opposed to rest with musculoskeletal injuries) anterior uveitis (25% of cases) enthesopathy of achilles tendon. (swelling at insertion site) Workup for Ankylosing Spondylitis ESR elevated in 85% rheumatoid factor and anti-ccp antibodies are negative CBC for anemia HLA-B27 (90% of white pts, 50% black) ( not a specific test) Radiographs: sacroiliac usually earliest affected. Hallmarks of Ankylosing Spondylitis 30 with back pain, inflammatory quality; morning stiffness,, pain improves with activity. should r/o AS Pharm Ankylosing Spondylitis NSAIDS (first line tx) TNF inhibitors if NSAID resistant. pharmacokinetics SSRI's Absorption well absorbed in GI tract peak plasma levels 1-8 hrs Food doesn't affect absorption. SSRI: bind to proteins and are widely distributed throughtout the body, including the brain. SSRI's are Lipophilic. Metabolism of SSRI's metabolism and elimination occur largely in the Liver. Elimination SSRI's half life is aprox 1 day ranging from 20-30 hours. fluoxeting: 1-3 days norfluoxetine: 4-16 days fluvoxamine: 15 hrs. escitalopram/lexapro: 27-32 hrs absorption SNRI's food decreased the rate but not degree of absorption (food helps decrease nausea) Most common SSRI's ...