Elite NP Certification Exam Review Guide a The Elite _ Fit nn8 a= | practitioner Justin Allan, N.P.THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE For the FNP and AGNP Tests Justin Allan, N.P.Copyright © 2021 by Justin Allan All rights reserved. No part ofthis publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise without written permission from the publisher. It is illegal to copy this book, post it to a website, or distribute it by any ather means without permission First Edition This book is aimed at medical professionals, more specifically nurse practitioner students. This information should be used like any other type of medical iterature: think critically about the information provided and ensure that you understand how the information presented here fits with your own skills, work environment, and resources. = This book was written to help you pass your certification exam. This guide was not designed to teach you 2d, 3-4N)- SABA, Low dose ICS “Altern. Cromolyn, leukotriene, theophylline. * Mod Persistent (DAILY, NOT NIGHTLY}- SABA, Low dose ICS plus LABA or Medium dose ICS. ‘+ Severe- (Throughout the day, nightly} SABA, Med ICS plus LABA. All asthma patients need rescue inhaler! Treatment of mild persistent asthma adolescent + low dose ICS plus SABA (albuterol) PRN (preferred treatment) * alternative treatment — cromolyn, Montelukast, nedocromil, or theophyline ‘+ Remember all asthma patients must have SABA as rescue med (safety issue) Stage 1 - Intermittent - FEV >80 (-2 days/wk, -2 nights/mo) = SABA. Stage 2 - Mild - FEV >80 (+2 days/wk, 3-4 nights/mo) = SABA + ICS Stage 3 - Mod - FEV 60-80 (Daily symptoms, > 1 nightwk) = SABA + ICS or Med ICS Stage 4 - Severe - FEV <60 (All day, Every night) = SABA, Med ICS + LABA ‘SABAs - Albuterol, Levalbuterol ICS (Inhaled corticosteroids) - Fluticasone, Mometasone, Beclomethasone, Budesonide LABA - Salmeterol, Formoterol MNEMONIC: ASTHMA Management of ASTHMA: Adrenergic (albuterol) + S= steroids theophylline * He hydration IV * M= mask (02)RESPIRATORY DISORDERS ‘* A= antibiotics (infection) Emphysema Lungs Percussion- HYPERENNOSANCE Taztile fremitus + egophony- decreased CXR- flattened diaphragms with hyperinfiation. Inc. AP diameter, accessory muscles Pursed-lip breathing Weight loss. Bronchiolitis (TEST) The infant had 2 episodes of RSV/bronchi wheezing; differentials do not include: foreign body now presents with fever, cough, Pulmonary Embolism Use of Coumadin in pulmonary embolism (KNOW, ON TEST) ‘Teenager comes in with pulmonary embolism after sitting on plane for 5 hours. She is on birth control. You start Coumadin. Where do you want her INR? INR 2-3 for 3 months ‘+ therapeutic INR range - 2.0-3.0 ‘+ <2 increase coumadin dosage and repeat INR in 1 week + >3.and <7 - decrease coumadin dosage and repeat INR in 1 week + >7 and <10—stop coumadin for 2 days and repeat INR in 1 week ‘+ >10—stop coumadin and examine patient Bactrim can increase INR. Rifampin can lower INR IFINR >10, administer Vitamin K and hold coumadin dose. (TEST) Post-partum patient travelling from a long flight and complaining of SOB and feeling of impending doom, what should be suspected... Pulmonary Embolism Tuberculosis ‘Sputum culture for TB + for diagnostic purposes, sputum for AFB smear and culture should be obtained ‘+ atleast 3 consecutive sputum specimens in 8-to-24-hour intervals — 1 of which is an early morning specimen ‘+ sputum may be collected through cough (most common), sputum induction, bronchoscopy, gastric aspiration. It leads to fatigue, fever, cough. Never do fewer than 3-4 drugs initially if positive, then you can narrow it down. Latent TB usually treated with INH. Ifyou suspect ACTIVE TB order, NAAT, C&S, AFB. The AFB is not diagnostic.THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE SPUTUM FOR C & Sis gold standard. Deep morning cough collected for three "consecutive days” TB is usually upper lobes. >5mm-think immunocompromised or person in close contacts. >10 think Immigrants, working status, drug users, home life >16 Think no risks CXR: shows big black holes Pneumonia (TEST) Signs and symptoms of Mycoplasma pneumonia (walking pneumonia)... low- grade fever, fatigue, headache, non-productive or dry hacking cough. Treat: CXR middle lobe, macrolide or doxy According to 2019 ATS/IDSA guidelines: Remember, if patient exposed to one drug class of antibiotics in last 90 days, then choose another drug class. If severe, refer to hospital for inpatient treatment (Either respiratory distress or sepsis. Or 3 of the following: confusion, fluid resuscitation, hypothermia, RR >30, multlobe infiltrates, uremia, leukopenia, or thrombocytopenia.) Otherwise, outpatient treatment for community acquired pneumonia’ If >18 without comorbidities or risk of MRSA/Pseudomonas: Amoxil 1g TID or Doxy 100mg BID or a macrolide (zpack) If >18 with risk factors of drug resistant strep pneumonia or comorbidities (elderly, recent abx treatment in last 3 months, heart/lung/kidneylliver disease, DM, alcoholism, cancer): Monotherapy with a fluoroquinolone such as Levaquin 750mg daily OR ‘Augmentin 500 mg TID or Augmentin 875 BID or Augmentin 2000 BID or a cephalosporin such as Cefpodoxime AND a macrolide (zpack) or doxycycline 100mg BID MENOMINIC: CURB-€5: Criteria to determine PNA treatment- outpatient vs inpatient. 2 or more criteria = hospital * C= confusion urea > 7 Resp > 30 SBP <90 or DBP <60 65= Age > 65 Obstructive sleep apnea (TEST)Answer: Does not include Microglossia which is an absent tongue- congenital.RESPIRATORY DISORDERS Hypercapnia Causes greatest increase in respiration. Bronchiolitis (TEST) Don't give antibiotics, treat with cool mist breathing treatments. Croup (TEST) No antibiotics. Stridor barking cough. Dexamethasone x1 dose. Epiglottitis + Symptoms - acute onset of high fever, chills, toxicity; child complains of severe sore throat; drooling; child won't eat or drink; may have muffled ("hot potato’) voice; anxiety; may present with hyperextended neck with open-mouth breathing: may notice stridor, tachycardia, tachypnea + Usually occurs between ages 2 and 6 + Medical emergency (call 911) Anaphylaxis MNEMONIC: SSHHUUDD F GAP Clinical manifestations of anaphylaxis substernal pain = seizure hypotension headache urticaria upper air way edema dyspnea and wheezing Dizziness and syncope flush * G= GI symptoms \= angioedema pruritis (itch without rash) MNEMONIC: ACID Hypersensitivity reactions ype 1 Anaphylactic type 2 Cytotoxic type 3 Immune complex type 4 delayed hypersensitivityTHE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Acidosis and Alkalosis MNEMONIC: ROME: + Respiratory Opposite pH up PCO2 down =ALKALOSIS pH down PCO2 up= ACIDOSIS. + Metabolic equal PH up HCO3 up= ALKALOSIS PH down HCO3 down= ACIDOSIS MNEMONIC: RUB MUB Compensation Respiratory Uses Bicarb, Metabolic Uses Breathing ‘+ Respiratory ACIDOSIS Retains Bicarb INCREASED * Respiratory ALKALOSIS Excrete Bicarb DECREASED ‘+ Metabolic ACIDOSIS Increased Ventilations, Decreased bicarb ‘+ Metabolic Alkalosis, Decreased Ventilations, Increased bicarb Tracheoesophageal fistula MNEMONIC: 3 C’s Signs of esophageal atresia and tracheoesophageal fistula = Coughing * Choking + Cyanosis Dyspnea MNEMONIC: 6 P's 6 p's of dyspnea ‘+ Pneumonia ‘+ Pulmonary bronchial constriction * Possible foreign body ‘+ Pulmonary embolus ‘+ Pneumothorax © Pump failure Hypoxia MNEMONIC: RAT BED Early hypoxia symptomsRESPIRATORY DISORDERS restlessness + Acanxiety ‘achycardia/Tachypnea Late hypoxia symptoms bradycardia extreme restlessness + Dedyspnea MNEMONIC: 5 A's ‘Smoking cessation evaluation + Ask + Advise + Assess © Assist © Arrange Questions and Topics to Know! 1. Signs and symptoms of Mycoplasma pneumonia....low grade fever, headache, non-productive or dry hacking cough. 2. What can cause a chest x-ray to have a false negative reading......Dehydration 3. Patient with nasal turbinate's, bluish, pale, swollen with nasal discharge... Allergic rhinitis 4. Patient has runny nose, congestion, and round swollen mass in the nose... Nasal polyps 5. Postpartum patient travelling from a long flight and complaining of SOB and feeling of impending doom, what should be suspected... Pulmonary Embolism 6. Asthma first line treatment? SABA 7. Patient has TB- fatigue, fever, cough, and upper lobe infitrates on Xray 8. What causes the greatest increase in respiratory rate- hypercapnia 9. You suspect sleep apnea which includes everything but -obesity, enlarge tonsils, macrognathia or microglossia. Answer: MICROGLOSSIA 10. RML CXR for mycoplasma 11, Acute bronchitis description. Do not treat with what? Antibiotics 12. Croup/Epiglottitis: Question about what condition would make you order Lateral X-ray of the neck. Answer: Drooling, Unable to do ROM of the neck / stiff neck. 13. Know CURBS: Which of the options does not require hospitalization for pneumonia. Review CURSES: It's a criterion for pneumionia hospital admission 14, What causes an increase in respiration. hypercapnia! 15, Bronchiolits is a virus...... no antibiotics! 16. To diagnose COPD the NP should look for...... FEV1, FVC <70 17. How does Atrovent works in a patient with COPD. ..helps to expel secretions. 18. Acne cause from everything EXCEPT... peppermint and sodasIntegumentary System Actinic keratosis Precursor to squamous cell carcinoma. “numerous dry round and pink to red lesions” with a rough and scaly texture. Does not heal. Slow growing in sun-exposed areas. Diagnosis: BIOPSY is the Golden Standard. Treatment: small (cryotherapy), large (5-FU cream)- which causes your skin to 00ze, crust, scab, redness. REMEMBE! © Older to elderly fair-skinned adults * Numerous dry, round, pink to red-colored, slow-growing lesions that do not heal * Lesions common on sun-exposed areas (cheeks, nose, face, arms, back) Precancerous precursor of squamous cell carcinoma Frequent sunburns as child places person at higher risk * Diagnosed with biopsy ‘+ Treat with cryotherapy (small number) or 5-FU (5% fluorouracil) cream (large number) ‘© Follow up with dermatology Seborrheic keratosis ‘Soft round wart that is light tan to black and looks pasted on. Asymptomatic and benign. REMEMBER: ‘© soft, round, wart-like fleshy growths on trunk (mostly on back) © can range in color from light tan to black © appear to be pasted on asymptomatic = benign Herpes keratitis (TEST) Fluorescein dye “fern ”, affects CN V. Abrupt onset of pai Atopic Dermatitis (eczema) Inherited. Extremely itchy. On flexural folds, neck, hands. Increased IgE serology. ‘small vesicles that rupture leaving painful, bright-red, weepy lesions.” They can become lichenified from itching. First line: Topical steroids. Avoid hot water/soaps. PO antihistamines. (TEST)Patients with atopic dermatitis would be at risk for what other conditions? asthma, allergic rhinitis, multiple allergies REMEMBER: Atopic dermatitis (eczema) is marked by extremely pruritic rashes on hands, flexural folds (antecubital/popliteal space), and neck; rash is exacerbated by stress and environmental 8INTEGUMENTARY SYSTEM factors; rash appears as multiple small vesicles that rupture and leave painful, bright red, weepy lesions that become lichenified from chronic itching; fissures can form and can be infected with bacteria Treatment — topical steroids (1st line); systemic oral antihistamines; skin lubricants; hydrating baths Acne Vulgaris (common acne) Mild (topicals only} open/closed comedone w/ or wio small papules. Retin-A first, if acne worsens in 4-6 weeks or if no improvement in 8-12 weeks, then increase dose or add erythromycin, benzoyl peroxide. Moderate (topicals plus antibiotics)- papules, pustules w/ comedones. Continue with topicals combined with topical antibiotics. Then add ORAL antibiotics tetracycline, minocycline, doxycycline. Severe- with painful indurated nodules, cysts, abscesses, pustules. Accutane- check LFTs, 2 forms of contraceptives!, monthly pregnancy testing, only prescribe 1 month supply! Accutane needs to be prescribed and managed by a Dermatologist. REMEMBER Acne treatment: ‘+ mild — topical treatment only; tretinoin (Retin-A), benzoyl peroxide with erythromycin (Benzamycin) cream, clindamycin topical (Cleocin) ‘+ moderate — topical plus antibiotic; prescription topicals plus oral tetracycline/minocycline/doxycyciine (tetracyclines can be given starting at about age 13, category D); certain oral contraceptives (Desogen, Yaz) '* severe — isotretinoin (Accutane) ~ Accutane is category X and require special consent forms, approved pregnancy prevention program, 2 forms of reliable contraception, monthly pregnanoy tests. Acne Rosacea ‘+ These are chronic small acne like papules/pustules around nose, mouth, and chin. '* Impetigo on the other hand- Gram positive. Honey crusting. Itchy pink-red lesions evolve into vesiculopustules that rupture. If severe bullous-large blisters - Keflex, dicloxacillin. PCN Allergic-Azithromycin, clindamycin. If NO BULLAE ARE PRESENT- Bactroban ‘Acne Rosacea presentation + light-skinned adult with Celtic background (Irish, Scottish, English); usually blonde/red hair and blue eyes ‘+ papules and pustules around nose, mouth, and chin ‘+ facial redness, especially in central part of face + patient blushes easily + may have red eyes, dry eyes, or chronic blepharitis TREATMENT- Metrogel, Azelex, Low dose tetracycline,THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Pediatric Rashes/Exanthems ‘+ Scarlantiform rash, sandpaper erythematous rash on body, patient will have group A strep pharyngitis, a strawberry tongue can be present. Treat same as strep ‘+ Roseola, maculopapular rash that occurs AFTER fever. General URI symptoms. Viral, self-limiting ‘+ Rubsola, 7 day measles, 3 "Cs" (Cough, Conjunctivitis, Coryza), will have KOPLIK spots (clustered, white lesions on buccal mucosa) ‘+ Rubella, 3 day measles, German measles, lymphadenopathy in neck, fever, DANGEROUS in pregnant women (can cause miscarriage), rash are very small erythematous macular lesions that start on face and spread to neck, truck, extremities. Skin may flake after rash finishes. Small petechial lesions can be on soft palate/uvual (Forchheimer sign) + 5" Disease, erythema infectiosum, slapped cheek appearance, cause by Parvovirus B19 Neurofibromatosis '* Genetic disorder that causes tumors to form on nerve tissue * Café au lait spots = Flat, light brown spots on the skin, Common in many people, if more than 6, than a sign of neurofibromatosis type 1 Most common skin cancer Basal cell carcinoma. ‘+ Early, waxy, skin lesions, atrophic, ulcerated center that does not heal. Possibly umbilicated and pearly looking. MOST COMMON SKIN CANCER Squamous Cell Carcinoma ‘+ Rough/scaly appearance, can be umbilicated appearing, usually bleeds very easily. ‘+ Ensure to biopsy and refer to Dermatology HSV1 and HSV2 ‘+ Remember, HSV1 is oral and usually on the lips and oral mucous, HSV2 will be genital lesions ‘+ Vesicular in appearance. Painful ‘+ If vesicular lesions on finger, think herpetic whitlow and treat with acyclovir Skin Cancer Screening Asymmetry irregular borders = color variegation (can see black or blue) diameter .Gmm or greater E= elevation above skin level 10INTEGUMENTARY SYSTEM MNEMONIC: CAUTION UP Cancer's early warning signs (Cancer in general) change in bowel or bladder a lesion that does not heal unusual bleeding or discharge = thickening or lump in breast or elsewhere igestion or difficulty swallowing = obvious changes in wart or mole nagging cough or persistent hoarseness Us unexplained weight loss pernicious anemia Molloscum contagiosum Psoriasis ‘Small papules (5mm) that are dome-shaped with central umbilication and white “plug.” Fleshy appearance. Self-limiting Contagious, spread by skin-to-skin contact If found on the genital area of young children, should raise suspicion of child sexual abuse. Inherited. Pruritic erythematous plaques. fine silvery-white scales with pitted fingernails that bleed when scratched, Scalp, elbows, knees, sacrum, intergluteal folds can be affected. (Koebner phenomenon- new psoriatic plaques form over skin trauma) (Auspitz sign- pinpoint bleeding when plaques are removed). TREATMENT: Topical steroids, Tar preps (mild). For (severe) do anti-TNF, or immunologic. Fingernail hematoma treatment + Trephination — make hole in nail through drilling or piercing and allow blood to drain Erysipelas ‘+ Subtype of cellulitis involving upper dermis and superficial lymphatics ‘+ Usually caused by Group A Strep ‘+ Symptoms — single large lesion, hot, indurated, red, clear demarcated margins, usually found on lower legs (shins) or cheeks, fever, chills TREATMENT- Dicloxacillin QID x10d. Cephalexin, Clindamycin. PCN ALLERGY? Do Azithromycin x 5 days "1THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Scabies * Infestation of the skin by sarcoptes scabiel mite; burrows under skin; transmitted by close contact ‘+ Symptoms ~ pruritic rashes located in the interdigital webs of the hands, axillae, breasts, buttock folds, waist, scrotum, and penis; severe itching that is worse at night and interferes with sleep; serpiginous (snakelike) rash and/or linear burrows; lesions can be popular, vesicular, or crusted ‘+ “Treatment — permethrin 5% (apply to entire body ~ wash off in 8 hours); treat everyone in the household; wash all clothes/bedding in hot water and dry (TEST) Itching at bedtime. Permethrin cream to treat everyone, wash sheets and everything else in hot water. Tinea Corporis Ring-like itchy rash, slowly enlarging "central clearing” Treatment: most respond to topical antifungals, if severe do oral Lamisil (terbinafine). Erythema Migraines (TEST)(Stage 1 Lyme) Target bullseye, usually appears in 7-14 days POST being bitten by a deer tick. Rash is hot to touch with rough texture, flu like symptoms can develop. B, Burgdorferi serology via ELISA, then confirm with western blot. Increased TREATMENT: Less than 7 years of age ~ Amoxicillin or cefuroxime axetil, Older than 7 years of age- Doxycyciine. Pityriasis Rosea Itchy, herald patch, XMAS tree pattern, rash on hands solesifeet. Think to test for secondary syphilis RPR then VDRL screening, then diagnose by FTA-ABS. Secondary syphilis can mimic Pityriasis. Kawasaki disease Acute high fever enlarged lymph nodes, BRIGHT RED RASH, conjunctivitis, dry cracked lips, strawberry tongue, swollen hands and feet. AFTER the fever resides the rash PEELS on hands/feet. Treated with high dose aspirin and gamma globulin. This is TOXIC and VASCULAR, think blood clots, heart problems etc. Treatment: high dose aspirin. MNEMONIC: CRASH Kawasaki's symptoms conjunctivitis rash- all over body- polymorphous exanthem, 12INTEGUMENTARY SYSTEM adenopathy- cervical + S= strawberry tongue hands and feet swollen (TEST) Expect to see a question about Kawasaki's! Impetigo Gram positive. Honey crusting, Itchy pink-red lesions evolve into vesiculopustules that rupture. If severe bullous-large blisters - Keflex, dicloxacillin. PCN Allergic-Azithromycin, clindamycin. If NO BULLAE ARE PRESENT- Bactroban Melanoma Dark Moles, uneven texture, different colors, irregular, >6mm, could be itchy. Rocky Mountain Spotted Fever Includes fever, chills, N/V, photophobia, myalgia, arthralgias. THEN 2-5 days later you develop a petechial rash on forearms, ankles, and wrists that spreads towards the trunk and becomes generalized. Think rocky areas like NC/OK/AK/TN/MO. Diagnosis: PCR assay with Rickettsia Antigen. TREATMENT- doxycyaiine. Stevens Johnson Syndrome Classic is target or bulls-eye rash. Onset is abrupt with hives, blisters, petechiae, purpura, necrosis, and sloughing of tissues. Extensive mucosal involvement. Prodrome of fevers with flu like symptoms. Triggers: Allopurinol, anticonvulsants, penicillin, sulfonamides, NSAIDS. HIV patients have higher risk for this syndrome. MNEMONIC: 4 S's Sulfonamide Side effects * Steven Johnson Syndrome Skin rash ‘+ Solubility low (causes crystalluria) + Serum albumin displaced (causes newborn kernicterus and potentiation of other serum albumin binders like warfarin) ‘Steven-Johnson Syndrome Causes: MNEMONIC: BAPS H&M + B= barbiturates antibiotics (PCNs) = Phenytoin and other anticonvulsants 13THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE sulfonamides + He herpes simplex virus ‘+ M= Mycoplasma Burns MNEMONIC: Rule of 9’s For determining body surface area- helpful for bums + Head= 9% (front 4.5, back 4.5) = Chest 9% * Abd 9% * Back 18%- split between upper and lower ‘+ Leg 18%- split between front and back ‘+ Arm 9% split between front and back © Genitals 1% + Each palm = 1% Acanthosis Nigricans Velvet hyperpigmented patches most common on back of neck or skin folds- can mean glucose resistance. Cellulitis Deep dermis infection. Poorly demarcated rash. Typically, on lower legs (TEST) Multiple questions likely... INCREASES DVT RISK, DM WITH CELLULITIS WATCH FOR OSTEOMYLITIS! MRSA Treatment Bactrim, doxycyctine, minocycline, clindamycin. If sulfa allergy, do not use Bactrim. Varicella Zoster Virus “Contagious 48 hours before rash starts and until all lesions crusted over” Symptoms include low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “Initially on trunk, then scalp and face” TREATMENT is supportive, antihistamines, acyclovir 20mg/kg 5x daily for 7 days. If given first 24 hours works best. Scarlet fever (Scarlatina) (TEST) “Sandpaper textured-pink rash with sore throat.” Strawberry tongue, rash starts on head and neck, spreads to trunk. The skin THEN desquamates. 14INTEGUMENTARY SYSTEM Lichen planus * Small, flat topped, red to purple bumps that may have white scales/flakes; bumps may have wispy gray/white streaks called Wickham's Striae; itching mild to severe: commonly occurs on inner wrists, forearms, and ankles ‘+ [fit occurs on scalp, can cause hair loss '* Can affect nails and cause them to become brittle or split with ridges. ‘+ In the mouth, it looks like lacy white patches on cheeks or tongue + Causes — hepatitis C, medications (beta blockers), contact with certain cleaning chemicals ‘+ Treatment — usually goes away on its own; treatment focuses on symptom management (reducing itching) + Ifon scalp, treat quickly or hair may not grow back Spider bite Fever, chills, nlv, located on arms, upper legs, or the trunk. Bitten area becomes swollen, red, and tender, and blisters appear within 24-48 hours. Necrotic in center, which kills the tissue. lee packs to wound and cold inactivates the toxin, treatment is like cellulitis of the skin. Antibiotic ointment at first, monitor symptoms, if worsening, then oral antibiotios. Erythema Migrans The rash associated with tick bites and Lyme disease. Red bullseye lesion Treat with doxycycline Questions and Topics to Know! Patient with subungual hematoma, what would you do? ... Drain the nail bed What is honey crusted lesions, how do you treat? Impetigo and Mupirocin Patient has a high fever of 104.5 dry cracked lips, desquamation of skin on hands and soles of feet and strawberry tongue, what should the NP suspect? Kawasaki Disease 4. What is not a condition of concern in the elderly? Seborrheic keratosis (because it is benign) 5. Actinic keratosis precursor to squamous cell carcinoma 6. Rosacea treatment with metronidazole gel 7. 8. eR How do you treat shingles? — acyclovir Older induration that has been there awhile what do you do? Biopsy it. 9. Basal Cell Cancer: Waxy, pearly, telangiectasia, ulcer center lesion 10. Actinic Keratosis: know why it is dangerous 11, Melanoma question: Know ABCDE. Irregular, 3 different colors... 12, Subungual Hematoma treatment: Make a hole and drain the blood 13, Treatment for moderate acne (know acnes) 114. Review your skin issues for adult and kids. Question about Rubeola (Koplick) 15. How do you treat a fungal skin infections? 16. Scarlet fever... Sand paper rash 15THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE 17. Impetigo.........Honey crusted color 18, Patient with a brown recluse spider bite, the NP should do all except.... Apply heat, ice is the correct treatment! 19. How does NP treat a patient with red rash around the nose, cheeks, and forehead... Flagyl gel 20. Infant presents with tiny white pimples on the nose and cheek and mother is concemed about spots on child's face...Itis just Milia and it will go away 21. Dog/animalicat bite, treat with Augmetin 16Cardiovascular System Disorders Murmurs Grades of murmurs 1. 2. 3. 4. 5. 6. very soft, heard only under optimal conditions mild to moderately loud murmur loud murmur that is easily heard once the stethoscope is placed on the chest louder murmur; first time thrill is present very loud murmur heard with edge of stethoscope off chest; thrill more obvious murmur so loud it can be heard even with stethoscope off chest; thrill easily palpable All diastolic murmurs are abnormal First time thrill is palpable is grade IV MR, ASS - Mitral Regurgitation, Aortic Stenosis ~ Systolic MR, Peyton Manning AS MVP — Mitral Regurgitation, Physiologic Murmur, Aortic Stenosis, Mitral Vaive Prolapse - Systolic MS. ARD — Mitral Stenosis, Aortic Regurgitation — Diastolic right-sided — louder on Inspiration LEft-sided — louder on Expiration aoRtic - Right side pulmonic — Left side Mitral Regurgitation — pansystolic/holosystolic; heard best at apex; radiates to left axilla; loud blowing/high-pitched; usually result of congenital condition, rheumatic heart disease, acute endocarditis, MVP, calcified annulus; symptoms include CHF, fatigue, dyspnea, bacterial ‘endocarditis; LV/LA enlarged on XR; A fib common on EKG Aortic Stenosis — midsystolic; best heard at 2nd ICS on right side; radiates to neck; harsh/noisy; patients should avoid physical overexertion (increased risk of sudden death); complications include angina, syncope, CHF; cardiomegaly occurs late; EKG usually normal; usually audible $4; usually congenital; rheumatic fever 2nd most common cause; monitor with echo; surgical valve replacement if worsens. Mitral Valve Prolapse — systolic; heard best at apex: more common in women ages 14-20; symptoms include palpitations, chest pain, dyspnea, dizziness, numbness; first finding is midsystolic “click”; EKG usually normal. Rule out Marfans syndrome in tall thin female with hypermobile joints. Arm span greater than height etc. Mitral Stenosis — low-pitched diastolic; rumbling: heard best at apex; “opening snap’, etiology is rheumatic fever; 4 stages (1 - long asymptomatic period followed by gradual reduction in exercise tolerance, 2 - pulmonary congestion, 3 - pulmonary HTN, 4 — severe low CO); ‘symptoms include dyspnea, A fib, hemoptysis, RV hypertrophy; loud S1; may radiate toward axilla Aortic Regurgitation — diastolic; high-pitched; blowing; best heard at 2d ICS on right side of sternum; symptoms include angina, CHF, dizziness, chest pain; etiology includes rheumatic 7THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE heart disease, congenital deformity, aortic root abnormalities, syphilis; PMI displaced downward and left; water-hammer pulse (TEST) Murmur that radiates to the neck: Aortic stenosis MNEMONIC: Heart Murmurs: Mr. Ass and Mrs. Always right: Systolic $1 ‘+ Mr= mitral regurgitation- diaphragm- pansystolic * Ass= Aortic stenosis- diaphragm * He puts himself 1* (S1) and his is Selfish (systolic) + He is always going uptown (MR travels to axillary, AS travels to neck) ‘+ He thinks he is such an MVP with his CLICKish friends (hear a click) Diastolic S2 ‘+ Ms.- Mitral stenosis (bell) ‘+ AR- aortic regurgitation- diaphragm ‘+ She always comes 2° (S2) and she's dying inside (diastolic) '* She never goes uptown because she never leaves home (does not travel) ‘+ Her friends S3 and S4 are always checking on her and ringing her doorbell Motivated Apples + Motivated= $1 M- mitral T- tricuspid AV- atrioventricular + Apples= S2 aortic P- pulmonic S- semilunar Heart valves by ozder of blood flow MNEMONIC: Toilet Paper My Ass + Tricuspid © Pulmonic Mitral © Aortic Most common cause of death in women + heart disease ‘+ heart disease is also the most common cause of death in men 18CARDIOVASCULAR SYSTEM DISORDERS ‘* cancer is second most common Afib “Afib is the most common arrhythmia. Rate control by CCB, BBs, digoxin.” Antiarrhythmics- Amiodarone. (TEST) Simvastatin and Amiodarone has huge risk for Rhabdomyolysis Anticoagulants such as Warfarin for Afib, Over the age of 70- 2.5mg... NOT 5mg, which is the dose for patients under 70. INR goal 2-3. INR goal for synthetic/prosthetic valves is 2.5-3.5 Do not give Vitamin K dose unless INR at 5.0 or above, just hold a dose. Congestive Heart failure ‘Signs/symptoms of CHF ‘+ Dyspnea/tachypnea, fatigue, dry cough, edema (feet and ankles), bibasilar crackles, $3 heart sound, resting tachycardia, diaphoresis ‘+ Early signs/symptoms involve heart and lungs '* Later signs/symptoms involve periphery Medication that can cause CHF + NSAIDs ‘+ Diabetes medications (glitazones) ‘+ Calcium channel blockers/beta blockers ‘+ Cancer medications Bacterial endocarditis ‘+ Symptoms — fever, chills, malaise associated with subungual hemorrhages (splinter hemorrhages on nailbed) and tender, violet-colored nodules on fingersitoes (Osler’s nodes); palms and soles may have tender red spots on skin (Janeway lesions); may have heart murmur ‘+ Treatment — refer to cardiologist or ED for hospitalization and IV antibiotics; blood cultures x3; CBC (WBCs will be elevated); ESR (elevated) '* Complications — valvular destruction; myocardial abscess; emboli + Prophylaxis ~ not recommended for MVP, GU/GI incisionsfinvasive procedures (unless known infection present); recommended for patients with previous history of bacterial endocarditis, prosthetic valves, certain types of congenital heart disease, and cardiac transplant with valvopathy when having dental procedures that traumatize oral mucosa, gingiva, or periapical area of teeth and invasive procedures on the respiratory tract; treat prophylactically with amoxicillin 1 hour before procedure (adults — 2g; children — 50mg/kg) or with clindamycin 600mg, clarithromycin (500mg) or cephalexin (2g) if penicilin allergic ‘Symptoms of endocarditis, 49THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE MNEMONIC: FROM JANE F= fever Roth's spots (cotton wool spot surrounded by hemorrhage, or white centered hemorrhage of the retina) O= Osier's nodes (tender, red purplish raised lesions with a pale center usually on fingersitoes) M= murmur Janeway lesions (non-tender, hemorrhat at the base of thumb or pinky finger and soles) anemia N= Nail hemorthages (splinter hemorrhages) emboli lesions mostly noted on palms, commonly Sinus tachycardia causes Exercise Stress Infection Hyperthyroidism, Blood loss Paroxysmal Supraventricular Tachycardia EKG shows tachycardia with PEAKED QRS complex with P waves. Wolff Parkinson White ‘Syndrome, common in kids, Causes: Dig toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drugs, etc 150-200 bpm with palpitations, SOB, anxiety etc. ‘Treatment if EKG shows WPW or symptomatic refer to Cardiologist for possible cardioversion and call 911 Vagal maneuvers can be used to treat. If carotid massage needed refer to cardiologist. Carotid massage is contraindicated with a history of TIA or Stroke in past 3 months or has carotid bruits. Pulsus paradoxus Apical pulse can be heard but radial pulse is not palpable Causes - asthma, emphysema (increased positive pressure), tamponade, pericarditis, cardiac effusion Measured by using BP cuff and stethoscope 20CARDIOVASCULAR SYSTEM DISORDERS Peripheral Artery Disease (PAD) ‘+ Symptoms — intermittent claudication (leg pain when walking; no pain at rest); lower extremities cool to touch; shiny, hyperpigmented, hairless skin on lower extremities; decreased/absent pedal pulse; increased capillary refil; bruits over partially blocked arteries * Higher risk for PAD with HTN, smoking, diabetes, hyperlipidemia * Treatment — smoking cessation, daily exercise, ankle and brachial BP before and after exercise, ‘+ Pletal/Cilostazol or phosphodiesterase inhibitor vasodilator can be taken with ASA or Plavix. '* Grapefruit juice, Cardizem, or Prilosec can increase serum concentration if taken together. ‘+ Last resort is percutaneous angioplasty or surgery for severe cases. ‘+ Gold standard for diagnosis — angiography ‘+ Complications — gangrene of foot or lower limb — requires amputation; increased risk of CAD or carotid plaques * Ankle-Brachial Index ABI 140 with diastolic <90 (TEST) Old lady with weakness on 2 HTN meds, 2 DM meds, vitamins polypharmacy hypotension hypoglycemia MNEMONIC: SHED the GAPS * Calcium channel blocker side effects Steven Johnson syndrome = palpitations sleepiness MNEMONIC: ASPIRIN Aspirin side effects ‘+ P= peptic ulcer disease testinal blood loss, * R= Reye's syndrome idiosyncrasy I= noise (tinnitus) MNEMONIC: CAPTOPRIL ACE! side effects cough ‘+ A= angioedemalagranulocytosis 23THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE potassium excess T= taste changes = orthostatic hypotension = pregnancy contraindication renal artery stenosis contraindication inflammation related pain L= lower GFR MNEMONIC: Halt Dangerous Hypertension: ARB Side effects H= headache I= hyperkalemia Temporal Arteritis (TEST) Gold standard for diagnosis — temporal artery biopsy done by ophthalmologist Screening test — erythrocyte sedimentation rate (ESR) ‘Symptoms — acute onset of unilateral headache located on the temple; jaw claudication (with chewing); fever; visual loss; pain in temple area Treatment — refer to ophthalmologist or ED; high-dose steroids are part of 1st line (prednisone 40-60/daily) Complications ~ permanent blindness if not diagnosed early Carotid bruit Statins caused by carotid stenosis (cholesterol plaque accumulation) HMG CoA reductase inhibitors Do not mix with grapefruit juice Drug-induced hepatitis or rhabdomyolysis higher if mixed with azole antifungals Also interact with fibrates (except fenofibrate), macrolides, amiodarone, and some CCBs High-dose Zocor has highest risk of rhabdomyolysis. High intensity statins lower LDL by 35-63% Moderate intensity statins (Simvastatin, Pitavastatin, Pravastatin) lower LDL by 22-47% Secondary Prevention ASCVD (Atherosclerotic Cardiovascular Disease): Patient with any form of ASCVD- history of MI, CAD, Angina, Stroke/TIA, PAD, coronary revascularization. If younger than 75 start on HIGH INTENSITY STATIN. Older than 75 (or not a candidate for high intensity) MODERATE INTENSITY statin. PRIMARY PREVENTION: NO ASCVD history of LDL at 190 or higher - HIGH INTENSITY DM aged 40-75 with LDL 70-189 - MODERATE INTENSITY 24CARDIOVASCULAR SYSTEM DISORDERS ‘+ Without DM or ASCVD age 40-75 with an estimated 10-year ASCVD risk of 7.5% or higher -MODERATE to HIGH INTENSITY. ‘* Lack of any ASCVD but 10-year risk is 5-<7.5% - FIRST LINE Is heart healthy lifestyle changes. When to start patient on high intensity statin ‘+ LDL >190; history of CHD or stroke + High intensity statins include Atorvastatin (Lipitor) and Rosuvastatin (Crestor) * Start screening at 20 years of age then every 5 years until 40 if no issues. At 40 every 2- 3 years. If diagnosed with dyslipidemia, then annually etc What should be done before starting a statin? + Baseline LFTs ‘+ Statins affect CYP450 system and increases risk for rhabdomyolysis and drug-induced hepatitis * LFTs should be monitored periodically (more frequent for higher doses) MNEMONIC: HMG-CoA Statin side effects hepatotoxicity + M= myalgiasimyopathy ‘+ G= Gi symptoms (constipation, pain, flatulence) = CPK increased afi Venous insufficiency ‘Symptoms — edema, hyperpigmentation, chronic cellulitis, ulcerations, dilated leg veins, warm skin Temporal arteritis (Giant Cell) Unilateral temple, indurated cord-like strands. Biopsy. S/S- abrupt visual changes, blindness. lammatory markers (Sed. rate, ANA). Treat NSAIDs, Hi-dose steroids. Many will have PMR (Polymyalgia Rheumatica). Shock MNEMONIC: CPR Stages of shock compensatory stage progressive stage 25THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Re refractory stage MNEMONIC: HAVANA Causes of shock Stroke hypovolemia adrenal crisis ascular stasis acute respiratory obstruction I= neurogenic anaphylaxis, MNEMONIC: FAST For recognizing strokes facial drooping arm weakness S= slurred speech ime Anterior Wall MI or anterior STEMI is the most common and serious type of MI. EKG includes ST ‘segment elevations in V2 and V4, and Q waves. Wide QRS complex resembles a tombstone. Metabolic syndrome Cluster of symptoms — abdominal obesity, HTN, hyperlipidemia or elevated triglycerides and low HDL, elevated fasting glucose >100 Patients are at higher risk for type 2 diabetes and CV disease Questions and Topics to Know! 1 PNOASON Elderly patient comes in with worsening of CHF and is on multiple medications. Which one of their meds may be causing the CHF? NSAIDs Isolated systolic hypertension normal or abnormal in the elderly... Never normal ‘What disorder will have an arteriole crosses over the vein (AV nicking)... Hypertension Young male presents with complaints of palpitations and flip flop heart rate... PSVT Alpha Blocker side effects... Orthostatic hypotension ‘What medication is contraindicated in CHF... Calcium Channel Blocker First line treatment for Post MI and Hypertension.......Beta Blocker Side effect of Calcium Channel Blocker... Peripheral edema 26CARDIOVASCULAR SYSTEM DISORDERS 9. Patient was diagnosed with cellulitis and return to clinic and symptoms not getting better, what would you suspect... DVT 10. Calcium Channel Blocker can cause ... Peripheral Edema 11. On examination of a patients eye the NP observed an arteriole crosses over the vein, what is this suggestive of ... Hypertension 12. A scenario of a lady with a $3 heart sound, what would that suggest... CHF 13, What will you hear in patients with a grade IIVVI murmur... moderately loud murmur without a thrill 14. Older man requesting Viagra (sildenafil). What should NP do next?... EKG 15. What is true about Pulsus Paradoxus... A significant decrease in blood pressure 16. Patient reported irregular heartbeat 3 to 5 times daily with occasional forceful beat and tachycardia, what will the EKG show... PVCs 17.A patient is in the 95th percentile, weight 75th percentile; he has a pectus chest and systolic murmur heard. What should the NP suspect... Marfan Syndrome 18. Child with coarctation of the aorta, what will you find... Decrease femoral pulses 19. What would be your diagnosis for a patient with hyperpigmentation in the lower extremity, normal pulse and tight edema... PVD 22. Patient diagnosed with Reynaud syndrome: what med should be considered... Calcium Channel Blockers 23. You have a patient on coumadin INR is 1.4 and has hx of DVT what do you do? Increase it, INR not at goal! 24. Temporal arteritis symptoms and the gold standard for diagnosis is biopsy of artery! Extra Information Know S3, what does it mean. You will hear a 3rd heart sound question. S3 was not an option. Know S4 it is a sign of what? Sounds like Tennessee. ‘A murmur that is loud and heard with your scope plus thrill is grade 4. A loud murmur that you don't need a stethoscope for is a grade 6 What does a Ill/VI murmur sound like? Moderately loud Systolic murmur that radiates to the neck (Aortic Stenosis) and one the radiates to the axilla (Mitral regurgitation) How do you rule out AAA — ultrasound is gold standard in 65 and older especially if they smoke You have a patent with HTN and osteoporosis, what medication do you put them on for HTN- thiazides HTN drug for DM with neuropathy- ACE or ARB. 27THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE You have a patient that on eye exam you notice copper and silver arterioles (AV nicking) what else do you assess them for— HTN You have an elderly patient with ISH, what medication do you start? CCB PAD patient what is treatment- exercise PAD what test- brachial index Know chronic venous insufficiency symptoms - edema, thick skin discolored What test you do for stable angina — stress test. Know Systolic and Diastolic Murmur. A heart murmur with high pitch holosystolic and one that is, mid systolic. Know Grade IIIVVI Murmur: Moderately Loud without a thrill Know the difference between Peripheral Arterial Disease and Chronic Venous Insufficiency. Know about jugular vein distention and possible causes. Know Bacterial endocarditis (Patient with gradual onset of fever, hemorrhages on nail beds, painful raised red nodules) - Osler's nodes Carotid bruit signs can signify what - narrowing of the carotid 28Musculoskeletal System MNEMONIC: PRISH Signs of inflammation Pain + Re redness . mobility + S= swelling + He heat Degenerative joint disease treatment + Exercise (swimming, walking, biking) + Lose weight ‘+ Stop smoking ‘+ First line medication - acetaminophen (Tylenol) ‘+ Alternative therapies — glucosamine, SAM-e, acupuncture, Tai Chi Osgood Schlatter Disease '* Common cause of knee pain in young athletes, especially if recent growth spurt ‘+ Anterior knee pain that increases over time ‘+ Osteochondritis of tibial tubercle + Caused by overuse of knee ~ repetitive stress on patellar tendon by quadriceps causes pain, tendemess, swelling ‘+ Usually affects one knee, but can be bilateral ‘+ Treatment — rest/activity as tolerated; ice; analgesics PRN ‘+ Rule out avulsion fracture if acute onset of pain post-trauma (lateral x-ray) Legg-Calves-Perthes ‘+ Osteonecrosis of the capital femoral epiphysis due to interrupted vascular supply ‘+ Common in ages 3-12 (pre-pubescent) ‘+ More common in males + Pain in hip or referred to medial aspect of knee (may be present for 2-3 weeks before complaints) + Limp gait ‘+ Positive Trendelenburg's Test (asking child to stand on affected side causes pelvic tilt - affected side lower) Rotator cuff description Apprehension test rules it in or out. Positive test means pain is reduced on rotation. If increased, then someone else going on. 29THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Rotator cuff injury - disturbed sleep, arm weakness, dull ache. Bicep Tendon Rupture (TEST) HOOK TEST (description of the test, used to assess distal biceps tendon rupture) = bicep will roll into a giant ball Navicular fracture Falling with outstretched arm hyperextension. Thumb spica splint and refer out. Can take 2 weeks to see on x ray. Slipped capital femoral epiphysis Spontaneous dislocation of femoral head. Pain in groin that is referred to the knee. Unable to properly flex. No ambulation is permitted because this will cause irreversible damage. Could be due to puberty or hormonal changes. You will have a shortening of the leg with this. McMurray Sign © Knee pain and a “click” sound upon manipulation of the knee equals positive sign ‘© Suggests injury to medial meniscus ‘© Gold standard test for joint damage is MRI of knee Drawers sign “Knee stability” Anterior checks ACL, posterior checks PCL Medial Pain in knee (Valgus/Varus) ‘+ Valgus stress test ~ medial collateral ligament (MCL) * Varus stress test - lateral collateral ligament (LCL) - Varus and Lateral both have R '* Positive finding is an increase in laxity of the damaged knee (ligament tear) Fractures Scaphoid fracture still having pain © Repeat x-ray, splint wrist, refer to surgeon © Scaphoid fractures may not show on initial x-ray © Patient usually has history of falling forward on outstretched hand * Common complaint is deep, dull wrist pain that worsens with gripping or squeezing High risk of avascular necrosis and nonunion ‘* Positive snuff box tendemess (TEST) Treatment to prevent fracture in patients with low vitamin D, high TSH, low Hct 30MUSCULOSKELETAL SYSTEM Vitamin D 600-800 IU/day Calcium 1000-1200mg/day Osteoporosis Diagnosed with DEXA scan to measure bone mineral density. T score < -2.5 indicates osteoporosis. Treated with bisphosphonates Exercises for osteoporosis ‘+ Weight-bearing exercises (walking, jogging, biking, aerobic dance) + Swimming and isometric exercises are not considered weight-bearing! Ways to decrease risk for osteoporosis ‘+ Vitamin D supplementation ‘+ Weight-bearing exercise ‘+ Stop smoking ‘+ Decrease alcohol/caffeine intake De Quervain’s Tenosynovitis ‘+ Pain on the thumb side of the wrist + Positive Finkelstein test + thumb spica spiint, physical therapy/ortho referral RA vs. OA + RA ~ systemic autoimmune disorder; more common in women; manifested through Multiple joint inflammation and damage: patients at higher risk for other autoimmune disorders; symptoms include gradual onset of symptoms, daily fatigue, low-grade fever, generalized body aches, myalgia, morning stiffness lasts longer, generalized aching joints that usually involves fingers/hands/wrist, painful/warm/swollen joints, swollen fingers with warm tender joints (PIP and DIP); joint involvement is symmetrical; elevated ESR; treated with NSAIDs, steroids, DMARD. surgery, biologics, anti-TNF; complications include Uveitis, sclertis, vasculitis, pericarditis, increased risk of certain malignancies ‘+ OA (Degenerative Joint Disease) — arthritis occurs when cartilage covering the articular surface of joints becomes damaged; affects large weight-bearing joints (hips, knees) and hands; risk factors include older age, over use, positive family history; symptoms include gradual onset, early moming joint stiffness with inactivity, shorter duration of joint stiffness than RA, pain aggravated by overuse, joint may be swollen and tender during exacerbation, may be one-sided, no systemic symptoms, Heberden’s nodes (distal) Bouchard node (proximal); treatment includes acetaminophen (first line), NSAIDs (if 3THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE acetaminophen fails), capsaicin cream, weight loss, smoking cessation, exercise; rule our osteoporosis Slipped capital femoral epiphysis History of several weeks/months of hip/knee pain with an intermittent limp Common in adolescents Diagnosis often missed because only 50% have hip pain and 25% have knee pain (On x-ray, the femoral head is seen displaced, posteriorly, and inferiorly in relation to the femoral neck and within the confines of the acetabulum ‘Treatment — surgical repair with internal fixator Goal is to prevent complications like avascular necrosis Polymyalgia rheumatica ‘Symptoms — bilateral morning stiffness and aching (more than 30 minutes) in shoulders, neck, hips, and torso; difficulty putting on clothes/bra Mostly affects females age 50 and above Treatment ~ oral steroids (prednisone) PMR patients are at very high risk for developing temporal arteritis (educate on recognizing symptoms) (TEST) Typically presents as bilateral shoulder pain in older female. Scoliosis Scoliosis exam Adams Forward Bend Test (Forward Bend Test) — have patient bend forward with both arms hanging free and knees straight; look for asymmetry of spine, scapula, thoracic and lumber curvature; inspect the shoulders and hips for asymmetry Monitor height Morton’s Neuroma (TEST) Do Mulder test. “Feels like a pebble. Symptoms burning, numbness” 3° and 4th metatarsals. Refer to podiatry. Fibromyalgia Requirements for diagnosis of fibromyalgia Widespread pain ‘Tenderness when pressure is applied to at least 11 out of 18 body points Experienced symptoms for at least 3 months. All other possible causes ruled out 32MUSCULOSKELETAL SYSTEM ‘* 14/18 trigger points. Polymyalgia Rheumatica Bilateral joint stiffness, aching. Typically found in shoulders, neck, hips, and torso. Females are more likely to have this. Treat with low-dose steroids 9-12 months. Low back pain MAI (to evaluate herniated disk) Sciatica is a form of radiculopathy and one of the most common causes is a herniated disc. Hemiated disc/radiculopathy are aggravated by long periods of sitting and feel better with WALKING. Lumbar stenosis is aggravated by long periods of standing and walking. Relieved by SITTING and rest Medial Tibial Stress Syndrome of Fracture OVERUSE INJURY, “inner border” painful on palpation. Do bone scan or MRI because a plain X- ray won't show a stress fracture. RICE, Crest syndrome Limited scleroderma or limited cutaneous systemic scleroderma CREST syndrome C= calcinosis (calcium deposits, usually in fingers) R= Raynaud's syndrome (vascular disorder where fingers and/or toes turn white and/or blue when exposed to cold or stress and may be red when re-warmed) E= esophageal motility disorder (loss of esophageal muscle control, which can cause dysphagia) ‘S= sclerodactyly= deformity of fingers (tapering of finger bones) lelangiectasias (dilated superficial blood vessels that result in red spots on the skin or side the mouth) MNEMONIC: 5 P’s of Compartment Syndrome Pain + Paresthesia + Paralysis + Pallor 33THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE * Pulse Questions and Topics to Know! 1. Patient presents with lower back pain and loss of lumbar curvature plus decrease thoracic excursion... Ankylosing Spondylosis 2. Patient presents with osteoporosis type 2, what should be suspected... bone loss, cortical loss and trabecular loss, and lack of vitamin D Intermittent calf pain... PAD Lateral epicondylitis... Pain with extension of wrist, tennis elbow Lumbar spinal stenosis... Tingling, weakness or numbness that ra back into the buttocks and legs What is the McMurray test used for... Assess Meniscus injury Boy with pain and swelling at tibial tuberosity... Osgood Schlatter Disease The ACL test is used to test... Lachman ‘What would concern the NP most about a diabetic patient that she sutured a wound on his lower extremity 1 week ago and is now back with redness, swelling, and pain... Osteomyelitis 10. What med that reduces uric acid levels would NP add in gout patient who is already taking NSAIDS? Allopurinol 11, When assessing a child during a well-child visit, the NP notices that Genu valgum (knock knees) is present. The NP knows that this is normal from... 3- 5 years 12, Patient diagnosed with lumbar spinal stenosis and having pain at LS and S1 what test ‘would you order to help with diagnosis... X-Ray and MRI he ©2no Extra information A lot of musculoskeletal questions on some exams! Treatment for mild ankle sprain - RICE Treatment for medial tibial stress syndrome - shin splint, RICE Know what the Lachman and Drawer tests are for. Lateral epicondylitis treatment Morton's Neuroma description as someone has a mass or nodule on the 4th/Sth toe 88-year-old patient in for follow up. She has been treated with Tylenol for arthritis. Her SED rate was checked after 6 weeks of treatment and it was 28. Normal range is < 25. How would you treat the patient? (Do nothing, Increase Tylenol, change to NSAID, and patient is expected to have a high SED rate due to age). Know about medial tibial stress fractures. 34MUSCULOSKELETAL SYSTEM Know about osteoporosis risk factors. Options include (low estrogen level, obesity, sedimentary lifestyle, etc.) Treatment to prevent fracture in a patient with low vitamin d hydroxyl, high TSH and low HCT (Option include Calcium carbonate 600mg, vitamin d 800 IU) Navicular fracture does not show up on Xray right away, they will in 2 weeks Paget's disease first line treatment- bisphosphonates Your patient t-score is 1.5. what does that mean — osteopenia 35Endocrine Disorders Thyroid Hypothyroid Primary — elevated TSH: low T4; low or normal T3 Subclinical - elevated TSH; normal T4: normal T3 Common cause is Hashimoto's (autoimmune) — Hashimoto and Hypo both have “O" ‘Symptoms are variable - may include fatigue Treatment — levothyroxine (Synthroid) daily in AM on empty stomach Starting dose of levothyroxine (Synthroid) is 25-5Omeg Check TSH every 6-8 weeks to monitor treatment response Hyperthyroid Dosi Primary — low TSH; high T4; normal or high T3 Subelinical — low TSH; normal T4; normal T3 Most common cause is Grave's Disease (autoimmune) — Grave and Hyper both have “R’ Common symptoms — female; rapid weight loss; increased heart rate; tremors; sweating: irritability; anxiety: hyperactivity: insomnia; diarrhea; amenorrhea; hypertension; exophthalmos; heat intolerance: goiter Treatment — Propyithiouracil (PTU); Methimazole (Tapazole); Radioactive iodine (causes hypothyroid for life, contraindicated in pregnancy) Thyroid Storm (thyrotoxicosis) — acute worsening of symptoms; may be caused by stress or infection; look for LOC, fever, abdominal pain; life-threatening; immediate hospitalization needed ing thyroid medication in elderly Consider starting levothyroxine at 25meg daily Increase by 25mcg every 3-6 weeks until normal TSH Recheck TSH every 6-8 weeks until normal TSH ‘Small decreases in thyroid replacement may be needed as patient ages Upper limit of normal in TSH in 80-year-old is 7.5 Advise patient to report palpitations, nervousness, tremors (indicate levothyroxine dose is too high) lab is ELEVATED in BOTH hyper/hypothyroidism. TPO is GOLD standard for diagnosis in Hashimoto's. But you always want to order a TSH first. Check your TSH lab on both in 6-8 weeks but never sooner than 6 weeks, that is how long these meds take to work. Normal TSH 0.5-5 36ENDOCRINE DISORDERS Cushing's syndrome Central obesity, moon face, purple striae, hairy, hypertension, elevated plasma CORTISOL in AM. “Think increased blood glucose and sodium, decreased potassium” You must draw cortisol levels in the morning. Addison's Disease Deficient in cortisol “Think low sodium and blood glucose, but increased potassium’ You must give cortisol. (Diagnosis Plasma Cortisol <5 meg/dl @ 0800.) Parathyroid PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract. Hypo/Hyper diagnosed by checking PTH and calcium. In hyper, you will have elevated calcium because the increased parathyroid hormone (PTH) will be releasing too much calcium from bones. TREATMENT: BISPHOSPHONATES FOR HYPERPARATHYROIDISM, Diagnosis of hyperparathyroidism ‘+ elevated levels of serum calcium and parathyroid hormone (PTH) Estrogen replacement Contraindications for estrogen replacement + History of breast cancer Coronary heart disease * Previous venous thromboembolic event or stroke/TIA Active liver disease ‘+ Unexplained vaginal bleeding ‘+ High-risk endometrial cancer ‘+ Hypertriglycerider * Active gallbladder disease ‘+ Thrombophilia (Factor V Leiden) Diabetes If you are already on TWO oral drugs for diabetes and A1C is 9 or higher, start BASAL insulin. If you cannot tolerate metformin and your A1C is 9 or higher, start BASAL insulin. Diabetic Screenings 37THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Proteinuria - Type 1 diabetics can wait due to no long-term complications. Type 2 diabetics need screening now due to unknown factor of time having the disease. Eye exams- Type 1 diabetics can wait for an eye exam. Type 2 diabetics need eye exam now due to unknown factor of time having the disease. Somogyi Effect Hyperglycemia in early moming......Lower PM dose of insulin Dawn Phenomenon ‘Abnormal early moming hyperglycemia..........Inerease PM dose of insulin Diabetes Initial tests Fasting plasma glucose (126 or higher on any two occasions is diagnostic of diabetes) AIC (6.5 or higher on any two occasions is diagnostic for diabetes) Oral glucose tolerance test Goals of treatment DM2: HgbA1C <7, elderly is <8, pregnant <6 DM1: HgbAIC <6.5, MNEMONIC: THAL Sulfonylurea side effects Teratogenicity + H=Hypoglycemia Abd upset = Lipid deposit MNEMONIC: 3 P's Signs of hyperglycemia + Polyphagia + Polyuria Polycipsia Hot and dry sugar high! Questions and Topics to Know! 38oane oN 10. "1 ENDOCRINE DISORDERS Patient presents with high calcium level of 13, what should the NP check... Parathyroid and repeat calcium level Obese boy with an elevated BMI and family history of diabetes, what would be the most beneficial test for the NP to do- fasting blood sugar Patient with a high TSH level of 14 what would you do.... Increase the dose of levothyroxine Husband reports his wife is craving salt what should be ordered... Cortisol level Understand Hyper and Hypothyroidism Know the FRUCTOSESAMINE TEST. Test for how long sugar storage in system - 2-4 weeks Hyperthyroid- how it presents and treatment What single test should be done for Hypo and Hyperthyroidism? TSH A patient was diagnosed with diabetes and prescribed metformin, what is important for the NP to monitor for... Lactic Acidosis Boy with Gynecomastia. The NP knows that? This should resolve on its own in 2 to 3 years What medication can cause Gynecomastia... Spironolactone 39Neurological and Psych Crawial nerves CN ¥- Trigeminal Herpes. CAN MIMIC CORNEAL ABRASION/KERATITIS (TEST) I, IV, VI - EOM (TEST) IV- superior oblique muscles VI- lateral muscles. CN I- Nose CN IX- Shoulder shrug/ ROMBERG test (TEST) CN Vill ears 8 (TEST) CN VIl- Facial nerve, BELL’S PALSY (TEST) Cranial Nerves: MNEMONIC Oh, Oh, Oh To Touch And Feel Virgin Girls Vaginas, Such Heaven (sorry its dirty) On Old Olympus Towering Tops A Finn and German Viewed Some Hops © 1 Olfactory © Ml Optic * Ill Oculomotor * IV Trochlear + V Trigeminal ‘+ VI Abducens © Vil Facial ‘+ VIL Vestibulocochlear/Acoustic ‘+ IX Glossopharyngeal + X Vagus nerve = XI Spinal Xi Hypoglossal Cranial Nerve Functions: MNEMONIC: ‘S= sensory, M= motor, B= both ‘Some Say Marry Money But My Brother Says Bad Business Marry Money = ISensory ll Sensory II Motor = IV Motor © VBoth + VI Motor « VII Both * vill Sensory * IX Both © XBoth = XI Motor = XII Motor 40Dementia NEUROLOGICA: AND PSYCH Tests CN8 ‘Tuning fork placed on midline on forehead Normal finding — no lateralization; sound heard equally in both ears Lateralization to affected/"bad” ear — abnormal finding — conductive hearing loss — AC (affected = conductive) LLateralization to unaffected/"good” ear — abnormal finding — sensorineural loss — US (unaffected = sensorineural) Tests CN 8 Place tuning fork fist on mastoid process, then at front of ear; time each area Normal finding — air conduction is longer than bone conduction; heard in front of ear longer than on mastoid ‘Abnormal finding — bone conduction longer than air conduction — conductive hearing loss (ceruminosis (impacted cerumen), AOM) Decreased executive function! Inability to manage a calendar Agnosia (cannot recognize familiar things), Apraxia (inability to do learned movements), Aphasia (speech difficulties) (TEST) Patient with history of HTN and stroke now having memory loss; indicative of? Vascular dementia Autism Onset may be as early as 18 months. Begin screening at 18-24 months. Most apparent in 2-6 year olds. Extremely sensitive to noises, touch smells, textures, poor language, repeated body movements. Five behaviors to look for: Doesn’ 't pointiwavelgrasp by 12 months. No babbling or cooing by 12 months, does not say single words by 16 months Does not say two-word phrases on their own by 24 months Any loss of language or social skills by 24 months Does not gesture by 24 months. Think about kids who do not act normal especially with interactions. 4THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Depression Treatment for depression * First line for mild-to-moderate — SSRI (sertraline, escitalopram, fluoxetine, paroxetine, citalopram, fluvoxamine) ‘+ First line for major — SNRI (duloxetine, Effexor, Pristiq) ‘+ Other treatment options - TCA (amitriptyline, Pamelor, doxepin, amoxapine) and atypical (Wellbutrin, Trintellix) Benzodiazepines are not used as treatment for depression + SSRIs are safest ‘+ TCAs are easiest to overdose on, which has caused a drastic decline in use MNEMONIC: TCA’s Tricyclic Antidepressant side effects T= thrombooytopenia cardiac arrhythmias, Ml, stroke \= anticholinergic effects eizures MNEMONIC: HAHA MAOI side effects H= hypertension/hypertensive crisis anticholinergic side effects ‘+ H= hepatocellular jaundice arrhythmia/anorexia MNEMONIC: PASS on E-CIG Diagnosis of depression psychomotor agitation Cluster headaches High dose 02 via Mask 12L 100%, Imitrex (abort) and a CCB for prophylaxis - VERAPAMIL, 42NEUROLOGICAL AND PSYCH Treatment for generalized anxiety disorder * SSRI, SNRI, buspirone + May need benzodiazepine for limited time (TEST) Kava Kava- supplementitea used for anxiety and insomnia, don’t mix with other sedating medications, such as benzos. Subarachnoid hemorrhage Usually accompanied by photophobia, nausea, vomiting, meningeal irritation (positive Brudzinski and Kemig signs), rapid dectine in level of consciousness + May experience “sentinel headache’ a few days before the hemorrhage ‘+ Common causes — fall (elderly), MVA (younger) + Medical emergency Acute subdural hematoma ‘+ Diagnosed with CT ‘+ Depending on severity, watchful waiting may be appropriate treatment or, if more severe, may need draining or surgical intervention Trigeminal neuralgia (tic douloureux) ‘+ Mostly composed by compression of nerve root by an artery or tumor, causing unilateral facial pain that is usually located close to the nasal border and cheeks ‘+ Classic case — sudden onset of severe and sharp shooting pains on one side of the face triggered by chewing, eating cold foods, and cold air; severe pain lasts a few seconds ‘+ Treatment — high doses of anticonvulsants (carbamazepine or phenytoin); MRI/CT if patient is young, bilateral involvement, or numbness Upper arm tremor ‘+ Likely essential tremor ‘+ Treated with beta-blocker (Propranolol 60-320mg per day) ‘+ Alternative treatment is primidone (50-1000mg per day) ADHD + Core symptoms — hyperactivity, impulsivity, inattention (behavior disorder) '* Diagnostic criteria - symptoms present prior to age 12; symptoms last > 6 months; symptoms should be evident in 2 different settings (school and home — get feedback from caregiver/parent and teacher/coach) * Generally treated with Schedule II medications — high potential for abuse 43THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Morton’s neuroma Inflammation of the digital nerve of the foot between the 3rd and 4th metatarsals Increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners Symptoms ~ burning pain or numbness between 3rd and 4th toes; may have small palpable “pebble-like" nodule between 3rd and 4th toes Mulder tesUMTP squeeze test - grasp 1st and Sth metatarsal and squeeze forefoot ~ positive test is hearing click along with patient reporting pain during compression — pain relieved when compression stops Treatment — avoid wearing tight, narrow shoes and high heels; use forefoot pad; wear welkpadded shoes Diagnosed by clinical presentation and history refer to podiatrist Migraine treatment Triptans are used as abortive treatment for migraines, Prophylactic treatment for migraines includes — avoid triggers, beta blockers (propranolol), TCAs (amitriptyline, nortriptyline), anticonvulsants (topiramate), gabapentin Nervous system drugs Zyprexa (olanzapine) Recommendations High risk of weight gain, metabolic syndrome, and type 2 diabetes Monitor weight every 3 months Monitor TSH, lipids, BMI Benzodiazepine use for 6 years Do not discontinue abruptly ~ increased risk of seizures MNEMONIC: MORPHINES. Morphine side effects Me=myosis = orthostatic hypotension resp depression pneumonia (aspiration) I= hypotension infrequent water release (constipation, urinary retention) N= nausea 44NEUROLOGICAL AND PSYCH + S= sedation MNEMONIC: PHENYTOIN Phenytoin side effects P450 interactions hirsutism enlarged gums/gingival hyperplasia wstagmus = yellow browning of skin teratogenicity * = osteomalacia terference with B12 metabolism (leading to anemia) I=neuropathies (vertigo, ataxia, headache) Neuroblastoma Painful abdominal mass that is fixed, firm, irregular, and frequently crosses the midline; the most common site is the adrenal medulla; about haif of patients present with metastatic disease; may be accompanied by weight loss, fever, Horner's syndrome (miosis, ptosis, anhidrosis), periorbital ecchymosis ("racoon eyes”), bone pain, hypertension; most are diagnosed in children between ages 1 and 4; elevated urinary catecholamines and anemia; initial imaging is ultrasound; refer to nephrologist Serotonin syndrome ‘Symptoms of serotonin syndrome + fever © agitation/restlessness + tachycardia + hypertension * muscle twitching + diarrhea + sweating MNEMONIC: BAD SSRI + SSRI side effects ‘+ B= body weight increase anxiety dizziness serotonin syndrome stimulated CNS (upset stomach) 45THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE reproductive (sexual dysfunction for M and W) + = Insomnia MENOMINIC: Shivers: Serotonin syndrome shivering hyperrefiexia \creased temp = vital signs encephalopathy + Re restless sweating MNEMONIC: They cause HARM Serotonin syndrome hyperthermia autonomic instability (delirium) Rigidity | M= Myoclonus MNEMONIC: BAD SNRI SNRI side effects body weight increases anorexia izziness suicidal thoughts nausea/vomiting reproductive/sexual dysfunction isomnia MNEMONIC: VALPROATE Valproic acid side effects + V= vomiting alopecia iver toxicity Pancreatitis/Pancytopenia retention of fate oh edema (edema) appetite increase 46NEUROLOGICAL AND PSYCH tremorithrombocytopenia + E= enzyme inducer (liver) MNEMONIC: CAN HAM SUCS Acute Lithium Toxicity Syndrome confusion an increase of urine and thirst I= uncontrollable eye movements oma + S-slurred speech Assess cognitive function in patient with signs/symptoms of memory loss ‘+ History is essential to diagnosis — focus on cognitive and functional concerns, psychiatric and behavioral changes ‘+ MMSE — score < 24 strongly suggestive of dementia ‘+ Physical exam —look for neuro deficits, tremors, signs consistent with stroke, gait difficulty, cogwheel rigidity ‘+ Diagnostic labs will ikely be normal in dementia patients Cephalohematoma in infant (TEST) Swelling does not cross midline. Caput succedaneum in infant (TEST) Crosses midline. Cone shaped head Dizziness ‘Assessment when chief complaint of dizziness is present: Dix-Hallpike maneuver — positive would suggest benign paroxysmal positional vertigo (peripheral vertigo) Seasonal affective disorder ‘+ Depression that generally occurs in the winter months + Causative factors might include circadian rhythm, drop in serotonin level, change in melatonin level 47THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE © Treatment — light therapy, antidepressants, psychotherapy/talk therapy MMSE (Mini mental status exam) Used to evaluate confusion and dementia. Orientation, Immediate recall, Attention and Calculation, Writing and copying. 0 bad 30 good. <24 - dementia highly suggestive Bipolar Type I- class manic- severe anxiety, rage, chronic relationship difficulties, euphoria, talkativeness, flight of ideas. Type Il- Hypomanic. T REATMENT: Lithium salts (affect TSH, Kidney), anticonvulsants, Antipsychotic Antipsychotic drug side effects MNEMONIC: iSHADE |= impotence sedation, seizures ‘+ H= hypotension akathisia (inability to sit still) = dermatologic side effects extrapyramidal reactions (acute dystonia, rigidity, tremor, tachycardia) Anorexia Lanugo, osteoporosis, BMI <18.5, peripheral edema, heart problems. Neuroleptic malignant syndrome MNEMONIC: FEVER ‘Symptoms of neuroleptic malignant syndrome + V= Vitals unstable levated Enzymes (CK) = rigidity of muscles Hypothalamus MNEMONIC: TAN HATS: 48NEUROLOGICAL AND PSYCH Hypothalamus functions Hypothalamus wears TAN HATS hirst and water balance + A= adenohypophysis- control through releasing factors neurohypophysis- releases hormones made in the hypothalamus nuclei ‘+ H= hunger and satiety automimic regulation ‘=temperature regulation sexual urges and emotions Alzheimer's disease MNEMONIC: 5 A's of Alzheimer’s + Amnesia + Anomia © Apraxia © Agnosia = Aphasia CAGE questionnaire for alcoholics C- Cut down (Have you ever felt the need to cut down?) A- Annoyed (Have people annoyed you about your drinking?) G - Guilt (Have you ever felt guilty about drinking?) E - Eye opener (Have you ever needed a drink in the AM to get rid of a hangover?) Questions and Topics to Know! 1. What is the acronym for CRAFFT: (Tool used in the assessment of adolescent substance abuse) (1) Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs (2) Do you ever use alcohol other drugs to RELAX, feel better about yourself or fit in? (3) Do you ever use alcohol or other drugs while you are ALONE? (4) Do you ever FORGET things you did while using alcohol or other drugs? (5) Do you family or FRIENDS ever tell you that you should cut down on your drinking or drug use? (6) Have you ever gotten into TROUBLE while you were using alcohol or drugs? 2. Patients with bipolar... They have a flight of ideas 498 9. THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Lumbar spinal stenosis.... Tingling, weakness or numbness that radiates from the lower back into the buttocks and legs. Patient comes in with hearing loss to high frequency sound, what hearing loss is this...Sensory neural hearing loss Daughter reported mother always cook thanksgiving dinner, this year she forgets to cook, and the turkey is stil sitting in the sink... Executive function Patient had a stroke 2 years ago but recovered with no memory loss, now she is forgetting to do things, what kind of dementia is she having (a) Alzheimer’s dementia (b) Vascular dementia (look up signs and symptoms of both dementias) ‘Aman with severe headache on one side of the face with nasal discharge on the same side. Cluster headache Which cranial nerve is responsible for movement of the eye... Ill, IV, and VI First sign and symptom of serotonin syndrome... Fever 10. What treatment would the NP give to a woman with postherpetic neuralgia... Capsaicin 11. What is a side effect of marijuana... low sperm count Extra information Your patient has essential/familial tremor what is first line treatment - propranolol How drug aborts migraines? Triptans Prophylactic tx migraines? Propranolol Trigeminal neuralgia - how do you treat? Tegretol (carbamazepine) Treatment of cluster HA - high dose 02 Patient with dizziness and lateral gaze that returns to normal - this means what? Normal Papilledema is a sign of increased cranial pressure Patient with headache after trauma: subdural hemorthage Migraine headache: Know the description and duration of headaches. Question about CN 3,4,6 (EOM) Romberg test and how it’s done? Eyes must be closed! Patient complaining about upper arm tremor that seems to be hereditary. What's the treatment? Propranolol 50Gastrointestinal Tract Pancreatitis Pancreas secretes enzymes lipase, amylase, proteases. Digest protein, fat, and carbs. Diagnosed with amylase and lipase labs Amylase begins increasing 2-12 hours after onset of symptoms Amylase is most widely used method of diagnosing pancreatitis Lipase begins to increase 4-8 hours after onset of symptoms Lipase more specific and sensitive to alcoholic pancreatitis (TEST) ACUTE: Grey Turner/ Cullen sign (bruising of abdomen). Abd pain that radiates to. midback, “boring” epigastric pain. Fever, NIV (TEST) High triglycerides and pancrea High risk of acute pancreatitis with triglycerides greater than 500 Normal level is less than 150 If triglycerides are greater than 500, treat with niacin or fibrate or Niaspan to lower triglycerides; if less than 500, consider lifestyle modifications first Once triglycerides are under control, switch target to lowering LOL Recommend low fat diet, weight loss, and increased physical activity MNEMONIC: | GET SMASHED Causes of acute pancreatitis, liopathic- thought to be results of a hypertensive sphincter or micro lithiasis G= gallstones- usually travelling down common bile duct and becoming trapped in the ampulla of vater E= ethanol rauma steroids M=mumps jutoimmune disease- polyarteritis nodosa, SLE = scorpion sting/snake bite hyperglycemia, hyperlipidemia and hyponatremia E= ERCP drugs- sulfonamides, azathioprine, NSAIDs, diuretic use, didanosine, DDP-4 inhibitor and duodenal ulcers Encopresis (TEST) Five-year-old child who was potty trained at age 3; has been soiling himself for 3 months 51THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Involuntary soiling of stool in a child 4 years or older As stool accumulates in rectum, enlargement can result in loss of sensation, loss of urge to defecate, internal anal sphincter relaxes, then stool leaks out Constipation is underlying cause 80% of the time 4 times more common in males — in females, investigate sexual abuse Management ~ laxative for initial cleansing, behavior changes (toileting habits), dietary changes Goal is one soft stool per day Zollinger-Ellison Syndrome Caused by gastrinoma - causes multiple ulcers. First line is PPI. Screening done by serum fasting gastrin level GERD with Barrett's esophagus and GERD Barrett's esophagus is a long-term complication of GERD and is a premalignancy to esophageal cancer Barrett's esophagus is diagnosed by upper endoscopy with biopsy Any patient with at least a decade history of chronic heartburn should be referred to Gl for endoscopy to rule out Barrett's esophagus Treatment for Barrett's is PPI BID and H2 blocker every night Gerd- Barrett's “pre cancer’- chronic cough, acid sour breath, sore throat, thinning tooth enamel. First line for mild/intermittent — lifestyle changes. BB, CCB, HTN meds increase GERD. First line for mild/intermittent — lifestyle changes FIRST LINE: H2, only 6-8 weeks (mild to moderate symptoms), if not effective do a PPI. Never discontinue PPI abruptly. If patient still complains of GERD with 6-8 weeks of treatment, refer to GI PPI- prilosec, protonix, prevacid, nexium (omeprazole, pantoprazole, think “zole"), Monitor for osteoporosis and B12 deficiency with long term use. H2- Pepcid (famotidine) Barrett's treatment- PPI daily and H2 bedtime. ALWAYS GIVE h2 at BEDTIME. If patient not experiencing relief from PPI, refer to GI for endoscopy and further evaluation! Gilbert's Disease Common syndrome Can be hereditary, congenital, benign, chronic, intermittent hyperbilirubinemia *Fluctuating Jaundice with unconjugated bilirubin in urine Affects both sexes (male to female 4:1) Jaundice detected shortly after birth or later in life 52GASTROINTESTINAL TRACT Scleral jaundice a constant factor Signs and symptoms- Asthenia, fatigue, anxiety, nausea, abdominal pain ‘Symptoms precipitated by exertion, alcohol, or infection Familial disorder transmitted as an autosomal dominant trait Pyloric stenosis 4-6 weeks after birth, nonbilious vomiting, Diagnosis by ultrasound, will see a string. Differentials include: GERD, mi intestinal obstruction. Treatment - surgical correction. protein intolerance, Diverticulitis LLOQ pain with diarrhea, typically will have a history of this. Treat with combination of Cipro and Metronidazole. If allergic to either one of these, can be treated with Augmentin monotherapy. Hypoglycemia (TEST) Pancreas releases glucagon which stimulates your liver to convert stored glycogen to glucose — What does the pancreas secrete besides this? digestive enzymes. What does the liver produce in response to hypoglycemia? Glucose — the pancreas releases glucagon which signals the liver to convert stored glycogen to glucose and release it into the bloodstream MNEMONIC: STENGG Hormones that increase blood glucose somatotropin (growth hormone) thyroid hormones epinephrine Ne norepinephrine G= glucagon * G= glucocorticosteroids MENOMINIC: TIRED Signs of hypoglycemia = tachycardia ritability 53THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE restlessness + E= excessive hunger diaphoresis '* Cold and clammy needs some candy! Testing for pinworms + Scotch tape test '* Apply scotch tape on the anal area in the morning before showering, then transfer the tape toa slide and take to the health care provider who will check the tape for eggs '* The worms come out at night to lay eggs in the anal area — that's why the morning is the best time to test ‘* Scotch tape test will need to be done several days in a row as females do not lay eggs everyday Hepatitis C CDC recommendation on screening for Hep C ‘+ Adults born between 1945 and 1965, Current or former IV drug users (even if use was only once and many years ago) '* Persons who have HIV infection ‘+ Persons who have persistently abnormal ALT ‘+ Persons who received blood, blood components, or organ transplant before July 1992 ‘+ Known exposure (needlestick, child born to HCV+ mom) MNEMONIC: Very Angry Hepatocytes Hepatic necrosis causing drugs + V= valproic acid/Valproate acetaminophen {= halothane Hepatitis Screening Hepatitis C Screening Results: Anti-HCV Antibody - and HCV RNA - = Not infected, Anti-HCV Antibody + and HCV RNA - = Resolved HCV infection. 54GASTROINTESTINAL TRACT ‘Anti-HCV Antibody — and HCV RNA + = Early acute infection or chronic infection in immunocompromised individual Anti-HCV Antibody + and HCV RNA + = Acute or chronic infection. Remember, HCV RNA and/or PCR confirm active infection Hepatis B Screening Results: HBsAg +, Anti-HBc +, Anti-HBs - = Chronic Hepatitis B infection. Can test for HBV DNA to determine state of disease. HBsAg -, Anti-HBc +, Anti-HBs + = Past infection that is now resolved HBsAg -, Anti-HBc +, Anti-HBs - = Past infection that is resolved or false positive results. HBsAg -, Anti-HBc -, Anti-HBs + = Immune due to vaccination. HBsAg -, Anti-HBc -, Anti-HBs - = Never infected and not immune. Diarrhea ‘+ Norovirus in adults is most common cause + Rotavirus in pediatrics is most common cause Evaluate fluid status (CMP, mucous membranes, cap refill) and obtain stool studies + C. Difficile leading cause of antibiotic associated diarrhea. First line treatment is PO Vancomycin, metronidazole is no longer recommended as first line treatment. Intussusception ‘Sausage shaped mass in upper right quadrant. (TEST) Currant jelly stool. The bowels prolapse into another part of your intestine. Barium enema can help to reduce this. Previously healthy then they get sick. Usually before 2 years of age H. Pylori and Ulcers (TEST) H. pylori negative ulcers: H2 first line taken at bedtime, may combine them with PPI. Treat for 6-8 weeks. Refer if no improvement. Positive H. Pylori: Always do antibiotics for 14 days. Triple therapy: Biaxin, Flagyl OR Amoxicillin. With a PPI Quad: Pepto Bismuth, PPI, tetracycline, Flagyl Colon Cancer Thin ribbon like stools is a common symptom. This needs to be referred to GI for further evaluation of colon cancer. 55THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Gastrointestinal tract anatomy MNEMONIC: Dow Jones Industrial Average Closing Stock Report Gl tract ‘+ Duodenum + Jejunum = tleum * Appendix * Colon + Sigmoid + Rectum Question 1. Patient with triglycerides 1250 already on Niacin, what should be added? ‘+ very low-fat diet, weight loss, increase physical activity + add a fibrate medication (Gemtfibrozil, Tricor) + can do insulin infusion to quickly lower triglyceride level What is a worrisome sign of GERD... Dysphagia Which would not be pathological for jaundice in a baby... Jaundice within 24 hour Patient with splenomegaly three months ago, today he is asymptomatic and wants to know when he can retum to sports, what will you tell him... He can return now 5. Triglycerides 1000 +... Pancreatitis 6. Geriatric patient with change in bowel habits, she has loose watery stool and pencil stool, what should the NP suspect... Descending colon Cancer 7. 44-year-old female taking Methotrexate and ibuprofen, has been stopped. She now has increasing abdominal pain and dark tarry stools with @ lot of mucus. What would be her diagnosis... Ulcerative colitis 8. Infant bom with flat nose, thin upper lip, wide set/square eyes....Fetal Alcohol Syndrome 9. According to evidenced base research which medication is mostly used to help improve gastric symptoms... Proton Pump Inhibitors 10. A question on diagnosing Barrett's’ Esophagus... Upper endoscopy diagnostic 11, How can you tell that @ patient with anorexia is returning to her normal weight... increase in BMI or normal BMI 12. Patient with 12 hours of history of periumbilical pain, voriting and nausea, all differential diagnosis should be considered EXCEPT... something with diverticulum 13. Patient with Hep B ag + and Hep b anti IgM +... Acute hepatitis B BON Extra information High triglycerides increase the risk of — pancreatitis 56GASTROINTESTINAL TRACT You have a patient with chronic Hep C, what will be high the AST or ALT- ALT First ine treatment GERD - H2 blocker Understand all the hepatitis serology testing! YOU WILL HAVE A QUESTION ON THIS! You have a positive psoas maneuver, and itis positive. What does this mean? Appendicitis Rovsing's sign? Appendicitis, Patient with GERD and Barrett's esophagus: Refer to Oncologist Pyloric stenosis- non bilious vomiting, olive like firm mass palpated on right upper quadrant Common causes of GERD. - BB, CCB Increase in triglyceride can cause pancreatitis First line treatment for Zollinger is PPI Positive psoas/obturator/rovsing- acute appendix 57Genitourinary and Renal BPH Treatment for BPH alpha-adrenergic antagonist — terazosin (Hytrin) or Tamsulosin (Flomax) 5-alpha-reductase-inhibitors — finasteride (Proscar) Proscar causes the prostate to shrink 50%, so PSA should be doubled when checked. To check effectiveness of treatment, obtain PSA and multiply by 2. Proscar is teratogenic, category X. Reproductive-aged females should not handle with bare hands. Medication for BPH with HTN: start with alpha blocker (Hytrin) — works by relaxing smooth muscles on prostate gland and bladder neck Testicular torsion Usually occurs in adolescents (majority between ages 10 and 20) Abrupt onset; extremely painful, swollen red scrotum; frequently accompanied by nausea and voriting Affected testicle is closer to the body/higher than unaffected Missing cremasteric reflex Spermatic cord becomes twisted interrupting the blood supply Permanent damage can occur if not corrected in less than 6 hours Medical emergency ~ call 911, get to ER ASAP Preferred test — Doppler ultrasound with color flow study Treatment — manual reduction or surgery with fixation sutures Acute bacterial prostatitis Definitive diagnosis UA and culture (treat empirically until results are back) Under age 35, treat ike gonorrhea or chlamydia ~ Rocephin 250-500mg IM plus doxycycline 100mg PO BID x 10 days Over age 35, unlikely STD in nature, treat with Cipro PO BID or Levaquin PO daily x 4-6 weeks Avoid vigorous palpation and massage of prostate - can lead to septicemia Reiter's Disease Assyndrome consisting of urethritis, arthritis, and conjunctivitis Urethritis usually occurs first 58GENITOURINARY AND RENAL Polyarthritis is the most dominant of symptoms. Signs and symptoms- Pain, swelling, redness, and heat in the joints Urine tests UTI (TEST) Patient has 3+ proteinuria, what labs are needed? ‘+ 24-hour urine for protein and creatinine clearance (TEST) Adolescent UA results show WBC and SQUAMOUS CELLS ‘+ likely contaminated sample (TEST) Elderly woman on digoxin; creatinine went from 0.8 to 1.2 ‘+ As creatinine increases, digoxin dosage wil ikely need to be decreased to prevent toxicity (TEST) Baby with UTI - renal and bladder ultrasound (RBUS) for all infants 2-24 months for first febrile UTI (TEST) If there is grade 2 VUR (vesicoureteral reflux), then this usually resolves as the child gets older. First line treatment in women is nitrofurantoin for uncomplicated UTI. Bactrim can be the 3° trimester of pregnancy (avoid in 1" trimester due to neuro tube defects), othe with nitro. NO CIPRO IN PREGNANCY. Treatment 3-7 days in length Complicated UTI (pyelonephritis, back pain, fever) treat with ciprofloxacin Wilms tumor ‘+ Nephroblastoma ‘+ Asymptomatic abdominal mass that extends from flank toward midline ‘+ Nontender, smooth mass that rarely crosses midline of abdomen ‘+ Higher incidence in black, female children + Peak age 2-3, * Most common renal malignancy in children When performing PE, palpate gently to avoid rupturing renal capsule ‘+ Initial test is abdominal ultrasound Gynecomastia ‘+ Abnormal breast growth in men. '* Spironolactone can cause this men 59THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE Phimosis and Paraphimosis + Phimosis- Inability to retract foreskin ‘+ Paraphimosis — Inability to pull foreskin forward over penile head, medical emergency because it can cut off circulation to the penile glans Urinary incontinence MNEMONIC: DIAPPERS Treatable Causes of urinary incontinence delirium I= infection (urinary) atrophic urethritis and vaginitis pharmaceuticals (diuretics, others) psychological disorders (depression) excessive urine output (HF, hyperglycemia due to undetected or poorly controlled DM) restricted mobility tool impaction Nephrotic syndrome MNEMONIC: PHARAO For nephrotic syndrome ‘+ P= proteinuria and edema hematuria azotemia elevated blood nitrogen levels RBC casts Anti-strep titers (if post strep) * = Oliguria HTN MNEMONIC: People Have Endless Appetites Features of Nephrotic Syndrome proteinuria \yperlipidemia edema albuminuria & hypoalbuminemia MACHINE: 60GENITOURINARY AND RENAL Causes of hyperkalemia M= Meds (ACEI, steroids, beta blockers) acidosis C= cellular destruction (rhabdo, burns, trauma) hypoaldosteronism, hemolysis = intake excessive nephrons, renal failure xcretion impaired Electrolyte levels MNEMONIC: MURDER Signs of hyperkalemia M= muscle weakness Us urine oliguria or anuria respiratory distress. = decreased cardia contractility EKG changes (Peaked T waves or small P waves) reflexes hyper or hypo MNEMONIC: 6 L's Signs of hypokalemia Lethargy Lethal cardiac arrythmia Leg cramps Limp muscles Low shallow respirations Less stool (constipation) MNEMONIC: GRAPHIC IDEA Causes of hypokalemia G= Gl losses Re renal Aldosterone P= Periodic paralysis \ypothermia I= Insulin excess Cushing's Syndrome |- Insufficient intake D=diuretios 61THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE elevated beta-adrenergic activity Signs of hypernatremia fever + Re restless increased BP E= edema D= decreased urinary output MNEMONIC: }e Prepared to Look Happy During Computer-based Testing Flow fluid through kidney * B= bowman's capsule ‘+ Proximal tubules + Loop of Henle ‘+ Distal and Convoluted tubules Questions and Topics to Know! Acute prostatitis...do UA and culture (no aggressive massage, swab) 2, Incontinence worsened by all EXCEPT (a) femoral hernia (b) Atrophic vaginitis (c) Cystitis (d) Stool impaction ‘What may still be normal in elderly with renal disease? Creatinine level. 4. Elderly woman with atrophic vaginitis and on examination you felt a palpable mass on the right side of her abdomen, what should be done... Ultrasound 5. What would be the diagnosis for a female patient with acne, hirsutism, and amenorthea... PCOS 6. Male patient with testicular pain that is not relieved with elevation... testicular torsion 7. UA done for a 19-year-old female and culture found to have multiple organisms, how will you treat... this is contaminated, teach her how to properly clean the perineal area and have her follow up for repeat urine 8. Treatment for stress incontinence... Kegel exercise 9. Older man requesting Viagra. What should NP do next?.. EKG to ensure heart is healthy 10. What would be the finding of a patient with BPH... Firm, smooth and symmetrically enlarged 11. What is the best of assessing renal function in the elderly... Glomerular filtration rate Extra information How do you dx a kidney stone- US, not CT 62GENITOURIVARY AND RENAL Old lady with new onset of incontinence- how do you start the assessment? UA and culture Know UA findings! 63OB/GYA Pregnancy Positive signs ‘+ Palpation of fetus by health care provider '* Ultrasound and visualization of fetus ‘+ Fetal heart tones (FHT) auscultated by health care provider (10-12 weeks by Doppler, 20 weeks by stethoscope) ‘+ 16 weeks screen with AFP, can determine if down syndrome is present if low, if high could mean multiple gestation pregnancy + Remember, fundal height will be at symphysis pubis at 12 weeks, umbilicus at 20 weeks, xiphoid process at 36 weeks. Week of pregnancy = +/-2cm fundal height. Fundal height decreases by 1m per day post-partum Calcium supplement in pregnancy ‘+ 600mg BID (1200mg per day) (TEST) Pregnant patient who is 18 weeks pregnant with fundal height measuring 23 weeks... Fundal height too much, order an ultrasound! Coombs’ test * Indirect Coombs’ test is performed early in pregnancy to determine if there are antibodies to the Rh factor in the mother's blood ‘+ If pregnant woman is found to be Rh negative, she will receive RhoGam at 28 weeks gestation and within 72 hours of delivery '* If pregnant woman is Rh negative and miscarries or terminates the pregnancy, she should still receive RnoGam Galactorrhea (TEST) You have multi-Sravida patient, hasn't given birth in 5 years and is producing milk? Common causes ‘+ Too much prolactin is most common cause '* Other causes include certain medications/drugs (sedatives, antipsychotics, antidepressants, antihypertensives, opioids, cocaine, marijuana, birth control pills, herbal supplements); pituitary tumor; hypothyroidism; CKD; excessive breast stimulation; spinal cord injury; nerve damage to chest wall Placenta Previa 2nd-3rd trimester new PAINLESS vaginal bleeding worsened by intercourse. Blood is bright red. Uterus soft non-tender. If cervix is not dilated, treatment is strict bed rest. Administer IV MAG IF THERE IS UTERINE CRAMPING. Do not insert anything into the vagina/rectum. If dilated cervix then deliver via c-section 64oB/GYN Placenta Abruption ‘Sudden pain in the 3rd trimester. Hard uterus. Dark blood. Preeclampsia Late third trimester >34 weeks. Sudden onset of headache, visual abnormalities, pitting edema. Edema easily seen on face eyes fingers, sudden rapid weight gain within 1-2 days (>2-4lb/wk). RUQ pain. BP >140/90. Proteinuria 1+, dec. urine. IF SEIZURES THEN ECLAMPSIA. Earliest is at 20 weeks that they can have this... Have them lay on the left side. Pelvic inflammatory disease (TEST) Patient with a history of PID (Pelvic inflammatory disease) has increased risk for? Infertility ‘+ Cervical motion tendemess indicates PID ‘+ Treat symptomatic PID even if GC and chlamydia tests are negative ‘+ Follow up with vaginal bimanual exam in 2-3 days to make sure symptoms are improving Ectopic pregnancy Increased risk of ectopic pregnancy + Risk factors — previous ectopic, salpingitis, tubal surgery, current IUD use, previous cervicitis, history of PID + Symptoms — abdominal pain (worsens when supine or with jarring), vaginal bleeding, amenorthea, low grade fever, pain referred to right shoulder (may indicate rupture) Candida Vaginitis Wet smear= pseudo hyphae/spores with large WBC. Cheese curd like pruritus, itching, swelling, redness. TREAT: Diflucan 100 mgx1. Can use OTC= Monistat, clotrimazole Bacterial Vaginosis Wet smear= Squamous epithelial cells with a large amount of bacterial coating. Milky discharge and fishy odor, no redness or irritation. KOH to cotton swab for whiff test. TREATMENT: FLAGYL BID x7d, Alternative- Cleocin or metronidazole cream Atrophic vaginitis Painful intercourse, postcoital bleeding, friable cervix. Due to lack of estrogen, apply topical estrogens (premarin) Perinatal infections MNEMONIC: TORCH: Perinatal infections passed from other to child 65THE RAPID ELITE NP CERTIFICATION EXAM REVIEW GUIDE + T= Toxoplasmosis + O= Other infections Rubella = Cytomegalovirus Herpes Teratogenic substances MNEMONIC: TAP CAP + T= thalidomide alcohol progestins. corticosteroids aspirin P= phenytoin MNEMONIC: Chadwick's sign: Chad is a guy and guys like blue * Blue coloration of the cervix during pregnancy Bartholomew's Rule of Fours Estimating gestational age based on position of uterus. Where the top of the uterus will be located during pregnancy + 12.weeks ‘Symphysis pubis + 16 weeks Midway between symphysis pubis and umbilicus + 20weeks Umbilicus + 36 weeks Xyphoid process Breast changes Breast changes in elderly ‘+ Breasts lose fat, tissue, and mammary glands ‘+ Breasts can become lumpy — from benign fibrocystic changes or from breast cancer '* Breasts can become elongated, stretched, and flattened in appearance 66