Exam 4: NSG554/ NSG 554 (NEW 2023/ 2024) – Nurse Practitioners in Primary Care I Exam Review | 100% Correct| Complete Guide with Verified Answers
Exam 4: NSG554/ NSG 554 (NEW 2023/
2024) – Nurse Practitioners in Primary Care I
Exam Review | 100% Correct| Complete
Guide with Verified Answers
QUESTION
Pelvic inflammatory disease
Answer:
-polymicrobial infection of the upper genital tract associated with STI neosseria gonorrhea,
chlaymdia and endogenous organisms including: anaerobes, haemophilus influenzae, enteric
gram negative rods, strepto- cocci
-most common in young nulliparous, sexually active with multiple partners
-leading causes of ectopic pregnancy and infertility
-use of barrier methods may provide significant protection
QUESTION
Pelvic inflammatory disease: S&S
Answer:
-lower abdominal pain, chills, fever, men- strual disturbances, purulent cervical discharge,
-cervical and adnexal tenderness
-RUQ pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepati- tis
-dx is complicated by subtle or mild symptoms (post coital bleeding, urinary frequen- cy, low
back pain)
QUESTION
Pelvic inflammatory disease: minimum diagnostic criteria
Answer:
-cervical motion, uterine or adnexal tenderness
QUESTION
Pelvic inflammatory disease: additional criteria
Answer:
-no single historical, physi- cal, laboratory finding is definitive for PID
-Criteria for specificity of dx:
1.oral temp >38.3C
2.abnormal cervical/vaginal discharge with white cells on saline microscopy (>1 leukocyte per
epithelial cell)
3.elevated erythrocyte sedimentation rate
4.elevated C-reactive protein
5.laboratory documentation of cervical infection w/n. gonorrhea or chlamydia
culture should be performed routinely but tx should not be delayed while awaiting results
QUESTION
Pelvic inflammatory disease: treatment mild/moderate
Answer:
Early tx of abx
Mild to moderate: outpatient tx with single dose cefoxtin 2g IM with probenecid 1g PO + doxy
100mg PO BID for 14 days or ceftriazone 250 mg IM + doxy 100mg PO BID for 14 days
metronidazole 500mg PO BID for 14 days can be added to either and treat bacterial vaginosis
frequent associated with PID
QUESTION
Combined Oral Contraceptives: efficacy and methods of use
Answer:
-suppression of ovulation
-can start on the 1st day of menstrual cycle, the 1st Sunday after the onset of the
cycle or on any day of the cycle (backup method should be used if started on any day)
-if active pill is missed at any time, and no intercourse occurred in 5 days prior, 2 pills should be
taken immediately & backup method for 7 days after
-if intercourse in 5 days, emergency contraception should be used immediately, pills should be
restarted the following day & backup method for 5 days
QUESTION
Combined Oral Contraceptives: Benefits of contraception
Answer:
-lighter menses
-improvement of dysmenorrhea
-decreased risk of endometrial cancer
-improvement of acne
-lower risk of myomas if taken longer than 4 years
-bone mass
QUESTION
Combined Oral Contraceptives: Selection of oral contraceptive
Answer:
-any com- bo containing 35mcg or less of ethinyl estradiol or 3mg of estradiol valerate
-variation of potency of progestins
-no evidence of differences btw triphasic, monophonic in effectiveness, bleeding patterns or
discontinuation rates
-monophasic pills 1st choice for women starting OC
QUESTION
Combined Oral Contraceptives: drug interactions
Answer:
-decrease efficacy: phenytoin, phenobarbital primidone, topiramate, carbamazepine, rifampin,
St. John’s wort
-antiretroviral meds (ritonavir-boosted protease inhibitors)
QUESTION
Combined Oral Contraceptives: Contraindications & adverse effects (MI)-
Answer:
1.MI- esp with higher dose 50mcg of estrogen or more, smoking, obesity, HTN, diabetes,
hypercholesterolemia increases risk
*smokers over age 35 and women w/ CV risk factors should use other non-estrogen contained
methods of BC
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Gynecomastia causes
-Aging
-Neonatal period, puberty (tall/overweight teenagers)
-Obesity
Hypothyroidism
-85% women
-May be due to failure or resection of the thyroid gland itself or deficiency of pituitary TSH
Goiter
-May be present with thyroiditis, iodine deficiency, genetic thyroid enzyme defects, drug goitrogens (lithium, iodine, propylthiouracil or methimazole, sulfonamides, amiodarone, interferon-alpha, interferon-beta, interluekin-2, food goitrogens in iodine-deficient areas
- often absent in autoimmune thyroiditis
Hypothyroidism labs
Serum TSH – high in primary and low in secondary hypothyroidism
Elevated in Hashimoto thyoiditis
Hyperthyroidism labs
Serum TSH= suppressed except in TSH-secreting pituitary tumor or pituitary hyperplasia (rare)
T3 uptake and scan= elevated, increased uptake
Subclinical hypothyroidism
Normal T4 with increased TSH
may or may not have symptoms
Hypothyroid Treatment
-Synthetic levothyroxine
-Average does 1.6mcg/kg/day
-Repeat TSH in 4-6 week after initiation
-TSH levels should be between 0.4-2
Hyperthyroidism (Thyrotoxicosis)
-Clinical manifestations of elevated T4 or T3
-Most common form is Graves Disease
Grave’s Disease
-Most common cause of thyrotoxicosis
-Autoimmune disorder affecting the thyroid gland
-Increase in the synthesis & release of thyroid hormones
-More common in women
-Onset age 20-40
-Dietary iodine supplementation, chemotherapy can trigger
-Increased r/f systemic autoimmune dx including Sjogren, celiac, pernicious anemia, Addison’s, alopecia aerate, vitiligo, DM1, hypoparathyriodism, myasthenia gravis, cardiomyopathy
Hyperthyroid examination findings
-Diffusely enlarged thyroid
-Frequent asymmetric and often with bruit
-Subacute: moderately enlarged/tender, dysphagia, jaw/ear pain
-toxic multi nodular goiter: palpable nodules
-Silent thyroiditis: small nontender goiter
PALM-COEIN
-Polyp, adenomyosis, leiomyoma, malignancy and hyperplasia
-Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, Not yet classified
Abnormal premenstrual bleeding: Laboratory studies
-CBC, pregnancy test, thyroid tests.
-Vaginal and urine samples for PCR or culture to r/o chlamydia
Vaginitis
-inflammation and infection of the vagina
-caused by a variety of pathogens, allergic reactions to contraceptives or other products, vaginal atrophy, friction during coitus
-normal pH is 4.5 or less
Vaginitis: Clinical findings
-vaginal irritation, pain, unusual or malodorous discharge
-Hx including LMP, recent sexual activity, use of contraceptives, tampons, douches, recent changes in meds or use of abx, presence of burning, pain, pruritus, profuse discharge
Vaginitis: PE
-inspection of vulva
-speculum exam of vagina, cervix
-vaginal/cervical/urine sample for detection of chlamydia
-discharge inspected under microscope in a drop of 0.9% saline solution to look for trichomonads or clue cells and in a drop of 10% potassium hydroxide to look for candida
-pH should be tested: if >4.5 infections d/t trichomonads or bacterial vaginosis
-bimanual exam to look for evidence of pelvic infection ** cervical motion tenderness
Vulvovaginal candidiasis
-R/F include pregnancy, DM, use of broad spectrum abx or corticosteroids
-Heat, moisture, occlusive clothing increase risk
Vulvovaginal candidiasis: S&S
-pruritus
-vulvovaginal erythema
-white, curd like discharge not malodorous
-Microscopic exam with 10% potassium hydroxide= hyphae and spores
-culture swab with Nickerson medium or for PCR testing if candida is suspected but not demonstrated
Trichomonas vaginalis vaginitis
-STI protozoal flagellate infects vaginal, skene ducts, lower urinary tract in women; lower genitourinary tract in men
Trichomonas vaginalis vaginitis: S&S
-pruritus
-malodorous, frothy, yellow/green discharge
-diffuse vaginal erythema and red macular lesions on cervix in severe cases (strawberry cervix)
-motile organisms with flagella are seen with saline solution wet mount
Bacterial vaginosis
-polymicrobial dx not sexually transmitted
-overgrowth of gardnerella and other anaerobic
-associated with malodorous discharge w/o vulvitis or vaginitis
-discharge is grayish, can be frothy
-pH of 5-5.5
Bacterial vaginosis: S&S
-associated with malodorous discharge w/o vulvitis or vaginitis
-discharge is grayish, can be frothy
-pH of 5-5.5
-fishy odor if a drop of discharge is alkalinized with 10% potassium hydroxide
-wet mount with saline: epithelium cells are covered with bacteria that cell borders are obscured (clue cells)
-cultures are generally not useful in dx however PCR is available
Vulvovaginal candidiasis treatment: uncomplicated
-topical and oral regimes
-women with uncomplicated: 1-3 day of topical azole or a 1x dose of PO fluconazole
Vulvovaginal candidiasis treatment: single dose regimen
-miconazole 1200 mg vaginal suppository
-tioconazole 6.5% cream 5g vaginally
-ER butoconazole 2% cream 5g vaginally
-fluconazole 150mg PO
trichamonas vaginitis treatment
-both partner simultaneous tx recommended
-metronidazole or tinidazole, 2 g PO single dose or 500 mg PO BID for 7 days
-tx failure with metronidazole in absence of re exposure pt should retreated with metronidazole 500 mg PO BID for 7 days or tinidazole, 2 g PO single dose
-if tx failure again: same as above 2g PO once daily for 5 days
-if continued failure= metro/tini susceptibility testing can be arranged with CDC
-women infected with t. vaginalis are at increased r/f concurrent infection w/other STDs and should be offered comprehensive STD testing
Bacterial vaginosis: treatment
-reccomened regimens:
- metronidazole 500 mg PO BID for 7 days
- clindamycin vag cream 2%, 5g, 1x daily for 7 days
- metronidazole gel 0.75% 5 g BID for 5 days
Pelvic inflammatory disease
-polymicrobial infection of the upper genital tract associated with STI neosseria gonorrhea, chlaymdia and endogenous organisms including: anaerobes, haemophilus influenzae, enteric gram negative rods, streptococci
-most common in young nulliparous, sexually active with multiple partners
-leading causes of ectopic pregnancy and infertility
-use of barrier methods may provide significant protection
Pelvic inflammatory disease: S&S
-lower abdominal pain, chills, fever, menstrual disturbances, purulent cervical discharge,
-cervical and adnexal tenderness
-RUQ pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis
-dx is complicated by subtle or mild symptoms (post coital bleeding, urinary frequency, low back pain)
Pelvic inflammatory disease: minimum diagnostic criteria
-cervical motion, uterine or adnexal tenderness
Pelvic inflammatory disease: additional criteria
-no single historical, physical, laboratory finding is definitive for PID
-Criteria for specificity of dx:
- oral temp >38.3C
- abnormal cervical/vaginal discharge with white cells on saline microscopy (>1 leukocyte per epithelial cell)
- elevated erythrocyte sedimentation rate
- elevated C-reactive protein
- laboratory documentation of cervical infection w/n. gonorrhea or chlamydia
culture should be performed routinely but tx should not be delayed while awaiting results
Pelvic inflammatory disease: treatment mild/moderate
Early tx of abx
Mild to moderate: outpatient tx with single dose cefoxtin 2g IM with probenecid 1g PO + doxy 100mg PO BID for 14 days or ceftriazone 250 mg IM + doxy 100mg PO BID for 14 days
metronidazole 500mg PO BID for 14 days can be added to either and treat bacterial vaginosis frequent associated with PID
Combined Oral Contraceptives: efficacy and methods of use
-suppression of ovulation
-can start on the 1st day of menstrual cycle, the 1st Sunday after the onset of the cycle or on any day of the cycle (backup method should be used if started on any day)
-if active pill is missed at any time, and no intercourse occurred in 5 days prior, 2 pills should be taken immediately & backup method for 7 days after
-if intercourse in 5 days, emergency contraception should be used immediately, pills should be restarted the following day & backup method for 5 days
Combined Oral Contraceptives: Benefits of contraception
-lighter menses
-improvement of dysmenorrhea
-decreased risk of endometrial cancer
-improvement of acne
-lower risk of myomas if taken longer than 4 years
-bone mass
Combined Oral Contraceptives: Selection of oral contraceptive
-any combo containing 35mcg or less of ethinyl estradiol or 3mg of estradiol valerate
-variation of potency of progestins
-no evidence of differences btw triphasic, monophonic in effectiveness, bleeding patterns or discontinuation rates
-monophasic pills 1st choice for women starting OC
Combined Oral Contraceptives: drug interactions
-decrease efficacy: phenytoin, phenobarbital primidone, topiramate, carbamazepine, rifampin, St. John’s wort
-antiretroviral meds (ritonavir-boosted protease inhibitors)
Combined Oral Contraceptives: Contraindications & adverse effects (MI)
- MI- esp with higher dose 50mcg of estrogen or more, smoking, obesity, HTN, diabetes, hypercholesterolemia increases risk
*smokers over age 35 and women w/ CV risk factors should use other non-estrogen contained methods of BC
Combined Oral Contraceptives: contraindications & adverse effects (Thromboembolic dx and CV dx)
- higher risk of venous thromboembolism esp in doses of 50 mcg or higher, if at risk should not take
- small increased risk of hemorrhagic stroke, subarachnoid hemorrhage, thrombotic stroke
-risk increases with smoking, HTN, 35 years +
-Should stop if severe HA, blurred/lost vision, transient neurologic disorders develop
Combined Oral Contraceptives: carcinoma
-no increased risk for breast cancer in women aged 35-64 who are current or former users
-r/t hepatocellular ademoas increase with dose, duration, older age
Combined Oral Contraceptives: HTN
-increased risk with duration and age
-with HTN use of non-estrogen containing OC
-With regular BP monitoring, non smokers, well-controlled mild HTN can use OC
Combined Oral Contraceptives: headache
-migraine or other vascular headache may occur or worsen with pill use
-with severe or frequent HA pill should be d/c
-migraine with aura should not use
Combined Oral Contraceptives: lactation
-combined OC can impair quality and quantity of breast milk
-combination OC should be started no earlier than 6 week PP
-Progestin only pills, levonorgestrel implants, DMPA are alternatives with no adverse effects on milk quality
Combined Oral Contraceptives: other disorders
-depression may occur or worsen
-fluid retention may occurs
-cholestatic jaundice during pregnancy may reoccur
Combined Oral Contraceptives: obesity
-obese or overweight women less effective
-risk for thromboembolic complications
-alternatives= progestin only injections, implants, IUD
Combined Oral Contraceptives: minor side effects
-nausea, dizziness in first few months
-weight gain of 2-5 lbs
-spotting/breakthrough bleeding between menstrual cycles may occur especially if pill is skipped or taken labs
-missed menstual cycles may occur especially with lose dose pills
-fatigue, decreased libido, chloasma increased by exposure to light
progestin minipill: efficacy and methods of use
-formulation containing 0.35 mg of norethindrone
-efficacy is similar to combo pill but highly dependable on consistent use (taking the pill within the same 3 hr window daily)
-prevents conception by thickening cervical mucus, causing alternation of ovum transport and causes inhibition of implantation
-take on the 1st day of menstrual cycle
-no “placebo” week
progestin minipill: advantages
-low dose of progestin and absence of estrogen makes it safe during lactation
-may increase flow of milk
-good for patients who want minimal doses of hormones or women over 35
-lacks cardiovascular ZSE
-can use with sickle cell disease
progestin minipill: contraindications/complications
-bleeding irregularities (prolonged flow, spotting, amenorrhea)
-ectopic pregnancies more frequent
-weight gain, mild HA
menopause: average age
average age: 51
condyloma acuminata: diagnosis
-diagnosed after application of 4% acidic acid (vinegar) and colposcopy
-whitish with prominent papillae
-diffuse hypertrophy or cobblestone appearance
condyloma acuminata: treatment
-vulvar: podophyllum resin 10-25% in tincture of benzoin (not during pregnancy/bleeding lesions)
-80-90% trichloroacetic or bichloroacetic acid
-pain of acid application can be lessed by sodium bicarb paste applied after tx
-podophyllum resin must be washed off after 2-4 hours
-cryotherapy, liquid nitrogen, electrocautery also effective
-pt applied regimes useful when entire lesion is accessible to the patient and include podofilox 0.5% soltuoin/gel, imiquimod 5% cream or sinecatechins 15% ointment
-co2 laser, electrocauter or excision
acute bacterial prostatitis
-caused by gram negative rods esp e.coli and psuedomas species, less common by gram positive organisms ex. enterococci
-likely routes include ascent up the urethra and reflux of infected urine into the prostatic ducts
-lymphatic and hematogenous routes rare
acute bacterial prostatitis: clinical findings
-perineal, sacral or suprapubic pain
-fever
-irritative voiding complaints
-varying degree of obstructive symptoms
-urinary retention
-tender prostate on exam
-prostatic massage contraindicated
acute bacterial prostatitis: laboratory findings
-CBC with leukocytosis with left shift
-UA: pyuria, bacteriuria, varying degrees of hematuria -cultures: pathogen
acute bacterial prostatitis: imaging
-transrectal US, pelvic CT if no response to therapy within 24-48 hours
acute bacterial prostatitis: treatment
-hospitalization may be required and parental abx (ampicillin & amioglycoside) should be initiated until organisms are available
-after being afebrile for 24-48 hours PO abx are used to complete 4-6 weeks of therapy
-if UR develop in and out catheterization can be used
-outpatient: trimethoprim-sulfamethoxazole 160/800 mg every 12 hours for 3 weeks or ciprofloxacin 250-500mg every 12 hours for 3 weeks
chronic bacterial prostatits
-can evolve from acute bacterial prostatitis or from recurrent UTI over 1/2 of men have no hx of acute infection
-gram negative rods most common etiology agents but only 1 gram positive organism (enterococcus) is associated with chronic infection
chronic bacterial prostatits: S&S
-varying degrees of irritative voiding symptoms: urethral pain, obstructive urinary symptoms
-low back and perineal pain common
-unremarkable physical examination although prostate may feel normal, indurated or boggy
-post void residual volume should be measured for retention
chronic bacterial prostatitis: laboratory findings
-urinalysis normal unless secondary cystitis is present
-expressed prostatic secretions or post prostatic massage increased numbers of leukocytes >5-10 per high powered field
-bacterial growth when cultured
-cultures of secretions/massage/urine necessary for diagnosis
-if no organisms are identified on culture = nonbacterial prostatitis, chronic pelvic pain or interstitial cystitis should be suspected
chronic bacterial prostatitis: treatment
-febrile or systemically ill; may need initial IV therapy with broad spectrum abx (ampicillin + gentamicin, 3rd gen. cephalosporin or floraquinole)
-therapy continues with oral trimethoprim-sulfamethoxazole, fluoroquinolone or extended spectrum beta lactamase based on culture and sensitivity of expressed secretion or post massage urine
-optimal duration is controversial ranging from 4-6 weeks
-symptomatic relief may be provided by anti-inflammatory agents such as indomethacin, NSAIDs, hot sitz bath, tamsulosin (alpha blockers)
chronic bacterial prostatitis: first line treatment
-ciprofloxacin 500mg PO Q12 (1-3 month)
-levofloxacin 750mg PO daily (28 days)
chronic bacterial prostatitis: second line treatment
-doxycycline 100mg PO BID (4-12 weeks)
-azithromycin 500mg PO daily (4-12 weeks)
-clarithromycin 500mg PO daily (4-12 weeks)
nonbacterial chronic prostatitis
-caused by interrelated cascade of inflammatory immunologic, endocrine, muscular, neuropathic, psychologic mechanisms
-variety of subtypes based on pronounced symptoms
-unknown cause: one of exclusion
-decreased quality of life
nonbacterial chronic prostatitis: S&S
-chronic peroneal, suprapubic or pelvic pain
-pain during or after ejaculation
-psychosocial factors (depression, anxiety, poor social support, stress)
nonbacterial chronic prostatitis: laboratory findings
-increased leukocytes
-cultures of secretions and urine are negative
nonbacterial chronic prostatitis: treatment
-multimodal therapy recommended
-with voiding symptoms treated with alpha blocker (tamsulosin, alfuzosin, silodosin)
-abx for newly diagnosed antimicrobial naive patients
-cognitive behavioral therapy, antidepressants, anxiolytics
-neuropathic pain: gabapentinoids, amitriptyline, neuromodulation, acupuncture or referall to pain mangement
-pelvic floor therapy, shock wave, heat therapy
-sexual dysfunction: sexual therapy, phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil)
BPH: signs and symptoms (obstructive)
-most common benign tumor in men
-hesitancy
-decreased force
-caliber of stream
-sensation of incomplete bladder emptying
-double voiding (urinating a 2nd time in 2 hrs)
-straining to urinate
-postvoid dribbling
BPH: signs and symptoms (irritative)
-urgency
-frequency
-nocturia
BPH: symptom index
-American Urological Association symptom index
-single most important tool for evaluation
-0-35 increasing severity of symptoms
BPH: signs
-Digital rectal examination and focused neurological exam
-size and consistency of prostate (size doesn’t correlate with severity)
-smooth, firm, elastic enlargement of the prostate
-induration, if detected may be cancer
-PSA, transrectal US, biopsy
-lower abdomen exam for distention
BPH: laboratory findings
-urinalysis to exclude infection or hematuria
-serum PSA
BPH: treatment: watchful waiting
-mild symptoms
-can have spontaneous resolution
-no specific timeline
BPH: alpha blockers
-classified by half time and receptor selectivity
-prazosin effective, short acting, no selective blocker but requires dose titration and BID dosing
-SE: orthostatic hypotension, dizziness, tiredness, retrograde ejaculation, rhinitis, HA
-Long acting alphas= daily dosing, need to titrate
-terazosin 1mg po daily for 3 days increased to 2 mg po daily for 11 days 5mg po daily (escalating to 10 mg daily if necessary)
-Alpha 1a-receptors are localized to the prostate and bladder neck = fewer systemic SE and no dose titration
-tamsulosin 0.4mg daily
-floppy iris syndrome is a compilation of cataract surgery
BPH: 5-alpha-reductase inhibitors
-Finasteride and dutasteride block the conversion of testosterone to dihydrotestosterone
-impact epithelial component of the prostate=reducing size of gland and improvement of symptoms
-6 months therapy required for maximum effects on prostate size and symptomatic improvement
-SE: decreased libido, volume of ejaculate, erectile dysfunction
-Lowered PSA & chem-preventive agents
BPH: phosphodiesterase-5 inhibitor
-Tadalafil to treat S&S of BPH and ED
-5 mg PO daily
-improvement in 2-4 weeks
BPH: combination therapy
-finasteride + doxazosin
-reduced risk of clinical progression
Common organisms for chronic bacterial prostatitis
gram – = klebseilla, acinetobacter, pseudomonas, proteus mirabellis, enterococcus
Major depressive disorder
-syndrome of mood, physical and cognitive symptoms
-loss of interest/pleasure (anhedonia)
-difficultly concentrating
-anxiety
-fatigue
hypoparathyroid levels
-magnesium deficiency (1.7-2.2)
-low serum calcium (should be 8-8.6)
-low vitamin D (20-40 or 30-50)