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MSN 625 FINAL EXAM LATEST 2024/2025 100% ACCURATE
FALL/SPRING EXAM COMPLETE ALL QUESTION AND ANSWER
Causes of Type 4 renal tubular acidosis Addison's Disease Diabetic Neuropathy Drugs Diuretics Symptoms of Acute Pancreatitis Abrupt severe epigastric pain radiating to back that can be relieved when the person leans forward. Triggers-alcohol, fatty meal N/V Jaundice Labs for Acute Pancreatitis Amylase, Lipase, Hyperglycemia Elevated LFTs-hyper bili, hyper triglyceride Leukocytosis, Hypoxemia HypoCa, HypoAlbumin, low platelets-thrombocytopenia Increase in hgb/hct Causes of Acute Pancreatitis alcoholism, NASH, Gallstones Hyperlipidemia Drugs Trauma post ERCP-iatrogenic Imaging for Acute Pancreatities
CT w IV & oral contrast/ MRI is best-detect pseudocysts MRCP-useful in determining etiology of disease (stone, strictures, tumor). MRCP diagnostic, ERCP is therapy Abd X-ray-air-filled piece of small bowel in L upper Quadrant CXR to assess for effusion/atalectasis U/S: Very poor accuracy, overlying bowel blocks precise imaging Ranson's Criteria Age > WBC >16000 cell/mm BG>10mmol/L (>200 mg/dL) Serum AST >250 IU/L Serum LDH >350 IU/L in 48 hours 0 - 1 score means no complications scoring used for inpatients used to determine the mortality of pancreatitis patients at initial hour labs 48hr labs Treatment for Acute Pancreatitis Bowel Rest IVF-possible parenteral nutrition Analgesia Emperic Antibiotics ERCP for duct disruption/gallstone extraction Complications of Acute Pancreatitis Shock-peripancreatic hemorrhage pseudocyst-causes elevated amylase DIC & ARDS-enzymes can activate coagulation, can also destroy lung tissue if they get into blood Chronic Pancreatitis Recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland. Eventually causes loss of endocrine and exocrine function
variable n/v, anorexia, leukocytosis Gynecologic conditions that can mimic appendicitis PID ectopic pregnancy ovarian cyst rupture Gallstones Risk factors: female, forty, fertile, fat Meds: ursodial types: cholesterol or pigment (think bilirubin) Symptoms of Gallstones Upper Right Abdominal Pain especially after eating Gas, bloating, N/V Acute Choleycystitis Acute inflammation of the GB wall RUQ pain, fever, n/v Murphy's sign obstructive jaundices Choleycystitis Treatment IV, pain control, npo, surgery, or stone removal DDx: pancreatitis, hepatits, PUD, renal lithiasis, AMI, PE CBC, CMP, lipase, UA ultrasound outpatient surgical consult for most cholelithiasis admission for cholecystitis-medicine v surgery Complication of Acute CHolecystitis Empyema, gangrene, ilius, cholangitis, increased fever
hypotension, gram negative bacteremia > sepsi Post Choleycystectomy syndrome persistant abd pain after surgery, elevated ALP and dilated CBD on u/s-DO ERCP vs PBS-will not show dilated duct Ilius partial or complet blockage of the small and/or lg intestine TX: rest bowels, NPO-adv diet slowly IVF NG tube Hepatitis A Acute-does not cause chronic fecal-oral transmission n/v-RUQ pain, jaundice vaccine Hepatitis B DNA virus blood and body fluids (hep c same) 5 - 10% of adults develop chronic; higher percentage in newborn transmission from mother leading cause of liver cancer Hep B symptoms Jaundice-up to 4 weeks Angioneurotic edema or angioedema Polyarteritis Nodusa-inflammation of the arteries abd pain. hematuria Hepatitis C RNA virus
Endogenous causes of hyperthyroid-thyrotoxicosis Autoimmune disorders GRAVES excess secretion of TSH from pituitary-adenoma(rare) neoplasms Exogenous causes of hyperthyroid Meds too much levothyroxine Thyrotoxocosis in older pts looks like A fib-other arrhythmias Hyperthyroid labs to check TSH-if low(<.05), check T3 and T If TSH is low, & T3 or T4 is high-diagnosis? Primary hyperthyroid Common hyperthyroid Graves Sx of GRAVES widened pulse pressure hypertension & tachycardia thyrid bruit eyelid retraction/proptosis pretibial myxedema
Pretibial myxedema Puffy shiny shins Diagnosing Graves Disease TSI-thyroid stimulating immunoglobulin will be elevated radioactive iodine reputable-normal is 6-14% p 6 hrs. A pt w GRAVES will hv marked increase in the reuptake Tx GRAVES 1st line-anti thyroid drugs-PTU, methimazole for up to 2 yrs radioactive ablation Thyroidectomy-if malignant nodules suspicious give beta blockers for symptomatic tachy If elevated TSH and elevated T4, consider Secondary hyperthyroid-TSH secreting adenoma Subclinical hyperthyroidism Common during pregnancy-labs will show a decreased TSH but normal t Thyroid storm a relatively rare, life-threatening condition caused by exaggerated hyperthyroidism. An event triggers it Thyroid storm triggers SURGERIES PREGNANCY INFECTION RADIOACTIVE IODINE TREATMENT MYOCARDIAL INFARCTION
TX Desomopressin Thyroiditis Types
- autoimmune thyroiditis (Hashimoto's)
- painful subacute thyroiditis (de Quervain)
- infectious thyroiditis-Hep C
- Reidel thyroiditis-fibrosis of gland Thyroiditis TX Hashimotos-levothyroxine subacute thyroiditis-ASA, propranolol Sx Hypothyroidism
- Cold intolerance
- Dry skin
- Fatigue
- Muscle cramps
- Voice changes
- Coarse hair/loss of hair
- Menorrhagia (heavy periods)
- Goiter
- Constipation
- Weight gain
- Mylagia
- Weakness
- Depression
- Bradycardia Hypothyroid labs TSH 0.4- 4 Antithyroperoxidase high in Hashimoto's Antithyroglobulin antibodies high in Hashimotos
Prolonged Dopamine infusion causes supression of TSH cells Hypothyroid Treatments levothyroxine assess for angina and adrenal insufficiency Myxedema Crisis Treatments-swelling and thickening of skin Slow warming avoids cardiovascular collapse Lower levothryoxine doses w CAD Myxedema Crisis Treatments (sodium) Na 120-130= NS fluids Na< 120=3% bolus q 6 hours with lasix Hyperthyroidism Labs Low TSH, high T3 and T Antithyroperoxidase/antithyroglobulin is hi in graves Thyroglobulin low in thyrotoxicosis factitia Amiodarone and hyperthyroidism Causes high T4 LOW T Hight TSH dont check tsh within 3 mo of starting amio check every 6 months Amioderone type 1 vs type 2 labs 1 - bulging eyeballs (ptosis) and TSH Type 2-interleukin 6 Radioisotope uptake imaging scan
Block T4 & T3 (PTU & Propranolol) Beta Blocker (Esmolol & Propranolol) Thyroid Cancer painless swelling, labs are normal Iodine Deficiency Disorder low iodine --> increased TSH--> thyroid hormone production and thyroid gland grows Goiters-don't tx w iodine-thyrotoxicosis should have 150mcg miniumum daily intake Parathyroid Hormone increases blood calcium levels stimulates bone to release calcium osteoclastic Osteopenia thinner than avg bone density Osteoporosis matrix decreased, minerals decreased, bones break easily Osteomalacia disease marked by softening of the bone caused by calcium and vitamin D deficiency minerals decreased Osteoporosis Treatment Calcium Vitamin D supplements Weight-bearing exercise Hormone replacement therapy
Calcitonin, PTH analogs, Serms, biphosponates denosumab- prevents osteoclast formation Addison's Disease a condition that occurs when the adrenal glands do not produce enough cortisol or aldosterone- primary low ACTH-secondary Addison's labs hypoglycemia, hyponatremia, hyperkalemia, hyperca, low cort. Acute Adrenal Crisis Etomidate synthroid if given to someone who already has adrenal insufficiency Addison Treatment
- Add Steroids "-sone" Prednisone)
- Diet HIGH in Protein, Carbs & Sodium
- Don't "Abruptly" STOP Steroids! (Crisis)
- Lifelong" hormone replacement Give Card, give IM dose for home if sick educate on sick day dosage Addison's crisis treatment hydrocortisone Treat electrolytes and blood sugar Progressive shock in not responsive to fluids Solumedrol if ARDS DM 1 Diagnosis
abdominal obesity High LDL low HDL high fasting blood sugar DM 1 labs high osmolality high ketones DM labs urine ketones blood ketones Oral Glucose Tolerance Test (OGTT) 150 - 200 g carbs/day for 3 days npo at mn 75g glucose in 300ml water drank in 5 minutes blood glucose at 0 and 120 minutes normal <100 and less than 140 bad >126 and > glucose tolerance is 140- 200 Metformin MOA insulin sensitizer inhibits hepatic glucose output improves glucose uptake in insulin-sensitive tissues (e.g muscles) Not for CKD patients Thiazolidinediones Pioglitazone Rosiglitazone Sensitize tissues to insulin
reduce absorption of glucose acarbose Miglitol Incretins enhance insulin release and inhibit glucagon Fast Acting Insulin lispro, aspart, glulisine onset 15 min peak 1.5 hrs Duration 3-4 hrs Short Acting Insulin Regular Insulin Onset 30- 60 Peak 2 hours Duration 6-8 hours Intermediate Insulin NPH Onset 2-4 hours Peak 6-7 hours Duration 10-20 hours Long Acting Insulin Glargine, Detemir Onset 1 hour Peak-Flat Duration- 24/. 17 hours(detemir)
- pH 7.25-7.
- Anion Gap > 10
- Alert BHB 3- 4 Treat in ED Moderate DKA
- Bicarbonate 10- 15
- pH 7.0-7.
- Anion Gap > 12
- Alert/Drowsy Severe DKA
- Bicarbonate < 10
- pH < 7
- Anion Gap > 12
- Stupor/Coma Why no opiates for DKA to reduce masking of cerebral edema Changing DKA Fluids Change to D5 1/2NS when BG about 250mg/dl maintain glucose 250- 300 DKA fluid replacement NS @ 1L hr for 2L NS@300-400/hr use 1/2NS if Na is > 3 - 4L NOT 5L in 8 hours Too rapid decline of glucose can cause
cerebral edema mannitol 1-2g/kg over 15 minutes Insulin inhibits by the liver gluconeogenesis glycogenolysis Glucose needs to decrease at least what % in first hour 10%, or repeat a loading dose of 0.1kg Insulin should lower by about 50 - 70/hr You can still give long acting insulin during DKA Reduces the iv need smoother transition to subQ at 250 IM Insulin .1/kg/hr Initial potassium replacement in DKA Delay insulin until K = 3. or give in hour 2 or 3 when acidosis starts to correct CKD can cause K to stay elevated Bicarb in DKA pH <6. 1 amp in 1 L 1/2NS w 20mEQ KCL over 1-2hrs 1amp in 400ml h20 w 20meq K NOT in NS
