Nurse Practitioner - Fitzgerald, Margaret A.
Nurse Practitioner - Fitzgerald, Margaret A.
Fitzgerald
urse
Certification Examination and Practice Preparation
FOURTH EDITION
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Nurse Practitioner
Certification Examination and Practice Preparation
FOURTH EDITION
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Nurse Practitioner
Certification Examination and Practice Preparation
FOURTH EDITION
Margaret A. Fitzgerald,
DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC
President, Fitzgerald Health Education
Associates, Inc.
North Andover, Massachusetts
Family Nurse Practitioner
Greater Lawrence Family Health Center
Lawrence, Massachusetts
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Library of Congress Cataloging-in-Publication Data
Fitzgerald, Margaret A., author.
Nurse practitioner certification examination and practice preparation / Margaret A. Fitzgerald. — Fourth
edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-4074-0 (alk. paper)
I. Title.
[DNLM: 1. Nursing Care—methods—Examination Questions. 2. Certification—Examination Questions.
3. Nurse Practitioners—Examination Questions. WY 18.2]
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Dedication
v
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Contributors
vii
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viii Contributors
Monica N. Tombasco, MS, MSNA, FNP-BC, Christy M. Yates, MS, FNP-BC, NP-C, AE-C
CRNA Senior Lecturer
Senior Lecturer Fitzgerald Health Education Associates, Inc.
Fitzgerald Health Education Associates, Inc. Clinical Practice, Family Allergy and Asthma
Clinical Practice, CRNA, Catholic Medical Center Louisville, Kentucky
Manchester, New Hampshire
Nurse Practitioner, Emergency Medicine
Central New Hampshire Emergency Physicians
Huggins Hospital
Wolfeboro, New Hampshire
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Acknowledgments
ix
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Introduction
xi
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Contents
xiii
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Health Promotion
and Disease Prevention 1
Primary Prevention 6. Active immunity is defined as:
A. resistance developed in response to an antigen.
Measures B. immunity conferred by an antibody produced in
another host.
1. An example of a primary prevention measure for a C. the resistance of a group to an infectious agent.
78-year-old man with chronic obstructive pulmonary D. defense against disease acquired naturally by the
disease is: infant from the mother.
A. reviewing the use of prescribed medications.
B. conducting a home survey to minimize fall risk. 7. Which of the following is usually viewed as the most
C. checking FEV1 (force expired volume at 1 second) to cost-effective form of healthcare?
FVC (forced vital capacity) ratio. A. primary prevention
D. ordering fecal occult blood test (FOBT). B. secondary prevention
C. tertiary prevention
2. Which of the following is an example of a primary preven- D. cancer-reduction measures
tion activity in a 76-year-old woman with osteoporosis?
A. bisphosphonate therapy 8. An 18-year-old woman with allergic rhinitis presents for
B. calcium supplementation primary care. She is sexually active with a male partner
C. ensuring adequate illumination in the home and is 1 year post-coitarche; during this time she had had
D. use of a back brace two sex partners. An example of a primary prevention
activity for this patient is:
3. Secondary prevention measures for a 78-year-old man A. screening for sexually transmitted infection.
with chronic obstructive pulmonary disease include: B. counseling about safer sexual practices.
A. screening for mood disorders. C. prescribing therapies for minimizing allergy.
B. administering influenza vaccine. D. obtaining a liquid-based Papanicolaou (Pap) test.
C. obtaining a serum theophylline level.
D. advising about appropriate use of car passenger 9. When a critical portion of a community is immunized
restraints. against a contagious disease, most members of the com-
munity, even the unimmunized, are protected against
4. Tertiary prevention measures for a 69-year-old woman that disease because there is little opportunity for an
with heart failure include: outbreak. This is known as _________ immunity.
A. administering antipneumococcal vaccine. A. passive
B. adjusting therapy to minimize dyspnea. B. humoral
C. surveying skin for precancerous lesions. C. epidemiologic
D. reviewing safe handling of food. D. community
5. Which of the following products provides passive
immunity? Answers
A. hepatitis B immune globulin (HBIG)
B. measles, mumps, and rubella (MMR) vaccine 1. B. 4. B. 7. A.
C. pneumococcal conjugate vaccine 2. C. 5. A. 8. B.
D. live attenuated influenza vaccine (LAIV) 3. A. 6. A. 9. D.
1
4074_Ch01_001-026 20/11/14 10:25 AM Page 2
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians discuss these preventive services with eligible patients and offer them as a
priority. All these services have been given “A” or a “B” (recommended) grade from the Task Force.
CHAPTER 1
Asymptomatic Bacteriuria in Adults, Screening
■
Health Promotion and Disease Prevention
Cervical Cancer, Screening
Figure 1-1 Preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). Available at http://www.ahrq.gov/clinic/
pocketgd2012/gcp12s1.htm.
Continued
3
4074_Ch01_001-026 20/11/14 10:25 AM Page 4
4
CHAPTER 1
Section 1: Preventive Services Recommended by the USPSTF (continued)
Gonorrhea, Screening
■
HIV, Screening
Osteoporosis, Screening
Phenylketonuria, Screening
Figure 1-1—cont’d
4074_Ch01_001-026 20/11/14 10:25 AM Page 5
TABLE 1-1
Secondary Prevention Principles
Principle Comment
Prevalence is sufficient to justify screening. Routine mammography is appropriate in women but
not men.
Health problem has significant effect on quality or Target diseases for secondary prevention include hyperten-
quantity of life. sion, type 2 diabetes mellitus, dyslipidemia, and certain
cancers.
The target disease has a long asymptomatic period. The Treatment is available for the target disease. Providing
natural history of the disease, or how the disease un- treatment alters the disease’s natural history.
folds without intervention, is known.
A population-acceptable screening test is available. The test should be safe, should be available at a reason-
able cost, and have reasonable sensitivity and specificity.
Source: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/preventive-medicine/principles-
of-screening/, Principles of Screening
15. When advising a patient about the influenza nasal spray 20. Which of the following should not receive vaccination
vaccine, the NP considers the following: against influenza?
A. Its use is acceptable during pregnancy. A. a 19 year-old with a history of hive-form reaction
B. Its use is limited to children younger than 6 years. to eating eggs
C. It contains live, attenuated virus. B. a 24-year-old woman who is 8 weeks pregnant
D. This is the preferred method of influenza protection C. a 4-month-old infant who was born at 32 weeks
in the presence of airway disease. of gestation
D. a 28-year-old woman who is breastfeeding a
16. Approximately ____ of healthcare providers receive in-
2 week old.
fluenza immunization annually.
A. one-quarter 21. A healthy 6-year-old girl presents for care. Her parents
B. one-half request that she receive vaccination for influenza and
C. two-thirds report that she has not received this vaccine in the past.
D. three-quarters or more How many doses of influenza vaccine should she re-
ceive this flu season?
17. The most common mode of influenza virus transmission
A. 1
is via:
B. 2
A. contact with a contaminated surface.
C. 3
B. respiratory droplet.
D. 4
C. saliva contact.
D. skin-to-skin contact.
18. In an immunocompetent adult, the length of incuba- Answers
tion for the influenza virus is on average:
10. D. 14. A. 18. B.
A. less than 24 hours.
11. C. 15. C. 19. C.
B. 1 to 4 days.
12. C. 16. D. 20. C.
C. 4 to 7 days.
13. A. 17. B. 21. B.
D. more than 1 week.
19. Influenza protection options for a 62-year-old man An individual who presents with an abrupt onset of signs and
with hypertension, dyslipidemia, and type 2 diabetes symptoms including fever, myalgia, headache, malaise, non-
mellitus include receiving: productive cough, sore throat, and rhinitis typically has un-
A. live attenuated influenza vaccine via nasal spray. complicated influenza illness, more commonly known as “the
B. high-dose trivalent inactivated vaccine (TIV) via in- flu.” Children with influenza commonly have acute otitis
tramuscular injection media, nausea, and vomiting in addition to the aforemen-
C. trivalent inactivated vaccine (TIV) in standard dose tioned signs and symptoms. Although the worst symptoms
via intramuscular injection. in most uncomplicated cases resolve in about 1 week,
D. appropriate antiviral medication as the initial onset the cough and malaise often persist for 2 or more weeks.
of influenza-like illness. Individuals with ongoing health problems such as pulmonary
4074_Ch01_001-026 20/11/14 10:25 AM Page 6
or cardiac disease, young children, and pregnant women also Considering these factors, influenza, regardless of the viral
have increased risk of influenza-related complications includ- strain, is not just a bad cold, but rather a potentially serious
ing pneumonia. Rarely, influenza virus infection also has illness with significant morbidity and mortality risk across
been associated with encephalopathy, transverse myelitis, the life span. Even in the absence of complications, this viral
myositis, myocarditis, pericarditis, and Reye syndrome. illness typically causes many days of incapacitation and suf-
Influenza viruses spread from person to person largely via fering and the risk of death. The influenza vaccines are about
respiratory droplet from an infected person, primarily 70% to 80% effective in preventing influenza or reducing the
through a cough or sneeze. In an immunocompetent adult, severity of the disease. The injectable vaccine does not contain
the influenza virus has a short incubation period, with a range live virus and is not shed; there is no risk of transmitting an
of 1 to 4 days (average of 2 days). Adults pass the illness on infectious agent to household contacts. Mild to moderate ill-
1 day before the onset of symptoms and continue to remain ness or current antimicrobial therapy is not a contraindica-
infectious for approximately 5 days after the onset of the tion to any immunization, including the administration of
illness. Children remain infectious for 10 or more days after the influenza vaccine.
the onset of symptoms and can shed the virus before the Immunization rates against influenza for individuals with
onset of symptoms. People who are immunocompromised chronic illness are typically the highest, although there is con-
can remain infectious for up to 3 weeks. siderable room for improvement. Certain groups have very low
Historically, the risks for complications, hospitalizations, immunization rates and should be targeted for improvement.
and deaths from influenza are higher among adults older These include persons who live with or care for persons at high
than age 65 years, young children, and individuals of any risk for influenza-related mortality and morbidity. Persons
age with certain underlying health conditions than among who provide essential community services should be consid-
healthy older children and younger adults. In children ered for vaccination to minimize disruption of essential activ-
younger than 5 years, hospitalization rates for influenza- ities during influenza outbreaks. Students and other persons
related illness have ranged from approximately 500/100,000 in institutional or other group-living situations should be en-
for children with high-risk medical conditions to 100/100,000 couraged to receive vaccine to minimize the risk of an outbreak
for children without high-risk medical conditions. Hospital- in a relatively closed community. According to the recommen-
ization rates for influenza-related illness among children dation of the Centers for Disease Prevention and Control
younger than 24 months are comparable to rates reported (CDC), all members of the population age 6 months and older
among adults older than 65 years. Influenza strains such as should receive annual immunization against seasonal in-
H1N1, an influenza A virus also known as swine flu, and fluenza. If supply of influenza vaccines is limited, certain
H5N1, an influenza A virus also known as avian flu, appear groups at highest risk of influenza complication or transmis-
to cause a greater disease burden in younger adults. sion should be prioritized for immunization. (Table 1–2).
TABLE 1-2
Advisory Committee on Immunization Practices (ACIP) Recommendations
on Influenza Immunization
Routine influenza vaccination is recommended for all persons aged 6 months and older. While everyone should get a flu
vaccine each flu season, certain patient populations are at high risk of having serious flu-related complications or live
with or care for people at high risk for developing flu-related complications. Populations include:
• All children aged 6 through 59 months.
• Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension),
renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus). Individuals age 50 years
of age and older.
• Persons who have immunosuppression (including immunosuppression caused by medications or by HIV infection).
• Women who are or will be pregnant during the influenza season.
• Children and adolescents (aged 6 months – 18 years) who are receiving long-term aspirin therapy and who might be
at risk for experiencing Reye’s syndrome after influenza virus infection.
• Residents of nursing homes and other long-term care facilities.
• American Indians/Alaska Natives.
• Persons who are morbidly obese (BMI ≥40) kg/m2.
• People who live with or care for those at high risk for complications from flu, including:
• Healthcare workers.
• Household contacts of persons with medical conditions that put them at high risk for complications from the flu.
• Household contacts and out of home caregivers of children aged ≤59 months and adults aged ≥50 years, with par-
ticular emphasis on vaccinating contacts of children less than 6 months of age. (These children are too young to be
vaccinated.)
4074_Ch01_001-026 20/11/14 10:25 AM Page 7
TABLE 1-2
Advisory Committee on Immunization Practices (ACIP) Recommendations
on Influenza Immunization—cont’d
All children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive 2 doses
spaced ≥4 weeks apart.
There are a variety of vaccines to protect against influenza currently available.
• Trivalent inactivated vaccine (TIV) in standard dose administered intramuscularly approved for all ages ≥6 months who
have no other contraindications. This is the typical “flu shot.” A quadrivalent inactivated vaccine is also available.
• Intradermal TIV in a lower dose when compared to standard flu vaccine administered IM (9 mcg rather than 15 mcg of
each strain per dose) in a smaller volume (0.1 mL rather than 0.5 mL) approved for use in adults 18 to 64 years of age,
with a preferred injection site over the deltoid.
• Inactivated TIV containing a greater dose of antigen when compared to standard flu vaccine (60 mcg rather than
15 mcg per dose) approved for use in adults age ≥65 years
• Live, attenuated influenza vaccine (LAIV) via nasal spray: A flu vaccine made with live, weakened flu viruses that is
given as a nasal spray. The viruses in the nasal spray vaccine do not cause the flu. LAIV (trivalent or quadrivalent) is
approved for use in healthy individuals, excluding pregnant women, ages 2 through 49 years.
• A trivalent cell culture-based inactivated influenza vaccine, which is indicated for persons aged 18 through 49 years.
• A recombinant hemagglutinin (HA) vaccine, which is indicated for persons aged 18 through 49 years.
The following recommendations apply when considering influenza vaccination of persons who have or report a history of
egg allergy.
1. Persons who have experienced only hives following exposure to egg should receive influenza vaccine. Because little
data are available for use of LAIV in this setting, IIV (inactivated influenza vaccine) or RIV (recombinant influenza
vaccine) should be used. RIV is egg-free and indicated for persons 18–49 years of age. IIV (egg- or cell-culture-based)
can also be used with the following additional safety measures:
• Vaccine should be administered by a healthcare provider who is familiar with the potential manifestations of egg
allergy.
• Vaccine recipients should be observed for at least 30 minutes for signs of a reaction following administration of
each vaccine dose.
2. Persons who report having had reactions to egg involving angioedema, respiratory distress, lightheadedness, or
recurrent emesis, or persons who required epinephrine or other emergency medical intervention may receive RIV3,
if aged 18–49 years and there are no other contraindications. If RIV3 is not available or the recipient is not within
the indicated age range, such persons should be referred to a physician with expertise in the management of allergic
conditions for further risk assessment before receipt of the vaccine.
3. All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treat-
ment of anaphylaxis are available.
4. Some persons who report allergy to egg might not be egg allergic. Those who are able to eat lightly cooked egg
(scrambled eggs) without reaction are unlikely to be allergic. Conversely, egg-allergic persons might tolerate egg in
baked products (bread, cake other bakery products); tolerance to egg-containing foods does not exclude the possibil-
ity of egg allergy. Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and
egg-containing foods, plus skin and/or blood testing for immunoglobulin E antibodies to egg proteins.
5. For individuals who have no known history of exposure to egg, but who are suspected of being egg-allergic on the
basis of previously performed allergy testing, consultation with a physician with expertise in the management of
allergic conditions should be obtained prior to vaccination. Alternatively, RIV3 may be administered if the recipient
is aged 18–49 years.
6. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for
the reaction, is a contraindication to receipt of influenza vaccine.
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm
The Advisory Committee on Immunization Practices job is particularly important, given the increased patient vol-
(ACIP), sponsored by the CDC, recommends that healthcare ume and work burden to the healthcare system during flu
administrators consider the level of vaccination coverage season. At least three-quarters of all HCP report having had
among healthcare personnel (HCP) to be one measure of an influenza vaccination during a recent influenza season.
patient safety quality programs; keeping HCP well and on the This rate of immunization marks a significant improvement
4074_Ch01_001-026 20/11/14 10:25 AM Page 8
from rates in prior decades but falls far short of universal im- Food and Drug Administration (FDA) for use against in-
munization for this important target population. Highest rates fluenza: amantadine (Symmetrel), rimantadine (Flumadine),
are found in acute care facilities where influenza vaccination is zanamivir (Relenza), and oseltamivir (Tamiflu). The adaman-
mandatory, whereas lowest rates are noted in long-term care tane derivatives (amantadine and rimantadine) are approved
facilities. Injectable trivalent influenza vaccine (TIV), more only for treatment and prevention of influenza A, whereas the
commonly called the “flu shot,” is available in a variety of forms. neuraminidase inhibitor drugs (zanamivir and oseltamivir)
(See Table 1–2 for details on candidates for each vaccine). are approved for use in influenza A and influenza B. Ongoing
The nasal spray flu vaccine, also known as live attenuated CDC viral surveillance has shown high levels of resistance of
influenza vaccine (LAIV) (FluMist), differs from the in- influenza A viruses to amantadine and similar medications.
jectable influenza vaccine. Administered via a well-tolerated Because of this significant level of resistance, amantadine and
nasal mist, LAIV offers an easily administered, noninjection rimantadine are no longer recommended by the CDC for the
method of influenza immunization. LAIV contains influenza treatment of influenza. Relatively little resistance to the an-
viruses that are sufficiently weakened as to be incapable of tiviral drugs oseltamivir and zanamivir has been noted in
causing disease but with enough strength to stimulate a pro- North America, but higher levels have been noted in Asia and
tective immune response. The viruses in the LAIV are cold- other parts of the world. The healthcare provider should keep
adapted and temperature-sensitive. As a result, the viruses well informed of these developments.
can grow in the nose and throat but not in the lower respira- Zanamivir and oseltamivir are used to treat influenza A
tory tract, where the temperature is higher. LAIV is approved and B infections caused by susceptible viral strains; if treat-
for use in healthy people ages 2 to 49 years old. Individuals ment with either of these drugs is started during the first
who should not receive LAIV include children younger than 2 days of illness, the time a person feels ill is shortened by
2 years; adults older than 49 years; patients with a health con- approximately 1 day. Zanamivir is inhaled and can cause
dition that places them at high risk for complications from bronchospasm, especially in patients with asthma or other
influenza, including chronic heart disease, chronic lung dis- chronic lung disease. The adverse effects of oseltamivir are
ease such as asthma or reactive airways disease, diabetes or largely gastrointestinal; the risk of nausea and vomiting is sig-
kidney failure, and immunosuppression; children or adoles- nificantly reduced if the medication is taken with food.
cents receiving long-term high-dose aspirin therapy; people Although many antiviral medications carry indications for
with a history of Guillain-Barré syndrome; pregnant women; the post-exposure prevention of influenza, all have a less
and people with a history of allergy to any of the components favorable adverse reaction profile than influenza vaccine;
of LAIV. Adverse effects of LAIV include nasal irritation and these products are also significantly more expensive. Active
discharge, muscle aches, sore throat, and fever. immunization against influenza A and B is the preferred
Two special influenza immunization situations bear men- method of disease prevention.
tion. Children younger than 9 years who are receiving initial
influenza immunization need two doses of vaccine separated D I S C U SSI O N S O U R C E S
by 4 or more weeks. Pregnant women should be immunized Centers for Disease Control and Prevention, http://www.cdc.gov/
against influenza; the vaccine can be given regardless of preg- flu/index.htm, Seasonal Influenza
nancy trimester. Because of the change in the respiratory and Centers for Disease Control and Prevention, http://www.cdc.gov/
immune system normally present during pregnancy, in- flu/healthcareworkers.htm, Influenza Vaccination Information
fluenza is five times more likely to cause serious disease in for Healthcare Workers / Influenza Vaccination
a pregnant woman when compared with a nonpregnant Centers for Disease Control and Prevention, http://www.cdc.gov/
flu/professionals/antivirals/index.htm, Antiviral Drugs
woman. In addition, women who are immunized against
influenza during pregnancy are able to pass a portion of this
protection on to the unborn child, providing important pro-
tection during the first 6 months of life. Flu vaccine is also Measles, Mumps,
safe to give during lactation. Children younger than 9 years
who are receiving initial influenza immunization need
and Rubella
two doses of vaccine separated by 4 or more weeks. Immunization
Until recently, egg allergy was considered a contraindica-
tion to receiving all forms of influenza vaccine. Current rec- 22. When considering an adult’s risk for measles, mumps,
ommendations advise that most individuals who are allergic and rubella (MMR), the NP considers the following:
to eggs can safely receive influenza vaccine (Table 1–2). A. Patients born before 1957 have a high likelihood of
In the Northern Hemisphere, the optimal time to receive immunity against these diseases because of a history
any influenza vaccine is usually in fall months, at least of natural infection.
1 month prior to the anticipated onset of the flu season; this B. Considerable mortality and morbidity occur with all
timing is reversed in the Southern Hemisphere. The vaccine three diseases.
is given annually and its contents are reflective of the viruses C. Most cases in the United States occur in infants.
anticipated to cause influenza for the upcoming flu season. D. The use of the MMR vaccine is often associated with
In the United States, four antiviral drugs are approved by the protracted arthralgia.
4074_Ch01_001-026 20/11/14 10:25 AM Page 9
23. Which of the following is true about the MMR vaccine? (native or wild infection); vaccine against these three for-
A. It contains inactivated virus. merly common illnesses was unavailable until the 1960s. As
B. Its use is contraindicated in patients with a history with all vaccines, giving additional doses to patients with an
of egg allergy. unclear immunization history is safe. (See Figure 1–2 for
C. Revaccination of an immune person is associated adult immunization schedules.) A quadrivalent vaccine, pro-
with risk of significant systemic allergic reaction. tecting against measles, mumps, rubella, and varicella (chick-
D. Two doses at least 1 month apart are recommended enpox), is also available and usually used to immunize
for young adults who have not been previously younger children.
immunized. Rubella typically causes a relatively mild, 3- to 5-day ill-
24. A 22-year-old man is starting a job in a college health ness with little risk of complication to the person infected.
center and needs proof of German measles, measles, When rubella is contracted during pregnancy, however, the
and mumps immunity. He received childhood immu- effects on the fetus can be devastating. Immunizing the en-
nizations and supplies documentation of MMR vacci- tire population against rubella exploits herd or community
nation at age 1.5 years. Your best response is to: immunity and protects pregnant women from contracting
A. obtain rubella, measles (rubeola), and mumps rubella and therefore eliminating the risk of congenital
titers. rubella syndrome in the unborn. Measles can cause severe
B. give MMR immunization now. illness with serious sequelae, including encephalitis and
C. advise him to obtain IG if he has been exposed to pneumonia; sequelae of mumps include orchitis and possi-
measles or rubella. ble decreased male fertility.
D. advise him to avoid individuals with skin rashes. In the past, a history of egg allergy was considered a con-
traindication to receiving MMR vaccine. The vaccine now is
25. Concerning the MMR vaccine, which of the following deemed safe in people with egg allergy. However, patients
is true? with a history of anaphylactic reaction to neomycin or gelatin
A. The link between use of MMR vaccine and child- should not receive MMR. The MMR vaccine is safe to use
hood autism has been firmly established. during lactation, but its use during pregnancy is discouraged
B. There is no credible scientific evidence that MMR because of the theoretical but unproven risk of congenital
use increases the risk of autism. rubella syndrome from the live virus contained in the vaccine.
C. The use of the combined vaccine is associated MMR vaccine is well tolerated; there have been rare reports
with increased autism risk, but giving the vaccine’s of mild, transient adverse reactions such as rash and sore
three components as separate vaccines minimizes throat.
this risk. At the request of the CDC and the National Institutes of
D. The vaccine contains thimerosal, a mercury Health (NIH), the Institute of Medicine and National Acad-
derivative. emy of Sciences conducted a review of all the evidence related
26. Which of the following is not recommended to receive to the MMR vaccine and autism. This independent panel ex-
the MMR vaccination? amined completed studies, ongoing studies, published med-
A. A 1-year-old boy with a history of hive-form reac- ical and scientific articles, and expert testimony to assess
tion egg ingestion whether or not there was a link between autism and the MMR
B. A 24-year-old woman who is 20 weeks pregnant vaccine. The groups concluded that the evidence reviewed
C. A 4-year-old girl who was born at 32 weeks of did not support an association between autism and the MMR
gestation vaccine. Although the preservative thimerosal, a mercury de-
D. A 32-year-old woman who is breastfeeding a rivative, has been mentioned as a possible autism contributor,
2 week old. the MMR vaccine licensed for use in the United States does
not contain this preservative.
D I S C U SSI O N S O U R C E S
Answers Centers for Disease Control and Prevention, http://www.cdc.gov/
vaccines/default.htm, Vaccines and Immunizations
22. A. 24. B. 26. B.
Centers for Disease Control and Prevention, http://www.cdc.gov/
23. D. 25. B. vaccines/vpd-vac/measles/default.htm#clinical, Measles
Centers for Disease Control and Prevention, http://www.cdc.
The MMR vaccine contains live but weakened (attenuated) gov/vaccines/vpd-vac/rubella/default.htm, Rubella (German
virus. Two immunizations 1 month apart are recommended measles)
for adults born after 1957 because adults born before then are Centers for Disease Control and Prevention, http://www.cdc.gov/
considered immune as a result of having had these diseases vaccines/vpd-vac/mumps/default.htm, Mumps
4074_Ch01_001-026 20/11/14 10:25 AM Page 10
VACCINE d AGE GROUP f 19-21 years 22-26 years 27-49 years 50-59 years 60-64 years ≥ 65 years
2,*
1 dose annually
Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
Zoster 6 1 dose
7,*
Measles, mumps, rubella (MMR) 1 or 2 doses
Figure 2. Vaccines that might be indicated for adults based on medical and other indications1
Immuno- HIV infection Heart Asplenia (including
compromising CD4+ T lymphocyte disease, elective splenectomy
4,6,7,8,15
conditions count Men who Kidney failure, chronic and persistent
(excluding human have sex end-stage renal lung disease, complement Chronic
< 200 ≥ 200 with men disease, receipt chronic component liver Healthcare
VACCINE d INDICATION f Pregnancy virus [HIV])4,6,7,8,15 cells/μL cells/μL (MSM) of hemodialysis alcoholism 8,14
disease Diabetes personnel
2,* 1 dose IIV or 1 dose IIV or LAIV
1 dose IIV annually LAIV annually 1 dose IIV annually annually
These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly
indicated for adults ages 19 years and older, as of February 1, 2014. For all vaccines being recommended on the Adult Immunization Schedule:
a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be
used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed
recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package
inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/hcp/acip-recs/index.html). Use of
d does not imply endorsement by the U.S. Department of Health and Human Services.
Figure 1-2 Recommended immunization schedule by vaccine and age group—United States, 2013
4074_Ch01_001-026 20/11/14 10:25 AM Page 11
Footnotes
Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2014
1. Additional information 5. Human papillomavirus (HPV) vaccination (cont’d)
• Additional guidance for the use of the vaccines described in this supplement • HPV4 is recommended for men who have sex with men through age 26
is available at www.cdc.gov/vaccines/hcp/acip-recs/index.html. years for those who did not get any or all doses when they were younger.
• Information on vaccination recommendations when vaccination status is • Vaccination is recommended for immunocompromised persons
unknown and other general immunization information can be found in (including those with HIV infection) through age 26 years for those who
the General Recommendations on Immunization at did not get any or all doses when they were younger.
www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm. • A complete series for either HPV4 or HPV2 consists of 3 doses. The second
• Information on travel vaccine requirements and recommendations (e.g., dose should be administered 4 to 8 weeks (minimum interval of 4 weeks)
for hepatitis A and B, meningococcal, and other vaccines) is available at
http://wwwnc.cdc.gov/travel/destinations/list.
• Additional information and resources regarding vaccination of pregnant women at least 12 weeks).
can be found at http://www.cdc.gov/vaccines/adults/rec-vac/pregnant.html. • HPV vaccines are not recommended for use in pregnant women. However,
2. pregnancy testing is not needed before vaccination. If a woman is found
• to be pregnant after initiating the vaccination series, no intervention
aged 6 months or older. is needed; the remainder of the 3-dose series should be delayed until
• Persons aged 6 months or older, including pregnant women and persons completion of pregnancy.
6. Zoster vaccination
vaccine (IIV). An age-appropriate IIV formulation should be used. • A single dose of zoster vaccine is recommended for adults aged 60 years
• or older regardless of whether they report a prior episode of herpes zoster.
(RIV) (FluBlok). RIV does not contain any egg protein. Although the vaccine is licensed by the U.S. Food and Drug Administration
• Healthy, nonpregnant persons aged 2 to 49 years without high-risk medical for use among and can be administered to persons aged 50 years or older,
conditions can receive either intranasally administered live, attenuated ACIP recommends that vaccination begin at age 60 years.
• Persons aged 60 years or older with chronic medical conditions may be
for severely immunocompromised persons (i.e., those who require care in vaccinated unless their condition constitutes a contraindication, such as
a protected environment) should receive IIV or RIV rather than LAIV.
• The intramuscularly or intradermally administered IIV are options for 7. Measles, mumps, rubella (MMR) vaccination
adults aged 18 to 64 years. • Adults born before 1957 are generally considered immune to measles and
• Adults aged 65 years or older can receive the standard-dose IIV or the mumps. All adults born in 1957 or later should have documentation of 1 or
high-dose IIV (Fluzone High-Dose). more doses of MMR vaccine unless they have a medical contraindication
3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination to the vaccine or laboratory evidence of immunity to each of the three
• Administer 1 dose of Tdap vaccine to pregnant women during each diseases. Documentation of provider-diagnosed disease is not considered
pregnancy (preferred during 27 to 36 weeks’ gestation) regardless of acceptable evidence of immunity for measles, mumps, or rubella.
interval since prior Td or Tdap vaccination. Measles component:
• Persons aged 11 years or older who have not received Tdap vaccine • A routine second dose of MMR vaccine, administered a minimum of 28
or for whom vaccine status is unknown should receive a dose of Tdap
followed by tetanus and diphtheria toxoids (Td) booster doses every 10 — are students in postsecondary educational institutions;
years thereafter. Tdap can be administered regardless of interval since — work in a health care facility; or
the most recent tetanus or diphtheria-toxoid containing vaccine. — plan to travel internationally.
• Adults with an unknown or incomplete history of completing a 3-dose • Persons who received inactivated (killed) measles vaccine or measles
primary vaccination series with Td-containing vaccines should begin or vaccine of unknown type during 1963–1967 should be revaccinated with
complete a primary vaccination series including a Tdap dose. 2 doses of MMR vaccine.
• Mumps component:
and the third dose 6 to 12 months after the second. • A routine second dose of MMR vaccine, administered a minimum of 28
• For incompletely vaccinated (i.e., less than 3 doses) adults, administer
remaining doses. — are students in a postsecondary educational institution;
• Refer to the ACIP statement for recommendations for administering Td/ — work in a health care facility; or
Tdap as prophylaxis in wound management (see footnote 1). — plan to travel internationally.
4. Varicella vaccination • Persons vaccinated before 1979 with either killed mumps vaccine
• or mumps vaccine of unknown type who are at high risk for mumps
should receive 2 doses of single-antigen varicella vaccine or a second infection (e.g., persons who are working in a health care facility) should
dose if they have received only 1 dose. be considered for revaccination with 2 doses of MMR vaccine.
• Vaccination should be emphasized for those who have close contact Rubella component:
with persons at high risk for severe disease (e.g., health care personnel • For women of childbearing age, regardless of birth year, rubella immunity
and family contacts of persons with immunocompromising conditions) should be determined. If there is no evidence of immunity, women who
or are at high risk for exposure or transmission (e.g., teachers; child are not pregnant should be vaccinated. Pregnant women who do not have
evidence of immunity should receive MMR vaccine upon completion or
including correctional institutions; college students; military personnel; termination of pregnancy and before discharge from the health care facility.
adolescents and adults living in households with children; nonpregnant Health care personnel born before 1957:
women of childbearing age; and international travelers). • For unvaccinated health care personnel born before 1957 who lack
• Pregnant women should be assessed for evidence of varicella immunity. laboratory evidence of measles, mumps, and/or rubella immunity or
dose of varicella vaccine upon completion or termination of pregnancy vaccinating personnel with 2 doses of MMR vaccine at the appropriate
and before discharge from the health care facility. The second dose should interval for measles and mumps or 1 dose of MMR vaccine for rubella.
8. Pneumococcal conjugate (PCV13) vaccination
• Evidence of immunity to varicella in adults includes any of the following: • Adults aged 19 years or older with immunocompromising conditions
— documentation of 2 doses of varicella vaccine at least 4 weeks apart; (including chronic renal failure and nephrotic syndrome), functional or
—U.S.-born before 1980, except health care personnel and pregnant women;
— have not previously received PCV13 or PPSV23 should receive a single
by a health care provider; dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later.
— • Adults aged 19 years or older with the aforementioned conditions who
zoster disease by a health care provider; or have previously received 1 or more doses of PPSV23 should receive a dose
— of PCV13 one or more years after the last PPSV23 dose was received. For
5. Human papillomavirus (HPV) vaccination
• Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) be given no sooner than 8 weeks after PCV13 and at least 5 years after
and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in the most recent dose of PPSV23.
males (HPV4). • When indicated, PCV13 should be administered to patients who are
• For females, either HPV4 or HPV2 is recommended in a 3-dose series for uncertain of their vaccination status history and have no record of previ-
routine vaccination at age 11 or 12 years and for those aged 13 through ous vaccination.
26 years, if not previously vaccinated. • Although PCV13 is licensed by the U.S. Food and Drug Administration
• For males, HPV4 is recommended in a 3-dose series for routine vaccination for use among and can be administered to persons aged 50 years or
at age 11 or 12 years and for those aged 13 through 21 years, if not older, ACIP recommends PCV13 for adults aged 19 years or older with
previously vaccinated. Males aged 22 through 26 years may be vaccinated.
Figure 1-2—cont’d
4074_Ch01_001-026 20/11/14 10:25 AM Page 12
Figure 1-2—cont’d
4074_Ch01_001-026 20/11/14 10:25 AM Page 13
antibody levels, including sickle cell disease, splenectomy, 32. In which of the following groups is routine HBsAg
chronic renal failure, nephrotic syndrome, immunocompro- screening recommended?
mise, generalized malignancy, or on immunosuppressing A. hospital laboratory workers
medications. If initial PPSV23 vaccine was received at age B. recipients of hepatitis B vaccine series
65 years or older, a repeat dose is not required. This immu- C. pregnant women
nization, with initial and repeat vaccination, is generally well D. college students
tolerated (Table 1–3).
33. You see a woman who has been sexually active
DI SCUS SION SOURCES with a man newly diagnosed with acute hepatitis B.
Centers for Disease Control and Prevention, http://www.cdc.
She has not received hepatitis B vaccine in the past.
gov/vaccines/vpd-vac/pneumo/vac-PCV13-adults.htm, PCV13 You advise her that she should:
(Pneumococcal Conjugate) Vaccine A. start a hepatitis B immunization series.
Centers for Disease Control and Prevention, http://www.immunize. B. limit the number of sexual partners she has.
org/askexperts/experts_pneumococcal_vaccines.asp, Pneumococcal C. be tested for hepatitis B surface antibody
Vaccines (PCV13 and PPSV23) (HBsAb).
D. receive hepatitis B immune globulin (HBIG)
and hepatitis B immunization series.
Hepatitis B 34. Hepatitis B vaccine should not be given to a person
Vaccination with a history of anaphylactic reaction to:
A. egg.
31. Concerning hepatitis B virus (HBV) vaccine, which of B. baker’s yeast.
the following is true? C. neomycin.
A. The vaccine contains live, whole HBV. D. streptomycin.
B. Adults should routinely have anti-hepatitis B sur-
35. Risks associated with chronic hepatitis B include all
face antibody titers measured after three doses of
of the following except:
vaccine.
A. hepatocellular carcinoma.
C. The vaccine should be offered during treatment
B. cirrhosis.
for sexually transmitted diseases in unimmunized
C. continued infectivity.
adults.
D. systemic hypertension.
D. Serologic testing for hepatitis B surface antigen
(HBsAg) should be done before hepatitis B vaccina- 36. Jason is a healthy 18-year-old who presents
tion is initiated in adults. for primary care. According to his immunization
record, he received two dose of HBV vaccine
1 month apart at age 14 years. Which of the
following best describes his HBV vaccination
TABLE 1-3 needs?
A. He should receive a single dose of HBV
Pneumococcal Vaccine Adverse vaccine now.
Reactions B. A three-dose HBV vaccine series should be started
Local Reactions during today’s visit.
Including Pain, C. He has completed the recommended HBV vaccine
Redness 30%–50% series.
D. He should be tested for HBsAb and further
Fever, myalgia Polysaccharide (Pneumovax immunization recommendations should be
23-valent polysaccharide made according to the test results.
vaccine) = Uncommon, <1%
Conjugate (Prevnar 13-valent con- 37. All of the following individuals have not received
jugate vaccine) = 11%–40% in vaccination against HBV. The vaccine should not
children, significantly less in be given in which of the following patients?
adults with adverse reaction A. a 35-year-old man with multiple sclerosis
profile similar to 23-valent B. a 25-year-old woman with a past history of
polysaccharide vaccine Guillain-Barré syndrome
Severe, potentially Rare C. a 48-year-old woman with systemic lupus
life-threatening erythematosus
D. a 28-year-old man who is acutely ill with bacterial
Source: www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm meningitis
4074_Ch01_001-026 20/11/14 10:25 AM Page 15
Exposure to the virus is followed by an incubation period serious cutaneous illnesses including generalized vaccinia and
of about 7 to 17 days, during which the individual does not eczema vaccinatum. As a result, the vaccination site must be
have any symptoms and the disease is not contagious. The cared for to prevent the vaccinia virus from spreading. As
prodromal stage lasts 2 to 4 days, during which the individual with most vaccines, mild reactions include a few days of arm
has a temperature of 101°F to 104°F (38.3°C to 40°C), soreness and body aches. Fever is occasionally reported. The
malaise, headache, body aches, and sometimes vomiting. The NP needs to be aware of current recommendations for small-
individual is likely contagious at this time but is typically too pox vaccine candidates and vaccine contraindications.
sick to carry on normal activities. In the next stage, the rash
appears first as small red spots on the tongue and in the D I S C U SSI O N S O U R C E
mouth that develop into open sores that spread large Centers for Disease Control and Prevention, http://www.bt.cdc.gov/
amounts of the virus into the mouth and throat. The individ- agent/smallpox/clinicians.asp, Smallpox Overview for Clinicians
ual becomes most contagious at this time. The rash appears
on the skin, starting on the face and spreading first to the
arms and legs and then to the hands and feet. Usually the rash Varicella-Zoster
spreads to all parts of the body within 24 hours, and the tem-
perature typically decreases. By day 3 of the rash, the skin le- Virus Vaccination
sions become raised, and by day 4, the lesions fill with a thick,
43. Which of the following statements is correct about the
opaque fluid and become umbilicated. The temperature often
varicella vaccine?
increases again until the lesions crust over, in about another
A. It contains killed varicella-zoster virus.
5 days. About 1 week later, the crusts begin to fall off, usually
B. The use of the vaccine is associated with an increase
leaving a pitted scar. The individual remains contagious until
in reported cases of shingles.
all of the crusts have fallen off.
C. Varicella vaccine should be offered to adults who
Although smallpox and varicella cause vesicular lesions,
were U.S. born prior to 1980 and report a childhood
the clinical presentation of smallpox differs considerably from
history of chickenpox.
that of varicella (chickenpox). In varicella, the lesions typically
D. Although highly protective against invasive vari-
erupt over days and are at various stages; some are vesicular,
cella disease, mild cases of chickenpox have been
whereas some older lesions may be starting to crust over. In
reported in immunized individuals.
smallpox, all the skin lesions are usually at the same stage.
Smallpox treatment is largely supportive; no smallpox- 44. For which of the following patients should an NP order
specific therapy is currently available. An individual with sus- varicella antibody titers?
pected smallpox must be swiftly isolated. The NP should be A. a 14 year old with an uncertain immunization history
aware of which local experts and governmental authorities B. a healthcare worker who reports having had varicella
need to be notified for a suspected case of smallpox. as a child
In anticipation of possible exposure via bioterrorism, C. a 22-year-old woman who received two varicella
smallpox vaccination has been offered to or required of se- immunizations 6 weeks apart
lected health and defense personnel, such as first responders, D. a 72 year old with shingles
emergency healthcare providers, and members of the mili-
45. A woman who has been advised to receive varicella-
tary. Vaccination within 3 days of smallpox exposure pre-
zoster immune globulin (VZIG) asks about its risks.
vents or significantly reduces the severity of smallpox
You respond that IG is a:
symptoms in most people, whereas vaccination 4 to 7 days
A. synthetic product that is well tolerated.
after exposure likely offers some protection from disease or
B. pooled blood product that often transmits infectious
may modify the severity of disease. The U.S. government has
disease.
stockpiled enough vaccine to vaccinate every person in the
C. blood product obtained from a single donor.
United States in the event of a smallpox emergency.
D. pooled blood product with an excellent safety profile.
Made from a live smallpox-related virus called vaccinia,
the vaccine is given through a unique immunization method: 46. Maria is a 28-year-old healthy woman who is 6 weeks
A two-pronged needle is dipped into the vaccine solution. pregnant. Her routine prenatal laboratory testing reveals
When removed, the needle retains a droplet of the vaccine. she is not immune to varicella. She voices her intent to
The needle is then used to prick the skin numerous times in breastfeed her infant for at least 6 months. Which of the
a few seconds, producing a few drops of blood and some local following represents the best advice for Maria?
discomfort. A red, itchy bump develops at the vaccine site in A. She should receive VZV vaccine once she is in her
3 to 4 days; this progresses to a large draining pustule over second trimester of pregnancy.
the next few days. During the second week, the blister begins B. Maria should be advised to receive two doses of
to dry up, and a scab forms. The scab falls off in the third VZV vaccine after giving birth.
week, leaving a small scar. Until the scab falls off, the vaccine C. Once Maria is no longer breastfeeding, she should
recipient can shed the vaccinia virus. Although this is not the receive one dose of VZV vaccine.
smallpox virus, infection with vaccinia virus can result in D. A dose of VZIG should be administered now.
4074_Ch01_001-026 20/11/14 10:25 AM Page 18
47. How is the varicella virus most commonly transmitted? be done in healthcare workers because of their risk of expo-
A. droplet transmission sure and potential transmission of the disease.
B. contact with inanimate reservoirs The varicella vaccine is administered to children after their
C. contact transmission first birthday with a repeat dose usually given between ages
D. water-borne transmission 4 and 6 years. Older children and adults with no history of
varicella infection or previous immunization should receive
two immunizations 4 to 8 weeks apart. In particular, health-
Answers care workers, family contacts of immunocompromised pa-
tients, and daycare workers should be targeted for varicella
43. D. 45. D. 47. A. vaccine, as should adults who are in environments with high
44. B. 46. B. risk of varicella transmission, such as college dormitories,
military barracks, and long-term-care facilities. Pregnant
Varicella-zoster virus (VZV) causes the highly contagious, women should be assessed for evidence of varicella immu-
systemic disease commonly known as chickenpox; VZV nity. Women who do not have evidence of immunity should
infection typically presents with 300 to 500 vesicular lesions, receive the first dose of varicella vaccine on completion or
fever, itch, and fatigue. The virus is transmitted via respira- termination of pregnancy and before discharge from the
tory droplet and contact with open lesions. Chickenpox can healthcare facility. The second dose should be administered
be serious, especially in infants, adults, and individuals of 4 to 8 weeks after the first dose. The vaccine is highly protec-
all ages who are immunocompromised. A history of natu- tive against severe, invasive varicella. Mild cases of chicken-
rally occurring or wild varicella infection usually confers pox may be reported after immunization, however. Because
lifetime immunity. Reinfection is, on rare occasion, seen in this is a live, attenuated virus vaccine, it should be used with
immunocompromised patients, however. More often, reex- caution in certain clinical situations (Table 1–5).
posure causes an increase in antibody titers without causing For healthy children and adults without evidence of im-
disease. Although most cases are seen in children younger munity, vaccination within 3 to 5 days of exposure to vari-
than 18 years, the greatest rate of mortality from varicella cella is beneficial in preventing or modifying the disease.
is in adults 30 to 49 years old. Prior to the availability of the Studies have shown that vaccination administered within
VZV vaccine, chickenpox was a prevalent childhood illness. 3 days of exposure to rash is at least 90% effective in pre-
Evidence of immunity to varicella includes documentation venting varicella, whereas vaccination within 5 days of ex-
of age-appropriate vaccination with VZV vaccine, laboratory posure to rash is approximately 70% effective in preventing
evidence of immunity or laboratory confirmation of disease, varicella and 100% effective in modifying severe disease.
birth in the United States before 1980, or the diagnosis or ver- For individuals without evidence of immunity who have
ification of a history of varicella disease or herpes zoster by a contraindications for vaccination but are at risk for severe
healthcare provider. Among adults born before 1980 with an disease and complications, use of VZIG is recommended
unclear or negative varicella history, most are also seroposi- for post-exposure prophylaxis. VZIG, as with all forms of
tive. Confirming varicella immunity through varicella titers, IG, provides temporary, passive immunity to infection. IG
even in the presence of a history of varicella infection, should is a pooled blood product with an excellent safety profile.
TABLE 1-5
Live, Attenuated Virus Vaccines
Vaccine prepared from live microorganisms or viruses cultured under adverse conditions leading to loss of virulence but
retention of their ability to induce protective immunity.
Live Attenuated Virus Vaccine Examples Precautions For Use in Special Populations
MMR (Measles, mumps, rubella) Pregnancy because of theoretical risk of passing virus to unborn
Varicella (Chickenpox) child
Intranasal influenza virus vaccine (FluMist) Immune suppression, with the exception of HIV infection, because
Zoster (Zostavax) of potential risk of becoming ill with virus
With HIV infection, live virus vaccines usually are not given with
CD4 T lymphocyte cell counts <200 cell/uL. See adult immuniza-
tion guidelines for further information.
Rotavirus vaccine (oral vaccine only given to young Use contraindicated in infants diagnosed with severe combined
infants) immunodeficiency (SCID)
Source: www.cdc.gov/vaccines/pubs/acip-list.htm
4074_Ch01_001-026 20/11/14 10:25 AM Page 19
The NP should check current recommendation about post- soil, particularly if it contains manure. The organism enters
exposure prophylaxis. the body through a contaminated wound, causing a life-
The VZV can lie dormant in sensory nerve ganglia. Later threatening systemic disease characterized by painful muscle
reactivation causes shingles, a painful, vesicular-form rash in weakness and spasm (lockjaw) with at least a 10% mortality
a dermatomal pattern. About 15% of individuals who have rate. Diphtheria, caused by Corynebacterium diphtheriae, a
had chickenpox develop shingles during their lifetime. Shin- gram-negative bacillus, is typically transmitted from person-
gles rates are markedly reduced in individuals who have re- to-person contact via respiratory droplets or cutaneous
ceived varicella vaccine compared with individuals who have lesion. This organism causes a severe illness involving the
had wild or native VZV disease. The virus is present in the respiratory tract, including the appearance of pseudomem-
vesicles seen in shingles. If an individual without varicella im- branous pharyngitis and possible airway obstruction. Owing
munity comes in contact with shingles skin lesions, that in- to high immunization rates, a confirmed case of diphtheria
dividual could contract chickenpox. An individual with has not been reported in the United States for more than a
shingles cannot transmit shingles to another person. decade.
In the developed world, tetanus and diphtheria are un-
DI SCUSSION SOURCE common infections because of widespread immunization.
Centers for Disease Prevention and Control, http://www.cdc.gov/ Because protective titers wane over time, and adults are fre-
vaccines/vpd-vac/varicella/default-hcp.htm, - Varicella Vaccina- quently lacking in up-to-date immunization, most cases of
tion: Information for Healthcare Providers tetanus occur in adults older than 50 years.
A primary series of three tetanus vaccine injections sets
the stage for long-term immunity. A booster tetanus dose
Tetanus every 10 years is recommended, but protection is probably
Immunization present for 20 to 30 years after a primary series. Using Td
vaccine rather than tetanus toxoid for primary series and
48. An 18-year-old man has no primary tetanus immuniza- booster doses in adulthood also assists in keeping diphtheria
tion series documented. Which of the following repre- immunity (Fig. 1–2). Early childhood tetanus and diphthe-
sents the immunization needed? ria immunizations also include acellular pertussis vaccine,
A. three doses of diphtheria, tetanus, and acellular providing protection for this highly contagious cough-
pertussis (DTaP) vaccine 2 months apart transmitted illness. A single dose of Tdap during adulthood
B. tetanus IG now and two doses of tetanus-diphtheria provides additional protection from pertussis. For adults re-
(Td) vaccine 1 month apart ceiving initial immunization, a series of three vaccine doses
C. tetanus, diphtheria, and acellular pertussis (Tdap) vac- is needed. Two of the three can be Td, and one should be
cine now with a dose of Td vaccine in 1 and 6 months Tdap. Rarely have cases of tetanus occurred in persons with
D. Td vaccine as a single dose a documented primary tetanus series.
The use of tetanus and diphtheria with or without acellular
49. Which wound presents the greatest risk for tetanus pertussis immunizations is well tolerated and produces few
infection? adverse reactions. A short-term, localized area of redness and
A. a puncture wound obtained while gardening warmth is quite common and is not predictive of future prob-
B. a laceration obtained while trimming beef lems with tetanus immunization.
C. a human bite When a patient presents with a clean minor wound and
D. an abrasion obtained by falling on a sidewalk an unclear tetanus immunization history or inadequate
50. A 50-year-old man with hypertension and dyslipidemia tetanus immunization (0–2 doses), a dose of tetanus vac-
presents for a primary care visit. He states, “It has been cine should be provided. In the presence of all other
at least 10 years since my last tetanus shot.” He should wounds and an unclear or inadequate tetanus immuniza-
be immunized with: tion history (0–2 doses), a dose of tetanus vaccine with
A. Td. tetanus immunoglobulin (TIG), an example of passive im-
B. Tetanus IG. munization, is advised. With TIG use, temporary immunity
C. Tdap. is provided.
D. None of the above, owing to his concomitant health D I S C U SSI O N S O U R C E S
problems. Centers for Disease Control and Prevention, http://www.cdc.gov/
ncidod/dbmd/diseaseinfo/diptheria_t.htm, Vaccine preventable
disease: Diphtheria
Answers Centers for Disease Control and Prevention, http://www.cdc.gov/
vaccines/pubs/pinkbook/tetanus.html, Vaccine preventable
48. C. 49. A. 50. C. disease: Tetanus
Centers for Disease Control and Prevention, http://www.immunize.
Tetanus infection is caused by Clostridium tetani, an anaerobic, org/askexperts/experts_per.asp, Ask the Experts: Diphtheria,
gram-positive, spore-forming rod. This organism is found in tetanus, pertussis
4074_Ch01_001-026 20/11/14 10:25 AM Page 20
booster dose at month 12. Optimally, HAV vaccine should to poliovirus, resulting in a rare risk of vaccine-associated
be given 4 to 6 weeks prior to travel to an area where the dis- paralytic poliomyelitis (VAPP). Because of VAPP risk, OPV
ease is endemic. With HAV exposure, immune globulin or is no longer used in the United States, but it is used in other
HAV vaccine can be given with 2 weeks to minimize the risk countries. Use of IPV, containing inactivated virus, poses
of hepatitis A infection. no such risk.
Treatment for HAV is largely supportive. There is no
chronic form of the infection. D I S C U SSI O N S O U R C E
Centers for Disease Control and Prevention, http://www.cdc.
DI SCUSSION SOURCES gov/vaccines/vpd-vac/polio/default.htm, Polio Vaccine
Centers for Disease Control and Prevention, http://www.cdc.gov/
hepatitis/hav/index.htm, Hepatitis A Information for Healthcare
Professionals
(See also Figures 2–1 and 2–2.)
Preventing Disease
59. When working with a middle-aged man with a body
mass index of 33 kg/m2 on weight reduction, an NP
Poliovirus considers that one of the first actions should be to:
A. add an exercise program while minimizing the need
Vaccination for dietary changes.
57. Which of the following statements is true about B. ask the patient about what he believes contributes
poliovirus infection? to his weight issues.
A. It is transmitted via the fecal−oral route. C. refer the patient to a nutritionist for diet
B. Rates of infection among household contacts are counseling.
about 30%. D. ask for a commitment to lose weight.
C. Sporadic outbreaks continue to occur in North 60. A sedentary, obese 52-year-old woman is diagnosed
America. with hypertension and states, “It is going to be too hard
D. It is transmitted via aerosol and droplets. to diet, exercise, and take these pills.” What is the least
58. A 30-year-old man with HIV lives with his two pre- helpful response to her statement?
school-aged children. Which of the following state- A. “Try taking your medication when you brush your
ments best represents advice you should give him teeth.”
about immunizing his children? B. “You really need to try to improve your health.”
A. Immunizations should take place without regard C. “Tell me what you feel will get in your way of
for his health status. improving your health.”
B. The children should not receive influenza D. “Could you start with reducing the amount of salty
vaccine. foods in your diet?”
C. MMR vaccine should not be given. 61. During an office visit, a 38-year-old woman states,
D. The children should not receive poliovirus “I drink way too much but do not know what to do
immunization. to stop.” According to the Stages of Change Transtheo-
rectical Model, her statement is most consistent with a
person at the stage of:
Answers A. precontemplation.
B. contemplation.
57. A. 58. A. C. preparation.
D. action.
Polioviruses are highly contagious and capable of causing
paralytic, life-threatening infection. The infection is trans- 62. During an office visit, a 48-year-old man who smokes
mitted by the fecal−oral route. Rates of infection among two packs of cigarettes per day states, “My kids are
household contacts can be as high as 96%. Since 1994, North begging me to quit. My dad smoked and died when
and South America have been declared free of indigenous he was 80. I am not sure what all the fuss is about.”
poliomyelitis, largely because of the efficacy of the po- According to the Stages of Change Transtheoretical
liovirus immunization. The vaccine is available in two Model, his statement is most consistent with a person
forms: a live-virus vaccine that is given orally (oral polio at the stage of:
vaccine [OPV]) and an injectable vaccine that contains in- A. precontemplation.
activated poliovirus (IPV). When OPV is used, a small B. contemplation.
amount of weakened virus is shed via the stool. This shed- C. preparation.
ding presents household members with possible exposure D. action.
4074_Ch01_001-026 20/11/14 10:25 AM Page 22
63. Linda is a 52-year-old woman who presents for a fol- improved health. Change occurs dynamically and often un-
low-up visit for hypertension, type 2 diabetes mellitus, predictably. A commonly used change framework is based
and dyslipidemia. She has a 50-pack year cigarette on the work of Prochaska and DiClemente and is known as
smoking history, quit smoking 6 months ago, and now the Stages of Change Model/Transtheoretical Model (TTM).
reports smoking about 10 cigarettes per day for the In this model, five stages of preparation for change are
past 2 weeks while being particularly stressed during reported.
her 78-year-old mother’s recent serious illness. Linda • Precontemplation: The patient is not interested in change
states, “I give up. I guess I cannot quit.” Which of the and might be unaware that the problem exists or mini-
following is the most appropriate response to Linda’s mizes the problem’s impact.
statement? • Contemplation: The patient is considering change and
A. Do you think your mother’s illness was a trigger for looking at its positive and negative aspects. The person
your smoking? often reports feeling “stuck” with the problem, unable to
B. Can we work on a plan to help you to get back to figure out how to change to solve or minimize the health
being smoking-free? issue.
C. Once your mom is well again, you should try • Preparation: The patient exhibits some change behaviors
quitting again. or thoughts and often reports feeling that he or she does
D. You sound really discouraged about this. not have the tools to proceed.
• Action: The patient is ready to go forth with change,
often takes concrete steps to change, but is often incon-
Answers sistent with carrying through.
• Maintenance/relapse: The patient learns to continue the
59. B. 61. B. 63. B. change and has adopted and embraced the healthy habit.
60. B. 62. A. Relapse can occur, however, and the person learns to deal
with backsliding.
Possessing information about methods for preventing dis- As health counselor, the NP provides a valuable role in
ease and maintaining health is an important part of patient continually “tapping” the patient with a message of concern
education. Knowledge alone does not ensure a change in about health and safety, helping to move the person in the
behavior, however. NPs need to consider many factors in precontemplation stage to the contemplation stage. After
patient counseling and education (Box 1–1). the patient is at this stage, presenting treatment options and
In providing primary care, the NP should maintain an at- support for change is a critical part of the NP’s role. During
titude that the patient is capable of changing and achieving action and maintenance stages, the NP needs to be positive
BOX 1-1
Orderly Approach to Patient Education and Counseling
■ Assess the patient’s knowledge base about factors contributing to the problem.
■ Evaluate the contribution of the patient’s belief system to the problem.
■ Ask the patient about perceived barriers to action and supporting factors.
■ Match teaching to the patient’s perception of the problem.
■ Inform the patient about the purpose and benefit of an intervention.
■ Give the patient an anticipated time of onset of effect of a therapy.
■ Suggest small rather than large changes in behavior.
■ Give accurate, specific information.
■ Consider adding new positive behaviors, rather than attempting to discontinue established behaviors.
■ Link desired behavior with established behavior.
■ Give a strong, personalized message about the seriousness of health risk.
■ Ask for a commitment from the patient.
■ Use a combination of teaching strategies, such as visual, oral, and written methods.
■ Strive for an interdisciplinary approach to patient education and counseling, with all members of the team giving
the same message.
■ Maintain frequent contact with the patient to monitor progress.
■ Expect gains and periodic setbacks.
and encouraging, even with the occasional relapse. With re- life spans. Please see additional information on cancer
lapse, an important message to convey to the patient is that screening in other chapters of this book.
he or she was successfully able to make the change once and
D I S C U SSI O N S O U R C E S
can do it again and that the patient is continuing to learn
how to change behavior. Using statements that begin with American Cancer Society, http://www.cancer.org/healthy/find-
“we” convey the message that the NP is there to help facili- cancerearly/cancerscreeningguidelines/american-cancer-society-
guidelines-for-the-early-detection-of-cancer, American Cancer
tate success.
Society Guidelines for the Early Detection of Cancer
DI SCUSSION SOURCE United States Preventive Services Task Force, http://www.uspreven-
tiveservicestaskforce.org/adultrec.htm#cancer, cancer screening
Substance Abuse and Mental Health Services Administration,
http://www.samhsa.gov/co-occurring/topics/training/change.
aspx, Motivational Interviewing and the Stages of Change
Tobacco Use
67. The components of brief intervention for treating
Cancer Screening tobacco use include:
64. Which of the following women should have screening A. Ask, Advise, Assess, Assist, Arrange.
for cervical cancer? B. Advise, Intervene, Counsel, Follow up, Prescribe.
A. An 18-year-old who has a history of genital warts C. Document, Counsel, Caution, Describe, Demon-
B. A 17-year-old with coitarche 3 years ago and four strate.
male sexual partners D. Advise, Describe, Confer, Prescribe, Document.
C. An 80-year-old with heart failure and a remote his- 68. Brief intervention that provides motivation to quit
tory of normal Pap test results tobacco use should be:
D. A 21-year-old who has had one male sexual partner A. used at every clinical visit that the tobacco user has,
and consistent condom use regardless of reason for the visit.
65. Which of the following is a recommended method of B. offered when the tobacco user voices concern about
annual colorectal cancer screening for a 62-year-old the health effects of smoking.
man? C. applied primarily during visits for conditions that
A. digital rectal examination are clearly related to or exacerbated by tobacco use,
B. in-office fecal occult blood test (FOBT) such as respiratory tract disease.
C. at-home FOBT D. when the clinician is conducting a comprehensive
D. sigmoidoscopy health assessment, such as with the annual physical
examination.
66. Which of the following types of cancer screening
is not routinely recommended in a 55-year-old 69. The use of FDA-approved pharmacologic intervention
woman? in tobacco use:
A. breast A. makes little difference in smoking cessation rates.
B. skin B. reliably increases long-term smoking abstinence
C. endometrial rates.
D. colorectal C. is helpful but generally poorly tolerated.
D. poses a greater risk to health than continued
tobacco use.
Answers 70. You see a 48-year-old patient who started taking
varenicline (Chantix) 4 weeks ago to aid in smoking
64. D. 66. C. 66. C. cessation. Which of the following is the most important
question to ask during today’s visit?
Cancer screening is an important part of providing com- A. “How many cigarettes a day are you currently
prehensive primary healthcare. Adherence to current, na- smoking?”
tionally recognized guidelines is an important part of B. “On a scale of 0 to 10, how strong is your desire to
effective clinical practice. At the same time, different organ- smoke?”
izations can have slightly different guidelines. When this C. “Have you noticed any changes in your mood?”
occurs, rather than be concerned about the minor differ- D. “Are you having any trouble sleeping?”
ence, focus on the commonalities. At the same time, all
guidelines advocate for a 50-year-old woman to have a
mammogram. All organizations are in agreement that a Pap Answers
test should not be done prior to age 21 years, nor continue
to be conducted in elderly women with anticipated short 67. A. 68. A. 69. B. 70. C.
4074_Ch01_001-026 20/11/14 10:25 AM Page 24
Tobacco use poses a tremendous health hazard; tobacco-re- and clinicians should encourage their use by all patients
lated diseases result in a significant burden to public health attempting to quit smoking—except when medically con-
and healthcare costs. Tobacco dependence is a chronic dis- traindicated or with specific populations for which there is
ease that often requires repeated intervention and multiple less evidence of effectiveness (i.e., pregnant women, smoke-
attempts to quit. Effective treatments exist, however, that can less tobacco users, light smokers, and adolescents). These
significantly increase rates of long-term abstinence. Treating medications include nicotine replacement therapy (NRT)
tobacco use and dependence guidelines from the Agency for (e.g., patch, gum, inhaler, nasal spray, and lozenge) and
Healthcare Research and Quality (AHRQ) offer the following medications to reduce the desire to smoke (bupropion
recommendations for smoking cessation. [Zyban, Wellbutrin] and varenicline [Chantix]).
Clinicians and healthcare delivery systems must consis- The use of these medications reliably increases long-term
tently identify and document tobacco use status and treat smoking abstinence rates. Generally, the risk associated with
every tobacco user seen in a healthcare setting. Brief tobacco the use of these medications is less than that associated
dependence treatment is effective. Clinicians should offer with continued tobacco use. Adverse effects occasionally at-
every patient who uses tobacco at least the brief treatments tributed to the use of smoking cessation medications are
shown to be effective. An example of a brief intervention sometimes actually a result of nicotine withdrawal. The FDA
includes the “5 As”: Ask, Advise, Assess, Assist, Arrange added a warning, however, regarding the use of varenicline.
(Table 1–6). This strategy should be used with all tobacco Specifically, depressed mood, agitation, changes in behavior,
users, including individuals with no current desire to quit suicidal ideation, and suicide have been reported in patients
because this can serve as a motivating factor in future attempting to quit smoking while using varenicline. Patients
attempts to discontinue tobacco use. should tell their healthcare provider about any history of psy-
Individual, group, and telephone counseling are helpful, chiatric illness before starting this medication; clinicians
and their effectiveness increases with treatment intensity. should also ask about mental health history before starting
Two components of counseling—practical counseling this medication. Close monitoring for changes in mood and
(problem solving/skills training) and social support—are behavior should follow.
especially effective, and clinicians should use these when Counseling and medication are effective when used
counseling patients making a quit attempt. Telephone quit by clinicians as solo interventions for treating tobacco
line counseling has been shown to be effective with diverse dependence. The combination of counseling and medica-
populations and has broad reach. Clinicians and healthcare tion is more effective, however, than either alone. Clini-
delivery systems should ensure patient access to quit lines cians should encourage all individuals making a quit
and promote quit line use. attempt to use both counseling and medication. For an
Tobacco-dependence treatments are effective across a individual who is not interested in quitting, motivational
broad range of populations. Clinicians should encourage intervention is often helpful and should be provided at
every patient willing to make a quit attempt to use the coun- every clinical visit.
seling treatments and appropriate medications. Numerous Treatments for tobacco dependence are clinically effective
effective medications are available for tobacco dependence, and highly cost-effective relative to interventions for other
TABLE 1-6
Five As
Ask about tobacco use Identify and document tobacco use status for every patient at every visit.
Advise to quit In a clear, strong, and personalized manner, urge every tobacco user to quit.
Assess willingness to make a quit attempt Is the tobacco user willing to make a quit attempt at this time?
Assist in quit attempt For the patient willing to make a quit attempt, offer medication and provide
or refer for counseling or additional treatment to help the patient quit.
For patients unwilling to quit at the time, provide interventions designed to
increase future quit attempts.
Arrange follow-up For the patient willing to make a quit attempt, arrange for follow-up con-
tacts, beginning within the first week after the quit date.
For patients unwilling to make a quit attempt at the time, address tobacco
dependence and willingness to quit at next clinic visit.
Neurological Disorders 2
Cranial Nerves Cranial Nerve
1. Assessing vision and visual fields involves testing cranial Mnemonic
nerve (CN):
A. I. A commonly used mnemonic for identifying and remember-
B. II. ing the cranial nerves is: On Old Olympus Towering Tops, A
C. III. Finn And German Viewed Some Hops. The details of the cra-
D. IV. nial nerves are as follows:
• CN I—Olfactory: You have one nose, where CN I resides.
2. You perform an extraocular movement test on a middle- Its function contributes to the sense of smell.
aged patient. He is unable to move his eyes upward and • CN II—Optic: You have two eyes, where you will find
inward. This indicates a possibility of paralysis of CN: CN II. Function of this CN is vital to vision and visual
A. II. fields and, in conjunction with CN III, pupillary reaction.
B. III. • CN III—Oculomotor: CN III, the eye (oculo-) movement
C. V. (motor) nerve, works with CNs III, IV, and VI (abducens,
D. VI. which helps the eyeball abduct or move). The actions of
3. Loss of corneal reflex is in part seen in dysfunction these CNs are largely responsible for the movement of
of CN: the eyeball and eyelid.
A. III. • CN IV—Trochlear: This nerve innervates the superior
B. IV. oblique muscle of the eye.
C. V. • CN V—Trigeminal: Three (tri) types of sensation (tem-
D. VI. perature, pain, and tactile) come from this three-
branched nerve that covers three territories of the face.
4 to 6. Match the CN with the appropriate function or test. For normal corneal reflexes to be present, the afferent
4. CN I A. Tongue and throat, swallowing limb of the first division of CN V and the effect limb of
5. CN VII B. Sense of smell CN VII need to be intact.
6. CN IX C. Facial asymmetry, drop of • CN VI—Abducens
mouth (Bell’s palsy) • CN VII—Facial: Dysfunction of this nerve gives the
characteristic findings of Bell’s palsy (facial asymmetry,
droop of mouth, absent nasolabial fold, impaired eyelid
Answers movement).
• CN VIII—Auditory or vestibulocochlear: When this
1. B. 3. C. 5. C. nerve does not function properly, hearing (auditory) or
2. B. 4. B. 6. A. balance is impaired (vestibulocochlear). Rinne’s test is
part of the evaluation of this CN.
Knowledge of the cranial nerves (CNs) is critical for perform- • CN IX—Glossopharyngeal: The name of this CN pro-
ing an accurate neurological assessment. Because these are vides a clue that its function affects the tongue (glosso)
paired nerves arising largely from the brainstem, a unilateral and throat (pharynx). Along with CN X, the function of
CN dysfunction is common, often reflecting a problem in the this nerve is critical to swallowing, palate elevation, and
ipsilateral cerebral hemisphere. gustation.
27
4074_Ch02_027-046 20/11/14 10:32 AM Page 28
• CN X—Vagus: This CN is involved in parasympathetic symptoms. Though the exact cause is unknown, the condi-
regulation of multiple organs, including sensing aortic tion is believed to result from inflammation of the cranial
pressure and regulating blood pressure, slowing heart nerve within the temporal bone, presumably related to me-
rate, and regulating taste and digestive rate. chanical compression. Bell’s palsy is often linked to viral in-
• CN XI—Accessory or spinal root of the accessory: Func- fections, including herpes simplex virus, herpes zoster,
tion of this CN can be tested by evaluating shoulder Epstein-Barr, cytomegalovirus, adenovirus, rubella, and
shrug and lateral neck rotation. mumps virus. Other conditions can mimic facial muscle
• CN XII—Hypoglossal: Function of this CN is tested by weakness observed with Bell’s palsy, including stroke, in-
noting movement and protrusion of the tongue. fection, Lyme disease, and tumors. Diagnostic approaches
that can be used to determine the cause of the symptoms
DI SCUS SION SOURCE include electromyography (to measure electrical activity of
http://www.med.yale.edu/caim/cnerves/, Cranial nerves, accessed the facial muscle in response to stimulation); imaging scans
9/20/13. to rule out tumor or skull fracture are typically only ordered
when there is uncertainty with the diagnosis and are not
See full color images of this topic routinely ordered. Appropriate antibody testing for Lyme
on DavisPlus at disease should be obtained in a patient presenting with signs
http://davisplus.fadavis.com |
Keyword: Fitzgerald of Bell’s palsy; Bell’s palsy is a rare finding during secondary
stage of Lyme disease.
For most people, Bell’s palsy is temporary and symptoms
usually start to improve within a few weeks with complete
recovery by 6 months. A small percentage of people will
Bell’s Palsy have permanent symptoms. Updated guidelines from the
7. You examine a 29-year-old woman who has a sudden American Academy of Neurology (AAN) recommend the
onset of right-sided facial asymmetry. She is unable to use of corticosteroids to treat Bell’s palsy. Current evidence
close her right eyelid tightly, frown, or smile on the af- demonstrates little benefit on the use of antivirals as part of
fected side. Her examination is otherwise unremarkable. Bell’s palsy therapy. With ocular involvement, such as im-
This presentation likely represents paralysis of CN: paired eye closure and abnormal tear flow, consultation
A. III. with an eye care professional should be obtained. The use
B. IV. of tear substitutes, lubricants, and eye protection may be
C. VII. needed to reduce the risk of corneal drying and foreign-
D. VIII. body exposure to the eye.
11. A 22-year-old woman presents with a 3-year history 18. A 45-year-old man experiences rapidly progressing mi-
of recurrent, unilateral, pulsating headaches with graine headaches that are accompanied by significant
vomiting and photophobia. The headaches, which GI upset. Appropriate acute headache (abortive) treat-
generally last 3 hours, can be aborted by resting in a ment includes all of the following except:
dark room. She can usually tell that she is going to get A. injectable sumatriptan.
a headache. She explains, “I see little ‘squiggles’ be- B. dihydroergotamine nasal spray.
fore my eyes for about 15 minutes.” Her physical C. oral naproxen sodium.
examination is unremarkable. This presentation is D. zolmitriptan nasal spray.
most consistent with:
19. With migraine, which of the following statements is
A. tension-type headache.
true?
B. migraine without aura.
A. Migraine with aura is the most common form.
C. migraine with aura.
B. Most migraineurs are in ongoing healthcare for the
D. cluster headache.
condition.
12. Indicators that a headache can be the presenting symp- C. The condition is equally common in men and
tom of a serious illness and may require neuroimaging women.
include all of the following except: D. The pain is typically described as pulsating.
A. headaches that occur periodically in clusters.
20. In tension-type headache, which of the following is
B. increasing frequency and severity of headaches.
true?
C. headache causing confusion, dizziness, and/or lack
A. Photophobia is seldom reported.
of coordination.
B. The pain is typically described as “pressing” in
D. headache causing awakening from sleep.
quality.
13. Prophylactic treatment for migraine headaches C. The headache is usually unilateral.
includes the use of: D. Physical activity usually makes the discomfort
A. amitriptyline. worse.
B. ergot derivative.
C. naproxen sodium. 21. Risk factors for cluster headaches include all of the
D. clonidine. following except:
A. over 65 years of age.
14. Among the following beta blockers, which is the least B. heavy alcohol use.
effective in preventing migraine headache? C. heavy tobacco use.
A. acebutolol D. male gender.
B. metoprolol
C. atenolol 22. Treatment options in cluster headache include the
D. propranolol use of:
A. nonsteroidal anti-inflammatory drugs (NSAIDs).
15. Antiepileptic drugs useful for preventing migraine B. oxygen.
headaches include all of the following except: C. the triptans.
A. divalproex. D. all of the above therapies.
B. valproate.
C. lamotrigine. 23. Which of the following oral agents has the most rapid
D. topiramate. analgesic onset?
A. naproxen (Naprosyn)
16. Evidence supports the use of all of the following B. liquid ibuprofen (Motrin, Advil)
vitamins and supplements for migraine prevention C. diclofenac (Voltaren)
except: D. enteric-coated naproxen (Naproxen EC)
A. butterbur.
B. riboflavin. 24. The mechanism of action of triptans is as a(n):
C. feverfew. A. selective serotonin receptor agonist.
D. ginkgo biloba. B. dopamine antagonist.
C. vasoconstrictor.
17. You are examining a 65-year-old man who has a his-
D. inhibitor of leukotriene synthesis.
tory of acute coronary syndrome and migraine. Which
of the following agents represents the best choice of 25. Limitations of use of butalbital with acetaminophen
acute headache (abortive) therapy for this patient? and caffeine (Fioricet) include its:
A. verapamil A. energizing effect.
B. ergotamine B. gastrointestinal (GI) upset profile.
C. timolol C. high rate of rebound headache if used frequently.
D. sumatriptan D. excessive cost.
4074_Ch02_027-046 20/11/14 10:32 AM Page 30
45. A 37-year-old woman complains of migraine The primary headaches, including migraine, tension-type,
headaches that typically occur after eating out in and cluster headache, are the most common chronic pain
restaurants. Potential triggers that can influence the syndromes seen in primary care practice (Table 2–1). Devel-
onset and severity of migraine symptoms include all opment of the appropriate diagnosis is critical to caring for
of the following except: patients with headache (Table 2–2). Despite the existence of
A. cheese pizza.
B. pickled or fermented foods.
C. freshly baked yeast products.
D. baked whitefish. TABLE 2-1
Headache: Primary versus Secondary
Answers Primary Headache Secondary Headache
10. C. 22. D. 34. A. Not associated with other Associated with or caused
11. C. 23. B. 35. D. diseases, likely complex by other conditions, gener-
12. A. 24. A. 36. C. interplay of genetic, de- ally does not resolve until
13. A. 25. C. 37. B. velopmental, and environ- specific cause is diagnosed
14. A. 26. B. 38. A. mental risk factors and addressed
15. C. 27. A. 39. CT scan Migraine, tension-type, Intracranial issue such as
16. D. 28. C. 40. MRI cluster brain tumor, intracranial
17. C. 29. B. 41. CT scan bleeding, or inflammation,
18. C. 30. A. 42. MRI viremia, or any condition
19. D. 31. C. 43. Neither that causes increased in-
20. B. 32. B. 44. A. tracranial pressure
21. A. 33. C. 45. D.
TABLE 2-2
Primary Headache: Clinical Presentation and Diagnosis
Headache Type Headache Characteristics
Tension-type headache Lasts 30 minutes to 7 days (usually 1–24 hours) with two or more of the following
characteristics
Pressing, nonpulsatile pain
Mild to moderate in intensity
Usually bilateral location
Notation of 0–1 of the following (>1 suggests migraine): nausea, photophobia,
or phonophobia
Female:male ratio 5:4
Migraine without aura Lasts 4–72 hours with two or more of the following characteristics
Usually unilateral location, although occasionally bilateral
Pulsating quality, moderate to severe in intensity
Aggravation by normal activity such as walking, or causes avoidance of these activities
During headache, one or more of the following
Nausea/vomiting, photophobia, phonophobia
Female:male ratio 3:1
Positive family history in 70%–90%
Migraine with aura Migraine-type headache occurs with or after aura
Focal dysfunction of cerebral cortex or brainstem causes one or more aura symptoms to
develop over 4 minutes, or two or more symptoms occur in succession
Symptoms include feeling of dread or anxiety, unusual fatigue, nervousness or excitement,
GI upset, visual or olfactory alteration
No aura symptom should last >1 hour. If this occurs, an alternative diagnosis should be
considered
Positive family history in 70%–90%
Continued
4074_Ch02_027-046 20/11/14 10:32 AM Page 32
TABLE 2-2
Primary Headache: Clinical Presentation and Diagnosis—cont’d
Headache Type Headache Characteristics
Cluster headache Tendency of headache to occur daily in groups or clusters, hence the name cluster headache
Clusters usually last several weeks to months, then disappear for months to years
Usually occur at characteristic times of year, such as vernal and autumnal equinox with one
to eight episodes per day, at the same time of day. Common time is ~1 hour into sleep; the
pain awakens the person (hence the term “alarm clock” headache)
Headache is often located behind one eye with a steady, intense (“hot poker in the eye”
sensation), severe pain in a crescendo pattern lasting 15 minutes to 3 hours, with most in
the range of 30–45 minutes. Pain intensity has helped earn the condition the name “suicide
headache.” Most often occurs with ipsilateral autonomic sign such as lacrimation, conjuncti-
val injection, ptosis, and nasal stuffiness
Female:male ratio ~1:3 to 1:8 (depending on source)
Family history of cluster headache present in ~20%
Source: Standards of Care for Headache Diagnosis and Treatment. Chicago, National Headache Foundation,
http://www.headaches.org/content/standards-care-headache-diagnosis-and-treatment
TABLE 2-4
Evidence-Based Guidelines in the Primary Care Setting: Neuroimaging in Patients with
Nonacute Headache
Significantly increased odds of finding abnormality on neuroimaging
• Rapidly increasing headache frequency
• History
• Dizziness or lack of coordination
• Subjective numbness or tingling
• Headache causing awakening from sleep
• Headache worse with Valsalva maneuver
• Accelerating, new-onset headache
• Abnormal neurological examination
• Increasing age
• More likely nonacute finding such as old infarct, atrophy
Unlikely to correlate with abnormal neuroimaging; neuroimaging unlikely to yield helpful clinical information
• Neurological examination normal
• Long-standing history of similar headache
• “Worst headache of my life”
Consensus-based principles
• Testing should be avoided if it would not lead to a change in management
• Not recommended if individual no more likely than general population to have significant abnormality
• Testing not normally recommended as population policy, although may make sense at individual level (e.g., with pa-
tient or provider fear)
TABLE 2-5
Head CT Scan Versus MRI
CT Scan MRI
• Rapid imaging (~5–10 min; important if intracranial hemorrhage • Longer procedure (~45 min)
is suspected)
• Exposes patient to ionizing radiation (cancer risk) • No exposure to ionizing radiation
• Greater risk of allergic reaction to contrast agent (iodine) • Contrast agent less likely to cause allergic
reaction (gadolinium)
• Can be used in patients with implantable devices • Cannot be used in patients with implantable
devices
• Better at detecting acute hemorrhage and bone abnormalities • Better at detecting small and subtle lesions
• Less cost • More expensive
Migraine without aura affects about 80% of persons with 20 minutes, lasts less than 1 hour, and is accompanied or
migraine. On careful questioning, many patients report a followed by migraine. Patients who have migraines with
migraine warning, however, such as agitation, jitteriness, aura do not have more severe headaches than patients with-
disturbed sleep, or unusual dreams (see Table 2–2 for diag- out aura, but the former patients are more likely to be of-
nostic criteria). Migraine with aura is found in about 20% fered a fuller range of therapies. Patients without aura may
of patients with migrainous disorders. The aura is a recur- be misdiagnosed as having tension-type headaches and are
rent neurological symptom that arises from the cerebral often not offered headache therapies specifically suited for
cortex or brainstem. Typically, the aura develops over 5 to migraines, such as the triptans.
4074_Ch02_027-046 20/11/14 10:32 AM Page 34
Symptoms: A Comprehensive
Headache Treatment Plan Includes
therapy, aimed at limiting the number and severity of future
Minimizing or Eliminating These headaches, is also often indicated. Rescue therapy is used when
Triggers Whenever Possible abortive therapy is ineffective in providing headache relief.
When a migraine abortive agent is chosen, a number of
Menses, ovulation, or pregnancy
considerations should be kept in mind. These medications
Birth control/hormone replacement (progesterone)
are available in many forms (i.e., oral, parenteral, nasal
therapy
spray, rectal suppository). Migraine is also present in many
Illness of virtually any kind, whether acute or chronic
forms. A thoughtful match between the presentation of typ-
Intense or strenuous activity/exercise
ical migraine and the form of medication is helpful. Follow-
Sleeping too much/too little/jet lag
ing are some examples:
Fasting/missing meals
• Oral products generally take 1⁄2 to 1 hour before there is
Bright or flickering lights
significant relief of migraine pain. These products are
Excessive or repetitive noises
best suited for patients with migraine who have a slowly
Odors/fragrances/tobacco smoke
developing headache with minimum GI distress. As with
Weather/seasonal changes
all migraine therapies, oral medications should be used as
High altitudes
soon as possible after the onset of symptoms. The use of
Medications
oral products to manage migraine is the least expensive
Stress/stress letdown
option and facilitates patient self-care.
Source: http://www.guideline.gov/summary/summary.aspx?ss= • Injectable products (e.g., sumatriptan (Imitrex) and dihy-
15&doc_id=6578&nbr=4138 droergotamine (D.H.E. 45, Migranal) have a rapid onset
4074_Ch02_027-046 20/11/14 10:32 AM Page 35
of action, usually within 15 to 30 minutes. These products naproxen sodium (Aleve, Anaprox) use is associated with
are best suited for patients with rapidly progressing mi- a significantly more rapid onset of pain relief. Acetamino-
graines accompanied by significant GI upset. Sumatriptan phen and aspirin can also provide relief in migraine and
is available as a self-injector for patient administration. tension-type headache, but provide less analgesic effect.
Dihydroergotamine is usually given intravenously for • Fioricet is a combination medication consisting of caf-
severe migraine along with parenteral hydration. Injecta- feine, butalbital, and acetaminophen. Caffeine enhances
bles are usually the most expensive treatment option, and the analgesic properties of acetaminophen, and butal-
using these products sometimes means that a patient with bital’s barbiturate action enhances select neurotransmit-
migraine requires a provider visit to facilitate the use of ter action, helping to relieve migraine and tension-type
the medication. Certain triptans (sumatriptan [Imitrex] headache pain. With infrequent use, this product offers
and zolmitriptan [Zomig]) and the ergot derivative dihy- an inexpensive and generally well-tolerated headache
droergotamine (Migranal) are available as nasal sprays, treatment. Frequent or excessive use of Fioricet should
have a similarly rapid onset of action, and are tolerable in be discouraged because of the potential for barbiturate
the presence of GI upset. Analgesics (aspirin, acetamino- dependency from butalbital and analgesic rebound
phen) or antiemetics (prochlorperazine [Compazine], headache from the acetaminophen component of the
promethazine [Phenergan] and ondansetron hydrochlo- product.
ride {Zofran}) can be used for pain control or treatment • Excedrin Migraine is an over-the-counter aspirin, aceta-
of GI upset, respectively. minophen, and caffeine combination product that is
• Triptans act as selective serotonin receptor agonists and approved by the U.S. Food and Drug Administration
work at the 5-HT1D serotonin receptor site, allowing an (FDA) for migraine therapy and is effective in tension-
increased uptake of serotonin. Because of potential vaso- type headache. Its advantages include ease of patient ac-
constrictor effect, their use is contraindicated in patients cess to the product, excellent side-effect profile, and low
with Prinzmetal angina or established or high risk for cost; the product is available as a branded form as well as
coronary artery disease, in pregnant women, and in indi- a less costly generic. Excessive acetaminophen use can
viduals who have recently used ergots. Because of the risk lead to analgesic rebound headache.
of serotonin syndrome, a condition of excessive availabil- • Neuroleptics are a class of medications historically used
ity of this neurotransmitter, triptans should be used with to treat major mental health problems; this class of
caution with monoamine oxidase inhibitors (MAOIs) drugs is also known as the first-generation antipsy-
or high-dose selective serotonin reuptake inhibitors. chotics. Examples of neuroleptics are prochlorperazine
Although triptans are specifically labeled for use only (Compazine) and promethazine (Phenergan). Because
in migraine, some patients with severe tension-type of their antiemetic effect, these products are occasionally
headache benefit from their use, which lends further used as adjuncts in migraine therapy. Because these
support to the hypothesis that there is a shared mecha- drugs generally are highly sedating, using them in the
nism in migraine and tension-type headache. Adding an clinician’s office can make it difficult for patients to
analgesic such as an NSAID to the use of a triptan yields return home. Use should be limited to 3 days a week be-
improved pain control in many migraineurs. An example cause of the risk of extrapyramidal movements (EPMs).
of a combined triptan/NSAID product is Treximet Other antiemetics used in migraine include ondansetron
(sumatriptan with naproxen sodium). (Zofran), a nonsedating, albeit more expensive, option
• Ergotamines are ergot derivatives that act as 5-HT1A that is helpful if the patient needs to return quickly to
and 5-HT1D receptor agonists and do not alter cerebral work or other responsibilities. Metoclopramide (Reglan),
blood flow. Because of potential vasoconstrictor effect, a prokinetic agent that is generally well tolerated with in-
their use should be avoided in the presence of coronary frequent use, is helpful in relieving milder GI symptoms;
artery disease and pregnancy. Ergotamines are available this drug should not be used on a daily basis because of
in various forms, including oral and sublingual tablets, EPM risk.
suppositories, injectables, and nasal sprays; examples in- • Use of systemic corticosteroids is helpful with intractable
clude dihydroergotamine mesylate [Migranal, D.H.E. 45] or severe migraine and in cluster headache. Owing to
and ergotamine tartrate with caffeine [Migergot]). These the well-known adverse effects of this drug class, corti-
products are helpful in the treatment of migraine, but costeroid use for this purpose is not recommended
not tension-type headache. more often than once a month. Examples of corticos-
• NSAIDs can be highly effective in tension-type and teroid types and doses include prednisone 20 mg qid
migraine headache. These products inhibit prostaglandin for 2 days.
and leukotriene synthesis and are most helpful when used • Opioids such as hydrocodone and oxycodone can pro-
at the first sign of headache, when GI upset is not a signif- vide analgesia and are often prescribed for migraine
icant issue. The National Health Foundation Guidelines rescue. These products are sedating and potentially
advise the use of rapid-onset NSAIDs such as ibuprofen in habituating, in addition to being substances of abuse.
high doses with booster doses. Plain naproxen (Naprosyn) Use of prophylactic therapy for migraine, tension-type,
has a relatively slow onset of analgesic activity, whereas or cluster headache should be considered if abortive
4074_Ch02_027-046 20/11/14 10:32 AM Page 36
51. When evaluating the person who has bacterial meningi- 58. During an outbreak of meningococcal meningitis, all of
tis, the NP expects to find cerebrospinal fluid (CSF) the following can be used as chemoprophylaxis except:
results of: A. a single dose of ceftriaxone.
A. low protein. B. multiple doses of rifampin.
B. predominance of lymphocytes. C. multiple doses of amoxicillin.
C. glucose at about 30% of serum levels. D. a single dose of meningococcal conjugate vaccine
D. low opening pressure. (MCV4 or Menactra).
52. When evaluating a patient who has aseptic or viral
meningitis, the NP expects to find CSF results of:
A. low protein.
Answers
B. predominance of lymphocytes. 46. B. 51. C. 56. A.
C. glucose at about 30% of serum levels. 47. A. 52. B. 57. D.
D. low opening pressure. 48. A. 53. C. 58. C.
53. Which of the following describes the Kernig sign? 49. B. 54. C.
A. Neck pain occurs with passive flexion of one 50. D. 55. B.
hip and knee, which causes flexion of the con-
tralateral leg. Meningitis is an infection of the meninges, CSF, and
B. Passive neck flexion in a supine patient results in ventricles. The disease is typically defined further by its
flexion of the knees and hips. cause, such as bacterial (pyogenic), viral (aseptic), fungal,
C. Elicited with the patient lying supine and the or other cause. Encephalitis is inflammation of the brain,
hip flexed 90 degrees, it is present when most commonly caused by a virus. Encephalitis can cause
extension of the knee from this position elicits flu-like symptoms, such as fever or severe headache, and
resistance or pain in the lower back or posterior can also result in confusion, seizures, and sensory or motor
thigh. impairment.
D. Headache worsens when the patient is supine. In bacterial meningitis, the causative pathogens differ
according to patient age and certain risk characteristics.
54. Physical examination findings in papilledema
Bacterial seeding usually occurs via hematogenous spread,
include:
when organisms can enter the meninges through the blood-
A. arteriovenous nicking.
stream from other parts of the body; the pathogen likely was
B. macular hyperpigmentation.
asymptomatically carried in the nose and throat. Another
C. optic disk bulging.
mechanism of acquisition is local extension from another
D. pupillary constriction.
infection, such as acute otitis media or bacterial rhinosinusi-
55. Which of the following organisms is a gram-negative tis. Congenital problems and trauma can provide a pathway
diplococcus? via facial fractures or malformation (e.g., cleft lip or palate).
A. Streptococcus pneumoniae Common pathogens in bacterial meningitis in adults in-
B. Neisseria meningitidis clude Streptococcus pneumoniae (gram-positive diplococci),
C. Staphylococcus aureus Neisseria meningitidis (gram-negative diplococci), Staphy-
D. Haemophilus influenzae lococcus species (gram-positive cocci), and Haemophilus
influenzae type b (Hib; gram-negative coccobacilli). Vac-
56. Which of the following signs and symptoms
cines against certain bacterial strains that cause meningitis
most likely suggests meningitis cause by
have been shown to be highly effective in preventing the in-
N. meningitidis?
fection. The pneumococcal conjugate vaccine (PCV7) re-
A. a purpura or a petechial rash
sults in 96% effectiveness in preventing invasive disease in
B. absence of fever
healthy children, whereas the pneumococcal polysaccharide
C. development of encephalitis
vaccine (PPV23) has been shown to be 50% to 85% effective
D. absence of nuchal rigidity
in preventing invasive disease in healthy adults by the
57. All of the following persons should receive a dose of serotypes covered in the vaccine. Both meningococcal vac-
the meningococcal vaccine except: cines (MCV4 and MPSV4), when given at recommended
A. a 19-year-old who received a first dose at 12 years schedules, are also about 90% effective in preventing
of age. meningococcal infection caused by strains covered in the
B. a 22-year-old who has not received the vaccine and vaccine.
will be moving to a college dormitory. The issue of meningitis contagion needs to be addressed.
C. a 35-year-old who will be traveling to a country N. meningitidis, an organism normally carried in about 5%
where meningococcal disease is hyperendemic. to 10% of healthy adults and 60% to 80% of individuals in
D. a 14-year-old who received a first dose at 11 years closed populations, such as military recruits, is transmitted
of age. through direct contact or respiratory droplets from infected
4074_Ch02_027-046 20/11/14 10:32 AM Page 38
people. Meningococcal disease most likely occurs within a 90 degrees. A positive sign is present when extension of the
few days of acquisition of a new strain, before the develop- knee from this position elicits resistance or pain in the
ment of specific serum antibodies. Individuals acquire the lower back or posterior thigh. Papilledema, or optic disk
infection if they are exposed to virulent bacteria and have bulging, or absence of venous pulsations on funduscopic
no protective bactericidal antibodies. Smoking and concur- examination indicates increased ICP. Less common pre-
rent upper respiratory tract viral infection diminish the senting symptoms include vomiting, seizures, and altered
integrity of the respiratory mucosa and increase the likeli- consciousness. In meningitis caused by N. meningitidis,
hood of invasive disease. Other risk factors include less than a purpura or a petechial rash is noted in about 50% of
20 years of age, living in a community setting, pregnancy patients. Patients with viral meningitis usually have less
(for meningitis caused by listeriosis), and having a compro- severe symptoms that have a gradual onset; skin rash is
mised immune system. The incubation period of the organ- uncommon.
ism averages 3 to 4 days (range 1 to 10 days), which is the For patients with suspected encephalitis, brain imaging
period of communicability. Bacteria can be found for 2 to (MRI or CT) is often the first test used. This will reveal if the
4 days in the nose and pharynx and for up to 24 hours after symptoms are caused by swelling of the brain or a tumor.
starting antibiotics. Public health authorities should be Similar to meningitis, a lumbar puncture can be used to
contacted when a person presents with suspected or docu- identify the causative virus or other infectious agent. An
mented bacterial meningitis. EEG may also be used to detect abnormal patterns of elec-
The clinical presentation of bacterial meningitis in an trical activity in the brain that are consistent with a diagnosis
adult usually includes the classic triad of fever, headache, and of encephalitis. In rare cases, a brain biopsy may be used for
nuchal rigidity, or stiff neck. As with most forms of infec- patients with worsening symptoms and/or when treatment
tious disease, however, atypical presentation in older adults has no effect.
is common. In particular, nuchal rigidity and fever are often Vaccination against the organism can be used for close
absent. Encephalitis is more likely viral in origin and usu- contacts of patients with meningococcal disease resulting
ally manifests with fewer meningeal signs. Some common from A, C, Y, or W135 serogroups to prevent secondary
viruses that cause encephalitis include herpes simplex virus, cases. No effective vaccine exists to protect individuals from
other herpesviruses (e.g., Epstein-Barr virus, varicella-zoster meningococcal meningitis caused by serogroup B. Wide-
virus), enteroviruses, mosquito- and tick-borne viruses, spread or universal chemoprophylaxis is not recommended
the rabies virus, and childhood viruses (e.g., measles and during a meningococcal meningitis outbreak. Chemoprophy-
mumps). A virus can be acquired from mosquito or tick bites laxis should be considered for individuals in close contact,
that transmit the virus or through contact with a person or including household-type contact when there is a potential
object contaminated with the virus. In areas known to have for sharing glassware and dishes, with patients in an endemic
mosquitoes that carry encephalitis-causing viruses, it is im- situation but has limited efficacy interrupting transmission
portant to take measures to prevent being bitten. during an epidemic. Options include a single dose of oral
To eliminate or support the diagnosis of meningitis, ciprofloxacin or intramuscular ceftriaxone. An alternative is
lumbar puncture with CSF evaluation should be part of the four oral doses of rifampin over 2 days. Given rifampin’s abil-
evaluation of a febrile adult or child who has altered find- ity to induce cytochrome 450 isoenzymes, this medication
ings on neurological examination. Pleocytosis, defined should only be used after a complete inventory of all medica-
as a WBC count of more than 5 cells/mm3 of CSF, is an tions the patient could be taking has been conducted and no
expected finding in meningitis caused by bacterial, viral, potential interactions identified.
tubercular, fungal, or protozoan infection; an elevated CSF Immunization against N. meningitidis can also be used in
opening pressure is also a nearly universal finding. The typ- an outbreak; this option is helpful against current and future
ical CSF response in bacterial meningitis includes a WBC outbreaks. In the United States, two vaccines against the
median count of 1200 cells/mm3 of CSF with 90% to 95% organism are available: meningococcal polysaccharide vac-
neutrophils; additional findings are a reduced CSF glucose cine (MPSV4 or Menomune-A/C/Y/W-135) and meningo-
amount below the normal level of about 40% of the plasma coccal conjugate vaccine (MCV4 or Menactra). Both vaccines
level, and an elevated CSF protein level. In viral or aseptic can prevent four types of meningococcal disease, including
meningitis, CSF results include normal glucose level, nor- two of the three types most common in the United States
mal to slightly elevated protein levels, and lymphocytosis. (serogroup C, Y, and W-135) and a type that causes epi-
Further testing to ascertain the causative organism is demics in Africa (serogroup A); protection from all possible
warranted. Head CT or MRI should be considered before meningococcal strains is not provided by the vaccines.
lumbar puncture is performed. MCV4 is recommended for all children as part of routine
Brudzinski and Kernig signs, suggestive of nuchal rigid- preadolescent visit (11 to 12 years old). For children who
ity and meningeal irritation, are often positive in children have never received MCV4 previously, a dose is recom-
2 years or older and adults with meningitis. The Brudzinski mended for all 13- to 18-year-olds. For those 19 to 21 years
sign is elicited when passive neck flexion in a supine patient of age, the vaccine is not routinely recommended but can
results in flexion of the knees and hips. The Kernig sign is be administered as catch-up vaccination for those who have
elicited with the patient lying supine and the hip flexed at not received a booster dose after their 16th birthday. A
4074_Ch02_027-046 20/11/14 10:32 AM Page 39
booster dose is recommended at age 16 for children who re- 60. Common symptoms of MS include all of the following
ceived the MCV4 vaccine at ages 11 to 12 years. Other in- except:
dividuals at increased risk for whom routine vaccination is A. numbness or weakness in one or more limbs.
recommended are college freshmen living in dormitories, B. double vision or blurring vision.
microbiologists who are routinely exposed to meningococ- C. facial weakness or numbness.
cal bacteria, individuals who are functionally or surgically D. cold sensitivity.
asplenic, individuals with immune system disorder, those
61. Risk factors for MS include all of the following except:
with HIV (if another indication for vaccination exists), peo-
A. older than 50 years of age.
ple who are likely to travel to countries that have an out-
B. female gender.
break of meningococcal disease, and people who might have
C. northern European ancestry.
been exposed to meningitis during an outbreak. MCV4 is
D. autoimmune disease.
the preferred vaccine for individuals 11 to 55 years old in
these risk groups, but MPSV4 can be used if MCV4 is un- 62. The diagnosis of MS can typically involve all of the
available. MPSV4 should be used for adults age 56 years and following approaches except:
older who are at risk. A. MRI.
Meningitis caused by most other agents is a result of a B. analysis of CSF.
patient rather than contagion factor; that is, the meningitis C. check for presence of Kernig sign.
is a result of extension of an existing illness such as bacterial D. evoked potential test.
sinusitis and otitis media. Treatment of a patient with
63. Treatment options in MS to attenuate disease progres-
meningitis includes supportive care and the use of the ap-
sion include:
propriate anti-infective agents. Empiric therapy will de-
A. interferon beta-1b.
pend on findings from the Gram stain, culture, or other
B. methylprednisolone.
CSF testing. If gram-positive diplococci are present, treat-
C. ribavirin.
ment should consist of ceftriaxone or cefotaxime plus van-
D. phenytoin.
comycin plus timed dexamethasone. For gram-negative
diplococci, treatment should consist of cefotaxime or cef-
triaxone. If gram-positive bacilli or coccobacilli are present, Answers
then treat with ampicillin with or without gentamicin. If
gram-negative bacilli are present, treat with ceftazidime or 59. A. 61. A. 63. A.
cefepime with or without gentamicin. Susceptibility results 60. C. 62. C.
can also be used to guide appropriate treatment selection.
Acyclovir is an option in aseptic meningitis, pending iden- Multiple sclerosis (MS), a recurrent, chronic demyelinating
tification of the offending virus. Prudent clinical practice disorder of the central nervous system, is a disease character-
requires keeping abreast of current trends in causative ized by episodes of focal neurological dysfunction, with
pathogens and microbial resistance. symptoms occurring acutely, worsening over a few days, and
lasting weeks, followed by a period of partial to full resolu-
DI SCUSSION SOURCES tion. Symptoms of MS can vary and depend on the location
Centers for Disease Control and Prevention. Meningococcal disease. of affected nerve fibers. Common symptoms include weak-
http://www.cdc.gov/meningococcal/about/index.html ness or numbness of a limb, monocular visual loss, diplopia,
Centers for Disease Control and Prevention. Viral meningitis. vertigo, facial weakness or numbness, sphincter disturbances,
http://www.cdc.gov/meningitis/viral.html ataxia, and nystagmus. Heat sensitivity is also common in
Gondim F, Singh M, Croul S. http://emedicine.medscape.com/
persons with MS, with small increases in body temperature
article/1165557, eMedicine: Meningococcal meningitis
triggering or exacerbating MS symptoms. MS is usually clas-
Centers for Disease Control and Prevention. Prevention and control
of meningococcal disease: Recommendations of the Advisory sified into two forms: (1) relapsing, remitting MS (RRMS),
Committee on Immunization Practices (ACIP). MMWR in which episodes resolve with good neurological function
62(RR02):1–22, 2013. between exacerbations and minimal to no cumulative defects,
and which accounts for approximately 85% of patients with
the condition; and (2) primary progressive MS, in which
Multiple Sclerosis episodes do not fully resolve, and there are cumulative de-
fects. Most patients with RRMS enter a stage referred to as
59. The cause of multiple sclerosis is best described as: secondary progressive MS.
A. a destructive process of the nerve fiber protecting MS can occur at any age but most commonly affects peo-
myelin. ple between the ages of 20 and 40 years. Women are about
B. an intracranial viral infection. twice as likely to develop MS compared with men. Other
C. inflammation of the brain and/or spinal cord. risk factors include family history of MS, ethnicity (highest
D. an autoimmune disorder that destroys muscle incidence with northern European ancestry), certain viral
fibers. infections (e.g., Epstein-Barr), and the presence of another
4074_Ch02_027-046 20/11/14 10:32 AM Page 40
autoimmune disease (e.g., thyroid disease, type 1 diabetes, management therapies are aimed at the specific needs of the
or IBS). individual patient and often include nondrug interventions,
The initial diagnosis of MS is often difficult to make be- such as physical and occupational therapy, and management
cause the signs of recurrent fatigue, muscle weakness, and of urological problems such as altered bladder function.
other nonspecific signs and symptoms are often attributed to Expert consultation should be sought while providing care for
other diseases or simply to stress and fatigue. MRI can reveal the complex healthcare needs of patients with MS.
demyelinating plaques, a typical finding in MS. However,
these lesions can also be present with other conditions, such D I S C U SSI O N S O U R C E
as lupus, migraines, or diabetes. A lumbar puncture is con- Dangond, F. http://emedicine.medscape.com/article/1146199,
ducted to evaluate for abnormal findings in the CSF and can eMedicine: Multiple sclerosis.
help rule out viral infections or other conditions that can
cause neurological symptoms similar to MS. Characteristic
CSF findings include pleocytosis with predominance of Parkinson Disease
monocytes and abnormal protein levels, including a modest
64. Parkinson disease is primarily caused by:
increase in total protein, a markedly increased gamma-
A. degradation of myelin surrounding nerve fibers.
globulin fraction, a high immunoglobulin G index, presence
B. alteration in dopamine-containing neurons within
of oligoclonal bands, and an increase in myelin basic protein.
the midbrain.
Evoked potential testing can contribute to the development
C. deterioration of neurons in the brainstem.
of the diagnosis by detecting lesions or nerve damage in the
D. excessive production of acetylcholinesterase in
optic nerves, brainstem, or spinal cord. As with other condi-
the CSF.
tions that have a complex origin and complicated course,
expert consultation should be sought when diagnosing sus- 65. Which of the following is most consistent with findings
pected MS and caring for the patient with the condition. in patients with Parkinson disease?
MS treatment generally falls into three categories: therapy A. rigid posture with poor muscle tone
for relapses, long-term disease-modifying medications, and B. masklike facies and continued cognitive function
symptomatic management. Triggers for exacerbations are C. tremor at rest and bradykinesia
varied, but often include onset of common infectious disease D. excessive arm swinging with ambulation and flexed
such as urinary tract infection; however, most exacerbations posture
have no identifiable trigger. Treatment of exacerbations in-
66. The diagnosis of Parkinson disease relies on findings of:
cludes treatment of the underlying precipitating illness, if
A. clinical evaluation of six cardinal features.
present, and systemic high-dose corticosteroids. Because
B. head MRI or CT scan.
most exacerbations improve without specific therapy, dis-
C. pleocytosis in the CSF.
agreement exists as to the utility of this treatment. This ther-
D. a visual evoked potential test.
apy seems to shorten the course of most exacerbations, but
does not seem to have an impact on long-term disease pro- 67. Dopamine or dopamine agonists used to treat
gression. Some clinicians opt for lower-dose corticosteroid Parkinson disease include all of the following except:
therapy with variable results. A. levodopa.
Immunomodulatory therapy with interferon beta-1b B. chlorpromazine.
(Betaseron, Extavia) or interferon beta-1a (Avonex, Rebif) has C. ropinirole.
been shown to reduce significantly the frequency of exacer- D. pramipexole.
bations and long-term disability in RRMS. Immunosuppres-
68. In addition to dopamine agonists, other drug classes
sive therapy with mitoxantrone (Novantrone) also has some
used to treat Parkinson disease include all of the follow-
utility in reducing the rate of progression. Natalizumab
ing except:
(Tysabri) is a monoclonal antibody with considerable clinical
A. MAO B inhibitors.
efficacy in treating MS, but this medication carries a warning
B. catechol O-methyltransferase (COMT) inhibitors.
about progressive multifocal leukoencephalopathy, a rare, de-
C. SSRIs.
structive brain infection, associated with its use. Subcutaneous
D. anticholinergics.
glatiramer acetate (Copaxone) may reduce the number of MS
attacks by blocking the immune system’s attack on myelin. 69. Surgical intervention such as deep brain stimulation
Fingolimod (Gilenya) is an oral medication that traps immune can be helpful in the management of Parkinson disease-
cells in lymph nodes. Because of associated bradycardia with related symptoms:
this drug, patients should have their heart rate monitored for A. in early disease as a first-line therapy.
6 hours following the first dose. Teriflunomide (Aubagio), B. in patients with advanced disease who have unstable
which inhibits the production of T- and B-cells, has been medication responses.
shown to reduce MS attacks and associated lesions. However, C. related to memory loss.
liver function must be closely monitored for patients taking D. only as a last resort when all other options have been
this medication as it can cause serious liver damage. Symptom exhausted.
4074_Ch02_027-046 20/11/14 10:32 AM Page 41
70. Which of the following statements regarding “on” and Apomorphine (Apokyn) is an injectable-only dopamine ago-
“off” periods of Parkinson disease is false? nist that can be used in advanced Parkinson disease as a rescue
A. A person can move with relative ease during an therapy for the treatment of hypomobility or “off” periods.
“on” period. Other medications used in the treatment of Parkinson disease
B. An “off” period typically occurs at the Cmax follow- include anticholinergics, such as benztropine (Cogentin), to
ing levodopa dosing. help with tremor; however, this class of drugs is well known
C. Medication adjustment can usually minimize “off” to cause dry mouth, urinary retention, and altered mentation,
periods. particularly in older adults. In view of the complexity of pre-
D. Surgical treatment may be needed to manage scribing Parkinson disease medications, the prescriber should
dyskinesia during “off” periods. be well versed in these products and seek expert consultation.
As Parkinson disease progresses, patients often develop
variability in response to treatment, known as motor fluctu-
Answers ations, often referred to as “on” and “off” periods. During an
“on” period, a person can move with relative ease. An “off”
64. B. 67. B. 70. B. period describes times when a person has more difficulty with
65. C. 68. C. movement; this can be manifested either by significant diffi-
66. A. 69. B. culty in initiating movement or with uncontrolled body
movements including dyskinesia. A common time for a per-
Parkinson disease is a slowly progressive movement disorder son with Parkinson disease to experience an “off” period is
that is largely caused by an alteration in dopamine-containing toward the end of a levodopa dosing period, when the drug
neurons of the pars compacta of the substantia nigra. Age at seems to be “wearing off.” This problem can usually be man-
onset is usually in the sixth decade and older, but the onset aged with medication adjustment. If this approach is not
can occur in much younger adults. helpful, surgical treatment offers another form of treatment
The diagnosis of Parkinson disease is made by clinical for uncontrolled writhing movement (choreiform movement
evaluation and consists of a combination of six cardinal or dyskinesia) of the body or a limb.
features: tremor at rest, rigidity, bradykinesia (slowness in For most people with Parkinson disease, “off” periods
the execution of movement), flexed posture, loss of pos- and dyskinesias can be managed with changes in medica-
tural reflexes, and masklike facies. At least two of these, tions. However, when medication adjustments do not im-
with one being tremor at rest or bradykinesia, must be prove mobility or when medications cause significant side
present. Classically, an individual with Parkinson disease effects, surgical treatment can be considered. Pallidotomy
holds the arms rigidly at the sides with little movement can be helpful in tremor, rigidity, bradykinesia, and
during ambulation; forward falls are common. The parkin- levodopa-induced dyskinesias. Deep brain stimulation
sonian gait usually consists of a series of rapid small steps; surgery for Parkinson disease is helpful in making the “off”
to turn, patients must take several small steps, moving state more like movement in the “on” state, and is helpful
forward and backward. in the reduction of levodopa-induced dyskinesias. As with
Because Parkinson disease is characterized by an alteration other therapies, expert consultation should be sought, and
in the dopaminergic pathway, dopamine agonists such as all options should be thoroughly discussed with the patient
ropinirole (Requip) and pramipexole (Mirapex) are usually before pursuing surgical intervention.
the early disease treatment of choice, in part because of a
proposed neuroprotective effect and a better adverse-effect D I S C U SSI O N S O U R C E S
profile than levodopa. Levodopa, a metabolic precursor of National Parkinson Foundation. http://www.parkinson.org/NET-
dopamine, continues to be used to minimize symptoms, but COMMUNITY/Page.aspx?pid=226&srcid=216, Parkinson primer
tends to be less effective with more adverse effects as the dis- Jankovic J, Poewe W. Therapies in Parkinson’s disease. Curr Opin
ease progresses; most patients who take levodopa for more Neurol 25:433–447, 2012.
than 5 to 10 years develop dyskinesia. Levodopa is often given
with carbidopa in the fixed-dose combination known as
Sinemet or Parcopa. Seizure Disorders
Amantadine (Symmetrel) is an antiviral drug with time-
limited (usually less than 1 year) antiparkinsonian benefits, 71. Which of the following best describes patient presenta-
but it can be used in later stages of the disease to help reduce tion during an absence (petit mal) seizure?
dyskinesias. Catechol O-methyltransferase (COMT) in- A. blank staring lasting 3 to 50 seconds, accompanied
hibitors including tolcapone (Tasmar) and entacapone by impaired level of consciousness
(Comtan) are clinically helpful because these medications B. awake state with abnormal motor behavior lasting
increase the half-life of levodopa by reducing its metabolism. seconds
Monoamine oxidase-B (MAO-B) inhibitors, such as selegi- C. rigid extension of arms and legs, followed by sudden
line (Eldepryl, Zelapar) or rasagiline (Azilect), also help jerking movements with loss of consciousness
increase levodopa’s half-life by reducing its metabolism. D. abrupt muscle contraction with autonomic signs
4074_Ch02_027-046 20/11/14 10:32 AM Page 42
72. Which of the following best describes patient presenta- 78. A patient taking phenytoin can exhibit a drug interac-
tion during a simple partial seizure? tion when concurrently taking:
A. blank staring lasting 3 to 50 seconds, accompanied A. cyclosporine.
by impaired level of consciousness B. famotidine.
B. awake state with abnormal motor behavior lasting C. acetaminophen.
seconds D. aspirin.
C. rigid extension of arms and legs, followed by sudden
jerking movements with loss of consciousness
D. abrupt muscle contraction with autonomic signs Answers
73. Which of the following best describes patient 71. A. 74. D. 77. D.
presentation during a tonic-clonic (grand mal) 72. B. 75. D. 78. A.
seizure? 73. C. 76. A.
A. blank staring lasting 3 to 50 seconds, accompanied
by impaired level of consciousness
The type of seizure directs the treatment of a seizure disorder.
B. awake state with abnormal motor behavior lasting
Knowledge of the presentation of common forms of seizures
seconds
is critical (Table 2–8).
C. rigid extension of arms and legs, followed by sudden
Numerous seizure therapies, including standard or older
jerking movements with loss of consciousness
products such as phenytoin, carbamazepine, clonazepam,
D. abrupt muscle contraction with autonomic signs
ethosuximide, and valproic acid, and more recently devel-
74. Which of the following best describes patient presenta- oped antiepileptic drugs (AEDs), such as gabapentin, lamot-
tion during a myoclonic seizure? rigine, and topiramate, are now available. Expert knowledge
A. blank staring lasting 3 to 50 seconds, accompanied of the indications and adverse reactions of these medications
by impaired level of consciousness is needed before AED therapy is initiated or continued.
B. awake state with abnormal motor behavior lasting Certain AEDs, including phenytoin and carbamazepine,
seconds are narrow therapeutic index (NTI) drugs. A certain amount
C. rigid extension of arms and legs, followed by sudden of such drugs is therapeutic, and just slightly more than this
jerking movements with loss of consciousness amount is potentially toxic. Conversely, a slightly lower dose
D. brief, jerking contractions of arms, legs, trunk, or all might not be therapeutic. Other NTI drugs include warfarin,
of these theophylline, and digoxin. Many of these drugs have high lev-
els of protein binding and significant use of hepatic enzymatic
75. Treatment options for an adult with seizures include all
pathways for drug metabolism, such as CYP 450. Phenytoin
of the following agents except:
is highly protein bound (greater than 90%); when taken with
A. carbamazepine.
other highly protein-bound drugs, it can potentially be
B. phenytoin.
displaced from its protein-binding site, leading to increased
C. gabapentin.
free phenytoin and a risk of toxicity. Carbamazepine and
D. tamsulosin.
phenytoin can increase the metabolic capacity of hepatic en-
76. Medications with narrow therapeutic indexes (NTIs) zymes, which leads to more rapid metabolism of the drug and
include all of the following except: reduced levels of this and other drugs. Phenytoin use in-
A. topiramate. creases theophylline clearance by increasing CYP 450 enzyme
B. phenytoin. activity. Concomitant use of theophylline and phenytoin can
C. carbamazepine. lead to altered phenytoin pharmacokinetics. The net result is
D. valproate. that when phenytoin and theophylline are given together, lev-
els of both drugs can decrease by 40%. When taken with birth
77. Which of the following statements about potential drug
control pills, carbamazepine induces estrogen metabolism,
interactions with phenytoin is false?
potentially leading to contraceptive failure. The prescriber
A. Phenytoin increases theophylline clearance by increas-
should be familiar with the drug interactions of all AEDs and
ing cytochrome P-450 (CYP 450) enzyme activity.
monitor therapeutic levels and for adverse reactions.
B. When taken with other highly protein-bound drugs,
the free phenytoin concentration can increase to D I S C U SSI O N S O U R C E S
toxic levels.
Indiana University School of Medicine Division of Clinical Pharma-
C. Phenytoin can increase the metabolic capacity of cology. http://medicine.iupui.edu/clinpharm/ddis/clinical-table/,
hepatic enzymes, thus leading to reduced drug P450 drug interaction table: Abbreviated clinically relevant
levels. table.
D. When phenytoin and theophylline are given to- Jankovic SM, Dostic M. Choice of antiepileptic drugs for the elderly:
gether, the result is a higher concentration of both Possible drug interactions and adverse effects. Expert Opin Drug
drugs than when given separately. Metab Toxicol 8:81–91, 2012.
4074_Ch02_027-046 20/11/14 10:32 AM Page 43
TABLE 2-8
Description of Common Seizure Disorders
Seizure Type Description of Seizure Comments
Absence (petit mal) Blank staring lasting 3–50 seconds accompa- Usual age of onset 3–15 years
nied by impaired level of consciousness
Myoclonic Awake state or momentary loss of conscious- Difficult to control; at least half also
ness with abnormal motor behavior lasting have tonic-clonic seizures. Usual age
seconds to minutes; one or more muscle of onset 2–7 years
groups causing brief jerking contractions of
the limbs and trunk, occasionally flinging
patient
Tonic-clonic (grand mal) Rigid extension of arms and legs followed by Onset at any age; in adults, new onset
sudden jerking movements with loss of con- may be found in brain tumor, post-
sciousness; bowel and bladder incontinence head injury, alcohol withdrawal
common with postictal confusion
Simple partial or focal Awake state with abnormal motor, sensory, Typical age of onset 3–15 years
seizure (jacksonian) autonomic, or psychic behavior; movement
can affect any part of body, localized or
generalized
Complex partial Aura characterized by unusual sense of smell Onset at any age
or taste, visual or auditory hallucinations,
stomach upset; followed by vague stare and
facial movements, muscle contraction and re-
laxation, and autonomic signs; can progress
to loss of consciousness
Transient Ischemic 82 to 84. Rank the following causes of stroke from the
most common (1) to least common (3):
Attack 82. Cerebral hemorrhage
83. Cerebral ischemia
79. Risk factors for transient ischemic attack (TIA) include
84. Subarachnoid hemorrhage
all of the following except:
A. atrial fibrillation. 85. Antiplatelet agents commonly used in secondary
B. carotid artery disease. prevention of stroke include all of the following
C. combined oral contraceptive use. except:
D. pernicious anemia. A. aspirin.
B. clopidogrel.
80. A TIA is characterized as an episode of reversible
C. aspirin plus extended-release dipyridamole.
neurological symptoms that can last:
D. rivaroxaban.
A. 1 hour.
B. 6 hours. 86. Which of the following conditions is least likely to
C. 12 hours. contribute to an increased risk of stroke?
D. 24 hours. A. hyperlipidemia
B. diabetes mellitus
81. When caring for a patient with a recent TIA, you
C. Crohn’s disease
consider that:
D. hypertension
A. long-term antiplatelet therapy is likely indicated.
B. this person has a relatively low risk of future stroke.
C. women present with this disorder more often than men.
D. rehabilitation will be needed to minimize the effects
of the resulting neurological insult.
4074_Ch02_027-046 20/11/14 10:32 AM Page 44
102. One of the most serious complications of giant cell Apart from relieving pain, treatment of giant cell arteritis
arteritis is: helps minimize the risk of blindness, which is one of the
A. hemiparesis. most serious complications of the disease. Approximately
B. arthritis. 50% of patients with giant cell arteritis experience visual
C. blindness. symptoms, including transient visual blurring, diplopia, eye
D. uveitis. pain, or sudden loss of vision; transient repeated episodes
of blurred vision are usually reversible, but sudden loss of
vision is an ominous sign and is almost always permanent.
Answers As soon as the diagnosis is made, high-dose systemic corti-
costeroid therapy should be initiated; this therapy typically
95. C. 98. A. 101. A. involves prednisone, 1 to 2 mg/kg per day, until the disease
96. C. 99. B. 102. C. appears to be under control, followed by a careful dose
97. B. 100. B. reduction until the lowest dose that can maintain clinical
response can be determined. This dose is continued for
See full color images of this topic 6 months to 2 years. When symptoms have been stable, and
on DavisPlus at the corticosteroid therapy is going to be discontinued, a
http://davisplus.fadavis.com | slow taper with close monitoring is warranted because
Keyword: Fitzgerald
of the risk of adrenal suppression and disease resurgence.
Gastrointestinal cytoprotection with misoprostol or a pro-
ton pump inhibitor and bone protection with a bisphospho-
Giant cell or temporal arteritis is an autoimmune vasculitis
nate plus calcium/vitamin D supplement should also be
that is most common in patients 50 to 85 years old; average
provided to minimize these corticosteroid-related adverse
age at onset is 70 years. A systemic disease affecting medium-
effects. Aspirin can also be considered to reduce the risk of
sized and large-sized vessels, giant cell arteritis also causes
stroke. Corticosteroid-sparing agents, such as methotrexate,
inflammation of the temporal artery. Inflammation and
azathioprine, cyclophosphamide, and cyclosporine, can be
swelling of the arteries causes decreased blood flow and its
helpful in reducing adverse effects associated with long-
associated symptoms. The swelling normally affects just part
term steroid therapy. However, data are lacking on the
of an artery with sections of normal artery in between. Ex-
effectiveness of these agents in treating giant cell arteritis.
tracranial branches of the carotid artery are often involved; this
Diagnosis of giant cell arteritis should include a confir-
often results in a tender or nodular, pulseless vessel, usually the
matory arterial biopsy. Color duplex ultrasonography of the
temporal artery, accompanied by a severe unilateral headache.
temporal arteries has been used as an alternative or com-
On examination, the temporal artery is occasionally normal,
plement to superficial temporal artery biopsy. Because the
however. Giant cell arteritis and polymyalgia rheumatica are
disease frequently skips portions of the vessel, biopsy spec-
thought to represent two parts of a spectrum of disease and are
imens of multiple vessel sites should be obtained. C-reactive
often found together. Other risk factors for giant cell arteritis
protein (CRP) and erythrocyte sedimentation rate (ESR),
include female gender and Northern European descent, par-
although nonspecific tests of inflammation, are usually
ticularly people of Scandinavian origin.
markedly elevated.
In an older adult, these clinical syndromes are often
accompanied by respiratory tract symptoms (cough, sore D I S C U SSI O N S O U R C E S
throat, hoarseness) or mental status changes, rather than by Roque M. http://www.emedicine.com/OPH/topic254.htm, eMedi-
the classically reported findings of headache, jaw claudica- cine: Giant cell arteritis
tion, and acute reduction or change in vision. The headache Barraclough K, Mallen CD, Helliwell T, et al. Diagnosis and man-
that is usually part of the presentation is occasionally reported agement of giant cell arteritis. Br J Gen Pract 62:329–30, 2012.
as being located in the frontal, vertex, or occipital area, rather Charlton R. Optimal management of giant cell arteritis and
than in the temporal area. polymyalgia rheumatic. Ther Clin Risk Manag 8:173–179, 2012.
4074_Ch03_047-078 20/11/14 10:35 AM Page 47
Skin Disorders 3
Skin Lesions
1 to 12. Match the following descriptions to the correct lesion or distribution name.
1. multiple lesions blending together A. ulcer
B. atrophy
2. flat discoloration less than 1 cm in diameter
C. fissure
3. circumscribed area of skin edema D. reticular
E. wheal
4. narrow linear crack into epidermis, exposing dermis
F. pustule
5. vesicle-like lesion with purulent content G. patch
H. plaque
6. flat discoloration greater than 1 cm in diameter
I. macule
7. raised lesion, larger than 1 cm, may be same or different color from the J. confluent or coalescent
surrounding skin K. annular
L. lichenification
8. netlike cluster
9. loss of epidermis and dermis
10. loss of skin markings and full skin thickness
11. skin thickening usually found over pruritic or friction areas
12. in a ring formation
Answers
1. J. confluent or coalescent 5. F. pustule 9. A. ulcer
2. I. macule 6. G. patch 10. B. atrophy
3. E. wheal 7. H. plaque 11. L. lichenification
4. C. fissure 8. D. reticular 12. K. annular
47
4074_Ch03_047-078 20/11/14 10:35 AM Page 48
Identification of common dermatologic lesions is important to safe clinical practice (Table 3–1).
TABLE 3-1
Skin Lesions
Lesion Description Example
COMMON PRIMARY SKIN LESIONS
Macule Flat discoloration, usually <1 cm in diameter Freckle
Patch Flat area of skin discoloration, larger than a Vitiligo
macule
Papule Raised lesion, <1 cm, may be same or different Raised nevus
color than the surrounding skin
Vesicle Fluid-filled, <1 cm Varicella
Plaque Raised lesion, ≥ 1 cm, may be same or different Psoriasis
color than surrounding skin
Purpura Lesions caused by red blood cells leaving circula- Petechiae, ecchymosis
tion and becoming trapped in skin
Pustule Vesicle-like lesion with purulent content Impetigo, acne
Wheal Circumscribed area of skin edema Hive
Nodule Raised lesion, ≥1 cm, usually mobile Epidermal cyst
Bullae Fluid-filled, ≥1 cm Blister with second-degree
burn
COMMON SECONDARY SKIN LESIONS
Excoriation Marks produced by scratching Seen in areas of pruritic skin
diseases
Lichenification Skin thickening resembling callus formation Seen in areas of recurrent
scratching
Fissure Narrow linear crack into epidermis, exposing Split lip, athlete’s foot
dermis
Erosion Partial focal loss of epidermis; heals without Area exposed after bullous
scarring lesion opens
Ulcer Loss of epidermis and dermis; heals with Pressure sore
scarring
Scale Raised, flaking lesion Dandruff, psoriasis
Atrophy Loss of skin markings and full skin thickness Area treated excessively
with higher potency
corticosteroids
TERMS DESCRIBING PATTERNS OF SKIN LESIONS
Annular In a ring Erythema migrans in Lyme
disease
Confluent or coalescent Multiple lesions blending together Multiple skin conditions
Reticular Netlike cluster Multiple skin conditions
Dermatomal Along a neurocutaneous dermatome Herpes zoster
Linear In streaks Poison ivy
Source: James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin: Clinical Dermatology, ed. 11.
Philadelphia: Saunders, 2011, pp. 8, 1–11.
4074_Ch03_047-078 20/11/14 10:35 AM Page 49
DI SCUSSION SOURCES
James WD, Berger TG, Elston DM. Andrews’ Diseases of the
Answers
Skin: Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
13. B. 14. C. 15. B.
pp. 12–17.
Czerkasij, V. A strategy for learning dermatology. J Nurse Pract 6:
555–556, 2010. http://www.dermatologylexicon.org
Knowledge of the amount of a cream or ointment needed to
treat a dermatologic condition is an important part of the
See full color images of this topic prescriptive practice (Table 3–2). Clinicians often write pre-
on DavisPlus at scriptions for an inadequate amount of a topical medication
http://davisplus.fadavis.com | with insufficient numbers of refills, possibly creating a situa-
Keyword: Fitzgerald tion in which treatment fails because of an inadequate length
of therapy.
D I S C U SSI O N S O U R C E
Topical Medication Habif TP, Campbell JL, Chapman SM, et al. Skin Disease: Diagnosis
and Treatment, ed. 3. Philadelphia: Elsevier Saunders; 2011.
Dispensing
13. How many grams of a topical cream or ointment are
needed for a single application to the hands?
Topical Medication
A. 1 Absorption
B. 2
C. 3
16. You write a prescription for a topical agent and
D. 4
anticipate the greatest rate of absorption when it is
14. How many grams of a topical cream or ointment are applied to the:
needed for a single application to an arm? A. palms of the hands.
A. 1 B. soles of the feet.
B. 2 C. face.
C. 3 D. abdomen.
D. 4
17. You prescribe a topical medication and want it to have
15. How many grams of a topical cream or ointment are maximum absorption, so you choose the following
needed for a single application to the entire body? vehicle:
A. 10 to 30 A. gel
B. 30 to 60 B. lotion
C. 60 to 90 C. cream
D. 90 to 120 D. ointment
TABLE 3-2
Topical Medication-Dispensing Formula
Amount Needed in
Amount Needed for Twice-a-Day Application Amount Needed in Twice-a-Day
One Application for 1 Week Application for 1 Month
Hands, head, face, 2g 28 g 120 g (4 oz)
anogenital region
One arm, anterior or 3g 42 g 180 g (6 oz)
posterior trunk
One leg 6g 84 g 320 g (12 oz)
Entire body 30–60 g 420–840 g (14–28 oz) 1.8–3.6 kg (60–120 oz or 3.75–7.5 lb)
Source: Habif TP, Campbell JL, Chapman SM et al. Skin Disease: Diagnosis and Treatment, ed. 3. Philadelphia:
Saunders, 2011, pp. 6, 644–645.
4074_Ch03_047-078 20/11/14 10:35 AM Page 50
Answers Answers
16. C. 17. D. 18. C. 19. B. 20. C.
The safe prescription of a topical agent for patients with der- Corticosteroids are a class of drugs often used to treat in-
matologic disorders requires knowledge of the best vehicle flammatory and allergic dermatologic disorders. Although
for the medication. Certain parts of the body, notably the corticosteroids reduce inflammatory and allergic reactions
face, axillae, and genital area, are quite permeable, allowing through numerous mechanisms (including immunosuppres-
greater absorption of medication than less permeable areas, sive and inflammatory properties), their relative potency is
such as the extremities and trunk. In particular, the thickness based on vasoconstrictive activity; that is, the most potent
of the palms of the hands and soles of the feet creates a bar- topical steroids, such as betamethasone (class 1), have signifi-
rier so that relatively little topical medication is absorbed cantly greater vasoconstricting action than the least potent
when applied to these sites. Cutaneous drug absorption is agents, such as hydrocortisone (class 7) (Table 3–3).
typically inversely proportional to the thickness of the stra-
D I S C U SSI O N S O U R C E S
tum corneum. Hydrocortisone absorption from the forearm
is less than one-third of the amount that is absorbed from James, WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin:
the forehead. Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
pp. 136–137.
In general, the less viscous the vehicle containing a top-
Robertson D, Mailbach H. Dermatologic pharmacology. In:
ical medication, the less of the medication is absorbed. As a Katzung B (ed). Katzung’s Basic and Clinical Pharmacology,
result, medication contained in a gel or lotion is absorbed ed 12. New York: McGraw-Hill Medical, 2012, pp. 991–1008.
in smaller amounts than medication contained in a cream Stringer J. Adrenocortical hormones. In: Stringer J (ed). Basic Con-
or ointment. Besides enhancing absorption of the therapeu- cepts in Pharmacology, ed 4. New York: McGraw-Hill Medical,
tic agent, creams and ointments provide lubrication to the 2011, pp. 185–188.
region, often a desirable effect in the presence of xerosis or
lichenification.
DI SCUSSION SOURCE
TABLE 3-3
Robertson D. Mailbach H. Dermatologic pharmacology. In: Examples of Topical Corticosteroid
Katzung, B (ed). Katsung’s Basic and Clinical Pharmacology. Potency
ed. 12. New York: McGraw-Hill Medical; 2012, pp. 991–1008.
LOW POTENCY
Hydrocortisone (0.5%, 1%, 2.5%)
Topical Fluocinolone acetonide 0.01% (Synalar)
Triamcinolone acetonide 0.025% (Aristocort)
Corticosteroids Fluocinolone acetonide 0.025% (Synalar)
Hydrocortisone butyrate 0.1%
18. One of the mechanisms of action of a topical corticos- Hydrocortisone valerate 0.2% (Westcort)
teroid preparation is as: Triamcinolone acetonide 0.1%
A. an antimitotic.
B. an exfoliant. MIDRANGE POTENCY
C. a vasoconstrictor. Betamethasone dipropionate, augmented, 0.05%
D. a humectant. (Diprolene AF cream)
Mometasone furoate 0.1% (Elocon ointment)
19. To enhance the potency of a topical corticosteroid,
the prescriber recommends that the patient apply the HIGH POTENCY
preparation: Fluocinolone acetonide 0.2% (Synalar-HP)
A. to dry skin by gentle rubbing. Desoximetasone 0.25% (Topicort)
B. and cover with an occlusive dressing. Fluocinonide 0.05% (Lidex)
C. before bathing. SUPER-HIGH POTENCY
D. with an emollient. Betamethasone dipropionate, augmented, 0.05%
20. Which of the following is the least potent topical (Diprolene gel, ointment)
corticosteroid? Clobetasol propionate 0.05% (Temovate)
A. betamethasone dipropionate 0.1% (Diprosone) Halobetasol propionate 0.05% (Ultravate 0.05%)
B. clobetasol propionate 0.05% (Cormax) Source: Benson HA, Watkinson AC. Topical and Transdermal Drug
C. hydrocortisone 2.5% Delivery: Principles and Practice. Hoboken, NJ: John Wiley & Sons,
D. fluocinonide 0.05% (Lidex) 2012, pp. 357–366.
4074_Ch03_047-078 20/11/14 10:35 AM Page 51
D I S C U SSI O N S O U R C E
Antihistamine Robertson D, Mailbach H. Dermatologic pharmacology. In:
21. Antihistamines exhibit therapeutic effect by: Katzung B (ed), Katzung’s Basic and Clinical Pharmacology,
ed. 12. New York: McGraw-Hill Medical; 2012, pp. 991–1008.
A. inactivating circulating histamine.
B. preventing the production of histamine.
C. blocking activity at histamine receptor sites.
D. acting as a procholinergic agent.
Impetigo
22. A possible adverse effect with the use of a first- 24. Clinical features of bullous impetigo include:
generation antihistamine such as diphenhydramine A. intense itch.
in an 80-year-old man is: B. vesicular lesions.
A. urinary retention. C. dermatomal pattern.
B. hypertension. D. systemic symptoms such as fever and chills.
C. tachycardia. 25. The likely causative organisms of nonbullous impetigo
D. urticaria. in a 6-year-old child include:
23. Which of the following medications is likely to cause A. H. influenzae and S. pneumoniae.
the most sedation? B. group A streptococcus and S. aureus.
A. chlorpheniramine C. M. catarrhalis and select viruses.
B. cetirizine D. P. aeruginosa and select fungi.
C. fexofenadine 26. The spectrum of antimicrobial activity of mupirocin
D. loratadine (Bactroban) includes:
A. primarily gram-negative organisms.
Answers B. select gram-positive organisms.
C. Pseudomonas species and anaerobic organisms.
21. C. 22. A. 23. A. D. only organisms that do not produce beta-lactamase.
27. An impetigo lesion that becomes deeply ulcerated is
Antihistamines prevent action of formed histamine, a potent
known as:
inflammatory mediator, and can be used to control acute
A. cellulitis.
symptoms of itchiness and allergy. All antihistamines work
B. erythema.
by blocking histamine-1 (H1) receptor sites, preventing the
C. ecthyma.
action of histamine.
D. empyema.
Systemic antihistamines are usually divided into two
groups: standard or first-generation products, such as 28. First-line treatment of impetigo with less than
diphenhydramine (Benadryl) or chlorpheniramine (Chlor- 5 lesions of 1-2 centimeters in diameter on the legs
Trimeton), and newer or second-generation products, such in a 9-year-old girl is:
as loratadine (Claritin), desloratadine (Clarinex), cetirizine A. topical mupirocin.
(Zyrtec), fexofenadine (Allegra), and levocetirizine (Xyzal). B. topical neomycin.
The first-generation antihistamines readily cross the blood- C. oral cefixime.
brain barrier, causing sedation; as a result, these medica- D. oral doxycycline.
tions should be used with appropriate caution and should
29. An oral antimicrobial option for the treatment of
not be taken during activities when risk of accident or in-
methicillin-sensitive S. aureus includes all of the
jury is significant. Their anticholinergic activity can result
following except:
in drying of secretions, visual changes, and urinary reten-
A. amoxicillin.
tion; the last mentioned is most often a problem for older
B. dicloxacillin.
men with benign prostatic hyperplasia. The use of first-
C. cephalexin.
generation antihistamines by older adults, particularly in
D. cefadroxil.
higher doses as a sleep aid, can result in negative cognitive
effects. The second-generation antihistamines do not easily 30. Which of the following is an oral antimicrobial option
cross the blood-brain barrier, which results in lower rates for the treatment of a community-acquired methicillin-
of sedation. With little anticholinergic effect, the use of a resistant S. aureus cutaneous infection?
product such as loratadine is likely to provide less drying A. amoxicillin
of nasal secretions compared with diphenhydramine use, B. dicloxacillin
but also will have less negative effect on cognition, partic- C. cephalexin
ularly in older adults. D. trimethoprim-sulfamethoxazole
4074_Ch03_047-078 20/11/14 10:35 AM Page 52
31. You see a kindergartner with impetigo and advise that organisms into the skin by abrasions, minor trauma, or insect
she can return ________ hours after initiating effective bites then ensues. Streptococcal strains can be transferred from
antimicrobial therapy. the skin or impetigo lesions to the upper respiratory tract.
A. 24 Rarely, an impetigo lesion can become deeply ulcerated,
B. 48 known as ecthyma. Although regional lymphadenitis occurs,
C. 72 systemic symptoms are usually absent.
D. 96 When impetigo results in a few lesions, topical therapy is
indicated with mupirocin (Bactroban or Centany) as the pre-
ferred agent. Mupirocin use is associated with higher cure
Answers rates compared with oral erythromycin, and both are noted
to be superior to penicillin. Retapamulin (Altabax) ointment
24. B. 27. C. 30. D. is also an effective, albeit more expensive, therapeutic option.
25. B. 28. A. 31. A. Bacitracin and neomycin are less effective topical treatments;
26. B. 29. A. use of these products is not recommended for the treatment
of impetigo.
Impetigo is a contagious skin infection that usually consists Patients who have numerous lesions or who are not re-
of discrete purulent lesions. Although most common among sponding to topical agents should receive oral antimicrobials
children in tropical or subtropical regions, the prevalence effective against S. aureus and Streptococcus pyogenes. In the
increases in northern climates during the summer months. past, penicillin was a common choice that was clinically effec-
Its peak incidence is among children 2 to 5 years old, al- tive because most cases were caused by Streptococcus species.
though older children and adults can also be affected. There Because S. aureus currently accounts for most cases of bullous
is no sex or racial predilection for the condition. Impetigo impetigo and for a substantial portion of nonbullous infec-
skin lesions are nearly always caused by the gram-positive tions, antimicrobials with a gram-positive spectrum of activ-
organisms group A streptococci, Staphylococcus aureus, or ity and stability in the presence of beta-lactamase, such
a mix of both. as dicloxacillin or a first-generation or second-generation
Impetigo usually occurs on exposed areas of the body; the cephalosporin are now often used as a first-line choice, par-
infection most frequently affects the face and extremities. ticularly if methicillin-sensitive S. aureus (MSSA) is consid-
The lesions remain well localized but are frequently multiple ered to be the likely causative pathogen. Impetigo caused by
and can be either bullous or nonbullous. Bullous impetigo methicillin-resistant S. aureus (MRSA) is increasing in fre-
is usually caused by strains of S. aureus that produce a toxin quency, however. In addition, nearly one-half of MRSA
causing cleavage in the superficial skin layer, with the strains show resistance to mupirocin, These strains are gen-
causative pathogens usually present in the nose before the erally macrolide-resistant as well; the macrolides are a class
outbreak of the cutaneous disease. The bullous lesions usu- of antimicrobials including azithromycin, clarithromycin,
ally appear initially as superficial vesicles that rapidly enlarge and erythromycin. The advent of infection by these resistant
to form a bulla or blister that is often filled with a dark or pathogens requires that other options also be considered.
purulent liquid and can take on a pustular appearance. The These options include trimethoprim-sulfamethoxazole and
lesion ruptures, and a thin, lacquer-like crust typically forms clindamycin. Minocycline and doxycycline, both tetracycline
quickly. The pattern of the lesion often reflects autoinocula- forms, can also be helpful but should not be used in children
tion with the offending organism. younger than 11 years due to the risk of staining of the per-
The lesions of nonbullous impetigo usually begin as manent teeth. Even in these times of resistant pathogens,
papules that rapidly evolve into vesicles surrounded by an most episodes of impetigo resolve without complication or
area of erythema. The pustules increase in size, breaking need for a second-line agent. In many areas of the world,
down in the next 4 to 6 days, forming characteristic thick however, cutaneous infections with nephritogenic strains of
crusts. About 70% of patients with impetigo have nonbullous group A streptococci are the major antecedent of poststrep-
lesions. In either form, the lesions heal slowly and leave tococcal glomerulonephritis. No conclusive data indicate that
depigmented areas. treatment of streptococcal pyoderma prevents nephritis.
Until more recently, nonbullous impetigo was usually At the same time, treatment of impetigo is important to
caused by Streptococcus species. Now, most cases are caused by minimize risk of infectious transmission. Children with im-
staphylococci alone or in combination with streptococci. Strep- petigo should be kept out of school or daycare for 24 hours
tococci isolated from lesions are primarily group A organisms, after initiation of antibiotic therapy, and family members
but occasionally other serogroups (e.g., groups C and G) are re- should be checked for lesions.
sponsible. Prospective studies of streptococcal impetigo have D I S C U SSI O N S O U R C E S
shown that the responsible microorganisms initially colonize Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
the unbroken skin. As a result, personal hygiene has an influ- Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA:
ence on disease incidence in that colonization with a given Antimicrobial Therapy, Inc; 2014, pp. 55.
streptococcal strain precedes the development of impetigo Lewis, LL. http://emedicine.medscape.com/article/965254-treatment,
lesions by a mean duration of 10 days; inoculation of surface eMedicine: Impetigo
4074_Ch03_047-078 20/11/14 10:35 AM Page 53
Bolaji RS, Dabade TS, Gustafson CJ, Davis SA, Krowchuk DP, 38. In a 22-year-old woman using isotretinoin (Accutane)
Feldman SR. Treatment of impetigo: Oral antibiotics most com- therapy, the NP ensures follow-up to monitor for all of
monly prescribed. J Drugs Dermatol 11(4):489–494, 2012. the following tests except:
A. hepatic enzymes
B. triglyceride measurements
Acne Vulgaris C. pregnancy test
D. platelet count
32. The use of which of the following medications con-
tributes to the development of acne vulgaris? 39. Leonard is an 18-year-old man who has been taking
A. lithium isotretinoin (Accutane) for the treatment of acne for
B. propranolol the past 2 months. Which of the following is the most
C. sertraline important question for the clinician to ask at his
D. clonidine follow-up office visit?
A. Are you having any problems remembering to take
33. First-line therapy for acne vulgaris with closed your medication?
comedones includes: B. Have you noticed any dry skin around your mouth
A. oral antibiotics. since you started using Accutane?
B. isotretinoin. C. Do you notice any improvement in your skin?
C. benzoyl peroxide. D. Have you noticed any recent changes in your mood?
D. hydrocortisone cream.
40. A 14-year-old male presents with acne consisting of
34. When prescribing tretinoin (Retin-A), the NP advises 25 comedones and 20 inflammatory lesions with no
the patient to: nodules. This patient can be classified as having:
A. use it with benzoyl peroxide to minimize irritating A. mild acne.
effects. B. moderate acne.
B. use a sunscreen because the drug is photosensitizing. C. severe acne.
C. add a sulfa-based cream to enhance antiacne effects. D. very severe acne.
D. expect a significant improvement in acne lesions
after approximately 1 week of use. 41. In a 13-year-old female patient with mild acne and who
experiences an inadequate response to benzoyl perox-
35. In the treatment of acne vulgaris, which lesions respond ide treatment, an appropriate treatment option would
best to topical antibiotic therapy? be to:
A. open comedones A. add a topical retinoid.
B. cysts B. add an oral antibiotic.
C. inflammatory lesions C. consider isotretinoin.
D. superficial lesions D. consider hormonal therapy.
36. You have initiated therapy for an 18-year-old man
with acne vulgaris and have prescribed doxycycline.
He returns in 3 weeks, complaining that his skin is Answers
“no better.” Your next action is to:
32. A. 36. A. 40. B.
A. counsel him that 6 to 8 weeks of treatment is often
33. C. 37. B. 41. A.
needed before significant improvement is achieved.
34. B. 38. D.
B. discontinue the doxycycline and initiate minocycline
35. C. 39. D.
therapy.
C. advise him that antibiotics are likely not an effective
Acne vulgaris is a common pustular disorder caused by a
treatment for him and should not be continued.
combination of factors. An increase in sebaceous activity
D. add a second antimicrobial agent such trimethoprim-
causes plugging of follicles and retention of sebum, allowing
sulfamethoxazole.
an overgrowth of the organism Propionibacterium acnes. This
37. Who is the best candidate for isotretinoin (Accutane) overgrowth allows an inflammatory reaction with the result-
therapy? ing wide variety of lesions, including open and closed come-
A. a 17-year-old patient with pustular lesions and poor dones, cysts, and pustules. Due to follicular plugging, the use
response to benzoyl peroxide of a keratolytic agent is advised as well as an antibacterial to
B. a 20-year-old patient with cystic lesions who has minimize the inflammatory effects of P. acnes.
tried various therapies with minimal effect Benzoyl peroxide is an inexpensive, generally well toler-
C. a 14-year-old patient with open and closed come- ated antibacterial agent suitable for the treatment of mild to
dones and a family history of “ice pick” scars moderate acne; the product also has comedolytic activity.
D. an 18-year-old patient with inflammatory lesions Topical and systemic antibiotics are also used to treat acne
and improvement with tretinoin (Retin-A) and are particularly helpful as therapy for pustular lesions.
4074_Ch03_047-078 20/11/14 10:35 AM Page 54
The mechanism of action of antibiotics in acne therapy is acne treatment, therapeutic options should be based on the
probably not based solely on their antimicrobial action but is severity of acne (mild, moderate, or severe) (Table 3–5).
likely in part a result of antiinflammatory activity. Additional Nearly all adolescents develop some acne vulgaris to some
acne vulgaris agents include topical vitamin A derivatives such degree, with milder cases resolving by early adulthood. Only
as tretinoin (Retin-A), synthetic retinoid (Accutane), and 15% seek treatment for this problematic condition, which
comedolytic (benzoyl peroxide). (Table 3–4). When selecting affects teenagers at a time in their lives when body image and
TABLE 3-4
Acne Medications
Acne Medication Mechanism of Action and Considerations for Use
Benzoyl peroxide gel, cream, lotion, • Antimicrobial against P. acnes and comedolytic effects
various concentrations • Safe and effective over-the-counter availability
• Lower strength formulation often as effective as higher strength and likely to
cause less skin irritation
• Often given in combination with topical antibiotics, usually used with a keratolytic
Azelaic acid (Finacea, Azelex) 15% • Likely antimicrobial against P. acnes, keratolytic, possibly alters androgen
and 20% cream metabolism
• Expect ~6 weeks of therapy before noting improvement
• Mild skin irritation with redness and dryness common with initial use, improves
over time
• Less potent, but less irritating than tretinoin preparations
Tretinoin (retinoic acid) gel, cream, • Decreases cohesion between epidermal cells, kerotolytic, increases epidermal cell
various concentrations turnover, transforms closed to open comedones
Adapalene (Differin, Tazarotene) • Mild skin irritation with redness and dryness common with initial use, improves
synthetic tretinoin over time; expect ~6 weeks of therapy before noting improvement
• Photosensitizing; advise patient to use sunscreen
Oral antibiotics (doxycycline, • Antimicrobial against P. acnes, anti-inflammatory
minocycline are primary, others • Indicated for treatment of moderate papular inflammatory acne, usually when
include clindamycin, erythromycin, topical therapy has been inadequate
azithromycin, others) • Once skin clears (usually about 3-6 months) , taper off slowly over a few months
while adding topical antibiotic agents; rapid discontinuation results in return
of acne
• Long-term therapy is often needed
Topical antibiotics (clindamycin, • Antimicrobial against P. acnes, antiinflammatory
erythromycin, tetracycline, others) • Indicated in treatment of mild to moderate inflammatory acne vulgaris; less ef-
fective than oral antibiotics; often given in combination with benzoyl peroxide
Combined estrogen-progestin • Reduction in ovarian androgen production, decreased sebum production
hormonal contraceptives such as
birth control pills, ring, or patch
Isotretinoin (Accutane, • Likely inhibits sebaceous gland function
Ro-Accutane, Claravis, Sotret, • Indicated for treatment of cystic acne that does not respond to other therapies
Amnesteem, Absorica) capsules, • Usual course of treatment is 4–6 months; discontinue when nodule count is
various strengths reduced by 70%; repeat course only if needed after 6 months off drug
• Prescriber and patient must be properly educated in use of drug and fully
aware of adverse reactions profile, including cheilitis, conjunctivitis, hypertriglyc-
eridemia, xerosis, photosensitivity, and potent teratogenicity. Women must use
two types of highly effective contraception while on isotretinoin. Careful moni-
toring for mood destabilization and suicidal thoughts is an important part of
patient care during isotretinoin use.
Sources: Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The Sanford Guide to Antimicrobial
Therapy. ed. 44. Sperryville, VA: Antimicrobial Therapy, Inc., 2014, p. 51.
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin: Clinical Dermatology, ed. 11. Philadelphia:
Saunders, 2011, pp. 8, 228–235.
4074_Ch03_047-078 20/11/14 10:35 AM Page 55
TABLE 3-6
Treatment Recommendations for Acne
Mild Acne Moderate Acne
(comedonal or (comedonal or Severe Acne
inflammatory/ inflammatory/ (inflammatory/mixed
mixed lesions) mixed lesions) and/or nodular lesions)
Initial treatment Benzoyl peroxide (BP) Topical combination therapy Combination therapy
or BP + retinoid Oral antibiotic +
topical retinoid or topical retinoid +
Retinoid + (BP + antibiotic) BP ±
or consider oral isotretinoin
(Retinoid + antibiotic) + BP
Continued
4074_Ch03_047-078 20/11/14 10:35 AM Page 56
TABLE 3-6
Treatment Recommendations for Acne—cont’d
Mild Acne Moderate Acne
(comedonal or (comedonal or Severe Acne
inflammatory/ inflammatory/ (inflammatory/mixed
mixed lesions) mixed lesions) and/or nodular lesions)
Initial treatment Topical combination therapy Oral antibiotic + topical
(alternative) BP + antibiotic retinoid + BP
or or
BP + retinoid Topical retinoid + antibiotic
or + BP
BP + retinoid + antibiotic
Inadequate response Add BP or retinoid if not Change topical retinoid Consider changing oral
already prescribed concentration, type, and/or antibiotic
or formulation and
Change topical retinoid and/or consider oral isotretinoin*
concentration, type, and/or Change topical combination
formulation therapy
or and/or
Change topical combination Add or change oral
therapy antibiotic*
or
Consider oral isotretinoin
47. You see a 52-year-old woman who was bitten by a rat patient’s history must include a complete documentation of
while opening a Dumpster. The examination reveals a events leading up to the bite.
wound approximately 1 cm deep that is oozing bright All bites should be considered to carry infectious risk.
red blood. Treatment of this patient should include This risk can vary from the relatively low rate of infection
standard wound care with the addition of: from dog bites (approximately 5%) to the very high rate
A. rabies immune globulin. from cat bites (approximately 80%). Initial therapy for all
B. rabies vaccine. bite wounds should include vigorous wound cleansing with
C. oral ciprofloxacin. antimicrobial agents as appropriate and débridement if
D. oral amoxicillin-clavulanate. necessary. Starting short-term antimicrobial prophylactic
therapy within 12 hours of the injury should be considered
48. You see a 28-year-old man who was involved in a fight
as directed by the location and origin of the bite wound,
approximately 1 hour ago with another person. The
and tetanus immunization should be updated as needed
patient states, “He bit me in the arm.” Examination of
(Table 3–7).
the left forearm reveals an open wound consistent with
The clinician should check with local authorities for in-
this history. Your next best action is to:
formation on rabies when a bite involves domestic pets; be-
A. obtain a culture and sensitivity of the wound site.
cause the rabies risk in this situation is usually negligible,
B. refer for rabies prophylaxis.
rabies prophylaxis is not indicated. In recent years, there has
C. irrigate the wound and débride as needed.
been an increase in cases of rabies domestically, primarily
D. close the wound with adhesive strips.
from bites by usually docile, often nocturnal wild animals
that attack without provocation. These include bats, foxes,
woodchucks, squirrels, and skunks. Human bites carry no
Answers rabies risk.
42. B. 45. A. 48. C. D I S C U SSI O N S O U R C E S
43. C. 46. A.
Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
44. C. 47. D.
Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA:
Antimicrobial Therapy, Inc., 52:48–49, 2014.
Bite wounds should not be considered benign or inevitable. Ballentine JR. http://www.emedicinehealth.com/human_bites/article_
Intervention includes education to avoid further bites; a em.htmed.
TABLE 3-7
Infectious Agents and Treatment in Bites
Type of Bite Infective Agent Prophylaxis or Treatment of Infection
Bat, raccoon, skunk Uncertain; significant rabies risk For bacterial infection
Primary: amoxicillin with clavulanate, 875 mg/125 mg bid or
500 mg/125 mg tid
Alternative: doxycycline, 100 mg bid
Animal should be considered rabid, and patients should be
given rabies immune globulin and vaccine and consider
tetanus prophylaxis
Cat Pasteurella multocida, Primary: amoxicillin with clavulanate, 875 mg/125 mg bid
Staphylococcus aureus 500 mg/125 mg tid
Alternative: cefuroxime, 0.5 g bid; doxycycline, 100 mg
orally bid
Switch to penicillin if P. multocida is cultured from wound
Because 80% become infected, all wounds should be cul-
tured and treated empirically
Dog P. multocida, S. aureus, Primary: amoxicillin with clavulanate, 875 mg/125 mg bid
Bacteroides spp., others Alternative: clindamycin, 300 mg qid, plus a fluoro-
quinolone; or clindamycin with TMP-SMX (children)
Only 5% become infected. Treat only if bite is severe, or if
significant comorbidity such as diabetes mellitus or im-
munosuppression
Continued
4074_Ch03_047-078 20/11/14 10:35 AM Page 58
TABLE 3-7
Infectious Agents and Treatment in Bites—cont’d
Type of Bite Infective Agent Prophylaxis or Treatment of Infection
Human Streptococcus viridans, Early, not yet infected: amoxicillin with clavulanate, 875 mg/
Staphylococcus epidermidis, 125 mg bid for 5 days Later (3–24 hours, signs of infec-
Corynebacterium, Eikenella tion): parenteral therapy with ampicillin with sulbactam,
corrodens, S. aureus, cefoxitin, others
Bacteroides spp., Penicillin allergy: Clindamycin with ciprofloxacin or
Peptostreptococcus TMP-SMX
Rat Streptobacillus moniliformis, Primary: amoxicillin with clavulanate, 875 mg/125 mg bid
Spirillum minus Alternative: doxycycline
Rabies prophylaxis not indicated
Pig or swine Polymicrobial gram-positive Primary: amoxicillin with clavulanate, 875mg/125 mg bid
cocci, gram-negative bacilli, Alternative: parenteral third-generation cephalosporin,
anaerobes, Pasteurella spp. others
Nonhuman primate Herpesvirus simiae Acyclovir
Source: Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The Sanford Guide to Antimicrobial
Therapy. ed. 44th. Sperryville, VA: Antimicrobial Therapy, Inc., 2014, p. 52.
Burn Wounds 53. A burn that is about twice as large as an adult’s palmar
surface of the hand including the fingers encompasses a
49. A patient presents with a painful, blistering thermal BSA of approximately ____%.
burn involving the first, second, and third digits of his A. 1
right hand. The most appropriate plan of care is to: B. 2
A. apply an anesthetic cream to the area and open the C. 3
blisters. D. 4
B. apply silver sulfadiazine cream (Silvadene) to the 54. to 56. Match the following:
area followed by a bulky dressing.
C. refer the patient to burn specialty care. 54. First-degree A. Affected skin
D. wrap the burn loosely with a nonadherent dressing burn blanches with
and prescribe an analgesic agent. ease.
55. Second-degree
B. Surface is raw
50. Gram-negative bacteria that commonly cause burn burn
and moist.
wound infections include all of the following except: 56. Third-degree C. Affected area is
A. P. aeruginosa. burn white and
B. E. coli. leathery.
C. K. pneumoniae.
D. H. influenzae.
51. Which of the following is recommended for preventing
Answers
a burn wound infection?
49. C. 52. B. 55. B.
A. topical corticosteroid
50. D. 53. A. 56. C.
B. topical silver sulfadiazine
51. B. 54. A.
C. oral erythromycin
D. oral moxifloxacin
As with bites, burn intervention includes asking for a com-
52. You examine a patient with a red, tender thermal burn plete history of the events leading up to the injury to develop
that has excellent capillary refill involving the entire a plan for avoiding future events. In addition, education for
surface of the anterior right thigh. The estimated in- burn avoidance for high-risk individuals for burn injury, such
volved body surface area (BSA) is approximately: as children, elderly adults, and smokers, should be a routine
A. 5%. part of primary care.
B. 9%. Generally, smaller (less than 10% of body surface area),
C. 13%. minor (second-degree or lower) burns not involving a
D. 18%. high-function area such as the hand or foot and of minimal
4074_Ch03_047-078 20/11/14 10:35 AM Page 59
cosmetic consequence can be treated in the outpatient Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
setting. Gram-positive bacteria, such as Staphylococcus Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA:
aureus or coagulase-negative streptococci (CNS), can col- Antimicrobial Therapy, Inc., 2014, p. 53.
onize the burn area within 48 hours of injury unless a top- Plantz SH. http://www.emedicinehealth.com/wilderness_burns/
article_em.htm, eMedicine: Burns
ical antimicrobial is used. Eventually, colonization with
Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound
other Gram-positive (e.g., enterococci) or Gram-negative
infections. Clin Microbiol Rev. 19:403–434, 2006.
bacteria (i.e., Pseudomonas aeruginosa, Escherichia coli,
Klebsiella pneumoniae) can occur. Treatment options
include prevention of infection by the use of a topical
antibiotic such as mafenide acetate (Sulfamylon) or silver
Atopic Dermatitis
sulfadiazine (Silvadene). The use of systemic antibiotics for 57. A mother brings to the clinic her 3-year-old daughter,
prophylaxis is generally not as effective as topical agents. who presents with dry red patches on her face around
An alternative is to use petroleum gauze dressing that pro- the eyes. The mother has observed her daughter con-
vides protection to the affected area. Patients with any burn stantly rubbing the area, which has caused swelling
involving areas of high function such as the hands and feet, around the eyes. Physical examination is consistent
of significant cosmetic consequence such as the face, or any with atopic dermatitis. The NP considers that this is a
burns involving the genitalia should be referred promptly diagnosis that:
to specialty care. A. requires a skin culture to confirm contributing
First-degree and second-degree burns are characterized bacterial organisms.
by erythema, hyperemia, and pain. With first-degree burns, B. should be supported by a biopsy of the affected area.
the skin blanches with ease; skin with second-degree burns C. necessitates obtaining peripheral blood eosinophil
has blisters and a raw, moist surface. In third-degree burns, level
pain may be minimal, but the burns are usually surrounded D. Is usually made by clinical assessment alone.
by areas of painful first-degree and second-degree burns. The
surface of third-degree burns is usually white and leathery. It 58. Type I hypersensitivity reactions, such as atopic
is important to estimate the body surface area (BSA) affected dermatitis, involve the action of which antibodies
by the burn (Fig. 3–1).The palmar surface of the hand includ- binding to receptor sites on mast cells?
ing the fingers represents a BSA of 1% throughout the life A. IgG
span and can provide a helpful guide in estimating the extent B. IgM
of a burn. C. IgE
D. IgA
DI SCUSSION SOURCES
59. During type I hypersensitivity reactions, histamine re-
James, WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: leased from degraded mast cells causes all of the follow-
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
ing except:
pp. 18–19.
A. vasodilation.
B. mucous gland stimulation.
4.5% 4.5%
C. enhanced sebum production.
D. tissue swelling.
60. The most important aspect of skin care for individuals
with atopic dermatitis is:
18% 18% A. frequent bathing with antibacterial soap.
4.5% 4.5% 4.5% 4.5%
B. consistent use of medium-potency to high-potency
topical steroids.
C. application of lubricants.
1%
D. treatment of dermatophytes.
9% 9% 9% 9%
61. One of the most common trigger agents for contact
dermatitis is:
A. exposure to nickel.
B. use of fabric softener.
C. bathing with liquid body wash.
D. eating spicy foods.
Anterior Posterior
Figure 3-1 Rule of nines for calculating total burn surface 62. A common site for atopic dermatitis in an adult is on the:
area. (Source: Adapted from Richard R, Staley M. Burn Care A. dorsum of the hand.
and Rehabilitation. Philadelphia: F.A. Davis, 1994, p. 109. B. face.
Wedro, BC. http://www.emedicinehealth.com/burn_ C. neck.
percentage_in_adults_rule_of_nines/article_em.htm D. flexor surfaces.
4074_Ch03_047-078 20/11/14 10:35 AM Page 60
63. A common site for atopic dermatitis in an infant is: The atopy subgroup includes many common clinical con-
A. the diaper area. ditions, such as allergic rhinitis, atopic dermatitis, allergic
B. the face. gastroenteropathy, and allergy-based asthma. Atopic diseases
C. the neck. have a strong familial component and tend to cause localized
D. the posterior trunk. rather than systemic reactions. Individuals with atopic disease
are often able to identify allergy-inducing agents. Allergic
64. In counseling a patient with atopic dermatitis, you
contact dermatitis is a form of eczematous dermatitis. Com-
suggest all of the following can be used to alleviate
mon causes of contact dermatitis include exposure to metals
symptoms of a flare except:
including nickel, rubber additives to shoes and gloves, some
A. the use of oral antihistamines.
toiletries, and topical medications.
B. applying a heating pad on the affected region for
A key symptom of atopic dermatitis is pruritus (itching).
30 minutes.
The disease typically has an intermittent course with flares
C. the use of topical corticosteroids.
and remissions occurring. The primary physical findings
D. applying cool, wet dressings made from a clean
include xerosis (dry skin), lichenification, and eczematous
cloth and water to the affected area.
lesions. The eczematous changes and morphology can occur
65. The mechanism of action of pimecrolimus (Elidel) in at various body sites and will depend on the age of the patient
the treatment of atopic dermatitis is as a/an: (i.e., infant, child, or adult).
A. immunomodulator. Criteria for the diagnosis of atopic dermatitis include
B. antimitotic. the presence of itching and subsequent scratching plus
C. mast cell activator. three or more of the following: red or inflamed rash, pres-
D. exfoliant. ence of excessive dryness/scaling, and location in skin folds
of arms or legs. With severe outbreaks, vesicles are often
66. When counseling a patient about the use of tacrolimus
present. Additional findings include early age at initial
(Protopic) or pimecrolimus (Elidel), you mention that:
onset (0 to 5 years) and elevated serum IgE and peripheral
A. this is the preferred atopic dermatitis treatment in
blood eosinophil levels. In infants, the face is often in-
infants.
volved, whereas the diaper area, owing to the occlusive,
B. there is a possibility of increased cancer risk with
damp environment, is usually spared. The diagnosis of
its use.
atopic dermatitis is usually made by clinical assessment
C. the product is used interchangeably with topical
without the need for confirmatory testing.
corticosteroids.
Treatment for atopic dermatitis includes avoiding of-
D. the product is a potent antihistamine.
fending agents, minimizing skin dryness by limiting soap
67. You see a 34-year-old man with atopic dermatitis local- and water exposure, and using lubricants consistently. In
ized primarily on the arms who complains of severe general, the patient should be encouraged to treat the skin
itching. The condition becomes worse at night and with care because it tends to be sensitive; the person with
interferes with his sleep. You recommend: atopic dermatitis has an abnormal skin barrier that allows
A. taking a bedtime dose of antihistamine. for loss of water and resulting dryness. When flares occur,
B. taking a bedtime dose of acetaminophen. the skin eruption is caused largely by histamine release. An-
C. taking a hot shower prior to bedtime. tihistamines, topical and systemic corticosteroids, or both
D. applying a warm compress to the affected areas are typically used to control flares. Cool, wet dressings made
30 minutes prior to bedtime. from a clean cloth with cool water or Burow’s solution
(Domeboro), a liquid preparation containing aluminum
sulfate, acetic acid, precipitated calcium carbonate, and
Answers water, can be applied to the affected area for 30 minutes to
provide significant symptom relief; application of an inter-
57. D. 61. A. 65. A. mediate-potency topical corticosteroid is usually needed to
58. C. 62. D. 66. B. control acute symptoms. After control of acute symptoms
59. C. 63. B. 67. A. is achieved, the topical corticosteroid of lowest potency that
60. C. 64. B. yields the desired effect should be used (see Table 3–3).
Pimecrolimus (Elidel) and tacrolimus (Protopic) are im-
Atopic dermatitis, or eczema, is one manifestation of a type I munomodulators that are helpful in the treatment of atopic
hypersensitivity reaction. This type of reaction results from dermatitis and offer an additional, noncorticosteroid option
immunoglobulin E (IgE) antibodies occupying receptor sites for atopic dermatitis. These products block T-cell stimulation
on mast cells. This causes a degradation of the mast cell and by antigen-presenting cells and inhibit mast cell activation.
subsequent release of histamine, resulting in vasodilation, Because of information from animal studies, case reports in
mucous gland stimulation, and tissue swelling. Type I hyper- a small number of patients, and knowledge of how drugs in
sensitivity reactions are usually divided into two subgroups: this class work, an advisory about the potential for increased
atopy and anaphylaxis. cancer risk with the use of these products has been released.
4074_Ch03_047-078 20/11/14 10:35 AM Page 61
Tacrolimus and pimecrolimus should be used only as labeled 72. When caring for an adult with an outbreak of shingles,
and only if other prescription and supportive treatments have you advise that:
failed to work or cannot be tolerated. These products should A. there is no known treatment for this condition.
not be used in children younger than age 2 years. B. during outbreaks, the chickenpox (varicella) virus is
Itch (pruritus) is a distressing symptom; many patients say shed.
it is more bothersome than pain. Pruritus is a cardinal symp- C. although they are acutely painful, the lesions heal
tom of many forms of dermatitis. Histamine contributes to well without scarring or lingering discomfort.
the development of itching; the use of an antihistamine can D. this condition commonly strikes young and old
provide relief. Pruritus tends to be worst at night, often caus- alike.
ing disturbance in sleep. In particular, providing the patient
73. Analgesia options for a patient with shingles can in-
with a bedtime dose of antihistamine can yield tremendous
clude all of the following except:
relief from itching and improve sleep. Hydroxyzine (Atarax)
A. topical lidocaine gel 5% with oral acetaminophen.
seems to provide better relief of itching than other antihista-
B. Burow’s solution with a high-potency oral NSAID.
mines. Cetirizine (Zyrtec) is a less sedating antihistamine that
C. Burow’s solution with an oral opioid.
is a metabolite of hydroxyzine.
D. fentanyl transdermal patch and a topical medium-
DI SCUSSION SOURCES potency corticosteroid on the affected area.
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin: 74. Risk factors for the development of postherpetic neu-
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011, ralgia include:
pp. 62–69. A. age younger than 50 years at the time of the outbreak.
Chamlin S. Atopic dermatitis. In: Rakel R, Bope E, eds. Conn’s Cur- B. severe prodromal symptoms.
rent Therapy 2013. Philadelphia: Saunders, 2012, pp. 207–210.
C. lumbar location of lesions.
Robertson D, Mailbach H. Dermatologic pharmacology. In:
Katzung, B, Katzung’s Basic and Clinical Pharmacology, ed. 12.
D. low volume of lesions.
New York: McGraw-Hill Medical, 2012, 991–1008. 75. Treatment options in postherpetic neuralgia include all
of the following except:
A. injectable methylprednisolone.
Herpes Zoster B. oral pregabalin.
C. oral nortriptyline.
68. A 38-year-old woman with advanced human immun- D. topical lidocaine.
odeficiency virus (HIV) disease presents with a chief
76. The zoster vaccine (Zostavax) is a(n):
complaint of a painful, itchy rash over her trunk. Exam-
A. inactivated/killed virus vaccine.
ination reveals linear vesicular lesions that do not cross
B. conjugate vaccine containing a virus-like particle
the midline and are distributed over the posterior
(VLP).
thorax. This presentation is most consistent with:
C. live, attenuated vaccine.
A. herpes zoster.
D. inactivated toxin vaccine.
B. dermatitis herpetiformis.
C. molluscum contagiosum.
D. impetigo.
Answers
69.A Tzanck smear that is positive for giant multinucleated
cells was taken from a lesion caused by: 68. A. 71. D. 74. B.
A. herpesvirus. 69. A. 72. B. 75. A.
B. S. aureus. 70. C. 73. D. 76. C.
C. streptococci.
D. allergic reaction. Herpes zoster infection, commonly known as shingles, is
an acutely painful condition caused by the varicella-zoster
70. What is the most effective protection against shingles?
virus, the same agent that causes chickenpox. The virus lies
A. previous episode of chickenpox as a child
dormant in the dorsal root ganglia of a dermatome. When
B. prior episode of shingles
activated, the characteristic blistering lesions occur along a
C. receipt of varicella-zoster immunization
dermatome, usually not crossing the midline. The resulting
D. avoiding children and daycare centers
pain is burning, throbbing, or stabbing; intense itch is also
71. Shingles most commonly involve the dermatomes occasionally described. The thoracic dermatomes are the
of the: most commonly involved sites, followed by the lumbar
A. legs and pubic area. dermatomes.
B. face. Anyone who has had chickenpox is at risk for shingles,
C. upper arms and shoulders. whereas recipients of varicella-zoster immunization have vir-
D. thorax. tually no risk. Shingles is usually seen in elderly individuals,
4074_Ch03_047-078 20/11/14 10:35 AM Page 62
patients who are immunocompromised, and individuals with even with a history of shingles. The clinician should check
some other underlying health problem. When shingles is seen for the latest recommendations on candidates for the zoster
in younger adults, the possibility of HIV infection or other vaccine.
immunocompromised condition should be considered.
During the acute attack, the chickenpox (varicella-zoster) D I S C U SSI O N S O U R C E S
virus is shed; patients can transmit this infection. Shingles is James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin:
not communicable from person to person, however. Approx- Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
imately 4% of patients with zoster develop a recurrent episode pp. 372–376.
later in life. Krause R. http://www.emedicine.com/emerg/TOPIC823.HTM,
Diagnosis of shingles is usually straightforward because of eMedicine: Herpes zoster
its characteristic lesions. If confirmation is needed, a Tzanck McElveen WA, Gonzalez R, Sinclair D. http://www.emedicine.com/
smear reveals giant multinucleated cells, a finding in all neuro/TOPIC317.HTM, eMedicine: Postherpetic neuralgia
herpetic infections.
Scarring and postherpetic neuralgia are problematic se-
quelae of shingles. Initiating antiviral therapy with high-dose Onychomycosis
acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir
(Famvir), preferably within the first 72 hours of herpes zoster 77. Characteristics of onychomycosis include all of the
outbreak, helps limit the severity of the lesions and minimize following except:
the risk of postherpetic neuralgia and scarring. Systemic cor- A. it is readily diagnosed by clinical examination.
ticosteroids are often prescribed during the acute stage of B. nail hypertrophy.
shingles along with antivirals. This combination therapy C. brittle nails.
usually results in more rapid resolution of pain but not of D. fingernails respond more readily to therapy than
zoster lesions. toenails.
Adequate analgesia should be offered to a person with
78. Oral antifungal treatment options for onychomycosis
shingles. Using topical agents such as topical lidocaine
include all of the following except:
gel 5%, Burow’s solution with a high-potency nonsteroidal
A. itraconazole.
antiinflammatory drug or opioid, or combination of these
B. fluconazole.
helps provide considerable relief. The patient should also be
C. metronidazole.
monitored for superinfection of lesions. Because of the risk
D. terbinafine.
of complication and possible compromise of vision, expert
consultation should be sought if herpes zoster involves a 79. When prescribing itraconazole (Sporanox), the NP
facial or ocular dermatome. The rash usually resolves within considers that:
14 to 21 days. A. the drug is a cytochrome P-450 3A4 inhibitor.
Postherpetic neuralgia is defined as pain persisting at B. one pulse cycle is recommended for fingernail
least 1 month after the rash has healed. Risk factors for the treatment, and two cycles are needed for toenail
development of postherpetic neuralgia include the site of therapy.
initial involvement, with greatest risk if outbreak involved C. continuous therapy is preferred in the presence of
the trigeminal or brachial plexus region; moderate risk with hepatic disease.
a thoracic outbreak; and lower risk with jaw, neck, sacral, D. taking the drug on an empty stomach enhances the
and lumbar involvement. Additional risks include severe efficacy of the product.
rash and intense prodromal pain. The incidence increases
80. When prescribing pulse dosing with itraconazole
dramatically with age, with only 4% of adults 30 to 50 years
for the treatment of fingernail fungus, the clinician
old reporting postherpetic neuralgia and approximately
realizes that:
50% of adults older than 80 years reporting it. Tricyclic an-
A. a transient increase in hepatic enzymes is commonly
tidepressants (e.g., amitriptyline, nortriptyline), gabapentin
seen with its use.
(Neurontin), pregabalin (Lyrica), and topical lidocaine
B. drug-induced leukopenia is a common problem.
patches are effective and are often used in the treatment of
C. the patient needs to be warned about excessive
postherpetic neuralgia.
bleeding because of the drug’s antiplatelet effect.
Zoster vaccine (Zostavax) is an immunization for pro-
D. its use is contraindicated in the presence of iron-
tection against herpes zoster (or shingles). The vaccine is
deficiency anemia.
prepared from a live, attenuated strain of varicella-zoster
virus. Zostavax is designed to yield a more potent, higher 81. When prescribing fluconazole, the NP considers that it
titer than varicella virus live vaccine (Varivax), used in chil- is a cytochrome P-450:
dren for chickenpox. Because reactivation of the varicella A. 3A4 inhibitor.
virus appears to be related to a decline in varicella-zoster B. 2CP inhibitor.
virus-specific immunity, the use of zoster vaccine signifi- C. 2D6 inducer.
cantly reduces shingles risk. This vaccine should be used D. 1A2 inducer.
4074_Ch03_047-078 20/11/14 10:35 AM Page 63
82. In diagnosing onychomycosis, the NP considers that: Topical treatment has proved to be of little value because
A. nails often have a single midline groove. the antifungal agent is held within the nail matrix. Oral agents
B. pitting is often seen. such as griseofulvin require months of therapy with a high
C. microscopic examination reveals hyphae. rate of relapse. Topical over-the-counter creams and medica-
D. Beau lines are present. tions, such as Vicks VapoRub, thymol oil, and tree tea oil,
are usually not effective as the nails are too thick and hard for
83. In counseling a patient on the use of topical products to external applications to penetrate to the site of infection.
treat nail fungal infections, the NP considers that: Antifungal nail lacquers, consist of an antifungal agent
A. nail lacquers, such as ciclopirox olamine 8% solu- (e.g., ciclopirox or amorolfine) in a clear, stable, film-forming
tion (Penlac), offer similar effectiveness to oral lacquer vehicle. When applied to the nails, these products
antifungals. provide a hard, clear, water-resistant film containing the
B. some herbal products, such as tea tree oil, can be an antifungal agent. However, the effectiveness of these products
effective alternative to oral agents. in treating nail fungal infections is limited and typically
C. topical products have limited penetration through poorer than oral antifungal agents.
the nail matrix to reach the site of infection.
D. cream-based products are more effective than gel- D I S C U SSI O N S O U R C E S
based products in treating nail fungal infections. James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin:
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
pp. 295–296.
Answers Blumberg M. http://www.emedicine.com/derm/topic300.htm,
eMedicine: Onychomycosis
77. A. 80. A. 83. C. Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
78. C. 81. B. Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA:
79. A. 82. C. Antimicrobial Therapy, Inc., 2014, pp. 123–124.
Robertson D, Mailbach H. Dermatologic pharmacology. In:
Onychomycosis, or dermatophytosis of the nail, is a chronic Katzung B. Katzung’s Basic and Clinical Pharmacology. ed. 12.
disfiguring disorder. The nails are dull, thickened, and lus- New York: McGraw-Hill Medical, 2012, pp. 991–1008.
terless with a pithy consistency. Parts of the nail often break
off. Because trauma and other conditions can cause a simi-
lar appearance, confirmation of the diagnosis with micro- Scabies
scopic examination for hyphae of the nail scrapings mixed
with potassium hydroxide (KOH) is important, although 84. A 78-year-old resident of a long-term care facility com-
it has a high rate of false-negative results. Fungal cultures plains of generalized itchiness at night that disturbs her
should be obtained from pulverized nail scrapings or sleep. Her examination is consistent with scabies. Which
clippings. of the following do you expect to find on examination?
Antifungals such as itraconazole (Sporanox), terbinafine A. excoriated papules on the interdigital area
(Lamisil), and fluconazole (Diflucan) offer well-tolerated ef- B. annular lesions over the buttocks
fective treatment for fingernail and toenail fungal infections. C. vesicular lesions in a linear pattern
These medications can be used in pulse cycles, with times of D. honey-colored crusted lesions that began as vesicles
drug use alternating with abstinent periods. An example of
85. In counseling a patient with scabies, the NP recom-
pulse dosing is itraconazole, 400 mg daily, for the first week
mends all of the following methods to eliminate the
of the month for 2 months to treat the fingernails and for
mite from bedclothes and other items except:
3 months to treat the toenails. The products are held within
A. wash items in hot water.
the nail matrix for months after therapy; this produces effec-
B. run items through the clothes dryer for a normal cycle.
tive treatment at a considerably reduced cost compared with
C. soak items in cold water for at least 1 hour.
constant therapy. In addition, all oral antifungals have hepa-
D. place items in a plastic storage bag for at least 1 week.
totoxic potential and may cause an increase in hepatic enzyme
levels. Pulse therapy reduces this risk considerably, however. 86. Which of the following represents the most accurate
Caution is needed when itraconazole is prescribed because patient information when using permethrin (Elimite)
it inhibits cytochrome P-450 3A4, a pathway also used by for treating scabies?
drugs such as diazepam, digoxin, anticoagulants, and certain A. To avoid systemic absorption, the medication should
HIV protease inhibitors. In addition, fluconazole is a cy- be applied over the body and rinsed off within 1 hour.
tochrome P-450 2CP inhibitor, a pathway also used by drugs B. The patient should notice a marked reduction in
such as carbamazepine, some benzodiazepines, and calcium pruritus within 48 hours of using the product.
channel blockers. The concomitant use of these antifungals C. Itch often persists for a few weeks after successful
with the aforementioned medications can lead to significant treatment.
drug interactions. Terbinafine has significantly less drug in- D. It is a second-line product in the treatment of
teraction potential. scabies.
4074_Ch03_047-078 20/11/14 10:35 AM Page 64
87. When advising the patient about scabies contagion, in infection. Bedclothes and other items used by a person with
you inform her that: scabies must be either washed in hot water or placed in the
A. mites can live for many weeks away from the host. clothes dryer for a normal cycle. Alternatively, items can be
B. close personal contact with an infected person is placed in plastic storage bags for at least 1 week because mites
usually needed to contract this disease. do not survive for more than 3 to 4 days without contact with
C. casual contact with an infected person is likely to the host. The mites tend to burrow in areas of warmth, such
result in infestation. as the finger webs, axillary folds, belt line, areolae, scrotum,
D. bedding used by an infected person must be destroyed. penis, under the breasts, with lesions developing and cluster-
ing in these areas. The lesions often start with the characteristic
88. The use of lindane (Kwell) to treat scabies is discouraged
burrows but in most cases progress to a vesicular or papular
because of its potential for:
form, usually with excoriation caused by scratching.
A. hepatotoxicity.
Permethrin (Elimite) lotion is the preferred method of
B. neurotoxicity.
treatment for scabies. The lotion must be left on for 8 to
C. nephrotoxicity.
14 hours to be effective. Despite effective therapy, individuals
D. pancreatitis.
with scabies often have a significant problem with pruritus
after permethrin treatment because of the presence of dead
mites and their waste trapped in the skin, which causes an in-
Answers flammatory reaction. This debris is eliminated from the body
over a few weeks; the distress of itchiness passes at that time.
84. A. 86. C. 88. B. Oral antihistamines, particularly for nighttime use, and low-
85. C. 87. B. potency to medium-potency topical corticosteroids should be
offered to help with this problem (Table 3–8). In the past, lin-
Scabies is a communicable skin disease caused by a host- dane (Kwell) was used, but the use of this product presents
specific mite, generally requiring close personal, skin-to-skin potential problems with neurotoxicity and a resulting seizure
contact to achieve contagion. Contact with used, unwashed risk and lower efficacy. In particular, lindane should not be
bedding and clothing from an affected person also can result used by pregnant women, children, and elderly patients.
TABLE 3-8
Medications Used in the Treatment of Acute IgE-Mediated Hypersensitivity Reaction
Medications Mechanism of Action Comments
Antihistamines Antagonize H1-receptor In acute reaction, give parenterally or in a quickly absorbed oral form
sites. Prevent action of such as chewable tablet or liquid
formed histamine, so First-generation products (diphenhydramine [Benadryl], chlorpheni-
helpful in treatment of ramine [Chlor-Trimeton])
acute allergic reaction • Cross blood-brain barrier, causing sedation
• Anticholinergic activity can cause blurred vision, dry mucous
membranes
Second-generation products (loratadine [Claritin], cetirizine [Zyrtec],
fexofenadine [Allegra])
• Little transfer across blood-brain barrier. Low rates of sedation
• Less anticholinergic effect
Epinephrine Alpha-1, beta-1, beta-2 • Initial therapy for anaphylaxis because of its multiple modes of
parenterally, agonists. Potent vaso- reversing airway and circulatory dysfunction
usually given constrictor, cardiac stim- • Anaphylaxis usually responds quickly to epinephrine given
IM (preferred) ulant, bronchodilator parenterally
or SC
Oral Inhibit eosinophilic action • In higher dose and with longer therapy (>2 weeks), adrenal
corticosteroids and other inflammatory suppression can occur
mediators • Taper usually not needed if use is short-term (<10 days) and at lower
dose (prednisone, 40–60 mg/day)
• Potential for causing gastropathy
Source: http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/anaphylaxis.aspx
4074_Ch03_047-078 20/11/14 10:35 AM Page 65
DI SCUSSION SOURCES 96. For severe, recalcitrant psoriasis that affects more than
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the 30% of the body, all of the following treatments are
Skin: Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011, recommended except:
pp. 442–444. A. methotrexate.
Gunning K, Pippitt K, Kiraly B, et al. Pediculosis and scabies: treat- B. topical anthralin (Drithocreme).
ment update. Am Fam Physician, 86(86):535–541, 2012. C. tumor necrosis factor (TNF) modulators.
Cordoro KM, Elston DM. http://emedicine.medscape.com/article/ D. cyclosporine.
1109204-overview#showall, Dermatologic manifestations of
scabies 97. The use of TNF modulators for the treatment of psoriasis
is associated with an increased risk for:
A. gastrointestinal disorders.
Psoriasis Vulgaris B. nephrotoxicity.
C. QTc prolongation.
89. Psoriasis vulgaris is a chronic skin disease caused by: D. reactivation of latent tuberculosis.
A. bacterial colonization.
B. absence of melanin.
C. accelerated mitosis. Answers
D. type I hypersensitivity reaction.
89. C. 92. A. 95. C.
90. You examine a patient with psoriasis vulgaris and ex- 90. B. 93. D. 96. B.
pect to find the following lesions: 91. B. 94. A. 97. D.
A. lichenified areas in flexor areas
B. well-demarcated plaques on the knees
Psoriasis vulgaris is a chronic skin disorder caused by
C. greasy lesions throughout the scalp
accelerated mitosis and rapid cell turnover, which lead to
D. vesicular lesions over the upper thorax
decreased maturation and keratinization. This process pre-
91. Psoriatic lesions arise from: vents the dermal cells from “sticking” together, allowing for
A. decreased skin exfoliation. a shedding of cells in the form of characteristic silvery scales
B. rapid skin cell turnover, leading to decreased matu- and leaving an underlying red plaque. Psoriasis is typically
ration and keratinization. found in extensor surfaces; the lesions are most often found
C. inflammatory changes in the dermis. in plaques over the elbows and knees. The scalp and other
D. lichenification. surfaces are occasionally involved.
Topical corticosteroids have antiinflammatory and mild
92. Anthralin (Drithocreme) is helpful in treating psoriasis
antimitotic activity, which allows for regression of psoriatic
because it has what kind of activity?
plaques. A common treatment plan is to use a medium-
A. antimitotic
potency to high-potency drug for short periods until the
B. exfoliative
plaques resolve and then to use a lower potency product three
C. vasoconstrictor
to four times a week to maintain remission. As with all der-
D. humectant
matoses, consistent use of high-potency topical steroids is
93. Treatment options in generalized psoriasis vulgaris in- discouraged because of potential risk of skin atrophy, telang-
clude all of the following except: iectasia formation, corticosteroid-induced acne, and striae.
A. psoralen with ultraviolet A light (PUVA) therapy. In addition, the extensive use of topical corticosteroids leads
B. methotrexate. to significant systemic absorption and potential subclinical
C. cyclosporine. adrenal function suppression. Tar preparations can be help-
D. systemic corticosteroids. ful, but these products have a low level of patient acceptance
because of the messiness and odor associated with these
94. Which of the following is not a potential adverse effect
preparations.
with long-term high-potency topical corticosteroid use?
Additional treatment options include use of anthralin
A. lichenification
(Drithocreme), a topical antimitotic, and calcipotriene, a top-
B. telangiectasia
ical vitamin D3 derivative. Although offering effective psori-
C. skin atrophy
asis therapy, these products are significantly more expensive
D. adrenal suppression
than topical corticosteroids and tars. Use should be reserved
95. Biological agents to treat psoriasis, such as infliximab for corticosteroid-resistant conditions.
and etanercept, work by blocking the action of: If psoriasis is generalized, covering more than 30% of
A. IL-9. body surface area, treatment with topical products is diffi-
B. CD4. cult and expensive. Ultraviolet A light exposure three times
C. TNF-␣ weekly is highly effective but is associated with an increase
D. IgG. in skin cancer risk and photoaging. For severe, recalcitrant
4074_Ch03_047-078 20/11/14 10:35 AM Page 66
psoriasis, cyclosporine, methotrexate, systemic retinoids, 101. In counseling a patient with seborrheic dermatitis
and newer biological agents such as tumor necrosis factor on the scalp about efforts to clear lesions, you advise
(TNF) modulators etanercept (Enbrel), adalimumab her to:
(Humira), or ustekinumab (Stelara) are also used. TNF-␣ A. use ketoconazole shampoo.
is a proinflammatory cytokine that amplifies inflammation B. apply petroleum jelly nightly to the affected area.
through various pathways and has been implicated in pso- C. coat the area with high-potency corticosteroid
riasis pathogenesis. TNF-␣ antagonists bind to the cytokine cream three times a week.
and block its proinflammatory action. Although these bio- D. expose the lesions periodically to heat by carefully
logic agents can be effective in treating psoriasis, they are using a hair dryer.
associated with significant adverse effects, including injec-
102. A 64-year-old man with seborrhea mentions that his
tion site and infusion reactions, infection, and reactivation
skin condition is “better in the summer when I get
of latent tuberculosis. The risk of infection is highest in
outside more and much worse in the winter.” You
patients with predisposing conditions, such as diabetes,
respond:
heart failure, or concomitant use of immunosuppressive
A. Sun exposure is a recommended therapy for the
drugs. Referral to a clinician with expertise in prescribing
treatment of this condition.
these agents is indicated.
B. Although sun exposure is noted to improve the
skin lesions associated with seborrhea, its use as a
DI SCUS SION SOURCES
therapy is potentially associated with an increased
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin: rate of skin cancer.
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011, C. The lower humidity in the summer months noted
pp. 190–198.
in many areas of North America contributes to the
Meffert J, O’Connor RE. http://emedicine.medscape.com/article/
1943419-overview, accessed 7/20/13.
improvement in seborrheic lesions.
Robertson D, Mailbach H. Dermatologic pharmacology. In: D. Use high-potency topical corticosteroids during
Katzung, B, Katzung’s Basic and Clinical Pharmacology, ed.12. the winter months, tapering these off for the
New York: McGraw-Hill Medical, 2012, pp. 991–1008. summer months.
Taheri A, Feldman SR. Biologics in practice: How effective are
103. You see a 67-year-old man with seborrheic dermatitis
biologics? The Dermatologist, November:34–37, 2012.
Weger W. Current status and new developments in the treatment
that has failed to respond to treatment with ketocona-
of psoriasis and psoriatic arthritis with biological agents. Br J zole shampoo. An appropriate second-line treatment
Pharmacol. 160:810–820, 2010. option can include all of the following except:
A. oral fluconazole.
B. a topical immune modulator.
C. topical propylene glycol.
Seborrheic D. high-potency topical corticosteroid.
Dermatitis
98. Seborrheic dermatitis is likely caused by: Answers
A. accelerated mitosis of skin cells.
B. colonization of skin by Staphylococcus aureus. 98. C. 100. D. 102. B.
C. an inflammatory reaction to Malassezia species 99. B. 101. A. 103. D.
on skin.
D. exposure to excessive UV radiation. Seborrheic dermatitis is a chronic, recurrent skin condition
found in areas with a high concentration of sebaceous glands,
99. Which of the following best describes seborrheic
such as the scalp, eyelid margins, nasolabial folds, ears, and
dermatitis lesions?
upper trunk. Numerous theories are proposed for its cause.
A. flaking lesions in the antecubital and popliteal spaces
Because of the lesions’ response to antifungal agents, the
B. greasy, scaling lesions in the nasolabial folds
backbone of therapy for the condition, seborrheic dermati-
C. intensely itchy lesions in the groin folds
tis is most likely caused by an inflammatory reaction to
D. silvery lesions on the elbows and knees
Malassezia species (formerly Pityrosporum species), a yeast
100. Among the following, who is at greatest risk of devel- form present on the scalp of all humans. Further supporting
oping seborrheic dermatitis? this hypothesis is the fact that seborrhea is often found in
A. a 15-year-old boy residing in a rural setting patients who are immunocompromised or chronically ill
B. a 34-year-old woman who smokes 2 packs per day (e.g., elderly adults and people with Parkinson disease).
(PPD) Malassezia organisms are likely a cofactor linked to T-cell
C. a 48-year-old male truck driver depression, increased sebum levels, and an activation of the
D. a 72-year-old man with Parkinson disease alternative complement pathway.
4074_Ch03_047-078 20/11/14 10:35 AM Page 67
Skin lesions associated with seborrhea usually respond to 108. When examining a mole for malignant melanoma, all
topical antifungals such as ketoconazole. Class IV or lower of the following characteristics can indicate a
corticosteroid creams, lotions, or solutions are also helpful melanoma except:
during a flare (see Table 3–3); topical immune modulators A. asymmetry with nonmatching sides.
such as pimecrolimus and tacrolimus, sulfur or sulfonamide B. color is not uniform.
combinations, and propylene glycol offer additional treat- C. a recently formed lesion.
ment options. The use of lubricants such as petroleum jelly D. a lesion that has been present for at least 2 years.
can help remove stubborn lesions so that the lesions can be
109. The most common sites for squamous and basal cell
exposed to antifungal therapy (e.g., selenium sulfide or
carcinoma include:
ketoconazole shampoo). Systemic ketoconazole or flucona-
A. palms of hands and soles of feet.
zole is occasionally used if seborrheic dermatitis is severe or
B. pelvic and lumbar regions.
unresponsive.
C. the abdomen.
As with any skin condition, high-potency topical corticos-
D. the face and scalp.
teroid use is discouraged because of the risk of subcutaneous
atrophy, telangiectatic vessels, and other problems. Although 110. A 56-year-old truck driver presents with a new
seborrhea usually worsens in the winter and improves in the nodular, opaque lesion with nondistinct borders on
summer, exposing lesions to sunlight is not recommended his left forearm. This most likely represents a(n):
because of the potential increase in skin cancer risk and A. actinic keratosis.
photoaging. B. squamous cell carcinoma.
C. basal cell carcinoma.
DI SCUSSION SOURCES
D. malignant melanoma.
Selden S. http://emedicine.medscape.com/article/1108312-overview#
showall, Seborrheic dermatitis 111. Risk factors for malignant melanoma include:
Schmidt, JA. Seborrheic dermatitis: A clinical practice snapshot. A. Asian ancestry.
Nurse Pract (8):36, 32–37, 2011. B. history of blistering sunburn.
C. family history of psoriasis vulgaris.
D. presence of atopic dermatitis.
Skin Cancer
112. Definitive diagnosis of skin cancer requires:
104. A 49-year-old man presents with a skin lesion suspi- A. skin examination.
cious for malignant melanoma. You describe the B. CT scan.
lesion as having: C. biopsy.
A. deep black–brown coloring throughout. D. serum antigen testing.
B. sharp borders.
113. Nonsurgical options for the treatment of squamous
C. a diameter of 3 mm or less.
and basal cell carcinoma include all of the following
D. variable pigmentation.
except:
105. The use of sunscreen has minimal impact on reducing A. cryotherapy.
the risk of which type of skin cancer? B. electrodissection with curettage.
A. squamous cell carcinoma C. topical cancer chemotherapy.
B. basal cell carcinoma D. oral hydroxyurea.
C. malignant melanoma
114. A skin biopsy results indicate the presence of malignant
D. all forms of skin cancer
melanoma for a 53-year-old woman. You recommend:
106. A 72-year-old woman presents with a newly formed, A. excision of the entire lesion.
painless, pearly, ulcerated nodule with an overlying B. electrodissection with curettage.
telangiectasis on the upper lip. This most likely C. initiating treatment with topical cancer
represents: chemotherapy.
A. an actinic keratosis. D. consultation with a skin cancer expert to direct
B. a basal cell carcinoma. next best action.
C. a squamous cell carcinoma.
115. Skin lesions associated with actinic keratoses can be
D. molluscum contagiosum.
described as:
107. Which of the following represents the most effective A. a slightly rough, pink or flesh-colored lesion in a
method of cancer screening? sun-exposed area.
A. skin examination B. a well-defined, slightly raised, red, scaly plaque in a
B. stool for occult blood skinfold.
C. pelvic examination C. a blistering lesion along a dermatome.
D. chest radiography D. a crusting lesion along flexor aspects of the fingers.
4074_Ch03_047-078 20/11/14 10:35 AM Page 68
116. Treatment options for actinic keratoses include Compared with BCC, squamous cell carcinoma (SCC)
topical: tends to grow more rapidly and has a low but significant
A. vitamin D derivative cream. metastatic risk. Although difficult to distinguish from BCC
B. 5-fluorouracil. by skin examination alone, the mnemonic “NO SUN” can
C. acyclovir. help with the identification of early SCC lesions:
D. doxepin. N = nodular
O = opaque
117. Recommended nonpharmacological options to treat
S = sun-exposed areas
actinic keratosis include all of the following except:
U = ulcerating
A. chemical peel.
N = nondistinct borders
B. cryotherapy.
Later lesions may also include scale and firm margins.
C. laser resurfacing.
Although the aforementioned mnemonics are helpful in
D. Mohs micrographic surgery.
identifying these lesions, diagnosis of cutaneous malignancy
requires a biopsy. Intervention depends on biopsy results and
final diagnosis. Therapy is usually surgical, involving removal
Answers of the lesion with a reasonable “clean” or disease-free margin.
Mohs micrographic surgery is recommended in the presence
104. D. 109. D. 114. D. of skin tumors with aggressive histologic patterns or invasive
105. C. 110. B. 115. A. features. Nonsurgical options in BCC and SCC include de-
106. B. 111. B. 116. B. struction of the lesion with cryotherapy, electrodesiccation
107. A. 112. C. 117. D. with curettage, focal radiation, and topical cancer chemother-
108. D. 113. D. apy. Intervention in malignant melanoma is based on addi-
tional factors including staging and sentinel node biopsy
As with any area of dermatology, accurate diagnosis of a con- results; this requires expert opinion consultation.
dition depends on knowledge of the description of the lesion Actinic keratoses are UV-induced skin lesions that can
and its most likely site of occurrence. The most potent risk evolve into squamous cell carcinoma. Actinic keratoses begin
factor for any skin cancer is sun exposure; patients should be as small rough spots that are easier felt than seen; the lesions
instructed on sun avoidance. The consistent use of high–sun are often best identified by rubbing the examining finger over
protection factor (SPF) sunscreen is critical and helps reduce, the affected area and appreciating the sandpaper-like quality.
but not eliminate, the risk of squamous or basal cell carci- Over time, the lesions enlarge, typically 3 to 10 mm in diam-
noma. Sunscreen use likely does little to minimize malignant eter, and usually become scaly and red, although color can
melanoma risk. vary. Treatment of actinic keratoses, also known as solar ker-
Skin examination has the benefit of enabling the examiner atoses, includes cryotherapy with liquid nitrogen. This causes
to detect premalignant lesions (e.g., actinic keratoses and destruction of the lesions with resulting crust for about
other precursor lesions to squamous cell carcinoma including 2 weeks, revealing healed tissue and usually an excellent cos-
keratoacanthoma) and malignant lesions. metic outcome. Alternatives include the use of 1% to 5% flu-
Malignant melanoma is a malignancy that arises from orouracil creams once a day for 2 to 3 weeks until the lesions
melanocytes, cells that make the pigment melanin, and is the become crusted over. As another alternative, 5% fluorouracil
most common fatal dermatologic malignancy. “ABCDE” is a cream can be used once a day for 1 to 2 days weekly for 7 to
mnemonic for assessing malignant melanoma: 10 weeks. This regimen yields a similar therapeutic outcome
A = asymmetric with nonmatching sides without crusting or discomfort. Additional options include
B = borders are irregular 5% imiquimod cream, topical diclofenac gel, and photody-
C = color is not uniform; brown, black, red, white, blue namic therapy (PDT) with topical delta-aminolevulinic acid.
D = diameter usually larger than 6 mm, or the size of a Resurfacing with chemical peels and laser are additional
pencil eraser destructive treatment options for actinic keratoses.
E = evolving lesions, either new or changing (most
melanomas manifest as new lesions) D I S C U SSI O N S O U R C E S
The characteristics of basal cell carcinoma (BCC) include Latha MS, Martis J, Bellary S, et al. Sunscreening agents: A review.
a long latency period and low metastatic risk. Depending J Clin Aesth Dermatol. 6(1):16–26, 2013.
on lesion location, untreated BCC can lead to significant de- Ortel E, Bolotin D. Cancers of the skin. In: Rakel R, Bope E, eds. Conn’s
formity and possibly altered function. As a result, early Current Therapy 2013. Philadelphia: Saunders, 2012, pp. 219–222.
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin:
recognition and intervention is recommended. To help with
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
BCC, remember this mnemonic; “PUT ON” sunscreen”: pp. 676, 685–690.
P = pearly papule Spencer, JM. Elston, DM. http://emedicine.medscape.com/article/
U = ulcerating 1099775-overview#showall
T = telangiectasia Rosen T, Lebwohl MG. Prevalence and awareness of actinic keratosis:
O = on the face, scalp, pinnae barriers and opportunities. J Am Acad Dermatol. Jan;68(1 Suppl),
N = nodules = slow growing 2013.
4074_Ch03_047-078 20/11/14 10:35 AM Page 69
Urticaria Answers
118. Type I hypersensitivity reaction is mediated through: 118. C. 121. A. 124. C.
A. TNF-␣ binding to T cells. 119. A. 122. A. 125. B.
B. IgG antibodies binding to T cells. 120. B. 123. D.
C. IgE antibodies binding to mast cells.
D. IL-10 binding to basophils.
Urticaria is a condition in which eruptions of wheals or hives
119. Which of the following do you expect to find in the occur most often in response to allergen exposure. The most
assessment of the person with urticaria? common cause is a type I hypersensitivity reaction. This type
A. eosinophilia of reaction is caused when IgE antibodies occupy receptor
B. low erythrocyte sedimentation rate sites on mast cells, causing degradation of the mast cell and
C. elevated thyroid-stimulating hormone level subsequent release of histamine, vasodilation, mucous gland
D. leukopenia stimulation, and tissue swelling. As with most allergen-based
120. Common clinical conditions included in the atopy conditions, eosinophilia, an increase in the number of circu-
subgroup of type I hypersensitivity reactions include lating eosinophils, is usually present. Type I hypersensitivity
all of the following except: reactions consist of two subgroups: atopy and anaphylaxis.
A. allergic rhinitis. Urticarial lesions often develop as groups of intensely itchy
B. rosacea. wheals or hives. The lesions usually last less than 24 hours and
C. atopic dermatitis. often only 2 to 4 hours. New lesions can form, however, ex-
D. allergic gastroenteropathy. tending the outbreak to 1 to 2 weeks.
Many common clinical conditions are included in the
121. A 24-year-old woman presents with hive-form linear atopy subgroup, such as allergic rhinitis, atopic dermatitis, al-
lesions that develop over areas where she has lergic gastroenteropathy, and allergy-based asthma. Atopic
scratched. These resolve within a few minutes. This diseases have a strong familial component and tend to cause
most likely represents: localized rather than systemic reactions. The person with
A. dermographism. atopic disease is often able to identify allergy-inducing agents.
B. contact dermatitis. In addition to avoidance of offending agents, treatment for
C. angioedema. systemic atopic disease includes antihistamines, topical corti-
D. allergic reaction. costeroids, and leukotriene modifiers (zafirlukast [Accolate],
122. An urticarial lesion is usually described as a: montelukast [Singulair]); systemic corticosteroids are often
A. wheal. needed for severe flares.
B. plaque. Anaphylaxis typically causes a systemic IgE-mediated reac-
C. patch. tion to exposure to an allergen, often a drug (e.g., penicillin), in-
D. papule. sect venom (e.g., bee sting), or food (e.g., peanuts). Anaphylaxis
is characterized by a wide variation in presentation, ranging from
123. Common clinical manifestations of anaphylaxis can an urticarial reaction being noted in its mildest form to the pres-
include all of the following except: ence of widespread vasodilation, urticaria, angioedema, and
A. upper airway edema. bronchospasm creating a life-threatening condition of airway
B. itch without rash. obstruction coupled with circulatory collapse. First-line treat-
C. dizziness with syncope. ment includes avoiding or discontinuing use of the offending
D. hypertension. agent. Parenteral epinephrine is the preferred initial drug therapy
124. Common triggers for anaphylaxis include exposure to for anaphylaxis because of its multiple modes of reversing airway
certain types of all of the following except: and circulatory dysfunction. In the presence of anaphylaxis,
A. medications. there are no contraindications to epinephrine use. Additional
B. food. therapy is based on the clinical presentation. Simultaneously,
C. pet dander. maintaining airway patency and adequate circulation is critical.
D. insect bites. Angioedema and urticaria are subcutaneous anaphylactic reac-
tions but are not life-threatening unless tissue swelling impinges
125. You see a 28-year-old man who is having an anaphy- on the airway (Tables 3–9 and 3–10).
lactic reaction following a bee sting and is experienc-
ing trouble breathing. Your initial response is to D I S C U SSI O N S O U R C E S
administer: Linscott MS. http://www.emedicine.com/emerg/TOPIC628.HTM,
A. oral antihistamine. eMedicine: Urticaria
B. injectable epinephrine. American Academy of Allergy, Asthma & Immunology. Anaphy-
C. supplemental oxygen. laxis: Tips to remember. http://www.aaaai.org/conditions-and-
D. vasopressor therapy. treatments/library/at-a-glance/anaphylaxis.aspx
4074_Ch03_047-078 20/11/14 10:35 AM Page 70
Answers
126. B. 127. A. 128. A. 129. C.
Warts
126. When counseling a person who has a 2-mm verruca- Verruca vulgaris lesions are also known as warts. Human pa-
form lesion on the hand, you advise that: pillomavirus types 1, 2, and 4 cause most nongenital warts;
A. bacteria are the most common cause of these virus is passed through direct person-to-person contact. Over
lesions. a 12- to 24-month period, nearly all lesions resolve without
B. lesions usually resolve without therapy in 12 to therapy. Surgical excision is rarely indicated. Intervention is
24 months. warranted if warts interfere with function, such as with
C. there is a significant risk for future dermatologic painful plantar warts on the soles of the feet, or if the lesions
malignancy. are cosmetically problematic (Table 3–11).
D. surgical excision is the treatment of choice.
D I S C U SSI O N S O U R C E S
127. The mechanism of action of imiquimod is
Housman T, Williford P. Warts (verrucae). In: Rakel R, Bope E,
as a/an: eds. Conn’s Current Therapy 2008. Philadelphia: Saunders, 2008,
A. immunomodulator. pp. 811–815.
B. antimitotic. Dall’oglio F, D’Amico V, Nasca MR, Micali G. Treatment of cuta-
C. keratolytic. neous warts: An evidence-based review. Am J Clin Dermatol.
D. irritant. 13:73–96, 2012.
TABLE 3-10
Treatment of Anaphylaxis in Patient With Currently Patent Airway
Intervention Comment
Immediate SC or IM administration No contraindications to epinephrine use in anaphylaxis
of epinephrine Failure to or delay in use associated with fatalities
Administer antihistamine such as An important part of anaphylaxis treatment but should be used only with, not
diphenhydramine (Benadryl) instead of, epinephrine
Additional measures as dictated Airway maintenance including supplemental oxygen
by patient response IV fluids, vasopressor therapy corticosteroids
Repeat epinephrine every 5 minutes if symptoms persist or increase
Repeat antihistamine with or without H2 blocker if symptoms persist
Observe as dictated by patient response, keeping in mind that anaphylaxis
reactions often have a protracted or biphasic response
Arrange follow-up care Provide instruction on avoidance of provoking agent
Give epinephrine autoinjector (EpiPen) and safety of use prescription with
appropriate education about indications
TABLE 3-11
Treatment Options for Warts
Treatment Instructions for Use Comments
Liquid nitrogen Apply to achieve a thaw time Usually good cosmetic results
of 20–45 seconds Can be painful, requires multiple treatments
Two freeze–thaw cycles may be
administered every 2–4 weeks
until lesion is gone
Keratolytic agents Apply as directed until lesions Often needs long-term therapy before resolution
(Cantharidin, resolve Well tolerated
Occlusal, Duofilm, With plantar warts, pare down lesion, then apply 40%
DuoPlant, ViraSal, salicylic acid plaster, changing every 5 days
others)
Podophyllum resin Patient applies three times a Multiple cycles often needed
(podofilox) week for 4–6 weeks Skin irritation common
Tretinoin Apply bid to flat warts for Needs consistent treatment for optimal results
4–6 weeks
Imiquimod (Aldara) Frequency and duration of use Immunomodulator
depend on wart location Low rate of wart recurrence
Laser therapy Used to dissect lesions Needs 4–6 weeks to granulate tissue
Best reserved for treatment-resistant warts
Source: Rosen AE. Warts (verrucae). In: Rakel R, Bope E, eds. Conn’s Current Therapy 2013. Philadelphia:
Saunders, 2012, p. 294.
including methicillin-resistant S. aureus (MRSA), must be 138. All CA-MRSA strains are capable of causing
considered. Treatment options for cellulitis when MRSA risk necrotizing infection.
is considered low include dicloxacillin. With significant
139. The mechanism of resistance of MRSA is via the
MRSA risk, or when cellulitis surrounds an area of furuncu-
production of beta-lactamase.
losis or abscess, treatment should be aimed at treating MRSA
and streptococcal infection (see next section on MRSA). In 140. If a skin and soft tissue infection does not im-
addition to antimicrobial treatment, other actions that can prove in 48 to 72 hours with antimicrobial ther-
help facilitate resolution of cellulitis include applying warm apy, infection with a resistant pathogen is
compresses to the affected area, keeping the affected limb virtually the only cause.
rested, and elevating the affected area when possible.
141. Most acute-onset necrotic skin lesions reported
DI SCUS SION SOURCES in North America are caused by spider bites.
Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The 142. In an adult with BMI greater than 40 kg/m2 who
Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA: is being treated with TMP-SMX for CA-MRSA,
Antimicrobial Therapy, Inc., 2014, pp. 254–256. the recommended dose is two tablets bid.
Stevens DL. Bacterial diseases of the skin. In: Rakel R, Bope E, eds.
Conn’s Current Therapy 2013. Philadelphia: Saunders, 2012,
pp. 211–214.
Answers
134. A.
Staphylococcus 135. B.
137. False
138. False
140. False
141. False
aureus Infection 136. False 139. False 142. True
134. You see a 36-year-old man with no chronic health Staphylococcus aureus is a ubiquitous gram-positive organ-
problems who presents with two furuncles, each ism that normally grows on the skin and mucous mem-
around 4 cm in diameter, on the right anterior thigh. branes and is a common cause of skin and soft tissue
These lesions have been present for 3 days, slightly in- infections. Strains of S. aureus that produce beta-lactamase,
creasing in size during this time. He has no fever or which is an enzyme capable of neutralizing penicillins, were
other systemic symptoms. You advise the following: first noted in the 1940s and became the dominant commu-
A. incision and drainage of the lesion nity and hospital pathogenic forms of the organism from
B. a systemic antibiotic empirically the 1950s through the early 2000s. During that time,
C. a topical antibiotic S. aureus skin and soft tissue infections were treated with
D. aspiration of the lesion contents and prescription antimicrobials possessing activity against gram-positive or-
of a systemic antibiotic based on culture results ganisms and had stability in the presence of beta-lactamase,
such as the macrolides (erythromycin, azithromycin,
135. A woman was treated as an inpatient for a serious
clarithromycin), certain cephalosporins (e.g., cephalexin,
soft tissue infection with parenteral linezolid and
cefadroxil), and semisynthetic penicillin forms that possess
now is being seen on day 3 of her illness and is being
beta-lactamase stability (dicloxacillin, methicillin [no longer
discharged to home. She is feeling better and appears
used clinically], oxacillin, nafcillin). As a result, these strains
by examination to be clinically improved. Culture
are known as methicillin-sensitive S. aureus (MSSA). An ad-
results reveal MRSA, sensitive to trimethoprim-
ditional treatment option was an antimicrobial with a beta-
sulfamethoxazole, linezolid, daptomycin, vancomycin,
lactamase inhibitor, such as amoxicillin-clavulanate. In the
and clindamycin and resistant to cephalothin and
past 3-4 decades, strains of S. aureus resistant to methicillin
erythromycin. Her antimicrobial therapy should be
(MRSA) evolved into an important pathogen in infection
completed with:
associated with hospitals and long-term-care facilities. Until
A. oral cephalexin.
the early 2000s, however, MRSA was seldom noted in the
B. oral trimethoprim-sulfamethoxazole.
community.
C. parenteral vancomycin.
Across the United States, disease caused by MRSA ac-
D. oral linezolid.
quired in the community (known as community-acquired
Answer the following questions true or false or community-associated MRSA [CA-MRSA]) has been
reported with increasing frequency. CA-MRSA is not simply
136. Skin lesions infected by community-acquired
an organism that has escaped the healthcare facility and taken
MRSA (CA-MRSA) often occur spontaneously
up residence in the community; in contrast to healthcare–
on intact skin.
associated MRSA (HC-MRSA), in which numerous clones
137. CA-MRSA is most commonly spread from have been identified, two major clones are responsible for
one person to another via airborne pathogen most CA-MRSA. One of these clones was implicated in a
transmission. worldwide infectious disease outbreak more than 60 years
4074_Ch03_047-078 20/11/14 10:35 AM Page 73
ago. CA-MRSA infections usually involve the skin and soft Linezolid (Zyvox) is another effective, albeit expensive, oral
tissues in the form of cellulitis, bullous impetigo, folliculitis, treatment option, which is usually reserved for use when the
abscess, or an infected laceration. Less common is CA- aforementioned medications are not tolerated or ineffective.
MRSA–associated disease in the form of blood, bone, or joint When parenteral treatment is needed, commonly used man-
infection or pneumonia. The Panton-Valentine leukocidin agement options include linezolid, vancomycin, and dapto-
(PVL) toxin is present in approximately 77% of CA-MRSA mycin. Daptomycin is not indicated in the treatment of
strains and is less common in healthcare–associated MRSA pneumonia.
strains. The PVL toxin promotes lysis of human leukocytes, Although TMP-SMX is usually active against CA-MRSA,
and it is associated with severe necrotizing skin infections and its coverage against streptococcus is uncertain. If the causative
hemorrhagic pneumonia. pathogen of the skin and soft tissue infection is unclear and
CA-MRSA is usually acquired during person-to-person, streptococcal infection is considered a possibility, such as is
skin-to-skin contact, but inanimate objects such as coun- seen in cellulitis or erysipelas, the antimicrobial choice should
tertops or other surfaces also contribute to CA-MRSA be aimed at medications that provide coverage against staphy-
transmission. Although MRSA acquired in healthcare lococci and streptococci. In this situation, using TMP-SMX
facilities usually affects frail individuals, CA-MRSA is with a beta-lactam such as a cephalosporin is recommended.
found predominately in otherwise healthy children and A person with CA-MRSA infection requires careful
adults. Bearing this in mind, CA-MRSA infection does follow-up to ensure clinical resolution. Post-treatment cul-
appear more common in low income populations and in tures are unnecessary. Serious disease such as pneumonia
certain ethnic groups, including African Americans and or death resulting from CA-MRSA is, in many locations, a
Native Americans. Additional risks include living in reportable disease.
crowded conditions such as correctional facilities, partici- As mentioned, the clinical presentation of CA-MRSA is
pating in occupational or recreational activities with regular usually as a cutaneous and soft tissue lesion in the form of
skin-to-skin contact such as wrestling, exposure to a person boils and abscesses. Because a CA-MRSA lesion often has a
with CA-MRSA, and recent use of an antibiotic or recurrent dark or black center, the condition has often been attributed
skin infection (or both). Prevention of CA-MRSA includes to a spider bite. In reality, spider bites are uncommon, usually
appropriate hand hygiene, reduction of unnecessary skin- occurring only when the arachnid is trapped in clothing or a
to-skin contact, and thorough cleaning of surfaces with a shoe. In addition, few spider species have the capability of
disinfectant solution. causing a significant bite. In particular, the brown recluse spi-
The choice of therapy for skin and soft tissue infection der, or Loxosceles reclusa, can cause a necrotizing bite and is
must take into consideration issues of antimicrobial resist- often blamed for lesions that are actually caused by CA-
ance and minimizing unnecessary antimicrobial use. In an MRSA. Found primarily in the U.S. Midwest and Southeast,
afebrile patient with an abscess less than 5 cm in diameter, this arachnid hibernates during the winter, so bites, which
the first-line treatment of community-acquired skin and soft are generally painless, occur between March and October.
tissue infection is incision, drainage, and localized care such The term recluse depicts a shy creature that typically hides in
as warm soaks. A wound culture and sensitivity should be shoes, boxes, and other small enclosed spaces. A single spider
obtained to help guide treatment. If the abscess is equal to is occasionally spotted outside of its native region, having
or greater than 5 cm in diameter, antimicrobial therapy traveled in a suitcase or box. Only a small proportion of
should be added to the aforementioned localized treatment. brown recluse spider bites become necrotic. When this
Given that the antimicrobials effective against MSSA occurs, a characteristic pattern known as the “red, white, and
(certain cephalosporins, penicillins, penicillin with beta- blue” sign follows, with a central purple-to-gray discoloration
lactamase inhibitor combinations, and select macrolides) surrounded by a white ring of blanched skin and a large red
are ineffective in CA-MRSA, documentation of the organ- halo. If necrosis occurs, a black eschar forms.
ism’s pattern of resistance can help direct therapy. Most
strains of CA-MRSA remain sensitive to trimethoprim- D I S C U SSI O N S O U R C E S
sulfamethoxazole (TMP-SMX, Bactrim), doxycycline, Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
or clindamycin. Given cost and efficacy, TMP-SMX is the Sanford Guide to Antimicrobial Therapy, ed. 44. Sperryville, VA:
primary antimicrobial therapy recommended, particularly Antimicrobial Therapy, Inc., 2014, p. 52.
in a person who is immunocompetent and without fever. CA-MRSA Definition, symptoms, diagnosing, treatment, statistics-
Because successful therapy depends on achieving adequate http://www.cdc.gov/mrsa/
James, WD, Berger TG, Elston, DM. Andrews’ Diseases of the Skin:
concentration of the antimicrobial at the site of the infec-
Clinical Dermatology, ed. 11. Philadelphia: Saunders, 2011,
tion, the recommended TMP-SMX dose is 1 double- pp. 8, 414–447.
strength tablets for 5 to 10 days, but duration should Herchline, TE. Cunha, BA. Staphylococcal infections. http://
be individualized on the basis of the patient’s clinical emedicine.medscape.com/article/228816-overview#showall,
response; with BMI > 40 kg.m2, TMP-SMX 2 tablets bid is accessed 7/20/2013.
recommended. Centers for Disease Control. Venomous spider identification, pre-
In patients who are intolerant of sulfa drugs, alternatives vention, symptoms and first aid for consumers. http://www.cdc
to TMP-SMX therapy include doxycycline or minocycline. .gov/niosh/topics/spiders/
4074_Ch03_047-078 20/11/14 10:35 AM Page 74
Barankin B. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949217/,
Angular Cheilitis National Institute of Health, angular cheilitis
154. Preferred antimicrobials for the treatment of adults of joint damage. Neuropsychiatric symptoms can ap-
with Lyme disease include all of the following except: pear, including memory problems, depression, and
A. a tetracycline. neuropathy.
B. an aminoglycoside. Serum testing for B. burgdorferi by enzyme-linked im-
C. a cephalosporin. munosorbent assay and a confirmatory Western blot assay
D. a penicillin. for IgM antibodies help to support the clinical diagnosis of
Lyme disease; IgM antibodies decline to low levels after 4 to
155. Which of the following would not be recommended
6 months of illness, whereas IgG is noted about 6 to 8 weeks
to prevent Lyme disease when visiting a Lyme-en-
after onset of symptoms and often persists at low levels de-
demic area?
spite successful treatment. Careful correlation of patient his-
A. Wear long pants and long-sleeved shirts.
tory and physical examination and astute interpretation of
B. Use insect repellent.
laboratory diagnostics are critical to prevent overdiagnosing
C. If a tick bite occurs, wait until after consulting a
and underdiagnosing this condition.
healthcare provider before removing the insect.
Effective antimicrobials for treatment of Lyme disease in-
D. If a tick bite occurs and the tick is engorged, ad-
clude doxycycline, cefuroxime axetil (Ceftin), amoxicillin, and
minister a single 200-mg dose of doxycycline.
select macrolides. The clinician needs to be aware of the latest
recommendation for dosage and duration of treatment with
these products; recommendations include treatment for 14 to
Answers 21 days for earlier disease and up to 28 days with more ad-
147. C. 150. A. 153. C. vanced disease. Most adults with Lyme disease recover in weeks
148. B. 151. D. 154. B. with appropriate treatment, although some have a late relapse.
149. D. 152. B. 155. C. Prevention of Lyme disease includes avoiding areas with
known or potential tick infestation, wearing long-sleeved
shirts and pants, and using insect repellents. Inspecting the
Lyme disease is a multisystem infection caused by B. burgdorferi, skin and clothing for ticks with appropriate tick removal is
a tick-transmitted spirochete. Although original reports of also helpful. If a tick bite occurs, a single 200-mg dose of
this disease, also known as Lyme borreliosis, were clustered doxycycline taken orally appears to be effective in reducing
through select areas of the United States, primarily in the Lyme disease risk if the tick is engorged and the patient lives
Northeast and Mid-Atlantic states, it has now been diagnosed or has visited a Lyme-endemic area; observation is also a rea-
in every state. The disease’s name comes from the town of sonable option given the low rate of infection after tick bite,
Old Lyme, Connecticut, where it was first diagnosed after a particularly with nonengorged tick bite in low risk areas.
community epidemic of rash and arthritis. Lyme disease is
the most common vector-borne disease in the United States. D I S C U SSI O N S O U R C E S
Overdiagnosis of Lyme disease is a problem, as is the issue of American Lyme Disease Foundation. http://www.aldf.com/lyme.
significant but understandable anxiety about any tick expo- shtml. Symptoms, diagnosis and treatment of Lyme disease
sure. Infected ticks must feed on the human host for more Centers for Disease Control and Prevention. http://www.cdc.gov/
than 24 hours to transmit the spirochete. In addition, not all lyme/. Lyme disease, Symptoms, prevention, diagnosis, treat-
ticks are infected, with rates varying from 15% to 65% in areas ment and tick identification
where Lyme disease is endemic. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assess-
Lyme disease is typically divided into three stages: ment, treatment, and prevention of Lyme disease, human granu-
Stage 1 (early localized disease): This is a mild flulike illness, locytic anaplasmosis, and babesiosis: Clinical practice guidelines
often with a single annular lesion with central clearing by the Infectious Diseases Society of America. Clin Infect
Dis. 43:1089_1034, 2006. Available at: http://www.idsociety.org/
(erythema migrans). The lesion is rarely pruritic or
uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/
painful. Signs and symptoms can resolve in 3 to 4 weeks Lyme%20Disease.pdf, accessed 7/28/13.
without treatment.
Stage 2 (early disseminated infection): Typically months later,
the classic rash may reappear with multiple lesions, usually
accompanied by arthralgias, myalgia, headache, and fa-
Bed Bugs (Cimex
tigue. Less commonly, cardiac manifestations such as heart lectularius)
block and neurological findings such as acute facial nerve
paralysis (Bell’s palsy) and aseptic meningitis may also be 156. All of the following characteristics about bed bugs are
present. Individuals with Bell’s palsy should undergo care- true except:
ful examination and serological testing for Lyme disease. A. they can be found in furniture, carpeting, and
Regression of symptoms can occur without treatment. floorboards.
Stage 3 (late persistent infection): Starting approximately B. their peak feeding time is at dawn.
1 year after the initial infection, musculoskeletal signs C. during feeding, they are attracted to body heat and
and symptoms usually persist, ranging from joint pain carbon dioxide.
with no objective findings to frank arthritis with evidence D. they prefer to harbor unsanitary environments.
4074_Ch03_047-078 20/11/14 10:35 AM Page 76
157. All of the following statements are true regarding skin Confirming a diagnosis of a bed bug bite can be difficult,
reactions to bed bugs except: and a history of the home environment, work conditions, and
A. skin reactions are more common with repeated presence of domestic animals should be obtained. Bed bug
exposure to bed bug bites. bites are usually red (often with a darker red spot in the mid-
B. skin reactions can typically involve papules, dle); itchy; arranged in a rough line or in a cluster; and located
macules, or wheals. on the face, neck, arms, and hands. Repeated exposure to
C. allergic reactions can be treated with topical bed bug bites can lead to skin reactions. Cutaneous reactions
corticosteroids. can include macules, papules, wheals, vesicles, bullae, and
D. systemic skin reactions frequently occur following nodules. These reactions are typically self-limited and re-
an initial exposure to bed bug bites. solve within 1 to 2 weeks. Treatment of bites is not usually
required. If a secondary infection occurs, treat with an anti-
158. You see a 42-year-old woman with a cluster of red,
septic lotion or topical antibiotic. For allergic reactions, top-
itchy spots on her left arm. She informs you that she
ical corticosteroids or oral antihistamines may be helpful. A
recently stayed at a hotel that she later discovered was
disseminated bullous eruption with systemic reaction caused
infested with bed bugs. You advise her that:
by bed bug bites may occur, but this is rare.
A. she should immediately begin a regimen of oral
If bed bug bites are suspected, the home should be thor-
antibiotics.
oughly inspected for insects. The inspection may need to be
B. the reaction is usually self-limiting and should
performed at night when the insects are active. Signs for the
resolve in 1 to 2 weeks.
presence of bed bugs include dark specks typically found
C. given that bed bug bites are usually not itchy, an
along the mattress seams, light brown empty exoskeletons,
alternative diagnosis should be considered.
or bloody smears on bed sheets (due to crushing an engorged
D. she should wash all of her clothes in cold water.
bed bug during sleep). Eliminating bed bugs can be difficult
159. Signs that bed bugs are present in a home include all because they can live for weeks without feeding. If bed bugs
of the following except: are present in a home, professional extermination is recom-
A. small drops of fresh blood on floorboards. mended. A combination of pesticides and nonchemical treat-
B. blood smears on bed sheets. ments may be used. Nonchemical treatments can include
C. presence of light brown exoskeletons. vacuuming crevices where the insects may be present, wash-
D. dark specks found along mattress seams. ing clothes and other items in hot water (at least 120ºF),
placing items in a clothes dryer at medium to high heat for
160. Nonchemical means to eliminate bed bugs can in-
at least 20 minutes, or freezing items, preferably in a freezer
clude all of the following except:
that is set for 0 degrees F (-17ºC), for at least 4 days.
A. vacuuming crevices.
B. washing bedding and other items in hot water. D I S C U SSI O N S O U R C E
C. isolating the infested area from any hosts for at Studdiford JS, Conniff KM, Trayes KP, Tully AS. Bedbug infestation.
least 2 weeks. Am Fam Physician. 86:653–658, 2012.
D. running bedding and other items in a dryer on
high heat for 20 minutes.
Rosacea
Answers
161. All of the following organisms have been implicated
156. D. 158. B. 160. C. in the development of rosacea except:
157. D. 159. A. A. viruses.
B. bacteria.
Bed bugs (Cimex lectularius) are parasitic insects belonging C. yeast.
to the family Cimicidae and are typically less than 1 cm in D. mites.
length and reddish brown in color. Bed bug infestations have
162. Patients with rosacea are recommended to use daily:
been increasing worldwide, likely because of increased resist-
A. sunscreen.
ance to insecticides, such as pyrethroid insecticides, and a ban
B. astringents.
on the use of DDT. They can be found in furniture, floor-
C. exfoliant.
boards, carpeting, peeling paint, areas of clutter, or other
D. antimicrobial cream.
small spaces. Bed bugs do not have a preference for clean or
unsanitary environments; they are found even in pristine 163. Topical therapies for the treatment of rosacea include
homes and hotels. These parasites only need a warm host and all of the following except:
hiding places. The insects come out at night to feed on the A. metronidazole cream.
blood of a host, with peak feeding times just before dawn. B. azelaic acid gel.
They are typically attracted to body heat, carbon dioxide, C. medium-potency corticosteroid cream.
vibration, sweat, and odor. D. benzoyl peroxide.
4074_Ch03_047-078 20/11/14 10:35 AM Page 77
164. Oral antimicrobial treatments recommended for one or both ears, and/or the eyelids. Ocular rosacea can
rosacea include all of the following except: include a variety of manifestations, including blepharitis,
A. metronidazole. conjunctivitis, inflammation of the lids, and conjunctival
B. levofloxacin. telangiectasias.
C. erythromycin. Prior to initiating therapy for rosacea, the triggers for
D. doxycycline. rosacea should be identified and lifestyle modifications
should be made to minimize exposure to these triggers. The
165. Which of the following is not a recommended option
daily use of sunscreen is recommended for all patients with
to make cosmetic improvements for phymatous
rosacea. Patients should also avoid the use of astringents, ton-
rosacea?
ers, menthols, camphor, exfoliants, waterproof cosmetics that
A. laser peel
require solvents for removal, or products containing sodium
B. ablative laser surgery
laurel sulfate. Nonablative lasers can be effective in remodel-
C. surgical shave technique
ing the dermal connective tissue and improving the epider-
D. mechanical dermabrasion
mal barrier. Typically, one to three treatment sessions are
needed to achieve the best results. Mechanical dermabrasion,
laser peel, and surgical shave techniques can be used to
Answers achieve cosmetic improvements of phymatous rosacea.
161. A. 163. C. 165. B. Effective treatment of rosacea may involve a combination
162. A. 164. B. of topical and oral medications. Topical treatments for
rosacea include antimicrobials, immunosuppresants, and
acne products. Metronidazole gel (0.75% or 1%) is commonly
Rosacea is a common condition characterized by symptoms used as a first-line agent. Other topical antimicrobial options
of facial flushing and a spectrum of clinical signs, including include erythromycin and clindamycin. Acne products can
erythema, telangiectasia, and inflammatory papulopustular be effective for patients with papules, pustules, and the phy-
eruptions resembling acne. The symptoms are usually inter- matous and glandular types of rosacea. Topical products can
mittent but can progressively lead to permanently flushed skin include azelaic acid, sulfacetamide products, benzoyl perox-
and, in some cases, permanent telangiectasia. The cause of ide, or retinoid-like agents (i.e., isotretinoin and tretinoin).
rosacea is unknown, although inflammation plays a critical Dapsone can be considered in patients with severe, refractory
role in pathogenesis. Several organisms on the skin have been rosacea or those who cannot take isotretinoin. Tacrolimus
implicated in the development of rosacea. The Demodex ointment (Protopic) inhibits immune reactions by blocking
species of mites that normally inhabit human hair follicles tend the release of cytokines from T-cells and can be helpful in
to prefer skin regions affected by rosacea. Bacterial species, reducing itching and inflammation. Tacrolimus should only
such as Helicobacter pylori and Staphylococcus aureus, and be considered after other treatment options have failed. Use
yeast (Malassezia species) are also thought to contribute to of topical medium and high-potency corticosteroids on the
the development of rosacea and would explain the effects of face should be avoided because it can produce rosacea-like
antimicrobials in the treatment of rosacea. Triggers for rosacea symptoms or worsen pre-existing rosacea. Oral antibiotics
flares can be varied and specific for individual patients and can may also be considered, more for their anti-inflammatory
include UV/sunlight exposure, hot/cold exposure, exercise, properties than for their antimicrobial activity. Oral antibiotic
stress, coffee, chocolate, caffeine, alcohol, spicy foods, and options include minocycline, doxycycline, tetracycline,
certain cosmetic products or medications. metronidazole, or erythromycin. Oral isotretinoin may also
The goal of treatment is to minimize the signs and symp- be useful in patients whose rosacea does not respond to other
toms of the disease. Rosacea can be classified into four sub- therapies. However, the patient and provider need to be aware
types with treatment selection guided by this classification. of potentially serious adverse effects associated with its use
The erythematotelangiectatic type involves central facial (see Table 3–4).
flushing often accompanied by burning or stinging. Papulo-
pustular rosacea typically affects middle-age women who D I S C U SSI O N S O U R C E S
present with a red central portion of their face that contains Van Onselen J. Rosacea: Symptoms and support. Br J Nurs. 21:
erythematous papules surmounted by pinpoint pustules. 1252–1255, 2012.
Phymatous rosacea is defined by marked skin thickenings Baldwin HE. Diagnosis and treatment of rosacea: State of the art.
and irregular surface nodularities of the nose, chin, forehead, J Drugs Dermatol. 11:725–730, 2012.
4074_Ch03_047-078 20/11/14 10:35 AM Page 78
4074_Ch04_079-104 20/11/14 10:38 AM Page 79
TABLE 4-1
Allergic Conjunctivitis: Defining Terms
Intermittent (seasonal) allergic conjunctivitis IgE-mediated diseases related to seasonal allergens
Common triggers—depend on time of year and geographic location
(April/May, tree pollens; June/July, grass pollens; July/August, mold spores
and weed pollens; others dependent on local environmental factors)
Persistent (perennial) allergic conjunctivitis IgE-mediated diseases related to perennial allergens
Common trigger—house dust mites (present in all geographic areas)
TABLE 4-2
Treatment of Common Bacterial Eye, Ear, Nose, and Throat Infection
Site of Infection Common Pathogens Recommended Antimicrobial Comments
Suppurative S. aureus, Primary: Ophthalmic treatment with Viral conjunctivitis (“pink eye,”
conjunctivitis S. pneumoniae, FQ ocular solution (gatifloxacin, usually caused by adenovirus)
(nongonococcal, H. influenzae levofloxacin, moxifloxacin) often self-limiting. Relieve
non-chlamydial) Outbreaks due to Alternative: Ophthalmic treatment irritative symptoms
atypical S. pneumoniae with polymyxin B plus trimethoprim with use of cold artificial tear
solution or azithromycin solution solution
Most S. pneumoniae is resistant
to tobramycin, gentamicin
Otitis externa Pseudomonas spp., Otic drops with ofloxacin or Ear canal cleansing important.
(swimmer’s ear) Proteus spp., Enter- ciprofloxacin with hydrocortisone Decrease risk of reinfection by
obacteriaceae or polymyxin B with neomycin and use of eardrops of 1:2 mixture
Acute infection often hydrocortisone or white vinegar and rubbing
S. aureus For acute disease: dicloxacillin alcohol after swimming
Fungi rare etiology If MRSA is a concern: TMP-SMX, Do not use neomycin if tym-
doxycycline, or clindamycin panic membrane punctured
Malignant otitis Pseudomonas Imipenem IV or meropenem IV Surgical débridement usually
externa in a person aeruginosa in >90% ciprofloxacin (IV or PO) or needed. MRI or CT to evaluate
with diabetes ceftazidime IV or cefepime IV or for osteomyelitis often
mellitus, HIV/AIDS, (piperacillin IV pus tobramycin) or indicated
on chemotherapy (ticarcillin plus tobramycin) Parenteral antimicrobial therapy
possibly warranted for severe
disease
Acute otitis media S. pneumoniae, Patient has had no antibiotics in the Consider drug-resistant
H. influenzae, prior month: S. pneumoniae (DRSP) risk:
M. catarrhalis, viral or • Amoxicillin high dose 1000 mg antimicrobial therapy in past
no pathogen (approxi- tid OR 1 month, age <2 years, day-
mately 55% bacterial, • Amoxicillin-clavulanate extended care attendance. HD amoxicillin
S. pneumoniae most release 2000/125 mg po bid OR usually effective in DRSP
common) • Cefdinir 300 mg q12h or 600 mg Length of therapy: <2 years,
q24h OR 10 days; ≥2 years, 5–7 days.
• Cefpodoxime proxetil 200 mg If allergy to beta-lactam drugs:
bid OR TMP-SMX, clarithromycin,
• Cefprozil 250-500 mg bid azithromycin; all less effective
4074_Ch04_079-104 20/11/14 10:38 AM Page 81
TABLE 4-2
Treatment of Common Bacterial Eye, Ear, Nose, and Throat Infection—cont’d
Site of Infection Common Pathogens Recommended Antimicrobial Comments
Patient has had antibiotics in the against DRSP compared with
prior month: other options.
• Amoxicillin-clavulanate extended If penicillin allergy history is
release 2000/125 mg bid unclear or rash (no hive-form
• Levofloxacin 750 mg q24h x lesions), cephalosporins likely
5 days okay
• Moxifloxacin 400 mg q24h Clindamycin effective against
Duration of therapy if not DRSP, ineffective against
mentioned, 5-7 days H. influenzae, M. catarrhalis
See Chapter 15, Pediatrics,
for additional information
Exudative Group A, C, G strepto- First-line for strep pharyngitis: Vesicular, ulcerative pharyngitis
pharyngitis coccus, Fusobacterium penicillin V PO × 10 days or benza- usually viral. Only 10% of adult
(in research studies), thine penicillin IM × 1 dose or pharyngitis due to group A
infectious mononucle- (cefdinir or cefpodoxime) × 5 days. streptococcus
osis, primary HIV, If penicillin allergy: clindamycin × No treatment recommended
N. gonorrhea, respira- 10 days. Azithromycin or clar- for asymptomatic group A
tory viruses ithromycin are alternatives. streptococcus carrier
Up to 35% S. pyogenes isolates For recurrent, culture-proven
resistant to macrolides. S. pyogenes, primary treatment
with cefdinir or cefpodoxime.
Alternative with amoxicillin-
clavulanate or clindamycin
Source: Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS. The Sanford Guide to Antimicrobial
Therapy. 44th ed. Sperryville, VA: Antimicrobial Therapy, Inc, 2014.
an “entire nose pinched closed” position by the patient for a 16. Mrs. Allen is a 67-year-old woman with type 2 diabetes
minimum of 10 minutes. If this action is ineffective, second- who complains of seeing flashing lights and floaters,
line therapies include nasal packing and cautery. Antifibri- decreased visual acuity, and metamorphopsia in her
nolytic agents are also available when other methods are not left eye. The most likely diagnosis is:
successful or for patients with a bleeding disorder. One such A. open-angle glaucoma.
product contains a gel composed of collagen-derived particles B. central retinal artery occlusion.
and bovine-derived thrombin (Floseal). For refractory cases, C. anterior uveitis.
arterial embolization or surgical therapy may be needed, in- D. retinal detachment.
cluding ligation of the internal maxillary artery, anterior eth-
17. For Mrs. Allen, the most appropriate next course of
moid artery, and/or external carotid artery.
action is:
DI SCUS SION SOURCES A. placement of an eye shield and follow-up in 48 hours.
Shukla PA, Chan N, Duffis EJ, et al. Current treatment strategies for
B. initiate treatment with an ophthalmic antimicrobial
epistaxis. J Neuro Intervent Surg 5:151–156, 2013. http://www. solution.
medscape.com/viewarticle/779484_1 C. initiate treatment with a corticosteroid ophthalmic
Fatakia A, Winters R, Amedee RG. Epistaxis: A common problem. solution.
Ochsner J 10:176–178, 2010. http://www.ncbi.nlm.nih.gov/pmc/ D. immediate referral to an ophthalmologist.
articles/PMC3096213
18. A 45-year-old man presents with eye pain. He reports
that he was cutting a tree with a chain saw when some
Ophthalmological wood fragments hit his eye. You consider all of the
following except:
Emergencies A. educating the patient on the use of appropriate eye
protection for primary prevention of eye trauma.
12. All of the following are components of the classic B. immediately removing any protruding foreign body
ophthalmological emergency except: from the eye.
A. eye pain. C. using fluorescein staining to detect small objects in
B. purulent eye discharge. the eye.
C. red eye. D. prompt referral to an eye care specialist.
D. new onset change in visual acuity.
13. Mrs. Murphy is a 58-year-old woman presenting with a
sudden left-sided headache that is most painful in her Answers
left eye. Her vision is blurred, and the left pupil is slightly
12. B. 15. D. 18. B.
dilated and poorly reactive. The left conjunctiva is
13. C. 16. D.
markedly injected, and the eyeball is firm. Vision screen
14. A. 17. D.
with the Snellen chart is 20/30 OD and 20/90 OS. The
most likely diagnosis is:
A. unilateral herpetic conjunctivitis. The classic components of an ophthalmological emergency
B. open-angle glaucoma. are a painful, red eye with a documented change in visual
C. angle-closure glaucoma. acuity. In the case of angle-closure glaucoma, the patient
D. anterior uveitis. usually presents with all of these findings, and, without in-
tervention, blindness ensues in 3 to 5 days. Prompt referral
14. In caring for Mrs. Murphy, the most appropriate next
to expert ophthalmological care focused on relieving acute
action is:
intraocular pressure is needed; laser peripheral iridectomy
A. prompt referral to an ophthalmologist.
after reduction of intraocular pressure with appropriate
B. to provide analgesia and repeat the evaluation when
medications is usually curative. In contrast, open-angle
the patient is more comfortable.
glaucoma, the disease’s most common form, is a slowly
C. to instill a corticosteroid ophthalmic solution.
progressive disease that seldom produces symptoms. In un-
D. to patch the eye and arrange for follow-up in 24 hours.
treated open-angle glaucoma, the eventual visual loss is
15. A 48-year-old man presents with a new-onset right eye largely in the periphery, leading to the development of tun-
vision change accompanied by dull pain, tearing, and pho- nel vision.
tophobia. The right pupil is small, irregular, and poorly In anterior uveitis, another cause of an occasionally
reactive. Vision testing obtained by using the Snellen chart dully painful red eye with visual change, the pupil is usually
is 20/30 OS and 20/80 OD. The most likely diagnosis is: constricted, nonreactive, and irregularly shaped. Treatment
A. unilateral herpetic conjunctivitis. includes medications to assist in pupillary dilation and cor-
B. open-angle glaucoma. ticosteroids, administered topically, by periocular injec-
C. angle-closure glaucoma. tion, or systemically. Evaluation for the underlying cause,
D. anterior uveitis. including autoimmune and inflammatory diseases and
4074_Ch04_079-104 20/11/14 10:39 AM Page 83
ocular trauma, of this uncommon condition should also 22. Risk factors for POAG include all of the following
be done. except:
Mechanical trauma to the eye can cause globe rupture, A. African ancestry.
which should be considered in all patients with eye injury. Pri- B. type 2 diabetes mellitus.
mary prevention of trauma to the eye includes the use of ap- C. advanced age.
propriate protective eyewear or face shield. Eye injury from D. blue eye color.
high-velocity trauma (e.g., flying object) should be treated as
23. Key diagnostic findings in POAG include which of the
a penetrating injury. Injury from a small object is often de-
following?
tected only as a small corneal defect by fluorescein staining.
A. intraocular pressure greater than 25 mm Hg.
Endophthalmitis and possible vision loss can result if not
B. papilledema.
treated appropriately. If a protruding foreign body is present,
C. cup-to-disk ratio greater than 0.4
it should not be removed if globe rupture is suspected. The
D. sluggish pupillary response.
use of an eye shield and immediate referral to an ophthalmol-
ogist is recommended. 24. Adults at high risk for POAG should undergo a
Retinal detachment, the separation of the neurosensory complete eye exam every:
layer of the retina from the choroid and retinal pigment ep- A. 1 to 2 years.
ithelium, can lead to rapid degeneration of photoreceptors B. 3 to 4 years.
because of ischemia. Early diagnosis and treatment can pre- C. 5 to 6 years.
vent permanent vision loss. Risk factors include myopia D. 3 to 6 months.
(nearsightedness), cataract surgery, diabetic retinopathy,
25. Treatment options for POAG include all of the
family history of retinal detachment, older age, and trauma.
following topical ocular agents except:
Patients with retinal detachment complain of unilateral pho-
A. beta-adrenergic antagonists.
topsia, increasing number of floaters in the affected eye, de-
B. alpha2-agonists.
creased visual acuity, and metamorphopsia (wavy distortion
C. prostaglandin analogues.
of an object). If retinal detachment is suspected, immediate
D. mast cell stabilizers.
referral to an ophthalmologist is needed.
DI SCUSSION SOURCES
Kilborne G. http://emedicine.medscape.com/article/798323, eMed-
icine: Iritis and uveitis Answers
Romaniuk VM. Ocular trauma and other catastrophes. Emerg Med
Clin North Am 31:399–411, 2013. 19. A. 22. D. 25. D.
20. B. 23. A.
21. A. 24. A.
Primary Open-Angle Although the etiology of POAG is not completely under-
Glaucoma stood, the result is elevated intraocular pressure caused by
abnormal drainage of aqueous humor through the trabec-
19. Which of the following is a common vision problem ular meshwork. POAG risk factors include African ances-
in the person with untreated primary open-angle try, diabetes mellitus, family history of POAG, history of
glaucoma (POAG)? certain eye trauma and uveitis, and advancing age. A grad-
A. peripheral vision loss ual onset peripheral vision loss is most specific for open-
B. blurring of near vision angle glaucoma; this disease is the second most common
C. difficulty with distant vision cause of irreversible blindness in North America. Although
D. need for increased illumination all of these changes may be seen in patients with advanced
open-angle glaucoma, changes in near vision are common
20. POAG is primarily caused by:
as part of the aging process because of hardening of the lens
A. hardening of the lens.
(i.e., presbyopia) and the need for increased illumination.
B. elevated intraocular pressure.
New onset of difficulty with distance vision can be found
C. degeneration of the optic nerve.
in patients with cataracts.
D. hypotension in the anterior maxillary artery.
Glaucoma, either open-angle or angle-closure, is prima-
21. Which of the following is most likely to be found on the rily a problem with excessive intraocular pressure. Tonom-
funduscopic examination in a patient with untreated etry reveals intraocular pressure greater than 25 mm Hg;
POAG? in angle-closure glaucoma, the abnormal measurement is
A. excessive cupping of the optic disk usually documented on more than one occasion. As a re-
B. arteriovenous nicking sult, the optic disk and cup are “pushed in,” creating the
C. papilledema classic finding often called glaucomatous cupping. This
D. flame-shaped hemorrhages creates a cup-to-disk ratio of greater than 0.3 or asymmetry
4074_Ch04_079-104 20/11/14 10:39 AM Page 84
of cup-to-disk ratio of 0.2 or more. Papilledema, in which antagonists such as timolol, alpha2 agonists such as bri-
the optic disk bulges and the margins are blurred, is seen monidine, carbonic anhydrase inhibitors such as dorzo-
when there is excessive pressure behind the eye, as in in- lamide, and prostaglandin analogues such as latanoprost.
creased intracranial pressure (Fig. 4–1). Although the USP- Because of their ability to cause pupillary constriction,
STF has concluded that there is insufficient evidence to pilocarpine and similar medications are now seldom used.
support routine screening for POAG in asymptomatic Laser trabeculoplasty and other surgical interventions are
adults, some experts recommend a comprehensive eye additional treatment options (Table 4–3).
exam including measurement of intraocular pressure for
high-risk patients every 1 to 2 years. D I S C U SSI O N S O U R C E S
Medication treatment options for primary open-angle Mayo Clinic. Glaucoma. http://www.mayoclinic.com/health/glaucoma/
or angle-closure glaucoma include topical beta-adrenergic DS00283
Eyelid Disorders
26. A 22-year-old woman presents with a “pimple” on her
right eyelid. Examination reveals a 2 mm pustule on the
lateral border of the right eyelid margin. This is most
consistent with:
A. a chalazion.
B. a hordeolum.
C. blepharitis.
D. cellulitis.
27. A 22-year-old woman presents with a “bump” on her
right eyelid. Examination reveals a 2 mm, hard, non-
tender swelling on the lateral border of the right eyelid
margin. This is most consistent with:
A. a chalazion.
A
B. a hordeolum.
C. blepharitis.
D. cellulitis.
28. First-line treatment for uncomplicated hordeolum is:
A. topical corticosteroid.
B. warm compresses to the affected area.
C. incision and drainage.
D. oral antimicrobial therapy.
29. A potential complication of hordeolum is:
A. conjunctivitis.
B. cellulitis of the eyelid.
C. corneal ulceration.
B D. sinusitis.
30. Initial treatment for a chalazion is:
A. topical fluoroquinolone.
B. topical corticosteroid.
C. warm compresses of the affected area.
D. surgical excision.
Answers
26. B. 28. B. 30. C.
27. A. 29. B.
C
A hordeolum is often called a stye and is usually caused by a
Figure 4-1 (A) Normal optic disk. (B) Glaucomatous cupping. staphylococcal infection of a hair follicle on the eyelid. An in-
(C) Bulging optic disk in papilledema. ternal hordeolum points toward the conjunctival eye surface,
4074_Ch04_079-104 20/11/14 10:39 AM Page 85
TABLE 4-3
Treatment Options in Glaucoma
Chronic, Primary Open-Angle Intervention (POAG) Acute, Angle-Closure Intervention
• Reduce production of intraocular fluid • Prompt ophthalmological referral
• Topical beta-adrenergic antagonists • Relieve acute intraocular pressure
• Topical alpha2-agonist – Reduce production of intraocular fluid
• Topical carbonic anhydrase inhibitors • Topical beta-adrenergic antagonists
• Surgical intervention if needed to attain normal pressures • Topical alpha2-agonist
• Photocoagulation • Topical carbonic anhydrase inhibitors
• Increase fluid outflow – Increase fluid outflow
– Prostaglandin analogues • Prostaglandin analogues
– Surgical intervention if needed to attain normal pressures • Surgical intervention when pressure normalized
• Trabeculoplasty – Laser peripheral iridectomy
• Trabeculectomy
• Drainage implants
37. The Rinne’s test reveals that air exceeds bone imbalance, a pressure sensation in the ear, and vertigo. The
conduction. reason for the pressure changes varies, but most often they
are caused by an increase in endolymphatic pressure that
38. Pneumatic otoscopy in the affected ear can elicit
causes a break in the membrane separating the two fluids.
symptoms or cause nystagmus.
When these fluids mix, the vestibular nerve receptors are
39. The Romberg test is negative. bathed in the new, abnormal chemical mix, which leads to
depolarization blockade and sudden change in the vestibular
40. A positive Fukuda marching step test.
nerve firing rate. This creates an acute vestibular imbalance
41. When evaluating a patient with Ménière’s disease, the and the resulting sense of vertigo. Symptoms improve after
procedure of observing for nystagmus while moving the membrane is repaired, and normal sodium and potas-
the patient from sitting to supine with the head angled sium concentrations are restored.
45 degrees to one side and then the other is called: A distinction needs to be made between Ménière’s disease,
A. the Romberg test. usually idiopathic in origin, and Ménière’s syndrome, usually
B. Dix-Hallpike test. secondary to various processes that interfere with normal
C. the Rinne’s test. production or resorption of endolymph, such as endocrine
D. the Fukuda test. abnormalities, trauma, electrolyte imbalance, autoimmune
dysfunction, medications, parasitic infections, and hyperlipi-
42. Prevention and prophylaxis in Ménière’s disease
demia. Ménière’s disease is largely a diagnosis of exclusion;
include all of the following except:
diagnosis is made after other possible causes for the recurrent
A. avoiding ototoxic drugs.
and often debilitating symptoms of dizziness, tinnitus, and
B. protecting the ears from loud noise.
low-frequency hearing loss have been ruled out. A distinct
C. limiting sodium intake.
causative lesion cannot be identified. This condition is com-
D. restricting fluid intake.
mon and is characterized by repeat attacks; risk factors include
43. to 46. Match the following to the lettered descriptions: use of ototoxic drugs such as aminoglycosides, long-term,
high-dose salicylate use, certain cancer chemotherapeutics,
43. dizziness A. perception that the person or
and exposure to loud noise.
the environment is moving
44. vertigo Clinical presentation of Ménière’s disease and Ménière’s
B. subjective perception of
syndrome usually involves a history of episodes of vertigo
45. nystagmus altered equilibrium
with a sensation that the room is whirling about, often pre-
C. rhythmic oscillations of the
46. tinnitus ceded by decreased hearing, low-tone roaring tinnitus, and a
eyes
feeling of increased ear pressure. Particularly severe episodes
D. perception of abnormal hear-
are accompanied by nausea and vomiting. Attacks can last
ing or head noises
minutes to hours, with exhaustion often reported after the
most severe symptoms have passed. Duration and frequency
of attacks can vary, although common triggers include certain
Answers foods and drinks, mental and physical stress, and variations
in the menstrual cycle.
31. S. 37. yes 43. B. Examination of a person with Ménière’s disease typically
32. D. 38. yes 44. A. reveals significant nystagmus or rhythmic oscillations of the
33. S. 39. no 45. C. eyes and slow movement toward one side, usually the side of
34. C. 40. yes 46. D. the affected ear, with a rapid correction to the midline. The
35. C. 41. B. Weber tuning test result usually lateralizes to the unaffected
36. no 42. D. ear, whereas the Rinne’s test shows that air exceeds bone con-
duction, a normal finding. Performing pneumatic otoscopy
Ménière’s disease, an idiopathic condition, and Ménière’s in the affected ear can elicit symptoms or cause nystagmus,
syndrome, a condition with symptoms identical to those of whereas the same maneuver to the unaffected ear yields little
Ménière’s disease but in which an underlying cause has been response. Objective measures of hearing often reveal dimin-
identified, are believed to result from increased pressure ished hearing. The Romberg test is positive, with the patient
within the endolymphatic system. In health, two fluids, one showing increased swaying and difficulty staying balanced
potassium-rich and the other potassium-poor, separated by when standing with the eyes closed. Additional findings
a thin membrane, fill the chambers of the inner ear: en- include a positive Fukuda marching step test, in which a
dolymph and perilymph. Housed within the separating directional drift—usually toward the affected ear—is noted
membrane is the nervous tissue of hearing and balance. when the patient is asked to perform a march step with the
Normally, the pressure exerted on these fluids is constant, eyes closed. This latter maneuver may be impossible for a
allowing for normal balance and hearing. If the pressure of patient with severe symptoms. The result of the Dix-Hallpike
these fluids varies, the nerve-rich membranes are stressed, test (i.e., observation of nystagmus while moving a patient
which causes disturbance in hearing, ringing in the ears, from sitting to supine with the head angled 45 degrees to
4074_Ch04_079-104 20/11/14 10:39 AM Page 87
one side and then to the other) is occasionally also positive, 50. An independent risk factor of oral cancer is infection
indicating coexisting benign positional vertigo. Neuroimag- with:
ing is usually not warranted, unless the examination reveals A. human herpes virus type 1.
additional findings, or the diagnosis is unclear. B. human papillomavirus type 16.
Treatment of Ménière’s disease is aimed at minimizing C. adenovirus type 16
or preventing symptoms. Antihistamines such as meclizine D. Epstein-Barr virus
(Antivert, Bonine), antiemetics, or benzodiazepines can min-
51. Screening for oral cancer is recommended:
imize symptoms. Benzodiazepines can be used to help rein-
A. for high-risk patients only.
force rest and minimize anxiety associated with severe
B. at regularly scheduled dental visits.
symptoms; these options do not treat the underlying condi-
C. every two years.
tion. Thiazide diuretics decrease fluid pressure load in the
D. to be conducted by qualified healthcare providers
inner ear and can be used to prevent, but not treat, attacks;
only.
these medications do not help after the attack has been trig-
gered. Corticosteroids also have been shown to be helpful,
likely because of their antiinflammatory properties, causing
a reduction in endolymph pressure and potentially amelio- Answers
rating vertigo, tinnitus, and hearing loss.
When standard therapy is ineffective and severe symp- 47. C. 49. C. 51. B.
toms persist, chemical labyrinthectomy with intratympanic 48. D. 50. B.
gentamicin is a treatment option. Surgery is reserved for pa-
tients with frequent, severely debilitating episodes that are
unresponsive to other, less radical therapies; options include Risk factors for oral cancer include male gender, advancing
endolymphatic sac decompression, vestibular neurectomy, age, and tobacco and alcohol abuse. More recently, chronic
and surgical labyrinthectomy. The possible risk of permanent infection with human papillomavirus type 16 has been ap-
hearing loss with these interventions must be reviewed with preciated as an oral cancer risk factor. Most commonly
the patient. In Ménière’s syndrome, symptomatic treatment squamous cell carcinoma, an oral cancer is usually charac-
and intervention for the underlying cause are warranted. terized by a relatively painless, firm ulceration or raised
lesion. The lymphadenopathy associated with oral cancer
DI SCUSSION SOURCES consists of immobile nodes that are nontender when pal-
http://www.merckmanuals.com/professional/ear_nose_and_throat_ pated. Self-limiting oral lesions, such as herpes simplex,
disorders/inner_ear_disorders/menieres_disease.html?qt=&sc= oral candidiasis, and aphthous stomatitis, usually cause dis-
&alt=, Merck Manual online: Meniere’s disease comfort. With infection, the associated lymphadenopathy
Li J. http://www.emedicine.com/ent/TOPIC232.HTM, eMedicine: that follows drainage tracts is characterized by tenderness
Inner ear, Meniere disease, medical treatment and mobility. Oral cancer screening can occur during reg-
ularly scheduled dental checkups that include an exam of
the entire mouth. The American Cancer Society also rec-
Oral Cancer ommends that healthcare providers examine the mouth
and throat as part of a routine cancer-related checkup.
47. You inspect the oral cavity of a 69-year-old man who has If oral cancer is suspected, referral for a lesion biopsy is
a 100-pack per year cigarette smoking history. You find a recommended.
lesion suspicious for malignancy and describe it as:
A. raised, red, and painful. D I S C U SSI O N S O U R C E S
B. a denuded patch with a removable white coating. http://www.merckmanuals.com/professional/ear_nose_and_throat_
C. an ulcerated lesion with indurated margins. disorders/tumors_of_the_head_and_neck/oral_squamous_cell_
D. a vesicular-form lesion with macerated margins. carcinoma.html, Merck Manual online: Oral squamous cell
carcinoma
48. A firm, painless, relatively fixed submandibular node
http://www.oralcancerfoundation.org/facts, The Oral Cancer Foun-
would most likely be seen in the diagnosis of: dation: Oral cancer facts
A. herpes simplex.
B. acute otitis media (AOM).
C. bacterial pharyngitis.
D. oral cancer. Antibiotic Allergy
49. Which of the following is the most common form 52. Which of the following medications is not a penicillin
of oral cancer? form?
A. adenocarcinoma A. amoxicillin
B. sarcoma-form B. ampicillin
C. squamous cell carcinoma C. dicloxacillin
D. basal cell carcinoma D. imipenem
4074_Ch04_079-104 20/11/14 10:39 AM Page 88
53. A cutaneous reaction nearly always occurs with the 58. A 27-year-old woman presents with acute bacterial rhi-
use of amoxicillin in the presence of infection with: nosinusitis that has failed to respond to 5 days of treat-
A. human herpes virus type 1. ment with amoxicillin. She reports that she experienced
B. human papillomavirus type 11. an allergic reaction to levofloxacin a few years ago that
C. adenovirus type 20. caused a rash as well as swelling of the lips and tongue.
D. Epstein-Barr virus. In deciding on a new antimicrobial, you consider
avoiding the use of:
54. In a person with a well-documented history of systemic
A. amoxicillin-clavulanate.
cutaneous reaction without airway impingement fol-
B. azithromycin.
lowing penicillin use, the use of which of the following
C. moxifloxacin.
cephalosporins is most likely to result in an allergic
D. cefpodoxime.
response?
A. cephalexin 59. You prescribe a regimen of doxycycline to treat
B. cefprozil an acute exacerbation of chronic bronchitis for a
C. ceftriaxone 56-year-old man. This is his first exposure to this
D. cefpodoxime antimicrobial. You advise that:
A. he should not experience an allergic reaction since
55. Which of the following antimicrobial classes is
he has no reported penicillin allergy.
associated with the highest rate of allergic
B. if he experiences any allergic reaction, he should
reaction?
stop taking the antibiotic and contact a healthcare
A. the macrolides
provider immediately.
B. the beta-lactams
C. if he experiences an allergic reaction, he should
C. the aminoglycosides
continue taking the medication until he meets
D. the sulfonamides
with a healthcare provider to avoid resistance
56. A 36-year-old man presents for his initial visit to development.
become a patient in a primary care practice. He is D. any allergic reaction will eventually resolve once the
generally in good health with a history of hyperlipi- regimen is complete.
demia and is currently taking an HMG-CoA reduc-
tase inhibitor. He reports that he is “allergic to just
about every antibiotic,” and reports a variety of Answers
reactions including diffuse urticaria, gastrointestinal
upset, and fatigue but without respiratory involve- 52. D. 55. B. 58. C.
ment. He is unclear as to which antibiotics have 53. D. 56. B. 59. B.
caused these reactions and states that much of what 54. A. 57. D.
he knows is from his mother who “told me I always
got sicker instead of better when I took an antibiotic.”
The penicillins, including penicillin, amoxicillin, dicloxacillin,
His last use of an antimicrobial was more than
ampicillin, and many others, and the cephalosporins, including
10 years ago and was without reaction. He does
a number of antibiotics containing the ceph- or cef- prefix, share
not recall the name of this medication, but he remem-
a common feature: a beta-lactam nucleus in their molecular
bers that he was being treated for a “sinus infection.”
structures. Additional antibiotics with this property include less
The next most appropriate step in his care is to:
commonly used products such as the carbapenems (e.g.,
A. advise the patient to obtain a more detailed
imipenem, usually given with cilastatin [Primaxin]) and the
history of what antibiotics he was given during
monobactams (e.g., aztreonam [Azactam]). Collectively, these
his childhood.
antibiotics are known as the beta-lactams, the antimicrobial class
B. refer to allergy and immunology for evaluation.
with the highest rate of allergic reaction.
C. inform the patient to start an antihistamine
The most common allergic reactions to antibiotics includ-
whenever he is given an antibiotic.
ing the cephalosporins and penicillins are maculopapular
D. provide a prescription for a systemic corticosteroid
skin eruptions, urticaria, and pruritus; more severe reactions
to take if he develops a reaction to his next
include respiratory and cardiovascular compromise. The re-
antimicrobial course.
action’s onset can occur rapidly post drug ingestion, partic-
57. Serious allergic reactions caused by the use of ularly if the patient has been sensitized to the antibiotic by
trimethoprim-sulfamethoxazole include all of the previous exposure; rapid-onset classic symptoms including
following except: urticaria, pruritus, anaphylaxis, and bronchospasm are usu-
A. anaphylaxis. ally considered to be IgE-mediated Type I reactions. Less
B. Stevens-Johnson syndrome. common reaction includes a hypersensitivity syndrome char-
C. toxic epidermal necrolysis. acterized by fever, eosinophilia, and other extracutaneous
D. fixed drug eruptions. manifestations. Approximately 10% of the general population
4074_Ch04_079-104 20/11/14 10:39 AM Page 89
report penicillin allergy. However, this is likely a significant immediate and delayed reactions. Delayed reactions can range
overestimation of this condition’s prevalence. from mild maculopapular exanthema and fixed drug eruptions
Conventional practice is to assume that a patient with to serious manifestations (i.e., anaphylaxis, Stevens Johnson syn-
allergy to penicillin will also exhibit this reaction to the drome, or toxic epidermal necrolysis). Immediate reactions to
cephalosporins. However, the assumption of a 100% cross- fluoroquinolones are uncommon (0.4% to 2.0%) and can involve
sensitivity rate is inaccurate, as historical data suggest that at IgE- or non-IgE-mediated reactions. In rare cases, serious hy-
best, approximately 8% of patients with penicillin allergy will persensitivity and/or anaphylactic reactions have been reported
exhibit cephalosporin sensitivity; when select cephalosporins following the first dose of a fluoroquinolone. Cross reactivity has
are eliminated, the rate is likely less than 1%. Indeed, the ma- been demonstrated with the fluoroquinolones; thus, patients
jority of what has been reported about penicillin-cephalosporin who are allergic to a fluoroquinolone should avoid use of this
allergy has been derived from older retrospective studies in class. Allergic reaction to the macrolides is relatively uncommon
which penicillin allergy was not routinely confirmed by skin (ranging from 0.4% to 3%). Symptoms can range from mild to
testing. Also, many reported penicillin reactions are not allergic life-threatening, including rash or hives, swelling of the face, lips,
in nature. For example, a toddler who develops Candida diaper and tongue, as well as difficulty breathing or swallowing. At the
rash during amoxicillin therapy is brought in by the parents first sign of an allergic reaction, patients should stop taking the
who now believe that since the rash occurred while taking an medication and contact their healthcare provider.
antibiotic, the baby must be penicillin allergic. Some post- When seeing a patient who reports being allergic to virtu-
penicillin–use reactions are not allergic in nature. For example, ally all antibiotics, referral to allergy and immunology for an-
when certain penicillin forms, such as ampicillin and amoxi- tibiotic allergy testing is critical to confirm what medications
cillin, are administered to a person with Epstein-Barr virus are safe to use if the patient presents with an infectious disease
infection, the most common causative organism in mononu- where such therapy is warranted.
cleosis, a cutaneous reaction nearly always occurs; this rash
is thought to be the result of altered immune status during D I S C U SSI O N S O U R C E S
the infection and not indicative of penicillin allergy. In addi- Allergic cross-reactivity among beta-lactam antibiotics: An update.
tion, these historic data were gathered during a time when Pharmacist’s Letter/Prescriber’s Letter 25(4):250427, 2009.
cephalosporins were often contaminated with traces of peni- Gruchalla R, Pirmohamed M. Antibiotic allergy. N Engl J Med
cillin, an obvious trigger for an allergic reaction. 354:601–609, 2006.
James C, Gurk-Turner C. Cross-reactivity of beta-lactam antibiotics.
More recent study supports that the rate of cross-reactivity
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291320/
between penicillins and cephalosporins is probably less than Pichichero, ME. Use of selected cephalosporins in penicillin-allergic
1% and determined by similarity in side chains and not the patients: A paradigm shift. http://www.ncbi.nlm.nih.gov/pubmed/
beta-lactam ring structure. Simply put, the greatest rate of 17349459
cross-reactivity to the penicillins appears to arise from the use Thong BYH. Update on the management of antibiotic allergy.
of the first-generation cephalosporins, including cephalexin Allergy Asthma Immunol Res 2:77–86, 2010.
(Keflex) and cefadroxil (Duricef). As a result of Pichichero’s
meta-analysis, the use of certain second-, third-, and fourth-
generation cephalosporins, including cefprozil (Ceftin), ce- Otitis Externa
furoxime, cefpodoxime (Vantin), ceftazidime, and ceftriaxone
(Rocephin), appears to result in lower allergic risk. 60. A 45-year-old man presents with otitis externa. Likely
For patients with a history of penicillin allergy, whether to causative pathogens include all of the following except:
prescribe a cephalosporin or not requires careful data-gathering A. Enterobacteriaceae.
on the exact reaction that occurs post penicillin use. If the B. P. aeruginosa.
history is consistent with a severe, rapid-onset IgE-mediated- C. Proteus spp.
type response, referral for allergy testing is the most prudent D. M. catarrhalis.
course; this approach should also be considered if the penicillin 61. Risk factors for otitis externa include all of the following
allergy history is unclear. When testing is undertaken, confir- except:
mation of both the presence of penicillin allergy and the pres- A. frequent air travel.
ence or absence of cephalosporin sensitivity is important. This B. vigorous use of a cotton swab.
advice extends to the use of carbapenems and the monobac- C. frequent swimming.
tams. With a history of less severe reactions, clinical judgment D. cerumen impaction.
is warranted. Additional research is needed before the recom-
mendation to use the second-, third-, and fourth-generation 62. Appropriate oral antimicrobial therapy for otitis
cephalosporins can be routinely recommended, although these externa with an accompanying facial cellulitis suitable
medications are listed in a number of treatment guidelines for for outpatient therapy includes a course of an oral:
use in the person with a history of penicillin allergy. A. macrolide.
Allergic reactions to other antibiotic classes can also B. cephalosporin.
occur, though typically less frequently than beta-lactams. C. fluoroquinolone.
Trimethoprim-sulfamethoxazole (TMP-SMX) can cause both D. penicillin.
4074_Ch04_079-104 20/11/14 10:39 AM Page 90
63. Physical examination findings in otitis externa include: if soft tissue extension is of concern. Surgical débridement is
A. tympanic membrane immobility. typically needed. Antipseudomonal antimicrobial therapy is
B. increased ear pain with tragus palpation. usually reserved for severe cases. Parenteral antimicrobial
C. tympanic membrane erythema. therapy is often warranted for severe disease (Table 4–2).
D. tympanic membrane bullae. Effective topical therapies for otitis externa include otic
suspension of an antimicrobial, such as a fluoroquinolone
64. A risk factor for malignant otitis externa includes:
(ofloxacin or ciprofloxacin), or polymyxin B plus neomycin,
A. the presence of an immunocompromised condition.
with or without hydrocortisone solution. When the ear canal
B. age younger than 21 years.
is edematous to the point at which topical antimicrobial drops
C. a history of a recent upper respiratory tract infection
cannot be well distributed, an ear wick is usually inserted and
(URI).
left in place for 2 to 3 days. Aural hygiene using gentle suction
D. a complicated course of otitis media with effusion.
to remove debris can be helpful; irrigation in the presence of
65. Diagnostic approaches commonly used to identify ma- acute infection is usually not advocated. Oral antibiotics
lignant otitis externa include all of the following except: should be prescribed in individuals with cellulitis of the face
A. CT scan. or neck skin, in persons in whom severe edema of the ear
B. x-ray imaging. canal limits penetration of topical agents, and in immuno-
C. radionucleotide bone scanning. compromised persons. If this therapy proves ineffective or in
D. gallium scanning. the presence of severe disease, inpatient hospital admission
and parenteral antimicrobial therapy are likely indicated.
D I S C U SSI O N S O U R C E S
Answers
Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF,
60. D. 62. C. 64. A. Saag MS. The Sanford Guide to Antimicrobial Therapy. 44th ed.
61. A. 63. B. 65. B. Sperryville, VA: Antimicrobial Therapy, Inc., 2014, p 10.
Waitzman A. http://www.emedicine.com/ped/TOPIC1688.HTM,
Risk factors for otitis externa include a history of recent ear eMedicine: Otitis externa
canal trauma, usually after vigorous use of a cotton swab or
other item to clean the canal, and conditions in which moisture
is frequently held in the ear canal, such as with cerumen im- Acute Otitis Media
paction and frequent swimming. Otitis externa can be caused
66 to 69. Indicate which of the following viruses are implicated
by numerous pathogens, including various gram-positive
in causing acute otitis media (AOM). (Answer yes or no.)
organisms and fungi such as Candida or Aspergillus species.
P. aeruginosa is the most common causative agent and the most 66. respiratory syncytial virus
likely organism in refractory otitis externa or accompanying
67. herpes simplex virus 2
cellulitis; cellulitis is an occasional complication of otitis externa,
particularly in the presence of protracted infection or comor- 68. influenza virus
bidity, such as diabetes mellitus or immunosuppression.
69. rhinovirus
Clinical presentation includes redness and edema of the
ear canal accompanied by purulent or serous discharge and 70 to 74. Indicate which of the following bacteria are com-
the hallmark finding of pain on tragus palpation or with the monly implicated in causing AOM. (Answer yes or no.)
application of traction to the pinna. Facial, neck, or auricular
70. S. pneumoniae
cellulitis and unilateral neck lymphadenopathy are noted
with complicated infection. When otitis externa is fungal in 71. H. influenzae
origin, usually the clinical presentation includes a report of
72. E. coli
less pain but more itch; ear discharge is usually described as
being thicker and white to gray in color. 73. M. catarrhalis
Malignant or necrotizing otitis externa, in which infection
74. Risk factors for AOM include all of the following except:
invades the deeper soft tissue, is a complication that occurs
A. upper respiratory tract infection.
in patients who are immunocompromised or in those who
B. untreated allergic rhinitis.
have received radiotherapy to the skull base; osteomyelitis of
C. tobacco use.
the temporal bone is often seen in this rare condition. Pres-
D. aggressive ear canal hygiene.
entation includes the usual features of otitis externa and pain
disproportionate to clinical findings. Radiography is often 75. Expected findings in AOM include:
used to depict the extent of the infection. CT is preferred as A. prominent bony landmarks.
this modality better depicts bony erosion; however, radionu- B. tympanic membrane immobility.
cleotide bone scanning and gallium scanning can also be used C. itchiness and crackling in the affected ear.
to make the diagnosis. MRI can be considered secondarily or D. submental lymphadenopathy.
4074_Ch04_079-104 20/11/14 10:39 AM Page 91
76. A 25-year-old woman has a 3-day history of left ear pain 83. Treatment of otitis media with effusion usually
that began after 1 week of URI symptoms. On physical includes:
examination, you find that she has AOM. She is allergic A. symptomatic treatment.
to penicillin (use results in a rapidly developing hive- B. antimicrobial therapy.
form reaction accompanied by difficulty breathing). She C. an antihistamine.
took an oral antimicrobial for the treatment of a urinary D. a mucolytic.
tract infection 2 weeks ago. The most appropriate oral
antimicrobial option for this patient is:
A. clarithromycin. Answers
B. levofloxacin.
C. amoxicillin. 66. yes 72. no 78. D.
D. cefadroxil. 67. no 73. yes 79. A.
68. yes 74. D. 80. C.
77. A reasonable treatment option for AOM in an adult 69. yes 75. B. 81. B.
who is develops GI upset while taking amoxicillin is: 70. yes 76. B. 82. C.
A. cefpodoxime. 71. yes 77. A. 83. A.
B. erythromycin.
C. cephalexin.
Although often considered a disease limited to childhood,
D. trimethoprim-sulfamethoxazole.
AOM still ranks among the most frequent diagnoses noted
78. Drug-resistant S. pneumoniae is least likely to exhibit re- in adult office visits. S. pneumoniae, H. influenzae,
sistance to which of the following antimicrobial classes? M. catarrhalis, and various viruses contribute to the infec-
A. advanced macrolides tious and inflammatory process of the middle ear. Eu-
B. tetracycline forms stachian tube dysfunction usually precedes the development
C. first-generation cephalosporins of AOM, allowing negative pressure to be generated in the
D. respiratory fluoroquinolones middle ear; this negative pressure enables pharyngeal
pathogens to be aspirated into the middle ear, and the infec-
79. Characteristics of M. catarrhalis include:
tion takes hold. Avoiding conditions that can cause eustachian
A. high rate of beta-lactamase production.
tube dysfunction, such as upper respiratory infection, un-
B. antimicrobial resistance resulting from altered
treated or undertreated allergic rhinitis, tobacco use, and
protein-binding sites.
exposure to air pollution, can lead to a reduction in the
C. often being found in middle ear exudate in recurrent
occurrence of AOM.
otitis media.
S. pneumoniae causes 40% to 50% of AOM. It is the least
D. gram-positive organisms.
likely of the three major causative bacteria to resolve without
80. Which of the following is a characteristic of H. influenzae? antimicrobial intervention (~10% of cases), and infection
A. Newer macrolides are ineffective against the organism. with this organism usually causes the most significant otitis
B. Its antimicrobial resistance results from altered media symptoms. Numerous isolates of this organism exhibit
protein-binding sites within the wall of the bacteria. resistance to many standard, well-tolerated, inexpensive
C. Some isolates exhibit antimicrobial resistance via antibiotic agents, including lower-dose amoxicillin, certain
production of beta-lactamase. cephalosporins, and the macrolides (azithromycin, clar-
D. This is a gram-positive organism. ithromycin, erythromycin). The mechanism of resistance
is an alteration of intracellular protein-binding sites, which
81. Which of the following is a characteristic of
can typically be overcome by using higher doses of amoxi-
S. pneumoniae?
cillin and select cephalosporins. A major risk factor for in-
A. mechanism of antimicrobial resistance primarily
fection with drug-resistant S. pneumoniae is recent systemic
because of the production of beta-lactamase
antimicrobial use.
B. mechanism of antimicrobial resistance usually
H. influenzae and M. catarrhalis are gram-negative organ-
via altered protein-binding sites held within the
isms capable of producing beta-lactamase, an enzyme that
microbe’s cell
cleaves the beta-lactam ring found in the penicillin, amoxi-
C. organisms most commonly isolated from mucoid
cillin, and ampicillin molecule, rendering these antibiotics in-
middle ear effusion
effective against the pathogen. These two organisms have high
D. gram-negative organisms
rates of spontaneous resolution in AOM (50% and 90%, re-
82. Which of the following is absent in otitis media with spectively); however, H. influenzae is the organism most com-
effusion? monly isolated from mucoid and serous middle ear effusion.
A. fluid in the middle ear Organisms producing beta-lactamase likely contribute less to
B. otalgia AOM treatment failure than does prescribing inadequate
C. fever dosages of amoxicillin needed to eradicate drug-resistant
D. itch S. pneumoniae. Common viral agents that cause AOM include
4074_Ch04_079-104 20/11/14 10:39 AM Page 92
human rhinovirus, respiratory syncytial virus, adenovirus, and 86. S. pyogenes is transmitted primarily through:
influenza virus. AOM caused by these viral agents usually A. sexual intercourse.
resolves in 7 to 10 days with supportive care alone. B. skin-to-skin contact.
Appropriate assessment is critical for arriving at the diag- C. saliva and droplet contact.
nosis of AOM. The tympanic membrane may be retracted or D. contaminated surfaces.
bulging and is typically reddened with loss of translucency
87. You are seeing a 25-year-old man with S. pyogenes
and mobility on insufflation. With recovery, tympanic mem-
pharyngitis. He asks if he can get a “shot of penicillin”
brane mobility returns in about 1 to 2 weeks, but middle ear
for therapy. He has no history of drug allergy. You
effusion usually persists for 4 to 6 weeks. Itching and crack-
consider the following when counseling about the use
ling in the ear is common in patients with AOM and in pa-
of intramuscular penicillin:
tients with serous otitis, also known as otitis media with
A. There is nearly a 100% cure rate in streptococcal
effusion. The bony landmarks usually appear prominent
pharyngitis when it is used.
when the tympanic membrane is retracted, a condition usu-
B. Treatment failure rates approach 20%.
ally seen with eustachian tube dysfunction, which may not
C. This is the preferred agent in treating group G
be present in patients with AOM. The submental node is not
streptococcal infection.
in the drainage tract of the middle ear and is not enlarged in
D. Injectable penicillin has a superior spectrum of
patients with AOM. Rather, the nodes within the anterior
antimicrobial coverage compared with the oral
cervical chain on the ipsilateral side of the infection are often
version of the drug.
enlarged and painful.
Initial antimicrobial selection will depend on whether 88. With regard to pharyngitis caused by group C
the patients had recent prior antimicrobial use (within streptococci, the NP considers that:
the past month). High-dose amoxicillin can be used if no A. potential complications include
prior antimicrobials have been used; otherwise, high-dose glomerulonephritis.
amoxicillin, high-dose amoxicillin-clavulanate, or certain B. appropriate antimicrobial therapy helps to
cephalosporins are recommended for patients with recent facilitate more rapid resolution of symptoms.
prior antimicrobial use (Table 4–2). C. infection with these organisms carries a significant
risk of subsequent rheumatic fever.
DI SCUS SION SOURCES D. acute infectious hepatitis can occur if not treated
Cook K. http://www.emedicine.com/emerg/TOPIC351.HTM, eMed- with an appropriate antimicrobial.
icine: Otitis media
Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, 89. A 26-year-old man presents with a progressively
Saag MS. The Sanford Guide to Antimicrobial Therapy. 44th ed. worsening sore throat with dysphagia, trismus, and
Sperryville, VA: Antimicrobial Therapy, Inc., 2014 , p 11. unilateral otalgia. His voice is muffled, and examina-
tion reveals an erythematous, swollen tonsil with
contralateral uvular deviation. The most likely
Acute Pharyngitis diagnosis is:
A. infectious mononucleosis.
84. An 18-year-old woman has a chief complaint of a “sore
B. viral pharyngitis.
throat and swollen glands” for the past 3 days. Her
C. peritonsillar abscess.
physical examination includes a temperature of 101° F
D. early-stage scarlet fever.
(38.3° C), exudative pharyngitis, and tender anterior
cervical lymphadenopathy. Right and left upper quad- 90. Patients with strep throat can be cleared to return to
rant abdominal tenderness is absent. The most likely work or school after _______ hours of antimicrobial
diagnosis is: therapy.
A. Streptococcus pyogenes pharyngitis. A. 12
B. infectious mononucleosis. B. 24
C. viral pharyngitis. C. 36
D. Vincent angina. D. 48
85. Treatment options for streptococcal pharyngitis for a 91. Common causative organisms of peritonsillar abscess
patient with penicillin allergy include all of the follow- include all of the following except:
ing except: A. Fusobacterium necrophorum.
A. azithromycin. B. Candida albicans.
B. trimethoprim-sulfamethoxazole. C. group C or G streptococcus.
C. clarithromycin. D. group A beta-hemolytic streptococcus
D. clindamycin. (GABHS).
4074_Ch04_079-104 20/11/14 10:39 AM Page 93
92. When advising a patient with scarlet fever, the NP 100. A 23-year-old man is diagnosed with pharyngitis
considers that: caused by S. pyogenes serotype 4. Which of the
A. there is increased risk for poststreptococcal following statements is false regarding this patient?
glomerulonephritis. A. Antimicrobial therapy will reduce the risk of
B. the rash often peels during recovery. developing rheumatic fever.
C. an injectable cephalosporin is the preferred treat- B. Onset of glomerulonephritis symptoms can
ment option. occur 1 to 3 weeks after pharyngeal infection.
D. throat culture is usually negative for group A C. Antimicrobial therapy minimizes the risk of
streptococci. glomerulonephritis.
D. Poststreptococcal glomerulonephritis is usually a
93. The incubation period for S. pyogenes is usually:
self-limiting condition.
A. 1 to 3 days.
B. 3 to 5 days. 101. The rash associated with scarlet fever typically
C. 6 to 9 days. occurs how long after the start of the symptomatic
D. 10 to 13 days. infection?
A. 2 days
94. The incubation period for M. pneumoniae is usually:
B. 4 days
A. less than 1 week.
C. 7 to 10 days
B. 1 week.
D. 2 to 3 weeks
C. 2 weeks.
D. 3 weeks. 102. Treatment of scarlet fever in a 19-year-old woman
with no allergy to penicillin can include all of the
95 to 97. Match the patient with the likely causative pathogen
following except:
for pharyngitis.
A. penicillin.
95. S. pyogenes A. A 17-year-old man with B. cefdinir.
a bothersome dry cough, C. TMP-SMX.
96. M. pneumoniae
lymphadenopathy, and D. cefpodoxime.
97. respiratory virus tonsillar enlargement
B. A 34-year-old with
cough, nasal discharge, Answers
hoarseness, conjunctival
inflammation, and 84. A. 91. B. 98. A.
diarrhea 85. B. 92. B. 99. B.
C. A 26-year-old woman 86. C. 93. B. 100. C.
with sore throat and 87. B. 94. D. 101. A.
fever, swollen tonsils 88. B. 95. C. 102. C.
covered with exudate, 89. C. 96. A.
palatal petechiae, 90. B. 97. B.
and anterior cervical
lymphadenopathy S. pyogenes, also known as group A beta-hemolytic strep-
tococcus, is the causative pathogen in 15% to 40% of sore
98. All of the following are common causes of penicillin
throats in school-aged children but is less common in chil-
treatment failure in streptococcal pharyngitis except:
dren younger than 3 years and in teenagers and adults. The
A. infection with a strain of Streptococcus producing
organism is transmitted primarily via saliva and droplet
beta-lactamase.
contact. The incubation period lasts an average of 3 to
B. failure to initiate or complete the antimicrobial
5 days, but can be up to 3 months. Clinical presentation
course.
of exudative pharyngitis caused by S. pyogenes includes
C. concomitant infection or carriage with an organism
complaints of sore throat and fever, and evidence of large,
producing beta-lactamase.
beefy tonsils, usually covered with exudate, palatial pe-
D. inadequate penicillin dosage.
techiae, and anterior cervical lymphadenopathy. Commu-
99. The symptoms of rheumatic fever include: nicability gradually decreases over several weeks in
A. severe, intermittent headaches. untreated patients. Patients are no longer contagious within
B. carditis and arthritis. 24 hours of initiation of appropriate antimicrobial therapy
C. hepatic dysfunction. and when without fever. Asymptomatic nasopharyngeal
D. generalized rash. carriage is common.
4074_Ch04_079-104 20/11/14 10:39 AM Page 94
S. pyogenes is not the sole cause of bacterial exudative but potentially purulent complications of streptococcal
pharyngitis. Another causative pathogen implicated is pharyngitis include otitis media, sinusitis, peritonsillar and
Mycoplasma pneumoniae. Infection with this organism is retropharyngeal abscess, and suppurative cervical adenitis.
uncommon in children 5 years or younger and is most Scarlet fever is the clinical condition seen when a scarla-
often seen in teenagers and younger adults. Clinical pres- tiniform rash with a fine sandpaper-like texture erupts dur-
entation includes inflammatory exudate, pharyngeal edema ing streptococcal pharyngitis, usually on the second day of
and erythema, cervical lymphadenopathy, and tonsillar illness. The rash starts on the trunk and spreads widely, usu-
enlargement. Because this organism is also a cause of acute ally sparing the palms and soles, and usually peels during
bronchitis, the person with M. pneumoniae pharyngitis recovery. Treatment of scarlet fever is identical to treatment
often has a bothersome dry cough; rapid streptococcal of streptococcal pharyngitis and carries no increased risk of
screen and standard throat culture fail to reveal the pres- complications or sequelae.
ence of this organism and yield negative results. The incu- A positive throat culture for Streptococcus pyogenes is con-
bation period for M. pneumoniae is approximately 3 weeks, sidered the diagnostic standard in streptococcal pharyngitis.
and it is usually contracted via cough and respiratory A potential drawback is that a positive result does not distin-
droplet. guish between acute viral pharyngitis with group A strepto-
Clinical findings most often associated with viral pharyn- coccus carriage and acute streptococcal pharyngitis. Despite
gitis include cough, nasal discharge, hoarseness, pharyngeal this, all patients with a positive throat culture should be
ulcerations, conjunctival inflammation, and diarrhea. Groups treated with an appropriate antimicrobial. Rapid antigen
C and G streptococci cause pharyngitis, but infection with detection tests detect the presence of the group A streptococ-
these organisms carries minimal risk for rheumatic fever or cus carbohydrate antigen and can be completed in minutes,
glomerulonephritis. The infection and its resulting symptoms but with lower sensitivity and specificity than standard throat
clear without antimicrobial therapy, but taking an appropri- culture. As a result, many authorities advocate treating in the
ate antimicrobial helps minimize symptoms. presence of a positive rapid streptococcal screen and follow-
Complications of bacterial pharyngitis include periton- ing up negative studies with a throat culture in a patient in
sillar abscess, rheumatic fever, and acute glomerulonephri- whom there is a high index of suspicion. If a rapid strepto-
tis. Peritonsillar abscess is most commonly caused by coccal test result is positive, antimicrobial treatment should
Fusobacterium necrophorum, group A beta-hemolytic be initiated immediately.
streptococcus (GABHS), or groups C and G streptococcus. If a rapid strep screen is negative and a throat culture is
Clinical presentation of peritonsillar abscess includes pro- performed, the question is raised as to whether treatment
gressively worsening sore throat, often worse on one side; should be initiated while awaiting results. In delaying therapy
trismus (inability or difficulty in opening the mouth); until throat culture results are available, treatment for pa-
drooling; a muffled, “hot potato” voice with an erythema- tients with positive cultures is delayed by 2 days. This delay
tous, swollen tonsil with contralateral uvular deviation; and poses little risk in an otherwise well person.
cervical lymphadenopathy. Because airway compromise is In the treatment of bacterial pharyngitis caused by S. pyo-
a potentially life-threatening consequence of peritonsillar genes, penicillin remains highly effective. When the total
abscess, ultrasonography or CT of the affected region daily dosage is given in equally divided twice-daily doses,
should be promptly obtained to confirm the diagnosis. Re- treatment outcomes are equivalent to regimens of three or
ferral to emergency and specialty ENT care and treatment four times daily with significantly improved adherence. A
with appropriate antimicrobial therapy, needle aspiration, single dose of injectable penicillin given intramuscularly
and airway maintenance must be initiated promptly. An- offers a one-time treatment option. Limitations include
timicrobial therapy initiated early in the course of acute increased risk of serious reaction with penicillin allergy and
pharyngitis minimizes peritonsillar abscess risk. a treatment failure rate similar to that of a completed course
Rheumatic fever is usually caused by S. pyogenes of oral therapy. For patients with a penicillin allergy,
serotypes 1, 3, 5, 6, 14, 18, 19, and 24; on average, onset of azithromycin, clarithromycin, or clindamycin are alterna-
symptoms of carditis and arthritis begins about 19 days tives (Table 4–2). Of group A beta-hemolytic streptococcus
(range 7 to 35 days) after the onset of sore throat symp- isolates, 35% are resistant to macrolides or clindamycin;
toms. Antimicrobial treatment is helpful in minimizing these drugs should be used only when a patient has a peni-
rheumatic fever risk. Acute glomerulonephritis is also cillin allergy. Advice on the use of symptomatic treatment
a complication of S. pyogenes, usually serotypes 1, 3, 4, 12, with salt-water gargles, throat lozenges, and analgesics
and 25 when associated with pharyngitis and serotypes 2, should also be given.
4, 9, 55, 57, 59, and 60 when associated with skin infection. When penicillin therapy fails, it is seldom because of a re-
Onset of glomerulonephritis symptoms is usually 1 to sistant S. pyogenes strain. Rather, oropharyngeal carriage
3 weeks after pharyngeal or skin infection. Although post- with an organism producing beta-lactamase, such as H. in-
streptococcal glomerulonephritis is usually a self-limiting fluenzae, is often the problem; the presence of beta-lactamase
condition, patients can develop renal scarring with chronic renders the penicillin ineffective. Treatment with an antimi-
proteinuria or hematuria. Antimicrobial therapy does crobial stable in the presence of beta-lactamase, such as
not minimize glomerulonephritis risk. Infrequently seen amoxicillin-clavulanate or a cephalosporin, is likely to be
4074_Ch04_079-104 20/11/14 10:39 AM Page 95
effective. If the streptococcal test result is negative, and the 109. You prescribe nasal corticosteroid spray for a
patient continues to have symptoms, infection with M. pneu- patient with perennial allergic rhinitis. What is
moniae or Chlamydophila (Chlamydia) pneumoniae should the anticipated onset of symptom relief with
be considered, particularly if cough is present. A macrolide its use?
or fluoroquinolone should be prescribed because beta- A. immediately with the first spray
lactams (penicillins, cephalosporins) are less effective. B. 1 to 2 days
The treatment of S. pyogenes carriage, defined as a positive C. a few days to a week
throat culture in an individual who has no symptoms, war- D. 2 or more weeks
rants mention. Antimicrobial therapy for S. pyogenes carriage
110. Which of the following medications is most appropri-
is indicated only when an outbreak of rheumatic fever or
ate for allergic rhinitis therapy in an acutely sympto-
glomerulonephritis is in progress, when there is a family his-
matic 24-year-old machine operator?
tory of acute rheumatic fever, when multiple documented
A. nasal cromolyn
pharyngitis episodes occur within a family over several weeks
B. diphenhydramine
despite therapy, or when there is an outbreak of streptococcal
C. flunisolide nasal spray
pharyngitis in a closed or semi-closed environment, such as
D. loratadine
a correctional facility or college dormitory. First-line therapy
includes treatment with clindamycin or amoxicillin with 111. Antihistamines work primarily through:
clavulanate; rifampin with penicillin can also be used. A. vasoconstriction.
B. action on the histamine-1 (H1) receptor sites.
DI SCUSSION SOURCES C. inflammatory mediation.
Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, D. peripheral vasodilation.
Saag MS. The Sanford Guide to Antimicrobial Therapy. 44th ed.
Sperryville, VA: Antimicrobial Therapy, Inc., 2014 , pp 48–49. 112. Decongestants work primarily through:
University of Michigan Health System: Acute pharyngitis in children A. vasoconstriction.
2–18 years old. Ann Arbor, MI: University of Michigan Health B. action on the H1 receptor sites.
System, 2011. http://www.guideline.gov/content.aspx?id=25757 C. inflammatory mediation.
Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic D. peripheral vasodilation.
fever and diagnosis and treatment of acute streptococcal pharyn-
gitis (American Heart Association guidelines). Circulation 119: 113. Which of the following medications affords the best
1541–1551, 2009. relief of acute nasal itch?
A. anticholinergic nasal spray
B. oral decongestant
Allergic Rhinitis C. corticosteroid nasal spray
D. oral antihistamine
103. A 25-year-old woman who has seasonal allergic
114. According to the Allergic Rhinitis and Its Effects on
rhinitis likes to spend time outdoors. She asks you
Asthma (ARIA) treatment guidelines, which of the
when the pollen count is likely to be the lowest. You
following medications affords the best relief of acute
respond:
nasal congestion?
A. “Early in the morning.”
A. anticholinergic nasal spray
B. “During breezy times of the day.”
B. decongestant nasal spray
C. “After a rain shower.”
C. corticosteroid nasal spray
D. “When the sky is overcast.”
D. oral antihistamine
104. The physiological response causing allergic rhinitis is
115. According to the ARIA treatment guidelines, which
primarily mediated through:
of the following medications affords the least control
A. IL-10.
of rhinorrhea associated with allergic rhinitis?
B. IgE antibodies.
A. anticholinergic nasal spray
C. anti-IgM antibodies.
B. antihistamine nasal spray
D. anti-TNF antibodies.
C. corticosteroid nasal spray
105 to 108. Match each allergen with the appropriate char- D. cromolyn nasal spray
acteristic. An answer can be used more than once.
116. Ipratropium bromide (Atrovent) helps control nasal
105. pollens A. most common perennial secretions through:
allergen A. antihistaminic action.
106. pet dander
B. most common seasonal B. anticholinergic effect.
107. dust mites allergen C. vasodilation.
C. common indoor allergen D. vasoconstriction.
108. mold spores
4074_Ch04_079-104 20/11/14 10:39 AM Page 96
117. Oral decongestant use should be discouraged in Allergic rhinitis is due to genetic-environmental interac-
patients with: tions. A person with a genetic predisposition to allergens
A. allergic rhinitis. has environmental influences that cause the immune system
B. migraine headache. to shift from a Th1 (non-allergic) state to a predominantly
C. cardiovascular disease. Th2 (allergic) state, which then promotes IgE production.
D. chronic bronchitis. Upon re-exposure to an allergen he/she has been sensitized
to (development of allergen-specific IgE antibodies), an
118. Cromolyn’ s mechanism of action is as a/an:
allergic response will occur with release of histamine and
A. anti–immunoglobulin E antibody.
inflammatory mediators from the mast cells.
B. vasoconstrictor.
Allergic rhinitis is due to both indoor and outdoor aeroal-
C. mast cell stabilizer.
lergens. Dust mites are the most common trigger of perennial
D. leukotriene modifier.
allergy symptoms. Pets, cockroaches, and mold spores are
119. In the treatment of allergic rhinitis, leukotriene other indoor allergens found to cause nasal and ocular allergy
modifiers should be used as: symptoms. Pollens (trees, grasses, and ragweed) are major
A. an agent to relieve nasal itch. triggers in seasonal allergic rhinitis and allergic conjunctivitis.
B. an inflammatory inhibitor. Pollen counts are generally the highest early in the morning,
C. a rescue drug. released shortly after dawn. Pollen travels best on warm, dry,
D. an intervention in acute inflammation. breezy days and is lowest during chilly, wet periods. Some
outdoor mold spores can also cause allergy symptoms.
120. According to the Global Resources in Allergy
Certain spores are highest in dry, breezy weather. Others
(GLORIA) guidelines, which of the following is
need high humidity to release spores, and their counts are
recommended for intervention in persistent allergic
highest during rainy periods.
conjunctivitis?
The most important component of allergic rhinitis and al-
A. topical mast cell stabilizer with a topical antihistamine
lergic conjunctivitis therapy is avoidance of the allergen or re-
B. ocular decongestant
duction if avoidance cannot be achieved. Second-line therapy
C. topical nonsteroidal antiinflammatory drug
includes pharmacotherapy agents designed to relieve and/or to
D. topical corticosteroid
control symptoms. Medications that are used to acutely relieve
121. Allergen subcutaneous immunotherapy should be symptoms (“relievers”) include antihistamines, decongestants,
considered in all of the following except: and, in severe cases, oral corticosteroids. Medications used
A. when allergy symptoms are controlled with to control allergy symptoms (“controllers”) include intranasal
environmental management. corticosteroids, leukotriene modifiers, and mast cell stabilizers.
B. when allergy symptoms persist despite optimal use According to ARIA guidelines, “reliever” medications
of appropriate medications. recommended to treat allergy symptoms include antihist-
C. when there is a desire to reduce the use of allergy amines, decongestants, and a short course of oral corticos-
medications. teroids for severe uncontrolled symptoms. Antihistamines
D. to prevent progression or development of asthma. work by blocking H1 receptor sites. These medications pre-
vent the action of formed histamine, a potent inflammatory
122. Which of the following is most appropriate for the
mediator, and can be used to treat acute allergy symptoms.
treatment of moderate-to-severe allergic rhinitis and
Second-generation antihistamines, such as loratadine
conjunctivitis when symptoms are not controlled with
(Claritin), are to be given first-line. They are effective in re-
current therapy?
lieving symptoms and have little or no sedation. ARIA rec-
A. short course of an oral corticosteroids
ommends avoiding first-generation antihistamines, such
B. single dose of a long-acting parenteral or IM
as diphenhydramine (Benadryl), due to their sedative and
corticosteroids
anticholinergic adverse effects. Nasal antihistamines have
C. daily dose of oral first-generation antihistamine
first-line benefits with seasonal allergic rhinitis associated
D. immediate initiation of allergy immunotherapy
with nasal congestion. Decongestants act as vasoconstric-
tors, opening edematous nasal passages and relieving
congestion. ARIA guidelines suggest limiting topical de-
Answers congestant use to less than 5 days and avoiding use in
preschoolers. Regular use of oral decongestants is to be
103. C. 110. D. 117. C. avoided due to potential adverse effects. Intranasal anti-
104. B. 111. B. 118. C. cholinergic sprays work to inhibit parasympathetic trans-
105. B. 112. A. 119. B. mission to submucosal glands. Their use is limited to
106. C. 113. D. 120. A. relieving refractory rhinorrhea. A short course of oral cor-
107. A. 114. B. 121. A. ticosteroids is recommended in moderate-to-severe allergic
108. C. 115. D. 122. A. rhinitis and conjunctivitis when symptoms are not con-
109. C. 116. B. trolled with current therapy. ARIA strongly recommends
4074_Ch04_079-104 20/11/14 10:39 AM Page 97
TABLE 4-4
Allergic Conjunctivitis Treatment
Nondrug therapies for all classifications • Nondrug therapies
• Avoidance of allergen
• Cool compresses
• Preservative-free artificial tears
• Sunglasses to ameliorate photosensitivity, and possibly provide a degree
of barrier protection against air-borne allergens
For intermittent, seasonal allergic • Controller therapy with
conjunctivitis • Topical antihistamine or topical cromolyn or
• Topical antihistamine with mast cell stabilizer or
• Topical antihistamine with vasoconstrictor or
• Topical NSAID
• If inadequate control for intermittent, seasonal
• Oral antihistamine
Specific allergen immunotherapy • Helpful in managing persistent allergic rhinitis and conjunctivitis
(allergen vaccination) • Of value in patients with multiorgan symptoms of IgE-mediated allergic
sensitization
• Risk-to-benefit ratio must be considered in all cases
• Highly effective in selected patients
• Evaluation and treatment must be made by a clinician with background
in allergen immunotherapy with facilities to treat anaphylaxis
OTC and older pharmacotherapies • Can be helpful, but should not be overused or abused. These products
generally treat the presenting problem (eye redness or itch), but do not
fully address the underlying problem (allergy)
• Ocular vasoconstrictors, helpful at reducing eye redness, but not recom-
mended for regular use. OTC products are often combined with an
antihistamine
• Topical NSAID such as ketorolac, helpful in reducing ocular itch and
redness
Topical ocular corticosteroids • Topical ocular corticosteroids should be prescribed and monitored only
by a suitably qualified clinician, such as a specialist in allergy or ophthalmol-
ogy, and only in the presence of severe allergic ocular disease for
short-term use
• Prolonged use can lead to secondary bacterial infection, glaucoma, and
cataracts. With short-term use, increased risk for ocular viral or fungal
infection
TABLE 4-5
Medications Used in the Treatment of Allergic Rhinitis
Therapeutic Goal Intervention Comment
Controller therapy to prevent • Corticosteroid nasal spray (beclometha- • Controller therapy usually needs
formation of inflammatory sone [Beconase], fluticasone [Flonase], to be used for a few days to
mediators others) 2 weeks before maximum effect
• Leukotriene modifiers (montelukast noted. Little effect on acute
[Singulair], zafirlukast [Accolate]) symptoms
• Mast cell stabilizer (intranasal and
optic cromolyn [NasalCrom])
Rescue therapy by inactivating • Oral antihistamines (first-generation • Using only antihistamine rescue
formed inflammatory mediators [chlorpheniramine, diphenhydramine, therapy usually not as effective
others], second-generation [loratadine, on overall disease control as
cetirizine, fexofenadine, levocetirizine, consistent use of controller
others]) therapy with rescue therapy
• Antihistamine nasal spray (azelastine as an adjunct
[Astelin] nasal spray)
• Antihistamine optic drops (ketotifen
[Zaditor] optic drops)
• Short-term oral corticosteroids
if needed for severe allergic
symptoms
Rescue therapy and symptom • Anticholinergic nasal spray (Ipratropium • Helpful adjuncts as part of rescue
relief by minimizing nasal bromide [Atrovent]) therapy for patient with bother-
discharge • Antihistamine nasal spray (Astelin, some profuse nasal discharge
others)
Rescue therapy and symptom Oral and nasal decongestants • Potential for vasoconstriction
relief by minimizing nasal (alpha-adrenergic agonists such as and increased blood pressure
congestion pseudoephedrine [Sudafed]) and heart rate. Avoid or use
with caution in hypertension,
cardiovascular disease
TABLE 4-6
Causative Pathogens in ABRS (ABS)
Organism Description Resistance
S. pneumoniae Gram-positive diplococci, ABRS causative organism ≥25% drug-resistant (DRSP) via altered pro-
in adults=38%, children=21–33% tein-binding sites that limit antibiotic’s
ability to bind to the pathogen
H. influenzae Gram-negative bacillus, ABRS causative organism ≥30% penicillin-resistant via production of beta-
in adults=36%, children=31–32% lactamase that cleaves to beta-lactam ring
M. catarrhalis Gram-negative coccus, ABRS causative organism ≥90% penicillin-resistant via beta-lactamase
in adults=16%, children=8–11% production
Abbreviations URI-like signs and symptoms either: Risk for antibiotic resistance
CT: computed tomography a) Persistent and not improving (≥10 days); • Age <2 or >65, daycare
MRI: magnetic resonance imaging b) Severe (≥3–4 days); or • Prior antibiotics within
c) Worsening or “double-sickening” (≥3–4 days) the past month
• Prior hospitalization past 5 days
• Comorbidities
Risk for Resistance • Immunocompromised
No Yes
Symptomatic
management
Initiate first-line Initiate second-line
antimicrobial therapy antimicrobial therapy
Improvement after 3–5 days Worsening or no improvement Improvement after 3–5 days
after 3–5 days
Worsening or no improvement
after 3–5 days
Source: Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis
in children and adults. Clin Infect Dis 54:e72–112, 2012.
4074_Ch04_079-104 20/11/14 10:39 AM Page 101
and macrolides. The mechanism of resistance is alterations and patterns of recent antimicrobial use (Table 4–7).
of intracellular protein-binding sites, which can typically Intervention in underlying contributory causes, such as
be overcome by using higher doses of amoxicillin, certain treating allergic rhinitis and encouraging the cessation of
cephalosporins, and respiratory fluoroquinolones (lev- tobacco use, is crucial to treatment success.
ofloxacin [Levaquin] or moxifloxacin [Avelox]). Recent Treatments should also be considered to reduce the
antimicrobial use is the major risk for infection with drug- symptoms associated with ABRS. Saline via nasal spray or
resistant S. pneumoniae. neti pot can be used to rinse nasal passages while a nasal cor-
H. influenzae and M. catarrhalis are gram-negative or- ticosteroid (fluticasone [Flonase], mometasone [Nasonex],
ganisms capable of producing beta-lactamase; the presence budesonide [Rhinocort Aqua], or triamcinolone [Nasacort],
of this enzyme renders the penicillins ineffective. Although others) can be used to reduce inflammation. According to
these two organisms have relatively high rates of sponta- EBP recommendations, the use of decongestants, either oral
neous resolution without antimicrobial intervention in or nasal sprays, is not recommended as adjunctive treatment
AOM, infections caused by these pathogens seldom resolve for patients with ABRS as their use has little to no influence
without antimicrobial therapy in ABRS (see Table 4–6). on patient outcomes. However, an individual patient can
Empiric antimicrobial therapy in ABRS should be aimed at find a degree of symptom relief with these adjunctive thera-
choosing an agent with significant activity against gram- pies. OTC pain relievers (acetaminophen or ibuprofen) can
positive (S. pneumoniae) and gram-negative organisms help alleviate pain.
(H. influenzae, M. catarrhalis), with consideration for
drug-resistant S. pneumoniae risk and possible need for sta- D I S C U SSI O N S O U R C E S
bility in the presence of beta-lactamase. If there is treat- Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice
ment failure, the choice of a new antimicrobial depends on guideline for acute bacterial rhinosinusitis in children and adults.
the initial medication that failed to eradicate the infection Clin Infect Dis 54:e72–e112, 2012.
TABLE 4-7
Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in Adults
Indication Daily dose Comments
Initial empiric therapy First-line High dose (HD, 3-4 g/d) amoxicillin
• Amoxicillin-clavulanate 500 mg/125 mg needed against DRSP
PO TID, or 875 mg/125 mg PO BID Clavulanate as a beta-lactamase in-
Second-line hibitor, allows amoxicillin to have
• Amoxicillin-clavulanate 2000 mg/125 mg activity against beta-lactamase
PO BID producing organisms such as
• Doxycycline 100 mg PO BID or 200 mg H. influenzae, M. catarrhalis
PO daily Doxycycline: DRSP treatment failure
risk, activity against gram-negative
organisms, stable in presence of
beta-lactamase
Pregnancy risk category D
β-lactam allergy Doxycycline 100 mg PO BID or 200 mg PO Respiratory fluoroquinolones (FQ)-
(Allergy to antimicrobials daily Activity against DRSP, gram-negative
with beta-lactam ring Levofloxacin 500 mg PO daily organisms, stable in presence of
such as penicillins, Moxifloxacin 400 mg PO daily beta-lactamase
cephalosporins)
Risk for antibiotic Amoxicillin-clavulanate 2000 mg/125 mg All options with activity against DRSP,
resistance or failed PO BID gram-negative organisms, stable in
initial therapy Levofloxacin 500 mg PO daily presence of and/or active against
Moxifloxacin 400 mg PO daily beta-lactamase
Source: Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis
in children and adults. Clin Infect Dis 54:e72–112, 2012.
4074_Ch04_079-104 20/11/14 10:39 AM Page 102
distress when enlarged tonsils and lymphoid tissue impinge and convalescent stages. The risk for splenic rupture is great-
on the upper airway. A use of a systemic corticosteroid such est in the second and third weeks of illness—hence the man-
as prednisone, 40 to 60 mg/day for 3 days, is the treatment of date of abstaining from collision or contact sports for at least
choice, although little evidence exists to support this practice. one month. The risk of rupture is greatest in the enlarged
However, the use of prednisone in a person with infectious spleen; the size of the normal spleen can be recalled by the
mononucleosis who is having difficulty swallowing due to “rules of odds”: 1 × 3 × 5 inches in size, weighing 7 oz. (about
pharyngeal edema often provides symptomatic relief. In un- 200 g), and lying between ribs 9 and 11. When the spleen is
complicated infectious mononucleosis, neither the use of an- easily palpated, its size is usually increased by two or more
tiviral agents such as acyclovir nor routine prescribing of times normal. The physical examination is a relatively insen-
systemic corticosteroid agents is indicated. Use of amoxicillin sitive measure of splenic size, however. Obtaining an ultra-
or ampicillin should be avoided as this can cause a cutaneous sound examination may be a prudent measure to ensure
reaction (rash) in patients with Epstein-Barr virus infection. splenic regression before approving return to sports play. All
This rash is thought to be the result of altered immune status persons with infectious mononucleosis are at risk of splenic
during the infection and not indicative of penicillin allergy. rupture, however, regardless of spleen size.
In a person who participates in contact or collision sports
or other activities, the risk of splenic rupture, the most com- D I S C U SSI O N S O U R C E
mon cause of mortality and morbidity in patients with in- Singer-Leshinsky S. Pathogenesis, diagnostic testing, and manage-
fectious mononucleosis, needs to be considered during acute ment of mononucleosis. JAAPA 25:58–62, 2012.
4074_Ch04_079-104 20/11/14 10:39 AM Page 104
4074_Ch05_105-126 20/11/14 10:40 AM Page 105
Cardiac Disorders 5
Hypertension 4. Diagnostic testing for a patient with newly diagnosed
primary hypertension diagnosis should include all of
1. You examine a 38-year-old woman who has presented the following except:
for an initial examination and Papanicolaou test. She has A. hematocrit.
no complaint. Her blood pressure (BP) is 154/98 mm Hg B. uric acid.
bilaterally and her body mass index (BMI) is 31 kg/m2. C. creatinine.
The rest of her physical examination is unremarkable. D. potassium.
Your next best action is to: 5. In the person with hypertension, which of the following
A. initiate antihypertensive therapy. would likely yield the greatest potential reduction in BP
B. arrange for at least two additional BP measurements in a patient with a BMI of 30 kg/m2?
during the next 2 weeks. A. 10-kg (22-lb) weight loss
C. order blood urea nitrogen, creatinine, and potassium B. dietary sodium restriction to 2.4 g (6 g NaCl) per day
ion measurements and urinalysis. C. regular aerobic physical activity, such as 30 minutes
D. advise her to reduce her sodium intake. of brisk walking most days of the week
2. You see a 68-year-old woman as a patient who is trans- D. moderation of alcohol consumption
ferring care into your practice. She has a 10-year history 6 to 10. Match the antihypertension medication with its
of hypertension, diabetes mellitus, and hyperlipidemia. appropriate class.
Current medications include hydrochlorothiazide, glip- 6. amlodipine A. beta-adrenergic receptor
izide, metformin, simvastatin, and daily low-dose as- 7. diltiazem antagonist
pirin. Today’s BP reading is 158/92 mm Hg, and the rest 8. trandolapril B. nondihydropyridine calcium
of her history and examination is unremarkable. Docu- 9. telmisartan channel blocker
mentation from her former healthcare provider indicates 10. pindolol C. dihydropyridine calcium
that her BP has been in the range for the past 12 months. channel blocker
Your next best action is to: D. angiotensin receptor
A. prescribe an angiotensin-converting enzyme inhibitor antagonist
(ACEI). E. ACE inhibitor
B. have her return for a BP check in 1 week.
C. advise that her current therapy is adequate. 11. You see a 38-year-old African-American male with hy-
D. add therapy with an aldosterone antagonist. pertension who is currently being treated with thiazide-
type diuretic. His current blood pressure reading is
3. You examine a 78-year-old woman with long-standing, 156/94 mm Hg and he has no history of diabetes melli-
poorly controlled hypertension. When evaluating her tus or chronic kidney disease. Following current best
for hypertensive target organ damage, you look for evidence, you consider adding which of the following
evidence of: medications?
A. lipid abnormalities. A. ACE inhibitor
B. insulin resistance. B. angiotensin receptor blocker
C. left ventricular hypertrophy. C. beta-adrenergic receptor antagonist
D. clotting disorders. D. calcium channel blocker
105
4074_Ch05_105-126 20/11/14 10:40 AM Page 106
12. Nondihydropyridine calcium channel blockers are 18. Which of the following can have a favorable effect on a
contraindicated in patients with: comorbid condition in a person with hypertension?
A. type 1 diabetes mellitus. A. chlorthalidone in gout
B. history of venous thromboembolism. B. propranolol with airway disease
C. severe left ventricular dysfunction. C. aldosterone antagonist in heart failure
D. concomitant treatment with an ACEI. D. methyldopa in an older adult
13. In obtaining an office BP measurement, which of the 19. According to JNC-8 guidelines, all of the following
following is most reflective of the best practice? medications are first-line agents for use in a middle-
A. Patient should sit in chair with feet flat on floor for aged white man without diabetes mellitus except:
at least 5 minutes before obtaining the reading. A. lisinopril.
B. The BP cuff should not cover more than 50% of B. hydrochlorothiazide.
the upper arm. C. metoprolol.
C. The patient should sit on the edge of the examina- D. amlodipine.
tion table without arm support to enhance reading
20. You see a 59-year-old man with poorly controlled
accuracy.
hypertension. On physical examination, you note
D. Obtaining the BP reading immediately after the patient
grade 1 hypertensive retinopathy. You anticipate all
walks into the examination room is recommended.
of the following will be present except:
14. A BP elevation noted only at an office visit is commonly A. patient report of acute visual change.
known as _____________ hypertension. B. narrowing of the terminal arterioles.
A. provider-induced C. sharp optic disc borders.
B. clinical D. absence of retinal hemorrhage.
C. white coat
21. According to JNC-8, a 52-year-old well woman with
D. pseudo
a healthy BMI whose blood pressure is consistently
15. The most important long-term goal of treating 130–135/82–86 mm Hg is considered to have:
hypertension is to: A. normal blood pressure.
A. strive to reach recommended numeric BP B. hypertension requiring therapy with a CCB.
measurement. C. hypertension requiring therapy with an alpha
B. avoid disease-related target organ damage. blocker.
C. develop a plan of care with minimal adverse effects. D. hypertension requiring therapy with a thiazide-type
D. treat concomitant health problems often noted in diuretic.
the person with this condition.
22. Which of the following is associated with the highest
16. You start a patient with hypertension who is already risk of ischemic heart disease?
receiving an ACEI on spironolactone. You advise the A. presence of microalbuminuria plus heavy alcohol
patient to return in 4 weeks to check which of the intake
following laboratory parameters? B. absence of microalbuminuria plus use of a
A. sodium thiazolidinedione
B. calcium C. absence of microalbuminuria plus chronic physical
C. potassium inactivity
D. chloride D. presence of microalbuminuria plus cigarette
smoking
17. A 68-year-old woman presents with hypertension
and BP of 152–158/92–96 mm Hg documented over 23. When compared with Caucasians, African Americans
2 months on three different occasions. Electrocardio- tend to have a reduced effect with monotherapy
gram (ECG) and creatinine are normal, and she has no with all of the following blood pressure medications
proteinuria. Clinical findings include the following: except:
BMI 26.4 kg/m2; no S3, S4, or murmur; and point of A. ACEIs.
maximal impulse at fifth intercostal space, mid-clavicu- B. ARBs.
lar line. Which of the following represents the best in- C. calcium channel blockers.
tervention? D. beta blockers.
A. Initiate therapy with metoprolol.
B. Initiate therapy with hydrochlorothiazide.
C. Initiate therapy with methyldopa.
D. Continue to monitor BP, and start drug therapy if
evidence of target organ damage.
4074_Ch05_105-126 20/11/14 10:40 AM Page 107
24 to 29. Match the recommended blood pressure goal for each patient according to JNC-8 guidelines. An answer can be
used more than once.
24. a 57-year-old white male with no history of diabetes mellitus (DM) or A. <130/80 mm Hg
chronic kidney disease (CKD) B. <140/80 mm Hg
25. a 62-year-old African-American male with diabetes mellitus C. <140/90 mm Hg
26. a 67-year-old female with CKD D. <150/90 mm Hg
27. a 62-year-old female with no history of DM or CKD
28. an 82-year-old male with no history of DM or CKD
29. a 72-year-old female with DM and CKD
30. You see a 62-year-old man without chronic kidney 31. Which of the following statements concerning postural
disease or diabetes mellitus who is currently being hypotension in the elderly is false?
treated with low dose HCTZ and losartan. His blood A. It increases the risk of falls and syncope.
pressure is currently 162/88 mm Hg. All of the follow- B. It is characterized by a drop in blood pressure
ing are appropriate next courses of action except: when going from a standing to a sitting position.
A. increasing the dose of losartan. C. It increases the risk of cardiovascular events.
B. adding a beta-adrenergic receptor antagonist. D. It is associated with the use of vasodilating
C. adding a calcium channel blocker. medications.
D. increasing the dose of HCTZ.
32 to 37. According to American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guide-
lines, when treating elderly patients with hypertension, which of the following medications have a compelling indication
for use in the following patient conditions? (The medications listed can be used more than once. A given condition can
have more than one medication indicated.)
32. Heart failure A. thiazide diuretic
B. beta blocker
33. Diabetes mellitus
C. ACEI
34. Angina pectoris B D. angiotensin receptor blocker (ARB)
E. aldosterone antagonist
35. Coronary artery disease
F. calcium channel blocker
36. Aortic aneurysm
37. Recurrent stroke prevention
Answers
1. B. 14. C. 27. D.
2. A. 15. B. 28. D.
3. C. 16. C. 29. C.
4. B. 17. B. 30. B.
5. A. 18. C. 31. B.
6. C. 19. C. 32. A, B, C, D, E, F.
7. B. 20. A. 33. A, B, C, D, F.
8. E. 21. A. 34. B, F.
9. D. 22. D. 35. A, B, C, F.
10. A. 23. C. 36. A, B, C, F.
11. D. 24. C. 37. A, C, D, F.
12. C. 25. C.
13. A. 26. C.
Hypertension (HTN) is a complex disease with a core defect myocardial infarction (MI) by 20% to 25%, and reduction of
of vascular dysfunction that leads to select target organ damage heart failure by 50%. Long-standing poorly controlled HTN is
(TOD); the target organs include the brain, eye, heart, and kid- the leading cause of new-onset heart failure.
neys (Table 5–1). Appropriate HTN treatment significantly Evidence-based guidance for the diagnosis, prevention, and
reduces TOD risk. When a BP reading of 115/75 mm Hg is treatment of HTN include the following recommendations.
used as a starting point, cardiovascular disease risk doubles • Accurate clinical assessment depends on proper measure-
with each increment of 20/10 mm Hg. HTN control leads to a ment of BP. The patient should be seated in a chair with
reduction of stroke incidence by 35% to 40%, reduction of feet flat on floor, without crossed legs, with arm supported
4074_Ch05_105-126 20/11/14 10:40 AM Page 108
TABLE 5-1
Hypertension: A Complex Disease With a Core Defect of Vascular Dysfunction That Leads
to Select Target Organ Damage
Target Organ Potential Damage Outcome With Known Moderation as a Result of Effective
Antihypertension Therapy
Brain Stroke, vascular (multi-infarct) dementia
Cardiovascular system Atherosclerosis, myocardial infarction, left-ventricular hypertrophy, heart failure
Kidney Hypertensive nephropathy, renal failure
Eye Hypertensive retinopathy with risk for blindness
at heart level, for at least 5 minutes before taking the BP initiating pharmacologic therapy in the general popula-
measurement, not on an examination table with feet tion ≥60 years when SBP is ≥150 mm Hg or DBP
dangling. Failure to perform these measures can lead to ≥90 mm Hg, with a treatment goal of <150/90 mm Hg.
an artificially elevated reading and lack of standardization For those <60 years, pharmacologic therapy should be
from visit to visit. The BP cuff should be wide enough to initiated when SBP is ≥140 mm Hg or DBP ≥90 mm Hg,
cover more than 80% of the upper arm, and the cuff’s with a treatment goal of <140/90 mm Hg.
bladder should be approximately 40% of the arm circum- • JNC-8 recommendations for BP goals include less than
ference. The use of a cuff that does not meet these 140/90 mm Hg in the presence of chronic kidney disease
qualifications can lead to a falsely elevated BP reading (CKD) or diabetes mellitus. In those with CKD and
(Table 5–2). ≥18 years (regardless of race or diabetes status), initial
• Lifestyle modification can yield significant improvement or add-on therapy should include an ACEI or ARB to
in BP measurements (Table 5–3). improve kidney outcomes.
• JNC-8 limits the preferred first-line and later-line med- • In more than two-thirds of individuals with hyperten-
ications to four classes: thiazide-type diuretics, calcium sion, their HTN cannot be controlled on one drug, and
channel blockers (CCBs), angiotensin-converting enzyme they require two or more antihypertensive agents selected
inhibitors (ACEIs), and angiotensin receptor blockers from different drug classes.
(ARBs). Second- and third-line alternatives can include • Along with the traditional risks, microalbuminuria (MA)
higher doses or combinations of agents in these four or glomerular filtration rate of less than 60 mL/min is
classes. identified as a cardiovascular risk factor. When adjusted
• Prior to using beta blockers, aldosterone antagonist or for other risk factors, the relative risk of ischemic heart
other classes of agents, JNC-8 recommends patients first disease associated with MA is increased twofold. An inter-
receive a dose adjustment and combination of the four action between MA and cigarette smoking has been
first-line agents. Triple therapy with an ACEI/ARB, CCB, noted, and the presence of MA more than doubled the
and thiazide-type diuretic would precede use of a beta predictive effect of the conventional atherosclerotic risk
blocker, aldosterone antagonist or other alternative agent. factors for development of ischemic heart disease. MA not
• The most important goal of HTN treatment is the avoid- only is an independent predictor of ischemic heart dis-
ance of target organ damage (TOD). JNC-8 recommends ease, but it also substantially increases the risk associated
TABLE 5-2
Keys to an Accurate Blood Pressure Measurement
• Take ≥2 measurements per visit (auscultatory method preferred)
• Have patient be seated comfortably for ≥5 minutes with back supported, feet on floor, and arm supported in
horizontal position
• Blood pressure cuff placed at heart level
To detect postural hypotension or hypertension
• Take blood pressure measurement with patient standing for 1–3 minutes
4074_Ch05_105-126 20/11/14 10:40 AM Page 109
TABLE 5-3
Lifestyle Modification in Hypertension
Average Systolic Blood
Modification Recommendation Pressure Reduction Rate
Weight reduction Maintain normal body weight (body mass index 5–20 mm Hg/10 kg
18.5–24.9 kg/m2)
DASH eating plan Adopt a diet rich in fruits, vegetables, and low-fat 8–14 mm Hg
dairy products with reduced content of saturated
and total fat
Dietary sodium reduction Reduce dietary sodium intake to <100 mmol/d 2–8 mm Hg
(2.4 g sodium or 6 g sodium chloride)
Aerobic physical activity Regular aerobic physical activity (e.g., brisk 4–9 mm Hg
walking) at least 30 min per day, most days of
the week
Moderation of alcohol Men: limit to ≤2 drinks* per day 2–4 mm Hg
consumption Women and lighter weight persons: limit to
≤1 drink* per day
with other established risk factors. Because the person and thus should be limited to patients with normal left
with MA has significant cardiovascular disease risk, ventricular function. These agents are contraindicated
recommendations for HTN treatment include thiazide in patients with severe left ventricular dysfunction and
diuretics, beta blockers, ACEIs, and calcium channel in those with second- or third-degree AV block in the
blockers, particularly nondihydropyridine; in the absence of a pacemaker.
presence of chronic renal disease, as manifested by The prevalence of hypertension increases in older popu-
MA, recommendations also include the use of an ACEI lations. In the elderly, hypertension is characterized by
and an ARB. an elevated systolic blood pressure with normal or low
• People of African ancestry show reduced BP responses to diastolic blood pressure, which is a consequence of age-
monotherapy with ACEIs, ARBs, and beta blockers com- associated stiffening of the large arteries. The therapeutic
pared with diuretics or calcium channel blockers. Al- target blood pressure goal in the elderly is <140/90 mm Hg
though complete explanations for these racial differences in persons aged 65–79 years and a systolic blood pressure of
are unknown, what is known is that HTN is the most 140–145 mm Hg in persons aged 80 years, if reasonable.
common cause of renal failure in African Americans. When considering blood pressure medications, healthcare
• In the presence of CKD, JNC-8 recommends an ACEI providers must be vigilant about treatment-related adverse
or an ARB should be prescribed to minimize renal effects due to a high prevalence of cardiovascular and non-
disease risk regardless of race. Using an ACEI or an cardiovascular comorbidities among the elderly. Some major
ARB as part of multidrug therapy, including a calcium concerns with the use of blood pressure medications include
channel blocker and thiazide diuretic, is likely to electrolyte disturbances, renal dysfunction, and excessive
be needed. ACEIs and ARBs should not be used in orthostatic blood pressure decline. Postural hypotension,
combination. defined as a fall in blood pressure of ≥20 mm Hg systolic,
• Nondihydropyridine calcium channel blockers (vera- ≥10 mm Hg diastolic, or both within 3 minutes of standing
pamil, diltiazem) are particularly helpful for BP control upright, increases the risk of falls, syncope, and cardiovas-
and renal protection. However, these drugs are potent in- cular events in the elderly. Similar to younger adults, a
hibitors of cytochrome P450 3A4 isoenzyme and should combination of medications is often needed to control
be used with caution with other medications that are sub- hypertension in the elderly, and initiation with combination
strates of this isoenzyme, such as calcineurin inhibitors. therapy should be considered if blood pressure is >20/10 mm
Nondihydropyridines also reduce the heart rate as they Hg above goal. Many conditions provide compelling indica-
induce bradycardic and negatively inotropic effects tions to use certain drugs in the elderly (Table 5–4).
4074_Ch05_105-126 20/11/14 10:40 AM Page 110
TABLE 5-4
Compelling Indications for Individual Drug Classes in Elder Patients
Angiotensin Calcium
Beta-adrenergic Converting Angiotensin Antagonist
Receptor Enzyme Receptor (Calcium
Thiazide Antagonist Inhibitor Blocker Channel Aldosterone
Diuretic (Beta Blocker) (ACEI) (ARB) Blocker) Antagonist
Heart failure √ √ √ √ √ √
Post myocardial √ √ √ √
infarction
CAD or high CVD √ √ √ √
risk
Diabetes √ √ √ √ √
Angina pectoris √ √
Aortopathy/aortic √ √ √ √
aneurysm
Recurrent stroke √ √ √ √
prevention
Source: Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 Expert consensus document on hypertension in
the elderly. J Am Coll Cardiol. 57:2037–2114, 2011. Available at: http://www.medpagetoday.com/upload/
2011/4/25/j.jacc.2011.01.008v1.pdf
43. When a heart valve fails to open to its normal orifice 51. Of the following patients, who is in greatest need of
size, it is said to be: endocarditis prophylaxis when planning dental work?
A. stenotic. A. a 22-year-old woman with MVP with trace mitral
B. incompetent. regurgitation noted on echocardiogram
C. sclerotic. B. a 54-year-old woman with a prosthetic aortic valve
D. regurgitant. C. a 66-year-old man with cardiomyopathy
D. a 58-year-old woman who had a three-vessel coronary
44. When a heart valve fails to close properly, it is said
artery bypass graft with drug-eluting stents 1 year ago
to be:
A. stenotic. 52. Of the following people, who has no significant in-
B. incompetent. creased risk for developing bacterial endocarditis?
C. sclerotic. A. a 43-year-old woman with a bicuspid aortic valve
D. regurgitant. B. a 55-year-old man who was diagnosed with a Still’s
murmur during childhood
45. Upon detection of a suspected pathologic cardiac mur-
C. a 45-year-old woman with a history of endocarditis
mur, the next step in obtaining a diagnostic procedures
D. a 75-year-old man with dilated cardiomyopathy
usually includes a:
A. ventilation perfusion scan. 53. You are examining an 85-year-old woman and find a
B. echocardiogram. grade 3/6 crescendo–decrescendo systolic murmur with
C. pulmonary artery angiography. radiation to the neck. This is most likely caused by:
D. cardiac CT scan. A. aortic stenosis.
B. aortic regurgitation.
46. You are evaluating a patient who has rheumatic heart
C. anemia.
disease. When assessing her for mitral stenosis, you
D. mitral stenosis.
auscultate the heart, anticipating finding the following
murmur: 54. Aortic stenosis in a 15-year-old male is most likely:
A. systolic with wide radiation over the precordium A. a sequela of rheumatic fever.
B. localized diastolic with little radiation B. a result of a congenital defect.
C. diastolic with radiation to the neck C. calcific in nature.
D. systolic with radiation to the axilla D. found with atrial septal defect.
47. In evaluating mitral valve incompetency, you expect to 55. A risk factor for acquired aortic stenosis is:
find the following murmur: A. history of pulmonary embolism.
A. systolic with radiation to the axilla B. COPD.
B. diastolic with little radiation C. type 2 diabetes.
C. diastolic with radiation to the axilla D. prior rheumatic fever.
D. localized systolic
56. Management of mild aortic stenosis in a 12-year-old
48. In evaluating the person with aortic stenosis, the NP boy usually includes:
anticipates finding 12-lead ECG changes consistent A. ongoing monitoring with ECG and echocardiogram.
with: B. use of a balloon catheter to separate fused valve
A. right bundle branch block. leaflets.
B. extreme axis deviation. C. valve replacement.
C. right atrial enlargement. D. use of warfarin or other anticoagulant.
D. left ventricular hypertrophy.
57. A physiological murmur has which of the following
49. Signs and symptoms consistent with endocarditis in- characteristics?
clude all of the following except: A. occurs late in systole
A. bradycardia. B. is noted in a localized area of auscultation
B. Osler’s nodes. C. becomes softer when the patient moves from supine
C. hematuria. to standing
D. petechiae. D. frequently obliterates S2
50. From the list below, the most helpful test in suspected 58. You are examining an 18-year-old man who is seeking
bacterial endocarditis includes: a sports clearance physical examination. You note a
A. urine culture. mid-systolic murmur that gets louder when he stands.
B. blood culture. This may represent:
C. chest X-ray. A. aortic stenosis.
D. myocardial biopsy. B. hypertrophic cardiomyopathy.
C. a physiologic murmur.
D. a Still’s murmur.
4074_Ch05_105-126 20/11/14 10:40 AM Page 112
59. According to recommendations of the American Heart Heart murmurs are caused by the sounds produced from tur-
Association (AHA), which of the following antibiotics bulent blood flow. Blood traveling through the chambers and
should be used for endocarditis prophylaxis in patients great vessels is usually silent. When the flow is sufficient to
who are allergic to penicillin? generate turbulence in the wall of the heart or great vessel, a
A. erythromycin murmur occurs.
B. dicloxacillin Murmurs are often benign; the examiner simply hears the
C. azithromycin blood flowing through the heart, but no cardiac structural
D. ofloxacin abnormality exists. Certain cardiac structural problems, such
as valvular and myocardial disorders, however, can con-
60. A grade III systolic heart murmur is usually:
tribute to the development of a murmur (Table 5–5).
A. softer than the S2 heart sound.
Normal heart valves allow one-way, unimpeded, forward
B. about as loud as the S1 heart sound.
blood flow through the heart. The entire stroke output
C. accompanied by a thrill.
is able to pass freely during one phase of the cardiac cycle
D. heard across the precordium but without
(diastole with the atrioventricular valves, systole with the
radiation.
others), and there is no backflow of blood. When a heart
61. The S3 heart sound has all of the following characteris- valve fails to open to its normal orifice, it is stenotic. When
tics except: it fails to close appropriately, the valve is incompetent, caus-
A. heard in early diastole ing regurgitation of blood to the previous chamber or vessel.
B. a presystolic sound Both of these events place a patient at significant risk for
C. noted in the presence of ventricular overload embolic disease.
D. heard best with the bell of the stethoscope Physiologic murmurs are heard in the absence of cardiac
pathology. The term physiologic implies that the reason for
62. The S4 heart sound has which of the following
murmur is something other than obstruction to flow and that
characteristics?
the murmur is present with a normal gradient across the
A. After it is initially noted, it is a permanent
valve. This murmur is heard in 80% of thin adults or children
finding.
if the cardiac examination is performed in a soundproof
B. It is noted in the presence of poorly controlled
booth, and it is best heard at the left sternal border. The phys-
hypertension.
iological murmur occurs in early to mid systole, leaving the
C. It is heard best in early diastole.
S1 and S2 heart sounds intact. In addition, an individual with
D. It is a high-pitched sound best heard with the
a benign systolic ejection murmur denies having cardiac
diaphragm of the stethoscope.
symptoms and has an otherwise normal cardiac examination,
63. Of the following individuals, who is most likely to including an appropriately located point of maximum im-
have a physiological split S2 heart sound? pulse and full pulses. Because no cardiac pathology is present
A. a 19-year-old healthy athlete with a physiologic murmur, no endocarditis prophylaxis is
B. a 49-year-old with well-controlled hypertension needed. Once a heart murmur is detected, an ECG is used to
C. a 68-year-old with stable heart failure detect heart rhythm and structure problems including cham-
D. a 78-year-old with cardiomyopathy ber hypertrophy. A transthoracic or transesophageal echocar-
diogram is used to create moving images of the heart to
64. Idiopathic hypertrophic subaortic stenosis (IHSS) is
identify abnormal heart valves, such as those that are calcified
inherited in a:
or leaking, as well as other heart defects. A cardiac CT or MRI
A. sex-linked recessive manner.
can also be used to visualize heart defects that may cause the
B. sex-linked dominant manner.
murmur; its use is typically limited to clinical situations
C. autosomal-recessive manner.
where the echocardiogram results require clarification.
D. autosomal-dominant manner.
Aortic stenosis (AS) is the inability of the aortic valves to
open to an optimal orifice. The aortic valve normally opens
to 3 cm2; AS usually does not cause significant symptoms
Answers until the valvular orifice is limited to 0.8 cm2. The disease is
characterized by a long symptom-free period with rapid clin-
38. A. 47. A. 56. A. ical deterioration at the onset of symptoms, including dysp-
39. D. 48. D. 57. C. nea, syncope, chest pain, and heart failure (HF). Low pulse
40. D. 49. A. 58. B. pressure, the difference between the systolic and diastolic
41. B. 50. B. 59. C. blood pressure, is a characteristic of severe AS.
42. D. 51. B. 60. B. When AS is present in adults who are middle-aged and
43. A. 52. B. 61. B. older, it is most often the acquired form. Risk factors for ac-
44. B. 53. A. 62. B. quired AS include older age and previous rheumatic fever.
45. B. 54. B. 63. A. In an older adult, the problem is usually calcification, leading
46. B. 55. D. 64. D. to the inability of the valve to open to its normal orifice.
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TABLE 5-5
Assessment of Common Cardiac Murmurs in Adults
WHEN EVALUATING AN ADULT WITH CARDIAC MURMUR
Ask about major symptoms of heart disease: chest pain, heart failure symptoms, palpitations, syncope, activity intolerance
The bell of the stethoscope is most helpful for auscultating lower pitched sounds, whereas the diaphragm is most helpful
for higher pitched sounds
Systolic murmurs are graded on a 1–6 scale, from barely audible to audible with stethoscope off the chest. Grade 3 mur-
mur is about as loud as S1 or S2, whereas grade 2 murmur is slightly softer; grade 1 murmur is difficult to hear. Grade
≥4 murmurs are usually accompanied by a thrill, or the feel of turbulent blood flow. Diastolic murmurs are usually graded
on the same scale but abbreviated to grades 1–4 because these murmurs are not loud enough to reach grades 5 and 6.
A critical part of the evaluation of a person with a heart murmur is to decide to offer antimicrobial prophylaxis. No prophy-
laxis is needed with benign murmurs. Please refer to the American Heart Association’s Guideline for the latest advice.
Important Cardiac
Murmur Examination Findings Additional Findings Comments
Physiological Grade 1–3/6 early- to mid-systolic No radiation beyond Etiology probably flows over aortic
(also known murmur heard best at left sternal precordium. Softens valve. May be heard in ~80% of
as innocent, border, but usually audible over or disappears with thin adults if examined in sound-
functional) precordium standing, increases in proof room. Asymptomatic with no
intensity with activity, report of chest pain, heart failure
fever, anemia. S1, S2 symptoms, palpitations, syncope,
intact, normal PMI activity intolerance
Aortic stenosis Grade 1–4/6 harsh systolic Radiates to carotids, In younger adults, usually congenital
murmur, usually crescendo– may have diminished bicuspid valve. In older adults, usu-
decrescendo pattern, heard best S2, slow filling carotid ally calcific, rheumatic in nature.
at second right intercostal space, pulse, narrow pulse Dizziness and syncope ominous
apex, softens with standing pressure, loud S4, signs, pointing to severely
heaving PMI. The decreased cardiac output
greater the degree of
stenosis, the later the
peak of murmur
Aortic sclerosis Grade 2–3/6 systolic ejection Carotid upstroke full, Benign thickening or calcification,
murmur heard best at second not delayed, no S4, or both, of aortic valve leaflets. No
right intercostal space absence of symptoms change in valve pressure gradient.
Also known as “50 over 50”
murmur as found in >50% adults
>50 y.o.
Aortic Grade 1–3/4 high-pitched blow- May be enhanced by More common in men, usually from
regurgitation ing diastolic murmur heard best forced expiration, rheumatic heart disease, but occa-
at third left intercostal space leaning forward. sionally due to latent syphilis
Usually with S3,
wide pulse pressure,
sustained thrusting
apical impulse
Mitral stenosis Grade 1–3/4 low-pitched late Often with opening Nearly all rheumatic in origin.
diastolic murmur heard best snap, accentuated S1 Protracted latency period, then
at the apex, localized. Short in the mitral area. En- gradual decrease in exercise toler-
crescendo–decrescendo rumble, hanced by left lateral ance leading to rapid downhill
similar to a bowling ball rolling decubitus position, course owing to low cardiac output.
down an alley or distant thunder squat, cough, imme- Atrial fibrillation common
diately after Valsalva
Continued
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TABLE 5-5
Assessment of Common Cardiac Murmurs in Adults—cont’d
Important Cardiac
Murmur Examination Findings Additional Findings Comments
Atrial septal Grade 1–3/6 systolic ejection Widely split S2, right Typically without symptoms until
defect murmur at the pulmonic area ventricular heave middle age, then present with
(uncorrected) congestive heart failure. Persistent
ostium secundum in mid septum
Pulmonary Narrow splitting S2, murmur of Report of shortness Seen with right ventricular hypertro-
hypertension tricuspid regurgitation of breath nearly phy, right atrial hypertrophy as
universal identified by ECG, echocardiogram.
Secondary pulmonary hypertension
may be a consequence of dexfenflu-
ramine (Redux), “phen/fen” (phen-
termine with fenfluramine) use
(Dexfenfluramine and fenfluramine
no longer available on the North
American market due to safety
issues.)
Mitral Grade 1–4/6 high-pitched blow- Radiates to axilla, Found in ischemic heart disease,
regurgitation ing systolic murmur, often often with laterally endocarditis, RHD. With RHD, often
extending beyond S2. Sounds displaced PMI. with other valve abnormalities
like long “haaa,” “hooo.” Heard Decreased with (aortic stenosis, mitral stenosis,
best at right lower scapular standing, Valsalva aortic regurgitation)
border maneuver. Increased
by squat, hand grip
Mitral valve Grade 1–3/6 late-systolic With Valsalva or Often seen with minor thoracic
prolapse crescendo murmur with standing, click moves deformities such as pectus excava-
honking quality heard best forward into earlier tum, straight back, and shallow
at apex. Murmur follows systole, resulting in anterior–posterior diameter. Chest
mid-systolic click a longer sounding pain is sometimes present, but there
murmur. With is a question as to whether mitral
hand grasp, squat, valve prolapse itself is cause
click moves back
further into systole,
resulting in a
shorter murmur
Valvular changes in middle-aged adults without congenital such as running. The physical examination is usually normal
AS are usually the sequelae of rheumatic fever and represent except for the associated cardiac findings. For mild AS, treat-
about 30% of valvular dysfunction seen in rheumatic heart ment is not necessary, but ongoing monitoring is important
disease. to detect any change toward moderate to severe level. This
AS may be present in children and younger adults and is may involve ECG, echocardiogram, exercise stress test, CT
usually caused by a congenital bicuspid (rather than tricus- scan, or MRI. Surgical correction or replacement of the valve
pid) valve or by a three-cusp valve with leaflet fusion. This is often needed for moderate to severe AS.
defect is most often found in boys and young men and is The heart murmur of mitral regurgitation (MR) arises
commonly accompanied by a long-standing history of be- from mitral valve incompetency or the inability of the
coming excessively short of breath with increased activity mitral valve to close properly. This incompetency allows a
4074_Ch05_105-126 20/11/14 10:40 AM Page 115
retrograde flow from a high-pressure area (left ventricle) should be encouraged for patients with MVP. Treatment
to an area of lower pressure (left atrium). MR is most with a beta-adrenergic antagonist (beta blocker) is indicated
often caused by the degeneration of the mitral valve, com- only when symptomatic recurrent tachycardia or palpita-
monly by rheumatic fever, endocarditis, calcific annulus, tions is an issue.
rheumatic heart disease, ruptured chordae, or papillary Hypertrophic cardiomyopathy is a disease of the cardiac
muscle dysfunction. In MR resulting from rheumatic heart muscle. The ventricular septum is thick and asymmetrical,
disease, there is usually some degree of mitral stenosis. leading to potential blockage of the outflow tract. Patients
After the person becomes symptomatic, the disease pro- often exhibit symptoms of cardiac outflow tract blockage with
gresses in a downhill course leading to HF over the next activity because the hypertrophic ventricular walls better ap-
10 years. proximate with the increased force of myocardial contraction
Mitral valve prolapse (MVP) is likely the most common associated with exercise. The presentation of hypertrophic
valvular heart problem; it is present in perhaps 10% of the cardiomyopathy can be sudden cardiac death. Idiopathic
population. The degree of distress (chest pain, dyspnea) hypertrophic subaortic stenosis is a type of cardiomyopathy.
may depend in part on the degree of MR, although some A mutation in one of several genes can cause the condition.
studies have failed to reveal any difference in the rates of The mutation is inherited in an autosomal-dominant pattern,
chest pain in patients with or without MVP. Potentially the thus requiring only one copy of the mutant gene to cause the
greatest threat is the rupture of chordae, usually seen only disorder. In most cases, an affected person has one parent
in those with connective tissue disease, especially Marfan with the condition. Patients with this disorder are usually
syndrome. young adults with a history of dyspnea with activity, but they
Most patients with MVP have a benign condition in are often asymptomatic.
which one of the valve leaflets is unusually long and buckles Infective endocarditis is an infection of the inner lining of
or prolapses into the left atrium, usually in mid systole. At the heart, most commonly occurring in persons with dam-
that time, a click occurs that is followed by a short murmur aged heart valves, prosthetic heart valves, or other heart
caused by regurgitation of blood into the atrium. Cardiac defects. Risk factors also include a history of endocarditis
output is usually uncompromised, and the event goes un- or injected drug use. The infection can develop slowly or
noticed by the patient; however, the clinician may detect rapidly, depending on the causative pathogen, and signs
this on examination. Echocardiography fails to reveal any and symptoms can vary accordingly. The most common in-
abnormality, simply noting the valve buckling followed by clude fever, chills, a new or altered heart murmur, fatigue,
a small-volume MR. If there are no cardiac complaints and aching joints and muscles, shortness of breath, edema, per-
the rest of the cardiac examination, including the ECG, is sistent cough, unexplained weight loss, hematuria, tenderness
normal, no further evaluation is needed. of the spleen, Osler’s nodes, and petechiae. Diagnosis involves
One way of describing this variation from the norm is to a blood culture to detect the infection as well as a trans-
inform the patient that one leaflet of the mitral valve is a bit esophageal echocardiogram to identify vegetation formation
longer than usual. The “holder” (valve orifice) is of average or infected tissue in the heart. An ECG can be used to detect
size, however. This discrepancy causes the valve to buckle a alteration to heart function, whereas a chest X-ray, CT scan,
bit, just as a person’s foot would if forced into a shoe that is or MRI may be used to detect spread of the infection to other
one or two sizes too small. As a result, the heart makes an sites. Endocarditis is treated with high doses of intravenous
extra set of sounds (click and murmur) but is not diseased or antibiotics that should be tailored to the causative pathogen
damaged. MVP is often found in patients with minor thoracic and susceptibility profile. Treatment lasts at least 4–6 weeks
deformities such as pectus excavatum, a dish-shaped concave to eradicate the infection. Surgery is occasionally required
area at T1, and scoliosis. The exact nature of this correlation to repair or replace a damaged valve caused by infective
of findings is not understood. endocarditis.
The second and much smaller group of patients with The American Heart Association (AHA) has developed
MVP has systolic displacement of one or both of the mitral guidelines for the evaluation of infectious endocarditis risk.
leaflets into the left atrium alone with valve thickening and Although in the past, infectious endocarditis prophylaxis was
redundancy, usually accompanied by mild to moderate MR. used liberally for most individuals with a past or current
This group typically has additional health problems, such as history of heart murmur or structural cardiac abnormality,
Marfan syndrome or other connective tissue disease. There the AHA has long advocated for restraint in this practice,
is a risk of bacterial endocarditis in this group because struc- recognizing that infectious endocarditis is much more likely
tural cardiac abnormality is present. to result from frequent exposure to random bacteremias as-
Barring other health problems, patients with MVP usually sociated with daily activities than from bacteremia caused by
have normal cardiac output and tolerate a program of aero- a dental, gastrointestinal tract, or genitourinary tract proce-
bic activity. This activity should be encouraged to promote dure; maintenance of optimal oral health and hygiene is likely
health and well-being. The degree of MVP is increased, how- more important than prophylactic antibiotics for a dental
ever, which increases intensity of the murmur, when circu- procedure in reducing infectious endocarditis risk. Infectious
lating volume is low. Maintaining a high level of fluid intake endocarditis prophylaxis is considered a reasonable option,
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TABLE 5-6
Prevention of Endocarditis: Guidelines from the American Heart Association
PRIMARY REASONS FOR REVISIONS OF INFECTIOUS ENDOCARDITIS (IE) PROPHYLAXIS GUIDELINES
IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from
bacteremia caused by a dental, gastrointestinal (GI) tract, or genitourinary (GU) tract procedure.
Prophylaxis may prevent very few, if any, cases of IE in individuals who undergo a dental, GI tract, or GU tract procedure.
The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.
Maintenance of optimal oral health and hygiene may reduce incidence of bacteremia from daily activities and is more
important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.
CARDIAC CONDITIONS ASSOCIATED WITH HIGHEST RISK OF ADVERSE OUTCOME FROM ENDOCARDITIS FOR WHICH
PROPHYLAXIS WITH DENTAL PROCEDURES IS REASONABLE
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous IE
Congenital heart disease (CHD)*
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by
catheter intervention, during the first 6 mo after the procedure†
• Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibits endothelialization)
• Cardiac transplantation recipients who develop cardiac valvulopathy
DENTAL, ORAL, OR RESPIRATORY TRACT OR ESOPHAGEAL PROCEDURES: GIVE 30–60 MINUTES BEFORE PROCEDURE
Adults Children
Amoxicillin 2 g PO Amoxicillin 50 mg/kg PO
IF UNABLE TO TAKE ORAL MEDICATION
Ampicillin 2 g IM or IV Cefazolin or ceftriaxone 1 g IM or IV Ampicillin 50 mg/kg IM or IV
Cefazolin or ceftriaxone 50 mg/kg IM or IV
ORAL, IF PENICILLIN OR AMPICILLIN ALLERGIC
Clindamycin 600 mg Clindamycin 20 mg/kg
Cephalexin‡,§ 2 g Cephalexin§ 50 mg/kg
Azithromycin or clarithromycin 500 mg Azithromycin or clarithromycin 15 mg/kg
IF PENICILLIN OR AMPICILLIN ALLERGIC AND UNABLE TO TAKE ORAL MEDICATION
Cefazolin§ or ceftriaxone§ 1 g IM or IV Cefazolin§ or ceftriaxone§ 50 mg/kg IM or IV
Clindamycin 600 mg IM or IV Clindamycin 20 mg/kg IM or IV
*Except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD.
†Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 mo after the
procedure.
‡Or other first-generation or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
§Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria
TABLE 5-7
Heart Sounds
Heart Sound Significance Comment Heard Best
S1 Marks beginning of systole. Best heard at apex with “Lub dub” heard nearly simul-
Produced by events surround- the diaphragm taneous with carotid upstroke
ing closure of mitral and
tricuspid valve.
S2 Marks end of systole. Best heard at base with “Lub dub” heard
Produced by events surround- diaphragm
ing closure of aortic and
pulmonic valves
Physiological split S2 Widening of normal interval Heard best in pulmonic The split increases on patient
between aortic and pulmonic region inspiration.
components of S2. Caused by Found in most adults <30 y.o.,
delay in pulmonic component fewer beyond this age. Benign
finding
Pathological split S2 Fixed split—no change with Heard best in pulmonic Fixed split often found in
inspiration region uncorrected septal defect
Paradoxical split—narrows or Paradoxical split often found
closes with inspiration in conditions that delay aortic
closure, such as left bundle
branch block
Finding can resolve with treat-
ment of underlying condition
Pathological S3 Marker of ventricular overload, Heard in early diastole, For diagnosis of heart failure,
systolic dysfunction, or both can sound like it is correlate with additional
“hooked on” to the findings such as dyspnea,
back of S2 tachycardia, crackles
Low pitch, best heard Finding can resolve with treat-
with bell, might miss ment of underlying condition
with diaphragm
S4 Marker of poor diastolic Heard late in diastole, Finding can resolve with
function, most often found can sound like it is treatment of underlying
in poorly controlled hyperten- “hooked on” to the condition
sion or recurrent myocardial front of S1
ischemia Sometimes called a
presystolic sound
Soft, low pitch (higher
pitch than S3), best
heard with bell
Acute Coronary 66. Which of the following is most consistent with a person
presenting with unstable angina?
Syndrome A. a 5-minute episode of chest tightness brought on by
stair climbing and relieved by rest
65. Causes of unstable angina include all of the following B. a severe, searing pain that penetrates the chest and
except: lasts about 30 seconds
A. ventricular hypertrophy. C. chest pressure lasting 20 minutes that occurs
B. vasoconstriction. at rest
C. nonocclusive thrombus. D. “heartburn” relieved by position change
D. inflammation or infection.
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67. The initial manifestation of coronary heart disease in 71. Which of the following changes on the 12-lead ECG
men is most commonly: do you expect to find in a patient with acute coronary
A. unstable angina. syndrome?
B. myocardial infarction. A. flattened T wave
C. intracranial hemorrhage. B. R wave larger than 25 mm
D. stable angina. C. ST segment deviation (>0.05 mV)
D. fixed Q wave
68. In assessing a woman with or at risk for acute coronary
syndrome (ACS), the NP considers that the patient will 72. Beta-adrenergic antagonists are used in ACS therapy
likely present: because of their ability to:
A. in a manner similar to that of a man with equivalent A. reverse obstruction-fixed vessel lesions.
disease. B. reduce myocardial oxygen demand.
B. at the same age as a man with similar health C. enhance myocardial vessel tone.
problems. D. stabilize arterial volume.
C. more commonly with angina and less commonly
73. Nitrates are used in ACS therapy because of their ability
with acute MI.
to:
D. less commonly with HF.
A. reverse fixed vessel obstruction.
69. Rank the following signs and symptoms in the order B. reduce myocardial oxygen demand.
of most common to least common in a 60-year-old C. cause vasodilation.
woman in the time preceding an ACS event. D. stabilize cardiac rhythm.
A. dyspnea
74. Which of the following is most consistent with a patient
B. anxiety
presenting with acute MI?
C. sleep disturbance
A. a 5-minute episode of chest tightness brought on by
D. unusual fatigue
stair climbing
70. The cardiac finding most commonly associated with B. a severe, localized pain that penetrates the chest and
unstable angina is: lasts about 3 hours
A. physiological split S2. C. chest pressure lasting 20 minutes that occurs at rest
B. S4. D. retrosternal diffuse pain for 30 minutes accompa-
C. opening snap. nied by diaphoresis
D. summation gallop.
79. Which of the following changes on the 12-lead ECG 81. Thrombolytic therapy is indicated in patients with chest
would you expect to find in a patient with history of pain and ECG changes such as:
acute transmural MI 6 months ago? A. 1-mm ST segment depression in leads V1 and V3.
A. 2-mm ST segment elevation B. physiologic Q waves in leads aVF, V5, and V6.
B. R wave larger than 25 mm C. 3-mm ST segment elevation in leads V1 to V4.
C. T wave inversion D. T wave inversion in leads aVL and aVR.
D. deep Q waves
82. An abnormality of which of the following is the most
80. Which of the following changes on the 12-lead ECG sensitive marker for myocardial damage?
would you expect to find in a patient with myocardial A. aspartate aminotransferase
ischemia? B. creatine phosphokinase (CPK)
A. 2-mm ST segment elevation C. troponin I (cTnI)
B. S wave larger than 10 mm D. lactate dehydrogenase
C. T wave inversion
D. deep Q waves
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TABLE 5-9
Likelihood That Signs and Symptoms Represent Acute Coronary Syndrome Secondary to
Coronary Artery Disease
Intermediate Likelihood: Low Likelihood: Absence
Absence of High-Likelihood of High- or Intermediate-
High Likelihood: Any of Features and Presence of Likelihood Features but
Features the Following Present Any of the Following Many Have the Following
History Chest or left arm pain or dis- Chest or left arm pain or dis- Probable ischemic symptoms in
comfort as chief symptom comfort as chief symptom absence of any intermediate-
producing documented Age >70 yr at onset likelihood characteristics
angina Male sex Recent cocaine use
Diabetes mellitus
Examination Pulmonary edema Extracardiac vascular disease Chest discomfort reproduced
New rales or crackles by palpation
Transient mitral regurgita-
tion murmur
Hypotension
ECG findings New or presumably new Fixed Q waves T wave flattening or inversion
transient ST segment devia- Abnormal ST segments or in leads with dominant R
tion ( ≥0.05 mV) or T wave E waves not documented as waves
inversion ( ≥0.2 mV) with new ECG
symptoms
Cardiac markers Elevated cTnT, cTnI, or Normal Normal
CPK-MB
Source: American College of Cardiology/American Heart Association 2007 Guidelines for the Management of
Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction.
http://circ.ahajournals.org/cgi/content/short/CIRCULATIONAHA.107.185752v1, Executive summary: A report
of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non–ST-
Elevation Myocardial Infarction)
4074_Ch05_105-126 20/11/14 10:40 AM Page 121
to be more potent vasodilators than nondyhydropyridines Troponin is a regulatory protein of the myofibril with
(e.g., verapamil, diltiazem), whereas the latter tend to have three major subtypes: C, I, and T. Subtypes I (cTnI) and
more marked inotropic effects. Sustained-effect nitroglyc- T (cTnT) are released in the presence of myocardial damage.
erin via the oral or topical route (patch or ointment) can Both increase rapidly within the first 12 hours after MI; cTnT
be added, particularly if nocturnal symptoms are present. typically remains elevated for about 168 hours, and cTnI
Nitroglycerin via sublingual tablet or spray should be remains elevated for about 192 hours. cTnI is the more
prescribed with advice on its use for acute symptoms and cardiac-specific measure and is sensitive for small-volume
education to monitor frequency of use to detect patterns myocardial damage. CTnT levels can be elevated in chronic
of anginal triggers and disease instability. Use of nitrates renal failure, muscle trauma, and rhabdomyolysis. cTnI is
enhances myocardial perfusion through peripheral and cen- more sensitive and specific than ECG and creatine phospho-
tral vasodilation. Overall cardiovascular risk reduction is kinase isoenzyme MB (CK-MB) in diagnosing unstable
also important with the use of appropriate dyslipidemia angina and non–Q-wave MI. In addition, cTnI results are
agents, with HMG-CoA reductase inhibitor therapy (statin) available quickly through a rapid assay. Protracted elevation
therapy nearly always indicated. Coronary angiography of cTnI after MI or unstable angina is a predictor of increased
should be considered if exercise tolerance is poor, signifi- mortality. People with angina without documented MI have
cant abnormality is noted on resting or exercise ECG or a significantly higher risk of death within 42 days if cTnI is
myocardial imaging, or symptoms become less stable. An persistently elevated.
exercise tolerance test can be performed on a routine basis CK-MB has long been used as a serum marker of myocar-
for patients at high risk to check the effectiveness of proce- dial damage. CK-MB level increases within 6 to 12 hours of
dures done to improve coronary circulation and can predict MI, begins to decrease within 24 to 48 hours, and usually re-
the risk of future cardiovascular events, such as a myocar- turns to normal in about 60 hours. Because CK-MB clears
dial infarction. quickly, its use in late detection of MI is limited. In addition,
S4 is often heard with myocardial ischemia and poorly false-positive and false-negative results are noted.
controlled angina pectoris. This sound of poor myocardial The AHA periodically publishes guidelines for the man-
relaxation (compliance) and diastolic dysfunction may po- agement of patients with ST segment elevation MI, unstable
tentially cause decreased cardiac output. The third heart angina, and non–ST segment elevation MI developed from
sound (S3) is that of poor myocardial contractility and systolic consensus of nursing and medical experts and evidence-
dysfunction and usually leads to decreased cardiac output; based health care. The AHA recommends the following
this abnormal heart sound is often heard in the presence of therapy:
heart failure. • Nitroglycerin via sublingual spray or tablet should be
MI/ACS most commonly occurs when an atherosclerotic given, followed by parenteral nitroglycerin.
plaque ruptures, leading to the formation of an occlusive • Supplemental oxygen should be administered to patients
thrombus. Coronary artery spasm can also occur, adding to with cyanosis or respiratory distress, and pulse oximetry
the vessel obstruction. A patient with suspected ACS needs or arterial blood gas determination should be done to
to be assessed promptly and accurately because therapy to confirm adequate arterial SaO2 (>90%).
reinstitute vessel patency (e.g., thrombolysis, percutaneous • Adequate analgesia should be provided with intravenous
angioplasty, stent placement, coronary artery bypass graft- morphine sulfate when symptoms are not immediately
ing) should be initiated early in the process to limit myocar- relieved by nitroglycerin or when pulmonary congestion
dial damage. The 12-lead ECG should be assessed for or severe agitation or both are present.
changes consistent with myocardial ischemia, myocardial • A beta blocker should be given if there are no con-
injury, and MI. traindications. The first dose should be administered
In approximately 75% of patients admitted to the hospital intravenously. An ACEI should be given if no con-
for MI, this condition is ruled out. At least 25% of all MIs are traindications exist.
clinically silent, however. To reduce unneeded hospitalization • Aspirin (160 to 325 mg orally in a chewable, nonenteric
and to detect asymptomatic MI/ACS, diagnostic tests that are form) should be given as soon as possible after hospital
highly sensitive and specific for myocardial damage are presentation and continued indefinitely in patients who
needed. An electrocardiogram (ECG) is typically the first can tolerate it. Other antiplatelet agents, such as clopido-
test done to diagnose MI and is often performed while the grel (Plavix), may be used if aspirin allergy or intolerance
patient is en route to the hospital by EMT to activate the is present or as adjunctive therapy.
cardiac team. This can be critical in reducing the arrival- • A history, physical examination, 12-lead ECG, and car-
to-catheterization time. Other tests may be used to determine diac marker tests should be performed promptly.
the extent of heart damage caused by a myocardial infarction With a diagnosis of ACS and ST segment elevation, the
or to determine if symptoms are from another cause. These patient should be evaluated for reperfusion; the examiner
tests include a chest X-ray, echocardiogram, nuclear scan, CT should look for ST segment elevation greater than 1 mm
angiogram, or coronary angiogram. Blood tests are also used in contiguous leads. The presence of these changes usually in-
to detect specific enzymes produced in the presence of heart dicates acute coronary artery occlusion, usually from throm-
damage induced by MI. bosis. In addition, clinically significant ST segment elevation
4074_Ch05_105-126 20/11/14 10:40 AM Page 122
largely dictates reperfusion therapy with the use of throm- thrombolysis. These patients should be hospitalized and placed
bolytic therapy, primary percutaneous transluminal coronary on continuous ECG monitoring for rhythm disturbances; dis-
angioplasty, or other revascularization options. These thera- turbances that are noted should be appropriately treated. Serial
pies have the best effect on clinical outcomes if used within 12-lead ECGs should be obtained, and results should be cor-
6 hours after onset of chest pain but may be helpful 7 to related with clinical measures of myocardial necrosis, such as
12 hours or more after MI symptoms begin. Percutaneous CK isoenzymes and troponin. Aspirin therapy should be con-
coronary intervention (PCI) is recommended in the presence tinued, and heparin use should be considered, particularly in
of STEMI and ischemic symptoms of less than 12 hours du- the presence of a large anterior MI or left ventricular mural
ration. If fibrinolytic therapy is contraindicated, PCI should thrombus because of increased risk of embolic stroke.
be performed in patients with STEMI and ischemic symp- If no contraindications are present, beta blocker and ACEI
toms of less than 12 hours duration, irrespective of any time therapy should be initiated promptly because the use of these
delay in first medical contact. Following PCI, dual antiplatelet products is associated with reduced mortality and morbidity
therapy (aspirin plus clopidogrel, prasugrel, or ticagrelor) after MI. Beta blocker and ACEI therapy should be continued
should be given for at least 12 months. When thrombolysis indefinitely. Before hospital discharge, patients should un-
is used, heparin is usually given for at least 48 hours to ensure dergo standard exercise testing to assess functional capacity,
continued vessel patency. Before giving a thrombolytic agent efficacy of current medical regimen, and risk stratification for
such as tissue plasminogen activator or streptokinase, the subsequent cardiac events.
prescriber must be aware of absolute and relative contraindi- Ongoing care includes a goal of reducing low-density
cations to thrombolytic therapy (Table 5–10). lipoprotein cholesterol to less than 100 mg/dL (<2.6 mmol/L)
If left bundle branch block is evident on ECG and the clin- and in some patients at very high risk, including individuals
ical scenario is consistent with acute MI, standard acute MI with diabetes mellitus and established coronary artery dis-
care should be offered. Patients with a presentation suggestive ease, reducing it to less than 70 mg/dL (<1.8 mmol/L) using
of MI but without ST segment changes should not receive diet; exercise; and, as is typically needed, drug therapy. This
TABLE 5-10
Contraindications and Cautions for Fibrinolysis in ST Segment Elevation Myocardial
Infarction*
Absolute Contraindications Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo except acute ischemic stroke within 4.5 hr
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 mo
Relative Contraindications History of chronic, severe, poorly controlled hypertension
Significant hypertension on presentation (systolic blood pressure >180 mm Hg or
diastolic blood pressure >110 mm Hg)
History of prior ischemic stroke <3 mo, dementia, or known intracranial pathology
not covered in absolute contraindications
Traumatic or prolonged (>10 min) CPR
Major surgery (within past 3 weeks)
Recent (within 2–4 weeks) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
Oral anticoagulant therapy
*Viewed as advisory for clinical decision making and may not be all-inclusive or definitive.
INR, international normalized ratio.
Source: American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guide-
lines. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol.
61:e78-e140, 2013. Available at: http://content.onlinejacc.org/article.aspx?articleid=1486115.
4074_Ch05_105-126 20/11/14 10:40 AM Page 123
ongoing care is in keeping with an overall plan to reduce or 92 to 94. Match each of the following conditions with
eliminate all cardiac risk factors, including inactivity, smok- its mechanism for contributing to heart
ing, and obesity. At the same time, other sources advocate failure:
that a ⭓ 50% reduction in LDL cholesterol from baseline via 92. pneumonia A. increase in circulating
intensive statin therapy is preferred over a strict number goal. 93. anemia volume of blood
See the Endocrine Chapter for further information on this 94. high sodium B. increased right-sided
important topic. intake heart workload
C. decreased oxygen-
DI SCUSSION SOURCES carrying capacity of
American Association of Clinical Endocrinologists’ Comprehensive blood
Diabetes Management Algorithm 2013 Consensus Statement,
Endocr Pract 2013;19 (Suppl 1):1-48. https://www.aace.com/files/ 95. The condition of a sudden shortness of breath that usu-
consensus-statement.pdf ally occurs after 2-3 of hours of sleep that leads to sud-
American College of Cardiology/American Heart Association den awakening followed by a feeling of severe anxiety
2007 Guidelines for the Management of Patients with Unsta- and breathlessness is known as:
ble Angina/Non–ST-Elevation Myocardial Infarction: Exec- A. dyspnea.
utive Summary. http://circ.ahajournals.org/cgi/content/short/ B. orthopnea.
CIRCULATIONAHA.107.185752v1, A Report of the American C. resting dyspnea.
College of Cardiology/American Heart Association Task Force D. paroxysmal nocturnal dyspnea.
on Practice Guidelines (Writing Committee to Revise the
Guidelines for the Management of Patients with Unstable 96. You examine an 82-year-old woman who has a history
Angina/Non–ST-Elevation Myocardial Infarction) of heart failure (HF). She is in the office because of in-
American College of Cardiology/American Heart Association creasing shortness of breath. When auscultating her
(ACC/AHA) Task Force on Practice Guidelines. http://circ. heart, you note a tachycardia with a rate of 104 beats
ahajournals.org/cgi/content/full/116/23/2762, 2007 Chronic per minute and a single extra heart sound early in dias-
Angina Focused Update of the ACC/AHA Guidelines for the
tole. This sound most likely represents:
Management of Patients with Chronic Stable Angina
American College of Cardiology/American Heart Association
A. summation gallop.
(ACC/AHA) Task Force on Practice Guidelines. 2012 ACCF/ B. S3.
AHA Focused Update of the Guideline for the Management of C. opening snap.
Patients with Unstable Angina/Non-ST-Elevation Myocardial D. S4.
Infarction (Updating the 2007 Guideline and Replacing the
97. You examine a 65-year-old man with dilated cardiomy-
2011 Focused Update). Circulation. 126:875–910, 2012. http://
content.onlinejacc.org/article.aspx?articleid=1217906, accessed
opathy and HF. On examination, you expect to find all
12/2/13. of the following except:
American College of Cardiology/American Heart Association A. jugular venous distention.
(ACC/AHA) Task Force on Practice Guidelines. 2013 ACCF/ B. tenderness on right upper-abdominal quadrant
AHA Guideline for the Management of ST-Elevation Myocardial palpation.
Infarction. J Am Coll Cardiol. 61:e78–e140, 2013. http:// C. point of maximal impulse at the fifth intercostal
content.onlinejacc.org/article.aspx?articleid=1486115, accessed space, mid-clavicular line.
12/2/13. D. peripheral edema.
McSweeney J, Cody M, O’Sullivan P, Elberson K, Moser D, Garvin B.
Women’s early warning symptoms of acute myocardial infarc- 98. In patients with heart failure, the point of maximum
tion. Circulation. 108:2619–2623, 2003. impulse:
A. remains unchanged near the fourth intercostal
space.
Heart Failure B. remains unchanged near the fifth intercostal
space.
90. Heart failure pathophysiology is characterized by: C. shifts lower on the mid-clavicular line.
A. impaired atrial filling and ejection of blood. D. shifts laterally by one or more intercostal
B. incomplete closure of tricuspid valve. spaces
C. near normal ventricular function.
D. inadequate cardiac output to meet oxygen and 99 to 101. Match the term with the correct impact on the
metabolic demands of the body. heart.
99. inotropic A. cardiac rate
91. A leading cause of heart failure is: 100. chronotropic B. cardiac
A. hypertensive heart disease. 101. dromotropic conduction
B. atrial fibrillation. C. force of the
C. pulmonary embolism. cardiac
D. type 2 diabetes. contraction
4074_Ch05_105-126 20/11/14 10:40 AM Page 124
102. The rationale for using beta blocker therapy in treat- 110. Which of the following is unlikely to be noted in the
ing a patient with HF is to: person experiencing HF?
A. increase myocardial contractility. A. elevated serum B-type natriuretic peptide (BNP)
B. reduce the effects of circulating catecholamines. B. Kerley B lines noted on chest X-ray
C. relieve concomitant angina. C. left-ventricular hypertrophy on ECG
D. stabilize cardiac rhythm. D. evidence of hemoconcentration on hemogram
103. An ECG finding in a patient who is taking digoxin in 111. Which of the following medications is an alpha/
a therapeutic dose typically includes: beta-adrenergic antagonist?
A. shortened P-R interval. A. atenolol
B. slightly depressed, cupped ST segments. B. metoprolol
C. widened QRS complex. C. propranolol
D. tall T waves. D. carvedilol
104. A potential adverse effect of ACEI when used with 112. Which of the following best describes the patient
spironolactone therapy is: presentation of New York Heart Association
A. hypertension. stage III heart disease?
B. hyperkalemia. A. Ordinary physical activity does not cause undue
C. renal insufficiency. fatigue, dyspnea, or palpitations.
D. proteinuria. B. Ordinary physical activity results in fatigue,
palpitations, dyspnea, or angina.
105. ECG findings in a patient with digoxin toxicity would
C. Less-than-ordinary activity leads to fatigue,
most likely include:
dyspnea, palpitations, or angina.
A. atrioventricular heart block.
D. Discomfort increases with any physical activity.
B. T wave inversion.
C. sinus tachycardia. 113. The risk for digoxin toxicity increases with concomi-
D. pointed P waves. tant use of all of the following medications except:
A. amiodarone.
106. Patients reporting symptoms of digoxin toxicity are
B. clarithromycin.
most likely to include:
C. cyclosporine.
A. anorexia.
D. levofloxacin.
B. disturbance in color perception.
C. blurred vision.
D. diarrhea.
Answers
107. Which of the following is among the most common
causes of HF? 90. D. 98. D. 106. A.
A. dietary indiscretion 91. A. 99. C. 107. C.
B. COPD 92. B. 100. A. 108. B.
C. hypertensive heart disease 93. C. 101. B. 109. B.
D. anemia 94. A. 102. B. 110. D.
95. D. 103. B. 111. D.
108. Which of the following medications is an aldosterone 96. B. 104. B. 112. C.
antagonist? 97. C. 105. A. 113. D.
A. clonidine
B. spironolactone
Heart failure (HF) occurs as a result of altered cardiac function
C. hydrochlorothiazide
that leads to inadequate cardiac output and a resulting inabil-
D. furosemide
ity to meet the oxygen and metabolic demands of the body.
109. Which of the following best describes orthopnea? HF results from any structural or functional impairment
A. shortness of breath with exercise of ventricular filling or ejection of blood. Hypertensive heart
B. dyspnea that develops when the individual is disease and atherosclerosis are the leading causes of HF.
recumbent and is relieved with elevation of Less common causes in the at-risk adult include pneumonia
the head (as a result of increased right-sided heart workload), anemia
C. shortness of breath that occurs at night, character- (because of the resulting decreased oxygen-carrying capability
ized by a sudden awakening after a couple of hours of the blood), and increased sodium intake (because of the
of sleep, with a feeling of severe anxiety, breathless- resultant increase in circulating volume).
ness, and suffocation Clinical presentation of an acute exacerbation of HF
D. dyspnea at rest includes dyspnea, or shortness of breath (SOB), that increases
4074_Ch05_105-126 20/11/14 10:40 AM Page 125
in severity, seen in a spectrum from exertional dyspnea (SOB After treatment, the assignment of lower category (NYHA I
with exercise), orthopnea (SOB that typically develops quickly or II) is likely noted and should be a clinical goal.
when the individual is recumbent and is relieved with eleva- ECG helps to identify the presence of left atrial enlarge-
tion of the head), paroxysmal nocturnal dyspnea (SOB that ment, left ventricular hypertrophy, and dysrhythmias often
occurs at night, characterized by a sudden awakening after a noted in HF but not specific to the diagnosis. ECG changes
couple hours of sleep, with a feeling of severe anxiety, breath- consistent with acute myocardial ischemia or MI as the cause
lessness, and suffocation), and dyspnea at rest to acute pul- of HF may also be revealed.
monary edema. Additional reported history often includes Laboratory testing in HF usually includes evaluation to
nocturia, fatigue, and weakness. Except for the mildest cases, rule in or rule out potential underlying causes (e.g., anemia,
crackles heard over the lung bases are characteristic; in severe infection, renal insufficiency). B-type natriuretic peptide
cases, there is wheezing and expectoration of frothy, blood- (BNP) is an amino acid structure common to all natriuretic
tinged sputum. S3 is usually noted, typically disappearing on peptides. The cardiac ventricles are the major source of
resolution of the acute event. Additional findings usually in- plasma BNP; the amount in circulation is in proportion to
clude tachycardia, diaphoresis, pallor, and peripheral cyanosis ventricular volume expansion and pressure overload. As part
with pallor. Although edema is considered a classic finding in of the evaluation of a patient with dyspnea and suspected HF,
HF, a substantial gain of extracellular fluid volume (i.e., a min- an elevated BNP level helps to support the diagnosis. The in-
imum of 5 L in adults) must occur before peripheral edema is creased circulating volume found in HF can occasionally lead
manifested. As a result of liver engorgement from elevated to evidence of hemodilution on hemogram; this corrects as
right-sided heart pressures, hepatojugular reflux, hepatic en- circulating volume is normalized.
gorgement, and tenderness are typically noted. The point of Findings on chest radiograph in HF include cardiomegaly
maximal impulse is normally at the fifth intercostal space, and alveolar edema with pleural effusions and bilateral infil-
mid-clavicular line. This shifts laterally and perhaps over more trates in a butterfly pattern. Additional findings are loss of
than one intercostal space in the presence of dilated cardiomy- sharp definition of pulmonary vasculature; haziness of hilar
opathy and its resultant increase in cardiac size. shadows; and thickening of interlobular septa, also known as
Patients with HF are often assigned a classification of heart Kerley B lines. As part of the evaluation of heart valve func-
disease from either the ACCF/AHA (Stages A-D) or the New tion and competency, an echocardiogram is usually obtained.
York Heart Association (NYHA I-IV). The ACCF/AHA Radionuclide evaluation of left ventricular function provides
stages of HF emphasize development and progression of dis- helpful information on global heart function. Angiography
ease, whereas the NYHA classes focus on exercise capacity and further studies should be directed by clinical presentation
and symptomatic status of the disease (Table 5–11). In treat- and other health risks.
ing an acute HF exacerbation, a patient often is initially con- The goal of HF therapy is threefold: reduction of preload,
sistent with a higher classification category (NYHA III or IV). reduction of systemic vascular resistance (afterload reduction),
TABLE 5-11
Comparison of HF Classification Criteria for ACCF/AHA and NYHA
ACCF/AHA Stages of HF NYHA Functional Classification
A At high risk for HF but without structural heart I No limitation of physical activity. Ordinary physical
disease or symptoms of HF activity does not cause symptoms of HF.
B Structural heart disease but without signs or II Slight limitation of physical activity. Comfortable at
symptoms of HF rest, but ordinary physical activity results in symp-
toms of HF.
C Structural heart disease with prior or current III Marked limitation of physical activity. Comfortable
symptoms of HF at rest, but less than ordinary activity causes symp-
toms of HF.
D Refractory HF requiring specialized interventions IV Unable to carry on any physical activity without
symptoms of HF, or symptoms of HF at rest.
Source: Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure:
A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Circulation. 128:e240–e327, 2013. Available at: http://circ.ahajournals.org/content/128/16/e240.
extract.
4074_Ch05_105-126 20/11/14 10:40 AM Page 126
and inhibition of the renin and sympathetic nervous system. reduce the incidence of sudden cardiac death. This drug class
Because ACEIs and angiotensin receptor blockers (ARBs) is underused in HF therapy.
cause central and peripheral vasodilation, these medications Digoxin has a positive inotropic effect and slows conduc-
result in a reduction in cardiac workload and improvement in tion through the atrioventricular node. A prolongation of
cardiac output. Although ACEIs and ARBs are the cornerstone the P-R interval and cupping of the ST segment are typically
of HF therapy, their use can be associated with adverse effects. seen in ECGs of patients taking a therapeutic dose of
Most common is hypotension, particularly when one of these digoxin. Because it is a medication with narrow therapeutic
agents is prescribed for a person who is currently taking a di- index and with significant drug–drug interactions and a
uretic or vasodilator. To avoid hypotension, ACEI or ARB potential proarrhythmic effect, clinical vigilance is needed
therapy should be started at low dosages and increased slowly with digoxin use. Drugs that interact with digoxin include
to achieve a therapeutic response. Renal insufficiency can be amiodarone, diltiazem, select macrolides (clarithromycin
precipitated by ACEI or ARB therapy; this usually occurs only and erythromycin), azole antifungals, cyclosporine, and ve-
in the presence of renal artery stenosis or underlying renal rapamil. Drugs that can cause potassium loss, such as many
disease. Hyperkalemia with ACEI or ARB use is usually seen diuretics, can also increase the risk of digoxin toxicity. In
only with concurrent use of a potassium-sparing diuretic/ digoxin toxicity, numerous cardiac effects can be seen; atri-
aldosterone antagonist, such as spironolactone (Aldactone); in oventricular block is the most common, whereas anorexia
advancing renal disease; or in a poor hydration state, including is the most commonly reported by patients. Visual changes
overly aggressive diuretic use. are rarely reported. Digoxin use for 1 to 3 months is associ-
Diuretics assist with circulating volume and preload ated with reduced hospital admissions along with improved
reduction. Unless contraindicated, a potassium-sparing symptoms of HF, quality of life, and exercise tolerance in
diuretic such as spironolactone should be used because of patients with mild to moderate HF. Long-term use of
its neurohumoral effects, allowing sodium excretion and digoxin in patients with more severe HF (NYHA II or III)
enhanced vasodilation. These effects are achieved by the has been shown to have no effect on mortality but can re-
drug’s ability to bind competitively at receptors found in duce hospitalizations.
aldosterone-dependent sodium-potassium exchange sites
in the renal tubule. D I S C U SSI O N S O U R C E S
Beta-adrenergic blockers are used to inhibit chronotropic Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline
and inotropic responses to beta-adrenergic stimulation; the for the management of heart failure: a report of the American
use of an alpha/beta blocker such as carvedilol (Coreg) can College of Cardiology Foundation/American Heart Association
provide the additional benefit of a vasodilating effect through Task Force on Practice Guidelines. Circulation. 128:e240–e327,
2013. Available at: http://circ.ahajournals.org/content/128/16/
its action blockade at the alpha receptors. Long-term beta-
e240.extract
adrenergic antagonist (beta blocker) use has been shown Dumitru I. eMedicine. http://emedicine.medscape.com/article/
to improve cardiac function, to reduce myocardial ischemia, 163062-overview, Heart failure
to decrease myocardial oxygen consumption, and possibly to
4074_Ch06_127-152 20/11/14 10:41 AM Page 127
Respiratory Disorders 6
Asthma 4. You examine Jane, a 24-year-old woman who has an
acute asthma flare following a 3-day history of upper
1. Which of the following best describes asthma? respiratory tract symptoms (clear nasal discharge, dry
A. intermittent airway inflammation with occasional cough, no fever). She has a history of moderate persistent
bronchospasm asthma that is in good control and an acceptable peak ex-
B. a disease of bronchospasm that leads to airway piratory flow (PEF). She is using budesonide (Pulmicort)
inflammation and albuterol as directed and continues to have difficulty
C. chronic airway inflammation with superimposed with coughing and wheezing. At home, her PEF is 55%
bronchospasm of personal best. In the office, her forced expiratory vol-
D. relatively fixed airway constriction ume at 1 second (FEV1) is 65% of predicted. Her med-
ication regimen should be adjusted to include:
2. The patient you are evaluating is having a severe asthma A. theophylline.
flare. You have assessed that his condition is appropriate B. salmeterol (Serevent).
for office treatment. You expect to find the following on C. prednisone.
physical examination: D. montelukast (Singulair).
A. tripod posture
B. inspiratory crackles 5. For Jane in the above question, you also prescribe:
C. increased vocal fremitus A. amoxicillin.
D. hyperresonance on thoracic percussion B. azithromycin.
C. levofloxacin.
3. A 44-year-old man has a long-standing history of D. no antimicrobial therapy.
moderate persistent asthma that is normally well
controlled by fluticasone with salmeterol (Advair) 6. Peak expiratory flow meters:
via metered-dose inhaler, one puff twice a day, and A. should only be used in the presence of a medical
the use of albuterol 1 to 2 times a week as needed for professional.
wheezing. Three days ago, he developed a sore throat, B. provide a convenient method to check lung function
clear nasal discharge, body aches, and a dry cough. at home.
In the past 24 hours, he has had intermittent wheezing C. are as accurate as spirometry.
that necessitated the use of albuterol, two puffs every D. should not be used more than once daily.
3 hours, which produced partial relief. Your next 7. Which of the following is most likely to appear on a
most appropriate action is to obtain a: chest radiograph of a person during an acute severe
A. chest radiograph. asthma attack?
B. measurement of oxygen saturation (SaO2). A. hyperinflation
C. spirometry measurement. B. atelectasis
D. sputum smear for white blood cells (WBCs). C. consolidation
D. Kerley B signs
127
4074_Ch06_127-152 20/11/14 10:42 AM Page 128
8. A 36-year-old man with asthma also needs antihyper- 13. According to the National Asthma Education and
tensive therapy. Which of the following products Prevention Program Expert Panel Report-3 (NAEPP
should you avoid prescribing? EPR-3) guidelines, which of the following is not a risk
A. hydrochlorothiazide for asthma death?
B. propranolol A. hospitalization or an emergency department visit
C. amlodipine for asthma in the past month
D. enalapril B. current use of systemic corticosteroids or recent
withdrawal from systemic corticosteroids
9. Which of the following is inconsistent with the presen-
C. difficulty perceiving airflow obstruction or its
tation of asthma that is not well controlled?
severity
A. a troublesome nocturnal cough at least 2 nights
D. rural residence
per week
B. need for albuterol to relieve shortness of breath 14. An 18-year-old high school senior presents, asking
at least twice a week for a letter stating that he should not participate
C. morning sputum production in gym class because he has asthma. The most appro-
D. two or more exacerbations/year requiring oral priate action is to:
corticosteroids A. write the note because gym class participation could
trigger asthma symptoms.
See full color images of this topic B. excuse him from outdoor activities only to avoid
on DavisPlus at pollen exposure.
http://davisplus.fadavis.com | C. assess his level of asthma control and make
Keyword: Fitzgerald
changes in his treatment plan if needed so he
can participate.
10. The cornerstone of moderate persistent asthma drug D. write a note excusing him from gym until his
therapy is the use of: follow-up exam in 2 months.
A. oral theophylline.
15. You see a 34-year-old man with moderate persistent
B. mast cell stabilizers.
asthma who has a severe asthma flare and a regimen
C. short-acting beta2-agonists (SABA).
of oral prednisone is being considered. Which of the
D. inhaled corticosteroids.
following is true?
11. Sharon is a 29-year-old woman with moderate per- A. A taper is needed for prednisone therapy lasting
sistent asthma. She is not using prescribed inhaled longer than 4 days.
corticosteroids, but is using albuterol PRN to relieve B. A taper is not needed if the prednisone regimen is
her cough and wheeze with reported satisfactory for 7 days or less.
clinical effect. Currently she uses about two albuterol C. A taper is not needed regardless of duration of
metered-dose inhalers per month and is requesting prednisone therapy.
a prescription refill. You consider that: D. A taper is needed if the patient is taking concomi-
A. her asthma is well controlled and albuterol use tant inhaled corticosteroids.
can continue.
16. After inhaled corticosteroid is initiated, improvement
B. excessive albuterol use is a risk factor for asthma
in control is usually seen:
death.
A. on the first day of use.
C. her asthma is not well controlled and salmeterol
B. within 2 to 8 days.
(Serevent) should be added to relieve bronchospasm
C. in about 3 to 4 weeks.
and reduce her albuterol use.
D. in about 1 to 2 months.
D. her asthma has better control with albuterol than
inhaled corticosteroids. 17. Compared with albuterol, levalbuterol (Xopenex) has:
A. a different mechanism of action.
12. In the treatment of asthma, leukotriene receptor
B. the ability potentially to provide greater bronchodi-
antagonists should be used as:
lation with a lower dose.
A. controllers to prevent bronchospasm.
C. an anti-inflammatory effect similar to that of an
B. controllers to inhibit inflammatory responses.
inhaled corticosteroid.
C. relievers to treat acute bronchospasm.
D. a contraindication to use in elderly patients.
D. relievers to treat bronchospasm and inflammation.
4074_Ch06_127-152 20/11/14 10:42 AM Page 129
18. Which of the following is consistent with the NAEPP 25. Compared with short-acting beta2-agonists, long-
comment on the use of inhaled corticosteroids (ICS) acting beta2-agonists:
for a child with asthma? A. are recommended as a first-line therapy in mild
A. The potential but small risk of delayed growth with intermittent asthma.
ICS is well balanced by their effectiveness. B. have a significantly different pharmacodynamic
B. ICS should be used only if leukotriene modifiers fail profile.
to control asthma. C. have a rapid onset of action across the drug class.
C. Permanent growth stunting is consistently noted in D. should be added to therapy only when ICS use
children using ICS. does not provide adequate asthma control.
D. Leukotriene modifiers are equal in therapeutic effect
26. Which of the following statements is false regarding
to the use of a long-acting beta2-agonist.
the use of omalizumab (Xolair)?
19. A potential adverse effect from ICS use is: A. Its use is recommended for patients with mild
A. oral candidiasis. persistent asthma to prevent asthma flares.
B. tachycardia. B. The medication selectively binds to IgE to reduce
C. gastrointestinal upset. exacerbations.
D. insomnia. C. Labeled indication is for patients with poorly
controlled asthma with frequent exacerbations.
20. Clinical findings characteristic of asthma include all
D. Special evaluation is required prior to its use and
of the following except:
ongoing monitoring is needed during use.
A. a recurrent spasmodic cough that is worse at night.
B. recurrent shortness of breath and chest tightness 27. Subcutaneous immunotherapy is recommended for
with exercise. use in patients:
C. a congested cough that is worse during the day. A. with well-controlled asthma and infrequent
D. wheezing with and without associated respiratory exacerbations.
infections. B. with allergic-based asthma.
C. with moderate persistent asthma who are intolerant
21. Which of the following best describes the mechanism
of ICS.
of action of short-acting beta2-agonists?
D. with poorly-controlled asthma who fail therapy
A. reducer of inflammation
with omalizumab.
B. inhibition of secretions
C. modification of leukotrienes Answer the following questions true or false.
D. smooth muscle relaxation
28. Most prescribers are well versed in the relative
22. Regarding the use of long-acting beta2-agonists potency of ICS and prescribe an appropriate dose
(LABAs), which of the following is not true? for the patient’s clinical presentation.
A. LABAs enhance the antiinflammatory action of
29. Approximately 80% of the dose of an ICS is
corticosteroids.
systemically absorbed.
B. Use of LABAs is associated with a small increase
in risk of asthma death. 30. Leukotriene modifiers and ICS are interchange-
C. LABA use reduces the risk of asthma exacerbations. able clinically because both groups of medications
D. LABAs can be used as monotherapy to relieve have equivalent anti-inflammatory effect.
bronchospasms in asthma.
31. Little systemic absorption of mast cell stabilizers
23. Which of the following is the therapeutic objective occurs with inhaled or intranasal use.
of using inhaled ipratropium bromide?
32. Due to safety concerns, mast cell stabilizers are
A. as an antiinflammatory.
no longer available.
B. an increase in vagal tone in the airway
C. inhibition of muscarinic cholinergic receptors
D. an increase in salivary and mucous secretions
Answers
24. Which of the following is true regarding the use of
systemic corticosteroids in the treatment of asthma? 1. C. 9. C. 17. B.
A. Frequent short bursts are preferred over daily 2. D. 10. D. 18. A.
inhaled corticosteroids. 3. C. 11. B. 19. A.
B. The oral corticosteroid should be started at day 3-4 4. C. 12. B. 20. C.
of the asthma flare for optimal effect. 5. D. 13. D. 21. D.
C. The oral route is preferred over parenteral therapy. 6. B. 14. C. 22. B.
D. The adult dose to treat an asthma flare should not 7. A. 15. B. 23. C.
exceed the equivalent of prednisone 40 mg daily. 8. B. 16. B. 24. C.
4074_Ch06_127-152 20/11/14 10:42 AM Page 130
25. D. 28. False 31. True have a normal exam and yet have a lung function 50% of
26. A. 29. False 32. False personal best. A poor perception of symptoms, use of two or
27. B. 30. False more short-acting beta2-agonist canisters/month, and prior
severe exacerbations are important risk factors for death from
Asthma is a common chronic disorder of the airways that is asthma and should influence decisions regarding asthma man-
complex and characterized by variable and recurring symp- agement (Table 6–3). The history and measurement of lung
toms, airflow obstruction, bronchial hyperresponsiveness, and function is essential and more reliable than the physical exam.
underlying inflammation. Risk factors contributing to the de- A decrease in forced expiratory volume at 1 second (FEV1) pre-
velopment of asthma include atopy, genetic-environmental dicted best or peak expiratory flow rate (PEFR) is usually noted
interactions, and viral respiratory tract infections. Historical before the onset of clinical obstructive findings. Various
data consistent with asthma include a family history of asthma devices can be used to test for lung function. Spirometry is the
or allergies, personal history of allergies, recurrent symptoms
and triggers, and improvement of symptoms and lung func-
tion with asthma therapies, especially a short-acting beta2-
agonist (Table 6–1). TABLE 6-2
Asthma is a lower airway obstructive disease that can Clinical Findings in Asthma or Chronic
have clinical findings that are consistent with air trapping
(Table 6–2). In asthma exacerbations, breath sounds may be Obstructive Pulmonary Disease Flare
reduced and hyperinflation is present on a chest radiograph Condition Physical Examination Findings
due to significant air trapping. At the same time, chest x-ray
is not required when treating a person with an asthma flare Lower airway Hyperresonance on thoracic
unless there is a suspicion of pneumonia. However, particu- disease with percussion
larly in primary care, the physical exam is often normal and resulting air Decreased tactile fremitus wheeze
does not correlate well with asthma severity. Though wheez- trapping as (expiratory first, inspiratory later)
ing can occur with asthma, it is not required for the diagnosis. found in asthma Prolonged expiratory phase of
Variable degrees of cough and/or difficulty breathing may be or chronic forced exhalation
present without wheezing. The patient may be asymptomatic, obstructive Low diaphragms
pulmonary Increased anterior-posterior
disease flare or diameter
poor disease Reduction in forced expiratory vol-
control ume at 1 second (FEV1) or peak
TABLE 6-1 expiratory flow rate (early finding)
Making the Diagnosis: Is it Asthma? Reduction in arterial oxygen satu-
ration (SaO2) (later finding)
• Symptoms consistent with asthma
- Recurrent cough, wheeze, shortness of breath Source: Mangione S. Physical Diagnosis Secrets, 2nd ed. St. Louis,
MO: Elsevier Health Sciences, 2007.
and/or chest tightness
- Symptoms occur or worsen at night, exercise, viral
respiratory infections, aeroallergens and/or pul-
monary irritants (such as second-hand smoke) TABLE 6-3
• Airflow obstruction is at least partially reversible
- Increase in FEV1≥12% from baseline Risk Factors for Death from Asthma
- Increase in FEV1≥12% post-short-acting
• Infants <1 year old
beta2-agonist
• Previous severe exacerbations
Per EPR-3:
• ≥2 hospitalizations in past year
• Consider the diagnosis of asthma and perform
• ≥3 ED visits in past year
spirometry if any of these indicators are present.
• Hospitalization/ED visit in past month
These indicators are not diagnostic by themselves
• >2 canisters SABA use per month
but the presence of multiple key indicators increases
• Poor patient perception of symptoms
the probability of the diagnosis of asthma.
• Lack of written asthma care plan
• Spirometry is needed to make the diagnosis of
• Sensitivity to Alternaria
asthma.
• Low socioeconomic status
• Peak flow meter is used for monitoring, not for
• Illicit drug use
diagnosing, asthma.
• Major psychosocial problems
Source: Expert Panel Report Guideline for the Diagnosis and Manage- • Comorbidities (CV disease, Other chronic lung disease)
ment of Asthma, EPR-3, p. 42. Available at www.nhlbi.nih.gov/ • Major psychological disease
guidelines/asthma/asthgdln.htm
4074_Ch06_127-152 20/11/14 10:42 AM Page 131
most common lung function test used to diagnose and monitor The role of inhaled anticholinergics in the treatment of asthma
asthma and provides a rapid method to evaluate lungs and is evolving.
airways. Peak expiratory flow meters are less accurate than Systemic corticosteroids are indicated in moderate to
spirometry, but allow patients a convenient method to regu- severe asthma exacerbations and when there is partial re-
larly test lung function at home. sponse to initial SABA use in exacerbations. Oral prednisone
According to the NAEPP EPR-3, the goals of therapy for is preferred over parenteral corticosteroids. These medication
achieving asthma control are to reduce impairment and to forms are equally effective, and there is less risk of serious
reduce risk. Reduction of impairment is achieved by the pre- adverse reaction with oral corticosteroids. Duration of oral
vention of symptoms, use of a short-acting beta2-agonist corticosteroids for asthma is usually 5 to 10 days. There is no
limited to 2 or fewer days/week (unless for prevention of need to taper the dose for a 7-day course and usually no need
exercise-induced bronchospasm), maintenance of normal to taper for a 10-day course, particularly if a patient is on an
pulmonary function and normal activity levels, and meeting inhaled corticosteroid (Table 6–5).
patients’ and families’ expectations of and satisfaction with The backbone of persistent asthma therapy is medications
asthma care. Reduction of risk is achieved by the prevention that prevent and/or reduce airway inflammation to gain and
of exacerbations, prevention of lung function loss, and maintain asthma control. Asthma controllers consist of
minimal or no adverse effects from medications. inhaled corticosteroids (ICS), leukotriene modifiers (LTM)
Upon initial diagnosis of asthma, the level of asthma sever- and inhaled corticosteroids combined with long-acting
ity is assessed to guide decisions regarding therapeutic inter- beta2-agonist (ICS/LABA). ICS (i.e. fluticasone [Flovent],
ventions. Asthma severity is classified as intermittent or mometasone [Asmanex], budesonide [Pulmicort], others) have
persistent and is determined by the level of impairment and proved to be most effective in preventing airway inflammation
level of risk. Persistent asthma is subdivided as mild, moderate, and are the preferred controller treatment for all levels of
and severe. The emphasis on follow-up visits is assessment of persistent asthma. Improvement in asthma control is seen
asthma control. The level of control (well controlled, not well within 2 to 8 days. Risk of asthma exacerbations are reduced
controlled, or very poorly controlled) determines whether with routine use of ICS. Local adverse effects include sore
to maintain therapy, step-up therapy, or step-down therapy throat, oral candidiasis, and hoarseness. Rinsing the mouth
(Figures 6–1 to 6–3). after ICS use and use of a spacer can help reduce these effects.
Because of the wide range of asthma medications cur- Primary care providers are often poorly informed as to the
rently available, the NP, patient, and family can work to- relative potency of a given ICS and prescribe too low a dose
gether to find a lifestyle and treatment regimen that provide for the asthma severity; this is a major issue and impacts the
optimal care with minimal to no adverse medication effects. attainment of asthma control (Table 6–6). Systemic absorp-
Therapies are divided into two groups: relievers and con- tion varies among the ICS agents but is usually much less than
trollers. Relievers consist of short-acting beta2-agonists thought; at the recommended dose it can be less than 1% for
(SABA), short-acting muscarinic agents (SAMA), and oral certain ICS molecules, such as mometasone (Asmanex). It is
corticosteroids (OCS) (Table 6–4). advised, however, to monitor for systemic adverse effects, par-
SABAs include albuterol (Proventil, Ventolin, ProAir), ticularly if a patient is chronically on a high-dose ICS or has
levalbuterol (Xopenex), and pirbuterol (Maxair). SABAs are frequent oral corticosteroid use. Use the lowest ICS dose pos-
the drug of choice for all age groups to relieve acute asthma sible and implement corticosteroid-sparing strategies.
symptoms including bronchoconstriction and to prevent There is a potential but small risk of delayed growth and
exercise-induced bronchoconstriction. SABA use more than a potential in select children, such as those at high risk, for a
2 days/week (unless for prevention of exercise-induced small reduction (0.2 cm) in final adult height with ICS use.
bronchospasm) indicates a need for better asthma control. However, this potential risk is well balanced by the effective-
SABAs work by binding to the beta2 adrenergic receptor, ness of these medications. Interpretations of study results
causing smooth muscle relaxation and bronchodilation. evaluating linear growth in childhood asthma are difficult
This effect occurs within 3 to 5 minutes. Compared with because of the unknown influence from the uncontrolled
albuterol and pirbuterol, levalbuterol, a single isomer of the disease itself versus the treatment.
racemic albuterol, may be better tolerated than the other Leukotriene modifiers (LTM), such as montelukast
short-acting beta2-agonists, because of greater bronchodi- (Singulair) and zafirlukast (Accolate) are used to control
lation at a reduced dose. asthma by inhibiting the inflammatory actions of leukotrienes.
Ipratropium bromide (Atrovent) is a short-acting mus- These medications are indicated as an alternative to ICS
carinic agent indicated for the treatment of moderate or severe in mild persistent asthma and as add-on therapy to ICS in
asthma exacerbations to provide additional bronchodilation moderate and severe persistent asthma. Zileuton (Zyflo) is
to albuterol. This anticholinergic inhaled agent inhibits mus- a seldom-used LTM used in uncontrolled asthma; periodic
carinic cholinergic receptors, reducing vagal tone in the airway, hepatic enzyme monitoring is required during use.
decreasing mucus secretion and blocking reflex bronchocon- Long-acting beta2-agonists, including salmeterol (Serevent)
striction because of reflex esophagitis. Its additive benefit to and formoterol (Foradil), have a pharmacodynamic profile
albuterol is primarily in the outpatient setting. Studies have identical to SABAs, but with a significantly different phar-
not shown additional benefit to albuterol once hospitalized. macokinetic profile. LABAs improve symptoms, improve
4074_Ch06_127-152 20/11/14 10:42 AM Page 132
Step 6 Step up if
Step 5 Preferred: needed
Preferred: High-dose (first, check
Step 4 High-dose ICS + LABA adherence,
ICS + LABA + oral environmental
Preferred: control, and
Step 3 and corticosteroid
Low-dose comorbid
Preferred: and
ICS + LABA Consider conditions)
Step 2 Low-dose and Omalizumab Consider
Preferred: ICS + LABA for patients Omalizumab Assess
and Alternative: who have for patients control
Low-dose
Step 1 Medium- Medium- allergies who have
ICS
Preferred: dose ICS dose ICS + allergies Step down
Alternative: either LTRA, if possible
SABA PRN Alternative:
Cromolyn*, Theophylline, (and asthma
LTRA, Low-dose
ICS + either or Zileuton* is well
Nedocromil*, LTRA, controlled
or Theophylline, at least 3
Theophylline or Zileuton* months)
* Nedocromil and cromolyn no longer available in US, remain mentioned in guidelines. Zileuton seldom used but available.
Stepwise Approach for Managing Asthma in Youths ≥ 12 Years of Age and Adults
Notes:
• The stepwise approach is meant to assist, not replace, the clinical decision making requried to meet individual patient needs.
• If alternative treatment is used and response is inadequate, discontinue it and use the preffered treatment before stepping up.
• Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the neeed to monitor liver function.
Theophylline requires monitoring of serum concentration levels.
• In step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or
zileuton may be considered, although this approach has not been studied in clinical trials.
• Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA,
Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative
therapy is based on Evidence B for LTRA and theophylline and Evidence D for zileuton. Step 5 preferred therapy is based on
Evidence B. Step 6 preferred therapy is based on the Expert Panel Report Guideline for the Diagnosis and Management of
Asthma (EPR-2, 1997), and Evidence B for omalizumab.
• Immunotherapy for steps 2–4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or
lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma
is greater in children than in adults.
• Clinicians who administer immunotherapy or omalizumab should be prepared and equipped to identify and treat anaphylaxis
that may occur.
Figure 6-1 Stepwise approach for managing asthma in patients 12 years of age and older.
(Source: https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf)
4074_Ch06_127-152 20/11/14 10:42 AM Page 133
Step 3 Step 4
Step 1 Step 2
Recommended Step for and consider short course of
Initiating Therapy oral systemic corticosteroids
In 2–6 weeks, evaluate level of asthma control that is achieved, and adjust therapy
accordingly.
• Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4
weeks and spirometry. Assign severity to the most severe category in which any feature occurs.
• At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent
and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization or ICU admission) indicate greater underlying disease severity.
For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same
patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Figure 6-2 Classifying asthma severity in youths ≥12 years of age and adults.
lung function, reduce exacerbations, and enhance the anti- medication, such as an inhaled corticosteroid. The NAEPP
inflammatory action of corticosteroids. Adding a LABA to EPR-3 guidelines recommend achieving and maintaining
an ICS is the preferred treatment for moderate and severe control for at least 3 months before trying to step down.
asthma. The LABA class received a boxed warning from the Many factors contribute to the decision-making process with
U.S. Food and Drug Administration (FDA) because LABA individualization of care and consideration of the risk for
use is associated with increased risk of death in certain future exacerbation being crucial.
patient groups and should not be used without an ICS in Mast cell stabilizers (cromolyn and nedocromil) are men-
asthma. Prescribe combination ICS/LABA only for patients tioned in EPR-3; however, these agents are no longer avail-
with asthma not adequately controlled on a long-term able in the United States because of superior agents on the
asthma control medication, such as an inhaled corticos- market. These are older inhalation agents that are safe, but
teroid, or whose disease severity clearly warrants initiation inferior in potency to the newer agents such as ICS, and re-
of treatment with both inhaled corticosteroid and LABA. quire multiple dosing daily. Theophylline is also mentioned,
Once asthma control is achieved and maintained, assess however rarely used due to superior agents now available,
the patient at regular intervals and step down therapy (dis- and its significant drug-drug interaction potential, a narrow
continue LABA) if possible without loss of asthma control, therapeutic index, and requirement for periodic serologic
while maintaining the patient on a long-term asthma control drug level monitoring (Table 6–7).
4074_Ch06_127-152 20/11/14 10:42 AM Page 134
Nighttime
≤2x/month 1−3x/month ≥4x/week
awakenings
Interference with
None Some limitation Extremely limited
normal activity
Impairment Short-acting
beta2-agonist use for
≤2 days/week >2 days/week Several times per day
symptom control
(not prevention of EIB)
Normal FEV1 >80% predicted/ 60–80% predicted/ <60% predicted/
or peak flow personal best personal best personal best
Validated
Questionnaires
ATAQ 0 1–2 3–4
ACQ ≤0.75* ≥1.5 N/A
ACT ≥20 16–19 ≤15
• Maintain current step • Step up 1 step and reevaluate • Consider short course of oral
• Regular follow-ups every 1–6 2–6 wks systemic corticosteroids
Recommended Action months to maintain control • For side effects, consider • Step up 1-2 steps and
• Consider step down if alternative treatment options reevaluate in 2 weeks
for Treatment
well-controlled for at least • For side effects, consider
three months alternative treatment options
Figure 6-3 Assessing asthma control in youths ≥12 years of age and adults.
TABLE 6-5
Relative Potency of Systemic Corticosteroids
Higher potency corticosteroids Betamethasone, 0.6–0.75 mg Dexamethasone, 0.75 mg Half-life 36–54 hr
(equipotent doses)
Medium potency corticosteroids Methylprednisolone, 4 mg Triamcinolone, 4 mg Half-life 18–36 hr
(equipotent doses) Prednisolone, 5 mg
Prednisone, 5 mg
Lower potency (equipotent doses) Hydrocortisone, 20 mg Cortisone, 25 mg Half-life 8–12 hr
Source: Drug Facts and Comparisons. Philadelphia, PA: Wolters Kluwer Health, 2013.
www.factsandcomparisons.com.
TABLE 6-6
Estimated Comparative Daily Doses for Inhaled Corticosteroid (ICS) Therapy in Patients
12 Years and Older
Low Daily Dose Medium Daily Dose High Daily Dose
Beclomethasone HFA (Qvar) 40 or 80 mcg/puff 80–240 mcg >240–480 mcg >480 mcg
Budesonide DPI (Pulmicort Flexhaler) 180–540 mcg >540–1080 mcg >1080 mcg
180 mcg/inhalation
Fluticasone HFA MDI (Flovent HFA) 44, 110, 88–264 mcg 264–440 mcg >440 mcg
or 220 mcg/puff
Fluticasone DPI (Flovent Diskus) 50, 100, or 100–300 mcg 300–500 mcg >500 mcg
250 mcg/puff
Mometasone DPI (Asmanex) 200 mcg/puff 200 mcg 400 mcg >400 mcg
TABLE 6-7
Medications Used for Treating Patients With Asthma and Chronic Obstructive
Pulmonary Disease (COPD)
Medication Mechanism of Action Indication Comment
Short-acting SABA: bronchodilation SABA: reliever drug; treat- Onset of action within
bronchodilators via stimulation of beta2 ment of acute asthma and 15 minutes SABA,
*Short-acting beta2- receptor site COPD symptoms 30 minutes SAMA
agonists (SABA) SAMA: anticholinergic and SAMA: Reliever drug for Duration 4–6 hrs
albuterol (Proventil, muscarinic antagonist; COPD; add-on for asthma
Ventolin, ProAir) & yielding bronchodilation exacerbation
pirbuterol (Maxair)
levalbuterol (Xopenex)
*Short-acting muscarinic
agents (SAMA)
iptratropium (Atrovent)
Continued
4074_Ch06_127-152 20/11/14 10:42 AM Page 136
TABLE 6-7
Medications Used for Treating Patients With Asthma and Chronic Obstructive
Pulmonary Disease (COPD)—cont’d
Medication Mechanism of Action Indication Comment
Long-acting LABA: bronchodilation LABA: controller drug; treat- LABA: Onset of action 1 hr
bronchodilators through stimulation of ment and prevention of (15–30 min for formoterol)
*Long-acting beta2- receptor site beta2 bronchospasm in asthma Duration of action 12 hr
agonists (LABA) LAMA: and COPD Not to be used as
(salmeterol (Serevent), LAMA: treatment of bron- monotherapy in
formoterol (Foradil), chospasm in COPD asthma
indacaterol (Onbrez)
*Long-acting muscarinic
agents (LAMA):
tiotropium (Spiriva),
aclidium (Pressair)
Inhaled corticosteroids Block late-phase activation Controller drug, preferred Need consistent use to
mometasone (Asmanex) to allergen, inhibit inflam- treatment for persistent be helpful. Cornerstone
fluticasone (Flovent) matory cell migration and asthma to prevent and con- medication of most
budesonide (Pulmicort) activation trol inflammation asthma levels
beclomethasone (Qvar), In COPD, routine use recom-
ciclesonide (Alvesco) mended with FEV1 <60%
predicted and/or with recur-
rent exacerbations.
Leukotriene receptor Inhibit action of inflamma- Controller drug, prevention Likely less effective than
antagonist, also known tory mediator (leukotriene) of inflammation in asthma inhaled corticosteroids
as leukotriene modifier by blocking select receptor Particularly effective add-
(montelukast [Singulair], sites on medication with inhaled
zafirlukast [Accolate], corticosteroid and with
(zileuton [Zyflo]) allergic rhinitis. In mild
persistent asthma, an
alternative, although not
preferred
Systemic corticosteroids Inhibit eosinophilic action Treatment of acute inflam- Oral route preferred when-
and other inflammatory mation such as in asthma ever possible. Indicated
mediators flare or COPD exacerbation in treatment of acute
asthma flare to reduce
inflammation
In higher dose and with
longer therapy (>2 weeks),
adrenal suppression may
occur
No taper needed if use is
short-term (<10 days) and
at lower dose (prednisone,
40–60 mg/d or less)
Mast cell stabilizers Halts degradation of mast Controller drug, prevention No longer available in
Cromolyn sodium (Intal) cells and release of of inflammation in asthma United States
nedocromil (Tilade) histamine and other Need consistent use to be
inflammatory mediators helpful
Less effective than other
controller therapies
4074_Ch06_127-152 20/11/14 10:42 AM Page 137
TABLE 6-7
Medications Used for Treating Patients With Asthma and Chronic Obstructive
Pulmonary Disease (COPD)—cont’d
Medication Mechanism of Action Indication Comment
Theophylline Mild bronchodilator via non- Prevention of bronchospasm Narrow therapeutic index
phosphodiesterase inhibitor. in asthma and COPD drug with numerous poten-
Possible mild anti-inflamma- tial drug interactions
tory effect Monitor carefully for toxicity
by checking drug levels and
clinical presentation
Phosphodiesterase-4 Not well defined; thought to Indicated as a treatment to Is not a bronchodilator and is
inhibitors be because of the effects of reduce the risk of COPD ex- not indicated for the relief
Roflumilast (Daliresp) increased intracellular cAMP acerbations in patients with of acute bronchospasm.
in lung cells severe COPD associated
with chronic bronchitis and
a history of exacerbations.
Source: Report of the Expert Panel. www.nhlbi.nih.gov/guidelines/asthma/, Guidelines for the diagnosis
and management of asthma (EPR-3), accessed 12/3/13.
DI SCUSSION SOURCES
34 to 37. Indicate whether each statement is true or false.
Cox, et al. Allergen immunotherapy: A practice parameter third
update. 2010. Available at www.aaaai.org (American Academy 34. Seasonal influenza vaccination is generally
of Allergy, Asthma and Immunology), accessed 1/28/13. recommended for all persons over the age of
Guilbert TW, et al. Growth of preschool children at high risk for 6 months.
asthma 2 years after discontinuation of fluticasone. J Allergy Clin
Immunol 128:956–963, 2011. 35. A 66-year-old woman is an acceptable candidate
National Asthma Education and Prevention Program. Guidelines for the high-dose inactivated influenza vaccine
for the Diagnosis and Management of Asthma-update on shot.
Selected Topics. NIH-NHLBI. Available at www.nhlbi.nih.gov/
guidelines/asthma 36. Cigarette smokers should not receive the pneumo-
Skoner DP. Balancing safety and efficacy in pediatric asthma man- coccal vaccine until 65 years of age.
agement. Pediatrics 109:381–392, 2002. 37. A 52-year-old immunocompetent patient with
Strunk R, et al. Long-term budesonide or nedocromil treatment,
COPD who receives the pneumococcal vaccine
once discontinued, does not alter the course of mild-moderate
asthma in children and adolescents. J Pediatr 154:682–687, 2009.
should get revaccinated in 5 years.
Thomas A, et al. Approaches to stepping up and stepping down care 38. When used in treating COPD, ipratropium bromide
in asthmatic patients. J Allergy Clin Immunol 128:915–924, 2011. (Atrovent) is prescribed to achieve which of the
following therapeutic effects?
A. increase mucociliary clearance
COPD B. reduce alveolar volume
C. bronchodilation
33. When discussing immunizations with a 67-year-old
D. mucolytic action
woman with chronic obstructive pulmonary disease
(COPD), you advise that she: 39. What is the desired therapeutic action of inhaled
A. receive live attenuated influenza virus vaccine. corticosteroids when used to treat COPD?
B. avoid immunization against influenza because of A. reversal of fixed airway obstruction
the risk associated with the vaccine. B. improvement of central respiratory drive
C. receive inactivated influenza virus vaccine. C. reduction of airway inflammation
D. take an antiviral for the duration of the influenza D. mucolytic activity
season.
4074_Ch06_127-152 20/11/14 10:42 AM Page 138
40. Which is most consistent with the diagnosis of 47. Which is the most appropriate choice of therapy in
COPD? the treatment of a mild acute COPD exacerbation in a
A. FEV1/FVC ratio equal to or less than 0.70 after 42-year-old man?
properly timed SABA use A. A 5-day course of levofloxacin
B. dyspnea on exhalation B. A 7-day course of amoxicillin
C. elevated diaphragms noted on x-ray C. A 10-day course of doxycycline
D. polycythemia noted on complete blood cell D. Antimicrobial therapy is usually not indicated.
count
48. Which is the most appropriate statement about therapy
41. The most effective nonpharmacologic method to for a severe COPD exacerbation in a 52-year-old man?
prevent exacerbations in patients with COPD is: A. A 5-day course azithromycin should be prescribed.
A. weight loss for those with a BMI greater than B. A 10-day course of amoxicillin/clavulanate is advisable,
25 kg/m2. C. A 7-day course of trimethoprim-sulfamethoxazole is
B. avoid exposure to children or day-care centers. recommended.
C. brisk walking for at least 5 minutes 3-5 times a day D. The role of antimicrobial therapy is debated, even
as tolerated. for severe disease.
D. avoid exposure to pulmonary irritants, such as
49. You see a 67-year-old man with stage IV (very severe)
cigarette smoke.
COPD who asks, “When should I use my home oxygen?”
42. When managing patients with COPD who continue You respond:
to smoke cigarettes, a discussion on the importance of A. as needed when short of breath.
smoking cessation should occur: B. primarily during sleep hours.
A. at the initial diagnosis visit. C. preferably during waking hours.
B. with each COPD flare. D. for at least 15 hours a day.
C. once inhaled corticosteroid therapy is initiated.
50. With a COPD exacerbation, a chest x-ray should be
D. at every office visit.
obtained:
43. According to the Global Initiative for Chronic Obstruc- A. routinely in all patients
tive Lung Disease (GOLD) COPD guidelines, which of B. when attempting to rule out a concomitant pneumonia.
the following medications is indicated for use in all C. if sputum volume is increased.
COPD stages? D. when work of breathing is increased.
A. short-acting inhaled beta2-agonist
51. Which of the following best describes the role of theo-
B. inhaled corticosteroid
phylline in COPD treatment?
C. long-acting anticholinergic
A. indicated in moderate to very severe COPD
D. long-acting beta2-agonist
B. use limited by narrow therapeutic profile and drug-
44. According to the GOLD COPD guidelines, the goal drug interaction potential
of inhaled corticosteroid use in stage III or severe C. a potent bronchodilator
COPD is to: D. available only in parenteral form
A. minimize the risk of repeated exacerbations.
52. All of the following are consistent with the GOLD COPD
B. improve cough function.
recommendation for pulmonary rehabilitation except:
C. reverse alveolar hypertrophy.
A. reserved for very severe COPD.
D. help mobilize secretions.
B. goals include improvement in overall well-being.
45. Which of the following systemic corticosteroid doses is C. an underused therapeutic option.
most potent? D. components aimed at reducing the deconditioning
A. methylprednisolone 8 mg common in COPD.
B. triamcinolone 10 mg
C. prednisone 15 mg
D. hydrocortisone 18 mg Answers
46. Which of the following pathogens is often implicated 33. C. 40. A. 47. D.
in a COPD exacerbation caused by respiratory tract 34. True 41. D. 48. D.
infection? 35. True 42. D. 49. D.
A. Legionella species 36. False 43. A. 50. B.
B. Streptococcus pyogenes 37. False 44. A. 51. B.
C. Respiratory tract viruses 38. C. 45. C. 52. A.
D. Staphylococcus aureus 39. C. 46. C.
4074_Ch06_127-152 20/11/14 10:42 AM Page 139
Chronic obstructive pulmonary disease (COPD) is a considered the most sensitive indicator of early airflow lim-
preventable and treatable disease with significant extrapul- itation. The presence of a post-bronchodilator FEV1:FVC
monary effects that can contribute to the severity in indi- less than 70% confirms persistent airflow obstruction. The
vidual patients. The pulmonary component is characterized degree of spirometric abnormality generally reflects the
by airflow limitation that is not fully reversible. The airflow severity of COPD. However, symptoms often do not cor-
limitation is usually progressive and associated with an ab- relate well with objective measurements and/or patients
normal inflammatory response of the lung to noxious par- may deny symptoms and meet diagnostic criteria for
ticles or gases. This response results in a decrease in the COPD. The COPD Assessment Test (CAT) is a useful
ratio of forced expiratory volume at 1 second (FEV1) to adjunct to symptoms, spirometry abnormality, and identi-
forced vital capacity (FVC). fication of risk for exacerbations for the assessment of
Historically, the hallmark symptom of chronic bronchitis the level of COPD severity and choosing pharmacologic
is a chronic productive cough, whereas for emphysema it is therapy (Tables 6–8 to 6–10).
shortness of breath. However, these terms are not used as part
of the Global Obstructive Lung Disease (GOLD) guidelines
for the diagnosis and management of COPD. Instead, em-
phasis is on the symptoms of dyspnea, chronic cough, and
sputum production with the understanding that airway in- TABLE 6-8
flammation, smooth muscle constriction, and altered lung Classification of Severity of Airflow
mechanics occurs. Patients with COPD typically present for
care in the fifth and sixth decades of life, usually after having
Limitation in COPD Based on Post-
symptoms for more than a decade. bronchodilator FEV1
Diagnosis should be considered in any patient with pro- IN PATIENTS WITH FEV1/FVC<0.70:
gressive dyspnea, chronic cough or sputum production,
and/or with a history of risk factors, such as tobacco use. GOLD 1 Mild FEV1≥80% predicted
Dyspnea is typically persistent and progressive and is worse GOLD 2 Moderate 50%≤FEV1<80% predicted
with exercise and exacerbations. Cough can be intermittent GOLD 3 Severe 30%≤FEV1<50% predicted
and is often unproductive. However, often the cough is GOLD 4 Very severe FEV1<30% predicted
productive and chronic. Spirometry should then be per-
Source: Global Initiative for Chronic Obstructive Lung Disease, Pocket
formed and is required to make the clinical diagnosis Guide to COPD Diagnosis, Management and Prevention, www.
of COPD. The forced expiratory volume in the first second goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html,
of expiration (FEV1):forced vital capacity (FVC) ratio is accessed 12/3/13.
TABLE 6-9
Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD)
Pharmacologic Therapy for Stable COPD
Patient group First choice Second choice Alternative choice**
A SA anticholinergic LA anticholinergic (tiotropium [Spiriva]) Theophylline
Low Risk (ipratropium or
Less Symptoms [Atrovent]) PRN LA beta2-agonist (salmeterol
or [Serevent])
SA beta2-agonist or
(albuterol [Ventolin SA beta2-agonist and
HFA, Proventil HFA]) SA anticholinergic (ipratropium
PRN bromide with albuterol [Combivent
Respimat])
B LA anticholinergic LA anticholinergic (tiotropium [Spiriva]) SA beta2-agonist (albuterol
Low Risk (tiotropium [Spiriva]) and [Ventolin HFA, Proventil
More Symptoms or LA beta2-agonist (salmeterol HFA]) and/or
LA beta2-agonist [Serevent]) SA anticholinergic
(salmeterol [Serevent]) (ipratropium [Atrovent])
(ipratropium bromide
with albuterol [Combivent
Respimat])
Continued
4074_Ch06_127-152 20/11/14 10:42 AM Page 140
TABLE 6-9
Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD)
Pharmacologic Therapy for Stable COPD—cont’d
Patient group First choice Second choice Alternative choice**
C ICS (fluticasone, LA anticholinergic (tiotropium [Spiriva]) PDE-4 inhibitor (roflumilast
High Risk budesonide) + LA and [Daliresp***])
Less Symptoms beta2-agonist (salme- LA beta2-agonist (salmeterol SA beta2-agonist (albuterol
terol, formoterol [Serevent]) [Ventolin HFA, Proventil
[Advair, Symbicort]) HFA]) and/or
or SA anticholinergic
LA anticholinergic (ipratropium [Atrovent])
(tiotropium [Spiriva]) Theophylline (do not use
w/roflumilast)
D ICS (fluticasone, budes- ICS (fluticasone [Flovent HFA], Carbocysteine (mucolytic)
High Risk onide) + LA beta2- budesonide [Pulmicort Flexhaler]) SA beta2-agonist (albuterol
More Symptoms agonist (salmeterol, and LA anticholinergic (tiotropium [Ventolin HFA, Proventil
formoterol [Advair, [Spiriva]) HFA]) and/or
Symbicort]) or SA anticholinergic
or ICS (fluticasone, budesonide) + LA (ipratropium [Atrovent])
LA anticholinergic beta2-agonist (salmeterol, formoterol Theophylline
(tiotropium [Spiriva]) [Advair, Symbicort])
and
LA anticholinergic (tiotropium [Spiriva])
or
ICS + LA beta2-agonist (Advair,
Symbicort) and
PDE-4 inhibitor (roflumilast
[Daliresp***])
or
LA anticholinergic (tiotropium [Spiriva])
and
LA beta2-agonist (salmeterol
[Serevent])
or
LA anticholinergic (tiotropium [Spiriva])
and
PDE-4 inhibitor (roflumilast
[Daliresp***])
*Medications in each box are mentioned in alphabetical order and therefore not necessarily in order of
preference.
**Medications in this column can be used alone or in combination with other options in the First and Second
choice columns
Source: Global Initiative for Chronic Obstructive Lung Disease, Pocket Guide to COPD Diagnosis, Management,
and Prevention 2011.
***Roflumilast (Daliresp) {phosphodiesterase 4 (PDE4) inhibitor}, therapeutic option to reduce the risk of
COPD exacerbations in patients with severe and very severe COPD associated with chronic bronchitis who
have a history of exacerbations. Not a bronchodilator and not indicated for relief of acute bronchospasm.
Adverse effects include unintended weight loss, changes in mood, thinking, and behavior. Not to be used
with theophylline.
Medications mentioned represent examples of the given drug class not a comprehensive list of all options.
Source: Global Initiative for Chronic Obstructive Lung Disease, Pocket Guide to COPD Diagnosis, Management
and Prevention, www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html, accessed 11/20/13.
4074_Ch06_127-152 20/11/14 10:42 AM Page 141
TABLE 6-10
Combined Assessment of COPD
Patient Characteristic Spirometric classification Exacerbations per year CAT
A Low Risk GOLD 1–2 ≤1 <10
Less Symptoms
B Low Risk GOLD 1–2 ≤1 ≥10
More Symptoms
C High Risk GOLD 3–4 ≥2 <10
Less Symptoms
D High Risk GOLD 3–4 ≥2 ≥10
More Symptoms
The goals of COPD treatment are to relieve symptoms, 65 years and older, as well as younger adults at high risk
reduce the impact of the symptoms, and reduce future ad- for disease. PCV13 or Prevnar 13 is a pneumococcal con-
verse health events including exacerbations. Nonpharma- jugate vaccine that is approved for adults 50 years and older
cologic achievement of these goals includes smoking and protects against 13 serotypes. Check label recommen-
cessation and avoidance of other pulmonary irritants. Be- dations for the use of pneumococcal vaccine.
cause 80% of all cases of COPD can be attributed directly The backbone of pharmacologic therapy for COPD is the
to tobacco use, encouraging the patient to stop smoking is inhaled bronchodilators. Patients at all levels of COPD
an important clinical goal. Despite symptoms, many severity should be prescribed a short-acting beta2-agonist
patients continue to smoke. Raising the issue of smoking for acute relief of symptoms. Routine, daily bronchodilators
cessation at every visit and offering assistance with this is are begun at the moderate severity stage COPD (Stage 2) and
an important part of the ongoing care of the person with continued throughout very severe COPD (Stage 4). Options
COPD. Counseling about general hygiene should also be include a long-acting anticholinergic agent (tiotropium
provided, including information on minimizing exposure [Spiriva], aclidium bromide [Turdoza Pressair]), a long-
to passive smoking, allergens, and air pollution, and advice acting beta2-agonist (salmeterol [Serevent], formoterol
on hydration, nutrition, and avoiding respiratory tract [Foradil], arformoterol [Brovana], indacaterol [Onbrez]),
infection. or a short-acting anticholinergic agent dosed several times
Patients with COPD are at higher risk of a number of daily (ipratropium [Atrovent]). The long-acting bron-
vaccine-preventable diseases and immunization should be chodilators are preferred over the multi-dosed, short-
encouraged. Routine seasonal influenza vaccination is rec- acting agents due to superior effectiveness and conven-
ommended for all persons older than 6 months of age and ience. The choice between the long-acting bronchodilators
should be encouraged and given annually for COPD patients. depends on availability of the drug, the patient’s individual
There are currently a variety of influenza vaccines that can response in terms of symptom relief, and adverse effects.
be used. The trivalent or quadrivalent inactivated vaccine Combining bronchodilators of different pharmacologic
administered intramuscularly can be used for all patients classes may improve efficacy. Routine use of inhaled corti-
6 months and older with no contraindications. The live, at- costeroids in COPD patients with FEV1 less than 60% pre-
tenuated influenza vaccine (LAIV) administered via a nasal dicted improves symptoms and lung function, and reduces
spray is approved for most individuals aged 2 through the frequency of exacerbations. Combination inhaled orti-
49 years but should not be used in individuals with airway costeroid/long-acting bronchodilator is more effective in
disease. Meanwhile, a high-dose inactivated vaccine is avail- improving symptoms and lung function, and reducing ex-
able for those 65 years and older that is likely to improve the acerbations in patients with moderate to very severe COPD
immune response in this older patient population. Pneumo- than either individual component. Long-term treatment
coccal vaccination is currently recommended for all adults with oral corticosteroids is not recommended. Theo-
65 years and older as well as younger adults considered at phylline is less effective and less well tolerated than other
higher risk of disease, including cigarette smokers, people bronchodilators. There is a risk for drug-drug interactions,
with asthma, and anyone with COPD. Two pneumococcal and it has a narrow therapeutic index. Roflumilast
vaccines are approved for use in adults. Pneumovax is a 23- (Daliresp) is a phosphodiesterase-4 inhibitor indicated for
valent polysaccharide vaccine that protects against 23 the reduction of exacerbations in severe and very severe
pneumococcal serotypes and is recommended for adults chronic bronchitis.
4074_Ch06_127-152 20/11/14 10:42 AM Page 142
Patients at all severity levels of COPD benefit from ex- of systemic corticosteroid therapy has been advised, recent
ercise training and pulmonary rehabilitation. The goal of study supports the efficacy and safety of a shorter 5-day
this intervention is to improve quality of life, decrease course.
symptoms, and increase physical participation in activities Antimicrobial therapy is not always needed as part of
of daily living. Components of a pulmonary rehabilitation treatment of a COPD exacerbation because the cause
program include reversing the effects of physical decondi- can be nonbacterial in origin, such as an environmental
tioning, social isolation, weight loss, muscle wasting, and problem or viral infection. Use of an antibiotic is likely
altered mood often noted with COPD. Improvements in indicated, however, when symptoms of breathlessness
exercise tolerance and symptoms of dyspnea and fatigue and cough are accompanied by altered sputum character-
can be sustained even after a single pulmonary rehabilita- istics that suggest bacterial infection, such as increased
tion program. Because of issues of funding, access, and lack purulence or change in volume. The therapeutic choice
of provider and patient knowledge of this helpful interven- should be dictated by antimicrobial coverage for the major
tion, pulmonary rehabilitation is an underused, yet helpful bacterial pathogens involved in COPD exacerbation, while
intervention. taking into account local patterns of bacterial resistance
Long-term oxygen therapy for patients with COPD (Table 6–12). Because of the possibility of a concomitant
should be considered, particularly as the disease progresses, pneumonia, a chest x-ray should be obtained when the
or when a patient presents with advanced disease (Table 6–11). patient presents with fever or unusually low SaO 2 or
The goal of therapy is to ensure adequate oxygen delivery both; in the absence of these findings, a chest x-ray is not
to the vital organs by increasing the baseline PaO2 at rest usually needed.
to 60 mm Hg or greater at sea level, or producing SaO2
equal to or greater than 90%, or both. In patients with D I S C U SSI O N S O U R C E S
chronic respiratory failure, oxygen therapy administered Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
more than 15 hours per day has been shown to increase Sanford Guide to Antimicrobial Therapy, 44th ed. Sperryville, VA:
survival. Many patients wait until they are breathless, then Antimicrobial Therapy, Inc., 2014.
attempt to correct this with as-needed oxygen use and Global Initiative for Chronic Obstructive Lung Disease. Pocket
Guide to COPD Diagnosis, Management and Prevention, http://
fail to achieve maximum benefit; these benefits include
www.goldcopd.org/Guidelines/guidelines-resources.html
not only improved overall well-being, but also increased
survival.
Exacerbations of respiratory symptoms that necessitate Tuberculosis
treatment are important clinical events in COPD. The most
common causes of an exacerbation are infection of the tra- 53. You examine a 28-year-old woman who has emigrated
cheobronchial tree and air pollution, but the cause of at least from a country where tuberculosis (TB) is endemic.
one-third of severe exacerbations cannot be identified. In- She has documentation of receiving Bacille Calmette-
haled bronchodilators (beta2-agonists or anticholinergics or Guérin (BCG) vaccine as a child. With this informa-
both) are effective for the treatment of COPD exacerbation. tion, you consider that:
Consider adding a long-acting bronchodilator if the patient A. she will always have a positive tuberculin skin test
is not currently using one and adding an inhaled corticos- (TST) result.
teroid to reduce the risk of future exacerbations. If baseline B. biannual chest radiographs are needed to assess her
FEV1 is less than 60% of predicted, a systemic corticosteroid, health status accurately.
with oral route preferred, such as prednisone 40 mg daily for C. a TST finding of 10 mm or more induration should
5 to 10 days, should be added; knowledge of the relative be considered a positive result.
potency of these drugs is important to safe and effective D. isoniazid therapy should be given for 6 months
clinical practice. (See Table 6–5). Although a 10-day course before TST is undertaken.
TABLE 6-11
Long-term Oxygen Therapy in Chronic Obstructive Pulmonary Disease
Goal To ensure adequate oxygen delivery to vital organs by increasing baseline PaO2 at
rest to ≥60 mm Hg at sea level or producing SaO2 ≥90%, or both
Indications to Initiate Long-Term PaO2 <55 mm Hg or SaO2 <88% with or without hypercapnia PaO2 55–69 mm Hg
(>15 Hours/Day) Oxygen Therapy or SaO2 89% in the presence of cor pulmonale, right heart failure, or poly-
cythemia (hematocrit >56%)
Source: Global Initiative for Chronic Obstructive Lung Disease, Pocket Guide to COPD Diagnosis, Management
and Prevention, www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html
4074_Ch06_127-152 20/11/14 10:42 AM Page 143
TABLE 6-12
Etiology and Recommendations for Antimicrobial Therapy in Chronic Obstructive
Pulmonary Disease (COPD) Exacerbations
ETIOLOGY Viruses (20%–50%)
Bacteria:
• Aside from bacterial infection, tobacco use, air pollution, and viruses
common contributing factors
• Causative pathogens (30-50%) include Haemophilus influenzae,
Haemophilus parainfluenzae, Streptococcus pneumoniae, Moraxella
catarrhalis.
• Less common pathogens include atypical pathogens, other gram-positive
and -negative organisms.
MILD-TO-MODERATE DISEASE Antimicrobial therapy usually not indicated. If prescribed, consider using the
following agents:
• Amoxicillin
• Doxycycline
SEVERE DISEASE (INCREASED DYSPNEA, Use one of the following agents:
INCREASED SPUTUM VISCOSITY/ • Amoxicillin-clavulanate
PURULENCE, AND INCREASED SPUTUM • Cephalosporin
VOLUME) • Azithromycin
Role of antimicrobial therapy • Clarithromycin
debated even for severe disease. • Fluoroquinolone with activity against drug-resistant S. pneumoniae
Source: Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS. The Sanford Guide to Antimicrobial
Therapy, 44th ed. Sperryville, VA: Antimicrobial Therapy, Inc., 2014.
54. A 33-year-old woman works in a small office with a 56. A 45-year-old woman with type 2 diabetes melli-
man recently diagnosed with active pulmonary TB. tus and chest radiograph finding consistent with
Which of the following would be the best plan of care previous TB and a 7-mm induration
for this woman?
57. A 21-year-old man with no identifiable TB risk
A. She should receive TB chemoprophylaxis if her TST
factors and a 10-mm induration
result is 5 mm or more in induration.
B. Because of her age, TB chemoprophylaxis is con- 58. A 31-year-old man with HIV and a 6-mm induration
traindicated even in the presence of a positive TST
59. A 45-year-old woman from a country in which TB
result.
is endemic who has an 11-mm induration
C. If the TST result is positive but the chest radiograph
is normal, no further evaluation or treatment is 60. A 42-year-old woman with rheumatoid arthritis
needed. who is taking etanercept (Enbrel) who has a 7-mm
D. Further evaluation is needed only if the TST result is induration
15 mm or more in induration.
61. Risk factors for development of infection reactivation
55. Compared with TST, potential advantages of the in patients with latent TB infection include all of the
QuantiFERON-TB Gold test (QTF-G) include all of following except:
the following except: A. diabetes mellitus.
A. ability to have entire testing process complete with B. immunocompromise.
one clinical visit. C. long-term oral corticosteroid therapy.
B. results are available within 24 hours. D. male gender.
C. interpretation of test is not subject to reader bias.
62. Clinical presentation of progressive primary TB most
D. provides a prediction as to who is at greatest risk
commonly includes all of the following except:
for active disease development.
A. malaise.
For the following questions, answer “yes” or “no” in re- B. fever.
sponse to the question, “Does this patient have a reactive C. dry cough.
TST?” D. frank hemoptysis.
4074_Ch06_127-152 20/11/14 10:42 AM Page 144
TABLE 6-13
Classification of Tuberculin Skin Test Reaction
An induration of ≥5 mm is considered An induration of ≥10 mm is considered An induration of ≥15 mm
positive in: positive in: is considered positive in any
• HIV-infected persons • Recent immigrants (<5 yr) from high- person, including persons
• A recent contact of a person with prevalence countries with no known risk factors
tuberculosis (TB) disease • Injection drug users for TB. Targeted skin testing
• Persons with fibrotic changes on chest • Residents and employees of high-risk programs should be con-
radiograph consistent with prior TB congregate settings ducted only in high-risk
• Patients with organ transplants • Mycobacteriology laboratory personnel groups, however
• Persons who are immunosuppressed • Persons with clinical conditions that
for other reasons (e.g., taking the place them at high risk
equivalent of >15 mg/d of prednisone • Children <4 y.o.
for ≥1 mo, taking TNF-α antagonists) • Infants, children, and adolescents ex-
posed to adults in high-risk categories
4074_Ch06_127-152 20/11/14 10:42 AM Page 145
reported. The chest examination is usually normal, with dys- 65. A 78-year-old woman with a history of COPD, hyper-
pnea seldom reported unless disease is extensive. tension, and dyslipidemia who is taking lovastatin and a
Chemoprophylaxis therapy with isoniazid and other dihydropyridine calcium channel blocker?
agents to prevent the development of active pulmonary TB A. clindamycin
should be considered for patients with latent tuberculosis— B. high-dose amoxicillin with doxycycline
that is, positive tuberculin test results, but negative chest C. clarithromycin
radiograph results and no suspicion of disease revealed D. ceftriaxone
by health history or physical examination. The duration of
66. A 69-year-old man with heart failure, prior myocardial
isoniazid therapy is 6 to 9 months, depending on the dosing
infarction, and type 2 diabetes?
regimen. Rifampin is an alternative choice if isoniazid cannot
A. respiratory fluoroquinolone
be taken or is poorly tolerated. Although the risk of liver tox-
B. amoxicillin with a beta-lactamase inhibitor
icity with anti-TB drug use increases with age, age alone is
C. cephalosporin
not a contraindication to its use, particularly in individuals
D. beta-lactam plus macrolide
at higher risk.
In the presence of active pulmonary TB, multiple antimi- 67. A 28-year-old woman with a severe beta-lactam allergy
crobial therapies are administered that are aimed not only at who has a dry cough, headache, malaise, no recent
eradicating the infection, but also at minimizing the risk of antimicrobial use, and no comorbidity who takes no
developing a resistant pathogen. In this era of multidrug- medication?
resistant TB, it is prudent to consult with local TB experts to A. clarithromycin
ascertain the local patterns of susceptibility. With latent and B. amoxicillin
active disease, public health involvement is critical to maxi- C. levofloxacin
mize the patient outcome and minimize risk to the general D. ceftriaxone
population.
68. A 47-year-old woman who was recently treated within
DI SCUSSION SOURCES the past two months with a beta-lactam for acute
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Pre-
bacterial sinusitis?
vention, Division of Tuberculosis Elimination. www.cdc.gov/tb/ A. amoxicillin-clavulanate
Sharma S, Mohan A. Tuberculosis and other mycobacterial diseases. B. high-dose amoxicillin
In: Rakel R, Bope E (eds): Conn’s Current Therapy 2014. C. clarithromycin
Philadelphia, PA: Saunders Elsevier. D. moxifloxacin
69. Criteria to distinguish if pneumonia is community-
Community- acquired include all of the following except:
A. lives in the community.
Acquired B. not a resident of a long-term care facility.
C. no prior antimicrobial use in the previous 3 months.
Pneumonia D. no recent hospitalization.
63 to 68. According to the American Thoracic Society/ 70. Common symptoms of community-acquired pneu-
Infectious Disease Society of American (ATS/ monia in otherwise well adults include all of the
IDSA) Consensus Guidelines on the Manage- following except:
ment of Community-Acquired Pneumonia in A. cough.
Adults, which of the following is the most B. altered mental status.
appropriate antimicrobial for treatment of C. dyspnea.
community-acquired pneumonia (CAP) in: D. pleuritic chest pain.
63. A 42-year-old man with no comorbidity, no reported 71. A diagnosis of pneumonia is confirmed by:
drug allergy, and no recent antimicrobial use? A. sputum culture.
A. azithromycin B. sputum gram stain
B. cefpodoxime C. bronchoalveolar lavage.
C. trimethoprim-sulfamethoxazole D. chest radiograph.
D. ciprofloxacin
72. Which of the following is a quality of respiratory
64. A 46-year-old well woman with a history of a bilateral fluoroquinolones?
tubal ligation who is macrolide intolerant? A. activity against drug-resistant S. pneumoniae (DRSP)
A. clarithromycin B. poor activity against atypical pathogens
B. amoxicillin C. predominantly hepatic route of elimination
C. doxycycline D. poor activity against beta-lactamase producing
D. fosfomycin organisms.
4074_Ch06_127-152 20/11/14 10:42 AM Page 146
73. The mechanism of resistance of DRSP is through the 82. Which of the following best describes the mechanism of
cell’s: transmission in an atypical pneumonia pathogen?
A. beta-lactamase production. A. microaspiration
B. hypertrophy of cell membrane. B. respiratory droplet
C. alteration in protein-binding sites. C. surface contamination
D. failure of DNA gyrase reversal. D. aerosolized contaminated water
74. The primary mechanism of antimicrobial resistance of 83. Risk factors for death resulting from pneumonia
H. influenzae is through the organism’s: include:
A. beta-lactamase production. A. viral origin.
B. hypertrophy of cell membrane. B. history of allergic reaction to multiple antimicrobials.
C. alteration in protein-binding sites. C. renal insufficiency.
D. failure of DNA gyrase reversal. D. polycythemia.
75. Which of the following characteristics applies to 84. All of the following antimicrobial strategies help facili-
macrolides? tate the development of resistant pathogens except:
A. consistent activity against DRSP A. longer course of therapy.
B. contraindicated in pregnancy B. lower antimicrobial dosage.
C. effective against atypical pathogens C. higher antimicrobial dosage.
D. unstable in the presence of beta-lactamase D. prescribing a broader spectrum agent.
76. According to the ATS/IDSA guidelines, what is the 85. Findings of increased tactile fremitus and dullness to
usual length of antimicrobial therapy for the treatment percussion at the right lung base in the person with
of CAP for outpatients? CAP likely indicate an area of:
A. less than 5 days A. atelectasis.
B. 5 to 7 days B. pneumothorax.
C. 7 to 10 days C. consolidation.
D. 10 to 14 days D. cavitation.
77 to 79. Based on the CURB-65 criteria, indicate which 86. You are caring for a 52-year-old man who is currently
patients should be treated as an inpatient (I) or smoking 1.5 PPD, has a 40-pack-year cigarette smoking
outpatient (O). history, and has CAP. It is the third day of his antimi-
crobial therapy, and he is without fever, is well hydrated,
77. A 47-year-old man with no confusion, BUN =
and is feeling less short of breath. His initial chest x-ray
17 mg/dL, respiratory rate = 32/min, and blood
revealed a right lower lobe infiltrate. Physical examina-
pressure = 110/72 mm Hg
tion today reveals peak inspiratory crackles with in-
78. A 56-year-old woman with no confusion, BUN = creased tactile fremitus in the right posterior thorax.
22 mg/dL, respiratory rate = 27/min, blood pressure = Which of the following represents the most appropriate
88/56 mm Hg next step in this patient’s care?
A. His current plan of care should continue because he
79. A 72-year-old man with confusion, BUN = 18 mg/dL, res-
is improving by clinical assessment.
piratory rate = 35/min, blood pressure = 102/66 mm Hg
B. A chest radiograph should be taken today to confirm
80. Risk factors for pneumonia caused by P. aeruginosa resolution of pneumonia.
include all of the following except: C. Given the persistence of abnormal thoracic findings,
A. mechanical ventilation. his antimicrobial therapy should be changed.
B. cystic fibrosis. D. A computed tomography scan of the thorax is
C. community residence. needed today to image better any potential thoracic
D. chronic tracheostomy. abnormalities.
81. Which of the following most accurately describes 87. While seeing a 62-year-old who is hospitalized with
sputum analysis in the evaluation of the person with CAP, the NP considers that:
community-acquired pneumonia? A. pneumococcal vaccine should be given when an-
A. Gram stain is routinely advised. timicrobial therapy has been completed.
B. Antimicrobial therapy should not be initiated until B. pneumococcal vaccine can be given today, and in-
sputum specimen for culture has been obtained. fluenza vaccine can be given in 2 weeks.
C. Sputum analysis is not recommended in the majority C. influenza vaccine can be given today, and antipneu-
of patients with community-acquired pneumonia. mococcal vaccine can be given in 2 weeks.
D. If required, chest physical therapy can be used to D. influenza and antipneumococcal vaccines should be
facilitate sputum production. given today.
4074_Ch06_127-152 20/11/14 10:42 AM Page 147
88. Risk factors for infection with DRSP include all of the pneumonia (CAP) is used to describe the onset of disease
following except: in a person who resides within the community, not in a
A. systemic antimicrobial therapy in the previous nursing home or other care facility, with no recent (less than
3 months. 2 weeks) hospitalization.
B. exposure to children in day care. Patients with pneumonia usually present with cough
C. age older than 65 years. (more than 90%), dyspnea (66%), sputum production (66%),
D. use of inhaled corticosteroids. and pleuritic chest pain (50%), although nonrespiratory
symptoms, including fatigue and gastrointestinal upset, are
89. The mechanism of transmission of Legionella species is
also commonly reported. As with other infectious diseases,
primarily via:
elderly patients often report fewer symptoms and often pres-
A. respiratory droplet.
ent with an elevated resting respiratory rate and generally
B. inhalation of aerosolized contaminated water.
feeling ill; altered mental status is often noted in the older
C. contact with a contaminated surface.
adult with pneumonia.
D. hematogenous spread.
Chest x-ray is helpful in the assessment of the person with
90. Which pneumococcal vaccine offers protection against CAP. Characteristic infiltrate patterns are typically seen with
the greatest number of serotypes? certain pathogens, such as interstitial infiltrates with atypical
A. Pneumovax pathogens or viruses and areas of consolidation with Strep-
B. Prevnar tococcus pneumoniae. Therapy should be based on patient
C. PCV7 characteristics and risk factors, however, rather than the
D. LAIV pattern of the radiographic abnormality. According to the
recommendations of the IDSA/ATS Consensus Guidelines,
Identify the following organisms as a gram-positive, gram-
an abnormal chest radiograph and clinical findings are re-
negative, or atypical pathogen.
quired to confirm the diagnosis of pneumonia.
91. Streptococcus pneumoniae Although numerous organisms are capable of causing
pneumonia, relatively few are seen with frequency. S. pneumo-
92. Haemophilus influenzae
niae, also known as the pneumococcal organism, is a gram-
93. Legionella species positive diplococcus, is the most common CAP pathogen
in adults, and is found in most deaths caused by CAP.
94. Chlamydophila pneumoniae
H. influenzae is a predominant pathogen in CAP patients
95. Mycoplasma pneumoniae with COPD. Mycoplasma pneumoniae and Chlamydophila
(formerly Chlamydia) pneumoniae are common causative
pathogens of CAP. These organisms are transmitted by
Answers coughing and are often found among people living in closed
communities, such as households, college dormitories, mil-
63. A. 75. C. 87. D. itary barracks, and residential centers, including long-term
64. C. 76. B. 88. D. care facilities. M. pneumoniae, C. pneumoniae, Legionella
65. B. 77. O 89. B. species and respiratory viruses are often referred to as
66. A. 78. I 90. A. atypical pathogens (causing atypical pneumonia) because
67. A. 79. I 91. gram- these organisms are not detectable via gram stain, cannot
68. D. 80. C. positive be cultured on standard bacterial media, and clinically do
69. C. 81. C. 92. gram- not present with a classic pneumonia presentation. Usually
70. B. 82. B. negative contracted by inhaling mist or aspirating liquid that comes
71. D. 83. C. 93. atypical from a water source contaminated with the organisms, pul-
72. A. 84. C. 94. atypical monary infection with Legionella species can result in pneu-
73. C. 85. C. 95. atypical monia ranging from mild to severe disease; there is no
74. A. 86. A. evidence for person-to-person spread of the disease. Risk fac-
tors for severe disease with Legionella species, capable of caus-
Pneumonia is the most common cause of death from infec- ing the most serious illness of the atypical pathogens, include
tious disease and is the eighth leading cause of overall mor- tobacco use, airway disease, and diabetes mellitus. With air-
tality in the United States. Although pneumonia is often way impairment, pneumonia is often caused by anaerobic
considered a disease primarily of older adults and persons gram-negative bacilli or mixed gram-negative organisms.
with chronic illness, most episodes occur in immunocom- Successful community-based care of a person with pneu-
petent community-dwelling individuals; about 20% of chil- monia depends on many factors. The patient must have intact
dren develop pneumonia by age 5 years. Most often caused gastrointestinal function and be able to take and tolerate oral
by bacteria or virus, pneumonia is an acute lower respira- medications and adequate amounts of fluids. A competent
tory tract infection involving lung parenchyma, interstitial caregiver must be available. Also, the patient should be able
tissues, and alveolar spaces. The term community-acquired to return for follow-up examination and evaluation.
4074_Ch06_127-152 20/11/14 10:42 AM Page 148
Certain patient characteristics increase the likelihood of for 48–72 hours, and should have no more than one CAP-
death from pneumonia and should alert the NP to consider associated sign of clinical instability (e.g., elevated heart rate
hospitalization and aggressive therapy. These include age and respiratory rate, hypotension) before discontinuing ther-
older than 65 years and severe electrolyte or hematological apy. A longer duration may be needed if the initial therapy
disorder, such as serum sodium concentration of less than was not effective against the identified pathogen or if an
130 mEq/L, hematocrit less than 30%, or absolute neutrophil extrapulmonary complication is present (e.g., meningitis).
count of less than 1000/mm3. The CURB-65 criteria can assist S. pneumoniae has shown increasing resistance to beta-
the clinician in determining whether a patient should be lactams (antimicrobials containing the beta-lactam ring,
hospitalized. CURB-65 allocates one point for each of the including penicillins and cephalosporins), macrolides (an
following five criteria: confusion; BUN greater than19 mg/dL; antimicrobial class including erythromycin, clarithromycin,
respiratory rate greater than 30/minutes; blood pressure less and azithromycin), and tetracyclines (an antimicrobial class
than 90/60 mm Hg; and 65 years of age and older. A score of including tetracycline, doxycycline, and minocycline); strains
one or less indicates that the patient can be treated as an out- with these resistance characteristics are known as drug-
patient, whereas a score greater than 1 indicates hospitaliza- resistant S. pneumoniae (DRSP) or, less commonly, mul-
tion is needed. The presence of a comorbid disease—such as tidrug-resistant S. pneumoniae (MDRSP). The mechanism of
impaired renal function, diabetes mellitus, heart failure, im- resistance of DRSP is a result of an alteration in intracellular
munosuppression, and airway dysfunction—poses increased protein-binding sites, rendering formerly effective antimicro-
risk, as do abnormalities in vital signs, such as fever, tachy- bials incapable of destroying the pathogen. Risk factors for
cardia, tachypnea, and hypotension. DRSP include systemic antimicrobial therapy in the previous
The pathogen responsible for pneumonia also needs to be 3 months, exposure to children in day care, age older than
considered because pneumonia death risk is increased when 65 years, alcohol abuse, multiple comorbidities (e.g., COPD,
S. aureus, often seen in postinfluenza pneumonia, or gram- coronary heart disease, diabetes mellitus), and immunosup-
negative rods such as Klebsiella pneumoniae or Pseudomonas pressive state including use of corticosteroids and other im-
aeruginosa, cause infection. Risk factors for pneumonia munosuppressing medications and chronic illness.
caused by gram-negative bacilli include alcoholism, under- Respiratory fluoroquinolones (e.g., levofloxacin [Levaquin],
lying chronic bronchiectasis (e.g., cystic fibrosis), chronic gemifloxacin [Factive], moxifloxacin [Avelox]) provide en-
tracheostomy and/or mechanical ventilation, and febrile neu- hanced activity against DRSP and atypical organism coverage
tropenia. Sputum analysis for Gram stain or culture is not and stability in the presence of beta-lactamase. High-dose
recommended for the majority of patients with community- amoxicillin (≥3 g/d) and certain cephalosporins, such as
acquired pneumonia though is commonly obtained during cefuroxime, are additional treatment options. Macrolides
the evaluation of a person with pneumonia who is treated in (erythromycin, azithromycin [Zithromax, Zmax], clar-
hospital. ithromycin [Biaxin]) and tetracyclines (tetracycline, minocy-
Because definitive identification of the organism is unlikely, cline [Minocin], doxycycline) do not exhibit activity against
the choice of antimicrobial agent to treat pneumonia is largely DRSP; use of these products could result in treatment failure
empirical, directed at the most likely causative organism in in the presence of DRSP risk.
view of patient characteristics, such as age and comorbidity. H. influenzae has the capacity to produce beta-lactamase,
Since pneumococcal pneumonia, caused by S. pneumoniae, rendering penicillins ineffective; this varies regionally, but
carries a significant risk for mortality, the chosen antimicrobial averages approximately 30% nationwide. Antimicrobials stable
should always be effective against this pathogen, regardless of in the presence of beta-lactamase include macrolides, respira-
patient presentation. Choosing an antimicrobial with activity tory fluoroquinolones, and cephalosporins; adding clavulanate
against atypical organisms (M. pneumoniae, C. pneumoniae, to amoxicillin (Augmentin) inactivates beta-lactamase and
Legionella species) and gram-positive and gram-negative provides effective activity against H. influenzae.
organisms (S. pneumoniae, H. influenzae if patient risk is pres- Because atypical pathogens (M. pneumoniae, C. pneumo-
ent) helps ensure optimal outcome. niae, Legionella) do not have a cell wall, beta-lactams are
An additional consideration is antimicrobial resistance. ineffective against these organisms. Macrolides, tetracyclines,
Factors that facilitate the development of resistant microbes and respiratory fluoroquinolones provide activity against these
include repeated exposure to a given agent, underdosing pathogens. When considering the use of macrolides, it is
(eradicating more sensitive organisms, leaving more resistant important to note that these agents are associated with QTc
pathogens untouched), and an unnecessarily prolonged pe- interval prolongation and risk for torsades de pointes. This is
riod of treatment. Shorter course high-dose therapy maxi- a result of a metabolic interaction potential (drug-drug inter-
mizes and exploits concentration-dependent killing by actions) as well as an intrinsic arrhythmogenic capability of
achieving higher maximum concentration and area under the these agents. With a growing number of medications available
curve/minimal inhibitory concentration values; allowing associated with QTc prolongation, NPs should be aware of
treatment of difficult pathogens, increased tissue penetration, concomitant use of multiple QTc-prolonging agents that can
and improved patient adherence to the regimen; and mini- put the patient at risk for cardiovascular events. Additionally,
mizing the development of resistance. Patients with CAP the use of clarithromycin or erythromycin, potent cytochrome
should be treated for a minimum of 5 days, should be afebrile P450 3A4 inhibitors, concomitantly with select calcium
4074_Ch06_127-152 20/11/14 10:42 AM Page 149
channel blockers has been associated with an increased risk for intervention. Factors influencing the choice of antimicrobial
profound hypotension. Clarithromycin’s use with select statins agent include patient comorbidity and risk if treatment fails.
(lova-, simva- and atorvastatin, all CYP3A4 substrates) can All treatment options offer activity against S. pneumoniae,
dramatically increase the risk of myositis and rhabdomyolysis. H. influenzae, and atypical pathogens, the most common
The American Thoracic Society and the Infectious Disease organisms implicated in CAP; consideration also needs to
Society of America offer guidelines for CAP assessment and be given for DRSP risk (Tables 6–14 and 6–15).
TABLE 6-14
Community-acquired Pneumonia: Likely Causative Pathogens, Characteristics,
and Effective Antimicrobials
Pathogen Description Antimicrobial Resistance Comment
S. pneumoniae Gram-positive Via altered protein binding sites in bacterial cell Most common cause of
diplococci (~25% nationwide) fatal community-acquired
DRSP risk: Recent antimicrobial use (within past pneumonia
3 mo), age ≥65 yr, exposure to a child in day
care, alcohol abuse, medical comorbidities,
immunosuppressive therapy or illness
Effective antimicrobials for nonresistant
S. pneumoniae: Macrolides (azithromycin,
clarithromycin, erythromycin), standard-dose
amoxicillin (1.5–2.5 g/d), select cephalosporins,
tetracyclines including doxycycline
Preferred antimicrobials for DRSP: High-dose
(3–4 g/d) amoxicillin, telithromycin* (Ketek),
respiratory fluoroquinolones (moxifloxacin,
levofloxacin, gemifloxacin)
M. pneumoniae Not revealed by Effective antimicrobials: Macrolides, respiratory Largely transmitted by
C. pneumoniae Gram stain fluoroquinolones, tetracyclines including cough, often seen in people
doxycycline who have recently spent ex-
Ineffective antimicrobials: Beta-lactams tended time in close proxim-
(cephalosporins, penicillins) ity (closed communities such
as correctional facilities,
college dormitories, long-
term care facilities)
H. influenzae Gram-negative Beta-lactamase production (~40% nationwide) Common respiratory
bacillus Effective antimicrobials: Agents with activity pathogen with tobacco-
against gram-negative organisms and stable in related lung disease
presence of or active against beta-lactamase—
macrolides, cephalosporins, amoxicillin-
clavulanate, respiratory fluoroquinolones,
tetracyclines including doxycycline
Legionella spp. Not revealed by Effective antimicrobials: Macrolides, respiratory Usually contracted by inhal-
Gram stain fluoroquinolones, tetracyclines, including ing mist or aspirating liquid
doxycycline that comes from a water
Ineffective antimicrobials: Beta-lactams source contaminated with
(cephalosporins, penicillins) Legionella. No evidence for
person-to-person spread of
the disease
TABLE 6-15
Infectious Disease Society of America/American Thoracic Society (IDSA/ATS)
Community-acquired Pneumonia Classification and Recommended Treatment
IDSA/ATS Classification Likely Causative Pathogens Recommended Treatment Comment
Previously healthy S. pneumoniae (gram-positive) Strong recommendation Erythromycin:
No recent (within 3 mo) with low DRSP risk Macrolide such as Limited
antimicrobial use Atypical pathogens azithromycin, clarithromycin, gram-negative
(M. pneumoniae, or erythromycin coverage
C. pneumoniae, Legionella) Or Erythromycin,
Respiratory virus Weak recommendation clarithromycin:
Doxycycline CYP3A4
inhibitors
Comorbidities including S. pneumoniae (gram-positive) Respiratory fluoroquinolone Recent
COPD, diabetes, renal or with DRSP risk (levofloxacin,* moxifloxacin antimicrobial
congestive heart failure, H. influenzae (gram-negative) or gemifloxacin) use increases
asplenia, alcoholism, Atypical pathogens Or risk of infection
immunosuppressing (M. pneumoniae, Advanced macrolide plus with DRSP.
conditions or use of C. pneumoniae) beta-lactam such as high- Given comor-
immunosuppressing Respiratory virus dose amoxicillin (3–4 g/d), bidity, risk of
medications, malignancy, high-dose amoxicillin- poor outcome
or use of an antimicrobial clavulanate (4 g/d), if treatment
in past 3 mo ceftriaxone (Rocephin), failure
cefpodoxime (Vantin), Recent use of
cefuroxime (Ceftin) fluoroquinolone
Alternative to macrolide: should dictate
Doxycycline selection of
a nonfluoro-
quinolone
regimen, and
vice versa
NPs are ideally positioned to help minimize risk for pneu- severe illness. Ensuring adequate ventilation, reinforcing
monia through immunization and hygienic measures. Nearly cough hygiene, and proper hand washing can help minimize
two-thirds of all fatal cases of pneumonia are caused by pneumonia risk.
S. pneumoniae, the pneumococcal organism. Although avail-
able for decades, antipneumococcal vaccine (e.g., Pneu- D I S C U SSI O N S O U R C E S
movax, Prevnar) continues to be underused. Pneumovax Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF,
is a 23-valent polysaccharide vaccine that protects against Saag MS. The Sanford Guide to Antimicrobial Therapy, 44th ed.
23 pneumococcal serotypes and is recommended for adults Sperryville, VA: Antimicrobial Therapy, Inc., 2014, pp. 39–41.
Mandell L, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD,
65 years and older, as well as younger adults at high risk for
Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS,
disease. PCV13 or Prevnar 13 is a pneumococcal conjugate Torres A, Whitney CG. Infectious Diseases Society of America;
vaccine that is approved for adults 50 years and older and American Thoracic Society. Infectious Disease Society of America/
protects against 13 serotypes. The use of influenza vaccine American Thoracic Society consensus guidelines on the man-
can help minimize the risk of postinfluenza pneumonia, an agement of community-acquired pneumonia in adults. Clin
often debilitating and potentially fatal condition. Both vac- Infect Dis 44(Suppl 2):S27–S72, 2007. http://cid.oxfordjournals.
cines can be given together and in the presence of moderately org/content/44/Supplement_2/S27.full.pdf+html
4074_Ch06_127-152 20/11/14 10:42 AM Page 151
101. Symptoms of lung cancer caused by a primary tumor Typical presentation occurs at late-stage disease when
include all of the following except: patients become symptomatic. Patients may present with
A. chest discomfort. nonspecific systemic symptoms of fatigue, anorexia, and
B. dyspnea. weight loss. A primary tumor may be associated with chest
C. hoarseness. discomfort, cough, dyspnea, and hemoptysis. Forty percent
D. hemoptysis. of patients diagnosed with lung cancer initially present with
signs and symptoms of intrathoracic spread. This can be as-
102. According to ACCP guidelines, annual screening for
sociated with hoarseness (from laryngeal nerve paralysis),
lung cancer should occur in 55- to 74-year-old smok-
phrenic nerve paralysis, a superior pulmonary sulcus tumor
ers with a smoking history of at least ___ pack-years.
(Pancoast tumor) with Horner syndrome, and/or chest wall
A. 15
invasion with persistent, pleuritic pain. Nearly one-third of
B. 30
patients present with extrathoracic spread, including spread
C. 50
to the bones, liver, adrenal glands, lymph nodes, brain, and
D. 70
spinal cord.
103. Guidelines from the National Comprehensive Cancer Guidelines from the American College of Chest Physicians
Network (NCCN) recommend screening high-risk (ACCP) recommend that patients at significant risk for lung
smokers beginning at age: cancer be offered annual screening with low-dose computed
A. 40 years. tomography (LDCT). High-risk patients include current
B. 45 years. smokers aged 55 to 74 years with a smoking history of at least
C. 50 years. 30 pack-years as well as former smokers of the same age who
D. 55 years. have quit within the past 15 years but have the same smoking
history. Guidelines from the NCCN differ on who should be
104. When compared with screening for breast cancer,
screened. NCCN recommends annual CT screening for
screening for lung cancer results in:
younger patients (50 years or older) with a less extensive
A. a lower number needed to screen to prevent one
smoking history (at least 20 pack-years) who have one addi-
death.
tional risk factor, such as a history of cancer or lung disease,
B. approximately the same number needed to screen
family history of lung cancer, radon exposure, or occupa-
to prevent one death.
tional exposure. Screening of high-risk smokers is predicted
C. a higher number needed to screen to prevent one
to prevent one death from lung cancer for every 320 screened.
death.
In comparison, breast cancer screening with mammograms
D. a higher percentage of patients identified where
prevents one death for every 780 screened.
cancer can be prevented.
Although screening certain high-risk patients offers the
105. Current limitations of screening smokers with CT potential to reduce lung cancer mortality, the decision-
scan include all of the following except: making process concerning whether to offer screening must
A. a high false-positive rate. take into consideration its associated risks. These include high
B. low sensitivity. false-positive rates, radiation exposure from multiple CT
C. radiation exposure from multiple CT scans. scans, patient anxiety, and unnecessary invasive procedures.
D. patient anxiety. Clinicians can mitigate these risks by offering screening only
to those patients who fall within the parameters outlined in
the ACCP or NCCN guidelines.
Answers
D I S C U SSI O N S O U R C E S
100. A. 102. B. 104. A. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for
101. C. 103. C. 105. B. lung cancer: Diagnosis and management of lung cancer, 3rd ed:
American College of Chest Physicians evidence-based clinical
In the United States, lung cancer is the leading cause of practice guidelines. Chest 143(5 suppl):e78S–92S, 2013.
cancer-related death in both men and women, accounting for National Lung Screening Trial Research Team, Aberle DR, Adams
AM, Berg CD, et al. Reduced lung-cancer mortality with low-
nearly 160,000 deaths in 2013. This is more than the expected
dose computed tomographic screening. N Engl J Med 365(5):
number of deaths from breast, colon, prostate, and pancreatic
395–409, 2011.
cancer combined. Early detection is essential since early-stage American Cancer Society. Cancer Facts and Figures. 2013. Available at
lung cancers are more likely to respond to treatment, such www.cancer.org/acs/groups/content/@epidemiologysurveilance/
as surgery. The 5-year survival rate for localized stage lung documents/document/acspc-036845.pdf
cancer is 52% versus 16% for all stages combined. Currently,
however, only 15% of lung cancers are diagnosed at the
localized stage.
4074_Ch07_153-188 20/11/14 10:45 AM Page 153
Gastrointestinal
Disorders 7
Anal Fissure 6. Which of the following is the most likely patient report
with anal fissure?
1. The most common anal fissure location is: A. “I have anal pain that is relieved with having a bowel
A. posterior midline of the anus. movement.”
B. anterior anal midline. B. “Even after having a bowel movement, I feel like I still
C. anterior and posterior anal midline. need to ‘go’ more.”
D. transversely across the anal mucosa. C. “I have anal pain for up to 1–2 hours after I have a
bowel movement.”
2. Rectal bleeding associated with anal fissure is usually D. “I itch down there almost all the time.”
described by the patient as:
A. drops of blood noticed when wiping. 7. Long term, recurrent high-dose oral use of mineral oil
B. dark brown to black in color and mixed in with can lead to deficiency in:
normal-appearing stool. A. iron.
C. a large amount of brisk red bleeding. B. vitamin A.
D. significant blood clots and mucus mixed with stool. C. vitamin C.
D. vitamin B12.
3. A 62-year-old woman who reports frequent constipa-
tion is diagnosed with an anal fissure. First-line therapy
includes all of the following except: Answers
A. stool-bulking supplements.
B. high fiber diet. 1. A. 4. D. 7. B.
C. intraanal corticosteroids. 2. A. 5. D.
D. the periodic use of oral mineral oil. 3. C. 6. C.
4. A 54-year-old man with an anal fissure responds
inadequately to dietary intervention and standard See full color images of this topic
on DavisPlus at
therapy during the past 2 weeks. Additional http://davisplus.fadavis.com |
treatment options include all of the following Keyword: Fitzgerald
except:
A. intraanal nitroglycerine ointment.
In anal fissure, there is an ulcer or tear of the margin of
B. botulinum toxicum injection to the internal anal
the anus; most fissures occur posteriorly. The most common
sphincter.
patient report is one of severe anal pain during a bowel move-
C. surgical sphincterotomy.
ment, with the pain lasting several minutes to hours after-
D. rubber band ligation of the lesion.
ward. The pain recurs with every bowel movement, and the
5. In a patient who presents with a history consistent with patient commonly becomes afraid or unwilling to have a
anal fissure but with notation of an atypical anal lesion, bowel movement, leading to a cycle of worsening constipa-
alternative diagnoses to consider include all of the tion, harder stools, and more anal pain. If rectal bleeding is
following except: noted with anal fissure, this is usually limited to drops of
A. condyloma acuminata. blood noted when wiping, not protracted bleeding.
B. Crohn’s disease. Anal fissure risk factors include a history of recent or re-
C. anal squamous cell carcinoma. current constipation (most potent risk factor), recurrent or
D. C. difficile colitis. recent severe diarrhea, recent childbirth, and anal intercourse
153
4074_Ch07_153-188 20/11/14 10:45 AM Page 154
or other anal insertion practices. The best treatment for anal 9. Therapy for hemorrhoids includes all of the following
fissure is avoidance of the trigger condition or activity that except:
triggers or contributes to the condition. A. weight control.
Given that constipation is the most common anal fissure B. low-fat diet.
risk factor, the primary treatment goal is to prevent constipa- C. topical corticosteroids.
tion and, therefore, break the cycle that contributes to the con- D. the use of a stool softener.
dition. First-line therapies include increased dietary fiber and
10. The NP is advising a 58-year-old woman about the ben-
fiber supplementation and stool softener. These interventions
efits of a high-fiber diet. Which of the following foods
alone are often not sufficient to facilitate stool passing and a
provides the highest fiber content?
laxative needs to be added. Mineral oil helps lubricate the stool
A. a small banana
and renders defecation more comfortable and minimizes anal
B. 1 cup of cooked oatmeal
mucosal damage; long-term use is discouraged due to its po-
C. a 1/2 cup serving of brown rice
tential to attenuate the absorption of the fat soluble vitamins
D. a medium-size blueberry muffin
A D, E, and K, and essential fatty acids when used consistently
in large amounts. Local measures such as sitz baths and cool 11. A 62-year-old man presents with a 2-month history
compresses can provide additional relief. With this approach, of noting a “bit of dark blood mixed in with my stool
the majority of anal fissures will heal within a few weeks. Re- most days.” Physical examination reveals external
lapse is common and is usually noted when recommended hemorrhoids, no rectal mass, and a small amount of
therapy is abandoned and constipation recurs. dark brown stool on the examining digit. In-office fecal
If symptoms persist with the above-mentioned therapies occult blood test is positive, and hemogram reveals a
or are particularly severe, intraanal application of 0.4% nitro- microcytic hypochromic anemia. The next best step in
glycerin (NTG) can be applied directly to the internal sphinc- his care is to:
ter. NTG is believed to relax the internal sphincter and A. perform in-office anoscopy.
increase blood flow to the anal mucosa. This can provide pain B. advise the patient use sitz baths post bowel
relief. Adverse effects are identical to what is reported with movement.
other NTG forms and include headache and dizziness; this C. refer to gastroenterology practice for colonoscopy.
significantly limits the use of the product. An additional op- D. order a double contrast barium enema.
tion, available through specialty consultation, is the use of
12. Risk factors for the development of hemorrhoidal
botulinum toxin (Botox) into the anal sphincter; spasm at this
symptoms include all of the following except:
point is thought to be the cause of particularly painful anal
A. prolonged sitting.
fissure. Botulinum injections provide relief for approximately
B. insertive partner in anal intercourse.
3 months during which time the hope is that the fissure will
C. chronic diarrhea.
heal. Surgical sphincterotomy is an option in the most recal-
D. excessive alcohol use.
citrant of cases.
A number of other conditions can present similar to anal 13. Which of the following best describes Grade III internal
fissure. If the fissure is off the midline, transverse or irregu- hemorrhoids?
lar, another diagnosis should be considered. These include A. The hemorrhoids do not prolapse.
Crohn’s disease, anal squamous cell cancer, and anal condy- B. The hemorrhoids prolapse upon defecation but
loma acuminata, among others. reduce spontaneously.
C. The hemorrhoids prolapse upon defecation and
DI SCUS SION SOURCE must be reduced manually.
Poritz L., Geibel J. Anal Fissure. http://emedicine.medscape.com/ D. The hemorrhoids are prolapsed and cannot be
article/196297 reduced manually.
14. Which of the following patients should be evaluated for
Hemorrhoids possible surgical intervention for hemorrhoids?
A. a 28-year-old woman with symptomatic external
8. Rectal bleeding associated with hemorrhoids is usually hemorrhoids who gave birth 6 days ago
described as: B. a 48-year-old man with Grade II internal hemor-
A. streaks of bright red blood on the stool. rhoids and improvement with standard medical
B. dark brown to black in color and mixed in with therapy
normal-appearing stool. C. a 44-year-old woman who has internal and external
C. a large amount of brisk red bleeding. hemorrhoids with recurrent prolapse
D. significant blood clots and mucus mixed with D. a 58-year-old man who has Grade I internal hemor-
stool. rhoids and improvement with psyllium supplements
4074_Ch07_153-188 20/11/14 10:45 AM Page 155
19. The obturator sign can be best described as abdominal 26. Rebound tenderness is best described as abdominal
pain elicited by: pain that worsens with:
A. passive extension of the hip. A. light palpation at the site of the discomfort.
B. passive flexion and internal rotation of the hip. B. release of deep palpation at the site of the discomfort.
C. deep palpation. C. palpation on the contralateral side of the abdomen.
D. asking the patient to cough. D. deep palpation at the site of the discomfort.
20. An 18-year-old man presents with periumbilical pain, 27. Abdominal palpation that yields rebound tenderness is
vomiting, and abdominal cramping over the past also known as a positive _______ sign.
48 hours. Physical examination reveals rebound tender- A. Markel’s
ness, and laboratory analysis shows the presence of B. Murphy’s
bandemia and a total WBC of 28,000 mm3. To support C. Blumberg’s
the diagnosis of acute appendicitis with suspected D. Nikolsky’s
appendiceal rupture, you consider obtaining the
28. Which of the following findings would you expect
following abdominal imaging study:
to encounter in a 33-year-old man with appendiceal
A. magnetic resonance image (MRI).
abscess?
B. computed tomography (CT) scan.
A. leukopenia with lymphocytosis
C. ultrasound.
B. positive Cullen’s sign
D. flat plate.
C. protracted nausea and vomiting
21. Which of the following WBC forms is an ominous find- D. dullness to percussion in the abdominal right lower
ing in the presence of severe bacterial infection? quadrant
A. neutrophil
B. lymphocyte
C. basophil Answers
D. metamyelocyte
15. D. 20. B. 25. A, B, C
22. Which of the following best represents the peak ages for 16. C. 21. D. 26. B.
occurrence of acute appendicitis? 17. A. 22. C. 27. C.
A. 1 to 20 years 18. A. 23. A. 28. D.
B. 20 to 40 years 19. B. 24. A.
C. 10 to 30 years
D. 30 to 50 years
Acute appendicitis is an inflammatory disease of the vermi-
23. Clinical findings most consistent with appendiceal form appendix caused by infection or obstruction. The peak
rupture include all of the following except: age of patients with acute appendicitis is 10 to 30 years; this
A. abdominal discomfort less than 48 hours in duration. condition is uncommon in infants and elderly adults. At
B. fever greater than 102°F (>38°C). either end of the life span, a delay in diagnosis of appendicitis
C. palpable abdominal mass. commonly occurs because providers do not consider appen-
D. marked leukocytosis with total WBC greater than dicitis a possibility.
20,000/mm3. There is no true classic presentation of acute appendicitis.
Vague epigastric or periumbilical pain often heralds its
24. Which of the following imaging studies potentially
beginning, with the discomfort shifting to the right lower
exposes the patient being evaluated for abdominal
quadrant over the next 12 hours. Pain is often aggravated by
pain to the lowest ionizing radiation burden?
walking or coughing. Nausea and vomiting are late symp-
A. ultrasound
toms that invariably occur a number of hours after the onset
B. barium enema
of pain; this late onset helps to differentiate appendicitis
C. CT scan
from gastroenteritis, in which vomiting usually precedes
D. abdominal flat plate
abdominal cramping. The presentation of appendicitis also
25. Commonly encountered diagnoses other than acute differs significantly according to the anatomical position of
appendicitis can include which of the following in a the appendix, with pain being reported in the epigastrium,
28-year-old with a 2-day history of lower abdominal flank, or groin. The obturator and psoas signs indicate in-
pain and with right-sided pain slightly worse than left? flammation of the respective muscles and strongly suggest
(More than one can apply.) peritoneal irritation and the diagnosis of appendicitis; these
A. constipation signs are also known as obturator muscle and iliopsoas
B. pelvic inflammatory disease muscle signs. Rebound tenderness, which is abdominal
C. ectopic pregnancy pain that worsens with release of deep palpation, indicates
D. splenetic infarct the likelihood of peritoneal irritation and helps with the
4074_Ch07_153-188 20/11/14 10:46 AM Page 157
diagnosis of acute appendicitis. The presence of rebound or when an atypical presentation raises the issue of another
tenderness is also known as a positive Blumberg’s sign. possible diagnosis. Because of concerns about patient exposure
A total WBC count and differential are obtained as part of to radiation during a CT scan, abdominal or pelvic ultrasonog-
the evaluation of patients with suspected appendicitis. The raphy (US) can be considered as a safer primary diagnostic
most typical WBC count pattern found in this situation is modality for appendicitis. With abnormality noted on ultra-
the “left shift.” A “left shift”, a colloquial term, is usually seen sound, including inability to clearly visualize the appendix,
in the presence of severe bacterial infection, such as acute CT is then used to further help with the diagnostic process. In
appendicitis, bacterial pneumonia, and pyelonephritis. The particular, this is an appealing option to minimize radiation
following are typically noted in the “left shift”: exposure in children and women of reproductive age. MRI has
• Leukocytosis: An elevation in the total WBC. limited use in the evaluation of suspected appendicitis. Due to
• Neutrophilia: An elevation in the number of neutrophils its lack of ionizing radiation, this is an option when evaluating
in circulation. Neutrophilia is defined as an absolute neu- a pregnant woman with suspected appendicitis; unfortunately,
trophil count (ANC) of greater than 7000 neutrophils/mm3. the normative changes noted during pregnancy render abdom-
The ANC is calculated by multiplying the percentage inal ultrasound of limited use for evaluation of a pregnant
of neutrophils by the total WBC in mm3. A total WBC woman with abdominal pain.
(TWBC) of 12,000 mm3 x 70% neutrophils yields an Given the variety of imaging modalities available and the
ANC of 8300 neutrophils/mm3. Neutrophils are also frequency of their use, the ionizing radiation burden of a
known as “polys” or “segs,” both referring to the poly- study should be considered prior to ordering. (See Table 7–9,
morph shape of the segment nucleus of this WBC. Radiation Doses from Common Imaging Studies). The long
• Bandemia: An elevation in the number of bands or young time risk of excessive ionizing radiation is presumed to in-
neutrophils in circulation. Usually less than 4% of the clude carcinogenesis; children and women of reproductive
total WBCs in circulation are bands. When this percent- age are considered to be particularly vulnerable.
age is exceeded, and the absolute band count (ABC) is Appendiceal perforation, commonly referred to as a rup-
greater than 500 mm3, bandemia is present. A TWBC of tured or burst appendix, is usually associated with a marked
12,000 mm3 with 8% bands yields an ABC of 860/mm3. leukocytosis with total WBC count often exceeding 20,000 mm3
The presence of bandemia indicates that the body has to 30,000 mm3, fever greater than 102°F (greater than 38°C),
called up as many mature neutrophils as were available peritoneal inflammation findings, and symptoms lasting longer
in the storage pool and is now accessing less mature than 48 hours. An ill-defined right lower quadrant abdominal
forms. The presence of bandemia further reinforces the mass, usually dull to percussion with or without a degree of
seriousness of the infection. An increase in circulating rebound tenderness, in a person with a presentation consistent
bands also occurs in pneumonia, meningitis, septicemia, with appendiceal perforation is suggestive of abscess forma-
pyelonephritis, and tonsillitis when caused by bacterial tion. Surgical removal of an inflamed appendix via laparoscopy
infection. or laparotomy is indicated. If there is evidence of rupture with
Although additional neutrophil forms exist, these do not localized abscess and peritonitis, CT-directed abscess aspira-
belong in circulation even with severe infection. Myelocytes tion may be indicated first, with an appendectomy performed
and metamyelocytes are immature neutrophil forms that are after appropriate antimicrobial therapy.
typically found in only the granulopoiesis pool. The presence
of these cells is an ominous marker of life-threatening infec- D I S C U SSI O N S O U R C E S
tion, and these are occasionally found in the presence of Craig S, Brenner B. Appendicitis. http://emedicine.medscape.com/
appendiceal rupture. article/773895,
Given that appendicitis is an inflammatory disease, adding Ferri F. Appendicitis. In: Ferri’s Best Test: A Practical Guide to
a test to detect inflammation, such as the C-reactive protein Clinical Laboratory Medicine and Diagnostic Imaging, 2nd ed.
Philadelphia, PA: Elsevier Mosby, 2009, p. 190.
(CRP), is also an option. An elevated CRP provides a degree
of support for the diagnosis whereas a normal value helps to
rule out the condition. For women of childbearing age, preg- Gallstones
nancy should be ruled out via urinary beta-human chorionic
gonadotropin (beta-hCG); the presentations of acute appen- 29. A 43-year-old woman has a 12-hour history of sudden
dicitis and early ectopic pregnancy have many features in onset of right upper quadrant abdominal pain with
common. radiation to the shoulder, fever, and chills. She has
Abdominal computerized tomography (CT) of the ab- had similar, milder episodes in the past. Examination
domen is generally considered the imaging of choice in sus- reveals marked tenderness to right upper quadrant
pected appendicitis; its ability to define better the anatomical abdominal palpation. Her most likely diagnosis is:
abnormality associated with appendicitis is superior to other A. hepatoma.
imaging options. Abdominal CT is the preferred diagnostic B. acute cholecystitis.
procedure when there is a suspicion of appendiceal perforation C. acute hepatitis.
because this study reveals periappendiceal abscess formation D. cholelithiasis.
4074_Ch07_153-188 20/11/14 10:46 AM Page 158
30. Which of the following is usually not seen in the Gallstone formation occurs when substances in bile are
diagnosis of acute cholecystitis? present in high concentration; the bile becomes supersatu-
A. elevated serum creatinine rated and the substance precipitates out into a microscopic
B. increased alkaline phosphatase level crystal. The crystals are trapped in the gallbladder mucosa,
C. leukocytosis with resulting formation of sludge. Over time, more sub-
D. elevated aspartate aminotransferase (AST) level stance precipitates out and the crystals grow, forming
macroscopic stones. Duct occlusion by stones or sludge
31. Murphy’s sign can be best described as abdominal pain
causes the majority of the symptoms and clinical problems
elicited by:
with gallstone disease. The most common form of stones is
A. right upper quadrant abdominal palpation.
cholesterol or cholesterol-dominant (80% to 85%).
B. asking the patient to stand on tiptoes and then
Major risk factors for gallstone formation include age
letting body weight fall quickly onto the heels.
older than 50 years, female gender, obesity, hyperlipidemia,
C. asking the patient to cough.
rapid weight loss (including patients who have undergone
D. percussion.
bariatric surgery), pregnancy, genetic factors, European or
32. Which of the following is the most common serious Native American ancestry, and ingestion of a diet with a high
complication of cholecystitis? glycemic index.
A. adenocarcinoma of the gallbladder Cholelithiasis is defined as a condition in which there is
B. gallbladder empyema the formation of calculi or gallstones, but without the pres-
C. hepatic failure ence of gallbladder or associated structure. About 75% of all
D. pancreatitis patients with cholelithiasis have no symptoms and become
aware of the condition only when it is found during evalua-
33. A 58-year-old man reports intermittent right upper
tion for another health problem. About 10% to 25% of indi-
quadrant abdominal pain. He is obese and being ac-
viduals initially without symptoms become symptomatic over
tively treated for hyperlipidemia. Imaging in a patient
the next decade. In the absence of symptoms, prophylactic
with suspected symptomatic cholelithiasis usually
cholecystectomy is not usually indicated.
includes obtaining an abdominal:
Many patients with gallstones have intermittent discom-
A. magnetic resonance image (MRI).
fort as a result of this condition. The pain is described as
B. CT scan.
being of sudden onset, usually post prandial, particularly
C. ultrasound of the right upper quadrant.
within 1 hour of a fatty meal, in the abdominal right upper
D. flat plate.
quadrant or epigastrium, occasionally radiating to the tip
34. Which of the following is most likely to be found in a of the right scapula; the presence of radiating pain is known
person with acute cholecystitis? as Collins’ sign. Episodes of discomfort typically last 1 to
A. fever 5 hours, with a pattern of increasing then decreasing dis-
B. vomiting comfort as the gallbladder contracts and the stone position
C. jaundice shifts. Nausea and vomiting are common during painful
D. palpable gallbladder episodes. Indeed, vomiting often provides significant pain
relief. Biliary colic is a term used to describe these acutely
35. Risk factors for the development of cholelithiasis in-
painful paroxysms.
clude all of the following except:
Acute cholecystitis results from an acute inflammation
A. rapid weight loss.
of the gallbladder, nearly always caused by gallstones. Right
B. male gender.
upper quadrant or epigastric pain and tenderness are pres-
C. obesity.
ent along with vomiting (70% or more) and occasional
D. Native American ancestry.
fever (33%); vomiting often affords temporary symptom
36. A gallstone that is not visualized on standard x-ray is relief. Tenderness on palpating the right upper quadrant of
said to be: the abdomen significant enough to cause inspiratory arrest
A. radiopaque. (Murphy’s sign) is nearly always present. A palpable gall-
B. radiolucent. bladder is rarely noted. Approximately 25% to 50% of those
C. calcified. affected have some degree of jaundice. Leukocytosis is usu-
D. unclassified. ally present, with a typical total WBC count of 12,000 mm3
to 20,000 mm3, and elevated levels of the hepatic enzymes
(Table 7–1).
Answers Combined with the health history, physical examination
findings, and laboratory testing, imaging results help to
29. B. 32. D. 35. B. support the diagnosis of cholecystitis. Right upper quad-
30. A. 33. C. 36. B. rant abdominal ultrasound usually reveals stones and is
31. A. 34. B. considered the diagnostic test of choice; given the lack of
4074_Ch07_153-188 20/11/14 10:46 AM Page 159
TABLE 7-1
Hepatic Enzyme Elevations and Their Significance
Enzyme Elevation Comment, Associated Conditions Example
Alanine aminotransferase Measure of hepatic cellular enzymes found in A 22 y.o. woman with acute
(ALT, formerly known circulation, elevated when hepatocellular hepatitis A
as SGPT) damage is present. Highly liver specific. This AST 678 U/L (normal 0–31 U/L)
enzyme has circulatory half-life of 37–57 hr; ALT 828 U/L (normal 0–31 U/L)
levels increase relatively slowly in response to ALT:AST ratio ≥1
hepatic damage and clear gradually after A 66 y.o. woman with obesity,
damage ceases. See AST for contrast in this type 2 diabetes mellitus, and
rise and fall pattern nonalcoholic fatty liver disease
In hepatitis A, B, C, D, or E, or drug-associated AST 44 U/L
or industrial chemical–associated hepatitis, ALT 78 U/L
ALT usually increases higher than AST, with ALT:AST ratio >1
enzyme increases ≥10 times ULN
In nonalcoholic fatty liver steatohepatitis
(NASH, also known as nonalcoholic fatty liver
disease [NAFLD]), ALT usually increases higher
than AST, with enzyme increases usually
within 3 times ULN
Aspartate aminotransferase Measure of hepatic cellular enzymes found in A 38 y.o. man with a 10-yr
(AST, formerly known as circulation, elevated when hepatocellular history of increasingly heavy
SGOT) damage is present. Enzyme also present alcohol use
in lesser amounts in skeletal muscle and AST 83 U/L (normal 0–31 U/L)
myocardium ALT 50 U/L (normal 0–31 U/L)
AST has circulatory half-life of ~12–24 hr; levels AST:ALT ratio ≥1
increase in response to hepatic damage and A 26 y.o. man with intentional
clear quickly after damage ceases acetaminophen overdose
In alcohol-related hepatic injury AST usually AST 15,083 U/L (normal 0–31 U/L)
increases higher than ALT ALT 10,347 U/L (normal 0–31 U/L)
In acetaminophen overdose, massive increases
in AST and ALT are often noted, ≥20 times
ULN
Alkaline phosphatase (ALP) Enzyme found in rapidly dividing or metaboli- A 40 y.o. woman with acute
cally active tissue, such as liver, bone, intes- cholecystitis
tine, placenta. Elevated levels can reflect AST 45 U/L (0–31)
damage or accelerated cellular division in any ALT 55 U/L (0–31)
of these areas. Most in circulation is of hepatic ALP 225 U/L (0–125)
origin. Levels increase in response to biliary
obstruction and are a sensitive indicator of
intrahepatic or extrahepatic cholestasis
Gamma glutamyl transferase Enzyme involved in the transfer of amino acids A 40 y.o. woman with acute
(GGT) across cell membranes. Found primarily in the cholecystitis
liver and kidney AST 45 U/L (0–31)
In liver disease, usually parallels changes in ALT 55 U/L (0–31)
alkaline phosphatase ALP 225 U/L (0–125)
Marked elevation often noted in obstructive GGT 245 U/L (0–45)
jaundice, hepatic metastasis, intrahepatic
cholestasis
ionizing radiation with ultrasound, this is also a test 39. Which of the following is most likely to be noted in a
that can be used during pregnancy. Abdominal CT is less person with colorectal cancer?
helpful in the diagnosis when compared to US but can A. gross rectal bleeding
assist in ruling out other GI pathology. A hepatoiminodi- B. weight loss
acetic acid (HIDA) scan is more sensitive and specific C. few symptoms
at revealing an obstructed cystic duct. Most gallstones are D. nausea and vomiting
radiolucent—that is, unable to be visualized on standard
40. Which of the following does not increase a patient’s
x-ray. As a result, an abdominal flat plate is of limited
risk of developing colorectal cancer?
value. Abdominal MRI seldom plays a role in diagnosing
A. family history of colorectal cancer
gallstone disease. A variety of percutaneous and endoscopic
B. familial polyposis
diagnostic procedures are utilized in complicated or uncer-
C. personal history of neoplasm
tain scenarios.
D. long-term aspirin therapy
Acute cholecystitis symptoms usually subside with con-
servative therapy, such as a low-fat diet of clear liquids and 41. According to current American Cancer Society data,
analgesics. Antimicrobial therapy is occasionally indicated colorectal cancer is the number _______ cause of
with evidence of infection. Cholecystectomy, usually per- cancer death in men and women.
formed via laparoscope, should be considered because of the A. 1
likelihood of recurrence. B. 3
Complications of gallstone disease include pancreatitis C. 5
and sepsis; both are most common in elders who develop D. 7
the condition. In a person who is seriously ill with other
health problems and considered too high a risk to undergo
cholecystectomy, ultrasound-guided gallbladder aspiration Answers
or percutaneous cholecystectomy can delay or occasionally
eliminate the need for further surgical intervention. Stone- 37. D. 39. C. 41. B.
dissolving medications, such as ursodeoxycholic acid, are 38. B. 40. D.
available but can take 2 years to dissolve stones. Approxi-
mately 50% of patients treated with stone-dissolving medica- Colorectal cancer is the third leading cause of cancer death
tions have a return of stones within 5 years; consequently, the in both genders in the United States, with approximately
use of this therapy has largely fallen out of favor. 5% of the population developing the disease. Only lung can-
cer (both genders), prostate cancer (men), and breast cancer
DI SCUSSION SOURCE
(women) exceed this disease in cancer-related mortality.
Bloom A, Katz, J. Cholecystitis. http://emedicine.medscape.com/ Most colorectal malignancies prove to be adenocarcinomas,
article/175667 with about 70% found in the colon and 30% found in the
rectum. Risk factors include a history of inflammatory
bowel disease (ulcerative colitis [UC] and Crohn’s disease),
Colorectal Cancer personal history of neoplasia, age older than 50 years, a
family history of colorectal cancer, and familial polyposis
37. Which of the following is true concerning colorectal
syndrome. In addition, an autosomal dominant condition
cancer?
known as hereditary nonpolyposis colorectal cancer (HNPCC)
A. Most colorectal cancers are found during rectal
has been identified. Although this condition accounts
examination.
for only about 3% of all colorectal cancers, persons with
B. Rectal carcinoma is more common than cancers
this risk factor tend to develop disease earlier and have a
involving the colon.
70% likelihood of colon cancer by age 65 years. A thorough
C. Early manifestations include abdominal pain and
family history is important in assessing an individual’s risk
cramping.
of colorectal cancer. A diet high in fat, high in red meat, and
D. Later disease presentation often includes iron-
low in calcium has also been implicated as a contributing
deficiency anemia.
factor. The use of antioxidants, calcium supplements, and
38. According to the American Cancer Society recom- low-dose aspirin has been shown in limited study to reduce
mendations, which of the following is the preferred colorectal cancer rates.
method for annual colorectal cancer screening in a A person presenting with colorectal cancer is usually
51-year-old man? asymptomatic until disease is quite advanced. At that time,
A. digital rectal examination vague abdominal complaints coupled with iron-deficiency
B. fecal occult blood test anemia (as a result of chronic low-volume blood loss) is often
C. colonoscopy noted. The mass is most often beyond the examining digit.
D. barium enema study As a result, digital rectal examination is an ineffective method
4074_Ch07_153-188 20/11/14 10:46 AM Page 161
of colorectal cancer screening. In addition, the American 43. Approximately what percent of the population will
Cancer Society colorectal cancer screening guidelines do develop diverticulosis by the time they reach 50 years
not recommend the use of the fecal occult blood test (FOBT) of age?
obtained via the digital rectal examination in the provider’s A. 10%
office, which is not an adequate substitute for the recom- B. 20%
mended at-home procedure of collecting two samples from C. 33%
three consecutive specimens. Toilet-bowl FOBT tests also are D. 50%
not recommended. Compared with guaiac-based tests for the
44. Which of the following is most consistent with the
detection of occult blood, immunochemical tests are more
presentation of a patient with colonic diverticulosis?
patient-friendly and are likely to be equal or better in sensi-
A. diarrhea and leukocytosis
tivity and specificity. There is no justification for repeating
B. constipation and fever
FOBT in response to an initial positive finding. Colonoscopy
C. few or no symptoms
should be done if test results are positive.
D. frank blood in the stool with reduced stool caliber
The most commonly recommended colorectal cancer
screening method in adults is a colonoscopy at 10-year inter- 45. Which of the following is most consistent with the pres-
vals, starting at age 50 years. Alterative testing methods and entation of a patient with acute colonic diverticulitis?
schedules include flexible sigmoidoscopy, double-contrast A. cramping, diarrhea, and leukocytosis
barium enema, and CT colonography (virtual colonoscopy) B. constipation and fever
every 5 years starting at age 50 years. C. right-sided abdominal pain
Alternative screening schedules, usually including more D. frank blood in the stool with reduced stool caliber
frequent testing or earlier testing or both, are considered
46. Major risk factors for diverticulosis include all of the
when colorectal cancer risk factors are increased. These risk
following except:
factors include a personal history of colorectal cancer or
A. low-fiber diet.
adenomatous polyps, Crohn’s disease or UC, a strong fam-
B. family history of the condition.
ily history (first-degree relative [parent, sibling, or child]
C. older age.
younger than 60 years or two or more first-degree relatives
D. select connective tissue disorders (e.g., Marfan
of any age) of colorectal cancer or polyps, or a known fam-
syndrome).
ily history of hereditary colorectal cancer syndromes such
as familial adenomatous polyposis or HNPCC. These alter- 47. To avoid the development of acute diverticulitis,
native schedules should be pursued in conjunction with ex- treatment of diverticulosis can include:
pert consultation. A. avoiding foods with seeds.
Treatment of colorectal cancer usually includes surgery B. the use of fiber supplements.
combined with chemotherapy and radiation. Long-term C. ceasing cigarette smoking.
survival depends on many factors, including the size and D. limiting alcohol intake.
depth of the tumor, the presence of positive nodes, and the
48. The location of discomfort with acute diverticulitis is
overall health of the patient.
usually in which of the following areas of the abdomen?
DI SCUSSION SOURCES A. epigastrium
Albo D. Tumors of the colon and rectum. In: Rakel R, Bope E, (eds).
B. left lower quadrant
Conn’s Current Therapy. Philadelphia, PA: Saunders Elsevier; C. right lower quadrant
2013, pp. 558–563. D. suprapubic
Rex D, Johnson D, Anderson J, Schoenfield P, Burke C, Inadomi J. 49. Which of the following best describes colonic
American College of Gastroenterology Guidelines for Colorectal
diverticulosis?
Cancer Screening. Am J Gastroenterol 104:739–750, 2009.
http://gi.org/guideline/colorectal-cancer-screening/
A. bulging pockets in the intestinal wall
B. poorly contracting intestinal walls
C. strictures of the intestinal lumen
Colonic D. flaccidity of the small intestine
50. You are seeing Mr. Lopez, a 68-year-old man with
Diverticulosis suspected acute colonic diverticulitis. In choosing an
42. Colonic diverticulosis most commonly occurs in the appropriate imaging study to support this diagnosis,
walls of the: which of the following abdominal imaging studies is
A. ascending colon. most appropriate?
B. descending colon. A. flat plate
C. transverse colon. B. ultrasound
D. sigmoid colon. C. CT scan with contrast
D. barium enema
4074_Ch07_153-188 20/11/14 10:46 AM Page 162
51. In the evaluation of acute diverticulitis, the most appro- When symptoms are present in diverticulosis, left-sided
priate diagnostic approach to rule out free air in the abdominal cramping, increased flatus, and a pattern of con-
abdomen includes: stipation alternating with diarrhea are often reported. Inter-
A. barium enema. vention includes a high-fiber diet, along with the use of fiber
B. plain abdominal film. supplements such as bran, psyllium, and methylcellulose. The
C. abdominal ultrasound. goal of treatment is to minimize the risk of complications
D. lower endoscopy. such as diverticulitis. Although avoidance of seeds and other
similar food products has been recommended in the past as
52. A 56-year-old woman is diagnosed with mild divertic-
a way to avoid acute diverticulitis, few studies exist to support
ulitis. In addition to counseling her about increased
this dietary change.
fluid intake and adequate rest, you recommend an-
In acute colonic diverticulitis, the diverticula are inflamed,
timicrobial treatment with:
causing fever, leukocytosis, diarrhea, and left lower quadrant
A. amoxicillin with clarithromycin.
abdominal pain. Intestinal perforation is the likely origin
B. linezolid with daptomycin.
of the condition, with the perforation ranging from pinpoint
C. ciprofloxacin with metronidazole.
lesions that cause local infection and respond to conservative
D. nitrofurantoin with doxycycline.
management to major tears, which necessitate surgical repair
53. Lower gastrointestinal (GI) hemorrhage associated with and are often complicated by intra-abdominal abscess or
diverticular disease usually manifests as: peritonitis. Imaging is often obtained to support the diagnosis
A. a painless event. and assess disease severity or complications. An abdominal
B. a condition noted to be found with a marked febrile CT scan with contrast is helpful in identifying findings con-
response. sistent with the condition inducing bowel wall thickening;
C. a condition accompanied by severe cramp-like complications including abscess and fistulas can also be iden-
abdominal pain. tified with this diagnostic modality. A plain abdominal film
D. a common chronic condition. is often normal in milder disease but can be helpful in iden-
tifying free air, indicated diverticular perforation, or altered
54. Measures to prevent colonic diverticulosis and divertic-
bowel air patterns consistent with obstruction. Because of the
ulitis include all of the following except:
potential risk of complication, a barium enema should not be
A. increased whole grain intake.
obtained during an acute episode of diverticular disease. Ab-
B. regular aerobic exercise.
dominal ultrasound is not helpful in this condition. Endo-
C. adequate hydration.
scopic evaluation of the colon is contraindicated in acute
D. refraining from excessive alcohol intake.
diverticulitis, as insufflation of air can result in or exacerbate
free perforation and peritonitis.
Occasionally, diverticular hemorrhage, caused by an
Answers erosion of a vessel by a fecalith held in a diverticular sac, can
42. D. 47. B. 52. C. occur. The condition usually manifests with painless lower
43. C. 48. B. 53. A. GI bleeding. The management is usually directed by the clin-
44. C. 49. A. 54. D. ical presentation and usually includes fluid and blood
45. A. 50. C. replacement; surgical intervention is often required.
46. A. 51. B. In mild cases of diverticulitis, conservative management
is adequate, including a liquid diet to ensure gut rest, with an
emphasis on an adequate hydration, for the duration of the
In colonic diverticulosis, bulging pockets are present in the illness and antimicrobial therapy. Because of its strong activ-
intestinal wall, most commonly in the wall of the sigmoid ity against anaerobic organisms implicated in the conditions,
colon, though the abnormality can occur in any part of the metronidazole is an antibiotic of choice. Since the infection
large intestine. In the United States, approximately one-third is often polymicrobial, a second agent should be added that
of the population will develop diverticulosis by age 50 years exhibits activity against the gram-negative organisms that are
and approximately two-thirds by age 80 years. Inflammation implicated, such as E. coli. These antimicrobials include
is not present, however, and the patient is usually asympto- ciprofloxacin, levofloxacin, moxifloxacin, tigecycline, or
matic; diverticulosis is often found during studies done for trimethoprim-sulfamethoxazole (TMP-SMX) (Table 7–2). If
other reasons, such as colorectal cancer screening. Histori- the patient fails to respond within 2 to 3 days or becomes sig-
cally, a major risk factor for the condition was thought to be nificantly worse during that time, particularly if peritoneal
long-term low-fiber diet, since the condition is more com- signs develop, an abdominal CT scan and specialty surgical
mon in developed countries in which a diet focused on high consultation should be obtained. With recurrent diverticulitis
levels of processed foods is the normal. However, more recent episodes, particularly with a complicated course, surgical in-
studies fail to support this as a cause. Major risk factors are tervention with partial colectomy is an option.
considered to be aging, family history of the disease, and se- Measures to prevent colonic diverticulosis and divertic-
lect connective tissue disorders, including Marfan syndrome. ulitis include regular aerobic exercise, adequate hydration,
4074_Ch07_153-188 20/11/14 10:46 AM Page 163
TABLE 7-2
Antimicrobial Treatment Options in Acute Diverticulitis
Alternative Oral Treatment
Primary Oral Treatment Regimen When Regimen When Suitable for
Causative Organisms Suitable for Outpatient Therapy Outpatient Therapy
Enterobacteriaceae, TMP-SMX-DS bid or ciprofloxacin 750 mg bid Amoxicillin-clavulanate ER
P. aeruginosa, Bacteroides or levofloxacin 750 mg qd plus metronidazole 1000/62.5 mg 2 tabs bid for
spp., enterococci 500 mg q 6 hr, all for 7–10 days 7–10 days or
Moxifloxacin 400 mg q 24 hr for
7–10 days
TMP-SMX, trimethoprim-sulfamethoxazole.
Source: Gilbert D, Moellering R, Eliopoulos G, Chambers HF, Saag MS. The Sanford Guide to Antimicrobial
Therapy. 44th ed. Sperryville, VA: Antimicrobial Therapy, Inc., 2014.
and a high-fiber diet. All of these measures help increase 58. When choosing pharmacological intervention to pre-
bowel motility and tone. vent recurrence of duodenal ulcer in a middle-aged
man, you prescribe:
DI SCUSSION SOURCES A. a proton pump inhibitor (PPI).
Ferri F. Diverticular disease. In: Ferri’s Fast Facts. Philadelphia, PA: B. timed antacid use.
Elsevier Mosby; 2005, p. 1156. C. antimicrobial therapy.
Wilkins T, Embry K, George R. Diagnosis and management of acute D. a histamine2-receptor antagonist (H2RA).
diverticulitis. Am Fam Physician 87:612–620, 2013.
Gilbert D, Moellering R, Eliopoulos G, Chambers HF, Saag MS. The 59. The H2RA most likely to cause drug interactions with
Sanford Guide to Antimicrobial Therapy, 44th ed. Sperryville, VA: phenytoin and theophylline is:
Antimicrobial Therapy, Inc., 2014. A. cimetidine.
B. famotidine.
C. nizatidine.
Peptic Ulcer Disease D. ranitidine.
55. The gastric parietal cells produce: 60. Which of the following is least likely to be found in a
A. hydrochloric acid. patient with gastric ulcer?
B. a protective mucosal layer. A. history of long-term naproxen use
C. prostaglandins. B. age younger than 50 years
D. prokinetic hormones. C. previous use of H2RA or antacids
D. cigarette smoking
56. Antiprostaglandin drugs cause stomach mucosal injury
primarily by: 61. Nonsteroidal antiinflammatory drug (NSAID)-induced
A. a direct irritative effect. peptic ulcer can be best limited by the use of:
B. altering the thickness of the protective mucosal A. timed antacid doses.
layer. B. an H2RA.
C. decreasing peristalsis. C. an appropriate antimicrobial.
D. modifying stomach pH level. D. misoprostol.
57. A 24-year-old man presents with a 3-month history 62. Cyclooxygenase-1 (COX-1) contributes to:
of upper abdominal pain. He describes it as an inter- A. the inflammatory response.
mittent, centrally located “burning” feeling in his B. pain transmission.
upper abdomen, most often occurring 2 to 3 hours C. maintenance of gastric protective mucosal layer.
after meals. His presentation is most consistent with D. renal arteriole constriction.
the clinical presentation of: 63. Cyclooxygenase-2 (COX-2) contributes to:
A. acute gastritis. A. the inflammatory response.
B. gastric ulcer. B. pain transmission inhibition.
C. duodenal ulcer. C. maintenance of gastric protective mucosal layer.
D. cholecystitis. D. renal arteriole dilation.
4074_Ch07_153-188 20/11/14 10:46 AM Page 164
64. You see a 48-year-old woman who has been taking a 71. A 56-year-old man with a 60 pack-year cigarette smok-
cyclooxygenase-2 (COX-2) inhibitor for the past 3 ing history, recent 5-lb unintended weight loss, and a
years. In counseling her, you mention that long-term 3-month history of new-onset symptoms of peptic dis-
use of COX-2 inhibitors is associated with all of the fol- ease presents for care. He is taking no medications on
lowing except: a regular basis and reports drinking approximately six
A. hepatic dysfunction. 12-oz beers per week with no more than 3 beers per
B. gastropathy. day. Physical examination is unremarkable except for
C. cardiovascular events. mild pharyngeal erythema and moderate epigastric ten-
D. cerebrovascular events. derness without rebound. The most helpful diagnostic
test at this point in his evaluation is a:
65. A 64-year-old woman presents with a 3-month history
A. upper endoscopy.
of upper abdominal pain. She describes the discomfort
B. barium swallow.
as an intermittent, centrally located “burning” feeling in
C. evaluation of H. pylori status.
the upper abdomen, most often with meals and often ac-
D. esophageal pH monitoring.
companied by mild nausea. Use of an over-the-counter
H2RA affords partial symptom relief. She also uses di- 72. Which of the following medications is a prostaglandin
clofenac on a regular basis for the control of osteoarthri- analog?
tis pain. Her clinical presentation is most consistent with: A. sucralfate
A. acute gastroenteritis. B. misoprostol
B. gastric ulcer. C. esomeprazole
C. duodenal ulcer. D. metoclopramide
D. chronic cholecystitis.
73. Long-term PPI use is associated with all of the follow-
66. Which of the following statements about Helicobacter. ing except:
pylori is false? A. increased risk of pneumonia in hospitalized
A. H. pylori is a gram-negative, spiral-shaped bacterium. patients.
B. Infection with H. pylori is the most potent risk factor B. increased risk of C. difficile colitis in hospitalized
for duodenal ulcer. patients.
C. The organism is often resistant due to the produc- C. reduced absorption of calcium and magnesium.
tion of beta-lactamase. D. reduced absorption of dietary carbohydrates.
D. H. pylori is transmitted via the oral-fecal or oral-oral
74. To avoid rebound gastric hyperacidity following dis-
route.
continuation of long-term PPI use, all of the following
67. The most sensitive and specific test for H. pylori methods can be used except:
infection from the following list is: A. gradually tapering the PPI dose with supplemental
A. stool Gram stain, looking for the offending organism. antacid.
B. serological testing for antigen related to the infection. B. switch to every-other-day dosing of PPI with supple-
C. organism-specific stool antigen testing. mental antacid.
D. fecal DNA testing. C. switch to a low-dose H2RA therapy with supplemen-
tal antacid.
68. Which of the following medications is a PPI?
D. empiric H. pylori therapy.
A. loperamide
B. metoclopramide
C. nizatidine
D. lansoprazole
Answers
69. Peptic ulcer disease can occur in any of the following 55. A. 62. C. 69. D.
locations except: 56. B. 63. A. 70. C.
A. duodenum. 57. C. 64. A. 71. A.
B. stomach. 58. C. 65. B. 72. B.
C. esophagus. 59. A. 66. C. 73. D.
D. large intestine. 60. B. 67. C. 74. D.
61. D. 68. D.
70. An ulcer that is noted to be located in the region below
the lower esophageal sphincter and before the pylorus
is usually referred to as a(n) ________ ulcer. GI irritation and ulcer occur when there is an imbalance
A. duodenal between gastric protective mechanisms and irritating fac-
B. esophageal tors such as hydrochloric acid and other digestive juices.
C. gastric Gastric parietal cells secrete hydrochloric acid, mediated
D. stomach by histamine2-receptor sites.
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In a resting state, the stomach’s pH in health is about 2, mucosae, that is at least 5 mm in diameter, with most losses
which kills many swallowed potentially harmful bacteria and two to five times this size.
viruses. Gastric acid production is about 1 to 2 mEq/hr in a The clinical presentation of peptic ulcer disease (PUD) dif-
resting, empty stomach and increases to 30 to 50 mEq/hr after fers according to the location of the lesion. Symptoms asso-
a meal. The stomach is protected by numerous mechanisms, ciated with acute gastritis and gastric ulcer often become
including a mucus coat with a gel layer. This layer provides worse with eating because of the increase in irritating stom-
mechanical protection from shearing as a result of ingestion ach acid production on top of the lesion. The symptoms often
of rough substances. In addition, bicarbonate is held within lessen within an hour as food buffers the acid. In contrast,
the protective layer and helps maintain pH to protect the duodenal ulcer symptoms often worsen as the stomach pH
mucosa from stomach acidity. Endogenous prostaglandins decreases when emptying after a meal, resulting in a sensation
stimulate and thicken the mucus layer, enhance bicarbonate of stomach burning about 2 hours after a meal. However, sig-
secretion, and promote cell renewal and blood flow. Endoge- nificant variation in clinical presentation is common and the
nous prostaglandin levels normally decrease with age, which exact diagnosis of PUD location cannot be made by history
places older adults at increased risk for gastric damage. and presentation alone.
As part of the stress response, there is an increase in endoge- Duodenal ulcer is more common than gastric ulcer. The
nous gastric acid and pepsin production and the potential for most potent risk factor for this condition is most likely
gastric mucosa injury and gastritis. Exogenous reasons for infection with H. pylori, a gram-negative, spiral-shaped
damage to the stomach’s protective mechanism include the organism with sheathed flagella found in at least 90% of
use of standard NSAIDs, such as ibuprofen and naproxen. patients with duodenal ulcer. The pathogen is also found in
A significant amount of peptic ulcer disease, particularly about 40% to 70% of individuals with gastric ulcer. Infection
gastric ulcer, acute gastritis, and NSAID-induced gastropa- with H. pylori is transmitted via the oral-fecal and oral-oral
thy, is caused by use of NSAIDs and the use of systemic route, and rates of infection approach 100% in developing
corticosteroids. This is partly because of the action of nations with impure water supplies. In developed nations
these products against cyclooxygenase. Cyclooxygenase-1 with pure water supplies, at least 75% of the population
(COX-1) is an enzyme found in gastric mucosa, small and older than 50 years has been infected at some time. Eradi-
large intestine mucosa, kidneys, platelets, and vascular cation of the organism dramatically alters the risk of relapse.
epithelium. COX-1 contributes to the health of these or- Numerous antimicrobial combinations are effective in
gans through numerous mechanisms, including the main- treating symptomatic H. pylori infection (Table 7–3).
tenance of the protective gastric mucosal layer and proper In the past, the adage “no stress, no extra acid, no ulcer”
renal perfusion. Cyclooxygenase-2 (COX-2) is an enzyme was often quoted. Treatment for peptic ulcer disease often
that produces prostaglandins important in the inflammatory included the use of psychotropic medications for relief of
cascade and pain transmission. The standard NSAIDs and stress, according to the hypothesis that this would reduce the
systemic corticosteroids inhibit the synthesis of COX-1 and acid production. In reality, only 30% to 40% of persons with
COX-2, controlling pain and inflammation, but producing duodenal ulcer have higher than average acid secretion rates.
gastric and renal complications. NSAIDs, such as celecoxib In addition, coffee drinking and occasional alcohol use are
(Celebrex®), spare COX-1 and are more COX-2-selective and not risk factors for peptic ulcer disease. Alcohol abuse with
afford pain and inflammatory control. Although short-term cirrhosis remains a risk factor, however. H. pylori is also
studies supported lower rates of gastropathy with COX- found in individuals with asymptomatic gastritis and dyspep-
2-selective NSAIDS (COX-2 inhibitors), this effect usually sia without ulceration; eradication of the organism does not
attenuates with long-term use and is absent with concomi- seem to make a difference in symptoms in patients with these
tant aspirin use. In addition, use of COX-2 inhibitors is conditions.
associated with increased risk for cardiovascular and cere- A variety of diagnostic measures are available when con-
brovascular events. Besides the use of NSAIDs and systemic firmation of the lesion(s)’s location is required. An upper
corticosteroid use, major risk factors for gastric ulcer include GI series identifies more than 80% of all ulcers larger than
age older than 60 years, history of peptic ulcer disease 0.5 cm, whereas upper GI endoscopy identifies nearly all
(especially gastric ulcer), and previous use of H2RA or such ulcers. In particular, upper endoscopy should be con-
antacids for the treatment of GI symptoms. Additional, less sidered as a first-line diagnostic test in adults older than
potent risk factors include: cigarette smoking, cardiac dis- 50 years of age who present with new-onset PUD symp-
ease, and alcohol use; taking more than one NSAID; and the toms, as this modality also allows for ruling out gastric ulcer
concurrent use of NSAIDs and anticoagulants. or gastric cancer. (See Table 7–4 for further information on
Peptic ulcer disease is located in areas, such as the duode- diagnostic testing in PUD.)
num, stomach, esophagus, and small intestine that are ex- Stool antigen testing is the most cost-effective method
posed to peptic juices such as acid and pepsin. Clinically, the of diagnosing H. pylori infection, particularly when cou-
description of the resulting disease includes a notation of pled with a clinical presentation consistent with peptic
where the ulcer is—for example, duodenal ulcer, gastric ulcer disease. Serological testing is also available, with the
(stomach) ulcer, or esophageal ulcer. Peptic ulcer disease usu- limitation that titers can take years to decline after effective
ally includes loss of mucosal surface, extending to muscularis treatment; however, 50% of patients have undetectable
4074_Ch07_153-188 20/11/14 10:46 AM Page 166
TABLE 7-3
Treatment Options in Helicobacter pylori Infection Associated
With Duodenal/Gastric Ulcer
Antimicrobials and Acid-Suppressing Usual Duration
Medication of Therapy Comments
Sequential therapy with rabeprazole 20 mg bid 10 days total Generally well tolerated. Helpful when a shorter
plus amoxicillin 1 g bid x 5 days then rabeprazole course of therapy is desirable.
20 mg bid plus clarithromycin 500 mg plus
tinidazole 500 mg bid x additional 5 days
Bismuth salicylate 2 tabs qid plus metronidazole 10–14 days With 10 days of quadruple therapy, eradication
500 mg qid plus tetracycline 500 mg qid plus rates were 93% in a per protocol population.
omeprazole 20 mg bid Exercise caution regarding potential interac-
tions with other medications, contraindications
in pregnancy, and warnings for other special
populations.
Source: Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The Sanford Guide to Antimicrobial
Therapy. 44th ed. Sperryville, VA: Antimicrobial Therapy, Inc., 2014
TABLE 7-4
Assessing a Patient With Peptic Ulcer Disease
Location and Type
of Peptic Ulcer Risk and Contributing Presenting Signs
Disease Factors and Symptoms Diagnostic Testing
Duodenal ulcer Helicobacter pylori infec- Epigastric burning, Stool antigen testing ≥90% sensitive
tion (most common), gnawing pain about and specific
NSAID use, corticos- 2–3 hr after meals; If H. pylori stool antigen test is positive
teroid use (much less relief with foods, and PUD history, assume active infec-
common) antacids tion and treat because cost of treat-
Clusters of symptoms ment less than that of confirmatory
with periods of feel- endoscopy. Repeat stool antigen test
ing well; awakening ≥8 wk posttreatment. H. pylori testing;
at 1–2 a.m. with serological testing for anti-H. pylori
symptoms common, antibodies positive with acute infec-
morning waking tion but can take decades post infec-
pain rare tion to decline. A less sensitive and
Tender at the epigas- specific option when compared with
trium, left upper stool antigen testing
quadrant abdomen; Urea breath test establishes presence of
slightly hyperactive acute infection
bowel sounds Endoscopy with biopsy and urease test-
ing of biopsy specimen or staining,
looking for H. pylori organisms, is
diagnostic gold standard
Gastric ulcer NSAID and corticosteroid Pain often reported Difficulty distinguishing gastric ulcer
use (potent risk factor) with or immediately from stomach cancer through UGI
Cigarette smoking after meals imaging
Male:female ratio Nausea, vomiting, UGI endoscopy with biopsy vital to rule
equal weight loss common out gastric malignancy.
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TABLE 7-4
Assessing a Patient With Peptic Ulcer Disease—cont’d
Location and Type
of Peptic Ulcer Risk and Contributing Presenting Signs
Disease Factors and Symptoms Diagnostic Testing
Peak incidence in fifth Need confirmation of presence of
and sixth decades of H. pylori before treatment, as is
life; nearly all found present in some of cases
in patients without
H. pylori infection are a
result of chronic NSAID
or long term systemic
corticosteroid use
Nonerosive gastritis, Most likely caused by Nausea Upper GI endoscopy is helpful
chronic type B H. pylori infection Burning and pain diagnostic test, likely with H. pylori
(antral) gastritis limited to upper testing
abdomen without
reflux symptoms
Erosive gastritis Usually secondary to Nausea Upper GI endoscopy is helpful
alcohol and NSAID use, Burning and pain diagnostic test, likely with H. pylori
ASA use, stress limited to upper testing
H. pylori infection abdomen without
usually not a factor reflux symptoms;
bleeding common
titers 12 to 18 months after therapy. The organism pro- Proton pump inhibitors (PPIs) include omeprazole
duces urease, which breaks down urea into ammonia and (Prilosec®), esomeprazole (Nexium®), and lansoprazole
CO2; this allows the organism to control pH in its local en- (Prevacid®). These drugs inhibit gastric acid secretion by in-
vironment in the stomach by neutralizing H+ ions in gastric hibiting the final step in acid secretion by altering the activ-
acid. As a result, urea breath testing is also a helpful diag- ity of the “proton pump” (H+,K+-ATPase). As a result, there
nostic procedure when attempting to establish the presence is a virtual cessation of stomach hydrochloric acid produc-
of H. pylori infection, although it is usually more expensive tion, particularly owing to its significant action against the
than the stool antigen test. postprandial acid surge. PPI use is indicated in the treat-
Suppression or neutralization of gastric acid is a critical ment of peptic ulcer disease and gastroesophageal reflux
part of peptic ulcer disease therapy. H2RAs (whose names disease (GERD) when an H2RA is ineffective, and in refrac-
have the “-tidine” suffix, such as ranitidine [Zantac®], famoti- tory erosive esophagitis and Zollinger-Ellison syndrome.
dine [Pepcid®], and cimetidine [Tagamet®]) competitively With many of the PPIs, clinical efficacy is improved when
block the binding of histamine to the H2-receptor site, reduc- the medication is taken on an empty stomach one-half hour
ing the secretion of gastric acid. In prescription dosages, these prior to breakfast. Protracted PPI use had been associated
products suppress approximately 90% of hydrochloric acid with reduced absorption of iron, vitamin B12, and other mi-
production, whereas over-the-counter dosages suppress about cronutrients. An increase in fracture risk of the hip, spine,
80%. These products are generally well tolerated. Cimetidine wrist, and forearm has also been noted with long-term PPI
is the only H2RA that significantly inhibits cytochrome P-450, use; this risk is possibly associated with the decreased ab-
slowing metabolism of many drugs. As a result, drug interac- sorption of calcium and magnesium during PPI use. In par-
tions between cimetidine and warfarin, diazepam, phenytoin, ticular, individuals with multiple health problems when
quinidine, carbamazepine, theophylline, imipramine, and hospitalized or in long-term care who are on chronic PPI
other medications can occur; these interactions are not noted therapy have an increased risk of contracting pneumonia
with the use of the other H2RAs. and of developing C. difficile colitis. As a result, PPI use
4074_Ch07_153-188 20/11/14 10:46 AM Page 168
should not extend beyond the period of time needed for the 78. A 38-year-old nonsmoking man presents with signs
clinical condition. and symptoms consistent of GERD. He has self-treated
Often patients report an increase in upper GI distress with over-the-counter antacids and acid suppression
when discontinuing long-term PPI use. The likely cause is therapy with effect. His weight is stable, and he denies
rebound gastric hyperacidity; this problem can be mini- nausea, vomiting, diarrhea, or melena. Which of the
mized by gradually tapering the PPI dose (if possible) or try- following represents the most appropriate diagnostic
ing every-other-day dosing with a supplemental dose of an plan for this patient?
antacid when symptoms flare. An alternative is to try low- A. fecal testing for H. pylori antigen
dose H2RA therapy with supplemental antacid use as B. upper GI endoscopy
needed. This gap therapy is usually continued for approxi- C. barium swallow
mately 1 month. D. no specific diagnostic testing is needed
H2RAs likely offer protection against NSAID-induced
79. Which of the following is most likely to be found in a
duodenal ulcer and perhaps gastritis, but not against gastric
50-year-old woman with new-onset reflux esophagitis?
ulcer. PPIs afford better protection against peptic ulcer dis-
A. recent initiation of estrogen-progestin hormonal
ease. A prostaglandin analogue, misoprostol (Cytotec®), is a
therapy
drug specifically designed for gastric protection with NSAID;
B. recent weight loss
the use of this medication is possibly helpful in minimizing
C. report of melena
renal injury secondary to NSAID use.
D. evidence of H. pylori infection
DI SCUS SION SOURCES 80. Which of the following is likely to be reported in a
Abraham N. Proton Pump Inhibitors: Potential Adverse Effects, patient with persistent GERD?
Curr Opin Gastroenterol 28(6):615–620, 2012. A. hematemesis
Ferri F. Peptic ulcer disease. In: Ferri’s Fast Facts. Philadelphia, PA: B. chronic sore throat
Elsevier Mosby; 2005, pp. 324–326. C. diarrhea
Gilbert D, Moellering R, Eliopoulos G, Chambers H, Saag M. The
D. melena
Sanford Guide to Antimicrobial Therapy. 44th ed. Sperryville, VA:
Antimicrobial Therapy, Inc., 2014. , p. 81. A 58-year-old man recently began taking an antihyper-
Kenthu S, Moss S. Gastritis and peptic ulcer disease. In: Rakel R, tensive medication and reports that his “heartburn”
Bope E (eds). Conn’s Current Therapy. Philadelphia, PA: has become much worse. He is most likely taking:
Saunders Elsevier; 2013, pp. 527–533. A. atenolol.
B. trandolapril.
C. amlodipine.
GERD D. losartan.
75. A 35-year-old woman complains of a 6-month his- 82. You prescribe a fluoroquinolone antibiotic to a
tory of periodic “heartburn” primarily after eating 54-year-old woman who has occasional GERD symp-
tomato-based sauces. Her weight is unchanged toms that she treats with an antacid. When discussing
and examination reveals a single altered finding of appropriate medication use, you advise that she
epigastric tenderness without rebound. As first-line should take the antimicrobial:
therapy, you advise: A. with the antacid.
A. avoiding trigger foods. B. separated from the antacid use by 2 to 4 hours before
B. the use of a prokinetic agent. or 4 to 6 hours after taking the fluoroquinolone.
C. addition of sucralfate with meals. C. without regard to antacid use.
D. increased fluid intake with food intake. D. apart from the antacid by about 1 hour on either
side of the fluoroquinolone dose.
76. You see a 62-year-old man diagnosed with esophageal
columnar epithelial metaplasia. You realize he is at 83. A 48-year-old man with obesity and a 1-year history of
increased risk for: classic GERD symptoms has been on the consistent use
A. esophageal stricture. of a therapeutic dose of a PPI for the past 6 months.
B. esophageal adenocarcinoma. He states he is “really no better with the medicine and
C. gastroesophageal reflux. I have cut out most of the food that bothers my stom-
D. H. pylori colonization. ach. I even cut out all alcohol and soda.” Physical exam-
ination reveals stable weight, mildly erythematous
77. In caring for a patient with symptomatic gastroe-
pharynx, and epigastric tenderness without rebound.
sophageal reflux, you prescribe a PPI to:
Next step options include:
A. enhance motility.
A. obtaining an upper GI series.
B. increase the pH of the stomach.
B. referral for GERD surgery.
C. reduce lower esophageal pressure.
C. further evaluation with upper GI endoscopy.
D. help limit H. pylori growth.
D. obtaining FOBT testing.
4074_Ch07_153-188 20/11/14 10:46 AM Page 169
84. Which of the following is not an “alarm” finding in 92. The presence of esophageal cancer is commonly
the person with GERD symptoms? associated with:
A. weight gain A. renal impairment.
B. dysphagia B. chronic bronchitis.
C. odynophagia C. iron-deficiency anemia.
D. iron-deficiency anemia D. unexplained weight gain.
85. Risk factors for Barrett esophagus include all of the
following except: Answers
A. history of cigarette smoking.
B. older than 50 years of age. 75. A. 81. C. 87. D.
C. male gender. 76. B. 82. B. 88. B.
D. African American ethnicity. 77. B. 83. C. 89. C.
86. A 57-year-old male is in need of evaluation for Barrett 78. D. 84. A. 90. A.
esophagus. You recommend: 79. A. 85. D. 91. B.
A. H. pylori testing. 80. B. 86. C. 92. C.
B. CT scan.
GERD (gastroesophageal reflux disease) is a common but
C. upper GI endoscopy with biopsy.
troublesome condition. Reflux of stomach contents occurs
D. barium swallow.
regularly. Most reflux is asymptomatic with no resulting
87. A 64-year-old male with diagnosed Barrett esophagus esophageal injury. GERD is present when there are symp-
has shown no sign of dysplasia in two consecutive toms or evidence of tissue damage. The most common
evaluations within the past year. You recommend GERD presentation includes dyspepsia, chest pain at rest,
additional surveillance testing should be conducted and postprandial fullness. In addition, non-GI symptoms,
every: including chronic hoarseness, sore throat, nocturnal cough,
A. 6 months. and wheezing, are often reported, occasionally in the absence
B. 12 months. of more classic GERD symptoms, and particularly when the
C. 2 years. condition is chronic. (For additional information on diag-
D. 3 years. nosing GERD, see Table 7–5.)
Decreased lower esophageal sphincter tone and the result-
88. The most common form of esophageal cancer in the
ing reflux of gastric contents cause GERD. Esophageal mu-
United States is:
cosal irritation results from exposure to hydrochloric acid
A. squamous cell cancer.
and pepsin.
B. adenocarcinoma.
The use of certain medications including estrogen, prog-
C. basal cell carcinoma.
esterone/progestins, theophylline, calcium channel blockers,
D. melanoma.
and nicotine; can result in a decrease in lower esophageal
89. Esophageal adenocarcinoma is usually located: sphincter pressure and worsen GERD, these medications
A. in the upper esophagus. should be discontinued if clinically possible. Initial therapy
B. near the upper esophageal sphincter. for patients with GERD includes identifying trigger foods and
C. at the junction of the esophagus and stomach. reducing their intake. Most commonly mentioned food
D. in the lower esophagus. includes alcohol, tomato-based products, chocolate, pep-
permint, colas, citrus juices, and food high in fat content.
90. Esophageal squamous cell cancer is usually
Behavioral intervention includes avoiding or minimizing
located:
conditions or situations that encourage esophageal reflux: re-
A. in the upper esophagus.
maining upright and avoiding assuming the supine position
B. near the upper esophageal sphincter.
within 3 hours of a meal, eating smaller meals, and eliminat-
C. at the junction of the esophagus and
ing occasions of overeating. Because abdominal obesity con-
stomach.
tributes to GERD, weight loss can also be helpful. Elevation
D. in the lower esophagus.
of the head of the bed on 4-inch blocks can also offer some
91. Which of the following is at greatest risk of relief; propping the head and upper thorax on pillows is not
esophageal cancer? effective. (For additional information on managing GERD,
A. 34-year-old male who eats a high-fat diet see Table 7–5.) In patients with classic GI and extra-GI symp-
B. 76-year-old male who stopped smoking toms, the diagnosis of GERD is usually made clinically with
15 years ago no specific diagnostic testing performed, particularly when
C. 45-year-old woman with a history of 6 full-term clinical response is noted with standard therapy.
pregnancies The use of antacids after meals and at bedtime is often suf-
D. 58-year-old female vegetarian ficient to control milder, particularly intermittent, GERD
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TABLE 7-5
Diagnosis and Management of GERD
ESTABLISHING THE DIAGNOSIS OF GERD
• A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation.
Empiric medical therapy with a proton pump inhibitor (PPI) is recommended in this setting.
• Screening for Helicobacter pylori infection is not recommended in GERD patients. Treatment of H. pylori infection is
not routinely required as part of antireflux therapy.
• Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the
presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not
indicated in patients without Barrett’s esophagus in the absence of new symptoms.
• Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD
• Barium radiographs should not be performed to diagnose GERD.
• Esophageal manometry plays no role in the diagnosis of GERD. If GERD surgical intervention is being considered,
esophageal manometry is recommended for preoperative evaluation.
• Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in
patients with non-erosive disease, as part of the evaluation of patients refractory to PPI therapy, and in situations
when the diagnosis of GERD is in question. Ambulatory reflux monitoring is the only test that can assess reflux
symptom association.
MANAGEMENT OF GERD
• An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis.
• PPI therapy should be initiated at once a day dosing, before the first meal of the day. For patients with partial response
to once daily therapy, tailored therapy with adjustment of dose timing and/or twice daily dosing should be considered
in patients with night-time symptoms, variable schedules, and/or sleep disturbance. Switching to another PPI is also an
option though there are no major differences in efficacy between the different PPIs.
• Traditional delayed release PPIs such as omeprazole should be administered 30–60 min before a meal for maximal pH
control.
• Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is dis-
continued and in patients with complications including erosive esophagitis and Barrett’s esophagus.
• Patients who do not respond to PPI should be referred for evaluation.
• Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic foods) is not
recommended in the treatment of GERD. At the same time, foods that are known to trigger symptoms should be
eliminated or minimized.
• Weight loss is recommended for GERD patients who are overweight, obese, or have had recent weight gain.
• Head of bed elevation and avoidance of meals 2–3 h before bedtime should be recommended for patients with
nocturnal GERD.
• For patients who require long-term PPI therapy, the medication should be administered in the lowest effective dose,
including on demand or intermittent therapy. H2-receptor antagonist (H2RA) therapy can be used as a maintenance
option in patients without erosive disease if patients experience heartburn relief.
• Sucralfate and prokinetic agents do not play a role in the treatment of GERD.
symptoms. Antacids neutralize secreted acids and inactivate unlikely to be helpful. With moderate to severe symptoms that
pepsin and bile salts. These medications are most effective do not respond to a prescription dosage of H2RA, a PPI such
when used 1 to 3 hours after meals and at bedtime. Antacids as omeprazole (Prilosec) or lansoprazole (Prevacid) should
interact with many other medications and should be used at be prescribed; an alternative is to simply start therapy with a
least 2 hours apart; with the use of a fluoroquinolone such as PPI. Compared with H2RAs, PPIs have superior postprandial
ciprofloxacin, antacid use should be 2 to 4 hours before or and nocturnal acid suppression. An 8-week course of PPI ther-
4 to 6 hours after the fluoroquinolone. apy is usually adequate to heal acute esophageal inflammation
If the use of antacids and lifestyle modification are inade- noted with ongoing GERD. If symptoms do not resolve with
quate to control milder, intermittent GERD symptoms, an this PPI course, referral to gastroenterology for further evalu-
H2RA at full prescription strength bid should be added. If there ation, including upper GI endoscopy, is warranted. In the
is no improvement in 6 weeks, longer term H2RA therapy is past, sucralfate and prokinetic agents were considered to be
4074_Ch07_153-188 20/11/14 10:46 AM Page 171
treatment options for GERD; little evidence supports the use In early esophageal cancer, regardless of etiology, the patient
of these medications and these medications are no longer is usually without symptoms. In later disease, dysphagia—
considered therapeutic option in this condition. particularly difficulty swallowing solid foods—and weight
The course of GERD is usually straightforward. However, loss are among the most commonly reported findings. Less
“alarm” symptoms in GERD that warrant further evalua- commonly reported symptoms are epigastric or retroster-
tion include dysphagia (difficulty swallowing), odynophagia nal pain, persistent hoarseness, and cough, though these
(painful swallowing), gastrointestinal bleeding, unexplained are also common to GERD. Due to chronic low volume
weight loss, and persistent chest pain. The development of bleeding from the esophageal tumor, iron-deficiency ane-
iron-deficiency anemia as a result of chronic low volume GI mia often develops. Often, esophageal cancer is not de-
blood loss in the presence of GERD symptoms is a rare but tected until advanced. Prognosis is dependent on the extent
worrisome finding. A component of the additional evaluation of the disease. When esophageal cancer is suspected, esoph-
is referral to gastroenterology for upper endoscopy. These agogastroduodenoscopy (upper GI endoscopy) with appro-
alarm findings can be indicative of erosive esophagitis or priate biopsies is the preferred method of initial diagnostic
esophageal cancer; upper endoscopy can clarify the diagnosis testing. Additional testing is based on initial findings.
and provide, if required, a vehicle of esophageal biopsy.
Surgical intervention in GERD is a treatment option usu- D I S C U SSI O N S O U R C E S
ally limited to patients with the most severe symptoms that American Gastroenterological Association Medical Position Statement
are not improved by the use of standard treatment. As addi- on the Management of Barrett’s Esophagus. Available at www.
tional endoscopic interventions become available, with evi- gastrojournal.org/article/S0016-5085(11)00084-9/fulltext
dence of the long-term efficacy and safety of the procedures, American College of Gastroenterology, Diagnosis and Management
of Gastroesophageal Reflux Disease. Available at http://gi.org/
this option is likely to increase in utility. Obese patients con-
guideline/diagnosis-and-management-of-gastroesophageal-
templating surgical therapy for GERD should be considered reflux-disease
first for bariatric surgery. Gastric bypass would be the pre- Baldwin K, Espat J. Esophageal Cancer. Available at http://emedicine.
ferred operation in these patients; restrictive bariatric surgery medscape.com/article/277930
will likely contribute to GERD symptoms.
Reflux-induced esophageal injury, also known as reflux
esophagitis, is present in 40% of patients with GERD. Erosions Viral Hepatitis
and ulcerations in squamous epithelium of the esophagus are
present and are most common in elderly patients and individ- 93. A 36-year-old man complains of nausea, fever, malaise,
uals with longstanding GERD history. Complications of reflux and abdominal pain. He shows signs of jaundice and re-
esophagitis include esophageal stricture and columnar epithe- ports darkly-colored urine. Diagnostic results show ele-
lial metaplasia, also known as Barrett esophagus (BE), which vated serum aminotransferase less than 10 times upper
typically involves the distal esophagus. In patients at risk for limits of normal (ULN). His most likely diagnosis is:
BE, an upper GI endoscopy should be performed and appro- A. GERD.
priate biopsy specimens taken. Although BE has long been B. viral hepatitis.
mentioned as a potent risk factor for esophageal adenocarci- C. Crohn’s disease.
noma, this risk is not thought to be as significant as in the past. D. Barrett esophagus.
Risk factors for BE include GERD of long duration, certain eth-
94. A serological marker for acute hepatitis A virus (HAV)
nicity (i.e., white, Hispanic), male gender, advancing age (older
infection is:
than 50 years of age), tobacco use, and obesity. Intervention in
A. HAV IgM.
BE is based on aggressive acid suppression, with the anticipated
B. HAV viral RNA.
end product of minimizing further esophageal damage. For
C. TNF-α.
patients with established BE of any length and with no dyspla-
D. IL-10.
sia after two consecutive examinations within 1 year, an
acceptable interval for additional surveillance is every 3 years. 95. You are caring for a 45-year-old woman from a devel-
The clinician should remain aware of the latest recommenda- oping country. She reports that she had “yellow jaun-
tions on BE intervention and surveillance. dice” as a young child. Her physical examination is
Esophageal cancer can be found in a variety of forms. unremarkable. Her laboratory studies are as follows:
Squamous cell cancer, usually found in the upper part of the AST, 22 U/L (normal, 0 to 31 U/L); alanine amino-
esophagus, represents approximately 90% to 95% of all transferase (ALT), 25 U/L (normal, 0 to 40 U/L); hepa-
esophageal cancer worldwide. Adenocarcinoma, usually lo- titis A virus immunoglobulin G (HAV IgG) positive.
cated at the junction of the esophagus and stomach, com- Laboratory testing reveals:
prises more than 50% of all esophageal cancer in the United A. chronic hepatitis A.
States. As with BE, esophageal cancer is more common in B. no evidence of prior or current hepatitis A
men, with a male to female ratio of approximately 3:1. The infection.
disease is most often diagnosed in the sixth and seventh C. resolved hepatitis A infection.
decades of life. D. prodromal hepatitis A.
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96. The most common source of hepatitis A infection is: 103. A 38-year-old man with a recent history of injection
A. sharing intravenous drug equipment. drug use presents with malaise, nausea, fatigue, and
B. cooked seafood. “yellow eyes” for the past week. After ordering diag-
C. contaminated water supplies. nostic tests, you confirm the diagnosis of acute hep-
D. sexual contact. atitis B. Anticipated laboratory results include:
A. the presence of hepatitis B surface antibody
97. In addition to the laboratory work described, results
(HBsAb).
reveal the following for the above-mentioned patient:
B. neutrophilia.
hepatitis B surface antigen (HBsAg) positive. These
C. thrombocytosis.
findings are most consistent with:
D. the presence of HBsAg.
A. no evidence of hepatitis B infection.
B. resolved hepatitis B infection. 104. Clinical findings in patients with acute hepatitis B
C. chronic hepatitis B. likely include all of the following except:
D. evidence of effective hepatitis B immunization. A. abdominal rebound tenderness.
B. scleral icterus.
98. The average incubation time for HAV is
C. a smooth, tender, palpable hepatic border.
approximately:
D. report of myalgia.
A. 10 days.
B. 28 days. 105. Risk factors for hepatitis B virus (HBV) infection
C. 60 days. include all of the following except:
D. 6 months. A. having multiple sexual partners.
B. having an occupation that exposes you to human
99. Current vaccine guidelines recommend administer-
blood.
ing the immunization against HAV to:
C. injection drug user.
A. those living in or traveling to areas endemic
D. eating food prepared by a person with an HBV
for the disease.
infection.
B. food handlers and day-care providers.
C. military personnel. 106. You see a woman who has been sexually involved
D. any person who wishes to receive the vaccine. without condom use with a man newly diagnosed
with acute hepatitis B. She has not received hepatitis
100. All of the following are effective methods to kill the
B immunization. You advise her to:
hepatitis A virus except:
A. start hepatitis B immunization series.
A. heating food to more than 185°F (85°C) for
B. limit the number of sexual partners.
at least 1 minute.
C. be tested for HBsAb.
B. adequately chlorinating water.
D. receive hepatitis B immune globulin and start
C. cleaning surfaces with a 1:100 bleach solution.
hepatitis B immunization series.
D. freezing food for at least 1 hour.
107. The HBV vaccine should not be offered to individu-
101. You see a 27-year-old man who says he ate at a
als who have a history of anaphylactic reaction to:
restaurant last week that was later reported to have a
A. eggs.
worker identified with hepatitis A. He is healthy and
B. Baker’s yeast.
shows no sign of infection but is concerned about
C. peanuts.
contracting HAV infection. You recommend:
D. shellfish.
A. HAV vaccine.
B. HAV immune globulin. 108. Which of the following groups should be screened
C. HAV vaccine plus immune globulin. for hepatitis B surface antigen (HBsAg)?
D. no intervention at this time and wait until A. pregnant women with no history of receiving
symptoms manifest. HBV vaccine
B. pregnant women with documented prior HBV
102. A 54-year-old man has been recently diagnosed with
infection
HAV infection. You recommend all of the following
C. all pregnant women regardless of HBV vaccine
except:
history
A. eating smaller, more frequent meals to help
D. all newborn infants born to mothers with chronic
combat nausea.
HBV infection
B. avoiding consumption of any alcohol.
C. reviewing current medication use for considera-
tion of discontinuation.
D. taking daily acetaminophen to alleviate joint
pains.
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109. Routine testing for the presence of HBsAb after im- 115. When answering questions about hepatitis A vaccine,
munization with the HBV vaccine is recommended you consider that all of the following are true except:
for all of the following except: A. it does not contain live virus.
A. healthcare providers. B. it should be offered to individuals who frequently
B. immunocompromised patients. travel to developing countries.
C. restaurant workers. C. it is a recommended immunization for healthcare
D. dialysis patients. workers.
D. it is given as a single dose.
110. A 26-year-old male reports that he has shared a nee-
dle with a friend during injection drug use. He is cer- 116. To prevent an outbreak of hepatitis D infection, a NP
tain that his friend has chronic hepatitis B infection plans to:
and is uncertain about his own immunization history. A. promote a campaign for clean food supplies.
You recommend: B. immunize the population against hepatitis B.
A. starting the HBV vaccine series. C. offer antiviral prophylaxis against the agent.
B. administering hepatitis B immune globulin. D. encourage frequent hand washing.
C. starting the HBV vaccine series and administering
117. Which of the following is true concerning hepatitis B
hepatitis B immune globulin.
vaccine?
D. waiting until the HBsAg results before administer-
A. The vaccine contains live hepatitis B virus.
ing hepatitis B immune globulin.
B. Most individuals born since 1986 in the United
111. You see a 22-year-old male who is an injection drug States who have been fully immunized have
user who has recently been diagnosed with chronic received vaccine against HBV.
HBV infection. You recommend additional testing for C. The vaccine is contraindicated in the presence of
all of the following except: HIV infection.
A. Lyme disease. D. Postvaccination arthralgias are often reported.
B. HIV.
118. Hyperbilirubinemia can cause all of the following
C. HAV.
except:
D. HCV.
A. potential displacement of highly protein-bound
112. Antiviral treatment for chronic HBV infection in- drugs.
cludes all of the following except: B. scleral icterus.
A. entecavir. C. cola-colored urine.
B. tenofovir. D. reduction in urobilinogen.
C. lamivudine.
119. Monitoring for hepatoma in a patient with chronic
D. fidaxomicin.
hepatitis B or C often includes periodic evaluation of:
113. Which of the following statements is true concerning A. erythrocyte sedimentation rate.
hepatitis C infection? B. HBsAb.
A. It usually manifests with jaundice, fever, and sig- C. alpha-fetoprotein.
nificant hepatomegaly. D. bilirubin.
B. Among health-care workers, it is most commonly
120. Which of the following is an expected laboratory re-
found in nurses.
sult in a patient with acute hepatitis A infection (nor-
C. At least than 50% of persons with acute hepatitis C
mal values: AST, 0 to 31 U/L; ALT, 0 to 40 U/L)?
go on to develop chronic infection.
A. AST, 55 U/L; ALT, 50 U/L
D. Interferon therapy is consistently curative.
B. AST, 320 U/L; ALT, 190 U/L
114. Which of the following characteristics is predictive of C. AST, 320 U/L; ALT, 300 U/L
severity of chronic liver disease in a patient with D. AST, 640 U/L; ALT, 870 U/L
chronic hepatitis C?
121. Which of the following is most likely to be reported
A. female gender, age younger than 30
in a patient on long-term use of a 3-hydroxy-3-
B. co-infection with hepatitis B, daily alcohol use
methylglutaryl–coenzyme A (HMG-CoA) reductase
C. acquisition of virus through intravenous drug use,
inhibitor (statin)?
history of hepatitis A infection
A. AST, 22 U/L; ALT, 28 U/L
D. frequent use of aspirin, nutritional status
B. AST, 320 U/L; ALT, 190 U/L
C. AST, 32 U/L; ALT, 120 U/L
D. AST, 440 U/L; ALT, 670 U/L
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122. When discussing the use of immunoglobulin (IG) for nearly 50% of the reported cases, though overall reported
with a 60-year-old woman who was recently exposed cases have decreased in the last decade. Due to the risk to a
to the hepatitis A virus, you consider that: given population, the local public health department should
A. IG is derived from pooled donated blood. be consulted for advice when an outbreak of hepatitis A
B. the product must be used within 1 week of expo- infection occurs.
sure to provide protection. The clinical presentation of all forms of acute viral hepatitis
C. its use in this situation constitutes an example typically includes nausea, anorexia, fever, malaise, abdominal
of active immunization. pain, and jaundice. Clay-colored stools, dark-colored urine,
D. a short, intense flu-like illness often occurs and joint pains are commonly reported. Laboratory findings
after its use. include elevated serum aminotransferase (hepatic enzyme)
levels, most often 20 or more times the upper limits of normal.
123. You see a 48-year-old woman with nonalcoholic
Since the clinical presentation is the same for all types of acute
fatty liver disease. Evaluation of infectious hepatitis
viral hepatitis, the diagnosis must be confirmed by a positive
includes the following:
serological test for the specific hepatitis. In hepatitis A, im-
Anti-HAV IgG—negative
munoglobulin M (IgM) antibody to hepatitis A virus develops
Anti-HBs—negative
(HAV) (see Table 7–6). The onset of symptoms in hepatitis A
Anti-HCV—negative
usually occurs about 15 to 50 days after the organism is con-
When considering her overall health status, you
tracted; the average incubation period for the virus is about
advise receiving which of the following vaccines?
28 days, with a range of 15 to 50 days. The majority (more than
A. immunization against hepatitis A and B as based
70%) of children less than age 6 years will have few or no
on her lifestyle risk factors
symptoms during infection with the HAV.
B. immunization against hepatitis B and C
All children and select other groups should be immunized
C. immunization against hepatitis A and B
against HAV. Candidates for immunization include individ-
D. immunization against hepatitis A, B, and C
uals who reside in or travel to areas in which the disease is
124. Which of the following hepatitis forms is most effec- endemic, food handlers, sewage workers, animal handlers,
tively transmitted from the man to the woman via day-care attendees and workers, long-term care residents and
heterosexual vaginal intercourse? workers, military personnel, and health-care workers. Injec-
A. hepatitis A tion drug users also benefit from the vaccine. HAV is rarely
B. hepatitis B transmitted sexually or from needle sharing; rather, injection
C. hepatitis C drug users often live in conditions that facilitate the oral-fecal
D. hepatitis D transmission of HAV. In addition, co-infection with hepatitis
A and C, co-infection with hepatitis A and B, or acute hepa-
titis A in addition to chronic liver disease can lead to a rapid
Answers deterioration in hepatic function. Persons with chronic hep-
atitis B or C or both or any chronic liver disease should be
93. B. 104. A. 115. D. immunized against hepatitis A. Persons who have clotting
94. A. 105. D. 116. B. factor disorders and are receiving clotting factor concentrates
95. C. 106. D. 117. B. who have not had hepatitis A should also be immunized.
96. C. 107. B. 118. D. Currently, hepatitis A vaccine guidelines have been expanded
97. C. 108. C. 119. C. to include all individuals who would like to be immunized
98. B. 109. C. 120. D. against the condition.
99. D. 110. C. 121. A. HAV is a heat-sensitive virus that can be killed by heating
100. D. 111 A. 122. A. food to higher than 185°F (higher than 85°C) for one minute.
101. A. 112. D. 123. C. Adequate chlorination of water, as recommended in the
102. D. 113. C. 124. B. United States, kills HAV that enters the water supply. The
103. D. 114. B. virus is capable of surviving on select surfaces for many
weeks. Proper hand hygiene and cleaning environmental sur-
Numerous infective agents cause viral hepatitis (Table 7–5). faces with a 1:100 bleach solution are measures that can help
Hepatitis A infection is caused by hepatitis A virus (HAV), a minimize the spread of this infection.
small RNA virus. Transmitted primarily by fecal-contaminated Two doses of HAV vaccine are usually given 6 to 12 months
drinking water and food supplies, hepatitis A is typically a apart to ensure an enhanced immunological response; an
self-limiting infection with a very low mortality rate. Fecal- alternative accelerated dosing schedule is also licensed for use
contaminated water supplies are the most common source of with a combined hepatitis A and B vaccine. Hepatitis A vac-
infection, although eating raw shellfish that grew in impure cine, which does not contain live virus, is usually well tolerated
water can be problematic. In developing countries with without systemic reaction. Postvaccine HAV immunity typi-
limited pure water, most children contract this disease by age cally lasts at least 15 to 25 years. Postexposure prophylaxis
5 years. In North America, adults 20 to 39 years old account against hepatitis A is also available; IG and HAV vaccine are
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TABLE 7-6
Infectious Hepatitis: Key Features to Transmission and Diagnosis
IZ available?
Route of Postexposure
Type Transmission prophylaxis? Sequelae Disease Marker
HEPATITIS A Fecal-oral IZ=Yes None, survive or die Acute disease marker
Postexposure (low mortality rate) • HAV IgM (M=miserable)
prophylaxis • Elevated hepatic enzymesⱖ10 x ULN
with IZ and/or Chronic disease marker
IG for close • None, as chronic hepatitis A does not
contacts exist
Disease in past, Hx IZ=
• Anti-HAV (total of HAV IgM and HAV
IgG [G=gone]) present
• Hepatic enzymes normalize
Still susceptible to hepatitis A infection
• Anti-HAV negative (Negative=”Never
had”)
HEPATITIS B Blood, body IZ=Yes Chronic hepatitis B, Acute disease markers
fluids Postexposure hepatocellular • HBsAg=Always growing
prophylaxis carcinoma (HCC, • HBeAg=Extra contagious, extra
with IZ and/or primary liver cancer, growing
HBIG for blood, hepatoma), hepatic • Elevated hepatic enzymesⱖ10 x ULN
body fluid failure Chronic disease marker
contacts • Patient without symptoms
• NL or slight elevated hepatic enzymes
• HBsAg (Ag=Always growing)
• Only present if HBV on board
• Surrogate marker for HBV
Hepatitis B in past, Hx IZ
• HBsAb (Anti-HBs)
• B=Bye, as no HBV on board
• A protective antibody, unable to
get HBV in the future
• Hepatic enzyme normalized
Still susceptible to hepatitis B infection
• HBsAg negative
• Anti-HBc negative
• HBsAb (Anti-HBs) negative
HEPATITIS C Blood, body No Chronic hepatitis C, Acute disease marker
fluids No hepatocellular • Anti-HCV present
carcinoma (HCC, • HCV viral RNA
primary liver cancer, • Elevated hepatic enzymes
hepatoma), hepatic Chronic disease marker
failure • Anti-HCV present
• HCV viral RNA
• Normal to slightly elevated hepatic
enzymes
Disease in the past
• Anti-HCV present (nonprotective
antibody)
• HCV RNA absent
• Normalized hepatic enzymes
Continued
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TABLE 7-6
Infectious Hepatitis: Key Features to Transmission and Diagnosis—cont’d
IZ available?
Route of Postexposure
Type Transmission prophylaxis? Sequelae Disease Marker
HEPATITIS D Blood, body No, but prevent Severe infection, Acute or chronic hepatitis B (HBsAg)
fluids B and you can hepatic failure, markers plus hepatitis D IgM. Usually
prevent D death with markedly elevated hepatic
enzymes.
NB: The content of this table is not meant to be a comprehensive guide for the diagnosis of infectious hepatitis
but rather an overview. For additional information, see Ferri F. Ferri’s Best Test: A Practical Guide to Clinical
Laboratory Medicine and Diagnostic Imaging, 2nd Ed. St. Louis: Elsevier Health Sciences, 2009; and Desai S.
Clinician’s Guide to Laboratory Medicine. Houston, TX, Pocket, 2009, MD2B.
used for this purpose. For healthy persons 12 months to drug use. HBV is also a major occupational hazard of health
40 years old, a dose of hepatitis A vaccine at the age-appropriate workers. HBV cannot be spread by contaminated food or
dose is preferred to IG because of vaccine advantages that in- water, nor can it be spread casually in the workplace. The
clude long-term protection and ease of administration. For per- virus can be killed with a 1:10 dilution of bleach to clean up
sons older than 40 years, IG is preferred because of the lack of blood spills. Gloves and eye protection should be worn
information regarding vaccine performance and the more when cleaning up blood spills.
severe manifestations of hepatitis A in this age group; vaccine Acute hepatitis B is a serious illness that can lead to he-
can be used if IG cannot be obtained. IG, a form of passive im- patic failure. Approximately 5% of individuals with acute
munity, is highly effective in preventing HAV infection if given hepatitis B go on to develop chronic hepatitis B; chronic
within 2 weeks of exposure. IG is a product derived from pooled hepatitis B is a potent risk factor for hematoma or primary
blood that contains preformed antibodies against the virus and hepatocellular carcinoma and hepatic cirrhosis. A person
has an outstanding safety profile. HAV vaccine should be en- with chronic hepatitis B continues to be able to transmit the
couraged with IG use. virus, although the person appears clinically well.
There is no specific treatment for HAV infection as the Hepatitis B infection can be prevented by limiting expo-
body will clear the virus on its own, with the liver typically sure to blood and body fluids and through immunization.
healing itself within a month or two. Treatment primarily Recombinant hepatitis B vaccine, which does not contain live
focuses on alleviating the signs and symptoms of the infec- virus, is well-tolerated; one contraindication to receiving the
tion. Patients may feel tired and have less energy, and thus vaccine is a personal history of anaphylaxis to baker’s yeast.
should rest when needed. To combat nausea, patients can In the United States, this vaccine has been routinely used in
try to eat small snacks rather than 3 large meals, and choose children since 1986; as a result, most of the population born
higher-calorie foods over lower-calorie foods if the patient during or after 1986 has been immunized. The vaccine should
is having trouble eating enough calories. Finally, any insult be offered to adults born before 1986 and to all who have not
to the liver should be avoided during HAV infection. If been immunized, particularly persons at highest risk for con-
possible, any medications processed by the liver, including tracting the virus. Nonimmunized individuals being treated
acetaminophen, should be stopped or changed, and alcohol for other sexually transmitted infections should be encour-
consumption should be avoided while signs and symptoms aged to receive protection against HBV. Refer to the latest
persist. immunization guidelines for further information on this im-
Hepatitis B is caused by a small double-stranded DNA portant public health issue.
virus that contains an inner core protein of hepatitis B core Infants who become infected perinatally with HBV have
antigen and an outer surface of HBsAg. Hepatitis B virus an estimated 25% lifetime chance of developing hepatocel-
(HBV) is usually transmitted through an exchange of blood lular carcinoma or cirrhosis. As a result, all pregnant
and body fluids. Risk factors for HBV infection include women should be screened for HBsAg at the first prenatal
having sex with more than one partner, men who have visit, regardless of HBV vaccine history. Because the HBV
sexual contact with other men, sharing needles during in- vaccine is not 100% effective and perinatal transmission
jection drug use, having a job with exposure to human is possible, a woman could have carried HBV before be-
blood, or traveling to areas with high infection rates of coming pregnant. About 90% to 95% of individuals who
HBV (such as Africa, Central and Southeast Asia, and receive the vaccine develop HBsAb (anti-HBs) after three
Central Europe). The predominant mode of transmission doses, implying protection from the virus. Routine testing
of the HBV virus is through sexual activity and injection for the presence of HBsAb after immunization is not
4074_Ch07_153-188 20/11/14 10:46 AM Page 177
recommended. HBsAb testing should be considered, how- when shared or poorly sanitized equipment is used. Trans-
ever, to confirm the development of HBV protection in mission through sexual contact is possible, but this risk seems
persons with high risk for infection (e.g., certain healthcare to be relatively low. Maternal-fetal transmission is also un-
workers who have risk for frequent and high-volume blood common and is usually limited to women with high circulat-
exposures, injection drug users, sex workers) and persons ing HCV levels. Transmission through breastfeeding has not
at risk for a poor immune response (e.g., dialysis patients, been reported.
patients with immunosuppression). The HCV incubation period is about 6 to 7 weeks, and
Booster doses of hepatitis B vaccine are recommended the infection rarely causes a serious acute illness. Diagnosis
only in certain circumstances. For hemodialysis patients, is made by the presence of anti-HCV, an antibody that
the need for booster doses should be assessed by annual persists in the presence of the virus and is not protective.
testing for antibody to hepatitis B surface antigen (anti- At least 50% to 80% of individuals with hepatitis C go on
HBs). A booster dose should be administered when anti- to develop chronic infection and exhibit anti-HCV along
HBs levels decline to less than 10 mIU/mL. For other with a positive hepatitis C viral load. Progression to cirrho-
immunocompromised persons (e.g., HIV-infected persons, sis occurs in about 20% of people infected with chronic
hematopoietic stem-cell transplant recipients, and persons hepatitis C after 20 years of disease. HCV-related cirrhosis
receiving chemotherapy), the need for booster doses has not risk is increased in men, with disease acquisition after age
been determined. When anti-HBs levels decline to less than 40 years, and in people who drink the equivalent of 50 g or
10 mIU/mL, annual anti-HBs testing and booster doses more of alcohol per day (15 g alcohol = 12 oz beer, 5 oz
should be considered for persons with an ongoing risk for wine, 1.5 oz 80 proof whiskey). If anti-HCV persists in the
exposure. Ongoing serological surveillance in immunocom- absence of a positive hepatitis C viral load, this suggests
petent persons is not recommended. that active infection is not present.
Postexposure prophylaxis is effective in preventing HBV Because of the significant potential sequelae of chronic
infection. In a person who has written documentation of a hepatitis C infection, expert consultation should be obtained
complete hepatitis B vaccine series and who did not receive so that the patient and primary care provider are well versed
postvaccination testing, a single vaccine booster dose should on the latest evaluation, monitoring, and treatment options.
be given with a nonoccupational known HBsAg-positive Currently, treatment with pegylated interferon with or with-
exposure source. A person who is in the process of being out select antivirals has shown clinical utility in inducing
vaccinated, but who has not completed the vaccine series, remission in some patients with chronic hepatitis C; response
should receive the appropriate dose of hepatitis B im- depends on many factors, including other health problems,
munoglobulin (HBIG) and should complete the vaccine viral genotype, and viral load. Because of the rapid advances
series. Unvaccinated persons should receive HBIG and being made in this area, the clinician and patient must be
hepatitis B vaccine as soon as possible, preferably within aware of the most up-to-date treatment options.
24 hours, after exposure. Testing for HIV, other sexually Because the hepatitis D virus is an RNA virus that can
transmitted infections, and hepatitis A and C should also be occur only concurrently in the presence of HBV, it is found
offered, and postexposure prophylaxis and immunization only in persons with acute or chronic hepatitis B. A patient
should be offered when applicable. Owing to the complexity with hepatitis B and D acute coinfection has a course of ill-
of care, intervention for a person with occupational exposure ness similar to that in a patient with only hepatitis B infection.
should be done with expert consultation in this area. If a patient with chronic hepatitis B becomes superinfected
Currently, treatment with pegylated interferon and an an- with hepatitis D virus, a fulminant or severe acute hepatitis
tiviral such as entecavir, adefovir, and lamivudine has shown often results. Prevention of hepatitis B through immunization
clinical utility in inducing remission in some patients with also prevents hepatitis D.
chronic hepatitis B. Additional options include telbivudine The presentation of viral hepatitis, most commonly with
and tenofovir. Because of the rapid advances being made acute HAV and HBV infection, usually includes malaise,
in this area, the NP and patient must be aware of the most myalgia, fatigue, nausea, and anorexia. Aversion to cigarette
up-to-date treatment options. smoke exposure is often reported. Occasionally, arthritis-
Hepatitis C infection is transmitted through the exchange like symptoms and skin rash are also noted. Mild fever
of blood and body fluids. A single-strain RNA virus causes occasionally occurs. Hepatomegaly with usually mild right
the infection. Although this is the most frequent cause of upper quadrant abdominal tenderness without rebound
blood transfusion-associated hepatitis, less than 4% of all is found in about 50% of patients, with splenomegaly in
cases of hepatitis C can be attributed to this cause. Since the about 15%. Jaundice typically occurs about 1 week after the
advent of screening of the blood supply for hepatitis C virus onset of symptoms. Jaundice is not found in most cases,
(HCV), the risk of transfusion-associated hepatitis C has however. The course of the illness is typically 2 to 3 weeks.
decreased from 10% in the early 1980s to 0.1% or less today. During this period, a gradual increase in energy, appetite,
More than 50% of cases of HCV infection are caused by in- and well-being is reported.
jection drug use with needle sharing. Other risk behaviors in- Laboratory findings common to all forms of viral hepatitis
clude tattooing, branding, piercing, or other similar practices include leukopenia with lymphocytosis. Atypical lymphocytes
4074_Ch07_153-188 20/11/14 10:46 AM Page 178
are often found. Bilirubin in the urine is usually found in the When unconjugated bilirubin is released into the circu-
absence of icterus. Hepatic enzyme elevation is universal. lation, it binds to albumin and is transported to the liver.
Serological findings help with the diagnosis of the type of hep- When unconjugated bilirubin arrives at the liver, hepato-
atitis. Knowledge of measures to prevent hepatitis or minimize cytes detach bilirubin from the albumin. It is then in a
its acquisition after exposure is important to safe, effective water-soluble form, also known as conjugated, or direct,
practice (see Table 7–6). bilirubin. Conjugated bilirubin loosely attaches to albumin
The test of liver enzymes is an evaluation of the degree and is easily detached in the kidney. The passing of small
of hepatic inflammation. Hepatic enzymes are found in amounts of conjugated bilirubin through the kidney gives
the circulation because of hepatic growth and repair. The urine its characteristic yellow color. Conjugated bilirubin
aspartate aminotransferase (AST) level increases in re- not excreted by the kidney is reabsorbed by the small in-
sponse to hepatocyte injury, as often occurs in alcohol testine and converted to urobilinogen by bacterial action
abuse, acetaminophen misuse or overdose, and quite rarely in the gut. This urobilinogen can be reabsorbed into the
the therapeutic use of HMG-CoA reductase inhibitors circulation, and excess amounts can appear in the urine.
(lipid-lowering drugs whose names have the “-statin” suf- Small amounts of urobilinogen may also be found in a fe-
fix, such as simvastatin). This enzyme is also found in cally contaminated urine sample because urobilinogen is
skeletal muscle, myocardium, brain, and kidneys in smaller normally found in the large intestine.
amounts, and so damage to these areas may also cause an When there is an excess of urinary excretion of bilirubin,
increase in AST. as found in patients with viral hepatitis, urine develops a char-
AST (formerly known as serum glutamic oxaloacetic acteristic brown color, often described by a patient as looking
transaminase [SGOT]) is a hepatic enzyme with a circula- like cola or dark tea. Also, excess bilirubin could displace
tory half-life of approximately 12 to 24 hours; levels increase drugs with a high propensity for protein (albumin) binding,
in response to hepatic damage and clear quickly after dam- increasing free drug and possibly causing drug toxicity.
age ceases. AST elevation is generally found in only about Treatment of acute viral hepatitis is largely supportive.
10% of problem drinkers. If the AST level is elevated with Corticosteroids, antiviral agents, and interferon are used oc-
normal alanine aminotransferase (ALT) level and mild casionally. Because of the seriousness of hepatitis B and C se-
macrocytosis (mean corpuscular volume 100 fL or greater, quelae and risk of the development of chronic infection,
seen in about 30% to 60% of men who drink five or more considerable research is under way to develop effective, well-
drinks per day and in women who drink three or more tolerated therapies. Chronic hepatitis B and C are potent risk
drinks per day), long-standing alcohol abuse is the likely factors for hematoma or primary hepatocellular carcinoma.
cause. Periodic monitoring for alpha-fetoprotein is often used to
ALT (formerly known as serum glutamate pyruvate look for an increase in the level that indicates hepatic tumor
transaminase [SGPT]) is more specific to the liver, having growth, usually coupled with imaging such as abdominal ul-
limited concentration in other organs. This enzyme has a trasound or CT. Consultation with a hepatitis specialist and
longer half-life, 37 to 57 hours, than AST. Elevation of ALT awareness of the latest recommendations for ongoing moni-
levels persists longer after hepatic damage has ceased. The toring are critical.
greatest elevation of this enzyme is likely seen in hepatitis
caused by infection or inflammation, with a lesser degree of D I S C U SSI O N S O U R C E S
elevation noted in the presence of alcohol abuse. When eval- Centers for Disease Control and Prevention: Hepatitis A FAQs for
uating a patient with suspected substance abuse causing he- Health Professionals. Available at www.cdc.gov/hepatitis/hav/
patic dysfunction, the NP must note the degree of AST or havfaq.htm
ALT elevation. Centers for Disease Control and Prevention: Hepatitis B Infor-
mation for Health Professionals. Available at www.cdc.gov/
An increase in bilirubin level is typically found in pa-
hepatitis/hbv
tients with viral hepatitis. Clinical jaundice is found when
the total bilirubin level exceeds 2.5 mg. Bilirubin is the
degradation product of heme, with 85% to 90% arising from IBS and IBD
hemoglobin and a smaller percentage arising from myoglo-
bin. Bilirubin is produced at a rate of about 4 mg/kg/d in 125. In a 28-year-old man who presents with a 6-month
healthy individuals. Because the rate of excretion usually history of involuntary weight loss, recurrent abdomi-
matches the rate of production, the levels remain low and nal cramping, loose stools, and anterior and posterior
stable. Reticuloendothelial cells take in haptoglobin, a pro- anal fissure, which of the following diagnoses should
tein that binds with hemoglobin from aged red blood cells be considered?
(RBCs). The reticuloendothelial cells remove the iron from A. ulcerative colitis
hemoglobin for recycling. The remaining substances are B. Crohn’s disease
degraded to bilirubin in its unconjugated, or indirect, form. C. C. difficile colitis
This form is not water soluble. D. condyloma acuminata
4074_Ch07_153-188 20/11/14 10:46 AM Page 179
126. Which of the following patient complaints should be 132. Concerning IBS, which of the following statements is
evaluated further in making a differential of irritable most accurate?
bowel syndrome (IBS)? A. Patients most often report chronic diarrhea as the
A. a 52-year-old female with a first degree family most distressing part of the problems.
history of colorectal cancer, recent constipation, B. Weight gain is often reported.
and abdominal pain C. Patients can present with bowel issues ranging
B. a middle-aged adult with low albumin and from diarrhea to constipation.
leukocytosis D. The condition is associated with a strongly
C. both patients outlined in responses A and B increased risk of colorectal cancer.
D. a 16-year-old female with chronic, alternating
133. An example of a medication with prokinetic
constipation and diarrhea when she is studying
activity is:
for high school exams and worrying about her
A. dicyclomine (Bentyl).
parents’ impending divorce
B. metoclopramide (Reglan®).
127. The pathophysiology of IBS can be best described as: C. loperamide (Imodium).
A. shares the same pathophysiology as inflammatory D. psyllium (Metamucil®).
bowel disease.
134. Diagnostic testing in IBS often reveals:
B. a patchy inflammatory process in the small bowel
A. evidence of underlying inflammation.
that most adolescents will outgrow with vigorous
B. anemia of chronic disease.
exercise and a low residue diet.
C. normal results on most testing.
C. a condition that is the result of abnormal gut
D. mucosal thickening on abdominal radiological
motor/sensory activity
imaging.
D. an overstimulation of pancreatic beta cell production.
135. Which of the following is an appropriate treatment
128. Diagnostic criteria for irritable bowel syndrome
for IBS?
include abdominal pain that is associated with all
A. high fat, low residue diet.
of the following except:
B. high fiber, low fat diet and stress modification.
A. improvement with defecation.
C. antispasmotics and loperamide for diarrhea
B. a change in frequency of stool.
predominance.
C. a change of stool form.
D. tricyclic antidepressants for constipation
D. unexplained weight loss.
predominance.
129. When considering an IBS diagnosis, the NP should be
136. The clinical indication for the use of lubiprostone
aware that:
(Amitiza®) is for:
A. diagnosis is largely based on clinical presentation
A. the treatment of constipation that is not amenable
and application of the Rome III Criteria.
to standard therapies.
B. a colonoscopy should be done routinely when the
B. intervention in intractable diarrhea.
diagnosis is suspected.
C. control of intestinal inflammation.
C. CBC, ESR, CRP and serum albumin should be the
D. the relief of intestinal spasms.
initial labs for an IBS workup.
D. once an IBS diagnosis has been confirmed, you 137. Irritable bowel syndrome is characterized by all of the
can assure the patient that treatment is generally following except:
curative. A. weight loss and malnutrition.
B. abdominal pain or discomfort (hypersensitivity) at
130. Altering the gut pain threshold in IBS is a possible
least three times per month for a 6-month period.
therapeutic outcome with the use of:
C. ltered bowel pattern in the absence of detected
A. loperamide (Imodium®).
structural abnormalities.
B. dicyclomine (Bentyl®).
D. occurs two to three times more often in women
C. bismuth subsalicylate (Pepto-Bismol®).
than men.
D. amitriptyline (Elavil®).
138. Diagnostic testing in inflammatory bowel disease
131. Tenesmus is defined as which of the following?
(IBD) often reveals:
A. rectal burning with defecation
A. evidence of underlying inflammation.
B. a sensation of incomplete bowel emptying that is
B. notation of intestinal parasites.
distressing and sometimes painful
C. normal results on most testing.
C. weight loss that accompanies many bowel diseases
D. a characteristic intraabdominal mass on radiologi-
D. appearance of frank blood in the stool
cal imaging.
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139. Laboratory evaluation during an IBD flare will reveal 148 to 158. Which of the following statements is most con-
elevated levels of all of the following except: sistent with IBD, IBS, or both conditions?
A. CRP.
148. Onset of symptoms is before age 30 to 40 years
B. SeCr.
in most cases.
C. ESR.
D. WBC. 149. The patient population is predominately female.
140. IBD is associated with all of the following types of 150. The condition is often referred to as spastic
anemia except: colon by the general population.
A. anemia of chronic disease.
151. Extraintestinal manifestations occasionally
B. iron-deficiency anemia.
include nondestructive arthritis and renal
C. megaloblastic anemia.
calculi.
D. anemia associated with acute blood loss.
152. This is a potentially life-threatening condition.
141. Which of the following best describes the hemogram
results in a person with anemia of chronic disease that 153. The etiology likely involves an autoimmune re-
often accompanies IBD? sponse to the GI tract.
A. microcytic, hypochromic
154. Patients should be advised to avoid trigger foods.
B. macrocytic, normochromic
C. normocytic, normochromic 155. Involvement can be limited to intestinal mucosa
D. hyperproliferative only, or the full thickness of the intestinal wall
can be involved.
142. IBD is a term usually used to describe:
A. ulcerative colitis and irritable bowel syndrome. 156. The etiology is considered to be an alteration in
B. C. difficile colitis and Crohn’s disease. small and large bowel motility.
C. Crohn’s disease and ulcerative colitis.
157. Potential complications include fistula formation
D. inflammatory colitis and ileitis.
and perineal disease.
143. “Skip lesions” are usually reported during
158. Potential complications include increased risk
colonoscopy in:
for colonic malignancy.
A. irritable bowel syndrome.
B. ulcerative colitis.
C. Crohn’s disease.
D. C. difficile colitis.
Answers
144. First-line therapy for Crohn’s disease or ulcerative 125. B. 137. A. 149. IBS
colitis is: 126. C. 138. A. 150. IBS
A. oral aminosalicylates. 127. C. 139. B. 151. IBD
B. parenteral corticosteroids. 128. D. 140. C. 152. IBD
C. antibiotics. 129. A. 141. C. 153. IBD
D. immune modulators. 130. D. 142. C. 154. Both
131. B. 143. C. 155. IBD
145. Immune modulators are often used for intervention in: 132. C. 144. A. 156. IBS
A. ulcerative colitis. 133. B. 145. D. 157. IBD
B. irritable bowel syndrome. 134. C. 146. B. 158. IBD
C. Crohn’s disease. 135. C. 147. A.
D. ulcerative colitis and Crohn’s disease. 136. A. 148. Both
146. After a decade of disease, a person with ulcerative co-
litis is at increased risk of malignancy involving the:
Irritable bowel syndrome (IBS) is a functional bowel disor-
A. small bowel.
der characterized by abdominal pain or discomfort and
B. large intestine.
altered bowel habits in the absence of detectable structural
C. duodenum.
abnormalities. This condition is sometimes called spastic
D. stomach.
colon, irritable colon, or nervous colon. Around the world,
147. Crohn’s disease is associated with increased risk of 10% to 20% of adults and adolescents have symptoms con-
malignancy involving the: sistent with IBS and most studies show a female predomi-
A. small bowel. nance. IBS affects all ages but most have their first symptoms
B. large intestine. before age 45. Women are diagnosed two to three times as
C. duodenum. often as men and make up 80% of the population with severe
D. stomach. IBS. IBS symptoms tend to come and go over time and often
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overlap with other functional disorders such as fibromyalgia, alternative GI diagnosis, including malignancy, becomes
headache, backache, and genitourinary symptoms. Severity more likely and should be carefully considered.
of symptoms varies and can significantly impact quality of Advances in research and science have demonstrated that
life and drive up healthcare costs. the etiology of IBS may be multifactorial, with proposed
Diagnosis of the condition is usually made via careful mechanisms involving abnormal gut motor/sensory activity,
history and clinical presentation, with a focus on excluding central neural dysfunction, psychological disturbances,
other conditions as there are no clear diagnostic markers. mucosal inflammation, stress, and luminal factors. Although
The Rome III criteria for the diagnosis of IBS require that the mood component of the disease has often been attributed
patients must have recurrent abdominal pain or discomfort to the resulting disease-induced suffering, in reality, anxiety
(uncomfortable sensation not described as pain) at least or depression or both often predate IBS onset.
3 days/month in the last 3 months associated with two or Unstimulated colonic myoelectric and motor activity
more of the following: discomfort relieved by defecation, studies have not shown consistent abnormalities in IBS.
symptom onset associated with a change in stool frequency, Patients frequently exhibit exaggerated sensory responses
or symptom onset associated with a change in stool form or to visceral stimulation. Central nervous system factors are
appearance. Abdominal pain/discomfort is highly variable strongly suggested by clinical associations of emotional
in its intensity and location. Often it is episodic and crampy, disorders and stress that affect the mid-cingulate cortex—
may be mild, or it may interfere with activities of daily living the brain region concerned with attention processes and
(ADLs). Additional symptoms usually include altered stool response selection—showing greater activation in response
frequency, form, or passage (or a combination of two or all to distal colonic stimulation. The risk of developing IBS
three), usually accompanied by mucorrhea and abdominal increases after an episode of acute gastroenteritis. Addition-
bloating or the sensation of distention or both. Malnutrition ally, a high prevalence of small intestinal bacterial over-
is rare and sleep deprivation is infrequent except for those growth detected by positive lactulose hydrogen breath
with severe IBS; nocturnal pain is a poor discriminator of testing has been seen. Probiotic use is an emerging treat-
organic versus functional bowel disease. Bleeding is not a ment option that likely helps to normalize the possibly
feature of IBS unless hemorrhoids are present. Malabsorp- altered gut flora. A small subset of IBS-D patients also have
tion and weight loss does not occur. elevated serotonin (5HT)-containing enterochromaffin cells
People with IBS often present with one of four typical in the colon as a contributing factor to their disease.
bowel patterns: Due to the nonspecific GI symptoms of IBS, several other
• IBS, diarrhea prominent (IBS-D): small volumes of loose diagnoses must be considered, including inflammatory
stools, volumes less than 200 ml without nocturnal diar- bowel disease (IBD), colonic neoplasia, Celiac disease, lactase
rhea. Is often aggravated by emotional stress or eating, deficiency, endometriosis, depression and anxiety, sexual
with passage of large amounts of mucous, and physical abuse, and small bowel bacterial overgrowth.
• IBS, constipation predominant (IBS-C): can be first On physical presentation, a person with IBS usually has ten-
episodic then become intractable to laxatives with hard, derness in the sigmoid region; the remainder of the exami-
narrowed stool caliber and a sense of incomplete evacua- nation is usually normal. Diagnostic testing is not required
tion for weeks or months interrupted with brief periods initially in patients whose symptoms are compatible with
of diarrhea, IBS. However, further tests are warranted in those who do
• IBS, diarrhea and constipation alternating (IBS-A): even- not improve in 2 to 4 weeks of empiric therapy. Laboratory
tually one becoming more predominant or a mixed stool analysis is usually directed at ruling out another cause for
pattern, the condition and typically reveals a normal hemogram, a
• IBS, mixed diarrhea and constipation (IBS-M). normal erythrocyte sedimentation rate, and a negative test
Also, gut dysfunction occurs along a continuum, with for fecal occult blood. Glucose or lactulose breath tests are
most patients moving from type to type. Usually the patient used to rule out small bowel bacterial overgrowth. Stool
reports that these symptoms have been present for many analysis for ova, parasite, enteric pathogens, leukocytes, and
years before care was sought. Patients frequently complain Clostridium difficile toxin are negative. If imaging studies,
of abdominal distension, increased belching or flatulence, such as GI barium study, ultrasound, or abdominal CT or
which they contribute to increased gas. Most IBS patients endoscopy, are indicated by clinical presentation, the results
have normal amounts of intestinal gas, but have impaired are usually normal. Referral to a gastroenterology specialist
transit and tolerance to the intestinal gas loads. Belching may should be considered, particularly if the diagnosis is in ques-
be explained by reflux gas from the distal to more proximal tion; a gastroenterology specialist also can provide input to
intestine. Approximately 25% to 50% of patients complain the treatment plan.
of upper GI symptoms, including dyspepsia, heartburn, nau- Intervention in IBS involves patient support and education
sea, and vomiting. about the nature of the condition, including information that
Women are diagnosed with the condition more often. life expectancy is not affected, the condition is usually chronic
Most individuals with the condition have onset of symptoms with periodic exacerbations, and stress is a common trigger.
before age 35 years, often reporting problems since child- Nutritional intervention can be helpful, with adequate hydra-
hood. Although IBS onset can occur after age 40 years, an tion, addition of dietary fiber (at least 25 to 35 grams daily with
4074_Ch07_153-188 20/11/14 10:46 AM Page 182
at least four to six glasses of water), avoidance of trigger foods, GI tract. This condition has a genetic component; whether
and moderation of caffeine intake often reported as being this is a predisposition or susceptibility is unclear. The
helpful. Common triggers to aggravate IBS symptoms include two major types of IBD are ulcerative colitis (UC), in which
coffee, disaccharides, legumes, cabbage, a high carbohydrate the pathological changes are limited to the colon, and Crohn’s
diet, and excessive fructose and artificial sweeteners, such as disease, in which the changes can involve any part of the GI
sorbitol or mannitol. Fiber supplementation is often helpful tract. In contrast to IBS, the male-to-female ratio is approxi-
with diarrhea and constipation; polycarbophil-based prod- mately equal for UC and Crohn’s disease. Similar to IBS, IBD
ucts, such as FiberCon®, offer a potential advantage over is most often diagnosed in late adolescence to early adult-
psyllium by causing less flatulence. Although some patients hood, with most individuals who develop the disease showing
report improvement with avoidance of lactose or fructose, symptoms by their late 20s. Less commonly, new-onset IBD
others do not. is diagnosed in a child or adult.
Intervention with medications is usually aimed at treating The diagnosis of IBD is usually made through a combina-
the predominant symptom (Table 7–7). Loperamide (Imod- tion of careful health history, physical examination, and ap-
ium) and anticholinergics/antispasmodics such as dicy- propriate diagnostic investigations, including radiography,
clomine (Bentyl) are prescribed to treat diarrhea; the use of endoscopy, and biopsy. The manifestations of IBD generally
these medications can result in constipation. Low-dose tri- depend on the area of the intestinal tract involved. Patients
cyclic antidepressant or selective serotonin reuptake inhibitor with UC or Crohn’s disease frequently have bloody diarrhea,
use can be helpful in altering the gut pain threshold, resulting occasionally with tenesmus. Patients with Crohn’s disease in-
in less abdominal pain; the anticholinergic effects of the tri- volving the small intestine frequently have abdominal pain,
cyclic antidepressants can help with limiting stool frequency, involuntary weight loss, diarrhea, and occasionally they have
but also worsen constipation. Prokinetic or promotility agents symptoms of intestinal obstruction. The presence of anterior
have been used for patients with constipation-dominant and posterior anal fissures should raise suspicion for Crohn’s
symptoms. Because of safety issues, many of these products disease. A cobblestone mucosal pattern is often identified on
have significant use limitations; some have been withdrawn endoscopy or contrast radiography in Crohn’s disease. “Skip
from the market. Other prokinetics, such as metoclopramide lesions,” areas of affected mucosal tissue alternating with nor-
(Reglan) and erythromycin, have not yielded consistent ben- mal tissue, are common; the rectum is often spared with the
efits in patients with IBS. Lubiprostone (Amitiza), approved terminal ileum and right colon involved in most cases. In UC,
for the treatment of constipation that is not amenable to stan- inflammation is limited to the mucosa, whereas in Crohn’s
dard therapies, promotes fluid secretion into the intestinal disease, the entire intestinal wall is involved.
lumen and is a helpful option in constipation-dominant IBS. During an IBD flare, serological markers of inflammation,
Inflammatory bowel disease (IBD) is a disease of unclear including C-reactive protein (CRP) and erythrocyte sedimen-
etiology, but likely involves an autoimmune response to the tation rate (ESR or sed rate) are usually elevated. Leukocytosis
is often present. In Crohn’s disease, fistulas and perianal dis-
ease are often noted. Toxic colitis, characterized by nonob-
structive colonic dilation with signs of systemic toxicity, can
TABLE 7-7 occur as a potentially life-threatening complication of either
Treatment Medication Classifications condition; this condition is usually infectious in origin, with
C. difficile often implicated.
for IBD Anemia is a common problem in IBD; its etiology is often
ANTISPASMODICS (ANTICHOLINERGIC) AGENTS: from multiple causes. Iron-deficiency anemia, manifesting
Dicyclomine, hyoscyamine, methscopolamine as a microcytic, hypochromic anemia, occurs as a result of
chronic blood loss. Anemia of chronic disease, a normocytic,
ANTIDIARRHEAL AGENTS: normochromic anemia, is a result of inflammation of IBD,
Loperamide whereas anemia associated with acute blood loss can occur
OSMOTIC LAXATIVES: as a result of GI hemorrhage during a flare. Vitamin B12
Miralax® deficiency, manifesting as a macrocytic, normochromic
Milk of magnesia anemia, can also result in Crohn’s disease, usually in the
Lubiprostone presence of significant terminal ileum disease. Because of the
difficulty with micronutrient absorption, including iron and
TRICYCLIC AND RELATED ANTIDEPRESSANTS (NOT vitamin B12, with Crohn’s disease, parenteral replacement
RECOMMENDED WITH PATIENTS WITH PREDOMINANT therapy is often preferred over the oral route. Additional ex-
CONSTIPATION): traintestinal manifestations in IBD include a nondestructive
Nortriptyline, desipramine, or imipramine axial or peripheral arthritis in 15% of cases. Renal calculi are
SEROTONIN REUPTAKE INHIBITORS (NOT RECOMMENDED often found with Crohn’s disease.
FOR PATIENTS WITH PREDOMINANT DIARRHEA): The care for a person with IBD is usually a combination
Sertraline, Fluoxetine, Citalopram, Paroxetine of lifestyle support, medication, and occasionally surgery. A
person with IBD should be counseled to keep track of dietary
4074_Ch07_153-188 20/11/14 10:46 AM Page 183
triggers. Lactose intolerance is common in Crohn’s disease, individuals with UC. Additional biologicals approved for
but no more common than in the general population in the treatment of IBD include adalimumab (Humira®, mon-
people with UC. Tobacco use is associated with greater oclonal antibody against TNF-α), certolizumab (Cimzia®,
Crohn’s disease, but not UC, activity. Smoking cessation monoclonal antibody against TNF-α), and natalizumab
should be encouraged for this and its numerous additional (Tysabri®, monoclonal antibody against alpha-4 integrin).
health benefits. Gut rest is often used during treatment of Other immune modulators such as methotrexate and
Crohn’s disease, but not UC flares. Although IBD is likely cyclosporine have been used with some success. Probiotic
genetic, not psychological, in origin, mental health and social therapy is an emerging option, used to help normalize gut
support are important treatment components as the patient flora.
and family cope with this chronic, life-altering, and poten- The course of IBD is quite variable. A person with UC
tially life-threatening disease. has approximately a 50% chance of having a flare in 2 years
Medication therapy in IBD is usually initiated at the time after achieving disease remission; this number is lower,
of a flare, often the most common point of disease diagnosis. about 40%, for a person with Crohn’s disease. With UC, col-
In Crohn’s disease and UC, oral aminosalicylates, including orectal cancer risk is greatly increased after about a decade of
sulfasalazine (Azulfidine®) and mesalamine (Apriso®), are disease; as a result, surveillance colonoscopy is recommended
usually the first-line therapy and are equally effective. every 2 years after 8 to 10 years of disease. In contrast, with
Mesalamine is usually better tolerated and can be used in the Crohn’s disease, there is an increased risk for small bowel
presence of sulfa allergy. In UC, when disease is limited to malignancy. At present, no effective screening is available for
the distal colon, mesalamine and corticosteroids can be ad- IBD. Given the complexities in diagnosis and treatment for
ministered rectally. Oral or parenteral corticosteroid use can a person with IBD, expert consultation should be sought.
provide rapid symptom relief because of potent anti-inflam- Table 7–8 compares IBS and IBD.
matory effects. In Crohn’s disease, metronidazole and
D I S C U SSI O N S O U R C E S
ciprofloxacin are used when perineal disease or an inflam-
matory mass is noted; antibiotic use in UC is discouraged Lehrer J, Lichtenstein G. http://emedicine.medscape.com/article/
180389, eMedicine: Irritable bowel syndrome
because of the increased risk of C. difficile infection. Immune
Rowe W. Inflammatory bowel disease. http://emedicine.medscape.
modulators including 6-mercaptopurine and azathioprine com/article/179037, eMedicine
are often prescribed to provide long-term disease control. A Harrison’s Principles of Internal Medicine, 18th Edition Textbook.
monoclonal antibody against tumor necrosis factor-alpha, Accessed from: www.harrisonsim.com.
infliximab (Remicade®), is also a potentially helpful, although Quick Answers to Medical Diagnosis and Treatment: Lange Medical
costly, treatment option, assisting in remission in about Books. Accessed from: www.accessmedicine.com/content.aspx?
80% of individuals with Crohn’s disease and about 50% of aID=3267440&searchStr=irritable+bowel+syndrome.
TABLE 7-8
Irritable Bowel Syndrome (IBS) versus Inflammatory Bowel Disease (IBD)
WHAT THESE HAVE IN COMMON: HISTORY
Chronically recurring symptoms of abdominal pain, discomfort (urgency and bloating), and alterations in bowel habits
WHAT ARE THEIR DIFFERENCES?
IBS IBD (Ulcerative Colitis, Crohn’s Disease)
No detectable structural abnormalities Intestinal ulceration, inflammation
Absence of rectal bleeding, fever, weight loss, • Crohn’s: Mouth to anus
elevated CRP, ESR • UC: Colon only
Intervention Rectal bleeding, diarrhea, fever, weight loss, elevated CRP,
• Lifestyle modification such as diet, fiber, fluids, exercise ESR, leukocytosis, especially during flares
• Medications as indicated by symptoms (antidiarrheals Intervention
or promotility agents) • Lifestyle modification such as diet, fluids, exercise
• Immune modulators
• Anti-inflammatory medications as indicated by clinical
presentation and response
• Surgical intervention often needed and careful ongoing
monitoring for gastrointestinal malignancy
TABLE 7-9
Radiation Doses from Common Imaging Studies*
Equivalent Period of
Test Dose (mSv) Background Radiation
Chest x-ray (standard two views) 0.06–0.1 8–12 days
Abdomen x-ray 0.5–0.7 62–88 days
Abdomen and pelvis CT* 10.0 3 years
Virtual colonoscopy 10.2 3 years
Whole-body PET/low dose CT 8.5–10.3 3 years
Whole-body PET/full dose CT 23.7–26.4 8–9 years
Abdominal ultrasound No ionizing radiation exposure Not applicable
Abdominal MRI No ionizing radiation exposure Not applicable
*The ionizing radiation doses mentioned here represent an average for the study.
Source: Coakley F, Gould R, Yeh B, Arenson R. CT Radiation Dose: What Can You Do Right Now in Your
Practice? www.ajronline.org/content/196/3/619.full.pdf+html
4074_Ch07_153-188 20/11/14 10:46 AM Page 186
171. Ms. Lane, a 38-year-old woman with a long-standing 177. Common signs and symptoms of a pancreatic
history of alcohol abuse, presents with a 4-day history pseudocyst include all of the following except:
of a midabdominal ache that radiates through to the A. abdominal pain that radiates to the back.
back, remains relatively constant, and has been accom- B. nausea and vomiting.
panied by nausea and three episodes of vomiting. She C. jaundice.
has tried taking antacids without relief. Her skin is D. a mass that can be felt in the upper abdomen.
cool and moist with a blood pressure of 90/72 mm Hg,
178. Which of the following diagnostic tests is most effec-
pulse rate of 120 bpm, and respiratory rate of 24/min.
tive in determining if a pseudocyst is benign?
Findings that would support a diagnosis of acute pan-
A. CT scan
creatitis include all of the following except:
B. MRI scan
A. elevated serum amylase level.
C. analysis of cyst fluid
B. elevated lipase level.
D. serum amylase and lipase levels
C. jaundice.
D. upper abdominal tenderness without localization 179. A 56-year-old man with a history of colon cancer
or rebound. undergoes a follow-up abdominal MRI scan. A
small mass is identified on the pancreas that is later
172. Your next best action in caring for Ms. Lane in the
diagnosed as a benign pseudocyst. The pseudocyst
previous question is to:
is not causing any symptoms and measures 8 mm
A. refer to the acute care hospital for admission.
in diameter. You consider:
B. attempt office hydration after administration of
A. repeating the scan in 1 year to check for any
an analgesic agent.
changes.
C. initiate therapy with ranitidine (Zantac) and an
B. draining the pseudocyst.
antacid.
C. surgical removal of the pseudocyst.
D. obtain serum electrolyte levels.
D. initiating a regimen of antiinflammatory medica-
173. Other than the pancreas, other sources of amylase tion to decrease the size of the pseudocyst.
include all of the following except:
180. Risk factors for pancreatic cancer include all of the
A. salivary glands.
following except:
B. lung cancer.
A. hypertension.
C. ovarian cyst.
B. history of chronic pancreatitis.
D. adipose tissue.
C. tobacco use.
174. Elevated lipase levels can be a result of all of the D. diabetes mellitus.
following conditions except:
181. In assessing a person with suspected pancreatic
A. hepatic failure.
cancer, the nurse practitioner anticipates which
B. renal failure.
of the following findings?
C. perforated duodenal ulcer.
A. palpable midline abdominal mass
D. bowel obstruction or infarction.
B. midepigastric pain that radiates to the midback or
175. Which of the following statements is true when lower back region
evaluating a patient with acute pancreatitis? C. presence of Cullen sign
A. Diagnosis can be made by clinical assessment D. positive obturator and psoas signs
alone.
182. All of the following laboratory findings are expected
B. The pancreas can be clearly visualized by abdominal
in a patient with pancreatic cancer except:
ultrasound.
A. elevated total bilirubin.
C. Measuring serum lipase level along with amylase
B. diminished platelet count.
level increases diagnostic specificity in acute
C. elevated alkaline phosphatase.
pancreatitis.
D. elevated direct bilirubin.
D. Hypocalcemia is a nearly universal finding.
183. The clinical presentation of pancreatic cancer involv-
176. When using the Ranson criteria to evaluate the
ing the head of the pancreas usually includes:
severity of acute pancreatitis, a severe clinical course
A. painless jaundice.
is predicted with a score of:
B. polycythemia.
A. less than 2.
C. hematuria.
B. 3 or greater.
D. hyperkalemia.
C. 6 or greater.
D. 8 or greater.
4074_Ch07_153-188 20/11/14 10:46 AM Page 187
184. Which of the following is least likely to be found in a duodenal ulcer and other surgical abdominal emergencies,
person with pancreatic cancer? concurrently measuring serum lipase level increases diag-
A. history of chronic pancreatitis nostic specificity (Table 7–10). If amylase and lipase levels
B. lesion identified on abdominal CT are initially three times the upper limit of normal and
C. normocytic, normochromic anemia gut perforation and infarction have been ruled out, these
D. elevation of amylase level lab values clinch the diagnosis of pancreatitis. Abdominal
ultrasound can assist in diagnosing contributing gallbladder
disease; this study does not typically help with diagnosing
Answers acute or chronic pancreatitis because of limited views of
the organ. Abdominal computed tomography (CT) scan
170. A. 175. C. 180. A. usually provides a diagnostic view of the inflamed pancreas.
171. C. 176. B. 181. B. Guidelines from the American College of Gastroenterology
172. A. 177. C. 182. B. state that at least two of the following three criteria should
173. D. 178. C. 183. A. be present to diagnose acute pancreatitis: 1) characteristic
174. A. 179. A. 184. D. (severe) abdominal pain; 2) serum amylase and/or lipase
exceeding 3 times the upper limit of normal; and/or 3) char-
Pancreatitis, characterized by an acute or chronic inflam- acteristic abdominal imaging findings. With expert consul-
mation of the organ, is a potentially life-threatening con- tation, additional studies are occasionally obtained if the
dition. The most common risks for pancreatitis are biliary diagnosis is unclear.
tract disease including gallstones (45%), excessive alcohol Significant pain and volume constriction are common in
use (35%), and elevated triglyceride levels and idiopathic patients with acute pancreatitis. Intervention includes par-
causes (20% combined). Although alcohol abuse is com- enteral hydration and analgesia and gut rest. Treatment of
monly thought of as being one of the most common con- the underlying cause, such as gallbladder disease or hyper-
tributing factors for the disease, a small percentage of triglyceridemia, or discontinuation of the causative agent,
people who are problem drinkers develop the condition; such as alcohol, corticosteroids, or thiazide diuretics, is
likely the etiology of pancreatitis is multifactorial. Binge also indicated. The clinical course of pancreatitis can range
drinkers are at risk; most alcohol-related acute pancreatitis from a self-limiting condition to life-threatening illness. The
occurs in people with a minimum of 5 to 7 years of heavy Ranson criteria (Table 7–11) are usually used in assessing
ethanol ingestion, with binge drinkers having much lower severity of pancreatitis. When three or more criteria are
risk. Less common risk factors are use of opioids, corticos- found on clinical presentation, a severe clinical course can be
teroid use, and thiazide diuretics, viral infection, and blunt predicted with significant risk for pancreatic necrosis.
abdominal trauma. Persons with pancreatic cancer most commonly present
In a patient with acute pancreatitis, serum amylase level with abdominal pain, weight loss, anorexia, nausea, and vom-
is typically elevated. Because elevated amylase level is often iting. The pain is generally abrupt in onset, steady, boring,
found in many other conditions, including perforated and severe, often made worse with walking and lying supine
TABLE 7-10
Lipase and Amylase Evaluation in Acute Pancreatitis
Amylase Lipase
• In pancreatitis • In pancreatitis
• Appears 2–12 hr after symptom onset • Appears 4–8 hr after symptom onset
• Back to normal within 7 days of pancreatitis resolution • Peaks at 24 hr, decreases 8–14 days after pancreatitis
resolution
• Amylase level >1000 U/L
• 80% cholelithiasis diagnosis
• 6% alcoholic pancreatitis diagnosis
• Nonpancreatic amylase sources • Nonpancreatic reasons for elevated lipase
• Salivary glands • Renal failure
• Ovarian cysts • Perforated duodenal ulcer
• Ovarian tumors • Bowel obstruction
• Tubo-ovarian abscess • Bowel infarction
• Ruptured ectopic pregnancy
• Lung cancer
4074_Ch07_153-188 20/11/14 10:46 AM Page 188
TABLE 7-11
Ranson Criteria of Severity of Acute Pancreatitis
Development of the Following Within First 48 Hours
At Time of Patient Presentation Indicative of Worsening Prognosis
Age >55 years Hematocrit decrease >10%
WBC >16,000 mm3 Arterial PO2 <60 mm Hg
Blood glucose >200 mg/dL (>11.1 mol/L) Serum Ca++ <8 mg/dL
AST >250 U/L Base deficit >4 mEq/L
LDH >350 IU/L Estimate fluid sequestration of >6 L
BUN increase >5 mg/dL over admission value
NO. CRITERIA MORTALITY RATE PER RANSON CRITERIA
0–2 1%
3–4 15%
5–6 40%
>6 100%
and improved with sitting and leaning forward. Nausea and Pseudocysts that are not causing any signs or symptoms
vomiting are typically present. Weakness, sweating, and anx- can be left alone but monitored. Cysts smaller than 10 mm
iety are often present in severe attacks. There may be a history can be imaged by CT scan after 1 year and then less frequently
of alcohol ingestion or a heavy meal immediately preceding if they remain stable. Cysts larger than 10 mm usually require
the attack. The upper abdomen is usually tender without an endoscopic ultrasound to search for features of concern. A
guarding, rigidity or guarding with abdominal distension and pseudocyst that is causing bothersome symptoms or growing
absence of bowel sounds if ileus is present. Fever (38.4°C to larger must be drained. This is usually performed via endo-
39.0°C [101.1°F to 102.2°F]), tachycardia, hypotension (even scopic ultrasound-guided fine needle aspiration. Surgery may
shock), pallor, cool, clammy skin, and mild jaundice may be be needed to remove an enlarged pseudocyst.
noted. Occasionally, an upper abdominal mass is palpable Pancreatic cancer has high mortality rates because clinical
due to an inflamed pancreas or the presence of a pancreatic presentation usually occurs with late disease and the spread of
pseudocyst. Acute renal injury may be seen in the early course the cancer. Risk factors for pancreatic cancer include a history
of acute pancreatitis. In addition, when the disease involves of chronic pancreatitis, tobacco use, and DM. About 5% of the
the head of the pancreas, jaundice is often present, but usually time, a genetic factor contributes to the disease. About 40% of
without localized right upper quadrant abdominal tenderness cases occur sporadically with no identifiable risk factors.
seen in hepatic and biliary disorders such as cholecystitis and Abdominal CT scan is helpful in identifying pancreatic
acute hepatitis. cancer. The usefulness of abdominal ultrasound is limited by
Pancreatic pseudocysts consist of benign pockets of fluid the presence of intestinal gas. Normochromic, normocytic
lined with scar or inflammatory tissue. Though pseudocysts anemia is a common finding, as is elevated total and direct
are often asymptomatic, signs and symptoms can include bilirubin and alkaline phosphatase. An elevation in amylase
persistent abdominal pain that may radiate to the back, a is an uncommon finding, unless concomitant pancreatitis is
mass that can be felt in the upper abdomen, and nausea and present.
vomiting. A ruptured pseudocyst can be life-threatening as
fluid released can damage nearby blood vessels and cause D I S C U SSI O N S O U R C E S
massive bleeding. In addition, infection can occur in the ab- Erickson R, Larson C, Shabahang C. eMedicine. Pancreatic cancer.
dominal cavity. Often, pancreatic pseudocysts are identified http://emedicine.medscape.com/article/280605,
during abdominal scans for other medical issues. MRI and Gardner TB, Katz J, Berk BS. Acute pancreatitis. http://emedicine.
CT scans are used to help differentiate a pseudocyst from can- medscape.com/article/181364-overview,
Papadakis MA, McPhee SJ, Rabow MW. Current Medical Diagnosis
cer, but may require additional testing for a conclusive diag-
& Treatment 2013, 52nd ed. The McGraw-Hill Companies,
nosis. Fluid collected from the pseudocyst can be used to test Inc., 2013.
for signs of cancer.
4074_Ch08_189-206 20/11/14 10:50 AM Page 189
Male Genitourinary
System 8
Benign Prostatic 5. A 78-year-old man presents with a 3-day history of
new-onset fatigue and difficulty with bladder emptying.
Hyperplasia Examination reveals a distended bladder but is otherwise
unremarkable. Blood urea nitrogen level is 88 mg/dL
1. Which of the following is inconsistent with the descrip- (31.4 mmol/L); creatinine level is 2.8 mg/dL (247.5 μmol/L).
tion of benign prostatic hyperplasia (BPH)? The most likely diagnosis is:
A. obliterated median sulcus A. prerenal azotemia.
B. size larger than 2.5 cm × 3 cm B. acute glomerulonephritis.
C. sensation of incomplete emptying C. tubular necrosis.
D. boggy gland D. postrenal azotemia.
2. When prescribing antihypertensive therapy for a man 6. Surgical intervention in BPH should be considered with
with BPH and hypertension, the NP considers that: all of the following except:
A. loop diuretics are the treatment of choice. A. recurrent urinary tract infection.
B. an alpha1 antagonist should not be used as a solo B. bladder stones.
or first-line therapeutic agent. C. persistent obstruction despite medical therapy.
C. angiotensin receptor antagonist use is contraindicated. D. acute tubular necrosis.
D. beta-adrenergic antagonist use often enhances
urinary flow. 7. Finasteride (Proscar, Propecia) and dutasteride (Avodart)
are helpful in the treatment of BPH because of their
3. When assessing a 78-year-old man with suspected BPH, effect on:
the NP considers that: A. bladder contractility.
A. prostate size does not correlate well with severity of B. prostate size.
symptoms. C. activity at select bladder receptor sites.
B. BPH affects less than 50% of men of this age. D. bladder pressure.
C. he is at increased risk for prostate cancer.
D. limiting fluids is a helpful method of relieving severe 8. Tamsulosin (Flomax) is helpful in the treatment of BPH
symptoms. because of its effect on:
A. bladder contractility.
4. Which of the following medications can contribute to B. prostate size.
the development of acute urinary retention in an older C. activity at select bladder receptor sites.
man with BPH? D. bladder pressure.
A. amitriptyline
B. loratadine See full color images of this topic
C. enalapril on DavisPlus at
D. lorazepam http://davisplus.fadavis.com |
Keyword: Fitzgerald
189
4074_Ch08_189-206 20/11/14 10:50 AM Page 190
9. Concerning BPH, which of the following statements apparently small on digital rectal examination can cause sig-
is true? nificant symptoms. The use of a validated tool such as the
A. Digital rectal examination is accurate in diagnosing American Urological Association Symptom Score for Benign
the condition. Prostatic Hyperplasia (available at http://www.auanet.org/
B. The use of a validated patient symptom tool is an common/pdf/education/clinical-guidance/Benign-Prostatic-
important part of diagnosing the condition. Hyperplasia.pdf [see Appendix 6 of document]) increases the
C. Prostate size directly correlates with symptoms and likelihood of an accurate diagnosis. Other tests can be used
bladder emptying. to rule out infection or other conditions that can cause similar
D. Bladder distention is usually present in early disease. symptoms. These include a urinalysis (to assess for presence
of blood, leukocytes, bacteria, protein, or glucose), and/or
10. Concerning herbal and nutritional therapies for BPH
urine culture. Additional diagnostic procedures used to con-
treatment, which of the following statements is false?
firm that an enlarged prostate is causing the symptoms
A. The mechanism of action of the most effective and
include urinary flow test, postvoid residual volume test, tran-
best studied products is similar to prescription med-
srectal ultrasound, and a prostate biopsy. A systematic eval-
ications for this condition.
uation for prostate cancer must be done on any man who
B. These therapies are currently considered emerging
has an abnormal prostate examination with or without
therapy by the American Urological Association.
urinary symptoms.
C. Major areas of concern with use of these therapies
BPH can lead to bladder outlet obstruction from ure-
include issues of product purity and quality control.
thral narrowing. As a result, men with BPH develop symp-
D. These therapies are safest and most effective when
toms of increased frequency of urination, decreased force
used with prescription medications.
of urinary stream, nocturia, and the sensation of incom-
plete emptying. Other symptoms can include urinary
urgency, hesitancy (i.e., difficulty initiating the urinary
Answers stream; interrupted, weak stream), and a need to strain
or push to initiate or maintain urination to more fully
1. D. 5. D. 9. B. empty the bladder. Prolonged obstruction can lead to hy-
2. B. 6. D. 10. D. dronephrosis and compromised renal function; this is the
3. A. 7. B. etiology of postrenal azotemia, a potentially life-threatening
4. A. 8. C. condition. Postrenal azotemia accounts for about 5% of
all renal failure. It is characterized by urea nitrogen and
Benign prostatic hyperplasia (BPH) is a common disorder creatinine elevation and evidence of urinary retention and
in older men. Based on autopsy studies, the prevalence of outflow tract obstruction; other reasons for renal failure
BPH increases from approximately 8% in men 31 to 40 years have been ruled out. Intervention in postrenal azotemia is
old to approximately 50% in men 51 to 60 years old and to focused on relieving the urinary outflow tract obstruction.
more than 80% in men 80 years old and older. Far fewer men When postrenal azotemia is promptly detected, renal func-
have clinically symptomatic disease. This enlargement of the tion returns to baseline after treatment.
prostate, not associated with or a precursor to malignancy, Patient education about BPH should include informa-
can lead to bladder outlet obstruction, likely as a result of an tion on measures to avoid making symptoms worse. Drugs
enlargement in prostatic connective tissue and an increase with anticholinergic effect, such as tricyclic antidepressants
in the number of epithelial and smooth muscle cells. To and first-generation antihistamines (e.g., diphenhydramine
empty the bladder effectively in the face of increasing [Benadryl], chlorpheniramine [Chlor-Trimeton]), can cause
outflow tract obstruction, bladder detrusor hypertrophy oc- acute urinary retention in men with BPH; opioid use and in-
curs with occasional notation of subsequent diverticula. activity also increase the risk of urinary retention. In addi-
Chronic incomplete bladder emptying causes stasis and pre- tion, urinary frequency occasionally becomes worse with
disposes to calculus formation and infection with secondary ingestion of certain bladder irritants, such as caffeine, alco-
inflammatory changes, including prostatitis and urinary hol, and artificial sweeteners. Although men with BPH are
tract infection. The cause of BPH is not fully understood, often tempted to limit fluid intake to minimize urinary fre-
but it seems to be at least partly a response to androgenic quency, this can yield more concentrated and perhaps irri-
hormones. tating urine, possibly leading to increased symptoms.
Diagnosis of BPH is based on numerous components of The prostate and bladder base contain numerous alpha1
the evaluation. Digital rectal examination (DRE) is an integral receptor sites. When these receptor sites are stimulated, the
part of the evaluation where prostate size and contour can be prostate contracts, increasing outflow tract obstruction. As
assessed, nodules can be evaluated, and areas suggestive of a result, treatment with alpha1 receptor antagonists (alpha
malignancy can be detected. On rectal examination, the blockers) including tamsulosin (Flomax) can be helpful in
prostate usually is enlarged, has a rubbery consistency, and improving the symptoms of BPH. The use of alpha blockers
in many cases has lost the median sulcus or furrow. DRE of as a solo or first-line antihypertensive agent has been asso-
prostate size is often misleading, however; a prostate that is ciated with higher than expected rates of stroke and heart
4074_Ch08_189-206 20/11/14 10:50 AM Page 191
failure. Alpha blockers should be considered as a desirable 13. The causative organism of chancroid is:
agent in treating a man with hypertension and BPH but A. Ureaplasma species.
only as medication added on to existing therapy; an alpha B. Chlamydia trachomatis.
blocker that is specifically indicated for BPH therapy only, C. Mycoplasma hominis.
such as tamsulosin, has minimal effect on blood pressure. D. Haemophilus ducreyi.
The use of finasteride (Proscar) and dutasteride (Avodart),
14. Treatment options for chancroid include all of the
5-alpha-reductase inhibitors that block the conversion of
following except:
testosterone to dihydrotestosterone, helps to reduce the size
A. azithromycin.
of the prostate and ameliorate symptoms. Tadalafil (Cialis),
B. ciprofloxacin.
a phosphodiesterase inhibitor, is also approved for the treat-
C. ceftriaxone.
ment of BPH. However, this agent cannot be used in com-
D. amoxicillin.
bination with alpha blockers or with patients taking nitrates.
Surgical intervention in BPH should be considered when 15. When ordering laboratory tests to confirm chancroid,
medication and lifestyle modification therapy is ineffective the NP considers that:
and any of the following are present and clearly secondary to A. concomitant infection with herpes simplex is
the condition: recurrent urinary tract infection, recurrent or often found.
persistent gross hematuria, bladder stones, or renal insuffi- B. a disease-specific serum test is available.
ciency. Surgeries can include transurethral resection of the C. a white blood cell count with differential is
prostate or open prostatectomy. A number of minimally in- indicated.
vasive therapies, including thermal and laser interventions, D. dark-field examination is needed.
are now available and offer an attractive alternative to more
aggressive surgery, although less is known about long-term
outcomes. Answers
Herbal and nutritional therapies, including saw palmetto,
rye, and pumpkin, are considered emerging therapies by 11. B. 13. D. 15. A.
the American Urological Association, pending further study. 12. C. 14. D.
The observed effect of these plant-based therapies is usually
attributed to a mechanism of action similar to approved pre-
scription BPH therapies. As with other herbal and nutritional The gram-negative bacillus Haemophilus ducreyi causes
therapies available over-the-counter (OTC), issues of product chancroid. The organism is most often contracted sexually
purity and strength and potential interaction with prescrip- (Table 8–1). Transmission to healthcare providers and other
tion and other OTC products remain a concern. caregivers through direct contact with chancroid lesions has
also been documented. The chancroid lesion is typically
DI SCUSSION SOURCES found at the site of inoculation with a vesicular-form to pus-
Deters LA, Costabile RA, Leveillee RJ, et al. Benign prostatic hyper- tular-form lesion that creates a painful, soft ulcer with a
trophy. http://emedicine.medscape.com/article/437359-overview necrotic base. Multiple lesions, acquired through autoinoc-
McVary KT, Roehrborn CG, Avins AL, et al. American Urological ulation, usually are found. A dense, matted lymphadenopa-
Association Guideline: Management of benign prostatic hyper- thy can be found on the ipsilateral side of the lesion. The
plasia. http://www.auanet.org/education/guidelines/benign- affected nodes often spontaneously rupture. A definitive
prostatic-hyperplasia.cfm diagnosis of chancroid involves identification of H. ducreyi
on special culture media. However, diagnosis of the condi-
tion can be challenging because cultures often fail to reveal
Chancroid the offending organism (sensitivity is <80%). Although
not FDA approved, polymerase chain reaction testing is
11. You examine a 32-year-old man with chancroid and
100% sensitive; drawbacks include the expense of the test.
anticipate finding:
Treatment options include azithromycin, ciprofloxacin, and
A. a verruciform lesion.
ceftriaxone.
B. a painful ulcer.
As with all sexually transmitted infections (STIs), a crit-
C. a painless, crater-like lesion.
ical part of care is discussion of preventive strategies, in-
D. a plaquelike lesion.
cluding using condoms and limiting the number of sexual
12. All of the following are typical findings for a patient partners. NPs should offer and encourage testing for other
with chancroid except: STIs, including HIV, hepatitis B, and syphilis. Considera-
A. multiple lesions. tion should also be given to offering testing for hepatitis C
B. spontaneous rupture of affected nodes. and human herpesvirus type 2 (herpes simplex type 2). Im-
C. blood-tinged penile discharge. munization that provides protection against hepatitis A,
D. dense, matted lymphadenopathy on the ipsilateral hepatitis B, and HPV should be offered as needed and
side of the lesion. appropriate.
4074_Ch08_189-206 20/11/14 10:50 AM Page 192
TABLE 8-1
Sexually Transmitted Male Genitourinary Infections
Conditions Causative Organism Clinical Presentation Treatment Options
Chancroid H. ducreyi Painful genital ulcer, Primary: Azithromycin 1 g orally
multiple lesions common, in a single dose, or ceftriaxone
inguinal lymphadenitis. 250 mg intramuscularly (IM) in
a single dose.
Alternative: Ciprofloxacin
500 mg orally twice a day for
3 days, or erythromycin base
500 mg orally three times a day
×7 days.
Genital herpes Human herpesvirus 2 Common to be asympto- For primary infection (initial
(HHV-2) (also known as matic or have atypical episode): Acyclovir (Zovirax®)
herpes simplex type 2) symptoms; subclinical, 400 mg PO tid ×7–10 days or
less common by HHV-1 asymptomatic transmis- acyclovir 200 mg PO five times
(also known as herpes sion common. Classic per day for 7–10 days or
simplex type 1) presentation with famciclovir (Famvir®) 250 mg
painful ulcerated lesions, PO tid ×7–10 days or valacy-
lymphadenopathy with clovir (Valtrex®) 1 g PO bid
initial lesions. ×7–10 days.
For episodic recurrent infection:
Acyclovir 800 mg tid ×2 days
or 400 mg tid ×5 days or
800 mg bid ×5 days or famci-
clovir 1000 mg bid ×1 day or
125 mg bid ×5 days or 500 mg
once followed by 250 mg bid
×2 days or valacyclovir 1 g
PO qd ×5 days or 500 mg
bid ×3 days.
For suppression of recurrent
infection: Acyclovir 400 mg
PO bid or famciclovir 250 mg
PO bid or valacyclovir 1g PO qd.
For patient with ≤9 recurrences
per year, another treatment
option: Valacyclovir 500 mg
qd with an increase to 1 g qd
if breakthrough.
Lymphogranuloma Invasive serovar L1, L2, Vesicular or ulcerative Primary therapy: Doxycycline
venereum L3 of C. trachomatis lesion on external 100 mg PO bid ×21 days.
genitalia with inguinal Alternative therapy: Erythromy-
lymphadenitis or buboes. cin base 500 mg qid ×21 days.
Nongonococcal Chlamydia trachomatis, Irritative voiding symp- Primary therapy: Azithromycin
urethritis Ureaplasma urealyticum, toms, occasional mucop- 1 g PO as a single dose or
Mycoplasma genitalium urulent penile discharge. doxycycline 100 mg PO bid
In women: Often without ×7 days.
symptoms. Alternative therapy: Erythromycin
Microscopic examination base 500 mg PO qid ×7 days
of discharge: Large or erythromycin ethylsuccinate
number of WBCs. 800 mg PO qid ×7 days or
ofloxacin 300 mg PO bid ×7 days
or levofloxacin 500 mg PO
qd ×7 days.
4074_Ch08_189-206 20/11/14 10:51 AM Page 193
TABLE 8-1
Sexually Transmitted Male Genitourinary Infections—cont’d
Conditions Causative Organism Clinical Presentation Treatment Options
Gonococcal N. gonorrhoeae Irritative voiding symp- Recommended therapy:
urethritis toms, occasional Combination therapy for
purulent discharge. uncomplicated infection.
Often without Single dose ceftriaxone 250 mg
symptoms in either IM plus either single dose
gender. azithromycin 1 g PO or
Microscopic examination doxycycline 100 mg PO bid
of discharge: Large ×7 days.
number of WBCs. Alternative: single dose cefixime
400 mg PO plus either single-
dose azithromycin 1 g PO
or doxycycline 100 mg PO
bid × 7 days.
Alternative therapy in the pres-
ence of severe beta-lactam
allergy: Azithromycin 2 g PO
as a single dose.
Genital warts Human papillomavirus, Verruca-form lesions, Location of lesion can guide
(condyloma most commonly can be subclinical or choice of treatment. Patient-
acuminata) HPV-6 or HPV-11, unrecognized. applied therapy: Podofilox
causing genital warts. 0.5% solution or gel or
(HPV-16, -18, -31, -33 imiquimod 5% cream or
are most commonly sinecatechins 15% ointment.
associated with GU Provider-applied therapy:
malignancies. Infection Liquid nitrogen or cryoprobe,
with multiple HPV trichloroacetic acid or
types is common.) bichloroacetic acid (80%–90%),
podophyllin resin (10%–25%
in a compound tincture of
benzoin), or surgical removal.
Balanitis Candida (40%), Group B Occurs in about 1/4 of all Oral azole therapy: Single dose
(inflammation streptococcus, male sex partners of of metronidazole 2 g PO or sin-
of glans of Gardnerella women with Candida gle dose of fluconazole 150 mg
penis) vaginitis. Can also occur PO or itraconazole 200 mg PO
in presence of immuno- bid ×1 day.
suppression systemic
antimicrobial use, or DM.
Trichomoniasis Trichomonas vaginalis Males without symptoms, Oral metronidazole 2 g or
treatment usually trig- tinidazole 2 g as a one-time
gered by female part- dose.
ner’s diagnosis. Alternative therapy: Oral
metronidazole 500 mg bid
×7 days.
Patients should be advised to
avoid consuming alcohol dur-
ing treatment with oral
metronidazole or tinidazole.
Abstinence from alcohol use
should continue for 24 hours
after completion of metronida-
zole or 72 hours after
completion of tinidazole.
Continued
4074_Ch08_189-206 20/11/14 10:51 AM Page 194
TABLE 8-1
Sexually Transmitted Male Genitourinary Infections—cont’d
Conditions Causative Organism Clinical Presentation Treatment Options
Syphilis Treponema pallidum Primary stage: Chancre, Antimicrobial therapy, with
a firm, round, painless dose and length of therapy
genital and/or anal usually dictated by disease
ulcer(s) with clean base stage. Options include in-
and indurated margins, jectable penicillin (preferred),
accompanied by localized tetracycline or doxycycline
lymphadenopathy, used with beta-lactam
~3 weeks duration, re- allergy.
solve without therapy.
Secondary stage: Nonpru-
ritic skin rash, often in-
volving palms and soles,
as well as mucous mem-
brane lesions. Fever,
lymphadenopathy,
sore throat, patchy hair
loss, headaches, weight
loss, muscle aches,
and fatigue commonly
reported. Resolution
without treatment
possible.
Latent stage: Presentation
variable occurs when
primary and secondary
symptoms have resolved.
Sources: Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS. The Sanford Guide to Antimicrobial
Therapy, ed. 44th. Sperryville, VA: Antimicrobial Therapy, Inc., 2014, pp. 23–27.
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR
59(No. RR-12):1–116, 2010.
19. Treatment options for lymphogranuloma venereum 22. A likely causative pathogens in a 25-year-old man with
include: acute epididymitis who has sex with men is:
A. doxycycline. A. Escherichia coli.
B. penicillin. B. Mycoplasma spp.
C. ceftriaxone. C. Chlamydia trachomatis.
D. dapsone. D. Acinetobacter baumannii.
23. Which of the following is a reasonable treatment option
for a 30-year-old man with acute epididymitis who
Answers presents without gastrointestinal upset and will be
16. B. 17. B. 18. B. 19. A. treated as an outpatient?
A. doxycycline with ceftriaxone
B. amoxicillin with clavulanate
Lymphogranuloma venereum is an STI caused by Chlamy-
C. metronidazole with linezolid
dia trachomatis types L1 to L3. The clinical presentation,
D. clindamycin with cefixime
usually occurring approximately 1 to 4 weeks after contact
with an infected host, consists of a vesicular or ulcerative 24. Appropriate treatment of acute epididymitis for a
lesion on the external genitalia, often not noted by the 32-year-old man who has sex with other men is:
patient, which progresses to cause inguinal lymphadenitis A. ceftriaxone.
or buboes. These can fuse and then drain, forming multiple B. azithromycin.
sinus tracts with resultant scarring. Polymerase chain C. levofloxacin.
reaction assays have been used to aid in the diagnosis but D. TMP-SMX.
have had availability limited to reference laboratories.
25-30. Indicate whether each finding would be present in
Treatment options include doxycycline and erythromycin
acute epididymitis (yes or no).
(see Table 8–1).
As with all STIs, a critical part of care is discussion of 25. irritative voiding symptoms
preventive strategies, including using condoms and limiting
26. penile discharge
the number of sexual partners. NPs should offer and en-
courage testing for other STIs, including HIV, hepatitis B, 27. ulcerative lesion
and syphilis. Consideration should also be given to offering
28. scrotal swelling
testing for hepatitis C and human herpes type 2 (herpes
simplex type 2). Immunization that provides protection 29. boggy prostate
against hepatitis A, hepatitis B, and HPV should be offered
30. epididymoorchitis in later stages of disease
as needed and appropriate.
DI SCUSSION SOURCES
Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF, Saag
Answers
MS. The Sanford Guide to Antimicrobial Therapy, ed. 44th.
20. A. 24. C. 28. yes
Sperryville, VA: Antimicrobial Therapy, Inc., 23–27, 2014.
Centers for Disease Control and Prevention. Sexually transmitted
21. C. 25. yes 29. no
diseases treatment guidelines, 2010. MMWR 59(No. RR-12):1–116, 22. A. 26. yes 30. yes
2010. 23. A. 27. no
are often found. As the disease progresses, the ipsilateral testis culture. A fluoroquinolone such as ciprofloxacin is likely to
may become involved, swelling so that the two testes cannot be effective. In men who have sex with other men and likely
be distinguished; this is known as epididymo-orchitis. infected with an enteric organism, recommended treatment
Treatment options differ according to age and risk factors. is oral levofloxacin or ofloxacin.
In younger men with low risk for epididymo-orchitis as a As with all STIs, a critical part of care is discussion of pre-
complication of urinary tract infection, particularly with risk ventive strategies, including using condoms and limiting the
for STI, antimicrobials effective against gonorrhea and number of sexual partners. NPs should offer and encour-
chlamydia such as ceftriaxone followed by doxycycline age testing for other STIs, including HIV, hepatitis B, and
should be used (Table 8–2). In men at risk for epididymo- syphilis. Consideration should also be given to offering test-
orchitis as a complication of urinary tract infection, the ing for hepatitis C and human herpes type 2 (herpes simplex
choice of antimicrobial agent should be directed by urine type 2). Immunization that provides protection against
TABLE 8-2
Assessment and Treatment of Male Genitourinary Infections
Causative Conditions/Organism Clinical Presentation Treatment Options
Epididymitis N. gonorrhoeae, Irritative voiding symptoms, Primary: Ceftriaxone 250 mg in-
Epididymoorchitis C. trachomatis fever, and painful swelling tramuscularly (IM) as a single
Age ≤35 y.o. of epididymis and scrotum dose plus doxycycline 100 mg
bid ×10 days.
Advise scrotal elevation to help
with symptom relief.
Advise scrotal elevation to help
with symptom relief.
Epididymitis Enterobacteriaceae Irritative voiding symptoms, Primary: Ciprofloxacin 500 mg qd
Epididymoorchitis (coliforms) fever, and painful swelling or levofloxacin 750 mg qd
Age >35 y.o. or of epididymis and scrotum ×10–14 days.
insertive partner in Alternative: Intravenous ampicillin
anal intercourse with sulbactam, third-generation
cephalosporin, other parenteral
agents as indicated by severity of
illness.
Acute bacterial N. gonorrhoeae, Irritative voiding symptoms, Primary: One-time dose of ceftri-
prostatitis C. trachomatis suprapubic, perineal pain, axone 250 mg IM or cefixime
(≤35 y.o.) fever, tender, boggy 400 mg PO, then doxycycline
prostate, leukocytosis 100 mg PO bid ×10 days.
Acute bacterial Enterobacteriaceae Irritative voiding symptoms, Levofloxacin 500–750 mg IV/PO
prostatitis (coliforms) suprapubic, perineal pain, qd or ciprofloxacin 500 mg
(age 35 y.o. or fever, tender, boggy PO bid or 400 mg IV bid
older, or men prostate, leukocytosis ×10–14 days
who have sex
with other men)
Chronic bacterial Enterobacteriaceae Irritative voiding symptoms, Ciprofloxacin 500 mg PO bid
prostatitis (coliforms) (80%), dull, poorly localized, ×4–6 weeks or levofloxacin
entero-cocci(15%), suprapubic, perineal pain 750 mg PO qd ×4 weeks.
P. aeruginosa Alternative: TMP-SMX DS 1 tab
bid ×1–3 mo.
With treatment failure, consider
prostatic stones.
Sources: Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS. The Sanford Guide to Antimicrobial
Therapy, ed. 43. Sperryville, VA: Antimicrobial Therapy, Inc., 2013, pp. 23–27.
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR
59(No. RR-12):1–116, 2010.
4074_Ch08_189-206 20/11/14 10:51 AM Page 197
hepatitis A, hepatitis B, and HPV should be offered as needed 36–39. Indicate whether each finding normally would be pres-
and appropriate. ent in gonorrheal urethritis in an otherwise well 28-year-old
man (yes or no).
DI SCUSSION SOURCES
Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF,
36. dysuria
Saag MS. The Sanford Guide to Antimicrobial Therapy, 37. milky penile discharge
ed. 44th. Sperryville, VA: Antimicrobial Therapy, Inc., 2014,
pp. 23–27. 38. scrotal swelling
Centers for Disease Control and Prevention. Sexually transmitted
39. fever
diseases treatment guidelines, 2010. MMWR 59(No. RR-12):
1–116, 2010.
Answers
Gonorrhea 31. C. 34. C. 37. yes
31. Neisseria gonorrhoeae are best described as: 32. A. 35. A. 38. no
A. gram-positive cocci. 33. A. 36. yes 39. no
B. gram-positive rods.
C. gram-negative diplococci. Gonorrhea, caused by the gram-negative diplococcus
D. gram-negative bacilli. N. gonorrhoeae, is one of the most common STIs. This
pathogen has a short incubation period, 1 to 5 days, and is
32. The preferred treatment for uncomplicated gonococcal
likely to cause infection in approximately 20% to 30% of
proctitis is:
men who have sexual contact with an infected woman and
A. ceftriaxone 250 mg IM as a single dose plus a single
approximately 60% to 80% of women who have sexual con-
dose of azithromycin 1 g po.
tact with an infected man. Male-to-male and female-to-
B. oral erythromycin 500 mg bid for 7 days.
female rates of transmission are not as well documented.
C. oral norfloxacin 400 mg bid with metronidazole
In men, presentation typically includes dysuria with a
500 mg bid for 3 days
milky, occasionally blood-tinged penile discharge. Most men
D. azithromycin 1 g po as a single dose plus single dose
are asymptomatic, however. With anal-insertive sex, rectal
of injectable doxycycline 100 mg.
infection leading to proctitis is often seen. Gonorrheal infec-
33. Which of the following is recommended by the tion is usually confirmed by amplification testing of the DNA
Centers for Disease Control and Prevention as single- present in the organism.
dose therapy for uncomplicated urethritis caused by Because the organism frequently produces beta-lactamase,
N. gonorrhoeae when an oral product is the most therapeutic agents should include those with beta-lactamase
appropriate option? stability and a cephalosporin, such as injectable ceftriaxone
A. cefixime or oral cefixime (see Table 8–1). Due to increasing rates of
B. metronidazole resistance where dual antimicrobial therapy is possibly helpful
C. azithromycin and there is the likelihood of coinfection with C. trachomatis
D. amoxicillin or other similar organisms, current guidelines recommend the
addition of either a single dose of azithromycin 1 g orally or
34. You see a 42-year-old man with uncomplicated
doxycycline 100 mg orally twice daily for 7 days. Increasing
urogenital gonorrhea. His medical records indicate
prevalence of fluoroquinolone-resistant gonococcus limits the
a severe allergic reaction to penicillin that includes
usefulness of these medications; fluoroquinolone is no longer
difficulty breathing and diffuse urticaria. You recom-
recommended for gonorrheal infection. For those with a
mend treatment with:
severe allergic reaction to cephalosporins, an alternative reg-
A. cefixime.
imen is azithromycin 2 g orally in a single dose. For those
B. levofloxacin.
treated with this alternative regimen, the patient should return
C. azithromycin.
in 1 week for a test-of-cure.
D. tigecycline.
As with all STIs, a critical part of care is discussion of pre-
35. In gonococcal infection, which of the following state- ventive strategies, including using condoms and limiting the
ments is true? number of sexual partners. NPs should offer and encourage
A. Risk of transmission from an infected woman to testing for other STIs, including HIV, hepatitis B, and
a male sexual partner is about 20% to 30% with a syphilis. Consideration should also be given to offering test-
single coital act. ing for hepatitis C and human herpes type 2 (herpes simplex
B. Most men have symptomatic infection. type 2). Immunization that provides protection against hep-
C. The incubation period is about 2 to 3 weeks. atitis A, hepatitis B, and HPV should be offered as needed
D. The organism rarely produces beta-lactamase. and appropriate.
4074_Ch08_189-206 20/11/14 10:51 AM Page 198
test. If the PSA level was <2.5 ng/mL, retesting should occur
Answers every 2 years. If the PSA was ≥2.5 ng/mL, testing should be
52. B. 55. B. 58. B. conducted annually.
53. D. 56. C. Because of its low sensitivity and specificity, transrectal ul-
54. B. 57. D. trasound should not be used as a first-line screening test for
prostate cancer. This test can be helpful, however, when cou-
pled with PSA and DRE findings and for guiding prostatic
Prostate cancer is the most common noncutaneous cancer in biopsy, the usual next step when a diagnosis of prostate can-
men in the United States. Although clinically detectable cer is considered. Pathology and disease staging guide
prostate cancer is a cause of considerable mortality and mor- prostate cancer treatment options. Watchful waiting is often
bidity, most cancers are likely occult and limited to the a reasonable option for older men with local disease.
prostate with little risk of metastasis. Prostate cancer has been
found on autopsy in two-thirds of men 80 to 89 years old. D I S C U SSI O N S O U R C E S
The average American man has a 40% lifetime risk of latent American Cancer Society. http://www.cancer.org/cancer/prostatecancer/
prostate cancer, an approximate 10% risk of clinically signifi- moreinformation/prostatecancerearlydetection/prostate-cancer-
cant disease, and an approximate 3% risk of dying of prostate early-detection-acs-recommendations, American Cancer Society
cancer; prostate cancer is the second cause of male cancer recommendations for prostate cancer early detection
death in the United States, after lung cancer. Risk factors in- American Urological Association. http://www.auanet.org/education/
clude older age, African American ancestry, a family history guidelines/prostate-cancer.cfm, Guideline for the management
of prostate cancer, and obesity. of clinically localized prostate cancer, 2007 (validity confirmed
Most cases of prostate cancer are asymptomatic unless the 2011)
disease is advanced. Consequently, a high level of vigilance
for prostate cancer is important. Although periodic digital
rectal examination (DRE) and prostate-specific antigen Testicular Torsion
(PSA) testing are advised for some men, this screening pro-
59. A 24-year-old man presents with sudden onset of
tocol has limitations in the effectiveness. The prostatic DRE
left-sided scrotal pain. He reports having intermittent
can reveal a discrete, painless lesion or area of induration in
unilateral testicular pain in the past but not as severe
the posterior lobe of the prostate but is often normal until
this current episode. Confirmation of testicular
disease is advanced. PSA is a glycoprotein produced in benign
torsion would include all of the following findings
and malignant prostate cells. Nearly two-thirds of men with
except:
PSA levels greater than 10 ng/mL (normal PSA <4 ng/mL in
A. unilateral loss of the cremasteric reflex.
an older man, <2.5 ng/mL in a younger man) have prostate
B. the affected testicle held higher in the scrotum.
cancer, whereas about 25% of men with PSA values of 4 to
C. testicular swelling.
10 ng/mL have disease, and approximately the same percent-
D. relief of pain with scrotal elevation.
age of men in the at-risk age group have evidence of prostate
cancer with a normal PSA. Correlating an abnormal prostate 60. In assessing a man with testicular torsion, the NP is
examination finding with an abnormal PSA level increases most likely to note:
the likelihood of a diagnosis of prostate cancer. PSA level can A. elevated PSA level.
also be elevated transiently in conditions other than prostate B. white blood cells reported in urinalysis.
cancer, including prostatitis or immediately after prostatic C. left testicle most often affected.
instrumentation such as cystoscopy. Levels often remain D. increased testicular blood flow by color-flow
chronically elevated in patients with BPH. Serial increases Doppler ultrasound.
even in the presence of a normal prostate examination should
61. Anticipated organ survival exceeds 85% with
be evaluated further.
testicular decompression within how many hours
The American Cancer Society recommends that a discus-
of torsion?
sion about screening should take place at age 50 for men who
A. 1
are at average risk of prostate cancer and expected to live at
B. 6
least 10 more years. For men at higher risk (such as African
C. 16
Americans and men who have a first-degree relative [father,
D. 24
brothers] diagnosed with prostate cancer at <65 years of age),
the discussion should take place at age 45 years. Men at even 62. To prevent a recurrence of testicular torsion, which
higher risk because of multiple first-degree relatives affected of the following is recommended?
at an early age should have the discussion at age 40 years. Fol- A. use of a scrotal support
lowing the discussion, those men who want to be screened B. avoidance of testicular trauma
should be tested with the PSA blood test. The DRE can also C. orchiopexy
be done as part of screening. If no cancer is detected, the fre- D. limiting the number of sexual partners
quency of future screenings depends on the result of the PSA
4074_Ch08_189-206 20/11/14 10:51 AM Page 201
Answers Answers
59. D. 60. C. 61. B. 62. C. 63. D. 64. A. 65. C.
Testicular torsion is a urological emergency caused by a twist- A varicocele is an abnormally dilated spermatic vein within
ing of the testis and spermatic cord around a vertical axis; ex- the scrotum. Typically described as a “bag of worms” lesion
perimental modeling of the event reveals that a 720-degree and most often found in the left scrotum, a varicocele is pres-
twist is needed to occlude arterial and venous blood flow and ent while the man is standing and disappears in the supine
cause the resulting testicular swelling and testicular tissue position. A decreased sperm count with an increase in abnor-
death. Findings include severe unilateral scrotal pain and mal forms is noted in about two-thirds of men with the con-
swelling, the affected testicle held high in the scrotum, absent dition. Although varicocele is considered one of the most
cremasteric reflex, and lack of pain relief with scrotal eleva- common correctable forms of male infertility, many men
tion. Approximately 50% of men presenting with torsion re- with the condition have normal fertility. Although there are
port intermittent unilateral testicular pain in the past, perhaps no apparent significant risk factors for varicocele, being over-
caused by partial, reversible torsion. The left testicle is most weight may increase the risk.
often affected. Radionuclide testicular scan and color-flow Treatment of varicocele might not be necessary unless it
Doppler ultrasound usually show reduction of blood flow. causes pain, testicular atrophy, or infertility. Varicocele repair
Prompt referral to a urological surgeon for detorsion of the involves surgery that aims to seal off the affected vein to redi-
organ and restoration of testicular blood flow is indicated. Tes- rect blood flow into normal veins. Varicocele repair can in-
ticular survival surpasses 85% if detorsion is accomplished volve open surgery, laparoscopic surgery, or percutaneous
within 6 hours. Manual manipulation of the testicle to unwind embolization (not as commonly used as surgery). A scrotal
the torsion is occasionally helpful, although surgical interven- support can be helpful for relief of discomfort associated with
tion is more common. A bilateral orchiopexy, a procedure in varicocele. The impact of varicocele repair on infertility is
which both testes are brought down and tacked lower in the unclear.
scrotum, is usually performed to avoid subsequent torsion.
D I S C U SSI O N S O U R C E
DI SCUSSION SOURCE Men’s Health. http://www.mayoclinic.com/health/Varicocele/DS00618,
Rupp T. eMedicine. http://www.emedicine.com/emerg/TOPIC573. Varicocele
HTM, Testicular torsion
Syphilis
Varicocele
66. How long after contact does the onset of clinical mani-
63. A 23-year-old man has a nontender “bag of worms” festations of syphilis typically occur?
mass within the left scrotum that disappears when he is A. less than 1 week
in the supine position. He is diagnosed with a varico- B. 1 to 3 weeks
cele. What is a risk factor that may have contributed to C. 2 to 4 weeks
this condition? D. 4 to 6 weeks
A. younger age
67. Which of the following is not representative of the
B. current cigarette smoker
presentation of primary syphilis?
C. multiple sexual partners
A. a painless ulcer
D. none of the above
B. localized lymphadenopathy
64. Which of the following is a common finding in a man C. flulike symptoms
with varicocele? D. a spontaneously healing lesion
A. lower sperm count with increased number of
68. Which of the following is representative of the
abnormal forms
presentation of secondary syphilis?
B. increased rate of testicular cancer
A. generalized rash
C. recurrent scrotal pain
B. chancre
D. BPH
C. pupillary alterations
65. Treatment options for varicocele repair include all of D. aortic regurgitation
the following except:
69. Which of the following is found in tertiary syphilis?
A. open surgery.
A. arthralgia
B. laparoscopic surgery.
B. lymphadenopathy
C. treatment with a thrombolytic agent.
C. maculopapular lesions involving the palms and soles
D. percutaneous embolization.
D. gumma
4074_Ch08_189-206 20/11/14 10:51 AM Page 202
70. Syphilis is most contagious at which of the following Caused by the spirochete Treponema pallidum, syphilis is a
times? complex, multiorgan disease. Sexual contact is the usual route
A. before onset of signs and symptoms of transmission. The initial lesion forms about 2 to 4 weeks
B. during the primary stage after contact; contagion is greatest during the secondary
C. during the secondary stage stage. Treatment is guided by the stage of disease and clinical
D. during the tertiary stage manifestation (Table 8–3).
As with all STIs, a critical part of care is discussion of
71. First-line treatment options for primary syphilis
preventive strategies, including using condoms and limiting
include:
the number of sexual partners. NPs should offer and encour-
A. penicillin.
age testing for other STIs, including HIV, hepatitis B, and
B. ciprofloxacin.
syphilis. Consideration should also be given to offering test-
C. erythromycin.
ing for hepatitis C and human herpes type 2 (herpes simplex
D. ceftriaxone.
type 2). Immunization that provides protection against hep-
atitis A, hepatitis B, and HPV should be offered as needed
and appropriate.
Answers
D I S C U SSI O N S O U R C E S
66. C. 68. A. 70. C. Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF,
67. C. 69. D. 71. A. Saag MS. The Sanford Guide to Antimicrobial Therapy, ed. 44th.
Sperryville, VA: Antimicrobial Therapy, Inc., 2014, pp. 23–27.
TABLE 8-3
Stages of Syphilis, Clinical Manifestations, and Recommended Treatment
Stage of Syphilis Clinical Manifestations Treatment Options Comment
Primary syphilis Painless genital ulcer with Recommended therapy: Azithromycin 2 g as a
clean base and indurated • Benzathine penicillin G 2.4 million U one-time dose has been
margins, localized intramuscularly (IM) as a one-time suggested, although
lymphadenopathy dose issues of emerging
Alternative therapy in penicillin allergy: resistance are
• Doxycycline 100 mg PO bid ×2 weeks concerning.
or
Ceftriaxone 1 g IM or intravenously
q24h ×8–10 days
Secondary syphilis Diffuse maculopapular Recommended therapy: Also treatment for latent
rash involving palms • Benzathine penicillin G 2.4 million U syphilis of <1 year
and soles, generalized IM as a one-time dose duration.
lymphadenopathy, Alternative therapy in penicillin allergy:
low-grade fever, • Doxycycline 100 mg PO bid ×2 weeks
malaise, arthralgias
and myalgia,
headache
Late or tertiary Gumma (granulomatous Recommended therapy: Also treatment for latent
syphilis lesions involving skin, • Benzathine penicillin G 2.4 million syphilis of >1 year or
mucous membranes, U IM ×3 weekly doses unknown duration.
bone), aortic insuffi- Alternative therapy in penicillin
ciency, aortic aneurysm, allergy:
Argyll Robertson pupil, • Doxycycline 100 mg PO bid
seizures ×4 weeks
Expert consultation advisable, especially
in the face of neurosyphilis.
Source: Sexually Transmitted Diseases Treatment Guidelines, 2010. Centers for Disease Control and Prevention
Website. http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf, accessed 8/13/13.
4074_Ch08_189-206 20/11/14 10:51 AM Page 203
Centers for Disease Control and Prevention. Sexually transmitted can be consequences of HPV infection. Not all HPV types
diseases treatment guidelines, 2010. MMWR 59(No. RR-12): are correlated with malignancy, however. HPV types with a
1–116, 2010. high-malignancy risk include types 16, 18, 31, 33, 35, 39,
and 45, whereas low malignancy risk is seen with infection
from types 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, and 81. HPV
Human types 6 and 11 most often cause genital warts.
Papillomavirus About 50% of patients have a spontaneous regression of
warts without intervention. The most common treatment
72. Sequelae of genital human papillomavirus (HPV) infec- options include podofilox, imiquimod, trichloroacetic acid,
tion in a man can include: or cryotherapy. Patient-administered therapies such as im-
A. anorectal carcinoma. iquimod (Aldara) or podofilox save on the cost and inconven-
B. low sperm count. ience of office visits. Surgical intervention and laser ablation
C. paraphimosis. are typically reserved for complicated, recalcitrant lesions.
D. Reiter syndrome. Screening for anal cancer is not routinely recommended
for men, although some experts recommend anal cancer
73. Which of the following best describes the lesions asso- screening every 1-3 years via anal Pap tests for MSM and
ciated with condyloma acuminatum? HIV-positive men. The rate of anal cancer among HIV-
A. verruciform negative MSM is 20 times higher than the general population;
B. plaquelike among HIV-positive MSM the rate is 80 times higher. Anal
C. vesicular Pap tests can also be considered for women with a history
D. bullous of anogenital HPV infection, anal-receptive intercourse, mul-
74. Treatment options for patients with condyloma acumi- tiple sexual partners, and a history of sexually transmitted
natum include all of the following except: disease or anal condyloma.
A. imiquimod. Primary prevention of HPV disease is now available
B. podofilox. through immunization. As with all STIs, a critical part of care
C. topical acyclovir. is discussion of preventive strategies, including using con-
D. cryotherapy. doms and limiting the number of sexual partners. NPs should
offer and encourage testing for other STIs, including HIV,
75. Which HPV types are most likely to cause anorectal hepatitis B, and syphilis. Consideration should also be given
carcinoma? to offering testing for hepatitis C and human herpes type 2
A. 1 and 3 (herpes simplex type 2). Immunization that provides protec-
B. 6 and 11 tion against hepatitis A, hepatitis B, and HPV should be
C. 16 and 18 offered as needed and appropriate.
D. 72 and 81
D I S C U SSI O N S O U R C E S
76. Which HPV types are most likely to cause condyloma
Gilbert D, Moellering RC, Eliopoulos GM, Chambers HF, Saag MS.
acuminatum?
The Sanford Guide to Antimicrobial Therapy, ed. 44th. Sperryville,
A. 1, 2, and 3 VA: Antimicrobial Therapy, Inc., 2014, pp. 23–27.
B. 6 and 11 Centers for Disease Control and Prevention. Sexually transmitted
C. 16 and 19 diseases treatment guidelines, 2010. MMWR 59(No. RR-12):
D. 22 and 24 1–116, 2010.
77. Routine anal Pap tests can be considered for all of the
following patient populations except: Genital Herpes
A. men with HIV.
B. men who have sex with men (MSM). 78. What approximately what percentage of sexually active
C. women with a history of anogenital HPV infection. adults has serological evidence of human herpesvirus 2
D. all males under age 25 years. (HHV-2 or herpes simplex type 2)?
A. 5
B. 15
Answers C. 25
D. 40
72. A. 74. C. 76. B.
73. A. 75. C. 77. D. 79. All of the following are likely reported in a man with an
initial episode of genital HSV-2 (HHV-2) infection except:
Condyloma acuminatum, the verruciform lesion seen in gen- A. painful ulcer.
ital warts, is an STI. The causative agent is human papillo- B. inguinal lymphadenopathy.
mavirus (HPV), and multiple HPV types are usually seen C. fever and body aches.
with genital infection. Anal, penile, and cervical carcinoma D. pustular lesions.
4074_Ch08_189-206 20/11/14 10:51 AM Page 204
80. In the person with HSV-2 infection, the virus can the virus occurs on 10% of days, even in the absence of any
spread via contact through which of the following signs or symptoms. Transmission most commonly occurs
methods? More than one can apply. from an infected partner who does not have a visible sore and
A. genital secretions. may not know that he or she is infected.
B. oral secretions. Diagnosis can be performed through direct (virologic)
C. intact skin. or indirect (serologic) testing. Viral culture is the standard
for diagnosing genital herpes, which requires a collection
of a sample from a lesion. PCR can also be used to test for
81. During asymptomatic HSV-2 infection, genital shed-
the presence of viral DNA or RNA and can allow for more
ding of the virus occurs during approximately
rapid and accurate results. Serologic approaches can detect
________ of days.
for the presence of antibodies in the blood. In symptomatic
A. 10%
patients, the use of direct and indirect assays can differen-
B. 25%
tiate between a new infection versus a newly recognized
C. 50%
older infection. A positive virologic test with a negative
D. 100%
serologic test would suggest a new infection. Positive re-
82. Diagnostic testing of a person with primary HSV-2 in- sults for both tests would indicate a recurrent infection.
fection would likely show: Approximately 15% of the adult population in the United
A. negative virologic and serologic test results. States is seropositive for HHV-2; at the same time, only
B. negative virologic test result and positive serologic about 10-20% of the seropositive popluation have clinically
test result. evident disease in the form of genital herpes.
C. positive virologic test result and negative serologic Although there is no curative treatment for herpes,
test result. antiviral therapy for recurrent outbreaks can be given as
D. positive virologic and serologic test results. suppression therapy to reduce the frequency of recurrences
or episodically to shorten the duration of lesions. Treatment
83. Treatment options for HSV-2 genital infection include:
with an antiviral such as acyclovir, famciclovir, or valacy-
A. ribavirin.
clovir for acute infection, recurrence, or suppression is
B. indinavir.
highly effective. Suppressive therapy reduces the frequency
C. famciclovir.
of genital herpes recurrences by 70%–80% in those who
D. cyclosporine.
have frequent recurrences. Treatment is also effective in
84. Suppressive therapy reduces the frequency of genital those who have less frequent recurrences. Suppression ther-
herpes recurrences by: apy also has the advantage of decreasing the risk for viral
A. 5%–10%. transmission to susceptible partners.
B. 20%–25%. As with all STIs, a critical part of care is discussion of
C. 40%–50%. preventive strategies, including using condoms and limiting
D. 70%–80%. the number of sexual partners. NPs should offer and en-
courage testing for other STIs, including HIV, hepatitis B,
and syphilis. Consideration should also be given to offering
Answers testing for hepatitis C. Immunization that provides protec-
tion against hepatitis A, hepatitis B, and HPV should be
78. B. 81. A. 84. D. offered as needed and appropriate.
79. D. 82. C.
80. A, B, C 83. C. D I S C U SSI O N S O U R C E S
2010 Sexually Transmitted Diseases Surveillance. Centers for
Disease Control and Prevention Website. http://www.cdc.gov/
Genital herpes is a result of infection with a HHV (human std/stats10/other.htm#herpes
herpesvirus, also known as herpes simplex virus [HSV]). Genital Herpes—CDC Fact Sheet. Centers for Disease Control and
Most often, HSV-2 is the causative organism; HSV-1, the Prevention Website. http://www.cdc.gov/std/herpes/STDFact-
virus form that causes cold sores (herpes labialis), is rarely Herpes.htm
implicated. HSV-2 can infect the perioral area, however.
The clinical presentation usually includes a painful ulcer-
ated genital lesion, often accompanied by inguinal lym- Erectile Dysfunction
phadenopathy. An initial outbreak can also be associated
with flulike symptoms, including fever, body aches, and 85. Which of the following is not a common risk factor for
swollen glands. erectile dysfunction (ED)?
HSV-2 can be spread through contact with lesions, mu- A. diabetes mellitus
cosal surfaces, genital secretions, or oral secretions. The virus B. hypertension
can also be shed from skin that is intact and appears normal. C. cigarette smoking
In those with asymptomatic infections, genital shedding of D. testosterone deficiency
4074_Ch08_189-206 20/11/14 10:51 AM Page 205
86. Patient education about the use of sildenafil (Viagra) kidney disease, chronic alcohol abuse, vascular disease, to-
includes the following: bacco use, neuropathy, and urological surgery such as radical
A. A spontaneous erection occurs about 1 hour after prostatectomy are implicated in at least 70% of cases of ED.
taking the medication. Certain medications, such as antihypertensives, antidepres-
B. This medication helps regain erectile function in sants, and cimetidine, can produce ED as an adverse effect.
nearly all men who use it. The presence of a mood disorder significantly contributes to
C. With the use of the medication, sexual stimulation the risk of ED. Hormonal disorders, particularly testosterone
also is needed to achieve an erection. deficiency, pose a significant but uncommon ED risk.
D. Nitrates can be safely used concurrently. The incidence of ED increases with age; it is found in
about 5% of 40-year-old men and 15% to 25% of 65-year-old
87. When discussing ED with a 70-year-old man, the NP
men. ED should not be thought to be an inevitable conse-
considers that:
quence of aging, however. Although most ED in older men
A. it is a normal consequence of aging.
has a physical cause, such as disease, injury, or adverse effects
B. most cases have an underlying contributing cause.
of drugs, treatment can often help the patient regain satisfac-
C. although depression is common in older men, it is
tory sexual function.
usually not correlated with increased rates of ED.
Intervention in ED starts with treating or minimizing the
D. treatment options for younger men are seldom
underlying cause. With currently available therapies, effective
effective in older men.
treatment can be provided for most men with ED. Medica-
88. Which of the following medications for ED treatment tions such as the phosphodiesterase-5 (PDE-5) inhibitors,
has the longest half-life? sildenafil, vardenafil, avanafil, and tadalafil, work by enhanc-
A. sildenafil (Viagra) ing the effects of nitric oxide, a chemical that relaxes smooth
B. tadalafil (Cialis) muscles in the penis during sexual stimulation and allows in-
C. vardenafil (Levitra) creased blood flow. Use of these agents does not trigger an
D. avanafil (Stendra) automatic erection, and they should be taken about 1 hour
before the anticipated onset of sexual activity. The half-life of
89. When taking a PDE-5 inhibitor, concomitant use of
sildenafil, avanafil vardenafil is approximately 4 to 5 hours,
which medication must be avoided?
whereas tadalafil has a longer half-life of approximately
A. statins
17 hours; as a result of its long T 1/2, tadalafil is the only
B. sulfonylurea
ED medication recommended for lower dose daily use. The
C. ACE inhibitors
concomitant use of a drug such as sildenafil with a nitrate is
D. nitrates
contraindicated because of the risk of profound hypotension;
90. For patients with erectile dysfunction who fail therapy the duration of an adverse effect of a PDE-5 inhibitor is likely
with a PDE-5 inhibitor, alternative approaches include to persist for a period related to the drug’s duration of action
all of the following except: and half-life.
A. alprostadil injection into the penis. Drugs injected directly into the penis, such as alprostadil
B. mechanical vacuum devices. (Caverject), cause vasodilation and are highly effective. An
C. insertion of a nitroglycerin pellet in the urethra. alprostadil pellet inserted into the urethra (Muse) can
D. implantation of a prosthetic device. achieve the same effect. Mechanical vacuum devices cause
erection by creating a partial vacuum, which draws blood
into the penis, engorging and expanding it. An elastic band
Answers is placed around the base of the penis to maintain the erec-
tion after the cylinder is removed and during intercourse
85. D. 87. B. 89. D. by preventing blood from flowing back into the body. This
86. C. 88. B. 90. C. mechanical method of ED treatment is particularly helpful
when other methods fail to achieve desired results. Surgical
Erectile dysfunction (ED), also known as impotency, is de- options include vessel repair to treat the underlying ED; it
fined as the repeated inability to get or keep a penile erection should be kept in mind, however, that atherosclerosis is a
firm enough for sexual intercourse. The spectrum of ED in- widespread disease, and outcomes are unpredictable. Im-
cludes the total inability to achieve erection, an inconsistent plantation of devices such as prostheses or pumps is an-
ability to do so, and a tendency to sustain only brief erections. other option, albeit with the associated risks and costs of
Achieving and sustaining a penile erection requires a precise any surgical procedure.
sequence of events that depends on healthy nervous system
function (brain, spinal column, and penile innervation), ap- D I S C U SSI O N S O U R C E S
propriate muscle response, and intact blood flow via patent Grant P, Jackson G, Baig I, Quin J. Erectile dysfunction in general
veins and arteries in and near the corpora cavernosa. Any dis- medicine. Clin Med 13:136–140, 2013.
order that causes injury to the nerves or impairs blood flow Shamloul R, Ghanem H. Erectile dysfunction. Lancet 381:153–165,
in the penis has the potential to cause ED. Diabetes mellitus, 2013.
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4074_Ch09_207-246 20/11/14 10:53 AM Page 207
Musculoskeletal
Disorders 9
Bursitis 7. First-line therapy for prepatellar bursitis should include:
A. bursal aspiration.
1. The most common cause of acute bursitis is: B. intrabursal corticosteroid injection.
A. inactivity. C. acetaminophen.
B. joint overuse. D. knee splinting.
C. fibromyalgia. 8. Clinical conditions with a presentation similar to acute
D. bacterial infection. bursitis include: (More than one option can apply.)
2. First-line treatment options for bursitis usually include: A. rheumatoid arthritis.
A. corticosteroid bursal injection. B. septic arthritis.
B. heat to area. C. joint trauma.
C. weight-bearing exercises. D. pseudogout.
D. nonsteroidal anti-inflammatory drugs (NSAIDs).
3. Patients with olecranon bursitis typically present with: Answers
A. swelling and redness over the affected area.
B. limited elbow range of motion (ROM). 1. B. 4. C. 7. A.
C. nerve impingement. 2. D. 5. A. 8. A, B, C, and D
D. destruction of the joint space. 3. A. 6. D.
4. Patients with subscapular bursitis typically present with:
A. limited shoulder ROM. The human body contains more than 150 bursa. These
B. heat over affected area. fluid-filled sacs act as a cushion between tendons and bones.
C. localized tenderness under the superomedial angle of Bursitis develops when the synovial tissue that lines the sac
the scapula. becomes thickened and produces excessive fluid, leading to
D. cervical nerve root irritation. swelling and resulting pain. The bursae are lined by synovial
tissue, which produces fluid that lubricates and reduces fric-
5. Patients with gluteus medius or deep trochanteric bursi- tion between these structures. The most commonly affected
tis typically present with: bursa are the subdeltoid, olecranon, ischial, trochanter, and
A. increased pain from resisted hip abduction. prepatellar. In contrast to most forms of arthritis, bursitis
B. limited hip ROM. typically presents with an abrupt onset with focal tenderness
C. sciatic nerve pain. and swelling. The joint range of motion (ROM) is usually
D. heat over the affected area. full but is often limited by pain (Table 9–1).
6. Likely sequelae of intrabursal corticosteroid injection include: Risk factors for acute bursitis include joint overuse,
A. irreversible skin atrophy. trauma, infection, or arthritis conditions such as rheumatoid
B. infection. arthritis or osteoarthritis. Because recurrence is common,
C. inflammatory reaction. prevention of further joint overuse and trauma should be
D. soreness at the site of injection. emphasized.
With prepatellar bursitis, bursal aspiration should be
considered as a first-line therapy because this procedure
See full color images of this topic
on DavisPlus at affords significant pain relief and allows the bursa to reap-
http://davisplus.fadavis.com | proximate. In other sites, first-line therapy includes mini-
Keyword: Fitzgerald mizing or eliminating the offending activity, applying ice
207
4074_Ch09_207-246 20/11/14 10:53 AM Page 208
TABLE 9-1
Clinical Presentation of Bursitis
Location of Bursitis Clinical Presentation Comments
Prepatellar (knee) Knee swelling and pain in the front of the Risk factors include frequent kneeling (also
knee, normal ROM known as housemaid’s knee)
Olecranon (elbow) Pain, swelling behind the elbow, swelling Risk factors include prolonged pressure or
in same area, often described as ball or trauma to the elbow (also known as drafts-
sac hanging from the elbow man’s elbow)
Trochanter (hip) Gait disturbance, local trochanter tender- Risk factors include back disease, leg-length
ness, pain on hip rotation, and resisted discrepancy, and leg problems that lead to
hip abduction with normal hip ROM altered gait
OA seldom implicated
Subscapular (shoulder) Local tenderness under superomedial Risk factors include repeated back-and-forth
angle of the scapula over the adjacent motion
rib, normal shoulder ROM, no nerve root Common in assembly-line workers
impingement
Pre-Achilles (heel) Pain and localized swelling behind the Usually not disabling and does not contribute
heel, minimal pain with dorsiflexion, to tendon rupture
normal ankle ROM Often confused with Achilles tendonitis
Retrocalcaneal (heel) Pain behind ankle worsened by walking Risk factors include wearing high-heeled
Patient often runs fingers along both sides shoes and repetitive ankle motion such as
of Achilles tendon stair-climbing, running, jogging, and walking
to the affected area for 15 minutes at least four times per 10. Risk factors for lateral epicondylitis include all of the
day, and taking nonsteroidal anti-inflammatory drugs following except:
(NSAIDs). If these conservative measures have not worked A. repetitive lifting.
after approximately 4 to 8 weeks, intrabursal corticosteroid B. playing tennis.
injection should be performed. Before injection, patients C. hammering.
should be informed of the risks of this procedure, especially D. gout.
the most common problem, soreness at the injection site.
11. Up to what percent of patients with medial epicondyli-
After corticosteroid injection, infection, tissue atrophy, and
tis recover without surgery?
inflammatory reaction are possible, but rarely encountered,
A. 35%
complications.
B. 50%
DI SCUS SION SOURCES C. 70%
Del Buono A, Franceschi F, Palumbo A, et al. Diagnosis and man-
D. 95%
agement of olecranon bursitis. Surgeon 10:297–300, 2012. 12. Initial treatment of lateral epicondylitis includes all of
Lohr K, Gellman H. Bursitis. http://emedicine.medscape.com/ the following except:
article/2145588 A. rest and activity modifications.
B. corticosteroid injections.
C. topical or oral NSAIDs,
Epicondylitis D. counterforce bracing.
9. Patients with lateral epicondylitis typically present with: 13. Extracorporeal shock-wave therapy can be used in the
A. electric-like pain elicited by tapping over the median treatment of epicondylitis as a means to:
nerve. A. improve ROM.
B. reduced joint ROM. B. build forearm strength.
C. pain that is worst with elbow flexion. C. promote the natural healing process.
D. decreased hand grip strength. D. stretch the extensor tendon.
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14. Patients with medial epicondylitis typically present (Table 9–2). Medial epicondylitis, often called golfer’s elbow,
with: is similar to lateral epicondylitis but occurs on the inside of
A. forearm numbness. the elbow.
B. reduction in ROM. Approximately 80% to 95% of patients with epicondylitis
C. pain on elbow flexion. can be successfully treated without surgery. Rest and avoid-
D. decreased grip strength. ance of the precipitating activity for up to several weeks is
the first course of treatment. NSAIDs (aspirin and ibupro-
15. Risk factors for medial epicondylitis include playing:
fen) can be used to reduce pain and inflammation. For
A. tennis.
sports-related injuries, conducting an equipment check and
B. golf.
working with an expert on proper form can reduce the risk
C. baseball.
of aggravating the injury. Physical therapy can be helpful in
D. volleyball.
strengthening muscles in the arm or performing muscle-
stimulating techniques to improve healing. For lateral epi-
condylitis, a counterforce brace centered over the back of
Answers the forearm can help relieve symptoms. Local corticosteroid
9. D. 12. B. 15. B. injection can be helpful if symptoms persist beyond 6 to 8
10. D. 13. C. weeks or are particularly severe. Extracorporeal shock-wave
11. D. 14. D. therapy can also be considered, which uses sound waves to
create microtrauma to the elbow that promotes the body’s
natural healing process. The use of a tennis elbow band can
The painful condition that arises as a result of injury to the help prevent recurrence.
extensor tendon at the lateral epicondyle is called tennis
elbow or lateral epicondylitis. Patients usually give a history D I S C U SSI O N S O U R C E
of an aggravating activity followed by forearm weakness and Lohr K, Gellman H. Bursitis, available at http://emedicine.medscape.
point to tenderness over the inner aspect of the humerus com/article/2145588.
TABLE 9-2
Clinical Presentation of Epicondylitis
Condition Presentation Comments
Medial epicondylitis Patient complains of pain over medial epi- Often called golfer’s elbow; results from
condyle or inner aspect of lower humerus. repetitive activity such as lifting, use of
Pain worsens with wrist flexion and prona- certain tool, playing sports involving a tight
tion activities. Local epicondylar tender- grip.
ness, elbow pain, forearm weakness, pain Prevent recurrence by using palm-up lifting,
aggravated by wrist flexion, and pronation using a tennis elbow band, avoiding precipi-
activities with decreased grip strength and tating causes, ensuring proper use of tools,
full ROM occur. using proper body mechanics, and develop-
ing flexibility and strength of the involved
musculature
Lateral epicondylitis Patient complains of pain over lateral epi- Often called tennis elbow; results from
condyle or outer aspect of lower humerus, repetitive activity such as lifting, use of
which increases with resisted wrist exten- certain tools, playing sports involving a
sion, especially with elbow. Hand grip is tight grip
often weak on affected side. Elbow ROM Prevent recurrence by avoiding precipitating
usually is normal. causes, ensuring proper use of tools, using
proper body mechanics, and developing of
flexibility and strength of the involved
musculature
24. The most common locations for tophi include all of the
Gouty Arthritis following except:
16. Risk factors for acute gouty arthritis include: A. the auricles.
A. obesity. B. the elbows.
B. female gender. C. the extensor surfaces of the hands.
C. rheumatoid arthritis. D. the shoulders.
D. joint trauma. 25. Dietary recommendations for a person with gouty
17. The use of all of the following medications can trigger arthritis include avoiding foods high in:
gout except: A. artificial flavors and colors.
A. aspirin. B. purine.
B. statins. C. vitamin C.
C. diuretics. D. protein.
D. niacin. 26. Which of the following dietary supplements is associated
18. Secondary gout can be caused by all of the following with increased risk for gout?
conditions except: A. vitamin A
A. psoriasis. B. gingko biloba
B. hemolytic anemia. C. brewer’s yeast
C. bacterial cellulitis. D. glucosamine
D. renal failure. 27. Pseudogout is caused by the formation of what type of
19. The clinical presentation of acute gouty arthritis affect- crystals in joints?
ing the base of the great toe includes: A. uric acid
A. slow onset of discomfort over many days. B. calcium oxalate
B. greatest swelling and pain along the median aspect C. struvite
of the joint. D. calcium pyrophosphate dihydrate
C. improvement of symptoms with joint rest. 28. Pseudogout has been linked with abnormal activity
D. fever. of the:
20. The most helpful diagnostic test to perform during A. liver.
acute gouty arthritis is: B. kidneys.
A. measurement of erythrocyte sedimentation C. parathyroid.
rate (ESR). D. adrenal gland.
B. measurement of serum uric acid. 29. Differentiation between gout and pseudogout can
C. analysis of aspirate from the affected joint. involve all of the following diagnostic approaches
D. joint radiography. except:
21. First-line therapy for treating patients with acute gouty A. analysis of minerals in the blood.
arthritis usually includes: B. analysis of joint fluid.
A. aspirin. C. x-ray of the affected joint.
B. naproxen sodium. D. measuring thyroid function.
C. allopurinol. 30. Treatment of pseudogout can include all of the follow-
D. probenecid. ing except:
22. Tophi are best described as: A. NSAIDs.
A. ulcerations originating on swollen joints. B. colchicine.
B. swollen lymph nodes. C. allopurinol.
C. abscesses with one or more openings draining pus D. oral corticosteroids.
onto the skin.
D. nontender, firm nodules located in soft tissue. Answers
23. Which of the following patients with acute gouty
arthritis is the best candidate for local corticosteroid 16. A. 21. B. 26. C.
injection? 17. B. 22. D. 27. D.
A. a 66-year-old patient with a gastric ulcer 18. C. 23. A. 28. C.
B. a 44-year-old patient taking a thiazide diuretic 19. B. 24. D. 29. C.
C. a 68-year-old patient with type 2 diabetes mellitus 20. C. 25. B. 30. C.
D. a 32-year-old patient who is a binge drinker
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Gouty arthritis, often simply called gout, manifests as acute reducing inflammation first and then treating hyperuricemia,
monoarticular arthritis, usually triggered by a disorder trying to avoid a rapid reduction in serum uric acid, which
causing a decrease of uric acid excretion that allows an can make the episode worse. A loading dose of an NSAID,
accumulation of urates in joints, bones, and subcutaneous such as 750 mg of naproxen followed by lower doses, can be
tissues. Urate precipitates out of biological fluids when helpful. Because aspirin use can precipitate gout, its use in
levels are elevated, a condition that usually follows the the presence of the condition is contraindicated. Colchicine
inability of the kidney to eliminate uric acid. About 90% of can be used but is often poorly tolerated. Suggested dosing is
patients presenting with primary gout are men; the condi- 1.2 mg initially, then 0.6 mg 1 hour later followed by 0.6 mg
tion is rarely seen in women before menopause. Gout risk once or twice daily (up to 2.4 mg total dose in 24 hours) or
factors include obesity, diabetes mellitus, and a family when gastrointestinal symptoms occur. A short course of a
history of the condition. Less often, acute gout is caused systemic corticosteroid, such as prednisone (0.5 mg/kg/day
by excessive uric acid production, usually coupled with de- for 5–10 days, or 0.5 mg/kg/day for 2–5 days, then taper for
creased urate excretion. The use of select medications, in- 7–10 days), is a helpful alternative to colchicine. Local injec-
cluding thiazide diuretics, niacin, aspirin, and cyclosporine, tion with corticosteroids can provide significant relief and
can precipitate gout by causing hyperuricemia; alcohol use offers a treatment alternative to NSAIDs, particularly in the
is also a possible precipitant. Other causes of secondary presence of warfarin use, renal failure, or peptic ulcer disease.
gout include conditions characterized by increased catab- Several medications are available to prevent gout attacks
olism and purine turnover, such as psoriasis, myeloprolif- by blocking uric acid production or improving uric acid
erative and lymphoproliferative diseases, and chronic removal. Xanthin oxidase inhibitors (XOIs), including allop-
hemolytic anemia, and conditions with decreased renal urinol (Aloprim, Lopurin, Zyloprim) or febuxostat (Uloric),
uric acid clearance, such as intrinsic kidney disease and limit the amount of uric acid the body produces. Common
renal failure. adverse effects of allopurinol include rash and low blood
This acutely painful condition typically affects the counts, whereas febuxostat is associated with rash, nausea,
metacarpophalangeal joint of the great toe. The onset is and reduced liver function. Probenecid (Probalan) improves
sudden and is accompanied by significant distress. Al- the kidney’s ability to remove uric acid from the body.
though the disease manifests acutely, the metabolic disorder Probenecid use leads to higher concentrations of uric acid in
behind the problem is typically present for months to years the urine, resulting in a greater risk of kidney stones. Other
before the clinical presentation. Patients report the inability adverse effects include rash and abdominal pain.
to walk, move the joint, or even tolerate the weight of a bed Dietary modification to avoid foods with high purine
sheet on the affected joint because of severe pain. The entire content is an important and often overlooked intervention
great toe is usually reddened and enlarged, with the greatest to minimize the risk of future gout episodes. Examples of
amount of swelling noted along the medial border of the high-purine foods include certain seafood (scallops, mus-
joint; this usually is also the point of greatest discomfort. sels), organ and game meats, beans, spinach, asparagus,
Although the clinical presentation of gout can mimic that oatmeal, and baker’s and brewer’s yeasts when taken as
of an acutely infected joint, gout is 100 times more common dietary supplements.
than monoarticular septic arthritis. With repeated episodes, After the acute flare has subsided, a 24-hour urine collec-
nontender firm nodules known as tophi can develop in soft tion for uric acid helps assess whether the patient overpro-
tissue. Because the gouty crystals that fill tophi precipitate duces or undersecretes uric acid. Long-term care to avoid
more easily in cooler areas of the body, these lesions often future attacks is directed by the result; undersecretors benefit
develop in the external ear; less common locations include from probenecid, and overproducers benefit from allopurinol
nasal cartilage, extensor surfaces of the hands and feet, and or febuxostat. Other medications not specifically designated
over the elbows. for gout treatment, including fenofibrate and losartan, have
The diagnosis of acute gouty arthritis is usually straight- been studied and found to be helpful with urate excretion and
forward, particularly with repeated episodes. With the first can be used as therapeutic adjuncts as part of a comprehen-
episode, an initial uric acid level is obtained in most cases sive uric acid–lowering strategy.
but is usually normal. Uric acid levels are often reduced dur- Pseudogout, also called calcium pyrophosphate deposition
ing the acute phase, or the etiology of the attack is largely (CPPD) disease, presents similarly to gout but is caused
poor urate excretion. Analysis of joint aspirate for urate by the presence of calcium pyrophosphate dehydrate crystals
crystals is diagnostic; the erythrocyte sedimentation rate in the joint. The knees are most commonly affected but the
(ESR) or C-reactive protein (CRP) is usually high, but these wrists and ankles also can be involved, with symptoms of
findings are neither sensitive nor specific for gout and sim- swollen, warm, and severely painful joints. Risk factors in-
ply reflect the inflammation associated with the condition. clude older age, joint trauma, family history of the condition,
Radiographs are not needed unless a concurrent history of and mineral imbalances (e.g., hemochromatosis, hypercal-
trauma and risk of fracture are present. cemia, or hypomagnesemia). Pseudogout has also been asso-
The treatment of acute gouty arthritis should include min- ciated with hypothyroidism or hyperparathyroidism.
imizing or removing contributing factors, such as alcohol use Proper diagnosis of pseudogout involves detecting cal-
or use of certain medications. Treatment should be aimed at cium pyrophosphate crystals in the affected joint. Blood tests
4074_Ch09_207-246 20/11/14 10:53 AM Page 212
can detect abnormal thyroid or parathyroid function and 37. Which of the following best describes the presentation
abnormal mineral levels linked to pseudogout. The goal of of a patient with OA?
treatment is primarily to relieve pain and improve joint func- A. worst symptoms in weight-bearing joints later in the
tion and includes the use of NSAIDs, colchicine, and oral day
corticosteroids. B. symmetrical early morning stiffness
C. sausage-shaped digits with associated skin lesions
DI SCUSSION SOURCES D. back pain with rest and anterior uveitis
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College
of Rheumatology guidelines for management of gout. Part 1: 38. As part of the evaluation of patients with OA, the NP
Systematic nonpharmacologic and pharmacologic therapeutic anticipates finding:
approaches to hyperuricemia. Arthritis Care Res (Hoboken) A. anemia of chronic disease.
64:1431–1446, 2012. B. elevated CRP level.
Cassagnol M, Saad M. Pharmacologic management of gout. US Phar- C. no disease-specific laboratory abnormalities.
macist 38:22–26, 2013, available at http://www.uspharmacist. D. elevated antinuclear antibody (ANA) titer.
com/content/d/feature/c/39863.
39. First-line pharmacological intervention for milder OA
should be a trial of:
Osteoarthritis A. acetaminophen.
B. tramadol.
31. Which of the following joints is most likely to be C. celecoxib.
affected by osteoarthritis (OA)? D. intraarticular corticosteroid injection.
A. wrists 40. In caring for a patient with OA of the knee, you advise
B. elbows that:
C. metacarpophalangeal joint A. straight-leg raising should be avoided.
D. distal interphalangeal joint B. heat should be applied to painful joints after
32. Changes to the joint during osteoarthritis can typically exercise.
include all of the following except: C. quadriceps-strengthening exercises should be
A. widening of the joint space. performed.
B. articular cartilage wears away. D. physical activity should be avoided.
C. formation of bone spurs. 41. The mechanism of action of glucosamine and
D. synovial membrane thickens. chondroitin is:
33. Clinical findings of the knee in a patient with OA in- A. via increased production of synovial fluid.
clude all of the following except: B. through improved cartilage repair.
A. coarse crepitus. C. via inhibition of the inflammatory response in
B. joint effusion. the joint.
C. warm joint. D. largely unknown.
D. knee often locks or a pop is heard. 42. An adverse effect associated with the use of
34. Radiographic findings of osteoarthritis of the knee glucosamine is:
often reveal: A. elevated ALT and AST.
A. microfractures. B. bronchospasm.
B. decreased density of subchondral bone. C. increased bleeding risk.
C. osteophytes. D. QT prolongation.
D. no apparent changes to the joint structure. 43. A 72-year-old man presents at an early stage of os-
35. Approximately what percent of patients with radiologi- teoarthritis in his left knee. He mentions that he heard
cal findings of osteoarthritis of the knee will report hav- about the benefits of using glucosamine and chon-
ing symptoms? droitin for treating joint problems. In consulting the
A. 25% patient, you mention all of the following except:
B. 50% A. any benefit can take at least 3 months of consistent
C. 70% use before observed.
D. 95% B. glucosamine is not associated with any drug
interactions.
36. Deformity of the proximal interphalangeal joints found C. clinical studies have consistently shown benefit of
in an elderly patient with OA is known as: long-term use of glucosamine and chondroitin for
A. Heberden nodes. treating OA of the knee.
B. Bouchard nodes. D. chondroitin should be used with caution because of
C. hallus valgus. its antiplatelet effect.
D. Dupuytren contracture.
4074_Ch09_207-246 20/11/14 10:53 AM Page 213
44. The American Academy of Orthopaedic Surgeons 50. Recommended exercises for patients with OA of the
(AAOS) favors all of the following in the management hip include all of the following except:
of symptomatic OA of the knee except: A. stretching exercises of the gluteus muscles.
A. low-impact aerobic exercises. B. straight-leg raises without weights.
B. weight loss for those with a BMI ≥25 kg/m2. C. isometric exercises of the iliopsoas and gluteus
C. acupuncture. muscles.
D. strengthening exercises. D. weight-bearing aerobic exercises.
45. AAOS strongly recommends all of the following thera-
peutic agents for the management of symptomatic OA
of the knee except:
Answers
A. oral NSAIDs. 31. D. 38. C. 45. D.
B. topical NSAIDs. 32. A. 39. A. 46. D.
C. tramadol. 33. C. 40. C. 47. D.
D. opioids. 34. C. 41. D. 48. B.
46. Among surgical and procedural interventions, 35. B. 42. B. 49. A.
AAOS strongly recommends the use of which of the 36. B. 43. C. 50. D.
following for the management of symptomatic OA 37. A. 44. C.
of the knee?
A. intraarticular corticosteroid use
Osteoarthritis (OA) is the most common joint disease in
B. hyaluronic acid injections
North America; it is a degenerative condition that manifests
C. arthroscopy with lavage and/or débridement
without systemic manifestations or acute inflammation. Al-
D. none of the above
though the distal interphalangeal joint is the most common
47. Regarding the current scientific evidence on the use of OA site, the most problematic joint involvement is in the hip
glucosamine and chondroitin for the management of and knee. Worst symptoms are reported with use of the
symptomatic OA of the knee, AAOS: joints. As a result, discomfort typically increases as the day
A. strongly favors their use. progresses, and there is minimal morning stiffness; in con-
B. provides a moderate-strength recommendation trast, with rheumatoid arthritis (RA), morning stiffness is
for their use. usually most problematic. Risk factors for OA include a pos-
C. cannot recommend for or against the use of itive family history of the condition and contact sport partic-
these supplements (limited evidence). ipation. Obesity is likely the most common personal risk
D. cannot recommend the use of these factor, especially with hip and knee involvement. In OA, the
supplements. articular cartilage becomes rough and wears away. Bone spurs
often form, and the synovial membrane thickens. Conse-
48. You see a 67-year-old woman who has been treated
quently, the joint space narrows. The clinical presentation in
for pain due to OA of the hip for the past 6 months
patients with OA includes an insidious onset of symptoms,
and who asks about hip replacement surgery. She
including use-related joint pain that is relieved by rest and
complains of pain even at night when sleeping and
joint stiffness that occurs with rest but resolves with less than
avoids walking even moderate distances unless ab-
15 minutes of activity. Physical examination usually reveals
solutely necessary. In counseling the patient, you
smooth, cool joints and coarse crepitus. Particularly when the
mention all of the following except:
knee is affected, joint effusion is common and can be minimal
A. arthroplasty can be considered when pain is not
to severe with up to 20 mL of fluid. Patients cannot achieve
adequately controlled.
full knee flexion in the effused joint. The knee often locks, or
B. arthroplasty is not needed if the patient can walk
a pop is heard, which suggests a degenerative meniscal tear.
even short distances.
Radiological findings in patients with OA include narrow-
C. arthroplasty candidates must be able to tolerate a
ing of the joint space and increased density of subchondral
long surgical procedure.
bone. Bone cysts and osteophytes are often present, devel-
D. rehabilitation following surgery is essential to
oped as part of the body’s repair process; however, only about
achieve maximal function of the joint.
50% of patients with radiological findings have symptoms.
49. Recommended exercises for patients with OA Because OA is typically a noninflammatory disease, ESR and
of the knee include all of the following except: CRP levels, both markers of inflammation, are typically nor-
A. squatting with light weights. mal. In contrast to RA and systemic lupus erythematosus
B. straight-leg raises without weights. (SLE), antinuclear antibodies (ANAs), rheumatoid factor,
C. quadriceps sets. and other markers of systemic arthritis syndromes are absent
D. limited weight-bearing aerobic exercises. from the serum unless there is concomitant disease.
4074_Ch09_207-246 20/11/14 10:53 AM Page 214
Therapeutic goals for patients with OA include prevent- as an over-the-counter nutritional supplement in the
ing further articular cartilage destruction, minimizing pain, United States. The results of research studies have differed
and enhancing mobility. Therapies for symptom control in- on the effectiveness of its use, with many reporting no im-
clude lifestyle modifications, such as weight loss and exercise provement in arthritis symptoms and others reporting a re-
with minimal weight-bearing, such as swimming or water- duction in pain, increased joint flexion, and increased
based activities, and exercise to maintain joint flexibility and articular function. If effective, glucosamine must be used
enhance strength in the surrounding muscles (Table 9–3). consistently for a minimum of 2 weeks and likely 3 months
Application of heat to minimize pain and stiffness in the before therapeutic effect is seen. Although no drug interac-
morning before activity can be helpful, and applying ice to tions or hepatotoxicity has been noted with its use,
the joint after activity can minimize discomfort; the use of glucosamine should be used with caution because there is a
heat or ice should be directed by patient response. For OA risk of bronchospasm. Chondroitin is often used in con-
of the knee, guidelines from the American Academy of Or- junction with glucosamine because the two appear to have
thopaedic Surgeons (AAOS) recommend the use of NSAIDs synergistic activity, although this has been disputed in lim-
(oral or topical) and tramadol (Ultram) for controlling pain. ited studies. The mechanism of action of these products is
Although NSAIDs also have potential anti-inflammatory not well understood. Although chondroitin is generally
activity, this mechanism of drug action is seldom needed in well tolerated, it should be used with caution because of a
OA therapy because inflammation is a minor contributor to potential anticoagulant effect. As with all nutritional sup-
symptoms. Tramadol, an opioid analgesic, is effective for plements, using a preparation that is supplied by a manu-
treating moderate to moderately severe pain. Long-term facturer with United States Pharmacopeia or other similar
use of this agent, however, can lead to physical or mental verification is advised. In particular, a 2-year study demon-
dependence and cause adverse effects when discontinued. strated no clinically significant change in pain or function
Duloxetine (Cymbalta) has also been approved for the treat- as compared with placebo over 2 years with the use of glu-
ment of chronic osteoarthritis pain. AAOS does not recom- cosamine alone or in combination with chondroitin. AAOS
mend for or against the use of acetaminophen, other opioids, does not recommend using glucosamine and chondroitin
or pain patches for managing symptomatic OA of the for patients with symptomatic OA of the knee.
knee. Because of the gastropathy potential associated with Intraarticular corticosteroid joint injection is often rec-
long-term use of NSAIDs, a trial of acetaminophen is war- ommended when conservative therapy has failed. AAOS,
ranted for symptom control in less severe cases of OA, however, does not recommend for or against the use of
recognizing that NSAIDs are usually associated with supe- intraarticular corticosteroid injections because of a lack of
rior analgesic effect. Long-acting opioids are occasionally compelling evidence comparing the benefits with risks.
required if symptom control cannot be achieved. The risks AAOS also does not recommend using hyaluronic acid in-
versus benefits of opioid analgesia need to be carefully jections for treating symptomatic OA of the knee because of
evaluated with each patient. lack of efficacy observed in clinical trials.
Glucosamine, an amino acid, is usually used as first-line Treatment of OA of the hip is similar to treating OA of
treatment for OA in many European nations and is available the knee. Resting the hip, physical therapy to strengthen the
TABLE 9-3
Exercise Regimens in Osteoarthritis
Joint Condition Exercise Regimen Comments
Osteoarthritis in the knee • Straight-leg raises without weights, advance to using Avoid squatting and
weights as tolerated kneeling, high-impact
• Quadriceps sets exercise
• Non–weight-bearing or limited weight-bearing aerobic
activity
Osteoarthritis of the hip • Straight-leg raises without weights, advance to using Avoid high-impact
weights as tolerated exercise
• Stretching exercises of adductors, rotator, and gluteus
muscles
• Isometric exercises of iliopsoas and gluteus muscles
• Non–weight-bearing or limited weight-bearing aerobic
activity
4074_Ch09_207-246 20/11/14 10:53 AM Page 215
muscles surrounding the hip, and decreasing body mass if 53. NSAIDs cause gastric injury primarily by:
overweight can be helpful. NSAIDs can be used to help man- A. direct irritative effect.
age pain. Hip injection of corticosteroids is a technically B. slowing gastrointestinal motility.
challenging procedure that can be done with fluoroscopic C. thinning of the protective gastrointestinal
guidance. For advanced stages of OA, when pain occurs even mucosa.
when resting at night, and/or the hip is severely deformed, D. enhancing prostaglandin synthesis.
arthroplasty may be considered.
54. Of the following individuals, who is at highest risk
Knee and hip joint replacement should be considered
for NSAID-induced gastropathy?
when pain cannot be adequately controlled, when function
A. a 28-year-old man with an ankle sprain who has
is severely compromised, or when more than 80% of the ar-
taken ibuprofen for the past week and who drinks
ticular cartilage is worn away. The ideal candidate for joint
four to six beers every weekend
replacement is able to tolerate a surgical procedure that lasts
B. a 40-year-old woman who smokes and takes about
for several hours, followed by an aggressive postoperative
six doses of naproxen sodium per month to control
course of rehabilitation. Many patients with OA who have
dysmenorrhea
been debilitated by poor mobility have improved health when
C. a 43-year-old man with dilated cardiomyopathy
ambulation becomes possible after hip or knee replacement.
who uses ketoprofen one to two times per week
Rehabilitation following joint replacement is critical to re-
for low back pain
store flexibility of the joint and strengthen muscles needed
D. a 72-year-old man who takes aspirin four times a
for normal functioning.
day for pain control of osteoarthritis
DI SCUSSION SOURCES 55. Which of the following is the preferred method of
Anderson B. Office Orthopedics for Primary Care: Diagnosis, ed. 1,. preventing NSAID-induced gastric ulcer?
Philadelphia: Saunders Elsevier, 2006. A. a high-dose histamine 2 receptor antagonist
Anderson B. Office Orthopedics for Primary Care: Treatment, ed. 3. B. timed antacid use
Philadelphia: Saunders Elsevier, 2006. C. sucralfate (Carafate)
Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT),
D. misoprostol (Cytotec)
available at http://nccam.nih.gov/research/results/gait.
AAOS. Treatment of osteoarthritis of the knee: Evidence-based 56. Taking a high dose of aspirin or ibuprofen
practice guidelines, ed. 2, available at http://www.aaos.org/ causes:
research/guidelines/TreatmentofOsteoarthritisoftheKneeGuide- A. an increase in the drug’s half-life.
line.pdf. B. enhanced renal excretion of the drug.
Stone L. Aches, pains and osteoarthritis. Aust Fam Physician 37:
C. a change in the drug’s mechanism of action.
912–917, 2008.
D. a reduction of antiprostaglandin effect.
57. Which of the following statements is most accurate
Rheumatoid concerning RA?
A. Joint erosions are often evident on radiographs
Arthritis or MRI.
B. RA is seldom associated with other autoimmune
51. Which of the following is not characteristic of rheuma-
diseases.
toid arthritis (RA)?
C. A butterfly-shaped facial rash is common.
A. It is more common in women at a 3:1 ratio.
D. Parvovirus B19 infection can contribute to its
B. Family history of autoimmune conditions often is
development.
reported.
C. Peak age for disease onset in individuals is age 50 to 58. Which of the following hemograms would be
70 years. expected for a 46-year-old woman with poorly
D. Wrists, ankles, and toes often are involved. controlled RA?
A. Hg = 11.1 g/dL (12–14 g/dL); MCV = 66 fL
52. Which of the following best describes the presentation
(80–96 fL); reticulocytes = 0.8% (1%–2%).
of a person with RA?
B. Hg = 10.1 g/dL (12–14 g/dL); MCV = 103 fL
A. worst symptoms in weight-bearing joints later in
(80–96 fL); reticulocytes = 1.2% (1%–2%).
the day
C. Hg = 9.7 g/dL (12–14 g/dL); MCV = 87 fL
B. symmetrical early-morning stiffness
(80–96 fL); reticulocytes = 0.8% (1%–2%).
C. sausage-shaped digits with characteristic skin
D. Hg = 11.4 g/dL (12–14 g/dL); MCV = 84 fL
lesions
(80–96 fL); reticulocytes = 2.3% (1%–2%).
D. back pain with rest and anterior uveitis
4074_Ch09_207-246 20/11/14 10:53 AM Page 216
59. X-rays will fail to show changes in affected joints in 66. A 52-year-old woman has RA. She now presents with
approximately what percent of patients with RA at decreased tearing, “gritty”-feeling eyes, and a dry
disease onset? mouth. You consider a diagnosis of:
A. 30% A. systemic lupus erythematosus.
B. 50% B. vasculitis.
C. 75% C. Sjögren syndrome.
D. 95% D. scleroderma.
60. RA disease progression is typically evaluated using all 67. Cyclooxygenase-1 (COX-1) contributes to:
of the following approaches except: A. inflammatory response.
A. x-ray. B. pain transmission.
B. MRI. C. maintenance of gastric protective mucosal layer.
C. echosonography. D. renal arteriole function.
D. ultrasound.
68. Cyclooxygenase-2 (COX-2) contributes to all of the
61. Mrs. Sanchez is a 42-year-old mother of three who re- following except:
ports pain and stiffness in multiple joints that have A. inflammatory response.
lasted for more than 6 months. She is diagnosed with B. pain transmission.
rheumatoid arthritis. She has no other clinical condi- C. maintenance of gastric protective mucosal layer.
tions of significance. You recommend which of the D. renal arteriole constriction.
following treatments for first-line therapy?
69. Which of the following special examinations should
A. topical analgesics and oral NSAIDs
be periodically obtained during hydroxychloroquine
B. methotrexate plus oral NSAIDs
sulfate use?
C. acetaminophen plus leflunomide
A. dilated eye retinal examination
D. anakinra and systemic corticosteroids
B. bone marrow biopsy
62. You see a 37-year-old man with rheumatoid arthritis C. pulmonary function tests
who has been treated with hydroxychloroquine and D. exercise tolerance test
oral NSAIDs for the past 3 months with little improve-
70. Common physical findings of SLE include all of the
ment in symptoms. Radiography indicates slight
following except:
progression of RA in several major joints. You
A. weight gain.
recommend:
B. joint pain and swelling.
A. maintaining the current regimen.
C. fatigue.
B. increasing the dose of NSAIDs.
D. facial rash.
C. adding methotrexate to his regimen.
D. switching from hydroxychloroquine to a biologic 71. All of the following diagnostic findings are expected in
agent. a patient with SLE except:
A. elevated ESR.
63. A significant adverse effect of biologic therapy for
B. anemia.
treating RA is:
C. negative ANA test.
A. myopathy.
D. proteinuria.
B. infections.
C. renal impairment. 72. First-line treatment of SLE in a patient with mild
D. elevated liver enzymes. symptoms is:
A. systemic corticosteroids.
64. Which of the following tests is most specific to the
B. hydroxychloroquine plus NSAIDs.
diagnosis of RA?
C. anakinra.
A. elevated levels of rheumatoid factor
D. methotrexate.
B. abnormally high ESR
C. leukopenia 73. All of the following agents can be considered for the
D. positive ANA titer treatment of severe cases of SLE except:
A. leflunomide.
65. A positive ANA test is a sensitive marker for the
B. azathioprine.
presence of:
C. rituximab.
A. hyperparathyroidism.
D. belimumab.
B. systemic lupus erythematosus (SLE).
C. Kawasaki disease.
D. leukocytosis.
4074_Ch09_207-246 20/11/14 10:53 AM Page 217
74. You see a 26-year-old woman who has been recently Rheumatoid arthritis (RA) is a disease that causes chronic
diagnosed with SLE and has initiated therapy to systemic inflammation, including the synovial membranes
control moderate symptoms of the disease, including of multiple joints. As with most autoimmune diseases, RA
fatigue and joint pain. She mentions that she and her is more common in women (ratio approximately 3:1);
husband are hoping to start a family soon. In coun- RA is often seen in people with other autoimmune diseases.
seling her about pregnancy, you consider that: Although new-onset RA can occur at any age, peak age at
A. there is a low probability of conception during onset is 20 to 40 years. A family history of rheumatoid
symptomatic flares of SLE. arthritis and other autoimmune diseases is often noted. Ini-
B. most treatments for SLE must be discontinued once tial presentation may be with acute polyarticular inflamma-
a woman becomes pregnant. tion. A clinical picture of slowly progressive malaise, weight
C. SLE is associated with a high risk of pregnancy loss. loss, and stiffness is more common, however. The stiffness
D. there is a higher risk of gestational diabetes in is symmetrical, is typically worst on arising, lasts about
women with SLE. 1 hour, involves at least three joint groups, and can recur
after a period of inactivity or exercise. The hands (with spar-
ing of the distal interphalangeal joints), wrists, ankles, and
Answers toes are most often involved. Soft tissue swelling or fluid is
also present, as are subcutaneous nodules. The disease is
51. C. 59. A. 67. C. characterized by periods of exacerbation and remission. A
52. B. 60. C. 68. C. set of classification criteria was developed to help identify
53. C. 61. B. 69. A. newly presenting patients with RA (Table 9–4). Although
54. D. 62. C. 70. A. in the past RA was believed to be a debilitating condition
55. D. 63. B. 71. C. with little impact on longevity, more recent research shows
56. A. 64. A. 72. B. that RA is now known potentially to shorten the life span
57. A. 65. B. 73. C. while producing considerable disability, particularly with-
58. C. 66. C. 74. C. out optimal treatment (Table 9–5).
TABLE 9-4
American College of Rheumatology/European League Against Rheumatism Classification
Criteria for Diagnosis of Rheumatoid Arthritis in Newly Presenting Patients
Criterion Score
Test patients who:
1) have at least 1 joint with definite clinical synovitis
2) have synovitis not better explained by another disease
A. Joint involvement:
1 large joint 0
2–10 large joints 1
1–3 small joints (with or without involvement of large joints) 2
4–10 small joints (with or without involvement of large joints 3
>10 joints (at least 1 small joint) 5
B. Serology (at least 1 test result is needed for classification):
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
C. Acute-phase reactants (at least 1 test result is needed for classification):
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D. Duration of symptoms:
<6 weeks 0
≥6 weeks 1
TABLE 9-5
Treatment of Rheumatoid Arthritis
Medication Examples
Antiinflammatory agents NSAIDs, COX-2 inhibitors, corticosteroids
Analgesics Oral—NSAIDs, COX-2 inhibitors, acetaminophen, opioids
Topical agents—NSAIDs, lidocaine, capsaicin, salicylates, menthol, camphor
DMARDs Traditional DMARDS—methotrexate, leflunomide, sulfasalazine, hydroxychloroquine,
minocycline, others
Biological response modifiers—
Non-TNF: abatacept, rituximab, anakinra, tocilizumab, others
Anti-TNF: infliximab, adalimumab, , etanercept, certolizumab, golimumab, others
Oral JAK inhibitors: tofacitinib
The diagnosis of RA can be made only when clinical fea- • ANAs are antibodies against cellular nuclear components
tures are supported by laboratory testing. Usually initial diag- that act as antigens. ANA is occasionally present in
nostic tests include ANA, ESR, CRP, anti-citrullinated protein healthy adults, but it is usually found in individuals with
antibody (ACPA), and rheumatoid factor (RF) measurements systemic rheumatic or collagen vascular disease. ANA is
and radiographs, with additional testing often ordered because the most sensitive laboratory marker for SLE, detected in
of diagnostic uncertainty. When interpreting results, the NP approximately 95% of patients, but it is found in only
should bear in mind the following: 30% to 50% of patients with RA. Patterns of immunoflu-
• Radiographs typically reveal joint erosion and loss of orescence vary and have been given misplaced credence
normal joint space. X-rays can help in detecting RA as to type of disease. Following are some examples of
but often do not show any signs at the early stages of ANA patterns:
disease. Classic radiographic changes are not present in • Homogeneous, diffuse, or solid pattern to DNA:
about 30% at disease onset. Musculoskeletal ultrasound High titers strongly associated with SLE
and joint magnetic resonance imaging (MRI) are helpful • Peripheral or rim pattern: Associated with anti–
in revealing RA-associated erosions and determining the double-stranded DNA and strongly correlated
severity of disease. Radiographic imaging at the early with SLE
stages of disease can be helpful in determining disease • Nucleolar pattern: Associated with antiribonucleopro-
progression. tein and strongly correlated with scleroderma or
• ESR and CRP are nonspecific tests of inflammation. In CREST syndrome
general, the higher the values, the greater the degree and • Speckled pattern: Further antigen testing should be
intensity of the inflammatory process. Although ESR and ordered with this result.
CRP are frequently elevated in patients with RA, abnor- • Cytoplasmic pattern is often found in the presence of
mal results are diagnostic of this or other conditions. In biliary cirrhosis.
addition, a single elevated ESR or CRP is seldom helpful; The goal of treatment of patients with RA is to reduce
however, following trends during flare and regression of inflammation and pain, while preserving function and pre-
disease often aids in charting the therapeutic course and venting deformity. Behavioral management is important be-
response. cause physiological and psychological stress precipitates RA
• Rheumatoid factor, an immunoglobulin M antibody, is flares. Allowing for proper rest periods is critical. Physical
present in approximately 50% to 90% of patients with therapists can help develop a reasonable activity plan. Main-
RA. The level of the titer often corresponds to the severity tenance of physical activity through appropriate exercise is
of disease. of greatest importance. Water exercise in particular is help-
• An antibody to cyclic citrullinated peptide (anti-CCP), a ful because it includes mild resistance and buoyancy. Splints
ring-form amino acid that is usually not measurable in may provide joint rest while maintaining function and pre-
health, is a more specific, although less sensitive, marker venting contracture.
of RA. As helpful as NSAIDs are in symptom control, these
• Hemogram usually reveals normocytic, normochromic, products do not alter the underlying disease process; joint
hypoproliferative anemia associated with chronic disease. destruction continues despite control of symptoms and re-
4074_Ch09_207-246 20/11/14 10:53 AM Page 219
duction in swelling. Disease-modifying antirheumatic gland biopsy for the presence of mononuclear cell infiltra-
drugs (DMARDs) help minimize the risk of joint damage tion is useful. Intervention for patients with Sjögren syn-
and disease progression and should be started as soon drome includes management of presenting symptoms with
as the diagnosis of RA is made (see Table 9–4). As the num- appropriate lubricants. Treating the underlying disease is
ber and types of DMARDs available increase, knowledge critical.
of current RA therapy is critical for providing optimal SLE is a chronic autoimmune disease that can affect any
patient care. organ system, including joints, skin, kidneys, blood cells,
If an adequate trial of a DMARD and an NSAID fails to brain, heart, and lungs. Diagnosis can be difficult because
achieve control of pain or symptoms, additional therapy signs and symptoms often mimic other conditions. Symp-
should be added. One option is intra-articular corticos- toms of SLE are highly variable and can include malar rash
teroid injection. This therapy can be quite helpful but (covering the cheeks and nasal bridge but sparing the na-
should be limited to not more than two to three injections solabial folds); fever; fatigue; headaches; weight loss; and joint
per joint per year to minimize risk of joint deterioration. pain, stiffness, and swelling. Complications associated with
Systemic corticosteroids can be most helpful in relieving in- SLE vary depending on the organ system that is affected. For
flammation, but use should not exceed 2 to 8 weeks, if pos- pregnant women, SLE is a major risk factor for miscarriage;
sible, because of adverse reactions associated with these the condition increases the risk of preeclampsia and preterm
agents. With more advanced disease or for patients who fail birth. If possible, pregnancy should be delayed until SLE is
to respond adequately to DMARDs, biologics are increas- under control for at least 6 months.
ingly being used to achieve disease remission. Biologics are Diagnosis of SLE depends on findings from multiple
now available in injection and oral formulations. However, laboratory and radiographic tests. Common findings in-
a major adverse effect of biologics is an increased risk for clude anemia, elevated ESR, proteinuria, and a positive
infection with some dormant infections (such as tubercu- ANA test. A chest x-ray may reveal inflammation in the
losis) activating once treatment begins. Vaccinations should lungs, whereas an echocardiogram will detect any changes
be considered for patients considering initiating biologic to the heart. A kidney biopsy can be used to detect damage
therapy. to these organs.
NSAIDs have been the backbone of RA drug treatment for Treatment of SLE will depend on the manifestation of the
years. These medications are helpful in controlling inflam- disease. The antimalarial drug hydroxychloroquine has been
mation and pain. Aspirin and ibuprofen are two more com- shown to be effective for the long-term treatment of SLE.
monly used products. With many of the NSAIDs, the half-life Mild disease that waxes and wanes is often controlled with
of the drug is increased as the dose is increased. oral NSAIDs. Systemic corticosteroids are used to counter
A significant amount of peptic ulcer disease, particularly the inflammation caused by SLE, although long-term use of
gastric ulcer and gastritis, is caused by NSAID use. NSAIDs these agents should be done with caution because of their
inhibit synthesis of prostaglandins from arachidonic acid, potential adverse effects. For more severe cases or those that
yielding an anti-inflammatory effect. This effect is caused do not respond to initial therapy, immune suppressants can
in part by the action of these products against cyclooxyge- be beneficial. These include cyclophosphamide (Cytoxan),
nase (COX). COX-1 is an enzyme found in gastric mucosa, azathioprine (Imuran), mycophenolate (Cellcept), lefluno-
small and large intestine mucosa, kidneys, platelets, and vas- mide (Arava), and methotrexate (Trexall). These agents
cular epithelium. This enzyme contributes to the health of are associated with increased risk of infection, liver damage,
these organs through numerous mechanisms, including the decreased fertility, and increased risk of cancer. Belimumab
maintenance of the protective gastric mucosal layer and (Benlysta), a B-lymphocyte stimulator-specific inhibitor,
proper perfusion of the kidneys. COX-2 is an enzyme that is the first biologic agent approved for adults with SLE
produces prostaglandins important in the inflammatory and may provide added benefits when added to current
cascade and pain transmission. The standard NSAIDs and treatments.
corticosteroids inhibit the synthesis of COX-1 and COX-2,
controlling pain and inflammation, but with gastric and D I S C U SSI O N S O U R C E S
renal complications. NSAIDs such as celecoxib (Celebrex) American College of Rheumatology. http://www.rheumatology.
that spare COX-1 and are more COX-2-selective afford con- org/public/factsheets/diseases_and_conditions/ra.asp?aud=pat,
trol of the potential for arthritis symptoms. The gastroin- Fact sheet on rheumatoid arthritis, update August 2012.
testinal benefit of the COX-2 inhibitors is likely attenuated Ferri, FF. Ferri’s Best Test: A Practical Guide to Laboratory Medicine
with long-term use, whereas the cardiovascular risk associ- and Diagnostic Imaging, ed. 3. Philadelphia: Mosby Elsevier,
2014.
ated with their use is increased.
Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 Amer-
Sjögren syndrome is an autoimmune disease that usually ican College of Rheumatology recommendations for the use of
occurs in conjunction with another chronic inflammatory disease-modifying antirheumatic drugs and biologic agents in
condition, such as RA or SLE. Complaints usually concern the treatment of rheumatoid arthritis. Arthritis Care Res 64:
problems related to decreased oral and ocular secretions. In 625–639, 2012.
addition, mouth ulcers and dental caries are common, and Bartels CM. Systemic lupus erythematosus (SLE). http://emedicine.
ESR is elevated in more than 90% of patients. A salivary medscape.com/article/332244-overview.
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Meniscal Tears
75. To confirm the results of a McMurray test, you ask the
patient to:
A. squat.
B. walk.
C. flex the knee.
D. rotate the ankle.
76. The most common type of injury causing a sport- Figure 9-1 McMurray’s test assesses the menisci. The medial
related meniscal tear involves: meniscus is tested with the hip flexed and the knee externally
A. twisting of the knee. rotated as the examiner moves the knee from full flexion to
B. hyperextension of the knee. extension. To test the lateral meniscus, the knee is internally
C. repetitive hard impact on the knee (i.e., running on rotated during the procedure. A snap heard or felt during
hard surface). this maneuver suggests a tear of the tested meniscus. (From
D. an unknown origin in most cases. Goolsby, Advanced Assessment, 3rd ed. Philadelphia, PA:
FA Davis; 2014.)
77. Which of the following best describes the presentation
of a patient with complete medial meniscus tear?
A. joint effusion Meniscal tears are typically classified as complex or partial;
B. heat over the knee traumatic or degenerative; lateral, posterior, horizontal, or
C. inability to kneel vertical; and radial, parrot-beak, or bucket-handle. Patients
D. loss of smooth joint movement with partial, horizontal, and anterior tears often have rela-
78. To help prevent meniscal tear, you advise: tively normal examination findings because the knee’s me-
A. limiting participation in sports. chanics are relatively unchanged even though these patients
B. quadriceps-strengthening exercises. continue to have knee locking and pain with certain posi-
C. using a knee brace. tions. The McMurray test, a palpable popping on the joint
D. applying ice to the knee before exercise. line, is highly specific but poorly sensitive for a meniscal tear;
the Apley grinding test gives similar results. Squatting or
79. Initial treatment for meniscal tear includes all of the kneeling is nearly impossible for patients with a large, com-
following except: plete, or bucket-handle meniscal tear. Joint effusion is typical,
A. NSAID use. with ROM being limited by discomfort.
B. applying ice to the affected area. Knee radiographs, which can reveal osteoarthritic changes,
C. elevation of the affected limb. foreign bodies, or other injuries, are reasonable as initial eval-
D. joint aspiration of the affected knee. uation. Because the meniscus does not contain calcium, the
structure is not visible on a plain film. MRI can identify the
type and extent of the tear and should be considered if milder
Answers symptoms do not resolve within 2 to 4 weeks or if severe
symptoms do not resolve earlier.
75. A. 77. C. 79. D.
Initial treatment includes rest, elevation, ice application,
76. A. 78. B.
and analgesia. Because joint effusion is nearly always present
but is relatively mild, aspiration should be considered only if
A meniscal tear results from a disruption of the meniscus, there is no improvement after 2 to 4 weeks of conservative
the C-shaped fibrocartilage pad located between the therapy. Crutch walking should be encouraged, and a patellar
femoral condyles and the tibial plateaus. This injury is stabilizer may be needed when significant knee instability is
often seen in athletes because of a twist-type injury to the present. Straight-leg–raising exercises help strengthen the
knee. This condition can also be found in older, sedentary quadriceps and stabilize the joint. Arthroscopy, which pro-
adults; in this case, the injury is usually because of degen- vides the most accurate diagnosis with the possibility of con-
erative changes. Because the purpose of the fibrocartilage current treatment through débridement and repair, should
pad is shock absorption and smooth joint mobility, patients be considered at 4 to 6 weeks if there is no improvement and
with larger tears often report that the knee locks, makes a earlier if joint locking, giving out, and effusion are particu-
popping sound, or “gives out.” Effusion is also common, larly problematic.
with the patient reporting a sensation of knee tightness and
stiffness. With certain positions, there is often sudden- D I S C U SSI O N S O U R C E S
onset, sharp, localized pain, usually on the medial aspect Achar S, Espinoza A. Common sports injuries. In: Rakel R, Bope E,
of the knee. Over time, premature OA is often seen as the eds. Conn’s Current Therapy 2013. Philadelphia: Saunders
normal joint space is compromised. Elsevier, 2013.
4074_Ch09_207-246 20/11/14 10:53 AM Page 221
Anderson B. Office Orthopedics for Primary Care: Diagnosis, ed. 1. 86. Acroparesthesia, frequently reported in patients with
Philadelphia: Saunders Elsevier, 2006. CTS, is best described as:
Anderson B. Office Orthopedics for Primary Care: Treatment, ed. 3. A. constant pain radiating from the elbow.
Philadelphia: Saunders Elsevier, 2006. B. a transient inability to move the fingers.
C. waking up at night with numbness and burning
pain in the fingers.
Carpal Tunnel D. muscle spasms that cause fist clenching.
Syndrome 87. Initial therapy for patients with CTS includes:
A. intra-articular injection.
80. The Phalen test is described as: B. joint splinting.
A. reproduction of symptoms with forced flexion of C. systemic corticosteroids.
the wrists. D. referral for surgery.
B. abnormal tingling when the median nerve is
tapped. 88. Patients whose CTS fails to respond to
C. pain on internal rotation. conservative treatment measures should be
D. palmar atrophy. considered for:
A. systemic corticosteroid use.
81. The Tinel test is best described as: B. low-dose opioids.
A. reproduction of symptoms with forced flexion of C. surgery.
the wrists. D. vitamin B6 injections in the carpal tunnel.
B. abnormal tingling when the median nerve is
tapped. 89. Primary prevention of CTS includes:
C. pain on internal rotation. A. screening for thyroid dysfunction.
D. palmar atrophy. B. treatment of concomitant arthritis forms.
C. stretching and toning exercises.
82. All of the following statements about electromyography D. wrist splinting.
(EMG) are true except:
A. EMG measures electrical impulses caused by
muscles. Answers
B. diagnosis of carpal tunnel syndrome involves com-
paring EMG results of the muscles at rest versus 80. A. 84. D. 88. C.
contraction. 81. B. 85. C. 89. C.
C. EMG can detect muscle damage. 82. D. 86. C.
D. EMG involves sending a small electrical impulse 83. D. 87. B.
through the muscle tissue.
83. Results of a nerve conduction study in a person with Carpal tunnel syndrome (CTS) is a painful condition caused
carpal tunnel syndrome (CTS) would reveal: by compression of the median nerve between the carpal lig-
A. erratic nerve impulses during forearm muscle ament and other structures within the carpal tunnel. This
contraction. compression leads to an entrapment neuropathy, causing
B. a lack of nerve impulses in the carpal tunnel. symptoms in the distribution of the median nerve. The re-
C. continued firing of the median nerve while the sulting symptoms are likely because of nerve ischemia rather
forearm muscles are at rest. than nerve damage.
D. a slowing of nerve impulses in the carpal tunnel. The most common risk factor is repetitive motion; the
condition is common with protracted computer keyboard use
84. Risk factors for CTS include all of the following
and in workers such as cake decorators and soldiers, who
except:
must consistently grasp a small object. CTS can also be part
A. pregnancy.
of the manifestation of a systemic disease, such as RA and
B. untreated hypothyroidism.
sarcoidosis. Primary prevention of CTS includes limiting
C. repetitive motion.
time spent in these activities, ensuring proper work breaks,
D. multiple sclerosis.
and encouraging toning and stretching exercises.
85. Which of the following is least likely to be reported by Patients with CTS, the most commonly encountered
patients with CTS? peripheral compression neuropathy, usually report a burn-
A. worst symptoms during the day ing, aching, or tingling pain radiating to the forearm in the
B. burning sensation in the affected hand distribution of the median nerve and occasionally to the
C. tingling pain that radiates to the forearm shoulder, neck, and chest. Symptoms are often worst at
D. nocturnal numbness night. A classic finding is the report of acroparesthesia,
4074_Ch09_207-246 20/11/14 10:53 AM Page 222
Sarcoidosis is an inflammatory condition that results in the inhibitors [e.g., infliximab]). Other agents include chloram-
production of noncaseating granulomas in various sites of bucil, cyclophosphamide, and cyclosporine. For patients
the body, predominantly in the lungs, lymph nodes, eyes, and with extensive pulmonary damage resulting from the dis-
skin. Although the exact cause of sarcoidosis is unknown, this ease, lung transplantation may be a viable option.
disease is likely the result of an exaggerated immune response
to an unidentified antigen, possibly inhaled from the air. The D I S C U SSI O N S O U R C E
condition often occurs in adults between the ages of 20 and Kamangar N. Sarcoidosis. http://emedicine.medscape.com/article/
40 years, with a slightly higher incidence in women than men. 301914-overview.
Individuals of African ancestry are also more likely to have
the disease than white Americans and tend to have more
severe disease that can cause pulmonary issues. A family Low Back Pain
history of the disease is also a risk factor.
Symptoms depend on the organs involved and severity of 97. Approximately what percent of patients experiencing
the disease. Sarcoidosis can develop gradually with symptoms low back pain will have the symptoms resolve within
that last for years, whereas others can have more rapid pro- 1 month without specific therapy?
gression and resolution of the disease. Systemic symptoms A. 33%
include fever, fatigue, anorexia, and arthralgias, whereas pul- B. 57%
monary complaints include dyspnea on exertion, cough, and C. 78%
chest pain. Dermatologic signs include rash, lesions, color D. 90%
change, and nodule formations just under the skin. Ocular 98. Risk factors for the development of low back pain
symptoms include blurred vision, eye pain, severe redness, include all of the following except:
and sensitivity to light. A. older age.
Diagnosis sarcoidosis can be difficult because there can B. carpal tunnel syndrome.
be few signs and symptoms in early disease and the symp- C. scoliosis.
toms can mimic several other disorders. The diagnostic D. spinal stenosis.
process aims to exclude other disorders while also determin-
ing which organ systems are affected by the disease. Some 99. Most episodes of low back pain are caused by:
serological markers have also been associated with sarcoido- A. an acute precipitating event.
sis, including serum amyloid A (SAA), soluble interleukin- B. disk herniation.
2 receptor, angiotensin-converting enzyme (ACE), and the C. muscle or ligamentous strain.
glycoprotein KL-6. Patients with sarcoidosis are also more D. nerve impingement.
likely to present with hypercalcemia and hypercalciuria. Im- 100. With the straight-leg–raising test, the NP is evaluating
aging studies are a key component of diagnosis. Chest x-ray tension on which of the following nerve roots?
can be used to check for lung damage or enlarged lymph A. L1 and L2
nodes in the chest. High-resolution CT scanning of the chest B. L3 and L4
can detect the presence of alveolitis or fibrosis. PET or MRI C. L5 and S1
can detect if the disease is affecting the heart or central nerv- D. S2 and S3
ous system. Pulmonary function tests and carbon monoxide
capacity tests are used in evaluation and follow-up to gauge 101. A patient with a lumbosacral strain will typically
pulmonary involvement and progression of the disease. report:
Confirmation of the disease typically requires biopsy to A. numbness in the extremities.
check for the presence of noncaseating granulomas. This can B. stiffness, spasm, and reduced ROM.
involve a transbronchial biopsy (which gives a high diagnos- C. “electric” sensation running down one or both
tic yield regardless of disease stage) or can occur from af- legs.
fected skin or the outer membrane of the eye. D. pain at its worst when in sitting position.
Sarcoidosis is often self-limiting. Mild disease can be 102. You see a 54-year-old man complaining of low back
treated with NSAIDs to help relieve symptoms of arthralgias pain and is diagnosed with acute lumbosacral strain.
and other rheumatic complaints. Corticosteroids are the Which of the following is the best advice to give about
mainstay of treatment and can be taken orally, as a cream exercising?
to affected skin, or inhaled for those with endobronchial A. You should not exercise until you are free of pain.
disease. Optimal dosing for the treatment of sarcoidosis is B. Back-strengthening exercises can cause mild
unclear; some suggest using a low dose (10–40 mg daily) that muscle soreness.
is tapered to every other day over several weeks to months. C. Electric-like pain in response to exercise is to be
Other agents used in the treatment of sarcoidosis include expected.
the antimalarial drug hydroxychloroquine and immune- D. Conditioning exercises should be started
suppressing medications used to treat rheumatoid arthritis immediately.
(e.g., methotrexate, azathioprine, and tumor necrosis factor
4074_Ch09_207-246 20/11/14 10:53 AM Page 224
103. Risk factors for lumbar radiculopathy include all of 111. Immediate diagnostic imaging for low back pain
the following except: should be reserved for all of the following except:
A. male gender. A. presence of signs of the cauda equina syndrome.
B. age <50 years. B. presence of severe neurologic deficits.
C. overweight. C. presence of risk factors for cancer.
D. cigarette smoking. D. presence of moderate pain lasting at least 2 weeks.
104. A patient with sciatica will typically report: 112. Which of the following tests yields the greatest
A. loss of bladder control. amount of clinical information in a patient with acute
B. stiffness, spasm, and reduced ROM. lumbar radiculopathy?
C. shooting pain that starts at the hip and radiates to A. lumbosacral radiograph series
the foot. B. ESR measurement
D. pain at its worst when lying down. C. MRI
D. bone scan
105. Early neurological changes in patients with lumbar
radiculopathy include: 113. The most common site for cervical radiculopathy is:
A. loss of deep tendon reflexes. A. C3 to C4.
B. poor two-point discrimination. B. C4 to C5.
C. reduced muscle strength. C. C5 to C6.
D. footdrop. D. C6 to C7
106. Common causes of sciatica include all of the follow- 114. The most common sites for lumbar disk herniation
ing except: are:
A. herniated disk. A. L1 to L2 and L2 to L3.
B. spinal stenosis. B. L2 to L3 and L4 to L5.
C. compression fracture. C. L4 to L5 and L5 to S1.
D. soft tissue abnormality. D. L5 to S1 and S1 to S2.
107. You see a 48-year-old woman who reports low back 115. You see a 37-year-old man complaining of low back
pain. During the evaluation, she mentions new-onset pain consisting of stiffness and spasms but without
loss of bowel and bladder control. This most likely any sign of neurologic involvement. You recommend
indicates: all of the following interventions except:
A. cauda equina syndrome. A. application of cold packs for 20 minutes 3–4 times
B. muscular spasm. a day.
C. vertebral fracture. B. use of NSAIDs or acetaminophen for pain control.
D. sciatic nerve entrapment. C. initiation of aerobic and toning exercises.
D. bed rest for at least 5 days.
108. Loss of posterior tibial reflex often indicates a
lesion at:
A. L3. Answers
B. L4.
C. L5. 97. D. 104. C. 111. D.
D. S1. 98. B. 105. A. 112. C.
109. Loss of Achilles tendon reflex most likely indicates a 99. C. 106. D. 113. D.
lesion at: 100. C. 107. A. 114. C.
A. L1 to L2. 101. B. 108. C. 115. D.
B. L3 to L4. 102. B. 109. C.
C. L5 to S1. 103. B. 110. A.
D. S2 to S3.
Low back pain is at least an occasional problem for nearly all
110. Which test is demonstrated when the examiner ap- adults, with a lifetime prevalence of 60% to 90%. In about
plies pressure to the top of the head with the neck 90% of patients with low back pain, symptoms are short-lived
bending forward, producing pain or numbness in the and resolve within 1 month without specific therapy. A few
upper extremities? individuals have recurrent or chronic low back pain, how-
A. Spurling ever, and significant disability. Risk factors for low back pain
B. McMurray include older age, overactivity, overweight or obesity and cer-
C. Lachman tain physiologic and degenerative disorders (e.g., spinal
D. Newman stenosis, degenerative spondylolisthesis, and scoliosis).
4074_Ch09_207-246 20/11/14 10:53 AM Page 225
Lumbosacral strain or disk herniation and resulting lum- of these conditions, little is likely to be revealed. Radiography
bar radiculopathy and sciatica can cause musculoskeletal low is likely to reveal the presence of lumbar arthritis, which
back pain. Most often, contributing factors include muscle or has been observed in more than 90% of adults older than
ligamentous strain, degenerative joint disease, or a combina- 40 years of age, although most do not report low back pain.
tion of these factors. Lumbosacral strain is the most common Lumbosacral radiographs should not be routinely obtained.
reason for a patient to present to the primary care practi- Computed tomography (CT) scanning or MRI should be
tioner with acute low back pain. In the typical scenario, the considered if radiculopathy is present and clinical presenta-
patient complains of stiffness, spasm, and reduced ROM. The tion does not improve after a reasonable trial of conservative
erector spinae muscle is most often implicated. Sitting usually therapy because these studies might reveal contributing
aggravates the pain, but there may be some relief if the patient factors, such as spinal stenosis and disk herniation. MRI is a
lies supine on a firm surface. A precipitating event is reported superior study for revealing soft tissue problems, whereas
by only a few patients because lumbosacral strain is usually CT provides superior information on bony structures.
the culmination of many events, including repeated use of Lumbosacral disk herniation usually occurs after years
improperly stretched muscles in patients with overall poor of episodes of back pain caused by repeated damage to the
conditioning. In addition, poor posture, scoliosis, and spinal annular fibers of the disk and is less common than lum-
stenosis can be predisposing factors. The physical examina- bosacral strain as a cause of low back pain. Risk factors for
tion usually reveals a straightening of the lumbosacral curve, lumbar radiculopathy include smoking, diabetes, spinal in-
paraspinal muscle tenderness, spasm worst at the level of L3 fection, overweight or obesity, male gender, and older age.
to L4, and decreased lumbosacral flexion and lateral bending. Lumbar disk herniation often leads to sciatica, neurological
The neurological examination findings are typically normal changes, and significant distress. Because the intravertebral
in lumbar sacral strain; if there is a neurological abnormality disks contain less water and are more fibrous, the risk of disk
demonstrated on a well-performed clinical examination on rupture decreases after age 50 years. The most common sites
a person presenting with low back pain, then the diagnosis of lumbosacral disk herniation are L4 to L5 and L5 to S1, with
of lumbar radiculopathy needs to be considered. the posterolateral aspect of the disk protruding.
Diagnostic tests in lumbosacral strain vary according to Neuralgia along the course of the sciatic nerve is known
the length and severity of symptoms. Radiographs are helpful as sciatica. The cause of sciatica is usually pressure on lum-
only if there is a high degree of suspicion for spondylolisthe- bosacral nerve roots from a herniated disk, spinal stenosis,
sis, scoliosis, cancer, or fracture (Table 9–6). In the absence or a compression fracture. Occasionally, sciatica can be
TABLE 9-6
Diagnostic Imaging for Low Back Pain
Immediate Action Suggestions for Initial Imaging
IMMEDIATE IMAGING
Radiography plus ESR*, MRI Major risk factors for cancer
Risk factors for spinal infection
Consider MRI if risk factors for or signs of the cauda equine syndrome; severe neuro-
logic deficits, particularly if sudden onset
DEFER IMAGING AFTER A TRIAL
OF STANDARD THERAPY
Radiography ± ESR Weaker risk factors for cancer; risk factors for or signs of ankylosing spondylitis; risk
factors for vertebral compression fracture
MRI Signs and symptoms of radiculopathy in patients who are candidates for surgery or
epidural steroid injection; risk factors for or symptoms of spinal stenosis in patients
who are candidates for surgery
NO IMAGING No criteria for immediate imaging and back pain improved or resolved after at least
1-month trial of therapy; previous spinal imaging with no change in clinical status
*Consider MRI if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains.
ESR, erythrocyte sedimentation rate.
Source: Chou, R., et al. Diagnostic imaging for low back pain: Advice for high-value health care from the
American College of Physicians. Ann Intern Med 154:181–189, 2011, http://annals.org/article.aspx?
articleid=746774.
4074_Ch09_207-246 20/11/14 10:53 AM Page 226
caused by external pressure on the sciatic nerve, such as that can worsen when the patient coughs, sneezes, stands, or sits.
often found in people who carry a wallet in a rear pants Numbness, weakness, or tingling in the back of the legs is
pocket and develop symptoms after prolonged sitting. Pa- common. With cauda equina involvement, there is compres-
tients with sciatica complain of shooting pain that starts over sion of the lower portion of the nerve root inferior to the
the hip and radiates to the foot, often accompanied by leg spinal cord, usually secondary to disk herniation. This com-
numbness and weakness. The degree of pain can vary ac- pression can lead to rectal or perineal pain and disturbance
cording to the degree of nerve involvement; it ranges from in bowel and bladder function. Signs of lumbosacral strain
mildly bothersome and occasionally reported to be more are present, and the straight-leg–raising maneuver repro-
itchy than painful to incapacitating pain. duces pain.
Neck pain, a common clinical complaint, can result from Management of patients with low back pain differs accord-
abnormalities in the soft tissues, such as muscles, ligaments, ing to presentation. In most patients with acute low back pain
and nerves, and in bones and joints of the spine. The most and intact neurological examination, treatment is aimed at
common causes of neck pain are soft tissue abnormalities maintaining function and minimizing symptoms. Longer pe-
caused by injury, poor posture, or prolonged wear and tear; riods of immobilization can contribute to deconditioning and
rare causes of neck pain include infection and tumors. The are potentially harmful. Intervention for acute neck pain is
most common site for a cervical disk lesion is C6 to C7. similar. Application of cold packs for 20 minutes three to four
Cervical vertebral sprains is a frequent injury observed in times a day can help with pain control, and heat applications
athletes and victims of motor vehicle accidents and can in- may help before gentle stretching exercise. NSAIDs or aceta-
clude acute strains and sprains of neck muscles as well as minophen should be prescribed for pain control. Muscle re-
soft-tissue contusions. Pain and stiffness are the chief com- laxants have been shown to be helpful in some patients. These
plaints. An acute cervical sprain can be associated with a medications are usually sedating, however, and need to be
jammed-neck sensation with localized pain. After the in- used with caution; occasionally, these are used as drugs of
jury, pain, swelling, and tenderness can become evident as abuse. Treatment should also include initiating aerobic and
local bleeding occurs in the muscle fibers. Neck motion can toning exercises and teaching the patient to minimize back
become painful, with peak pain occurring several hours stress through appropriate use of body mechanics.
later or the next day. However, the patient should have no Prompt referral to specialty care is needed when there is
radiation of pain to the extremities. limb, bowel, or bladder dysfunction. Surgery is usually con-
In patients who have herniated disks, whether in the neck sidered only if severe radiculopathy symptoms persist beyond
or back, the degree of neurological involvement ranges from 3 months. In addition, early referral is indicated in certain
more minor symptoms of numbness to loss of extremity conditions that are particularly worrisome (Table 9–7).
function. Deep tendon reflexes are usually absent. In cervical
D I S C U SSI O N S O U R C E S
radiculopathy, the patient presents with neck and arm dis-
Chou R, Qaseem A, Snow V, Casey V, Cross JT, Shekelle P, Owens D;
comfort that can range from a dull ache to severe burning
Clinical Efficacy Assessment Subcommittee of the American
pain. The pain is commonly referred to the medial border of College of Physicians and the American College of Physicians/
the scapula, and the chief complaint is shoulder pain. With American Pain Society Low Back Pain Guidelines Panel. http://
progression, the pain can radiate to the upper and lower arm www.annals.org/cgi/content/full/147/7/478, Diagnosis and treat-
and into the hand. Lumbar radiculopathy is associated with ment of low back pain: a joint clinical practice guideline from
pain that moves from the lower back to the buttocks, groin, the American College of Physicians and the American Pain
and back of the leg. The pain often travels below the knee and Society, 2007.
TABLE 9-7
Low Back Pain: “Red Flags” for a Potentially Serious Underlying Cause
Possible Fracture Possible Tumor or Infection Cauda Equina Syndrome
History of recent trauma, particularly Age <20 y.o. or >50 y.o. Bladder dysfunction, perineal sensory
fall from significant height or motor Constitutional symptoms such as loss, or anal laxity
vehicle accident unexplained weight loss, fever Neurological deficit in lower extremities
In person with or at risk for Recent bacterial infection, injection Lower extremity motor weakness
osteoporosis, minor trauma, or drug use, immunosuppression
strenuous lifting Increased pain with rest
History of cancer
Source.annals.org/cgi/content/full/147/7/478.
Chou, R., et al. Diagnostic imaging for low back pain: Advice for high-value health care from the American
College of Physicians. Ann Intern Med 154:181–189, 2011, http://annals.org/article.aspx?articleid=746774.
4074_Ch09_207-246 20/11/14 10:53 AM Page 227
Chou, R., et al. Diagnostic imaging for low back pain: Advice for
high-value health care from the American College of Physicians. Answers
Ann Intern Med 154:181–189, 2011, available at http://annals.
org/article.aspx?articleid=746774. 116. D. 118. A. 120. B.
117. B. 119. C. 121. B.
134. You hear a fixed split second heart sound (S2) in a A preparticipation sports screening examination is an
28-year-old woman who wants to start an exercise important step toward safe involvement in organized
program and consider that it is: sports. The purpose of these screening exams is to maintain
A. a normal finding in a younger adult. the health and safety of the athlete, not simply as a means
B. occasionally found in uncorrected atrial septal to disqualify or exclude athletes from participating in
defect. sports. The screening process should involve multiple
C. the result of valvular sclerosis. steps, including patient and family history, physical exam-
D. often found in patients with right bundle branch ination, and cardiovascular exam (Table 9–8). Urinalysis,
block. CBC, and radiographic imaging of the spine are generally
not recommended for individuals with an unremarkable
135. Which of the following characteristics about atrial
medical history because these are not helpful screening
septic defect is false?
tools.
A. It is more common in boys than girls.
Cardiovascular evaluation is an important component of
B. Child presentation can range from entirely well
the sports participation evaluation. Reducing the risk of
to heart failure.
exercised-induced sudden cardiac death and the progression
C. Full sports participation is typically acceptable
or deterioration of cardiovascular function caused by exer-
with correction.
cise are the primary goals of preparticipation evaluation.
D. Easy fatigability is a sign of atrial septic defect.
The precise conditions responsible for athletic field deaths
136. A 19-year-old man presents with Stage 1 hyperten- differ considerably according to age. In victims younger than
sion. Which of the following statements is correct 35 years, most sudden deaths are caused by cardiac malfor-
concerning sports participation? mations. Hypertrophic cardiomyopathy is the predominant
A. Full activity should be encouraged. abnormality in about one-third of cases, and congenital
B. Weight lifting is contraindicated. coronary anomalies rank as the second most common etiol-
C. An exercise tolerance test is advisable. ogy. Most of these deaths occur while the victims are playing
D. A beta-adrenergic antagonist should be prescribed. team sports. In athletes 35 years or older, most deaths are
caused by atherosclerotic coronary artery disease, usually
137. A 25-year-old woman presents with sinus arrhythmia.
while the victims are participating in an individual endeavor
Which of the following statements is correct concern-
such as long-distance running.
ing sports participation?
The preparticipation cardiovascular history should include
A. Full activity should be encouraged.
questions about the following:
B. Weight lifting is contraindicated.
• Prior occurrence of exertional chest pain/discomfort or
C. An exercise tolerance test is advisable.
syncope/near syncope
D. A calcium channel antagonist should be
• Excessive, unexpected, and unexplained shortness of
prescribed.
breath or fatigue associated with exercise
138. Among young adults with an implantable cardioverter • Past detection of a heart murmur or high blood
defibrillator (ICD), participation in sports should be: pressure
A. generally cautioned against. • Family history of the following: premature death (sudden
B. limited to noncontact sports. or otherwise), significant disability from cardiovascular
C. limited to anaerobic activities. disease in one or more close relatives younger than age
D. determined on an individual basis. 50 years, or specific knowledge of the occurrence of
certain conditions (hypertrophic cardiomyopathy,
139. Initial preparticipation screening of athletes should
dilated cardiomyopathy, long QT syndrome, Marfan
include:
syndrome, or clinically important dysrhythmias)
A. a resting 12-lead ECG.
The cardiovascular physical examination should in-
B. echocardiogram.
clude the following:
C. both a resting 12-lead ECG and echocardiogram.
• Precordial auscultation in the supine and standing posi-
D. neither a resting 12-lead ECG nor echocardiogram.
tions to identify heart murmurs consistent with dynamic
left ventricular outflow obstruction
• Assessment of the femoral artery pulses to exclude coarc-
Answers tation of the aorta
• Recognition of the physical stigmata of Marfan syndrome
122. C. 128. B. 134. B. • Blood pressure measurement in the sitting and standing
123. C. 129. C. 135. A. positions
124. D. 130. B. 136. A. If any abnormalities in the history or physical examination
125. A. 131. D. 137. A. are revealed, further evaluation or appropriate referral should
126. D. 132. A. 138. D. follow. The ability to participate in athletic activities is deter-
127. B. 133. C. 139. D. mined by the results of these studies.
4074_Ch09_207-246 20/11/14 10:53 AM Page 230
TABLE 9-8
Preparticipation Physical Examination Components
History/Exam Components
Past medical history • Allergies, asthma, birth defects, chickenpox, diabetes, eating disorders, glasses/con-
tacts, heart murmurs, heart problems, hepatitis, hernia, high blood pressure, kidney
disease, measles, medications, menstrual history, mental disorders, mononucleosis,
pneumonia, rheumatic fever, seizures, sickle cell trait or disease, tuberculosis
Sports-specific history • Orthopedic injuries (sprains, fractures, dislocations) or surgeries
• Back or neck injuries
• Dental trauma
• Chest pain with exercise
• Feeling faint or having passed out with exercise
• “Burners” or “stinger” caused by contact that produces burning pain that moves
into the extremity
• Withholding from participating in a sport for medical reason
Family history • Heart disease or high blood pressure
• Diabetes
• Unexpected death before the age of 50 years
Physical exam • Pulse rate
• Blood pressure rate
• Height and weight
• Vision and hearing
Exam by healthcare provider • Head—eyes, ears, throat, teeth, neck
• Thorax—heart, lungs, chest wall
• Abdomen—liver, spleen kidney, intestines
• Genitalia—sexual maturity, testicles, hernias
• Neurological—reflexes, strength, coordination
• Orthopedic—joints, spine, ligaments, tendons, bones (pain, range of motion,
strength)
Hypertension is a common clinical problem. Because of cardiac structural abnormality exists. Certain cardiac struc-
the cardiovascular benefit of exercise, activity restriction is tural problems, such as valvular and myocardial disorders,
usually not advisable unless severely elevated hypertension can contribute to the development of a murmur, however
or target organ damage is present. Certain antihypertensive (Table 9–9).
agents may influence exercise tolerance. Generally, the use Normal heart valves allow one-way, unimpeded forward
of angiotensin-converting enzyme inhibitors, angiotensin blood flow through the heart. The entire stroke output
receptor blockers, and calcium channel antagonists has is able to pass freely during one phase of the cardiac cycle
little to no impact on exercise tolerance. Use of a beta- (diastole with the atrioventricular valves, systole with the
adrenergic antagonist can reduce the ability to exercise, others), and there is no backward flow of blood. When a
however, because of its ability to blunt the normal increase heart valve fails to open to its normal size, it is stenotic.
in heart rate in response to exercise. Diuretic use should be When it fails to close appropriately, the valve is incompe-
avoided if possible because of increased risk of dehydration tent, causing regurgitation of blood to the previous chamber
and hypokalemia. or vessel. Both of these events place patients at significant
Cardiac rhythm disturbances are common and are usually risk for embolic disease.
benign. In particular, the presence of sinus arrhythmia in a Physiologic murmurs, also known as functional or inno-
younger adult is a normal finding and is not an indication for cent flow murmurs, are present in the absence of cardiac
curtailing activity. Dysrhythmias associated with ischemic pathology. There is no obstruction to flow, and there is a nor-
heart disease and certain supraventricular and ventricular mal gradient across the valve. This type of murmur can be
rhythms can preclude sports participation. heard in 80% of thin adults or children if the cardiac exami-
A systolic cardiac murmur is often benign. The examiner nation is performed in a soundproof booth, and it is best
simply hears the blood flowing through the heart, but no heard at the left sternal border. It occurs in early to middle
4074_Ch09_207-246 20/11/14 10:53 AM Page 231
TABLE 9-9
Cardiac Conditions: Findings and Impact on Sports Participation
Important Examination Impact on Sports
Cardiac Condition Findings Additional Findings Participation
Hypertension Elevated BP With target organ damage: With all but markedly ele-
S3, S4 heart sounds; PMI vated BP or evidence of
displacement; hypertensive target organ damage, full
retinopathy participation should be
encouraged because of
cardiovascular benefit of
exercise.
Physiologic murmur Grade 1–3/6 early to mid- No radiation beyond Full participation
(also called innocent systolic murmur, heard best precordium Patient should be asympto-
or functional murmur) at LSB, but usually audible Softens or disappears with matic, with no report of
over precordium standing, increases in in- chest pain, HF symptoms,
tensity with activity, fever, palpitations, syncope,
anemia and activity intolerance.
S1, S2 intact, normal PMI
Aortic stenosis (AS) Grade 1–4/6 harsh systolic Radiates to carotids; may Impact in participation
murmur, usually crescendo- have diminished S2, slow varies with degree of
decrescendo pattern, heard filling carotid pulse, stenosis.
best at second RICS, base narrow pulse pressure, Mild: Full participation
loud S4 Moderate: Selected
Softens with standing participation
The greater the degree of Severe: No participation
stenosis, the later the peak In younger adults, usually
of murmur. congenital bicuspid valve
In older adults, usually
calcific, rheumatic in
nature
Dizziness and syncope are
ominous signs, pointing
to severely decreased
cardiac output.
Mitral stenosis (MS) Grade 1–3/4 low-pitched late Often with opening snap, Impact on participation
diastolic murmur heard best accentuated S1 in the varies with degree of
at the apex, localized mitral area stenosis.
Short crescendo-decrescendo Enhanced by left lateral Mild: Full participation
rumble, similar to a bowling decubitus position, squat, Moderate: Selected
ball rolling down an alley or cough, immediately after participation
distant thunder Valsalva maneuver Mild with atrial fibrillation:
Selected participation
Severe: No participation
Nearly all cases rheumatic
in origin
Protracted latency period,
then gradual decrease in
exercise tolerance, lead-
ing to rapid downhill
course as a result of low
cardiac output
Atrial fibrillation
common
Continued
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TABLE 9-9
Cardiac Conditions: Findings and Impact on Sports Participation—cont’d
Important Examination Impact on Sports
Cardiac Condition Findings Additional Findings Participation
Mitral regurgitation (MR) Grade 1–4/6 high-pitched Radiates to axilla, often Impact in participation
blowing systolic murmur, with laterally displaced PMI varies with ventricular
often extending beyond S2 Decreased with standing, size and function.
Sounds like long “haaa,” Valsalva maneuver MR with normal LV size
“hooo” Increased by squat, hand and function: Full
Heard best at RLSB grip participation
MR with mild LV enlarge-
ment but normal func-
tion at rest: Selected
participation
MR with LV enlargement
or any LV dysfunction at
rest: No participation
Origin: Rheumatic,
ischemic heart disease,
endocarditis
Often with other valve ab-
normalities (AS, MS, AR)
Aortic regurgitation (AR) Grade 1–3/4 high-pitched May be enhanced by forced Impact in participation
blowing diastolic murmur expiration, leaning forward varies with ventricular
heard best at third LICS Usually with S3, wide pulse size, function, and
pressure, sustained thrust- dysrhythmias.
ing apical impulse AR with normal or mildly
increased LV size and
function: Full participation
AR with moderate LV
enlargement, premature
ventricular contractions
at rest and with exercise:
Selected participation
Mild to moderate AR with
symptoms, severe AR,
AR with progressive LVH:
No participation
More common in men,
usually caused by rheu-
matic heart disease but
occasionally by tertiary
syphilis
Mitral valve prolapse Grade 1–3/6 late systolic With Valsalva maneuver or Impact on participation
(MVP) crescendo murmur with standing, click moves for- varies with ventricular
honking quality, heard best ward into earlier systole, function and dysrhythmia.
at apex resulting in a longer MVP alone: Full
Murmur follows mid-systolic sounding murmur participation
click With hand grasp or squat, MVP with mild to
click moves back further moderate regurgitation,
into systole, resulting in a dysrhythmias such as
shorter murmur repetitive supraventricular
tachycardia, complex
ventricular dysrhythmias:
Selected participation
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TABLE 9-9
Cardiac Conditions: Findings and Impact on Sports Participation—cont’d
Important Examination Impact on Sports
Cardiac Condition Findings Additional Findings Participation
Often seen with minor
thoracic deformities such
as pectus excavatum,
straight back, and shallow
anteroposterior diameter
Hypertrophic Harsh mid-systolic Murmur may increase with Dyspnea, chest pain,
cardiomyopathy crescendo-decrescendo standing, squat, or Val- postexertional syncope
murmur heard best at LLSB salva maneuver. often are reported.
or at the apex Triple apical impulse, loud Sports participation should
S4, bisferiens carotid pulse be determined on an
individual basis according
to degree of ventricular
function and symptoms.
Still murmur (also called Grade 1–3/6 early systolic Softens or disappears when Benign finding
vibratory innocent ejection, musical or vibra- sitting or standing or with No limitation on sports
murmur) tory, short, often buzzing, Valsalva maneuver participation
heard best midway be- Usual onset, 2–6 y.o.;
tween apex and LLSB may persist through
adolescence
Benign condition
Atrial septal defect Grade 1–3/6 systolic ejection Twice as common in girls With correction, full sports
(without surgical murmur heard best at ULSB Child may be entirely well participation is typical.
intervention) with widely split fixed S2 or present with HF Without correction, sports
May be accompanied by a Often missed in the first participation should be
mid-diastolic murmur heard few months of life or even determined on an individ-
at the fourth ICS LSB com- entire childhood ual basis according to
mon, caused by increased Watch for child with easy degree of pulmonary
flow across tricuspid valve fatigability hypertension, right-to-left
shunt, and symptoms.
Ventricular septal defect Grade 2–5/6 regurgitant Usually without cyanosis With correction, full sports
(without surgical systolic murmur heard best With small to moderate- participation is typical.
intervention) at LLSB sized left-to-right shunt Without correction, sports
Occasionally holosystolic, and without pulmonary participation should be
usually localized hypertension, likely to have determined on an individ-
minimal symptoms ual basis according to
Larger shunts may result in degree of pulmonary
HF with onset in infancy hypertension, right-to-left
shunt, and symptoms.
BP, blood pressure; PMI, point of maximal impulse; LSB, left sternal border; S1, S2, S3, and S4, first to fourth
heart sounds; HF, heart failure; RICS, right intercostal space; RLSB, right lower sternal border; LV, left ventric-
ular; LICS, left intercostal space; LVH, left ventricular hypertrophy; LLSB, lower left sternal border; ULSB,
upper left sternal border; ICS, intercostal space.
systole, leaving the two heart sounds intact. In addition, Aortic stenosis is the inability of the aortic valves to open
patients with a benign systolic ejection murmur deny having to optimal size. The aortic valve normally opens to 3 cm2;
cardiac symptoms and have otherwise normal cardiac exam- aortic stenosis usually does not cause significant symptoms
ination results, including an appropriately located point of until the valvular orifice is limited to 0.8 cm2. In children and
maximal impulse and full pulses. Because no cardiac pathol- younger adults, aortic stenosis is occasionally found, usually
ogy is present in patients with a physiologic murmur, full caused by a congenital bicuspid (rather than tricuspid) valve
activity should be encouraged. or by a three-cusp valve with leaflet fusion. This defect is most
4074_Ch09_207-246 20/11/14 10:53 AM Page 234
often found in boys and men and is commonly accompanied at T1, and scoliosis. The second and much smaller group
by a long-standing history of becoming excessively short of with MVP has systolic displacement of one or more of the
breath with increased activity such as running. Other symp- mitral leaflets into the left atrium along with valve thickening
toms commonly experienced by athletes include angina and redundancy, usually accompanied by mild to moderate
or chest tightness, syncope or near syncope, fatigue during mitral regurgitation. These people typically have additional
exercise, heart palpitations, and heart murmur. The physical health problems, such as Marfan syndrome or other connec-
examination results are usually normal except for the mur- tive tissue disease. Because structural cardiac abnormality
mur. The ability to participate in sports or other vigorous ac- is present in these people, there is increased risk of bacterial
tivity is dictated by the degree of aortic stenosis and patient endocarditis.
symptoms (see Table 9–9). Barring other health problems, patients with MVP usually
In older adults, calcification aortic stenosis leading to the have normal cardiac output and tolerate a program of aerobic
inability of the valve to open to its normal size is usually the exercise well. Regular aerobic activity should be encouraged
problem. In middle-aged adults without congenital aortic to promote health and well-being. Maintaining a high
stenosis, the disease is usually sequelae of rheumatic fever, level of fluid intake should be encouraged in patients with
representing about 30% of cases of valvular dysfunction seen MVP because the mitral valve prolapses more, increasing the
in patients with rheumatic heart disease. As with patients who murmur, when circulating volume is low. Treatment with
have congenital aortic stenosis, the ability to participate in beta-adrenergic agonists (beta blockers) is indicated only
sports or an exercise program is dictated by the degree of when symptomatic recurrent tachycardia or palpitations are
valvular dysfunction, ventricular enlargement, and patient an issue. Although this degree of distress (i.e., chest pain, dys-
symptoms. pnea) may depend in part on the degree of mitral regurgita-
The murmur of mitral regurgitation arises from mitral tion, some studies have failed to reveal any difference in
valve incompetency, or the inability of the mitral valve to close the rates of chest pain in patients with or without MVP. The
properly. This incompetency allows a retrograde flow from a potentially biggest threat is the rupture of chordae, which
high-pressure area (left ventricle) to an area of lower pressure is usually seen only in individuals with connective tissue
(left atrium). Mitral regurgitation is most often caused by the diseases (especially Marfan syndrome).
degeneration of the mitral valve, most commonly by rheu- Hypertrophic cardiomyopathy is a disease of the cardiac
matic fever, endocarditis, calcific annulus, rheumatic heart muscle. The ventricular septum is thick and asymmetrical,
disease, ruptured chordae, or papillary muscle dysfunction. leading to potential outflow tract blockade. Patients with hy-
In mitral regurgitation from rheumatic heart disease, some pertrophic cardiomyopathy often exhibit symptoms of cardiac
mitral stenosis is usually present. After a patient becomes outflow tract blockage with activity because the hypertrophic
symptomatic, without intervention the disease progresses ventricular walls better approximate with the increased force
in a downhill course of chronic heart failure over the next of myocardial contraction associated with exercise. The pres-
decade. Sports or other vigorous activity participation is dic- entation of hypertrophic cardiomyopathy is occasionally sud-
tated by the degree of mitral regurgitation and ventricular den cardiac death. Idiopathic hypertrophic subaortic stenosis
chamber enlargement. is a type of cardiomyopathy. A strong family history is often
Mitral valve prolapse (MVP) is likely the most common present in individuals who have this autosomal-dominant
valvular heart problem; the condition is present in perhaps disorder. The typical patient is a young adult with a history of
10% of the general population. Most patients with MVP have dyspnea with activity, but those with hypertrophic cardiomy-
a benign condition in which one of the valve leaflets is unusu- opathy may also be asymptomatic.
ally long and buckles or prolapses into the left atrium, usually There are a growing number of teenagers and young
in mid systole. At that time, a click occurs, followed by a short adults susceptible to arrhythmias who are receiving im-
murmur caused by regurgitation of blood into the atrium. plantable cardioverter defibrillators (ICDs). These devices de-
Cardiac output is usually not compromised, and the event tect the problematic dysrhythmia and automatically provide
goes unnoticed by patients. Echocardiography fails to reveal an electrical shock that restores a normal heartbeat. Consen-
any abnormality, simply noting the valve buckling, followed sus statements offer a note of caution about participation in
by a small-volume or trace mitral regurgitation. If there are sports by individuals with ICDs. These recommendations are
no cardiac complaints and the rest of the cardiac examination, largely based on postulated risks of failure to defibrillate,
including ECG, is normal, no further evaluation is needed. potential injury resulting from loss of control caused by
One way of describing this variation from the norm is to in- dysrhythmia-related syncope, and damage to the ICD system
form patients that one leaflet of the mitral valve is a bit longer itself during contact sports. However, study indicates that
than usual. The “holder” (valve orifice) is of average size, how- athletes with ICDs can engage in vigorous and competitive
ever. This variation causes the valve to buckle a bit, just as a sports without physical injury or failure by the ICD to termi-
person’s foot would if forced into a shoe that is one or two nate the dysrhythmia. This was despite the occurrence of
sizes too small. The heart makes an extra set of sounds (click both appropriate and inappropriate electrical shocks. Patients
and murmur) but is not diseased or damaged. with ICDs should be aware of the benefits and risks of sports
MVP is often found in people with minor thoracic defor- participation, and the decision to participate should be made
mities, such as pectus excavatum, a dish-shaped concave area on an individual basis.
4074_Ch09_207-246 20/11/14 10:53 AM Page 235
In individuals with congenital heart disease such as atrial 144. The preferred screening test for osteoporosis is:
or ventricular septal defect, recommendations for sports par- A. quantitative ultrasound measurement.
ticipation vary according to patient presentation and surgical B. dual-energy x-ray absorptiometry.
intervention. Most often, if the defect has been surgically re- C. qualitative CT.
paired with little residual dysfunction, full sports participa- D. wrist, spine, and hip radiographs.
tion is allowed. If the defect is uncorrected, or if there is
145. Osteoporosis prevention measures include all of the
significant alteration in cardiac function despite repair, the
following except:
degree of participation should be assessed on an individual
A. calcium supplementation.
basis with expert consultation.
B. selective estrogen receptor modulator use.
Routine use of the resting 12-lead ECG or echocardiogram
C. vitamin B6 supplementation.
is not recommended to screen individuals during a prepartic-
D. weight-bearing and muscle-strengthening
ipation evaluation. However, the use of these tools can be con-
exercises.
sidered when initial screening raises suspicion of the presence
of a cardiovascular condition that needs further evaluation. 146. All of the following are common signs of osteoporosis
except:
DI SCUSSION SOURCES A. gradual loss of height with stooped posture.
American Heart Association Council on Nutrition, Physical Activ- B. hip or wrist fracture.
ity, and Metabolism. http://circ.ahajournals.org/cgi/content/ C. increase in waist circumference.
full/115/12/1643, Recommendations and considerations related D. patient report of back pain.
to preparticipation screening for cardiovascular abnormalities
in competitive athletes: 2007 update. 147. How much daily calcium is recommended for women
American Heart Association. Preparticipation cardiovascular screen- older than 50 years of age?
ing of young competitive athletes. Policy guidance (June 2012). A. 800 mg
http://www.heart.org/idc/groups/ahaecc-public/@wcm/@adv/ B. 1000 mg
documents/downloadable/ucm_443945.pdf. C. 1200 mg
American College of Sports Medicine. Pre-participation phys- D. 1500 mg
ical examinations. http://www.acsm.org/docs/brochures/
pre-participation-physical-examinations.pdf. 148. Nondairy sources of calcium include all of the
following except:
A. tofu.
Osteoporosis B. spinach.
C. brown rice.
140. All of the following are common sites of fracture in D. sardines.
patients with osteoporosis except:
A. the proximal femur. 149. Long-term bisphosphonate treatment (i.e., >5 years)
B. the distal forearm. has been associated with:
C. the vertebrae. A. atypical fractures.
D. the clavicle. B. hyperprolactinemia.
C. osteoarthritis.
141. Osteoporosis is more common in individuals: D. bone marrow suppression.
A. with type 2 diabetes mellitus.
B. on long-term systemic corticosteroid therapy. 150. The use of calcitonin to treat osteoporosis has been
C. who are obese. associated with an increased risk of:
D. of African ancestry. A. type 2 diabetes.
B. rheumatoid arthritis.
142. Clinical disorders that increase the risk for osteoporo- C. malignancy.
sis include all of the following except: D. systemic lupus erythematosus.
A. rheumatoid arthritis.
B. celiac disease. 151. Which of the following patients would be an appro-
C. hyperlipidemia. priate candidate for treatment with teriparatide
D. hyperprolactinemia. (Forteo)?
A. a 54-year-old woman with osteopenia
143. Osteoporosis is defined as having a bone density more B. a 64-year-old woman with BMD T-score of
than _____ standard deviation(s) below the average -2.5 and prior hip fracture
bone mass for women younger than 35 years old. C. a 67-year-old man with a BMD T-score of –1
A. 1 D. a 72-year-old woman who has a stable BMD
B. 1.5 T-score of –1.5 with bisphosphonate treatment
C. 2.5 for the past 3 years
D. 4
4074_Ch09_207-246 20/11/14 10:53 AM Page 236
152. The bisphosphonate therapy given as an annual Osteoporosis is a disorder of bone thinning in which bone
infusion is: absorption exceeds bone formation to the degree that bone
A. risedronate. density is insufficient to meet skeletal needs. Osteoporosis is
B. zoledronic acid. also defined as bone density more than 2.5 standard devia-
C. ibandronate. tions below the average bone mass for women who are
D. denosumab. younger than 35 years old. For every reduction of bone mass
by 1 standard deviation, the relative risk of fracture rises by
153. In counseling a postmenopausal woman, you advise
1.5-fold to 3-fold.
her that systemic estrogen therapy users can possibly
Estrogen deficiency is a potent risk factor, and osteoporo-
experience:
sis is most common in postmenopausal women; by age
A. an increase in breast cancer rates with long-term use.
80 years, the average woman has lost more than 30% of her
B. reduction in high-density lipoprotein cholesterol.
premenopausal bone density. Men appear to be at signifi-
C. a 10% increase in bone mass.
cantly less risk; this is partly because of inherently greater
D. no change in the occurrence of osteoporosis.
bone density. Body habitus and ethnicity can influence the
154. When counseling a patient taking a bisphosphonate risk of osteoporosis; the condition is most common in small-
such as alendronate (Fosamax), you advise that the framed women of Asian and European ancestry, who usually
medication should be taken with: have lower bone density in adulthood. At the same time,
A. a bedtime snack. all ethnic groups are at risk. Obesity appears to minimize os-
B. a meal. teoporosis risk, in part because of high endogenous estrogen
C. other medications. production by fatty tissue and increased bone weight-bearing.
D. a large glass of water. Additional risk factors for osteoporosis include select disor-
ders involving the endocrine, gastrointestinal and central
nervous systems as well as rheumatologic, autoimmune, and
Answers hematologic diseases; inactivity; and prolonged therapy with
certain medications, including some anticonvulsants, thyroid
140. D. 145. C. 150. C. hormones, and systemic corticosteroids (Table 9–10).
141. B. 146. C. 151. B. In patients with osteoporosis, hip, wrist, and spinal frac-
142. C. 147. C. 152. B. tures most commonly occur, but all bones are at risk. Early
143. C. 148. C. 153. A. disease usually does not have symptoms, but backache is com-
144. B. 149. A. 154. D. monly reported. Although hip fracture is often the first clinical
TABLE 9-10
Ligamentous Sprains: Grading, Presentation, and Intervention
Grade of Injury Pathology and Presentation Intervention
Grade I Slight stretching or microscopic tear RICE (rest, ice, compression, elevation)
No instability Immobilizer
Limit weight-bearing
Analgesia
Length of disability usually limited to a few days
Grade II Partial ligamentous tear Rest, ice, compression, elevation (RICE)
Moderate joint instability Immobilizer
Moderate swelling Limit weight-bearing
Mild to moderate ecchymosis Analgesia
Length of disability usually several weeks to a few months
Orthopedic referral
Grade III Complete ligamentous tear RICE
Complete ankle instability Immobilizer
Significant swelling Limit weight-bearing
Moderate to severe ecchymosis Analgesia
Length of disability may be many months
Sources: Anderson B. Office Orthopedics for Primary Care: Diagnosis, ed. 1. Philadelphia: Saunders, 2006.
Anderson B. Office Orthopedics for Primary Care: Treatment, ed. 3. Philadelphia: Saunders, 2006.
Turner S. Musculoskeletal system. In: Goolsby M, Grubbs L, eds. Advanced Assessment: Interpreting Findings
and Formulating Differential Diagnosis, ed. 2. Philadelphia: FA Davis, 2011, pp. 411-449.
4074_Ch09_207-246 20/11/14 10:53 AM Page 237
manifestation of osteoporosis, it usually indicates advanced Foods should be one source of this important micronutrient,
disease, as does loss of terminal adult height. although few foods are abundant vitamin D sources. Expos-
In patients with osteoporosis, the bone lost is from the ing the skin to sunlight is the most important vitamin D
baseline bone density. A small amount of loss can be of great source because the body readily synthesizes this nutrient in
significance against poor bone density, but of little conse- response to sunlight. Dietary calcium should be the primary
quence with greater density. Primary prevention of osteo- source of calcium from dairy and nondairy options (e.g.,
porosis includes ensuring the development of maximal adult spinach, sardines, tofu, select nuts, others). Given current
bone density. Because maximal bone density is achieved in lifestyles and dietary habits, supplements are often needed to
the early adult years, encouraging adequate calcium intake meet recommended requirements.
and weight-bearing exercise throughout the teen and adult Many tests are available to evaluate osteoporosis risk or
years is important. According to the latest recommendations detect progression of the disease (Table 9–11). Dual-energy
from the National Osteoporosis Foundation (NOF), the cal- x-ray absorptiometry is considered a reliable measure. Qual-
cium intake goal should be the equivalent of 1000 mg/d for itative CT is precise but uses more radiation than dual-energy
men between 50 to 70 years of age, and the dose should be x-ray absorptiometry. Quantitative ultrasound is relatively
1200 mg/day for women 51 years and older and men older inexpensive and can be performed with portable equipment.
than age 70 years. Vitamin D (minimal dose 800 to 1000 IU Plain radiographic films should not be used for screening or
daily) is recommended for all adults older than age 50 years, evaluation of osteoporosis because disease cannot be detected
with higher doses needed for those with vitamin D deficiency. until 40% to 50% of bone mass is lost.
TABLE 9-11
Osteoporosis: Risks, Screening Guidelines, and Treatment
RISK FACTORS FOR OSTEOPOROSIS
Lifestyle factors (e.g., physical inactivity, low calcium intake, alcohol abuse)
Genetic factors (e.g., cystic fibrosis, Gaucher disease)
Hypogonadal states (e.g., androgen insensitivity, hyperprolactinemia)
Endocrine disorders (e.g., diabetes mellitus, adrenal insufficiency)
Gastrointestinal disorders (e.g., celiac disease, inflammatory bowel disease)
Hematologic disorders (e.g., multiple myeloma, leukemia)
Rheumatologic and autoimmune disorders (e.g., rheumatoid arthritis, lupus)
Central nervous system disorders (e.g., epilepsy, multiple sclerosis)
• Miscellaneous other conditions and diseases (e.g., AIDS/HIV, congestive heart failure)
• Use of certain medications (e.g., long-term corticosteroid medications, some anticonvulsants, thyroid hormones)
RECOMMENDATIONS FOR OSTEOPOROSIS SCREENING
• Women age 65 and older and men age 70 and older, regardless of risk factors
• Younger postmenopausal women, women in the menopausal transition, and men age 50 to 69 with clinical risk
factors for fracture
• A woman or man after age 50 who has broken a bone
• Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., long-term glucocorticoid) associated
with low bone mass or bone loss
AVAILABLE SCREENING TESTS FOR OSTEOPOROSIS
Dual-energy x-ray absorptiometry (DXA) of the hip and spine. Using DXA to measure bone density of the hand, wrist,
forearm, and heel also seems to detect women who are at increased risk for fracture
• Other tests to measure bone mineral density: Ultrasound, radiographic absorptiometry, single-energy x-ray,
absorptiometry, peripheral DXA, and peripheral quantitative computed tomography
OSTEOPOROSIS TREATMENT
All to be used with appropriate calcium and vitamin D supplementation
• Bisphosphonates, such as alendronate, ibandronate, risedronate, and zoledronic acid
• Other antiresorptive medications including selective estrogen receptor modulators (SERMs), such as raloxifene,
calcitonin, estrogen, and RANK ligand inhibitor (denosumab)
• Bone-forming (anabolic) medications such as teriparatide (parathyroid hormone)
When taken with calcium supplements, postmenopausal given as a subcutaneous injection every 6 months. With all
hormone therapy (estrogen supplementation with or with- therapies, calcium supplementation should be continued, and
out a progestin) can help reduce the risk of postmenopausal vitamin D deficiency should be appropriately treated.
fracture by up to 34% by minimizing further bone loss; the
benefit must be balanced against the noted increased risk of D I S C U SSI O N S O U R C E S
breast cancer and other problems with short-term and long- National Osteoporosis Foundation. http://www.nof.org/professionals/
term use. A selective estrogen receptor modulator such as NOF_Clinicians_Guide.pdf, Clinician’s guide to prevention and
raloxifene (Evista) helps preserve bone density. Because treatment of osteoporosis.
raloxifene does not attach to estrogen receptor sites in the Watts NB, Diab DL. Long-term use of bisphosphonates in osteo-
breast or uterus, a selective estrogen receptor modulator is porosis. J Clin Endocrin Metab 95:1555–1565, 201oo, http://
often considered an alternative to hormone therapy. The jcem.endojournals.org/content/95/4/1555.full.
parathyroid hormone teriparatide (Forteo) is an anabolic
agent that can reduce the risk of vertebral fractures by
65% in patients with osteoporosis. This treatment is typi- Sprains
cally reserved for women with very low bone density or who
155. The most common site of sprain is the:
have had a prior fracture. Treatment with teriparatide
A. wrist.
should be limited to a 2-year duration because of a poten-
B. shoulder.
tially increased risk of osteosarcoma.
C. ankle.
Bisphosphonates such as alendronate (Fosamax), iban-
D. knee.
dronate (Boniva), risedronate (Actonel), and zoledronic acid
(Reclast) inhibit the resorptive activity of osteoclasts, can help 156. Risk factors for ankle sprain include all of the follow-
modestly increase bone mass, and can significantly reduce ing except:
fracture risk. To minimize the risk of drug-induced esophagi- A. poor conditioning.
tis, patients taking an oral bisphosphonate should be cau- B. running on paved surfaces.
tioned to take the medication in the morning with a full glass C. inappropriate footwear.
of water. At least 30 minutes must elapse before food, other D. lack of a warm-up period prior to exercising.
liquids, or medications are ingested. In addition, patients
157. A Grade II ankle sprain is best described as:
should remain upright for at least 1 hour. Zoledronic acid is
A. minor swelling and minimal joint instability.
administered as an IV infusion once a year to treat osteoporo-
B. moderate joint instability without swelling or
sis or every 2 years to prevent osteoporosis. In rare cases, low
ecchymosis.
trauma atypical femoral fractures have been associated with
C. moderate swelling, mild to moderate ecchymosis,
long-term use of bisphosphonates (i.e., >5 years). Pain in the
and moderate joint instability.
thigh or groin area often precedes these fractures. Because
D. complete ankle instability, significant swelling,
the most robust effects of bisphosphonates occur during the
and moderate to severe ecchymosis.
first 5 years of treatment and these agents provide some an-
tifracture reduction benefits even when treatment is discon- 158. A person with a Grade III ankle sprain presents with:
tinued, some recommend a drug holiday after 5 to 10 years A. minor swelling and minimal joint instability.
of therapy. The duration of therapy and the drug holiday B. moderate joint instability without swelling or
should be based on fracture risk, with low-risk patients con- ecchymosis.
sidering stopping treatment after 5 years and remaining off C. moderate swelling, mild to moderate ecchymosis,
treatment as long as BMD is stable. Higher-risk patients can and moderate joint instability.
be treated for 10 years and have a drug holiday of no more D. complete ankle instability, significant swelling,
than 1 to 2 years with consideration of a nonbisphosphonate and moderate to severe ecchymosis.
treatment during that time.
159. Patients with a Grade III ankle sprain should be
Calcitonin (Miacalcin or Fortical) is another antiresorp-
advised that full recovery is likely to take:
tive medication that is most helpful in building vertebral
A. a few days.
bone. The FDA advises that the risks associated with calci-
B. 2 to 3 weeks.
tonin use outweigh the benefits in treating osteoporosis,
C. 4 to 6 weeks.
largely based on two large studies indicating slightly higher
D. many months.
rates of malignancy among patients taking this agent. The
FDA supports the continued use of these agents because 160. Which of the following is usually not part of treat-
these medications provide an important option for patients ment of a sprain?
who do not tolerate other treatments. Denosumab (Prolia) is A. immobilization
a receptor activator of nuclear factor kappa-B ligand B. applying ice to the area
(RANKL) inhibitor that reduces the incidence of vertebral C. joint rest
fractures by about 68% in patients with osteoporosis. It is D. local corticosteroid injection
4074_Ch09_207-246 20/11/14 10:53 AM Page 239
170. A 36-year-old man has experienced shoulder pain is a question about accompanying soft tissue injury or
associated with tendonitis for the past 4 weeks despite suspected tendon tear, or for chronic tendonitis sufferers
the use of ice and analgesics (NSAIDs) and undergo- even after rehabilitation, MRI can be helpful in detecting
ing physical therapy. An appropriate next step would damage to the tendon.
include: Treatment of tendonitis includes limiting or discontin-
A. systemic corticosteroid use. uing the contributing activity. Applying ice to the region is
B. x-ray of the shoulder. helpful. NSAIDs can be used to reduce pain. When the hand
C. MRI of the shoulder. or wrist is affected, splinting can be beneficial. Achilles ten-
D. use of an upper arm sling. donitis often necessitates treatment with a posterior splint
to immobilize the heel and heel cord stretching and or-
thotics after the acute phase to prevent recurrence. There is
Answers a 10% risk of tendon rupture with recurrent Achilles ten-
donitis; the risk can exceed 12% with biceps tendonitis.
163. B. 166. A. 169. A. With rotator cuff involvement, the likelihood of concurrent
164. C. 167. A. 170. C. bursitis is high; treatment includes limiting overhead move-
165. A. 168. C. ment and intrabursal corticosteroid injection.
The most common sites for tendonitis are the rotator cuff, D I S C U SSI O N S O U R C E S
elbow, biceps (shoulder), wrist, and heel. In most cases, a mi- Anderson B. Office Orthopedics for Primary Care: Diagnosis, ed. 1.
croscopic tear causes tendon inflammation; the resulting Philadelphia: Saunders Elsevier, 2006.
swelling and inflammation in the tendon are a result of over- Anderson B. Office Orthopedics for Primary Care: Treatment, ed. 3.
use. The clinical presentation usually includes a report of re- Philadelphia: Saunders Elsevier, 2006.
duced ROM caused by joint stiffness and discomfort and a Turner S. Musculoskeletal system. In: Goolsby M, Grubbs L, eds.
dull, aching pain over the affected tendon, especially with Advanced Assessment: Interpreting Findings and Formulating
joint use. This pain can become sharp and acute when the Differential Diagnosis, ed. 2. Philadelphia: FA Davis, 2011,
tendon is squeezed. pp. 411-449.
Rotator cuff tendonitis is often associated with repetitive
overhead activities, such as throwing, raking, or washing cars
or windows, or it can be the result of injury. Symptoms in- Fibromyalgia
clude a dull pain radiating from the outer arm to several
171. Fibromyalgia is caused by:
inches below the top of the shoulder. With rotator cuff in-
A. increased production of serotonin.
volvement, abduction and elevation of the shoulder joint
B. an autoimmune reaction following infection.
worsen symptoms. A clicking in the shoulder can occur when
C. a genetic autoimmune disorder that targets neu-
raising the arm above the head.
ronal axons.
In the elbow region, tendonitis can occur as either biceps
D. a largely unknown mechanism.
tendinitis or triceps tendinitis. Biceps tendonitis occurs
through repetitive overhead activity, including throwing a 172. Which of the following statements is most consistent
baseball, swimming, or playing tennis or golf. Symptoms in- with fibromyalgia?
clude pain when the arm is overhead or bent and localized A. It is predominantly diagnosed in African Americans.
tenderness where the tendon passes over the groove in the B. It affects less than 1% of the general population.
upper arm bone. C. It is four to seven times more common in women
Wrist tendonitis, or tenosynovitis, typically occurs at than in men.
points where the tendons cross each other or pass over a bony D. It is most often initially diagnosed in adults younger
prominence. The condition is caused by overuse, such as than 20 years old and older than 55 years old.
repetitive motions during sports or work-related activities
173. Fibromyalgia is more common in patients with:
(e.g., writing, typing, and assembly-line work). Wrist ten-
A. type 2 diabetes.
donitis is associated with pain over the area of inflammation
B. rheumatoid arthritis and systemic lupus
with swelling of the surrounding soft tissue. Reduced ROM
erythematosus.
and muscle weakness are also common.
C. migraine headaches.
With initial presentation, the diagnosis of tendonitis is
D. COPD.
usually straightforward, with no special studies required. If
these signs and symptoms occur with a history of recent 174. Which of the following is inconsistent with the clini-
trauma, plain radiographic films of the affected area occa- cal presentation of fibromyalgia?
sionally reveal calcium deposits on the tendon. Because bur- A. widespread body aches
sitis and tendonitis often occur concurrently, assessment B. joint swelling
often reveals both conditions. MRI is generally not recom- C. fatigue
mended for routine diagnosis of tendonitis. However, if there D. cognitive changes
4074_Ch09_207-246 20/11/14 10:53 AM Page 241
175. The diagnosis of fibromyalgia involves: 182. Patients with fibromyalgia should be encouraged to
A. a CT scan of the head. all of the following except
B. MRI of various joints throughout the body. A. consider adopting a high-intensity aerobic activity
C. identifying multiple tender points throughout such as jogging.
the body. B. limit caffeine use.
D. a positive ANA or RF test result. C. utilize stress management techniques.
D. participate in a program of exercise focused on
176. When examining a patient with fibromyalgia,
maintaining flexibility.
tender points:
A. are located only above the waist.
B. can be identified by applying enough pressure to
blanch the nail bed of the examiner.
Answers
C. are easily identified through radiography. 171. D. 175. C. 179. C.
D. can wax and wane throughout the day. 172. C. 176. B. 180. D.
177. A diagnosis of fibromyalgia requires detecting at 173. B. 177. C. 181. C.
least how many tender points? 174. B. 178. C. 182. A.
A. 4
B. 7 Fibromyalgia is a common, complex disorder composed of
C. 11 a specific set of signs and symptoms that likely affects at least
D. 18 2% of the general population; the condition is one of the
most common central pain-related syndromes. Although its
178. When discussing physical activity with a
etiology is not fully understood, central nervous system dys-
40-year-old woman with fibromyalgia, you
function and central sensitization are likely the source of the
advise that:
multiple clinical findings associated with this condition. Bio-
A. limiting exercise is an important component of
chemical changes noted in the central nervous system in a
symptom management.
person with fibromyalgia include low serotonin levels, ele-
B. weight-bearing exercise would be most
vated levels of substance P, and other biological markers;
helpful.
these changes likely contribute to the diffuse hypersensitivity
C. physical activity aimed at increasing flexibility
to pain signals in the brain. Symptoms sometimes begin after
is an important part of treatment.
a physical trauma, surgery, infection, or significant psycho-
D. although possibly helpful in minimizing pain,
logical stress. In other cases, symptoms can gradually de-
physical activity usually significantly worsens
velop over time with no apparent triggering event. Genetic
fatigue.
factors may also play a role.
179. Analgesic approaches used in the management Fibromyalgia is four to seven times more common in
of fibromyalgia include all of the following women than in men; the reason for this finding is not un-
except: derstood. Symptom onset is usually between ages 20 and
A. acetaminophen. 55 years. Fibromyalgia is found in all ethnic groups. The
B. NSAIDs. presence of rheumatoid arthritis or lupus increases the risk
C. fentanyl patch. for fibromyalgia.
D. topical capsaicin. No particular test is diagnostic for fibromyalgia. The di-
agnosis is made after careful consideration of the patient’s
180. Drug classes used in the treatment of fibromyalgia
health history and physical examination. The patient usually
include all of the following except:
presents with a complaint of persistent fatigue combined with
A. tricyclic antidepressants.
nonrefreshing sleep. Chronic, often migratory, pain, usually
B. antiepileptics.
described as burning, aching, soreness, or feeling bruised
C. SSRIs.
(without objective evidence of bruising), is usually reported.
D. opioids.
Fibromyalgia is characterized by additional pain when pres-
181. Which of the following medications is approved sure is applied to specific tender points in certain parts of the
by the U.S. Food and Drug Administration body. Many with fibromyalgia also have tension headaches,
(FDA) for pain management in a person with temporomandibular joint disorder, irritable bowel syndrome,
fibromyalgia? anxiety, and/or depression.
A. trazodone According to the American College of Rheumatology
B. nortriptyline criteria, the diagnosis of fibromyalgia is supported by the
C. pregabalin presence of tender points in specific locations; the tender-
D. gabapentin ness is triggered at the area where pressure, enough to cause
4074_Ch09_207-246 20/11/14 10:53 AM Page 242
the examiner’s nail bed to blanch, or about 4 kg. pressure, is Mayo Clinic. Fibromyalgia. http://www.mayoclinic.com/health/
applied, and there is no referred pain. The locations of the fibromyalgia/DS00079.
tender points are as follows: on the anterior body, usually Gilliland R. eMedicine. http://emedicine.medscape.com/article/
bilaterally, at the fifth through seventh intertransverse spaces 312778-overview, Rehabilitation and fibromyalgia.
of the cervical spine, in the pectoral muscle at the second cos-
tochondral junctions, approximately three finger breadths
(2 cm) below the lateral epicondyle, and at the medial fat pad Vitamin D
proximal to the joint line. Posteriorly, bilateral findings are
as follows: tenderness at the upper border of the shoulder in
Deficiency
the trapezius muscle midway from the neck to the shoulder 183. Which of the following statements regarding vitamin D
joint, the craniomedial border of the scapula at the origin of is false?
the supraspinatus, in the upper outer quadrant of the gluteus A. diminishes secretion of insulin.
medius, and just posterior to the prominence of the greater B. inhibits abnormal cellular growth.
trochanter at the piriformis insertion. The diagnostic is C. encourages the absorption and metabolism of
supported by the presence of pain in all four quadrants of the calcium and phosphorus.
body and in the axial skeleton for 3 or more months and D. reduces inflammation.
is noted in 11 or more of 18 anatomically specific tender
points. Additional patient symptoms often include chronic 184. Which of the following provides the most abundant
gastrointestinal problems, including intermittent diarrhea source of vitamin D?
and constipation, cognitive changes, and/or altered mood. A. fortified dairy products
Intervention in fibromyalgia is complex and requires a B. fatty fish
comprehensive, interdisciplinary approach; simply attempt- C. exposure of the skin to the sun
ing to treat the pain associated with the condition is inade- D. leafy green vegetables
quate. Patient education should include information about 185. Which of the following statements is false
the need for physical activity, such as flexibility exercises, pro- regarding sunlight exposure and vitamin D
gressive stretching, and low-impact activities such as aquatic production?
exercise, which has been shown to reduce pain and increase A. In the continental United States, summertime
function. Exercise programs that involve high intensity and exposure to sunlight can produce the majority
high impact such as running or jogging, while not con- of the body’s requirement for vitamin D.
traindicated, are generally poorly tolerated by the person B. One glass of fortified milk has an equivalent
with fibromyalgia. Stress management techniques can be amount of vitamin D as what is produced after
helpful, and getting sufficient sleep is essential for those with 10 minutes of exposure to summer sunlight in a
fibromyalgia. Those with fibromyalgia should be encouraged healthy young individual.
to maintain a healthy lifestyle, including eating healthy C. Use of sunscreen can block the majority of solar-
foods, limiting caffeine intake, and participating in enjoyable induced vitamin D production.
and fulfilling activities each day. D. A person with a darker skin tone produces less
Pharmacotherapy can be used to reduce pain and improve vitamin D with sun exposure compared with a
sleep. Trigger point injection has been noted to be helpful in person with a lighter skin tone.
certain patients. Acetaminophen and NSAIDs can be used to
alleviate pain, although their effectiveness varies. Medications 186. The vitamin D needs for a 36-year-old person who
such as trazodone can be helpful in improving sleep latency is taking phenytoin are best described as:
and duration. Antidepressants (such as nortriptyline, dulox- A. easily met by a well-balanced diet.
etine [Cymbalta], or milnacipran [Savella]) and antiepileptics B. equivalent to what is required by other adults in
(including gabapentin [Neurontin] and pregabalin [Lyrica]) this age group.
have been shown to minimize symptoms in fibromyalgia and C. markedly increased by twofold to fivefold from
numerous other chronic pain conditions; these medications the age norm.
can be helpful in treating the concomitant altered mood that D. reduced from baseline because of the drug’s
often accompanies, but is not the cause of, fibromyalgia. vitamin D–preserving qualities.
Some of these medications, particularly the tricyclic antide- 187. Clinical manifestations of vitamin D deficiency
pressants, help promote sleep. Pregabalin and duloxetine are include all of the following except:
approved by the FDA for pain reduction in fibromyalgia. A. rickets.
Consistant use of topical treatments such as capsaicin are B. osteomalacia.
often helpful treatment adjuncts. C. antigravity muscle weakness.
D. azotemia.
DI SCUS SION SOURCES
American College of Rheumatology. http://www.rheumatology.org/
practice/clinical/classification/fibromyalgia/fibro_2010.asp.
4074_Ch09_207-246 20/11/14 10:53 AM Page 243
188. Which precursor of vitamin D is the form that is Vitamin D has long been recognized as essential for the
commonly measured in laboratory tests to determine efficient utilization of dietary calcium and for bone and
vitamin D status? muscle health. Recent studies have highlighted this impor-
A. vitamin D2 tant micronutrient’s multiple roles. As an inhibitor of
B. 25-hydroxyvitamin D abnormal cellular growth, vitamin D is needed to help with
C. vitamin D3 cell differentiation and minimizing abnormal cell prolifer-
D. 1,25-dihydroxyvitamin D ation, a key step in cancer development. A stimulator of
insulin secretion in response to increased insulin demands,
189. Which of the following provides the least amount of
vitamin D plays a role in the maintenance of normo-
vitamin D?
glycemia, possibly minimizing the risk of type 2 diabetes
A. fortified milk (8 oz.)
mellitus development. Because vitamin D receptors (VDR) are
B. fortified orange juice (8 oz.)
expressed by most cells of the immune system, the micronu-
C. 1 egg yolk
trient plays an important role as an immunomodulator. When
D. infant formula (8 oz.)
vitamin D is available in physiologic amounts, this micronu-
190. Which of the following servings of fish (3.5 oz.) trient acts as a renin producer, therefore contributing to blood
contains the greatest amount of vitamin D? pressure control.
A. fresh wild salmon Vitamin D deficiency is a common problem, with studies
B. fresh farmed salmon finding this problem in 36% of healthy adults aged 18 to 29
C. canned tuna in Boston by winter’s end and in 27% of otherwise healthy
D. canned mackerel Asian children in the United Kingdom. Additional studies
revealed vitamin D deficiency in 57% of patients on a hospital
191. A child must consume ___ oz. of fortified milk each
medical ward and in 93% of patients with nonspecific mus-
day to receive the recommended 400 IU daily of
culoskeletal pain at a Minneapolis pain clinic. Considering
vitamin D.
this, vitamin D deficiency is a common problem in the
A. 8
healthy and the sick.
B. 16
A combination of dietary intake of foods rich in vitamin D
C. 32
in addition to regular periods of skin exposure to the sun
D. 48
should provide the body with an adequate supply of this im-
192. For adults 70 years and younger, what is the recom- portant micronutrient (Table 9–12). However, with little time
mended daily intake of vitamin D? spent outdoors and diets replete with highly processed foods,
A. 200 IU seldom is vitamin D intake and synthesis sufficient to avoid
B. 400 IU deficiency. Fatty fish and vitamin D–enriched dairy products
C. 600 IU can supply a small amount of the estimated 3000 to 5000 IU/d
D. 1000 IU of vitamin D the body needs; the average U.S. dietary intake
is typically less than 5% of the body’s requirement. Vitamin D
193. The daily amount of vitamin D3 recommended for
intake recommendations from the Institute of Medicine sug-
pregnant or lactating women is:
gest 400 IU/day for infants (0–12 months), 600 IU/day for
A. 300 IU.
individuals 1–70 years old, and 800 IU/day for those older
B. 600 IU.
than 70 years of age. Pregnant and lactating women should
C. 1000 IU.
intake 600 IU/day.
D. 1200 IU.
Skin exposure to the sun’s rays should supply ≥95% of
194. You see a 46-year-old woman diagnosed with the daily requirements by triggering the body’s natural abil-
vitamin D deficiency with a 25(OH)D level of ity to synthesize this vitamin. The ability of the body’s unin-
18 ng/mL. Treatment should be initiated with duced vitamin D synthesis is determined by a number of
which of the following vitamin D dosing regimens? factors, including the skin’s melanin pigmentation. A per-
A. 400 IU twice a day son with a darker skin tone will synthesize less vitamin D
B. 1000 IU daily with sun exposure when compared with a person with a
C. 10,000 IU twice a week lighter skin tone. The use of sunscreen, although helpful in
D. 50,000 IU weekly minimizing the risk of certain skin cancers and other solar
damage, likely increases the risk of vitamin D deficiency
because application of a sunscreen with sun protection fac-
Answers tor 8 reduces the capacity of the skin to produce vitamin D
by as much as 95%. Obviously, individuals who spend little
183. A. 187. D. 191. C. time outdoors have a significant vitamin D deficiency risk.
184. C. 188. B. 192. C. The time of year and place of residence also influence sun-
185. B. 189. C. 193. B. induced vitamin D synthesis, with winter sun and northern
186. C. 190. A. 194. D. latitudes providing the weakest effect. Even people who are
4074_Ch09_207-246 20/11/14 10:53 AM Page 244
TABLE 9-12
Dietary and Supplemental Sources of Vitamin D
Source Vitamin D Content
Sunlight exposure ~3000 IU of vitamin D3 after 5–10 minutes exposure to arms and legs (dependent on
latitude)
Fortified milk ~100 IU/8 oz., usually vitamin D3
Fortified orange juice ~100 IU/8 oz., vitamin D3
Infant formulas ~100 IU/8 oz., vitamin D3
Fortified yogurts ~100 IU/8 oz., usually vitamin D3
Fortified breakfast cereals ~100 IU per serving, usually vitamin D3
Salmon
Fresh, wild (3.5 oz.) ~600-1000 IU of vitamin D3
Fresh, farmed (3.5 oz.) ~100–250 IU of vitamin D3 or D2
Tuna, canned (3.6 oz.) ~230 IU of vitamin D3
Mackerel, canned (3.5 oz.) ~250 IU of vitamin D3
Cod liver oil (1 tsp.) ~400–1000 IU of vitamin D3
Shitake mushrooms
Fresh (3.5 oz.) ~100 IU of vitamin D2
Sun-dried (3.5 oz.) ~1600 IU of vitamin D2
Egg yolk ~20 IU of vitamin D3 or D2
regularly involved in outdoor activities that facilitate expo- causes phosphate to be wasted via the kidney. The calcium
sure to sunshine can have vitamin D deficiency if little skin phosphate product in the circulation decreases and becomes
is exposed to the sun. Exposing the hands, face, arms, or legs inadequate to mineralize the bone properly, potentially
daily for about 5 to15 minutes of sun between the hours of leading to osteopenia and osteoporosis. At the same time,
11AM and 2PM at a strength found in northern latitudes osteoblasts deposit a rubbery collagen matrix layer on the
such as Boston will help provide an adequate amount of skeleton. This surface cannot provide sufficient structural
vitamin D synthesis. This level of sun exposure is unlikely support. The clinical effect is osteomalacia. This abnormal
to induce sunburn or increase skin cancer risk. The use of collagen matrix can absorb fluids and expand. With expan-
certain medications, including phenytoin (Dilantin) and sion, pressure builds under the richly innervated periosteal
phenobarbital, is potentially vitamin D depleting; as a result, covering. This process likely, at least in part, explains the
patients taking these medications require two to five times origin of the constant dull bone ache often reported in
the recommended daily amount of vitamin D. Vitamin D patients with osteomalacia. In these patients, minimal pres-
deficiency is also common in the presence of hepatic or sure applied with a fingertip on the sternum, anterior tibia,
renal disease after gastric bypass. radius, or ulna elicits a painful response. Because vitamin D
In infants and children, severe vitamin D deficiency re- deficiency symptoms overlap considerably with those of
sults in the failure of growing bone to mineralize. The result- fibromyalgia, one condition is often mistaken for the other.
ing condition is rickets. In contrast, adult bones are no Vitamin D deficiency has also been long recognized as a
longer growing but are in a state of constant cell renewal and cause of muscle weakness and muscle aches and pain in
therefore susceptible to problems related to vitamin D defi- all ages. Aside from osteomalacia and localized bone pain,
ciency including persistent, nonspecific musculoskeletal antigravity muscle weakness, difficulty rising from a chair
pain. To appreciate this, consider some of the clinical effects or walking, and pseudofractures also are noted in the person
of vitamin D deficiency. with vitamin D deficiency. These findings resolve with appro-
Without sufficient amounts of vitamin D, intestinal cal- priate treatment. Vitamin D deficiency also contributes to the
cium absorption is inadequate. The resulting calcium defi- development of hypocalcemia and hypophosphatemia. In
ciency prompts an increase in production and secretion of this situation, unless the vitamin D deficiency is addressed,
parathyroid hormone (PTH). PTH acts at the level of the kid- replacing calcium or phosphate alone does not restore the
ney by facilitating an increase in tubular calcium reabsorption body to homeostasis.
and stimulating renal production of 1,25-dihydroxyvitamin D, The preferred test for assessment of vitamin D status is
the hormonally active form of vitamin D. With continued measurement of serum 25-hydroxyvitamin D (25(OH)D).
deficiency, unusually high levels of PTH allow osteoclast ac- The results of this test are minimally influenced by recent
tivation so that bone can serve as a calcium source. In addi- dietary intake or recent sun exposure, and it is considered the
tion, the continued presence of high levels of circulating PTH most accurate functional indicator of vitamin D stores. The
4074_Ch09_207-246 20/11/14 10:53 AM Page 245
serum level of the biologically active form of vitamin D, 8 weeks is advised, with extension of this course to 16 weeks if
1,25-dihydroxyvitamin D (1,25(OH)2D), is not an accurate the initial 25(OH)D level was below 30 ng/mL. For long-term
indicator of nutritional vitamin D status because levels prevention, patients should be given 50,000 IU of vitamin D3
of 1,25(OH)2D typically are not altered until vitamin D once or twice per month plus 1000 to 2000 IU of vitamin D3
deficiency is well advanced. The cost of testing ranges from daily. Consuming a diet rich in vitamin D-containing foods
$50 to $200. and exposing the skin to a sensible and safe level of sunlight
Opinions differ on what constitutes deficiency. Physio- can aid in preventing the condition. A confirmation of
logic deficiency is defined as a level of serum 25(OH)D vitamin D correction should be obtained after the recom-
that is sufficiently low to cause an increase in parathyroid mended length of high-dose repletion therapy.
hormone (PTH) levels. Production and secretion of PTH Excessive supplementation, but not excessive sun expo-
increases to correct low calcium levels via increased bone sure, can cause vitamin D toxicity, leading to a variety of
turnover and accelerated bone loss, effects that clearly occur problems, including calcium deposition into solid organs.
later in the disease process. Clinical studies have revealed that This is rarely seen and is usually a consequence of chronic use
increased PTH levels occur with 25(OH)D levels of 20 ng/mL of ≥10,000 IU/d vitamin D3.
(50 nmol/L). As a result, most laboratories report the normal
range to be 20 to 100 ng/mL (50 to 250 nmol/L); however, D I S C U SSI O N S O U R C E S
the preferred minimum level is likely 35 to 40 ng/mL (87.5 to Holick MF. Vitamin D deficiency. N Engl J Med 357(3):266–281,
100 nmol/L). 2007.
Vitamin D3 is the preferred form of the micronutrient for Holick MF. Vitamin D deficiency: What a pain it is. Mayo Clin Proc
the treatment of vitamin D deficiency and for maintenance 78:1457–1459, 2003.
Linus Pauling Institute, Micronutrient Information Center. Vitamin D.
of vitamin D levels. Because vitamin D3 is stored in fat and
http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD.
has a long half-life, low-dose (400–800 IU per day) vitamin D3 Moyad MA. Vitamin D: A rapid review. Medscape Today News,
supplementation is not sufficient to correct a deficiency. Ap- http://www.medscape.com/viewarticle/589256.
proximately 100 IU given daily for 3 months will increase the Plotnikoff G, Quigley J. Prevalence of severe hypovitaminosis D in
25(OH)D level by just 1 ng/mL (2.5 nmol/L); considered in patients with persistent, nonspecific musculoskeletal pain. Mayo
multiples of 100 IU, 400 IU taken for 3 months will increase Clin Proc 78:1463–1470, 2003.
the level by 4 ng/mL (10 nmol/L). Tangpricha V, Griffing GT. Vitamin D deficiency and related dis-
For treatment of vitamin D deficiency in adults, a dose of orders. Medscape Reference, http://emedicine.medscape.com/
50,000 IU of vitamin D3 by mouth once per week for at least article/128762.
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4074_Ch10_247-260 20/11/14 10:55 AM Page 247
Peripheral Vascular
Disease 10
Raynaud Answers
Phenomenon 1. D 3. A. 5. C.
2. A. 4. B.
1. Who is most likely to have new-onset primary
Raynaud phenomenon? See full color images of this topic
A. a 68-year-old man on DavisPlus at
B. a 65-year-old woman http://davisplus.fadavis.com |
C. a 25-year-old man Keyword: Fitzgerald
D. an 18-year-old woman
Raynaud phenomenon, also known as Raynaud disease, is
2. All of the following are associated with secondary
characterized by paroxysmal digital vasoconstriction that re-
Raynaud phenomenon except:
sults in bilateral symmetrical pallor or cyanosis. The hands are
A. hypertension.
nearly always involved; foot involvement is rare. A period of
B. scleroderma.
rubor follows this initial response. Primary Raynaud phenom-
C. repeated use of vibrating tools.
enon, also known as primary Raynaud disease, is idiopathic
D. use of beta-adrenergic antagonists.
in origin in most patients and is most often found in women.
3. Lifestyle modification for patients with Raynaud phe- The condition usually appears between the ages of 15 and
nomenon includes: 45 years. Vasoconstriction triggers include exposure to cold
A. discontinuing cigarette smoking. relieved by warmth and, less commonly, emotional upset.
B. increasing fluid intake. Symptoms tend to be progressive, with vasospasm becoming
C. avoiding placing hands in warm water. more frequent and prolonged. There are no specific studies to
D. discontinuing aspirin use. help diagnose primary Raynaud disease. The diagnosis is
made if recurrent episodes occur for more than 3 years with-
4. Medications that are often helpful in relieving
out notation of associated disease or secondary cause.
symptoms associated with Raynaud phenomenon
Secondary Raynaud phenomenon is seen in the presence
include:
of an underlying condition, such as atherosclerosis, colla-
A. nonsteroidal anti-inflammatory drugs (NSAIDs).
gen vascular disease, and select autoimmune disease such
B. angiotensin-converting enzyme inhibitors.
as scleroderma; in scleroderma, this concomitant condition
C. beta-adrenergic antagonists.
is a nearly universal finding. In addition, the use of vibrat-
D. diuretics.
ing tools, repeated sharp digit movement such as piano
5. Which of the following is the most common presenta- playing or typing, frostbite, tobacco, ergotamine, and beta
tion in a patient with Raynaud phenomenon? blocker use can be contributing factors. The presentation
A. digital ulceration of secondary Raynaud phenomenon is the same as that of
B. worsening of symptoms in warm weather the idiopathic condition; the degree and length of va-
C. a period of intense itchiness after blanching sospasm are often more severe. Rarely, distal digital ulcer-
D. unilateral symptoms ation is seen.
247
4074_Ch10_247-260 20/11/14 10:55 AM Page 248
Whatever the cause, intervention in Raynaud phenome- 9. Which of the following statements is most accurate in
non is aimed primarily at preventing vasospasm by avoiding the assessment of a patient with varicose veins?
cold and other known triggers. At the onset of an episode, A. The degree of venous tortuosity is well-correlated
submerging the hands in warm water can be helpful in with the amount of leg pain reported.
limiting the length and severity of vasospasm; hot water B. As the number of affected veins increases, so does
should not be used because of risk of burn. Because wound the degree of patient discomfort.
healing may be delayed and infection is common, the hands C. Symptoms are sometimes reported with minimally
should be protected from even minor injury. Keeping the affected vessels.
skin well lubricated can help avoid small fissures. Tobacco D. Lower-extremity edema is usually seen only with
use exacerbates vasospasm. As a result, all forms of tobacco severe disease.
use should be discouraged; smoking cessation is usually
10. Spider varicosities are:
associated with a stabilization of or improvement in symp-
A. usually symptomatic.
toms. Biofeedback can be helpful because the patient can be
B. a potential site for thrombophlebitis.
taught to envision warming the digits, reducing symptoms.
C. responsive to laser obliteration.
The dihydropyridine calcium channel blockers (“-ipine”
D. caused by sun exposure.
suffix, such as amlodipine or nifedipine) and angiotensin-
converting enzyme inhibitors (“-pril” suffix, such as lisino-
pril or fosinopril) can be used for their vasodilator effect
when lifestyle modification is inadequate. In patients with
Answers
secondary Raynaud phenomenon, treatment of the associ- 6. D. 8. D. 10. C.
ated condition is important and often helps minimize 7. C. 9. C.
episodes. Surgical intervention with distal digital sympa-
thectomy and arterial reconstruction should be considered Varicose veins are seen in 15% of the adult population and are
when more conservative therapy is unsuccessful in manag- most often found in the lower extremities. Tortuous, dilated,
ing the condition. superficial veins are characteristic. An inherited venous defect
of either a valvular incompetence or a weakness in the walls
DI SCUS SION SOURCE of the vessel likely plays a significant role. In addition, situa-
Hansen-Dispenza, H. eMedicine. http://www.emedicine.medscape. tions that cause high venous pressure, such as leg crossing,
com/article/31197-overview, Raynaud phenomenon. wearing of constricting garments, prolonged standing, heavy
lifting, and current or prior pregnancy, contribute to their
development. Women are affected twice as often as men.
Varicose Veins The vessel most often affected is the great saphenous vein
and its tributaries. Often asymptomatic, varicose veins may
6. Which of the following does not directly contribute to also be associated with leg aching but usually not severe pain.
the development of varicose veins? The degree of discomfort is poorly correlated with the num-
A. leg crossing ber and appearance of the affected veins. Mild edema in the
B. pregnancy ankle area, particularly at the end of the day and in warm
C. heredity weather, is common. When palpated, the vein compresses
D. Raynaud disease easily and without pain. No specific diagnostic tests are
needed with typical presentation. Various diagnostic tests are
7. When advising a woman with varicose veins about
available, however, including duplex ultrasound and mag-
the use of support stockings, you consider that the
netic resonance venography; these tests are usually used to
preferred type:
rule out deep vein obstruction as a contributor of the severity
A. can be purchased in the hosiery section of a
of varicose veins.
department store.
With uncomplicated varicose veins, lifestyle modification
B. is a lightweight pair and available over-the-
usually helps minimize the symptoms and disease progress.
counter.
Attaining and maintaining normal weight helps to reduce
C. is a medium-weight to heavy-weight prescription
intravenous pressure and discourage the development and
product.
progression of varicose veins. Periodic leg elevation is helpful
D. is used in the form of panty hose.
in minimizing edema and encouraging venous return. The
8. In patients with varicose veins, which vessel is most use of medium-weight to heavy-weight elastic support hose
often affected? such as Jobst™ stockings should be encouraged. Support hose
A. femoral vein purchased in a department store or drugstore do not supply
B. posterior tibial vein enough compression. Wearing garments that are
C. peroneal vein potentially constricting, such as panty girdles and garters,
D. saphenous vein should be avoided.
4074_Ch10_247-260 20/11/14 10:55 AM Page 249
Various minimally invasive interventions, including en- 15. Which of the following is the most likely to be found in
dovenous laser venous ablation, are also available for varicose deep vein thrombophlebitis (DVT)?
vein treatment. Sclerotherapy is a common procedure done A. unilateral leg edema
for vein obliteration and involves injecting a sclerosing agent B. leg pain
into the affected vein followed by a period of compression, C. warmth over the affected area
which results in vessel obliteration. Surgery is often needed D. positive obturator sign
for symptomatic varicose veins that do not respond to con-
16. A positive Homans sign is present in approximately
servative therapy. Patients often prefer more aggressive treat-
what percentage of patients with DVT?
ment in this condition to yield the best cosmetic outcome and
A. 25%
to experience relief of discomfort.
B. 33%
Possible complications of varicose veins include superfi-
C. 50%
cial thrombophlebitis. Over time, varicose veins tend to dilate
D. 75%
progressively, which can lead to secondary changes in the
lower extremities, including chronic edema, skin hyperpig- 17. The initial diagnostic evaluation of a clinically stable
mentation, and development of chronic venous insufficiency. patient with suspected DVT most often includes
Spider varicosities are visible surface vessels usually seen with obtaining a/an:
varicose veins. These vessels do not usually cause symptoms A. impedance plethysmography.
and pose no thromboembolic risk. Vessel obliteration with B. iodine 125 fibrinogen scan.
laser or other modalities is helpful in reducing the appearance C. contrast venography.
of spider varicosities and is considered a cosmetic procedure. D. duplex ultrasonography.
23. The most common method of preventing venous throm- 20. C. 25. A. 30. True
boembolism in higher risk surgical patients is the use of: 21. A. 26. B. 31. True
A. vitamin K. 22. D. 27. True 32. False
B. LMWH. 23. B. 28. True
C. vena cava filter. 24. A. 29. False
D. warfarin.
24. When taken with warfarin, which of the following Blood coagulation can be activated by various pathways via
causes a possible increased anticoagulant effect? the tissue factor (TF) pathway (formerly known as the extrin-
A. clarithromycin sic pathway) and the contact activation pathway (formerly
B. carbamazepine known as the intrinsic pathway). Expressed by injured en-
C. pravastatin dothelial cells, TF is the clinically most significant initiator of
D. sucralfate coagulation. TF binds to and activates coagulation factor VII;
the TF/factor VIIa complex then activates factor X and fac-
25. When taken concomitantly with warfarin, which of tor IX to factors Xa and IXa. In the presence of factor XIIa,
the following causes a possibly decreased anticoagulant factor IXa can also convert factor X to factor Xa. The contact
effect? activation pathway is activated when factor XII comes in
A. cholestyramine contact with a foreign surface. The resulting factor XIIa acti-
B. allopurinol vates factor XI, which activates factor IX. Factor IXa activates
C. cefpodoxime factor X. These pathways work together to provide maximal
D. zolpidem stimulation of factor X, which, in the presence of factor V,
26. What is the international normalized ratio (INR) activates prothrombin to thrombin; this is also known as the
range recommended during warfarin therapy as part common pathway.
of the management of a patient with DVT? Equally as important as blood coagulation is the ability of
A. 1.5 to 2.0 blood to avoid clot formation. In the larger arteries, clot risk
B. 2.0 to 3.0 is usually limited because aggregating platelets are dislodged
C. 2.5 to 3.5 by high-velocity blood flow and thrombus formation is
D. 3.0 to 4.0 avoided. In smaller arteries and veins, blood flow is slower,
with platelet aggregation more likely to occur and increasing
True or False? clot risk. Working against thrombus formation, TF pathway
inhibitor binds to and inactivates the TF/factor VIIa/factor Xa
27. During the first 6 weeks of the postpartum period, complex. Antithrombin III inactivates circulating thrombin,
the childbearing woman is at increased risk for whereas proteins C and S are contributors to a complex
venous thrombus formation. process that down regulates thrombin activity by preventing
the activation of factor V. If a clot does form, circulating
28. In a patient with suspected superficial throm- plasminogen is incorporated into the thrombus; healthy en-
bophlebitis in the calf, the abnormalities in the dothelial cells adjacent to the vessel injury site release tissue
lower-extremity examination are potentially plasminogen activator and activate plasminogen to plasmin,
enhanced by having the patient stand for approxi- causing thrombolysis on the clot surface and minimizing
mately 2 minutes. thrombus size. Meanwhile, numerous factors, including
29. With the use of a direct thrombin inhibitor, plasminogen activator inhibitor, produced by the liver and
ongoing INR monitoring is required. endothelial cells, inhibit fibrin degradation by plasmin to
limit thrombolysis.
30. Prescribing a direct thrombin inhibitor is an ac- The Virchow triad of stasis, injury to the vascular intima,
ceptable therapeutic option to reduce the risk of and abnormal coagulation leading to clot usually contributes
recurrent DVT. to the development of vessel inflammation and the resulting
31. One of the potential serious adverse effects of thrombophlebitis. The lower extremities are most often
unfractionated heparin is thrombocytopenia. affected.
Thrombophlebitis, presence of coagulated blood or
32. An abnormally elevated D-dimer test is highly thrombus in a vein with resulting inflammation, can occur
sensitive and specific for the diagnosis of throm- in superficial or deep veins. Risk factors for superficial throm-
boembolic disease. bophlebitis include local trauma, prolonged travel or rest,
presence of varicose veins, history of prior episodes, and use
Answers of estrogen-containing hormonal contraceptives or post-
menopausal hormone therapy. Owing to the increased
11. D. 14. B. 17. D. platelet stickiness noted in late pregnancy through the first
12. C. 15. A. 18. B. 6 weeks postpartum, this time also marks a period for in-
13. A. 16. B. 19. A. creased thrombotic risk.
4074_Ch10_247-260 20/11/14 10:55 AM Page 251
Characteristics of superficial thrombophlebitis usually in- Because the triad of venous stasis, vessel wall injury, and
clude a localized, tender, dilated, thrombosed vessel, causing altered coagulation state is the primary mechanism underly-
a linear area of redness, often in the popliteal fossa. Homans ing DVT (as noted with superficial thrombophlebitis), risk
sign is absent. Having the patient stand for 2 minutes before factors include prolonged rest, recent trauma, recent surgery
examination enhances the findings because less severe cases (especially hip replacement and select additional orthopedic
might be missed on supine examination. Superficial throm- surgery), pregnancy, and the peripartum period. The hyper-
bophlebitis is often considered a benign condition; however, coagulation state associated with many malignancies also
this condition is likely a marker of further clotting issues. Ex- presents considerable risk. The use of hormone-containing
tension into a deep vein, the vessels that act as conduits to contraceptives (combined [estrogen/progestin] oral contra-
return blood to the heart, is typically present, however, in ceptive, topical patch, or vaginal ring) and postmenopausal
45% of patients with the condition. In particular, superficial, hormone therapy can increase DVT risk, particularly in cig-
noninfectious thrombophlebitis in hospitalized patients is arette smokers. Disorders of coagulation, such as factor V
more likely to be associated with DVT and PE. Until proven Leiden mutation and protein C and S and antithrombin III
otherwise, a patient with superficial thrombophlebitis should deficiencies, are recognized as a cause of DVT in otherwise
be assumed to have deep vein involvement. Compression healthy adults.
duplex venous ultrasonography should be performed to help Because the presentation of DVT varies, making the di-
rule out concurrent DVT. agnosis from clinical presentation alone is problematic
Because disordered coagulation tends to occur in multiple (Table 10–1). Only a few patients with suspected DVT have
locations simultaneously, superficial thrombophlebitis is the diagnosis supported, unless the Virchow triad of venous
often accompanied by DVT in a different location or extrem- stasis, vessel wall injury, and coagulation abnormalities is pres-
ity; the study should not be limited to the affected area. Serial ent. With regard to risk and clinical presentation, Table 10–2
studies are often needed if initial examination findings are provides a guide for estimating clinical suspicion.
negative but symptoms persist. Although direct venography To establish the diagnosis and develop an appropriate plan
is the most sensitive and specific test, its use has been limited of intervention, a thorough diagnostic evaluation is needed
because these less invasive tests have become available. Mag- in patients suspected to have DVT. Because of cost and the
netic resonance direct thrombus imaging provides an accu- invasive nature of the test and the risk of allergy to the con-
rate noninvasive modality in DVT diagnosis. trast medium associated with contrast venography, long con-
Further PE evaluation should be undertaken based on clin- sidered the standard for DVT diagnosis, noninvasive tests are
ical findings, such as shortness of breath or friction rub. Coag- used more commonly. Compression duplex ultrasound is the
ulation studies should be obtained, particularly if there is a most common first-line diagnostic technique in DVT. Mag-
history of previous episodes without such evaluation. D-dimer, netic resonance direct thrombus imaging is the diagnostic
a degradation product produced by plasmin-mediated prote- test of choice for suspected iliac vein or inferior vena caval
olysis of cross-linked fibrin, is often elevated in DVT and PE. thrombosis. In the second or third trimester of pregnancy,
The test has significant limitations, however, because d-dimer magnetic resonance imaging (MRI) is also more accurate
levels can be elevated whenever the coagulation and fibrinolytic than duplex ultrasound because the gravid uterus alters
systems are activated and are falsely elevated in the presence Doppler venous flow characteristics.
of high rheumatoid factor levels. Levels of d-dimer are elevated in DVT with high sensitivity
After the diagnosis of superficial thrombophlebitis is con- but low specificity; similar results are found with recent sur-
firmed, intervention is dictated by DVT risk factors and gery, trauma, myocardial infarction, pregnancy, and metastatic
patient history. In the absence of risk factors and history cancer. When findings are positive in DVT, the degree of
of similar episodes, warm packs, compression hose, and d-dimer elevation depends on the size of the clot. A lower risk
NSAIDs can be used to treat superficial thrombophlebitis. patient with a normal d-dimer level is unlikely to have DVT.
Ambulation should be encouraged because rest promotes sta- A growing body of knowledge compels the NP to consider an
sis and enhances coagulation, although leg elevation when at underlying clotting disorder in a person with DVT, and testing
rest is helpful in managing symptoms and edema. In the pres- for protein S, protein C, antithrombin III, fibrinogen, lupus
ence of prior episodes, a history of DVT, decreased mobility, anticoagulant, factor V Leiden, prothrombin 20210A muta-
hypercoagulability, or extensive saphenous vein involvement, tion, antiphospholipid antibodies, and other thrombophilia
subcutaneous LMWH therapy should be initiated, with con- forms is appropriate, particularly with a personal history
sideration for long-term warfarin use. The inflammation or strong family history of prior thromboembolic episodes.
associated with superficial thrombophlebitis usually subsides These tests should be obtained before initiating anticoagulation
within 2 weeks, with a firm cord remaining for a much longer therapy.
period. As with DVT, collateral venous flow develops over Therapy for patients with DVT should be aimed at mini-
the next few months. mizing the risk of PE and extension of peripheral thrombus.
Acute DVT usually involves the veins of the lower extrem- Anticoagulation therapy with medications, usually with a he-
ities and pelvis. PE, a potentially fatal condition, is largely a parin form first followed by warfarin (Coumadin), should be
sequela of DVT. Long-term sequelae of DVT include chronic prescribed. These products are aimed at allowing natural fib-
venous insufficiency and venous ulceration. rinolysis action and clot resolution to occur and minimizing
4074_Ch10_247-260 20/11/14 10:55 AM Page 252
TABLE 10-1
Clinical Presentation of Deep Vein Thrombophlebitis (DVT)
Finding Comment
Edema Usually unilateral (best true-positive finding)
Bilateral calf measurement with comparative readings help-
ful in clinical assessment
Leg pain Usually described as a tugging pain, heaviness, ache
Present in ~50% of patients with DVT
Degree of pain does not correlate well with extent of thrombus
Homans sign Pain on dorsiflexion of the foot
Present in about one-third of patients with DVT and up to
half without DVT
Pulmonary embolus (PE) signs and symptoms Present in ~10% of patients with DVT, but likely PE concur-
rently present in a higher percentage
Warmth over area of thrombosis Relatively rare
Venous distention and prominence of subcutaneous veins Relatively uncommon
Fever If present, typically mild
Tenderness over and adjacent to the affected area Found in ~75% of patients with DVT
Also can be found in many conditions other than DVT
Degree of tenderness does not correlate well with extent of
thrombus
TABLE 10-2
Wells Clinical Prediction Guide in Deep Vein Thrombophlebitis (DVT)
CLINICAL PARAMETER SCORE
Active cancer (treatment ongoing, within 6 mo, or palliative therapy) 1
Paralysis or recent plaster or other similar limb immobilization 1
Recently bedridden for >3 days or major surgery <4 weeks earlier 1
Localized tenderness along distribution of the deep venous system 1
Entire leg swelling 1
Calf swelling >3 cm compared with asymptomatic leg 1
Pitting edema (greater in the symptomatic leg) 1
Collateral superficial veins (nonvaricose) 1
Alternative diagnosis (as likely or greater than that of DVT) -2
TOTAL OF SCORES
High probability: Score ≥3
Moderate probability: Score 1–2
Low probability: Score 0
Wells Clinical Prediction Guide in Pulmonary Embolus (PE)
CLINICAL PARAMETER SCORE
Clinical signs/symptoms of DVT 3
No alternative diagnosis likely or more likely than PE 3
Heart rate >100 bpm 1.5
Immobilization or surgery in the past 4 weeks 1.5
Previous history of DVT or PE 1.5
Hemoptysis 1
Cancer actively treated within past 6 months 1
SCORING
Probability of PE is high if total score >6; moderate, if 2–6; and low, if <2
Source: Adapted from Anand SS, Wells PS, Hunt D, et al. Does this patient have deep vein thrombosis?
JAMA279:1094–1099, 1998.
4074_Ch10_247-260 20/11/14 10:55 AM Page 253
risk for clot extension; heparin and warfarin do not have in- accelerates antithrombin III activity; because of limited
trinsic thrombolytic activity. bleeding risk, monitoring of partial thromboplastin time is
Direct thrombin inhibitors (DTIs), including the oral not required during its use. LMWH has additional advan-
product dabigatran (Pradaxa), can also be considered as an tages, including superior bioavailability, a longer half-life
alternative to heparin and warfarin for treatment of DVT that allows for twice-a-day dosing, ease of calculating
and PE, particularly in patients who have previously under- dosage, and limited antiplatelet effect. LMWH is more ex-
gone parenteral anticoagulant treatment. The use of these pensive, however, than unfractionated heparin. Patients
agents, particularly for stroke prevention in rate-controlled with an isolated calf vein DVT who are clinically stable with
atrial fibrillation, is growing due to the ease of use and pre- few risks for a further embolic process and with access to
dictable anticoagulant effect that eliminates the need for on- careful provider follow-up should be considered for initial
going therapeutic monitoring. The use of these agents can outpatient treatment with self-administered injections of
also be considered to reduce the risk of recurrence of DVT LMWH twice a day. In the absence of this scenario, inpa-
and PE. DTIs have a number of limitations and should be tient admission and heparin anticoagulation are indicated.
avoided or used with caution in certain patient populations, Length of therapy is usually about 5 days, and therapy is
such as elderly patients. discontinued when heparin has been given for 5 days or
Because rapid-onset anticoagulation is needed in DVT until international normalized ratio (INR) is greater than
therapy, heparin is usually the initial treatment (Table 10–3). 2.0 as a result of the concomitant warfarin therapy. LMWH
A naturally occurring acidic carbohydrate, heparin poten- is often used for DVT prophylaxis for high-risk surgical and
tiates antithromboplastin III (a naturally occurring an- medical patients.
tithrombotic agent) and inhibits the activity of numerous Besides the obvious increased risk for bleeding events with
coagulating factors. Its effect on thrombus formation is im- its use, another problematic adverse effect is heparin-induced
mediate, in contrast to warfarin, which usually requires 3 to thrombocytopenia (HIT), a serious condition with potentially
5 days of use before therapeutic levels are reached and clin- life-threatening consequences. Expert consultation on the
ical effect is seen. management of a person who has HIT is required, for both
Heparin is available in the standard unfractionated form, immediate management and advice managing future throm-
with an average molecular weight of 15,000 daltons, and a boembolic events.
low-molecular-weight heparin (LMWH), with a molecular Long-term warfarin therapy usually follows an initial
weight of 4000 to 6500 daltons. Enoxaparin (Lovenox), heparin course in thromboembolic disease. Warfarin acts
dalteparin (Fragmin), and ardeparin (Normiflo) are exam- against coagulation factors II, VII, IX, and X as a result of
ples of LMWH. LMWH selectively enhances factor Xa and vitamin K antagonism. Warfarin is highly (99%) protein
TABLE 10-3
Indications and Length of Warfarin Treatment
Condition INR Duration of Therapy
ACUTE VENOUS THROMBOSIS
First episode 2.0–3.0 3–6 mo
High risk of recurrence 2.0–3.0 Indefinitely
With antiphospholipid syndrome or other 3.0–4.0 Lifelong
thrombophilia or coagulopathy
PREVENTION OF SYSTEMIC EMBOLUS
Tissue heart valves 2.0–3.0 3 mo
Valvular heart disease with history of 2.0–3.0 Indefinitely
thrombotic event
Mechanical heart valve (if initially 2.5–3.5 Indefinitely
indicated by valve type)
Acute myocardial infarction 2.0–3.0 As deemed by concomitant clinical problems
ATRIAL FIBRILLATION
Chronic or intermittent 2.0–3.0 Lifelong for chronic or intermittent atrial fibrillation
Cardioversion 2.0–3.0 With cardioversion, for 3 weeks before and 4 weeks
after conversion to sinus rhythm
bound, primarily to albumin, and has a narrow therapeutic given promptly. Vitamin K has little effect on hemostasis,
range. To avoid problems with warfarin therapy, patients however, until 24 hours after its administration. If immediate
must be well informed of the drug-to-drug and drug-to-food action is needed, such as in the case of hemorrhage or bleed-
interactions (Table 10–4). Because cigarette smoking likely ing into an enclosed space, fresh frozen plasma must be given.
increases thrombotic risk while reducing efficacy of warfarin, If anticoagulation therapy is continued after the bleeding cri-
developing a smoking cessation plan is important. sis, response to warfarin may fluctuate, which necessitates
Prothrombin time is used as the measure of the efficacy close monitoring.
of warfarin and is reported as an INR. INR prolongation is Thrombolytic therapy with streptokinase or a similar
seen in about 48 to 72 hours after the first warfarin dose product is also a therapeutic option for DVT. This treatment
(Table 10–5). Warfarin anticoagulant therapy is usually pre- is usually reserved for patients with extensive iliofemoral ve-
scribed for at least 3 to 6 months after the first DVT episode. nous thrombus and low risk for bleeding.
Studies have supported long-term low-intensity (INR 1.5 to With a mortality rate of 20% to 40%, PE is a feared com-
2.0) warfarin anticoagulation to minimize thrombus risk even plication of DVT. The diagnosis is often missed, however,
after a first DVT episode. With a second episode, abnormal because the presentation is nonspecific. PE presentation
clotting should be suspected, and anticoagulant therapy usually includes dyspnea, pleuritic chest pain, pleural fric-
should be lifelong. In the presence of a clotting disorder, such tion rub, and accentuation of the pulmonic component of S2
as factor V Leiden mutations or antiphospholipid antibodies, heart sound; tachypnea (respiratory rate ≥16/min) and
anticoagulation should also be lifelong. tachycardia are nearly universal findings. DVT signs and
Approximately 2% to 10% of patients taking warfarin de- symptoms are often noted, but their absence should not
velop a problematic bleeding episode. This complication is eliminate the consideration of PE. Hemoptysis, cyanosis,
rarely seen, however, in patients with INR of 2.0 to 3.0. In the and change in level of consciousness are rarely encountered
presence of significant bleeding in patients taking warfarin, but are often considered to be an expected part of the
the drug should be discontinued, and vitamin K should be presentation. The use of the Wells predictive scale can be
TABLE 10-4
Warfarin: Drug and Food Interactions
Note: The concomitant use of warfarin with one of the following medications is not contraindicated. The prescriber and
patient need to be aware, however, of the impact of concurrent use on anticoagulation state.
Increased Anticoagulant Effect Decreased Anticoagulant Effects Variable Effect
Alcohol (particularly in presence of liver disease) Barbiturates Phenytoin—increased
Amiodarone Carbamazepine and decreased effects
Cimetidine Chlordiazepoxide noted, and increase in
Clofibrate Cholestyramine phenytoin level
Cotrimoxazole Griseofulvin
Erythromycin Rifampin
Clarithromycin Sucralfate
Fluconazole Azathioprine
Isoniazid Cyclosporine
Metronidazole Trazodone
Miconazole
Omeprazole, other proton pump inhibitors
Piroxicam
Propafenone
Propranolol
Acetaminophen (inconsistent)
Ciprofloxacin
Disulfiram
Itraconazole
Quinidine
Tamoxifen
Tetracyclines including doxycycline, minocycline
TABLE 10-5
Warfarin: Initiation of Therapy and Long-Term Management
• Warfarin’s anticoagulation effect takes at least 3 days of use to achieve. If immediate anticoagulation effect is needed,
initiate heparin therapy while also starting warfarin 5–10 mg qd for 2 days, then reduce to 5 mg qd. Check INR daily;
when at goal, discontinue heparin.
• If there is no need for immediate anticoagulation, warfarin should be initiated at 5 mg/d, anticipating therapeutic effect
in ~4 days. In older adults, initiate warfarin at 4 mg/d, anticipating therapeutic effect in 6–7 days.
• If INR is not within goal during warfarin therapy, check for adherence to recommended therapy before adjusting dose
and use of medications or foods that may interfere with warfarin effect.
INR GOAL 2.0–3.0 ACTION
At desired range Repeat INR at interval determined by duration of therapeutic INR and underlying
condition
• 4–6 weeks if stable condition and typically therapeutic INR
• At least weekly when underlying condition can affect coagulation state (e.g.,
malignancy, clotting disorder, use of medications that can influence warfarin
effect)
INR <2.0 • Increase total weekly dose by 5%–20%
• Repeat INR two to three times/week until within desired range
INR 3.0–3.5 • Decrease total weekly dose by 5%–15%
• Repeat INR two to three times/week until within desired range
INR 3.6–4.0 • Consider withholding 1 daily dose, decrease total weekly dose by 10%–15%
• Repeat INR two to three times/week until within desired range
INR >4.0 without complications • Consider withholding 1 daily dose, decrease total weekly dose by 10%–20%
and no indication for rapid • Repeat INR two to three times/week until within desired range
reversal of anticoagulation effect
INR >4.0 and need for rapid • Vitamin K 2.5–5 mg PO x 1–2 doses or 3 mg subcutaneous (SC) or slow intra-
reversal of anticoagulant effect venous (IV) route
INR GOAL 2.5–3.5 ACTION
At desired range • Repeat INR at interval determined by duration of therapeutic INR and underly-
ing condition 4–6 weeks if stable. Repeat INR at interval determined by dura-
tion of therapeutic INR and underlying condition
• 4–6 weeks if stable condition and typically therapeutic INR
• At least weekly when underlying condition can affect coagulation state (e.g.,
malignancy, clotting disorder, use of medications that can influence warfarin
effect)
INR <2.0 • Increase weekly dose by 10%–20%
• Repeat INR two to three times/week until within desired range
INR 2.0–2.4 • Increase weekly dose by 5%–15%
• Repeat INR two to three times/week until within desired range
INR 3.5–4.6 • Decrease weekly dose by 5%–15%
• Repeat INR two to three times/week until within desired range
INR 4.7–5.2 • Consider withholding 1 dose, decrease weekly dose by 10%–20%
• Repeat INR two to three times/week until within desired range
INR >5.2 without complications • Withhold 1–2 doses, decrease weekly dose by 10%–20%
and no indication for rapid • Repeat INR two to three times/week until within desired range
reversal of anticoagulation effect
INR >5.2 or need for rapid reversal • Vitamin K 2.5 mg PO x 1–2 doses or 3 mg SC or slow IV route
of anticoagulant effect
helpful in forming the diagnosis (see Table 10–2). The use of 37. Comprehensive treatment for a person with peripheral
d-dimer testing in PE diagnosis has the same limitations as occlusive arterial disease and diabetes mellitus includes
noted in DVT diagnosis. Imaging with spiral CT pulmonary all of the following except:
angiography is a helpful confirmatory test. A. daily aspirin use.
In treating patients with PE, thrombolytic therapy is often B. lipid lowering with an HMG-CoA reductase in-
used, followed by heparin and then warfarin therapy for a hibitor (statin).
minimum of 3 months. If the patient is not a candidate for C. application of a topical antimicrobial to the affected
long-term anticoagulation therapy, or if clotting occurs de- area.
spite adequate anticoagulation therapy, a vena cava filter is D. maintenance of glycemic control.
usually used to minimize the risk of future PE. Follow-up is
38. Treatment options for venous stasis ulcers in the lower
recommended as needed to monitor INR and the underlying
extremities include:
clinical condition. Additional therapies for long-term anti-
A. cleansing with hydrogen peroxide.
coagulation include the use of oral factor Xa inhibitors such
B. applying Burow solution.
as rivaroxaban (Xarelto). Given the proliferation of warfarin
C. prescribing a systemic corticosteroid.
alternatives, prudent practice dictates keeping abreast of cur-
D. applying a moisture-retaining dressing.
rent evidence-based practice in this area.
39. Cilostazol (Pletal) should be used with great caution in
DI SCUS SION SOURCES the presence of which of the following diagnoses?
Ferri F. Pulmonary Embolism. In: Ferri F. Practical Guide to the Care A. diabetes mellitus
of the Medical Patient, 8. Philadelphia: Elsevier Mosby; 2011. B. heart failure
Ouellette, D.R. eMedicine. http://www.emedicine.medscape.com/ C. hypertension
article/300901-workup, Pulmonary Embolism Workup. D. dyslipidemia
Patel, K. eMedicine. http://www.emedicine.medscape.com/article/
1911303-overview, Deep Vein Thrombosis. 40. Clinical presentation of acute lower-extremity athero-
Spence, R.K. eMedicine. http://emedicine.medscape.com/article/ sclerotic arterial disease most likely includes:
210467-overview, Nonplatelet Hemostatic Disorders. A. pain and paresthesia.
B. pallor and pulselessness.
C. poikilothermy.
Peripheral Vascular D. paralysis or loss of limb strength.
Disease 41. More common etiologies of acute lower-extremity
atherosclerotic arterial disease include:
33. Which of the following is the most potent risk factor for A. arterial embolism with underlying atrial fibrillation.
lower-extremity vascular occlusive disease? B. chronic venous insufficiency.
A. hypertension C. extension of venous thrombosis.
B. older age D. vessel trauma.
C. cigarette smoking
D. leg injury 42. In ordering imaging studies in a patient with peripheral
vascular disease, the use of radiocontrast medium can
34. Clinical presentation of advanced lower-extremity potentially result in:
vascular disease includes all of the following except: A. hepatic failure.
A. resting pain. B. renal failure.
B. absent posterior tibialis pulse. C. bone marrow suppression.
C. blanching of the foot with elevation. D. thrombocytopenia.
D. spider varicosities.
43. The anticipated result of débridement as part of the
35. Drug therapy that had previously thought to worsen treatment of venous stasis ulcers includes all of the
symptoms in lower-extremity arterial vascular disease following except:
includes the use of: A. enhanced tissue granulation.
A. beta2-agonists. B. encouragement of reepithelialization.
B. calcium channel antagonists. C. reduction of bacterial burden.
C. direct thrombin inhibitors. D. prevention of peripheral arterial disease.
D. beta-adrenergic antagonists
36. Typically, the earliest sign of lower-extremity venous True or False
insufficiency is:
A. edema. 44. In the treatment of a venous stasis ulcer that is not
B. altered pigmentation. responding to standard therapy, additional thera-
C. skin atrophy. peutic options include hyperbaric oxygen therapy
D. shiny skin. (HBOT).
4074_Ch10_247-260 20/11/14 10:55 AM Page 257
45. A few as 3 days of malnutrition in the form of in- pain is worse with exertion and usually responds promptly
adequate protein-calorie intake can impair normal to cessation of the trigger activity. Claudication is caused by
wound-healing mechanisms. the inability of the diseased vessel to vasodilate and allow for
increased blood flow to handle the metabolic demands asso-
ciated with physical activity.
Answers Disease caused by atherosclerosis in the distal aorta or
iliac, femoral, or popliteal arteries results in the most com-
33. C. 38. D. 43. D. mon clinical form and is typically called lower-extremity oc-
34. D. 39. B. 44. True clusive disease. Presentation varies according to the area of
35. D. 40. A. 45. True vessel disease and dysfunction (Table 10–6). Atherosclerotic
36. A. 41. A. and calcific lesions usually cause occlusive disease of the aorta
37. C. 42. B. and its branches. Disease is often asymmetrical because the
distribution of obstructive lesions usually occurs in segments,
Peripheral vascular disease (PVD) refers to a group of con- rather than continuously.
ditions in which there is a reduction of blood flow to the ex- The diagnosis of lower-extremity occlusive disease is made
tremities. With PVD peripheral vascular disease, the venous, from clinical presentation and select diagnostic studies.
arterial, or lymphatic system is often affected. Risk factors for Doppler ultrasonography is often used first line to confirm
arterial occlusive disease, caused by extensive atherosclerosis, the diagnosis and monitor disease progress. Magnetic reso-
include diabetes mellitus, hypertension, and hyperlipidemia; nance angiography has largely replaced standard angiography
tobacco use is the most potent risk factor, in particular in as the “gold standard” of PVD imaging. High-definition com-
progressive disease. In the absence of these risk factors, pe- puterized tomography (CT) with contrast is also an option.
ripheral arterial occlusive disease is rare except in advanced In studies that require the use of contrast, assessment of renal
age; the condition is found in 10% of older adults. Clinical function preprocedure is critical because the risk of contrast-
presentation usually includes a patient complaint of claudi- induced renal impairment is greatest in the presence of
cation, which is a reproducible ischemic muscle pain where diffuse arterial disease. Angiography, although an invasive
TABLE 10-6
Clinical Presentation of Lower-Extremity Vascular Occlusive Disease
Patient Presentation Clinical Significance
Burning sensation or ache with walking Usually indicates femoropopliteal arterial disease
Pain in calf, hip, or buttock with activity, relieved by rest Classic report in intermittent claudication
Foot pain at rest Blood flow to extremity ≤10% of normal; indicates pro-
found disease and gangrene risk
Numbness, coldness, pain in extremity More common than claudication report in the older adult
Absent posterior tibialis pulse This pulse is always present in a healthy adult
Dorsalis pedis pulse absent in ~5% of healthy adults
Nail thickening Because numbness is often also a problem, meticulous nail
hygiene while minimizing injury is needed
Onychomycosis is often seen in PVD
Absent dorsalis pedis and tibial pulses Proximal pulses may remain palpable even in presence of
significant occlusive disease
≤10% of normal blood flow to extremity
Blanching of foot with elevation, poor capillary return, Most common with long-standing poorly controlled
dependent rubor diabetes mellitus
Ache in anterior tibial muscles, foot, and metatarsal arch Can be confused with peripheral neuropathy
with activity
Sexual dysfunction Most common in presence of smoking, hyperlipidemia,
diabetes mellitus
PVD contributes to its development but is likely one of
many influencing factors
procedure, gives the best measure of the extent of the disease; disease and diabetes mellitus, needs to be optimized preoper-
the information gained from angiography is sometimes atively, and surgical intervention for other forms of vascular
needed before clinicians proceed with percutaneous treat- disease also needs to be considered. Angioplasty, grafting pro-
ment or surgery. cedures, and/or vascular stenting can help improve blood flow
Because patients with lower-extremity arterial occlusive and minimize symptoms and complications. Owing to the
disease usually have other health problems, prevention complexity of care, intervention for peripheral arterial ulcers
and intervention measures, such as aggressive risk factor usually requires specialty consultation.
reduction—including cessation of tobacco use and blood Although lower-extremity arterial occlusive disease is
pressure, glucose, and lipid control—help improve overall characterized by a predictable, slower, progressive process,
well-being. In addition, the presence of concomitant disease, acute occlusion can occur. Caused by embolic, thrombotic,
such as cardiovascular or cerebrovascular disease, often limits or traumatic events, acute limb ischemia usually manifests
the patient’s ability to be physically active. Exercise such with the so-called six Ps: pain, paresthesia (the two most com-
as walking helps to minimize symptoms and should be mon manifestations), pallor, pulselessness, poikilothermy
encouraged; although exercise was previously thought to (variation in limb temperature), and paralysis. When acute
enhance collateral blood flow, the benefit is now recognized limb ischemia is caused by arterial embolism, the origin of
as being a result of improving oxygen extraction for the skele- the clot is usually the heart, with underlying atrial fibrillation.
tal muscles. Meticulous skin care is needed to avoid break- When caused by arterial thrombosis, chronic arteriosclerotic
down, and periodic podiatric care is recommended. In the occlusive disease is usually at the core of the problem. Prompt
presence of PVD, skin and nail disruptions are particularly assessment is needed to support the diagnosis. In the pres-
difficult to heal. ence of acute arterial occlusion, anticoagulation therapy with
Pharmacotherapy for individuals with lower-extremity heparin is standard along with consideration of procedural
arterial occlusive disease often yields variable results. The intervention to relieve the obstruction.
use of pentoxifylline (Trental), a medication thought to re- Chronic venous insufficiency is a common sequela of
duce blood viscosity and improve blood flow by altering the DVT and leg trauma, although the absence of this history
ability of red blood cells to pass through diseased vessels, is noted in about 25% of patients. There is decreased venous
can be helpful in increasing exercise tolerance. Outcomes return because of vessel damage, and lower-extremity edema
with pentoxifylline use are variable; patients without is usually the earliest sign. Symptoms usually include leg
diabetes mellitus and milder symptoms seem to gain the aching and itchiness. Over time, the edema progressively
most benefit. Cilostazol (Pletal), a medication that impairs worsens; this results in the development of thin, shiny, at-
platelet aggregation and increases vasodilation, is often rophic skin, often with brown pigmentation. Subcutaneous
helpful but has limitations. Its use is contraindicated in tissue thickens and becomes fibrous.
heart failure and carries an approximately 20% rate of The stage is set for stasis ulceration. Inflamed pruritic
adverse effects, including headache, dizziness, and diarrhea. patches usually precede the formation of an irregular ulcera-
The use of these medications does not alter the course of tion with a clean base. Yellow eschar is occasionally found.
the disease, but rather reduces symptoms. Daily aspirin and Therapies enhancing venous flow (i.e., limb elevation, exer-
statin therapy is usually indicated as part of a comprehen- cise, and compression therapy) improve oxygen transport
sive plan to reduce cardiovascular risk; concomitant control to the skin and subcutaneous tissues, decrease edema, and
of diabetes mellitus, which is often present, is critical. The reduce inflammation and can be utilized for any patient with
use of beta blockers (beta adrenergic antagonists) has been symptoms and signs of chronic venous disease. Compression
historically noted to worsen claudication symptoms; the use therapy has long been considered an important part of ve-
of the drug class in patients with PVD was at one time dis- nous ulcer therapy; high compression bandages, exerting 30 to
couraged. However, the use beta blockers of often is recom- 30 mm Hg at the ankle, are most effective. The use of a flexible
mended to treat the concomitant conditions including compression bandage is preferred over a rigid compression
cardiovascular disease found in the person with PVD. dressing such as an Unna boot. If compression therapy is not
Clopidogrel (Plavix) has been used in therapy for lower- successful when used alone, high-dose pentoxifylline therapy
extremity arterial occlusive disease, particularly in patients can be added to compression therapy. Pentoxifylline used as
who are allergic to aspirin or do not tolerate aspirin or have an adjunct to compression is more effective than medication
an underlying hypercoagulable state; its use prevents fibrino- without compression. When used without compression, it
gen binding and may reduce the risk of thrombus formation. is more effective than placebo or no treatment at a dose of
Warfarin therapy with a goal INR of 2.0 to 3.0 is occasionally 800 mg three times a day.
used for certain patients with high thrombus risk, particularly Although no particular wound care regimen has been
patients who have undergone a vascular procedure. The use associated with more rapid ulcer healing, ulcer débridement,
of vasodilators and anticoagulants does not appear to alter the various topical products, and hyperbaric oxygen are formi-
natural history of the disease. Surgical evaluation for percu- dable options to consider when deciding on a wound care
taneous or open procedures should be part of the care of treatment plan. Wound débridement is an essential compo-
patients with lower-extremity occlusive disease; medical man- nent in the management of venous ulcers. The presence of
agement of concomitant problems, such as cardiovascular devitalized tissue increases the potential for local bacterial
4074_Ch10_247-260 20/11/14 10:55 AM Page 259
infection and sepsis. Removal of necrotic tissue and fibri- are approximately 1.25 to 1.5 g of protein per kilogram of body
nous debris in venous ulcers aids in the formation of healthy weight and 30 to 35 calories/kg; these requirements are in-
granulation tissue and enhances reepithelialization. Surgical creased in the presence of sizable wounds.
débridement is occasionally needed, especially if an advanced The prognosis for healing of chronic wounds varies with
therapy such as a bioengineered skin graft is being consid- the etiology of the wound and the general health status of the
ered. Slow-release antiseptic bandages are helpful in reducing patient. If wound healing continues to be unsuccessful, a
bacterial burden. Moisture-retaining dressings improve pain biopsy specimen of the lesion should be obtained to rule out
and have utility in autolytic débridement. malignancy. Given the complexity of care in patients with ve-
Wounds that fail to heal are typically hypoxic. Multiple nous ulcers or chronic wounds, a referral to specialty wound
components of the wound healing process are affected by care is usually indicated. Indications for a specialty wound
oxygen concentration or gradients, which explains why hy- care referral include arterial insufficiency, nonhealing ulcers,
perbaric oxygen therapy (HBOT) can be an effective therapy ulcer recurrence, persistent stasis dermatitis, and suspected
to treat chronic wounds. HBOT significantly increases the contact dermatitis.
oxygen saturation of plasma, raising the partial pressure
available to tissues. HBOT should be used in conjunction D I S C U SSI O N S O U R C E S
with a complete wound healing care plan. As with all chronic Alguire, P.C. UpToDate. http://www.uptodate.com/contents/
wounds, other underlying host factors (large vessel disease, medical-management-of-lower-extremity-chronic-venous-
glycemic control, nutrition, infection, presence of necrotic disease?source=search_result&search=medical+management+of
tissue, fluid off-loading) must be simultaneously addressed +lower+extremity&selectedTitle=1~150, Medical management
of lower extremity chronic venous disease, accessed 2/12/13.
in order to have the highest chance of successful healing and
Chahin, C. eMedicine. http://www.emedicine.medscape.com/article/
functional capacity. 423649-overview, Imaging in Lower-Extremity Atherosclerotic
Nonhealing wounds not only lack oxygen, but also are Arterial Disease.
deficient in viable nutrients. Adequate nutrition is an often- Latham, E. eMedicine. http://www.emedicine.medscape.com/article/
overlooked requirement for normal wound healing. Address 1464149-overview#aw2aab6b7, Hyperbaric oxygen therapy.
protein-calorie malnutrition and deficiencies of vitamins and Stillman, R. eMedicine. http://www.emedicine.medscape.com/article/
minerals. Inadequate protein-calorie nutrition, even after just 194018-treatment#a25, Wound care treatment & management.
a few days of starvation, can impair normal wound-healing Torre, J. eMedicine. http://www.emedicine.medscape.com/article/
mechanisms. For healthy adults, daily nutritional requirements 1298452-overview, Chronic Wounds.
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Endocrine Disorders 11
6. The mechanism of action of metformin (Glucophage®)
Diabetes Mellitus is as:
1. Which of the following characteristics applies to type 1 A. an insulin-production enhancer.
diabetes mellitus (DM)? B. a product virtually identical in action to
A. Significant hyperglycemia and ketoacidosis result sulfonylureas.
from lack of insulin. C. a drug that increases insulin action in the peripheral
B. This condition is commonly diagnosed on routine tissues and reduces hepatic glucose production.
examination or work-up for other health problems. D. a facilitator of renal glucose excretion.
C. Initial response to oral sulfonylureas is usually 7. Generally, testing for type 2 DM in asymptomatic,
favorable. undiagnosed individuals older than 45 years should be
D. Insulin resistance (IR) is a significant part of the conducted every ____.
disease. A. year.
2. Which of the following characteristics applies to B. 3 years
type 2 DM? C. 5 years
A. Major risk factors are heredity and obesity. D. 10 years
B. Pear-shaped body type is commonly found. 8. You are seeing 17-year-old Cynthia. As part of the visit,
C. Exogenous insulin is needed for control of disease. you consider her risk factors for type 2 DM would likely
D. Physical activity enhances IR. include all of the following except:
3. You consider prescribing insulin glargine (Lantus®) A. obesity.
because of its: B. Native American ancestry.
A. extended duration of action. C. family history of type 1 DM.
B. rapid onset of action. D. personal history of polycystic ovary syndrome.
C. ability to prevent diabetic end-organ damage. 9. Criteria for the diagnosis of type 2 DM include:
D. ability to preserve pancreatic function. A. classic symptoms regardless of fasting plasma glucose
4. After use, the onset of action of lispro (Humalog®) measurement.
occurs in: B. plasma glucose level of 126 mg/dL (7 mmol/L) as a
A. less than 30 minutes. random measurement.
B. approximately 1 hour. C. a 2-hour glucose measurement of 156 mg/dL
C. 1 to 2 hours. (8.6 mmol/L) after a 75 g anhydrous glucose load.
D. 3 to 4 hours. D. a plasma glucose level of 126 mg/dL (7 mmol/L) or
greater after an 8 hour or greater fast on more than
5 Which of the following medications should be used one occasion.
with caution in a person with suspected or known sulfa
allergy? See full color images of this topic
A. metformin on DavisPlus at
B. glyburide http://davisplus.fadavis.com |
C. rosiglitazone Keyword: Fitzgerald
D. NPH insulin
261
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10. The mechanism of action of pioglitazone is as: 18. All of the following are risks for lactic acidosis in
A. an insulin-production enhancer. individuals taking metformin except:
B. a reducer of pancreatic glucose output. A. presence of chronic renal insufficiency.
C. an insulin sensitizer. B. acute dehydration.
D. a facilitator of renal glucose excretion. C. radiographic contrast dye use.
D. history of allergic reaction to sulfonamides.
11. Which of the following should be the goal measure-
ment in treating a person with DM and hypertension? 19. Secondary causes of hyperglycemia potentially include
A. blood pressure less than 140 mm Hg systolic and less the use of all of the following medications except:
than 90 mm Hg diastolic A. high dose niacin.
B. hemoglobin A1c equal to or greater than 7% B. systemic corticosteroids.
C. triglyceride 200 to 300 mg/dL (11.1 to C. high dose thiazide diuretics.
16.6 mmol/L) D. low dose angiotensin receptor blockers.
D. high-density lipoprotein (HDL) 35 to 40 mg/dL
20. Hemoglobin A1c best provides information on glucose
(0.9 to 1.03 mmol/L)
control over the past:
12. In caring for a patient with DM, microalbuminuria A. 1 to 29 days
measurement should be obtained: B. 21 to 47 days.
A. annually if urine protein is present. C. 48 to 63 days.
B. periodically in relationship to glycemia control. D. 64 to 90 days.
C. yearly.
21. Which of the following statements is not true concern-
D. with each office visit related to DM.
ing the effects of exercise and IR?
13. The mechanism of action of sulfonylureas is as: A. Approximately 80% of the body’s insulin-mediated
A. an antagonist of insulin receptor site activity. glucose uptake occurs in skeletal muscle.
B. a product that enhances insulin release. B. With regular aerobic exercise, IR is reduced by
C. a facilitator of renal glucose excretion. approximately 40%.
D. an agent that can reduce hepatic glucose production. C. The IR-reducing effects of exercise persist for
48 hours after the activity.
14. When caring for a patient with DM, hypertension and
D. Hyperglycemia can occur as a result of aerobic
persistent proteinuria, the NP prioritizes the choice of
exercise.
antihypertension and prescribes:
A. furosemide. 22 to 25. With an 8 a.m. dose of the following insulin forms,
B. methyldopa. followed by and inadequate dietary intake and/or excessive
C. fosinopril. energy use, at approximately what time would hypoglycemia
D. nifedipine. be most likely to occur?
15. Clinical presentation of type 1 DM usually includes all 22. Lispro _______________________________________
of the following except:
23. Regular insulin ________________________________
A. report of recent unintended weight gain.
B. ketosis. 24. NPH insulin ___________________________________
C. thirst.
25. Insulin glargine (Lantus) _________________________
D. polyphagia.
26. The meglitinide analogues are particularly helpful
16. Which of the following should be periodically moni-
adjuncts in type 2 DM care to minimize risk of:
tored with the use of a biguanide?
A. fasting hypoglycemia.
A. creatine kinase (CK)
B. nocturnal hyperglycemia.
B. alkaline phosphatase (ALP)
C. postprandial hyperglycemia.
C. alanine aminotransferase (ALT)
D. postprandial hypoglycemia.
D. creatinine (Cr)
27. What is the most common adverse effect noted with
17. Which of the following should be periodically moni-
alpha-glucosidase inhibitor use?
tored with the use of a thiazolidinedione?
A. gastrointestinal upset
A. CK
B. hepatotoxicity
B. ALP
C. renal impairment
C. ALT
D. symptomatic hypoglycemia
D. Cr
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28. Which of the following statements best describes the 34. The use of a thiazolidinedione is not recommended in
Somogyi effect? all of the following clinical scenarios except:
A. Insulin-induced hypoglycemia triggers excess A. a 57-year-old man who is taking a nitrate.
secretion of glucagon and cortisol, leading to B. a 62-year-old woman with heart failure.
hyperglycemia. C. a 45-year-old man who is using insulin.
B. Early morning elevated blood glucose levels result in D. a 35-year-old patient with newly diagnosed type 2 DM.
part from growth hormone and cortisol-triggering
35. In an older adult with type 2 DM with gastroparesis, the
hepatic glucose release.
use of which of the following medications should be
C. Late evening hyperglycemia is induced by inade-
avoided?
quate insulin dose.
A. insulin glargine (Lantus)
D. Episodes of postprandial hypoglycemia occur as a
B. insulin aspart (NovoLog®)
result of inadequate food intake.
C. glimepiride (Amaryl®)
29. Intervention in microalbuminuria for a person with D. exenatide (Byetta)
DM includes: (More than one can apply.)
36. Metformin should be discontinued for the day of and up
A. improved glycemic control.
to 48 hours after surgery because of increased risk of:
B. strict dyslipidemia control.
A. hypoglycemia.
C. use of an optimized dose of an angiotensin-
B. hepatic impairment.
converting enzyme inhibitor (ACEI) or
C. lactic acidosis.
angiotensin receptor blocker (ARB).
D. interaction with most anesthetic agents.
D. The use of an ACEI with an ARB.
37. All the following medications are recommended for
30. Hemoglobin A1c should be tested:
treatment of concomitant hypertension when seen with
A. at least annually for all patients.
type 2 DM except:
B. at least two times a year in patients who are meeting
A. beta blockers.
treatment goals and who have stable glycemic
B. calcium channel blockers
control.
C. alpha adrenergic receptor antagonist.
C. monthly in patients whose therapy has changed or
D. angiotensin receptor blockers.
who are not meeting glycemic goals.
D. only via standardized laboratory testing because of 38. Which of the following best describes the physical
inaccuracies associated with point-of-service testing. activity recommendations such as brisk walking for a
55-year-old woman with newly diagnosed type 2
31. The mechanism of action of the DPP-4 inhibitors is as:
diabetes mellitus? (More than one can apply.)
A. a drug that increases levels of incretin, increasing
A. The goal should be for a total increased physical
synthesis and release of insulin from pancreatic beta
activity of 150 min per week or more.
cells.
B. Increased physical activity is recommended for at
B. a product virtually identical in action to sulfony-
least 30 minutes per day, at least three times per
lureas.
week with no more than 48 hours without exercise.
C. a drug that increases insulin action in the peripheral
C. Some form of resistance exercise such as lifting
tissues and reduces hepatic glucose production.
dumbbells or using an exercise band should be in-
D. a facilitator of renal glucose excretion.
cluded at least three times per week.
32. The mechanism of action of exenatide (Byetta®) is as: D. Vigorous aerobic or resistance activity is potentially
A. a drug that stimulates insulin production in contraindicated in the presence of proliferative or
response to increase in plasma glucose. severe nonproliferative retinopathy due to the
B. a product virtually identical in action to possible risk of vitreous hemorrhage or retinal
sulfonylureas. detachment.
C. a drug that increases insulin action in the peripheral
39. In teaching a patient with type 2 diabetes mellitus about
tissues and reduces hepatic glucose production.
using rapid-acting insulin to help with the management
D. a facilitator of renal glucose excretion.
of post-prandial hyperglycemia, the NP advises that the
33. You see an obese 25-year-old man with acanthosis usual dose is ____ unit per 15 grams of carbohydrate.
nigricans and consider ordering: A. 1
A. FBS. B. 2
B. LFT. C. 3
C. RPR. D. 4
D. ESR.
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40. Which of the following patients has impaired glucose 46. The use of which of the following medications has the
tolerance? potential for causing the greatest reduction in HbA1c?
A. a 70-year-old man with a fasting glucose of 109 mg/dl A. A biguanide
(6.05 mmol/L) B. A thiazolidinedione
B. an 84-year-old woman with a 1 hour post-prandial C. A sulfonylurea
glucose of 98 mg/dl (5.44 mmol/L) D. An insulin form
C. a 33-year-old man with a hemoglobin A1c of 5.4%
47. Which of the following best describes ethnicity and in-
D. a 58-year-old woman with a 2 hour post-prandial
sulin sensitivity?
glucose of 152 mg/dl (8.44 mmol/L)
A. Little variation exists in insulin sensitivity among
41. Mr. Samuels is a 58-year-old man with type 2 DM different ethnic groups.
who is using a single 10 unit daily dose of the long- B. African Americans are typically less sensitive to the
acting insulin glargine. His fasting blood glucose has effects of insulin when compared to people of
been between 141 to 180 mg/dL (7.8 to 10 mmol/L). European ancestry.
Which of the following best describes the next step in C. Mexican Americans are likely the most insulin
his therapy? sensitive ethnic group residing in North America.
A. Continue on the current glargine dose. D. The degree of insulin sensitivity has little influence
B. Increase his glargine dose by 4 units per day. on insulin production.
C. Increase his glargine dose by 1 unit per day.
48. Recommended A1c goal in a 79-year-old woman with
D. Increase his glargine dose by 6 units per day.
a 20-year history of type 2 diabetes mellitus who has
42. Which of the following classes of medications is com- difficulty ambulating, uses a walker, and has a cardiac
monly recommended as part of first line therapy in the ejection fraction of 35% and a history of heart failure
newly diagnosed person with type 2 diabetes? should be equal to or less than:
A. Alpha-glucosidase inhibitor A. 7%
B. Meglitinide B. 7.5%
C. Thiazolidinedione C. 8%
D. Biguanide D. 8.5%
43. Pertaining to the use of sliding scale insulin in response 49. Consideration should be given to setting A1c goal in a
to elevated blood glucose, which of the following best 22-year-old man with a 8-year history of type 1 diabetes
describes current best practice? mellitus who has not comorbid conditions equal to or
A. The use of this type of sliding-scale insulin therapy at less than:
is discouraged as this method treats hyperglycemia A. 5.5%
after it has already occurred. B. 6%
B. Sliding scale insulin in response to elevated C. 6.5%
glucose is a safe and helpful method of treating D. 7%
hyperglycemia.
50. The use of exenatide has been associated with the
C. Delivering insulin in this manner is acceptable
development of:
within the acute care hospital setting only.
A. leukopenia.
D. The use of the sliding insulin scale is appropriate in
B. pancreatitis.
the treatment of type 1 DM only.
C. lymphoma.
44. In a healthy person, what percentage of the body’s total D. vitiligo
daily physiological insulin secretion is released as
51. The International Diabetes Federation’s diagnostic
basally?
criteria for metabolic syndrome include:
A. 10%
A. an obligatory finding of persistent hyperglycemia.
B. 25%
B. notation of ethnic-specific waist circumference
C. 50%
measurements.
D. 75%
C. documentation of microalbuminuria.
45. Five years or more after type 2 diabetes mellitus diagno- D. a family history of type 2 DM.
sis, which of the following medications is less likely to
52. Metformin has all of the following effects except:
be effective in controlling plasma glucose?
A. improved insulin-mediated glucose uptake.
A. Metformin
B. modest weight loss with initial use.
B. Pioglitazone
C. enhanced fibrinolysis.
C. Glipizide
D. increased LDL cholesterol production.
D. Insulin
4074_Ch11_261-292 20/11/14 11:00 AM Page 265
53. Cardiovascular effects of hyperinsulinemia include: Type 1 diabetes mellitus (DM) is polygenetic disease that re-
A. decreased renal sodium reabsorption. sults from autoimmune induced pancreatic beta cell destruc-
B. constricted circulating volume. tion with resulting insulin deficiency. This disease usually
C. greater responsiveness to angiotensin II. occurs in persons younger than 30 years, with symptomatic
D. diminished sympathetic activation. presentation often comprising involuntary weight loss and
the classic “polys”: polydipsia, polyphagia, and polyuria. If
54. Which of the following is an unlikely consequence of
type 1 DM is associated with ketoacidosis, DM presentation
untreated metabolic syndrome and IR in a woman of
can be dramatic, with severe dehydration, abdominal pain,
reproductive age?
vomiting, and decreased level of consciousness. In any event,
A. hyperovulation
prompt intervention with appropriate insulin therapy is in-
B. irregular menses
dicated. Lifelong insulin therapy is required, most often
C. acne
through the use of basal insulin with boluses of short-acting
D. hirsutism
insulin to provide coverage for carbohydrate intake with
55. Acanthosis nigricans is commonly noted in all of the meals and snacks. This can be done with multiple insulin in-
following areas except: jections or through the use of an insulin pump (Table 11–1).
A. groin folds. Insulin resistance (IR) is a genetically predetermined and
B. axilla. environmentally modified condition that is central to
C. nape of the neck. the pathogenesis of type 2 DM. In IR, there is a reduced sen-
D. face. sitivity in the tissues to insulin’s action at a given concen-
tration, which causes a subnormal effect on glucose
metabolism. Hyperglycemia results, which stimulates pan-
Answers creatic insulin production in an effort to reduce the blood
glucose level. Euglycemia occurs, albeit in the presence of
1. A. hyperinsulinemia. Elevated fasting insulin levels are noted
26. C.
2. A. to be an independent predictor for ischemic heart disease.
27. A.
3. A. When coupled with acquired or lifestyle characteristics that
28. A.
4. A. contribute to IR, such as obesity, physical inactivity, and
29. A, B, C
5. B. high carbohydrate (more than 60% of total calories) diet,
30. B.
6. C. the body has greater difficulty maintaining a normal blood
31. A.
7. B. glucose level. Over time, generally after many years of IR,
32. A.
8. C. pancreatic beta cell deficiency usually occurs, resulting in
33. A.
9. D. impaired glucose tolerance, hyperglycemia, and the diagno-
34. D.
10. C. sis of type 2 DM.
35. D.
11. A. Numerous conditions are seen in conjunction with IR. In-
36. C.
12. C. creased IR is inversely related to decreased urinary uric acid
37. C.
13. B. clearance; this leads to a dramatic increase in the rate of gout.
38. A, B, C, D
14. C. Most women with polycystic ovary syndrome have IR. Acan-
39. B.
15. A. thosis nigricans, hyperpigmentation of the skin often in the
40. D.
16. D. neck and axilla, is also correlated with IR. This finding is most
41. B.
17. C. common in post puberty and young adults with IR and DM
42. D.
18. D. risk. A personal history of birth weight that was low for ges-
43. A.
19. D. tational age is also correlated with increased risk of IR. Poly-
44. C.
20. D. cystic ovary syndrome (PCOS) is largely an IR consequence.
45. C.
21. D. As anovulation is a consequence of PCOS, this condition is
46. D.
22. Approximately 8:30 to 9:30 a.m. the leading cause of endocrine-based female infertility. When
47. B.
(with peak of insulin dose) IR is reduced, ovulation often resumes with resulting en-
48. C.
23. Approximately 10 to 11 a.m. hanced fertility. In addition, when IR is reduced, acne and
49. B.
(with peak of insulin dose) hirsutism, usually a consequence of hyperandrogenism asso-
50. B.
24. Approximately 2 to 10 p.m. ciated with PCOS, are usually improved.
51. B.
(with peak of insulin dose) IR is recognized as contributing to a prothrombotic and
52. C.
25. Because insulin glargine (Lan- proatherogenic state. Plasminogen activator inhibitor, pro-
53. C.
tus) has no peak, an episode of duced by the liver and endothelial cells, inhibits fibrin degra-
54. A.
hypoglycemia is unlikely. If hy- dation by plasmin and enhances clot formation; increased
55. D.
poglycemia were to occur, the levels are found in atherosclerotic lesions. High levels of
episode could be protracted if triglyceride, very low density lipoprotein (VLDL), and oxi-
left untreated because of the dized low density lipoprotein (LDL) stimulate the production
protracted duration of activity of plasminogen activator inhibitor. Plasminogen activator in-
of the medication. hibitor levels are significantly correlated with increased body
4074_Ch11_261-292 20/11/14 11:00 AM Page 266
TABLE 11-1
Insulin: Type, Onset, Peak, and Duration of Action
Insulin Type Onset of Action Peak Duration of Action
Short-acting, rapid onset of action 15–30 min, give within 30 min–2.5 hr 3–6.5 hr
(Lispro insulin solution [Humalog]) 15 min or right after meals
Short-acting, rapid onset of action 10–20 min, give 5–10 min 1–3 hr 3–5 hr
(Aspart insulin solution [NovoLog]) before meals
Short-acting, rapid onset of action 10–15 min, give within 1–1.5 hr 3–5 hr
(Insulin glulisine [Apidra®]) 15 min or right after meals
Short-acting (Regular [Humulin R®, 30 min–1 hr 2–3 hr 4–6 hr
Novolin R®])
Intermediate-acting (NPH [Novolin 1–2 hr 6–14 hr 16–24 hr
N®, Humulin N®])
Long-acting (Insulin glargine Clinical effect about 1 hr None ≥24 hr
solution [Lantus]) after injection
Long-acting (Insulin detemir solution Unknown, not stated in 6–8 hr Dose dependent; 12 hr
[Levemir®]) product information but (minimal for 0.2 units/kg, 20 hr
appears to be about peak) for 0.4 units/kg. Albumin
1–2 hr from PK graphics bound
Source: Comparisons of insulins based on U.S. product information (2006). Prescribers Letter Detail-Document
#220309. Available at: Prescribersletter.com
mass and high plasma insulin levels, whereas levels are plasma glucose level of 200 mg/dL or greater (11.1 mmol/L or
reduced when endogenous insulin levels are reduced by greater) with classic diabetic symptoms, or those with an oral
exercise, weight loss, or insulin-sensitizing medications, such glucose tolerance result of 200 mg/dL or greater (11.1 mmol/L
as metformin and thiazolidinediones. or greater) at 2 hours. Glycosylated (or glycated) hemoglobin,
Although the correlation of obesity with IR and type 2 DM also known as hemoglobin A1c (or simply A1c), increases in
is well established, not all body fat types and distribution are proportion to the amount of circulating glucose. The most
equally problematic. Some persons with IR and type 2 DM abundant glycohemoglobin subtype of hemoglobin A1 is A1c,
are of normal weight, whereas others with IR never develop which constitutes about 4% to 6% of the body’s total hemoglo-
hyperglycemia. Obesity dramatically increases the risk of dia- bin. Glycohemoglobin circulates as part of the red blood cell
betes in a person with IR, however. “Apple-shaped” or central for about 90 to 120 days, the length of the red blood cell’s life
abdominal obesity comprises metabolically active fat and is span. As a result, measurement of hemoglobin A1c provides
associated with high insulin levels, IR, and high mobilization a method for evaluating glucose control over time; the meas-
rate of free fatty acids; high insulin levels are often associated urement best reflects blood glucose trends over the preceding
with increased appetite. This genetic makeup helped increase 90 days but best measures glucose control in the past 28 to
the likelihood of survival in times of famine. In these times of 42 days. Correlation with average plasma glucose and hemo-
plentiful food, however, IR helps promote fat storage. globin A1c is an important clinical tool and can be used for
Patients with type 2 DM are most often asymptomatic at reinforcement in patient counseling. The ADA advises that
onset. As a result, the American Diabetes Association (ADA) hemoglobin A1c can be used as a tool for diagnosing DM,
recommends periodic fasting plasma glucose screening every with a measure equal to or greater than 6.5% consistent
3 years in all adults, regardless of appearance of risk; the ra- with the diagnosis. The test should be repeated in an asymp-
tionale for this testing interval is that type 2 DM is unlikely tomatic adult with glucose less than 200 mg/dL (less than
to develop in a 3-year interval if initial glucose was normal. 11.1 mmol/L). A repeat test is not needed in the presence of
Testing should be considered at a younger age or be done DM symptoms or glucose levels of 200 mg/dL or greater
more frequently in individuals with or with acquisition of (11.1 mmol/L or greater) (Table 11–3).
type 2 DM risk factors (Table 11–2). Sadly, patients with increased risk for type 2 DM are missed
When a fasting plasma glucose threshold level of 126 mg/dL due to lack of testing. Patients with impaired glucose tolerance
or greater (7.0 mmol/L or greater) after an 8-hour fast is used, (IGT), impaired fasting glucose (IFG), or an A1c of 5.7% to
this testing is 98% specific and 40% to 88% sensitive for type 2 6.4% should be identified and treated with lifestyle modifica-
DM. Typically, wide-scale screening done according to these tion including a target weight loss of 7% of body weight and
guidelines yields a 6% true-positive rate. Additional ADA di- referred increasing physical activity to at least 150 min per
agnostic criteria for type 2 DM include a casual (random) week; adding metformin therapy is also a consideration. These
4074_Ch11_261-292 20/11/14 11:00 AM Page 267
TABLE 11-2
Diabetes Mellitus Testing Recommendations
Criteria for Diabetes Testing in Asymptomatic Adults
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors:
• Physical inactivity
• First degree relative with type 2 diabetes
• Members of a high risk ethnic population (e.g., African American, Latino, Native American, Asian American, Pacific
Islander)
• Women who delivered a baby weighing >9 lb (4.08 kg) or were diagnosed with gestational DM (GDM) (screen
women with recent dx GDM at 6–12 weeks postpartum)
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
• Women with polycystic ovary syndrome
• A1c ≥5.7% (.057 proportion), impaired glucose tolerance (IGT), or impaired fasting glucose (IFG) on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
• History of cardiovascular disease (CVD)
In the absence of the above criteria, testing diabetes should begin at age 45 years.
If results are normal, testing should be repeated at least at 3 year intervals, with consideration of more frequent testing
depending on initial results and risk status.
TABLE 11-3
Diagnosis of Diabetes Mellitus, Categories of Increased Risk for Diabetes
Oral Glucose
Tolerance Test
Plasma Glucose (OGTT) A1c
Diabetes mellitus Fasting (no caloric in- 2-hr plasma glucose A1c ≥6.5%
take for ≥8 h) ≥126 ≥200 mg/dL No special patient prepara-
mg/dL ( ≥7.0 mmol/L) (≥11.1 mmol/L) tion, can be done nonfast-
Random ≥200 mg/dL after a 75 G ing, no protracted time
(≥11.1 mmol/L) with glucose load needed to test like OGTT,
symptoms including improved standardization
polyphagia, polyuria, of A1c measurement.
polydipsia, and unex- A1c repeat recommended
plained weight loss or in asymptomatic adult with
hyperglycemic crisis glucose <200 mg/dL
(<11.1 mmol/L)
Repeat not needed in
presence of DM symptoms
and/or glucose levels
≥200 mg/dL (≥11.1 mmol/L)
Categories of increased risk for IFG=100 mg/dL IGT=140 to A1c=5.7%–6.4%
diabetes (impaired fasting glucose (5.6 mmol/L) to 199 mg/dL
{IFG}, impaired glucose tolerance 125 mg/dL (7.8–11.0 mmol/L)
{IGT}, prediabetes) (6.9 mmol/L) on the 75 G OGTT
Source: American Diabetes Association Clinical Practice Recommendations, Diabetes Care January 2014 37:Sup-
plement 1 S1; doi:10.2337/dc14-S001.
International Expert Report on the Role of the A1c Assay in the Diagnosis of Diabetes. Available at: care.dia-
betesjournals.org/site/misc/DC09-9033.pdf, accessed 8/21/13.
4074_Ch11_261-292 20/11/14 11:00 AM Page 268
treatment options are demonstrated to minimize the risk of vigorous aerobic exercise that exceeds the demands of every-
progression to type 2 diabetes. day living.
Therapeutic lifestyle changes are critically important for a For a person with type 1 or type 2 DM, current ADA rec-
person with DM. Tobacco use in any form should be discour- ommendations advise a diet of 300 mg or less of cholesterol
aged due to its obvious cardiovascular risk. Because approx- per day, 8% to 9% or less of total dietary calories per day from
imately 80% of the body’s insulin-mediated glucose uptake saturated fat with similar proportions of polyunsaturated and
occurs in muscle and is enhanced by physical activity, a reg- monounsaturated fats, and 25 to 30 g of dietary fiber per day.
ular program of aerobic exercise such as brisk walking should Calories from protein should be no more than 10% to 20%
be prescribed. Exercise reduces IR by approximately 40%, of the daily total.
with the effects persisting for up to 48 hours after the activity, Weight loss improves insulin sensitivity and reduces blood
and aids in weight maintenance. People with diabetes should pressure; improvement is not related to the degree of weight
be advised to perform at least 150 minutes per week of mod- loss. Eating frequent, small, high-fiber meals and foods with
erate-intensity aerobic physical activity at 50% to 70% of a low glycemic index and smaller serving sizes should be en-
maximum heart rate. Exercise should be spread over at least couraged. Dietary fat should be limited, but not eliminated,
5 days per week with no more than 2 consecutive days with- with emphasis on decreasing saturated fats, while using mo-
out exercise; the insulin sensitizing effects of physical activity nounsaturated fat. A pound of fat contains approximately
wane after 48 hours. In the absence of contraindications, peo- 3500 stored calories. A deficit of 500 to 1000 calories per day
ple with type 2 diabetes should be encouraged to perform re- would lead to a 1 to 2 lb (0.45 to 0.9 kg) weight loss per week.
sistance training at least twice per week. Cardiac stress testing (Table 11–4). In addition to the appropriate A1c for the pa-
should be considered for the previously sedentary individual tient, an additional important marker is the achievement of
at moderate to high risk for cardiovascular disease or other at least 50% or greater of fasting, postprandial, and bedtime
patients who are clinically indicated who want to undertake glycemic goals through a combination of therapeutic lifestyle
TABLE 11-4
DM Type 2: Additional Care Considerations
A Aspirin 75–162 mg/d (use clopidogrel (Plavix®) 75 mg/d in aspirin allergy), ACEI or ARB
Counsel about moderation or abstinence in alcohol and/or recreational drug intake
B Beta blocker or alpha-beta blocker therapy as indicated by cardiovascular risk and complications
C Cholesterol—Controlling therapy to reach the following goals:
• LDL ↓100 mg/dL (2.6 mmol/L), perhaps ↓70 mg/dL (1.8 mmol/L), HDL ↑45 mg/dL (1.2 mmol/L) men,
↑55 mg/dL (1.4 mmol/L) women
• Alternative, moderate-intensity stain therapy to reduce LDL 30–50% or high intensity statin therapy to lower
LDL by greater than 50% as determined by patient’s estimated 10-year ASCVD risk
Check fasting lipid profile annually, consider less often if evidence of stability.
Creatinine (renal function)—Check serum creatinine, calculated glomerular filtration rate (GFR), and urine mi-
croalbumin annually
D Diet—Limit trans and saturated fats, healthiest foods in appropriate amounts every meal. Medical nutritional
therapy (MNT) with a registered dietician advisable.
Dental care—Reinforce ongoing dental care and treatment of dental disease
E Exercise/increase physical activity, if not contraindicated, to at least 150 min per week of moderate activity such
as walking, best in the form of ≥30 mins, ≥5 times per week at 50%–70% of maximum heart rate with no
more than 2 consecutive days without exercise. In addition, resistance training ≥2 times per week. Vigorous aer-
obic or resistance activity is potentially contraindicated in the presence of proliferative or severe nonproliferative
retinopathy due to the possible risk of vitreous hemorrhage or retinal detachment.
Eye exam (dilated) annually, increase frequency as dictated by developing retinopathy or other eye problems.
F Foot examination (visual) with every visit, teach protective foot behavior, comprehensive lower extremity sensory
exam annually using 10-g monofilament with ≥1 of the following; vibration using a 128 Hz tuning fork, pin-
prick sensation, ankle reflexes or vibration threshold.
G Goals—Periodically review overall goals of care with patient
Source: American Diabetes Association Clinical Practice Recommendations, Diabetes Care January 2014 37:
Supplement 1 S1; doi:10.2337/dc14-S001.
Massachusetts Guidelines for Adult Diabetic Care. Available at: http://files.hria.org/files/DB723.pdf
4074_Ch11_261-292 20/11/14 11:00 AM Page 269
changes and medications. Drug choices in type 2 DM are acid are cleared less effectively. Any condition that poten-
quite varied. Cost and efficacy are considerable factors in tially reduces renal perfusion, including hypovolemia, heart
choosing the most appropriate drug(s). If initial A1c is equal failure, or advanced age, increases the metformin-associated
to or greater than 2% above goal, at least two drugs will likely lactic acidosis risk. The time period around the use of radio-
be needed. An inexpensive, well-tolerated, efficacious initial contrast and surgery is considered a risk due to alterations
drug combination is metformin and a sulfonylurea; this is the in hydration. With consideration of all of these factors, the
most commonly used drug combination for the treatment of risk of lactic acidosis with metformin use is likely overstated;
type 2 DM. Critical to safe practice is the recognition of a best estimates are a rate of greater than 3 in 100,000 per pa-
given medications mechanism of action, adverse effect pro- tient treated. At the same time, in order to minimize the risk
file, and cost (Table 11–5 and Fig. 11–1). of lactic acidosis, warnings associated with metformin use
Metformin, a biguanide, improves insulin-mediated glucose include avoiding use in the presence of renal impairment,
uptake and metabolic parameters such as fibrinolysis. The an- heart failure, and age greater than 80 years. In addition, re-
ticipated A1c reduction with intensified or maximum safe and gardless of patient age, metformin use should be discontin-
tolerated dose, with metformin use is about 1% to 2%; an A1c ued for the day of surgery, radiocontrast use, or other
of 9% prior to metformin initiation can be reduced to 7% or 8% condition potentially impacting hydration status and only
with its use. One of the most commonly reported adverse effects reintroduced when hydration status and renal function is
with metformin use is gastrointestinal upset including diarrhea. back to baseline.
This can be minimized by titrating the dose upward over a 2 to The sulfonylureas (SU) are a drug class that includes med-
3 week time period, using the extended release rather than in- ication such as glipizide (Glucotrol®), glyburide (DiaBeta®),
termediate release form of the medication and by taking the glimepiride (Amaryl). These drugs act as insulin secretagogue
metformin dose with a meal. An increased body of knowledge resulting in the release of insulin for pancreatic beta cells. An-
demonstrates that metformin use in early metabolic syndrome ticipated A1c reduction with intensified use is approximately
can help in delaying the onset of type 2 DM. 1% to 2%. Since the medication is renally eliminated, the sul-
One are of concern with metformin use has been the rare fonylurea dose should be adjusted in the presence of renal
development of lactic acidosis, a potentially fatal illness, dur- impairment. The SUs require functioning pancreatic beta
ing its use. In a patient with normal renal function, lactic cells to be clinically effective. Due to declining beta cell func-
acid produced in the body, likely slightly enhanced with met- tion, these medications are typically less effective after 5 or
formin use, is excreted via the kidneys without causing harm. more years post type 2 DM diagnosis and in older adults. In
In a person with renal impairment, metformin and lactic addition, the presence of severe hyperglycemia inhibits
TABLE 11-5
Medications Used in the Treatment of Type 2 Diabetes Mellitus
Mechanism of Action
Medication A1c Reduction Comment
Sulfonylurea (SU) Insulin secretagogue Adjust dose in renal impairment
Examples: Glipizide (Glucotrol®), Anticipated A1C reduction Use with caution with sulfonamide al-
glyburide (DiaBeta®), glimepiride with intensified use=1%–2% lergy, though cross-allergy risk is low.
(Amaryl®) Potentially photosensitizing
Typically less effective after ≥5 years
T2DM dx, older adults, in the pres-
ence of severe hyperglycemia
Biguanide Reduces hepatic glucose production Monitor creatinine (Cr), do not initiate or
Example: Metformin (Glucophage®) and intestinal glucose absorption, continue with impaired renal function.
insulin sensitizer via increased periph- Avoid use in presence of heart failure.
eral glucose uptake and utilization Rare risk of lactic acidosis, most often
Anticipated A1C reduction with inten- with impaired renal function, hypov-
sified use=1%–2% olemia, low perfusion state, and/or
advanced age (>80 years)
With radiocontrast use, surgery, or
other condition that can potentially
Continued
4074_Ch11_261-292 20/11/14 11:00 AM Page 270
TABLE 11-5
Medications Used in the Treatment of Type 2 Diabetes Mellitus—cont’d
Mechanism of Action
Medication A1c Reduction Comment
Biguanide (Metforming)—cont'd alter hydration status, omit day of
and ≥48 h post-study, -procedure,
-condition, and reinitiate once base-
line renal function has been reestab-
lished. Little hypoglycemia risk when
used as a solo product.
Metformin use increases risk of vita-
min B12 deficiency due to B12 malab-
sorption, risk appears dose- and
length of therapy–dependent.
Metformin therapy for prevention of
type 2 diabetes can be considered in
those at highest risk for diabetes,
such as those with multiple risk fac-
tors, especially if demonstrated pro-
gression of hyperglycemia (i.e., A1C
≥6% [0.06 proportion]) despite
lifestyle interventions, those with BMI
>35 kg/m2, age <60 years, and
women with prior GDM.
Thiazolidinedione (TZD, glitazones) Insulin sensitizer via action at PPAR-γ Rare risk (<0.5%) of hepatic toxicity
Examples: Pioglitazone (Actos®), receptors found in muscle, adipose, with use. Monitor ALT periodically.
rosiglitazone (Avandia®)* and other tissue Edema risk, particularly when used
Anticipated A1C reduction with inten- with insulin or SU. TZD use can cause
sified use=1%–2% or exacerbate heart failure. Do not
initiate use in presence of heart fail-
ure, monitor at-risk patients carefully.
In consideration of cardiovascular risk,
use with insulin or nitrates not
recommended.
Pioglitazone use in excess of 1 year
may be associated with an increased
risk of bladder cancer. For additional
information, see www.fda.gov/
Drugs/DrugSafety/ucm259150
.htm
Glucagon-like peptide (GLP)-1 agonist Stimulates insulin production in re- Major adverse effect=N/V, usually bet-
(incretin mimetics) sponse to increase in plasma glucose, ter with dose adjustment, continued
Examples: Exenatide (Byetta®, inhibits postprandial glucagon release use; contraindicated in gastroparesis
Bydureon®), liraglutide (Victoza®) Slows gastric emptying, often leading Adjunct to improve glycemic control
Injection only to appetite suppression and weight in T2DM when not adequately
loss controlled with biguanide and/or
Anticipated A1C reduction with inten- sulfonylurea.
sified use=1%–2% Per FDA advisory, clinicians are ad-
vised to promptly discontinue exe-
natide use and to advise patients
using product to seek care if acute
pancreatitis symptoms (persistent ab-
dominal pain, usually with vomiting)
4074_Ch11_261-292 20/11/14 11:00 AM Page 271
TABLE 11-5
Medications Used in the Treatment of Type 2 Diabetes Mellitus—cont’d
Mechanism of Action
Medication A1c Reduction Comment
occur with drug’s use. Exenatide use
not recommended with pancreatitis
history.
Use with caution in patient with mild-
moderate renal impairment (creatinine
clearance [Cr Cl]=30 to 50 mL/min
[0.50–0.835 mL/s]). Do not use with
Cr Cl<30 mL/min (<0.50 mL/s).
Exenatide approved as add-on ther-
apy with insulin glargine, with or
without metformin in T2DM with in-
adequate glycemic control on insulin
glargine alone.
Dipeptidyl peptidase-4 (DPP-4) Increases levels of incretin, increasing Dose adjustment required in renal
inhibitor synthesis and release of insulin from impairment.
Examples: Sitagliptin (Januvia®), pancreatic beta cells and decreasing Well-tolerated, little hypoglycemia
saxagliptin (Onglyza®), linagliptin release of glucagon from pancreatic risk, weight-neutral
(Tradjenta®), alogliptin (Nesina®) alpha cells Indicated to improve glycemic control,
Anticipated A1C reduction with inten- in combination with metformin or TZD
sified used=0.6%–1.4% Per FDA advisory, monitor patients
carefully for the development of pan-
creatitis after initiation or dose in-
creases of sitagliptin or sitagliptin/
metformin. DPP-4 inhibitor use has
not been studied in patients with a
history of pancreatitis.
Sodium-glucose cotransporter 2 Lowers renal glucose threshold, in- Increased risk of genital candidiasis
(SGLT2) inhibitor creased urinary glucose excretion with use. Less clinical effect with
Canagliflozin (Invokana), dapagliflozin Anticipated A1C reduction with inten- renal impairment.
(Farxiga) sified use= 0.7%–1%
Alpha-glucosidase inhibitors Delays intestinal carbohydrate absorp- Taken with first bite of a meal
Examples: Acarbose (Precose®), tion by reducing postprandial diges- Helpful in management of postpran-
miglitol (Glyset®) tion of starches and disaccharides via dial hyperglycemia
enzyme action inhibition Does not enhance insulin secretion or
Anticipated A1C reduction with inten- sensitivity.
sified use=0.3%–0.9% GI adverse effects an issue
Avoid use in inflammatory bowel dis-
ease, impaired renal function.
insulin releases. Thus, a SU will appear to be less clinically ef- Insulin therapy is indicated for all patients with type 1 DM
fective during a hyperglycemic episode, such as during an and patients with type 2 DM with insulinopenia; short-term
acute illness, and its original effectiveness will resume once insulin therapy is indicated when type 2 DM is initially diag-
the blood sugar control improves. nosed, particularly with glucose values greater than 250 to
Various additional oral and noninsulin injectable thera- 300 mg/dL (greater than 13.9 to 16.7 mmol/L). Insulins come
pies are available for the treatment of type 2 DM. To prescribe in many forms, from short-acting to long-acting forms with
these medications appropriately and effectively, the pre- different onsets, peaks, and durations of action (Tables 11–5
scriber must know the mechanism of action, indications, an- and 11–6). The clinician needs to be aware of the characteris-
ticipated adverse effects, contraindications, and anticipated tics of each insulin form and how these different products
benefit with the available medications (Table 11-5). contribute to glycemic control. Keep in mind that the A1c
4074_Ch11_261-292 20/11/14 11:00 AM Page 272
TZD or SU or SU or SU or TZD or
DPP-4 inhibitor or DPP-4 inhibitor or TZD or TZD or DPP-4 inhibitor
GLP-1 agonist or GLP agonist or insulin insulin or GLP-1 agonist
insulin (usually basal) insulin (usually basal) (usually basal) (usually basal) or SGLT2 inhibitor
Note: Safe practice dictates that the prescriber be well informed as to the risks and benefits of all medications prescribed and be aware of
the clinical indications for emerging therapies. See Table 11-5 for background information on these medications and prescribing information
on each product for full details. Metformin with sulfonylurea therapy is usually the first line 2-drug therapy due to reasonable cost and
clinical efficacy.
Figure 11-1 Algorithm for drug therapy in type 2 diabetes mellitus. Note: TZD should not be used with insulin.
lowering potential is nearly limitless, as the dose can be not seen, however, until at least 50% of the nephrons are not
adjusted easily in response to persistent hyperglycemia. All cur- functioning. An elevated creatinine level is a late rather than
rently available insulin forms are true bioidentical hormones— early indicator of renal damage. A far more sensitive indica-
that is, replacing what the body would release naturally in the tor of diabetic nephropathy is the presence of proteinuria, a
absence of insulinopenia. With insulin use, two conditions harbinger of progressive renal failure. Urine protein consists
that can result in early morning hyperglycemia can occur. The of many forms, including the most abundant, albumin, and
Somogyi effect occurs when an insulin-induced hypoglycemia immunoglobulin, haptoglobin, and light chains. The standard
triggers excess secretion of glucagon and cortisol; this leads to dipstick test is sensitive to 100 to 150 mg/L of urine albumin,
hyperglycemia. Intervention is aimed at lowering the inap- an earlier marker of progressive renal failure than serum cre-
propriately high insulin dose, usually the dinnertime dose of atinine, but still a later disease marker. The persistent pres-
intermediate-acting insulin. The dawn phenomenon is a result ence of a small amount of albumin (microalbumin) is
of reduced insulin sensitivity developing between 5 and 8 a.m., considered a predictor of glomerular dysfunction associated
caused by earlier spikes in growth hormone. The net result is with diabetic nephropathy.
cortisol release, which triggers hepatic glucose secretion and Microalbuminuria can precede development of DM by
early morning hyperglycemia. Intervention for the dawn phe- 10 years. With type 2 DM, the patient should be screened for
nomenon includes splitting the evening intermediate insulin microalbuminuria at onset of disease, with an annual recheck
dose between dinner and bedtime. Alternative interventions if results are normal. Collection of a first morning specimen
include switching to a bedtime dose of insulin glargine or an is important because normal daily activity may cause a low
insulin pump. level of protein spillage into the urine, creating a false-positive
DM is the leading cause of chronic renal failure. After the result. The diagnosis of microalbuminuria should be con-
diagnosis of DM is made, periodic screening of renal function firmed by obtaining at least two positive results from three
should be done (Table 11–7). Often serum creatinine meas- collections in a 3 to 6 month period; results should be cor-
urement is used for this purpose. An increase in creatinine is related with serum creatinine level. Intervention includes
4074_Ch11_261-292 20/11/14 11:00 AM Page 273
TABLE 11-6
When to Use Insulin in DM Treatment
TYPE 1 DM TYPE 2 DM
• All patients • At time of diagnosis to help achieve initial glycemic con-
• Basal insulin (50% of total daily insulin trol, particularly when glucose values >250–300 mg/dL
requirements) with adjustments for meals and (13.9–16.7 mmol/L)
snacks (50% of total daily insulin requirements) • When acutely ill
via multiple injections or pump • In critically ill surgical and nonsurgical patients with
type 1 or type 2 DM, blood glucose levels should be
kept generally 140 mg/dL–180 mg/dL (7.8–10 mmol/L).
Overtreatment and undertreatment of hyperglycemia
represent major safety concerns.
• When ≥2 oral agents at optimized use are inadequate to
maintain glycemic control
Source: American Diabetes Association Clinical Practice Recommendations, Diabetes Care January 2014;
37:Supplement 1 S1; doi:10.2337/dc14-S001.
tightening of glycemic control to appropriate goal for overall have the “-sartan” suffix), beta blockers (drugs whose names
patient condition, controlling elevated blood pressure, treat- have the “-lol” suffix—metoprolol, atenolol), alpha-beta
ment of dyslipidemia, and addition of a medication recom- blockers (also “-lol” suffix—carvedilol, others), and calcium
mended for use in individuals with concomitant type 2 DM channel blockers (amlodipine [Norvasc®], diltiazem
and hypertension according to the ADA recommendations, [Cardizem®, others], verapamil [Calan®, Verelan®, others]).
including angiotensin-converting enzyme inhibitors (drugs Although use of beta blockers and alpha-beta blockers in
whose names have the “-pril” suffix—lisinopril, enalapril, patients with DM was discouraged or contraindicated in the
others), angiotensin receptor blockers (drugs whose names past, current practice supports the use of this drug class
TABLE 11-7
Guidelines for Adult Diabetes Mellitus Care
Frequency Description/Comments
HEALTH HISTORY AND Blood pressure (BP), height Every 3–6 mo Goal BP <140/<90, initiate
PHYSICAL EXAMINATION and weight measures to lower at this
level with lifestyle modifi-
cation and medication.
Dilated eye examination Annual, more often with Refer to eye care specialist
progressive retinopathy
Foot examination Initial/annual Visual examination without
shoes and socks every rou-
tine diabetes visit
Comprehensive lower Initial/annual Teach protective foot be-
extremity sensory havior if sensation dimin-
examination ished. Refer to podiatrist if
indicated
Dental examination Every 6 mo Refer to a dentist, reinforce
ongoing dental care
Smoking, tobacco use Ongoing Check every visit. Encour-
status age smoking cessation
LABORATORY TESTS A1c Every 3–6 mo Goal A1c according to indi-
vidual benefit/ risks
Fasting/postprandial blood As indicated Compare laboratory results
glucose with glucose self-monitoring
Continued
4074_Ch11_261-292 20/11/14 11:00 AM Page 274
TABLE 11-7
Guidelines for Adult Diabetes Mellitus Care—cont’d
Frequency Description/Comments
Fasting lipid profile Annual, consider less often As part of comprehensive
with stable levels plan to reduce cardiovas-
cular disease risk
Urine microalbumin/ Initial/annual If abnormal, recheck (2 in a
creatinine 3-mo period, then treat if
2 out of 3 collections show
elevated levels
Serum creatinine Annual Measure annually for
estimation of glomerular
filtration rate
EKG Initial If patient ≥40 y.o. or
DM ≥10 yr
Thyroid assessment Initial/as indicated Thyroid palpitation, thyroid
function test(s) if indicated
RECOMMENDED Influenza Annually in anticipation of Influenza vaccine form
IMMUNIZATIONS seasonal influenza should be guided by stan-
dard vaccine practice.
Antipneumococcal vaccine Recommended See latest recommendations
on use of PCV23 and
PCV13 vaccines.
Hepatitis B vaccine If < 60 y.o. at time as DM If ≥60 y.o., at the discretion
diagnosis, immunize as of the treating clinician
soon as possible after based on increased need
diagnosis for assisted blood glucose
monitoring in long-term
care facilities, likelihood of
acquiring hepatitis B infec-
tion, its complications
or chronic sequelae, and
likelihood of immune re-
sponse to vaccination
SELF-MANAGEMENT Review self-management Initial/ongoing Reinforce healthy habits,
SKILLS AND PATIENT skills monitoring, sick day care
COUNSELING Review treatment plan Initial/ongoing Check self-monitoring log
book, diet, physical activ-
ity, and medications
Review education plan Initial/ongoing Refer for diabetes self-
management education as
indicated
Review nutrition plan Initial/ongoing Refer for medical nutrition
therapy as indicated
Review physical activity plan Initial/ongoing Assess/prescribe based on
patient’s health status
Tobacco use Annual/ongoing Assess readiness, counsel
about cessation. Refer to
smoking cessation program.
Psychosocial adjustment Initial/ongoing Suggest diabetes support
group. Counsel and refer
as indicated
4074_Ch11_261-292 20/11/14 11:00 AM Page 275
TABLE 11-7
Guidelines for Adult Diabetes Mellitus Care—cont’d
Frequency Description/Comments
Sexuality/erectile Annual/ongoing Discuss diagnostic
dysfunction evaluation and therapeutic
options
Preconception/pregnancy Initial/ongoing Need for tight glucose con-
trol 3–6 mo preconcep-
tion. Consider early referral
to high risk prenatal care
Source: American Diabetes Association Clinical Practice Recommendations, Diabetes Care January 2014 37:
Supplement 1 S1; doi:10.2337/dc14-S001.
because of its ability to reduce the target population’s con- and glucose intolerance (Table 11–8). Various definitions for
siderable cardiovascular risk. In the presence of type 2 dia- metabolic syndrome have been offered by well-regarded
betes mellitus, dyslipidemia and hypertension must be groups, including the World Health Organization (WHO). Al-
aggressively treated to minimize risk of cardiovascular dis- though the definitions offered by these groups are similar, the
ease. Daily aspirin use is recommended to counteract the nuanced differences in them have led to confusion, particularly
proinflammatory and prothrombotic effects of IR. when attempting to compare data from studies using different
Known by numerous names, such as syndrome X, Reaven’s definitions. Also uncertain was which, if any, of the definitions
syndrome, the “deadly quartet,” metabolic cardiovascular syn- best detected persons at risk of cardiovascular disease (CVD)
drome, and cardiovascular dysmetabolic syndrome, the term and DM.
metabolic syndrome is now most commonly used to describe a To facilitate the use of a single definition, the International
complex health problem that usually includes three or more of Diabetes Federation (IDF) has issued a global consensus
the following: obesity, blood pressure problems, dyslipidemia, statement, proposing a consensus definition of metabolic
TABLE 11-8
Diagnostic Criteria for Metabolic Syndrome
International Diabetes
World Health Organization Adult Treatment Panel (ATP) III Federation
Insulin resistance (type 2 diabetes ≥3 of the following Central obesity, defined as ethnic-
mellitus or impaired fasting glucose) • Waist circumference: >102 cm specific waist circumference
plus ≥2 of the following (>40 in) in men, >88 cm (>35 in) European, sub-Saharan African,
• Abdominal/central obesity defined in women Eastern Mediterranean, Middle
as a waist-to-hip ratio >0.90 • Hypertriglyceridemia ≥150 mg/dL Eastern (Arabic) ancestry
(men), >0.85 (women), or ( ≥1.7 mmol/L) • Men ≥94 cm ( ≥37 in)
BMI ≥30 kg/m2 • Low HDL cholesterol <40 mg/dL • Women ≥80 cm ( ≥31.5 in)
• Hypertriglyceridemia ≥150 mg/dL (<1.036 mmol/L) South Asian, Chinese, ethnic South
( ≥1.7 mmol/L) for men, <50 mg/dL (<1.295 and Central American ancestry
• Low HDL cholesterol <35 mg/dL mmol/L) for women • Men ≥90 cm ( ≥35.5 in)
(<0.9 mmol/L) for men, • BP ≥130/ ≥85 mm Hg or docu- • Women ≥80 cm ( ≥31.5 in)
or <39 mg/dL (<1 mmol/L) mented use of antihypertensive Japanese ancestry
for women therapy • Men ≥90 cm ( ≥35.5 in)
• High BP ≥140/90 mm Hg or • Fasting glucose ≥100 mg/dL • Women ≥80 cm ( ≥31.5 in)
documented use of antihypertensive ( ≥5.6 mmol/L) with ≥2 of the following
therapy • Abnormal triglycerides
≥150 mg/dL ( ≥1.7 mmol/L)
Continued
4074_Ch11_261-292 20/11/14 11:00 AM Page 276
TABLE 11-8
Diagnostic Criteria for Metabolic Syndrome—cont’d
International Diabetes
World Health Organization Adult Treatment Panel (ATP) III Federation
• Microalbuminuria with urinary al- • HDL-cholesterol <40 mg/dL
bumin-to-creatinine ratio 30 mg/g, (<1.03 mmol/L) in men,
or albumin excretion rate <50 mg/dL (<1.29 mmol/L) in
20 mcg/min women
• BP ≥130 mm Hg systolic or
≥85 mm Hg diastolic or treatment
of previously diagnosed hypertension
• Fasting glucose ≥100 mg/dL
( ≥5.6 mmol/L) or previous diagno-
sis of type 2 diabetes or impaired
glucose tolerance
Heatstroke is a life-threatening emergency caused by a failure Optimally, a patient with heatstroke should be admitted to
of the body’s thermoregulatory system, usually in response to the hospital for at least 24 hours after stabilization because of
extreme environmental and personal factors. In exertional the risk of late complications, including one of the most feared
heatstroke, the illness has been triggered by exercise in a warm complications: rhabdomyolysis, a condition of rapid muscle
environment that adds to the thermal load produced by the tissue destruction. As the muscle breaks down, large amounts
muscular contraction. In addition, a protracted period of ex- of myoglobin and other cellular products are released into cir-
ercise, such as running a marathon or participating in a long culation to be excreted by the kidney. Renal hypoperfusion
football practice, usually poses greatest risk. Nonexertional from low blood pressure is common. As a result, about 50%
heatstroke is noted in the presence of extreme environmental of patients with rhabdomyolysis develop acute renal failure.
heat, usually defined as more than 10°F (12.2° C) greater than In heatstroke, the presence of myoglobinuria is an early indi-
is typical for the given geographic area for more than 3 days, cator of rhabdomyolysis. Typically, the patient also complains
and poses a particular risk to segments of the population who of muscle pain and weakness. Treatment of rhabdomyolysis
have the most difficulty with body temperature self-regulation is aimed at treating the potentially life-threatening conse-
including the very young (infants) and the elderly. quences, such as renal failure and profound hyperkalemia.
Risk factors for heatstroke include the use of medications
that alter adrenergic activity and possibly decrease cardiac out- D I S C U SSI O N S O U R C E S
put (negative inotrope), such as tricyclic antidepressants (drugs Centers for Disease Control and Prevention. Extreme heat: a pre-
whose names have the “-triptyline” suffix), beta-adrenergic an- vention guide to promote your personal health and safety.
tagonists, or beta blockers (drugs whose names have the “-lol” www.bt.cdc.gov/disasters/extremeheat/heat_guide.asp.
suffix), and vasoconstrictors, such as oral decongestants. The Helman, R, Habal, R, http://emedicine.medscape.com/article/
166320, heatstroke.
use of these products negates the body’s normal attempts to
decrease core temperature, such as increasing cardiac output
and cutaneous vasodilation. Obesity limits the ability of the
body to dissipate heat and is considered a heatstroke risk factor. Obesity
In addition, as mentioned previously, extremes of age, very
young or very old, with the associated difficulties in maintain- 60. Obesity is defined as having a body mass index (BMI)
ing body temperature, increases heatstroke risk. Alcohol use equal to or greater than ____ kg/m2.
also increases risk. Adequate hydration with nonalcoholic flu- A. 25
ids, particularly water, coupled with dressing lightly helps to B. 30
minimize heatstroke risk. C. 35
Individuals who participate in strenuous activity during D. 40
hot weather should be warned about early heatstroke symp- 61. An example of an appropriate question to pose to a
toms, such as extreme increase in heart rate, headache usually person with obesity who is in the precontemplation
described as pounding, and difficulty breathing. If any of change stage is:
these symptoms occur, the physical activity should be discon- A. “How do you feel about your weight?”
tinued immediately, and the person should move to a shady B. “What are barriers you see to losing weight?”
location and drink cool water. If symptoms do not dissipate C. “What is your personal goal for weight loss?”
rapidly, help should be sought. D. “How do you envision my helping you meet your
Assessment of a patient with heatstroke includes a com- weight loss goal?”
plete evaluation of electrolytes, hematologic parameters, and
liver enzymes. Total creatine kinase (CK) level is typically el- 62. An example of an appropriate question to pose to a per-
evated, owing to skeletal muscle injured by muscle cramping son with obesity who is in the contemplation change
and convulsion releasing this enzyme. Because of the release stage is:
of this intracellular electrolyte with tissue damage, hyper- A. “How do you feel about your weight?”
kalemia is common; potentially life-threatening levels can be B. “What are barriers you see to losing weight?”
reached. Heatstroke can lead to a transient polycythemia C. “What is your personal goal for weight loss?”
caused by volume constriction, hyponatremia with Na+ level D. “How do you envision my helping you meet your
of less than 120 mEq/L (less than 120 mmol/L), and stress- weight loss goal?”
induced leukocytosis. 63. When advising a person who will be using orlistat
Intervention for a patient with heatstroke includes con- (Xenical®, Alli®) as part of a weight loss program, the
trolled cooling by the use of tepid sprays and fanning or by NP provides the following information about when to
the application of cold packs to select areas such as the axillae, take the medication:
neck, and groin. Rapid cooling by total body ice packing is A. within an hour of each meal that contains fat.
discouraged because this can stimulate cutaneous vasocon- B. before any food with high carbohydrate content.
striction, inhibiting heat loss. Rehydration should be aggres- C. only in the morning, to avoid sleep disturbance.
sive, but with careful monitoring because of the risk of D. up to 3 hours after any meal, regardless of types of
pulmonary edema from reduced cardiac output. food eaten.
4074_Ch11_261-292 20/11/14 11:00 AM Page 278
64. The action of which of the following is believed to be 71. You are counseling a patient who is considering gastric
most responsible for the sensation of satiety? bypass surgery for weight loss. You advise the follow-
A. norepinephrine ing. (More than one can apply.)
B. epinephrine A. Calcium absorption will be reduced.
C. dopamine B. Rapid weight loss after obesity surgery can con-
D. serotonin tribute to the development of gallstones.
C. Chronic constipation is a common postoperative
65. A pound of fat contains approximately _______ stored
adverse effect.
calories.
D. Lifelong vitamin B12 supplementation is
A. 2500
recommended.
B. 3000
C. 3500 72 to 75. Weight loss medications: True or false?
D. 4000
72. Lorcaserin (Belviq®) should not be used with
66. The commonly recommended physical activity level medications that have serotonergic effect.
of 10,000 steps per day is roughly the equivalent of
73. Phentermine/ topiramate (Qsymia®) carries a
walking _____ miles.
warning about potential teratogenic effects.
A. 1 to 2
B. 2 to 3 74. Phentermine’s mechanism of action in weight loss
C. 3 to 4 is as a product that reduces GI motility.
D. 4 to 5
75. In general, weight lost post gastric bypass is signif-
67. With the use of weight loss medications, if the patient icantly more when compared with the postopera-
has not achieved a 5% weight loss by week ___ of treat- tive course of a restrictive procedure such as
ment, the therapy should be discontinued. adjustable gastric band.
A. 6
76. Which of the following are possible consequences of
B. 12
obesity? (More than one can apply.)
C. 18
A. Obstructive apnea
D. 24
B. Steatohepatitis
68. In a person with obesity, weight loss of ____% or more C. Female infertility
yields an immediate reduction in death rates from car- D. Endometrial cancer
diovascular and cerebrovascular disease.
A. 5
B. 10 Answers
C. 15
D. 20 60. B. 66. D. 72. True
61. A. 67. B. 73. True
69. When counseling about malabsorptive bariatric sur-
62. B. 68. B. 74. False
gery, the NP provides the following information:
63. A. 69. B. 75. True
A. Most people achieve ideal BMI postoperatively.
64. D. 70. A. 76. A, B, C, D
B. The most dramatic weight losses are seen in the first
65. C. 71. A, B, D
few postoperative months.
C. The death rate directly attributable to surgery is
Rates of obesity, usually defined as a body mass index (BMI)
about 10%.
of 30 kg/m2 or greater (Table 11–9), in North America are
D. Weight loss will continue for years postoperatively
currently at record levels and are projected to double over the
in most patients.
next 30 years; this mirrors the overall increase in overweight
70. The use of which of the following medications is often and obesity rates worldwide. Although no specific endocrine
associated with weight gain? disorder, including thyroid dysfunction, is usually found in
A. risperidone (Risperdal®) obese individuals, the cause of the overweight and obese con-
B. topiramate (Topamax®) dition is likely a combination of environmental, genetic, and
C. metformin (Glucophage) behavioral influences. Consequences of overweight and obe-
D. sitagliptin (Januvia®) sity include increased risk of all-cause morbidity and mortal-
ity, greater healthcare cost, lower workforce productivity, and
increased workplace absentee rates and employer costs. Di-
rect healthcare cost increases related to obesity are attributa-
ble largely to well-known obesity-related disease, including
gallbladder disease, coronary heart disease, DM, osteoarthri-
tis, and dyslipidemia. Less commonly known consequences
4074_Ch11_261-292 20/11/14 11:00 AM Page 279
TABLE 11-10
Facilitating Change in the Care of a Person Who Is Overweight or Obese
Stage Questions to Ask As the Provider, You Can:
PRECONTEMPLATION (NOT • How do you feel about your weight? Validate and acknowledge
INTERESTED IN CHANGE) • How does your weight affect you? • This will take working together but
• Are you considering/planning weight can be done.
loss now? Restate position, leave the door open
• On a scale of 0–10, how ready • It’s up to you to make the decision to
are you to start a weight loss lose weight. I cannot do this for you,
program? but I am here to help you.
CONTEMPLATION (THINKING • What are the pros and cons of Praise and validate
ABOUT CHANGE) weight loss? • I am happy that you want to deal
• Where are you on the scale of with this issue and feel ready to
0–10 as far as ready? do so.
• What are barriers/supports you Try to shift decisional balance
envision? • I am here to help you and point you
• How do you view me as helping? in the direction of other sources of
support.
Arrange follow-up
Continued
4074_Ch11_261-292 20/11/14 11:00 AM Page 280
TABLE 11-10
Facilitating Change in the Care of a Person Who Is Overweight or Obese—cont’d
Stage Questions to Ask As the Provider, You Can:
PREPARATION FOR CHANGE • What is your usual food and Help set small behavioral goals related to
activity pattern? diet, physical activity
• What is your personal goal for weight Assist in compiling food and activity
loss? diaries
• Health goal? Begin to negotiate goal weight
• Cosmetic goal? Identify support system
Help set a date to start
MAKING CHANGE • How can I help? Teach nutritional tactics to help control
MAINTAINING CHANGE • What is getting in your way? obesity
DEALING WITH RELAPSE • What is making this work? • Learn energy values of different foods
Monitor food consumption by keeping a
food diary; reduce portion size
Read and understand nutrition labels on
foods
• Learn new habits of food purchasing
• Eliminate high-calorie foods from
grocery list
Limit fats and oils in cooking, recipes;
high-calorie or “calorie-dense” foods
Increase physical activity
Source: Center for Disease Control and Prevention, Obesity, available at http://www.cdc.gov/obesity/.
Pharmacotherapy is an important tool in weight manage- therapy and use a highly effective form of contraception while
ment. Many antiobesity drugs are available. Orlistat (Xenical, taking the medication.
Alli) is taken with meals and contributes to weight loss by re- Lorcaserin (Belviq) is believed to decrease food con-
ducing dietary fat absorption by approximately 30%. The fat sumption and promote satiety by selectively activating
passes undigested, and weight loss is facilitated. The medica- 5-HT2C receptors on anorexigenic neurons located in the
tion is taken three times daily with or within 1 hour of a meal hypothalamus. Given this medication’s mechanism of ac-
that contains fat. The most common adverse effect is gas- tion, it is used with other medications with serotonergic
trointestinal disturbance, including loose stools and oily anal properties such as the triptans, monoamine oxidase in-
seepage. Older medications, sympathomimetics such as dex- hibitors (MAOIs), selective serotonin reuptake inhibitors
amphetamine and phentermine (Fastin®, others), work with (SSRIs), selective serotonin norepinephrine reuptake
norepinephrine and dopamine, reducing the appetite, with inhibitors (SNRIs), dextromethorphan, tricyclic antide-
resulting reduction in food intake. Sleep disturbances and pressants (TCAs), bupropion, lithium, tramadol, trypto-
nervousness rank among the most adverse effects associated phan, and St. John’s wort. With weight loss drugs, the
with the use of these medications. medication should be discontinued if the patient has not
Qsymia is a fixed dose combination of phentermine and achieved a 5% weight loss by week 12 of treatment; in this
topiramate that is FDA approved for weight management in circumstance, the weight loss medication is unlikely to be
adults with an initial BMI of 30 kg/m2 or greater or 27 kg/m2 helpful in weight reduction.
or greater when accompanied by weight-related comorbidi- As with many other weight loss approaches, weight loss
ties such as hypertension, type 2 DM, or dyslipidemia. The plateaus and then may slowly increase, particularly if lifestyle
effect of phentermine is likely mediated by release of cate- modification does not include increased activity and de-
cholamines, including norepinephrine in the hypothalamus, creased caloric intake.
resulting in reduced appetite and decreased food consump- The use of certain medications can result in weight
tion. The precise mechanism of action of topiramate on gain. These medications include atypical or second genera-
weight management is not known; the use of this medication tion antipsychotics (risperidone [Risperdal], olanzapine
has been associated with appetite suppression and satiety. [Zyprexa®], others), select antiepileptics (valproate [De-
Due to the topiramate portion of Qsymia, women of repro- pakote®], carbamazepine [Tegretol®], others), and corticos-
ductive potential should have a negative pregnancy test be- teroids (prednisone, methylprednisolone, others). The use
fore starting Qsymia and monthly thereafter during Qsymia of these medications is occasionally necessary in a person
4074_Ch11_261-292 20/11/14 11:00 AM Page 281
with obesity. The patient should be advised about the risk, gastric bypass due to risk of contraceptive failure related to
and weight-controlling efforts would need to be intensified. lower drug absorption. Study on other medications is ongoing.
Numerous surgical options are available for obesity inter-
vention. The most common options include gastric bypass D I S C U SSI O N S O U R C E S
and adjustable laparoscopic band. The ideal candidate for a Center for Chronic Disease Prevention and Health Promotion.
bariatric surgical procedure is a person with BMI equal to or Overweight and obesity. www.cdc.gov/nccdphp/dnpa/obesity.
greater than 40 kg/m2 or BMI equal to or greater than Hamdy O, Griffing G. Obesity Treatment and Management.
35 kg/m2 who also has DM, hypertension, dyslipidemia ob- http://emedicine.medscape.com/article/123702-treatment.
structive sleep apnea, cardiovascular disease, gastroe-
sophageal reflux, degenerative joint disease, fatty liver
(steatohepatitis), or other obesity-related conditions in whom Thyroid Disorders
behavioral and pharmacological therapy has failed. Con-
traindications to bariatric surgery include untreated or un- 77. Increased risk of thyroid disorder is found in individuals
stable mental health conditions, active drug or alcohol abuse, who are:
poor adherence to advised health regimens, and concomitant A. obese.
health conditions that would pose significant operative risk. B. hypertensive.
The Roux-en-Y gastroplasty, or gastric bypass, is one of the C. treated with systemic corticosteroids.
more common restrictive/malabsorptive bariatric surgeries. D. elderly.
With gastric bypass, not only is the stomach size dramatically 78. A 48-year-old woman with newly diagnosed hypothy-
reduced, thus limiting intake, the food that is eaten no longer roidism asks about a “natural thyroid” medication she
passes over the duodenum, the part of the gastrointestinal read about online and provides the drug’s name, desic-
tract where calories are normally absorbed. The adjustable la- cated thyroid. As you counsel her about this medica-
paroscopic band procedure, in which the stomach volume is tion, you consider all of the following except:
restricted, is an intervention that does not lead to malabsorp- A. This product is contains a fixed dose of T3 and T4.
tion because food still passes through the duodenum, but B. The medication is a planted-based product.
rather restricts the amount of calories that can be ingested. C. Its pharmacokinetics differ significantly when
High-calorie soft or liquid foods, such as milkshakes and ice compared to levothyroxine.
cream, can pass through the band, however, and the calories D. The majority of the study on treatment for hypothy-
in these foods are absorbed. roidism has been done using levothyroxine.
A person considering bariatric surgery must have a real-
istic idea regarding the anticipated outcome. In a well- 79. Hypothyroidism most often develops as a result of:
selected patient population, the average weight loss with the A. primary pituitary failure.
gastric band procedure is approximately 40% to 60% of excess B. thyroid neoplasia.
body weight. With gastric bypass, the expected weight loss is C. autoimmune thyroiditis.
approximately 70% to 80% of excess body weight. With either D. radioactive iodine exposure.
procedure, most of that weight is lost within the first 3 years 80. Which is following is the least helpful test for the
after surgery, and the most dramatic weight losses are seen assessment of thyroid disease?
in the first months postoperatively. With either procedure, A. Total T4
future weight regain can occur if recommended dietary and B. TSH
physical activity guidelines are not followed. About 85% C. Free T4
of patients lose a great deal of weight without major compli- D. Antithyroid antibodies
cations and maintain this loss long-term. About 10% have a
significant short-term problem after the surgery (e.g., reop- 81. Physical examination findings in patients with Graves’
eration, long hospital stay, insufficient weight loss, persistent disease include:
gastrointestinal upset), but most do well in the long-term. A. muscle tenderness.
Less than 5% have major unresolved problems over time, in- B. coarse, dry skin.
cluding, for some and rarely, death as a direct result of the C. eyelid retraction.
surgery. With all bariatric surgery, but in particular the mal- D. delayed relaxation phase of the patellar reflex.
absorptive procedures, expert consultation on continued mi- 82. The mechanism of action of radioactive iodine in the
cronutrient supplementation should be sought to avoid treatment of Graves’ disease is to:
anemia and other health problems. Micronutrient supple- A. destroy the overactive thyroid tissue.
mentation is needed post procedure; this supplementation B. reduce production of TSH.
usually includes vitamin B12, iron, zinc, calcium, protein, and C. alter thyroid metabolic rate.
most fat soluble vitamins. Given the alteration in the GI tract D. relieve distress caused by increased thyroid size.
post gastric bypass, absorption of certain medications is
altered. In particular, the use of combined oral contraceptives
(estrogen/progestin-containing) is not recommended post
4074_Ch11_261-292 20/11/14 11:00 AM Page 282
83. Which of the following medications is a helpful treat- 90. Which of the following is the most cost-effective
ment option for relief of tremor and tachycardia seen method of distinguishing a malignant from a benign
with untreated hyperthyroidism? thyroid nodule?
A. propranolol A. ultrasound
B. diazepam B. magnetic resonance imaging
C. carbamazepine C. fine-needle aspiration biopsy
D. verapamil D. radioactive iodine scan
84. In prescribing levothyroxine therapy for an elderly 91. Possible consequences of excessive levothyroxine use
patient, which of the following statements is true? include:
A. Elderly persons require a rapid initiation of levothy- A. bone thinning.
roxine therapy. B. fatigue.
B. TSH should be checked about 2 days after dosage C. renal impairment.
adjustment. D. constipation.
C. The levothyroxine dose needed by elderly persons is
92. Optimally, at what interval should TSH be reassessed
75% or less of that needed by younger adults.
after a levothyroxine dosage is adjusted?
D. TSH should be suppressed to a nondetectable level.
A. 1 to 2 weeks
85. Thyroid stimulating hormone (TSH) is released by the: B. 2 to 4 weeks
A. thyroid follicles. C. 4 to 6 weeks
B. adrenal cortex. D. 6 to 8 weeks
C. hypothalamus
93. As part of an evaluation of a 3-cm, round, mobile thy-
D. anterior lobe of the pituitary.
roid mass, you obtain a thyroid ultrasound scan reveal-
86. In the report of a thyroid scan done on a 48-year-old ing a fluid-filled structure. The most likely diagnosis is:
woman with a thyroid mass, a “cold spot” is reported. A. adenoma.
This finding is most consistent with: B. thyroid cyst.
A. autonomously functioning adenoma. C. multinodular goiter.
B. Graves’ disease. D. vascular lesion.
C. Hashimoto’s disease.
94. Periodic routine screening for hypothyroidism is indi-
D. thyroid cyst.
cated in the presence of which of the following clinical
87. You are advised a 58-year-old woman with hypothy- conditions?
roidism about the correct use of levothyroxine. She also A. digoxin use
takes a calcium supplement. All of the following infor- B. male gender
mation should be shared with the patient except: C. Down syndrome
A. Take the medication on an empty stomach. D. alcoholism
B. To help with adherence, take your calcium supple-
95 to 111. Identify each of the following findings as associ-
ment at the same time as your thyroid medication.
ated with hyperthyroidism, hypothyroidism, or both.
C. You should to take the medication at approximately
the same time every day. 95. heat intolerance
D. Do not take your medication with soy milk.
96. smooth, silky skin
88. The findings of a painless thyroid mass and TSH level
97. goiter
of less than 0.1 IU/mL in a 35-year-old woman is most
consistent with: 98. frequent, low-volume, loose stools
A. autonomously functioning adenoma.
99. secondary hypertriglyceridemia
B. Graves’ disease.
C. Hashimoto’s disease. 100. amenorrhea or oligomenorrhea
D. thyroid malignancy.
101. coarse, dry skin
89. A fixed, painless thyroid mass accompanied by hoarse-
102. menorrhagia
ness and dysphagia should raise the suspicion of:
A. adenomatous lesion. 103. hyperreflexia with a characteristic “quick
B. Graves’ disease. out–quick back” action at the patellar reflex
C. Hashimoto’s disease.
104. proximal muscle weakness
D. thyroid malignancy.
105. tachycardia with hypertension
4074_Ch11_261-292 20/11/14 11:00 AM Page 283
TABLE 11-11
Comparison of Hyperthyroidism With Hypothyroidism
Hyperthyroidism Hypothyroidism
CHARACTERISTICS Excessive energy release, rapid cell Reduced energy release, slow cell
turnover turnover
CAUSES Graves’ disease, thyroiditis, metabolically Post autoimmune thyroiditis (>95% in
active thyroid nodule North America), primary pituitary failure
(rare world-wide). Dietary iodine defi-
ciency most common reason for hy-
pothyroidism worldwide but relatively
uncommon in North America.
NEUROLOGICAL Nervousness, irritability, memory Lethargy, disinterest, memory problems
problems
WEIGHT Weight loss (usually modest, present in Weight gain (usually 5–10 lb [2.3–4.5 kg]
~50%, approximately 5–10 lb largely fluid, little fat))
[2.3–4.5 kg])
ENVIRONMENTAL RESPONSE Heat intolerance Chilling easily, cold intolerance
SKIN Smooth, silky skin Coarse, dry skin
HAIR Fine hair with frequent loss Thick, coarse hair with tendency to break
easily
NAILS Thin nails that break with ease Thick, dry nails
GASTROINTESTINAL Frequent, low volume, loose stools, Constipation
hyperdefecation
Continued
4074_Ch11_261-292 20/11/14 11:00 AM Page 284
TABLE 11-11
Comparison of Hyperthyroidism With Hypothyroidism—cont’d
Hyperthyroidism Hypothyroidism
MENSTRUAL Amenorrhea or low volume menstrual Menorrhagia
flow
REFLEXES Hyperreflexia with a characteristic “quick Overall hyporeflexia with characteristic
out–quick back” action slow relaxation phase, the “hung-up”
patellar deep tendon reflex
MUSCLE STRENGTH Proximal muscle weakness Usually no change
Tachycardia Bradycardia in severe cases
Although thyroid disease likely exists in less than 7% of Serum total T4 is a commonly performed but less than
the population, a high index of suspicion should be main- helpful test to assess thyroid function. Numerous factors can
tained for individuals at particular risk. Risk factors and as- cause an increase or decrease in total T4; however, that is not
sociated conditions include the following: indicative of a change in metabolic status. These factors in-
• Down syndrome: Hypothyroidism clude a change in thyroxine-binding globulin (TBG) levels,
• Elderly age: Hypothyroidism or hyperthyroidism with a the principal carrier protein of T3 and T4. The use of certain
high propensity for atypical presentation in either situation medications, including exogenous estrogen (oral contracep-
• Use of certain medications causing an alteration in thyroid tives, postmenopausal hormone therapy), opioids, and selec-
function, including iodide (hypothyroidism), amiodarone, tive estrogen receptor modifiers (tamoxifen, raloxifene) can
lithium (capable of inducing both hyperthyroidism and cause an alteration in TBG levels, resulting in an increase or
hypothyroidism), interferon-alpha, interluken-2, lithium decrease in total T4 (the total of protein-bound and free T4),
(capable of inducing thyroiditis) but no change in the metabolically active free T4; these results
• Female gender: Hyperthyroidism or hypothyroidism; be- are metabolically insignificant. As a result, the clinical use-
cause most thyroid dysfunction is autoimmune in nature, fulness of total T4 measurement is limited with results that
these diseases are more common in women than in men, can lead to errors in clinical judgment.
as are most autoimmune diseases The likelihood of normal free T4 if TSH level is normal is
• Postpartum period: A transient hypothyroidism is com- greater than 98%. In the small remainder, pituitary disorder
mon, as is a transient thyroiditis is the likely cause. If the clinician suspects thyroid disorder,
• Personal and/or family history of autoimmune disease, and TSH level is normal, it should be assumed that the hy-
such as pernicious anemia, vitiligo, and type 1 DM: pothalamic-pituitary-thyroid axis is intact, with no further
Hyperthyroidism and hypothyroidism testing required. TSH level is increased in hypothyroidism; a
• History of head and neck irradiation or surgery: 50% decrease in T4 concentration can yield a 90-fold increase
Hypothyroidism in TSH. Conversely, TSH level is decreased in hyperthy-
Using the currently available highly sensitive and specific roidism. If TSH level is elevated, hypothyroidism should be
test form, the measurement of TSH, also known as thy- confirmed by obtaining free T4 level. If TSH is low or unde-
rotropin) is the most helpful thyroid test, particularly when tectable, hyperthyroidism should be confirmed with a meas-
diagnosing the condition in the outpatient setting. TSH is urement of free T4.
produced and released by the anterior lobe of the pituitary Because thyroid disease can produce low-level symptoms
with secretion stimulated by thyrotropin-releasing hormone attributed to other conditions, especially stress, fatigue, and
through a negative feedback loop in response to amount of a variety of self-limiting illnesses, the issue of routine testing
circulating thyroid hormone (T4). Because only a small frac- for thyroid disorder with TSH has been long debated. Clinical
tion of T4 circulates free, with 99.7% bound to T4-binding Preventive Services Guidelines and other authorities advise
globulin or other plasma proteins, the unbound portion of that there is insufficient evidence to recommend for or
T4, or free T4, is metabolically active. The measurement of against routine screening for all asymptomatic lower risk
free T4 is the most helpful test to confirm an abnormal TSH adults, for thyroid disease.
level. Approximately 40% of T4 is converted in periphery to Chronic lymphocytic thyroiditis, also known as
triiodothyronine (T3). Compared with T4, T3 is likely four Hashimoto’s thyroiditis, is the most common inflamma-
times more metabolically active; T4 is often referred to as a tory disease of the thyroid and the leading cause of hy-
prodrug for T3. pothyroidism in parts of the world where iodine deficiency
4074_Ch11_261-292 20/11/14 11:00 AM Page 285
is uncommon, such as North America. This condition The treatment of subclinical hypothyroidism is a matter of
likely has a genetic predisposition as an inherited dominant differing approaches; some authorities recommend levothy-
trait and is often linked with other autoimmune disorders, roxine therapy in the presence of antithyroid antibodies versus
such as systemic lupus erythematosus, pernicious anemia, a watch-and-wait approach, with periodic TSH and free T4
rheumatoid arthritis, DM, and Sjögren’s syndrome. The testing every 6 months. When TSH level increases to more
condition is most often seen in women 30 to 50 years old; than 10 mIU/L, even in the presence of a normal free T4 level,
clinical presentation often includes a diffusely enlarged, a significant increase in LDL, increasing cardiovascular disease
firm thyroid with fine nodules, neck pain, and tightness. risk, is often noted, and levothyroxine therapy should be ini-
This Hashimoto goiter may regress over time; many indi- tiated. The American Association of Clinical Endocrinologists
viduals first present with the condition in the hypothyroid guidelines recommend treatment of patients with TSH greater
state, which necessitates the use of T4 replacement in the than 5 mIU/L if the patient has a goiter, or if thyroid antibod-
form of levothyroxine (Levothroid®, Levoxyl®, Synthroid®, ies are present. The presence of symptoms compatible with
Unithroid®, generic). Antimicrosomal thyroid antibodies, hypothyroidism, infertility, pregnancy, or plans to become
also known as antithyroid antibodies, likely reflecting cell- pregnant in the near future also favors treatment.
mediated immunity, are found in nearly all patients with In the treatment of subclinical hypothyroidism, T4 re-
Hashimoto’s thyroiditis. Environmental iodine deficiency placement is prescribed in the form of levothyroxine
is the most common cause of hypothyroidism on a world- (Levothroid, Levoxyl, Synthroid, Unithroid, generic). The an-
wide basis. ticipated dosage of thyroid replacement with levothyroxine
With an 8:1 female-to-male ratio, Graves’ disease is the for an adult with clinically detected hypothyroidism is
most common form of thyrotoxicosis, or hyperthyroidism. 1.6 mcg/kg/d, based on ideal body weight; actual body weight
The age at onset is usually 20 to 40 years, and there is a sig- should be used for the person who is underweight. A lower
nificant correlation with autoimmune diseases such as perni- dose is recommended for older adults. In the presence of sub-
cious anemia, myasthenia gravis, and type 1 DM. Clinical clinical hypothyroidism, a relatively low levothyroxine dose
presentation of Graves’ disease includes diffuse thyroid en- is often sufficient because some thyroid function remains.
largement, exophthalmos, nervousness, tachycardia, and heat Over time, thyroid failure progresses, and the patient’s
intolerance. Thyroid scan reveals a large “hot” (metabolically levothyroxine requirement typically increases.
active) gland with heterogeneous uptake. Treatment of In the treatment of hypothyroidism, T4 replacement is
Graves’ disease includes the use of antithyroid preparations needed in the form of levothyroxine (Levothroid, Levoxyl,
such as methimazole or propylthiouracil; the use of both drugs Synthroid, Unithroid, generic). The anticipated dosage of
carries a hepatotoxicity warning. Once euthyroid status is thyroid replacement for an adult is 75 to 125 mcg of levothy-
achieved, radioactive iodine for thyroid ablation is usually the roxine, or about 1.6 mcg/kg/d; ideal body weight should be
next step in therapy. Subsequent hypothyroidism is the norm, used for this calculation as this lean body mass, even in the
necessitating the use of levothyroxine. Expert consultation is presence of obesity, best reflects levothyroxine needs; for the
advised in caring for the person with hyperthyroidism. person who is underweight, actual body weight should be
Subclinical hypothyroidism is diagnosed based on the used. For an elderly person, the anticipated dosage is 75% or
presence of an elevated TSH level and a normal free T4 level less of the adult dosage. Because this drug has a long half-life,
in the absence of or with minimal symptoms. Given that fa- the effects of a dosage adjustment would not cause a change
tigue, often reported by a person with untreated or under- in TSH for approximately five to six drug half-lives. Hence,
treated hypothyroidism, is so common in this condition, mild the recommended testing interval post adjustment of a
hypothyroidism is likely a more appropriate term for this levothyroxine form is 6 to 8 weeks. The levothyroxine dose
condition. Goiter, or chronic thyroid enlargement, usually should be titrated so that TSH is within normal limits. All
caused by hypertrophic or degenerative changes, is a com- levothyroxine forms are acceptable, but due to its narrow
mon finding but is also found in many individuals with nor- therapeutic index, the same brand or generic should be taken.
mal thyroid function or other forms of thyroid disease. If the brand or generic form changes, the TSH should be
The prevalence of subclinical hypothyroidism varies by checked 6 to 8 weeks after the adjustment.
age and gender, and ranges from estimations of 1% to 10% Animal-derived desiccated thyroid such as Armour® thyroid
of the overall population to 20% in women 60 years and contains T4 and T3; drug levels vary substantially throughout
older. In men 74 years and older, the prevalence has been re- the day in those taking desiccated thyroid. The majority of study
ported as more than 15%. Most of these patients have TSH on thyroid treatment has been done with levothyroxine, a
values of 5 to 10 mIU/L; 50% to 80% have evidence of an- bioidentical hormone. There are no controlled trials supporting
tithyroid or antithyroperoxidase antibodies. The estimated the preferred use of desiccated thyroid hormone over levothy-
prevalence of this disorder is about 7% in women and 3% in roxine in the treatment of hypothyroidism or any other thyroid
men among community-dwelling individuals 60 to 89 years disease. Desiccated thyroid is animal-sourced, either bovine
old. There is a 2% to 5% likelihood of development of overt (cow) or porcine (pig) in nature; the use of the medication
hypothyroidism per year if clinical findings are consistent would likely pose difficulties for certain ethnic and religious
with subclinical hypothyroidism. groups as well as vegans and vegetarians.
4074_Ch11_261-292 20/11/14 11:00 AM Page 286
119. When providing care for a patient taking an HMG- 127. What is the average LDL reduction achieved with a
CoA reductase inhibitor, initial evaluation when change in diet as a single lifestyle modification?
starting medication includes checking which of the A. less than 5%
following serological parameters? B. 5% to 10%
A. potassium C. 11% to 15%
B. alanine aminotransferase D. 16% to 20% or more
C. bilirubin
128. You are seeing a patient who is taking warfarin and
D. alkaline phosphatase
cholestyramine and provide the following advice:
120. When prescribing a fibrate, the NP expects to see A. “Take both medications together.”
which of the following changes in lipid profile? B. “You need to have additional hepatic monitoring
A. marked decrease in LDL level tests while on this combination.”
B. increase in HDL level C. “Separate the cholestyramine from other medica-
C. no effect on triglyceride level tions by at least 2 hours.”
D. increase in very low density lipoprotein (VLDL) D. “Make sure you take these medications on an
level empty stomach.”
121. When prescribing niacin, the NP expects to see which 129. Which of the following medications is representative
of the following changes in lipid profile? of high-intensity statin therapy?
A. marked decrease in LDL level A. pravastatin 40 mg
B. increase in HDL level B. rosuvastatin 20 mg
C. no effect on triglyceride level C. simvastatin 40 mg
D. increase in VLDL level D. lovastatin 20 mg
122. In prescribing niacin therapy for a patient with 130. Which of the following daily doses has the lowest
hyperlipidemia, the NP considers that: lipid-lowering effect?
A. postdose flushing is often reported. A. simvastatin 10 mg
B. hepatic monitoring is not warranted. B. rosuvastatin 5 mg
C. low-dose therapy is usually effective in increasing C. atorvastatin 10 mg
LDL level. D. pravastatin 40 mg
D. drug-induced thrombocytopenia is a common
131. Untreated hypothyroidism can result in which of the
problem.
following changes in the lipid profile?
123. With the use of ezetimibe (Zetia), the NP expects A. increased HDL and decreased triglycerides
to see: B. increased LDL and total cholesterol
A. a marked increase in HDL cholesterol. C. increased LDL, total cholesterol, and triglycerides
B. a reduction in LDL cholesterol. D. decreased LDL and HDL
C. a significant reduction in triglyceride levels.
132. A program of regular aerobic physical activity can yield
D. increased rhabdomyolysis when the drug is used in
which of the following changes in the lipid profile?
conjunction with HMG-CoA reductase inhibitor.
A. increases HDL, lowers VLDL and triglycerides
124. With ezetimibe (Zetia), which of the following should B. lowers VLDL and LDL
be periodically monitored? C. increases HDL, lowers LDL
A. ALP D. lowers HDL, VLDL, and triglycerides
B. lactate dehydrogenase (LDH)
133. The anticipated effect on the lipid profile with high-
C. CPK
dose omega-3 fatty acid use includes:
D. No special laboratory monitoring is recommended.
A. increase in HDL.
125. With the use of a lipid-lowering resin, which of the B. decrease in LDL.
following enzymes should be periodically monitored? C. decrease in total cholesterol.
A. ALP D. decrease in triglycerides.
B. LDH
134. The anticipated effect on the lipid profile with plant
C. AST
stanol and sterol use includes:
D. No particular monitoring is recommended.
A. increase in HDL.
126. All of the following are risks for statin-induced B. decrease in LDL.
myositis except: C. decrease in select lipoprotein subfractions.
A. advanced age. D. decrease in triglycerides.
B. use of a low-intensity statin therapy with a resin.
C. low body weight.
D. high-intensity statin therapy.
4074_Ch11_261-292 20/11/14 11:00 AM Page 288
135. For patients with documented coronary heart disease, for atherosclerotic cardiovascular disease (ASCVD) risk re-
the American Heart Association advises intake of duction outweighs the risk of drug-induced adverse events.
approximately ____ of eicosapentaenoic acid (EPA) These groups include those: 1) with clinical ASCVD; 2) with
and docosahexaenoic acid (DHA) per day, preferably primary elevations of LDL-C 190 mg/dL or higher; 3) with di-
from oily fish. abetes aged 40 to 75 years, with LDL-C 70 to 189 mg/dL, and
A. 500 mg without ASCVD; or 4) without clinical ASCVD or diabetes
B. 1 g with LDL-C 70 to 189 mg/dL and estimated 10-year ASCVD
C. 2 g risk of 7.5% or higher. Patient risk factors and 10-year risk of
D. 4 g a cardiovascular event (based on the Pooled Risk Equation)
help determine the intensity of statin therapy. High intensity
136. Which of the following is an example of moderate-
statin therapy will lower LDL-C by 50% or more (e.g., ator-
intensity statin therapy?
vastatin 40 to 80 mg, rosuvastatin 20 to 40 mg), while
A. fluvastatin 10 mg
moderate-intensity statin therapy will lower LDL-C by 30%
B. atorvastatin 10 mg
to less than 50% (e.g., simvastatin 20 to 40 mg; atorvastatin
C. simvastatin 10 mg
10 to 20 mg; pravastatin 40 to 80 mg; or rosuvastatin 5 to
D. pravastatin 20 mg
10 mg). The ACC/AHA guidelines recommend the following
statin intensity for each risk group:
• Clinical ASCVD: high-intensity statin for age 75 years
Answers or younger, or moderate-intensity statin for age over
75 years or if not a candidate for high-intensity statin
116. B. 122. A. 128. C. 134. B.
• LDL-C of 190 mg/dL or less: high-intensity statin (or
117. D. 123. B. 129. B. 135. B.
moderate-intensity statin if not a candidate for
118. C. 124. D. 130. A. 136. B.
high-intensity statin)
119. B. 125. D. 131. C.
• Diabetes (type 1 or 2) and age 40 to 75 years: moderate
120. B. 126. B. 132. A.
intensity statin (high-intensity statin if 10-year ASCVD
121. B. 127. B. 133. D.
risk of 7.5% or less)
Treatment of hyperlipidemia is an important part of cardio- • 10-year ASCVD risk of 7.5% or less and age 40 to
vascular and cerebrovascular risk reduction. Intensive ther- 75 years: moderate-to-high intensity statin
apeutic lifestyle changes should be the first line of therapy. ACC/AHA guidelines note that the benefit of statin ther-
Dietary advice includes reducing saturated fat and cholesterol apy in prevention of cardiovascular events is less clear in
intake and adding dietary options to enhance LDL lowering, other patient groups. Causes of secondary dyslipidemia
such as adding plant stanols and sterols and increasing intake should be considered and eliminated or minimized, usually
of viscous or soluble fiber. Most adults achieve only a 5% to through lifestyle intervention or treatment of the underlying
10% reduction in LDL cholesterol with dietary advice as a sin- cause, or both.
gle intervention. Weight management and a program of reg-
D I S C U SSI O N S O U R C E S
ular aerobic exercise should be prescribed for overall health.
Dietary lipid improvement is often enhanced if coupled with American Heart Association. Fish oil and omega-3 fatty acids.
www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/
exercise; since physical activity reduces insulin resistance, the
HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_
anticipated improvement in the lipid profile includes an in- 303248_Article.jsp
crease in HDL and reduction of triglycerides. American Heart Association. Managing abnormal blood lipids: A
Pharmacological intervention in hyperlipidemia is likely collaborative approach. http://circ.ahajournals.org/cgi/content/
to be needed in patients with considerable cardiovascular full/112/20/3184,
and cerebrovascular risk, including patients with DM, hy- National Heart, Lung, and Blood Institute. Adult Treatment Panel
pertension, and existing vascular disease. The choice of a III (ATP III) Guidelines: National Cholesterol Education Pro-
lipid-lowering agent should be guided by the effect of the gram Adult Treatment Panel III guidelines for lipid goals.
agent on the lipid profile. www.nhlbi.nih.gov/guidelines/cholesterol/index.htm, a
Recommendations from the American College of Cardiol- Stone NJ, Robinson J, Lichtenstein AH, et al. ACC/AHA guideline
ogy (ACC) and American Heart Association (AHA) no longer on the treatment of blood cholesterol to reduce atherosclerotic
cardiovascular risk in adults: A report of the American College
advise on the use of multiple medications to attain LDL-
of Cardiology/American Heart Association Task Force on Prac-
C levels below certain targets. Instead, the guidelines recom- tice Guidelines. Circulation 2014;129(25 Suppl 2):S1-45.
mend statin treatment for four major groups in which therapy
4074_Ch11_261-292 20/11/14 11:01 AM Page 289
Damage to the adrenal gland will show limited or no response 146. Untreated Cushing’s syndrome can lead to all of the
to synthetic ACTH. Patients typically present with low blood following except:
pressure. An abdominal CT scan can be used to evaluate the A. rheumatoid arthritis.
size of the adrenal glands and identify any abnormalities. Ad- B. hypertension.
ditionally, an MRI scan of the pituitary gland can be used to C. type 2 diabetes.
identify secondary adrenal insufficiency. D. osteoporosis.
Symptoms of the disease are usually controlled with
147. Cushing’s disease is the specific type of Cushing’s
corticosteroid replacement therapy, which can include a
syndrome that is caused by:
combination of glucocorticoids (cortisone, prednisone, or hy-
A. long-term exposure to corticosteroids.
drocortisone) and mineralocorticoids (fludrocortisone). Oral
B. a benign tumor of the adrenal gland.
treatments are preferred, though injections may be needed if
C. a benign pituitary tumor.
the patient is vomiting and cannot retain oral medications.
D. an ectopic tumor that produces ACTH.
An ample amount of sodium is also recommended, especially
during heavy exercise, in hot climates, and during gastroin- 148. The most commonly recommended treatment of
testinal upsets, such as diarrhea. During an Addisonian crisis, Cushing’s disease is:
an immediate injection of hydrocortisone is needed along A. tapering or ceasing corticosteroid use.
with supportive treatment for low blood pressure. With B. eliminating trigger medications.
proper hormone replacement therapy, most people with Ad- C. antineoplastic therapy.
dison’s disease can lead normal lives. Expert consultation is D. surgical intervention.
required to provide appropriate care for the person with Ad-
dison’s disease.
Answers
DI SCUS SION SOURCE
Betterle C, Morlin L. Autoimmune Addison’s disease. Endocr Dev 143. B. 145. A. 147. C. 148. D.
20:161–172, 2011. 144. C. 146. A.
corticosteroids. These drugs have the same effect as cortisol patients taking long-term treatment of corticosteroids, tapering
and are often prescribed at doses that attain supraphysiolog- the dose as soon as possible is recommended. Abrupt discon-
ical levels in the body. tinuation of long-term corticosteroid therapy can lead to adre-
Endogenous causes of Cushing’s syndrome can also nal crisis; therefore reducing its use to a low or maintenance
occur. Overproduction of cortisol can occur from one or dose is the safest initial intervention. For endogenous Cushing’s
both adrenal glands, or can be due to overproduction of syndrome, surgical resection is the primary treatment of choice
adrenocorticotropic hormone (ACTH), which is produced to remove a tumor of the adrenal gland overproducing cortisol,
by the pituitary gland and regulates cortisol production. or to remove a tumor of the pituitary gland or other sites that
Overproduction of ACTH can occur due to a pituitary gland are overproducing ACTH. For those with Cushing’s disease,
tumor (pituitary adenoma) or an ectopic ACTH-secreting first-line treatment is transsphenoidal surgery, which results in
tumor (such as in the lung). Cushing’s disease is a specific an approximately 80% cure rate. Often surgery is curative,
form of Cushing’s syndrome caused by a benign tumor on though radiation therapy may be needed in conjunction with
the pituitary gland that overproduces ACTH. Overproduc- surgery. Radiation therapy is an option for those who are not
tion of cortisol can also occur from a benign tumor of the suitable candidates for surgery. Cortisol replacement therapy is
adrenal cortex (adrenal adenoma) or, more rarely, an often used following surgery to provide a normal physiological
adrenocortical carcinoma. level of cortisol. In most cases, this treatment can be tapered
Diagnosis of Cushing’s syndrome can be difficult, partic- over time as the body returns to normal adrenal hormone
ularly when endogenous in origin. For patients with long- production.
term use of high-dose corticosteroids, Cushing’s syndrome Certain medications can be used to control cortisol pro-
is usually suspected as a result of this exposure. For patients duction. These include mitotane (Lysodren®), and metyrapone
without a history of long-term corticosteroid use, urine, (Metopirone®). Mifepristone (Korlym®) has been approved
blood, and saliva tests can evaluate cortisol levels. MRI or CT for use in patients with endogenous Cushing’s syndrome and
scans can be used to detect abnormalities of the pituitary or type 2 diabetes or glucose intolerance and have failed surgery
adrenal glands. These tests can also help rule out other med- or cannot have surgery. This agent does not impact the pro-
ical conditions with similar signs and symptoms, such as duction of cortisol but blocks the effects of cortisol on tissues.
polycystic ovary syndrome, depression, eating disorders, and
alcoholism. Expert consultation is advised. D I S C U SSI O N S O U R C E S
Without intervention, Cushing’s syndrome is associated Prague JK, May S, Whitelaw BC. Cushing’s syndrome. BMJ
with increased rates of cardiovascular events (heart failure or 346:f945, 2013. Available at: www.bmj.com/content/346/bmj
myocardial infarction) and infection. In addition, this condition .f945
can lead to osteoporosis, hypertension, type 2 diabetes, frequent Castinetti F, Morange I, Conte-Devolx B, Brue T. Cushing’s disease.
Orphanet J Rare Dis 7:41, 2012. Available at: www.ncbi.nlm.nih
and unusual infections, and loss of muscle mass. Treatment
.gov/pmc/articles/PMC3458990/pdf/1750-1172-7-41.pdf
is designed to reduce the level of cortisol in the body. For
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4074_Ch12_293-306 20/11/14 11:01 AM Page 293
Renal Disorders 12
Renal Failure 6. A 68-year-old woman with heart failure presents with
tachycardia, S3 heart sound, and basilar crackles bilater-
1. All of the following electrolyte disorders are commonly ally. Blood pressure is 90/68 mm Hg; BUN is 58 mg/dL
found in a person with chronic renal failure except: (20.7 mmol/L); creatinine is 2.4 mg/dL (212.1 μmol/L).
A. hypernatremia. This clinical presentation is most consistent with:
B. hypercalcemia. A. prerenal azotemia.
C. hyperkalemia. B. acute glomerulonephritis.
D. hypophosphatemia. C. tubular necrosis.
D. postrenal azotemia.
2. All of the following are common precipitating factors in
acute renal failure except: 7. Which of the following is found early in the develop-
A. anaphylaxis. ment of chronic renal failure?
B. infection. A. persistent proteinuria
C. myocardial infarction. B. elevated creatinine level
D. type 1 diabetes. C. acute uremia
D. hyperkalemia
3. Common causes of chronic renal failure include all of
the following except: 8. You see a 63-year-old man with a suspected upper
A. type 2 diabetes. gastrointestinal bleed. Expected laboratory findings
B. recurrent pyelonephritis. would include:
C. hypotension. A. elevated BUN; elevated serum creatinine.
D. polycystic kidney disease. B. normal BUN; elevated serum creatinine.
C. elevated BUN; normal serum creatinine.
4. The use of which of the following medications can D. lowered BUN; elevated serum creatinine.
precipitate acute renal failure in a patient with bilateral
renal artery stenosis? 9. Angiotensin-converting enzyme inhibitors can limit
A. corticosteroids the progression of some forms of renal disease by:
B. angiotensin II receptor antagonists A. increasing intraglomerular pressure.
C. beta-adrenergic antagonists B. reducing efferent arteriolar resistance.
D. cephalosporins C. enhancing afferent arteriolar tone.
D. increasing urinary protein excretion.
5. A 78-year-old man presents with fatigue and difficulty
with bladder emptying. Examination reveals a distended 10. Objective findings in patients with glomerulonephritis
bladder but is otherwise unremarkable. The blood urea include all of the following except:
nitrogen (BUN) is 88 mg/dL (31.4 mmol/L); the creati- A. edema.
nine is 2.8 mg/dL (247.5 μmol/L). This clinical assess- B. urinary red blood cell (RBC) casts.
ment is most consistent with: C. proteinuria.
A. prerenal azotemia. D. hypotension.
B. acute glomerulonephritis.
C. acute tubular necrosis.
D. postrenal azotemia.
293
4074_Ch12_293-306 20/11/14 11:01 AM Page 294
11. An increase in creatinine from 1 to 2 mg/dL is typically Renal failure can be either acute or chronic. In acute renal
seen with a ____ loss in renal function. failure, a precipitating event or cause is often easily identifi-
A. 25% able. Acute renal failure can occur due to various conditions
B. 50% that result in: 1) decreased blood flow to the kidneys (e.g., due
C. 75% to blood or fluid loss, blood pressure medications, heart
D. 100% disease, infection, or severe allergic reaction); 2) damage
to the kidneys (e.g., glomerulonephritis, hemolytic uremic
12. Creatinine clearance usually:
syndrome, infection, lupus, or nephrotoxic medications);
A. approximates glomerular filtration rate (GFR).
or 3) urine blockage in the kidneys (e.g., various cancers, en-
B. does not change as part of normative aging.
larged prostate, or kidney stones). Causes of chronic renal
C. is greater in women compared with men.
failure include type 1 or type 2 diabetes mellitus, high blood
D. increases with hypotension.
pressure, glomerulonephritis, polycystic kidney disease, and
13. Creatinine is best described as: recurrent pyelonephritis.
A. a substance produced by the kidney. With prerenal azotemia, the most common cause of
B. a product related to skeletal muscle metabolism. acute renal failure, the kidneys are hypoperfused, which
C. produced by the liver and filtered by the kidney. often leads to acute tubular necrosis. Reasons for this hy-
D. a by-product of protein metabolism. poperfusion include: decreased circulating volume, as seen
in patients with dehydration and acute blood loss; decreased
14. Guidelines recommend considering initiating treat-
cardiac output, as seen in patients with heart failure; or ex-
ment with an erythropoiesis-stimulating agent
cessive sequestering of fluid, as seen in patients with burns.
(ESA) for patients with chronic renal failure and
Postrenal azotemia is caused by obstruction to urine flow
a hemoglobin (Hg) level:
and is an uncommon cause of renal failure. In intrinsic renal
A. less than 8.5 mg/dL.
failure, there is disease within the kidney at the levels of the
B. less than 9.0 mg/dL.
renal tubules, glomeruli, interstitium, or vessels. Etiologies
C. less than 10 mg/dL.
include glomerulonephritis and acute interstitial nephritis.
D. less than 11.5 mg/dL.
Laboratory findings in these more common forms of acute
15. Which of the following hemograms would be expected renal failure vary (Table 12–1).
for a 75-year-old woman with anemia and chronic Typical findings in renal failure include increased serum
renal failure? creatinine and blood urea nitrogen (BUN) levels. Creati-
A. Hg=9.7 g/dL (12 to 14 g/dL); MCV=69 fL (80 to nine is the end product of creatine metabolism, which
96 fL); reticulocytes=0.8% (1% to 2%). arises from skeletal muscle. Because creatinine excretion
B. Hg=10.2 g/dL (12 to 14 g/dL); MCV=104 fL (80 to by a healthy kidney is very efficient, measurement of crea-
96 fL); reticulocytes=1.2% (1% to 2%). tinine is used as a surrogate marker of kidney function;
C. Hg=9.4 g/dL (12 to 14 g/dL); MCV=83 fL (80 to creatinine production equals creatinine excretion. As the
96 fL); reticulocytes=0.7% (1% to 2%). kidney fails, the creatinine level increases. BUN is derived
D. Hg=10.4 g/dL (12 to 14 g/dL); MCV=94 fL (80 to from the breakdown of protein from dietary or other
96 fL); reticulocytes=2.6% (1% to 2%). sources. BUN level typically increases (uremia) more rap-
idly than creatinine level in response to decreased renal
16. Which of the following is the most likely candidate to
perfusion and can increase from prerenal, renal, and
initiate dialysis due to chronic kidney disease (CKD)?
postrenal causes of kidney failure. In particular, elevated
A. A 46-year-old man with hypertension and
BUN level with a normal creatinine level is occasionally
GFR=42 mL/min
found in patients with healthy kidneys but with severe
B. A 64-year-old woman with type 2 diabetes and
dehydration. In addition, upper GI bleeding usually causes
GFR=28 mL/min
a marked increase in BUN level without corresponding
C. A 76-year-old man with anemia and GFR=55 mL/min
increase in creatinine as the gut digests and absorbs pro-
D. A 58-year-old woman with heart disease and
teins found in the blood. Electrolyte disorders commonly
GFR=46 mL/min
associated with renal failure include hyperkalemia, hyper-
calcemia, and hypernatremia.
Anemia is typically seen in patients with chronic renal
Answers failure. Erythropoietin, a glycoprotein growth factor pro-
duced primarily by the kidneys, is normally released in the
1. D. 7. A. 13. B. bloodstream and binds with receptors in the bone marrow
2. D. 8. C. 14. C. to stimulate the production of erythrocytes (red blood cells
3. C. 9. B. 15. C. [RBCs]). With end-stage renal disease, erythropoietin re-
4. B. 10. D. 16. B. sponse is reduced because of limited supply; that is, as the
5. D. 11. B. kidney fails, erythropoietin production declines. In addition,
6. A. 12. A. as is common in chronic illness, RBC life span is shortened.
4074_Ch12_293-306 20/11/14 11:01 AM Page 295
TABLE 12-1
Etiology of and Findings in Acute Renal Failure
Disease Causing Acute Renal Failure Typical Etiology Laboratory Findings
Acute glomerulonephritis Poststreptococcal infection, BUN:Cr ratio >20:1
autoimmune diseases Urinalysis: renal casts, RBCs
Acute interstitial nephritis Allergic reaction, drug reaction BUN:Cr ratio <20:1
Urinalysis: WBC casts, eosinophils
Acute tubular necrosis Hypotension, nephrotoxins BUN:Cr ratio <20:1
Urinalysis: granular casts, renal
tubular cells
BUN— blood urea nitrogen; Cr—creatinine; RBCs—red blood cells; WBC—white blood cell.
These factors result in a normocytic, normochromic anemia 18. Poststreptococcal glomerulonephritis typically occurs
in the presence of a low reticulocyte count, the characteristics how long following a bacterial pharyngitis infection?
of anemia of chronic disease. This problem is treated with A. 4 to 6 days
recombinant erythropoietin, transfusion, and correction of B. 1 to 2 weeks
additional anemia risk factors. Guidelines recommend con- C. 3 to 4 weeks
sidering treatment with an erythropoiesis-stimulating agent D. 2 months
(ESA) for dialysis and nondialysis adult patients when hemo-
19. Diagnostic confirmation of glomerulonephritis
globin levels are less than 10 g/dL (less than 100 g/L). In
typically requires:
general, treatment should target a hemoglobin level not
A. urinalysis plus a CBC with differential.
exceeding 11.5 g/dL.
B. abdominal CT scan.
Chronic kidney disease can be classified into five stages
C. kidney ultrasound.
based on glomerular filtration rate (GFR). Dialysis and
D. kidney biopsy.
kidney transplantation should be considered for those
approaching Stage 4 (GFR=15 to 29 mL/min) who have 20. A 35-year-old man presents with edema of the
advanced kidney damage. Those at Stage 4 are likely to de- face, hands, and ankles along with hypertension
velop serious complications of CKD, including hyperten- (175/115 mm Hg). He reports urine that is darkly
sion, anemia, and cardiovascular disease. For those at Stage colored and foamy. You suspect acute glomeru-
5 (GFR less than 15 mL/min) or end-stage renal disease, lonephritis and would expect urinalysis results to
the kidneys have lost nearly all of their ability to perform include all of the following findings except:
and the person will require dialysis or transplantation for A. elevated level of protein.
survival. B. presence of red blood cells.
C. presence of renal casts.
DI SCUSSION SOURCES D. abnormally high glucose levels.
National Kidney Foundation Kidney Disease Outcomes Quality Ini-
tiative. www.kidney.org/professionals/kdoqi/index.cfm. 21. A 47-year-old woman with lupus erythematosus is
Kliger AS, Foley RN, Goldfarb DS, et al. KDOQI US commentary diagnosed with acute glomerulonephritis. Treatment
on the 2012 KDIGO clinical practice guideline for anemia in options include all of the following except:
CKD. Am J Kidney Dis 2013. www.kidney.org/Professionals/ A. systemic corticosteroids.
kdoqi/pdf/KDOQI_Commentary_on_KDIGO_Anemia.pdf. B. systemic antimicrobials.
C. immune suppressors.
D. plasmapheresis.
Glomerulonephritis 22. A complication of glomerulonephritis is:
17. Risk factors for acute glomerulonephritis include all of A. type 2 diabetes.
the following except: B. nephrotic syndrome.
A. bacterial endocarditis. C. pyelonephritis.
B. Goodpasture’s syndrome. D. bladder cancer.
C. Crohn’s disease.
D. polyarteritis.
4074_Ch12_293-306 20/11/14 11:01 AM Page 296
30. Which of the following is the most accurate informa- 39. Which of the following is not a gram-negative organism?
tion in caring for a 40-year-old man with cystitis? A. E. coli
A. This is a common condition in men of this age. B. K. pneumoniae
B. A gram-positive organism is the likely causative C. P. mirabilis
pathogen. D. S. saprophyticus
C. A urological evaluation should be considered.
40. You see a 70-year-old woman in a walk-in center with
D. Pyuria is rarely found.
a chief complaint of increased urinary frequency and
31. Evidence-based factors that prevent or minimize the dysuria. Urinalysis reveals pyuria and positive nitrites.
risk of UTIs include all of the following except: She mentions she has a “bit of kidney trouble, not too
A. male gender. bad.” Recent evaluation of renal status is unavailable.
B. longer urethra-to-anus length in women. In considering antimicrobial therapy for this patient,
C. timed voiding schedule. you prescribe:
D. zinc-rich prostatic secretions. A. nitrofurantoin.
B. fosfomycin.
32. Hemorrhagic cystitis is characterized by:
C. ciprofloxacin.
A. irritative voiding symptoms.
D. doxycycline.
B. persistent microscopic hematuria.
C. the presence of hypertension.
D. elevated creatinine and BUN levels.
Answers
33. A 44-year-old woman presents with pyelonephritis.
The report of her urinalysis is least likely to include: 23. A. 29. B. 35. B.
A. WBC casts. 24. D. 30. C. 36. B.
B. positive nitrites. 25. B. 31. C. 37. D.
C. 3+ protein. 26. C. 32. A. 38. A.
D. rare RBCs. 27. D. 33. C. 39. D.
28. D. 34. C. 40. C.
34. An example of a first-line therapeutic agent for the
treatment of pyelonephritis is:
A. amoxicillin with clavulanate. The urinary tract, adjacent to the bacteria-rich lower GI tract,
B. trimethoprim-sulfamethoxazole. produces and stores urine. The periurethral area is typically
C. ciprofloxacin. colonized with gut and other flora, some capable of causing
D. nitrofurantoin. urinary tract infection (UTI). Although the process of urina-
tion usually flushes bacteria from the urethral orifice, peri-
35. With fluoroquinolone use, length of antimicrobial ther-
urethral pathogens occasionally enter the urethra and ascend,
apy during uncomplicated pyelonephritis is typically:
reaching the bladder and resulting in UTI; this is the most
A. 5 days.
common route for UTI acquisition. Rarely, hematogenous
B. 1 week.
UTI occurs when a pathogen is delivered to the urinary tract
C. 2 weeks.
via the bloodstream from a distant source of infection, such
D. 3 weeks.
as the lungs in a patient with pneumonia and bacteremia.
36. Risk factors for UTI in women include: UTIs can involve mucosal tissue (cystitis) or soft tissue
A. postvoid wiping back to front. (pyelonephritis, prostatitis). Anatomically, the infection can
B. low perivaginal lactobacilli colonization. be limited to the lower urinary tract (cystitis involving the
C. hot tub use. bladder and urethra) or the upper tract (pyelonephritis).
D. wearing snug-fitting pantyhose. Complicated UTI can occur in either the upper or the lower
urinary tract, but is accompanied by an underlying condition
37. All of the following can negatively impact perivaginal
that increases the risk for failing therapy, such as obstruction,
lactobacilli colonization except:
urological dysfunction, or resistant pathogens. Most UTIs
A. recent antimicrobial use.
occur via an ascending route.
B. exposure to the spermicide nonoxynol-9.
UTI is typically diagnosed by clinical presentation and a
C. estrogen deficiency.
few physical examination and laboratory findings. In an oth-
D. postcoital voiding.
erwise healthy woman, history of the present illness usually
38. In children and the elderly, which of the following con- reveals a complaint of dysuria, often reported as an internal
ditions can contribute to bladder instability and in- discomfort, with urinary frequency and urgency, but without
crease the risk of a UTI? fever or constitutional symptoms. Although suprapubic ten-
A. constipation derness and pain are often considered part of the clinical
B. upper respiratory tract infection presentation, this is found in only about 20% of women with
C. chronic diarrhea an uncomplicated UTI. Back pain, fever, nausea, and vomit-
D. efficient bladder emptying ing are more often associated with pyelonephritis, an upper
4074_Ch12_293-306 20/11/14 11:01 AM Page 298
urinary tract infection, and, in rare cases, with cystitis, a lower often indicates a contaminated urine specimen, and collec-
urinary tract infection; many patients with pyelonephritis tion and testing should be repeated. The presence of 105 or
also report lower UTI symptoms. Although vaginal infection more colony-forming units (CFUs) per milliliter of bacteria
and irritation can cause dysuria, most women who have dy- is the traditional diagnostic indicator for UTI. In the presence
suria without vaginal discharge have a UTI, not vaginitis. of dysuria and other symptoms for UTI, more than 102
UTIs are one of the most common types of infection in CFU/mL confirms the diagnosis.
the elderly, occurring in both the community and long-term Certain factors protect against or increase the risk for UTI.
care settings. Symptomatic UTI can include the classic Male sex is recognized as a potent protective factor, in part
symptoms of dysuria but can also include new onset incon- because of the longer urethral length than in women; women
tinence, confusion or dementia, and muscle weakness. Fac- with a shorter urethra-to-anus length appear to be at in-
tors that predispose older patients to UTIs include the use creased UTI risk. In contrast to the periurethral area in
of urinary catheters and external urine collection devices, women, the male periurethral area does not support bacterial
and age-related neurological conditions that impair bladder growth. Zinc-rich prostatic secretions are antibacterial, fur-
emptying. ther discouraging pathogen growth.
Hemorrhagic cystitis is characterized by large quantities of In either sex, efficient emptying helps prevent urine stag-
visible blood in the urine. Its etiology can be bacterial infection nation and minimizes UTI risk. Factors that alter efficient
or infection with adenovirus types 7, 11, 21, and 35 and in- bladder emptying, such as cystocele, rectocele, and benign
fluenza A, or it can be a result of radiation, cancer chemother- prostatic hyperplasia, increase UTI risk. In addition, robust
apy, or certain immunosuppressive medications. The clinical fucosyltransferase activity, an enzyme found in the peri-
presentation usually depends on its origin; with all causes, urethral and perivaginal area, discourages bacterial adher-
irritative voiding symptoms are typically reported. When the ence; the presence of relatively few bacterial adhesion
disease is infectious in origin, signs and symptoms of infection receptor sites in the bladder and urethra has a similar effect.
may also be encountered. Adenovirus is a common cause and Women with these receptors who do not have mucosal
is self-limiting in nature. Hemorrhagic cystitis is often con- secretion of the fucosyltransferase enzyme to help block bac-
fused with glomerulonephritis, but hypertension and abnor- terial adherence are more likely to have colonization with E.
mal renal function are absent in the former. coli and other coliforms from the rectum and less likely to
Acute pyelonephritis is an infection of the renal parenchyma have lactobacilli in the periurethral area; this situation results
and renal pelvis, caused by ascending cystitis; most episodes in frequent episodes of cystitis. The urothelial receptors can
are uncomplicated and not accompanied by risk of treatment also be found in the upper urinary tract, increasing the risk
failure such as obstruction, urological dysfunction, or a mul- of pyelonephritis. Women who are nonsecretors of ABO
tidrug-resistant uropathogen. Irritative voiding symptoms blood group antigens show enhanced adherence of patho-
similar to symptoms of cystitis, fever, flank pain, an acutely ill genic E. coli to urothelial cells compared with women who
appearance, costovertebral tenderness, and pyuria are usually are secretors of these antigens; this becomes a major UTI risk
reported; GI upset including vomiting is often noted. WBC factor when coupled with spermicide use or frequent vaginal
with differential usually reveals leukocytosis, neutrophilia, and sexual intercourse.
bandemia. A woman who is exposed to the spermicide nonoxynol-9,
Urine dipstick testing is commonly done in the outpatient either through vaginal use or with a male partner who uses
setting when UTI is suspected because it is simple and con- condoms with this spermicide, is at increased risk of UTI. The
venient and yields immediate results. Leukocyte esterase, ni- proposed mechanism of this risk is the antibacterial effect of
trites, protein, and blood are the important features in the spermicide—reducing lactobacilli, a normal component
evaluating for UTI. The presence of leukocyte esterase on a of the periurethral flora. Lactobacilli produce hydrogen per-
urine dipstick is equivalent to 4 WBCs or more per high- oxide and lactic acid, providing the periurethral area and
power field (HPF). Nearly all (96% or more) patients with vagina with a pH that inhibits bacterial growth, blocks poten-
UTI have pyuria equivalent to more than 10 WBCs/HPF. tial sites of attachment, and is toxic to uropathogens. In post-
Some uropathogens are capable of reducing dietary nitrates menopausal women, estrogen deficiency leads to a marked
in the urine to nitrite; this is an indirect test for bacteriuria. reduction in lactobacilli colonization in the vaginal-perineal
When this finding is coupled with a leukocyte esterase re- areas; topical estrogen use results in re-establishment of the
sponse, the likely offending organism is a gram-negative normal protective flora and a reduction of UTI risk. Recent
pathogen (E. coli, Proteus species, Klebsiella pneumoniae). antimicrobial use potentially increases UTI risk by the same
The nitrite test result is occasionally falsely negative in UTI mechanism.
with a low colony count or with recently voided or dilute Voiding at regular intervals with efficient bladder empty-
urine. In addition, this test does not detect organisms unable ing, wiping patterns, and postcoital voiding have not been
to reduce nitrate to nitrite, such as enterococci, staphylococci, shown to provide UTI protection. In addition, use of hot
or adenovirus. Small amounts of protein and RBCs may also tubs, wearing pantyhose, douching, and obesity have not
be positive on dipstick testing in cases of UTI (Table 12–2). been shown to increase UTI risk. In children and elderly
Urine culture is important when diagnosis is unclear, or adults, constipation has been noted to contribute to bladder
UTI is recurrent. The presence of more than one organism instability and helps encourage UTI development.
4074_Ch12_293-306 20/11/14 11:01 AM Page 299
TABLE 12-2
Common Urinalysis Dipstick Findings in Urinary Tract Infection
Finding Significance Comment
Color Typically pale yellow to colorless Change in urine color is not synonymous with UTI
or disease
Clarity Typically clear Pyuria causes urinary turbidity
Odor Mild characteristic odor Rancid or ammonia odor in urea-splitting organism
(e.g., P. mirabilis)
Specific gravity (SG) Dilute urine: SG ≤1.008 Dilute or concentrated urine can influence results of
Concentrated urine: SG >1.020 urine chemical test strip testing
Leukocyte esterase Test for enzyme present in WBCs Positive results indicate presence of neutrophils
>5 WBCs/HPF, an indicator of UTI, reported
sensitivity of 75%–90%; results not valid in
neutropenic patients; decreased sensitivity with
increased urinary glucose concentration, high uri-
nary SG, and presence of antimicrobial in urine
Nitrites Surrogate marker for bacteriuria; pres- Best done on well-concentrated urine such as first
ence indicates bacterial reduction of AM void; for nitrites to be present, urine should
dietary nitrates to nitrites by select be held in bladder for ≤1 hr for nitrate-to-nitrite
gram-negative uropathogens including conversion to occur; dietary nitrate intake must be
E. coli, Proteus spp adequate; false-negative result possible with low
Normally absent in sterile urine and colony count UTI
infection caused by enterococci,
staphylococci
Protein Dipstick testing most sensitive for Common in febrile response or represents presence
albumin of protein-containing substance such as WBCs,
bacteria, mucus; in UTI, usually trace to 30 mg/dL
(1+), seldom ≥100 mg/dL
pH Average pH 5–6 If alkaline urine is found in presence of UTI symp-
Acid pH 4.5–5.5 toms and positive leukocyte esterase, likely that a
Alkaline pH 6.5–8 urea splitting organism such as Proteus is allowing
urea to be split into CO2 and ammonia, causing
increase in urine’s normally acid pH
Red blood cells (RBCs) Low number of RBCs noted Microscopic hematuria common with UTI, but not
Gross hematuria rare in uncomplicated in urethritis or vaginitis
UTI, but may be present in infection
complicated by nephrolithiasis
Most episodes of community-acquired cystitis in women, been exhibited by the organisms that most often cause UTI,
the most commonly encountered UTI, are caused by enteric potentially reducing the usefulness of this inexpensive med-
gram-negative rods from the Enterobacteriaceae group, such ication. Nitrofurantoin and fosfomycin are effective alterna-
as E. coli, P. mirabilis, and less commonly encountered tives in treating cystitis, especially in areas with high
K. pneumoniae. Staphylococcus saprophyticus, a gram-positive TMP-SMX resistance and/or for those with a sulfa allergy.
organism, and E. coli accounted for more than 90% of the Long-standing resistance to the beta-lactams, including ampi-
uropathogens in one study of more than 4000 urine isolates cillin, compounds the problem.
obtained from women of reproductive age with cystitis during Factors influencing the development of multidrug-resistant
a 5-year period. These organisms are usually susceptible to flu- E. coli strains in part include liberal use of antimicrobials, par-
oroquinolones such as ciprofloxacin and levofloxacin, though ticularly TMP-SMX, to treat UTI and other infections in
increasing resistance rates by community uropathogens are adults and to provide prophylaxis against select opportunistic
mitigating their effectiveness. Growing rates of resistance to infections in patients with HIV. In children, attendance at day
trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim®) have care, age younger than 3 years, and repeated antimicrobial use,
4074_Ch12_293-306 20/11/14 11:01 AM Page 300
particularly TMP-SMX and beta-lactams for respiratory P. mirabilis and K. pneumoniae account for approximately
infections, are risk factors for infection with a resistant one-third of all infections in this age group. Length of antimi-
uropathogen; child-to-child and child-to-parent transmission crobial treatment in elderly persons with uncomplicated UTI
of the organism often occurs. Also, the more liberal use of should be 7 to 10 days for women and 10 to 14 days for men;
ciprofloxacin in recent years, triggered in part by the decrease short-course therapy is not recommended. First-line therapy
in cost when this medication became available in a generic includes TMP-SMX or fluoroquinolones; nitrofurantoin
form, is a great cause for alarm as E. coli resistance to the flu- should not be used in elderly patients because safe and
oroquinolone antimicrobial class has gradually increased. effective use of the product requires a minimal creatinine
Current treatment recommendations for UTI therapy in clearance of 60 mL/min. In an elderly patient with impaired
younger women without comorbid conditions include the renal function, the fluoroquinolone dosage potentially needs
use of a short course (3 to 7 days) of an antimicrobial with adjustment, but is considered to be a safe, effective, first-line
significant activity against gram-negative (E. coli) and select intervention.
gram-positive (S. saprophyticus) organisms. Treatment for UTI prophylaxis should be considered for women of
pyelonephritis is also focused on coverage of gram-negative reproductive age who experience two or more symptomatic
pathogens, usually for 5 to 7 days with a fluoroquinolone or UTIs within 6 months or three or more UTIs over 12 months
2 weeks with certain other antimicrobials (Table 12–3). and for women with fewer infections but with severe discom-
Although E. coli is the most common uropathogen in the fort. Continuous prophylaxis with daily TMP-SMX has been
community and in elderly persons living in long-term care, shown to be effective in the management of recurrent
TABLE 12-3
Urinary Tract Infection Therapies
Type of Infection Usual Pathogens Regimens
Acute, uncomplicated UTI E. coli (gram-negative, PRIMARY
(cystitis, urethritis) in most common pathogen), If local E. coli resistance to TMP-SMX <20% and no allergy,
nonpregnant women S. saprophyticus then TMP-SMX-DS bid × 3 days; if sulfa allergy, nitrofuran-
(gram-positive), toin x 5 days or fosfomycin × one dose. All plus pyridium.
enterococci If local E. coli resistance to TMP-SMX >20% or sulfa allergy,
(gram-positive) ciprofloxacin, levofloxacin, or moxifloxacin 3 days, nitrofu-
rantoin × 5 days or fosfomycin ×1 dose. All plus pyridium.
Moxifloxacin and gemifloxacin not labeled for use in UTI.
Recurrent UTI ( ≥3/yr) E. coli, S. saprophyticus, PRIMARY
enterococci, other Eradicate organisms, then TMP-SMX 1 SS tablet qd
pathogens possible long-term.
ALTERNATIVE
TMP-SMX 1 DS tablet postcoitus or 2 DS tablets at first sign
of UTI.
For recurrent UTI in postmenopausal women, consider use
of estrogen cream, also consider urological factor, such as
cystocele, residual urine volume, incontinence.
Acute uncomplicated E. coli, enterococci PRIMARY
pyelonephritis suitable Ciprofloxacin 500 mg bid, ciprofloxacin ER 1000 mg qd,
for outpatient therapy levofloxacin 750 mg qd, ofloxacin 400 mg bid, or moxi-
(Note: Obtain urine and floxacin 400 mg qd, all for 7 days (levofloxacin 750 mg
blood cultures before approved for 5 days). Moxifloxacin and gemifloxacin not
initiating antimicrobial labeled for use in UTI.
therapy.) ALTERNATIVE
Amoxicillin with clavulanate, cephalosporin, or TMP-SMX-DS,
all for 14 days. Beta-lactams are not as effective as
fluoroquinolones.
uncomplicated cystitis. Alternatives to continuous prophy- 42. Which of the following is not a risk factor for bladder
laxis include self-administered single-dose therapy at symp- cancer?
tom onset, or a single-dose treatment postcoitus. Before UTI A. occupational exposure to textile dyes
prophylaxis is initiated, resolution of the previous UTI should B. cigarette smoking
be confirmed by a negative urine culture 1 to 2 weeks after C. occupational exposure to heavy metals
treatment. The method prescribed depends on the frequency D. long-term aspirin use
and pattern of recurrences and on patient preference.
43. A 68-year-old man presents with suspected bladder
Choice of an antimicrobial agent for recurrent UTI should
cancer. You consider that its most common presenting
be based on susceptibility patterns of the strains causing the
sign or symptom is:
patient’s previous UTIs and on patient history of drug aller-
A. painful urination.
gies or intolerance. Long-term TMP-SMX or nitrofurantoin
B. fever and flank pain.
therapy has been used successfully for many years. Compared
C. painless gross hematuria.
with TMP-SMX, nitrofurantoin has the advantage of lower
D. palpable abdominal mass.
rates of resistance by the more common UTI pathogens. At
the same time, long-term prophylaxis with nitrofurantoin 44. In a person diagnosed with superficial bladder cancer
should be used with caution due to a risk of pulmonary fi- without evidence of metastases, you realize that:
brosis. It is important to note that antimicrobial prophylaxis A. the prognosis for 2-year survival is poor.
does not appear to change the natural history of recurrences B. a cystectomy is indicated.
as most women reestablish their pattern and frequency of C. despite successful initial therapy, local recurrence
UTIs within 6 months of discontinuing prophylaxis. The use is common.
of a fluoroquinolone for UTI prophylaxis has gained some D. systemic chemotherapy is the treatment of choice.
popularity; concern about emerging resistance is an issue.
45. Persistent microscopic hematuria would be the primary
UTI prophylaxis in a postmenopausal woman should also in-
finding in about ___% of individuals with bladder cancer.
clude a topical or vaginal estrogen to encourage lactobacilli
A. 10
recolonization. Postmenopausal women with recurrent in-
B. 20
fections should be evaluated for potentially correctable uro-
C. 30
logic factors, including cystocele, incontinence, and an
D. 40
elevated residual urine volume.
Cranberry and blueberry juice intake has been touted as a 46. Preferred therapy for nonmuscle-invasive bladder
helpful measure to reduce the rate of recurrent infections. cancer without evidence of metastases is:
These juices were initially believed to cause high levels of A. cystectomy.
benzoic acid that resulted in urinary acidification and bacte- B. intravesical chemotherapy only.
riostatic action. However, meta-analyses of clinical studies C. transurethral resection with intravesical
demonstrated that cranberry or blueberry juice is not as effec- chemotherapy.
tive as initially thought and showed no significant benefit in D. systemic chemotherapy.
reducing the occurrence of symptomatic UTIs when com-
pared to placebo, water, or no treatment.
Answers
DI SCUSSION SOURCES
Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, 41. A. 43. C. 45. B.
Saag MS. The Sanford Guide to Antimicrobial Therapy, ed. 44. 42. D. 44. C. 46. C.
Sperryville, VA: Antimicrobial Therapy, Inc., 2014, p. 36.
Gupta K, Hooton TM, Naber KG, et al. International clinical
Bladder cancer is the sixth most common type of cancer in
practice guidelines for the treatment of acute uncomplicated
cystitis and pyelonephritis in women: A 2010 update by the
the United States, and the second most common urologic
Infectious Diseases Society of America and the European malignancy after prostate cancer. It is usually a disease that
Society for Microbiology and Infectious Diseases. Clin Infect occurs later in life—the mean age at diagnosis is 65 years—
Dis 52:e103–e120, 2011. and it is more common in men. Risk factors include cigarette
smoking, which accounts for most cases, family history
of bladder cancer, arsenic exposure (mainly occurring outside
Bladder Cancer the United States), and exposure to industrial chemicals,
including paints, dyes, and solvents. Certain medications,
41. Long-term use of which medication has been possibly such as the anticancer treatment cyclophosphamide and the
associated with increased risk for bladder cancer? diabetes medication pioglitazone, can also increase the risk
A. pioglitazone for bladder cancer. Primary prevention of bladder cancer
B. saxagliptin through risk reduction is critical.
C. rosuvastatin Gross painless hematuria is the most common presenting
D. clopidogrel sign of bladder cancer; persistent microscopic hematuria is
4074_Ch12_293-306 20/11/14 11:01 AM Page 302
the only finding in about 20% of individuals presenting with 51. Factors that contribute to urge incontinence include:
the disease. Irritative voiding symptoms and urinary fre- A. detrusor overactivity.
quency without fever are reported occasionally. Abdominal B. pelvic floor weakness.
mass is palpable only with advanced disease. C. urethral stricture.
Patients suspected of bladder cancer are referred to an D. UTI.
urologist to perform a cystoscopy. A biopsy sample is taken
52. Pharmacological intervention for patients with urge
via transurethral resection during the cystoscopy for analysis.
incontinence includes:
Cytology can also be used to detect the presence of cancer
A. doxazosin (Cardura®).
cells in the urine.
B. tolterodine (Detrol®).
Most patients with newly diagnosed bladder cancer have
C. finasteride (Proscar®).
superficial disease (nonmuscle-invasive bladder cancer).
D. pseudoephedrine.
Transurethral resection is used to remove bladder cancers
that are confined to the inner lining of the bladder, or a partial 53 to 55. Match the most appropriate behavioral interven-
cystectomy may be needed to remove the tumor and a small tion with each form of urinary incontinence.
portion of the bladder. Treatment also includes a single im-
53. urge incontinence
mediate instillation of intravesical chemotherapy (e.g., mit-
omycin C). Subsequent therapy is based on patient risk 54. stress incontinence
factors. Meticulous follow-up is critical because recurrence
55. functional incontinence
is often seen, necessitating repeat procedures. Long-term sur-
A. having an assistant who is aware of voiding cues
vival is the norm with this noninvasive form of the disease.
and helps with toileting activities
With invasive disease, treatment is dictated by type of tumor,
B. establishing a voiding schedule and gentle bladder
degree of invasion, and presence of metastatic disease; long-
stretching
term survival is based on numerous factors.
C. Kegel exercises and pelvic floor rehabilitation with
DI SCUS SION SOURCES biofeedback
Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhe- 56. Which form of urinary incontinence is most common
maturia (AMH) In Adults: AUA Guideline, www.auanet.org/ in elderly persons?
education/guidelines/asymptomatic-microhematuria.cfm. A. stress
Rodriguez Faba O, Gaya JM, Lopez JM, et al. Current management B. urge
of non-muscle-invasive bladder cancer. Minerva Med 104:
C. iatrogenic
273–286, 2013.
D. overflow
57. Common adverse effects of musculotropic relaxants
Urinary used in the treatment of urinary incontinence
include:
Incontinence A. dry mouth and constipation.
B. nausea.
47. Patients with urge incontinence often report urine loss:
C. headaches.
A. with exercise.
D. syncope.
B. at night.
C. associated with a strong sensation of needing to void. 58. You see an 82-year-old woman with early onset demen-
D. as dribbling after voiding. tia and urge incontinence. Which of the following med-
ications is least likely to contribute to worsening mental
48. Patients with urethral stricture often report urine loss:
status?
A. with exercise.
A. oxybutynin (Ditropan®)
B. during the day.
B. tolterodine (Detrol)
C. associated with urgency.
C. darifenacin (Enablex®)
D. as dribbling after voiding.
D. solifenacin (VESIcare®)
49. Patients with stress incontinence often report urine loss:
59. A 64-year-old woman presents with urge incontinence
A. with lifting.
and has not been able to tolerate treatment with anti-
B. at night.
cholinergic agents. You recommend the use of which of
C. associated with a strong sensation of needing to void.
the following? More than one can apply
D. as dribbling after voiding.
A. botulinum toxin injections.
50. Factors that contribute to stress incontinence include: B. fesoterodine fumarate (Toviaz®).
A. detrusor overactivity. C. mirabegron (Myrbetriq®).
B. pelvic floor weakness. D. finasteride (Proscar)
C. urethral stricture.
D. urinary tract infection (UTI).
4074_Ch12_293-306 20/11/14 11:01 AM Page 303
TABLE 12-4
Types of Urinary Incontinence
Type of Urinary Etiology and Population
Incontinence Most Often Affected Clinical Presentation Treatment Options
Urge incontinence Detrusor overactivity Strong sensation of needing Avoiding stimulants, gentle blad-
causing uninhibited to empty the bladder that der stretching by increasing
bladder contractions. cannot be suppressed, voiding interval by 15–30 min
Most common form of often coupled with invol- after establishing a half-hour
incontinence in elders. untary loss of urine. voiding schedule, cautious fluid
ingestion (sips of fluid rather
than large amounts ingested
rapidly).
Add agent to reduce bladder
contraction such as an anti-
cholinergic; options include
tolterodine (Detrol), oxybutynin
(Ditropan), solifenacin succinate
(VESIcare), darifenacin (Enablex),
fesoterodine fumarate (Toviaz).
Alternatives to anticholinergics
include mirabegron (Myrbetriq)
and botulinum toxin injections.
Stress incontinence Weakness of pelvic floor Loss of urine with activity Support to the area through the
and urethral muscles. that causes increase in use of a vaginal tampon, ure-
Most common form of intra-abdominal pressure thral stents, periurethral bulking
incontinence in women; such as coughing, sneez- agent injections, and pessary
rare in men, occasionally ing, exercise. use. Kegel and other similar ex-
noted post prostate/ ercises most helpful in younger
bladder surgery. patients. Pelvic floor rehabilita-
tion with biofeedback, electrical
stimulation and bladder training.
Surgical intervention can be help-
ful in well-chosen patients.
Topical and systemic estrogen
therapy formerly recommended
for this condition, now recog-
nized as not helpful and per-
haps contributing to stress
incontinence symptoms.
When both urge and stress in-
continence is present, the term
mixed urinary incontinence is
often used.
Continued
4074_Ch12_293-306 20/11/14 11:01 AM Page 304
TABLE 12-4
Types of Urinary Incontinence—cont’d
Type of Urinary Etiology and Population
Incontinence Most Often Affected Clinical Presentation Treatment Options
Urethral obstruction Obstruction of bladder Dribbling postvoid coupled Treatment of urethral
outflow through urethral with urge incontinence obstruction.
obstruction (prostatic, on presentation.
stricture, tumor) resulting
in urinary retention with
overflow and detrusor
instability.
Most commonly found in
older men.
Functional Associated with inability Usually in person with Ameliorated by having assistant
incontinence to get to the toilet or lack mobility issues or altered who is aware of voiding cue
of awareness of need to cognition. Worsened by no and is available to help with
void. availability of a helper to toileting activities.
assist in toileting activities.
Transient Associated with acute Presentation consistent Treatment of underlying process,
incontinence event such as delirium, with underlying process. discontinuation of offending
UTI, medication use, medication.
restricted activity.
patient presentation. If UTI is present, treatment with the Other forms of incontinence can be treated by behavioral
appropriate antimicrobial is indicated. therapy, treating the underlying cause of incontinence,
Urge incontinence (also called overactive bladder) is and/or surgery (e.g., urethral obstruction or stress inconti-
the most common form of urinary incontinence in elderly nence) (Table 12–4).
persons. Behavioral therapy, including a voiding schedule
and gentle bladder stretching, are helpful. Pharmacological D I S C U SSI O N S O U R C E S
intervention is indicated in conjunction with behavioral Vasavada SP, Carmel ME, Rackley R. Urinary incontinence. Avail-
therapy (Table 12–4). Tolterodine (Detrol) and solifenacin able at http://emedicine.medscape.com/article/452289.
succinate (VESIcare) are examples of selective muscarinic Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment
receptor antagonists that block bladder receptors and limit of overactive bladder (non-neurogenic) in adults: AUA/SUFU
guideline, 2012. www.auanet.org/common/pdf/education/clinical-
bladder contraction. Helpful in the treatment of urge in-
guidance/Overactive-Bladder.pdf.
continence, the use of these products is associated with
a decrease in the numbers of micturitions and of inconti-
nent episodes, along with an increase in voiding volume.
Oxybutynin (Ditropan) is a nonselective muscarinic recep-
Renal Stones
tor antagonist that blocks receptors in the bladder and oral 60. Risk factors for renal stones include all of the following
cavity, with activity similar to that of tolterodine; adverse except:
effects include dry mouth and constipation. Darifenacin A. male gender.
(Enablex) and fesoterodine fumarate (Toviaz) are newer B. vegetarian diet.
anticholinergic agents approved for urge incontinence. C. family history of renal stones.
Compared to older agents, darifenacin is associated with D. obesity.
fewer adverse effects, such as confusion, and is likely more
helpful in older patients with underlying dementia. 61. Medications known to increase the risk of renal stones
Mirabegron (Myrbetriq), a beta-3 adrenoceptor agonist, include all of the following except:
has been shown to be effective in treatment-naïve patients A. hydrochlorothiazide.
as well as those who fail therapy with anticholinergic B. moxifloxacin.
agents. Botulinum toxin injections in the bladder have also C. topiramate.
been approved and can be effective for those who fail or are D. indinavir.
intolerant of pharmacologic treatment.
4074_Ch12_293-306 20/11/14 11:01 AM Page 305
Treatment will depend on the size of the stone as well as (67 to 100 oz.) of fluid per day. Water and citrus drinks
whether the stones are causing pain or blocking the urinary are preferred for prevention. For those with calcium
tract. Small stones typically pass through the urinary tract oxalate or calcium phosphate stones, prevention can also
without treatment, though analgesics can be prescribed to include reducing sodium and animal protein while getting
alleviate the pain. An alpha blocker can be used to relax the enough calcium from food sources. If calcium supplements
muscles in the ureter in order to pass the stone more quickly are used, these should be taken with meals. Calcium oxalate
and with less pain. Intravenous hydration is needed if the stones can be prevented by reducing intake of oxalate-rich
patient experiences nausea and vomiting and is unable to foods, such as rhubarb, beets, okra, spinach, Swiss chard,
maintain hydration with oral intake. Several options are sweet potatoes, nuts, tea, chocolate, and soy products. For
available if more urgent measures are needed. Shock wave those with uric acid stones, limiting animal protein will
lithotripsy (SWL) generates shock waves that travel through help prevent further stone formation.
the body to break up the stones into smaller pieces that more
readily pass through the urinary tract. For stones located in D I S C U SSI O N S O U R C E S
the ureter, ureteroscopy can be used to retrieve the stone or National Kidney and Urologic Diseases Information Clearinghouse
break a stone into smaller pieces with a laser. For larger stones (NKUDIC). Kidney stones in adults. http://kidney.niddk.nih.
located in the kidney, percutaneous nephrolithotomy can be gov/kudiseases/pubs/stonesadults.
used to break up the stone with shock waves followed by the Wolf JS Jr. Nephrolithiasis. http://emedicine.medscape.com/
article/437096.
use of a nephrostomy tube to drain urine and stone fragments
directly from the kidneys.
Proper hydration is the optimal method to prevent renal
stones, with a recommendation of drinking 2 to 3 liters
4074_Ch13_307-318 20/11/14 11:05 AM Page 307
Hematological and
Select Immunological
Disorders 13
Anemia 6. A healthy 34-year-old man asks whether he should take
an iron supplement. You respond that:
1. Worldwide, which of the following is the most common A. this is a prudent measure to ensure health.
type of anemia? B. iron-deficiency anemia is a common problem in men
A. pernicious anemia of his age.
B. folate-deficiency anemia C. use of an iron supplement in the absence of a
C. anemia of chronic disease documented deficiency can lead to iatrogenic
D. iron-deficiency anemia iron overload.
D. excess iron is easily excreted.
2. Most of the body’s iron is obtained from:
A. animal-based food sources. 7. Which of the following is the best advice on taking
B. recycled iron content from aged red blood cells ferrous sulfate to enhance iron absorption?
(RBCs). A. “Take with other medications.”
C. endoplasmic reticulum production. B. “Take on a full stomach.”
D. vegetable-based food sources. C. “Take on an empty stomach.”
D. “Do not take with vitamin C.”
3. Which of the following is most consistent with
iron-deficiency anemia? 8. A 40-year-old woman with pyelonephritis is taking
A. low mean corpuscular volume (MCV), normal mean two mediations: ciprofloxacin and ferrous sulfate (for
corpuscular hemoglobin (MCH) iron-deficiency anemia). She asks about taking both
B. low MCV, low MCH medications. You advise that:
C. low MCV, elevated MCH A. she should take the medications with a large glass of
D. normal MCV, normal MCH water.
B. an inactive drug compound is potentially formed if
4. One of the earliest laboratory markers in evolving the two medications are taken together.
macrocytic or microcytic anemia is: C. she can take the medications together to enhance
A. an increase in RBC distribution width (RDW). adherence to therapy.
B. a reduction in measurable hemoglobin. D. the ferrous sulfate potentially slows gastrointestinal
C. a low MCH level. motility and results in enhanced ciprofloxacin
D. an increased platelet count. absorption.
5. A 48-year-old woman developed iron-deficiency anemia 9. One month into therapy for pernicious anemia, you wish
after excessive perimenopausal bleeding, successfully to check the efficacy of the intervention. The best labora-
treated by endometrial ablation. Her hematocrit (Hct) tory test to order at this point is a:
level is 25%, and she is taking iron therapy. At 5 days A. Schilling test.
into therapy, one possible observed change in laboratory B. hemoglobin measurement.
parameters would include: C. reticulocyte count.
A. a correction of mean cell volume. D. serum cobalamin.
B. an 8% increase in Hct level.
C. reticulocytosis.
D. a correction in ferritin level.
307
4074_Ch13_307-318 20/11/14 11:05 AM Page 308
10. A woman who is planning a pregnancy should increase 17. You examine a 22-year-old woman of Asian ancestry.
her intake of which of the following to minimize the She has no presenting complaint. Hemogram results
risk of neural tube defect in the fetus? are as follows:
A. iron Hgb = 9.1 g (normal 12 to 14 g)
B. niacin Hct = 28% (normal 36% to 42%)
C. folic acid RBC = 5 million mm3 (normal 3.2 to 4.3 million mm3)
D. vitamin C MCV = 68 fL (normal 80 to 96 fL)
MCHC = 33.2 g/dL (normal 32 to 36 g/dL)
11. Risk factors for folate-deficiency anemia include:
RBC distribution width (RDW) = 13% (normal ≤15%).
A. menorrhagia.
Reticulocytes = 1.5%
B. chronic ingestion of overcooked foods.
C. use of nonsteroidal antiinflammatory drugs. This is most consistent with the laboratory assessment of:
D. gastric atrophy. A. iron-deficiency anemia.
B. Cooley anemia.
12. Folate-deficiency anemia causes which of the following
C. alpha-thalassemia minor.
changes in the RBC indices?
D. hemoglobin Barts.
A. microcytic, normochromic
B. normocytic, normochromic 18. A 68-year-old man who is usually healthy presents with
C. microcytic, hypochromic new onset of “huffing and puffing” with exercise for the
D. macrocytic, normochromic past 3 weeks. Physical examination reveals conjunctiva
pallor and a hemic murmur. Hemogram results are as
13. Pernicious anemia is usually caused by:
follows:
A. dietary deficiency of vitamin B12.
Hgb = 7.6 g
B. lack of production of intrinsic factor by the gastric
Hct = 20.5%
mucosa.
RBC = 2.1 million mm3
C. RBC enzyme deficiency.
MCV = 76 fL
D. a combination of micronutrient deficiencies caused
MCHC = 28 g/dL
by malabsorption.
RDW = 18.4%
14. Pernicious anemia causes which of the following Reticulocytes = 1.8%
changes in the RBC indices?
The most likely cause of these finding is:
A. microcytic, normochromic
A. poor nutrition.
B. normocytic, normochromic
B. occult blood loss.
C. microcytic, hypochromic
C. malabsorption.
D. macrocytic, normochromic
D. chronic inflammation.
15. Common physical examination findings in patients
19. You examine a 57-year-old woman with rheumatoid
with pernicious anemia include:
arthritis who is on disease-modifying antirheumatic
A. hypoactive bowel sounds.
disease but continues to have poor disease control and
B. stocking-glove neuropathy.
find the following results on hemogram:
C. thin, spoon-shaped nails.
Hgb = 10.5 g
D. retinal hemorrhages.
Hct = 33%
16. You examine a 47-year-old man who presents with RBC = 3.1 million mm3
difficulty initiating and maintaining sleep and chronic MCV = 88 fL
pharyngeal erythema with the following results on MCHC = 32.8 g/dL
hemogram: RDW = 12.2%
Hemoglobin (Hgb) = 15 g Reticulocytes = 0.8%
Hct = 45%
The laboratory findings are most consistent with:
RBC = 4.2 million mm3
A. pernicious anemia.
MCV = 108 fL
B. anemia of chronic disease.
MCHC = 33.2 g/dL
C. beta-thalassemia minor.
These values are most consistent with: D. folate-deficiency anemia.
A. pernicious anemia.
B. alcohol abuse.
C. thalassemia minor.
D. Fanconi disease.
4074_Ch13_307-318 20/11/14 11:05 AM Page 309
20. You examine a 27-year-old woman with menorrhagia 27. Erythropoietin is a glycoprotein that influences a stem
who is otherwise well and note the following results on cell to become a:
hemogram: A. lymphocyte.
Hgb = 10.1 g B. platelet.
Hct = 32% C. neutrophil.
RBC = 2.9 million mm 3 D. red blood cell.
MCV = 72 fL
28. Intervention in anemia of chronic disease most often
MCHC = 28.2 g/dL
includes:
RDW = 18.9%
A. oral vitamin B12.
Physical examination is likely to include: B. treatment of the underlying cause.
A. conjunctiva pallor. C. transfusion.
B. hemic murmur. D. parenteral iron.
C. tachycardia.
29. Poikilocytosis refers to alterations in a red blood cells:
D. no specific anemia-related findings.
A. thickness.
21. Results of hemogram in a person with anemia of B. color.
chronic disease include: C. shape.
A. microcytosis. D. size.
B. anisocytosis.
30. Which of the following is not consistent with anemia of
C. reticulocytopenia.
chronic disease (ACD)?
D. macrocytosis.
A. NL RDW
22. When prescribing erythropoietin supplementation, the B. NL MCHC
NP considers that: C. Hct less than 24%
A. the adrenal glands are its endogenous source. D. NL to slightly elevated serum ferritin
B. the addition of micronutrient supplementation
31. In children younger than age 6 years, accidental over-
needed for erythropoiesis is advisable.
dose of iron-containing products is:
C. its use is as an adjunct in treating thrombocytopenia.
A. easily treated.
D. with its use, the RBC life span is prolonged.
B. a source of significant GI upset.
23. In the first weeks of anemia therapy with parenteral C. worrisome but rarely causes significant harm.
vitamin B12 in a 68-year-old woman with hypertension D. a leading cause of fatal poisoning in the age group.
who is taking a thiazide diuretic, the patient should be
32. When counseling a patient about the neurological alter-
carefully monitored for:
ations often associated with vitamin B12 deficiency, the
A. hypernatremia.
NP advises that:
B. dehydration.
A. these usually resolve within days with appropriate
C. hypokalemia.
therapy.
D. acidemia.
B. if present for longer than 6 months, these changes
24. Which of the following conditions is unlikely to result are occasionally permanent.
in anemia of chronic disease? C. the use of parenteral vitamin B12 therapy is needed
A. rheumatoid arthritis to ensure symptom resolution.
B. peripheral vascular disease D. cognitive changes associated with vitamin B12 defi-
C. chronic renal insufficiency ciency are seldom reversible even with appropriate
D. osteomyelitis therapy.
25. In health, the ratio of hemoglobin to hematocrit is 33. When the cause of a macrocytic anemia is uncertain,
usually: the most commonly recommended additional testing
A. 1:1. includes which of the following?
B. 1:2. A. haptoglobin and reticulocyte count.
C. 1:3. B. Schilling test and gastric biopsy.
D. 1:4. C. methylmalonic acid and homocysteine.
D. transferrin and prealbumin.
26. An increase in the normal variation of RBC size is
known as:
A. poikilocytosis.
B. granulation.
C. anisocytosis.
D. basophilic stippling.
4074_Ch13_307-318 20/11/14 11:05 AM Page 310
Anemia: True or False? The physical examination usually contributes little to the
diagnosis, unless the anemia is severe. Pallor of the skin and
34. Anemia in children is potentially associated with mucous membranes is an unreliable indicator and is usually
poorer school performance. seen only when the hemoglobin is less than 8 g/dL. In elderly
persons and in individuals with coronary artery disease, signs
35. During pregnancy, folic-acid requirements in-
of heart failure (i.e., distended neck veins, rales, tachycardia,
crease twofold to fourfold.
right upper quadrant abdominal tenderness, hepatomegaly)
36. The red blood cell content is approximately 90% are often seen with severe anemia. An early systolic murmur,
hemoglobin. also known as a hemic murmur, is often heard, owing in part
to the increase in blood flow over the heart valves. Neurolog-
37. Approximately 90% of the body’s erythropoietin
ical findings, such as paresthesia; stocking-glove neuropathy;
is produced by the kidney.
difficulty with balance; and, in extreme cases, confusion, can
38. The body’s normative response to anemia is be found in patients with vitamin B12 deficiency. Less com-
reticulocytopenia. monly, mental status changes are noted in folate-deficiency
anemia.
In evaluating the hemograms of patients with anemia,
Answers the following questions should be answered to ascertain the
origin of the anemia (Table 13–1).
1. D. 14. D. 27. D. • What are hemoglobin (hgb), hematocrit (hct), and
2. B. 15. B. 28. B. red blood cell (RBC) values? These values should be
3. B. 16. B. 29. C. proportionately decreased. Normally, the hemoglobin-
4. A. 17. C. 30. C. to-hematocrit ratio is 1:3, so that in health, 1 g of
5. C. 18. B. 31. D. hemoglobin is equivalent to 3% points of hematocrit.
6. C. 19. B. 32. B. Hemoglobin is an iron-containing protein responsible
7. C. 20. D. 33. C. for the transportation of oxygen and other gases. The
8. B. 21. C. 34. True hematocrit value reflects the percentage of RBCs in a
9. B. 22. B. 35. True given volume of blood; the value is influenced by the
10. C. 23. C. 36. True body’s hydration status. This ratio is usually violated
11. B. 24. B. 37. True only in severe dehydration, where the hematocrit is
12. D. 25. C. 38. False artificially elevated (e.g., hgb 12 g, hct 39%), or overhy-
13. B. 26. C. dration, where the hematocrit is artificially decreased
(e.g., hgb 12 g, hct 32%).
• What is the RBC size? This is reflected by the mean
Anemia is defined as a decrease in the oxygen-carrying capa- corpuscle volume (MCV); the method of categorizing
bility of the blood. This condition is not a disease, but rather anemia is known as Wintrobe’s classification. Using this
a sign of an underlying process. Anemia occurs only in the classification, anemias are categorized as being micro-
presence of a clinical insult severe enough to disturb the nor- cytic (abnormally low MCV), normocytic (MCV within
mal hematological homeostatic mechanisms and exceed the normal parameters), or macrocytic (abnormally high
body’s ample hematological reserves. MCV). The RBC maintains its size and color throughout
The clinical presentation of anemia is highly variable, and its 90- to 120-day lifespan.
compensation is common because most anemias are usually • Is the RBC abnormally small (microcytic or low MCV)?
gradual in onset. In addition, the oxyhemoglobin-dissociation Ninety percent of the RBC volume is composed of hemo-
curve is moved to the right as the hemoglobin level decreases, globin. As a result, hemoglobin is the major contributor
with the oxygen molecule given up more freely by the RBC. to cell size; microcytosis is seen in patients with anemia
As a result, symptoms of anemia seldom occur, unless the he- in whom hemoglobin synthesis is impaired, such as in
moglobin level decreases to less than 10 g/dL. presence of iron-deficiency anemia and the thalassemias.
The health history usually reveals clues about the cause of In addition, because hemoglobin gives RBCs their
the anemia (i.e., excessive menstrual flow, acute blood loss). characteristic red color, small (microcytic) and pale
Patients frequently report deep, sighing respiration with ac- (hypochromic) go together. A microcytic cell will also
tivity, often associated with a sensation of rapid, forceful have a low mean hemoglobin concentration (MCH).
heart rate; this is likely a reflection of the decreased oxygen- • Is the RBC abnormally large (macrocytic)? Impaired
carrying capability of the blood and a corresponding com- RNA and DNA synthesis in young erythrocytes most
pensatory mechanism. Fatigue, headache, and decreased commonly cause macrocytosis. Folic acid and vitamin B12
exercise tolerance are often present. Poor school perform- contribute significantly to RNA and DNA synthesis in
ance and learning difficulties have been reported in children the developing RBC. A lack of either or both of these
with anemia. In patients at risk for or who have coronary micronutrients can result in macrocytic anemia. Because
artery disease, anginal symptoms are commonly reported. hemoglobin synthesis is not the issue, macrocytic cells
4074_Ch13_307-318 20/11/14 11:05 AM Page 311
TABLE 13-1
Hemogram Evaluation in Anemia
Laboratory Parameter Comment
What are hgb and hct, RBC values? Values should be proportionately decreased.
Normally, hgb:hct ratio is 1:3.
• 10 g = 30%
• 12 g = 36%
• 15 g = 45%
What is the RBC size? Wintrobe’s classification of anemia by evaluation of mean corpuscle
volume (MCV)
• Microcytic: Small cell with MCV <80 fL
• Normocytic: Normal size cell with MCV 80–96 fL
• Macrocytic: Abnormally large cell with MCV >96 fL
What is the RBC’s hemoglobin content? Reflected by mean cell hemoglobin (MCH), mean cell hemoglobin
concentration (MCHC)
• Hemoglobin is the source of the cell’s color (“-chromic”)
• Normochromic: Normal color—MCHC 31–37 g/dL
• Hypochromic: Pale—MCHC <31 g/dL
What is the RDW? Index of variation in RBC size (normal 11.5%–15%)
Abnormal value: >15%, indicating that new cells differ in size (smaller
or larger) compared with older cells. This is one of the earliest labora-
tory indicators of an evolving microcytic or macrocytic anemia.
What is the reticulocyte percentage or count? The body’s normal response to anemia is to attempt correction via
increasing the number of new cells (reticulocytes).
Normal response to anemia is reticulocytosis.
Because the reticulocyte MCV >96 fL, marked reticulocytosis can
cause RDW to increase transiently.
are usually of normal color (normochromic or MCH refers to a variation in RBC shape and is not specific to
within normal limits). any anemia type but usually occurs with more severe
• Is the RBC of normal size (normocytic)? In these ane- anemia.
mias, the cells are made under ordinary conditions with • What is the hemoglobin content (color) of the cell? The
sufficient hemoglobin; there is no problem with RNA, hemoglobin content of the cell is reflected in the MCH,
DNA, or hemoglobin synthesis. Acute blood loss and reported as a percentage of the cell’s volume. Because
anemia of chronic disease result in a normocytic, nor- hemoglobin gives RBCs their characteristic red color,
mochromic anemia. the suffix “-chromic” is used to describe the MCH.
• What is the RDW (RBC distribution width)? RDW re- When a cell has a normal MCH, it is of normal color,
flects the degree of variation in RBC size; this is often or normochromic. When there is an impairment of
reported as anisocytosis on RBC morphologic study. hemoglobin synthesis, such as in iron-deficiency anemia
RDW measurement is elevated when RBCs are of varying or thalassemia, the cells are pale or hypochromic and the
sizes, which implies that cells were synthesized under MCH is low. RBCs seldom are hyperchromic, or contain-
varying conditions. In iron-deficiency anemia, normal- ing excessive amounts of hemoglobin.
sized cells produced before iron depletion continue to • What is the percentage of reticulocytes? The body’s
circulate until their 90- to 120-day life span ends. Mean- normal response to anemia is to attempt correction via
while, new, microcytic, iron-deficient cells containing less increasing the number of new cells (reticulocytes). The
hemoglobin are produced. There is wide variation in cell body’s normal response to anemia is reticulocytosis, or
size (newer cells are smaller, and older cells are larger) an increase in the percentage of circulating reticulocytes
and an increase in RDW. Because minor variation in cell to greater than the 1% to 2% noted in health. The nota-
size is normal, RDW is considered increased only when it tion of reticulocytopenia, or an abnormally low reticulo-
is greater than 15%. An elevated RDW is often the first cyte percentage, is evidence of inadequate hemopoiesis.
abnormal finding in the hemogram of a person with an Because the reticulocyte MCV >96 fL, marked reticulo-
evolving microcytic or macrocytic anemia. Poikilocytosis cytosis can cause RDW to increase transiently.
4074_Ch13_307-318 20/11/14 11:05 AM Page 312
Worldwide, iron deficiency is the most common reason an oozing gastritis or gastrointestinal malignancy, is a com-
for anemia (Table 13–2). Because an estimated 8 years of poor mon cause, as is excessive menstrual flow. Lower and upper
iron intake is needed in adults before iron-deficiency anemia GI tract evaluation is recommended to diagnose the cause of
occurs, diet is rarely the etiology in developed countries. IDA in men ≥50 and in postmenopausal women. Men and
Chronic blood loss causing a wasting of the RBCs’ recyclable postmenopausal women require 1 mg of iron each day. Dur-
iron, the body’s most important iron source, is the most com- ing reproductive years, women require 1.5 to 3 mg/d of iron,
mon cause. Occult gastrointestinal blood loss, such as from in part because of the monthly loss of RBCs with the menses.
TABLE 13-2
Identifying Common Anemias
Anemia Type Description Example
Normocytic (MCV 80–96 fL), normochromic Cells made under ordinary 72 y.o. man with an acute gastrointestinal
anemia with normal RDW conditions with sufficient he- bleed (acute blood loss)
Most common etiology: Acute blood loss moglobin. This yields cells that 32 y.o. woman with newly diagnosed
or anemia of chronic disease (ACD) are normal size (normocytic), lupus erythematosus (ACD)
normal color (normochromic), Hgb 10.1 g (12–14 g)
and about the same size Hct 32% (36%–43%)
(normal RDW) RBC 3.2 million mm3 (4.2–5.4 million)
MCV 82 fL (81–96 fL)
MCHC 34.8 g/dL (31–37 g/dL)
RDW 12.1% (11.5%–15%)
Microcytic (MCV <80 fL) hypochromic Small cell (microcytic) owing 68 y.o. man with erosive gastritis
anemia with elevated RDW to insufficient hemoglobin Hgb 10.1 g (12–14 g)
Most common etiology: Iron-deficiency (hypochromic) with new Hct 32% (36%–43%)
anemia cells smaller than old cells RBC 3.2 million mm3 (4.2–5.4 million)
(elevated RDW) MCV 72 fL (81–96 fL)
MCHC 26.8 g/dL (31–37 g/dL)
RDW 18.1% (11.5%–15%)
Microcytic (MCV <80 fL) hypochromic Through genetic variation, 27 y.o. man of African ancestry
anemia with normal RDW small (microcytic), pale Hgb 11.6 g (14–16 g)
Most common etiology: Alpha or beta (hypochromic) cells that are Hct 36.7% (42%–48%)
thalassemia minor all around the same size RBC 6.38 million mm3 (4.7–6.10 million)
At-risk ethnic groups for alpha thalassemia (normal RDW) MCV 69.5 fL (81–99 fL)
minor: Asian, African ancestry MCH 22 pg (27–33 pg)
At-risk ethnic groups for beta thalassemia RDW 13.8% (11.5%–15%)
minor: African, Middle Eastern,
Mediterranean ancestry
Macrocytic (MCV >96 fL) normochromic Abnormally large (macrocytic) 52 y.o. woman with untreated pernicious
anemia with elevated RDW cell owing to altered RNA: anemia
Most common etiology: Vitamin B12 DNA ratio, hemoglobin con- Hgb 10.2 g (12–14 g)
deficiency, pernicious anemia, tent normal (normochromic), Hct 32% (36%–43%)
folate-deficiency anemia new cells larger than old cells RBC 3.2 million mm3 (4.2–5.4 million)
(elevated RDW) MCV 125.5 fL (81–99 fL)
MCH 31 pg (27–33 pg)
RDW 18.8% (11.5%–15%)
Drug-induced macrocytosis usually Abnormally large (macrocytic) 32 y.o. woman who is taking phenytoin
without anemia cell owing to altered RNA: Hgb 12 g (12–14 g)
Etiology: Use of select medications such DNA ratio, hemoglobin con- Hct 37% (36%–43%)
as carbamazepine (Tegretol), zidovudine tent normal (normochromic), RBC 4.2 million mm3 (4.2–5.4 million)
(AZT), valproic acid (Depakote), pheny- new cells usually same size as MCV 105.5 fL (81–99 fL)
toin (Dilantin), alcohol, others. Reversible old cells (normal RDW) MCH 31 pg (27–33 pg)
when use of offending medication is RDW 12.8% (11.5%–15%)
discontinued
4074_Ch13_307-318 20/11/14 11:05 AM Page 313
In all these circumstances, these iron requirements are • Later disease: Microcytic, hypochromic anemia with low
achievable with a well-balanced diet. Because 1 mL of packed RBC count and elevated RDW greater than 15%. A de-
RBCs contains 1 mg of iron, losses of 2 to 3 mL of blood per crease in hemoglobin or RBC indices is a late rather than
day through chronic, low-volume gastrointestinal bleeding, an early marker of disease.
repeated phlebotomy, or persistent excessive menstrual flow Therapy for patients with iron-deficiency anemia involves
can lead to iron deficiency. not only iron replacement, but also treatment of the under-
The laboratory diagnosis of iron-deficiency anemia is lying cause. Drug interactions are common (Table 13–4).
supported by the following findings (Table 13–3): Iron use without a distinct clinical indication, including
• Early in the disease process: Low to normal hgb, low the use of iron-fortified multiple vitamins, is not recom-
hct, and low to normal total RBC count; normocytic, mended because this can lead to an iatrogenic iron overload.
possible hypochromic; RDW greater than 15%, a new Iron overload has been hypothesized to be a cardiovascular
iron-deficient cells are produced. risk factor. A lower rate of cardiovascular disease has been
• Low serum iron level: Reflecting iron concentration in noted in frequent blood donors with relatively low levels of
circulation. Serum iron is reflective of iron intake during stored iron compared with age-matched controls. In addi-
the past 24 to 48 hours and can be falsely elevated be- tion, cardiovascular disease rates in women equal rates in
cause of recent high levels of dietary iron ingestion or men 5 to 10 years after menopause, a time when ferritin levels
self-prescribed oral iron supplementation. in women and men are equal.
• Elevated total iron-binding capacity (TIBC): A measure Reticulocytosis begins quickly after initiation of iron ther-
of transferrin, a plasma protein that easily combines with apy, with the reticulocyte count peaking 7 to 10 days into
iron. When more of transferrin is available for binding, therapy. Hemoglobin increases at a rate of 2 g/dL every
the TIBC level increases, reflecting iron deficiency. 3 weeks in response to iron therapy and is likely to take
• Iron saturation less than 15%: Calculated by dividing the 2 months to correct if the underlying cause of the anemia has
serum iron level by the TIBC. been successfully treated. As a result, the following laboratory
• Low serum ferritin level: This is the body’s major iron tests may be used to evaluate the resolution of iron-deficiency
storage protein. Ferritin depletion is one of the first labo- anemia: reticulocytes at 1 to 2 weeks to ensure marrow re-
ratory markers of iron deficiency as stores are depleted sponse to iron therapy, hemoglobin at 6 weeks to 2 months
prior to abnormal cells being formed. to ensure anemia recovery, and ferritin at 2 months after
• Absence of iron from bone marrow, if aspiration is done. measure of normal hemoglobin (or 4 months after initiation
TABLE 13-3
Drug Interactions With Oral Iron Therapy
Drug Effect Comment
Antacids Decreased iron absorption Separate use by ≥2 hr
Caffeine Decreased iron absorption Separate use by ≥2 hr
Fluoroquinolones (ciprofloxacin, Decreased fluoroquinolone Avoid concurrent use or separate doses by ≥6 hr
moxifloxacin, levofloxacin, others) effect
Levodopa Decreased levodopa and Separate medications by as much time as possible;
iron effect increase levodopa dose as needed
Select antihypertensives (ACE Decreased antihypertensive Separate medications by ≥2 hr, monitor BP
inhibitors, methyldopa) effect Additional effect with IV iron: when ACE in-
hibitors are given concurrently, increased risk
of systemic reaction to iron (fever, arthralgia,
hypotension); concurrent use should be avoided
Tetracyclines including doxycycline Decreased tetracycline and Do not use concurrently, or separate by ≥3–4 hr
iron effect
Levothyroxine (Synthroid, Unithroid, Decreased levothyroxine Take levothyroxine ≥2 hr before or 4 hr after iron
Levoxyl, generic) o effect dose
Histamine-2 receptor antagonists Decreased dietary iron Less significant when compared to proton pump
absorption inhibitor use
Proton pump inhibitor Decrease dietary iron Potentially significant contributor to iron and
absorption other micronutrient deficiencies, particularly with
protracted use
TABLE 13-4
Oral Vitamin B12 Drug Interactions
Drug Effect
Aminoglycosides With concomitant use, decreased vitamin B12 absorption
Colchicine With concomitant use, decreased vitamin B12 absorption
Potassium supplements With concomitant use, decreased vitamin B12 absorption
Ascorbic acid Potential to destroy vitamin B12 if taken within 1 hr of oral vitamin B12 ingestion
Proton pump inhibitor With concomitant use, decreased vitamin B12 absorption, particularly with protracted use
of iron therapy) to ensure documentation of replenished iron early life; two altered genes are inherited, one from each par-
stores. ent. The thalassemia minors (thal minor or thal trait), where
A number of oral iron (Fe) forms are available, including one defective gene has been inherited, result in a mild micro-
ferrous gluconate and ferrous sulfate. Either is acceptable cytic hypochromic anemia. Because there is no micronutrient
as a supplement. Enteric-coated iron should be avoided. deficiency, the RDW and platelets are within normal limits.
Although this Fe form is often reported as causing less gas- Given the risk of passing the altered genes to offspring if both
trointestinal upset, iron is best absorbed in the duodenum. members of a couple are affected with thal minor, prior ge-
The use of enteric-coated iron results in relatively little of netic counseling is recommended. Otherwise, people with a
the dose being properly absorbed. In addition, the duode- thal minor have no particular health risks.
num is relatively refractory to iron absorption for about The most common causes of macrocytic anemia are folic-
6 hours post exposure to a high iron dose. As a result, oral acid (folate) deficiency and vitamin B12 deficiency. When
iron should be dosed no sooner than every 6 hours; twice- macrocytosis with anemia is detected on hemogram, the usual
daily supplementation is usually adequate to correct iron next step is to obtain a serum vitamin B12. Often labs bundle
deficiency. Oral iron overdose is the most common cause this test with a serum folate, although folic acid deficiency is
of fatal childhood overdose. The source of this iron is usu- much less common. When the diagnosis of macrocytic anemia
ally from an adult’s prescription, most often the child’s is uncertain, additional testing is recommended; elevated
mother. The use of carbonyl iron has been advocated due serum methylmalonic acid (MMA) and homocysteine levels
to its slow rate of GI absorption, yielding less toxicity in are found with pernicious anemia, whereas elevated homocys-
overdose. A typical adult iron dose for anemia correction teine levels with normal MMA levels are found in folic-acid
is 50 to 60 mg of elemental iron taken orally twice a day for deficiency.
3 to 6 months. Ascorbic acid is an enhancer of iron absorp- Folic acid (pteroylglutamic acid) is a water-soluble B com-
tion and can reverse the inhibiting effects of substances such plex vitamin found in abundance in peanuts, fruits, and veg-
as tea and calcium. Ascorbic acid (vitamin C) taken at the etables. Through a complex reaction, folic acid is reduced to
same time as ferrous sulfate can help with iron absorption. folate. Folate donates 1 carbon unit to oxidation at various
To minimize adverse GI effects, iron supplements are often levels, reactions vital to proper DNA synthesis. During times
taken often taken with food; this can result in as much as a of accelerated tissue growth and repair, such as in childhood,
two-thirds reduction in iron absorption. Taking iron on an pregnancy, recovery from serious illness, and recovery from
empty stomach allows for maximum absorption. Due to hemolytic anemia, folic-acid requirements increase from the
safety concerns and high cost, parenteral iron use should be baseline of twofold to fourfold. Folate deficiency causes a
limited to individuals who are unable to ingest, tolerate, or macrocytic, normochromic anemia.
properly absorb oral iron. The most common causes of folic acid–deficiency anemia
The thalassemias are a genetically based blood disorder are inadequate dietary intake, seen in elderly, alcohol abusers,
where the body makes an abnormal hemoglobin form. He- and impoverished persons and in persons with decreased abil-
moglobin is made of two proteins: alpha globin and beta ity to absorb folic acid, which occurs with malabsorption syn-
globin. In alpha thalassemia, the alteration is in the genes dromes such as sprue and celiac disease. Folic-acid deficiency
or genes related to alpha globin, and in beta form, it is an can be avoided with a healthy diet featuring folate-rich fruits
alteration on the beta globin. Alpha thalassemias occur most and vegetables. In addition, many foods, including most
commonly in persons from Southeast Asia, the Middle East, flours, are folic-acid supplemented, further reducing risk.
China, and Africa. Beta thalassemias occur in persons of Folic acid transfers readily through the placenta to the
Mediterranean origin and, to a lesser extent, in Chinese fetus, with fetal levels usually higher than maternal levels;
people, other Asians, and African Americans. The thalassemia there is evidence that pregnancy is a maternal folate–depleting
majors are life-threatening conditions that are identified in event. Repeated or multiple pregnancies, in particular, cause
4074_Ch13_307-318 20/11/14 11:05 AM Page 315
depletion of maternal folate stores. Folate deficiency during an essential role in RBC DNA synthesis. When deficiencies
pregnancy can be largely avoided through the consistent use of either of these micronutrients exist, DNA synthesis in the
of prescriptive prenatal vitamins, each tablet usually contain- RBC is impaired, which leads to the distinct changes in the
ing 0.8 to 1 mg of folic acid. Over-the-counter prenatal vita- RBC, macrocytosis, and bone marrow.
mins contain significantly less of this micronutrient, usually Vitamin B12 therapy should be initiated when the diagnosis
about 0.4 mg per tablet. Supplementation should continue is made. Usually there is a brisk hematological response, and
through lactation because approximately 0.5 mg/d of folic the anemia is resolved within 2 months. Reversal of neurolog-
acid is transferred to breast milk. Accumulation of the vitamin ical abnormalities is generally slower, but improvement is seen
in human milk takes precedence over maintaining maternal quickly. If neurological abnormalities associated with perni-
folate levels. cious anemia have been present for more than 6 months, the
Maternal folic-acid deficiency is a teratogenic state, changes are occasionally permanent even with appropriate
particularly during neural tube formation. To reduce the vitamin B12 repletion therapy.
rate of neural tube defects in the fetus, a woman planning a Vitamin B12 is available generically and in oral and in-
pregnancy should be advised to take additional amounts of jectable forms. The parenteral form is preferred because of its
folic acid, 0.4 mg/d, for 3 months before conception. This excellent absorption. In oral form, vitamin B12 is erratically
recommendation should be extended to all women capable absorbed in the distal portion of the small intestine, which
of conception. Over-the-counter multivitamin or diet sup- can potentially lead to treatment failure. The usual initial
plementation with vitamin-fortified foods can easily supply vitamin B12 dosage is 100 mcg/d intramuscularly for the first
the recommended folate dose. If a woman has a history week, then weekly for the first month, and then 100 mcg
of giving birth to an infant with a neural tube defect, the monthly for the rest of the patient’s life. Traditionally, doses
folic-acid dose should be increased to 4 mg/d for 3 months of 1000 mcg per injection have been used. A cyanocobalamin
before conception and continued at least through the first dose of more than 100 mcg in a single injection exceeds the
12 weeks of pregnancy. If the pregnancy is unplanned or binding capacity of transcobalamin II; however, the excess is
preconception counseling was not sought, initiating folic- excreted via the kidney and wasted. Concomitant adminis-
acid supplementation during the first 7 weeks of pregnancy tration of folic acid, iron, vitamin C, and other micronutri-
seems to offer some neural tube protection. Folic-acid sup- ents is often needed to help with hematological recovery.
plementation can be supplied by a prescription prenatal vi- When vitamin B12 deficiency is to be treated orally, a higher
tamin supplement. If a pregnant woman cannot tolerate the dose, 1000 mcg/d, is needed. Vitamin B12 is also available in
prenatal vitamin supplement because of nausea, a common a nasal gel, usually used weekly at a dose of 500 mcg. When
condition, she likely would be able to take folic acid alone the cause of macrocytic anemia has not yet been established,
without difficulty. A growing body of knowledge points to a prudent course of action is to give parenteral vitamin B12
genetic factors in metabolizing and using folic acid as a pos- initially while giving folic acid, 1 to 2 mg/d. With this plan,
sible contributor to the risk of neural tube defect. no intervention time is lost. After the appropriate diagnosis
Recommendations for folic-acid replacement for adults is established, the correct vitamin supplement is continued;
range from 0.5 to 1 to 5 mg/d, the usual dose being 1 mg/d. The drug interactions should be noted (Table 13–4).
underlying cause of the folate deficiency must also be treated. The hematological response is generally rapid after ther-
Reticulocytosis occurs rapidly, with a peak at 7 to 10 days apy is begun. Reticulocytosis is brisk and peaks at 5 to 7 days.
into folic-acid therapy. The hematocrit level increases by Hypokalemia, caused by serum-to-intracellular potassium
4% to 5% per week and generally returns to normal within shifts, is common if the anemia was particularly severe and
1 month. Leukopenia and thrombocytopenia resolve within is most likely seen with the peak of reticulocytosis. Monitor-
2 to 3 days of therapy. A repeat hemogram in 1 to 2 months ing serum potassium daily during the first week of therapy is
assists in monitoring of therapeutic effect. Resolution of the important, especially in patients receiving diuretic therapy,
related signs and symptoms generally follows the time frame at other risk of hypokalemia, or taking digoxin. If hy-
needed for the resolution of the anemia. pokalemia occurs, oral potassium replacement at 40 mEq/d
Vitamin B12, a member of the cobalamin family, is found is usually sufficient. Concomitant oral iron therapy is indi-
in abundance in foods of animal origin and is essential to cated if there is an iron deficiency or low iron stores. Full
the development of the RBC. When vitamin B12 is ingested hematological recovery usually takes about 2 months.
orally, it binds with intrinsic factor, a glycoprotein produced Reversal of the signs and symptoms of vitamin B12 defi-
by the gastric parietal cells, and is transported systemati- ciency is generally rapid. A sense of improved well-being is
cally. Within the portal blood flow, the vitamin is attached usually reported within 24 hours of the onset of treatment.
to transcobalamin II, a polypeptide synthesized in the liver Neurological changes, if present for less than 6 months, reverse
and ileum. Intrinsic factor is not absorbed, and the new quickly. Neurological reversal is likely impossible, however, if
compound is transported to the bone marrow and other these changes have been present for a protracted period.
sites, where it is available for use in RBC formation. Anemia is often noted in persons with select chronic
Two additional glycoproteins, transcobalamin I and III, health problems, such as acute and chronic inflammatory
combine with vitamin B12 and are used in the formation of conditions (infection, arthritis), renal insufficiency, and hy-
granulocytes. In synergy with folic acid, vitamin B12 plays pothyroidism. In part, this condition, known as anemia of
4074_Ch13_307-318 20/11/14 11:05 AM Page 316
chronic disease (ACD), is caused by reduced erythropoietin 40. Your priority in caring for Tom, the aforementioned
response in the marrow, resulting in RBC hypoproliferation. patient, is to:
In ACD, micronutrient deficiency is not an issue; this yields A. administer a rapidly acting oral antihistamine.
a normocytic, normochromic anemia. Seldom does ACD B. administer parenteral epinephrine.
result in a severe anemia; usually hct is ≥24%. C. initiate vasopressor therapy.
Worldwide, anemia of chronic disease is second only to D. administer a parenteral systemic corticosteroid.
iron deficiency in occurrence. Bone marrow can be sup-
41. Which of the following food-based allergies is likely to
pressed as a result of the use of certain drugs, including can-
be found in adults and children?
cer chemotherapy agents. Because normal RBC death occurs
A. milk
without the production of new RBC forms, anemia can occur.
B. egg
When glomerular filtration rate declines to less than 30 to
C. soy
40 mL/min, renal erythropoietin synthesis is reduced; a hy-
D. peanut
poproliferative normochromic, normocytic anemia develops,
usually with a hemoglobin level of 8 g/dL or greater. That is, 42. A person with latex allergy also often has a cross-allergy
as the kidney fails, erythropoietin production declines, and to all of the following except:
anemia of chronic disease develops. A. banana.
Recombinant human erythropoietin (epoetin alfa) is used B. avocado.
in the treatment of anemias associated with end-stage renal C. kiwi.
disease, HIV, and cancer chemotherapy and other forms of D. romaine lettuce.
anemia of chronic disease. The drug can be administered par-
43. The most common clinical manifestation of systemic
enterally (subcutaneously or intravenously) three times per
anaphylaxis typically is:
week with an expected increase in hematocrit of approxi-
A. dizziness.
mately 4% over 2 weeks. Iron therapy is also needed, unless
B. airway obstruction.
iron overload is present. Patient symptoms, such as altered
C. urticaria.
exercise capacity and sexual function, which are often attrib-
D. gastrointestinal upset.
uted to renal disease, are often attenuated if hemoglobin level
is appropriately corrected to 11 to 12 g/dL with the use of 44. Second-line drug intervention in the presence of
recombinant human erythropoietin (epoetin alfa); correction anaphylaxis should be:
beyond this hemoglobin level has been associated with in- A. oral diphenhydramine.
creased thrombotic risk without additional health benefit. B. nebulized albuterol.
C. nebulized epinephrine.
DI SCUS SION SOURCES D. oral prednisone.
Desai, S. Clinician’s Guide to Laboratory Medicine: Pocket. Houston,
TX: MD2B, 2009. 45. Which of the following is the best answer regarding
Gentili, A., Besa, E. http://emedicine.medscape.com/article/200184- anaphylaxis?
overview, Folic Acid Deficiency. A. Adults usually do not develop new anaphylaxis
Harper, J., Besa, E. http://emedicine.medscape.com/article/202333, triggers such as food allergies.
Iron deficiency anemia. B. Peanuts are the primary food that can cause a severe
A Physician’s Guide to Oral Iron Supplements, http://www.anemia. allergic reaction.
org/professionals/feature articles/content.php?contentid=306& C. Future anaphylactic reactions will become increas-
sectionid=15. ingly more severe.
Schick, P., Besa, E. http://emedicine.medscape.com/article/204930, D. Trace amounts of an allergen in a food can cause a
Pernicious Anemia.
severe anaphylactic reaction.
46. Increased risks for fatal reactions from anaphylaxis
Anaphylaxis include all of the following except:
39. Tom is a 19-year-old man who presents with sudden A. personal history of asthma.
onset of edema of the lips and face and a sensation of B. delay in administering epinephrine
“throat tightness and shortness of breath” after a bee C. age in the teen years.
sting. Physical examination reveals inspiratory and D. delay in administering antihistamines.
expiratory wheezing. Blood pressure is 78/44 mm Hg, 47. Which of the following plays an essential role in type 1
heart rate is 102 bpm, and respiratory rate is 24/min. hypersensitivity?
His clinical presentation is most consistent with the A. immunoglobulin E
diagnosis of: B. immunoglobulin A
A. urticaria. C. immunoglobulin G
B. angioedema. D. immunoglobulin F
C. anaphylaxis.
D. reactive airway disease.
4074_Ch13_307-318 20/11/14 11:05 AM Page 317
TABLE 13-6
Assessment and Management of Anaphylaxis
Assess Airway, breathing, circulation (ABC), vital signs (VS), and mental status
Upper and lower airways, CV, skin, and GI
Administer epinephrine No contraindications to epinephrine in anaphylaxis
Failure to or delay in use associated with fatalities
Aqueous 1:1000 concentration (1 mg/mL), IM preferred
Adult dose 0.2–0.5 mL (mg); autoinjector 0.3 mg, ≥25–30 kg
Child dose 0.01 mL (mg)/kg; autoinjector 0.15 mg, app 15–30 kg
May repeat every 5–10 minutes if needed
Activate EMS Notify others; usually need to call 911
Airway maintenance Ensure airway patent; use oxygen as indicated
Circulatory maintenance Epinephrine first line, IV fluids, vasopressors
H1 antihistamine (AH) Second line only; first- or second-generation AH may be used
H2 antihistamine Added to H1 antihistamine may be helpful
Inhaled B-adrenergic agonist Relieves bronchospasm and upper airway obstruction
Systemic corticosteroid Possibly prevents recurrent or protracted anaphylaxis
Observation Individualized; often several hours
Follow-up care Education: diagnosis, cause, how to avoid trigger(s), recognition of S&S, action plan
Give epinephrine autoinjector with instructions for and indications on use
Consider referral to allergist
Wear/carry identification indicating anaphylaxis
Source: http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/
Anaphylaxis-2010.pdf
are the more common medications identified. Insect venoms not been shown to be effective in altering the course of acute
and latex are other causes for anaphylaxis. Healthcare workers, anaphylaxis but can prevent recurrent or protracted anaphy-
children with spina bifida and genitourinary abnormalities, laxis. Length of time for observation is individualized; often it
and workers with occupational exposure to latex are at in- is several hours. The discharge plan should include the diagno-
creased risk for natural rubber latex-induced anaphylaxis. sis, including the suspected cause for the anaphylaxis, avoidance
Cross-sensitivity may occur between natural rubber latex pro- measures, recognition of signs and symptoms, and a treatment
tein and certain fruit proteins, potentially causing a reaction if plan. Recurrence later in the day of similar symptoms (a bipha-
the patient eats bananas, avocados, kiwi, melons, or chestnuts. sic reaction) occurs in 1% to 23% of episodes and may occur
The initial drug of choice for the management of anaphy- hours (most within 10 hours) after anaphylactic resolution. A
laxis is parenteral epinephrine (Table 13–6). It reverses the prescription for an epinephrine autoinjector with instructions
effects of anaphylaxis and inhibits further mediator release should be provided, and the patient should be well-informed
and should be administered as soon as the diagnosis is sus- on its use. A bracelet or similar identification, indicating ana-
pected. The time to highest blood concentration (Cmax) when phylaxis history, should be worn. Consider referring to an
studied in asymptomatic subjects is shorter when given IM in allergist to confirm cause and to reduce risk factors for future
the vastus lateralis muscle (lateral thigh) than when adminis- reactions. Venom immunotherapy should be recommended for
tered either subcutaneously or IM in the deltoid muscle. Un- patients with systemic sensitivity to stinging insects; this is a
usually severe or refractory anaphylaxis in patients taking highly (90%–98%) effective treatment option.
beta-adrenergic blockers has been reported. This might be due
to a blunted response to epinephrine, an increased propensity D I S C U SSI O N S O U R C E S
for bronchospasm, and reduced cardiac contractility with per- The diagnosis and management of anaphylaxis practice parame-
petuation of hypotension. H1 antihistamines are second-line ter, http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20
agents and do not replace epinephrine. Parenteral or oral Documents/Practice%20and%20Parameters/Anaphylaxis-2010.
pdf.
diphenhydramine is a common option for an H1 antihista-
Guidelines for the Diagnosis and Management of Food Allergy in
mine. However, other oral first- or second-generation H1 the US, http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%
antihistamines can also be used. There is no direct outcome 20Documents/Practice%20Resources/Food-Allergy-Guidelines-
data regarding the effectiveness of any antihistamine in Summary.pdf.
anaphylaxis. H2 antagonists, such as ranitidine, added to H1 an- Food Allergy: A Practice Parameter, http://www.aaaai.org/Aaaai/
tihistamines can be helpful and often are used. An inhaled beta- media/MediaLibrary/PDF%20Documents/Practice%20and%
adrenergic agent (i.e., albuterol) is indicated for bronchospasms 20Parameters/food-allergy-2006.pdf.
and/or upper airway obstruction. Systemic corticosteroids have The Food Allergy and Anaphylaxis Network, www.foodallergy.org.
4074_Ch14_319-346 20/11/14 11:18 AM Page 319
Psychosocial Disorders 14
Alcohol Abuse 5. The Diagnostic and Statistical Manual of Mental Disorders,
5th edition (DSM-5) criteria for substance use tolerance
1. A 44-year-old man who admits to drinking “a few beers includes:
now and then” presents for examination. After obtaining A. diminished effect with the same amount of substance
a health history and performing a physical examination, used.
you suspect he is a heavy alcohol user. Your next best B. desiring to get an amplified effect with higher doses.
action is to: C. ability to decrease the frequency of substance use.
A. obtain liver enzymes. D. absence of withdrawal symptoms when substance is
B. administer the CAGE questionnaire. not used for a prolonged period.
C. confront the patient with your observations. 6. During an office visit, a 38-year-old woman states, “I
D. advise him about the hazards of excessive drink way too much but do not know what to do to stop.”
alcohol use. According to Prochaska’s change framework, her state-
2. Which of the following is not a component of the ment is most consistent with a person at the stage of:
CAGE questionnaire? A. precontemplation
A. Have you ever felt you should cut down on your B. contemplation
drinking? C. preparation
B. Have you been annoyed by people criticizing your D. action
drinking? 7. The NP can consider presenting treatment options
C. Have you ever felt guilty about your drinking? and support for change after the patient has moved
D. Have you ever engaged in a violent act while into which of Prochaska’s stages?
drinking? A. precontemplation
3. Which of the following contains the greatest amount of B. contemplation
alcohol? C. preparation
A. 12 oz (360 mL) beer (9 proof) D. action
B. 4 oz (120 mL) wine (22 proof) 8. Lorazepam or oxazepam is the preferred benzodiazepine
C. 3.5 oz (105 mL) mixed drink (30 proof) for treating alcohol withdrawal symptoms when there is a
D. 3 oz (90 mL) liquor (80 proof) concomitant history of:
4. DSM-5 criteria for a substance use disorder include A. seizure disorder.
all of the following except: B. folate deficiency anemia.
A. substance use in larger amounts or over longer C. multiple substance abuse.
period than intended. D. hepatic dysfunction.
B. substance overuse resulting in hospitalization. 9. Peak symptoms of alcohol withdrawal are usually ob-
C. craving or strong desire to use. served how long after alcohol intake is discontinued?
D. substance use in potentially hazardous positions. A. less than 12 hours
B. 12 to 24 hours
C. 24 to 36 hours
D. more than 36 hours
319
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• Substance use in potentially hazardous positions addicted person can lead to potentially life-threatening
• Important social, occupational or recreational activities problems with autonomic hyperactivity (i.e., agitation, hal-
are given up or reduced due to substance use lucinations, disorientation) and seizures. The most serious
• Tolerance presentation of alcohol withdrawal is known as delirium
• Needing more to get same effect tremens, which has significant mortality in untreated pa-
• Diminished effect with the same amount tients. Use of a benzodiazepine is helpful in managing dis-
• Withdrawal tressing symptoms and preventing seizures. Treatment of
• Set of characteristic withdrawal symptoms concurrent problems, such as dehydration, malnutrition, and
• Same or other substances taken to avoid withdrawal infection, is also warranted.
Counseling the patient and family about alcoholism as a A highly motivated person with adequate social support
lifelong but treatable disease is a helpful clinical approach. In systems and a relatively low level of alcohol addiction is likely
addition, asking about current drinking habits and associated a suitable candidate for outpatient detoxification. In this type
consequences to health with each visit is important. Consis- of detoxification, the patient and support person contract
tently offering assistance in accessing treatment conveys the with the healthcare provider about a safe plan of detoxifica-
seriousness of this life-threatening condition. As with other tion. This plan includes daily office visits or contact; ongoing
health problems with a behavioral component, using state- involvement in Alcoholics Anonymous (AA), Employee As-
ments beginning with “I” is important—”I continue to be sistance Program (EPA) or similar program; counseling serv-
very concerned about your health and safety when I hear that ices; and use of a limited supply of medications for managing
you are drinking every day.” withdrawal symptoms.
In providing primary care, the NP must maintain an atti- Benzodiazepines have long been used to treat alcohol
tude that, as with any substance abuse, the patient is capable withdrawal symptoms. Chlordiazepoxide (Librium®) or
of changing and achieving sobriety. Change occurs dynami- diazepam (Valium®), therapeutic agents with a long half-
cally and often unpredictably. A commonly used change life, are reasonable treatment options for a patient with
framework is based on the work of James Prochaska, who adequate hepatic function, but agents with shorter half-
notes five stages of preparation for change: lives (e.g., lorazepam) or agents that have an absence of
• Precontemplation: The patient is not interested in change active metabolites (e.g., oxazepam), should be used in
and might be unaware that the problem exists or mini- patients with hepatic dysfunction to prevent prolonged
mizes the problem’s impact. effects. Providing a higher dose long-acting benzodi-
• Contemplation: The patient is considering change and azepine, such as diazepam 20 mg on day one, followed by
looking at its positive and negative aspects. The person a dosing schedule reduced by 5 mg daily (increased if
often reports feeling “stuck” with the problem. symptoms are particularly severe), is often effective and is
• Preparation: The patient exhibits some change behaviors currently favored over a fixed-dosed dose schedule. If ben-
or thoughts and often reports feeling that he or she does zodiazepine allergy or intolerance is an issue, carba-
not have the tools to proceed. mazepine offers a therapeutic alternative; atypical or
• Action: The patient is ready to go forth with change, standard antipsychotics play no role in managing alcohol
often takes concrete steps to change, but is inconsistent withdrawal symptoms. Alpha-adrenergic agonists (e.g.,
with carrying through. clonidine) or beta-adrenergic antagonists (i.e., propra-
• Maintenance/relapse: The patient learns to continue the nolol) are helpful in managing the distressing physical
change and has adopted and embraced the healthy habit. manifestations of alcohol withdrawal such as tachycardia
Relapse can occur, however, and the person learns to deal and tremor. Adjunctive therapy with an anticonvulsant can
with backsliding. be used to treat or prevent withdrawal seizures. The use of
As health counselor, the NP provides a valuable role in these medications does not prevent the progression of
continually “tapping” the patient with a message of concern alcohol withdrawal, and these should not be used as
about health and safety, possibly moving the person in the monotherapy but only with appropriate use of a benzodi-
precontemplation stage to the contemplation stage. After the azepine. Attention must be focused on treating alcohol-
patient is at this stage, presenting treatment options and sup- induced nutritional deficiencies, in particular with high-
port for change is a critical part of the NP’s role. dose vitamin B supplementation, including thiamine,
In a person who drinks more than 1 pint of hard liquor or pyridoxine, and folic acid, and vitamin C. Magnesium
six beers per day, alcohol withdrawal symptoms typically deficiency is a common correctable problem in alcohol
begin about 12 hours after the last drink. Peak symptoms are abuse. The recommended dietary allowance for magne-
seen at 24 to 48 hours with abatement over the next few days. sium in men is 400 to 420 mg/day, while for nonpregnant
The most common symptoms include anxiety or nervous- and nonlactating women, it is 310 to 320 mg/day. Support-
ness, depression, fatigue, irritability, jumpiness or shakiness, ive care, including sufficient fluid intake and frequent
mood swings, and nightmares. Other symptoms can include clinical reassessment, including vital signs, is important.
clammy skin, dilated pupils, headache, insomnia, loss of Although it is tempting to rely on laboratory markers in
appetite, nausea and vomiting, pallor, rapid heartbeat, sweat- assessing a person with alcohol abuse, typically few laboratory
ing, and tremors. Abrupt withdrawal of alcohol use in an markers are abnormal (Table 14–1). Evaluation of hepatic
4074_Ch14_319-346 20/11/14 11:18 AM Page 322
TABLE 14-1
Hepatic Enzyme Elevations and Their Significance
Enzyme Elevation Comment, Associated Conditions Example
Alanine aminotransferase (ALT, Measure of hepatic cellular enzymes found in A 22 y.o. woman with acute
formerly known as SGPT) circulation, elevated when hepatocellular hepatitis A
damage is present. Highly liver specific. This AST 678 U/L (normal 0–31 U/L)
enzyme has circulatory half-life of 37–57 hr; ALT 828 U/L (normal 0–31 U/L)
levels increase relatively slowly in response AST:ALT ratio <1
to hepatic damage and clear gradually after A 66 y.o. woman with obesity,
damage ceases. See AST for contrast in this type 2 diabetes mellitus, and
rise and fall pattern. nonalcoholic fatty liver disease
In hepatitis A, B, C, D, or E, and drug- or AST 44 U/L
industrial chemical–associated hepatitis, ALT 78 U/L
ALT usually increases higher than AST, with ALT:AST ratio >1
enzyme increases ≥10 times ULN.
In nonalcoholic fatty liver steatohepatitis
(NASH, also known as nonalcoholic fatty
liver disease [NAFLD]), ALT usually increases
higher than AST, with enzyme increases
usually within 3 times ULN.
Aspartate aminotransferase (AST, Measure of hepatic cellular enzymes found in A 38 y.o. man with a 10-yr history
formerly known as SGOT) circulation, elevated when hepatocellular of increasingly heavy alcohol use
damage is present. Enzyme also present AST 83 U/L (normal 0–31 U/L)
in lesser amounts in skeletal muscle and ALT 50 U/L (normal 0–31 U/L)
myocardium. AST:ALT ratio 1
AST has circulatory half-life of ~12–24 hr; A 26 y.o. man with intentional
levels increase in response to hepatic dam- acetaminophen overdose
age and clear quickly after damage ceases. AST 15,083 U/L (normal 0–31 U/L)
In alcohol-related hepatic injury AST usually ALT 10,347 U/L (normal 0–31 U/L)
increases higher than ALT.
In acetaminophen overdose, massive in-
creases in AST and ALT are often noted,
>20 times ULN.
Alkaline phosphatase (ALP) Enzyme found in rapidly dividing or metaboli- A 40 y.o. woman with acute
cally active tissue, such as liver, bone, intes- cholecystitis
tine, placenta. Elevated levels can reflect AST 45 U/L (0–31)
damage or accelerated cellular division in ALT 55 U/L (0–31)
any of these areas. Most in circulation is ALP 225 U/L (0–125)
of hepatic origin. Levels increase in response
to biliary obstruction and are a sensitive
indicator of intrahepatic or extrahepatic
cholestasis.
Gamma glutamyl transferase (GGT) Enzyme involved in the transfer of amino A 40 y.o. woman with acute
acids across cell membranes. Found cholecystitis
primarily in the liver and kidney. AST 45 U/L (0–31)
In liver disease, usually parallels changes in ALT 55 U/L (0–31)
alkaline phosphatase. ALP 225 U/L (0–125)
Marked elevation often noted in obstructive GGT 245 U/L (0–45)
jaundice, hepatic metastasis, intrahepatic
cholestasis.
Source: Ferri F. Ferri’s Best Test: A Practical Guide to Clinical Laboratory Medicine and Diagnostic Imaging, ed. 3.
Philadelphia, PA: Mosby; 2014.
4074_Ch14_319-346 20/11/14 11:18 AM Page 323
function is often ordered by providers, who then have the alcohol craving, such as acamprosate (Campral); and medica-
dilemma of presenting an alcohol-abusing patient with a set tions that induce unpleasant adverse effects if alcohol is
of relatively normal test results. This situation can help rein- ingested, such as disulfiram (Antabuse®). Although these med-
force further the patient’s denial or minimization of the effect ications can be helpful, the therapeutic effect is generally seen
excessive alcohol use has on health. As previously mentioned, only when these products are used in a motivated patient
physical health is negatively affected by alcohol abuse later in who has adequate psychosocial support and is involved in
the course of the abuse. All currently available hepatic tests counseling. Because of its significant adverse-effect profile,
indirectly measure liver function or capacity. The most com- disulfiram use has largely fallen out of favor. Other agents are
monly performed tests are measurement of hepatic enzymes, being studied to assist alcohol-dependent persons, such as ba-
protein molecules acting as catalysts and regulating metabo- clofen, nalmefene, and ondansetron. Treatment of underlying
lism within liver cells. mental health problems such as depression with a selective
Aspartate aminotransferase (AST, formerly known as serotonin reuptake inhibitor can also be helpful in maintain-
SGOT) is found in large quantities in hepatocytes. Small ing sobriety.
amounts are typically found in circulation as a result of he-
patic growth and repair. AST level increases in response to D I S C U SSI O N S O U R C E S
hepatocyte injury, as can occur in heavy alcohol use and Ferri F. Ferri’s Best Test: A Practical Guide to Clinical Laboratory
acetaminophen misuse or overdose. This enzyme is also Medicine and Diagnostic Imaging, ed. 3. Philadelphia, PA:
found in myocardium, brain, kidney, and skeletal tissue in Elsevier Mosby, 2014.
smaller amounts; damage to these areas can result in a mod- Ferri F. Management of alcohol withdrawal. In: Ferri F. Practical
est increase in AST. With a circulatory half-life (T1/2) of ap- Guide to the Care of the Medical Patient, ed. 8. Philadelphia, PA:
Elsevier Mosby; 2010.
proximately 12 to 24 hours, AST levels increase rapidly in
Prochaska JO, Redding CA, Evers KE. The transtheoretical model
response to hepatic damage and clear quickly after damage and stages of change. In: Glanz K, Lewis FM, Rimer BK (eds).
ceases. AST elevation is generally found in only about 10% Health Behavior and Health Education: Theory, Research, and
of problem drinkers. If AST is elevated, however, particularly Practice, ed. 2. San Francisco, CA: Jossey-Bass; 1997.
coupled with normal or minimally-elevated alanine amino- Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL,
transferase (ALT) and mild macrocytosis (MCV >100 fL), Hill A, Jara G, Kasser C, Melbourne J. Management of alcohol
long-standing alcohol abuse is the likely cause. This finding withdrawal delirium: An evidence-based practice guideline. Arch
is noted in about 30% to 60% of men who drink five or more Intern Med 164:1405–1412, 2004.
drinks per day and in women at a threshold of three or more Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results
drinks per day. in asymptomatic patients. N Engl J Med 342:1267, 2000.
Alanine aminotransferase (ALT, formerly known as Hoffman RS, Weinhouse GL. Management of moderate and severe
alcohol withdrawal syndromes, 2013. www.uptodate.com/
SGPT) is more specific to the liver, having limited concen-
contents/management-of-moderate-and-severe-alcohol-with-
tration in other organs. This enzyme has a longer T1/2 than drawal-syndromes.
AST at 37 to 57 hours. As a result, ALT levels increase slowly
after the onset of hepatic injury, and elevation persists longer
after hepatic damage has ceased. The greatest elevation of this
enzyme is likely seen in liver injury caused by hepatitis in- Substance Abuse
duced by acute infection or drug reaction. This enzyme is un-
15. When providing primary care for a middle-aged
likely to increase significantly if the only hepatic problem is
woman with a history of prescription benzodiazepine
related to alcohol abuse.
dependence, you consider that:
When evaluating a patient with suspected substance abuse
A. she is unlikely to have a problem with misuse of
causing hepatic dysfunction, the NP should note the degree
other drugs or alcohol.
of AST and ALT elevation. The AST-to-ALT ratio can also
B. rapid detoxification is the preferred method of
offer insight into the cause of hepatic enzyme elevations
treatment for this problem.
(Table 14–1). The hepatic enzymes generally return to base-
C. she likely has an underlying untreated or under-
line after 2 to 3 months of sobriety. This is an important pa-
treated mood disorder.
tient teaching point because a patient who has abused alcohol
D. she is at significant risk for drug-induced hepatitis.
for many years often believes that little health benefit is
gained from sobriety. The mild macrocytosis seen in alcohol 16. DSM-5 criteria for a substance abuse include all of the
abuse also resolves after about 2 to 3 months of alcohol following except:
abstinence. A. desire to cut down and/or has tried unsuccessfully
In addition to psychosocial support and counseling, many in the past.
medications are available to assist in preventing relapse in an B. inability to maintain major role obligations.
alcohol-dependent person. These products can be divided into C. excessive time spent obtaining substance, using
categories by anticipated clinical effect and include medica- substance, or recovering from its effects.
tions that modify the intoxicating effects of alcohol, such as D. involved in at least one incarceration related to
naltrexone (Revia®, Vivitrol®); medications that help to reduce substance use in the past 6 months.
4074_Ch14_319-346 20/11/14 11:18 AM Page 324
17. Demographic data indicate which of the following per- 25. Hyperthermia and a racing heart rate is a potentially
sons is most likely to misuse prescription medications? life-threatening presentation for a person using:
A. a 14-year-old male A. cannabis.
B. a 24-year-old female B. MDMA (e.g., Molly).
C. a 33-year-old male C. LSD.
D. a 38-year-old male D. barbiturates.
18. Risk of benzodiazepine misuse can be minimized by 26. Use of flunitrazepam (Rohypnol®) has been associated
use of: with:
A. agents with a shorter half-life. A. agitation.
B. the drug as an “as-needed” rescue medication for B. amnesia.
acute anxiety. C. increased appetite.
C. more lipophilic products. D. hallucination.
D. products with longer duration of action.
19. When discontinuing benzodiazepine treatment after
prolonged use, you recommend:
Answers
A. terminating treatment immediately. 15. C. 19. C. 23. B.
B. decreasing the dose 20% per day. 16. D. 20. A. 24. C.
C. decreasing the dose 25% per week. 17. B. 21. B. 25. B.
D. decreasing the dose 50% per week. 18. D. 22. B. 26. B.
20. Benzodiazepines taken concomitantly with which of the
following can lead to enhanced sedation and increased
risk of death? The misuse and overuse of various mood-altering products
A. alcohol such as alcohol, opioids, cocaine, amphetamines, and other
B. acetaminophen similar products is often referred to as substance abuse. Sub-
C. ibuprofen stance abuse is a common problem, affecting 10% to 14% of
D. statins primary care patients, with less than 10% being detected and
appropriately treated.
21. While counseling an adolescent about the risks of The Diagnostic and Statistical Manual of Mental Disorders,
marijuana use, the NP considers that: 5th edition, defines substance abuse as a problematic pattern
A. symptoms of physical and psychological dependency of substance use leading to significant impairment or distress
are rarely reported by regular users. (see Alcohol Abuse section for full description of DSM-5
B. the development of chronic obstructive airway criteria).
disease is often associated with regular use. When providing healthcare, the NP should remember
C. use on a daily basis among teens is significantly that substance abuse and dependence commonly means
less common than that of alcohol. misuse of multiple agents, including alcohol, prescription
D. driving ability is minimally impaired with its use. drugs, and illegal agents. Many substance abusers have an
22. When assessing a person with acute opioid withdrawal, underlying mental health problem, such as a mood disorder.
you expect to find: Substance abuse, including alcoholism, is often a method of
A. constipation. self-treatment in patients with an undetected or untreated
B. hypertension. psychiatric illness.
C. hypothermia. Young adults (18- to 25-year-olds) are most likely to mis-
D. somnolence. use prescription medications, with 13% using prescription
drugs for nonmedical purposes, compared to 7% of 12- to
23. An alternative to methadone that can be used to curb 17-year-olds and 4% of those 26 years of age and older. Com-
opioid withdrawal symptoms is the use of: pared to men, women have higher rates of misuse of prescrip-
A. gabapentin. tion medications, which is most likely related partly to their
B. buprenorphine plus naloxone. more frequent use of the healthcare system. In addition,
C. methylnaltrexone. women are more likely to have mood disorders, including
D. topiramate. anxiety and depression, and, consequently, are more likely to
24. When providing care for a middle-aged man with acute have potential drugs of abuse such as benzodiazepines pre-
cocaine intoxication, you inquire about: scribed by a healthcare provider. Benzodiazepine abuse is
A. feelings of anxiety. likely less common than perceived by prescribers, however,
B. difficulty maintaining sleep. who often fear that many patients receiving these anxiolytic
C. chest pain. agents would abuse or misuse the medications (Table 14–2).
D. abdominal pain. Prescribers often hesitate to use these highly effective agents
4074_Ch14_319-346 20/11/14 11:18 AM Page 325
TABLE 14-2
Psychotropic Medications Typically Prescribed to Treat Anxiety, as Adjunctive Therapy
in Depression with Anxiety
Medications Pharmacokinetics Indications Onset of Action Comments
Buspirone Slow onset of action Generalized anxiety syn- 2–4 weeks for some 5-HT1A receptor site
(BuSpar) (>7 days), lipophilic, drome, social phobia. relief of anxiety agonist, not a benzo-
T1/2 of metabolite 16 hr May be used as adjunct 4–5 weeks for full diazepine (BZD), not
in obsessive-compulsive therapeutic effect effective as a PRN or
disorder, posttraumatic sleep aid drug.
stress disorder. Minimal to no effect
Less effective in panic on performance,
disorder, acute anxiety. nonsedating. No
Not helpful in alcohol tolerance, withdrawal
withdrawal. syndrome.
No potentiation with
alcohol.
Little abuse potential.
If anxiety is disabling,
consider adding
short-term BZD while
awaiting other agent’s
action.
Lorazepam Plasma peak in 1–6 hr, Generalized anxiety Slow onset of As with all BZDs, abuse
(Ativan) about half as lipophilic syndrome, social phobia, action, sustained and habituation
as diazepam (Valium) adjunct in obsessive- effect potential.
No active metabolites compulsive disorder,
T1/2 10–20 hr posttraumatic stress
disorder, panic disorder.
Helpful in acute anxiety,
alcohol withdrawal.
Oxazepam About half as lipophilic as Generalized anxiety Slow onset of As with all BZDs,
(Serax) diazepam, slower onset syndrome, social phobia, action, relatively abuse and habituation
of action adjunct in obsessive- sustained effect potential.
Plasma peak in 1–4 hr compulsive disorder, Good choice for elderly
No active metabolites posttraumatic stress patients with anxiety
T1/2 3–21 hr disorder, panic disorder. because of short
Helpful in acute anxiety, elimination T1/2 and
alcohol withdrawal. lack of active metabo-
lites. BZDs should be
used with caution in
older adults because
of increased risk of
fall and potential for
altering mental status.
Alprazolam Plasma peak in 1–2 hr Generalized anxiety Slow onset of As with all BZDs, abuse
(Xanax) About half as lipophilic syndrome, social phobia, action, relatively and habituation
as diazepam adjunct in obsessive- sustained effect potential. When
Parent compound compulsive disorder, prescribed, sufficient
T1/2 12–15 hr posttraumatic stress daily doses should be
disorder, panic disorder. allotted.
Helpful in acute anxiety,
alcohol withdrawal.
Continued
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TABLE 14-2
Psychotropic Medications Typically Prescribed to Treat Anxiety, as Adjunctive Therapy
in Depression with Anxiety—cont’d
Medications Pharmacokinetics Indications Onset of Action Comments
Clonazepam Plasma peak in 1–2 hr Generalized anxiety syn- Slow onset of As with all BZDs, abuse
(Klonopin) About one quarter as drome, social phobia, action, highly and habituation
lipophilic as diazepam adjunct in obsessive- sustained effect potential.
No active metabolites compulsive disorder, Protracted T1/2 may
T1/2 18–50 hr posttraumatic stress pose a problem when
disorder, panic disorder. used in elderly adults,
Helpful in acute anxiety, but helpful in younger
alcohol withdrawal. adults to provide con-
Absence and petit mal sistent anxiety relief.
seizures.
Anxiety and panic.
Diazepam Plasma peak in 0.5–2 hr Generalized anxiety syn- Rapid onset of As with all BZDs, abuse
(Valium) Highly lipophilic drome, social phobia, action, relatively and habituation
Three active metabolites adjunct in obsessive- sustained effect potential.
with various T1/2 compulsive disorder, Protracted T1/2 may
Desmethyldiazepam posttraumatic stress dis- pose a problem
T1/2 30–200 hr order, panic disorder. when used in elderly
Oxazepam T1/2 3–21 hr Helpful in acute anxiety, patients.
3-hydroxydiazepam alcohol withdrawal.
T1/2 5–20 hr Anxiety
Seizures
Musculoskeletal pain
Source: Goldberg R, Posner D. Anxiety disorders: Diagnosis and management. In: Goldberg R (ed). Practical
Guide to the Care of the Psychiatric Patient, ed. 3. Philadelphia, PA: Mosby; 2007, pp. 158–177.
because of fear of providing the patient with a potentially ha- higher doses to reach therapeutic effect. Tolerance usually
bituating drug with the possibility of needing increasing precedes physical dependence.
doses. In reality, psychological dependence does occur occa- Physical dependence on benzodiazepines is a significant
sionally, but careful prescribing practices can help avoid this. problem. When working with a patient to discontinue ben-
Psychological dependence on benzodiazepines is usually zodiazepine use, the practitioner should consider reducing
associated with a rapid onset agent, one that possibly gives a the dose by 25% per week. Rapid withdrawal can lead to
sensation of intoxication. In addition, prescribing at dosing tremors, hallucinations, seizures, and a delirium tremens-like
intervals beyond duration of action of the drug gives alter- state. The onset of withdrawal symptoms occurs a few days
nating periods of drug effect and withdrawal. The perception after the last dose in a benzodiazepine with a shorter half-life
of difference is significant and possibly perceived as a buildup (e.g., lorazepam) and up to 3 weeks in one with a longer half-
of unpleasant anxiety followed by a period of relief or rescue life (e.g., clonazepam).
provided by the patient, with the cycle repeated with each Benzodiazepines rarely cause hepatic or renal impairment.
drug dose. Using a benzodiazepine as an “as needed” product When taken alone in overdose, benzodiazepines have a favor-
increases the likelihood of abuse because this heightens the able toxicity profile. Sedation risk is enhanced, however, when
patient’s awareness of drug versus no-drug state. Psycholog- benzodiazepines are combined with alcohol and barbiturates,
ical dependence on benzodiazepines can be avoided by using leading to a potentially life-threatening condition. Accidental
a slow onset product with a long half-life, such as clon- and intentional fatalities with benzodiazepine ingestion with
azepam. If using short-acting products, an adequate number alcohol often occur.
of doses per day should be given. If a benzodiazepine is being Opioid withdrawal shares many common characteristics
used on an as-needed basis, the practitioner should advise a with alcohol withdrawal. Hypertension, tachycardia, diarrhea,
maximum number of available or prescribed doses per week, nausea, temperature dysregulation, fever, papillary dilation,
such as three to four times per week, rather than once or twice restlessness, myalgia, lacrimation, and rhinorrhea are often
a day. This approach may help avoid benzodiazepine toler- reported in addition to intense cravings for opioids. Although
ance, a situation in which the patient requires increasingly very distressing, the condition is not life-threatening and
4074_Ch14_319-346 20/11/14 11:18 AM Page 327
usually resolves within a few days. Clonidine, an alpha-adren- dopamine, and norepinephrine, and the effects can last
ergic agonist, helps minimize opioid withdrawal symptoms. approximately 3 to 6 hours. In high doses, MDMA can inter-
As with any chemical dependence, long-term rehabilitation fere with regulation of body temperature that can lead to hy-
therapy is usually needed, necessitating a high level of patient perthermia, rapid heart rate, excessive sweating, shivering,
desire for sobriety. Methadone, a long-acting opioid, can help and involuntary twitching. In rare cases, the effect can lead
curb the use of illegal drugs when used in conjunction with to extreme hyperthermia with resulting liver, kidney, and
a comprehensive counseling and monitoring program. cardiovascular system failure and eventual death.
Buprenorphine with naloxone (Suboxone®) is a fixed-dose Flunitrazepam (Rohypnol) is a benzodiazepine, also
combination of an opioid agonist (buprenorphine) and known as “roofies” or the “date rape drug.” Flunitrazepam
antagonist (naloxone) that offers an alternative to methadone. is particularly potent with a rapid onset of action and is not
Compared with methadone, this drug combination has clini- available for prescription use in North America. This prod-
cally desirable qualities—such as lower abuse potential—less uct is a commonly prescribed sleep aid in other countries,
withdrawal discomfort, and greater safety against overdose. however. Flunitrazepam has been misused as a drug to
When used to treat addiction, methadone can be dispensed reduce sexual inhibition, often given without the knowl-
only through a qualified opioid treatment program, whereas edge of the recipient. Because its use can result in amnesia,
buprenorphine with naloxone (Suboxone) can be prescribed sexual assault can occur, possibly without the victim’s
in private practices and outpatient clinics by qualified clini- recalling the event.
cians. Although a helpful option that potentially increases ac-
cess to patients with opioid addiction, this medication is most D I S C U SSI O N S O U R C E S
helpful when used by a motivated patient who is actively in- Book S, Myrick H. The diagnosis and treatment of substance
volved in a comprehensive treatment program. abuse/dependence and co-occurring social anxiety disorder.
Marijuana has historically been considered a drug that has www.psychiatrictimes.com/display/article/10168/47706.
potential for psychological dependence but with little poten-
tial for physical addiction. For teens in many communities,
daily use of marijuana is more common than daily alcohol Eating Disorders
use. Marijuana currently being used is extremely potent,
however, because of its high tetrahydrocannabinol (THC) 27. Which of the following statements is true concerning
content. After a period of abstinence, physical withdrawal anorexia nervosa?
symptoms are often reported among daily marijuana users. A. The disease affects men and women equally.
Chronic marijuana use can lead to airway obstruction similar B. Onset is usually in the mid-20s for men and
to that found in heavy tobacco users. Individuals with women.
marijuana intoxication, when performing activities requiring C. Depression is often found concomitantly.
D. Individuals with anorexia nervosa are aware of the
concentration or physical skills, such as operating a motor
extreme thinness associated with the disease.
vehicle, show significant impairment.
Cocaine is a potent sympathomimetic. After cocaine in- 28. DSM-5 criteria for anorexia nervosa include all of the
gestion, the user has an increase in heart rate and myocardial following except:
contractility and generalized vasoconstriction, causing an in- A. refusal to maintain body weight at or above the
crease in blood pressure. In addition, cocaine preferentially minimum normal weight for age and height.
constricts the coronary and cerebral vessels, creating signifi- B. intense fear of gaining weight or becoming fat
cant risk for cerebral ischemia and stroke and myocardial is- despite being underweight.
chemia and infarction. Inquiring about chest pain is prudent C. distorted experience and significance of body
in caring for a patient with cocaine abuse. weight and shape.
Amphetamine use is second only to marijuana use in illicit D. absence of at least three consecutive menstrual
drug use in the United States; methamphetamine belongs cycles.
to the amphetamine drug class. These stimulants are rapidly
29. Treatment for anorexia nervosa usually includes:
absorbed and have a rapid onset of action (less than 1 hour),
A. referral for parenteral nutrition evaluation.
causing the desired effects of CNS stimulation, euphoria,
B. antidepressant therapy.
mood elevation, and appetite suppression. Withdrawal can
C. use of psychostimulants.
cause depressed mood, fatigue, vivid and disturbing dreams,
D. psychoanalysis.
sleep disturbance, increased appetite, and psychomotor
agitation or retardation. MDMA (3, 4-methylenedioxy- 30. Physical examination findings in patients with bulimia
methamphetamine), also known as ecstasy or Molly (a pur- nervosa often include:
portedly pure drug form), is a psychoactive drug that has A. body mass index (BMI) less than 75% of
similarities to amphetamine and the hallucinogen mescaline. anticipated.
Initially popular with white adolescents and young adults, use B. dental surface erosion.
of the drug has expanded to broader demographics. The drug C. tachycardia.
increases the activity of the neurotransmitters serotonin, D. hair that is easily plucked.
4074_Ch14_319-346 20/11/14 11:18 AM Page 328
31. DSM-5 criteria for bulimia nervosa include all of the 36. Bulimia nervosa, possible with anorexia nervosa if
following except: binge-purging type present
A. eating an excessively large amount of food within a 37. Both anorexia nervosa and bulimia nervosa
discrete amount of time. 38. Anorexia nervosa
B. a sense of lack of control during binge eating episode. 39. Bulimia nervosa, possible with anorexia nervosa if
C. binge eating and compensatory behavior occurring binge-purging type present
at least three times per week. 40. Both anorexia nervosa and bulimia nervosa
D. self-worth heavily influenced by body shape and
weight. Anorexia nervosa (AN) is a potentially life-threatening dis-
ease. DSM-5 criteria for AN include the following:
32. Use of laxatives and diuretics by persons with bulimia
• Inability or refusal to maintain body weight at or above
nervosa will most commonly result in:
the minimum normal weight for age and height
A. hypokalemia.
• Intense fear of gaining weight and becoming fat despite
B. hypercalcemia.
low body weight
C. proteinuria.
• Disturbance in perception of body weight and shape
D. hypernatremia.
A denial of the seriousness of the low body weight is
33. Which of the following is most consistent with the di- often found in patients with AN. Often despite extreme
agnosis of bulimia nervosa? thinness, a patient with AN looks in the mirror and
A. Patients with bulimia nervosa usually present asking comments on the need to lose “just a few more pounds.”
for treatment. Amenorrhea, which is common in women with AN, con-
B. Periods of anorexia often occur. tributes to establishing the diagnosis. The usual onset of
C. Hyperkalemia often results from laxative abuse. AN in women is during the teens to early 20s, with ages 14
D. Most patients with bulimia nervosa are significantly and 18 years being the most common; men with the con-
obese. dition typically present a few years later. AN is an over-
whelmingly female disease (90%), with either gender often
34. All of the following pharmacological interventions are
involved in an activity that has an emphasis on weight and
used in the treatment of patients with bulimia nervosa
shape, including wrestling, modeling, dancing, gymnastics,
except:
and swimming. Some of the activities are occasionally
A. fluoxetine (Prozac®).
called appearance as well as performance sports.
B. desipramine (Norpramin®).
Patients with AN usually exhibit one of two types of be-
C. bupropion (Wellbutrin®).
havior. With the restricting type, a patient with AN severely
D. paroxetine (Paxil®).
limits food intake, but does not use binge eating or purging.
35. Characteristics of binge eating disorder include all of In the binge-purge type, a patient with AN has cycles of these
the following except: behaviors.
A. lack of control over the amount and type of food In contrast to bulimia nervosa (BN), which is a secretive
eaten. disease with relatively few easily noted clinical findings, AN
B. behavior present for at least 6 months. is usually easy to identify clinically. Besides the marked re-
C. marked distress, self-anger, shame, and frustration duction in weight, muscle wasting, abdominal distention with
as a result of binging. hepatomegaly, cheilosis, oral and gum disease, coarse dry
D. purging activity after an eating binge. skin, and hypotension with bradycardia and hypothermia are
commonly noted.
36 to 40. Identify if the following characteristics are noted
AN is a potentially life-threatening disease with a mortal-
in anorexia nervosa, bulimia nervosa, or both disorders.
ity rate of 5% to 20%. Hospitalization to correct fluid and
36. Parotid gland enlargement electrolyte disorders and to initiate refeeding is often needed.
When physiological stability is reached, AN treatment usually
37. Hypokalemia
includes cognitive-behavioral and pharmacological and on-
38. Lanugo going nutritional therapy. In cognitive-behavioral therapy,
the focus is the disturbed eating and the patterns of thinking
39. Esophageal tears
that help perpetuated the binge-purge cycle. To be effective,
40. Dysrhythmias accessing care with a clinician or treatment team expert in
eating disorders is critical.
Pharmacological therapy usually involves the use of an-
Answers tidepressants, which are thought to have an effect because
of the high rate of comorbid depression. The choice of a
27. C. 30. B. 33. B. specific agent should be guided by the principles used in
28. D. 31. C. 34. C. choosing therapy for depression. Benzodiazepines are also
29. B. 32. A. 35. D. sometimes used to reduce anxiety associated with eating.
4074_Ch14_319-346 20/11/14 11:18 AM Page 329
49. Dysthymia is characterized by: 56. One week into sertraline (Zoloft®) therapy, a patient
A. suicidal thoughts. complains of a new onset recurrent dull frontal
B. multiple incidents of harming oneself. headache that is relieved promptly with acetamino-
C. social isolation. phen. Which of the following is true in this situation?
D. low level depression. A. This is a common, transient side effect of selective
serotonin reuptake inhibitor (SSRI) therapy.
50. Which of the following is most consistent with the
B. She should discontinue the medication.
diagnosis of dysthymia?
C. Fluoxetine should be substituted.
A. a 23-year-old man with a 2-month episode of
D. Desipramine should be added.
depressed mood after a job loss
B. a 45-year-old woman with “jitteriness” and 57. A patient has been taking fluoxetine for 1 week and
difficulty initiating sleep for the past 6 months complains of mild nausea and diarrhea. You advise
C. a 38-year-old woman with fatigue and anhedonia that:
for the past 2 years A. this is a common, long lasting side effect of SSRI
D. a 15-year-old boy with a school adjustment therapy.
problem and weekend marijuana use for the B. he should discontinue the medication.
past year C. another antidepressant should be substituted.
D. he should be taking the medication with food.
51. Treatment of dysthymia typically involves:
A. psychotherapy alone. 58. Sally is a 34-year-old married woman who is diagnosed
B. antidepressants alone. with major depressive disorder. She feels that it is likely
C. psychotherapy plus antidepressants. associated with stress resulting from her troubled mar-
D. electroconvulsive therapy (ECT). riage. She is initiated on an SSRI and reports initial im-
provement in symptoms. However, over the following
52. John is a 47-year-old man who reports constant
months, the medication loses its effectiveness despite
sadness following the death of his wife in a motor
her insistence that she is being adherent with the
vehicle accident 2 weeks ago. He has not been able to
dosing regimen. This is likely a result of:
function at work and avoids socializing with friends
A. an inadequate dose of the medication.
and family. You recommend:
B. development of tolerance to the SSRI.
A. giving him time and support during this period of
C. continued or escalated stress from the troubled
acute grief.
marriage.
B. weekly psychotherapy sessions.
D. missed doses despite her insistence on compliance.
C. prescribing an anxiolytic to help with grief
symptoms. 59. Which of the following medications is most likely to
D. psychotherapy plus a prescription for an cause sexual dysfunction?
antidepressant. A. vilazodone (Viibryd®)
B. fluoxetine (Prozac)
53. Successful treatment of a patient with reactive
C. nortriptyline (Pamelor®)
depression associated with a loss (e.g., death of a
D. bupropion (Wellbutrin)
loved one) would expect all of the following results
except: 60. SSRI withdrawal syndrome is best characterized as:
A. elevated mood. A. bothersome but not life-threatening.
B. restored function. B. potentially life-threatening.
C. improved decision-making ability. C. most often seen with discontinuation of agents with
D. elimination of sadness. a long half-life.
D. associated with seizure risk.
54. Drug treatment options for a patient with bipolar
disorder often include all of the following 61. Which of the following SSRIs is most likely to signifi-
except: cantly interact with warfarin?
A. atomoxetine (Strattera®). A. citalopram
B. lithium carbonate. B. paroxetine
C. risperidone (Risperdal®). C. fluoxetine
D. valproic acid (Depakote®). D. sertraline
55. Which of the following drugs is likely to be the most 62. Which of the following SSRIs is associated with the
dangerous when taken in overdose? greatest anticholinergic effect?
A. a 4-week supply of fluoxetine A. fluvoxamine
B. a 2-week supply of nortriptyline B. sertraline
C. a 3-week supply of venlafaxine C. fluoxetine
D. a 3-day supply of diazepam D. paroxetine
4074_Ch14_319-346 20/11/14 11:18 AM Page 331
63. Which of the following statements is true regarding 70. Which of the following agents has the longest T1/2?
depression and relapse? A. fluoxetine
A. Without maintenance therapy, the relapse rate is B. paroxetine
typically less than 50% in the first year. C. citalopram
B. The risk of relapse is less for those who have D. sertraline
experienced multiple episodes of major depressive
71. Which of the following agents should be avoided in
disorder.
heavy alcohol users due to a potential risk for hepato-
C. The risk of relapse is greatest in the first 2 months
toxicity?
after discontinuation of therapy.
A. duloxetine
D. Relapse rarely occurs if there is an absence of symp-
B. desvenlafaxine
toms after 9 months of treatment discontinuation.
C. escitalopram
64. All of the following are risk factors for relapse except: D. bupropion
A. current episode lasts more than 2 years.
72. Treatment with venlafaxine (Effexor®) can lead to
B. onset of depression occurs at younger than 20 years
dose-dependent increases in:
of age.
A. heart rate.
C. poor recovery between episodes.
B. serum glucose.
D. absence of dysthymia preceding the episode.
C. AST/ALT.
65. Which of the following is most consistent with the D. blood pressure.
presentation of a patient with bipolar I disorder?
73. You see a 28-year-old man who has been diagnosed
A. increased need for sleep
with moderate depression and has not responded
B. impulsive behavior
well to SSRI therapy over the past 3 months. He was
C. fatigue
involved in a motor vehicle accident 2 years ago that
D. anhedonia
resulted in head trauma and now occasionally experi-
66. In general, pharmacological intervention for patients ences occasional tonic clonic seizures. When consider-
with depression should: ing alternative antidepressant therapy, which of the
A. be given for about 4 months on average. following should be avoided?
B. continue for a minimum of 6 months after remis- A. bupropion
sion is achieved. B. trazodone
C. be continued indefinitely with a first episode of C. citalopram
depression. D. duloxetine
D. be titrated to a lower dose after symptom relief is
74. QT prolongation is a concern with higher doses of:
achieved.
A. citalopram.
67. Depression often manifests with all of the following B. sertraline.
except: C. venlafaxine.
A. psychomotor retardation. D. fluoxetine.
B. irritability.
75. Priapism is a potential adverse effect of which of the
C. palpitations.
following psychotropic medications?
D. increased feelings of guilt.
A. bupropion
68. A 44-year-old man has been taking an SSRI for the past B. sertraline
4 months and complains of new onset of sexual dys- C. trazodone
function and difficulty achieving orgasm. You advise D. amitriptyline
him that:
76. When using trazodone to aid sleep, the drug should be
A. this is a transient side effect often seen in the first
optimally taken _____ prior to sleep.
weeks of therapy.
A. immediately
B. switching to another SSRI would likely be helpful.
B. 15 minutes
C. this is a common adverse effect of SSRI therapy that is
C. 1 hour
unlikely to resolve without adjustment in his therapy.
D. 2 hours
D. he should see an urologist for further evaluation.
77. Patient presentation possibly common to anxiety and
69. The maximum recommended dose of citalopram for
depression includes:
patients older than 60 years of age is:
A. feeling of worthlessness.
A. 10 mg/day.
B. psychomotor agitation.
B. 20 mg/day.
C. dry mouth.
C. 30 mg/day.
D. appetite disturbance.
D. 40 mg/day.
4074_Ch14_319-346 20/11/14 11:18 AM Page 332
78. Which of the following describes prescriptions for anti- • Fatigue—with report of lack of energy.
depressant medications written by primary care • Self-worth—with report of worthlessness or inappropriate
providers? guilt.
A. dose too high • Concentration—with report of difficulty concentrating,
B. dose too low trouble thinking clearly, or indecisiveness.
C. excessive length of therapy • Thoughts of death—the patient has had repeated thoughts
D. appropriate length of therapy about death and dying (other than the fear of dying), or
has had thoughts of suicide (with or without a plan).
79 to 83. Match each serotonin receptor site with its asso-
The symptoms cause clinically important distress or impair
ciated activity when stimulated.
work, social, or personal functioning and cannot be attributed
79. 5-HT1A A. agitation, anxiety,
to another health condition. Other symptoms of depression
80. 5-HT1C, 5-HT2C panic
are often reported. Hypochondriasis is found in at least 30%
81. 5-HT1D B. antimigraine effect
of patients; such a patient is unable to process objective infor-
82. 5-HT2 C. antidepressant
mation that he or she has no particular health problem. Al-
83. 5-HT3 D. cerebral spinal fluid
ternatively, a person with hypochondriasis perceives that an
production
existing health problem is far more serious than it is in reality.
E. nausea, diarrhea
Suicidal ideation is occasionally present, with the patient
voicing thoughts (most common) or a plan (less common) of
Answers self-harm. Most patients with depression have a passive idea
of death without a plan. The patient often agrees with the
41. D. 56. A. 71. A. statement, “If I could just die in my sleep, that would be all
42. A. 57. D. 72. D. right,” but steadfastly denies a plan of self-harm. As with any
43. 1 58. C. 73. A. person with suicidal ideation or plan, a thorough safety evalu-
44. 2 59. B. 74. A. ation should be completed and appropriate referral facilitated;
45. 3 60. A. 75. C. this can include involuntary hospitalization for a patient who
46. B. 61. C. 76. C. is a risk of self-harm. Inquiring about thoughts or plans of
47. C. 62. D. 77. B. harm to others is also an important part of the patient’s safety
48. C. 63. C. 78. B. plan. All patients with a disordered mood should be made
49. D. 64. D. 79. C. aware of local resources for emergency mental healthcare.
50. C. 65. B. 80. D. In an older adult, depression is sometimes mistaken for
51. C. 66. B. 81. B. new onset or worsening dementia. A patient with dementia
52. A. 67. C. 82. A. typically has cognitive changes that are slowly progressive
53. D. 68. C. 83. E. over months to years, however. The cognitive changes re-
54. A. 69. B. ported by patients with depression usually have evolved over
55. B. 70. A. a much shorter period with the patient often accurately
reporting what changes have occurred.
Depression is a common health problem with at least a 15% Anxiety is often reported by a depressed person and is a
lifetime occurrence rate. DSM-5 criteria for depression in- common comorbid condition. In individuals with depression,
clude the presence of particular symptoms and findings the mood disturbance occurs first, followed in several weeks
within a 2-week period. The person has had five or more of by the addition of anxiety-related symptoms. Depression
the following symptoms, which are a definite change from should be considered as the diagnosis rather than anxiety if the
usual functioning. Either depressed mood or decreased in- patient reports feeling worse while taking benzodiazepines. The
terest or pleasure must be one of the five, with findings re- concept that a person has either depression or anxiety has been
ported by the patient or noted by others, or both: largely replaced with the realization that mood disorders occur
• Mood—often with a marked diurnal variation in mood, on a continuum, with most individuals with mood disorders
with morning mood being more depressed than later in showing features of depression and anxiety.
the day. Agitated mood and irritability are commonly Psychomotor agitation with fidgeting and irritability is
noted together. often found in patients with depression, especially in children
• Interests—with lack of interest or pleasure in activities and adolescents. In these age groups, this presentation is more
normally or formerly found to be pleasurable. likely than psychomotor retardation. This type of increased
• Eating—with a marked increase or decrease in appetite activity is also found in type A adults with depression.
noted with corresponding change in weight. Intervention for patients with depression includes a com-
• Sleep—with reports of excessive or insufficient amounts. bination of support, counseling, and medication. Interper-
Reports of early morning wakening, such as 3 or 4 a.m., sonal therapy, including counseling and support, alone has a
with inability to fall back to sleep, are common. 40% to 60% efficacy with a high relapse rate. As a single ther-
• Motor activity—with reports of activity being agitated or apeutic modality, this is most effective for individuals with
retarded. reactive depression. Combined therapy of pharmacological
4074_Ch14_319-346 20/11/14 11:18 AM Page 333
TABLE 14-3
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRI Half-life Labeled Indications Adverse Effect Profile Comments
Paroxetine T1/2 21 hr, Major depressive disorder Sedating (HS dosing likely Helpful in depression
(Paxil) no active Panic disorder with or best) with anxiety
metabolites without agoraphobia Likely most anticholiner- Elimination via renal
Obsessive-compulsive gic effect of the SSRIs. and hepatic routes
disorder More constipation Fewer problems with
Social anxiety disorder (13%) than limited renal/hepatic
Generalized anxiety diarrhea (11%) function
disorder Antihistamine-like, Low mania induction in
Posttraumatic stress anticholinergic activity bipolar; with relatively
disorder can lead to increased short T1/2 and lack of
Premenstrual dysphoric appetite active metabolites,
disorder helpful in the treat-
ment of depression in
elderly patients
Because of short T1/2,
slow tapering dose
when discontinuing
medication is recom-
mended to avoid sig-
nificant withdrawal
syndrome
Fluvoxamine T1/2 16 hr Obsessive-compulsive High rate of gastrointesti- Adverse-effect profile
(Luvox®) No active disorder nal upset and sleep can limit utility
metabolites Social anxiety disorder disturbance compared
with other SSRIs
Sertraline T1/2 26 hr Major depression, obses- Equal numbers find Take with food to
(Zoloft) Metabolite sive-compulsive disorder, medication sedating enhance absorption
T1/2 62–104 hr panic disorder, posttrau- and energizing
matic stress disorder, Low rate of nervousness,
premenstrual dysphoric anorexia
disorder, social anxiety
disorder
Citalopram Citalopram: Major depression, Equal numbers reporting Escitalopram 10 mg
(Celexa) Racemic generalized anxiety somnolence and is therapeutically
Escitalopram compound disorders insomnia. Favorable equivalent to citalo-
(Lexapro) T1/2 ~35 hr gastrointestinal profile pram 20–40 mg
for parent Low rates of agitation with a possibly
compound, and anorexia superior adverse-
metabolite T1/2 Due to risk of QT prolon- effect profile
2 days for one, gation with citalopram,
4 days for for patients >60 years
another of age, the maximum
Escitalopram: recommended dose is
Single isomer 20 mg/day, maximum
of citalopram 40 mg/day in all others.
with shorter
T1/2 27–32 hr
Prozac T1/2 24–72 hr Major depressive disorder Energizing, anorexia Morning dosing recom-
(Fluoxetine) Metabolite T1/2 Bulimia nervosa common mended. Protracted
4–16 days Obsessive-compulsive T1/2 can present prob-
disorder lem in elderly patients
4074_Ch14_319-346 20/11/14 11:18 AM Page 335
TABLE 14-3
Selective Serotonin Reuptake Inhibitors (SSRIs)—cont’d
SSRI Half-life Labeled Indications Adverse Effect Profile Comments
Premenstrual dysphoric Missed doses less of a
disorder problem because of
Panic disorder with or protracted T1/2
without agoraphobia Weight loss of ~3–5 lb
(1.4–2.3 kg) common
in early months of
use, but usually not
sustained long-term
Source: Posternak M, Zimmerman M. Antidepressants. In: Goldberg R (ed). Practical Guide to the Care of the
Psychiatric Patient, ed. 3. Philadelphia, PA: Mosby; 2007, pp. 108–136.
TABLE 14-4
Selective Serotonin Norepinephrine Reuptake Inhibitors, Tricyclic, Tetracyclic, and Other
Antidepressants
Agent Half-life Adverse Reactions Comments
Venlafaxine (Effexor and 5 hr for Activating in larger amounts SSRI-like effect only in low doses,
Effexor ER) venlafaxine Patients often need trazodone or with norepinephrine uptake block-
[selective serotonin and and 11 hr other agent to help with sleep ade at medium to high doses,
norepinephrine reuptake for its active Significant nausea with rapid onset similar to TCA effect, but with
inhibitor, SSNRI] metabolite of high dose fewer adverse effects. Withdrawal
(15 hr for Dose-dependent increases in syndrome similar to SSRIs
venlafaxine diastolic blood pressure
extended Average 5 mm Hg response
release
capsules)
Duloxetine (Cymbalta) 8–17 hr Rare liver toxicity risk, most often Serotonin norepinephrine reuptake
[selective serotonin and noted in presence of other inhibitor. Indicated for treatment of
norepinephrine reuptake hepatic risk factors. Few anti- mood disorders and neuropathic
inhibitor, SSNRI] cholinergic adverse effects pain
Bupropion (Wellbutrin) 9.8 hr Few anticholinergic effects Blocks reuptake of dopamine at
[selective dopamine (3.9–24 hr) Energizing presynaptic neuron, especially in
reuptake inhibitor] Extended- Possible increased libido, agitation high doses, some increase in norepi-
release (25%) nephrine transmission. Dopamine
29 hr Avoid with significant manifesta- receptor sites likely stimulated in
(20–38 hr) tion of anxiety, agitation, substance abuse, making bupropion
insomnia a helpful antidepressant for a person
with a history of substance abuse.
Nonaddicting and nonintoxicating
Avoid use in presence of eating dis-
order or if anorexia is a major com-
ponent of depression. Weight loss
often seen (28% >5 lb [2.3 kg])
after initiation of therapy
Do not give if history of or risk for
seizure, closed head injury history,
history of quiescent epilepsy
Seizure risk worsens if dose
increased rapidly
Continued
4074_Ch14_319-346 20/11/14 11:18 AM Page 336
TABLE 14-4
Selective Serotonin Norepinephrine Reuptake Inhibitors, Tricyclic, Tetracyclic, and Other
Antidepressants—cont’d
Agent Half-life Adverse Reactions Comments
Mirtazapine (Remeron) 20–40 hr Potent H1 inhibitor Effect likely due to increase in central
[Tetracyclic antidepressant] Weight gain common noradrenergic and serotoninergic
Major side effect is sedation that is activity
worse in lower doses. Little sexual Selectively stimulates 5HT1A while
dysfunction or gastrointestinal blocking 5HT2 and 5HT3
side effect Higher doses more receptor site-
selective and associated with
fewer side effects
Tricyclic antidepressants; 24–32 hr Weight gain Inexpensive, more effective than
includes nortriptyline Anticholinergic activity (blurred SSRI in more severe depression,
[Pamelor, active metabolite vision, dry mouth, memory loss, likely owing to its norepinephrine
of amitriptyline], sweating, anxiety, postural and serotonin activity
desipramine [Norpramin], hypotension, dizziness, and More bothersome side-effect profile
active metabolic of tachycardia) Constipation a leads to high dropout rate
imipramine) problem, but infrequent nausea. Primary care providers seldom pre-
Little sexual dysfunction scribe sufficient doses to relieve
depression
Taper off over 2–4 weeks to avoid
TCA withdrawal symptoms; sleep
disturbance, nightmares, gastroin-
testinal upset, malaise, irritability
Trazodone 5 hr (3–9 hr) Highly sedating, dizziness, favor- Anxiolytic and antidepressant activity
(Desyrel®, Oleptro®) able gastrointestinal side-effect 5-HT2 antagonist
[Triazolopyridine] profile. Priapism risk found in 1 in Clinical use limited by marked
6000 men using drug. Patient sedation
should be informed to go to Effective hypnotic with little morning
emergency department promptly drowsiness at doses 25–100 mg
for painful erection lasting taken 1 hr before sleep
>30 min Can use in low, frequent doses as
benzodiazepine alternative for
generalized anxiety
Vilazodone (Viibryd) 25 hr Diarrhea, nausea, vomiting and Works through enhancement of
[Novel class] insomnia most common; no serotonergic activity in the CNS
apparent effect on weight through selective inhibition of
or cardiac function (e.g., serotonin uptake as well as a
QT prolongation). partial agonist of serotonergic
5-HT1A receptors
Source: Posternak M, Zimmerman M. Antidepressants. In: Goldberg R (ed). Practical Guide to the Care of the
Psychiatric Patient, ed. 3. Philadelphia, PA: Mosby; 2007, pp. 108–136.
When choosing an antidepressant, the side-effect profile needs hospitalization to ensure safety and appropriate treat-
is critical. Often a given agent has a desirable side effect, such ment. As with many conditions, however, depression is
as sedation in a patient having difficulty with sleep or anxiety. a disease with episodes of improvement and deterioration.
In addition, the drug’s half-life influences the therapeutic The prescriber should consider the risk of an intentional
choice, with products with a shorter T1/2 being desirable in overdose.
elderly patients and patients with hepatic disease. A younger A 2-week supply of a tricyclic antidepressant (TCA) in full
adult could benefit from the use of a drug with a longer therapeutic dose would likely be lethal, with significantly
T1/2 if he or she skips a dose from time to time. smaller amounts capable of causing seizures and dysrhyth-
Another consideration in choosing an antidepressant is mias. SSRIs and atypical antidepressants have a significantly
its toxicity when taken in overdose. A suicidal patient clearly better safety profile when taken in overdose; usually more
4074_Ch14_319-346 20/11/14 11:18 AM Page 337
BOX 14-4
Cytochrome P450 Isoenzyme Inhibition by Selective Serotonin Reuptake
Inhibitors
CYP ISOENZYMES
1A2 2C9 2C19 2D6 3A4
Escitalopram 0 0 0 0 0
Citalopram + 0 0 + 0
Fluoxetine + ++ + to ++ +++ ++
Paroxetine + + + +++ +
Sertraline + + + to ++ + +
than a 2-month supply of a full therapeutic dose is needed to SSRIs are a heterogeneous group of drugs with a common
cause life-threatening effects. mechanism of action: blocking reuptake of serotonin in the
Antidepressants generally work by causing an increase in central nervous system and increasing amounts of serotonin
availability of certain neurotransmitters, such as serotonin, available to postsynaptic neurons. The end effect is that more
norepinephrine, and dopamine. This increased availability serotonin is available for action at selected receptors. Sero-
allows for greater activity at the neurotransmitter’s respec- tonin is active at numerous receptor sites (Table 14–5).
tive receptor sites. There is evidence that interpersonal ther- The use of serotonin norepinephrine reuptake inhibitors
apy also increases serotonin availability. (SNRIs) for the treatment of depression has been increasing.
TABLE 14-5
Serotonin Activity
Serotonin Receptor Site Activity When Activated Comments
5-HT1A Antidepressant, anti–obsessive- Action at this site basis of most antidepressant,
compulsive behavior, antipanic, antipanic therapy
anti–social phobia action, Reason that shyness often lifts with SSRI use
antibulimia effect
5-HT1C, 5-HT2C Influence cerebrospinal fluid Reason tachycardia, dizziness, alteration of
production, cerebral circulation sleep patterns and change in pain perception
Regulation of sleep occur with SSRI use
Perception of pain
Cardiovascular function
5-HT1D Antimigraine activity Triptan preparations work by stimulating this
receptor site
TCAs also work at this site and are helpful in
preventing migraine
5-HT2 Agitation, akathisia, anxiety, panic, Receptor site highly stimulated in activating
insomnia, sexual dysfunction SSRI such as fluoxetine. Activity at this receptor
Excessively upregulated in those site causes sexual dysfunction associated with
with depression SSRI use
Trazodone (Desyrel) antagonizes action at
this site and is helpful in treatment of anxious
depression and has a more favorable sexual
function profile
5-HT3 When stimulated, nausea, Particularly stimulated with antidepressants with
gastrointestinal distress, poor gastrointestinal side-effect profile
diarrhea, headache Products such as ondansetron (Zofran, a 5-HT3
antagonist) block activity at this site
Source: Maxmen J, Ward N. Psychotropic Drug Facts Fast, ed. 3. New York, NY: Norton, 2002.
4074_Ch14_319-346 20/11/14 11:18 AM Page 338
These can be considered for patients who fail to respond to with relatively infrequent sexual activity. This practice can
SSRIs and are also used to treat other conditions, such as lead to SSRI/SNRI-withdrawal symptoms toward the end of
anxiety and chronic nerve pain. These drugs block the ab- the drug-free period, however, with all products except flu-
sorption of serotonin and norepinephrine in the brain, oxetine. Given its long T1/2, this practice is unlikely to be
which changes the balance of these chemicals, thereby boost- helpful for a person taking fluoxetine.
ing mood. Adverse effects are generally similar to those Trazodone is used to treat depression or anxiety but has
caused by SSRIs, with the most common consisting of nau- the potential to cause priapism. Its use is for mood disorder
sea, dry mouth, dizziness, and excessive sweating. Tiredness, therapy, limited due to it being highly sedating. When used
difficulty urinating, anxiety, constipation, insomnia, sexual in patients with a sleeping disorder, trazodone should be
dysfunction, headache, and loss of appetite have also been administered about 1 hour prior to sleep for maximum
reported. effect. A withdrawal syndrome is often seen with SSRI/
With all antidepressants, a receptor site-induced effect is SNRI use longer than 5 weeks when the product is rapidly
immediate when therapy is initiated. The length of onset of discontinued.
therapeutic action is usually several weeks, however. This In SSRI/SNRI-withdrawal syndrome, there is a sudden
length of onset is likely associated with time needed for change in the amount of serotonin available and an alter-
change in receptor site activity. ation in receptor site action. Its onset is related to the T1/2
When a patient who is depressed takes antidepressants of the drug, with three to five drug-free half-lives needed
while undergoing an ongoing significant life stressor, such as before the medication clears fully. Symptoms occur more
family or marital discord or abuse, depressive symptoms usu- rapidly after SSRI/SNRI discontinuation with a drug with a
ally subside as the medication takes effect. If the stressor con- short T1/2 and may not occur at all in a drug with a pro-
tinues, however, the antidepressant may appear to lose its tracted T1/2 (e.g., fluoxetine). Symptoms of SSRI/SNRI-with-
initial effectiveness. Ongoing interpersonal therapy can be drawal syndrome include dizziness, paresthesia, anxiety,
highly effective in augmenting pharmacological treatment in nausea, sleep disturbance, and insomnia. Although disturb-
such situations. ing and uncomfortable, this syndrome, in contrast to benzo-
In early SSRI therapy, the patient often complains of drug- diazepine withdrawal, is not dangerous or life-threatening
related adverse effects, including headache, nausea, and di- and generally resolves within days to a few weeks.
arrhea; these resolve within 2 to 6 weeks. Advising the patient Bupropion is used to treat depression as well as seasonal
that these side effects are expected, easily treatable, and tran- affective disorder (SAD) and as an aid in smoking cessation.
sient helps avoid the problem of the patient discontinuing The agent is structurally unrelated to SSRIs or TCAs and
this important therapeutic agent. The headache is usually does not inhibit the activity of monoamine oxidase or the
frontal in location and resolves with acetaminophen. Using reuptake of serotonin. Bupropion blocks the reuptake of
a nonsteroidal antiinflammatory drug will likely contribute dopamine, which makes this agent especially useful for
further to the gastrointestinal upset often found in the first those with a history of substance abuse since dopamine
weeks of SSRI use. Taking the medication with food can min- receptor sites are likely stimulated in substance abuse. The
imize nausea and diarrhea. Because of the potential chelation drug is nonaddicting and nontoxicating and is associated
effect and impact of altered stomach pH on drug absorptions, with few anticholinergic effects. The most common adverse
taking many medications with an antacid can potentially effects include headache, dry mouth, nausea, weight loss,
limit the drug’s effectiveness. and insomnia.
The use of SSRIs and other psychotropics is often asso- TCAs are helpful but often misunderstood and under-
ciated with sexual function problems. Decreased libido and used medications. TCAs have a more problematic side-
anorgasmia in either gender are often reported; erectile dys- effect profile compared with SSRIs. In addition, they re-
function in men is also common. If this is a problem, quire considerable prescriber skill and patient cooperation.
switching the patient to an a selective dopamine reuptake TCAs are seldom well tolerated in a dose that is therapeutic
inhibitor such as bupropion (Wellbutrin) or a serotonin and for depression therapy. These medications are likely supe-
norepinephrine reuptake inhibitor (SNRI) such as venlafax- rior to SSRIs when depression is moderate to severe and
ine (Effexor®), duloxetine (Cymbalta®), or desvenlafaxine characterized by emotional withdrawal, guilt, anorexia, and
(Pristiq®), or a TCA can be considered because the use of middle to late insomnia. In addition, they are effective in
these products is associated less often with sexual dysfunc- depressed patients who also have chronic pain, fibromyal-
tion. Vilazodone (Viibryd) is a dual-acting serotonergic gia, migraine, or the need for sedative or hypnotic agents.
agent that combines the antidepressant effects of a SSRI Choosing a TCA (e.g., nortriptyline [Pamelor]) with less
with partial serotonin-receptor agonist activity and provides anticholinergic effect and slowly increasing the dose helps
an additional option. Additional options for SSRI sexual enhance patient adherence.
dysfunction include adding bupropion to the therapeutic If a patient with depression also has episodes of mania,
regimen; support for this common practice is largely based bipolar I disorder is present. Bipolar disorders occur in ap-
on anecdotal reports. Taking a 1-day “drug holiday” from proximately 1% of the general population. Characteristics
SSRI/SNRI use, with sexual activity planned for the end of of mania include those listed as follows. For at least 1 week,
the drug-free period, offers a reasonable option for a person or less if hospitalized, the person’s mood is persistently
4074_Ch14_319-346 20/11/14 11:18 AM Page 339
92. Which of the following is often reported by anxious 99. Which of the following is true regarding panic disor-
patients? der and agoraphobia?
A. constipation A. More men than women experience panic disorder
B. muscle tension without agoraphobia.
C. hive-form skin lesions B. More women than men experience panic disorder
D. somnolence without agoraphobia.
C. More men than women experience panic disorder
93. Pharmacological intervention in an anxiety disorder
with agoraphobia.
should be:
D. More women than men experience panic disorder
A. generally given for about 4 to 6 months.
with agoraphobia.
B. continued for at least 6 months after remission is
achieved. 100. Concomitant health problems found in a patient with
C. continued indefinitely with a first diagnosis of the panic disorder often include:
condition. A. irritable bowel syndrome.
D. titrated to a highest dose recommended after symp- B. thought disorders.
tom relief is achieved. C. hypothyroidism.
D. inflammatory bowel disease.
94. The use of which of the following drugs often mimics
generalized anxiety disorder? 101. When initiating SSRI therapy for a patient with panic
A. sympathomimetics disorder, the NP should consider all of the following
B. antipsychotics except:
C. anticholinergics A. start with a low dose and slowly escalate doses as
D. alpha-beta antagonists necessary.
B. preferable to use agents that are more energizing
95. When prescribing a benzodiazepine, the NP should
than less energizing.
consider that:
C. select agents with a low rate of insomnia and
A. the ingestion of 3 to 4 days of therapeutic dose can
akathisia.
be life-threatening.
D. SSRI therapy can precipitate panic attacks with
B. the medication must be taken at the same hour
early use.
every day.
C. concomitant use of alcohol should be avoided. 102. In providing primary care for a patient with posttrau-
D. onset of therapeutic effect takes many days. matic stress disorder (PTSD), you consider that all of
the following are likely to be reported except:
96. A middle-aged woman who has taken therapeutic dose
A. agoraphobia.
of lorazepam for the past 6 years wishes to stop taking
B. feeling of detachment.
the medication. You advise her that:
C. hyperarousal.
A. she can discontinue the drug immediately if she be-
D. poor recall of the precipitating event.
lieves it no longer helps with her symptoms.
B. rapid withdrawal in this situation can lead to 103. Among the preferred first-line pharmacological treat-
tremors and hallucinations. ment options for patients with PTSD include the
C. she should taper down the dose of the medication use of:
over the next week. A. methylphenidate (Ritalin®).
D. gastrointestinal upset is typically reported during the B. oxazepam (Serax®).
first week of benzodiazepine withdrawal. C. lithium carbonate.
D. sertraline.
97. Risk of benzodiazepine misuse is minimized by use of:
A. agents with a shorter T1/2. 104. Which of the following therapeutic agents is com-
B. the drug as an as-needed rescue medication for monly used to help with sleep difficulties such as in-
acute anxiety. somnia associated with PTSD?
C. more lipophilic products. A. duloxetine
D. products with long duration of action. B. bupropion
C. mirtazapine
98. Which of the following statements concerning panic
D. zolpidem
disorder is false?
A. Panic disorder rarely occurs with depression. 105. Which of the following is an over-the-counter herbal
B. Up to 4% of the general population suffers from preparation used to relieve symptoms of depression?
panic disorder. A. valerian root
C. New onset panic disorder rarely occurs after B. melatonin
45 years of age. C. kava kava
D. Family history of panic disorder is a risk factor for D. St. John’s wort
the condition.
4074_Ch14_319-346 20/11/14 11:18 AM Page 341
106. In treatment-resistant patients with panic disorder, Generalized anxiety disorder (GAD) is present in approx-
which drug class is occasionally used? imately 2% to 4% of the population. The typical age of onset
A. atypical antipsychotic is usually in the teen to young adult years; 15% have a first-
B. selective dopamine reuptake inhibitor degree relative with GAD. DMS-5 criteria for GAD include
C. monoamine oxidase inhibitor at least three of the following symptoms occurring on most
D. neuroleptic days for 6 or more months:
• Excessive anxiety or worry (this must be present)
107. In treating a person with panic disorder using an
• Difficulty controlling worry (this must be present)
SSRI, the NP should consider that there is:
• Difficulty concentrating or mind going blank
A. considerable abuse potential with these
• Sleep disturbance
medications.
• Muscle tension
B. no significant therapeutic advantage over TCAs.
• Restlessness or feeling keyed up/on edge
C. a reduction in number and severity of panic attacks.
• Fatigue
D. significant toxicity in overdose.
• Irritability
108. Concomitant use of an SSRI with which of the follow- Anxiety often occurs in patients with depression, making
ing herbal products can potentially lead to serotonin the differentiation between these two common disorders
syndrome? problematic. A patient with depression that has an anxious
A. St. John’s wort component usually reports nervous feelings after the onset of
B. kava kava depressed mood. Also in depression, the patient has feelings
C. gingko biloba of worthlessness and the feeling that situations are hopeless;
D. valerian root patients with anxiety often report feeling “worried sick” and
helpless. As with all mood disorders, anxiety most commonly
109. Use of St. John’s wort is known to impact the effec-
occurs on a continuum.
tiveness of all of the following medications except:
The cardinal presenting signs of anxiety disorder are re-
A. oral contraceptives.
lated to the hypersympathetic state. Physical manifestations
B. fluoroquinolones.
include tachycardia, hyperventilation, palpitations, tremors,
C. cyclosporine.
and sweating. When establishing the diagnosis of GAD, it is
D. select antiretrovirals.
important to rule out many clinical conditions that can
110. High doses or prolonged use of kava kava has been mimic the disorder, including thyrotoxicosis, alcohol with-
associated with cases of: drawal, or abuse of sympathomimetic drugs such as caffeine,
A. renal impairment. amphetamines, and cocaine.
B. hepatotoxicity. Treatment recommendations for pharmacological inter-
C. iron-deficiency anemia. vention in anxiety disorders are similar to the guidelines for
D. hyperthyroidism. depression therapy. Treatment should begin with a 3-month
trial period of working with the patient to find the correct
medication and dose that help abate symptoms. The practi-
Answers tioner should encourage psychotherapy to work on building
84. A. 93. B. 102. D. skills needed to help manage a long-term health problem. In
85. B. 94. A. 103. D. particular, the practitioner should convey the message to the
86. A. 95. C. 104. C. patient that the use of psychotropic agents can help facilitate
87. B. 96. B. 105. D. therapy. This acute care phase should be followed with a
88. A. 97. D. 106. C. 6- to 12-month maintenance period, yielding a minimal
89. D. 98. A. 107. C. treatment period of 9 months, although longer term therapy
90. C. 99. D. 108. A. should be considered, especially if symptoms recur with
91. B. 100. A. 109. B. depression. Choice of a therapeutic agent is guided by nu-
92. B. 101. B. 110. B. merous factors, including asking about what has worked in
the past and what has worked in the treatment of relatives
Anxiety is a normal human emotion that is an important with similar conditions.
part of fear response and helps a person focus on the issue Neurotransmitters implicated in anxiety include
at hand, such as anxiety associated with taking an important γ-aminobutyric acid (GABA), the brain’s major inhibitory
examination or making a presentation. Anxiety can also be chemical, and serotonin (5-HT). Norepinephrine, dopamine,
protective, heightening senses when an individual encoun- and epinephrine likely play a role as well. Drug therapy for
ters a dangerous situation. This is a rational, expected emo- patients with anxiety disorders includes agents that enhance
tion when present for an appropriate reason and should GABA function, such as benzodiazepines, and products
dissipate with the cessation of the stressor. Anxiety becomes that enhance the availability of serotonin, such as SSRIs. The
problematic, however, when it is exaggerated, is prolonged, first-line therapy for anxiety is a SSRI. An anxiolytic, such as
or interferes with daily function. a benzodiazepine, is occasionally used to help with symptom
4074_Ch14_319-346 20/11/14 11:18 AM Page 342
management until the SSRI exerts its therapeutic effect. The Physical benzodiazepine dependence is a significant prob-
SSRI choice is based on the previously identified factors when lem. When working with the patient to discontinue benzo-
used in the treatment of depression. diazepine use, reducing the dose by 25% per week should
The mechanism of action of benzodiazepines is as a me- be considered. Rapid withdrawal can lead to tremors, hallu-
diator of GABA, enhancing its activity. Benzodiazepines are cinations, seizures, and a delirium tremens-like state. Onset
highly effective in the treatment of anxiety disorders. Because occurs a few days after the last dose in a benzodiazepine with
numerous benzodiazepines are available, choosing the ap- a shorter T1/2 (e.g., lorazepam) to up to 3 weeks in one with
propriate agent can seem daunting. Critical differences can a longer T1/2 (e.g., clonazepam).
be found in these agents, however. Some agents, such as di- Panic disorder affects 2% to 4% of the general population.
azepam (Valium), are more lipophilic, entering the brain Average age of onset is 27 years; new onset is rare after age
more rapidly and igniting an effect promptly. Although this 45 years. There is a strong comorbidity with depression. The
may seem to be a desired therapeutic effect for severely anx- female-to-male ratio for panic disorder is approximately 1:1
ious patients, this rapid ignition can also be intoxicating. if seen without agoraphobia. Panic disorder with agoraphobia
More hydrophilic benzodiazepines, such as lorazepam, give is more common in women, however, with a ratio of 2:1. A
reasonable therapeutic effect while having a slower onset of strong family history of agoraphobia is often also reported.
action and tend to be less intoxicating. In addition, with a Diagnostic criteria for panic disorder include recurrent
highly lipophilic agent, excess is stored in body fat; this leaves and unexpected panic attacks and one or more of the panic
a large repository for the drug, resulting in a longer T1/2. attacks followed by at least one of the following: worry about
As with any drug, the T1/2 should be considered. Products an additional attack, pondering implications of attacks, or
such as diazepam and clonazepam (Klonopin®), with a long significant change of behavior related to attack. Panic attacks
T1/2, give sustained effect without periods of withdrawal. can occur with or without agoraphobia and should not be due
With drugs with a shorter T1/2, such as oxazepam (Serax), to a substance or medical condition or accounted for by
therapeutic gaps can occur. The use of drugs with a shorter another mental disorder.
T1/2 without active metabolites should be considered, how- Panic attack is central to panic disorder. This is a period of
ever, when treating elderly persons. intense fear or discomfort developing abruptly and peaking
One issue that needs to be considered when prescribing within 10 minutes with at least four characteristic symptoms
benzodiazepines is their abuse and misuse. Prescribers often present. Panic attack symptoms include palpitations, tachy-
hesitate to use these highly effective agents because of fear of cardia, sweating, trembling, shortness of breath, choking,
providing the patient with a potentially habituating drug with chest pain, chills, nausea, dizziness, and a sensation of dereal-
the possibility of needing increasing doses. In reality, psycho- ization and depersonalization. Additional symptoms include
logical dependence does occur occasionally, but careful pre- fear of losing control or dying, paresthesia, and hot flashes. In
scribing can help avoid this. addition to the characteristics mentioned, many individuals
Psychological benzodiazepine dependence is usually asso- with panic disorder have problems with alcohol abuse, depres-
ciated with a rapid onset agent, possibly giving a sensation of sion, dizziness, and chronic fatigue. Irritable bowel syndrome
intoxication. In addition, prescribing at dosing intervals be- is often found in patients with panic disorder.
yond the duration of action of the drug gives alternating peri- Because of the low abuse potential and favorable side-ef-
ods of drug effect and withdrawal. The perception of difference fect profile, SSRIs have become the initial treatment of choice
is significant and possibly perceived as a buildup of unpleasant for persons with panic disorder. SSRI use helps decrease the
anxiety followed by a period of relief or rescue provided by the number and severity of panic attacks and, to a lesser degree,
drug, with the cycle repeated with each drug dose. Using a ben- phobia and anxiety related to the attacks.
zodiazepine as an as-needed product increases the likelihood When using an SSRI for treating a patient with panic dis-
of abuse because this heightens the patient’s awareness of drug order, “start low, go slow, but get to goal” should guide ther-
versus no-drug state. Psychological benzodiazepine depend- apy. Individuals with panic disorder usually do not tolerate a
ency can be avoided by using a slow-onset product such as rapid induction or change in any therapy because of their
clonazepam that has a long T1/2. If using short-acting products, heightened sympathetic state. An agent with an early side-
the prescriber must give an adequate number of doses effect profile that the patient is likely to tolerate should be cho-
per day. If using on an as-needed basis, the prescriber should sen, such as a product that is less rather than more energizing
advise a maximal number of available or prescribed doses with a lower rate of insomnia, nervousness, and akathisia;
per week, such as three or four times per week, rather than such agents include paroxetine (Paxil), citalopram (Celexa) or
once or twice a day. Increasing tolerance to high therapeutic escitalopram (Lexapro®), but a more energizing SSRI such as
dose, usually at a level two to four times the prescribed level, fluoxetine (Prozac) is unlikely to be well tolerated. Also, SSRI
creates physical dependence on benzodiazepines. use can precipitate panic attacks with early use, but prevent
When taken alone in overdose, benzodiazepines have a these episodes after the full therapeutic effect is realized. TCAs
favorable toxicity profile. Sedation is enhanced, however, are occasionally used to treat panic disorder, recognizing this
when benzodiazepines are combined with alcohol and barbi- drug class’s limitation, including toxicity in overdose and
turates, leading to a potentially life-threatening condition. As adverse effect profile. Benzodiazepine use in panic disorder is
a result, accidental and intentional fatalities can occur. generally discouraged due to risk of habituation and abuse.
4074_Ch14_319-346 20/11/14 11:18 AM Page 343
Monoamine oxidase inhibitors are the most potent drugs venlafaxine to treat arousal symptoms and associated depres-
available for treating patients with panic disorder. Because of sion. Treatment can also include mirtazapine (for insomnia)
side effects and the need for dietary restriction while patients as well as a second-generation antipsychotic or mood stabi-
take the medications, their use is generally limited to individ- lizers. Benzodiazepines should be used with caution because
uals with treatment-resistant panic disorder. Consultation substance abuse is a common comorbid condition in patients
and care by a psychopharmacology team with experience in with PTSD. Carbamazepine (Tegretol) and valproic acid
prescribing these medications is recommended. (Depakote) have been used with some success in treating irri-
Posttraumatic stress disorder (PTSD) is a condition that tability, aggression, and impulsiveness. Clonidine (Catapres®)
occurs after a significant single event, such as a natural dis- and propranolol (Inderal®) can be helpful in minimizing hy-
aster, being the victim of a crime, or exposure to combat con- perarousal. Trazodone (Desyrel®) offers a nonaddicting option
ditions. It can also be precipitated by recurrent trauma, such to enhance sleep.
as serving in combat, living in a war-torn area, or domestic Patients often choose to treat mood disorder with herbal
abuse. Trauma can involve direct personal experience of an products, which are available over-the-counter in unlimited
event that involves actual or threatened death or serious in- supply. Although encouraging and facilitating patient self-
jury or witnessing an event that involves death, injury, or a care is an important part of the role of the NP, the use of
threat to the physical integrity of another person. Horror and herbal products should be approached with caution. Herbal
helplessness are expected emotions in response to a traumatic medications are considered nutritional supplements and are
life event for at least 1 month afterward. These emotions last not subject to the regulatory process common to prescription
significantly longer in patients with PTSD, however, and are and over-the-counter medications. As a result, quality control
coupled with intrusive recall of the event, numbing of emo- in their production may be lacking, leading to inconsistent
tions, detachment, hyperarousal, and impaired social and amounts of herbs per dose. In addition, when a patient takes
occupational function. When considering military personnel an herbal product to treat symptoms of anxiety and depres-
with PTSD, it should be noted that they do not always re- sion, he or she is self-medicating a potentially life-threatening
spond in the same manner as civilians, and criteria for “fear, disease. Using herbs with prescription medications can lead
helplessness, and horror” do not always apply. to problems with drug interactions or additive effects, such
Treatment of patients with PTSD requires an interdis- as when St. John’s wort is used concurrently with an SSRI.
ciplinary approach of expert providers. First-line pharma- The NP and patient need to be aware of the effects, efficacy,
cological intervention can include the use of an SSRI or and side-effect profiles of these products (Table 14–6).
TABLE 14-6
Over-the-Counter Herbal Products for Mood Disorders
Agent Mechanism of Action Comments
St. John’s wort Like MAOI-, SSRI-, TCA-like Compared with TCA, less anticholinergic effect, weight gain, less effi-
>10 active compounds cacy in more severe depression.
Compared with SSRI, similar potential for energizing such as fluoxetine,
similar efficacy in mild to moderate depression with limited study.
TID–QID dosing needed; 6–8 weeks before clinical effect. Prudent to
avoid concurrent use of SSRI, TCA, MAOI due to serotonin syndrome
risk. Potentially photosensitizing, peripheral neuropathy in high doses.
Capable of altering activity of CYP450 enzymes extensively involved
in drug metabolism, and thus may interact significantly with many
drugs. Can reduce serum levels of antiretrovirals (e.g., indinavir) and
cyclosporine. Use can reduce effectiveness of oral contraceptives.
Kava Action at GABA receptors Satisfactory response compared with placebo, low-dose oxazepam
similar to benzodiazepines (Serax).
Sedating, can potentiate effects of alcohol.
Cross-allergenic with pepper.
Hepatotoxicity risk with overdose, prolonged treatment, and/or
comedication.
Valerian root Action similar to 5%–10% with paradoxical stimulating effect.
benzodiazepines Available in aromatic tea, but weaker, with shorter duration of action.
Less drug hangover than with benzodiazepines.
DI SCUS SION SOURCES 119. When considering characteristics of the domestic vio-
Goldberg RJ. Practical Guide to the Care of the Psychiatric Patient, lence perpetrator, One of the best predictors of a sub-
ed. 3. St. Louis: Elsevier Health Sciences, 2007. sequent homicide of victims of domestic violence is
Department of Veteran Affairs, Department of Defense. VA/DoD which of the following?
clinical practice guideline for the management of posttraumatic A. history of perpetrator striking victim on the face
stress, 2010. www.healthquality.va.gov/ptsd/CPGSummaryFINAL with an open hand
MgmtofPTSDfinal021413.pdf, accessed 1/15/14. B. history of perpetrator attempting to strangle the
victim
C. perpetrator’s access to kitchen knives.
Interpersonal D. alcohol abuse history in the victim
Violence
111. You note that a 25-year-old woman has bruises
Answers
on her right shoulder. She states: “I fell up against
111. C. 114. False 117. True
the wall.” The bruises appear finger-shaped. She
112. C. 115. False 118. True
denies that another person injured her. What
113. False 116. False 119. B.
is your best choice of statement in response to
this? Interpersonal violence among family or household members
A. “Your bruises really look as if they were caused by (i.e., domestic violence) is found in all socioeconomic and
someone grabbing you.” ethnic groups. Because providers working with lower income
B. “Was this really an accident?” and certain ethnic groups are perhaps more vigilant about
C. “I notice the bruises are in the shape of a hand.” domestic violence, however, it often appears that this abuse
D. “How did you fall?” is more of a problem in certain groups.
112. Which of the following statements is true concerning Abuse can take numerous forms: psychological, financial,
domestic violence? emotional, and physical. Acts of violence are typically
A. It is found largely among people of lower socioeco- thought to be against the victim, but often include destruction
nomic status. of property, intimidation, and threats. A cycle of tension
B. The person in an abusive relationship usually building, including criticism, yelling, and threats followed by
seeks help. violence and then a quieter period of apologies and promises
C. Routine screening is indicated during to change, is often seen. This cycle usually accelerates over
pregnancy. time, however, with the violence being less predictable. Love
D. A predictable cycle of violent activity followed for the perpetrator, hope that things will change, and fear of
by a period of calm is the norm. the consequences of leaving the relationship help to keep the
victim in the relationship. These items also usually prevent
113 to 118. The following questions should be answered victims from coming forth and asking for help.
True or False. As with counseling and screening for other health prob-
113. Access to a firearm by a male perpetrator is asso- lems, using objective statements beginning with “I” is helpful.
ciated with increased risk of abuse toward When a patient denies that finger-shaped bruises are caused
women only in lower socioeconomic income by intentional injury by another person, the NP can simply
households. state what is seen. This statement reinforces the assessment of
abuse and allows the patient to offer more information. In a
114. The NP is in an ideal position to provide coun- situation in which a patient is verbally abused in the NP’s pres-
seling to both members of a couple involved in ence, the NP should reinforce his or her role as patient advo-
domestic violence, particularly if both members cate by stating that the behavior is unacceptable in the NP’s
of the couple are members of the NP’s practice presence. Some providers fear that this statement can possibly
panel. precipitate another episode of abuse; however, this is unlikely.
115. Women’s violence against male partners is Applying the BATHE model is helpful in framing the
as likely to result in serious injury as men’s problem and forming a therapeutic relationship and directing
violence toward women. intervention. Developed by Stuart and Lieberman, this model
provides a guide for gathering information while helping the
116. Interpersonal violence is uncommon in same- patient reflect on the issues at hand. The components of the
sex relationships. model are as follows:
117. Access to a firearm increases the risk for a • BATHE
completed suicide. • B—Background:
• How are things at home? At work? Has anything
118. Child abuse is present in about half of all homes changed? Good or bad? Anything you wish would
where partner mistreatment occurs. change?
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Female Reproductive
and Genitourinary
Systems 15
Contraception 5. Which of the following women is the best candidate for
progestin-only pill (POP) use?
1. Which of the following is a contraindication to estro- A. an 18-year-old woman who frequently forgets to take
gen/progestin-containing methods (combined oral prescribed medications
contraception [COC], patch [Ortho Evra], or ring B. a 28-year-old woman with multiple sexual
[NuvaRing])? partners
A. mother with a history of breast cancer C. a 32-year-old woman with adequately-controlled
B. personal history of hepatitis A at age 10 years hypertension
C. presence of factor V Leiden mutation D. a 26-year-old woman who wants to use the pill
D. cigarette smoking one pack per day in a 22-year-old to help “regulate” her menstrual cycle
2. A 22-year-old woman taking a 35-mcg ethinyl estradiol 6. The most common reasons for discontinuing oral
COC calls after forgetting to take her pills for 2 consecu- contraception use is breakthrough bleeding and:
tive days. She is 2 weeks into the pack. You advise A. nausea/vomiting.
her to: B. inconvenience of use.
A. take the last pill missed immediately, even if this C. cost.
means taking 2 pills today. D. high failure rate.
B. discard two pills and take two pills today. 7. A 38-year-old nulliparous woman who smokes two
C. discard the rest of the pack and start a new pack with and a half packs a day is in an “on-and-off” relationship.
the first day of her next menses. The woman presents seeking contraception. Which
D. continue taking one pill daily for the rest of of the following represents the most appropriate
the cycle. method?
3. When counseling a woman about COC use, you advise A. contraceptive ring (NuvaRing)
that: B. COC
A. long-term use of COC is discouraged because the C. contraceptive patch (Ortho Evra)
body needs a “rest” from birth control pills from D. vaginal diaphragm
time to time. 8. Due to an increased risk of blood clots, an alternative
B. fertility is often delayed for many months after to the contraceptive ring (NuvaRing) or patch
discontinuation of COC. (Ortho Evra) is preferred in all of the following
C. there is an increase in the rate of breast cancer after women except:
protracted use of COC. A. a 42-year-old nulliparous woman.
D. premenstrual syndrome symptoms are often B. 31-year-old woman with history of naturally
improved with use of COC. occurring multiple gestation pregnancy
4. Noncontraceptive benefits of COC use include a C. 28-year-old who smokes one pack per day.
decrease in all of the following except: D. 33-year-old woman with a family history of venous
A. iron-deficiency anemia. thrombosis.
B. pelvic inflammatory disease (PID).
C. cervicitis.
D. ovarian cancer.
347
4074_Ch15_347-372 20/11/14 11:19 AM Page 348
9. Which of the following statements is true concerning 21. a 33-year-old woman with low-grade squamous
vaginal diaphragm use? intraepithelial lesions noted on Pap test
A. When in place, the woman is aware that the di-
22. As you prescribe COC containing the progestin
aphragm fits snugly against the vaginal walls.
drospirenone (Loryna, Ocella, Vestura, Yasmin, Yaz),
B. This is a suitable form of contraception for women
you offer the following advice:
with recurrent urinary tract infection.
A. “Always take this pill on a full stomach.”
C. After insertion, the cervix should be smoothly covered.
B. “You should not take acetaminophen when using
D. The device should be removed within 2 hours of
this birth control pill.”
coitus to minimize the risk of infection.
C. “Avoid using potassium-containing salt substitutes.”
10. According to the U.S. Medical Eligibility Criteria for D. “You will likely notice that premenstrual
Contraception Use, which of the following is a clinical syndrome symptoms might become worse.”
condition in which use of a copper-containing IUD
23. A 26-year-old mother who breastfeeds her 10-month-
should be approached with caution?
old child queries about contraceptives. In counseling
A. uncomplicated valvular heart disease
her on the use of the progestin-only pill (POP), you
B. AIDS-defining illness
mention all of the following except:
C. hypertension
A. the pill is taken every day.
D. dysmenorrhea
B. POP is a more effective contraceptive than COC.
11. Which of the following is the most appropriate re- C. POP does not alter the quality or quantity of breast
sponse to a 27-year-old woman who is taking pheny- milk.
toin (Dilantin) for the treatment of a seizure disorder D. POP is associated with bleeding irregularity, ranging
and is requesting hormonal contraception? from prolonged flow to amenorrhea.
A. “A barrier method would be the preferable choice.”
24. By using a diaphragm with spermicide nonoxynol-9
B. “COC is the best option.”
during sexual intercourse, a woman is likely at
C. “Depo-Provera (medroxyprogesterone acetate
increased risk for:
in a depot injection [DMPA]) use will likely not
A. cervical stenosis.
interact with your seizure medication.”
B. urinary tract infection.
D. “Copper-containing IUD use is contraindicated.”
C. increased perivaginal lactobacilli colonization.
12. Which of the following is commonly found after 1 year D. ovarian malignancy.
of using DMPA (Depo-Provera)?
25. With the use of a levonorgestrel intrauterine system
A. weight gain
(Mirena), which one of the following is normally noted?
B. hypermenorrhea
A. endometrial hyperplasia
C. acne
B. hypermenorrhea
D. rapid return of fertility when discontinued
C. increase in PID rates
13 to 21. The following questions should be answered by D. reduction in menstrual flow
responding yes or no.
26. The reduction in free androgens noted in a woman
According to the U.S. Medical Eligibility Criteria for Con-
using COC can yield an improvement in:
traception Use, who is a category 1 or 2 COC candidate?
A. cycle control.
13. a 22-year-old woman who smokes one pack per day B. acne vulgaris.
C. breast tenderness.
14. a 29-year-old woman with PID
D. rheumatoid arthritis.
15. a 45-year-old woman with tension-type headache
27. With DMPA in depot injection (Depo-Provera), the
16. a 32-year-old woman breastfeeding a 6-month-old recommended length of use is usually:
infant A. less than 1 year.
B. no more than 2 years.
17. a 28-year-old woman with type 1 diabetes mellitus
C. as long as the woman desires this form of contraception.
18 to 21. According to the U.S. Medical Eligibility Criteria D. as determined by her lipid response to the
for Contraception Use, who is a candidate for a copper- medication.
containing intrauterine device (IUD)?
28. Irregular bleeding associated with DMPA (Depo-Provera)
18. a 45-year-old woman with fibroids with uterine can be minimized with the use of all of the following
cavity distortion except:
A. acetaminophen.
19. a 33-year-old woman who smokes two packs per day
B. ibuprofen.
20. a 25-year-old woman with hypertension C. naproxen sodium.
D. estrogen supplements.
4074_Ch15_347-372 20/11/14 11:19 AM Page 349
29. When can a woman safely conceive after discontinuing perfect use and 50 pregnancies per 1000 women with typical
COC use? use. The patch (Ortho Evra) and ring (NuvaRing) are also
A. immediately highly effective forms of contraception containing estrogen
B. after 1 to 2 months and progestin with reported rates of 99% efficacy when used
C. after 3 to 4 months as directed.
D. after 5 to 6 months Contraceptive effect is achieved through the action of the
COC, patch, and ring progestin and estrogen components.
30. When prescribing the contraceptive patch
Progestational effects help to inhibit ovulation by suppressing
(Ortho Evra) or vaginal ring (NuvaRing), the
luteinizing hormone (LH), thickening endocervical mucus,
NP considers that:
and hampering implantation by endometrial atrophy.
A. these are progestin-only products.
Through estrogenic effects, ovulation is inhibited by suppres-
B. candidates include women who have difficulty
sion of follicle-stimulating hormone (FSH) and LH and by
remembering to take a daily pill.
alteration of endometrial cellular structure.
C. there is significant drug interactions with both
When COC, ring, or patch is discontinued, fertility usually
products.
returns promptly. Contrary to common belief, there is no
D. contraceptive efficacy is less than with COC.
need to delay conception after discontinuing these contra-
31 to 33. Answer the following questions true or false. ceptive forms; prolonged combined hormonal contraceptive
use is not associated with future infertility or other health
31. The use of combined oral contraception
problems.
(COC) reduces menstrual volume by approxi-
Noncontraceptive benefits of combined hormonal con-
mately 60%, thereby reducing the risk of iron
traception include lower rates of benign breast tumors and
deficiency anemia.
dysmenorrhea. Menstrual volume is reduced by about 60%,
32. Nausea with oral contraceptive use can be resulting in decreased rates of iron deficiency anemia. De-
minimized by taking the pill on an empty creased rates of endometrial, ovarian, and colon cancers
stomach. are particularly noted among long-term users (more than
5 years). In part because of the endometrial thinning, COC
33. Calcium and vitamin D supplementation is
can be safely used for an extended time without withdrawal,
recommended for those taking DMPA (Depo-
which is an attractive option for a woman who does not wish
Provera) injections to minimize the risk of a
to menstruate or who has a health problem that is exacer-
loss in bone density.
bated by menstruation. Although COC is not protective
against sexually transmitted infections (STIs), COC users
have decreased frequency of pelvic inflammatory disease
Answers (PID), which results from thickened endocervical mucus;
this results in a lower rate of future ectopic pregnancy. De-
1. C. 14. Yes 23. B.
creased rates of acne, hirsutism, and ovarian cyst, as well as
2. A. 15. Yes 24. B.
reduction in premenstrual syndrome and improvement in
3. D. 16. Yes 25. D.
rheumatoid arthritis symptoms are also noted among COC
4. C. 17. Yes, in the 26. B.
users. Improvement in acne is usually noted after about
5. C. absence of 27. B.
3 months of use, whereas improvement in hirsutism usually
6. B. advanced 28. A.
takes about 6 months; these improvements persist while the
7. D. vascular 29. A.
woman is taking COC and are usually reversible when COC
8. B. disease 30. B.
is discontinued. COC is also a highly effective family plan-
9. C. 18. No 31. T
ning option for a wide variety of women with chronic health
10. B. 19. Yes 32. F
problems (Table 15–1).
11. C. 20. Yes 33. T
The highest dropout rates with COC and progestin-only
12. A. 21. Yes
pill (POP) use are in the first 3 months of use. The most fre-
13. Yes 22. C.
quently mentioned reasons are breakthrough bleeding (BTB)
and inconvenience of use. Although BTB is bothersome, it is
Despite the availability of numerous methods of highly re- not harmful and does not indicate lesser contraceptive ben-
liable contraception, nearly half of all pregnancies in the efit. BTB can be minimized by taking COC or POP within
United States are unplanned. Rates of continued contra- the same 4-hour period every day. Cigarette smoking in-
ception use vary greatly according to the method. Helping creases the likelihood of BTB and should be discouraged.
a woman choose an effective and acceptable form of family BTB rate increases dramatically when pills are missed. Advice
planning is an important part of providing healthcare. about what to do in the event of missed pills is an important
Available for more than 5 decades, COC has been used part of providing contraceptive care (Table 15–2). Compared
by millions of women. This highly reliable form of contra- with COC use, BTB rates with the use of the contraceptive
ception usually results in 1 pregnancy per 1000 women with ring and patch are usually lower after the first few weeks of
4074_Ch15_347-372 20/11/14 11:19 AM Page 350
TABLE 15–1
Summary of United States Medical Eligibility Criteria (USMEC) for Contraception Use:
Precautions for Use of Combined Hormonal Contraceptive
Combined hormonal contraceptives (CHCs) include low-dose (<35ug ethinyl estradiol [EE]) combined oral contraceptives
(COCs), combined hormonal patch (Ortho Evra), and combined vaginal ring (NuvaRing): Summary of US Medical Eligibility
Criteria for Contraceptive Use
Category 4: Category 3: Exercise
Use Represents Caution: Theoretical Category 2:
Unacceptable or Proven Risks Usually Advantages Category 1:
Health Risk Outweigh Benefit Outweigh Risk No Restriction
• Venous 21-42 days postpartum, with • Age ≥40 • Age menarche up to age 40
thromboembolism other risk factors for VTE (such • 21–42 days postpar- • Postpartum ≥42 days with-
• CHD, CVA as age ≥35 years, previous tum, without risk fac- out breastfeeding
• Structural heart VTE, thrombophilia, immobil- tors for VTE • Post therapeutic or sponta-
disease ity, transfusion at delivery, BMI • Cigarette smoking neous abortion
• Breast cancer ≥30 mg/kg2, postpartum hem- < age 35 • History gestational DM
• Pregnancy orrhage, postcesarean deliv- • Severe headache with • Varicose veins
• Postpartum ery, preeclampsia, or smoking oral contraceptive use • Mild headache
<21 days or with lactation) • DM type 1 or type 2 • PID, STI history
• Acute hepatitis • Undiagnosed vaginal without vascular • HIV
• Hepatic adenoma bleeding disease • Benign breast disease
• Migraine with • Age ≥35 and smoking less • Major surgery without • Family history breast,
aura (any age) than 15 cigarettes per day immobilization cervical, ovarian cancer
• Migraine without • History breast cancer but no • Sickle cell disease • Cervical ectropion
aura and age recurrence in past 5 yr • Hypertension (140/100– • Uterine fibroids
≥35 years (for • Interacting drugs (select 159/109 mm Hg) • Past history ectopic
continuation) antiepileptics such as pheny- • Undiagnosed breast pregnancy
• Major surgery toin, carbamazepine, mass • Thyroid disease
with prolonged valproate) • Cervical cancer • Depression
mobilization • Gallbladder disease • Age ≥40 • Minor surgery without
• Age ≥35 and • DM type 1 or type 2 • Nonadherence factors mobilization
smoking ≥20 years’ duration or • Family history lipid • Menorrhagia
≥15 cigarettes with vascular disease disorders • Irregular menses
per day • Past history breast cancer, • Family history • History gestational DM
• Hypertension no current disease for 5 yr premature MI • Ovarian or endometrial
(≥160/≥100 mm Hg • Hypertension adequately • BMI ≥30 kg/m2 cancer
or with vascular controlled without vascular • Lactation ≥42 days • Bariatric surgery with
disease) disease without risk for VTE restrictive procedure
• Known thrombotic • Untreated systolic • Migraine without aura (i.e., laparoscopic band
mutations (factor 140–159 mm Hg or and age <35 years for procedure)
V Leiden, diastolic 90–99 Hg initiation • Broad spectrum antimicro-
prothrombin • Bariatric surgery with mal- • Asymptomatic gall bial and antifungal use
mutations, absorptive procedures bladder disease
protein S, C, or (i.e., gastric bypass) for
antithrombin COC only
deficiency) • Migraine without aura and
age ≥35 years (for initiation)
• Rifampin or rifabutin
therapy
BMI—body mass index; CHD—congestive heart disease; CVA—cerebrovascular disease; DM—diabetes mellitus;
MI—myocardial infarction.
Source: Centers for Disease Control and Prevention. United States Medical Eligibility Criteria (USMEC) for
Contraception Use. www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm.
4074_Ch15_347-372 20/11/14 11:19 AM Page 351
TABLE 15–2
Missed Combined Oral Contraceptive Pill Advice
Missed Pill Situation Required Action Comment
If pill missed within Take today’s pills immediately. No additional or emergency contracep-
12 hours of the time tion needed; continue with the rest of
that should have been the pack.
taken
If 1 pill missed for more Take today’s pills immediately. No additional or emergency contracep-
than 12 hours but only tion needed; continue with the rest
1 pill missed in a day. of the pack.
If more than 1 pill missed Take today’s pill and the last forgotten pill Encourage use of EC if she has had
today (2 tablets in 1 day). unprotected intercourse in the prior
If she has a least 7 active pills in the pack, she 7 days.
has two options:
1. Take the rest of the active pills, skip the
placebo pills and start the next pack of
pills without interruption, and use
condoms or abstain for 7 days.
Or
2. Take the pills as in the pack and use con-
doms or abstinence until she has taken 7
of the pills in the pack.
EC—emergency contraception.
Source: Nelson AL, Cwiak C. Combined oral contraceptives (COCs). In: Hatcher RA, Trussell J, Nelson AL,
Cates Jr W, Kowal D, Policar MS (eds). Contraceptive Technology, ed. 20. New York: Ardent Media, Inc.;
2011, pp. 310–311.
use. This difference is largely due to the fact that the patch of barrier methods, IUDs, or levonorgestrel-containing in-
and ring do not require a daily action on the user’s part, and trauterine systems (Mirena) does not interfere with AEDs
adherence is significantly better. Therefore, the patch and ring and has no effect on seizure threshold.
may be preferable for women who are not as diligent in tak- The progestins used in most COC, patch, and ring for-
ing a pill every day. The patch and ring also contain a lower mulations are testosterone derivatives. Drospirenone,
dose of estrogen and progestin than COC, which can found in the COC products Yasmin and Yaz, is an analogue
result in fewer systemic adverse effects (e.g., headaches, breast of an aldosterone antagonist and has potassium-sparing
tenderness). qualities. Drospirenone should be used with caution in
Nausea with COC, patch, ring, and hormone therapy is a hepatic or renal dysfunction or with concomitant use of
commonly reported adverse effect. Nausea is usually a tran- angiotensin receptor blocker, angiotensin-converting en-
sient problem noted in the first months of use and can be zyme inhibitor, salt substitute, or potassium-sparing di-
minimized by taking the medication with food or at bedtime. uretic. Although POP inconsistently suppresses ovulation,
If vomiting occurs within 2 hours of taking COC, the dose this form of contraception likely works through thickening
should be retaken. of endocervical mucus and through the alteration of the
COC hormones interact with a few drugs. Interaction is endometrium. POP use offers certain advantages and dis-
noted, however, with many antiepileptic drugs (AEDs), in- advantages compared with COC. With failure rates of
cluding phenytoin, carbamazepine, phenobarbital, and prim- up to 13%, POP is a less effective contraceptive than COC.
idone, potentially causing a reduction in therapeutic levels of The nausea rate with its use is significantly lower than with
these important medications. The BTB rate is greater in COC use because of the lack of estrogen. POPs are taken
women using COC, patch, and ring and AEDs partly because daily, a schedule many women find more convenient than
of more rapid metabolism of estrogen. A woman with a the typically 3-weeks-on/1-week-off schedule with COC.
seizure disorder who wishes to use hormonal contraception POP must be used daily, however, for maximal efficacy. For
is likely to have a reduction in frequency and severity of lactating women who wish to use an oral hormonal con-
seizures while using DMPA (Depo-Provera) because prog- traceptive, POP is highly effective and does not alter the
estin use has long been noted to be protective against seizures. quality or quantity of breast milk. One significant disad-
In addition, DMPA does not appear to interact with AEDs. vantage with POP use is bleeding irregularity, ranging from
Levonorgestrel implants appear to have the same effect. Use prolonged flow to amenorrhea.
4074_Ch15_347-372 20/11/14 11:19 AM Page 352
The contraceptive patch (Ortho Evra) and contraceptive Standard IUDs, such as the copper-containing ParaGard
intravaginal ring (NuvaRing) contain estrogen and prog- (Copper T 380A), are an effective form of contraception with
estin as a birth control method in a nonoral form. Both of a failure rate of 0.5% to 2.2%. The mechanism of contracep-
these methods have the advantage of infrequent dosing, tive action is not entirely understood, but it is unlikely that
with a new patch needed once a week and a new ring these are abortifacients. There is often an increase in men-
needed every 3 weeks. With proper use, contraceptive effi- strual bleeding and upper reproductive tract infection with
cacy is similar to that of COC. Observed contraceptive fail- their use, and IUDs are not widely used, in part because of
ure rates are usually lower with the patch and ring likely the incorrect perception of the healthcare provider that few
because of greater ease of use. Adverse effects and con- women can safely use this highly effective contraceptive
traindications to patch and ring use are similar to those of method (Table 15–3). Mirena is a levonorgestrel-containing
COC use. Women who dislike or forget to take a daily pill intrauterine system of drug delivery that produces marked
often welcome the opportunity to use the patch or ring. endometrial atrophy. As a result, about 50% of Mirena users
Another potential adverse effect associated with the use of are amenorrheic at the end of 2 years of use. Thickened en-
the patch and ring is an increased risk of blood clots. The docervical mucus is also noted, which limits the ascent of in-
FDA issued a warning regarding a higher risk of venous fection into the upper reproductive tract and minimizes PID
thromboembolisms (VTEs) with patch and ring use com- risk. This is a particularly helpful method of contraception
pared with standard oral contraceptives. Therefore, it is for women with menorrhagia.
recommended that an alternative contraceptive be used in The diaphragm, a barrier method of contraception, is
women at higher risk of blood clots, including those over placed in the vagina before intercourse. This device, which
35 years old, obese women, smokers, or those with a per- has an effectiveness rate of 88% to 94%, should be used in
sonal or family history of venous thrombosis. conjunction with a spermicide and removed no sooner than
DMPA (Depo-Provera), given every 90 days, is a highly 6 hours after coitus. When properly fitted and in the appro-
reliable form of contraception (99.7% efficacy). DMPA is priate position, the device should rest snugly in the vagina
best suited for women who do not wish a pregnancy for at but without tension against the vaginal walls. The woman and
least 18 months because resumption of fertility is fre- her partner should be unaware of the diaphragm’s presence.
quently delayed 6 to 12 months. When the injection is If either partner can feel the diaphragm, the device is either
given within the first few days of menses, the contraceptive the wrong size or not properly inserted. Because a diaphragm
effect is immediate. When it is started 5 days after the onset should always be used with a spermicide, a woman with a his-
of menses, a backup method of contraception should be tory of recurrent urinary tract infection (UTI) is not an ideal
used for 1 week. Depo-Provera may be started immediately candidate for diaphragm use. Although the thought behind
postpartum if the woman is not breastfeeding and initiated this long-held advice is that the diaphragm increases UTI risk
3 to 6 weeks postpartum if she is breastfeeding. Earlier use as a result of potential pressure on the woman’s lower urinary
can diminish quantity but not quality of breast milk. Irreg- tract, the risk more likely arises from the concurrent use of a
ular bleeding, a common problem during the first few spermicide. A woman who is exposed to the spermicide
months of DMPA injection use, can be minimized by the nonoxynol-9, either through vaginal use or with a male part-
use of a prostaglandin inhibitor such as ibuprofen, 400 mg ner who uses condoms with this spermicide, is likely at in-
tid, or naproxen sodium, 375 to 540 mg bid, for 3 to 5 days. creased risk of UTI. The proposed mechanism of this risk is
Estrogen supplements, such as a 0.1-mg estrogen patch the antibacterial effect of the spermicide, which is to reduce
used for 7 to 10 days, can also be helpful but are seldom lactobacilli, a normal component of the periurethral flora.
needed to manage this bothersome, but not dangerous, ad- Lactobacilli produce hydrogen peroxide and lactic acid,
verse effect. After 1 year of DMPA use, 30% to 50% of providing the periurethral area and vagina with a pH that
women have amenorrhea. According to observations from inhibits bacterial growth and blocks potential sites of attach-
limited study, bone density is occasionally noted to be ment and is toxic to uropathogens.
reduced in women using DMPA. This condition is largely
reversible, however, when the medication is discontinued. D I S C U SSI O N S O U R C E S
The U.S. Food and Drug Administration (FDA) has as- Cates W, Harwood B. Vaginal barriers and spermicides. In: Hatcher
signed a boxed warning to DMPA, highlighting that pro- RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (eds).
longed use can result in the loss of bone density and Contraceptive Technology, ed 20. New York: Ardent Media, Inc.;
2011, pp. 391–408.
recommending that the medication not be used for more
Dean G, Bimla Schwarz E. Intrauterine contraceptives (IUCs). In:
than 2 years unless other methods cannot be used; bone Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar
density seems to normalize quickly with discontinuation MS (eds). Contraceptive Technology, ed 20. New York: Ardent
of the medication. Calcium supplementation, at 1000 to Media, Inc.; 2011, pp. 151 and 154.
1500 mg/d, weight-bearing exercise, and vitamin D supple- Raymond EG. Progestin-only pills. In: Hatcher RA, Trussell J,
mentation should be recommended; this advice is helpful Nelson AL, Cates W, Kowal D, Policar MS (eds). Contraceptive
for general bone health. Technology, ed. 20. New York: Ardent Media, Inc.; 2011, p. 240.
4074_Ch15_347-372 20/11/14 11:19 AM Page 353
TABLE 15–3
Summary of the United States Medical Eligibility Criteria (USMEC) for Contraception Use:
Precautions for the Use of Intrauterine Devices
Summary of Classification for Use of Intrauterine Devices, Including LNG-IUS (Mirena, Skyla) and Cu-IUD (Paragard)
Category 4: Category 3: Exercise
Use Represents Caution: Theoretical Category 2:
Unacceptable or Proven Risk Usually Advantages Category 1:
Health Risk Outweigh Benefit Outweigh Risk No Restriction
• Current PID (within • AIDS-defining illness • High risk for HIV • Immediately post first-
3 mo) • Cirrhosis with severe • HIV infection trimester therapeutic
• Current purulent decompensation • Age less than 20 years abortion
cervicitis or • Immediately post first- • Parous
chlamydia infection trimester therapeutic • Hypertension
or gonorrhea abortion • Vascular disease
• Unexplained vaginal • Nulliparous • Uncomplicated valvular
bleeding • Complicated valvular heart disease
• Cervical cancer, heart disease • Cervical intraepithelial
awaiting treatment • Severe dysmenorrhea neoplasia
• Uterine fibroids • Uterine fibroids without
with distortion of distortion of uterine cavity
uterine cavity • Postpartum > 4 weeks
• Positive antiphospholipids
(LNG-IUS)
Source: Centers for Disease Control and Prevention. United States Medical Eligibility Criteria (USMEC) for
Contraception Use, 2010 (updated 2012). www.cdc.gov/reproductivehealth/unintendedpregnancy/
usmec.htm.
Trussell J, Guthrie KA. Choosing a contraceptive: Efficacy, safety, Centers for Disease Control and Prevention. United States Medical
and personal considerations. In: Hatcher RA, Trussell J, Eligibility Criteria (USMEC) for Contraception Use, 2012.
Nelson AL, Cates W, Kowal D, Policar MS (eds). Contraceptive www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.
Technology, ed. 20. New York: Ardent Media, Inc.; 2011, htm, accessed 8/1/13.
pp. 50 and 65.
Bartz D, Goldberg AB. Injectable contraceptives. In: Hatcher RA,
Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (eds). Emergency
Contraceptive Technology, ed. 20. New York: Ardent Media, Inc.;
2011, pp. 213, 215, and 221. Contraception
Cates W, Harwood B. Vaginal barriers and spermicides. In: Hatcher
RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (eds). 34. An 18-year-old woman requests emergency contracep-
Contraceptive Technology, ed. 20. New York: Ardent Media, Inc.; tion after having unprotected vaginal intercourse ap-
2011, pp. 394 and 400. proximately 18 hours ago. Today is day 12 of her
Dean G, Bimla Schwarz E. Intrauterine contraceptives (IUCs). In: normally 27- to 29-day menstrual cycle and she has no
Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar contraindications to the use of any currently available
MS (eds). Contraceptive Technology, ed. 20. New York: Ardent forms of emergency contraception. You advise her that:
Media, Inc.; 2011, p. 158. A. emergency hormonal contraception use reduces the
Nelson AL, Cwiak C. Combined oral contraceptives (COCs). In:
risk of pregnancy by approximately 33%.
Hatcher RA, Trussell J, Nelson AL, Cates Jr W, Kowal D, Policar
MS (eds). Contraceptive Technology, ed. 20. New York: Ardent
B. all forms of emergency contraception must be used
Media, Inc.; 2011, pp. 264, 267, 282, 288, 308, 309, and 332. within 12 hours after unprotected intercourse.
Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety, C. the likelihood of conception is minimal.
and personal considerations. In: Hatcher RA, Trussell J, Nelson D. insertion of a copper-containing IUD offers a
AL, Cates W, Kowal D, Policar MS (eds). Contraceptive Technol- effective form of emergency and ongoing
ogy, ed. 20. New York: Ardent Media, Inc.; 2011, p. 65. contraception.
4074_Ch15_347-372 20/11/14 11:19 AM Page 354
35. Which of the following is likely not among the pro- As previously mentioned, nearly half of all pregnancies are un-
posed mechanisms of action of all forms of oral planned. Emergency contraception, used after coitus to mini-
emergency contraception? mize the risk of unintended pregnancy when a contraceptive
A. inhibits ovulation method fails or is not used, is an effective method of minimiz-
B. acts as an abortifacient ing the number of unintended pregnancies (Box 15–1). An
C. slows sperm transport estimated 800,000 annual pregnancy terminations could be
D. slows ovum transport
36. A 24-year-old woman who requests emergency contra-
ception pills wants to know the effects if pregnancy Box 15–1
does occur. You respond that there is the risk of
increased rate of:
Emergency Hormonal
A. spontaneous abortion. Contraception: Indications
B. birth defects. and Mechanism of Action
C. placental abruption.
Emergency Contraception
D. none of the above.
Mechanism of Action
37. In contrast to progestin-only emergency contraception, with Levonorgestrel (Plan
a possible mechanism of action of ulipristal is: Candidates for B, Plan B One Step, Next
A. inhibiting embryo implantation. Emergency Choice), or Ulipristal
B. impairing sperm transport. Contraception (ella®) Use
C. through spontaneous abortion. Any time unprotected Depending on time taken
D. impairing ovum transport. sexual intercourse during menstrual cycle
occurs including ■ Inhibit or delay ovulation
38. You see a 34-year-old woman who reports having un-
potential method (most likely effect)
protected sexual intercourse 4 days ago and requests
failure (e.g., late for ■ Inhibit tubal transport of
emergency contraception. She has a recent history of
or missed pills, late egg or sperm
gonorrhea that was treated successfully. The most
for DMPA, dislodged ■ Interfere with fertilization
acceptable and effective option in this clinical
or misplaced ■ Possible effect on
scenario is:
diaphragm, endometrium:
A. progestin-only emergency contraception.
condom break or ■ With levonorgestrel
B. ulipristal.
slippage, use as emergency con-
C. copper-containing IUD.
expelled IUD) traception, minimal
D. nothing, as 4 days is too long for emergency contra-
to no alteration to
ception to be effective.
endometrium, there-
39. Which of the following statements is false? fore unlikely to inhibit
A. Progestin-only emergency contraception can be implantation of a
taken as one dose or two doses. fertilized egg.
B. Ulipristal is available by prescription only. ■ With ulipristal use as
C. Progestin-only emergency contraception is available emergency contracep-
OTC for women 17 years old and older. tion, changes in the
D. Ulipristal is taken in two doses 12 hours apart. endometrium can
potentially alter likeli-
40. A woman who has used emergency contraception pills
hood of fertilized egg
should be advised that if she does not have a normal
implantation.
menstrual period within _____ weeks, a pregnancy test
Unlikely mechanism of action
should be obtained.
■ Emergency hormonal
A. 1 to 2
contraception use results
B. 2 to 3
in minimal to no alter-
C. 3 to 4
ation to endometrium
D. 4 to 5
and is unlikely to inhibit
implantation of a fertil-
ized egg
Answers
Source: Trussell J, Bimla Schwarz E. Emergency contraception. In:
34. D. 37. A. 39. D. Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (eds).
35. B. 38. B. 40. C. Contraceptive Technology, ed. 20. New York: Ardent Media, Inc.;
36. D. 2011, pp. 113–145.
4074_Ch15_347-372 20/11/14 11:19 AM Page 355
46. For a woman with bothersome hot flashes who cannot 54. Which of the following is likely to be noted with
take HT, alternative options with demonstrated efficacy short-term (less than 1 to 2 years) HT use in a post-
and limited adverse effects include the use of all of the menopausal woman?
following except: A. reduction in dementia risk
A. venlafaxine. B. significant increase in breast cancer risk
B. sertraline. C. minimized hot flashes.
C. gabapentin. D. increase in cardiovascular risk
D. clonidine.
55. Which body area has the greatest concentration of
47. Absolute contraindications to postmenopausal estrogen receptors?
HT include: A. vulva
A. unexplained vaginal bleeding. B. vascular bed
B. seizure disorder. C. heart
C. dyslipidemia. D. brain
D. migraine headache.
56. When counseling a 46-year-old woman who is experi-
48. In advising a perimenopausal woman about HT, you encing debilitating hot flashes, you advise all of the
consider that it may: following regarding higher and lower dose hormone
A. reduce the risk of venous thrombotic events. replacement therapy (HT) except:
B. significantly reduce serum triglyceride levels. A. current clinical guidelines recommend using the
C. worsen hypertension in most women. lowest effective dose possible.
D. help preserve bone density. B. higher-dose HT will relieve hot flashes faster than
lower-dose regimens.
49. Postmenopausal HT used for use can result in:
C. lower-dose HT is better tolerated than higher-
A. a reduction in the rate of cardiovascular disease.
dose HT.
B. an increase in the rate of rheumatoid arthritis.
D. the duration of lower-dose HT is usually shorter
C. a reduction in the frequency and severity of
than that of higher-dose regimens.
vasomotor symptoms.
D. a disturbance in sleep patterns. 57. You see a 45-year-old woman who is considering HT.
She has a family history of cervical dysplasia, hyperlipi-
50. The progestin component of HT is given to:
demia, and VTE. You advise her on all of the following
A. counteract the negative lipid effects of estrogen.
except:
B. minimize endometrial hyperplasia.
A. the use of progestin can minimize the risk of en-
C. help with vaginal atrophy symptoms.
dometrial cancer for a woman on HT and who has
D. prolong ovarian activity.
not had a hysterectomy.
51. Concerning selective estrogen receptor modulator ther- B. supplemental estrogen should be avoided in women
apy such as raloxifene (Evista), which of the following who are at high risk of breast cancer or uterine
statements is correct? cancer.
A. Concurrent progestin opposition is needed. C. supplemental estrogen should be avoided in
B. Hot flashes are reduced in frequency and severity. women who are at high risk of cardiovascular
C. Use is contraindicated when a woman has a history disease.
of breast cancer. D. short-term studies demonstrate that oral HT is
D. Osteoporosis risk is reduced with use. associated with lower thromboembolic risk than
transdermal forms of HT.
52. During perimenopause, which of the following is likely
to be noted? 58. Examples of phytoestrogens include all of the following
A. Symptoms are most likely in the week before the except:
onset of the menses. A. red clover.
B. The length of the perimenopausal period is predictable. B. ginseng.
C. Symptoms are less severe in women who smoke. C. vitamin E.
D. Hot flashes are uncommon. D. soy products.
53. A 48-year-old woman complains of increased fre- 59. The typical HT regimen contains ______ or less of the
quency and severity of hot flashes. Her last menses estrogen dose of COC.
occurred 6 months ago. You would expect all of the fol- A. one-eighth
lowing laboratory findings except: B. one-fourth
A. increased levels of LH. C. one-half
B. elevated levels of testosterone. D. three-fourths
C. reduced levels of estradiol.
D. reduced levels of progesterone.
4074_Ch15_347-372 20/11/14 11:19 AM Page 357
60. For the woman with a history of DVT who is having A woman’s life is characterized by a series of shifts: first, a
significant vasomotor symptoms, which of the follow- woman transitions to the reproductive years, then to the pre-
ing can be can be used for symptom management? menopausal period, and then to the menopausal and post-
A. 17- 17β-estradiol patch menopausal years. Each transition is normal, expected, and
B. drospirenone not a disease state. Perimenopause and menopause are often
C. estrone. symptom-producing events, however.
D. paroxetine. Perimenopause is the time surrounding menopause; its
onset is marked by the beginning symptoms of menopause
61. Long term calcium supplementation is recommended
and ends with the cessation of menses. The average age of
in postmenopausal women as its use reduces the risk of
onset of perimenopause is 40 to 45 years; it occurs earlier in
fracture by approximately:
cigarette smokers. Perimenopause lasts an average of 4 years
A. 25%.
but can range from a few months to 10 years. Menopause,
B. 50%.
when the final menstrual period occurs, marks another tran-
C. 65%.
sition in a woman’s reproductive life. By definition, a woman
D. 80%.
is in menopause when she has had no naturally occurring
62. In postmenopausal women, a major benefit from the menstrual period for 12 months. The average age for a North
use of topical or local estrogen is: American woman at menopause is 51.3 years, with some
A. decreased rate of breast cancer. women living one-third of their lives after this time.
B. reduced risk of recurrent UTIs. During perimenopause, menstrual irregularity is common,
C. reduced risk of type 2 diabetes. with the interval between periods becoming longer or shorter
D. increased levels of androgens. and flow becoming heavier or lighter. Ovulation becomes
more erratic, but pregnancy is still possible. Hot flashes and
63. When reviewing the use of nutritional supplements for
sleep problems are usually worse in the week before the
the management of menopausal symptoms, the NP
menses and are reported by approximately 65% to 75% of
considers that:
women during perimenopause. During this stage, estrogen
A. few high-quality studies support the use of these
levels are usually normal, but FSH levels are elevated. As men-
products.
tioned, the woman often notes hot flashes or flushes during
B. the use of these products is consistently reported to
the week before the onset of the menses, a time when hor-
be helpful.
monal shifts are most dramatic. Because most women associ-
C. the products can be safely used as long as blood hor-
ate menopause symptoms with irregular or absent menstrual
mone levels are carefully evaluated.
bleeding, these perimenopausal symptoms can be confusing
D. the use of these products is associated with a greater
as the woman is menstruating on a regular basis. Although
reduction in menopausal symptoms than with pre-
low estrogen levels have often been implicated as the cause of
scription HT.
perimenopausal symptoms, the shifting levels of multiple bi-
64. Which of the following statements is true? ological substances is likely implicated.
A. Many over-the-counter progesterone creams As the menopausal period progresses, LH and FSH levels
contain sterols that the human body is unable increase dramatically as the anterior lobe of the pituitary sends
to use. out an abundance of these substances in an attempt to induce
B. All progesterones are easily absorbed via ovulation; the ovaries fail to respond with ovulation, some-
the skin. times leading to heavy, anovulatory menstrual bleeding. Levels
C. Alfalfa is an example of a phytoprogesterone. of estrogen forms (estradiol, estrogen) and androgens (testos-
D. Progesterones, whether synthetic or plant-based, terone, progesterone, androsterone, and dehydroepiandros-
should not be used by a woman who has undergone terone) are reduced. Hot flashes now usually become more
a hysterectomy. frequent and severe, in part induced by the FSH surge. About
80% of woman going through menopause have hot flashes,
ranging in severity from mildly bothersome to debilitating.
Answers Compared with naturally occurring menopause, women with
surgical menopause usually have more severe symptoms, likely
41. B. 49. C. 57. D. because the hormonal shifts are more rapid and dramatic.
42. A. 50. B. 58. C. Estrogen receptors are found in high concentrations in the
43. B. 51. D. 59. B. vulva, vagina, urethra, and trigone of the bladder. As a result,
44. D. 52. A. 60. D. symptoms of urogenital atrophy from estrogen shifts are a
45. B. 53. B. 61. B. common perimenopausal and menopausal problem. These
46. D. 54. C. 62. B. receptors are found in lower concentrations in the vascular
47. A. 55. A. 63. A. bed, heart, brain, bone, and eye—areas of the body that also
48. D. 56. D. 64. A. exhibit changes during perimenopause and menopause.
4074_Ch15_347-372 20/11/14 11:19 AM Page 358
Vasomotor symptoms can be debilitating, causing dis- menopause, reduction of hot flashes by 80% to 95% is ex-
turbed sleep, avoidance of social situations in which hot pected. All types and routes of administration of estrogen are
flashes occur, and numerous other problems. Women often effective. Although the benefit seems to be related to the dose,
seek advice from their healthcare provider about minimizing even low doses of estrogen are often effective. Higher doses
these symptoms. Numerous lifestyle modifications can be (equivalent of 1 mg of oral estradiol) usually provide relief in
quite helpful (Table 15–4). When these measures are inade- about 4 weeks, whereas lower doses usually take about 8 to
quate, the addition of pharmacological intervention is often 12 weeks to provide similar hot flash effect. Lower-dose HT
appropriate. is usually better tolerated with less breast tenderness and uter-
HT, usually in the form of an estrogen supplement pre- ine bleeding. The FDA, American College of Obstetrics and
scription, is likely the most commonly used and most effec- Gynecology, and the North American Menopause Society
tive therapy that has been extensively studied for hot flash recommend using the lowest dose of HT that is effective; the
management. When given during the first years after length of therapy should be dictated by clinical response and
kept as short as possible (Table 15–5).
As with all medication use, HT comes with the possibil-
ity for adverse effects. Endometrial cancer risk with unop-
posed estrogen use is considerable, with the rate of 4 to
TABLE 15–4
5 per 1000 users per year, with a 5-year use risk of 2% and
Lifestyle Modification to Minimize a 10-year use risk of 4%. As a result, unless a woman taking
Hot Flash Triggers HT has undergone a hysterectomy, she must also take a
progestin to minimize this risk. An observed increased risk
Hot flashes can often be reduced in number and mini- of breast cancer in women who use HT has also been noted,
mized in severity with simple lifestyle changes particularly with long-term use. Supplemental estrogen use
Hot Flash Trigger Intervention should be avoided in women who have a history of or are
at high risk for cardiovascular disease, breast cancer, uter-
Spicy foods, choco- Keep food diary to track trig- ine cancer, or venous thromboembolic events and in
late, other foods gers. Avoid triggers or eat in women with active liver disease. Compared with the oral
small amounts. form, transdermal estrogen use is associated with a lower
Alcohol use Note if certain amounts of types thromboembolic risk in short-term studies.
of alcohol trigger hot flashes. Many women who use oral HT continue to have symptoms
Restrict or avoid use. of atrophic vaginitis; the addition of topical estrogen, via an es-
Elevated ambient Control room temperature and trogen-containing vaginal cream, ring, or tablet, can be helpful.
temperature and humidity. Using climate control
humidity to achieve a cool room with
low humidity is particularly
helpful in improving sleep TABLE 15–5
quality.
What Estrogen Form? What Dose?
Tight, restrictive Dress in layers that can be
clothing removed and replaced in How Much Relief?
response to hot flashes. The three most commonly used prescription hormone
Cigarette smoking Tobacco use is associated with a therapy agents include oral conjugated equine estro-
marked increase in hot flashes. gen and oral and transdermal estradiol-17β. The
Smoking cessation improves amount of hot flash relief women get from each form
overall health and reduces hot and dose differs.
flash frequency and severity.
Hot baths or showers Well-known hot flash trigger. Reported Hot
Also tends to worsen dry skin, a Estrogen Form Dose (mg) Flash Relief (%)
common complaint during peri- Oral conjugated 0.625 94
menopause and menopause. estrogen 0.4 78
Taking a cool shower or bath 0.3 78
minimizes hot flash risk. Oral 17β 2 96
Relaxation tech- In many smaller studies, shown estradiol- 1 89
niques, self- to be helpful in reducing hot 0.5 79
hypnosis flash severity and frequency. 0.25 55
Transdermal 0.1 96
Source: Nelson AL. Perimenopause, menopause and postmenopause:
Health promotion strategies. In: Hatcher RA, Trussell J, Nelson AL, 17β estradiol 0.05 96
Cates W, Kowal D, Policar MS (eds). Contraceptive Technology, 0.025 86
ed. 20. New York: Ardent Media, Inc.; 2011, pp. 737–777.
4074_Ch15_347-372 20/11/14 11:19 AM Page 359
DI SCUS SION SOURCES 70. Which of the following is not a normal finding in a
Goodman NF. Cobin RH. Ginzburg SB. Katz IA. Woode DE. woman during the reproductive years?
American Association of Clinical Endocrinologists Medical A. vaginal pH of 4.5 or less
Guidelines for Clinical Practice for the Diagnosis and Treatment B. Lactobacillus as the predominant vaginal organism
of Menopause. Endocr Pract 17 (suppl 6):1–25, 2011. https:// C. thick, white vaginal secretions during the luteal phase
www.aace.com/files/menopause.pdf. D. vaginal epithelial cells with adherent bacteria
Nelson AL. Perimenopause, menopause and postmenopause:
Health promotion strategies. In: Hatcher RA, Trussell J, Nelson 71. Which of the following findings is most consistent with
AL, Cates W, Kowal D, Policar MS (eds). Contraceptive Technol- vaginal discharge during ovulation?
ogy, ed. 20. New York: Ardent Media, Inc.; 2011, pp. 748, 755, A. dry and sticky
757, 758,762, 763, 765, 766, and 767. B. milky and mucoid
Santen RJ. Postmenopausal hormone therapy: An endocrine society C. stringy and clear
scientific statement. J Clin Endocrinol Metabolism 95(suppl 1): D. tenacious and odorless
S34, 2010.
The North American Menopause Society. Position statement: The 72. What is the approximate incubation period for
2012 hormone therapy positions statement of the North Amer- Neisseria gonorrhoea?
ican menopause society. Menopause: The Journal of the North A. 1 to 5 days
American Menopause Society 19(3):257–271, 2012. doi:10.1097/ B. 7 to 10 days
gme.0b013e33824b970a. C. 18 days
D. 28 days
Vulvovaginitis 73. A recommended treatment for rectal gonorrhea is:
A. oral amoxicillin.
65. Chlamydial infections occur most frequently among B. oral azithromycin.
women in which age group? C. oral ciprofloxacin.
A. younger than 25 years D. ceftriaxone injection.
B. 25 to 35 years
74. Physical examination of a 19-year-old woman with a
C. 40 to 50 years
3-day history of vaginal itch reveals moderate perineal
D. over 60 years
excoriation, vaginal erythema, and a white, clumping
66. Common sites of C. trachomatis infection in women discharge. Expected microscopic examination findings
include all of the following except: include:
A. ovaries. A. a pH greater than 6.0.
B. cervix. B. an increased number of lactobacilli.
C. endometrium. C. hyphae.
D. urethra. D. an abundance of white blood cells.
67. The incubation period for C. trachomatis is approximately: 75. Women with bacterial vaginosis typically present with:
A. 24 hours. A. vulvitis.
B. 3 days. B. pruritus.
C. 7 to 14 days. C. dysuria.
D. 24 days. D. malodorous discharge.
68. Which of the following include characteristics of a 76. Treatment of vulvovaginitis caused by Candida albicans
friable cervix? includes:
A. presence of a dull pain, particular prior to menses A. metronidazole gel.
B. a constant burning sensation B. clotrimazole cream.
C. presence of multiple polyps C. hydrocortisone ointment.
D. easily irritated and prone to bleeding, especially D. clindamycin cream.
following intercourse
77. A 24-year-old woman presents with a 1-week history of
69. An annual screening for C. trachomatis infection is thin, green-yellow vaginal discharge with perivaginal ir-
recommended for: ritation. Physical examination findings include vaginal
A. all sexually active women. erythema with petechial hemorrhages on the cervix,
B. sexually active women 25 years of age and numerous white blood cells, and motile organisms on
younger. microscopic examination. These findings most likely
C. sexually active women who have had 2 or more represent:
partners in the past 12 months. A. motile sperm with irritative vaginitis.
D. sexually active men 25 years of age and younger. B. trichomoniasis.
C. bacterial vaginosis.
D. condyloma acuminatum.
4074_Ch15_347-372 20/11/14 11:19 AM Page 361
78. A preferred treatment option for trichomoniasis is: 86. All of the following are likely reported in a woman with
A. oral metronidazole. an initial episode of genital HSV-2 (HHV-2) infection
B. clindamycin vaginal cream. except:
C. topical acyclovir. A. painful ulcer.
D. oral azithromycin. B. inguinal lymphadenopathy.
C. thin vaginal discharge.
79. Treatment options for bacterial vaginosis include all of
D. pustular lesions.
the following except:
A. oral metronidazole. 87. In the person with HSV-2 infection, the virus can
B. clindamycin cream. spread via:
C. oral clindamycin. A. genital secretions.
D. oral azithromycin. B. oral secretions.
C. normal-looking skin.
80. A 30-year-old woman presents without symptoms but
D. all of the above.
states that her male partner has dysuria without penile
discharge. Examination reveals a friable cervix covered 88. During asymptomatic HSV-2 infections, genital shed-
with thick yellow discharge. This description is most ding of virus occurs during approximately ________
consistent with an infection caused by: of days.
A. Chlamydia trachomatis. A. 10%
B. Neisseria gonorrhoeae. B. 25%
C. human papillomavirus (HPV). C. 50%
D. Trichomonas vaginalis. D. 100%
81. Which of the following agents is active against 89. Diagnostic testing of a person with primary HSV-2 in-
N. gonorrhoeae? fection would likely show:
A. ceftriaxone A. negative virological and serological test results.
B. metronidazole B. negative virological test result and positive serologi-
C. ketoconazole cal test result.
D. amoxicillin C. positive virological test result and negative serologi-
cal test result.
82. Which of the following agents is most active against
D. positive virological and serological test results.
C. trachomatis?
A. amoxicillin 90. Treatment options for HSV-2 genital infection include:
B. metronidazole A. ribavirin.
C. azithromycin B. indinavir.
D. ceftriaxone C. famciclovir.
D. cyclosporine.
83. Which of the following statements is true of gonococcal
infection? 91. Suppressive therapy reduces the frequency of genital
A. The risk of transmission from an infected woman to herpes recurrences by:
a male sexual partner is about 80%. A. 5% to 10%.
B. Most men have asymptomatic infection. B. 20% to 25%.
C. The incubation period is about 2 to 3 weeks. C. 40% to 50%.
D. The organism rarely produces beta-lactamase. D. 70% to 80%.
84. Complications of gonococcal and chlamydial genitouri- 92. Recommended comprehensive STI testing includes
nary infection in women include all of the following testing for all of the following except:
except: A. hepatitis B.
A. pelvic inflammatory disease (PID). B. syphilis.
B. tubal scarring. C. hepatitis A.
C. acute pyelonephritis. D. HIV.
D. acute peritoneal inflammation.
85. What percentage of sexually active adults has serologi-
cal evidence of human herpes virus 2 (HHV-2 or herpes
Answers
simplex type 2)? 65. A. 70. D. 75. D.
A. 5.8% 66. A. 71. C. 76. B.
B. 14.5% 67. C. 72. A. 77. B.
C. 18.9% 68. D. 73. D. 78. A.
D. 35.6% 69. B. 74. C. 79. D.
4074_Ch15_347-372 20/11/14 11:19 AM Page 362
TABLE 15–7
Female Genitourinary Infection
Conditions Causative Organism Clinical Presentation Treatment Options
Chancroid H. ducreyi Painful genital ulcer, mul- Primary: azithromycin 1 g orally in a single
tiple lesions common, dose; or ceftriaxone 250 mg intramuscu-
inguinal lymphadenitis larly (IM) in a single dose.
Alternative: ciprofloxacin 500 mg orally
twice a day for 3 days; or erythromycin
base 500 mg orally three times a day
for 7 days.
Genital herpes HSV-2, also known as Painful ulcerated lesions, For primary infection (initial episode): acy-
herpes simplex type 2 lymphadenopathy, par- clovir 400 mg PO tid for 7–10 days; or
(rarely human herpes ticularly with primary famciclovir 250 mg PO tid for 7–10 days;
virus 1) outbreak. Subsequent or valacyclovir 1 g PO bid for 7–10 days.
outbreaks often less For episodic recurrent infection: acyclovir
severe 800 mg tid for 2 days; or 400 mg PO tid
for 5 days; or famciclovir 1000 mg bid for
1 day or 125 mg PO bid for 5 days; or
valacyclovir 1g PO qd for 5 days; or valacy-
clovir 500 mg PO bid for 5 days.
For suppression of recurrent infection:
acyclovir 400 mg PO bid; or famciclovir
250 mg PO bid; or valacyclovir 1 g PO qd.
For patient with ≥9 recurrences per year,
another treatment option is valacyclovir
500 mg qd with an increase to 1 g qd if
breakthrough.
Lymphogranu- Invasive serovar L1, L2, Vesicular or ulcerative Primary therapy: doxycycline 100 mg PO
loma venereum L3 of C. trachomatis lesion on external bid for 21 days.
genitalia with inguinal Alternative therapy: erythromycin 500 mg
lymphadenitis or buboes qid for 21 days.
Nongonococcal C. trachomatis (50%), Irritative voiding symp- Primary therapy: azithromycin 1 g PO as a
urethritis and Mycoplasma hominis, toms, rarely mucopuru- single dose; or doxycycline 100 mg PO bid
cervicitis Mycoplasma lent vaginal discharge, for 7 days.
genitalium cervicitis, often Alternative therapy: erythromycin base
Assume concomitant asymptomatic 500 mg PO qid for 7 days; or ofloxacin
infection with 300 mg bid for 7 days; or levofloxacin
N. gonorrhoeae, 500 mg qd for 7 days.
unless ruled out by
accurate diagnostic
testing
Gonococcal N. gonorrhoeae Irritative voiding symp- Recommended therapy: single-dose therapy
urethritis and Assume concomitant toms, occasional puru- for uncomplicated infection ceftriaxone
cervicitis infection with C. lent vaginal discharge, 250 mg IM.
trachomatis cervicitis Concurrently treat with azithromycin 1 g as
a single dose; or doxycycline 100 mg bid
for 7 days.
Alternative therapy in the presence of se-
vere beta-lactam allergy: Azithromycin 2 g
as a single dose
4074_Ch15_347-372 20/11/14 11:19 AM Page 363
TABLE 15–7
Female Genitourinary Infection—cont’d
Conditions Causative Organism Clinical Presentation Treatment Options
Genital warts Human papillomavirus Verruca-form lesions or Patient-applied therapy: podofilox 0.5%
(condyloma can be subclinical or un- solution; or imiquimod 5% cream.
acuminata) recognized Provider-applied therapy: liquid nitrogen or
cryoprobe, trichloroacetic acid,
podophyllin resin, or surgical removal.
Bacterial Overgrowth of Increased volume of First-line therapies: metronidazole 500 mg
vaginosis anaerobes, including vaginal secretions; thin, bid for 7 days; or metronidazole gel 0.75%,
Gardnerella species gray, homogeneous dis- 1 applicator (5 g) intravaginally qd for
and Mycoplasma charge; burning; pruritus 5 days; or clindamycin cream 2%, 1 applica-
hominis On microscopic examina- tor (5 g) intravaginally at HS for 7 nights.
tion, vaginal pH < 4.5, Alternative regimens: metronidazole 2 g as
clue calls, positive single dose; or clindamycin 300 mg bid for
whiff test, few white 7 days; or clindamycin ovules 100 g intrav-
blood cells aginally at bedtime for 3 days; or tinida-
zole 2 g PO daily for 2 days or 1 g PO daily
for 5 days.
Candidiasis Candida albicans, Itching, burning, thick Single-day therapy options: fluconazole
Candida glabrata, white-to-yellow adher- (Diflucan) 150 mg PO as single dose); buto-
Candida tropicalis ent, curd-like discharge, conazole 2% SR cream (Gynazole-1); tio-
vulvovaginal excoriation, conazole 6.5% (Vagistat-1); miconazole
erythema, excoriation. (Monistat) 1200 mg, as single dose vaginally.
On microscopic examina- Various 3- and 7-day therapies with azole
tion, hyphae, pseudohy- antifungal vaginal creams, suppositories,
phae, pH less than 5, tablets (miconazole, butoconazole, ter-
few white blood cells conazole [Terazol], tioconazole).
Pelvic inflamma- N. gonorrhoeae, Irritative voiding symp- Recommended therapy for outpatient treat-
tory disease C. trachomatis, E. coli, toms, fever, abdominal ment: ceftriaxone 250 mg IM as a single
Mycoplasma and pain, cervical motion dose plus doxycycline 100 mg bid for
Ureaplasma species, tenderness, vaginal 14 days with or without metronidazole
others discharge 500 mg bid for 14 days.
Alternate oral regimens: ofloxacin 400 mg
PO bid; or levofloxacin 500 mg PO qd with
or without metronidazole 500 mg PO bid
for 14 days. Alternate regimen should be
used only with awareness of quinolone-
resistant N. gonorrhoeae, but may be the
primary treatment alternative in the
presence of significant penicillin or
cephalosporin allergy.
Trichomoniasis T. vaginalis Dysuria, itching, vulvovagi- Recommended therapy: metronidazole
nal irritation, dyspareu- (Flagyl) or tinidazole (Tindamax) 2 g as a
nia, yellow-green vaginal one-time dose.
discharge, cervical Alternative therapy: metronidazole, 500 mg
petechial hemorrhages PO bid for 7 days.
(“strawberry spots”) in
about 30%
On microscopic examina-
tion: motile organisms
and white blood cells
Sources: Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010.
www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
4074_Ch15_347-372 20/11/14 11:19 AM Page 364
immunotype D–K, is an obligate intracellular parasite closely injectable ceftriaxone (preferred) and oral cefixime. Because
related to gram-negative bacteria. This infection causes cer- of increasing rates of resistance, the use of the fluoro-
vicitis in most infected women. About one-half have urethral quinolones to treat this infection is no longer recommended.
infection, and one-third have endometrial involvement; de- Genital herpes is a result of infection with a HHV
spite this, many women are asymptomatic, although mucop- (human herpes virus, also known as herpes simplex virus
urulent vaginal discharge, dysuria, dyspareunia, and postcoital [HSV]). Most often, HSV-2 is the causative organism;
bleeding are often reported. The organism has an incubation HSV-1, the virus form that causes cold sores (herpes
period of approximately 7 to 14 days. labialis), is rarely implicated. HSV-2 can infect the perioral
Clinical presentation of C. trachomatis genitourinary in- area, however. The clinical presentation usually includes a
fection in women typically includes the presence of mucop- painful ulcerated genital lesion, often accompanied by
urulent discharge, often adherent to a friable cervix. Cervical inguinal lymphadenopathy. If lesions involve the vagina
motion and adnexal tenderness is usually present when there or its introitus, a thin, sometimes profuse discharge accom-
is upper reproductive tract infection such as PID. Diagnostic panies the infection.
testing includes DNA probe endocervical testing or urinalysis HSV-2 can be spread through contact with lesions, mu-
for ligase chain reaction. Routine screening—that is testing cosal surfaces, genital secretions, or oral secretions. The virus
that is encouraged and offered to all in a given group even in can also be shed from skin that looks normal. In those with
the absence of signs and symptoms—for C. trachomatis asymptomatic infections, genital shedding of the virus occurs
infection is recommended annually for all sexually active fe- on 10% of days, even in the absence of any signs or symp-
males age 25 years and younger. Evidence is insufficient to toms. Transmission most commonly occurs from an infected
recommend routine screening for C. trachomatis infection in partner who does not have a visible sore and may not know
sexually active young men based on feasibility, efficacy, and that he or she is infected.
cost-effectiveness. However, screening of sexually active Diagnosis can be performed through direct (virological)
young men should be considered in clinical settings associ- or indirect (serological) testing. Viral culture is the standard
ated with high prevalence of chlamydial infection including for diagnosing genital herpes, which requires a collection of
adolescent practices, correctional facilities, and STI clinics. a sample from a sore. PCR can also be used to test for the
Treatment options for uncomplicated C. trachomatis infec- presence of viral DNA or RNA and may allow for more rapid
tion include antimicrobials that act against intracellular organ- and accurate results. Serological approaches can detect for
isms, such as doxycycline, erythromycin, and azithromycin. the presence of antibodies in the blood. In symptomatic pa-
Azithromycin is preferred, given in a highly efficacious, tients, the use of direct and indirect assays can differentiate
well-tolerated, single-dose oral therapy. For uncomplicated between a new infection and a newly-recognized older infec-
infection, a test-of-cure following completion of the antimi- tion. A positive virological test with a negative serological test
crobial course is not needed unless the patient has persistent would suggest a new infection. Positive results for both tests
symptoms or is pregnant. In pregnancy, testing for cure should would indicate a recurrent infection.
be performed 3 weeks after completion of treatment. Because Though there is no definitive cure for herpes, antiviral
reinfection is common, all women with chlamydial infection therapy for recurrent outbreaks can be given as suppression
should be rescreened 3 to 4 months after completing antimi- therapy to reduce the frequency of recurrences, or episodi-
crobial treatment. If a woman presents within 12 months of cally to shorten the duration of lesions. Treatment with an
the initial infection and has not been previously screened, she antiviral such as acyclovir, famciclovir, or valacyclovir for
should be reassessed for infection regardless of whether she acute infection, recurrence, or suppression is highly effective.
says the partner was treated or not. Suppressive therapy reduces the frequency of genital herpes
Infections caused by the organisms Ureaplasma ure- recurrences by 70% to 80% in those who have frequent re-
alyticum and Mycoplasma genitalium present similarly as currences. Treatment is also effective in those who have less
chlamydial infection. Recommended antimicrobial treatment frequent recurrences. Suppression therapy also has the ad-
for these infections is similar for treating C. trachomatis. vantage of decreasing the risk for viral transmission to
Gonorrhea, caused by the gram-negative diplococcus susceptible partners.
N. gonorrhoeae, is also a common STI. This organism has a As with all STIs, a critical part of care is discussion of pre-
short incubation period of 1 to 5 days and is likely to cause ventive strategies, including condom use and limiting the
infection in approximately 20% of men who have sexual con- number of sexual partners. NPs should offer and encourage
tact with infected women and approximately 80% of women testing for other STIs, including HIV, hepatitis B, and
who have sexual contact with infected men. syphilis. Consideration should also be given to offering test-
Most men with gonococcal infection have no symptoms. ing for hepatitis C. Immunization that provides protection
In women, presentation typically includes dysuria with a against hepatitis A, hepatitis B, and HPV should be offered
milky to purulent, occasionally blood-tinged, vaginal dis- as needed and appropriate. In patients diagnosed with
charge. With anal-insertive sex, rectal infection leading chlamydia or gonorrhea, providing prescriptions or medica-
to proctitis is often seen. Because the organism frequently tion for the patient to take to his/her partner without clinical
produces beta-lactamase, the choice of a therapeutic agent visit, known as Expedited Partner Therapy (EPT), should be
should include agents with beta-lactamase stability, such as considered.
4074_Ch15_347-372 20/11/14 11:19 AM Page 365
TABLE 15–8
Diagnostic Criteria for PID
Empiric treatment for PID should be initiated in sexually One or more of the following additional criteria can be used
active young women and other women at risk for STDs to enhance the specificity of the minimum criteria and sup-
if they are experiencing pelvic or lower abdominal pain, port a diagnosis of PID:
if no cause for the illness other than PID can be identi- • oral temperature >101°F (>38.3°C);
fied, and if one or more of the following minimum • abnormal cervical or vaginal mucopurulent discharge;
criteria are present on pelvic examination: • presence of abundant numbers of WBC on saline mi-
• cervical motion tenderness croscopy of vaginal fluid;
or • elevated erythrocyte sedimentation rate;
• uterine tenderness • elevated C-reactive protein; and
or • laboratory documentation of cervical infection with
• adnexal tenderness. N. gonorrhoeae or C. trachomatis.
106. Which of the following terms describes the mecha- Marrazzo JM, Cates W. Reproductive tract infections, including
nism of action of imiquimod (Aldara)? HIV and other sexually transmitted infections. In: Hatcher RA,
A. keratolytic Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (eds). Con-
B. immune modulator traceptive Technology, ed. 20. New York: Ardent Media, Inc.;
2011, pp. 609 and 610.
C. cryogenic
D. cytolytic
107. About ____ of patients with genital warts have spon- Syphilis
taneous regression of the lesions?
A. 10% 108. How long after contact do clinical manifestations of
B. 25% syphilis typically occur?
C. 50% A. less than 1 week
D. 75% B. 1 to 3 weeks
C. 2 to 4 weeks
D. 4 to 6 weeks
Answers 109. Which of the following is not representative of the
presentation of primary syphilis?
101. A. 104. C. 106. B.
A. painless ulcer
102. A. 105. C. 107. C.
B. localized lymphadenopathy
103. B.
C. flu-like symptoms
D. spontaneously healing lesion
Condyloma acuminatum is a verruciform lesion seen in gen- 110. Which of the following is not representative of the
ital warts and is an STI. The causative agent is human papil- presentation of secondary syphilis?
lomavirus (HPV), and infection with multiple HPV types is A. generalized rash
usually seen with genital infection. Anal, penile, and cervical B. chancre
carcinomas can be consequences of HPV infection. Not all C. arthralgia
HPV types are correlated with malignancy, however. HPV D. lymphadenopathy
types with high malignancy risks include types 16, 18, 31, 33,
35, 39, and 45, whereas low malignancy risks are seen with 111. Which of the following is found in tertiary syphilis?
infection with types 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, and A. arthralgia
81. HPV types 6 and 11 most often cause genital warts, B. lymphadenopathy
whereas HPV types 16 and 18 are most often associated with C. macular or papular lesions involving the palms
genital malignancies. and soles
About 50% of patients have spontaneous regression of D. gumma
genital warts without intervention. The most common treat- 112. Syphilis is most contagious during which of the
ment options for genital warts include podofilox, imiquimod, following?
trichloroacetic acid, or cryotherapy. The location of lesions A. before onset of signs and symptoms
can dictate therapeutic choices; imiquimod use is only indi- B. at the primary stage
cated for external lesions. Prescribing patient-administered C. at the secondary stage
therapies, such as imiquimod (Aldara) or podofilox, saves the D. at the tertiary stage
cost and inconvenience of office visits. Surgical intervention
and laser ablation are typically reserved for complicated, 113. First-line treatment options for primary syphilis
recalcitrant lesions. include:
As with all STIs, a critical part of care is discussion of pre- A. penicillin.
ventive strategies, including condom use and limiting the B. ciprofloxacin.
number of sexual partners. NPs should offer and encourage C. erythromycin.
testing for other STIs, including HIV, hepatitis B, and D. ceftriaxone.
syphilis. Consideration should also be given to offering test-
ing for hepatitis C. Immunization that provides protection
against hepatitis A, hepatitis B, and HPV should be offered Answers
as needed and appropriate.
108. C. 110. B. 112. C.
DI SCUSSION SOURCES 109. C. 111. D. 113. A.
Centers for Disease Control and Prevention. Sexually Transmitted
Diseases Treatment Guidelines, 2010. www.cdc.gov/std/treat- Caused by the spirochete Treponema pallidum, syphilis is
ment/2010/STD-Treatment-2010-RR5912.pdf. a complex, multiorgan disease. Sexual contact is the usual
4074_Ch15_347-372 20/11/14 11:19 AM Page 368
TABLE 15–9
Stages of Syphilis, Clinical Manifestations, and Recommended Treatment
Stage of Syphilis Clinical Manifestations Treatment Options Comment
Primary syphilis Painless genital ulcer with Recommended therapy: Azithromycin 2 g as a
clean base and indurated • Benzathine penicillin G 1-time dose has been
margins, localized lym- 2.4 million U IM as a suggested, although issues
phadenopathy 1-time dose of emerging resistance are
Alternative therapy in penicillin concerning
allergy:
• Doxycycline 100 mg PO bid
for 2 weeks; or
• Ceftriaxone 1 g IM or IV
q 24 h for 8–10 days
Secondary syphilis Diffuse maculopapular rash Recommended therapy: Also treatment for latent
involving palms and soles, • Benzathine penicillin syphilis of greater than
generalized lymphadenopa- G 2.4 million U IM as a 1 yr duration
thy, low-grade fever, 1-time dose
malaise, arthralgias and Alternative therapy in penicillin
myalgia, headache allergy:
• Doxycycline 100 mg PO bid
for 2 weeks;
Late or tertiary Gumma (granulomatous Recommended therapy: Also treatment for latent
syphilis lesions involving skin, • Benzathine penicillin syphilis of greater than
mucous membranes, bone), G 2.4 million U IM for 1 yr or unknown duration
aortic insufficiency, aortic 3 weekly doses
aneurysm, Argyll Robertson Alternative therapy in penicillin
pupil, seizures allergy:
• Doxycycline 100 mg PO bid
for 4 weeks;
Expert consultation advisable,
especially in the face of neu-
rosyphilis
Source: Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010.
www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
4074_Ch15_347-372 20/11/14 11:19 AM Page 369
116. A 45-year-old woman just had a normal Pap test re- 121. You see a 41-year-old woman whose Pap smear result
sult and has an absence of high-risk HPV. You rec- reveals high-grade squamous intraepithelial lesion
ommend her next Pap test in: (HSIL). The HPV test is negative. You recommend:
A. 1 year. A. repeating the Pap test in 3 to 4 months.
B. 3 years. B. repeating the Pap test in 1 year.
C. 5 years. C. referral for colposcopy.
D. 7 years. D. referral for biopsy.
117. Which of the following is not part of the criteria for
an older woman to cease having any future Pap tests
performed?
Answers
A. over 55 years of age 114. D. 117. A. 120. C.
B. negative screening results on three consecutive 115. B. 118. D. 121. C.
cytology or two consecutive co-test results 116. C. 119. A.
within 10 years
C. the most recent cytology occurring within the past Cervical cancer impacts approximately 12,000 women in the
5 years United States each year, most commonly occurring in women
D. no history of cervical intraepithelial neoplasm over the age of 30 years. The main cause of cervical cancer is
(CIN) 2 or greater within the past 20 years the human papillomavirus (HPV), which is a common virus
118. You see a 48-year-old woman who underwent an ab- that is transmitted through sexual intercourse. At least half
dominal hysterectomy with cervical removal for uter- of sexually active women will have HPV at some point in
ine fibroids 6 months ago. She last had a normal Pap their lives, though few will develop cervical cancer.
test 11⁄2 years ago. You recommend her next Pap test. Through routine screening, follow-up, and the availability
A. immediately. of the HPV vaccine, cervical cancer is highly preventable.
B. in 1 1⁄2 years. There are two types of tests available for screening: cytology
C. in 3 1⁄2 years. (Pap test or Pap smear) and HPV testing. The Pap test is used
D. She does not need to have a pap test now or in the to detect precancers or cell changes on the cervix that can be
future. identified and treated early before cancer development. The
Pap test is recommended for women between 21 and 65 years
119. You see a 24-year-old woman who received the HPV of age. See Table 15–10 for recommendations on the use of
vaccine (three doses) as a teenager. She had a normal cytology and HPV testing and follow-up.
Pap test 3 years ago. You recommend:
A. conducting a Pap test. D I S C U SSI O N S O U R C E
B. conducting a Pap test and HPV testing. Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus
C. waiting 2 years for the next Pap test. guidelines for the management of abnormal cervical cancer
D. ceasing future Pap tests until she turns 30 years old. screening tests and cancer precursors. J Lower Genital Tract Dis
17:S1–27, 2013. Available at: www.asccp.org/Portals/9/docs/
120. You see a 33-year-old woman whose Pap smear result
ASCCP%20Updated%20Guidelines%20%20-%203.21.13.pdf.
reveals atypical cells of undetermined significance
(ASC-US). She is also positive for HPV, with
genotype testing revealing the presence of HPV
type 16. You recommend:
A. repeating Pap test immediately.
B. repeating the Pap test in 3 to 4 months.
C. referral for colposcopy.
D. administering the HPV vaccine.
4074_Ch15_347-372 20/11/14 11:19 AM Page 370
TABLE 15–10
Cervical Cancer Screening Recommendations
Patient Classification Recommendations
Ages ≤20 years: Regardless of age onset of sexual activity, sexual orientation, and history of
Should NOT be screened sexually transmitted infection (STI), or HPV immunization status
(no Pap test should be done) *Pelvic examination and appropriate STI screening should be performed as indicated
by clinical presentation and risk assessment.*
Ages 21–29 years: Screening with cytology only
Should be screened every Human papillomavirus (HPV) testing should NOT be used, either as a stand-
3 years alone test, or co-test to include reflex
(Pap test should be done) *Pelvic examination and appropriate STI screening should be performed as indicated
by clinical presentation and risk assessment.*
Ages 30–65 years: Screening with cytology and HPV “co-test” (preferred)
Should be screened at a Screening with cytology alone is acceptable every 3 years
maximum every 5 years *Pelvic examination and appropriate STI screening should be performed as indicated
(Pap test should be done) by clinical presentation and risk assessment.*
Age >65 years: If evidence of negative prior screening (3 consecutive cytology or 2 consecu-
Should NOT be screened tive co-test results within 10 years before ceasing screening, with the most
(no Pap test should be done) recent test occurring within the past 5 yrs ) and no history of cervical in-
traepithelial neoplasm (CIN) 2 or greater within the past 20 years.
Once screening is discontinued it should not be resumed
*Pelvic examination and appropriate STI screening should be performed as indicated
by clinical presentation and risk assessment.*
SPECIAL CIRCUMSTANCES:
Has undergone a hysterectomy If no history of CIN 2 or greater, no evidence of adequate negative prior
with removal of cervix screening is needed
regardless of age: Once screening is discontinued it should not be resumed
Should NOT be screened *Pelvic examination and appropriate STI screening should be performed as indicated
(no Pap test should be done) by clinical presentation and risk assessment.*
History of CIN2, CIN3, or Routine screening should continue for at least 20 years, even if this time-
adenocarcinoma in situ frame extends past age 65 years.
Should be screened
(Pap test should be done)
HPV Vaccination Status Regardless of immunization status, screening should be done based on the
(positive or negative) practice recommendations
(see recommendation)
Management of Abnormal Screening Pap Results
Follow American Society for Colposcopy and Cervical Pathology (ASCCP) Guidelines
INADEQUATE SAMPLES: • Repeat screening after 2–4 months with cytology only
Unsatisfactory cytology • All patients with repeat screening:
Ages 21–29 years: • If result returns negative, screen as routine
(Pap test should be repeated) • If result returns abnormal, manage per guideline
Ages ≥30 years: • If result returns unsatisfactory, refer for colposcopy
(Pap test should be repeated)
4074_Ch15_347-372 20/11/14 11:19 AM Page 371
TABLE 15–10
Cervical Cancer Screening Recommendations—cont’d
Patient Classification Recommendations
Negative cytology with absent
or insufficient endocervical/
transformation zone
Ages 21–29 years: • Screen as routine
Ages ≥30 years: • If no or unknown HPV result:
• repeat screening with HPV testing (preferred); or
• if HPV not performed, repeat cytology in 3 years (acceptable)
• If HPV result is negative, screen as routine in 1 year
• If HPV result is positive, repeat co-test in 1 year (acceptable) or immediate
genotyping
• for genotype absent HPV type 16 or 18, screen with co-test in 1 year
• for genotype present HPV type 16 or 18, refer for colposcopy
ABNORMAL RESULTS:
Negative cytology, Positive HPV Option 1) repeat co-testing in 12 months;
Ages 30 to ≥65 years: Option 2) immediate HPV genotype-specific testing for high risk HPV forms
(see recommendation) (HPV 16/18, others)
Option 1 Results at 12 Months:
• If HPV positive or low-grade squamous intraepithelial (LSIL) or greater,
refer for colposcopy
• If HPV and cytology are both negative, repeat co-testing in 3 years
• If negative HPV and atypical squamous cells of undetermined significance
(ASC-US), screen as routine in 1 year
Option 2 Results (Immediate Genotyping):
• If positive for HPV type 16 or type 18, refer for colposcopy
• In absence of high-risk HPV , repeat co-testing in 1 year
ASC-US cytology HPV testing (preferred)
or
Ages 25 to ≥65 years: Repeat cytology in 1 year (acceptable)
(see recommendation) With results positive of high-risk HPV result, refer for colposcopy
ASC-US or LGSIL cytology Repeat cytology in 1 year (preferred)
or
Ages 21–24 years: Reflex HPV testing (acceptable)
(see recommendation) for HPV result that is positive, repeat cytology in 1 year
ASC-US cytology, Screen as routine per age specific recommendations
Negative HPV
Ages ≥30 to ≥65 years:
(see recommendation)
LSIL cytology: No, Negative, If negative HPV, repeat co-test in 1 year (preferred)
or Positive HPV or
Ages 25 to ≥65 years: If no, negative, or positive high-risk HPV result, refer for colposcopy
(see recommendation)
4074_Ch15_347-372 20/11/14 11:19 AM Page 372
TABLE 15–10
Cervical Cancer Screening Recommendations—cont’d
Patient Classification Recommendations
Atypical squamous cells, Refer for colposcopy
cannot exclude high-grade
squamous intraepithelial
lesion (ASC-H) and high-
grade squamous
intraepithelial lesion
(HSIL), or Atypical
Glandular Cells (AGC)
Ages 21 to ≥65 years:
(see recommendation)
4074_Ch16_373-396 20/11/14 11:24 AM Page 373
Older Adults 16
The older adult population is usually classified into four
Demographics groups: the young old, 65 to 74 years old; the old old, 75 to
1. In the elderly population, the current fastest growing 84 years old; the oldest old, 85 to 100 years old; and the elite
group is the age range: old, more than 100 years old. Significant increase in the pop-
A. 71 to 75 years. ulation group older than 65 years is projected to occur from
B. 76 to 80 years. 2010 to 2030. This increase is largely attributable to the aging
C. 81 to 84 years. of the “Baby Boomers,” the demographic born from 1946
D. 85 years and older. to 1964, and to a sharp decline in mortality at older ages. Cur-
rently, the fastest growing group of older adults is those older
2. The age range referred to as “young old” is: than age 85 years.
A. 60 to 65 years. Among elderly people residing in the United States, Social
B. 66 to 70 years. Security is mentioned as the most important source of
C. 65 to 74 years. income. Private or public pension and income from other
D. 70 to 80 years. financial investments together are mentioned as most impor-
3. Which of the following is most commonly reported as tant at less than half the frequency. In the early 1970s, the
the largest single source of income for elderly people? poverty rate for elderly adults was approximately 20%. Cur-
A. Social Security rently, the older adult demographic has an overall poverty rate
B. public/private pension earnings of approximately 11%, which is a significant improvement.
C. asset income Certain groups, including the old old, women living alone, and
D. family financial support select ethnic groups, have poverty rates double the overall rate.
373
4074_Ch16_373-396 20/11/14 11:24 AM Page 374
6 to 10. Match the following biological theories with the key aspect.
6. Gene theory A. collagen molecules bind to each other to produce stiffness and rigidity
B. a senescence factor accumulates in the cell
7. Error theory
C. one or more latent harmful genes become activated
8. Programmed theory D. an essential gene is destroyed and causes the cell to stop dividing
E. proteins produced in the cell accumulate more errors during aging
9. Cross-link theory
10. Somatic mutation theory
TABLE 16-1
Age-Related Changes and Conditions That Result in Changes of the Senses
Condition Etiology Result Comment
Presbyopia Hardening Close vision problems Nearly all adults ≥45 y.o. need reading glasses.
of lens
Senile cataracts Lens clouding Progressive vision Risk factors: Tobacco use, poor nutrition, sun
dimming, distance exposure, corticosteroid therapy.
vision problems, Potentially correctable with surgery, lens
close vision usually implant.
retained and may
initially improve
Open-angle Painless, grad- Loss of peripheral ≥80% of all glaucoma.
glaucoma ual onset of vision Risk factors: elevated intraocular pressure,
increased in- African American race, age ≥40 years.
traocular pres- Periodic screening with tonometry, assessment
sure leading to of visual fields. Treatment with topical miotics,
optic atrophy beta blockers, other drugs, or surgery effective
in vision preservation.
Angle-closure Sudden Usually unilateral, Risk factors: older age, female gender, Asian
glaucoma increase in acutely red, painful ethnicity, family history, far-sightedness.
intraocular eye with vision Immediate referral to ophthalmology for rapid
pressure change including pressure reduction via medication, possible
halos around lights; surgery.
eyeball firm com-
pared with other
eyeball
Age-related Thickening, Painless vision Besides aging, risk factors include tobacco use,
maculopathy sclerotic changes including sun exposure, family history.
changes distortion of central Dry form: No treatment available except to
in retinal vision minimize risk factors that worsen the condition.
basement Wet form: Laser treatment and other therapies
membrane to obliterate neovascular membrane. Anti-
complex angiogenic drugs injected in the eye to block
new blood vessel development and leakage
from abnormal vessels.
Hyposmia Neural Decline in sense of Accelerated by tobacco use.
degeneration smell, usually grad- Risk factors: aging, head trauma, history
ual, resulting in fine of chronic rhinosinusitis.
taste discrimination
(largely a function of
smell)
Presbycusis Multifactorial Difficult with appreci- Accelerated by excessive noise exposure. Besides
including loss ating the content of aging, risk factors include family history,
of eighth conversation in smoking, cardiovascular diseases, diabetes,
cranial nerve noisy environment; otosclerosis, infection, and trauma.
sensitivity person can hear but Hearing aids helpful.
cannot understand
Cerumen Conductive General diminution Risk factors: ear canal hairs, use of hearing aids,
impaction hearing loss of hearing, easily bony growths secondary to osteophyte or
corrected through osteoma, history of impacted cerumen.
cerumen removal Cerumen removal.
Macular degeneration is the most common cause of 30. Age-related changes in the gastrointestinal system
newly-acquired blindness and vision loss in elderly adults. include all of the following except:
Vision changes seen in macular degeneration include loss of A. decreased gastric acid production.
the central vision field. This disease is seen more often in B. decreased gastric motility.
women of European descent. A history of cigarette smoking C. increased GI surface area.
and a family history of the disease are often found as well; ex- D. decreased gastric emptying.
cessive sun exposure has also been implicated as a risk factor
31. Long-term proton pump inhibitor (PPI) use is associated
for macular degeneration. The ophthalmological examination
with all of the following except:
reveals hard drusen or yellow deposits in the macular area.
A. increased risk of pneumonia in hospitalized patients.
Soft drusen can also be seen. These appear larger, paler, and
B. increased risk of C. difficile colitis in hospitalized
less distinct.
patients.
DI SCUSSION SOURCE C. reduced absorption of calcium and magnesium.
Merck Manual of Geriatrics. www.merckmanuals.com/professional/
D. increased absorption of iron and copper.
geriatrics.htm. 32. To avoid rebound gastric hyperacidity following
discontinuation of long-term PPI use, all of the
following methods can be used except:
Medication Use A. gradually tapering the PPI dose.
B. switch to every-other-day dosing of PPI.
25. Age-related changes in an elderly adult include all of C. switch to a low-dose H2RA therapy.
the following except: D. avoiding antacid therapy when symptoms flare.
A. total body water decreases by 10% to 15% between
33. Age-related renal changes in older adults potentially
ages 20 and 80 years.
include all of the following except:
B. body weight as fat increases from 18% to 36% in
A. decreased glomerular filtration rate (GFR).
men and from 33% to 45% in women.
B. diminished renal blood flow.
C. increase in serum albumin.
C. loss of functional nephrons.
D. increase in gastric pH.
D. increased renal mass to compensate for decreased
26. A general principle of drug absorption in an elderly function.
adult is best described as:
34. An expected age-related change in the older adult with
A. amount of absorption is decreased.
intact renal function is decreased muscle mass and an
B. rate of absorption is changed.
associated:
C. drug absorption is altered but predictable.
A. increase in serum creatinine.
D. bioavailability is altered.
B. decrease in serum creatinine.
27. When evaluating serum creatinine in an elderly adult, C. minimal impact on serum creatinine.
the clinician considers that: D. increase in creatinine clearance.
A. this value is influenced by glomerular filtration
35. In an older adult with advanced impaired renal function,
rate.
the clinician anticipates that there is usually no need to
B. age-related physiological changes do not influence
adjust the antimicrobial dose with the use of:
this laboratory value.
A. ceftriaxone.
C. male and female norms are equivalent.
B. tobramycin.
D. an increase is an expected age-related change.
C. levofloxacin.
28. Anticipated age-related changes that can result in less D. vancomycin.
drug effect include:
36. When dosing warfarin in older adults, it is important to
A. loss of beta-2 receptor sites.
consider:
B. lower gastrointestinal (GI) pH.
A. a lower dose is needed due to lower serum albumin.
C. increased renin-angiotensin production.
B. a lower dose is needed due to higher serum albumin.
D. increased GI motility.
C. a higher dose is needed due to lower serum albumin.
29. When prescribing a diuretic, the NP considers that the D. a higher dose is needed due to lower serum albumin.
older adult:
37. Which of the following medications has little
A. has diminished ability to conserve sodium.
anticholinergic effect?
B. has increased ability to excrete potassium.
A. diphenhydramine
C. has continued response to a thiazide despite
B. amitriptyline
increasing creatinine.
C. chlorpheniramine
D. often develops allergic reaction to these products.
D. loratadine
4074_Ch16_373-396 20/11/14 11:24 AM Page 378
Medications with significant systemic anticholinergic effect 50. Which of the following statements is true concerning
should be avoided in older adults because of risk of confusion, elder maltreatment?
urinary retention, constipation, visual disturbance, and hypoten- A. This problem is found mainly in families of lower
sion. If anticholinergic effect is unavoidable, a product in the socioeconomic status.
class with the least amount of this effect should be chosen. A tri- B. An elderly adult who is being mistreated usually
cyclic antidepressant can be a helpful and inexpensive treatment seeks help.
option for the management of chronic neuropathic pain but can C. Routine screening is indicated as part of the care of
have significant anticholinergic effect. Compared with amitrip- an older adult.
tyline, nortriptyline has significantly less of this effect, however, D. In most instances of elder maltreatment, a pre-
and is likely a better treatment option. Serotonin-norepinephrine dictable cycle of physical violence directed at the
reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, older adult followed by a period of remorse on the
have been found to be helpful in treating neuropathic pain. part of the perpetrator is the norm.
Other options for neuropathic pain include the anticonvulsants
51. Risk factors for becoming a perpetrator of elder mal-
gabapentin and pregabalin, though dose adjustment based on
treatment include all of the following except:
renal function may be needed in the elderly as these drugs are
A. a high level of hostility about the caregiver role.
renally excreted. Gabapentin is also associated with sedation and
B. poor coping skills.
should be started at a low dose and titrated as needed. If an an-
C. assumption of caregiving responsibilities at a later
tihistamine is needed, loratadine offers an option with little an-
stage of life.
ticholinergic effect, whereas diphenhydramine is a less attractive
D. maltreatment as a child.
option, owing to its strong anticholinergic effect.
The adage, “start low, go slow” in prescribing for elderly 52. Elder maltreatment is considered to be underreported,
adults has an often forgotten third part: “but get to goal.” Cli- with an estimated ___ cases going unreported to each
nicians, in their zeal to provide safe pharmacotherapeutic one case that is reported.
care for older adult patients, often prescribe enough of a med- A. three
ication to give anticipated adverse effects but not enough to B. four
provide the desired therapeutic effect. Knowledge of the safe C. five
and appropriate medication doses in older adults, keeping in D. six
mind the age-related effects on pharmacokinetics, is a critical
53. The most commonly reported form of elder maltreat-
part to safe prescriptive practice.
ment is:
DI SCUS SION SOURCES A. physical abuse.
AGS. American Geriatrics Society updated Beers Criteria for poten-
B. sexual exploitation.
tially inappropriate medication use in older adults. J Am Geriatr C. financial exploitation.
Soc 2012. Available at: www.americangeriatrics.org/files/docu- D. neglect.
ments/beers/2012BeersCriteria_JAGS.pdf. 54. The daughter of a 76-year-old woman expresses con-
Katzung B. Special aspects in geriatric pharmacology. In: Katzung
cern regarding her mother’s refusal for assistance in
B. Basic and Clinical Pharmacology, ed. 12. New York: McGraw
Medical; 2011 pp 1051-1060.
everyday living activities. The mother lives by herself
and is often found with poor hygiene and reports eating
one small meal a day. She also has poor adherence to
Elder Maltreatment her current medication regimens. This represents an
example of:
49. When making a home visit to a bedridden 89-year-old A. abandonment.
man, you note that he is cachectic and dehydrated but B. self-neglect.
cognitively intact. He states he is not receiving his C. early-onset dementia.
medications regularly and that his granddaughter is D. psychological abuse.
supposed to take care of him but mentions, “She seems
more interested in my Social Security check.” The
patient is unhappy but asks that you not “tell anybody” Answers
because he wants to remain in his home. The most
appropriate action would be to: 49. C. 51. C. 53. D.
A. talk with the patient’s granddaughter and evaluate 50. C. 52. C. 54. B.
her ability to care for the patient.
B. visit the patient more frequently to ensure that his The Centers for Disease Control and Prevention (CDC) de-
condition does not deteriorate. fines elder maltreatment as any abuse and neglect of persons
C. report the situation to the appropriate state agency. age 60 and older by a caregiver or another person in a rela-
D. honor the patient’s wishes because a competent tionship involving an expectation of trust. Elder maltreat-
patient has the right to determine care. ment can take various forms (Table 16–3). Every state in the
4074_Ch16_373-396 20/11/14 11:24 AM Page 381
TABLE 16-3
Forms of Elder Maltreatment
Form of Elder Maltreatment Descriptions
Physical abuse Elderly adult is injured by another individual, including being scratched,
bitten, slapped, pushed, hit, or burned; assaulted or threatened with a
weapon, including a knife, gun, or other object; or inappropriately restrained.
Sexual abuse or abusive sexual contact Any sexual contact against elderly adult’s will, including acts in which elderly
adult is unable to understand the act or is unable to communicate consent.
Abusive sexual contact is defined as intentional touching, either directly or
through the clothing, of the genitalia, anus, groin, breast, mouth, inner
thigh, or buttocks.
Psychological or emotional abuse Any event in which elderly adult experiences trauma after exposure to
threatening acts or coercive tactics. Examples include humiliation or embar-
rassment; controlling behavior such as prohibiting or limiting access to
transportation, telephone, money, or other resources; social isolation;
disregarding or trivializing needs; or damaging or destroying property.
Neglect Failure or refusal of a caregiver or other responsible person to provide for
elderly adult’s basic physical, emotional, or social needs, or failure to protect
elderly adult from harm. Examples include not providing adequate nutrition,
hygiene, clothing, shelter, or access to necessary healthcare, or failure to
prevent exposure to unsafe activities and environments.
Abandonment Willful desertion of elderly adult by caregiver or other responsible person.
Financial abuse or exploitation Unauthorized or improper use of resources of elderly adult for monetary or
personal benefit, profit, or gain by another individual. Examples include
forgery, misuse or theft of money or possessions, use of coercion or decep-
tion to surrender finances or property, or improper use of guardianship or
power of attorney.
Self-neglect This form of elder maltreatment is, as defined, instituted by the elderly adult,
not another individual, and is the failure or refusal of elderly adult to address
his or her own basic physical, emotional, or social needs. Examples include
self-care tasks, such as nourishment, clothing, hygiene, and shelter; proper
or appropriate use of medications; and managing or administering one’s
finances. This is also characterized by the lack of intervention to halt or
modify the behavior by another individual who is often in the position to
recognize the problem.
United States and many Canadian provinces have enacted a high level of hostility about the caregiver role, poor cop-
legislation to protect vulnerable older adults from abuse, ing skills, inadequate preparation for caregiving responsi-
with a requirement for healthcare workers and others who bilities, assumption of caregiving responsibilities at an early
come in contact with older adults to report this abuse to the age, and maltreatment as a child. At the relationship level,
appropriate protective authorities. Elder maltreatment is additional risk factors emerge, including a high level of
significantly underreported; for every one case reported, an financial and emotional dependence on a vulnerable elder,
estimated five other cases go unreported. Neglect is the most a past experience of disruptive behavior, and lack of social
commonly encountered type of elder maltreatment. In times support. Elder mistreatment is likely to be more prevalent
of economic difficulty, the rate of financial exploitation usu- in a cultural and community milieu in which tolerance of
ally increases. aggressive behavior and negative beliefs about aging and
A combination of individual, relational, community, elderly adults exist; formal services, such as respite care for
and societal factors contribute to the risk of an individual individuals providing care to elderly adults, are limited, in-
becoming a perpetrator of elder maltreatment. Under- accessible, or unavailable; family members are expected to
standing these factors can help identify various opportuni- care for elderly adults without seeking help from others;
ties for prevention. and individuals are encouraged to endure suffering or
Risk factors for perpetration of elder maltreatment in- remain silent regarding their pain. At the institutional level,
clude a current diagnosis of mental illness or alcohol abuse, such as in a long-term care or assisted living facility,
4074_Ch16_373-396 20/11/14 11:24 AM Page 382
unsympathetic or negative attitudes toward residents, chronic 59. In assessing a person with or at risk for orthostatic hy-
staffing problems, lack of administrative oversight, staff potension, the BP should be measured after 5 minutes
burnout, and stressful working conditions are considered in the supine position and then ___ and ___ minutes
risk factors for elder maltreatment. after standing.
Certain factors have been identified as protection against A. 1, 3
elder mistreatment, including strong personal relationships, B. 2, 4
community support for the caregiver role, and coordinated C. 3, 5
resources to help serve elderly adults and caregivers. Factors D. 5, 10
within institutional settings that can be protective include
effective monitoring systems in place; clear, understandable
institutional policies and procedures regarding patient care; Answers
ongoing education on elder abuse and neglect for employees;
education about and clear guidance on how durable power 55. C. 57. D. 59. A.
of attorney is to be used; and regular visits by family mem- 56. B. 58. C.
bers, volunteers, and social workers.
Although not a specific disease state, orthostatic (postural)
DI SCUS SION SOURCES
hypotension is a manifestation of abnormal blood pressure (BP)
Centers for Disease Control and Prevention. Elder abuse. Available regulation. Normal BP is usually maintained by the sympathetic
at: www.cdc.gov/violenceprevention/elderabuse/index.html. system causing an increase in heart rate and contractility in re-
Elder Maltreatment Alliance. Information. Available at: www.elder-
sponse to the pooling of blood in the lower extremity and trunk
maltreatment.com/information.
veins because of position change. Simultaneous parasympa-
thetic (vagal) inhibition also increases heart rate. With contin-
ued standing, activation of the renin-angiotensin-aldosterone
Orthostatic system and antidiuretic hormone secretion cause sodium and
water retention and increase circulating blood volume. When
Hypotension these mechanisms do not work properly, BP control is not
maintained with position change. The end result is a transient
55. Orthostatic (postural) hypotension is defined as an decrease in venous return, reduced cardiac output, and a
excessive decrease in blood pressure (BP) with decrease in BP; usually the first patient-reported effects from
position, usually greater than ____ mm Hg systolic the decrease in BP are light-headedness, dizziness, or blurred
and ____ mm Hg diastolic. vision that occur within seconds of changing position, most
A. 10, 5 often from sitting to standing. Orthostatic hypotension is
B. 15, 7 defined as an excessive decrease in BP when an upright position
C. 20, 10 is assumed; the change in BP is usually greater than 20 mm Hg
D. 30, 15 systolic and greater than 10 mm Hg diastolic, with resulting
56. Orthostatic hypotension is present in about ____% of symptoms that occur within seconds of changing position from
older adults. supine or sit to standing. This condition is present in about 20%
A. 10 of older adults and is a potent risk factor for falls.
B. 20 Although age-related changes in the cardiovascular and
C. 30 cerebrovascular systems contribute to orthostatic hypotension,
D. 40 the use of certain medications can cause or worsen the condi-
tion. The medications most often implicated typically cause a
57. The use of which of the following medications is associ- decrease in circulating volume or peripheral vasodilation; these
ated with the least risk of postural hypotension in the medications include loop diuretics, tricyclic antidepressants,
older adult? calcium channel blockers, alpha-adrenergic blockers, centrally
A. nifedipine acting antihypertensives such as clonidine, and nitrates. Cer-
B. furosemide tain disease states that alter baseline cardiac output and vascu-
C. clonidine lar capacity, increasing orthostatic risk, are common in older
D. lisinopril adults; these include aortic stenosis, dehydration, peripheral
58. Lifestyle interventions for an older adult with orthostatic vascular insufficiency, and electrolyte disturbances. Alcohol
hypotension should include counseling about: use is also a potent contributor, as is prolonged bedrest; beta
A. avoiding the use of compression stockings. blocker use is seldom implicated. Cardiac rhythm disturbances
B. minimizing salt intake. usually occur with regularity, which results in more consistent
C. flexing the feet multiple times before changing symptoms, not simply with position change, and are not a sig-
position. nificant orthostatic hypotension contributor.
D. restricting fluids. In assessing a person with or at risk for orthostatic hypoten-
sion, BP should be measured after the patient has been in a
4074_Ch16_373-396 20/11/14 11:24 AM Page 383
supine position for 5 minutes and then at 1 and 3 minutes after 63. In an older adult, the greatest risk of long-term
standing. Patient symptoms should be recorded. If the patient complication is associated with fracture of the:
is too symptomatic or ill to stand, the maneuvers should A. forearm.
be performed with supine to sit position change. If hypotension B. spine.
is accompanied by an increase of heart rate to greater than C. ankle.
100 bpm, altered circulating volume is the likely cause. D. hip.
When orthostatic hypotension is documented, possible
64. Fall risk in an older adult is decreased with the use of
contributing factors, such as medications implicated in the
which of the following footwear?
condition, should be modified. Fluid and electrolyte imbalance,
A. sandal
if a contributor, should be corrected. In addition, instruction
B. jogging shoe
about lifestyle modification to minimize risk is a critical and
C. slipper
often overlooked intervention. This instruction includes infor-
D. semirigid sole shoe
mation about moving slowly and deliberately with position
change from supine to sit or supine to stand, dorsiflexing the 65. With the use of insulin, fall risk in an older adult is
feet multiple times before position change, and avoiding stand- most likely to occur ____ of the medication.
ing in one position for an excessive length of time; the use of A. at the onset of action
compression stockings to enhance venous return can also be B. at the peak of action
helpful. If not contraindicated by cardiac or other health issues, C. at the middle point of duration of action
an increase in sodium and fluid intake usually helps increase D. toward the end of anticipated duration of action
circulating volume and minimizes orthostatic risk.
66. A 68-year-old man is taking multiple medications for
DI SCUSSION SOURCES various chronic conditions. Discontinuing or finding
Lanier J, Mote M, Clay E. Evaluation and management of orthostatic an alternative for which of the following medications
hypotension. Am Fam Physician 84(5):527–536, 2011. will have the greatest impact in decreasing the potential
Merck Manual for Health Professionals. Orthostatic Hypotension. for fall risk?
Available at: www.merckmanuals.com/professional/cardiovas- A. amitriptyline
cular_disorders/symptoms_of_cardiovascular_disorders/ortho- B. sitagliptin
static_hypotension.html. C. atorvastatin
D. aspirin
Falls 67. An older adult who has recently fallen has a(n) ____
times increased risk of falling again within the next year.
60. Most falls in older adults occur in: A. 1 to 2
A. a healthcare institution. B. 2 to 3
B. a public place. C. 3 to 4
C. the patient’s home. D. 4 to 5
D. an outdoor setting.
68. Which of the following is not part of the “Get Up and
61. Which of the following are identifiable risk factors for Go” criteria when evaluating gait and balance for a
falls in the older adult? Choose all that apply. 72-year-old woman who normally uses a walker?
A. negative prior history of a fall A. rising from a straight-backed chair
B. history of a stroke B. walking 10 feet without the use of a walking aid
C. current diagnosis of osteoporosis C. turning around after walking 10 feet
D. osteoarthritis of the hips D. returning to the chair and sitting down
62. The NP is asked to evaluate a 77-year-old woman who 69. With the use of a benzodiazepine in an older adult,
recently had an unexpected fall. The patient is normally the risk of fall is most likely to occur ____ of the
healthy and has no mobility limitations or other obvious medication.
risk factors. During the history, the NP learns that the A. at the onset of action
patient did not attempt to break the fall, “I just suddenly B. at the peak of action
found myself on the floor.” This statement suggests: C. at the middle point of duration of action
A. a previously undiagnosed cognitive impairment that D. toward the end of anticipated duration of action
requires further evaluation.
B. that underlying sensory deficits (visual, hearing) are
the most likely cause of the fall and require physical Answers
assessment.
C. that a history of alcohol use or abuse should be 60. C. 64. D. 67. B.
explored. 61. B, C, D 65. B. 68. B.
D. a syncopal episode requiring a cardiovascular and 62. D. 66. A. 69. B.
neurological evaluation. 63. D.
4074_Ch16_373-396 20/11/14 11:24 AM Page 384
Falls are a significant source of morbidity and mortality in • Did the patient experience dizziness?
the elderly population; multiple falls are associated with in- • Was there a loss of consciousness?
creased risk of death. Approximately one-third of commu- • Did the patient break the fall?
nity-dwelling elderly adults and two-thirds of long-term care • Is this an isolated incident, or are falls occurring more
residents experience falls each year. Of elderly adults who fall, frequently?
20% to 30% sustain moderate to severe injuries that reduce • What medications is the patient taking? In particular,
mobility and independence and increase the risk of prema- notation should be made of newly added medications or
ture death. Older adults are hospitalized for fall-related in- increased dose of existing medications.
juries five times more often than they are for injuries from • Was the patient drinking alcohol or taking other
other causes. For adults 65 years old or older, 60% of fatal potentially intoxicating medications?
falls happen at home, 30% occur in public places, and 10% The assessment of an older adult after a fall should focus
occur in healthcare institutions. on identification of possible correctable fall risk factors
Risk factors for falls are numerous and are modifiable and and fall-related injury and should include, at minimum, the
nonmodifiable (Table 16–4). following:
Polypharmacy, in particular the use of medications asso- • Vital signs and evaluation of orthostasis.
ciated with postural hypotension, increases fall risk. Addi- • Cardiovascular assessment.
tional risks include personal history of a stroke or fall; a • Sensory assessment.
person who has fallen is two to three times more likely to fall • Assessment of gait and balance, including the use of the
within the next year. Environmental hazards in the home, in- “Get Up and Go” test, in which the elderly adult is asked
cluding poorly placed furnishings and inadequate lighting, to rise from a straight-backed chair, walk 10 feet using
often contribute to falls. Wearing thick, soft-soled shoes, such usual walking aid such as a cane if applicable, turn, and
as a jogging shoe, also increases fall risk. return to the chair and sit down, with the clinician
Comprehensive elder care should focus on minimizing observing balance with sitting and on standing, pace
modifiable fall risks. When a fall does occur, the patient and stability with walking, ability to turn without
should be promptly and appropriately assessed. Questions staggering, and time to complete the task.
should be asked to investigate for an underlying condition • Survey for fall-related injuries.
that could have contributed to the fall and is amenable to in- The most common fall-related injuries are osteoporotic
tervention and often subtle age-related changes that can con- fractures of the hip, spine, or forearm. Of all fall-related
tribute to increased fall risk (see Table 16–4). These questions fractures, hip fractures are the most serious and lead to the
are as follows: greatest number of health problems and deaths.
• What was the patient doing when he or she fell? Nonpharmacological interventions to prevent falls include
• Was there an aura or warning that the fall was impending? the following:
• Was there a vision loss? • Review medications; assess doses, and eliminate high-risk
drugs that can contribute to falls (Table 16–5).
• Evaluate for postural hypotension.
• Provide prevention and treatment interventions for
TABLE 16-4 osteoporosis.
Fall and Fracture Risk Factors in • Recommend proper footwear, avoiding slippers, sandals,
Older Adults and soft-soled jogging shoes in favor of an enclosed toe,
tie shoe with a semirigid sole.
Postural hypotension • Provide an obstacle free, well-lit environment.
Sensory impairment including altered vision and • Raise chair heights and seat heights; add arm rests.
hearing • Prescribe physical therapy as indicated.
Parkinsonism • Counsel avoidance of quick position change and to
Osteoporosis perform multiple foot flex maneuvers before trying to
Osteoarthritis move from supine to stand or sit to stand.
Altered gait and balance, including decreased proprio- • Treat for any concomitant conditions associated with
ception, increased postural sway, slower righting increased fall risk.
reflexes, peripheral neuropathy, stroke
Psychotropic medication use, especially products with D I S C U SSI O N S O U R C E S
sedating effect Merck Manual of Geriatrics. Orthostatic hypotension. Available at:
Cardiac drug use, especially products with properties www.merckmanuals.com/professional/cardiovascular_disorders/
that cause or contribute to postural hypotension symptoms_of_cardiovascular_disorders/orthostatic_hypotension.
Environmental hazards html?qt=&sc=&alt.
Patient Safety Authority. Medication assessment: One determi-
Source: Wachel T. Falls. In: Wachel T. Geriatric Clinical Advisor. nant of falls risk. Available at: www.patientsafetyauthority.org/
Philadelphia: Mosby; 2007, pp. 77–78. ADVISORIES/AdvisoryLibrary/2008/Mar5(1)/Pages/16.aspx.
4074_Ch16_373-396 20/11/14 11:24 AM Page 385
TABLE 16-5
Medication Use Associated With Increased Fall Risk in Older Adults
Medication Class Example Comment
Anxiolytics and hypnotics Benzodiazepines, long-acting In particular, gait issues most likely to arise
and shorter acting, including with onset and peak of medication’s
lorazepam, oxazepam, alprazolam, action, usually 1⁄2–2 hr after benzodi-
temazepam, triazolam azepine or hypnotic is taken.
Nonbenzodiazepines including
zolpidem
Antidepressants Tricyclic antidepressants (TCAs), such Orthostatic hypotension risk, typically
as amitriptyline; selective serotonin worse with TCA compared with SSRI use.
reuptake inhibitors (SSRIs), such as
sertraline, citalopram
Neuroleptics and antipsychotics Neuroleptics, including haloperidol; Orthostatic hypotension and dizziness risk
including atypical or SGA including risperidone significant and extrapyramidal movement
second-generation risk.
antipsychotics (SGA)
Opioid analgesics/antagonists Meperidine, morphine, codeine Risk of sedation; meperidine particularly
problematic. Pain should be appropriately
and adequately treated and opioids used
if benefit outweighs risk and with careful
monitoring.
Insulin, oral hypoglycemics Insulins, short-acting and longer Fall risk most often seen in presence
acting; sulfonylureas, such as of drug-induced hypoglycemia. If this
glyburide, glipizide occurs, it is most likely noted at drug’s
peak of action. Glyburide use in the older
adult is not advised due to higher rate
of adverse effects with its use when
compared to other sulfonylureas.
Cardiac medications Antihypertensives including Fall risk increases with excessive diuretic
diuretics, calcium channel blockers use because of circulating volume
(CCBs), high-dose beta blockers, constriction or peripheral vasodilation
and nitrates related to CCB or nitrate use. With
high-dose beta blocker use, normative
heart rate increase with position change
can be blunted, resulting in dizziness.
Note: This list is not intended to include all medications associated with increased fall risk in older adults but
rather to highlight products with well-documented risk.
Source: Patient Safety Authority. Medication assessment: One determinant of falls risk. Available at: www.
patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Mar5(1)/Pages/16.aspx.
71. Factors that contribute to urge incontinence include: 73. Pharmacological intervention for patients with urge
A. detrusor overactivity. incontinence includes the use of:
B. pelvic floor weakness. A. doxazosin (Cardura).
C. urethral stricture. B. tolterodine (Detrol).
D. UTI. C. finasteride (Proscar).
D. pseudoephedrine (Sudafed).
4074_Ch16_373-396 20/11/14 11:24 AM Page 386
74. Intervention for patients with stress incontinence a normal part of aging. In reality, numerous treatment op-
includes: tions are available after the cause of urinary incontinence is
A. establishing a voiding schedule. established (Table 16–6). In all cases, urinalysis and urine
B. gentle bladder-stretching exercises. culture and susceptibility should be obtained. If UTI is pres-
C. periurethral bulking agent injection. ent, treatment with an appropriate antimicrobial is indi-
D. restricting fluid intake. cated. Further diagnostic testing should be directed by
patient presentation.
75. Which form of urinary incontinence is most common
Urge incontinence is the most common form of urinary in-
in older adults?
continence in elderly persons. Behavioral therapy, including a
A. stress
voiding schedule and gentle bladder stretching, are helpful.
B. urge
Pharmacological intervention is indicated in conjunction with
C. iatrogenic
behavioral therapy (Table 16–6). Medication such as toltero-
D. overflow
dine (Detrol) and solifenacin succinate (VESIcare) are selective
76. Medications used to treat urge incontinence and muscarinic receptor antagonists that block bladder receptors
overactive bladder usually have anticholinergic and and limit bladder contraction. Helpful in the treatment of urge
antimuscarinic effects that can lead to problems in incontinence, the use of these products is associated with a de-
older adults including: crease in the numbers of micturitions and of incontinent
A. tachycardia and hypertension. episodes, along with an increase in voiding volume. Oxybu-
B. sedation and dry mouth. tynin (Ditropan) is a nonselective muscarinic receptor antag-
C. agitation and excessive saliva production. onist that blocks receptors in the bladder and oral cavity, with
D. loose stools and loss of appetite. activity similar to that of tolterodine; adverse effects include
dry mouth and constipation with increased risk for fecal im-
77. Poorly controlled diabetes mellitus is a potential cause
paction. An over-the-counter oxybutynin transdermal patch
of reversible urinary incontinence primarily caused by
(Oxytrol for Women, 3.9 mg/day) is available for use in women
which of the following mechanisms?
only with overactive bladder. Darifenacin (Enablex) and fes-
A. increased urinary volume
oterodine fumarate (Toviaz) are newer anticholinergic agents
B. increased UTI risk
approved for urge incontinence. Compared with older agents,
C. irritating effect of increased glucose in the urine
darifenacin is associated with fewer adverse effects, such as con-
D. decreased ability to perceive need to void
fusion, and may be more helpful in older patients with under-
78. A 78-year-old woman who has osteoarthritis affecting lying dementia. Mirabegron (Myrbetriq), a beta-3 adrenoceptor
both knees but no current problems with urinary in- agonist, has been shown to be effective in treatment-naïve pa-
continence is placed on a loop diuretic. She is now at tients as well as those who fail therapy with anticholinergic
increased risk for _________ urinary incontinence. agents. Botulinum toxin injections in the bladder have also been
A. overflow approved and can be effective for those who fail or are intolerant
B. urge of pharmacological treatment. Common to virtually all med-
C. functional ications with systemic anticholinergic effect is the risk of seda-
D. idiopathic tion and alteration in sensorium (Table 16–7). Among the
treatments used for urinary incontinence, oxybutynin tends
79. The diagnosis of ________ should be considered in
to have the greatest anticholinergic effects that can impact the
an older adult with new-onset urinary incontinence
tolerability in older adults.
coupled with an acute change in mental status.
Numerous conditions can contribute to urinary inconti-
A. dementia
nence transiently or permanently. Potentially treatable causes
B. spinal cord compression
of urinary incontinence are represented in the DIAPPERS
C. bladder stone
mnemonic:
D. delirium
Delirium
Infection (urinary tract)
Atrophic urethritis and vaginitis
Answers Pharmaceuticals (diuretics, others)
70. B. 74. C. 78. C. Psychological disorders (depression)
71. A. 75. B. 79. D. Excessive urine output (heart failure, hyperglycemia)
72. B. 76. B. Restricted mobility
73. B. 77. A. Stool impaction
D I S C U SSI O N S O U R C E S
Urinary incontinence is the involuntary loss of urine in suffi- Katzung B. Special aspects in geriatric pharmacology. In: Katzung
cient amounts to be a problem. This condition is often B. Basic and Clinical Pharmacology, ed. 12. New York: McGraw
thought by many elderly adults, women in particular, to be Medical; 2011 pp 1051-1060.
4074_Ch16_373-396 20/11/14 11:24 AM Page 387
Vasavada SP. Urinary incontinence. Available at: http://emedicine. With the aging of the population, there are more elderly drivers
medscape.com/article/452289-overview. on the roads. Census data predict that by 2020, there will be
Resnick NM. Urinary incontinence in the elderly. Medical Grand 53 million persons in the United States more than the age of
Rounds 3:281–290, 1984. 65 years, and approximately 40 million will be licensed drivers.
Weiss B. Selecting medications for the treatment of urinary incon-
Though being older does not necessarily turn a person into an
tinence. Am Fam Physician 71(2):315–322, 2005. Available at:
unsafe driver, it is important to note that age-related changes
www.aafp.org/afp/20050115/315.html.
Vaugan CP, Goode PS, Burgio KL, Markland AD. Urinary incontinence can affect driving skills. These changes not only include dimin-
in older adults. Mt Sinai J Med 78:558–570, 2011. ished vision and hearing but also musculoskeletal changes that
can increase the time to react to changes on the road or the
ability to immediately hit the brakes when necessary. Cognitive
Driving Issues in changes can decrease the attention span of older drivers who
often become more easily distracted. Those with Alzheimer’s-
Older Adults type dementia (AD) can have a changed way of thinking and
behaving. This can include forgetting familiar routes or how
80. Which of the following is a true statement with regard to drive safely and can lead to more driving mistakes or “close
to driving and the elderly? calls.” Though people at early stages of AD are often able to
A. The number of elderly drivers will decrease over the drive safely for a period of time, driving ability will be affected
next decade. as the disease worsens and caregivers should monitor driving
B. Crashes with elderly drivers tend to involve dimin- behavior. Patients with AD typically do not stop driving for at
ished speed of visual processing. least 3 years after the initial diagnosis. There is an eight-fold
C. There is a greater incidence of accidents involving increase in accidents by drivers with mild-to-moderate AD.
right-hand turns compared with left-hand turns. Older driver accidents tend to be related to diminished
D. There is no evidence to suggest, if the elder’s health speed of visual processing and often involve multiple vehicle
is preserved, that the skills needed for safe driving events that occur at intersections and involve left-hand turns.
deteriorate with age. Common driving errors made by older adults include:
81. Which of the following is a false statement with regard • Difficulty backing up and making turns
to driving and Alzheimer’s-type dementia (AD)? • Not seeing traffic signs and other cars quickly enough
A. Patients with AD typically continue to drive for at • Difficulty in locating and retrieving information from
least 3 years following the diagnosis. dashboard displays and traffic signs
B. Those with mild-to-moderate AD have an eight-fold • Delayed glare recovery when driving at night
increase in the number of accidents. • Not checking rearview mirrors and blind spots
C. Those at early stages of AD can continue to drive • Bumping into curbs and objects
safely, though driving should be monitored • Not yielding to oncoming traffic and right-of-way
regularly. vehicles
D. The National Transportation and Safety Board • Irregular or slow vehicle speeds
recommends surrendering the driver’s license for all • Difficulty with situations requiring quick decision making
individuals with an AD diagnosis. Unfortunately, there are no reliable objective measures
available to assess driving competency in older adults. Neu-
82. Common driving errors observed with older drivers ropsychiatric testing cannot be used to indicate the level of
include all of the following except: impairment at which patients are not fit to drive. Addition-
A. difficulty backing up and making turns. ally, the Folstein Mini-Mental Status Examination (MMSE)
B. delayed glare recovery when driving at night. has not been demonstrated to reliably predict driver risk. The
C. bumping into curbs and objects. Clinical Dementia Rating (CDR) can be helpful but is im-
D. tailgating. practical for routine screening practice. The American Acad-
83. When counseling an older driver, you recommend emy of Neurology advocates on-road testing for dementia
all of the following except: patients with a CDR score of 0.5 or higher. The American
A. reviewing current medications for potential adverse Medical Association recommends two tools for screening
effects. older drivers. First, the Physician’s Guide to Assessing and
B. that having the radio on to an enjoyable talk show Counseling Older Drivers can help healthcare providers iden-
enhances driving skills. tify patients at risk for crashes, help enhance their driving
C. predetermining the route before driving. safety, and ease the transition to driving retirement if and
D. driving during the day and in good weather. when it becomes necessary. Second, the National Highway
Traffic and Safety Administration: Part B of the Trail Making
Test and the Clock Drawing Test can be used to assess driving
Answers skills. There is a significant correlation with misplacement of
the minute hand with the incidence of crashes, straddling of
80. B. 81. D. 82. D. 83. B. lanes during driving, and total hazardous errors.
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When counseling older adults on driver safety, several Although the mechanics of illness assessment are similar
steps can be taken to improve safety: when evaluating younger and older adults, certain principles
• Exercise regularly to increase strength and flexibility. must be remembered to ensure accurate interpretation of
• Review prescription and OTC medications to reduce history and physical examination findings in older adults.
adverse effects that can impair driving. Normal age-related changes must be differentiated from
• Have eyes checked annually and wear glasses or corrective indicators of illness. Examples of age-related changes include
lenses as needed. an increased anterior–posterior chest diameter, the presence
• Drive during daylight and good weather. of a corneal ring, and decreased skin turgor.
• Plan the route before you drive. Specific organ systems can be particularly affected by
• Find the safest route with well-lit streets and ample, easy age-related decline, most notably neurological, cardiovas-
to locate parking. cular, musculoskeletal, and lower urinary tract systems. Be-
• Maintain a large following distance behind the car in front. cause of the weakness in these four organ systems, the strain
• Avoid distractions in the car, such as a radio other than of illness or disease in any body system will tend to manifest
soft, background music, talking on the cell phone, texting, in one of these four. Therefore, in the older patient, the
and eating. organ system associated with a particular abnormality or
• Consider potential alternatives to driving, such as riding clinical finding is less likely to be the source of the symp-
with a friend or using public transit. toms when compared with a younger patient. Some com-
mon symptoms observed in older patients that can indicate
DI SCUS SION SOURCES a more serious illness include acute confusion, depression,
AMA Physician’s Guide to Assessing and Counseling Older Drivers. falls, incontinence, and syncope. Some common disease
Available at: www.ama-assn.org//ama/pub/physician-resources/ presentations include:
public-health/promoting-healthy-lifestyles/geriatric-health/ • UTI presents as confusion and/or urinary incontinence.
older-driver-safety/assessing-counseling-older-drivers. • Myocardial infarction presents as confusion.
• Pneumonia presents as a falling episode.
When assessing disease in the elderly, it is also important
Illness Assessment to consider that diseases usually present at an earlier stage
and Atypical when compared with younger patients. This is a result of nor-
mal, age-related decline in compensatory mechanisms. As a
Presentations result, these conditions are generally easier to treat.
Atypical presentations frequently observed in the elderly
84. Which of the following is a true statement with regard include:
to disease presentation in older adults? • Heart failure can be precipitated by mild hypothy-
A. Normal age-related changes do not alter the way an roidism
illness presents. • Mild hyperparathyroidism can result in significant
B. Diseases in the elderly are usually more difficult to cognitive dysfunction
treat because they present at later stages. • Mild prostate hypertrophy can result in urinary
C. A mild decline in memory and information processing retention
is not a normal age-related change. • Mild glucose intolerance can result in nonketotic coma
D. Diseases usually present at earlier stages due to
impaired compensatory systems. D I S C U SSI O N S O U R C E S
85. When evaluating illness symptoms in older patients, Merck Manual of Geriatrics: Evaluation of the Elderly
the disease often presents in a manner different from Patient, available at http://www.merckmanuals.com/
younger adults due to: professional/geriatrics/approach_to_the_geriatric_
A. polypharmacy. patient/evaluation_of_the_elderly_patient.html.
B. increased physiological responses to illness. Katzung B. Special aspects in geriatric pharmacology. In:
C. normal age-related decline. Katzung B. Basic and Clinical Pharmacology, ed. 12.
D. increased compensatory mechanisms. New York: McGraw Medical; 2011, pp 1051-1060.
88. Complications of pressure ulcers include all of the confined to a bed, repositioning should be done every 2 hours.
following except: Special cushions, foam mattress pads, and air- or water-filled
A. squamous cell carcinoma. mattresses can be helpful in keeping a patient in a certain po-
B. osteoporosis. sition and relieve pressure on vulnerable skin. The head of the
C. bone and joint infections. bed should be elevated no more than 30 degrees to prevent
D. cellulitis. shearing. Those in wheelchairs should change position as
much as possible on their own every 15 minutes and should
89. A pressure ulcer that exhibits full-thickness skin loss
have assistance with changing positions every hour.
with a crater-like appearance can be categorized as:
Pressure ulcers are categorized into four categories based
A. stage 1.
on their severity.
B. stage 2.
• Stage 1: a nonblanchable erythema is present on intact
C. stage 3
skin (induration may be present)
D. stage 4.
• Stage 2: presence of epidermal or dermal skin loss; can
90. Appropriate treatment of a stage 1 pressure ulcer can appear as an intact blister
include all of the following except: • Stage 3: full-thickness skin loss with exposure of some
A. ensuring proper nutrition and hydration of the amount of fat; ulcer has a crater-like appearance
patient. • Stage 4: full-thickness skin and tissue loss; wound exposes
B. regular repositioning of the patient. muscle, bone, and tendons
C. debridement of non-vital skin. Stage 1 and stage 2 pressure ulcers can usually heal within
D. special padding for vulnerable skin areas. several weeks to months of general care that manages risks
for pressure ulcers. Stage 3 and stage 4 ulcers are more diffi-
cult to treat and efforts may primarily focus on managing
Answers pain rather than complete healing of the wound. Debride-
ment can be used to remove dead tissue, and regular cleaning
87. D. 88. B. 89. C. 90. C. and dressing the wounds are needed to promote healing and
prevent infection.
Pressure ulcers (also known as bedsores or pressure sores) D I S C U SSI O N S O U R C E S
are injuries to the skin that result from prolonged pressure
Jaul E. Assessment and management of pressure ulcers in the
on the skin. Normally, there is a balance between pressure in-
elderly: Current strategies. Drugs Aging 27:311–325, 2010.
tensity and duration with tissue tolerability. Pressure ulcers
occur when vascular pressure inhibits adequate supply of
blood to the skin and underlying tissue. Significant contribut-
ing factors include sustained pressure, friction, shear, and nu-
Delirium, Dementia,
tritional debilitation. Pressure ulcers are most commonly and Depression
observed in individuals who have medical conditions that
limit their ability to change positions, require the use of a 91 to 95. Identify the following as most likely associated
wheelchair, or are confined to a bed for prolonged periods. with delirium or dementia.
Other risk factors include high moisture, advanced age, low
91. Insidious onset over months to years
blood pressure, smoking, elevated body temperature, lack of
sensory perception, weight loss, urinary or fecal incontinence, 92. Acute onset of change in mental status
decreased mental awareness, and dehydration. Some condi-
tions can mimic pressure ulcers and should be considered 93. Associated with use of medications with
during evaluation, such as fungal and yeast infection, malig- anticholinergic effect
nancy, venous and arterial ulcers, and neuropathic ulcers. 94. Mental status potentially returns to pre illness
Complications of pressure ulcers include sepsis, cellulitis, and baseline
bone and joint infections. Chronic, nonhealing wounds can
also increase the risk of an aggressive type of squamous cell 95. No perceptual disturbances (i.e., hallucinations)
carcinoma (Marjolin’s ulcer). until later disease
Prevention of pressure ulcers requires routine evaluation 96. The most common trigger for delirium is:
of patients at risk. This evaluation can involve using the A. alcohol withdrawal.
Braden scale or Norton scale that measures the physical and B. fecal impaction.
mental condition of the patient, as well as the state of nutri- C. head trauma.
tion, mobility, and continence. Regular nutritional and hydra- D. acute infection.
tion assessment is also important to evaluate risk for pressure
ulcers. Position changes are critical in prevention. For patients
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97. The most common etiology of dementia is: 104. A 81-year-old man who was recently diagnosed with
A. vascular disease. Alzheimer’s-type dementia is accompanied by his
B. Alzheimer’s disease. granddaughter for an office visit. The granddaughter
C. traumatic head injury. reports that her grandfather often acts erratic with
D. drug-drug interaction induced. angry outbursts that can soon be followed by a more
“normal” demeanor. She reports that the grandfather
98. Medications that commonly contribute to delirium
recently moved in with her, and she would like for this
include all of the following except:
to continue as long as possible. In counseling the grand-
A. first-generation antihistamines.
daughter, you consider all of the following except:
B. cardioselective beta-adrenergic antagonists.
A. behavioral difficulties often arise in patients with
C. opioids.
AD if their usual routine is disrupted.
D. benzodiazepines.
B. treatment with a cholinesterase inhibitor will likely
99. Which of the following electrolyte disorders is com- improve his mental status to a point similar to his
monly associated with delirium? pre-dementia baseline.
A. hyponatremia. C. a home safety evaluation should be conducted and
B. hypernatremia. appropriate modification performed.
C. hyperkalemia. D. any sudden change in mental status should be re-
D. hypophosphatemia. ported to the healthcare provider as soon as possible.
100. Older adults are at greater risk of subdural hematoma, 105. Which of the following supplements is used to poten-
even with minor head trauma, due to: tially slow cognitive decline in AD?
A. lower bone density in the skull. A. vitamin B12
B. relatively fragile blood vessels. B. vitamin E
C. decreased adipose tissue reserves. C. ginkgo biloba
D. age-related reduction in circulating clotting D. St. John’s wort
factors.
106. The NMDA receptor antagonist memantine works via:
101. When discussing the use of a cholinesterase inhibitor A. slowing the death of neurons in the brain.
with a 72-year-old woman with a recent diagnosis B. creating an environment that allows for storage
of Alzheimer’s-type dementia and her family, you and retrieval of information.
report that: C. promoting more rapid transduction of nerve signals.
A. this medication will help return memory to her D. a largely unknown mechanism.
pre-illness baseline.
107. Potential noncognitive reasons for behavioral issues ob-
B. the risk associated with the use of this medication
served in older adults include all of the following except:
outweighs its benefits.
A. ADHD.
C. this medication will likely afford clear, although
B. pain.
minor and time-limited, benefits.
C. infection.
D. the medication should have been started earlier to
D. depression.
help prevent any change in cognition.
108 to 110. Match the term with its correct definition.
102. When managing dementia, cholinesterase inhibitors
108. Aphasia A. failure to recognize objects de-
offer the greatest benefit:
109. Apraxia spite intact sensory function
A. for prevention of Alzheimer’s-type dementia.
110. Agnosia B. language disturbance
B. in patients with mild cognitive impairment.
C. impairment of motor activities
C. in patients with mild-to-moderate AD.
despite intact motor function
D. in patients with severe AD.
103. When assessing a 76-year-old man with new-onset 111. The use of antipsychotic medications in older adults is
mental status change, all of the following diagnostic associated with an increased risk for:
tests are essential except: A. stroke and cardiovascular events.
A. serum glucose. B. hypoglycemia.
B. PET scan. C. delirium.
C. CBC with white blood cell differential. D. hypertension.
D. ECG. 112. Dementia syndrome or cognitive impairment that is
associated with severe depression is called:
A. delirium.
B. pseudodementia.
C. Alzheimer’s disease.
D. bipolar disorder.
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113. When managing depression in older adults, all of the • Metabolic (poorly controlled diabetes mellitus, under-
following should be considered except: treated or untreated hypothyroidism or hyperthyroidism);
A. start at the highest dose possible of antidepressant Myocardial problems (myocardial infarction, heart
and then titrate down once symptoms resolve. failure, dysrhythmia).
B. encourage psychotherapy in addition to • Subdural hematoma—Can be as a result of relatively
pharmacotherapy. minor head trauma to brain atrophy, fragile vessels.
C. utilize electroconvulsive therapy for severe The evaluation of a patient with delirium should be focused
depression. on defining the underlying cause. A thorough health history,
D. conduct a medication review to minimize potential including social and home assessment, and a physical exami-
drug-drug interactions. nation should be conducted. A standardized evaluation of men-
tal status must be included in the evaluation. The evaluation of
the patient with mental status change starts with a comprehen-
Answers sive health history and physical examination. Diagnostic testing
should be focused to reveal the diagnosis of the underlying eti-
91. Dementia 99. A. 107. A. ology with potentially reversible conditions (Table 16–6).
92. Delirium. 100. B. 108. B. Delirium treatment is aimed at assessing patients at greatest
93. Delirium. 101. C. 109. C. risk to help avoid its occurrence. When delirium occurs, treat-
94. Delirium. 102. C. 110. A. ment is focused on the condition’s underlying cause. Mental
95. Dementia 103. B. 111. A. status should return to baseline with recovery, although ongo-
96. D. 104. B. 112. B. ing research suggests that perhaps this recovery is incomplete
97. B. 105. B. 113. A. in some individuals. In about two-thirds of all patients with
98. B. 106. B. delirium, the condition resolves within 1 week of onset.
Dementia is defined by a chronic loss of intellectual or cog-
Delirium is a condition in which the patient exhibits an nitive function of sufficient severity to interfere with social or
acute onset, over hours to a few days, of reduced ability to occupational function; this condition is a symptom of an un-
maintain attention to external stimuli and shift attention derlying diagnosis (Table 16–7). In dementia, mental status
appropriately to new stimuli. The result is disorganized changes can evolve insidiously over months or years with a
thinking. Two or more of the following are usually noted: gradually worsening course. The most common causes of
an altered level of consciousness from baseline; memory im- dementia are Alzheimer’s-type and multi-infarct or vascular
pairment; perceptual disturbance, such as hallucinations;
altered sleep; change in psychomotor activity; and disori-
entation to time, place, and person. Delirium is not a diag- TABLE 16-6
nosis but rather a clinical state caused by an underlying
health problem. Following is the DELIRIUMS mnemonic, Evaluation of the Person With
which can serve as a helpful memory aid regarding the most Mental Status Change
common causes of delirium.
The evaluation of the patient with mental status change
• Drugs—When any medication is added or dose is ad-
starts with a comprehensive health history and physical
justed. Particularly problematic medications include
examination. Diagnostic testing should be focused to
anticholinergics (tricyclic antidepressants [TCAs], first-
reveal the underlying etiology with potentially reversible
generation antihistamines), neuroleptics (haloperidol,
conditions.
others), opioids (in particular, meperidine), long-
acting benzodiazepines (diazepam, clonazepam), As Directed by Patient
and alcohol. Definite Presentation
• Emotional (mood disorders, loss); Electrolyte distur- BUN, Cr Brain imaging (CT vs. MRI)
bance, especially hyponatremia. Glucose PET scan
• Low PO2 (hypoxemia from CAP, COPD, PE, MI); Lack Calcium Toxic screen
of drugs (withdrawal from alcohol, other habituating Sodium CXR
substances). Hepatic enzymes ESR
• Infection—Urinary tract infection and community- Vitamin B12/folate HIV
acquired pneumonia (the most common delirium trigger). TSH Additional studies as
• Retention of urine or feces; Reduced sensory input needed
(blindness, deafness, darkness, change in surroundings). RPR
• Ictal or postictal state—Alcohol withdrawal is a common CBC with WBC
reason for an isolated first seizure in an older adult. differential
• Under-nutrition—Protein/calorie, vitamin B12, or folate UA, U C & S
deficiency, dehydration including postoperative volume ECG
disturbance.
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TABLE 16-8
Delirium versus Dementia
Delirium Dementia
DEFINED A sudden state of rapid changes in brain A slowly developing impairment of
function reflected in confusion, changes in intellectual or cognitive function that is
cognition, activity, and level of consciousness progressive and interferes with normal
functioning
ETIOLOGY Precipitated by acute underlying cause, such as Various causes
an acute illness
ONSET Abrupt onset, over hours to days, usually a precise Insidious onset that cannot be related to a
date, rapidly progressive change in mental status precise date, gradual change in mental status
MEMORY Impaired by variable recall Memory loss, especially for recent events
DURATION Duration hours to days Duration months to years
REVERSIBLE? Usually reversible to baseline mental status Chronically progressive and irreversible
when underlying illness resolved
SLEEP DISTURBANCE Disturbed sleep-wake cycle, with hour-to-hour Disturbed sleep-wake cycle but lacks hour-to-
variability, often worse as the day progresses hour variability, often day-night reversal
PSYCHOMOTOR Change in psychomotor activity, either hyperkinetic No psychomotor changes until later in
(25%), hypoactive (25%), or mixed (35%); no disease
change in motor activity in approximately 15%
PERCEPTUAL Perceptual disturbances including hallucinations No perceptual disturbances until later
DISTURBANCES disease.
SPEECH Speech content incoherent, confused with a Speech content sparse, progressing to
wide variety of often inappropriately used sparse speech content; mute in later
words such as misnamed persons and items disease
Note: Delirium and dementia often coexist. The diagnosis of delirium must be considered in the presence of a sudden-onset
change in mental status in the individual with dementia.
Sources: Merck Manual: Overview of Delirium and Dementia. Available at: www.merckmanuals.com/professional/
neurologic_disorders/delirium_and_dementia/overview_of_delirium_and_dementia.html#v1036234.
4074_Ch16_373-396 20/11/14 11:24 AM Page 393
TABLE 16-9
American Academy of Neurology Standards for Care in Alzheimer’s-type Dementia (AD)
Strategy Comment
To slow decline in AD. Vitamin E 1000 IU twice daily or selegiline 5 mg twice
daily. No added benefit to using both products.
The use of NSAIDs and postmenopausal hormone therapy
has not been supported for this purpose.
In mild to moderate stage disease, the use of cholinesterase Cholinesterase inhibitors (donepezil [Aricept], rivastigmine
inhibitors is considered to be the mainstay of treatment. [Exelon], galantamine [Razadyne]) have clear, although
The use of these products in mild cognitive impairment, minor and time-limited benefits by increasing availability
early AD, and severe AD is not supported though study of cholinesterase. This small effect is clinically significant.
on these issues is ongoing.
In moderate to severe AD, further studies of multiple Approved for use in moderate-to-severe AD, NMDA recep-
interventions are needed. tor antagonist memantine (Namenda). Through its effect
on glutamate, helps to create an environment that allows
for storage and retrieval of information. Also used in
earlier disease with cholinesterase inhibitor. Donepezil
also approved for use in more advanced disease.
Treat agitation and depression. Approximately 40% of individuals with dementia will
also have depression. SSRIs, select tricyclic antidepres-
sants, and MAOIs (monoamine oxidase inhibitors) are
appropriate treatment options, bearing in mind potential
drug-drug and drug-food interactions.
Consider reasons (noncognitive) not related to AD for Evaluate for depression, pain, infection, and other clinical
behavioral issues, such as behavioral disturbances. conditions commonly found in older adults.
If environmental manipulation fails to eliminate agitation Antipsychotics best studied for this indication, recognizing
or psychosis in the person with dementia, consider the increased risk of stroke and cardiovascular events
treatment with psychotropic medication. associated with the use of this drug class in older adults
with dementia.
Source: Doody RS, et al. Practice parameter: Management of dementia (an evidence-based review): Report of
the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 56:1154–1166, 2001.
Available at: www.neurology.org/content/56/9/1154.full.pdf.
can take increased effort to complete a mental status exam • Overeating or appetite loss
(MSE) but often do better on MSE questions with some encour- • Thoughts of suicide or suicide attempts
agement and coaching. Neurocognitive testing may be needed • Persistent aches and pains, headaches, cramps, or diges-
to differentiate between pseudodementia and dementia. Treat- tive problems that do not resolve, even with treatment
ing the depression often improves cognition in these patients. For those suspected of depression, several screening tools
Depression in older adults is common but should not be are available to aid in the diagnosis or indicate when further
considered a normal part of aging. Some estimates of major de- investigation is needed (Table 16–10). When considering
pression in older adults range from 1% to 5% for persons living treatment for depression, the patient should be encouraged
in the community but rises to 13.5% for those who require to undergo psychotherapy in addition to any pharmacologi-
home healthcare. Depression is also more common in those cal treatment in order to work on building skills needed to
who have comorbid conditions (e.g., heart disease, cancer). help manage this usually long-term health problem. There
Signs of depression in the elderly can be wide and varied: are several types of antidepressant medications that can be
• Feelings of hopelessness and/or pessimism used to treat depression, including SSRIs, SNRIs, tricyclic an-
• Feelings of guilt, worthlessness, and/or helplessness tidepressants (TCAs), and monoamine oxidase inhibitors
• Irritability and/or restlessness (MAOIs). The type and degree of depression as well as the
• Loss of interest in activities or hobbies that were once adverse effect profile must be considered when selecting an
pleasurable appropriate antidepressant. Some patients are candidates
• Fatigue and decreased energy for other forms of intervention, particularly if there is an in-
• Difficulty concentrating, remembering details, and adequate response to pharmacotherapy and/or psychother-
making decisions apy; one option is electroconvulsive therapy (ECT). ECT is
• Insomnia, early-morning wakefulness, or excessive sleeping safe and effective for all older adults with severe depression,
4074_Ch16_373-396 20/11/14 11:24 AM Page 394
imposed for the purpose of discipline or convenience and not exist in several forms. Living wills and do not resuscitate
required to treat healthcare needs. Restraints are often seen (DNR) orders are contracts between the patient and health-
as the only practical way to protect the safety of elderly care provider that specify wishes for end-of-life care in ter-
patients and reduce the potential for liability if they injure minal events. A durable power of attorney for healthcare
themselves. However, when injury occurs to unrestrained in- authorizes another person to make decisions regarding
dividuals in the institutional setting, successful lawsuits are healthcare when the patient is no longer able (not to be con-
typically not the result of failure to restrain but a failure to fused with a durable power of attorney, which covers decisions
meet reasonable standards of care—that is, there was negli- regarding property and financial matters). Alternatively, a val-
gence in duty to provide care for a wandering patient or ues history can be a written, videotaped, or audiotaped per-
alarm systems were not functional at the institution. Com- sonal discussion that can contain advanced directives that can
mon alternatives for restraints include the use of alarms, be taken into consideration when making end-of-life deci-
using beds or chairs that are close to the floor, and/or ensur- sions. It is important to note that advanced directives are not
ing the unit/floor/facility is equipped to care for a patient with legally binding and not all states recognize them in a legal
known behaviors. If restraints are needed for patient safety, sense. States that do recognize advanced directives only do
it is important for healthcare providers to have a thorough so when the patient is, in the opinion of the healthcare
understanding of the risks and benefits of using restraints. provider, hopelessly and terminally ill.
This will be important in explaining the need for restraints to
family members, who may see their use in a negative manner. D I S C U SSI O N S O U R C E S
Adverse effects of restraints include falls, pressure sores, de- Ziglar SP. Physical restraints in the elderly: To use or not to use.
pression, aggression, and even death. Physical restraints can http://nursing.advanceweb.com/Article/Physical-Restraints-in-
also be a source of aggravation to the patient under restraint. the-Elderly-To-Use-or-Not-to-Use.aspx.
End-of-life decision making has become an important as- National Institute on Aging. End of life: Helping with comfort and
pect of healthcare as technology has changed the circum- care. www.nia.nih.gov/health/publication/end-life-helping-com-
stances of death, providing options on when, where, and how fort-and-care/planning-end-life-care-decisions.
a patient dies. When considering end-of-life decisions for a
terminally ill patient who cannot communicate, several ap-
proaches can be used. Often, an appointed person can make Author’s Note
the decision based on the patient’s past wishes and values. A
rational approach can make the decision based on what a “ra- Please see Index for information on commonly encountered
tional” person would do under the circumstances. A substi- problems in older adults, including urinary tract infection,
tuted judgment approach attempts to determine what male and female genitourinary problems, endocrine disor-
decision the patient would make if he/she was able. ders, pneumonia, chronic obstructive pulmonary disease,
Advanced directives are durable statements of intent heart failure, and others.
based on the patient’s last written wishes and can be used to Dr. Sally Miller’s assistance in the development of this
help make end-of-life decisions. Advanced directives can chapter is gratefully acknowledged.
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4074_Ch17_397-462 20/11/14 4:30 PM Page 397
Pediatrics 17
Breastfeeding 6. Nursing infants generally maximally receive about
which percentage of the maternal dose of a drug?
1. Which of the following is appropriate advice to give to A. 1%
a mother who is breastfeeding her 10-day-old infant? B. 3%
A. “Your milk will come in today.” C. 5%
B. “To minimize breast tenderness, the baby should not D. 10%
be kept on either breast for more than 5 to 10 minutes.”
7. Most drugs pass into breast milk through:
C. “A clicking sound made by the baby during feedings
A. active transport.
signifies a good latch and suck.”
B. facilitated transfer.
D. “The baby’s urine should be light or colorless.”
C. simple diffusion.
2. Which of the following is appropriate advice to give to D. creation of a pH gradient.
a mother who is breastfeeding her 12-hour-old infant?
8. To remove a drug from breast milk through “pump and
A. “You will likely have enough milk to feed the baby
dump,” the nursing mother should refrain from taking
within a few hours of birth.”
the offending medication and the process must be
B. “The baby might need to be awakened to be fed.”
continued for:
C. “Supplemental feeding is needed unless the baby has
A. two infant feeding cycles.
at least four wet diapers in the first day of life.”
B. approximately 8 hours.
D. “The baby will likely have a seedy yellow bowel
C. three to five half-lives of the drug.
movement today.”
D. a period of time that is highly unpredictable.
3. Compared with the use of infant formula, advantages
9. When counseling a breastfeeding woman about alcohol
for the baby of breastfeeding include all of the following
use during lactation, you relate that:
except:
A. drinking a glass of wine or beer will enhance the
A. lower incidence of diarrheal illness.
let-down reflex.
B. greater weight gain in the first few weeks of life.
B. because of its high molecular weight, relatively little
C. reduced risk of allergic disorders.
alcohol is passed into breast milk.
D. lower occurrence of constipation.
C. maternal alcohol use causes a reduction in the
4. At 3 weeks of age, the average-weight, formula-fed amount of milk ingested by the infant.
infant should be expected to take: mL D. infant intoxication can be seen with mother’s having
A. 2 to 3 oz, or 60 to 90 mL, every 2 to 3 hours. as few as one to two alcoholic drinks.
B. 2 to 3 oz, or 60 to 90 mL, every 3 to 4 hours.
10. A 23-year-old woman is breastfeeding her healthy new-
C. 3 to 4 oz, or 90 to 118 mL, every 2 to 3 hours.
born. She wishes to start using hormonal contraception.
D. 3 to 4 oz, or 90 to 118 mL, every 3 to 4 hours.
Which of the following represents the best regimen?
5. In infants, solid foods are best introduced no earlier A. combined oral contraception initiated at 2 weeks
than: B. progesterone-only oral contraception initiated at
A. 1 to 3 months. 3 weeks
B. 3 to 5 months. C. medroxyprogesterone acetate (Depo-Provera) given
C. 4 to 6 months. day 1 postpartum
D. 6 to 8 months. D. use of all forms of hormonal contraception is
discouraged during lactation
397
4074_Ch17_397-462 20/11/14 4:30 PM Page 398
11. Guidelines recommend that a breastfeeding mother Breastfeeding provides the ideal form of nutrition during
waits until breastfeeding is well established for approxi- infancy. According to the Centers for Disease Control and
mately 6 months before using combined oral contra- Prevention (CDC), in the United States, approximately
ceptives (COC) because: 77% of all infants are breastfed at birth, with about 49% of all
A. in early breastfeeding, the amount of hormone in infants continuing at age 6 months. Healthcare providers can
COC could cause significant harm to the nursing help influence successful breastfeeding. Although the content
infant. of commercially prepared formula available in the developed
B. efficacy of COC could be compromised by world continues to be improved with composition closer to
breastfeeding. breast milk, infant formula continues to lack critically impor-
C. milk flow could be compromised by COC. tant components. Breast milk contains immunoactive factors
D. COC oral contraceptive use could affect mother’s that help protect infants against infectious disease and may
sleep patterns. reduce the frequency of allergic disorders. Human milk trans-
fers the mother’s antibodies to disease to the infant. About
12. At what point after childbirth can a combined oral con-
80% of the cells in breast milk are macrophages, cells that
traceptive be started without other risk factors for venous
kill bacteria, fungi, and viruses. In contrast to formula-fed
thrombosis in a woman who is not breastfeeding?
infants, a breastfed infant’s digestive tract contains large
A. 1 day
amounts of Lactobacillus bifidus, beneficial bacteria that
B. 1 week
prevent the growth of harmful organisms.
C. 3 weeks
To promote milk production and reduce the risk of devel-
D. 6 weeks
oping physiologic jaundice, a new mother should be advised
13. The anticipated average daily weight gain during the to keep well hydrated and breastfeed a minimum of 8, prefer-
first 3 months of life is approximately: ably 12, times per 24 hours. Supplementing feeding with
A. 15 g or 0.53 oz. dextrose and water or formula should be avoided because this
B. 20 g or 0.7 oz. will interfere with the newborn’s hunger drive to breastfeed
C. 25 g or 0.88 oz. and will delay and reduce breast milk production. Physiologic
D. 30 g or 1 oz. jaundice usually presents between days 3 and 5 and results
from to the normal breakdown of fetal hemoglobin and
14. The average required caloric intake in an infant from
immature liver metabolism. Unconjugated bilirubin is elevated
age 0 to 3 months is usually:
in this process. If there is an increase in conjugated bilirubin
A. 40 to 60 kcal/kg/d.
or jaundice occurs in the first 24 hours of life, pathological
B. 60 to 80 kcal/kg/d.
etiologies need to be considered, such as an ABO incompati-
C. 80 to 100 kcal/kg/d.
bility, familial Gilbert syndrome, or other anomaly.
D. 100 to 120 kcal/kg/d.
If an infant is formula fed, the parents and caregivers
15. Regarding physiologic jaundice in the newborn, should be encouraged to hold the infant during feeding to
select all that are correct: have the interaction inherent in breastfeeding. Questions
A. It occurs between the first 12 and 24 hours of about frequency, amount, and type of feedings are often
life. asked during well-baby visits. Counseling should be offered
B. It progresses from the abdomen toward the to help ensure optimal nutrition (Box 17–1 and Table 17–1).
head of the infant. If a nursing mother becomes ill or has a chronic health
C. Unconjugated bilirubin is elevated. problem, she is often erroneously advised to discontinue
D. Risk of development of hyperbilirubinemia can breastfeeding on the basis of the healthcare provider’s incor-
be reduced in a breastfed infant with frequent rect assumption by that most medications are harmful to the
breastfeeding every 2 to 3 hours per 24 hours. infant. Most medications can be used during lactation, but
E. It can be avoided by supplemental water and the benefit of improved maternal health should be balanced
dextrose feedings between breastfeeding in against the risk of exposing an infant to medication.
the first 3 to 4 days of life to increase infant Postpartum contraception is usually an important concern
hydration while awaiting mother’s milk to of new mothers. Some women opt not to breastfeed, fearing
come in. an inability to access reliable hormonal contraception while
lactating. Many options are available, however, including the
progestin-only pill (POP) and medroxyprogesterone acetate
Answers (Depo-Provera, Depo-SubQ Provera 104). For lactating
women who wish to use an oral hormonal contraceptive, POP
1. D. 6. A. 11. C. is highly effective and does not alter the quality or quantity of
2. B. 7. C. 12. C. breast milk. One significant disadvantage of POP use is bleed-
3. B. 8. C. 13. D. ing irregularity, ranging from prolonged flow to amenorrhea.
4. A. 9. C. 14. C. Medroxyprogesterone acetate in a depot injection given every
5. C. 10. B. 15. C and D. 90 days is a highly reliable form of contraception with 99.7%
4074_Ch17_397-462 20/11/14 4:30 PM Page 399
BOX 17-1 other risk factors for venous thrombosis (VTE), including
aged 35 or older, history of VTE, thrombophilia, immobil-
Guidelines for Nutrition in the ity, transfusion at delivery, a body mass index (BMI) of
First Months of Life ≥30 kg/m2. postpartum hemorrhage, postcesarean delivery,
preeclampsia, or smoking. In women with lower VTE risk
■ Frequency of feeding during months 1 and 2 and not breastfeeding, COCs can be started as soon as
Breastfed infants: A minimum of 10 minutes at each 21 days postpartum.
breast every 1.5 to 3 hours Nearly all breastfeeding mothers use some type of medica-
Bottle-fed infants: 2–3 oz (60–90 mL) every 2 to tion (most often analgesic agents such as nonsteroidal anti-
3 hours inflammatory drugs, acetaminophen, opioids, or antibiotics)
■ Fluoride supplementation is advisable for breastfed in the first 2 weeks after giving birth. About 25% need to
infants or if formula is not mixed with fluoridated use medication intermittently to manage episodic disease.
water in formula-fed infants Such medications usually include analgesics, antihistamines,
■ Solid foods are best introduced no sooner than age decongestants, and antibiotics.
4 to 6 months About 5% of breastfeeding women have a chronic health
■ Signs that an infant is ready for solid food problem necessitating daily use of a medication; the most
Doubled birth weight and at least 4 to 6 months common long-term medications used are for treating asthma,
of age mental health problems, seizure disorder, and hypertension.
Eats more than 32 oz (946 mL) formula per day or Nursing infants usually get about 1%, often less, of the ma-
more than 8 to 10 feedings (breast or bottle) per day ternal dose, and only a few drugs are contraindicated.
Source: Nemours Foundation, http://kidshealth.org/parent The “pump-and-dump” procedure is not an effective
/nutrition_fit/nutrition/feednewborn.html, Feeding your newborn. means to reduce drug levels in a mother’s milk because it
creates an area of lower drug concentration in the empty
breast. This enables the drug to diffuse from the area of high
concentration (maternal serum) to the area of low concen-
TABLE 17-1 tration (breast milk). If the mother takes a medication that
may be problematic for the nursing infant, she need to
Anticipated Weight Gain and Caloric immediately stop taking the medication. Pumping and
Requirements in the First 3 Years of discarding the milk needs to continue for three to five drug-
Life free half-lives of the medication.
Alcohol has a low molecular weight and is highly lipid sol-
Anticipated Required uble; both of these characteristics allow it to have easy passage
Average Weight Kilocalorie per into breast milk. Even in small amounts, alcohol ingestion by
Age Gain per Day (g) Kilogram per Day a nursing mother can cause a smaller amount of milk to be
0–3 mo 26–31 100–120 kcal produced, reduction in the let-down reflex, and less rhythmic
3–6 mo 17–18 105–115 kcal and frequent sucking by the infant, resulting in a smaller vol-
6–9 mo 12–13 100–105 kcal ume of milk ingested. Cigarette smoking is similarly prob-
9–12 mo 9 100–105 kcal lematic. Nicotine, a highly lipid-soluble substance with a low
1–3 yr 7–9 100 kcal molecular weight, passes easily into breast milk. Maternal cig-
arette smoking can reduce milk supply and expose an infant
to passive smoke. Infant crankiness, diarrhea, tachycardia,
and vomiting have been reported with high maternal nicotine
efficacy. Progestin-only oral contraceptive options can be intake.
started immediately postpartum if the woman is not breast-
feeding and as early as 3 weeks postpartum if she is breast- D I S C U SSI O N S O U R C E S
feeding. A progestin-only implant (Nexplanon or Implanon) Centers for Disease Control and Prevention Press Release: U.S.
is also an option. Earlier use, starting less than 3 weeks post- breastfeeding rates continue to rise, http://content.govdelivery
partum, could diminish the quantity, but not quality, of breast .com/accounts/USCDC/bulletins/858447
milk. Nonsystemic contraceptive methods, such as barrier Summary of Classifications for Hormonal Contraceptive Methods
and Intrauterine Devices: Appendix L. MMWR 59:76–81, 2010.
methods, intrauterine devices, and levonorgestrel intrauterine
Update to CDC’s Medical Eligibility Criteria for Contraceptive
systems, are also acceptable. Use, 2010. Revised Recommendations for the Use of Contra-
Combined oral contraceptives, which utilize both estro- ceptive Methods During Postpartum Period. MMRW 60:
gen and progesterone, could affect milk flow early postpar- 878–883, 2011.
tum and thus ideally should be avoided until the baby has Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation, ed.
been nursing for 6 months or longer and breastfeeding is 9. Philadelphia: Lippincott Williams & Wilkins, 2011.
well established. It is known that combined oral contracep- Hale T. Medications and Mothers’ Milk, 2012, ed. 76. Amarillo, TX:
tives can increase thromboembolic risk in women with Pharmasoft Medical Publishers, 2012.
4074_Ch17_397-462 20/11/14 4:30 PM Page 400
American Association of Clinical Chemistry Clinical Laboratory 24. You examine a healthy 9-month-old infant from a full-
Notes June 2010: Bilirubin, http://aacc.org/publications/cln/2010 term pregnancy and expect to find that the infant:
/june/pages/seriesarticle.aspx A. sits without support.
B. cruises.
C. has the ability to recognize his or her own name.
Early Childhood D. imitates a razzing noise.
Development 25. A healthy 3-year-old child is in your office for well-
child care. You expect this child to be able to:
16. Which of the following is most consistent with a nor- A. name five colors.
mal developmental examination for a 3-month-old in- B. alternate feet when climbing stairs.
fant born at 40 weeks’ gestation? C. speak in two-word phrases.
A. sitting briefly with support D. tie shoelaces.
B. experimenting with sound
C. rolling over 26. Which of the following would not be found in
D. having a social smile newborns?
A. best vision at a range of 8 to 12 inches
17. Which of the following is most consistent with a B. presence of red reflex
normal developmental examination for a thriving C. light-sensitive eyes
5-month-old infant born at 32 weeks’ gestation? D. lack of defensive blink
A. sitting briefly with support
B. experimenting with sound 27. Which of the following do you expect to find in an
C. rolling over examination of a 2-week-old infant?
D. performing hand-to-hand transfers A. a visual preference for the human face
B. a preference for low-pitched voices
18. A healthy full-term infant at age 3 to 5 months should C. indifference to the cry of other neonates
be able to: D. poorly developed sense of smell
A. gesture to an object.
B. bring hands together. 28. Which of the following is the most appropriate re-
C. reach for an object with one hand. sponse in a developmental examination of a healthy
D. feed self a biscuit. 5-year-old child?
A. being able to name a best friend
19. A healthy infant at age 9 to 11 months is expected to: B. giving gender appropriately
A. roll from back to stomach. C. naming an intended career
B. imitate “bye-bye.” D. hopping on one foot
C. play peek-a-boo.
D. hand toy on request. 29. You are examining an 18-month-old boy who is not
speaking any discernible words. Mom tells you he has
20. A healthy 2-year-old child is able to: not said “mama or dada” yet or babbled or smiled
A. speak in phrases of two or more words. responsively. You:
B. throw a ball at a target. A. encourage the mother to enroll her son in daycare to
C. scribble spontaneously. increase his socialization.
D. ride a tricycle. B. conduct further evaluation of milestone attainment.
21. At which age would a child likely start to imitate C. reassure the parent that delayed speech is common
housework? in boys.
A. 18 months D. order audiogram and tympanometry.
B. 24 months 30. The following benchmarks indicate normal develop-
C. 30 months ment by a healthy child born at term who is now
D. 36 months 12-months of age (choose all that apply):
22. A healthy 3-year-old child is expected to: A. talking in two-word sentences.
A. give his or her first and last name. B. pointing to a desired object.
B. use pronouns. C. reaching to a desired object.
C. kick a ball. D. walking backward.
D. name a best friend. 31. It is considered a developmental “red flag” if a child
23. A healthy 6- to 7-month-old infant is able to: does not respond to his or her name by nine months
A. roll from back to stomach. of age.
B. confidently feed self a cracker. A. true
C. reach for an object. B. false
D. crawl on abdomen.
4074_Ch17_397-462 20/11/14 4:30 PM Page 401
TABLE 17-3
Anticipated Early Childhood Developmental Milestones
Age Able to Be Observed During Office Visit Reported by Parent or Caregiver
Newborn • Moves all extremities • Able to be calmed by feeding, cuddling
• Spontaneous stepping • Reinforces presence of developmental tasks
• Reacts to sound by blinking, turning seen in examination room
• Responds to cries of other neonates
• Well-developed sense of smell
• Cries when uncomfortable
• Preference for higher pitched voices
• Primitive reflexes
• Tonic neck
• Palmar grasp
• Babinski response
• Rooting awake and asleep
• Sucking
1–2 mo • Lifts head • Social smile
• Holds head erect • Recognizes parents
• Regards face
• Follows objects through visual field
• Moro and palmar grasp reflexes fading
3–4 mo • Grasps cube • Laughs, squeals, vocalizes in response to
• Reaches for objects others
• Brings objects to mouth • Recognizes food by sight
• Raspberry sound • Rolls back to side
5 mo • Back straight when pulled to sitting • Imitates others
• Bears weight on legs when standing • Repeats interesting actions
• Plays with feet
• Sits with support • Coughs, snorts to attract attention
6–8 mo • Sits without support • Closes lips in response to dislike of food
• Scoops small object with rake grip; some • Rolls back to stomach and stomach to back
thumb use • Recognizes “no”
• Hand-to-hand transfer • Chains together syllables (dada, papa,
• Imitates “bye-bye” mama) but does not have meaning
• Stranger and separation anxiety begins (6 mo)
and increases during this time period
• Pulls feet into mouth
9–11 mo • Crawls, pulling self forward by hands, then • Cruises
creeps with abdomen off floor • Follows simple command, such as “Come
• Stands initially by holding onto furniture, here.” Assigns meaning to words such as
later stands solo “mama, papa, dada”
• Imitates peek-a-boo and pat-a-cake
• Picks up small object with thumb and index
finger
12–15 mo • Initially walks with help, progresses to walk- • Says one to two words
ing solo • Indicates wants by pointing
• Neat pincer grasp • Scribbles spontaneously
• Places cube in cup • Imitates animal sounds
• Hands over objects on request
• Builds tower of two bricks
15–20 mo • Points to several body parts • Uses a spoon with little spilling
• Throws a ball overhand • Walks up and down steps with help
• Seats self in chair • Understands two-step commands
• Climbs • Feeds self
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TABLE 17-3
Anticipated Early Childhood Developmental Milestones—cont’d
Age Able to Be Observed During Office Visit Reported by Parent or Caregiver
• Carries and hugs doll
• Imitates housework
• Speech: 4–6 words by 15 mo, increases to
≥10 words by 18 mo
• Scribbles vigorously
• Builds tower three cubes tall
24 mo • Speaks in sentences of ≥2 words • Runs
• Kicks ball on request • Copies vertical and horizontal lines
• Jumps with both feet • Has up to a 300-word vocabulary
• Uses pronouns • Washes and dries hands
• Is developing handedness • Engages in parallel play
• Puts on simple clothing
30 mo • Walks backward • Gives first and last name
• Hops on one foot • Uses plurals
• Copies circle • Usually separates easily from parents
36 mo • Holds crayons with fingers • Walks down stairs alternating steps
• Nearly all speech intelligible to people not in • Rides tricycle
daily contact with child • Copies circles
• Three-word sentences • Dresses with supervision
3–4 yr • Responds to command to place object in, • Takes off jacket and shoes
on, or under a table • Washes and dries face
• Knows gender • Engages in cooperative play
• Draws circle when one is shown • Speech includes plurals, personal pronouns,
verbs
• Skips
• Asks many questions
4–5 yr • Runs and turns while maintaining balance • Buttons clothes
• Stands on one foot for at least 10 seconds • Dresses self (not including tying shoelaces)
• Counts to four • Can play without adult input for about
• Draws a person without torso 30 min
• Copies (1) by imitation
• Verbalizes activities to do when cold, hungry,
tired
5–6 yr • Catches ball • Able to complete simple chores
• Knows age • Understands concept of 10 items; likely
• Knows right from left hand counts higher by rote
• Draws person with six to eight parts, includ- • Has sense of gender
ing torso
• Identifies best friend
• Likes teacher
6–7 yr • Copies triangle shape • Ties shoelaces
• Draws person with at least 12 parts • Counts to ≥30
• Prints name • Able to differentiate morning from later in
• Reads multiple single-syllable words day
• Generally plays well with peers
• No significant behavioral problems in school
• Can name intended career
7–8 yr • Copies diamond shape • Ties shoelaces
• Reads simple sentences • Knows day of the week
• Draws person with at least 16 parts
Continued
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TABLE 17-3
Anticipated Early Childhood Developmental Milestones—cont’d
Age Able to Be Observed During Office Visit Reported by Parent or Caregiver
8–9 yr • Able to give response to question such as • Able to add, subtract, borrow, carry
what to do if an object is accidentally broken • Understands concept of working as a team
9–10 yr • Knows month, day, year • Able to multiply and do complex subtraction
• Gives months of the year in sequence • Has increased reading fluency
10–12 yr • Beginning of pubertal changes for many • Able to perform simple division
children • Has complex reading skills
Source: Burns CE, Dunn AM, Brady MA, et al. Pediatric Primary Care, ed. 5. Philadelphia: Elsevier Saunders, 2012.
Table 17-4
Findings of Fragile X and Klinefelter Syndrome
Diagnosis Findings
FRAGILE X SYNDROME In males: Large testicles (macroorchidism) after the beginning of puberty, large body habi-
tus, learning and behavioral differences (hyperactivity, developmental disability common),
large forehead, ears, prominent jaw, tendency to avoid eye contact
In females: Significantly less common with fewer prominent findings, usually with less
severe developmental issues
Most common known cause of autism in either gender, 1 in 4000 males and 1 in 8000
females, and occurs in all racial and ethnic groups.
Blood testing available for carrier state (genetic risk for having a child with fragile X
syndrome) or for diagnosis of the condition. Antenatal diagnosis possible.
KLINEFELTER SYNDROME Only males affected, with developmental issues, most commonly language impairment.
XXY MALE Physical habitus = low testicular volume, hip and breast enlargement.
Blood testing available for carrier state (genetic risk for having a child with Klinefelter
syndrome) or for diagnosis of the condition. Antenatal diagnosis possible.
Sources: The National Fragile X Syndrome Society: Fragile X Syndrome Checklist, www.fragilex.org/fragile-x-
associated-disorders/fragile-x-syndrome.
National Institutes of Health: Klinefelter Syndrome, www.ghr.nlm.nih.gov/condition/klinefelter-syndrome.
39. At which of the following ages in a young child’s life is 41. At which of the following ages in a young child’s life is
parental anticipatory guidance about temper tantrums parental anticipatory guidance about protection from
most helpful? falls most helpful?
A. 8 to 10 months A. birth
B. 10 to 12 months B. 2 months
C. 12 to 14 months C. 4 months
D. 14 to 16 months D. 6 months
40. At which of the following ages in a young child’s life is 42. At which of the following ages in a young child’s life is
parental anticipatory guidance about using “time out” parental anticipatory guidance about toilet-training
as a discipline method most helpful? readiness most helpful?
A. 12 to 18 months A. 12 months
B. 18 to 24 months B. 15 months
C. 24 to 30 months C. 18 months
D. 30 to 36 months D. 24 months
4074_Ch17_397-462 20/11/14 4:30 PM Page 405
43. At which of the following ages in a young child’s life is 46. In evaluating a 9-year-old child with a healthy
parental anticipatory guidance about infant sleep posi- BMI during a well visit, a comprehensive cardio-
tion most helpful? vascular evaluation should be conducted by the
A. birth following methods (choose all that apply):
B. 2 weeks A. Obtain fasting lipid profile.
C. 2 months B. Screen for type 2 diabetes mellitus by measuring
D. 4 months HbA1c.
C. Assess for family history of thyroid disease.
D. Assess diet and physical activity.
Answers 47. At what age is it appropriate to recommend
38. C. 40. B. 42. C. dietary changes to parents if overweight or
39. B. 41. A. 43. A. obesity is a concern?
A. 12 months old
B. 5 years old
Developmental C. 10 years old
D. 18 years old
Benchmarks 48. The following are risk factors for type 2 diabetes
Providing health advice to the growing family is a critical role mellitus in children and teens (choose all that
of the NP. During anticipatory guidance counseling, the NP apply):
should review the normal developmental landmarks that the A. hyperinsulinemia.
child is expected to reach in the near future and offer advice B. abnormal weight-to-height ratio.
about how parents can cope with, adapt to, and avoid prob- C. onset of nonorganic failure to thrive in the
lems with these changes. This guidance is tailored to meet the toddler years.
needs of the family but typically follows a developmental D. Native American ancestry.
framework and should continue through adolescence. 49. Screening children with a known risk factor for type 2
diabetes mellitus is recommended at age 10 or at onset
DI SCUSSION SOURCE
of puberty, and should be repeated how often?
American Academy of Pediatrics Bright Futures Tool and Resource A. every other year.
Kit, http://brightfutures.aap.org/tool_and_resource_kit.html B. every year.
C. every six months.
D. if child presents with a body mass index in the 85th
Hypertension, Type percentile or higher.
2 Diabetes, and 50. Prediabetes in children is defined as (choose all
Dyslipidemia in that apply):
A. impaired fasting glucose (glucose level
Children ≥100 mg/dL or 6.2 mmol/L) but
≤125 mg/dL or 7 mmol/L).
44. The following are risk factors for hypertension in B. impaired glucose tolerance (2-hour postpran-
children and teens (choose all that apply): dial ≥140–199 mg/dL or 7.8 mmol/L–
A. being obese. 11 mmol/L).
B. drinking whole milk. C. body mass index in the 85th percentile or
C. being exposed to second-hand smoke. higher.
D. watching 2 or more hours of television per day. D. body mass index in the 60th percentile or
45. Fruit juice intake is acceptable in children 6 months higher.
and older per the following recommendation 51. Risk factors for dyslipidemia in children include
(choose all that apply): (choose all that apply):
A. The juice is mixed in small amounts to flavor A. blood pressure at the 70th to 80th percentile
water. for age.
B. Only 100% juice is used. B. breastfeeding into the toddler years.
C. Juice replaces no more than one serving of milk. C. family history of lipid abnormalities.
D. The juice is consumed in the morning with D. family history of type 2 diabetes mellitus.
breakfast.
E. No more than 6 oz (177 mL) per day is recom-
mended for children 6 months to 5 years.
4074_Ch17_397-462 20/11/14 4:30 PM Page 406
52. Screening cholesterol levels in children with one or follows: acceptable level is <170 mg/dL (<9.4 mmol/L),
more risk factors begins at what age? borderline is 170–199 mg/dL (9.4 mmol/L–11 mmol/L), and
A. birth high is >200 mg/dL (≥11.1 mmol/L) (Table 17–5). Definitions
B. 2 years for elevated low-density lipoprotein (LDL), high-density
C. 5 years lipoprotein (HDL), and triglyceride-specific levels in children
D. 10 years and teens depend on age, gender, and percentile of height.
Children should be screened for family history of cardiovas-
53. An acceptable level of total cholesterol (mg/dL) in chil-
cular disease (CVD) beginning at age 3 and should be peri-
dren and teens is:
odically updated annually or as required by risk factors
A. <170 mg/dL or 9.4 mmol/L.
during non-urgent health visits. As family history and/or risk
B. <130 mg/dL or 7.2 mmol/L.
factors for CVD are identified, the NP should evaluate the
C. 110–130 mg/dL or 6.2 mmol/L–7.2 mmol/L.
child’s family for risk factors, including parents, grandpar-
D. 130–199 mg/dL or 7.2 mmol/L–11 mmol/L.
ents, aunts, and uncles (Table 17–5). For at-risk children,
fasting lipid levels should be tested after 2 years of age
(but no later than 10 years of age) and should be retested in
Answers 3–5 years if the values fall within the reference range.
44. A and C. 48. A, B, D. 52. B. According to CVD screening guidelines, a child’s family
45. A, B, E. 49. A. 53. A. history for obesity should be reviewed beginning at birth.
46. A and D. 50. A and B. Weight-for-height tracking, growth chart, and healthy diet
47. A. 51. C and D. should be discussed with the parents. The NP should
encourage parents to promote physical activity from the
child’s birth. At age 2, encourage active play and recom-
Prevalence of hypertension, type 2 diabetes mellitus, and dys- mend limiting television and other screen time, including
lipidemia has increased in recent years in association with the video games, to no more than total of 2 hours or less per
rise in childhood obesity. Appropriate screening for these con- day. A smoke-free home should be encouraged and smok-
ditions in children and teens can result in earlier diagnosis ing cessation assistance offered to parents. Beginning be-
and treatment, potentially reducing the risk for adult disease tween ages 9 to 11 years, smoking status of the child should
and its complications. be assessed and anti-smoking counseling offered at each
Risk factors for hypertension in children and teens in- visit. Smoking cessation assistance or referral should be
clude a family history of heart disease, high blood pressure, offered when needed.
elevated lipid levels, exposure to tobacco smoke, a diet CVD screening guidelines state that the child’s diet should
low in daily recommended intake of nutrients, obesity, be evaluated at every visit. At birth, the mother should be en-
type 2 diabetes, and lack of physical activity. Risk factors for couraged to breastfeed at least until the infant is 12 months
type 2 diabetes in children include obesity, sedentary of age. If the mother is not breastfeeding, iron-fortified infant
lifestyle, race/ethnicity, family history, augmentation of formula is recommended for the first 12 months; the majority
growth hormone (GH) and insulin-like growth factor of the child’s caloric intake in the first year of life should come
(IGF) secretion during puberty, polycystic ovary syndrome from breast milk or iron-fortified infant formula. From 12 to
(PCOS), hyperandrogenism, intrauterine exposure to 24 months of age, drinking whole cows’ milk is recom-
maternal diabetes, low birth weight, and poor infant growth. mended. After 24 months, children should switch to skim
Risk factors for dyslipidemia in children include family or 1% milk. After 12 months, limit milk to a total of 16 to
history of lipid abnormalities and type 2 diabetes. 24 ounces (480–720 mL) a day. Fruit juice should contain
Prediabetes in children is defined as impaired fasting glucose 100% juice without added sugar if possible, should not
(glucose level ≥100 mg/dL or 5.6 mmol/L but ≤125 mg/dL or replace breast milk or formula, and should be introduced no
7 mmol/L) or impaired glucose tolerance (2-hour postprandial earlier than 6 months of age. Intake should be limited to
≥140–199 mg/dL or 7.8 mmol/L–11 mmol/L) or an A1C of 6 ounces a day for children 6 months to 5 years old. Parents
5.7% to 6.4%. Diagnosis of type 2 diabetes is confirmed if ran- and caregivers should be encouraged to use small amounts
dom plasma glucose level is ≥200 mg/dL or 11.1 mmol/L in of fruit juice to flavor water, therefore increasing fluid intake
conjunction with symptoms of 2 diabetes or an A1C ≥6.5%. while minimizing excessive juice intake. If vitamin C intake
Screening for type 2 diabetes begins at age 10 or at onset of pu- from fresh fruit is adequate, fruit juice does not need to be
berty and continues every 2 years until adulthood; at that point, part of the child’s diet. Dietary guidelines for children should
the adult guidelines should be followed. Criteria for screening be recommended and reinforced throughout childhood.
includes a BMI greater than 85th percentile for age and sex, Body mass index (BMI) should be measured beginning at
weight-for-height greater than 85% percentile, or weight of age 2. For children between 12 months and 2 years of age for
more than 120% of ideal for height, plus any two or more of the whom overweight or obesity is a concern, the use of reduced-
aforementioned risk factors. fat milk would be appropriate. Beginning at age 5, if BMI is
The AAP screening guidelines for total cholesterol levels ≥85th percentile, intensify dietary and activity changes to the
in children and adolescents aged 2 to 19 years old are as parent. The National Diabetes Education Program provides
4074_Ch17_397-462 20/11/14 4:30 PM Page 407
Table17-5
Lipid Screening and Cardiovascular Health in Childhood
1. The population approach to a healthful diet should be recommended to all children older than 2 years, according
to Dietary Guidelines for Americans. This approach includes the use of low-fat dairy products. For children between
12 months and 2 years of age for whom overweight or obesity is a concern or who have a family history of obesity,
dyslipidemia, or cardiovascular disease (CVD), the use of reduced-fat milk would be appropriate.
2. The individual approach for children and adolescents at higher risk for CVD and with a high concentration of low-
density lipoprotein (LDL) includes recommended changes in diet with nutritional counseling and other lifestyle inter-
ventions such as increased physical activity.
3. The most current recommendation is to screen children and adolescents with a positive family history of dyslipidemia
or premature ( ≤55 years of age for men and ≤65 years of age for women) CVD or dyslipidemia. It is also recom-
mended that pediatric patients for whom family history is not known or those with other CVD risk factors, such as
overweight (body mass index [BMI] ≥85th percentile, <95th percentile), obesity (BMI ≥95th percentile), hypertension
(blood pressure ≥95th percentile), cigarette smoking, or diabetes mellitus, be screened with a fasting lipid profile.
4. For these children, the first screening should take place after 2 years of age but no later than 10 years of age. Screen-
ing before 2 years of age is not recommended.
5. A fasting lipid profile is the recommended approach to screening because there is no currently available noninvasive
method to assess atherosclerotic CVD in children. This screening should occur in the context of well-child and health-
maintenance visits. If values are within the reference range on initial screening, the patient should be retested in 3 to
5 years.
6. For pediatric patients who are overweight or obese and have a high triglyceride concentration or low HDL concentra-
tion, weight management is the primary treatment, which includes improvement of diet with nutritional counseling
and increased physical activity to produce improved energy balance.
7. For patients 8 years and older with an LDL concentration of ≥190 mg/dL/10.6 mmol/L (or ≥160 mg/dL/8.9 mmol/L
with a family history of early heart disease or ≥2 additional risk factors present or ≥130 mg/dL/7.2 mmol/L if diabetes
mellitus is present), pharmacologic intervention should be considered. The initial goal is to lower LDL concentration to
<160 mg/dL/8.9 mmol/L. However, targets as low as 130 mg/dL/7.2 mmol/L or even 110 mg/dL/6.2 mmol/L may be
warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes
mellitus, the metabolic syndrome, and other higher risk situations.
Source: Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health in
childhood. Pediatrics 122;1:198–208, 2008.
This schedule includes recommendations in effect as of January 1, 2014. Any dose not administered at the
recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a
combination vaccine generally is preferred over separate injections of its equivalent component vaccines.
4074_Ch17_397-462 20/11/14 4:30 PM Page 409
Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement
for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically
significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting
System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).
Figure 17-1 Birth-18 Years & “Catch-up” Immunization Schedules United States, 2013 (CDC Guidelines). Available at
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html; accessed 10/16/13.
Continued
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – United States, 2014.
410
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the blue bars in Figure 1.
To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.
Diphtheria, tetanus, & acel- 1st dose 2nd dose 3rd dose 4th dose 5th dose
lular pertussis3 (DTaP: <7 yrs)
4074_Ch17_397-462 20/11/14 4:30 PM Page 410
Pneumococcal conjugate6
1st dose 2nd dose 3rd dose 4th dose
(PCV13)
Pneumococcal polysaccha-
ride6 (PPSV23)
Inactivated poliovirus7 (IPV) 1st dose 2nd dose 3rd dose 4th dose
(<18 yrs)
8 (IIV; LAIV) 2 doses
Annual vaccination (IIV only) Annual vaccination (IIV or LAIV)
for some: See footnote 8
Measles, mumps, rubella9 1st dose 2nd dose
(MMR)
Human papillomavirus1 2
(3-dose
(HPV2: females only; HPV4: series)
males and females)
Meningococcal1 3 (Hib-Men-
CY > 6 weeks; MenACWY-D Booster
See footnote 13 1st dose
>9 mos; MenACWY-CRM
≥ 2 mos)
Range of Range of recommended Range of recommended Range of recommended ages Not routinely
recommended ages for ages for catch-up ages for certain high-risk during which catch-up is recommended
all children immunization groups encouraged and for certain
high-risk groups
This schedule includes recommendations in effect as of January 1, 2014. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination
vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed
recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System
(VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including
precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]).
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of Family Physicians
(http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
NOTE: The above recommendations must be read along with the footnotes of this schedule.
Figure 17-1 —cont’d
FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2014.
that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow.
Persons aged 4 months through 6 years
4 weeks5
dose administered at < 7 months old
4074_Ch17_397-462 20/11/14 4:30 PM Page 411
4 weeks dose)5
12 months administered between 7 through 11 months (regardless of Hib
Haemophilus 8 weeks OR This dose only necessary for children aged 12 through
type b5 6 weeks 59 months who received 3 (PRP-T) doses before age
No further doses needed administered at younger than age 12 months; OR 12 months and started the primary series before age
7 months
12 months.
No further doses needed if previous dose administered at age
15 months or older
4 weeks
12 months 4 weeks if current age is younger than 12 months
if current age is 12 This dose only necessary for children aged 12 through
Pneumococcal6 6 weeks administered at age 12 months or older months or older 59 months who received 3 doses before age 12
No further doses needed No further doses needed for healthy children if previous dose months or for children at high risk who received 3
administered at age 24 months or older administered at age 24 months or older doses at any age
Measles, mumps, 12
months 4 weeks
rubella9
Measles, mumps,
rubella9 12 months 4 weeks
NOTE: The above recommendations must be read along with the footnotes of this schedule.
411
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For vaccine recommendations for persons 19 years of age and older, see the adult immunization schedule.
Additional information
• For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online
at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
• For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months.
• Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered ≥5 days earlier than the minimum interval or minimum age
should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further
details, see MMWR, General Recommendations on Immunization and Reports / Vol. 60 / No. 2; Table 1. Recommended and minimum ages and intervals between vaccine doses available online at
CHAPTER 17
http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
• Information on travel vaccine requirements and recommendations is available at http://wwwnc.cdc.gov/travel/destinations/list.
4074_Ch17_397-462 20/11/14 4:30 PM Page 412
• ,” in General Recommendations
on Immunization (ACIP), available at http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.; and American Academy of Pediatrics. Immunization in Special Clinical Circumstances, in Pickering LK, Baker CJ,
Kimberlin DW, Long SS eds. Red Book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics.
1. Hepatitis B (HepB) vaccine. (Minimum age: birth) 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks.
Routine vaccination: Exception: DTaP-IPV [Kinrix]: 4 years)
Pediatrics
• For unvaccinated children aged 15 months or older, administer only 1 dose. 3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the
• For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, please see the most recent dose of PPSV23.
meningococcal vaccine footnotes and also MMWR March 22, 2013; 62(RR02);1-22, available at • For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart
http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf. disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral
Vaccination of persons with high-risk conditions: corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received
• Children aged 12 through 59 months who are at increased risk for Hib disease, including PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be
chemotherapy recipients and those with anatomic or functional asplenia (including sickle cell disease), administered at least 8 weeks after any prior PCV13 dose.
•
with sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital
months of age, should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received
2 or more doses of Hib vaccine before 12 months of age should receive 1 additional dose. associated with treatment with immunosuppressive drugs or radiation therapy, including malignant
• For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ
received a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s) transplantation; or multiple myeloma.
at least 3 months following therapy completion. 7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)
• Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen Routine vaccination:
of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history; •
doses should be administered at least 4 weeks apart. dose in the series should be administered on or after the fourth birthday and at least 6 months after
• A single dose of any Hib-containing vaccine should be administered to unimmunized* children and the previous dose.
adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine Catch-up vaccination:
should be administered at least 14 days before procedure. •
• Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
should be administered to unimmunized* persons aged 5 years or older who have anatomic or • If 4 or more doses are administered before age 4 years, an additional dose should be administered at
functional asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age age 4 through 6 years and at least 6 months after the previous dose.
• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6
* Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine months after the previous dose.
after 14 months of age are considered unimmunized. • If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless
6. Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23) of the child’s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older.
Routine vaccination with PCV13: • For other catch-up guidance, see Figure 2.
• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months. 8.
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV
(PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). Routine vaccination:
Catch-up vaccination with PCV13: •
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should
CHAPTER 17
completely vaccinated for their age. NOT be administered to some persons, including 1) those with asthma, 2) children 2 through 4 years who
• For other catch-up guidance, see Figure 2. had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions that
■
Vaccination of persons with high-risk conditions with PCV13 and PPSV23: MMWR
• All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. 2013; 62 (No. RR-7):1-43, available at http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf.
• For children 2 through 5 years of age with any of the following conditions: chronic heart disease For children aged 6 months through 8 years:
(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including • For the 2013–14 season, administer 2 doses (separated by at least 4 weeks) to children who are
leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional vaccinated previously will also need 2 doses. For additional guidance, follow dosing guidelines in the
Pediatrics
asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment MMWR 2013; 62 (No. RR-7):1-43, available at
with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf.
•
1. Administer 1 dose of PCV13 if 3 doses of PCV (PCV7 and/or PCV13) were received previously. recommendations.
2. Administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV (PCV7 and/or PCV13) For persons aged 9 years and older:
were received previously. • Administer 1 dose.
413
9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination) 13. Meningococcal conjugate vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for
Routine vaccination: MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo])
• Administer a 2-dose series of MMR vaccine at ages12 through 15 months and 4 through 6 years. The second Routine vaccination:
• Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster
• Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the dose at age 16 years.
United States for international travel. These children should be revaccinated with 2 doses of MMR •
receive a 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.
risk is high), and the second dose at least 4 weeks later. • For children aged 2 months through 18 years with high-risk conditions, see below.
• Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the Catch-up vaccination:
• Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.
and the second dose at least 4 weeks later. •
CHAPTER 17
Catch-up vaccination: age 16 through 18 years with a minimum interval of at least 8 weeks between doses.
• Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum •
4074_Ch17_397-462 20/11/14 4:30 PM Page 414
interval between the 2 doses is 4 weeks. • For other catch-up guidance, see Figure 2.
10. Varicella (VAR) vaccine. (Minimum age: 12 months) Vaccination of persons with high-risk conditions and other persons at increased risk of disease:
Routine vaccination: • Children with anatomic or functional asplenia (including sickle cell disease):
• Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The 1. For children younger than 19 months of age, administer a 4-dose infant series of MenHibrix or Menveo
second dose may be administered before age 4 years, provided at least 3 months have elapsed since at 2, 4, 6, and 12 through 15 months of age.
2. For children aged 19 through 23 months who have not completed a series of MenHibrix or Menveo,
Pediatrics
interval of 12 weeks). 4. For other catch-up recommendations for these persons, refer to MMWR 2013; 62(RR02);1-22, available
Catch-up vaccination: at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm.
• Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18
years if not previously vaccinated. For complete information on use of meningococcal vaccines, including guidance related to
• Use recommended routine dosing intervals (see above) for vaccine series catch-up. vaccination of persons at increased risk of infection, see MMWR March 22, 2013; 62(RR02);1-22,
available at http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
American Academy of Pediatrics Bright Futures Practice Guides, 66. Which of the following should not receive vaccination
http://brightfutures.aap.org/practice_guides_and_other_ against influenza?
resources.html A. a 19 year old with a history of hive-form reaction to
eating eggs
B. A 24-year-old woman who is 8 weeks pregnant
Influenza C. a 4-month-old infant who was born at 32 weeks’
gestation
61. When advising parents about injectable influenza im- D. A 28-year-old woman who is breastfeeding a
munization, the clinician considers the following about 2 week old
the vaccine:
A. The vaccine is contraindicated with a personal his- 67. The most common mode of influenza virus transmis-
tory of an anaphylactic reaction to eggs. sion is via:
B. Its use is limited to children older than 2 years. A. contact with a contaminated surface.
C. The vaccine contains live virus. B. respiratory droplet.
D. Its use is recommended for members of households C. saliva contact.
of high-risk patients. D. skin-to-skin contact.
62. A 7-year-old child with type 1 diabetes mellitus is about
to receive injectable influenza vaccine. His parents and
Answers
he should be advised that:
A. the vaccine is more than 90% effective in preventing 61. D. 64. A. 67. B.
influenza. 62. C. 65. C.
B. use of the vaccine is contraindicated during antibi- 63. A. 66. C.
otic therapy.
C. localized immunization reactions are common.
D. a short, intense, flu-like syndrome typically occurs
Influenza is a viral illness that typically causes many days of
after immunization.
incapacitation and suffering and the risk of hospitalization
63. When giving influenza vaccine to a 7-year-old who has and death. Children with influenza commonly have acute
not received this immunization in the past, the NP con- otitis media, nausea, and vomiting in addition to the afore-
siders that: mentioned signs and symptom. Although the worst symp-
A. two doses 4 weeks or more apart should be given. toms in most uncomplicated cases resolve in about 1 week,
B. a single dose is adequate. the cough and malaise often persist for 2 or more weeks.
C. children in this age group have the highest rate of Individuals with ongoing health problems such as pul-
influenza-related hospitalization. monary or cardiac disease, young children, and pregnant
D. the vaccine should not be given to a child with shell- women also have increased risk of influenza-related com-
fish allergy. plications including pneumonia.
Influenza viruses spread from person to person largely via
64. With regard to seasonal influenza prevention in well
respiratory droplet from an infected person, primarily
children, the NP considers that:
through a cough or sneeze. Children remain infectious for 10
A. compared with school-aged children, younger chil-
or more days after the onset of symptoms and can shed the
dren (≤24 months old) have an increased risk of
virus before the onset of symptoms. People who are immuno-
seasonal influenza-related hospitalization.
compromised can remain infectious for up to 3 weeks.
B. a full adult dose of seasonal influenza vaccine should
Historically, the risks for complications, hospitalizations,
be given starting at age 4 years.
and deaths from influenza are higher among adults older than
C. the use of the seasonal influenza vaccine in well
65 years, young children, and individuals of any age with certain
children is discouraged.
underlying health conditions than among healthy older
D. widespread use of the vaccine is likely to increase the
children and younger adults. In children younger than 5 years,
risk of eczema and antibiotic allergies.
hospitalization rates for influenza-related illness have ranged
65. When advising a patient about immunization with the from approximately 500/100,000 for children with high-risk
nasal spray flu vaccine, the NP considers the following: medical conditions to 100/100,000 for children without high-
A. its use is acceptable during pregnancy. risk medical conditions. Influenza strains such as H1N1, an
B. its use is limited to children younger than age influenza A virus also known as swine flu, and H5N1, an in-
2 years. fluenza A virus also known as avian flu, appear to cause a
C. it contains live virus. greater disease burden in younger adults. Considering these
D. A potentially harmful virus can be shed to vulnera- factors, influenza is a potentially serious illness with significant
ble household members post vaccination. morbidity and mortality risk across the life span.
4074_Ch17_397-462 20/11/14 4:30 PM Page 416
Immunization is considered to be generally effective with TIV given intradermally, and the high-dose IM TIV. The
rates varying based on type of virus strain, regions of the standard dose is given to children and teens younger than
country, age; it also varies year to year. In general individuals 18 years old (see Table 17–6). Having a mild illness or taking
aged 2 through 50 tend to be well protected by the flu vaccine, an antibiotic is not a contraindication to any immunization,
whereas those on either end of the age spectrum having including influenza. The injectable vaccine does not contain
greater risk. Historically, influenza vaccine has been 70% to live virus and is not shed. Injectable influenza vaccine is
80% effective in preventing or reducing the severity of the recommended for household members of high-risk patients
influenza A and B viruses. to avoid transmission of infection.
The CDC recommends that all members of the population The nasal-spray flu vaccine, also known as live attenuated
age 6 months and older should receive annual immunization influenza vaccine (LAIV), differs from the injectable in-
against seasonal influenza (Table 17–6). In addition, certain fluenza vaccine or “flu shot” because it contains weakened
groups at highest risk of influenza complications or transmis- live influenza viruses instead of killed viruses and is admin-
sion should be prioritized for immunization. The optimal istered by nasal spray instead of injection. The nasal-spray flu
time to receive seasonal influenza vaccine is usually in Octo- vaccine contains three different influenza viruses that are
ber or November, about 1 month before the anticipated onset sufficiently weakened as to be incapable of causing disease
of the flu season in the northern hemisphere. When a child but have sufficient strength to stimulate a protective immune
younger than 8 years receives influenza vaccine for the first response. The viruses in the LAIV are cold adapted and
time, two doses 4 or more weeks apart should be given. temperature sensitive. As a result, the viruses can grow in the
Pregnant women should be immunized against influenza; nose and throat but not in the lower respiratory tract, where
the vaccine can be given regardless of pregnancy trimester. the temperature is higher. LAIV is currently approved for use
Partly because of the change in the respiratory and immune in healthy people 2 to 49 years old. Aside from the age restric-
system normally present during pregnancy, influenza is five tions, individuals who should not receive LAIV include those
times more likely to cause serious disease in a pregnant woman with a health condition that places them at high risk for
compared with a nonpregnant woman. In addition, women complications from influenza, including patients with
who are immunized against influenza during pregnancy are chronic heart or lung disease, such as asthma or reactive
able to pass a portion of this protection on to the unborn child, airway disease, patients with immunosuppression, children
providing important protection during the first 6 months of or adolescents receiving long-term aspirin therapy, people
life. Flu vaccine is also safe to give during lactation. Injectable with a history of Guillain-Barré syndrome, pregnant women,
trivalent influenza vaccine (TIV), more commonly called the and people with a history of allergy to any of the components
“flu shot,” is available in a variety of forms. These include the of LAIV. While there is a potential to have virus shed from
standard-dose TIV, given intramuscularly (IM), the low-dose the nose post LAIV administration, this is not harmful to
Table 17-6
Advisory Committee on Immunization Practices (ACIP) Recommendations on Influenza
Immunization
Routine influenza vaccination is recommended for all persons aged 6 months and older. Although everyone should get a
flu vaccine each flu season, certain patient populations are at high risk of having serious flu-related complications or live
with or care for people at high risk for developing flu-related complications. This populations include:
• Pregnant women
• Children younger than 5 years, especially children younger than 2 years old
• Individuals age 50 years of age and older
• Individuals of any age with certain chronic medical conditions
• Residents of nursing homes and other long-term-care facilities
• People who live with or care for those at high risk for complications from flu, including:
Healthcare workers
Household contacts of persons at high risk for complications from the flu
Household contacts and out-of-home caregivers of children younger than 6 months of age (these children are too
young to be vaccinated)
All children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive two doses.
Children who received only one dose of a seasonal influenza vaccine in the first influenza season should receive two
doses, rather than one, the following influenza season.
Source: Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)—United States, 2013–2014; MMWR 62(RR07);1–43, 2013.
4074_Ch17_397-462 20/11/14 4:30 PM Page 417
close contacts under virtually all circumstances. Adverse ef- 69. You are making rounds in the nursery and examine the
fects include nasal irritation and discharge, muscle aches, sore neonate of a mother who is HBsAg-positive. Your most
throat, and fever. appropriate action is to:
Until relatively recently, egg allergy was considered a con- A. administer hepatitis B immune globulin (HBIG).
traindication to receiving all forms of influenza vaccine. Current B. isolate the infant.
recommendations advise that most individuals with an egg C. administer hepatitis B immunization.
allergy can safely receive the influenza vaccine (Table 17–7). D. give hepatitis B immunization and HBIG.
Table 17-7
Providing Influenza Vaccine With Egg Allergy History
The following recommendations apply when considering influenza vaccination for patients who have or report a history
of egg allergy.
1. People who have experienced only hives following exposure to egg should receive influenza vaccine with the follow-
ing additional measures:
• Because studies published to date involved use of TIV, TIV (flu shot) rather than LAIV should be used.
• Vaccine should be administered by a healthcare provider who is familiar with the potential manifestations of egg allergy.
• Vaccine recipients should be observed for at least 30 minutes for signs of a reaction following administration of
each vaccine dose.
• Other measures, such as dividing and administering the vaccine by a two-step approach and skin testing with
vaccine, are not necessary.
2. People who report having had reactions to egg involving angioedema, respiratory distress, lightheadedness, or recur-
rent emesis, or persons who required epinephrine or other emergency medical intervention, particularly those that
occurred immediately or within minutes to hours after egg exposure, are more likely to have a serious systemic or
anaphylactic reaction upon re-exposure to egg proteins. Before receipt of vaccine, such persons should be referred to
a clinician with expertise in the management of allergic conditions for further risk assessment.
3. Some people who report allergy to egg might not be egg allergic. Those who are able to eat lightly cooked egg
(scrambled eggs) without reaction are unlikely to be allergic. Conversely, people with egg allergy might tolerate egg
in baked products (bread, cake, other bakery products); tolerance to egg-containing foods does not exclude the pos-
sibility of egg allergy. Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and
egg-containing foods plus skin and/or blood testing for immunoglobulin E antibodies to egg proteins.
4. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for
the reaction, is a contraindication to receipt of influenza vaccine.
Source: Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory
Committee on Immunization Practices (ACIP)—United States, 2013–2014; MMWR 62(RR07);1–43, 2013.
4074_Ch17_397-462 20/11/14 4:30 PM Page 418
73. In healthy children, the second and third doses of the third dose is delayed, it should be administered as soon as
HBV vaccine should be separated by at least how possible. However, it is not necessary to restart the series if
much time? a vaccine dose is missed.
A. 4 weeks Universal infant vaccination against HBV was recom-
B. 8 weeks mended in 1991, and routine adolescent vaccination was rec-
C. 6 months ommended in 1996. One major at-risk group is adults who
D. 1 year have not received the vaccine. As with all vaccines, immu-
nization against HBV should be delayed only in the face of
74. Jason is a healthy 18 year old who presents for primary
serious or life-threatening illness and not for milder illness.
care. According to his immunization record, he re-
Approximately 90% to 95% of people who receive the vaccine
ceived two doses of HBV vaccine 1 month apart at age
develop HBsAb after three doses, which implies protection
14 years. Which of the following best describes his HBV
from the virus. Routine testing for the presence of HBsAb
vaccination needs?
after immunization is not generally recommended.
A. He should receive a single dose of HBV vaccine now.
Perinatal transmission of HBV is highly efficient and usu-
B. A three-dose HBV vaccine series should be started
ally occurs during exposure to blood during labor and deliv-
during today’s visit.
ery. Infants who have been infected perinatally with HBV
C. He has completed the recommended HBV vaccine
have an estimated 25% lifetime chance of developing hepa-
series.
tocellular carcinoma or cirrhosis. As a result, all pregnant
D. He should be tested for HBsAb and further immu-
women should undergo screening for hepatitis B surface anti-
nization recommendations should be made accord-
gen (HBsAg) at the first prenatal visit, regardless of HBV vac-
ing to the test results.
cine history, because the vaccine is not 100% effective and a
75. Universal infant vaccination against HBV was recom- woman could have been infected with HBV before preg-
mended in what year? nancy. Women at particularly high risk for new HBV acqui-
A. 1972 sition during pregnancy should be retested for HBsAg in later
B. 1978 pregnancy.
C. 1982 During the first 24 hours of life, a neonate born to a
D. 1991 mother with HBV should receive HBV vaccine and hepatitis
B immune globulin (HBIG) to minimize the risk of perinatal
76. Routine adolescent vaccination against HBV was rec-
transmission and subsequent development of chronic HBV
ommended in what year?
infection. If maternal HBsAg status is unknown, a situation
A. 1996
common in children who have been adopted internationally,
B. 1991
consideration should be given to testing the child for evidence
C. 1982
of perinatal acquisition of HBV infection.
D. 1978
Without intervention, the risk for chronic HBV infection
is 70% to 90% by age 6 months in a newborn infant whose
mother is positive for both HBsAg and HBeAg and <10%
Answers for infants of women who are HBsAg positive but HBeAg
68. C. 71. B. 74. A. negative. HBV vaccine and one dose of HBIG administered
69. D. 72. B. 75. D. within 24 hours after birth are 85% to 95% effective in pre-
70. C. 73. B. 76. A. venting both acute HBV infection and chronic infection.
HBV vaccine administered alone beginning within 24 hours
after birth is 70% to 95% effective in preventing perinatal
Hepatitis B virus (HBV) infection is caused by a small, dou- HBV infection. Infants of infected mothers should then
ble-stranded DNA virus that contains the inner protein of complete the vaccine series, which should be followed by
hepatitis B core antigen and an outer surface of hepatitis B postvaccination serological testing to determine whether the
surface antigen. The virus is transmitted through exchange infant has developed immunity or chronic HBV infection.
of blood and body fluids. HBV infection can be prevented Infants diagnosed with chronic HBV infection should receive
by limiting exposure to blood and body fluids and through appropriate follow-up and treatment.
immunization. Recombinant HBV vaccine, which does not D I S C U SSI O N S O U R C E S
contain live virus, is well tolerated but is contraindicated in
Centers for Disease Control and Prevention: Hepatitis B for Health-
a person who has a history of anaphylactic reaction to
care Professionals, http://www.cdc.gov/NCIDOD/DISEASES/
baker’s yeast. HBV vaccine is recommended routinely for hepatitis/b,Viral hepatitis B.
all infants and is administered in a three-injection series at Advisory Committee on Immunization Practices (ACIP) recom-
0, 1, and 6 months of age. If the vaccine series is interrupted mended immunization schedule for persons aged 0 through
after the first dose, the second dose should be administered 18 years—United States, 2013. MMWR 62:2–8, 2013.
as soon as possible. The second and third doses should A comprehensive immunization strategy to eliminate transmission of
be separated by an interval of at least 8 weeks. If only the hepatitis B virus infection in the United States—Recommendations
4074_Ch17_397-462 20/11/14 4:30 PM Page 419
of the Advisory Committee on Immunization Practices (ACIP) — 82. How is the varicella virus most commonly transmitted?
Part 1: Immunization of infants, children, and adolescents. MMWR A. droplet transmission
54(RR16):1–23, 2005. B. contact with inanimate reservoirs
A comprehensive immunization strategy to eliminate transmission of C. contact transmission
hepatitis B virus infection in the United States—Recommendations
D. waterborne transmission
of the Advisory Committee on Immunization Practices (ACIP) —
Part II: Immunization of adults. MMWR 55(RR16):1–25, 2006. 83. Which groups with no history of varicella infec-
tion or previous immunization should be targeted
for vaccination (choose all that apply)?
Varicella A. those born before 1980
B. individuals >8 years old with HIV infection with
77. Which of the following statements is correct about the CD4+ T-lymphocyte counts ≥200 cells/L
varicella vaccine? C. adults and children with a history of anaphylactic
A. This vaccine contains killed varicella-zoster virus reaction when exposed to neomycin
(VZV). D. day-care workers
B. A short febrile illness is common during the first
days after vaccination. 84. Which group is shown to have the highest rate of vari-
C. Children should have a varicella titer drawn before cella mortality?
receiving the vaccine. A. children aged 6 and younger
D. Rarely, mild cases of chickenpox have been reported B. teenagers aged 12–19
in immunized patients. C. adults aged 30–49
D. health-care workers
78. Expected outcomes with the use of varicella vaccine
include a reduction in the rate of all of the following
except: Answers
A. shingles.
B. Reye syndrome.
C. aspirin sensitivity. 77. D. 80. C. 83. B and D.
D. invasive varicella. 78. C. 81. B. 84. C.
79. D. 82. A.
79. A parent asks about varicella-zoster immune globulin,
and you reply that it is a:
A. synthetic product that is well tolerated. VZV causes the highly contagious, systemic disease com-
B. derived blood product that has been known to monly known as chickenpox. Varicella infection usually
transmit infectious disease. confers lifetime immunity. Reinfection may be seen, however,
C. blood product obtained from a single donor. in patients who are immunocompromised. More often,
D. pooled blood product with an excellent safety re-exposure causes an increase in antibody titers without
profile. causing disease.
VZV can lie dormant in sensory nerve ganglion. Later
80. A healthy child with no evidence of immunity is ex-
reactivation causes shingles, a painful, vesicular-form
posed to chickenpox at school. How soon after expo-
rash in a dermatomal pattern. About 15% of people who
sure will a dose of the varicella vaccine prevent or
have had chickenpox develop shingles at least once during
modify the disease in the child?
their lifetime. Shingles rates are markedly reduced in peo-
A. only if given the same day
ple who have received the varicella vaccine compared with
B. only if given within 2 to 3 days
people who have had chickenpox. The virus is transmitted
C. if given within 3 to 5 days
via respiratory droplet and contact with open lesions.
D. if given within 1 week
Chickenpox can be serious, especially in infants, who are
81. Maria is a 28-year-old well woman who is 6 weeks preg- immunocompromised.
nant and voices her intent to breastfeed her infant for at A patient-reported history of varicella is considered a
least 6 months. Her routine prenatal laboratory testing valid measurement of immunity, with 97% to 99% of per-
reveals she is not immune to varicella. Which of the sons having serological evidence of immunity. Individuals
following represents the best advice for Maria? born before 1980 also have evidence of immunity. Individ-
A. She should receive VZV vaccine once she is in her uals who are recommended to present evidence of immu-
second pregnancy trimester. nity through serologic testing include pregnant women, and
B. Maria should be advised to receive two appropri- immunocompromised persons. Varicella immunity should
ately timed doses of VZV vaccine after giving birth. be confirmed through varicella titers, even in the presence
C. Once Maria is no longer breastfeeding, she should of a positive varicella history, in healthcare workers because
receive one dose of VZV vaccine. of their risk of exposure and potential transmission of the
D. A dose of VZIG should be administered now. disease.
4074_Ch17_397-462 20/11/14 4:30 PM Page 420
Diphtheria and
Tetanus
85. An 11-year-old well child presents with no documented
primary tetanus immunization series. Which of the fol-
lowing represents the immunization needed?
A. three doses of DTaP (diphtheria, tetanus, acellular
pertussis) vaccine 2 months apart
B. tetanus immune globulin now and two doses of
tetanus-diphtheria (Td) 1 month apart
Figure 17-2 Skin Lesions in Varicella. C. one dose of Tdap (tetanus, diphtheria, acellular per-
tussis vaccine) followed by two doses of Td (tetanus,
diphtheria) in 1 and 6 months
The varicella vaccine contains live attenuated virus. The D. Td (tetanus, diphtheria) as a single dose
vaccine is administered in two doses, one at age 1 year and
the second at age 4 to 6 years. Older children and adults with 86. Problems after tetanus immunization typically include:
no history of varicella infection or previous immunization A. localized reaction at site of injection
should receive two immunizations 4 to 8 weeks apart. In par- B. myalgia and malaise
ticular, healthcare workers, people >8 years old with HIV and C. low-grade fever
CD4+ T-lymphocyte counts ≥200 cells/L, family contacts D. diffuse rash
of immunocompromised patients, and daycare workers with- 87. Which wound presents the greatest risk for tetanus
out evidence of varicella immunity should be targeted for infection?
varicella vaccine. In addition, adults who are in environments A. a puncture wound obtained while playing in a garden
with a high risk of varicella transmission (e.g., college dormi- B. a laceration obtained from a knife used to trim raw
tories, military barracks, long-term-care facilities) should re- beef
ceive the immunization if there is no evidence of varicella C. a human bite
immunity. D. an abrasion obtained by falling on a sidewalk
Pregnant women should be assessed for evidence of vari-
cella immunity. Women who do not have evidence of immu- 88. Infection with Corynebacterium diphtheriae usually
nity should receive the first dose of varicella vaccine on causes:
completion or termination of pregnancy and before discharge A. a diffuse rash.
from the healthcare facility. The second dose should be ad- B. meningitis.
ministered 4 to 8 weeks after the first dose. C. pseudomembranous pharyngitis.
For healthy children older than 12 months without evi- D. a gastroenteritis-like illness.
dence of immunity, vaccination within 3 to 5 days of expo-
sure to varicella is beneficial in preventing or modifying the
disease. Studies have shown that vaccination administered Answers
within 3 days of exposure to rash is at least 90% effective in
preventing varicella, whereas vaccination within 5 days of ex- 85. C. 86. A. 87. A. 88. C.
posure to rash is approximately 70% effective in preventing
varicella and 100% effective in modifying severe disease. The tetanus infection is caused by Clostridium tetani, an anaer-
The vaccine is highly protective against severe, invasive obic, gram-positive, spore-forming rod. This organism is
varicella; however, mild forms of chickenpox are occasionally found in soil and is particularly potent in manure. If con-
reported after immunization. Varicella immune globulin, as tracted, it enters the body through a contaminated wound and
with all forms of immune globulin, provides temporary, causes a life-threatening systemic disease characterized by
passive immunity to infection. Immune globulin is a pooled painful muscle weakness and spasm (“lockjaw”). Diphtheria
blood product with an excellent safety profile. Although most is caused by C. diphtheriae, a gram-negative bacillus. This in-
cases are seen in children younger than age 18 years, fection is typically transmitted person-to-person or through
the greatest varicella mortality is found in persons 30 to contaminated liquids such as milk. Diphtheria is characterized
49 years old. by severe respiratory tract infection, including the appearance
of pseudomembranous pharyngitis. Pertussis, or whopping
DI SCUS SION SOURCES cough, is a highly contagious disease that is passed from per-
Centers for Disease Control and Prevention. Varicella vaccination: in- son to person by droplets from coughing or sneezing. Many
formation for healthcare providers, http://www.cdc.gov/vaccines/ infants are infected by older siblings, parents, or caregivers
vpd-vac/varicella/default-hcp.htm who might be unaware that they have the disease. Symptoms
Centers for Disease Control and Prevention. Assessing immunity of pertussis usually develop within 7 to 10 days after being
to varicella, http://www.cdc.gov/chickenpox/hcp/immunity.html exposed, but they may appear up to 6 weeks later. If left
4074_Ch17_397-462 20/11/14 4:30 PM Page 421
untreated, adverse outcomes from pertussis can lead to pneu- 90. When answering questions about hepatitis A vaccine,
monia, seizures, brain damage, or death. All three infections you consider stating that it:
are now uncommon because of widespread immunization. The A. contains live virus.
DTaP vaccine is administered to infants and children, and the B. should be given to all children unless contraindicated.
booster vaccine Tdap is given to adolescents and adults. Chil- C. frequently causes systemic postimmunization
dren should get five doses of DTaP vaccine, one dose at each reaction.
of the following ages: 2 months, 4 months, 6 months, 5 to D. is nearly 100% protective after a single injected dose.
18 months and 4 to 6 years. A child who has a life-threatening
91. The hepatitis A vaccine should be administered in
allergic reaction or has suffered a brain or nervous system dis-
childhood per the following schedule:
ease within 7 days after a dose of DTaP should not be given
A. two doses 3 months apart.
another dose. DT does not contain acellular pertussis and is
B. two doses 6 months apart.
used as a substitute for DTaP for children who cannot tolerate
C. two doses 1 year apart.
the pertussis vaccine. The rate of adverse effects with acellular
D. two doses are not recommended because of efficacy
pertussis vaccine is quite low; problems were more commonly
of a single dose.
noted with the older whole-cell pertussis vaccine form that is
no longer in use in North America. 92. Family members and caregivers of an international
Tetanus and diphtheria immunizations with or without adoptee should be given the hepatitis A vaccine per the
acellular pertussis are well tolerated and produce few adverse following schedule:
reactions. A short-term, localized area of redness and warmth A. two doses 6 months apart, one dose before the child
is common and is not predictive of future problems with arrives.
tetanus immunization. B. two doses 3 months apart, one dose before the child
A single dose of Tdap is recommended for people 11 arrives.
through 64 years of age. A booster tetanus dose every 10 years C. two doses 1 year apart, one dose before the child
is recommended, but protection is likely provided for 20 to arrives.
30 years after a primary series. Using the tetanus–diphtheria D. one dose before the child arrives in the United States.
(Td) vaccine rather than the tetanus toxoid form for the pri-
93. Usual treatment option for a child with hepatitis A
mary series and booster doses in adults also assists in keeping
includes:
diphtheria immunity.
A. interferon alpha.
The use of a single dose of Tdap during adulthood pro-
B. ribavirin.
vides additional protection from pertussis, whereas older
C. acyclovir.
children (7 through 18 years old) undergoing a “catch-up”
D. supportive care.
immunization schedule should receive one Tdap and two Td
doses at the appropriate interval. Women, including teens,
should receive Tdap during each of their pregnancies (prefer-
ably in the third trimester between the 27th and 36th week).
Answers
At the time of a wound-producing injury, tetanus immune 89. D. 91. B. 93. D.
globulin may provide temporary protection for individuals who 90. B. 92. A.
have not received tetanus immunization. The tetanus booster
and appropriate antibiotics should also be administered, if
needed. Hepatitis A infection is caused by hepatitis A virus (HAV), a
DI SCUSSION SOURCES small RNA virus. It is transmitted primarily by oral–fecal
contact, including through sexual and household contact;
Centers for Disease Control and Prevention: Diphtheria, http://www
however, common-source foodborne outbreaks also occur
.cdc.gov/diphtheria/clinicians.html.
Centers for Disease Control and Prevention: Tetanus, http://www periodically as a result of poor hand-washing by food han-
.cdc.gov/vaccines/vpd-vac/tetanus. dlers with HAV infection. The likelihood of having symp-
Centers for Disease Control and Prevention: Pertussis, http://www toms with HAV infection is related to age; children younger
.cdc.gov/vaccines/vpd-vac/pertussis/default.htm. than 6 years of age are likely to have symptoms (>70%),
whereas older children and adults are typically asymptomatic.
Signs and symptoms typically last <2 months, although 10%
Hepatitis A to 15% of symptomatic persons have disease lasting up to 6
months. Symptoms, which are not specific to which type of
89. Which of the following is one of the more common hepatitis, include fever, malaise, anorexia, nausea, abdominal
sources of hepatitis A infection in the United States? discomfort, dark urine, and jaundice. The only method of di-
A. receiving blood products agnosing the type of hepatitis is via laboratory diagnosis.
B. ingestion of raw shellfish Hepatitis A is typically a self-limited infection that resolves
C. drinking municipally sourced tap water drinking water with supportive care. Acute liver failure can occur in rare (<1%)
D. exposure to fecally contaminated food cases, including among adults age >50 years and in individuals
4074_Ch17_397-462 20/11/14 4:30 PM Page 422
with chronic liver disease. In developing countries with inade- 96. Which of the following is the route of transmission of
quately treated water, most children contract this disease by age the poliovirus?
5 years. Since the implementation of universal childhood HAV A. fecal–oral
vaccination in the United States, rates of hepatitis A infection B. droplet
have declined among all age groups. The local public health de- C. blood and body fluids
partment should be consulted for advice when a suspected or D. skin-to-skin contact
documented outbreak of hepatitis A infection occurs.
97. Post-polio syndrome is commonly marked by:
All children at 1 year of age (12–23 months), all children and
A. muscular hypertrophy.
adolescents age 2 to 18 years in communities with high inci-
B. muscle atrophy
dence of HAV, any person traveling to or from countries with
C. flulike symptoms
intermediate- to high-risk incidence of HAV (such as adoptees),
D. increased mortality
and select high-risk groups (such as injection drug users, men
who have sex with men, and persons with chronic liver disease)
should be immunized against HAV. HAV vaccination is also
recommended for all previously unvaccinated persons who
Answers
anticipate close personal contact (e.g., household contact or reg- 94. D. 95. B. 96. A. 97. B.
ular babysitting) with an international adoptee from a country
of high or intermediate endemicity during the first 60 days
following arrival of the adoptee in the United States. The first Polioviruses are highly contagious and capable of causing
dose of the two-dose hepatitis A vaccine series (given at 0 and paralytic, life-threatening infection. The viral infection is
6 months) should be administered as soon as adoption is transmitted by the fecal–oral route. Rates of infection among
planned, ideally 2 or more weeks before the arrival of the household contacts may be as high as 96%. Most people in-
adoptee. Two doses of HAV vaccine are recommended (at 0 fected with polio have no symptoms. Between 4% and 8% of
and 6 months) to ensure an enhanced immunological response. those infected have minor symptoms, including fever, fatigue,
However, the first dose of HAV vaccine is highly efficacious nausea, headache, flulike symptoms, stiffness in the neck and
(94%–100%). HAV vaccine, which does not contain live virus, back, and pain in the limbs, which often resolve. Less than
is usually well tolerated without systemic reaction. 1% of polio cases result in permanent paralysis of the limbs,
DI SCUS SION SOURCES usually the legs. Of those paralyzed, 5% to 10% die when the
paralysis strikes the respiratory muscles.
Wasley AF, Bell B. Prevention of Hepatitis A through active or pas-
Post-polio syndrome (PPS) is a condition that affects polio
sive immunization: Recommendations of the Advisory Commit-
tee on Immunization Practices (ACIP). MMWR 55:1–23, 2006. survivors years after recovery from an initial acute attack of
Updated recommendations from the Advisory Committee on Im- the poliomyelitis virus. Polio survivors may experience grad-
munization Practices (ACIP) for use of Hepatitis A vaccine in ual weakening of muscles that were affected by the polio
close contacts of newly arriving international adoptees. MMWR infection. The most common symptoms include slowly
58;1006–1007, 2009. progressive muscle weakness, generalized and muscular
fatigue, and muscle atrophy. Pain from joint degeneration
and increasing skeletal deformities such as scoliosis is
Polioviruses common and can precede the weakness and muscle atrophy.
PPS is rarely life-threatening, but the symptoms can signifi-
94. Which of the following statements is true about oral
cantly interfere with an individual’s quality of life.
poliovirus vaccine (OPV)?
Since 1994 North and South America have been declared
A. It contains killed virus.
free of indigenous poliomyelitis, largely because of the efficacy
B. It is the preferred method of immunization in North
of poliovirus immunization. The vaccine is available in two
America.
forms: a live-virus vaccine that is given orally (OPV) and an
C. Two doses should be administered by a child’s
injectable vaccine that contains inactivated virus (IPV).When
fourth birthday.
OPV is used, a small amount of weakened virus is shed via the
D. After administration of OPV, attenuated live
stool. This shedding presents household members with possible
poliovirus can be shed from the stool.
exposure to poliovirus, resulting in a rare risk of paralytic po-
95. Which of the following statements is true about inacti- liomyelitis, known as vaccine-associated paralytic poliomyelitis
vated poliovirus vaccine (IPV)? (VAPP). Because of VAPP risk, OPV is no longer used in the
A. It contains live virus. United States and Canada, but it is used in other countries.
B. It is the preferred method of immunization in North IPV is given as an injection in the leg or arm, depending on
America. the patient’s age. Most adults likely received polio vaccine in
C. Two doses should be administered by a child’s childhood if fully immunized. Children should be given four
fourth birthday. doses of IPV at the following ages: 2 months, 4 months, 6 to
D. After administration of IPV, live poliovirus is 18 months, and a booster dose at 4 to 6 years. A child with a
usually shed from the stool. life-threatening allergy to any component of IPV, including
4074_Ch17_397-462 20/11/14 4:30 PM Page 423
the antibiotics neomycin, streptomycin, or polymyxin B, 104. Intervention for a child with a lead level of 5 to
should not be given IVP. Children with severe allergic reac- 44 mcg/dL usually includes all of the following except:
tions to a dose of IVP should not receive another one. Al- A. removal from the lead source.
though adverse effects of IPV have not been documented B. iron supplementation.
among pregnant women or their fetuses, vaccination of preg- C. chelation therapy.
nant women should be avoided, according to CDC guidelines. D. encouraging a diet high in vitamin C.
to paint, other household products contain lead hazards, in- 107. The rate of bronchiolitis is highest in which age
cluding traditional home health remedies such as azarcon group:
and greta, which are used for upset stomach or indigestion A. toddlers.
in the Hispanic and other ethnic communities, and select im- B. school-aged children.
ported products including candies, toys, jewelry, cosmetics, C. preschool children.
pottery, and ceramics. Additional sources include drinking D. infants younger than age 2 years.
water contaminated by lead leaching from lead pipes, solder,
108. The most common causative organism of bronchioli-
brass fixtures, or valves and consumer products, including
tis is:
tea kettles and vinyl blinds.
A. Haemophilus influenzae.
Clinical manifestation of lead poisoning is usually not ap-
B. parainfluenza virus.
parent until a child’s lead level is markedly elevated. Symp-
C. respiratory syncytial virus.
toms of elevated lead levels include abdominal pain and
D. coxsackievirus.
cramping, aggressive behavior, anemia, constipation, diffi-
culty sleeping, headaches, irritability, loss of previous devel- 109. One of the most prominent clinical features of bron-
opmental skills in young children, low appetite and energy, chiolitis is:
and reduced sensations. Very high levels of lead can result in A. fever.
vomiting, staggering walk, muscle weakness, seizures, or B. vomiting.
coma. Because most children have low-level exposure or C. wheezing.
chronic lead exposure with few or no symptoms, periodic D. conjunctival inflammation.
screening of all children is recommended. Primary preven-
110. Which of the following laboratory tests can identify
tion of lead poisoning should be the goal to reduce risk for
the causative organism of bronchiolitis?
all children. After lead risk is identified, removing the child
A. nasal washing antigen test
or limiting exposure is vital.
B. antibody test via blood sample
A measure of 5 mcg/dL is now used to identify children
C. urine culture
with elevated blood lead levels. This value is in the highest
D. a laboratory test is not available
2.5% for children aged 1 to 5 years in the U.S. population.
In the past, blood lead levels of 10 mcg/dL were defined as 111. In most children with bronchiolitis, intervention in-
elevated. This lower value is being used to identify more cludes:
children likely to have lead exposure, allowing parents, A. aerosolized ribavirin therapy.
healthcare providers, public health officials, and communi- B. supportive care.
ties to take action earlier to reduce future exposure to lead. C. oral theophylline therapy.
Most children with lead levels of 5–44 mcg/dL are treated D. oral corticoid steroid therapy.
with removal from the source, improved nutrition, and iron
112. Common clinical findings in a young child with bron-
therapy. Those with lead levels of 45–50 mcg/dL are treated
chiolitis include all of the following except:
with a chelation agent such as succimer, in addition to the
A. pharyngitis.
previously listed interventions. For children with lead levels
B. tachypnea.
of greater than 51 mcg/dL, hospital admission with expert
C. bradycardia.
evaluation is likely the most prudent course to avoid serious
D. conjunctivitis.
problems (including encephalopathy) associated with
markedly elevated lead levels.
Additional findings include tachypnea, mild fever, conjunc- 115. An infant is born with port-wine stain and Sturge-
tivitis, and pharyngitis. Bronchiolitis is usually diagnosed by Weber syndrome. The two conditions are unlikely to
clinical findings; rapid antigen tests of nasal washings provide be related.
rapid, accurate RSV detection, which can be supplemented A. true
with cell culture. Early detection can be particularly helpful in B. false
the setting of an outbreak in a daycare or other similar setting.
116. A 10-day-old child presents with multiple raised le-
According to the CDC, these tests are 80% to 90% sensitive and
sions resembling flea bites over the trunk and nape of
are most reliable in young children and less accurate in older
the neck. The infant is nursing well and has no fever
children or adults.
or exposure to animals. These lesions likely represent:
Infants and children infected with RSV usually show
A. erythema toxicum neonatorum.
symptoms within 4 to 6 days of infection. Infants with a
B. milia.
lower respiratory tract infection typically have rhinorrhea
C. acne neonatorum.
and a decrease in appetite. Cough usually develops 1 to
D. staphylococcal skin infection.
3 days later, followed by sneezing, fever, and/or wheezing.
In very young infants (<3 months) irritability, decreased ac- 117. Milia is usually marked by white pinpoint papular le-
tivity, and apnea may be the only symptoms of infection. In sions found:
most children, bronchiolitis runs a course of 2 to 3 weeks. A. on the back and buttocks.
These findings resolve as ciliary function returns. Younger B. across the chest.
infants and children with weakened immune systems can be C. in the underarms.
contagious for as long as 3 weeks. D. on the nose and cheeks.
Supportive therapy is usually sufficient. In infants
118. Milia is typically caused by:
younger than 3 months and in children with chronic health
A. low levels of androgen.
problems, hypoxemia or hypercapnia may necessitate hos-
B. enlarged sebaceous glands.
pital admission for hydration and oxygenation. The use of
C. excessive oil production in the skin follicles.
corticosteroids, ribavirin, and bronchodilators, including
D. an unknown etiology.
beta2-agonists, remains controversial with little evidence of
efficacy, although standard asthma therapies are effective in 119. Milia are treated by the following method:
children who also have underlying reactive airway disease. A. no special skin care.
Long-term sequelae of bronchiolitis often include recurrent B. a topical retinoid.
airway reactivity. C. cryotherapy.
D. a topical antimicrobial.
DI SCUSSION SOURCES
Centers of Disease Control and Prevention: Respiratory Syncytial
120. Typical distribution of acne neonatorum consists of
Virus Infection, http://www.cdc.gov/rsv/. open and closed comedones and pustules:
National Institutes of Health: Bronchiolitis, http://www.nlm.nih.gov/ A. on the hands and wrists.
medlineplus/ency/article/000975.htm. B. on the neck and chest.
C. on the forehead and cheeks.
D. on the neck and ears.
Dermatology 121. Acne neonatorum treatment options include which of
Conditions in the following (more than one can apply)?
A. no special skin care is needed because these lesions
Younger Children are self-resolving
B. topical retinoids
113. You examine a newborn with a capillary hemangioma C. oral antibiotic
on her thigh. You advise her parents that this lesion: D. low-dose benzoyl peroxide
A. is likely to increase in size over the first year of life.
B. should be treated to avoid malignancy. 122. An Asian couple comes in with their 4-week-old in-
C. usually resolves within the first months of life. fant, who has blue–black macules scattered over the
D. is likely to develop a superimposed lichenification. buttocks. These most likely represent:
A. benign mottling.
114. You examine a 2-month-old infant with a port-wine B. mongolian spots.
lesion over her right cheek. You advise the parents C. ecchymosis.
that this lesion: D. hemangioma.
A. needs to be surgically excised.
B. grows proportionally with the child. 123. The clinician anticipates that a child with mongolian
C. becomes lighter over time. spots will cry out because of discomfort when the area
D. can become malignant. is gently pressed or palpated.
A. true
B. false
4074_Ch17_397-462 20/11/14 4:30 PM Page 426
124. Eczema is thought to be caused by: abundance of sebaceous glands. The cause is likely the ma-
A. overactive mucous glands. ternal androgenic effect on the sebaceous glands. Benign in
B. allergic reaction. nature, milia resolve without special therapy by 4 weeks to
C. degradation of mast cells. 6 months of life. The infant’s parents and caregivers should
D. dry air. be advised to avoid attempting to remove or open milia as
this could result in scarring.
125. The most important aspect of skin care for children
Erythema toxicum neonatorum is a benign rash of unknown
with eczema is:
etiology that occurs in about 50% of full-term infants. Usually
A. frequent bathing with antibacterial soap.
beginning in the first 10 days of life, the lesions look like flea
B. consistent use of medium- to high-potency topical
bites and are widely distributed; the palms and soles are spared.
steroids.
The lesions usually fade by 5 to 7 days after eruption without
C. application of lubricants.
specific treatment and do not seem to bother the infant.
D. treatment of dermatophytes.
Mongolian spots occur in about 90% of children of
126. A common site for eczema in infants is the: African and Asian ancestries and in less than 10% of children
A. dorsum of the hand. of European ancestry. The distribution is usually over the
B. face. lower back and buttocks but can occur over a wider area.
C. neck. Caused by an accumulation of melanocytes, these are benign
D. flexor surfaces. lesions that typically fade by age 7 without special therapy.
Uninformed providers can misinterpret this normal finding
as an ecchymotic area, raising the suspicion of child abuse.
Answers In contrast to an area of bruising or ecchymosis, when a mon-
golian spot is pressed or palpated, there is no discomfort.
113. A. 118. B. 123. B. Acne neonatorum consists of open and closed comedones
114. B. 119. A. 124. C. and pustules over the forehead and cheeks, similar to the ado-
115. B. 120. C. 125. C. lescent version of the condition. The etiology is likely the effect
116. A. 121. A, D. 126. B. of maternal androgens on the infant’s skin. It usually resolves
117. D. 122. B. in about 4 to 8 weeks but occasionally persists up to age 1 year.
Low-dose benzoyl peroxide can be used as therapy, although
the lesions typically resolve without intervention.
Numerous dermatologic conditions are found in infancy and Eczema or atopic dermatitis is a manifestation of a Type I
early childhood. Parents understandably have concerns about hypersensitivity reaction. This type of reaction is caused when
these lesions. It is important for the NP to have a thorough immunoglobulin E antibodies occupy receptor sites on mast
knowledge of common conditions (Table 17–8). cells, causing a degradation of the mast cells and subsequent
Capillary, or strawberry, hemangioma is a congenital vas- release of histamine, vasodilation, mucous gland stimulation,
cular malformation. Such lesions are rarely present at birth and tissue swelling. There are two subgroups of type I hyper-
but become evident in the first weeks of life, growing rapidly sensitivity reactions: atopy and anaphylaxis.
in the first year, then plateauing in size, and eventually re- The atopy subgroup comprises numerous common clinical
gressing. About 90% disappear by age 9, usually leaving conditions, such as allergic rhinitis, atopic dermatitis, allergic
bluish vascularity over the area. If the lesion is large or in- gastroenteropathy, and allergy-based asthma. Atopic diseases
volves a vital organ such as the eye or extremity, treatment have a strong familial component and tend to cause localized
by an expert in the condition is indicated. Oral propranolol rather than systemic reactions. Individuals with atopic disease
is commonly used for treatment; current recommendations are often able to identify allergy-inducing agents.
provide formulation, target dose, and frequency of dosing. Treatment for atopic disease of eczema includes avoiding
Other treatment options include systemic corticosteroids offending agents, minimizing skin dryness by limiting soap
and, less commonly, interferon alpha. Vincristine, injected and water exposure, and consistently using lubricants. The NP
corticosteroids, and laser therapy are used rarely for severe should explain to the patient that the skin tends to be sensitive
cases. and needs to be treated with some care. When flares occur,
A port-wine stain is a flat hemangioma with a stable course. the skin eruption is largely caused by histamine release. Anti-
These lesions usually appear on the face and are usually present histamines and topical corticosteroids can be used to control
at birth. Port-wine stains tend to deepen in color as time goes eczema flares. With an acute flare of eczema or with contact
on and grow proportionally with the child. Although not dermatitis in the older child, a topical corticosteroid with
malignant, the lesions are often cosmetically challenging and intermediate potency is likely needed to control acute symp-
can be minimized or occasionally eliminated through the toms. After this control is achieved, the lowest potency topical
use of laser therapy. Port-wine stain is occasionally associated corticosteroid that yields the desired effect should be used. For
with other congenital or genetic syndromes (Sturge-Weber or eczema or contact dermatitis on the face of infants and
arteriovenous [AV] malformation syndrome). children 3 months and older, the lowest potency (class 7)
The typical presentation of milia is as white pinpoint corticosteroid cream may be used, such as 1% hydrocortisone.
papular lesions caused by sebaceous hyperplasia. The usual Over-the-counter nonsteroid moisturizing and healing
distribution is over the nose, cheeks, and other areas with an ointment is recommended for frequent use.
4074_Ch17_397-462 20/11/14 4:30 PM Page 427
Table 17-8
Common Infant Dermatological Conditions
Condition Pathophysiology Presentation Management Comments
HEMANGIOMA Benign tumors of Often not present at Treatment depend- Active noninterven-
endothelium; local birth, rapid growth ent on location, risk tion for superficial
proliferative process from first days of of complication, lesions in low func-
that affects en- life to 6 months, scarring, ulceration; tion areas (i.e.,
dothelial cells; slow proliferation options to slow thigh, upper arm)—
perhaps genetic 6–12 months, then growth = oral pro- watchful waiting;
mutation of epithe- involution phase pranolol, systemic will involute slowly
lial regulation from 12 months to corticosteroids through early
age 3–6 years; one- Additional options = childhood
third present at vincristine, inter-
birth as light port feron alpha.
wine stain Uncommonly used =
injected corticos-
teroids, laser therapy
PORT WINE LESION Disorder of dermal Present from birth Pulse dye laser ther- Important to consider
capillaries and post- Blanchable from red apy is standard; genetic and congen-
capillary venules to dark pink, grows lightens lesion but ital syndrome when
Occasionally associ- proportionally does not remove these are present
ated with other with child Referral to ophthal-
congenital or ge- Will darken and mology if on eye-
netic syndromes often becomes lids; associated with
(Sturge-Weber or nodular as child glaucoma
AV malformation grows and will not Referral to neurology
syndrome) regress if facial lesions and
Lesions on face tend seizures
to follow branches
of trigeminal nerve
SEBORRHEA DERMATITIS Usually in areas of Erythematous Infant scalp treat- Common from
INFANTS—CRADLE CAP dense sebaceous plaque; appears ment: Apply emol- 3 weeks to
glands (scalp, face, greasy with yellow lient (petrolatum, 12 months
groin, underarms) scales vegetable or mineral 10% of cases pres-
Thought to be over- Commonly seen in oil) overnight, then ent before 1 month
stimulation of infants but can be remove plaque with of age
sebum production; present through life soft brush 70% present by
possibly lipid- For other parts of 3 months
dependent yeast body, ketoconazole Steadily decreases in
2% cream once prevalence at 7% in
daily for 1 week or 1–2 year olds
low-dose hydrocor-
tisone 1% daily for
1 week
Sources: Habif, T. Skin Disease, ed. 3. St. Louis: Elsevier Health Sciences, 2011.
Habif T. Dermatology DDxDeck, ed. 2. St. Louis: Elsevier Health Sciences, 2012.
Acute Otitis Media 134. A 3-year-old boy with AOM continues to have otalgia
and fever (≥39°C [ ≥102.2°F]) after 3 days of amoxi-
cillin 80 mg/kg/d with an appropriate dose of clavu-
127. Which of the following is the most prudent first-line lanate (Augmentin) therapy. Which of the following
treatment choice for an otherwise well toddler with is recommended?
acute otitis media (AOM) who requires antimicrobial A. Watch and wait while using analgesics.
therapy? B. Start antimicrobial therapy with oral azithromycin.
A. ceftibuten C. Initiate therapy with oral clindamycin.
B. amoxicillin D. Administer intramuscular ceftriaxone.
C. cefuroxime
D. azithromycin 135. Which of the following must be present for the diag-
nosis of AOM? More than one can apply.
128. Most AOM is caused by: A. bulging of the tympanic membrane (TM)
A. certain gram-positive and gram-negative bacteria B. TM retraction
and respiratory viruses. C. otalgia
B. atypical bacteria and pathogenic fungi. D. anterior cervical lymphadenopathy
C. rhinovirus and methicillin-resistant Staphylococcus
aureus. 136. Which of the following signs indicates possible AOM
D. predominately beta-lactamase–producing diagnosis in a preverbal child?
organisms. A. loss of appetite
B. colic
129. The incidence of AOM has decreased in the past C. tugging on the ear
decade in part because of: D. fever
A. earlier detection and treatment.
B. more effective treatment options. 137. Which of the following is usually absent in otitis
C. an increase in select vaccination use. media with effusion (OME)?
D. lower rates of viral infections. A. fluid in the middle ear
B. otalgia
130. Which of the following represents the best choice of C. fever
clinical agents for a child who has had a history of D. itch
penicillin allergy who requires antimicrobial therapy?
A. ciprofloxacin 138. The following criteria should be met for a child to be
B. cefdinir treated for AOM with observation and analgesia but
C. amoxicillin no antimicrobial therapy (choose all that apply):
D. trimethoprim-sulfamethoxazole (TMP-SMX) A. age greater than 6 months.
B. bilateral infection.
131. Which of the following does not represent a risk C. moderate illness.
factor for recurrent AOM in younger children? D. presumptively caused by bacterial infection.
A. pacifier use after age 10 months
B. history of first episode of AOM before age 139. Treatment of otitis media with effusion usually includes:
3 months A. symptomatic therapy.
C. exposure to second-hand smoke B. antimicrobial therapy.
D. beta-lactam allergy C. an antihistamine.
D. a mucolytic.
132. The main risk factor for AOM in infants is:
A. undiagnosed dairy allergy. 140. Characteristics of M. catarrhalis include:
B. eustachian tube dysfunction. A. high rate of beta-lactamase production.
C. cigarette smoke exposure. B. antimicrobial resistance because of altered protein
D. use of soy-based infant formula. binding sites.
C. difficult to eradicate even with antimicrobial therapy.
133. In the treatment of acute otitis media in the child, D. gram-positive organism.
which of the following antimicrobial agents affords
the most effective activity against Streptococcus
pneumoniae?
A. nitrofurantoin
B. cefixime
C. trimethoprim-sulfamethoxazole (TMP-SMX)
D. cefuroxime
4074_Ch17_397-462 20/11/14 4:30 PM Page 429
141. Characteristics of H. influenzae include: antibiotics are prescribed, the incidence of AOM and the re-
A. rare beta-lactamase production. sulting antimicrobial prescriptions have decreased over the past
B. antimicrobial resistance because of altered protein decade as a result of many factors, including increased rates of
binding sites. pneumococcal and influenza vaccination.
C. organism most commonly isolated from mucoid The eustachian tubes provide drainage of middle ear
middle ear effusion. secretions and protection of the middle ear from pharyn-
D. gram-positive organism. geal secretions and bacterial contaminants. As a result,
conditions that cause eustachian tube dysfunction or eu-
142. Characteristics of S. pneumoniae include:
stachian tube obstruction, such as allergic rhinitis, upper
A. beta-lactamase production common.
respiratory infection, and craniofacial abnormalities, en-
B. antimicrobial resistance because of altered protein
courage status of secretions and allow aspiration of pha-
binding sites.
ryngeal flora into the middle ear, resulting in AOM.
C. causative organism of skin infection associated
Eustachian tube obstruction caused by an upper respiratory
with acute otitis media.
viral illness remains the most common predisposing factor
D. gram-negative organism.
for developing AOM. Passive cigarette smoke exposure,
feeding in a supine position, and pacifier use beyond age
10 months likely also predispose a child to AOM secondary
Answers to eustachian tube dysfunction or eustachian tube obstruc-
127. B. 133. D. 139. A. tion. Because children in daycare settings typically have
128. A. 134. D. 140. A. more upper respiratory infections, attendance at group
129. C. 135. A and C. 141. C. child care is also a risk factor for nasopharyngeal carriage
130. B. 136. C. 142. B of bacteria implicated in AOM. Bottle-feeding is a risk fac-
131. D. 137. C. tor for AOM, with rates significantly lower among infants
132. B. 138. A and C. who were breastfed for the first 6 to 12 months of life; boys
and children of Native American ancestry are also noted to
be at increased risk. An additional intervention to reduce
Acute otitis media (AOM) is among the most frequent diag- AOM risk includes universal childhood pneumococcal and
noses noted in office visits in children younger than age influenza immunization.
15 years. Almost all cases of AOM are found to be caused either S. pneumoniae causes 49% of AOM (Table 17–9); it is the
by bacteria and viruses together (66%), bacteria alone (27%), or least likely of the three major causative bacteria to resolve
virus alone (4%). Streptococcus pneumonia (49%), Haemophilus without antimicrobial intervention and causes the most sig-
influenza (29%), Moraxella catarrhalis (28%), and various res- nificant symptoms. This organism has exhibited resistance
piratory tract viruses contribute to the infectious and inflam- more recently to numerous antibiotic agents, including
matory processes of the middle ear. Nearly two-thirds of amoxicillin, cephalosporins, and macrolides. The mechanism
all children have at least one episode by their second birthday; of resistance is an alteration of intracellular protein-binding
one-third have more than three episodes. Although AOM sites, which can typically be overcome by using higher doses
remains the most common childhood condition for which of amoxicillin and certain cephalosporins; on rare occasions,
Table 17-9
Causative Organisms in Acute Bacterial Otitis Media (AOM)
Overall pathogens in AOM = No pathogen (4%), virus (70%), bacteria plus virus (66%)
Organism Comment
S. pneumoniae (gram-positive diplococci) (49%) Consider drug-resistant S. pneumoniae risk
Treatment target in AOM Mechanism of resistance—Alter binding sites within bacterial cells
Low rate (~10%–20%) of spontaneous resolution without antimicro-
bial therapy
H. influenzae (gram-negative bacillus) (29%) Resistance via beta-lactamase production
Moderate rate (~50%) of spontaneous resolution without antimicro-
bial therapy
M. catarrhalis (gram-negative cocci) (28%) Resistance via beta-lactamase production
Nearly all spontaneously resolve without antimicrobial therapy
Source: Sanford Guide 2014: Otitis Media, Acute Empiric Therapy, webedition.sanfordguide.com/sanford-guide-
online/disease-clinical-condition/otitis-media?searchterm=otitis+media.
4074_Ch17_397-462 20/11/14 4:30 PM Page 430
clindamycin is also used. The pneumococcal conjugate Beta-lactamase production by organisms probably con-
vaccine is effective in reducing risk of invasive pneumococcal tributes less to AOM treatment failure than to prescribing an
disease and in minimizing AOM risk when caused by inadequate dosing of amoxicillin needed to eradicate drug-
serotypes included in the vaccine. resistant S. pneumoniae. Respiratory syncytial virus is com-
H. influenzae (29%) and M. catarrhalis (28%) are gram- monly isolated from the middle ear fluid in children with
negative organisms capable of producing beta-lactamase. AOM. Other common viral agents include human rhinovirus
Although these two organisms have relatively high rates and coronavirus. AOM caused by these viral agents usually
of spontaneous resolution (50% and 90% respectively), with- resolves in 7 to 10 days with supportive care alone.
out antimicrobial intervention, H. influenzae is the organism Appropriate assessment is critical to the diagnosis of AOM
most commonly isolated from mucoid and serious middle (Table 17–10). The AOM treatment guidelines emphasize
ear effusion, conditions often noted in recurrent AOM. proper diagnosis based on strict definitions of AOM and
Table 17-10
Diagnosis and Management of Acute Otitis Media (AOM) in Children
DIAGNOSIS OF AOM IN CHILDREN Moderate or severe bulging of tympanic membrane (TM) OR new onset of otor-
rhea not related to otitis externa (OE) with otalgia
• Mild bulging of TM AND recent (≤48 hrs) onset of ear pain (in nonverbal
child—tugging, holding, rubbing) OR intense TM erythema with otalgia
MANAGEMENT OF AOM Analgesics: Acetaminophen or ibuprofen is recommended
SHOULD INCLUDE ASSESSMENT Topical anesthetic agent can provide short-term (approximately 30 minutes) pain relief
OF PAIN AND, IF PRESENT, CLINICIAN
SHOULD RECOMMEND TREATMENT
FOR PAIN MANAGEMENT
WATCHFUL WAITING, CONSISTING In the otherwise well child, rationale for not immediately initiation antibiotic therapy
OF ANALGESIA WITHOUT • Low risk for adverse outcome without antimicrobial therapy
ANTIMICROBIAL THERAPY, IS AN • High rate of spontaneous AOM resolution without antimicrobial therapy or
ACCEPTABLE TREATMENT OPTION worsening of symptoms
IN AOM • Watchful waiting is only appropriate for the child ≥6 months with nonsevere illness
based on joint decision-making with parents/caregivers for unilateral AOM
• If watchful waiting is used, the follow-up must be ensured with ability to start
antibiotic therapy within 48–72 hours if symptoms do not improve or worsen
NONSEVERE VS. SEVERE ILLNESS Nonsevere illness:
• Mild otalgia for <48 hours
Or
• Fever <39°C (<102.2°F) in the past 24 hours
Severe illness:
• Moderate to severe otalgia
Or
• Otalgia for >48 hours
Or
Fever ≥39°C ( ≥102.2°F)
TREATMENT OPTIONS Antibiotic therapy at time of AOM diagnosis in the following.
INITIAL TREATMENT • Nonsevere or severe illness whether unilateral or bilateral AOM in children
younger than 6 months
• Severe illness with unilateral or bilateral AOM in children ≥6 months
• Nonsevere illness with bilateral AOM in young children (6–23 months)
Either prescribe antibiotic therapy OR offer observation with close follow-up of
AOM in children ≥6 months with nonsevere illness based on joint decision-
making with parents/caregivers for unilateral AOM
If observation is used, follow-up must be ensured with ability to start antibiotic
therapy within 48–72 hours if symptoms do not improve or worsen
Source: Lieberthal, AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media.
Pediatrics 31(3):e964–e999, 2013.
4074_Ch17_397-462 20/11/14 4:30 PM Page 431
decisions regarding initial treatment. Management of AOM three decades have shown consistently that selected children
should include assessment of pain, and if present, clinician who meet the criteria for observation do well, without adverse
should recommend treatment for pain management. Aceta- sequelae, without antibacterial therapy. Observation should
minophen or ibuprofen can be used as analgesics. Topical include assurance of follow-up, and appropriate analgesia
anesthetic agent can provide short-term (approximately 30 should be provided (Table 17–11).
minutes) pain relief. The components of AOM include Amoxicillin remains the first-line antimicrobial for
objective findings such as a bulging, erythematous tympanic AOM treatment for the majority of children who do not
membrane (TM) with limited or absent mobility on insuffla- have PCN allergy. Given the wide therapeutic index of
tion, or otorrhea unrelated to otitis externa. Presentation can this medication and the prevalence of drug-resistant
also include bulging of TM and recent (≤48 hours) onset of S. pneumoniae, 80 to 90 mg/kg/d is the recommended dose;
ear pain (seen as tugging, holding, rubbing in nonverbal in the overweight or obese child, the dose should not ex-
child) or intense TM erythema with otalgia. Distinct otalgia ceed the adult dose. Amoxicillin/clavulanate (Augmentin),
with discomfort clearly referable to the ear results in inter- 80 to 90 mg/kg/d, is recommended as first-line therapy
ference with or precludes normal activity or sleep. With in select situations.
recovery, TM mobility returns in about 1 to 2 weeks, but Children younger than 3 months old with AOM should
middle ear effusion typically persists for 4 to 6 weeks and be seen in 1 to 2 days because of increased risk of treatment
often up to 3 months. failure. In a child older than 3 months, otalgia, fever, and
The AOM evaluation and treatment recommendations other symptoms that persist beyond 48 to 72 hours of therapy
apply only to otherwise healthy children without underly- can indicate treatment failure, and repeat evaluation is in
ing conditions that could alter the natural course of order and a change in therapy is recommended.
AOM, including anatomic abnormalities such as cleft Otitis media with effusion (OME), formerly known as
palate, certain genetic conditions such as Down syndrome, serous otitis media, is defined as the presence of fluid in the
immunodeficiencies, presence of cochlear implants, and middle ear in the absence of signs or symptoms of acute in-
recurrent AOM. fection. With OME, 80% of children clear the middle ear by
Observation as initial treatment is only appropriate if child 8 weeks. If OME persists beyond 8 weeks, the presence of
is >6 months, has nonsevere illness, and infection is unilateral. communication problems and other symptoms dictates the
Placebo-controlled trials of AOM conducted during more need for further evaluation and treatment (Table 17–12). If
Table 17-11
Recommended Acute Otitis Media (AOM) Treatment Options
Length of therapy unless otherwise specified: Younger than age 2 years = 10 days,
2–6 years = 7 days, ≥6 years = 5–7 days
Recommended With PCN allergy
FIRST-LINE TREATMENT Amoxicillin (80–90 mg/kg/day in 2 divided Cefdinir (14 mg/kg/day in 1 or 2 doses)
doses) OR
OR Cefuroxime (30 mg/kg/day in 2 divided
Amoxicillin-clavulanate (90 mg/kg per day doses)
of amoxicillin, with 6.4 mg/kg/day of OR
clavulanate in 2 divided doses) Cefpodoxime (10 mg/kg/day in 2 divided
doses)
OR
Ceftriaxone (50 mg IM or IV/day for 1 or 3 d)
ANTIBIOTIC TREATMENT Amoxicillin-clavulanate (90 mg/kg/day of Ceftriaxone × 3 d (as above)
AFTER 48–72 H OF FAILURE amoxicillin, with 6.4 mg/kg/day of clavu- OR
OF INITIAL ANTIBIOTIC lanate in 2 divided doses) Clindamycin (30–40 mg/kg/day in 3 divided
TREATMENT OR doses) with or without a third-generation
Ceftriaxone (50 mg IM/IV for 3 d) cephalosporin
Tympanocentesis
Referral to specialist
Sources: Lieberthal, AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media.
Pediatrics 31(3):e964–e999, 2013.
Fitzgerald M. How would you prescribe cephalosporins to patients with penicillin allergies? FHEA News, 2012,
p. 13, http://fhea.com/main/content/Newsletter/fheanews_volume12_issue8.pdf.
4074_Ch17_397-462 20/11/14 4:31 PM Page 432
TABLE 17-12
Otitis Media with Effusion (OME)
DEFINED Fluid in middle ear without signs or symptoms of ear infection
FIRST-LINE Watchful waiting in most
INTERVENTION 75%–90% resolve within 3 mo without specific treatment
SELECT INTERVENTION Tympanostomy if chronic bilateral OME (3 months or longer) with documented hearing
IN AT-RISK CHILDREN difficulty and recurrent AOM with unilateral or bilateral middle ear effusion
persistent effusion is accompanied by language delay or sus- 145. The most common causative bacterial pathogen in
pected or documented hearing loss, intervention by tympa- ABRS is:
nostomy (ventilating tube) is warranted. Current guidelines A. M. pneumoniae.
recommend that clinicians should only offer tympanostomy B. S. pneumoniae.
to children with chronic bilateral OME (3 months or longer) C. M. catarrhalis.
with documented hearing difficulty and to those with recur- D. unidentified virus.
rent AOM who have unilateral or bilateral MEE. Routine re-
146. Risk factors for ABRS include all of the following
treatment with an antimicrobial is not indicated for OME
except:
(Table 17–12). When a child is seen for AOM, measures to
A. viral infection.
reduce AOM risk should be reviewed and reinforced.
B. environmental allergies.
DI SCUS SION SOURCES C. tobacco smoke exposure.
Lieberthal SA, Carroll AE, Chonmaitree T, et al. The diagnosis and
D. beta-thalassemia minor.
management of acute otitis media. Pediatrics 131:E964–E999, 2013. 147. Which of the following is a first-line therapy option
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the treatment of ABRS in an otherwise well child?
for the diagnosis and management of acute bacterial sinusitis in A. amoxicillin-clavulanate
children aged 1 to 18 years. Pediatrics 132:E262–E280, 2013.
B. clindamycin with cefixime
Rosenfeld RM, Schwartz SR, Pynnonnen MA, et al. Clinical practice
guideline: Tympanostomy tubes in children—Executive sum-
C. doxycycline
mary. Oto-Hns 149:8–16, 2013. D. levofloxacin
Otitis media with effusion. Pediatrics 113:1412–1429, 2004. 148. Which of the following represents a therapeutic op-
tion for ABRS in an otherwise well 7-year-old child
Acute Bacterial who has not had significant clinical improvement but
is not worse after 72 hours of observation?
Rhinosinusitis A. continued observation
B. oral levofloxacin
143. Which of the following findings is most consistent C. oral clindamycin and cefixime
with the diagnosis of acute bacterial rhinosinusitis D. injectable ceftriaxone
(ABRS) in children?
A. upper respiratory tract infection symptoms persist- 149. A 5-year-old girl presents with ABRS. She has a peni-
ing beyond 10 days cillin allergy but is otherwise well and is going to be
B. nasal discharge progresses from clear to purulent treated with an antimicrobial. You prescribe:
to clear without antibiotics A. no medication; continue observation.
C. headaches and myalgias that resolve in 24 to B. cefdinir.
48 hours as the respiratory symptoms worsen C. levofloxacin.
D. persistent cough D. amoxicillin.
Acute bacterial rhinosinusitis (ABRS) is a clinical condition without antimicrobial therapy in ABRS. Empirical antimi-
resulting from inflammation of the lining of the membranes crobial therapy in ABRS should be aimed at choosing
of the paranasal sinuses caused by bacterial infection. Risk an agent with significant activity against gram-positive (S.
factors include any condition that alters the normal cleansing pneumoniae) and gram-negative organisms (H. influenzae,
mechanism of the sinuses, including viral infection, allergies, M. catarrhalis), with consideration for drug-resistant S. pneu-
secondhand tobacco smoke exposure, and abnormalities in moniae risk and possible need for stability in the presence of
sinus structure. Inhaled tobacco smoke disturbs normal sinus beta-lactamase. Of childhood sinusitis cases, 25% are sterile
mucociliary action and drainage, causing secretions to pool, wherein the cause is likely viral.
and increases the risk of superimposed bacterial infection. In Initial treatment options for ABRS include observation,
addition, viral upper respiratory infections (URI) and poorly amoxicillin 80–90 mg/kg/day, or high-dose amoxicillin
controlled allergic rhinitis cause similar dysfunction, increas- (Table 17–14).If no improvement is seen in 3 days, treatment
ing ABRS risk. options include continued observation, antibiotic therapy,
Only a minority (6%–7%) of children presenting with high-dose amoxicillin, or change to clindamycin and cefixime
symptoms of URI will meet criteria for persistence and there- or linezolid and cefixime or levofloxacin only depending on
fore ABRS risk. It is important to differentiate between sequen- initial treatment. If symptoms worsen in 3 days, amoxicillin
tial episodes of uncomplicated viral URI from the onset of 80–90 mg/kg/day with or without clavulanate or high-dose
acute bacterial sinusitis with persistent symptoms and establish amoxicillin or clindamycin and cefixime or linezolid and
whether the symptoms are clearly not improving. Further, be- cefixime or levofloxacin only should be given depending
cause ABRS is a clinical diagnosis based on the child’s presen- on prior treatment (Table 17–14). Children who have a
tation, with findings also reported in children with a viral URI, penicillin allergy can safely be treated with cefdinir, cefurox-
the problem arises as to how to differentiate between these two ime, or cefpodoxime.
common conditions. Uncomplicated viral URI in children is Acute URI with persistent illness (nasal discharge of any
marked by nasal symptoms and/or cough; nasal discharge pro- quality) or daytime cough for >10 days without improvement
gresses from clear to purulent to clear without antibiotics, usu- should be treated with antibiotics or 3-day observation. Wors-
ally within 10 days, and fever early in the illness is associated ening course or new onset of nasal discharge, daytime cough
with constitutional symptoms such as headaches and myalgias or fever after initial improvement, or severe onset and con-
that resolve in 24 to 48 hours as the respiratory symptoms current fever (102.2ºF [39ºC]) and purulent nasal discharge
worsen (Table 17–13). ABRS in children should only be con- >3 consecutive days should be treated with antibiotics.
sidered if at least one of the following criteria are observed:
worsening URI course such as double sickening, defined as D I S C U SSI O N S O U R C E
acute worsening of respiratory symptoms or new fever at day Wald ER, Applegate KE, Bordley C, et al. Clinical practice guide-
6 or 7 of URI, persistence of URI-like symptoms without im- line for the diagnosis and management of acute bacterial si-
provement after 7 to 10 days, including nasal discharge, day- nusitis in children aged 1 to 18 years. Pediatrics 132:e262–280,
time cough, fetid breath odor, fatigue, headache, decreased 2013.
appetite, acute onset of a temperature of >102.2ºF (39ºC), and
purulent nasal discharge, or acutely ill appearing for 3-4 days
(Table 17–13). Urinary Tract
According the ABRS practice guidelines developed Infection
by the American Academy of Pediatrics, S. pneumoniae
(30%) is the causative organism in most childhood ABRS; 150. Rates of urinary tract infection (UTI) among uncir-
this pathogen is also the least likely of the three major cumcised infant boys are how much higher than those
causative bacteria to resolve without antimicrobial inter- in circumcised boys?
vention, and it causes the most significant symptoms. This A. as much as 10%
organism exhibits resistance to numerous antibiotic agents, B. as much as 20%
including lower dose amoxicillin, certain cephalosporins, C. as much as 30%
and macrolides. The mechanism of resistance is alteration D. less than 10%
of intracellular protein-binding sites, which can typically
be overcome by using higher doses of amoxicillin, certain 151. Which of the following is most likely to be part of the
cephalosporins, and respiratory fluoroquinolones (lev- clinical presentation of UTI in a 20-month-old child?
ofloxacin [Levaquin, not FDA approved for use in <18 years A. urinary frequency and urgency
but has a long history of safety in this age group]). Recent B. fever
antimicrobial use is the major risk for infection with drug- C. suprapubic tenderness
resistant S. pneumoniae. D. nausea and vomiting
H. influenzae (30%) and M. catarrhalis (20%) are gram- 152. Which of the following is the most common UTI or-
negative organisms capable of producing beta-lactamase; the ganism in children?
presence of this enzyme renders the penicillins ineffective. A. Pseudomonas aeruginosa
Although these two organisms have relatively high rates of B. Escherichia coli
spontaneous resolution without antimicrobial intervention C. Klebsiella pneumonia
in AOM, infections caused by these pathogens seldom resolve D. Proteus mirabilis
4074_Ch17_397-462 20/11/14 4:31 PM Page 434
Table 17-13
Diagnosis and Management of Acute Bacterial Rhinosinusitis (ABRS) in Children
Exclusions from these recommendations include children <1 year of age including neonates and children with subacute
and chronic sinusitis, anatomic abnormalities of the sinuses, immunodeficiencies, cystic fibrosis, and/or primary ciliary
dyskinesia
DIFFERENTIATE BETWEEN • Uncomplicated viral upper respiratory infection (URI) course
ACUTE URI AND ABRS Nasal symptoms and/or cough, nasal discharge progresses from clear to purulent to
DIAGNOSTIC CRITERIA clear without antibiotics, usually within 10 days
Fever early in the illness associated with constitutional symptoms such as headaches and
myalgias that resolve in 24–48 hours as the respiratory symptoms worsen
• ABRS should be considered only in the setting of ≥1 of the following.
Worsening URI course such as double sickening, defined as acute worsening of respira-
tory symptoms or new fever at day 6–7 of URI
Persistence of URI-like symptoms without improvement after 7–10 days, including nasal
discharge, daytime cough, bad breath, fatigue, headache, decreased appetite
Acute onset: Temperature >102.2ºF (>39ºC), purulent nasal discharge, ill appearing for
3–4 days
TREATMENT OPTIONS Acute URI with
• Persistent illness (nasal discharge of any quality) or daytime cough for >10 days with-
out improvement
Option: Antibiotic treatment or 3-day observation
• Worsening course or new onset of nasal discharge, daytime cough, or fever after initial
improvement
Option: Antibiotic treatment
• Severe onset/concurrent fever (>102.2ºF [>39ºC]) and purulent nasal discharge >3 con-
secutive days.
Option: Antibiotic treatment
RADIOGRAPHIC • In children with uncomplicated ABRS imaging is not necessary to differentiate viral
RECOMMENDATIONS from bacterial sinusitis.
• Contrast CT of paranasal sinuses and/or MRI with contrast should be obtained when-
ever a child is suspected of having orbital or central nervous system complications
LIKELY PATHOGENS S. pneumoniae = 30%
Decreased second to pneumococcal vaccine
• Nontypeable H. influenzae = 30%
• M. catarrhalis = 20%
• Sterile (no pathogen isolated, likely viral) = 25%
153. All of the following uropathogens are capable of re- 155. When choosing an antimicrobial agent for the treat-
ducing urinary nitrates to nitrites except: ment of UTI in a febrile female child who is 16 months
A. E. coli. old, the NP considers that:
B. Proteus species. A. gram-positive organisms are the most likely cause
C. K. pneumoniae. of infection.
D. S. saprophyticus. B. a parenteral aminoglycoside is the preferred treat-
ment choice.
154. Which of the following is considered the ideal method
C. the use of an oral third-generation cephalosporin is
for obtaining a urine sample for culture and sensitiv-
acceptable if gastrointestinal function is intact.
ity in an 18-month-old-old girl with suspected UTI?
D. nitrofurantoin use is considered first-line therapy.
A. suprapubic aspiration
B. transurethral bladder catheterization 156. When evaluating the urinalysis of a 10-month-old
C. bag collection infant with UTI, the NP considers that:
D. diaper sample A. leukocytes would be consistently noted.
B. proteinuria is usually absent.
C. the presence of urobilinogen is commonly noted.
D. 20% of urinalyses can be normal.
4074_Ch17_397-462 20/11/14 4:31 PM Page 435
Table 17-14
Acute Bacterial Rhinosinusitis (ABRS) Treatment in Children
Initial Treatment No Improvement in 72 Hours Worse at 72 Hours
Observation Additional observation OR antibiotic Amoxicillin 80-90 mg/kg/day with or with-
therapy out clavulanate
Amoxicillin* 80–90 mg/kg/day Additional observation OR HD amoxicillin/ HD amoxicillin/clavulanate
clavulanate
HD amoxicillin/clavulanate Continue high dose amoxicillin/clavulanate Clindamycin AND cefixime OR linezolid
or change to clindamycin AND cefixime AND cefixime OR levofloxacin
OR linezolid AND cefixime OR levofloxacin
*In the case of PCN allergy, both non-type 1 reaction (delayed or late, >72) and Type 1 (immediate, severe
reaction) can safely be treated with cefdinir, cefuroxime, or cefpodoxime. Consider allergy testing for PCN
and cephalosporin in both cases prior to initiation of treatment.
Source: Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management
of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 132;e262, 2013.
157. In children 2 months to 2 years old with UTI, 162. The urinary tract abnormality most often associated
antimicrobial therapy should be prescribed for: with UTI in younger children is:
A. 3 to 5 days. A. bladder neck stricture.
B. 5 to 10 days. B. ureteral stenosis.
C. 7 to 14 days. C. urethral stricture.
D. 14 to 21 days. D. vesicoureteral reflux.
158. A 12-month-old boy with fever who has a suspected
UTI who has vomited 5 times in the past 7 hours. His
last wet diaper was approximately 6 hours ago. He is
Answers
accompanied by his parents. The following action
should be taken: 150. B. 155. C. 160. A.
A. Recommend continued observation at home. 151. B. 156. D. 161. B.
B. Recommend antimicrobial therapy. 152. B. 157. C. 162. D.
C. Conduct renal ultrasound. 153. D. 158. D.
D. Arrange for the child to be admitted to the hospital. 154. A. 159. A.
159. The preferred urinary tract imaging study for a
22-month-old girl with first-time febrile UTI is:
A. renal-bladder ultrasound (RBUS). Although often thought of as a problem primarily of women
B. renal scan. during the reproductive years, UTIs do occur in early child-
C. voiding cystogram (VCUG). hood. Rates in girls younger than 1 year are about 6.5% and
D. none unless a second UTI occurs. at 1 to 2 years are 8.1%. The rates are lower in boys: 3.3% at
younger than 1 year and 1.9% at 1 to 2 years. Uncircumcised
160. Which of the following is the most compelling reason
boys can have rates of UTI many times higher than that in
to use RBUS instead of VCUG?
circumcised boys, but this difference decreases dramatically
A. This is a noninvasive test.
when normal penile growth loosens the foreskin, usually oc-
B. Results are available more rapidly.
curring by the time the boy is 1 to 2 years old. However, this
C. The test is less technically demanding.
potential health issue is not considered to be an indication
D. RBUS is less expensive.
for routine circumcision.
161. VCUG is indicated: The clinical presentation of UTI in children can be with-
A. after UTI diagnosis is confirmed to determine out the classic symptoms such as frequency, dysuria, or
course of antimicrobial therapy. flank pain. In younger children, UTI often manifests as
B. when UTI is recurrent. irritability, lethargy, and fever with no obvious focal infec-
C. to confirm high-grade reflux. tious source. Older children often present with abdominal
D. as an alternative to RBUS to assure accurate pain, unexplained fever, or both; as children approach
detection of scarring. puberty, flank pain becomes more common. UTI should
4074_Ch17_397-462 20/11/14 4:31 PM Page 436
be considered in infants and young children 2 months to patients for the treatment of UTI; this use is approved starting
2 years old with unexplained fever, particularly in boys at age 1 year.
younger than 6 months and girls younger than 2 years Urinary tract imaging should be considered for all chil-
who have a temperature greater than or equal to 39°C dren with UTI, particularly if this occurs before toilet train-
(≥102.2°F). ing. The two mainstays for imaging in young children are
A urinalysis should be obtained in a child with unex- renal-bladder ultrasound (RBUS) and voiding cystourethrog-
plained fever or symptoms that suggest a UTI; however, 20% raphy (VCUG). RBUS is an easily obtained, noninvasive test
of urinalyses from UTI cases return a false-negative result. but can miss a small number of high-grade reflux cases. The
Any of the following findings are suggestive, although not di- benefits of this imaging (no radiation exposure, non-invasive,
agnostic, of UTI: positive leukocyte esterase, positive nitrite, minimal discomfort for child and parents), however, outweigh
more than five white blood cells (WBCs) per high-power field the slight increase in specificity of VCUG. A renal scan is use-
in spun specimen, and bacteria present in unspun Gram- ful for detecting renal scarring, a finding present after infec-
stained specimen. An evaluation for sepsis should also be ini- tion, but is not recommended for routine, initial evaluation
tiated if clinical presentation warrants. of young child with their first febrile UTI. VCUG only is in-
The method of obtaining a urinalysis in younger children dicated if RBUS reveals hydronephrosis, scarring, or other
(generally younger than 5 or 6 years old) has been long de- findings that would suggest either high-grade vesicoureteral
bated. Suprapubic bladder aspiration yields the specimen that reflux (VUR) or obstructive uropathy, as well as other atypical
is least likely to be contaminated; for the parent and child this or complex clinical circumstances. VCUG may also be per-
method can be fraught with fear and it requires special formed if febrile UTI is recurrent. However, some parents
provider skill. The next acceptable method is transurethral may want to avoid VCUG even after the second UTI. These
bladder catheterization. An unacceptable method because of preferences should be considered. Only if high-grade
the high rate of skin and fecal contamination in a urine spec- (Grade V) VUR or other urinary tract abnormality is noted
imen collection via bag or from the diaper. on imaging should antimicrobial prophylaxis be continued
Urinary tract abnormality is a major risk factor for pediatric until the abnormality is corrected. Current studies do not
UTI, with vesicoureteral reflux noted in 30% to 50% of cases. support the use of antimicrobial prophylaxis to prevent
Reflux nephropathy increases the risk of ascending infection febrile recurrent UTI in infants with Grade I to IV VUR.
that can cause pyelonephritis and renal scarring. This is a risk
factor for renal failure but is largely avoidable with early reflux D I S C U SSI O N S O U R C E S
recognition and proper treatment. Little difference is usually Steering Committee on Quality Improvement and Management, Sub-
found in the clinical presentation and laboratory findings of committee on Urinary Tract Infection. Urinary Tract Infection:
cystitis or pyelonephritis in a febrile child, and determining Clinical Practice Guideline for the Diagnosis and Management of
the Initial UTI in Febrile Infants and Children 2 to 24 Months.
whether a UTI is limited to the lower urinary tract or involves
Pediatrics 128;3:595–610, 2011.
the soft tissue of the kidney is not clinically significant. The Medscape: Pediatric Urinary Tract Infection Medication, http://
management of a UTI in a child is dictated by the clinical sever- emedicine.medscape.com/article/969643-medication#2/
ity of the illness, rather than by the specific site of infection in
the urinary tract. As a result, a single documented UTI in a
child must be taken seriously. If an infant or young child Common Childhood
2 months to 2 years old with suspected UTI is assessed as toxic,
dehydrated, or unable to retain oral intake, hospitalization is Febrile Illness With
advised. In this circumstance, initial antimicrobial therapy
should be administered parenterally, usually with a second- or Skin Alterations
third-generation cephalosporin. An aminoglycoside such as
163. You examine a 10-year-old boy with suspected strep-
gentamicin can be used if there is a history of severe penicillin
tococcal pharyngitis. His mother asks if he can get a
allergy. For a child who is well hydrated and able to take an an-
“shot of penicillin.” Which of the following state-
timicrobial and fluids orally, home-based care is reasonable.
ments is/are true regarding the use of intramuscular
Oral amoxicillin, TMP-SMX, or a second- or third-generation
(IM) penicillin (PCN) (select all that apply)?
cephalosporin is recommended as options for initial therapy;
A. Injectable benzathine PCN, oral amoxicillin, and
the use of TMP-SMX has a small risk of treatment failure. Cur-
cephalexin are each strongly recommended for as
rent evidence-based practice recommendations indicate a 7-
treatment of Streptococcus pyogenes (GAS) pharyngitis
to 14-day course of antibiotics because the outcomes are supe-
B. Injectable benzathine PCN would be indicated for
rior to a 1- to 3-day course in preventing spread of infection
treatment of GAS if poor adherence to recom-
and subsequent renal scarring. Close clinical follow-up of the
mended therapy or inability to take full course of
child and instruction of parents regarding prompt attention to
oral antibiotics is anticipated.
recurrence of symptoms is highly recommended. Routine an-
C. The risk of severe allergic reaction with IM prod-
timicrobial treatment for prophylaxis of recurrent infection is
ucts is similar to that of oral preparations.
not recommended for children without verified urinary tract
D. Injectable penicillin has a superior spectrum of an-
abnormalities. Although fluoroquinolone antibiotics have not
timicrobial coverage compared with the oral form
been widely used in children, ciprofloxacin is approved by the
of the drug.
U.S. Food and Drug Administration (FDA) for use in pediatric
4074_Ch17_397-462 20/11/14 4:31 PM Page 437
164. You examine a 15-year-old presenting with a 1-day 170. A 6-year-old boy presents with a 1-day history of a
history of sore throat, low-grade fever, maculopapular fiery red, maculopapular facial rash concentrated on
rash, and posterior cervical and occipital lym- the cheeks. He has had mild headache and myalgia for
phadenopathy. The most likely diagnosis is: the past week. The most likely diagnosis is:
A. scarlet fever. A. erythema infectiosum.
B. roseola. B. roseola.
C. rubella. C. rubella.
D. rubeola. D. scarlet fever.
165. A 4-year-old child presents with fever; exudative 171. The incubation period for measles caused by the rube-
pharyngitis; anterior cervical lymphadenopathy; and a ola virus is:
fine, raised, pink rash. The most likely diagnosis is: A. 7–10 days.
A. scarlet fever. B. 10–14 days.
B. roseola. C. 1–2 weeks.
C. rubella. D. 2–3 weeks.
D. rubeola. 172. Most cases of roseola caused by human herpesvirus-6
166. An 18-year-old woman has a chief complaint of “a occur in:
sore throat and swollen glands” for the past 3 days. A. newborns who contracted the virus in utero.
Her physical examination reveals exudative pharyngi- B. infants younger than 3 months old.
tis, minimally tender anterior and posterior cervical C. children younger than 24 months old.
lymphadenopathy, and maculopapular rash. Abdomi- D. children older than 2 years.
nal examination reveals right and left upper quadrant 173. The following symptom indicates possible acute
abdominal tenderness. The most likely diagnosis is: human immunodeficiency virus (HIV) infection:
A. group A beta-hemolytic streptococcal pharyngitis. A. pustular lesions in a scattered pattern.
B. infectious mononucleosis. B. red wheals that begins on the face and spreads to
C. rubella. the truck and extremities.
D. scarlet fever. C. vesicular-form skin lesion.
167. Which of the following is most likely to be found in D. maculopapular rash.
the laboratory data of a child who has infectious 174. Kawasaki disease most commonly occurs in what age
mononucleosis? group?
A. neutrophilia A. infants
B. lymphocytosis B. children aged 2 to 3 years.
C. positive antinuclear antibody C. children approaching puberty
D. macrocytic anemia D. children aged 1 to 8 years
168. You examine a 15-year-old boy who has infectious
mononucleosis with marked tonsillar hypertrophy,
exudative pharyngitis, significantly difficulty swallow- Answers
ing, and a patent airway. You consider prescribing a
course of oral: 163. A and B. 167. B. 171. B.
A. amoxicillin. 164. C. 168. B. 172. C.
B. prednisone. 165. A. 169. A. 173. D.
C. ibuprofen. 166. B. 170. A. 174. D.
D. acyclovir.
169. A 2-year-old girl presents with pustular, ulcerating le-
sions on the hands and feet and oral ulcers. The child Developing an accurate diagnosis of an acute febrile illness
is cranky, well hydrated, and afebrile. The most likely with associated rash or skin lesion can be a daunting task.
diagnosis is: Knowledge of the infectious agent, its incubation period, its
A. hand-foot-and-mouth disease. mode of transmission, and its common clinical presentation
B. aphthous stomatitis. can be helpful (Table 17–15).
C. herpetic gingivostomatitis.
D I S C U SSI O N S O U R C E S
D. Vincent angina.
Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guide-
line for the diagnosis and management of group A strepto-
coccal pharyngitis: 2012 update by the Infectious Diseases
Society of America. Clin Infect Dis 55:e86–e102, 2012.
Habif T, Campbell J, Chapman, MS, et al. Skin Disease: Diagnosis
and Treatment, ed. 3. Philadelphia: Elsevier, 2011.
4074_Ch17_397-462 20/11/14 4:31 PM Page 438
Table 17-15
Rash-Producing Febrile Illness
Condition with Causative
Agent Presentation Comments
Scarlet fever Scarlatina-form or sandpaper- Presence of rash does not imply
Agent: S. pyogenes (group A beta like rash with exudative a more severe or serious disease
hemolytic streptococci) pharyngitis, fever, headache, or greater risk of contagion.
tender, localized anterior Treatment = Identical to strep-
cervical lymphadenopathy. tococcus pharyngitis, penicillin
Rash usually erupts on day 2 as first-line therapy, macrolide
of pharyngitis and often peels (azithro-, clarithro-, erythromy-
a few days later. cin) only in PCN allergy
Roseola Discrete rosy-pink macular or 90% of cases seen in children
Agent: Human herpesvirus-6 maculopapular rash lasting <2 years
(HHV-6) hours to 3 days that follows a Febrile seizures in 10% of chil-
3-7 day period of fever, often dren affected.
quite high. Supportive treatment
Rubella Mild symptoms; fever, sore Incubation period about 14–21
Agent: Rubella virus throat, malaise, nasal dis- days with disease transmissible
charge, diffuse maculopapular for ~1 week prior to onset of
rash lasting about 3 days. rash to ~2 weeks after rash
Posterior cervical and postauric- appears.
ular lymphadenopathy 5- Generally a mild self-limiting
10 days prior to onset of rash. illness. Greatest risk is effect of
Arthralgia in about 25% (most virus on the unborn child,
common in women). especially with 1st trimester ex-
posure (~80% rate congenital
rubella syndrome).
Vaccine-preventable disease.
Notifiable disease, usually to the
state and/or public health au-
thorities,* laboratory confirma-
tion by presence of serum
rubella IgM.
Measles Usually acute presentation with Incubation period about 10-
Agent: Rubeola virus fever, nasal discharge, cough, 14 days with disease transmis-
generalized lymphadenopathy, sible for ~1 week prior to
conjunctivitis (copious clear dis- onset of rash to ~2-3 weeks
charge), photophobia, Koplik after rash appears.
spots (appear ~2 days prior to CNS and respiratory tract com-
onset of rash as white spots plications common. Permanent
with blue rings held within red neurologic impairment or
spots in oral mucosa in ~1/3). death possible.
Pharyngitis is usually mild with- Supportive treatment as well as
out exudate. intervention for complications.
Maculopapular rash onset 3-4 Vaccine-preventable disease.
days after onset of symptoms, Notifiable disease usually to the
may coalesce to generalized state and/or public health au-
erythema. thorities,* laboratory confirma-
tion by presence of serum
rubeola IgM.
Infectious mononucleosis (IM) Rash: Maculopapular rash in Incubation period 20-50 days
Agent: Epstein-Barr virus (human ~20%, rare petechial rash >90% will develop a rash if given
herpesvirus 4) Fever, “shaggy” purple-white amoxicillin or ampicillin during
exudative pharyngitis, the illness. Potential for respira-
malaise, marked diffuse tory distress when enlarged
4074_Ch17_397-462 20/11/14 4:31 PM Page 439
Table 17-15
Rash-Producing Febrile Illness–cont’d
Condition with Causative
Agent Presentation Comments
lymphadenopathy, hepatic and tonsils and lymphoid tissue
splenic tenderness, occasionally impinges on the upper airway;
enlarged. corticosteroids may be helpful.
Diagnostic testing: Heterophil Splenomegaly most often occurs
antibody test (Monospot), between day 6 and 21 after the
leukopenia with lymphocytosis onset of the illness. Avoid con-
and atypical lymphocytes. tact sports for ⱖ1 month due to
risk of splenic rupture.
Hand-foot-and-mouth disease Fever, malaise, sore mouth, Transmission via oral-fecal or
Agent: Coxsackie virus A16 anorexia; 1-2 days later, droplet. Highly contagious
lesions; also can cause with incubation periods of
conjunctivitis, pharyngitis. 2-6 weeks.
Duration of illness: 2-7 days. Supportive treatment, analgesia
important.
Fifth disease 3-4 days of mild flu-like illness Droplet transmission; leukopenia
Agent: Human parvovirus B19 followed by 7-10 days of red common.
rash that begins on face with Risk of hydrops fetalis with re-
slapped cheek appearance, sulting pregnancy loss when
spreads to trunk and extremi- contracted by woman during
ties. Rash onset corresponds pregnancy.
with disease immunity with pa- Supportive treatment.
tient. Viremic and contagious
prior but not after onset of rash.
Acute HIV infection Maculopapular rash, fever, mild Most likely to occur in response
Agent: Human immunodeficiency pharyngitis, ulcerating oral to infection with large viral
virus lesions, diarrhea, diffuse load.
Kawasaki disease lymphadenopathy. Consult with HIV specialist
Agent: Unknown For acute phase illness (usually concerning initiation of anti-
lasts about 11 days), fever with retroviral therapy.
Tⱖ104ºF (40ºC) lastingⱖ5 Usually in children age 1-8 years
days, polymorphous exanthem Treatment with IV im-
on trunk, flexor regions, and munoglobulin and PO aspirin
perineum, erythema of the oral during the acute phase is asso-
cavity (“strawberry tongue”) ciated with a reduction in rate
with extensively chapped lips, of coronary abnormalities such
bilateral conjunctivitis usually as coronary artery dilatation
without eye discharge, cervical and coronary aneurysm. Expert
lymphadenopathy, edema and consultation and treatment
erythema of the hands and feet advice about aspirin use
with peeling skin (late finding, and ongoing monitoring
usually 1-2 weeks after onset of warranted.
fever), no other illness account-
able for the findings.
*A notifiable disease is one for which regular, frequent, and timely information regarding individual cases is
considered necessary for the prevention and control of the disease. Check with state public health department
to receive direction on notification.
Sources: Summary of notifiable diseases—United States, 2011. MMWR 60(53):1–117, 2013.
4074_Ch17_397-462 20/11/14 4:31 PM Page 440
Impairment Short-acting
beta2-agonist use
>2 days/week Several times
for symptom ≤2 days/week Daily
but not daily per day
control (not
prevention of EIB)
Interference with
None Minor limitation Some limitation Extremely limited
normal activity
≥2 exacerbations in 6 months requiring oral systemic
0−1/year corticosteroids, or ≥4 wheezing episodes/1 year lasting
Exacerbations >1 day AND risk factors for persistent asthma
Risk requiring oral
systemic Consider severity and interval since last exacerbation.
corticosteroids Frequency and severity may fluctuate over time.
Figure 17-3 Stepwise Approach to Managing Asthma in Children 0–4 Years of Age
Source: National Institutes of Health: Guidelines for the Diagnosis and Management of Asthma; Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
4074_Ch17_397-462 20/11/14 4:31 PM Page 442
Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
ICS, inhaled corticosteroids
Notes:
• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• Level of severity is determined by both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of the previous 2–4 weeks
and spirometry. Assign severity to the most severe category in which any feature occurs.
• At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent
and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity.
For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as
patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Figure 17-4 Classifying Asthma Severity and Initiating Treatment in Children 5–11 Years of Age
Source: National Institutes of Health: Guidelines for the Diagnosis and Management of Asthma; Available
at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
airway inflammation and its resulting symptoms, emer- flow (PEF) can be normal or near normal. The body’s normal
gency visits can be minimized or eliminated. circadian rhythm provides a variation of awakening to late-
Asthma is a disease of airway inflammation with super- evening PEF of 10% to 15%. With asthma, this variation in-
imposed bronchospasm. The need for a short-acting beta2- creases to more than 15%, reflecting the nocturnal
agonist as a rescue drug should be viewed as failure to bronchospasm that is a part of the disease. Usually a child
provide adequate airway inflammatory control. Excessive younger than 4 or 5 has some difficulty with obtaining a
beta2-agonist use is a risk factor for asthma death. peak flow.
When airway inflammation is inadequate, asthma symp- The approach to managing asthma is differentiated into
toms such as cough or wheeze can accompany or immedi- two age groups: those aged 0 to 4 (Fig. 17–5) and those aged
ately follow physical activity. A child with well-controlled 5 to 11 years (Fig. 17–6). Because of the wide range of asthma
asthma should be able and encouraged to participate in fit- medications currently available, the NP, patient, and family
ness and leisure activities. can work together to find an age-specific lifestyle and treat-
With asthma treatment that focuses on the prevention of ment regimen that provides optimal care with minimal to few
airway inflammation and bronchospasm, the peak expiratory adverse medication effects.
4074_Ch17_397-462 20/11/14 4:31 PM Page 443
Step 6 Step up if
Step 5 Preferred: needed
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, inhaled
corticosteroid; LABA, inhaled long-acting beta 2-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta 2-agonist.
Notes:
• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up.
• Theophylline is a less desirable alternative due to the need to monitor serum concentration levels.
• If clear benefit is not observed within 4–6 weeks and patient/family medication technique and adherence are satisfactory, consider adjusting therapy
or alternative diagnosis.
• Studies on children 0–4 years of age are limited. Step 2 preferred therapy is based on Evidence A. All other recommendations are based on expert
opinion and extrapolation from studies in older children.
* Cromolyn no longer availabe in US but remains mentioned in guidelines.
Figure 17-5 Estimated Comparative Daily Dosages for ICS in Children 0–4 Years of Age
Source: National Institutes of Health: Guidelines for the Diagnosis and Management of Asthma; Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
The formerly held concept in asthma was that no matter additional option includes a leukotriene modifier such as
how severe the airway obstruction, the process was fully re- montelukast. Although all these products have anti-inflam-
versible. The newer disease model acknowledges that contin- matory capability, inhaled corticosteroids have proved to be
ued airway inflammation contributes to significant and the most effective in preventing airway inflammation and
potentially permanent airway remodeling and fixed obstruc- are recognized as the preferred asthma controller drug. Dos-
tion. In addition, there is evidence that poorly controlled ing should be based on age and strength needed to control
asthma can contribute to overall attenuated lung develop- symptoms (Figs. 17–7 and 17–8). Adding a leukotriene mod-
ment in children. ifier to an inhaled corticosteroid (ICS) or increasing the
The backbone of therapy for mild persistent, moderate dosage of the inhaled corticosteroid also improves asthma
persistent, or severe persistent asthma is the use of an inflam- outcome. The clinical effects of inhaled corticosteroid and
matory controller drug, such as an inhaled corticosteroid; an leukotriene modifier take at least 1 to 2 weeks to be seen.
4074_Ch17_397-462 20/11/14 4:31 PM Page 444
Step 6 Step up if
Step 5 Preferred: needed
Preferred: High-dose (first, check
ICS + LABA adherence,
Step 4 High-dose inhaler
ICS + LABA + oral
Preferred: technique,
Step 3 systemic
Medium- Alternative environmental
corticosteroid
Preferred: dose ICS + High-dose control, and
Step 2 and comorbid
Either LABA ICS + either
High-dose conditions)
Preferred: Low-dose Alternative: LTRA or
ICS + either Theophylline ICS + either
Low-dose Medium- Assess
Step 1 LABA, LRTA, LTRA or
ICS dose ICS + control
Preferred: or Theophylline
Alternative: either LTRA + oral
Theophylline
SABA PRN Cromolyn*, or systemic Step down
or Theophylline if possible
LTRA, corticosteroid
Nedocromil*, Medium-
(and asthma
or dose ICS
is well
Theophylline controlled
at least 3
Each step: Patient education, environmental control, and management of comorbidities. months)
Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic
asthma (see notes).
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, inhaled
corticosteroid; LABA, inhaled long-acting beta 2-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta 2-agonist.
Notes:
• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up.
• Theophylline is a less desirable alternative due to the need to monitor serum concentration levels.
• Step 1 and step 2 medications are based on Evidence A. Step 3 ICS + adjunctive therapy and ICS are based on Evidence B for efficacy of each
treatment and extrapolation from comparator trials in older children and adults—comparator trials are not available for this age group; steps 4–6 are
based on expert opinion and extrapolation from studies in older children and adults.
• Immunotherapy for steps 2–4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or lacking for molds and
cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults.
Clinicians who administer immunotherapy should be prepared and equipped to identify and treat anaphylaxis that may occur.
* Nedocromil and cromolyn no longer available in US, remain mentioned in guidelines. Zileuton seldom used but available.
Figure 17-6 Stepwise Approach to Managing Asthma in Children 5–11 Years of Age
Source: National Institutes of Health: Guidelines for the Diagnosis and Management of Asthma; Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
Adding a long-acting beta2-agonist (LABA) such as salme- nedocromil and cromolyn continue to be mentioned as a
terol or formoterol is also an option when ICS therapy is in- controller option, these products are no longer available.
sufficient but should be prescribed only with the Medications for asthma in children should be age and
understanding of the boxed warning related to the small but symptom-specific (Table 17–16). Theophylline, a modestly
significant increased asthma death risk with use. Just as in the effective bronchodilator, remains an option in preventing
adult population, a LABA should never be used as monother- bronchospasm in children ≥5 years of age. Although inex-
apy for a child and is only be used in combination with an ICS pensive, the cost of using this medication is significant because
for prevention of symptoms in moderate–severe persistent of the required laboratory monitoring with its use. Theo-
asthma. Although the inhaled mast cell stabilizers including phylline has a narrow therapeutic index, but the dose must be
4074_Ch17_397-462 20/11/14 4:31 PM Page 445
TABLE 17-16
Pediatric Asthma Medications
Medication Mechanism of Action Indication Comment
Inhaled corticosteroids Inhibit eosinophilic action Controller drug, prevention Need consistent use to be
and other inflammatory me- of inflammation helpful
diators, potentate effects of
beta2-agonists
Leukotriene modifier Inhibits action of inflamma- Controller drug, prevention Likely less effective than in-
Leukotriene antagonists tory mediator, leukotriene, of inflammation haled corticosteroids. Partic-
(montelukast [Singulair], by blocking select receptor ularly effective add-on
zafirlukast [Accolate]) sites medication when disease
control inadequate with in-
haled corticosteroid, when
asthma complicated by al-
lergic rhinitis
Oral corticosteroids Inhibit eosinophilic action Treatment of acute inflam- • Indicated in treatment of
and other inflammatory mation such as in asthma acute asthma flare to re-
mediators flare duce inflammation
• In higher dose and with
longer therapy
• No taper needed if use is
short-term
Potential for causing gas-
tropathy, particularly gastric
ulcer and gastritis
Beta2-agonist Bronchodilation via stimula- Rescue drugs for treatment • Onset of action 15 min
Albuterol (Ventolin, tion of beta-2 receptor site of acute bronchospasm • Duration of action 4–6 hr
Proventil), pirbuterol
(Maxair), levalbuterol
(Xopenex)
Long-acting beta2- Beta2-agonist; bronchodila- Prevention of bronchospasm Example: Salmeterol
agonists (salmeterol tion via stimulation of beta- • Onset of action 1 hr
[Serevent], formoterol 2 receptor site • Duration of action 12 hr
[Foradil]) • Indicated for prevention
rather than treatment of
bronchospasm
Patient should also have
short-acting beta2-agonist
as rescue drug
• Onset of action 15–30 hr
• Duration of action 12 hr
• Indicated for prevention
rather than treatment of
bronchospasm
• Patient should also have
short-acting beta2-agonist
as rescue drug
Theophylline Mild bronchodilator, helps Prevention of bronchospasm, • Narrow therapeutic index
with diaphragmatic mild anti-inflammatory drug with numerous drug
contraction interactions
• Monitor carefully for toxi-
city by checking drug lev-
els and clinical
presentation
4074_Ch17_397-462 20/11/14 4:31 PM Page 447
Table 17-17
Assessment Criteria for Hydration Status
Parameter Mild 3%–5% Moderate 6%–9% Severe ≥10%
Blood pressure Normal Normal to decreased Weak, thready, impalpable
Pulse quality Normal Normal to slightly decreased Moderately decreased
Heart rate Normal Normal to increased Increased (sometimes brady-
cardia)
Turgor Normal Recoil <2 seconds Recoil >2 seconds, tenting
Fontanels Normal Slightly depressed Depressed
Mucous membranes Slightly dry lips, thick saliva Dry lips and oral mucosa Very dry lips, oral mucosa
Eyes Normal, tears present Slightly sunken, tears Deeply sunken, tears absent
decreased
Capillary refill Normal (<2 seconds) Prolonged Minimal
Mental status Normal Normal, fatigued, restless, Apathetic, lethargic,
irritable unconscious
Urine output Slightly decreased Decreased Minimal
Thirst Normal, to slightly increased Moderately increased Very thirsty or too lethargic
to assess
Table 17-18
Rehydration Therapy
For mild to moderate dehydration, oral rehydration therapy (ORT) with oral rehydration solution (ORS) is as effective as
parenteral therapy, is easier to administer, and is more cost-effective.
Degree of Dehydration Rehydration Therapy Replacement of Ongoing Losses
MINIMAL TO NONE Not applicable, sips of fluid frequently as <10 kg: 60–100 mL ORS for each loss;
tolerated to maintain circulating volume >10 kg 120–240 mL for each loss
and hydration status
MILD TO MODERATE ORT with ORS, 50–100 mL/kg over 3–4 Same
hours, often best tolerated in frequent,
small volumes, preferably supplied in the
office or urgent-care setting
SEVERE Lactated Ringers solution (LR) preferred over Same
normal saline (NS) intravenous fluid ther- If unable to drink, give through nasogastric
apy but used if LR not available—boluses tube or give D5W1/4 NS with K+ 20 mEq
20 mL/kg until improvement (perfusion, + IV
LOC) then 100 mL/kg over 4 hours
during acute gastroenteritis include fever coupled with 197. The most common reason for precocious puberty in
bloody or pus-filled stools. If these are present, a bacterial boys is:
source of infection such as shigellosis should be considered. A. testicular tumor.
Stool culture should be obtained, and appropriate antimicro- B. a select number of relatively uncommon health
bial therapy should be initiated. problems.
Improperly handled food is a common source of the C. exogenous testosterone.
gastrointestinal infection commonly known as food poi- D. early onset of normal puberty.
soning. A child typically presents, often along with family
198. Which of the following is noted in a child with pre-
members and caregivers who ate the same food, with a
mature thelarche?
history of sudden onset of abdominal pain, nausea, and
A. breast enlargement.
vomiting. Knowledge of the timing of the onset of symp-
B. accelerated linear growth.
toms is helpful when attempting to discern the offending
C. pubic hair.
organism. Most food poisoning episodes are short and self-
D. body odor.
limiting, resolving over a few hours to days without special
intervention. 199. Which of the following is noted in a child with pre-
mature adrenarche?
DI SCUS SION SOURCES A. breast development.
King, KC, Glass R, Bresee JS. Managing acute gastroenteritis among B. accelerated linear growth.
children. MMRW 2;RR16:1–16, 2003. C. pubic hair.
Medscape. Pediatric Dehydration Overview, http://emedicine D. menstruation.
.medscape.com/article/801012-overview.
200. Girls typically grow to their adult height by:
A. menarche.
Alterations in B. 1 year before menarche.
C. 1 year after onset of menstruation.
Puberty D. by their sixteenth birthday.
196. The most common reason for precocious puberty in 201. A 15-year-old male is found to be at Tanner stage 1
girls is: on exam. The least likely cause of this finding is:
A. ovarian tumor. A. a variation of normal based on ethnicity or familial
B. adrenal tumor. factors.
C. exogenous estrogen. B. human growth hormone abnormality.
D. early onset of normal puberty. C. Klinefelter syndrome.
D. nutritional factors.
4074_Ch17_397-462 20/11/14 4:31 PM Page 449
202. Which is not a reason for the delayed onset of puberty a child 5 to 6 years old has body odor, pubic hair, and (rarely)
in a 13-year-old boy? axillary hair. The child has no other signs of puberty, including
A. report of a high level of physical activity accelerated linear growth. Reassurance and ongoing monitor-
B. Kallmann syndrome ing constitute the typical course of treatment.
C. familial trait In boys, precocious puberty is defined as the onset of sec-
D. history of radiation exposure ondary sexual characteristics before his ninth birthday. Overall,
this condition is less common in boys than in girls and is un-
203. Which is possible reason for delayed onset of puberty
likely to be a benign normal variation. Gonadal and adrenal tu-
in a 13-year-old girl?
mors and a select number of genetically based diseases are the
A. history of abdominal irradiation
most likely causes. Prompt referral to expert care is indicated.
B. obesity
Delayed puberty is defined as no evidence of sexual mat-
C. report of a high level of physical activity
uration (Tanner stage 1) in girls older than age 13 and in boys
D. Turner syndrome
older than age 14. Delayed onset of puberty is multifactorial
in both boys and girls. This delay can occur because the child
is healthy but maturing more slowly when compared with
Answers same-age peers, a condition called constitutional delay of pu-
196. D. 199. C. 202. A. berty, which often runs in families. However, delay in puberty
197. B. 200. C. 203. D. can be caused by hypogonadism, in which the gonads (the
198. A. 201. A. testes in males and the ovaries in females) produce few or no
hormones. Numerous medical conditions can result in hy-
Precocious puberty in girls has long been defined as the onset pogonadism, including certain autoimmune disorders, de-
of secondary sexual characteristics before the child’s eighth velopmental disorders, history of radiation exposure and/or
birthday. A more recent study reveals that there is likely a chemotherapy, infection, surgery, or brain or pituitary tu-
group of girls who have the onset of slowly developing sec- mors. Chromosomal anomalies can also result in hypogo-
ondary sexual characteristics between ages 6 and 8 years as a nadism, such as Kallmann syndrome (occurring more often
benign normal variant. In particular, thelarche (the isolated in boys than girls), Turner syndrome in girls (XO female),
appearance of breast development) is common as early as age and Klinefelter syndrome in boys (XXY male). For both gen-
7 and pubarche (the appearance of pubic hair without other ders, poor diet lacking in the daily recommended values of
signs of puberty) as early as age 8 in otherwise healthy girls. nutrients can also contribute to delayed onset. Occasionally,
Consequently, the most common reason for precocious young girls who undergo intense physical training for a sport,
puberty in girls is early onset of normal puberty. such as running or gymnastics, experience delayed puberty,
A subset of girls, particularly girls with pubertal changes largely as a result of low body weight; this is not noted in
noted before their sixth birthday, often has significant health males with a similar level of activity.
problems, however, such as ovarian or adrenal tumors. D I S C U SSI O N S O U R C E S
Expert evaluation and referral is indicated in these children.
Medscape: Precocious Puberty, http://emedicine.medscape.com/
Evaluation typically includes measuring bone age, level of
article/924002-overview#a0104.
follicle-stimulating hormone, and level of luteinizing hor- National Institutes of Health: What Causes Normal Puberty, Preco-
mone; performing abdominal ultrasound; and conducting cious Puberty, & Delayed Puberty? http://nichd.nih.gov/health/
other studies warranted by clinical presentation. Treatment topics/puberty/conditioninfo/Pages/causes.aspx.
depends on the cause. In the absence of an adrenal or ovarian
tumor or other secondary cause, counseling about the nature
of the process of early puberty should be discussed with the Heart Murmur
child and family.
Because girls typically achieve nearly all of their adult 204. An innocent heart murmur has which of the follow-
height 1 year after the first menstrual period (menarche), a ing characteristics?
girl achieving menarche at a premature age often has short A. occurs late in systole
stature. If the child and family wish to attempt to halt the B. has localized area of auscultation
onset of puberty, a gonadotropin-releasing hormone ana- C. becomes softer when the patient moves from
logue and additional therapies can be given to counteract the supine to standing position
effects of endogenous hormones. This therapy is provided D. frequently obliterates the second heart sound (S2)
with expert consultation and family informed consent.
205. The murmur of atrial septal defect is usually:
Premature thelarche is a relatively common, benign process
A. found in children with symptoms of cardiac disease.
in which breast development is noted in female toddlers. Usu-
B. first found on a 2- to 6-month well-baby examina-
ally present unilaterally or bilaterally, the child has no other
tion.
signs of puberty including accelerated linear growth. Reassur-
C. found with mitral valve prolapse.
ance and ongoing monitoring are the typical course of treat-
D. presystolic in timing.
ment. In premature adrenarche, a parent usually reports that
4074_Ch17_397-462 20/11/14 4:31 PM Page 450
206. A Still murmur: The ability to appropriately assess children with a heart mur-
A. is heard in the presence of cardiac pathology. mur is an important part of the role of an NP. Knowledge of
B. has a humming or vibratory quality. the most common murmurs, the clinical presentation of the
C. is a reason for denying sports participation murmurs, etiology of the murmur, and the impact on a
clearance. child’s health is critical to appropriate assessment. It is also
D. can become louder when the patient is standing. necessary to be able to determine the need for specialty
referral (Table 17–19).
Answers D I S C U SSI O N S O U R C E
Park M. Pediatric Cardiology for Practitioners, ed. 5. St. Louis:
204. C. 205. B. 206. B. Mosby, 2007.
TABLE 17-19
Differential Diagnosis of Common Heart Murmurs in Children
When evaluating a child with cardiac murmur:
• Ask about major symptoms of heart disease: chest pain, congestive heart failure symptoms, palpitations, syncope, ac-
tivity intolerance, poor growth and development
• The bell of the stethoscope is most helpful for auscultating lower pitched sounds, and the diaphragm is better for
higher pitched sounds
• Systolic murmurs are graded on a 1 to 6 scale, from barely audible to audible with stethoscope off the chest. Diastolic
murmurs are usually graded on the same scale, but abbreviated to grades 1 to 4 because these murmurs are not loud
enough to reach grades 5 and 6.
• A critical part of the evaluation of a child with a heart murmur is the decision to offer antimicrobial prophylaxis. No
prophylaxis is needed with benign murmurs. Refer to the American Heart Association’s Guidelines for the latest advice.
Important Cardiac
Murmur Examination Findings Additional Findings Comments
Newborn Grade 1–2/6 early systolic, vi- Subsides or disappears when Heard in first few days
bratory, heard best at left pressure applied to abdomen of life; disappears in
lower sternal border (LLSB) 2–3 weeks
with little radiation Benign condition
Pulses intact, otherwise well
neonate
Still (vibratory innocent Grade 1–3/6 early systolic Softens or disappears when sit- Usual onset age 2–6 years;
murmur) ejection, musical or vibra- ting, when standing, or with may persist through
tory, short, often buzzing, Valsalva maneuver adolescence
heard best midway between Louder when supine or with Benign condition
apex and LLSB fever or tachycardia
Hemic Grade 1–2/6 systolic ejection, Heard only in presence of in- Disappears when underly-
high-pitched, heard best in creased cardiac output, such ing condition resolves
pulmonic and aortic areas as fever, anemia, stress Usually seen without car-
diac disease
Most often heard in chil-
dren and younger adults
with thin chest walls
Venous hum Grade 1–2/6 continuous Disappears in supine position, Believed to be produced by
musical hum heard best at when jugular vein is com- turbulence in subclavian
upper right sternal border pressed and jugular veins
(URSB) and upper left ster- Common after age 3 years. Benign condition
nal border (ULS) and the
lower neck
4074_Ch17_397-462 20/11/14 4:31 PM Page 451
TABLE 17-19
Differential Diagnosis of Common Heart Murmurs in Children—cont’d
Important Cardiac
Murmur Examination Findings Additional Findings Comments
Pulmonary outflow Grade 1–2/6 soft, short, Softens or disappears when sit- Heard throughout
ejection murmur systolic ejection murmur, ting, when standing, or with childhood
heard best at LLSB, usually Valsalva maneuver Benign condition but has
localized Louder when supine qualities similar to mur-
murs caused by pathologi-
cal condition such as atrial
septal defect (ASD), coarc-
tation of the aorta (COA),
pulmonic stenosis (PS)
Patent ductus arteriosus Grade 2–4/6 continuous In premature newborns, seen Normal ductus closure oc-
murmur heard best at ULSB with active precordium; in curs by day 4 of life
and left infraclavicular area older children, seen with full Often isolated finding but
pulses may be seen with COA,
ventricular septal defect
(VSD)
Accounts for ±12% of all
congenital heart disease
Twice as common in girls
In preterm infants <1500 g,
rate 20%–60%
Atrial septal defect Grade 1–3/6 systolic ejection Accompanying mid-diastolic Two times as common in
murmur, heard best at ULSB murmur heard at fourth inter- girls
with widely split fixed S2 costal space (ICS) left sternal Child is often entirely well
border (LSB); commonly or present with heart
caused by increased flow failure
across tricuspid valve Often missed in the first
few months of life or even
entire childhood
Watch for children with
easy fatigability
Cyanosis rare
Ventricular septal defect Grade 2–5/6 regurgitant sys- Thrill may be present and a Usually without cyanosis
tolic murmur heard best at loud P2 with large left-to-right Children with small- to
LLSB shunt moderate-sized left-to-
Occasionally holosystolic, right shunt without pul-
usually localized monary hypertension
likely to have minimal
symptoms
Larger shunts may result in
CHF with onset in infancy
Aortic stenosis Grade 2–5/6 systolic ejection Ejection click at apex, third left More common in boys than
murmur heard best in upper ICS, second right ICS girls
left sternal border (ULSB) or Radiation or thrill to the carotid In children, usually caused
second right ICS, possibly arteries by unicuspid (if noted in
with paradoxically split S2 infancy) or bicuspid (if
noted in childhood) valve
Mild exercise intolerance
common
Continued
4074_Ch17_397-462 20/11/14 4:31 PM Page 452
TABLE 17-19
Differential Diagnosis of Common Heart Murmurs in Children—cont’d
Important Cardiac
Murmur Examination Findings Additional Findings Comments
Coarctation of aorta Grade 1–5/6 systolic ejection Weak or absent femoral pulses, Often seen with aortic
murmur heard best at ULSB hypertension in arms stenosis (AS), mitral regur-
and left interscapular area gitation (MR)
(on back) Presence of dorsalis pedis
pulse in child essentially
rules out this condition
Mitral valve prolapsed Grade 1–3/6 mid-systolic click Murmur heard earlier in systole Often with pectus excava-
followed by late systolic and often louder with stand- tum, straight back (>85%)
murmur heard best at the ing or squatting
apex
Pulmonic valve stenosis Grade 2–5/6 heard best at Radiates to backS2 may be No symptoms with mild to
ULSB, ejection click at sec- widely split moderate disease
ond left ICS Usually a fusion of valvular
cusps
Source: Park M. Pediatric Cardiology for Practitioners, ed. 5. St. Louis: Mosby, 2007.
214. When counseling the family of an otherwise healthy 220. As part of the evaluation in a febrile 3-year-old boy,
2-year-old child who just had a febrile seizure, you the following white blood cell count with differential
consider the following regarding whether the child is is obtained:
at risk for future febrile seizures (choose all that WBCs = 22,100/mm3
apply): Neutrophils = 75% (normal 40% to 70%) with toxic
A. The occurrence of one febrile seizure is predictive granulation
of having another. Bands = 15% (normal 0% to 4%)
B. Intermittent diazepam can be used prophylactically Lymphocytes = 4% (normal 30% to 40%)
during febrile illness to reduce risk of recurrence. Which of the following best describes the WBC with
C. A milder temperature elevation in a child with a differential results?
history of a febrile seizure poses significant risk for A. leukocytosis with neutrophilia
future recurrent febrile and nonfebrile seizures. B. leukopenia with lymphocytosis
D. Consistent use of antipyretics during a febrile ill- C. lymphopenia with neutropenia
ness will significantly reduce the risk of a future D. leukopenia with neutropenia
febrile seizure.
221. These results increase the likelihood that the cause of
215. When evaluating a child who has bacterial meningitis, the above-mentioned child’s infection is:
the NP expects to find cerebrospinal fluid (CSF) A. viral.
results of: B. parasitic.
A. low protein. C. fungal.
B. predominance of lymphocytes. D. bacterial.
C. glucose at about 30% of serum levels.
222. Which of the following is the most appropriate way to
D. low opening pressure.
relieve fever and discomfort in a child with varicella?
216. When evaluating a child who has aseptic or viral A. ibuprofen
meningitis, the NP expects to find CSF results of: B. aspirin
A. low protein. C. acetaminophen
B. predominance of lymphocytes. D. cold bath
C. glucose at about 30% of serum levels.
223. Potential adverse events of acetaminophen in a child
D. low opening pressure.
with fever and mild dehydration include:
217. Sepsis is defined as the: A. seizure.
A. clinical manifestation of systemic infection. B. hepatotoxicity.
B. presence of bacteria in the blood. C. petechial rash.
C. circulation of pathogens. D. gastric ulcer.
D. allergenic response to infection.
218. Gina is 2 years old and presents with a 3-day history
of fever, crankiness, and congested cough. Her respi-
Answers
ratory rate is more than 50% of the upper limits of
normal for age. Tubular breath sounds are noted at 207. B. 213. D. 219. C.
the right lung base. Skin turgor is normal, and she is 208. D. 214. A and B. 220. A.
wearing a wet diaper. She is alert, is resisting the ex- 209. B. 215. C. 221. D.
amination as age appropriate, and engages in eye con- 210. B. 216. B. 222. C.
tact. Temperature is 38.3°C (101°F). Gina’s diagnostic 211. A. 217. A. 223. B.
evaluation should include: 212. B. 218. A.
A. chest x-ray.
B. urine culture and sensitivity measurement.
Most young children with an acute febrile illness do not have
C. lumbar puncture.
a serious bacterial infection and recover fully without seque-
D. sputum culture.
lae. On rare occasion, however, febrile young children with
219. An early indicator of hypoperfusion is: no obvious source of infection have serious sequelae includ-
A. an elevation in total white blood cell count. ing sepsis and death. The risk of serious illness in the presence
B. dehydration. of fever is now significantly reduced in the advent of immu-
C. capillary refill of >2 seconds. nization against H. influenzae type B and S. pneumoniae.
D. nonresponsive child. Nonetheless, the evaluation and treatment of a febrile child
4074_Ch17_397-462 20/11/14 4:31 PM Page 454
are an important part of providing pediatric healthcare. The illness is likely helpful in preventing recurrence. Although
NP needs to ascertain the febrile child’s immunization status, use of antipyretics may improve the comfort of the child,
including where in a particular series the child is or if any these agents do not prevent febrile seizures.
immunizations are missing, because this is an essential com- In the first 2 years of life, most children average four to six
ponent of assessing risk of possible pathogens. Unfortunately, acute febrile episodes per year, with healthcare sought in
as more parents chose not to immunize their children, a about two-thirds of cases. Of these younger children with
resurgence of serious, potentially life-threatening vaccine- temperatures lower than 39°C (<102.2°F), most have a viral
preventable diseases is inevitable. or obvious bacterial source, and less than 10% have no obvi-
Fever is a complex physiological reaction that occurs when ous source for fever. The most common causes of fever in
exogenous pyrogens (microorganisms and their products, young children are viruses and bacteria, with fungi, parasites,
drugs, incompatible blood products) are introduced to the neoplasms, collagen vascular disease, and factitious disease
body. This triggers the production of endogenous pyrogens being important but less common. Before pneumococcal
(polypeptides produced by host cells such as monocytes, conjugate vaccine (PCV13 [Prevnar]) became available, S.
macrophages, and interleukin-1). Prostaglandins activate pneumoniae was implicated in approximately 90% of cases of
thermoregulatory neurons and alter the hypothalamic set occult bacteremia in febrile infants and young children. This
point. Vasomotor center reactions increase heat conservation vaccine provides activity against the most common pneumo-
and heat production. coccal serotypes implicated in invasive pneumococcal disease
Although most parents and healthcare providers usually and dramatically reduces, but does not eliminate, the risk of
treat fever with antipyretics and other options, in the other- invasive pneumococcal disease. Rapid testing for influenza
wise well child, an increase in body temperature has benefits. and other viruses can help reduce the need for more invasive
During fever, viral replication rate is reduced. Increased body studies.
temperature is toxic to encapsulated bacteria, particularly S. In a previously well, febrile child who is alert, able to
pneumoniae. In animal models and clinical trials in humans, tolerate oral fluids, age 3 months to 3 years old, without an
the presence of fever has been associated with lower rates of identifiable source of fever and temperature lower than 39°C
morbidity and mortality associated with infectious diseases. (<102.2°F), the evaluation for the source of fever should start
Also, the use of antipyretics including acetaminophen and with a careful history and physical examination. Urine testing
ibuprofen has been associated with prolonged illness, espe- is indicated in those with unexplained fever because of an
cially when viral in origin. Conversely, a child with fever increase in the incidence of urinary tract infections in chil-
is often uncomfortable and cranky, which reinforces the dren. If the child is alert, the child’s caregivers should be ad-
perception that this is a condition that warrants treatment. vised about the judicious use of antipyretics, increased fluid
Fever also increases metabolic demands, a potential problem intake, and signs of deteriorating condition. Follow-up in 48
in a child or adult with a chronic health problem; in preg- hours is prudent if fever persists; follow-up should be sooner
nancy, fever is potentially teratogenic in the first trimester if the child’s condition worsens.
and increases metabolic demands throughout pregnancy. Advising the child’s caregivers about the appropriate choice
Fear of febrile seizure also contributes to the propensity and use of antipyretics is an important part of providing care
to treat fever aggressively, with the thought that if the body for a child with a non–life-threatening illness and fever. As pre-
temperature is reduced, seizure risk is reduced. The cause of viously mentioned, fever plays an important role in controlling
febrile seizures is unclear but likely involves a relationship infection. If a child with fever appears fairly comfortable, no
between endogenous pyrogens or cytokines and fever. Febrile treatment is needed. Even a cranky child usually is not harmed
seizures occur in young children when their seizure threshold and may be helped by allowing the fever to run its course. If
is lowest. A simple febrile seizure actually is most likely to the child is uncomfortable with fever, common-sense measures
occur as fever is increasing rather than at its peak; however, include dressing the child lightly and increasing fluid intake.
there is no evidence that the rapidity of the rate of increase is A cooling bath should not be used because the resulting shiv-
associated with febrile seizures. A familial tendency has been ering would drive up body temperature.
noted with febrile seizure, but the condition is not predictive The choice of an antipyretic is dictated by numerous
of the development of epilepsy. A simple febrile seizure is a factors, including the length of time for onset of action of the
benign, although frightening, common event in children product (ideally, less than half an hour) and the duration of
6 months to 5 years old; a child who has had one seizure is at action (ideally, 4 to 8 hours), with no or few major reported
increased risk for a recurrence. The majority of children with adverse effects. Ibuprofen and acetaminophen are the most
febrile seizures do not need to be treated with medication. commonly prescribed antipyretics; both have onset of action
Although effective therapies including phenobarbital and val- within half an hour of the dose. The duration of action of
proate, which need to be taken daily, reduce risk and could acetaminophen is about 4 hours, whereas the duration of
prevent the occurrence of additional simple febrile seizures, ibuprofen is around 6 hours. The antipyretic potential of acet-
the potential adverse effects of these therapies outweigh the aminophen is equal to that of ibuprofen. Acetaminophen has
potential benefit in this self-limiting condition. In situations an excellent gastrointestinal adverse event profile but can
in which parental anxiety about febrile seizures is severe, be hepatotoxic with excessive use and high dose. Ibuprofen
intermittent oral diazepam (Valium) at the onset of febrile is usually well tolerated but does have the potential to cause
4074_Ch17_397-462 20/11/14 4:31 PM Page 455
gastric ulcer and gastritis, albeit usually with long-term high- severe bacterial infection, such as appendicitis and pneumo-
dose use. Aspirin should not be prescribed to a child with a nia. The following is typically noted:
febrile illness because of its association with Reye syndrome. • Leukocytosis: An elevation in the total WBC count.
Ibuprofen should not be prescribed for varicella because its • Neutrophilia: An elevation in the number of neutrophils
use is implicated in necrotizing fasciitis. in circulation, defined as more than 10,000 neu-
A young child with a high fever (>39.4°C [>102.9°F]) is trophils/mm3. Neutrophils are also known as polys or
more likely to be bacteremic than a child with a temperature segs, both referring to the polymorph shape of the seg-
equal to or lower than 39.3°C (<102.8°F); this risk is most mented nucleus of this WBC.
pronounced in children who have not received immunization • Bandemia: An elevation in the number of bands or young
against S. pneumoniae and H. influenzae type B. The degree neutrophils in circulation. Usually, less than 4% of the
of temperature reduction in response to antipyretic therapy total WBCs in circulation are bands. When this percent-
is not predictive of presence or absence of bacteremia. In one age is exceeded and the absolute band counts exceed
major study among infants with bacteremia but without 500/mm3, bandemia is present. This finding indicates
meningitis, differences in children without bacteremia were that the body has called up as many mature neutrophils
detected in clinical appearance before fever reduction but not that were available in storage pool and is now accessing
after defervescence. All children with meningitis appeared less mature forms. Bandemia further reinforces the po-
seriously ill before and after defervescence. tential seriousness of the infection.
An early indicator of hypoperfusion is a capillary refill of • Toxic granulation: Often reported on WBC morphologic
>2 seconds. Decreased perfusion of the skin is associated with study.
an increase in systematic vascular resistance, which occurs • Other neutrophil forms do not belong in circulation even
early in an infant with hypovolemia. with severe infection; these include myelocytes and
When sepsis is suspected, a septic work-up should be ini- metamyelocytes, immature neutrophil forms that are typ-
tiated (Table 17–20) in an appropriate urgent or emergent ically found in granulopoiesis pool. The presence of these
setting. Empirical antimicrobial therapy with supportive care cells in the circulation is an ominous marker for life-
is prudent, pending the outcome of evaluation. An antiviral threatening bacterial infection.
such as acyclovir also may be indicated. The child can be • In viral infection, the total WBC count can be elevated
managed at home if the following conditions are met: the but is often normal or slightly depressed (leukopenia).
child is intact neurologically, adequate hydration can be Lymphocytes, the leukocytes most active in viral infec-
maintained via the oral route, the caregiver is willing and able tion, predominate. Atypical or reactive lymphocytes are
to provide the needed close attention to the child, and fol- often reported on WBC morphology.
low-up and emergency care are easily accessible. • To eliminate or support the diagnosis of meningitis, lum-
A total WBC count with differential is obtained as part bar puncture with cerebrospinal fluid (CSF) evaluation
of the evaluation of a child with suspected sepsis. The most should be part of the evaluation of a febrile younger child
typical WBC pattern found in severe bacterial infection is who has an altered neurological examination. Pleocytosis,
the “left shift.” A “left shift” is usually seen in the presence of defined as a CSF WBC count of more than 5 cells/mm3, is
TABLE 17-20
Evaluation of Young Child With Suspected Sepsis
Evaluation Rationale
Complete blood count with white blood cell (WBC) Identify viral versus bacterial shifts, general leukocytic
differential response
Blood culture Potentially identify causative organism in sepsis
Urinalysis and urine culture via transurethral catheter Evaluate for urinary tract infection including pyelonephritis,
or suprapubic tap particularly important in child ≤2 years old
Lumbar puncture with cerebrospinal fluid analysis Evaluate for bacterial or viral meningitis, particularly impor-
tant if alterations in neurological examination
Chest x-ray Rule in or out pneumonia or other respiratory tract condi-
tion that can contribute to sepsis, particularly important
if dyspnea, tachypnea, decreased breath sounds, WBC
(20,000 mm3, or other findings suggestive of lower
respiratory tract infection
Stool culture, fecal WBC count Only if diarrhea present, to evaluate for possible focus of
infection
an expected finding in meningitis caused by bacterial, 226. Which of the following is most likely to be noted in a
viral, tubercular, fungal, or protozoan infection. An ele- 3 year old with CAP?
vated CSF opening pressure is also a nearly universal A. complaint of pleuritic chest pain
finding. Typical CSF response in bacterial meningitis in- B. sputum production
cludes a median WBC count of 1200 cells/mm3 with 90% C. report of dyspnea
to 95% neutrophils; additional findings are a reduction in D. tachypnea
CSF glucose below the normal level of about 60% of the
227. What percentage of children have an episode of pneu-
plasma level and an elevated CSF protein level. CSF re-
monia before the age of age 5?
sults in viral or aseptic meningitis include normal glucose
A. 18% to 20%
level, normal to slightly elevated protein level, and lym-
B. 9% to 10%
phocytosis. Further testing to ascertain the causative or-
C. 3% to 4%
ganism is warranted. Measurement of serum lactate as
D. 20% to 30%
well as some inflammatory markers and acute-phase re-
actants can aid in the early identification and manage- 228. Which of the following antimicrobials provides effec-
ment of pediatric sepsis. These include erythrocyte tive activity against atypical pathogens?
sedimentation rate (ESR), C-reactive protein (CRP), in- A. amoxicillin
terleukin (IL)-1b, IL-6, IL-8, tumor necrosis factor-alpha B. cefprozil
(TNF-␣), leukotriene B4, and procalcitonin. C. ceftriaxone
• Treatment of a child with meningitis includes supportive D. clarithromycin
care and use of the appropriate anti-infective agent.
Acyclovir is an option in aseptic meningitis, pending
identification of the offending virus. Ceftriaxone with Answers
vancomycin is usually the initial treatment of choice in
suspected bacterial meningitis, pending bacterial sensitiv- 224. B. 226. D. 228. D.
ity results. Treatment of other forms of sepsis in a younger 225. A. 227. C.
child depends on its cause. Prudent practitioners should
seek expert help in evaluating and treating a child with
suspected or documented sepsis. In all age groups, pneumonia is the most common cause of
death from infectious disease worldwide and results in 20%
DI SCUS SION SOURCES
of all deaths in children younger than age 5 years. In the de-
National Institutes of Health: Feverish Illness in Children: Assess- veloped world, the annual incidence of pneumonia is 3 to
ment and Initial Management in Children Younger Than 5 Years, 4 cases per 100 children <5 years old. Most often caused by
http://www.ncbi.nlm.nih.gov/books/NBK45971.
bacteria or viruses, pneumonia is an acute lower respiratory
National Institutes of Health: Febrile Seizures, http://www.ninds
.nih.gov/disorders/febrile_seizures/detail_febrile_seizures.htm.
tract infection involving lung parenchyma, interstitial tissues,
Hamilton JL, John SP. Evaluation of fever in infants and young chil- and alveolar spaces. The term community-acquired pneumo-
dren. Am Fam Physician 87:254–260, 2013. nia (CAP) is used to describe the onset of the disease in an
individual who resides within the community, not in a nurs-
ing home or other care facility, with no recent (within
Pneumonia 2 weeks) hospitalization.
Most children with pneumonia present with cough.
Tachypnea is the most sensitive, although not specific, find-
224. When treating a 3-year-old well child with commu- ing. In particular, the diagnosis of lower respiratory tract dis-
nity-acquired pneumonia (CAP), the NP realizes that ease should be considered with a respiratory rate exceeding
the most likely causative pathogen is: 50/min in children younger than 1 year and a rate exceeding
A. Mycoplasma pneumoniae. 40/min in children older than 1 year. Pulse oximetry is also
B. a respiratory virus. informative but less so than respiratory rate. Compared with
C. H. influenzae. an adult with pneumonia, a child is less likely to complain of
D. S. pneumoniae. dyspnea, produce sputum, or report pleuritic chest pain. Di-
225. Which of the following is the most appropriate an- agnostic evaluation of a child with CAP usually includes a
timicrobial for treatment of CAP in a 2 year old who chest x-ray; further evaluation for invasive disease (sepsis)
is clinically stable and able to be treated in the outpa- should be dictated by clinical presentation.
tient setting? Although numerous organisms are implicated in CAP in
A. amoxicillin children, few are seen with significant frequency. Respiratory
B. doxycycline viruses are the causes in most; S. pneumoniae and the atypical
C. TMP-SMX pathogens including M. pneumoniae and C. pneumoniae are
D. levofloxacin also implicated. As with adults with CAP, in children with
CAP, sputum specimens are usually unobtainable, and the
4074_Ch17_397-462 20/11/14 4:31 PM Page 457
results are unreliable; the choice of an antimicrobial is largely activity against nonresistant S. pneumoniae and the atypical
empirically based. pathogens. Treatment failure is possible when a macrolide is
Successful community-based care of a child with CAP re- used and drug-resistant S. pneumoniae is the causative organ-
quires many factors. The child must have intact gastrointesti- ism, in which case high-dose amoxicillin can be used. Tetracy-
nal function and be able to take and tolerate oral medications clines, including doxycycline, are a treatment option in adult
and adequate amounts of fluids. A competent caregiver must CAP and provide coverage for S. pneumoniae and atypical
be available. Also, the child should be able to return for pathogens; their use in children younger than age 8 is not ad-
follow-up examination and evaluation. vised due to the risk of permanent tooth staining. Presumed in-
As previously mentioned and consistent with CAP fluenza pneumonia can be treated with oseltamivir in children
treatment in adults, antimicrobial therapy in children with ≤5 and with oseltamivir or zanamivir for those <7 years. Be-
pneumonia is chosen empirically (Table 17–21). In adequate cause most childhood CAP is viral in origin, watchful waiting
dosages, amoxicillin or a cephalosporin provides activity against can also be used, whereby the child is not placed on an antimi-
S. pneumoniae but is ineffective against the atypical pathogens. crobial regimen, but rather is observed to see whether the illness
A macrolide such as azithromycin or clarithromycin provides improves over a few days.
Table 17-21
Empiric Therapy for Pediatric Community-Acquired Pneumonia (CAP) in the Outpatient
Setting in Children Age 3 Months to 17 Years
Presumed Bacterial Presumed Atypical Presumed Influenza
Pneumonia Pneumonia Pneumonia
<5 years old (preschool) Amoxicillin, oral (90 mg/kg/day Azithromycin oral (10 mg/kg Oseltamivir
in 2 doses) on day 1, followed by
Alternative: Oral amoxicillin 5 mg/kg/day once daily
clavulanate (amoxicillin com- on days 2–5)
ponent, 90 mg/kg/day in Alternatives: Oral clarithromycin
2 doses) (15 mg/kg/day in 2 doses for
7–14 days) or oral erythromycin
(40 mg/kg/day in 4 doses)
≥5 years old Oral amoxicillin (90 mg/kg/ Oral azithromycin (10 mg/kg on
Oseltamivir or zanamivir
day in 2 doses to a maxi- day 1, followed by 5 mg/kg/day
(for children 7 years and
mum of 4 g/day); for chil- once daily on days 2–5 to a older)
dren with presumed maximum of 500 mg on day 1,Alternatives: Peramivir,
bacterial CAP who do not followed by 250 mg on oseltamivir, and zanamivir
have clinical, laboratory, or days 2–5) (all intravenous) are under
radiographic evidence that Alternatives: Oral clarithromycin
clinical investigation in
distinguishes bacterial CAP (15 mg/kg/day in 2 doses to a
children
from atypical CAP, a maximum of 1 g/day); erythro-
Intravenous zanamivir
macrolide can be added to mycin, doxycycline for children
available
a beta-lactam antibiotic for >7 years old
empiric therapy
Alternative: Oral amoxicillin
clavulanate (amoxicillin com-
ponent, 90 mg/kg/day in
2 doses to a maximum dose
of 4000 mg/day, e.g., one
2000-mg tablet twice daily)
For children with a history of possible, nonserious allergic reactions to amoxicillin, treatment is not well defined and should
be individualized. Options include a trial of amoxicillin under clinical observation; a trial of an oral cephalosporin that has
substantial activity against S. pneumoniae, such as cefpodoxime, cefprozil, or cefuroxime, can be provided under clinical
supervision. Additional options for the child with a penicillin allergy include levofloxacin, linezolid, clindamycin, or a
macrolide; close clinical follow-up and full knowledge of the use of all of these medications in children is needed.
Source: Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants
and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society
and the Infectious Diseases Society of America. Clin Infect Dis 53(7):e25–76, 2011.
4074_Ch17_397-462 20/11/14 4:31 PM Page 458
NPs are ideally positioned to help minimize risk for pneu- 233. An important part of the treatment of Kawasaki dis-
monia through immunization and hygienic measures. Nearly ease includes the use of:
two-thirds of all fatal pneumonia is caused by S. pneumoniae, A. antibiotics.
the pneumococcal organism. Pneumococcal conjugate vac- B. antivirals.
cine is recommended for all children, starting in infancy, to C. immune globulin.
minimize the risk of invasive pneumococcal disease. The D. antifungals.
use of influenza vaccine can help minimize the risk of postin-
fluenza pneumonia. Ensuring adequate ventilation, reinforc-
ing cough hygiene, and proper hand washing can help Answers
minimize pneumonia risk.
229. C. 231. B. 233. C.
DI SCUS SION SOURCES 230. C. 232. D.
Gilbert D, Moerlling R, Eliopoulos G, Chambers H, Saag M. The
Sanford Guide to Antimicrobial Therapy, ed. 42. Sperryville, VA: Kawasaki disease, also known as Kawasaki syndrome, is a typ-
Antimicrobial Therapy, Inc., 2014. ically self-limited vasculitis of unknown etiology, although an
Bradley JS, Byington CL, Shah SS, et al. The management of infectious or immunological basis is suggested. Clinical pres-
community-acquired pneumonia in infants and children older
entation includes fever lasting 5 or more days and presence of
than 3 months of age: Clinical Practice Guidelines by the
Pediatric Infectious Diseases Society and the Infectious Dis-
at least four of the following five symptoms: skin rash, bilateral
eases Society of America. Clin Infect Dis 53(7):e25–76, 2011. conjuctival injection, cervical lymphadenopathy, swelling of the
hands and feet, and mucocutaneous lesion. Disease implications
include myocarditis (early disease stage) and development of
Kawasaki Disease coronary artery aneurysms (later disease stage; Table 17–22).
Occurring primarily in the late winter and spring at 3-year
229. Sam is a 4-year-old boy who presents with a 1-week intervals, Kawasaki disease is more frequent among children
history of intermittent fever, rash, and “watery, red of Asian ancestry, twice as common in boys than in girls, and
eyes.” Clinical presentation is of an alert child who is now surpasses rheumatic fever as the leading cause of acquired
cooperative with examination but irritable, with a heart disease in the United States among children younger than
temperature of 38°C (100.4°F), pulse rate of 132 bpm, 5 years. The development of coronary artery aneurysms can
and respiratory rate of 38/min. Physical examination lead to coronary artery obstruction, myocarditis, heart failure,
findings include nasal crusting; dry, erythematous, pericarditis, mitral or aortic insufficiency, and dysrhythmias.
cracked lips; red, enlarged tonsils without exudate; Risk of aneurysm is increased in patients who have fever for
and elevated tongue papillae. The diagnosis of
Kawasaki disease is being considered. Additional
findings are likely to include:
A. vesicular-form rash. TABLE 17-22
B. purulent conjunctivitis. Diagnostic Criteria for Kawasaki
C. peeling hands.
D. occipital lymphadenopathy.
Disease
230. Laboratory findings in Kawasaki disease include all of • Fever ≥5 days in duration, usually abrupt in onset,
the following except: symptoms with no response to antibiotic therapy; if
A. sterile pyuria. given, usually with irritability out of proportion to de-
B. elevated liver enzyme levels. gree of fever or other signs
C. blood cultures positive for offending bacterial • In addition to fever lasting at least 5 days, ≥4 of the
pathogen. following should be present:
D. elevated erythrocyte sedimentation rate. • Changes in extremities (erythema, edema, desqua-
mation), usually with discomfort so that child may
231. Long-term consequences of Kawasaki disease include: refuse to bear weight
A. renal insufficiency. • Bilateral, nonexudative conjunctivitis
B. coronary artery obstruction. • Polymorphous rash
C. hepatic failure. • Cervical lymphadenopathy
D. hypothyroidism. • Changes in lips and oral cavity (pharyngeal edema,
232. The cause of Kawasaki disease is: dry/fissured or swollen lips, strawberry tongue)
A. fungal. Note: If fever is present with fewer than four of the above symptoms,
B. viral. the diagnosis is established with echocardiogram to evaluate the
C. bacterial. coronary arteries to support or exclude the disease.
D. unknown. Source: Centers for Disease Control and Prevention. Kawasaki Syn-
drome, http://www.cdc.gov/kawasaki, accessed 4/25/14.
4074_Ch17_397-462 20/11/14 4:31 PM Page 459
more than 16 days, have recurrence of fever after an afebrile 236. In general, children should ride in the back seat of the
period of at least 48 hours, are male, are younger than 1 year, car until age:
and have cardiomegaly at the time of diagnosis. Some patients A. 10 years.
who do not fulfill the criteria for Kawasaki disease have been B. 11 years.
diagnosed as having “incomplete” or “atypical” Kawasaki C. 12 years.
disease, a diagnosis that often is based on echocardiographic D. 13 years.
findings of coronary artery abnormalities.
Although no specific laboratory test for Kawasaki disease
exists, the presence of certain laboratory findings can support Answers
the diagnosis when coupled with clinical presentation. Blood
test often detects mild anemia, elevated white blood cell 234. C. 235. C. 236. D.
count, elevated sedimentation rate, and sharp increase in the
number of platelets. Urine test often reveals the presence of
albumin and white blood cells. In the acute stage (days 1 to Knowledge of appropriate child car seat restraint is an impor-
11), leukocytosis with a left shift and elevated erythrocyte sed- tant part of providing pediatric primary care (Table 17–23).
imentation rate are found; both are neither sensitive nor spe-
D I S C U SSI O N S O U R C E
cific for the condition. In the subacute stage (days 11 to 21),
the platelet count is often markedly elevated, with a measure- American Academy of Pediatrics: Updates Recommendations on
ment of more than 1 million/mm3 being common. These val- Car Seats, www.aap.org/advocacy/releases/carseat2011.htm.
ues begin to normalize during the convalescent stage (days
21 to 60) but may not reach baseline values for 8 weeks.
During the acute stage of Kawasaki disease, or if the diag- Pertussis
nosis is in question, an echocardiogram should be obtained. If
237. At which age is a child at greatest risk of death from
tests reveal an aneurysm or other heart or blood vessel abnor-
pertussis?
mality, repeated echocardiograms or other tests are usually
A. <1 year
necessary for several years. In children who return to com-
B. 2-4 years
pletely normal activity after the acute phase of the illness, the
C. 5-10 years
study should be repeated in the second or third week of disease
D. >10 years
and repeated 1 month after laboratory tests have resolved.
Treatment of Kawasaki disease includes consultation with 238. Common signs and symptoms of pertussis in a
experts in managing this condition and the use of intravenous 3-year-old child include all of the following except:
immune globulin and aspirin. Confirmation of the diagnosis A. uncontrollable cough.
and treatment are likely to involve consultation with a spe- B. vomiting.
cialist in this disease. Long-term prognosis is generally related C. fatigue.
to the degree of permanent cardiac involvement. D. diffuse rash.
DI SCUSSION SOURCES 239. The most helpful tests to support the diagnosis of per-
Centers for Disease Control and Prevention. Kawasaki Syndrome,
tussis include which of the following? More than one
http://www.cdc.gov/kawasaki. can apply.
Baker AN, Newburger JW. Kawasaki disease. Circulation 118:e110– A. chest x-ray.
e112, 2008. B. nasopharyngeal culture.
C. blood culture
D. polymerase chain reaction (PCR) testing
Car Seat Guidelines 240. Which of the following can be used to differentiate
pertussis from acute bronchitis or asthma
234. A young child should use a rear-facing car seat until
exacerbation?
at least age ____.
A. presence of fever
A. 12 months
B. PCR assay
B. 18 months
C. presence of productive cough
C. 24 months
D. evidence of consolidation on chest x-ray
D. 30 months
241. The preferred treatment option for a 6-year-old boy
235. You anticipate that adult car seat belts fit correctly when
with pertussis is:
a child is approximately _____ tall and is ____ old.
A. amoxicillin.
A. 51 inches (129.5 cm), 6 to 8 years
B. ceftriaxone.
B. 53 inches (134.6 cm), 5 to 7 years
C. azithromycin.
C. 57 inches (144.8 cm), 8 to 12 years
D. levofloxacin.
D. 59 inches (150 cm), 12 to 14 years
4074_Ch17_397-462 20/11/14 4:31 PM Page 460
Table 17-23
Car Safety Seat Use: The Most Current American Academy of Pediatrics Recommendations
Age Type of Seat General Guideline
Infants–age 2 years Rear-facing Rear-facing car seat until 2 years of age or
until the child reaches the highest weight
or height allowed by the car safety seat’s
manufacturer
Toddlers–preschoolers Convertible seats and forward-facing seats All children 2 years or older, or those
with harnesses younger than 2 years who have outgrown
the rear-facing weight or height limit for
their car safety seat, should use a forward-
facing car safety seat with a harness for as
long as possible, up to the highest weight
or height allowed by their car safety seat’s
manufacturer.
School-aged children Booster All children whose weight or height is higher
than the forward-facing limit for their car
safety seat should use a belt-positioning
booster seat until the vehicle seat belt fits
properly, typically when they have reached
4 feet 9 inches (144.8 cm) in height and are
between 8 and 12 years of age.
Older children Seat belts When children are old enough and large
enough to use the vehicle seat belt alone,
they should always use lap and shoulder
seat belts for optimal protection.
All children younger than age 13 years
should be restrained in the rear seats of
vehicles for optimal protection.
similar respiratory conditions, such as acute bronchitis or be considered for household or close contacts of children
asthma. Additionally, viral acute bronchitis typically has an diagnosed with pertussis.
incubation period of 1–3 days compared to up to 3 weeks for Immunization against pertussis remains the most effective
pertussis. Asthma is characterized by variable and recurring method to prevent these infections. A 5-dose series of the DTaP
symptoms, wheezing, airflow obstruction, and underlying (diphtheria and tetanus toxoids and acellular pertussis) is given
inflammation and will generally lack signs of many other at ages 2, 4, 6, 15–18 months, and 4–6 years of age. One dose
types of infection (e.g., elevated WBC with neutrophilia, of the Tdap vaccine is given to all adolescents aged 11 through
fever). Pertussis should also be suspected if there is an out- 12 years. In addition, women during pregnancy are recom-
break in the area and/or the patient had close contact with mended to have a Tdap dose with each pregnancy, regardless
another person diagnosed with pertussis. of previous Td or Tdap history, in order to provide protection
Infants with pertussis are often hospitalized for treatment to her unborn child. Prior to the baby’s birth, all household
due to an increased risk of death. Older children can usually members and anyone who will be in regular close contact with
be treated at home. Antimicrobial treatment can include a the newborn should have updated pertussis immunization.
macrolide with azithromycin being the preferred agent. Clar-
ithromycin and erythromycin are not recommended in D I S C U SSI O N S O U R C E S
infants younger than 1 month due to a risk of infantile Centers for Disease Control and Prevention: Pertussis, http://www
hypertrophic pyloric stenosis (IHPS). Children older than .cdc.gov/vaccines/pubs/pinkbook/pert.html#diagnosis.
2 months who exhibit hypersensitivity to macrolides can be Bocka JJ. Pertussis. http://emedicine.medscape.com/article/967268-
treated with TMP-SMX. Antimicrobial prophylaxis should overview.
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4074_Ch18_463-484 20/11/14 4:23 PM Page 463
Childbearing 18
11–13. Match each sign with its correct characteristic.
Stages of Pregnancy
______ 11. Hegar sign A. blue–violet
1–4. Match the stage of pregnancy with the appropriate term. vaginal color
______ 12. Goodell sign
____ 1. Fertilized A. Embryo B. softening of
ovum B. Fetus ______ 13. Chadwick sign uterus isthmus
C. Blastocyst C. softening of
____ 2. Up to 2 weeks
D. Zygote vaginal portion
postconception
of the cervix
____ 3. Up to 8 to
10 weeks
____ 4. 10 weeks Answers
to term
5. C. 8. B. 11. B .
6. D. 9. F. 12. C.
Answers 7. A. 10. E. 13. A.
1. D. 2. C. 3. A. 4. B.
See full color images of this topic
Knowledge of appropriate terminology is a critical compo- on DavisPlus at
nent to providing prenatal care (Table 18–1). http://davisplus.fadavis.com |
Keyword: Fitzgerald
463
4074_Ch18_463-484 20/11/14 4:23 PM Page 464
TABLE 18-1
Stages of Human Pregnancy
Period Stage
At fertilization Zygote
Up to 2 weeks Blastocyst
2–8 weeks Embryo
8–12 weeks to term Fetus
Born between 37 weeks 0 days and 38 weeks 6 days Early term
Born between 39 weeks 0 days and 40 weeks 6 days Full term
Born between 41 weeks 0 days and 41 weeks 6 days Late term
Born after 42 weeks 0 days Post-term
Source: American College of Obstetricians and Gynecologists. Committee Opinion No. 579. November 2013,
http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/
Definition_of_Term_Pregnancy.
TABLE 18-2
Uterine Size During Pregnancy
Stage of Pregnancy Uterine Size Comment
Nongravid Lemon Mobile, firm, nontender
8 weeks Tennis ball or orange Hegar sign (softening of uterine isthmus), Goodell
sign (softening of vaginal portion of the cervix), and
Chadwick sign (blue–violet vaginal color) often pres-
ent by this time
10 weeks Baseball First fetal heart tone via abdominal Doppler at 10–
12 weeks
12 weeks Softball or grapefruit Rising above symphysis pubis, uterine fundus palpable
through abdominal wall
16 weeks Halfway between symphysis Quickening first noted in woman who has been preg-
pubis and umbilicus nant before (second trimester or beyond) during
16–17 weeks, at ~18 weeks with first pregnancy
20–36 weeks ~1-cm gain in fundal height Uterine fundus at the umbilicus at 20 weeks. Usually
per week concordant with gestational age, plus or minus 1 cm
At term Uterus dips into pelvis with Vertex position (cephalic) in 95% by 36 weeks
fetal head engagement,
fundal height decreases
15. The recommended weight gain during pregnancy for a 17. For a healthy woman with a healthy or desirable pre-
woman with a desirable or healthy pre-pregnancy body pregnancy BMI, daily caloric requirements during lac-
mass index (BMI) is: tation are typical baseline caloric needs plus ___ kcal.
A. 15 to 20 lb (6.8 to 9.1 kg) A. 250
B. 20 to 30 lb (9.1 to 13.6 kg) B. 500
C. 25 to 35 lb (11.3 to 15.9 kg) C. 750
D. 35 to 45 lb (15.9 to 20.4 kg) D. 1000
16. For a healthy woman with a desirable or healthy pre- 18. Recommended calcium intake for a woman during
pregnancy BMI, daily caloric requirements during preg- pregnancy is ____________ mg of elemental calcium
nancy are typical baseline caloric needs plus ___ kcal. per day.
A. 100 A. 400 to 600
B. 300 B. 600 to 800
C. 600 C. 800 to 1000
D. 1000 D. 1000 to 1300
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19. Increased folic acid intake before conception is likely The clinician should have knowledge of nutritional require-
to reduce the risk of which of the following birth ments during pregnancy to provide appropriate counseling.
defects? Folic acid deficiency is a teratogenic state, leading to an in-
A. congenital cataract creased risk of neural tube defects (NTDs) and other defects in
B. pyloric stenosis the developing pregnancy. NTDs are common serious fetal
C. clubfoot malformations, affecting approximately 3000 pregnancies each
D. open neural tube defects year in the United States. Examples of NTDs include anen-
cephaly, spina bifida, and encephalocele. Correcting folic acid
20. Maternal iron requirements are greatest during what
deficiency before pregnancy by increased dietary and supple-
part of pregnancy?
ment intake dramatically reduces this risk, and continuing this
A. first trimester
increased intake throughout pregnancy minimizes the mother’s
B. second and third trimesters
risk of developing folate-deficiency anemia. Dietary-associated
C. equal throughout pregnancy
folic acid deficiency is rare unless severe malnutrition is present.
D. preconception
A genetic contribution to NTDs is likely and is thought to be
21. The most common form of acquired anemia during the result of a complex interaction of environment and heredity.
pregnancy is: As a result, if a woman has carried a pregnancy with an NTD,
A. iron deficiency. or there is a family history of NTD, recommended folic acid in-
B. folate deficiency. take increases to 4 mg/d 1 month before pregnancy and during
C. vitamin B12 deficiency. the first 3 months of gestation. Most prescription prenatal mul-
D. primary hypoproliferative. tivitamins contain 1 mg of folic acid.
22. Concerning the use of alcohol during pregnancy, which Increased calcium intake is important to the development of
of the following statements is most accurate? bones and teeth; the required amount can usually be met by en-
A. Although potentially problematic, maternal suring three to four servings of high-quality dairy products per
alcohol intake does not increase the risk of day. Examples of a single dairy serving include 8 oz (240 mL) of
miscarriage. milk, 1–1.5 oz (28–43 g) of cheese, 1 cup (240 mL) of yogurt, or
B. Risk to the fetus from alcohol exposure is greatest in 1 cup (240 mL) of calcium-fortified juice. Although dietary
the third trimester. sources of calcium are best, supplementation is sometimes re-
C. No level or time of exposure is considered to be safe. quired if a woman is lactose intolerant or is otherwise unable to
D. Risk of fetal alcohol syndrome is present only if meet these goals. The recommended daily intake of calcium for
alcohol exposure has occurred throughout the women 19–50 years of age is 1000 mg. Women 14–18 years of
pregnancy. age have an increased calcium requirement of 1300 mg daily.
Maternal iron requirements increase in the second and
23. Pica (ingestion of nonfood substances) during preg- third trimesters of pregnancy, in part because of the fetus’s
nancy should be considered: need to build iron stores. Iron deficiency is the most common
A. a harmless practice common in certain ethnic form of anemia during pregnancy, with most cases occurring
groups. because the woman enters pregnancy with iron deficiency,
B. problematic only if more nutritious food sources are rather than develops this problem because of increased iron
left out of the diet and are replaced by the nonfood requirements. Pregnancy-related iron requirements, given in
substance. terms of elemental iron, are as follows: in the absence of iron
C. a way of providing select micronutrients not usually deficiency, 30 mg/d; with iron deficiency or in a multiple-
found in food products. gestation pregnancy, 60 to 100 mg/d. A 325-mg ferrous sul-
D. potentially dangerous because of contaminants in fate tablet contains 65 mg of elemental iron, whereas most
the nonfood substance. prescription prenatal vitamins contain 30 to 65 mg.
24. Examples of neural tube defects include all of the fol- Fetal alcohol syndrome (FAS) has most often been noted
lowing except: in the offspring of women who drank heavily throughout
A. anencephaly. pregnancy. More commonly, infants whose mothers drink
B. spina bifida. lightly or moderately are born with lesser degrees of alcohol-
C. encephalocele. related problems. Given that FAS is the leading preventable
D. omphalocele. cause of developmental disability and can be eliminated by
avoiding alcohol consumption throughout pregnancy, no
level of maternal alcohol intake during pregnancy is deemed
Answers safe. Maternal alcohol intake also increases the risk of mis-
carriage. Less is known about fetal risks when exposed to
14. D. 18. D. 22. C. other recreational drugs, such as marijuana, a substance often
15. C. 19. D. 23. D. considered more benign and “natural” compared with alco-
16. B. 20. B. 23. D. hol. A safe level of maternal ingestion during pregnancy for
17. B. 21. A. marijuana and other intoxicating substances has not been
established, and abstinence should be encouraged.
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TABLE 18-3
Physiological Adaptations During Pregnancy
Body Area Physiological Adaptation
Uterus Size increases from ~10-mL capacity and 70-g weight pre-pregnancy to 5000-mL capacity and
1100-g weight at term. The uterine isthmus becomes soft and compressible (Hegar sign).
Cervix Its color and texture change, becoming cyanotic (Chadwick sign) and less firm (Goodell sign).
Skin Striae (stretch marks) in ~50%, melasma (pregnancy mask). Linea nigra (hyperpigmented line
on abdomen) appears or darkens as melanocytes are stimulated.
Breast Nipples and areolae darken and increase in size. Venous congestion noted. Breast tissue becomes
more nodular because of proliferation of lactiferous glands
Blood Blood volume increases by 40%–50%, peaking at week 32. Red blood cell production increases by
33% but still results in dilutional physiological anemia of pregnancy.
Cardiovascular Decrease in systolic blood pressure throughout pregnancy, with decrease in diastolic blood pres-
sure most notable during second trimester. Cardiac output dependent on maternal position,
with a noted decrease if in supine position because of reduced venous return caused by vena cava
compression to an increase of 30%–50% with lateral recumbent position. S1 heart sound be-
comes louder, and physiological systolic ejection murmur is usually evident. Heart is displaced,
resulting in a left axis deviation that resolves post birth.
Renal Increased renal blood flow, glomerular filtration rate, and dilation of renal collecting system occur.
Physiologic glucosuria and proteinuria occur partly because of increase in glomerular
filtration rate and resulting inability of renal tubules to reabsorb glucose and protein.
Respiratory Partly because of increased abdominal content, there is an increase in transverse thoracic
diameter and diaphragmatic contraction, and costal angle widens. Tidal volume increases
with reduced residual volume in later pregnancy.
Digestive Lower esophageal sphincter are more relaxed while corresponding pressures increase, resulting in
increased esophageal reflux. Decreased stomach and intestinal motility is seen, allowing for
greater nutrient absorption but increased risk for constipation. (Increased progesterone levels
influence aforementioned changes.) Gallbladder doubles in size with more dilute bile and less
soluble cholesterol, increasing risk of stones.
Metabolic/endocrine Insulin levels increase by 2-fold to 10-fold over pre-pregnancy levels. Fasting plasma glucose de-
creases slightly. Thyroid and pituitary increase in size. Maternal weight changes account for
weight gain in the first half of pregnancy, whereas uterine contents account for most weight gain
in second half.
43. The “quad screen” is used to help detect increased risk 45. Tina is a 26-year-old woman who is pregnant and has
for which of the following conditions in the fetus? an abnormal “quad screen.” When sharing this infor-
A. trisomy 21 and open neural tube defects mation with Tina, you consider that:
B. cystic fibrosis and Angelman syndrome A. this testing is diagnostic of specific conditions.
C. Tay-Sachs disease and trisomy 18 B. further testing is recommended.
D. sickle cell anemia and beta-thalassemia major C. the testing should be repeated.
D. no further testing is required.
44. Prenatal assessment for aneuploidy should be
offered to: 46. The rate of spontaneous fetal loss related to amniocentesis
A. only women older than 35 years of age. that is done at a facility that performs these procedures on
B. only women younger than 21 years of age. a regular basis is approximately 1 in _______ procedures
C. only women either younger than 21 years or older A. 75
than 35 years of age. B. 200
D. all women regardless of age. C. 400
D. 800
4074_Ch18_463-484 20/11/14 4:24 PM Page 468
47. Women at high risk for aneuploidy include all of the 55. A 25-year-old woman presents in the 10th week of
following except: gestation requesting antenatal screening for Down
A. maternal age 35 years and older at delivery. syndrome. What advice should the NP give?
B. history of prior pregnancy with trisomy. A. Because of her age, no specific testing is
C. fetal ultrasonographic findings indicating an in- recommended.
creased risk of aneuploidy. B. She should be referred for second-trimester
D. history of multiparity. ultrasound.
C. Screening that combines nuchal translucency meas-
48. All of the following can cause an elevated maternal
urement and biochemical testing is available.
alpha-fetoprotein (AFP) except:
D. She should be referred to a genetic counselor.
A. underestimated gestational age.
B. open neural tube defect. 56 to 58. Match the following at-risk ethnic groups for the
C. meningomyelocele. following genetically based conditions.
D. Down syndrome.
56. Tay-Sachs disease A. Ashkenazi Jewish ancestry
49. Edwards syndrome is the clinical manifestation of B. Northern European
trisomy ____. 57. Cystic fibrosis
ancestry
A. 13 58. Sickle cell trait C. African ancestry
B. 15
C. 18
D. 21 Answers
50. In Edwards syndrome, which of the following state-
ments is true? 38. B. 45. B. 52. D.
A. Edwards syndrome is more common than Down 39. A. 46. C. 53. D.
syndrome. 40. D. 47. D. 54. A.
B. Most affected infants with Edwards syndrome die 41. C. 48. D. 55. C.
during the first year of life. 42. C. 49. C. 56. A.
C. Edwards syndrome is unlikely to cause developmen- 43. A. 50. B. 57. B.
tal disability. 44. D. 51. C. 58. C.
D. Edwards syndrome is associated with elevated AFP.
51. In Down syndrome, which of the following is true? Numerous recommendations exist regarding frequency of
A. Most infants affected with Down syndrome are born prenatal care and associated laboratory and other testing
to women older than age 35 years. (Table 18–4). These are simply guidelines for the care that is
B. Down syndrome is noted in about 1 in 10,000 live needed for a well woman with a pregnancy with low physio-
births. logical and psychosocial risk. More frequent visits and testing
C. Down syndrome is associated with decreased mater- are often indicated, but a minimum of 8 to 10 visits should
nal serum AFP level. be scheduled.
D. Antenatal serum analysis is sufficient to make the According to the Centers for Disease Control and Pre-
diagnosis. vention (CDC), 1 out of 33 infants in the United States are
52. Down syndrome is the clinical manifestation of born with a birth defect. Prenatal screening and diagnostic
trisomy ___. procedures constitute an important clinical issue, although
A. 13 one that is often confusing, emotionally charged, and
B. 15 marked by disagreement among healthcare providers and
C. 18 patients. One point of confusion is the difference between
D. 21
53. Components of the antenatal screening test known as
the “quad screen” include all of the following except:
TABLE 18-4
A. AFP.
B. hCG. Frequency of Prenatal Visits
C. unconjugated estriol.
Time in Pregnancy Frequency of Visits
D. progesterone.
Up to 28 weeks Every 4 weeks
54. Elevated inhibin-A is noted when a pregnant woman is
28–36 weeks Every 2 weeks
at increased risk of having an infant with:
≥36 weeks Every week
A. Down syndrome.
B. Edwards syndrome. Source: Institute for Clinical Systems Improvement (ICSI). Healthcare
C. open neural tube defect. Guideline: Routine prenatal care, https://www.icsi.org/_asset
D. hemolytic anemia. /13n9y4/Prenatal.pdf.
4074_Ch18_463-484 20/11/14 4:24 PM Page 469
screening and diagnostic tests. Commonly offered prenatal the fact that women in this age group are more likely to
tests include maternal serum analysis for alpha-fetoprotein give birth compared with older women and because of the
(AFP), human chorionic gonadotropin (hCG), inhibin-A, lower rate of antenatal diagnostic testing such as amnio-
and unconjugated estriol levels, also known as the “quad centesis being performed in younger women giving birth.
(quadruple) screen.” When the amounts of these substances Edwards syndrome is much less common than Down
are analyzed, increased risk of open neural tube defects syndrome, occurring in 1 in every 6000 births. Edwards
(NTDs), trisomy 21 (Down syndrome), and trisomy 18 (Ed- syndrome is associated with low birth weight; developmen-
wards syndrome) can be detected. An abnormal “quad tal disability; and cranial, cardiac, and renal malformations.
screen” result is not diagnostic of any condition, however, The complexity and severity of these problems are such
and further testing is recommended, including amniocente- that most affected infants die within the first year of
sis and level II ultrasound. Consultation with a perinatology life; stillbirth or death in the first week of life is sadly quite
specialist is also indicated. common.
Fetal aneuploidy is defined as an abnormal number of NTDs are second only to cardiac defects in frequency,
chromosomes present in the fetus. A single additional with an incidence of NTDs of 1.2 for every 1000 births. Open
chromosome is called trisomy and is an important cause of NTDs such as meningomyelocele, anencephaly, and spina
congenital malformations and mental impairments. Down bifida carry risk of significant disability and the potential for
syndrome (trisomy 21), Edwards syndrome (trisomy 18), a shortened life span.
and Patau syndrome (trisomy 13) are the most common Alpha-fetoprotein is synthesized in the fetal yolk sac,
types. Initially, screening for fetal aneuploidy involved of- gastrointestinal tract, and liver. Maternal levels can be ele-
fering amniocentesis to higher risk mothers. However, vated for many reasons, including an open NTD such as
noninvasive methods are now available for initial screen- meningomyelocele, anencephaly, or spina bifida; fetal
ing. All women regardless of age should be offered prenatal nephrosis; cystic hygroma; fetal gastrointestinal obstruc-
assessment for aneuploidy either by screening or invasive tion; omphalocele; intrauterine growth restriction; multiple
prenatal diagnosis techniques. In addition to the quad fetuses; or fetal demise. Underestimated gestational age can
screen, the cell free fetal DNA test that assesses fetal DNA also lead to a misinterpreted test because maternal AFP is
derived from the plasma of pregnant women offers a con- higher in earlier pregnancy. The placenta, from precursors
venient method to screen for fetal aneuploidy. The cell free provided by the fetal adrenal glands, and the liver produce
fetal DNA test can be used as a primary screening test in unconjugated estriol; maternal levels are decreased in tri-
women at increased risk of aneuploidy. These risks include: somy 21 and trisomy 18. hCG is produced by trophoblast
(1) maternal age 35 years and older at delivery; (2) fetal ul- shortly after implantation into the uterine wall, with levels
trasonographic findings indicating an increased risk of ane- increasing rapidly in the first 8 weeks of pregnancy, then
uploidy; (3) history of a prior pregnancy with a trisomy; steadily decreasing until week 20, when levels plateau. An
(4) positive test result for aneuploidy, including first increased hCG level appears to be a relatively sensitive
trimester, sequential, or integrated screen, or a quad screen; marker for detecting trisomy 21, whereas a low hCG level
or (5) parental balanced robertsonian translocation with is associated with trisomy 18. The hCG levels are typically
increased risk of fetal trisomy 13 or trisomy 21. Women normal in the presence of NTDs. Inhibin-A is a hormone
should be counseled on the limitations of the cell free fetal produced by the placenta; levels of hCG and inhibin-A are
DNA test, which should include a discussion that this test higher than normal when a woman has an increased risk
may not be as accurate as diagnostic tests, such as amnio- of carrying a fetus with Down syndrome. Lower than nor-
centesis or chorionic villi sampling. mal levels of estriol can also indicate that a woman is at
Down syndrome is associated with developmental dis- high risk for carrying a fetus with Down syndrome
ability and an increased risk for cardiac and gastrointestinal Interpreting the results of a “quad screen” requires
malformation and early-onset Alzheimer disease. The risk knowledge of numerous factors, including the risk of false-
of Down syndrome is approximately 1 in 1000 live births, positive and false-negative results, the significance of the
with this number increasing to 1 in 270 in women 35 to results, and the woman’s individual risk of having an af-
40 years old and 1 in 100 in women older than 40 years; in- fected pregnancy. In addition, all antenatal testing must be
creased maternal age is a well-known risk factor for Down offered to a woman in a manner that allows her to make an
syndrome and other genetically-based congenital anom- informed decision to have or decline the test. Part of in-
alies. Although historically only pregnant women who formed consent includes the information that the “quad
would be 35 or older at the time of childbirth were offered screen” is simply that, a screening test that identifies higher
the opportunity for prenatal diagnosis with amniocentesis risk situations but is not diagnostic for the condition. With
or chorionic villus sampling, newer recommendations ad- abnormal results, further testing is indicated; results that
vise that all pregnant women, regardless of age, be offered are normal do not ensure that no problem will occur with
the option of antenatal diagnostic testing, including evalu- the pregnancy, but the risk is minimized.
ation for Down syndrome. One of the factors leading to As previously mentioned, if a “quad screen” yields abnor-
this recommendation is the finding that approximately mal results, further testing is indicated. For the detection of
75% of all infants with Down syndrome are born to moth- a genetic abnormality such as trisomy 18 or 21, the most
ers younger than age 35. This finding results in part from commonly used test is amniocentesis, a procedure that carries
4074_Ch18_463-484 20/11/14 4:24 PM Page 470
a rate of spontaneous fetal loss of about 1 in every 200 to 400 61. A drug with demonstrated safety for use in all
procedures; the rate is closer to 1 in every 400 procedures trimesters of pregnancy is categorized as U.S. Food
when done in facilities where it is performed on a regular and Drug Administration (FDA) risk category:
basis. The overall pregnancy loss after chorionic villi sampling A. A.
is higher at approximately 1%, or 1 out of every 100 proce- B. B.
dures. If a woman chooses not to have invasive testing, non- C. C.
invasive follow-up evaluation after an abnormal “quad D. D.
screen” often includes a level II ultrasound, a high-resolution
62. A drug shown to cause teratogenic effects in human
study that can reveal fetal abnormalities such as an open NTD
study, but the benefit of which could outweigh the risk
or increased nuchal folds and other anomalies often found in
of use in a life-threatening situation, is assigned FDA
Down syndrome. Ultrasound can assist with diagnosis but
risk category:
does not take the place of genetically based studies. When
A. A.
first-trimester testing is desired, screening using nuchal
B. B.
translucency as detected by ultrasound and serological testing
C. C.
for decreased pregnancy-associated plasma protein-A and in-
D. D.
creased free beta-hCG is effective in the general population
and is more effective than nuchal translucency alone. Women 63. A drug that has not been shown to be harmful to the
found to be at increased risk of having an infant with Down fetus in animal studies, but for which no human study
syndrome with first-trimester screening should be offered ge- is available, is assigned FDA risk category:
netic counseling and the option of chorionic villi sampling A. A.
or mid-trimester amniocentesis. B. B.
C. C.
DI SCUS SION SOURCES D. D.
American College of Obstetrics and Gynecology. Practice Bulletin
#77: Screening for fetal chromosomal abnormalities. Obstet 64. A drug shown to cause teratogenic effect in animal
Gynecol 109:217–228, 2007. studies, but for which no human study is available, is
American Pregnancy Association, http://americanpregnancy. assigned FDA risk category:
org/?s=cvs. A. A.
American Pregnancy Association, http://americanpregnancy.org/ B. B.
?s=quad+screen. C. C.
March of Dimes. Quick fact sheet: Amniocentesis, http://www.mar- D. D.
chofdimes.com/professionals/14332_1164.asp.
Centers for Disease Control and Prevention. Treating for two: Safer 65. Prior to day 31 post-LMP, the embryo is best
medication use in pregnancy, http://www.cdc.gov/ncbddd/birth described as:
defects/documents/ncbddd_birth-defects_medicationuseonepager_ A. a single, undifferentiated cell.
cdcrole.pdf. B. a group of poorly differentiated cells.
Akkerman D, Cleland L, Croft G, et al. Routine Prenatal Care. C. a conglomerate of highly differentiated cells and
Bloomington, MN: Institute for Clinical Systems Improvement primitive organs.
(ICSI), 2012, http://www.guideline.gov/content.aspx?id=38256& D. a small fetus with developed organs.
search=antenatal+care+and+prenatal.
66. What is the molecular weight requirement for a drug to
easily pass through the placental barrier?
Medication Use A. <250 daltons
B. <500 daltons
During Pregnancy C. <1000 daltons
D. <5000 daltons
59. Medications most commonly pass through the
placenta via: 67. What is the molecular weight requirement for a drug to
A. facilitated transport. be unable to pass through the placental barrier?
B. passive diffusion. A. >250 daltons
C. capillary pump action. B. >500 daltons
D. mechanical carrier state. C. >1000 daltons
D. >5000 daltons
60. During pregnancy, the most intense organogenesis
occurs how many days following the last menstrual 68. When treating a woman with a urinary tract infection
period (LMP)? who is 28 weeks pregnant, the NP considers prescribing:
A. 12–30 days A. trimethoprim-sulfamethoxazole (TMP-SMX).
B. 31–81 days B. cephalexin.
C. 92–120 days C. ciprofloxacin.
D. 121–150 days D. doxycycline.
4074_Ch18_463-484 20/11/14 4:24 PM Page 471
69. According to Hale’s Lactation Risk Category, a medica- 77. In counseling women about SSRI use during pregnancy,
tion in which there is no controlled study on its use the NP considers that studies reveal:
during lactation, or controlled study shows minimal, A. a clear teratogenic pattern has been identified for all
non–life-threatening risk, is listed as category: drugs in this class.
A. L2. B. the drugs have a negative effect on intellectual devel-
B. L3. opment.
C. L4. C. the use of paroxetine during pregnancy is associated
D. L5. with an increase in risk for congenital cardiac defect.
D. an increased rate of seizure disorder in exposed
70. According to Hale’s Lactation Risk Category, a medica-
offspring.
tion in which there is evidence of risk for its use in lac-
tation, but it can be used if there is a maternal 78. All of the following SSRIs are pregnancy risk category C
life-threatening situation, is listed as category: except:
A. L2. A. paroxetine
B. L3. B. fluoxetine
C. L4. C. citalopram
D. L5. D. sertraline
71. In a pregnant woman with asthma, in what part of her 79. Among the most commonly used medications by
pregnancy do symptoms and bronchospasm often women in the first trimester of pregnancy are:
worsen? A. antiepileptic drugs.
A. 6 to 14 weeks B. antibiotics.
B. 15 to 23 weeks C. antihypertensives.
C. 24 to 33 weeks D. opioids.
D. 29 to 36 weeks 80. Benzodiazepine withdrawal syndrome is best character-
72. In treating a pregnant woman with acute bacterial rhi- ized as:
nosinusitis, the NP would likely avoid prescribing: A. bothersome but not life-threatening.
A. amoxicillin. B. not observed during pregnancy.
B. cefuroxime. C. most often seen with agents that have a long half-life.
C. cefpodoxime. D. associated with seizure risk.
D. levofloxacin. 81. The cornerstone controller therapy for moderate per-
73. The duration of antimicrobial therapy for treatment of sistent asthma during pregnancy is the use of:
symptomatic urinary tract infection in a pregnant A. oral theophylline.
woman is: B. mast cell stabilizers.
A. 3 days. C. leukotriene receptor antagonist.
B. 5 days. D. inhaled corticosteroids.
C. 7 days. 82. You examine a 24-year-old woman with mild intermit-
D. 10 days. tent asthma who is 24 weeks pregnant and has an acute
74. Selective serotonin reuptake inhibitor (SSRI) with- asthma flare. Her medication regimen should be ad-
drawal syndrome is best characterized as: justed to include:
A. bothersome but not life-threatening. A. titration to a therapeutic theophylline level.
B. potentially life-threatening. B. addition of timed salmeterol (Serevent) use.
C. most often seen with medications with a longer C. a short course of oral prednisone.
half-life. D. use of montelukast (Singulair) on a regular basis.
D. associated with seizure risk. 83. For a pregnant woman with asthma, bronchospasm
75. The placenta is best described as: symptoms are often reported to improve during
A. poorly permeable. ______weeks of gestation.
B. an effective drug barrier. A. 8 to 13
C. able to transport lipophilic substances. B. 20 to 26
D. capable of impeding substances with molecular C. 29 to 36
weight ⱕthan 300 daltons. D. 36 to 40
76. Preferred treatment options for a pregnant woman in 84. Most SNRI are FDA pregnancy risk category:
the second trimester with migraine include: A. B.
A. sumatriptan. B. C.
B. codeine. C. D.
C. aspirin. D. X.
D. acetaminophen.
4074_Ch18_463-484 20/11/14 4:24 PM Page 472
85. The benzodiazepines are FDA pregnancy risk category: 94. Which of the following is FDA pregnancy risk cate-
A. B. gory B until the 36th week of pregnancy?
B. C. A. gentamicin
C. D. B. nitrofurantoin
D. X. C. clarithromycin
86. Bupropion is FDA pregnancy risk category: D. ciprofloxacin
A. B. 95. In a pregnant woman, asymptomatic bacteruria:
B. C. A. should be treated only if bladder instrumentation
C. D. or surgery is planned.
D. X. B. needs to be treated to avoid complicated urinary
87. Most tricyclic antidepressants are FDA pregnancy risk tract infection (UTI).
category: C. is a common, benign finding.
A. A or B. D. is a risk factor for the development of hypertension.
B. C. or D 96. Which of the following is the most common UTI
C. X. organism in pregnant women?
D. Unrated as these are older medications. A. Pseudomonas aeruginosa
88. The use of NSAIDs during pregnancy can potentially B. E. coli
increase the risk for: C. K. pneumoniae
A. premature birth. D. Proteus mirabilis
B. neural tube defects. 97. Recommended length of antimicrobial therapy for a
C. premature closure of ductus arteriosis. pregnant woman with asymptomatic bacteruria is:
D. ventricular septal defects. A. 1 to 3 days.
89. A 26-year-old woman has been taking an SSRI for de- B. 3 to 7 days.
pression during the entire course of her pregnancy. She C. 8 to 10 days.
gives birth to a full-term healthy girl. Five days after the D. 2 weeks.
birth, she reports that the baby is irritable with pro- 98. Postpartum “baby blues” typically begin:
tracted periods of crying. This is likely a result of: A. 1–2 weeks prior to the birth.
A. increased intracranial pressure from en utero SSRI B. within a few days following the birth.
exposure. C. 1–2 weeks following the birth.
B. SSRI withdrawal. D. approximately 1 month following the birth.
C. colic. 99. Risk factors for postpartum depression include all of
D. impending sepsis. the following except:
90. An example of an antimicrobial that is FDA pregnancy A. history of depression.
risk category B is: B. financial problems.
A. clarithromycin. C. history of caring two or more pregnancies to term.
B. doxycycline. D. unplanned pregnancy.
C. erythromycin. 100. Symptoms of postpartum depression include all of the
D. ofloxacin. following except:
91. An antimicrobial that is FDA pregnancy risk A. hallucinations.
category D is: B. overwhelming fatigue.
A. amoxicillin. C. insomnia.
B. levofloxacin. D. severe mood swings.
C. doxycycline. 101. Treatment of postpartum depression can typically
D. TMP-SMX. include all of the following except:
92. The penicillins are ranked as FDA pregnancy risk category: A. counseling.
A. B. B. antidepressants.
B. C. C. electroconvulsive therapy.
C. D. D. hormone therapy.
D. X.
102. The risk of infanticide is greatest in a woman with
93. All of the following uropathogens are capable of reduc- which of the following conditions?
ing urinary nitrates to nitrites except: A. postpartum depression
A. Escherichia coli. B. postpartum “baby blues”
B. Proteus species. C. postpartum psychosis
C. Klebsiella pneumoniae. D. There is little risk of infanticide with any of the
D. Staphylococcus saprophyticus. above conditions.
4074_Ch18_463-484 20/11/14 4:24 PM Page 473
103. A risk factor for postpartum psychosis is: damage would result because there are no organ systems to
A. history of depression. disrupt. After day 81 post-LMP, the organs are formed but
B. multiple births (i.e., twins, triplets, etc.). are still growing and developing. The likelihood of a sub-
C. history of bipolar disorder. stance exerting a teratogenic effect decreases.
D. illegal drug use. Many factors influence drug transfer across the placenta,
including the molecular weight of the substance, lipid solu-
104. Treatment of postpartum psychosis typically includes
bility, and duration of exposure. Medications usually pass
all of the following except:
by passive diffusion, where the maternal drug level is greater
A. hospitalization.
than that of the fetus; more drug is passed when maternal
B. estrogen replacement therapy.
levels are greatest. The degree of diffusion is influenced by
C. antipsychotic therapy.
many factors besides maternal drug levels including the
D. electroconvulsive therapy.
drug’s molecular weight and degree of lipophilicity. Drugs
with a low molecular weight (≤500 daltons) cross the pla-
cental barrier more easily than drugs with a molecular
Answers weight greater than 500 daltons, whereas drugs with a mo-
lecular weight greater than 1000 daltons cross the placenta
59. B. 75. C. 91. C.
infrequently. The lower the molecular weight, the greater
60. B. 76. D. 92. A.
the potential for passage of the drug through the placenta.
61. A. 77. C. 93. D.
Alcohol and cocaine have low molecular weights (≤100 dal-
62. D. 78. A. 94. B.
tons) and are easily passed. Insulin and heparin (molecular
63. B. 79. B. 95. B.
weight greater than 5000 daltons) are examples of drugs that
64. C. 80. D. 96. B.
are poorly transported to the fetus and can be given with
65. B. 81. D. 97. B.
relative safety in pregnancy. Most oral over-the-counter and
66. B. 82. C. 98. B.
prescription medications have molecular weights of less
67. C. 83. D. 99. C.
than 500 daltons and pass easily through the placenta. The
68. B. 84. B. 100. A.
placenta preferentially allows highly lipophilic drugs to pass
69. B. 85. C. 101. C.
through.
70. C. 86. B. 102. C.
Not all drugs with the same therapeutic endpoint have
71. D. 87. B. 103. C.
the same lipid solubility. Diphenhydramine (Benadryl) is
72. D. 88. C. 104. B.
a highly lipophilic antihistamine and penetrates the pla-
73. C. 89. B.
centa and maternal central nervous system easily, causing
74. A. 90. C.
sedation. In contrast, loratadine (Claritin) is more hy-
drophilic and has fewer fetal or maternal effects. Drugs
According to the CDC, 90% of American women take at with a long half-life or with extended-release formulations
least one medication during their pregnancy and about are usually held in maternal circulation for protracted pe-
70% take at least one prescription medication. Certain riods and have the potential to have a greater effect on the
medications are potentially teratogenic, or capable of in- fetus than similar drugs with shorter half-lives or drugs
ducing birth defects, and should be avoided or used with metabolized more rapidly.
great caution during pregnancy. By definition, a terato- Table 18–5 describes the U.S. Food and Drug Adminis-
genic drug is a substance that has the potential to create a tration (FDA) risk categories and provides examples for each.
characteristic set of malformations in the fetus. The classic A quick way to remember the categories is as follows:
teratogenic period occurs in a specific time of fetal devel- Category B for Best because very few products are category A.
opment, usually between day 31 and day 81 following the Category C for Caution because these products have been
last menstrual period when organogenesis is occurring. For shown to have risk in animal models.
a teratogen to exert its effect, the product must be taken at Category D for Danger because these products have been
the point in the pregnancy when the affected organ system shown to have risk when used in human pregnancy but
is developing. For example, lithium can cause a character- are used occasionally in life-threatening maternal disease.
istic teratogenic cardiac defect when taken as the cardiac Category X for “Cross these drugs off the list” because these
tube is forming; taken earlier or later in the organ develop- products have shown teratogenic risk and have no thera-
ment process, the drug likely has no effect on the heart. peutic indication for use during human pregnancy.
Fetal liver maturity also plays a role because 40% to 60% of Pregnant women have similar incidence of acute and
fetal blood circulation goes through the liver. With increas- chronic illnesses to age-matched women who are not pregnant.
ing maturity, the fetus’s hepatic enzymes become more ca- Up to 8% of pregnant women have asthma, with a documented
pable of metabolizing drugs. increase in maternal morbidity and mortality during preg-
Before day 31 post-LMP, the pregnancy exists as a group nancy for women with the most severe asthma before concep-
of poorly differentiated cells with no discrete organ systems tion. Most pregnant women with asthma have no change in
to damage. A teratogen could be taken at that point and no their symptoms or experience an improvement in symptoms.
4074_Ch18_463-484 20/11/14 4:24 PM Page 474
TABLE 18-5
Medication Use During Pregnancy
An FDA risk category is assigned to all drugs based on risk of drug exposure to the human fetus: A–X. New drugs un-
dergo animal studies and perhaps a small number of inadvertent human exposures during clinical trials are considered.
Risk Category Outcomes Example
Category A Well-controlled human study: No fetal risk Vitamins at RDA
in first trimester • Vitamin A caution (risk factor X in doses
No evidence of risk in second and third 8000 IU/d or more)
trimesters Levothyroxine
Risk to fetus appears remote
Category B Animal studies do not show fetal risk, Beta-lactam antimicrobials
B: Best because nothing but no controlled study in humans, or • Penicillins, cephalosporins
is A Animal studies show adverse effect not Select macrolides
shown in human study • Azithromycin, erythromycin
Acetaminophen
Category C No controlled study in humans available ~Two-thirds of all prescription medications
C: Caution Animal studies reveal adverse fetal effects Select antimicrobials
• Clarithromycin
• Fluoroquinolones (“-floxacin” suffix)
• TMP-SMX
Commonly prescribed medications
• Most SSRIs, corticosteroids, antihyperten-
sives, others
Category D Positive evidence of human fetal risk Gentamicin
D: Danger Use in pregnant women occasionally ACEI (“-pril” suffix), ARB (“-sartan” suffix)
acceptable despite risk Tetracyclines
• Doxycycline, minocycline
Paroxetine
Category X Animal or human studies show fetal Isotretinoin (Accutane), misoprostol
Cross these off your list abnormality (Cytotec), thalidomide
Evidence of fetal risk based on human
study
No therapeutic indication in pregnancy
Source: Briggs G, Freeman R, Yaffee S. Drugs in Pregnancy and Lactation, ed. 9. Philadelphia: Lippincott
Williams & Wilkins, 2011.
Bronchospasm symptoms are usually worse between 29 designation but should be used only to treat an asthma
and 36 weeks of gestation because of esophageal irritation flare. Beta2-agonist bronchodilators are also category C,
from gastroesophageal reflux disease. Symptoms usually based on studies on high oral doses in laboratory animals,
improve late in gestation when gradual fetal descent occurs. and should be prescribed as a rescue drug for a pregnant
Lifestyle changes that help improve symptoms of gastroe- woman with asthma. Leukotriene modifiers have not been
sophageal reflux disease help with asthma management. studied as extensively in pregnant women and carry a risk
Generally, the risk of fetal hypoxia is greater than the risk category B or C.
of medication exposure, so standard asthma medications Nausea and vomiting in pregnancy often are compli-
should be continued. Most inhaled corticosteroids are FDA cated by preexisting conditions such as gastritis. The pres-
risk category C (with budesonide [Pulmicort] being the ence of Helicobacter pylori infection can worsen nausea and
exception as risk category B), a designation that is based vomiting. Preconceptual evaluation and, if positive, treat-
on high oral or parenteral doses given to laboratory ani- ment of H. pylori should be considered for women with
mals, but seems to have little applicability in human use, history of a pregnancy complicated by severe nausea and
which involves inhaled medications that have low rates of vomiting or of recurrent gastrointestinal problems. Man-
systemic absorption. Oral corticosteroids have the same agement is targeted toward relieving nausea by increasing
4074_Ch18_463-484 20/11/14 4:24 PM Page 475
rest and decreasing stress. Patients can make their own shorter half-life such as paroxetine (half-life 26 hours) and
ginger or lemon aromatherapy “kit” by placing five ginger less severe with SSRIs with a longer half-life such as fluoxetine
or lemon teabags in an airtight plastic tub. When nausea (half-life 24 to 72 hours and metabolite half-life up to
occurs, the patient opens the tub and sniffs the vapors. 26 hours). If SSRIs are used late in the third trimester, fetal
Treating the concomitant gastritis that often accompanies withdrawal can also occur, which is the reason for the com-
severe nausea and vomiting during pregnancy with a chew- mon recommendation to taper a pregnant woman’s SSRI
able calcium antacid tablet every 2 hours for 2 to 3 days can dose over the last month of pregnancy. Neonatal effects are
be helpful. Taking vitamin B6, 25 mg twice a day, has been similar to maternal withdrawal and include irritability, pro-
noted to prevent future nausea and vomiting. A 5-HT3- tracted crying, and shivering; the timing of the onset of
receptor antagonist, such as ondansetron (Zofran, preg- neonatal SSRI withdrawal symptoms is related to the drug’s
nancy risk category B), can offer an effective therapeutic half-life and can occur within days to weeks of birth.
option for preventing severe morning sickness but is not In an FDA advisory, results of domestic and European
effective in managing acute symptoms. studies revealed that women who took paroxetine in early
Among women with a migraine history, most note fewer pregnancy had an approximately two-fold increased risk
and less intense headaches during pregnancy; however, about for having an infant with a cardiac defect compared with
5% to 10% have worsening headaches. Treatment options are the risk in the general population. The risk of a cardiac
limited and include acetaminophen. Nonsteroidal anti- defect was about 2% in infants exposed to paroxetine versus
inflammatory drugs (NSAIDs) are category C and their use 1% among all infants in one study, whereas a 1.5-fold
during pregnancy is controversial. NSAIDs are generally increased risk for cardiac malformations and a 1.8-fold in-
avoided after 30 to 32 weeks of pregnancy because of a po- creased risk for congenital malformations overall in the in-
tential for rare serious fetal abnormalities (i.e., premature clo- fants exposed to paroxetine was noted in another study.
sure of ductus arteriosis and persistent fetal circulation). Most of the cardiac defects reported in these studies were
Triptans are risk category C, partly because of the theoretical atrial or ventricular septal defects. As a result, paroxetine
risk of vasoconstriction, but no teratogenic effect in human is pregnancy risk category D.
pregnancy has been noted to date. Lidocaine 4% used as a Tricyclic antidepressants and benzodiazepines are risk cat-
nasal spray, applied to the nostril on the affected side of the egory C or D and are rarely prescribed during pregnancy. If
head, can help attenuate headache symptoms with minimal an expectant mother has been on long-term benzodiazepine
system drug absorption. therapy, it is critical to taper doses gradually (25% per week)
Women are twice as likely as men to experience major de- to avoid a withdrawal syndrome. Rapid withdrawal can lead
pressive disorder. Consequently, many women enter preg- to tremors, hallucinations, seizures, and a delirium tremens–
nancy in a depressed state or develop depression during the like state and is most common with the use of products with
course of the pregnancy. Therapy for any mood disorder usu- a shorter half-life. The onset of withdrawal symptoms occurs
ally includes lifestyle changes, counseling, and drug therapy. a few days after the last dose in a benzodiazepine with a
Mood disorder treatment options include serotonin, norep- shorter half-life (e.g., lorazepam) and up to 3 weeks in one
inephrine, and dopamine receptor modulators, tricyclic with a longer half-life (e.g., clonazepam).
antidepressants, and benzodiazepines. Although selective Postpartum mood and anxiety disorders can include the
serotonin receptor inhibitors (SSRIs) are in risk category C blues, depression, or psychosis (Table 18–6). Postpartum
(with the exception of paroxetine, which is risk category D), blues is the most common disorder and generally begins
long-term observational study of children born to women within a few days after giving birth. Symptoms include
who took these medications during pregnancy has failed weepiness or crying for no apparent reason, impatience,
to note significant differences compared with nonexposed irritability, restlessness, anxiety, fatigue, insomnia, sadness,
matched controls. Bupropion is a dopamine receptor modu- mood changes, and poor concentration. The condition may
lator and is also pregnancy risk category C. Serotonin– be linked to hormonal changes that occur during pregnancy
norepinephrine reuptake inhibitors such as venlafaxine and following birth. The symptoms generally lessen within
(Effexor) and duloxetine (Cymbalta) are risk category C. 14 days after delivery. Mothers should receive support, reas-
Although few clinical studies have investigated the effects of surance, and assistance in taking care of the newborn so the
these drugs during pregnancy, safety surveillance studies in- mother can get needed rest.
dicate the frequency of abnormal outcomes while taking these Postpartum depression can occur in up to 20% of new
agents during pregnancy is consistent with historic rates in mothers and presents around 2 to 4 months following
the general population. birth. The signs and symptoms are more intense than the
If a patient wishes to discontinue antidepressant therapy postpartum blues and last longer, which can interfere with
during pregnancy, she should be counseled about the risk of the mother’s ability to care for the baby. Symptoms include
depression recurrence. A slow taper of approximately 25% of loss of appetite, insomnia, intense irritability and anger,
the total dose per week is required to avoid SSRI withdrawal overwhelming fatigue, lack of sexual drive, lack of joy
syndrome. The withdrawal syndrome is bothersome, but not in life, severe mood swings, withdrawal from friends and
life-threatening. Symptoms include jitteriness, nausea, and family, and thoughts of harming themselves or the baby.
sleep disturbance and is more severe with SSRIs with a Risk factors include a history of depression or postpartum
4074_Ch18_463-484 20/11/14 4:24 PM Page 476
TABLE 18-6
Postpartum Mood Disorders
Disorder Incidence (%) Presentation Treatment
Postpartum blues 26–85 Often begins within a few Support and reassurance including recruit-
days of giving birth ing helpers so mother can get more rest
Postpartum depression 10–20 Most common at 2–4 months Psychotherapy, psychopharmacological,
postpartum medication therapy as indicated, recogniz-
ing all will be secreted in breast milk; hos-
pitalization as needed
Postpartum psychosis 0.2 Early onset usually by day 3 Hospitalization usually needed for safety
postpartum; characterized by of mother and infant. Psychopharmaco-
delusions logical medication therapy as indicated
(antipsychotics, mood stabilizers, benzodi-
azepines, antidepressants, others)
Source: Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum.
Psychiatr Clin North Am 33(2):273–293, 2010.
depression, experiencing stressful events during the past pregnancy; only 1% to 2% of women with a negative urine cul-
year, having problems in the relationship with spouse or ture develop UTI. Asymptomatic bacteriuria should be treated
significant other, a weak support system, financial prob- with a 3- to 7-day course of antimicrobials, which reduces the
lems, or pregnancy that was unplanned or unwanted. risk of symptomatic UTI by 80% to 90%. Options for the treat-
Treatment usually includes counseling, antidepressants, ment of asymptomatic bacteriuria and symptomatic UTI dur-
and/or hormone therapy (e.g., estrogen replacement ther- ing pregnancy are guided by pathogen susceptibility, and
apy). With appropriate treatment, postpartum depression preferred antimicrobials include those with FDA pregnancy risk
usually resolves within a few months. category B. Antimicrobials in pregnancy risk category B include
Postpartum psychosis is a rare condition that typically de- beta-lactams (amoxicillin, cephalexin, cefpodoxime, cefixime,
velops within a few weeks following delivery. Symptoms and amoxicillin/clavulanate) and nitrofurantoin. Nitrofuran-
include confusion and disorientation, hallucinations and delu- toin has the advantage of sparing disruption of normal vaginal
sions, paranoia, and attempts to harm themselves or the baby. flora and consistent efficacy against E. coli and S. saprophyticus.
Women with bipolar disorder are at higher risk of postpartum Nitrofurantoin should be avoided after the 36th week of gesta-
psychosis. Those with this disorder require immediate treat- tion because of the potential (although unlikely) risk for hemol-
ment, often in the hospital. Treatment involves a combination ysis if the fetus is glucose-6-phosphate dehydrogenase–deficient
of antidepressants, antipsychotics, and mood stabilizers. Elec- and in infections caused by Proteus mirabilis. Beta-lactam use
troconvulsive therapy also is commonly used. usually fails to eradicate the offending pathogen from the peri-
Pregnancy-related anatomic changes in the urinary urethral and perivaginal area, increasing the risk of reinfection.
tract, such as pressure on the bladder from the enlarging Women with symptomatic UTI during pregnancy
uterus and increase in the size of the ureters, contribute to should be treated for 7 days. When UTI is documented,
urinary reflux. Urinary tract infection (UTI) in a pregnant monthly screening urine cultures should be obtained for
woman is a significant risk factor for low-birth-weight in- the duration of the pregnancy. Daily antimicrobial prophy-
fants and prematurity. laxis with an appropriate agent should be considered with
Asymptomatic bacteriuria occurs in 5% to 9% of nonpreg- evidence of 2 days of a symptomatic UTI or persistent,
nant and pregnant women. If left untreated in pregnancy, pro- unresolved bacteriuria despite effective antimicrobial ther-
gression of asymptomatic bacteriuria to symptomatic UTI, apy. Urological evaluation should also be considered to rule
including acute cystitis and pyelonephritis, occurs in 15% to out structural abnormality.
45%, or fourfold higher than in nonpregnant women. This pro-
D I S C U SSI O N S O U R C E S
gression largely results from the lower interleukin-6 levels and
serum antibody responses to E. coli antigens that occur during Akkerman D, Cleland L, Croft G, et al. Routine Prenatal Care.
Bloomington, MN: Institute for Clinical Systems Improvement
pregnancy, resulting in a less robust immune response.
(ICSI), 2012, https://www.icsi.org/_asset/13n9y4/Prenatal.pdf.
Because asymptomatic bacteriuria, usually caused by Antonucci R, Zaffanello M, Puxeddu E, et al. Use of non-steroidal
aerobic gram-negative bacilli or Staphylococcus saprophyticus, anti-inflammatory drugs in pregnancy: impact on the fetus and
can lead to UTI, a urine culture should be obtained from all newborn. Curr Drug Metab 13(4):474–490, 2012.
women early in pregnancy, even in the absence of UTI symp- Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation: A
toms. Approximately 20% to 40% of women with asympto- Reference for Fetal and Neonatal Risk, ed. 9. Philadelphia:
matic bacteriuria develop UTI during the course of the Lippincott Williams & Wilkins, 2012.
4074_Ch18_463-484 20/11/14 4:24 PM Page 477
Centers for Disease Control and Prevention. Treating for two: Safer 112. Preeclampsia presentation is noted after the ___ week
medication use in pregnancy, http://www.cdc.gov/ncbddd/ of pregnancy.
birthdefects/documents/ncbddd_birth-defects_medication A. 10th
useonepager_cdcrole.pdf. B. 15th
Gilbert DN, Moellering RC, Eliopoulos GM, Chambers HF, Saag
C. 20th
MS. The Sanford Guide to Antimicrobial Therapy, ed. 43. Sper-
ryville, VA: Antimicrobial Therapy, Inc., 2013.
D. 25th
Ogunyemi DA. Hyperemesis gravidarum, http://emedicine. 113. The components of HELLP syndrome include all of
medscape.com/article/254751-overview#a0156. the following except:
A. hepatic enzyme elevations.
B. thrombocytosis.
Hypertensive C. hemolysis.
D. eclampsia.
Disorders, GBS
114. Which of the following is the most important part of
105 to 109. Match each hypertensive disorder with its char- care of a woman with preeclampsia?
acteristic. A. antihypertensive therapy
105. Chronic hypertension A. high blood B. anticonvulsant therapy
106. Gestational hypertension pressure diag- C. prompt recognition of the condition
107. Preeclampsia nosed after the D. induction of labor
108. Eclampsia 20th week of
109. HELLP syndrome pregnancy 115. Regarding the risk for neonatal group B streptococcus
B. presence of (GBS) disease, the NP considers that:
tonic-clonic A. about 50% to 70% of all pregnant women harbor
seizures or this organism.
other alteration B. there is no risk of disease with cesarean birth.
in mental status C. the organism is most often acquired by vertical
C. high blood transmission in the second trimester of preg-
pressure diag- nancy.
nosed before D. intrapartum antimicrobials should be given to all
pregnancy women with evidence of GBS colonization.
D. preeclampsia 116. GBS cultures should be obtained from:
accompanied A. the cervix.
by elevated he- B. the urethra.
patic enzymes C. urine.
and low D. the lower vagina and rectum.
platelets
E. high blood
pressure diag- Answers
nosed after the
20th week of 105. C. 109. D. 113. B.
pregnancy and 106. A. 110. A. 114. C.
accompanied 107. E. 111. B. 115. D.
by significant 108. B. 112. C. 116. D.
proteinuria
110. Risk factors for preeclampsia include all of the follow- Hypertensive disorders occur in 12% to 22% of all pregnan-
ing except: cies. These disorders are usually divided into the following
A. low maternal weight. categories: chronic hypertension, or high blood pressure
B. age younger than 16 years or older than 40 years. (BP) diagnosis that predates the pregnancy, and hyperten-
C. collagen vascular disease. sive disorders acquired during pregnancy. Hypertensive dis-
D. first pregnancy with a new partner. orders acquired during pregnancy include gestational
111. For a woman who was normotensive before 20 weeks hypertension, preeclampsia, and eclampsia. Preeclampsia
of gestation, an indication of preeclampsia is blood risk factors include age (≥40 years, ≤16 years), first preg-
pressure of more than ___ mm Hg systolic and more nancy or first pregnancy with a new partner, pregestational
than ___ mm Hg diastolic. diabetes mellitus, presence of collagen vascular disease, pre-
A. 130, 80 pregnancy or primary hypertension, presence of maternal
B. 140, 90 renal disease, a family history of pregnancy-induced hyper-
C. 150, 95 tension, or multiple gestation pregnancy.
D. 160, 100
4074_Ch18_463-484 20/11/14 4:24 PM Page 478
An early or milder case presentation of preeclampsia is usu- 300 neonatal deaths per year. Maternal lower genitourinary
ally characterized by an increase in systolic BP of 30 mm Hg, an tract colonization with this organism is a major risk factor for
increase in diastolic BP of 15 mm Hg, or an absolute BP reading early-onset, usually in the first week of life, GBS disease. The
of 140 mm Hg/90 mm Hg in a pregnant woman with minimal transmission of the organism from mother to fetus usually oc-
proteinuria and pathological edema, with presentation after the curs after the onset of labor or membrane rupture. The lower
20th week of gestation. Additional findings, usually with more gastrointestinal tract is the natural reservoir for this organism;
severe disease, include right upper quadrant abdominal pain, this most likely contributes to GBS vaginal or rectal colonization
nausea, and vomiting. A systolic BP greater than 160 mm Hg or in about 10% to 30% of pregnant women. GBS colonization
a diastolic BP greater than 110 mm Hg with significant protein- is not considered to be a sexually transmitted infection and
uria (≥5 g/d) and evidence of hepatic, renal, or central nervous can be transient, chronic, or intermittent. Intrapartum antimi-
system end-organ damage indicate severe preeclampsia. crobial chemoprophylaxis is currently the most effective inter-
Preeclampsia can progress to the syndrome of hemolysis with vention to help prevent infant GBS disease. As a result, GBS
resulting anemia, elevated liver enzymes indicating hepatocel- screening should be performed in all women at 35 to 37 weeks
lular damage, and low platelet count and eclampsia; this con- of pregnancy, including women who are to undergo cesarean
stellation is known as HELLP and is noted in 5% to 10% of birth because the organism can cause infection across intact
patients with preeclamptic symptoms (Table 18–7). membranes. The culture should be obtained by swabbing the
The most important intervention in preeclampsia is lower vagina and vaginal introitus, followed by the rectum; in-
maintaining a high index of suspicion in women with con- sertion of the swab into the anal sphincter is needed for optimal
siderable risk and prompt recognition of the condition results. The patient or healthcare provider can obtain the cul-
when it occurs. If preeclampsia is recognized, expert ob- ture. No vaginal speculum is needed, and cervical cultures
stetrical consultation should be obtained. Intervention in- should not be obtained because these can be negative in the
cludes rest, ongoing maternal and fetal monitoring, and presence of heavy lower vaginal GBS colonization.
antihypertensive or anticonvulsant medications or both; all
of these measures have only a small effect on outcome. D I S C U SSI O N S O U R C E S
Birth is the definitive intervention and is usually the treat- Akkerman D, Cleland L, Croft G, et al. Routine Prenatal
ment of choice in later pregnancy. Care. Bloomington, MN: Institute for Clinical Systems Im-
Prenatal care in later pregnancy should include screening for provement (ICSI), 2012, https://www.icsi.org/_asset/13n9y4/
group B streptococcus (GBS). Neonatal infection with GBS is a Prenatal.pdf.
leading cause of newborn morbidity and mortality, resulting in Lim K-H. Preeclampsia, http://emedicine.medscape.com/article/
an estimated 7,600 cases of neonatal sepsis and approximately 1476919-overview.
TABLE 18-7
Hypertensive Disorders During Pregnancy
Category of Hypertensive Disorder During Pregnancy Defining Characteristics of Disorder
Chronic hypertension High blood pressure diagnosed before pregnancy,
present before 20th week of pregnancy or persisting
≥6 weeks postpartum
Gestational hypertension High blood pressure diagnosed after 20th week of
pregnancy, but resolving within 6 weeks postpartum,
without significant proteinuria or other signs of
preeclampsia
Preeclampsia High blood pressure diagnosed after 20th week of preg-
nancy, accompanied by significant proteinuria (≥300 mg
protein in 24-hour urine collection) that cannot be
attributed to another cause; usually accompanied by
increased edema
Eclampsia Presentation as in preeclampsia with tonic-clonic
seizures or other alteration in mental status that cannot
be attributed to another cause
HELLP syndrome Preeclampsia accompanied by elevated hepatic enzymes
and low platelets
Source: Akkerman D, Cleland L, Croft G, et al. Routine Prenatal Care. Bloomington, MN: Institute for Clinical
Systems Improvement (ICSI), 2012, https://www.icsi.org/_asset/13n9y4/Prenatal.pdf.
4074_Ch18_463-484 20/11/14 4:24 PM Page 479
Acknowledge readiness or difficulty in making a change. 123. Approximately __% of spontaneous abortions are as-
“Change is hard and sometimes very scary.” sociated with chromosomal defects.
“It sounds to me like you are (not) ready to make a change.” A. 20
• P: Present focus B. 40
Assist client in focusing on the present without minimiz- C. 60
ing concerns of the past and future. D. 80
“How could you cope better?”
124. The classic clinical triad of ectopic pregnancy includes
“What could you do differently?”
all of the following except:
After you have gathered this information, you should do
A. abdominal pain.
the following:
B. vaginal bleeding.
• Negotiate a problem-focused contract for behavioral change:
C. large-for-gestational-age uterus.
Repeat after me, “I promise not to harm myself or any-
D. adnexal mass.
one else in any way between now and my next visit
with ______.” 125. The classic clinical triad of ectopic pregnancy is found
Homework assignment with “I” messages: in no more than ___% of women presenting with this
“I would like more help with the children.” condition.
“I feel really unimportant to you when ________.” A. 10
“I feel angry when _______________.” B. 25
How do you keep this to 15 minutes? C. 50
• Focus the client, using open and close-ended questions. Tell the D. 75
client how much time you have, particularly with a revisit. 126. In the first weeks of a viable intrauterine pregnancy,
“We have ___ (fill in the blank) minutes to chat. What serum quantitative hCG levels usually doubles every
would you like to focus on?” ___ hours until approximately 10,000-20,000mIU/mL.
If the client cannot focus, ask, “If one problem in your A. 24
life could just disappear, what would you choose?” B. 48
Interpersonal violence is likely as common in same-sex re- C. 72
lationships as in opposite-sex relationships, but it is not as D. 96
well studied. Violent behavior by a woman against a male
partner is unlikely to result in injury as serious as a man’s vi- 127. In ectopic pregnancy, all of the following statements
olence against a woman, partly because of the usual disparity are true except:
in body size and lower likelihood of weapon use. In all so- A. hCG is low for gestational age and is not increasing
cioeconomic groups, access to a firearm by a perpetrator is normally.
associated with increased risk of abuse with serious or fatal B. Ultrasound evaluation fails to reveal abnormality
injury; this is also a risk for completed suicide. The NP is in in 20% to 30% of cases.
an ideal position to direct the couple to appropriate resources C. Location of the pregnancy is often on the ovary or
for help in domestic violence but should not attempt to pro- cervix.
vide this counseling because of the complexity of this type of D. Risk factors include current pregnancy via assisted
care. Individual treatment is the rule as long as the violent reproduction.
behavior continues. Child abuse is present in about half of all 128 to 131. Match the clinical presentation of the following.
households where there is partner abuse. 128. Complete A. Uterine contents in-
abortion clude a nonviable
DI SCUS SION SOURCES
129. Inevitable pregnancy that is in
Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Arling- abortion the process of being
ton, VA: American Psychiatric Publishing, Inc., 2013. 130. Threatened expelled.
Stuart M, Lieberman J. The 15-Minute Hour: Practical Therapeutic
abortion B. Some portion of the
Intervention in Primary Care. ed. 4. Philadelphia: Saunders, 2008.
131. Incomplete products of concep-
abortion tion remains in the
uterus, although the
Early Pregnancy pregnancy is no longer
Loss viable.
C. The products of con-
122. Approximately ___% of all clinically recognized preg- ception have been
nancies end in spontaneous abortion. completely expelled.
A. 10 D. Ultrasound evaluation
B. 20 shows a viable preg-
C. 30 nancy, although vagi-
D. 40 nal bleeding is present.
4074_Ch18_463-484 20/11/14 4:24 PM Page 481
TABLE 18-8
Risk Factors for Ectopic Pregnancy
Strongest Evidence of Risk Significant but Less Potent
History of salpingitis (most potent risk factor) Progestin use
Prior ectopic pregnancy Current IUD use
Tubal or pelvic surgery Vaginal douching
Assisted reproduction Tubal ligation failure (more likely 2 or more years after procedure)
Cigarette smoking Increased maternal age (35 years of age or greater)
TABLE 18-9
Clinical Presentation in Ectopic Pregnancy
Clinical Presentation Laboratory Diagnosis Ultrasound
Abdominal pain (nearly universal, Serum progesterone (less than 15 mg/mL, Consider diagnosis if transvaginal
often bilateral) found in the majority of ectopic and ultrasound fails to identify in-
Adnexal tenderness (75%) nonviable intrauterine pregnancies). Low trauterine gestational sac and
Menstrual irregularity (75%) for gestational age serum hCG (IUP less hCG less than 1500 mIU/mL
Uterus size less than anticipated for than 6000 mIU/mL, relatively stalled
gestational age (90%) without normal hCG increases)
Adnexal mass (53%) Positive urine hCG (99% sensitivity and
specificity)
TABLE 18-10
Clinical Presentation in Viable Intrauterine Pregnancy (IUP)
Transvaginal ultrasound Gestational sac visible in viable IUP when hCG greater than 1500 mIU/mL
Transabdominal ultrasound Gestational sac in viable IUP when hCG greater than 6000 mIU/mL
Of women with ectopic pregnancy, approximately 15% fluid in the cul-de-sac, and there are no contraindications for
to 26% have a nondiagnostic ultrasound; thus, a normal ul- methotrexate use. A quantitative beta hCG of greater than
trasound scan does not rule out the condition. If ectopic 6,000 mIU/mL, evidence of fetal cardiac activity and free fluid
pregnancy is suspected, a serum progesterone level is often in the cul-de-sac (a common finding in tubal rupture) are all
obtained. Progesterone is a hormone produced by the de- contraindications to methotrexate use. Close follow-up is
veloping chorion. A progesterone level less than 15 ng/mL critical with medical management of ectopic pregnancy to
is seen in only 11% of viable intrauterine pregnancies but ensure pregnancy resolution; surgical intervention is some-
is noted in most ectopic pregnancies or with inevitable times needed if this therapy fails. Compared with surgical
abortion. Occasionally, pelvic computed tomography or therapy, tubal patency is usually better preserved with med-
magnetic resonance imaging is indicated, recognizing the ical management. Regardless of the treatment modality in
limitations of these studies in ectopic pregnancy but their ectopic pregnancy, considerable emotional support is also
utility in identifying other reasons for abdominal pain. needed because the woman has faced a potentially life-threat-
When the diagnosis of ectopic pregnancy is established, ening illness and the loss of a pregnancy (Table 18–11).
treatment depends on the patient’s condition. If the patient Spontaneous abortion is defined as the natural ending of
is stable, evaluation for a concurrent (heterotopic) intrauter- a pregnancy before 20 weeks of gestation. In about 60% of
ine pregnancy should be done because this can be found in spontaneous abortions, chromosomal defects of maternal or
10% of women presenting with this condition. If the patient paternal origin are responsible for the pregnancy loss. Ma-
is hemodynamically unstable, immediate surgical interven- ternal factors such as trauma, illness, or infection lead to the
tion is warranted. If the patient is stable, surgical or medical loss in about 15% of cases. In the remaining cases, no obvious
intervention is warranted according to the availability of cause can be found. With all threatened pregnancy loss, in-
treatment options. Surgical treatments include salpingos- tervention is aimed at maintaining a stable hemodynamic
tomy, in which the tube is opened and the pregnancy con- state and providing considerable emotional support.
tents are removed. The tube is then repaired. Salpingectomy About 25% to 30% of women experience some vaginal
is usually performed when the tubal rupture has occurred or bleeding in the first trimester, and at least 50% of these
tubal damage is severe, and repair is not possible. women have pregnancy loss. Four terms are usually used to
Medical therapy with methotrexate, a medication that in- modify the condition of spontaneous abortion: threatened,
hibits cell division and causes the pregnancy to regress and inevitable, incomplete, and complete.
resolve, is an option when ectopic pregnancy is diagnosed Threatened abortion manifests as vaginal bleeding or
while the tube is intact, the patient is hemodynamically stable, brown spotting during early pregnancy with or without
there is no ultrasound evidence of fetal cardiac activity or free cramping but without cervical dilation or change in cervical
TABLE 18-11
Ectopic Pregnancy Management
Many ectopic pregnancies resolve without intervention. No current reliable data are available on predictors of self-resolution.
SURGICAL MANAGEMENT Salpingostomy, salpingectomy
MEDICAL MANAGEMENT Methotrexate therapy can be offered if following criteria are met:
• Conceptus less than 3.5-4 cm with no evidence of cardiac activity
• Unruptured tube with no evidence of fluid in cul-de-sac
• Beta hCG level less than 5,000 mIU/mL
• Hemodynamically stable with no signs or symptoms of active bleeding or hemoperi-
toneum
• Patient is reliable, adherent to therapy, and available for close follow-up care
• (A beta hCG level >5,000 mIU/mL, fetal cardiac activity, and free fluid in the
cul-de-sac are usually considered contraindications for methotrexate therapy.)
Professional Issues 19
Medicaid 5. Along with the Children’s Health Insurance Program
(CHIP), Medicaid provides coverage for approximately
1. Medicaid is best defined as: what percentage of all children in the United States?
A. an entitlement program to provide healthcare cover- A. 10%
age for unemployed families. B. 20%
B. publicly financed health and long-term care coverage C. 33%
for low-income people. D. 55%
C. free acute care coverage for those who meet special 6. Federal core groups that states must cover to receive
criteria. federal matching Medicaid funding include all of the
D. publicly supported healthcare for low-income people following except:
under the age of 65 years. A. pregnant women.
2. A “dual eligible” beneficiary is an individual who re- B. elderly.
ceives Medicaid and: C. children.
A. private insurance. D. undocumented immigrants.
B. Social Security. 7. In concerning disabled individuals, Medicaid funding
C. government welfare benefits. can assist in all of the following except:
D. Medicare. A. fund education opportunities (i.e., tuition).
3. Concerning long-term care coverage, Medicaid: B. provide a fuller range of healthcare services.
A. does not provide any coverage of long-term care C. maximize independent living opportunities.
expenses. D. support participation in the workforce, if possible.
B. only covers eligible individuals younger than 65 years 8. What is the impact of the Affordable Care Act (ACA)
of age. on Medicaid coverage?
C. finances approximately 40% of all long-term care A. ACA will increase Medicaid coverage for the elderly
spending. (more than 65 years of age).
D. provides coverage only for those with physical B. ACA will increase coverage for uninsured adults
disabilities. younger than 65 years of age.
4. Which of the following statements concerning funding C. There will be no impact on Medicaid coverage.
for Medicaid is accurate? D. More individuals will switch from Medicaid to
A. Federal funding of Medicaid for each state is based Medicare coverage.
primarily on the state population size. 9. “Mandatory services” defined by federal law for
B. The federal government matches at least 50% of state inclusion in Medicaid include all of the following
Medicaid spending. except:
C. States are not required to provide funding for A. laboratory and x-ray services.
Medicaid as long as they meet guidelines to receive B. family planning services.
federal funding. C. rehabilitation therapy.
D. Federal funding typically accounts for less than D. nurse practitioner services.
20% of all Medicaid funding.
485
4074_Ch19_485-496 20/11/14 2:35 PM Page 486
10. Coverage of services from all of the following health- poverty line. Medicaid covers a broad population, including
care centers is considered mandatory for inclusion in pregnant women, children and some parents in both working
Medicaid by federal law except: and jobless families, and children and adults with physical
A. rural health clinic (RHC). and mental health conditions and disabilities. Additionally,
B. acute care hospital. Medicaid provides assistance to low-income Medicare bene-
C. hospice. ficiaries, known as “dual eligible” beneficiaries, providing as-
D. federally-qualified health center (FQHC). sistance with Medicare premiums and cost-sharing and
covering key services, particularly in long-term care, that
11. Which of the following statements is false regarding
Medicare excludes or limits.
Medicaid premiums and cost-sharing?
Medicaid is the main source of coverage and financing for
A. States have limited flexibility to charge Medicaid
long-term services and supports (LTSS) since Medicare and
premiums based on income level.
private insurance largely does not provide coverage for these
B. Preventive services for children are exempt from
services. Of the nearly 10 million Americans that utilize LTSS,
cost-sharing.
about half are elderly and about half are children and working-
C. States can terminate Medicaid coverage if premiums
age adults with disabilities. Medicaid finances 40% of all long-
are not paid by an individual.
term care spending; more than 60% of nursing home residents
D. Providers cannot deny care to Medicaid patients
are covered by Medicaid.
even if cost-sharing amounts are not paid.
The cost of Medicaid is shared by the federal government
12. When compared with children with private insurance, and the states. The federal government matches state Medi-
those with Medicaid and CHIP are: caid spending based on a specified formula that varies for
A. comparable in access to healthcare and meeting each state, but the federal match rate is at least 50% in every
several core measures in preventive care. state. Though state participation in Medicaid is voluntary,
B. more deficient in several core measures of preven- all states participate. The states administer Medicaid within
tive care. broad federal guidelines. The Centers for Medicare and
C. less likely to see primary care providers. Medicaid Services (CMS) provides oversight of each state to
D. more likely to receive mandatory immunizations. ensure that the core requirements are met. Beyond these core
requirements, each state has flexibility regarding eligibility,
13. Which of the following statements is most accurate
benefits, provider payment, delivery systems, and other
regarding the use of emergency department (ED)
aspects. Thus, Medicaid programs can vary considerably from
services by Medicaid patients?
state to state.
A. The majority of ED visits by Medicaid patients is
By design, Medicaid provides coverage for low-income
for nonurgent symptoms.
people. States must cover federal core groups of low-income
B. Those with Medicaid are more than twice as likely
individuals and have flexibility to expand coverage to other
to use the ED for nonurgent symptoms compared
groups. Federal core groups include pregnant women, chil-
with those with private insurance.
dren, parents, elderly individuals, and individuals with dis-
C. Medicaid patients use EDs at a similar rate when
abilities, with income below specified minimum thresholds.
compared with people with private insurance.
Along with the Children’s Health Insurance Program (CHIP),
D. ED visits by Medicaid patients more often involve
Medicaid covers more than a third of all children and more
multiple diagnoses compared with those with
than 50% of all low-income children. Only American citizens
private insurance.
and specific categories of lawfully present immigrants can
qualify for Medicaid; lawfully present immigrants typically
Answers must wait 5 years before enrollment in Medicaid. The Afford-
able Care Act (ACA) opens Medicaid to a greater number of
1. B. 6. D. 11. D. uninsured adults by creating a new eligibility group of adults
2. D. 7. A. 12. A. younger than 65 years of age with income at or below 138%
3. C. 8. B. 13. D. of the federal poverty line (FPL).
4. B. 9. C. Medicaid provides health and long-term care coverage for
5. C. 10. C. people with severe physical and mental disabilities, often in
circumstances in which they cannot obtain private insurance
The Medicaid program was started in 1965 and now covers or the coverage falls short of meeting their needs. Medicaid
over 62 million Americans, making it the largest healthcare currently covers approximately 9.3 million nonelderly people
insurance program in the United States. Medicaid is an enti- with disabilities, including 1.5 million children. This includes
tlement program that was initially established to provide coverage for those with Down syndrome, cerebral palsy, and
medical assistance to low-income individuals and families re- autism, among others. Medicaid can provide access to a
ceiving public assistance or government welfare benefits. broader range of services needed by the disabled, can help
Over time, Congress and the states have expanded Medicaid maximize independence, and, if possible, support participa-
to reach more uninsured Americans living below or near the tion in the workforce.
4074_Ch19_485-496 20/11/14 2:35 PM Page 487
TABLE 19-1
Mandatory Services Defined by Federal Law for Medicaid
MANDATORY SERVICES
• Physicians’ services • Family planning services and supplies
• Nurse Practitioners’ and Physician Assistants’ services • Pediatric and family nurse practitioner services
• Hospital services (inpatient and outpatient) • Nurse midwife services
• Laboratory and x-ray services • Nursing facility services for individuals 21 y.o. and older
• Early and periodic screening, diagnostic, and treatment • Home healthcare for persons eligible for nursing facility
(EPSDT) services for individuals under age of 21 services
• Federally-qualified health center (FQHC) and rural • Transportation services
health clinic (RHC) services
Source: The Kaiser Commission on Medicaid and the Uninsured. Medicaid: A Primer (March 2013). Available at:
http://kff.org/medicaid/issue-brief/medicaid-a-primer.
4074_Ch19_485-496 20/11/14 2:35 PM Page 488
20. to 22. Indicate (yes or no) if each of the following is monthly premium is typically paid by beneficiaries who
eligible for Medicare. enroll in these plans.
In addition to funding from payroll taxes and Medicare
20. A 67-year-old man with multiple comorbidities and
premiums, other sources of funding include taxation of Social
high income
Security benefits, payments from states, and interest.
21. A 72-year-old permanent legal resident (non-U.S. Individuals aged 65 and over are eligible for Medicare if
citizen) they are a U.S. citizen or permanent legal resident regardless
of prior medical history, comorbidities, income, or assets.
22. A 68-year-old undocumented resident
Persons younger than 65 years with permanent disabilities
23. Funding for Medicare include all of the following are eligible for Medicare after receiving Social Security Dis-
sources except: ability Income (SSDI) payments for 24 months. Some condi-
A. payroll taxes. tions, such as end-stage renal disease or Lou Gehrig’s disease,
B. monthly premiums from beneficiaries. allow immediate eligibility for Medicare without waiting
C. sales taxes on alcohol and tobacco products. through 24 months of SSDI payments.
D. taxes from Social Security benefits. Most beneficiaries of Part A do not pay a monthly pre-
mium but may be responsible for a deductible before
24. All of the following are not typically covered by
Medicare coverage begins. Some individuals who are not en-
Medicare except:
titled to Part A coverage (such as those who did not pay
A. long-term care services.
enough Medicare taxes during their working years) have the
B. preventive care.
option to pay a monthly premium for Part A benefits. There
C. hearing exams and hearing aids.
are also several limitations in Medicare coverage that are
D. routine vision care and eyeglasses.
commonly needed by the elderly or those with permanent
disabilities. These include coverage for custodial long-term
care services either at home or in an institution (such as a
Answers nursing home or assisted living facility), routine dental care
14. B. 18. A. 22. No and dentures, routine vision care and eyeglasses, or hearing
15. D. 19. C. 23. C. exams and hearing aids. Medicare also has significant de-
16. B. 20. Yes 24. B. ductibles and cost-sharing requirements for covered benefits.
17. D. 21. Yes Medicare Advantage (Part C) allows beneficiaries to enroll
in private health plans to receive Medicare-covered benefits.
These plans tend to provide all benefits covered under tradi-
Medicare was initially established in 1965 to provide health tional Medicare and can offer additional benefits, including
insurance for individuals over the age of 65 years regardless Part D prescription coverage. Medicare contracts with various
of income or medical history. The program has subsequently types of private plans to offer benefits, including HMOs,
been expanded to include individuals younger than 65 years preferred provider organizations (PPOs), provider-sponsored
with certain medical conditions and disabilities. In 2010, ap- organizations (PSOs), private fee-for-service (PFFS) plans,
proximately 43 million people received Medicare coverage, high deductible plans linked to medical savings accounts
including 8 million people under the age of 65 years with (MSAs), and special needs plans (SNPs) for those eligible for
disabilities. both Medicare and Medicaid, the institutionalized, or those
Medicare is divided into four parts that each provides dif- with chronic conditions. Enrollment in Medicare Advantage
ferent healthcare benefits: plans has steadily increased since its inception with approxi-
• Part A (Hospital Insurance Program): Covers inpatient mately one in four Medicare beneficiaries participating in
hospital services, skilled nursing facilities, home health, these plans.
and hospice care. This is funded by a tax of 2.9% of earn-
ings paid by employers and workers. D I S C U SSI O N S O U R C E
• Part B (Supplemental Medical Insurance Program): The Henry J. Kaiser Family Foundation. Medicare: A Primer (April
Helps pay the outpatient, home health, and preventive 2010). Available at: http://kff.org/medicare/issue-brief/medicare-
services of the healthcare provider. This is funded by gen- a-primer.
eral revenues and beneficiary premiums.
• Part C (Medicare Advantage Program): Allows benefici-
aries to enroll in a private plan, such as a health mainte- Malpractice
nance organization, preferred provider organization, or
25. to 28. Match each element of malpractice with its char-
private fee-for-service plan, as an alternative to the tradi-
acteristic.
tional fee-for-service plan. These plans receive payments
from Medicare to provide Medicare-covered benefits, 25. Duty of care
such as hospital and physician services.
26. Breach of the standard of care
• Part D: Provides prescription drug benefits delivered
through private plans that contract with Medicare. A 27. Injury
4074_Ch19_485-496 20/11/14 2:35 PM Page 489
that injures the patient, then there is no malpractice, even Buppert, C. Avoiding Malpractice: 10 rules, 5 systems, 20 cases
though the standard of care has been breached. (ed 3). Law Office of Carolyn Buppert, 2010. Available at:
For malpractice to have occurred, a breach of the stan- www.buppert.com/publications.html.
dard of care must have caused an injury to the plaintiff
(proximal cause). For example, a patient visits a NP and is Billing
diagnosed with otitis media. The NP prescribes amoxicillin,
though the patient’s chart indicates a penicillin allergy. The 33. to 37. In order for a NP to be reimbursed by a third-
patient leaves the clinic with the prescription filled, but party payer (i.e., Medicare, Medicaid, private insurance), the
before the patient takes any of the potentially problematic following questions must be answered “yes”:
medication, the patient falls on the front steps of the clinic,
causing a permanent scar on her face. The patient sues the 33. Does the service include a medical evaluation and
clinic and the NP, claiming the NP had a duty to the patient, medical decision making?
the NP breached the standard of care (by prescribing peni- 34. Does the clinician have legal authority to receive
cillin form for a penicillin-allergic patient), and the patient reimbursement for these services?
suffered an injury. All of the above claims are true, but there
is no malpractice, because the breach of the standard of 35. Does the service involve procedures the clinician
care—prescribing amoxicillin to a penicillin allergic patient— cannot perform?
did not cause the injury. 36. Is the clinician enrolled with the payer?
Statistics on lawsuits have shown that the top seven con-
ditions that lead to malpractice claims are: 37. Is the service covered by the patient’s health plan or
• Breast cancer insurance?
• Pregnancy 38. In medical coding, the abbreviation CPT stands for:
• Acute myocardial infarction A. Current Pricing Tier.
• Displacement of intervertebral disc B. Current Procedural Terminology.
• Cancer of bronchus or lung C. Clinical Practice Terminology.
• Appendicitis D. Compendium of Procedures and Therapy.
• Colon and rectal cancer
The following recommendations should be followed to 39. In medical coding, the abbreviation ICD stands for:
avoid malpractice: A. Insurance Code for Diagnoses.
• Comply with the state nurse practice act. B. Integrated Clinical Dilemmas.
• Maintain effective collaboration, based on state regula- C. International Classification of Diseases.
tions and prudent practice. D. Initial Classification of the Diagnosis.
• Participate in periodic peer review and comply with 40. When billing Medicaid, NPs get the authority to bill for
protocols and/or guidelines. their services from:
• Ensure that collaborating professionals and facilities A. state law only.
maintain appropriate insurance. B. federal law only.
• Maintain patient records, including an up-to-date prob- C. state and federal law.
lem list and medication list, test results, telephone com- D. neither state nor federal law.
munications, consultations, and referrals.
• Release information in accordance with the Health Insur- 41. When billing commercial insurance, NPs get the
ance Portability and Accountability Act (HIPAA) regula- authority to bill for their services from:
tions and federal rules on human immunodeficiency A. state law only.
virus (HIV), substance abuse, and mental health. B. federal law only.
• Have systems and policies in place that allow for C. state law and/or the commercial payers.
effective patient follow-up, particularly for high-risk D. federal law and/or commercial payers.
diagnoses. 42. All of the following are components of medical decision
• Follow up diagnostic tests and referrals. making according to CPT except:
• Was it done? A. patient history taking.
• Are results on record? B. diagnosing.
• If the test results were abnormal, was the condition C. deciding a course of treatment.
followed up to a diagnosis or ruled out? D. performing treatments.
• Revisit an unresolved problem until it is resolved.
43. A fee-for-service system is best defined as:
DI SCUS SION SOURCES A. Up-front payments are made prior to any service.
Buppert, C. The Nurse Practitioner’s Business Practice and Legal B. A practice gets a set amount each month for all serv-
Guide. Sudbury, MA: Jones & Bartlett Learning, 2012. ices needed by a patient.
Buppert, C. The Primary Care Provider’s Guide to Compensation and C. Payment for each service is based on a sliding scale
Quality: How to Get Paid and Not Get Sued. Sudbury, MA: Jones according to patient income.
& Bartlett Publishers, 2005. D. For every procedure, there is an associated payment.
4074_Ch19_485-496 20/11/14 2:35 PM Page 491
44. Which of the following statements is false regarding a 50. “Incident to” billing does not apply to services
capitated system of reimbursement? provided:
A. The institution or practice gets a set amount per A. in home care.
month for all services needed by the patient and cov- B. in a nursing home.
ered under a contract between the payer and practice. C. in the physician office.
B. Capitated rates are not negotiable. D. in a hospital.
C. Capitated rates are based on profit projections and
actuarial data.
D. When payment is capitated, clinics prefer to take care Answers
of patients as much as possible through phone calls
and mailings rather than seeing a NP or medical 33. Yes 39. C. 45. B.
doctor (MD). 34. Yes 40. C. 46. D.
35. No 41. C. 47. B.
45. Potential consequences of failing an audit because of 36. Yes 42. A. 48. B.
upcoding, that is applying an artificially high level code 37. Yes 43. D. 49. A.
to a visit, include all of the following except: 38. B. 44. B. 50. D.
A. repaying the money back to the payer.
B. malpractice lawsuit.
C. dismissal as a reimbursable provider. An important part of practice is understanding how the
D. mandated education. services the NP delivers are reimbursed. Reimbursement
follows proper billing. If services of a nurse practitioner
46. All of the following criteria can be used to distinguish a
(NP) are not billed, or not billed correctly, the practice or
level 3 office visit for an established patient except:
employer can miss a significant source of revenue. However,
A. at least six elements of physical examination.
overbilling or “upcoding” (assigning, for billing purposes,
B. at least one element of history of present illness and
a higher than justified billing code) can lead to charges of
at least one positive or negative response to review-
healthcare fraud. Therefore, NPs must have a thorough
of-systems questions.
understanding of the requirements to receive third-party
C. medical decision making of low complexity.
payments.
D. at least one new prescription or a prescription
NPs seeking reimbursement by third-party payers (Medicare,
refill.
Medicaid, and commercial health plans and insurers) will re-
47. All of the following criteria can be used to help deter- quire a “yes” response to each of the following questions:
mine if a level 4 office visit occurred for an established • Is the service historically performed by a physician—that
patient except: is, does the service include a medical evaluation and
A. at least four elements of physical examination. medical decision making, or is it a procedure which
B. at least four elements of history of present illness. only a physician (or other authorized provider) is able
C. medical decision making of moderate complexity. to perform?
D. positive or negative responses to at least two review- • Does the clinician have the legal authority to perform
of-systems questions and at least one notation about this level of services?
past history. • Does the clinician have the legal authority to receive
reimbursement for these services?
48. Services that are an integral, although incidental, part of
• Is the clinician enrolled with the payer?
the physician’s personal professional services in the
• Is the patient’s coverage current?
course of diagnosis or treatment of an injury or illness
• Is the service covered by the patient’s health plan or
can be classified as:
insurance?
A. capitated services.
• Is the service medically necessary?
B. “incident to” services.
• Is there a CPT code (Current Procedural Terminology, a
C. mandatory services.
compendium of codes for every medical procedure, pub-
D. shared services.
lished and maintained by the American Medical Associa-
49. Criteria for an “incident to” office visit include all of the tion) for the service? Has the appropriate CPT code been
following except: submitted on the claim form?
A. all prescriptions must be written by the physician. • Is there a diagnosis code (International Classification of
B. the physician must conduct the initial visit and any Diseases or ICD) for the patient’s illness or condition?
visit in which there is a new episode of illness or a Has the appropriate ICD code been submitted on the
change in the plan of care. claim form?
C. the physician, in most instances, must be in the suite • If the NP works for or is a specialist, has the primary care
of offices, though not in the same room while the provider authorized the visit or procedure?
NP performs the service. • Is the service one that is necessary and covered?
D. the physician must remain involved in the care of • Has a clean claim been submitted—that is, has the prac-
the patient. tice filled out the claim form fully and appropriately?
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• Has the payer’s process been followed? services needed by the patient and covered under a contract
• Have the payers’ rules been followed? between the payer company and the practice company.
Nurse practitioners get the legal authority to bill for their Capitated rates may be negotiable. The rates are based on
services from various sources, depending on the payer. For profit projections and actuarial data (i.e., data on past utiliza-
Medicare, the authority comes from federal law. For Medi- tion of services by males, females, and age cohorts). If a pa-
caid, the authority comes from federal and state law. Regard- tient’s services are reimbursed under a capitated schedule, the
ing commercial insurers and health plans, the authority practice generates revenue by signing up large numbers of
usually comes from state law or may not be mentioned by patients, negotiating favorable capitation rates, and keeping
state law. In the latter case, the commercial payers make their expenses to a minimum by providing as few face-to-face visits
own decisions about whether or not to reimburse nurse prac- and services as possible, while providing an acceptable level
titioners. Whether the payer is Medicare, Medicaid, or a com- of care. When payment is capitated, practices want to take
mercial insurer or health plan, there are rules and policies care of as much as possible through telephone calls, electronic
about what can be reimbursed, and these policies can differ communication, mailings, or visits with staff other than NPs,
significantly from company to company. MDs, or PAs.
Third-party payers reimburse NPs when they are perform- The type of payment system will impact how a NP provides
ing these services requiring a high level of clinical skill and care on a day-to-day basis. If a patient’s services are reimbursed
decision-making, but not when they are performing nursing under a fee-for-service schedule, a practice receives more
services. Nursing services are typically defined as those serv- revenue with an increasing number of visits and procedures
ices that would fall under the practice of the registered nurse. performed. An NP who wants to generate more revenue will
NPs’ authority to perform high level services is derived from see more patients and code comprehensively and at the highest
state law and that legal authority is called “scope of practice.” level of service justified by the work performed and the medical
Some state laws are more explicit than others in describing a necessity of the services. A practice that excels at fee-for-service
NP’s scope of practice. For example, in select state law, what reimbursement will negotiate favorable fee schedules and be
the NP can do is provided in great detail whereas in other adept at following up unpaid or denied claims.
states, the law tends to be more broadly stated. Under the CPT system, there are five levels of evaluation
At minimum, a nurse practitioner would need the scope and management visit performed in an office. For an office
of practice under state law to bill for “evaluation and man- visit with an established patient, the most frequently billed
agement” services. The components of evaluation and man- visit for Medicare patients is a level 3 visit (CPT 99213). How-
agement, according to CPT, are taking a history; physical ever, many evaluation/management visits with NPs are at
examination; medical (clinical) decision making at the level 4 (CPT 99214). Medicare reimbursement for a level 4
NP, MD, or physician's assistant level; counseling; and coor- visit is significantly greater than for a level 3 visit. As a result,
dination of care. Medical (clinical) decision making is defined if the NP can meet the requirements for a level 4 visit, he or
as diagnosing, deciding upon a course of treatment, and or- she will receive additional reimbursement. On the other
dering and performing treatments. hand, the NP who bills a level 4 visit but only documents
The first requirement for reimbursement is having a scope enough work to meet the requirement of a level 3 visit will be
of practice under state law that authorizes the NP to perform in danger of failing an audit, which can result in a demand
services that would historically be considered physician serv- from the payer for money already paid, fines, mandated ed-
ices. States’ laws are worded so that there is little question that ucation and auditing, and even possible dismissal as a reim-
a nurse practitioner can perform evaluation and management bursable provider. If billing errors are frequent, a clinician
services (taking a history, performing a physical examination, could be charged with healthcare fraud.
and making medical decisions about further diagnosis and Certain criteria must be met to distinguish between a
treatment). level 3 and level 4 visit. A level 3 office visit for an estab-
Payment for NP services can come in several forms— lished patient requires meeting two of the following three
fee-for-service, capitation, or pursuant to a contract be- levels of medical work:
tween the practice and another entity. A practice often • At least one element of history of present illness and at
receives payments under a mixture of fees-for-services, least one positive or negative response to review-of-
capitation, and contracts. systems questions.
In the fee-for-service payment system, every procedure • At least six elements of physical examination.
performed has an associated payment. A procedure might • Medical decision making of low complexity.
be a visit for evaluation and management, a consultation, or A level 4 office visit for an established patient requires
excising a lesion. Under a fee-for-service payment system, the meeting two of the following three levels of work:
more services that are billed, the more revenue the practice, • At least four elements of history of present illness,
agency, or institution will make. As a result, it is important positive or negative responses to at least two review-
to know which services will be reimbursed and to bill all of-systems questions, and at least one notation about
reimbursable services. past history, family history, or social history.
Under a capitated system of reimbursement, the agency, • At least 12 elements of physical examination.
institution, or practice gets a set amount, per month, for all • Medical decision making of moderate complexity.
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The difference between the levels is a matter of more ex- permissible to bill “incident to” in a nursing home but only
tensive history taking, more medical decisions, and higher if care is provided in an office space rented by the physician,
risk of morbidity and mortality with the higher level code. and the physician, NP, and patient all are present. Prudent
Proper coding is essential for the individual and the prac- practice dictates that the NP keeps abreast of current regu-
tice. A clinician who erroneously codes a level higher than is lations and advisories.
documented could be exposing the individual and the prac- “Incident to” billing does not apply to services provided
tice to a charge of false claims. However, coding a level lower in a hospital. However, NPs and physicians are able to “share”
than the documentation supports is failing to recover full re- evaluation and management visits to inpatients, emergency
imbursement to the practice. Documentation and coding department patients, and outpatients. NP visits for evaluation
need to be appropriate for the specific visit. and management can be billed under a physician employer’s
Incident-to billing under Medicare is the most misunder- number if the physician provides any face-to-face service on
stood concept in billing. “Incident-to” services are defined as the same day. The rules on shared visits are complicated;
those which are “an integral, although incidental, part of the prior to billing in this fashion, the NP should be well in-
physician’s personal professional services in the course of di- formed on the appropriate regulations.
agnosis or treatment of an injury or illness.” The purpose of There are certain monetary advantages for physicians to
“incident to” billing is to allow a physician to bill for services bill all NP services under the physician’s provider number.
provided by an assistant or delegate in the office. For exam- In this manner, the practice will get 100% of the physician’s
ple, if a patient being treated by a physician for high blood fee schedule rather than the 85% rate if billing is done under
pressure comes in for a blood pressure check, the physician the NP’s provider number. However, “incident to” billing
is able to have a nurse check the blood pressure, and cannot be used at all times, such as when the physician is not
the physician or practice can bill Medicare for CPT 99211 present in the practice (e.g., out to lunch, visiting hospitalized
(a level 1 visit). To accomplish this, the physician must be in patients, on vacation, etc.). During these times, visits to pa-
the office suite at the time of the patient visit, the physician tients covered by Medicare and conducted by a NP must be
must have documented the plan of care, the physician must billed under the NP’s name.
employ the nurse (or they both must be employed by the It is important for NPs to be familiar with when their
same entity), and the physician must remain involved in the services can be billed either under the physician’s provider
care of the patient. NPs, like physicians, are able to bill the number or the NP provider number. A practice can bill some
services of an assistant “incident to,” if the rules on incident NP services under a physician’s number when “incident-to”
to billing are followed. or “shared visit” rules are followed. Other services can be
Some physicians bill all NP services “incident to” the billed under the nurse practitioner’s number, such as when
physician’s service. This is legal, if Medicare’s rules or the the physician is out of the office, the patient is a new patient,
commercial payer’s rules are followed. Medicare’s rules for a or the patient has a new problem. To optimize reimburse-
physician billing “incident to” are: ment, NPs must understand the rules on “incident to” and
• Services of the NP must be rendered under a physician’s “shared” billing. The NP should preferably bill under the
“direct personal supervision.” physician’s name when the criteria for incident to or shared
• The NP must be an employee or independent contractor billing are met and under the NP’s name when the criteria
of a physician or physician group. are not met.
• Services must be furnished “during a course of treatment Medicaid prefers clinicians to bill under their own names.
where a physician performs an initial service and subse- However, each commercial payer (e.g., Blue Cross/Blue
quent services of a frequency which reflect the physician’s Shield and Cigna) develops its own rules and policies, with
active participation in and management of a course of some following Medicare’s incident to rules and some that
treatment.” do not insist on following those rules.
Medicare administrators have interpreted this last rule as
meaning: D I S C U SSI O N S O U R C E S
• The physician must conduct the initial visit and any visit American Medical Association. Current Procedural Terminology
in which there is a new episode of illness or a change in 2014 Professional Edition. Chicago: American Medical Associa-
the plan of care. Note that NPs can evaluate and manage tion, 2013.
new episodes of illness, but in those cases, the service Center for Medicare and Medicaid Services. Documentation Guide-
lines for Evaluation/Management Services. Available at: www.
must be billed under the NP’s name.
cms.gov/Outreach-and-Education/Medicare-Learning-Network-
• The physician must be in the suite of offices, though not MLN/MLNProducts/downloads/eval_mgmt_serv_guide-
in the same room, when the NP performs the service. ICN006764.pdf.
• The physician must remain involved in the care of the Buppert C. The Nurse Practitioner’s Business Practice and Legal
patient. Guide. Sudbury, MA: Jones & Bartlett Learning, 2012. Available
“Incident to” billing can only be used for services pro- at: www.jblearning.com.
vided during office visits, with two exceptions. It is permis- Buppert C. Billing NP services in specialist’s offices, hospitals, nursing
sible to bill “incident to” for a home visit, but both the facilities, homes and hospice. Law Office of Carolyn Buppert,
physician and NP must be present in the home. It is 2010. Available at: www.buppert.com.
4074_Ch19_485-496 20/11/14 2:35 PM Page 494
Buppert C, Productivity incentive plan for nurse practitioners: How 59. Written authorization by the individual is not needed
and why. Law Office of Carolyn Buppert, 2006. Available at: prior to disclosure of protected health information in
www.buppert.com. all of the following circumstances except:
Buppert C. Safe, Smart Billing and Coding: Evaluation and manage- A. cases of child abuse or neglect.
ment: An educational program on CD. Law Office of Carolyn
B. domestic violence incidents.
Buppert, 2012. Available at: www.buppert.com.
C. when a covered entity believes it is necessary to
prevent a serious and imminent threat to the
public.
Privacy Issues D. a request of information from a family member.
51. HIPAA stands for: 60. The principle of “minimum necessary” disclosure
A. Health Information Planning and Accessibility relates to:
Amendment. A. covered entities must provide the requested
B. Health Information Protection and Accountability Act. protected health information in as short a time
C. Health Insurance Portability and Accountability Act. as possible.
D. Healthcare Initiative for Patient Access B. covered entities can only charge a nominal fee for
Amendment. providing requested protected health information.
52. A major purpose of the Privacy Rule is to: C. covered entities must make reasonable efforts to use,
A. define and limit the circumstances in which an disclose, and request only the minimum amount of
individual’s protected health information can be protected health information needed to accomplish
used or disclosed by covered entities. the purpose of the request.
B. set standards for the distribution and selling of D. covered entities must make reasonable efforts to
health information to third parties. provide electronic records, including medical im-
C. define accountability by healthcare providers that ages, of protected health information in as small a
can be used in courts when there is suspected file as possible.
breach of information. 61. The penalty for the sale of individually identifiable
D. protect individuals’ health information when health information for personal gain is:
access to electronic medical records is illegally A. $100 fine and up to 1 year probation.
obtained. B. $5000 fine and up to 60 days imprisonment.
53. to 56. A covered entity as defined by the Privacy Rule C. $25,000 fine and up to 1 year imprisonment.
includes (yes or no): D. $250,000 fine and up to 10 years imprisonment.
53. Hospitals.
54. Private healthcare insurance companies. Answers
55. Nurse practitioners. 51. C. 55. Yes 59. D.
52. A. 56. Yes 60. C.
56. Medical assistants
53. Yes 57. D. 61. D.
57. Examples of “individually identifiable health 54. Yes 58. B.
information” can include all of the following
except:
In 1996, the U.S. Department of Health and Human Services
A. an individual’s past history of schizophrenia.
(HHS) established for the first time a set of national standards
B. the type of prescription written for an
for the protection of certain health information (“Privacy
individual.
Rule”) that implemented the requirement of the Health
C. a patient’s diagnosis of prostate cancer.
Insurance Portability and Accountability Act of 1996
D. the percentage of patients with type 2 diabetes
(HIPAA). A major goal of the Privacy Rule is to protect an
at a clinic.
individual’s health information but still allow the flow of
58. When specific identifiers have been removed from health information needed to provide and promote high
protected health information so that it no longer can quality healthcare. The Privacy Rule addresses the use of
be used to identify an individual, the information is “protected health information” by “covered entities” as well
said to be: as sets standards for individuals’ privacy rights to understand
A. cleansed. and control how their health information is used. A major
B. de-identified. purpose of the Privacy Rule is to define and limit the circum-
C. deprivatized. stances in which an individual’s protected health information
D. HIPAA-certified. may be used or disclosed by covered entities.
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A covered entity encompasses every healthcare provider • limited data set for the purpose of research, public health,
who electronically transmits health information in connection or healthcare operations
with certain transactions. These transactions can include Covered entities may use and disclose protected health
claims, benefit eligibility inquiries, referral authorization information without individual authorization as required by
requests, or other transactions identified by HHS under law in certain situations. This includes disclosure of infor-
HIPAA. Healthcare providers include any other person or mation to public health authorities authorized by law to col-
organization that furnishes, bills, or is paid for healthcare. lect or receive such information for preventing or controlling
These can include “providers of services” (e.g., institutional disease, injury, or disability and to public health or other
providers such as hospitals) or “providers of medical or health government authorities authorized to receive reports of child
services” (e.g., noninstitutional providers such as physicians, abuse or neglect. Additionally, covered entities may disclose
dentists, nurse practitioners, or others) as defined by protected health information to appropriate government
Medicare. authorities regarding victims of abuse, neglect, or domestic
The Privacy Rule protects information held or transmitted violence. Disclosure is also permitted when a covered entity
by a covered entity or its business associates in any form or believes it is necessary to prevent or lessen a serious and
media, such as electronic, paper, or oral. “Individually iden- imminent threat to a person or the public, when the disclosure
tifiable health information” protected by the Privacy Rule is made to someone they believe can prevent or lessen the
consists of information that identifies the individual or for threat. Covered entities can also disclose to law enforcement
which there is a reasonable basis to believe the information if the information is needed to identify or apprehend an
can be used to identify the individual, including: escapee or violent criminal.
• the individual’s past, present, or future physical or mental When disclosing information, the covered entity must
health or condition make reasonable efforts to use, disclose, and request only
• the provision of healthcare to the individual the minimum amount of protected health information
• the past, present, or future payment for the provision of needed to accomplish the intended purpose of the request.
healthcare to the individual This central aspect of the Privacy Rule is called the principle
There are no restrictions on the use of health information of “minimum necessary” use and disclosure.
that has been de-identified. De-identified health information Failure to comply with Privacy Rule requirements by a
does not identify an individual nor can it provide a reasonable covered entity can result in a fine of $100 per failure. A person
basis to identify an individual. Information can be de-identified who knowingly obtains and discloses individually identifiable
by either 1) having a formal determination made by a qualified health information can face a fine of $50,000 and up to 1 year
statistician, or 2) removing specified identifiers of the individ- of imprisonment. The penalty increases to $100,000 and up
ual as well as any relatives, household members, and employ- to 5 years of imprisonment if the wrongful conduct involves
ers, and is adequate only if the covered entity has no actual false pretenses. If the wrongful conduct involves the sale,
knowledge that the remaining information could be used to transfer, or use of individually identifiable health information
identify the individual. for commercial advantage, personal gain, or malicious harm,
A covered entity may not use or disclose protected health the penalty increases to $250,000 and up to 10 years of
information except either 1) as the Privacy Rule permits or imprisonment.
requires, or 2) as the individual who is subject of the infor-
mation authorizes in writing. A covered entity is allowed to D I S C U SSI O N S O U R C E
disclose protected health information without the individ- U.S. Department of Health and Human Services (HHS). Summary
ual’s authorization under certain circumstances, including: of the HIPAA Privacy Rule. Available at: www.hhs.gov/ocr/
• to the individual privacy/hipaa/understanding/summary/privacysummary.pdf.
• treatment, payment, and healthcare operations
A CK N O W L E D G M E N T
• opportunity to agree or object
• incident to an otherwise permitted use and disclosure The contributions of Carolyn Buppert, JD, NP to this chapter are
gratefully acknowledged.
• public interest and benefit activities
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Understanding Test
Design and Theory APPENDIX
Certification tests can be intimidating to nearly all people tak- as an adaptive expert: Based on the strong conceptual foun-
ing them because they take place outside of the clinical or dation, how do I apply what I know on this new context?
classroom setting and usually differ greatly from the assess-
ments that a student encountered in their academic program. Unlocking the Question
As a result, preparing for and taking these standardized tests
will usually require a shift in approach and preparation for The much maligned multiple-choice question is the bane of
the exam that is different from the one that saw you through many a test taker. In recent years, more and more educators
your graduate program. are moving away from the traditional multiple-choice test in
Consider that standardized tests differ from teacher favor of questions that encourage students to interact with
generated tests in that they tend to be global in focus, rather the test material in a more dynamic way. Nevertheless, the
than limited to a particular course, and rely heavily on the multiple-choice question is the standard instrument of at
ability to form associations, rather than recall specific least part of most high stakes tests.
details. Moreover, more than 50% of the questions on stan- The multiple-choice question is more easily tackled if you
dardized tests will ask you to apply your knowledge in a understand how it is designed, what it is attempting to meas-
manner of context fundamentally different from the one in ure, as well as effective strategies for decoding and answering
which you studied. the question. Make frequent practice testing part of your
Despite the major differences between assessment in the certification exam review.
context of a graduate program and standardized tests, Multiple-choice questions are made up of multiple parts:
roughly four of every five test takers who engage in focused, a stem (scenario, context), interrogatory (essential question,
purposeful study pass the exam on their first attempt. Part of action), and answer choices. Multiple-choice tests do not lend
effective test preparation involves “demystifying” test design, themselves to plentiful extraneous detail. Stem scenarios or
learning how to “unlock” questions, engaging in preparation context are there to support, not confuse, you in your analy-
that is most effective for your individual learning style, and sis. Typical answer choices consist of one best answer, one
knowing what to expect on exam day. (obviously) wrong answer, and two partially correct answers.
Expect that your certification exam will emphasize ques- Note: Partially correct answers can cause you to second-guess
tions that stress high order thinking skills such as analysis, yourself. Learn to differentiate between partially correct (the
synthesis, and evaluation of concepts and relationships. “sometimes” or “yes . . . but”) and the most common, best
Expect few questions that focus on facts, details, and answer. On high level tests, the difference between the best
particulars. The testing body is expecting you to think as a answer and the distractor answers will not always be clear;
competent entry-level nurse practitioner and employ adap- you will be asked to weigh options, interpret data, and arrive
tive expertise as you approach your test. NP certification at the correct action within the context or scenario of the test
candidates who are expert adaptive experts use conceptual question.
knowledge, including pathophysiology, pharmacology, and There could be many times when you feel that an answer
principles of assessment and diagnosis, as the basis for has more than one good choice. In these cases, take another
thinking but are open to flexibility of thought in relation- look at the question and then choose the response most
ship to a new context. On the certification exam, this is an specific to the given situation. Sometimes questions that
important mindset to have, as many questions will present relate to presentation of disease have more than one applica-
you with a brief context, unlike the one you may experience ble answer. The response with the most common presenta-
in clinical practice. Moreover, on test day, you do not have tion is likely to be correct. For example, an adult with
the ability to ask additional questions that might help to bacterial meningitis can present with nuchal rigidity and pa-
bring the “answer” into focus. Therefore, you need to think pilledema. Because nuchal rigidity is seen in most adults with
497
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this diagnosis, and papilledema is found far less often, nuchal information about a given condition but might not be the
rigidity is a better choice. Childhood development questions correct response for that particular question.
often have more than one correct response. A 4-month-old Remaining mindful of a conceptual framework that works
is expected to roll stomach to back and smile. Smiling is a for you can aid question comprehension and accuracy in
developmental milestone achieved by age 2 months, whereas your answering. If you are mathematically or visually
rolling is typically not seen until an infant is 4 months old. minded, a good strategy might be to think of the question as
Rolling stomach to back is the best response. Remember: Test a math problem or scientific equation with (patient) + (pre-
questions are designed to have one best, although perhaps sentation) + (context) = (best action). Consolidating and sto-
not perfect, answer. rytelling work for people who need to “talk through” answers
Although there are some test items that assess factual and thinking to find the best result. Turn the question into a
knowledge, such as identifying an anatomical landmark, the story and predict the ending before you look at the possible
majority of the test questions are seeking to measure higher answers. When in doubt, process of elimination can be a use-
order thinking and reasoning skills. These items are testing ful exercise. By eliminating wrong answers, you can narrow
your clinical judgment and expertise. Most items test your down your choices by re-reading the question with remaining
ability to assess or develop a plan of intervention for a clin- possibilities in mind.
ical situation. You should expect to apply clinical decision- With the strategies we have covered here, let’s look at the
making skills to the test question. Make sure you think following test item: You see 18-year-old Sam, who was seen
through each question. In particular, bear in mind how the approximately 36 hours ago at a local walk-in center for treat-
pathophysiology of the condition affects the presentation ment of ear pain. Diagnosed with (L) acute otitis media,
and treatment. amoxicillin was prescribed. Today, Sam states that he has
In clinical practice, you would likely gather more infor- taken five amoxicillin doses since the medication was pre-
mation than is given in a scenario in one of the test ques- scribed but continues to have discomfort in the affected ear.
tions. During the certification examination, you have to Left tympanic membrane is red and immobile.
decide on the best response given the information in front This is an action-oriented question, directing you to con-
of you by applying sound clinical judgment. Remember: sider Sam’s care and chief complaint. Based on the scenario
Multiple choice tests do not lend themselves to plentiful presented, you can assume:
extraneous detail. Decide whether extra information found • Because no chronic health problems are mentioned, im-
in a particularly long answer is pertinent to the question plied is that Sam is a young adult who is typically in good
and not simply a distractor. health.
When keeping in mind big information about presenting • Acute otitis media (AOM) is a common episodic illness usu-
issues, pharmacology, and best practices, it can be easy to lose ally caused by S. pneumoniae, H. influenzae, M. catarrhalis,
sight of important little words—words such as but, however, or respiratory virus.
despite, except, and if. These are common cuing words that • A first-line antimicrobial for AOM treatment is amoxi-
tell you that things may not always be as simple as they ap- cillin. When given in a sufficient dose, this antibiotic is ef-
pear. These words can indicate a shift, a possible contradic- fective against S. pneumoniae and both H. influenzae and
tion or contraindication, and a conditional situation or M. catarrhalis that do not produce beta-lactamase. Nearly
scenario. Pay attention to these words. A careful test taker all M. catarrhalis and about 30% of H. influenzae isolates
can use these words to construct a strategy for answering produce beta-lactamase, rendering amoxicillin ineffective.
the question. For example, in a question that reads “All of the Clavulanate is a beta-lactamase inhibitor and, when given
following are symptoms of ‘X’ except,” you can treat this as a in conjunction with amoxicillin, is an effective treatment
mini true/false question. You will be given three or four option when AOM fails to respond to amoxicillin alone.
“true” choices and one “false” choice. That false choice is your • As inflammation and purulent exudate forms in the mid-
answer. On a related note, be wary of options that include dle ear, a small space rich with pain receptors, otalgia is
extreme words, such as “always,” “never,” “all,” “best,” “worst,” an expected finding in AOM. This usually resolves after
and “none.” Seldom is anything absolute in healthcare. 2 to 3 days of antimicrobial therapy.
Sometimes identifying the verb in the question can help • Tympanic membrane immobility is a cardinal sign of
you determine the purpose of the question. In addition, look AOM that, despite antimicrobial therapy, does not re-
at the information presented and then ask yourself, “Is this solve for many weeks. A patient report of otalgia is also
question a test of the ability to gather subjective or objective needed to make the AOM diagnosis.
information? Is this question a test of the ability to develop The following answer choices are given:
a working diagnosis or to plan a course of intervention?” A. Advise Sam to discontinue the current antimicrobial
This thinking helps focus your thought process as you and start a course of amoxicillin/clavulanate.
choose the answer. Read each question and all responses B. Perform tympanocentesis and send a sample of the
thoroughly and carefully so that you mark your option exudate for culture and sensitivity.
choice only after you are sure you understand the concept C. Have Sam return in 24 hours for re-evaluation.
being tested in the question. Answering a question quickly D. Recommend that Sam take ibuprofen for the next 2 to
might lead to choosing a response that contains correct 3 days.
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Which answer included the best course of action for Sam? Let’s again look at the choices and reveal the correct
Let’s review the answers to see which one is correct and why. answer.
A. Advise Sam to discontinue the current antimicrobial A. Intermittent airway inflammation with occasional
and start a course of amoxicillin with clavulanate. bronchospasm
• Choosing this response infers amoxicillin treatment • Because asthma is a chronic, not intermittent, in-
failure. AOM antimicrobial treatment failure is usu- flammatory airway disease, this option is incorrect.
ally defined, however, as persistent otalgia with fever B. A disease of bronchospasm leading to airway
after 72 hours of therapy. Sam has taken fewer than inflammation
2 days of therapy, an interval too short to assign con- • Because asthma is first a chronic inflammatory
tinued symptoms to ineffective antimicrobial therapy. airway disease that leads to airway hyperresponsive-
In addition, there is no report of Sam’s condition ness, this option is incorrect.
worsening in the short time since he was initially C. Chronic airway inflammation with superimposed
seen. Therefore, prescribing an antimicrobial with bronchospasm
a broader spectrum activity, such as amoxicillin/ • This option most closely matches the definition of
clavulanate, is not warranted at this time. asthma and is the best option.
B. Perform tympanocentesis and send a sample of the D. Relatively fixed airway obstruction
exudate for culture and sensitivity. • Because the airway obstruction in asthma is largely
• AOM antimicrobial therapy is based on choosing an reversible, this option is incorrect. This answer is
agent with activity against the most likely organisms, more descriptive of chronic obstructive pulmonary
bearing in mind the most common resistant disease.
pathogens. Tympanocentesis is indicated only with
treatment failure after 10 to 21 days of antimicrobial Review That Works for You
therapy with a second-line agent, with the goal of de-
tecting a significantly resistant organism; at that point, With test design in mind, it’s time to think about planning
culture and sensitivity of middle ear exudate would be an effective study strategy. As you learned in your graduate
appropriate. With fewer than 2 days of treatment, studies, there are many “right” ways to study. The most im-
tympanocentesis is not indicated. portant factors to your success, regardless of learning style,
C. Have Sam return in 24 hours for re-evaluation. depend on an organized and purposeful study plan. This issue
• If Sam’s condition worsens in the next day, re- of time needed for certification preparation is unique to each
evaluation is prudent. However, choosing this exam candidate. That said, one of the major pitfalls in study
option ignores Sam’s complaint of pain. is the failure to put aside the time to prepare. Map out the de-
D. Recommend that Sam take ibuprofen for the next 2 to mands on your time in the first months after completing your
3 days. NP program, including work hours, family, personal and pro-
• Choosing option D response infers that treating Sam’s fessional commitments, as well as time you have perhaps set
pain is the most appropriate intervention. This is the aside for some well-deserved down time. After doing this, set
best response and the correct answer. up a schedule of study time, allotting a greater amount of time
Now consider this question: Which of the following best to areas of knowledge deficit and less to areas in which you
describes asthma? No clinical scenario is presented; the only need to refresh your knowledge base. Make sure you
question simply asks for a definition of a pathological state. cover all areas listed as possible exam content. Plan your date
When considering the options, the test-taker must recall for certification only after a period of well-planned, system-
that asthma is a chronic inflammatory disease of the airways atic, certification-focused study.
involving an increase in bronchial hyperresponsiveness. Start with reviewing the information on the exam con-
This condition leads to a potentially reversible decrease in tent. Make a list of the areas in which you feel your knowl-
FEV1-to-FVC ratio. This type of answer lends itself well to edge base is secure and in which just reviewing material to
becoming a “true/false” question. As you read each answer, refresh your memory will likely suffice. Also, make a second
ask yourself whether a choice is true or false. You are look- list in which you identify areas of weaknesses and areas in
ing for the “true” answer. If answers seem partially true, or which you need to concentrate your review. If you have
true sometimes, select the one that is mostly true, most of taken an NP review course, you are likely aware that the con-
the time. tent of certain parts of the program were truly review,
Here are your answer choices: whereas other sections help to point out areas in which you
A. Intermittent airway inflammation with occasional bron- need to expand on your knowledge base. Knowing on what
chospasm you need to concentrate your study helps you decide how to
B. A disease of bronchospasm leading to airway allocate your study time.
inflammation As you study, please keep in mind that the NP certification
C. Chronic airway inflammation with superimposed examination tests your ability to know the following:
bronchospasm • Why a patient is at risk for a problem.
D. Relatively fixed airway obstruction • How a clinical problem has developed.
4074_App_497-504 20/11/14 10:24 AM Page 500
• What is the most likely clinical presentation of the of a given session should also assume responsibility for keep-
condition. ing the discussion on track, facilitating the efficient use of
• Why a given intervention is effective. time and resources.
• How that intervention works. In order to help avoid the group deteriorating into a chat
• What is the most likely clinical outcome. session, plan for a short period of socialization following
• Why this clinical problem is of significance to the overall high-yield study sessions. Here is an example of a session
healthcare system. planned by a highly successful study group with three mem-
A poor approach to preparing for the exam and practice bers, Sarah, Ben, and Helena. “The session will start promptly
is to memorize information so you know what to do but not at 7 p.m. and end at 9 p.m., with the objective of identifying
why you are doing it, in both the exam room and as part of the risk factors, clinical presentation, assessment, and inter-
the larger healthcare system. A better approach to preparing vention in community-acquired pneumonia in the adult.
for the exam and practice is to understand concepts and apply Sarah is the presenter and also group leader for the evening
knowledge so you know what to do and why you are doing and is responsible for keeping us on track. A social period
it. The Fitzgerald Health Education Associates, Inc. NP from 9 to 9:30 p.m. will follow. We will meet at Helena’s
Certification Examination Review and Advanced Practice apartment. Ben is responsible for refreshments.”
Update prepares you in the why, how, and what of NP prac- Whenever possible, try to create a study situation that
tice, as well as helping to prepare you for success on the will mimic the actual test. Set a timer and be mindful of pac-
NP boards. ing yourself. During the test, expect to answer about 60 to
As you work through practice questions, make a note next 70 or more multiple-choice questions per hour. This means
to each with words or symbols that indicate how certain you you will likely be spending less than a minute, on average,
are of your answer. For some, you will be “sure” or “confi- on each question. Some questions take only a few seconds,
dent” that an answer is correct; for others you may be whereas others require more time for thought. Check your-
“mostly” or “somewhat sure”; and for others, you may be of- self at 15- or 20-minute intervals to determine if you are
fering a best guess. After you score your pretest, examine how progressing at an acceptable rate, setting a number of ques-
your answers match up with your predicted performance. If tions that you should have answered by a certain time.
you marked yourself “confident” on an item you got wrong,
start by studying the question and answer choices carefully Managing Nerves During Review
to glean the possible reasons you might have selected the and on Test Day
wrong answer for that particular question. Ask yourself the
following: Did I understand the context properly? If so, did I Everyone who sits for one of the certification examinations is
misinterpret or misread the question? Was there unfamiliar anxious to some degree. This anxiety can be a helpful emotion,
content or vocabulary that led me to an incorrect conclusion? focusing the NP certification candidate on the task at hand:
What was it about the distractors that distracted me? If you studying and successfully sitting for this important examina-
correctly answered a question about which you were not tion, a tangible end product of the candidate’s graduate or
completely certain of the best answer, ask yourself what in- postgraduate education. When excessive, however, anxiety
formation in the context, action, or answers helped to lead can get in the way of success. Stress yields anxiety, anxiety
you in the right direction. Frequent pretesting will not only yields stress; one can be viewed as the product of the other.
help you to become more comfortable on test day, it can also The stress of preparing for an important examination triggers
help you to be more effective at unlocking a question. the sympathetic nervous system to Seyle’s three phases of
When studying for the NP boards, some people will work the general adaptation syndrome: alarm, resistance, and
best alone, whereas others benefit from collaborating with a exhaustion. In the alarm stage, perhaps triggered by contem-
study group. Study groups can be helpful and a terrific way to plating the preparation needed to achieve certification success,
share information and resources. Alternatively, study groups the hypothalamus activates the autonomic nervous system,
can yield a poor return on time invested if all members are triggering the pituitary and the body defenses, resulting in a
not similarly committed. Study groups can meet in person as heightened sense of awareness of surroundings, alertness, and
well as over technology, such as Skype or Google groups. Here focus. At this level of arousal, studying for and taking a test
are some guidelines for forming a successful study group. often yields great results. A well-prepared examination can-
All group members must treat attendance and participa- didate is highly focused on what needs to be done to be suc-
tion as they would any other professional commitment, such cessful on the examination. Distractions can be filtered
as work or school. Well in advance, set a schedule, place, and out; extraneous information can be discarded in favor of the
time to meet, as well as a topic for the meeting. Plan a start essentials. During the examination, anxiety and knowledge
and end time, with a clear objective for the session. Study intersect; information retrieval is facilitated, and examination
groups usually work best when a group member volunteers questions are fluidly processed. Difficult examination items
to research and present information on a subject on a prede- are usually put in perspective, with the test-taker recognizing
termined schedule. The presentation is typically followed that most items were answered with relative ease. The NP cer-
with a discussion of the issue and a review of sample exam tification candidate emerges from the test feeling challenged
questions and rationales for the correct response. The leader but confident.
4074_App_497-504 20/11/14 10:24 AM Page 501
Although a moderate amount of anxiety is natural, and In an ideal world, we could all control schedules and set
even useful, many candidates can find themselves struggling aside vast periods of calm, focused review. Life, however, is
with anxiety that is causing physical or emotional distress. complicated. Although developing a study schedule is impor-
The process of completing a rigorous course of graduate tant, rescheduling study time is likely a good idea when a
education and study can result in a protracted period of day has been particularly difficult. Trying to learn when
stress. Now, the formerly helpful stress leads to the second exhausted and stressed by other influences is often counter-
stage of the general adaptation syndrome, resistance, in productive. Certain scents can be helpful for putting the NP
which epinephrine is released to help counteract or escape candidate in the right frame of mind to study, particularly
from the stressor. At that time, the feeling of milder anxiety under less-than-ideal conditions. These include basil, cinna-
present in the first stage gives way to a sense of greater nerv- mon, lemon, and peppermint for mental alertness and
ousness, often accompanied by uncomfortable physical chamomile, lavender, and orange for relaxation.
sensations such as dry mouth, tachycardia, and tremor. Learning a relaxation technique to use before studying
Studying or test taking becomes difficult; information or test taking can help you start your review session with a
retrieval is inhibited. This stage is mentally and physically clear mind and shift focus from whatever events or stress
taxing and, if left unchecked, can lead to exhaustion, com- your day may have contained. You can also employ these
plicating the challenging task of successfully completing the same techniques on test day to help center yourself if you
certification examination. Although the reaction is most feel overwhelming anxiety begin to creep in. Start the session
severe at the time of the test, most people who have severe by reading or repeating a positive message about being suc-
test-taking anxiety have a similar, although milder, reaction cessful on the examination. Avoid excessive amounts of
with the deep study needed to prepare for a critical exami- caffeinated beverages prior to studying, which can add to
nation such as NP certification. anxious feelings. Eat a light but nourishing meal containing
The following scenario describes a person with a problem- complex carbohydrates, fruit or vegetables, and high-quality
atic case of studying-testing anxiety: protein to feed the body and mind. Avoid refined sugars and
excessive fat intake, which can sap energy and derail quality
The NP certification examination candidate is having a
study.
tough day, with a work shift that stretched for 3 unex-
The NP candidate’s anxiety started when pondering the
pected hours and an unusually long commute, all fol-
wide range of possible topics on the certification examina-
lowing a poor night’s sleep as a result of a noisy
tion. Starting the session studying a narrowly focused topic
neighborhood party. To counteract this, the candidate
with a specific outcome goal rather than simply studying
drank a few extra cups of strong coffee and drank an
might have averted this. Setting up a system of study can en-
“energy drink,” really nothing more than a can of
hance the success of a study session further. One method is
sugar and caffeine. She also skipped lunch and made a
the SQ4R system, in which one surveys the study information
quick trip to a fast food restaurant for some fries as a
to establish goals; formulates questions about the informa-
snack. Studying was part of today’s plan, however, so
tion; and then reads to answer these questions, followed by
she sits down to prepare for the examination with
reciting the responses to the original questions, and reviewing
great intentions of reviewing critical information. Sur-
to see if the original goals were met. Study and test-taking
rounded by great stacks of study material, the NP can-
anxiety can also be tamed with the help of a learning specialist
didate thinks about what might be on the examination
who can work with the NP candidate to develop the needed
and ponders the wide scope and knowledge base
skills. Learning specialists can usually be contacted through
needed to be successful. Now the candidate becomes
the academic support centers at universities.
aware of a dry mouth and tight feeling in the throat.
Determined, she sits down and decides to study about
antimicrobial therapy. The words on the page seem to Test Day
blur when the candidate tries to read about the spec-
You have devoted years of study and months of preparation
trum of activity of an antibiotic; then, having difficulty
to this day, and this very thought can be daunting. Approach-
keeping this information straight, she decides to skip
ing test day with an empowered mindset can help alleviate
that and focuses on memorizing a few antibiotic dose
fears and prepare you for what lies ahead. Let’s assume you
ranges, information that is unlikely to be on the
have devoted careful time to a purposeful and organized
boards. Even with repeated tries, the NP candidate
study regimen, and you are starting to think about the test
cannot keep this information at hand and now be-
day itself. Coaches often advise their athletes to avoid any-
comes even more anxious, feeling tension in the back
thing new on game day. You will be wise to heed this advice
of the neck and a rapidly beating heart. The candidate
as well. This is not the time to change your diet, caffeine in-
now tries a few practice examination questions but an-
take, medications, or sleep schedule. The test environment
swers three questions about the appropriate use of an-
will be different from what you are used to, so try to keep your
timicrobial therapy in acute otitis media incorrectly.
routines as close to “normal” for you as possible.
Now, even the thought of sitting for the examination
Visit the website of the certifying body to learn all that you
causes the NP candidate to freeze.
can about test center rules, what you are and are not allowed
4074_App_497-504 20/11/14 10:24 AM Page 502
to bring to the test site, and information about pacing and uncommon disease. The fundamental tools of NP practice
breaks. On test day, leave yourself plenty of time to arrive at include the ability to procure comprehensively yet succinctly
your test center, to park, get settled, and enter the test without information needed to develop accurate diagnoses. Gather-
feeling rushed. Be sure to have a government-issued photo ing the needed subjective and objective information in the
ID as well as copies of all confirmation numbers and e-mails care of a person with common acute, episodic, and chronic
from the test center or organization. Expect that video sur- health problems is the most important skill the NP can de-
veillance will be used in test centers to limit fraud and ensure velop. Develop the skill of taking a thorough yet concise
security. At many test centers, you will be asked to empty health history that is pertinent to the patient’s presenting
your pockets and place all personal items in a locker provided complaint or health problem. As you proceed through the
for your use. history, recall the rationale behind each question you ask
ANCC’s test provider, Prometric, offers “test drives” that and how a given response impacts the possible etiology of the
allow NP certification candidates to practice going through patient’s health problem. Know how to perform a thorough
the test day routine ahead of their exam day. More informa- yet succinct symptom analysis. This process is when the de-
tion about test drives can be found on the Prometric Web tective work of diagnosis starts. Use the physical examina-
site, accessible through the ANCC’s Web site. tion to confirm the findings of the health history.
The ANCC examinations consist of 200 questions or test • Remember that the physical examination is guided
items. Of these, 175 items count toward your score, with the by the health history, not the other way around. The
remaining 25 questions serving as sample items that might advanced practice NP role includes the responsibility
be used on future examinations but do not contribute to your of arriving at a diagnosis, developing a treatment
examination score. The AANP examinations consist of 150 test plan, and providing ongoing evaluation of response
items, with 15 items as sample questions that do not contribute to treatment.
to your final score. One purpose of adding these items is to • Learn to recognize the typical clinical presentation
evaluate the question’s validity and reliability before incor- for the 10 most common health problems that present
porating the item in the certification examination. These to your practice site, including chief complaint and
items are integrated throughout the examination, not listed physical examination findings, needed diagnostics,
in a separate section. Please check with your certifying body and intervention. Armed with this information, you can
for the most up-to-date information. focus your study on a thorough knowledge of the assess-
As part of your review, you should have some practice ment and treatment of these conditions. Continue to
pacing yourself as you answer the test questions. Remember, evaluate the patient’s response to therapy.
you will have about one minute per test item. Don’t get Ask your preceptor to save laboratory results, EKGs, and
bogged down on a question or questions part of the way other diagnostics for you to review at the next session. Do
through the examination. If you are stumped by a question, so with a clean eye, as if you were developing a plan of in-
move on, with a plan to return to this item at the end of the tervention or further diagnosis for the patient. This will help
test. Remind yourself that you have answered many questions hone your skills. If you prescribed an intervention but will
with relative ease. Finish all of those questions that you can not have the opportunity to see the patient at a follow-up
answer and then come back later to process the problematic visit, ask your preceptor for an update. Family, cultural,
questions. The computer-based tests have a mechanism to community, developmental, and environmental factors as
highlight questions you want to revisit. Expect that the topics well as lifestyle and health behaviors influence patient
you studied will be presented in random order. A question health and the interaction between the NP and the patient.
on diabetes mellitus follows one on hypertension and can be As an advanced practice nurse, the NP provides holistic,
preceded by a question on women’s health. wellness-oriented care on an ongoing or episodic basis.
Preparing for and taking the NP certification exam takes • Remember to address a patient’s primary, secondary,
focus, determination, and courage. You have devoted years and tertiary healthcare needs at every visit. Check for
of study and months of preparation to this endeavor. Ap- needed immunization, screening tests, and follow-up on
proaching test day with an empowered mindset can help al- previous health problems with every encounter. Think
leviate fears and prepare you for what lies ahead. Emphasize long-term. Envision working with patients during the years
context and adaptive expertise over memorization, become ahead and the health problems you may help a person
a master at “unlocking” test questions, and be honest with avoid by working together. The healthcare provided by the
yourself about your learning style and study habits as you NP is guided by health and wellness research. The NP is
prepare to set yourself up for the best outcome. Additionally, accountable for his or her ongoing learning and professional
consider these clinical practice and certification tips to help development and is a lifelong learner. The NP is also
you prepare. knowledgeable in accessing resources to guide evidence-
Clinical practice and certification tips: based care.
• Remember that common disease occurs commonly and • Ask preceptors and peers what references are most
that the uncommon presentation of a common disease is helpful for that particular practice. Armed with this in-
more common than the common presentation of an formation, develop your own reference library that you can
4074_App_497-504 20/11/14 10:24 AM Page 503
use with ease. Your investment of time and money to go Mastering Tests. http://web.mit.edu/uaap/learning/test/index.html.
gather these resources will pay off in your practice. Sefcik D. How to Study for Standardized Tests. Sudbury, MA: Jones
& Bartlett Publishers, 2012.
REFERENCES Taking Multiple Choice Exams. www.uwec.edu/geography/
Nugent P, Vitale B. Test Success: Test-Taking Techniques for Begin- ivogeler/multiple.htm.
ning Nursing Students, ed. 5. Philadelphia: FA Davis, 2008. Test-taking Strategies. https://casc.byu.edu/testtaking-strategies.
Bloom BS (ed). Developing Talent in Young People. New York:
Ballantine Books, 1985.
Hatano G, Inagaki K. Two Courses of Expertise. In: Stevenson H,
Azuma H, Hakuta K (eds). Child Development and Education in
Japan. New York: Freeman; 1986.
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4074_Index_505-530 20/11/14 11:32 AM Page 505
Index
Note: Page numbers followed by f refer to figures, page numbers followed by t refer to tables, and page numbers followed by b refer to boxes.
1,25-dihydroxyvitamin D [1,25(OH)2D], 245 ACTH. See Adrenocorticotropic hormone Advisory Committee on Immunization Practices
25-hydroxyvitamin D [25(OH)D], 244, 245 ACTH stimulation test, 289 (ACIP), 409f
50 over 50, 113t Actinic keratoses, 68 AEDs. See Antiepileptic drugs
Active immunization, 2 Affordable Care Act (ACA), 485
A1c, 266, 267t, 267t Activity theory, 374 AFP. See Alpha-fetoprotein
Abatacept, 218t Actonel (risedronate), 238 Age-related changes, 375–377, 379t
ABC. See Absolute band count Actos (pioglitazone), 270t Age-related maculopathy, 376t
ABCDE, 68 Acute appendicitis, 155–157 Ageism, 394
Abdomen x-ray, 185t Acute bacterial prostatitis, 196t, 198–199 Aggrenox (dipyridamole), 44, 45
Abdominal computed tomography (CT). See also Acute bacterial rhinosinusitis (ABRS), 97–101, Aging theories, 373–374
Computed tomography 432–433, 434t Alanine aminotransferase (ALT), 159t, 178, 322t,
diverticulosis, 162 Acute cholecystitis, 160 323
hemorrhoids, 157 Acute cholecystitis, 158 Albuterol (Proventil, Ventolin)
pancreatic cancer, 187 Acute coronary syndrome (ACS), 117–123 anaphylaxis, 318
pancreatitis, 187 Acute epididymitis, 195–197 asthma, 131, 135t, 446t
radiation dose, 185t Acute febrile illness, 452–456 COPD, 135t, 139t, 140t
Abdominal MRI, 185t Acute glomerulonephritis, 94, 295t, 296 Alcohol abuse, 319–323
Abdominal ultrasound, 185t Acute hepatitis B, 15 Aldactone (spironolactone), 126
Abducens nerve, 27 Acute IgE-mediated hypersensitivity reaction, 64t Aldara. See Imiquimod
ABRS. See Acute bacterial rhinosinusitis Acute interstitial nephritis, 295t Aldomet (methyldopa), 359
Absence seizure, 43t Acute otitis media (AOM), 80–81t, 90–92, Aldosterone, 289
Absolute band count (ABC), 157 428–432 Aldosterone antagonists, 110t
Absolute neutrophil count (ANC), 157 Acute pancreatitis, 187 Alendronate (Fosamax), 238
Absorica, 54t Acute pharyngitis, 81t, 92–95 Aleve, 35
Acamprosate (Campral), 323 Acute pyelonephritis, 298 Alkaline phosphatase (ALP), 159t, 322t
Acarbose (Precose), 271t Acute renal failure, 294, 295t Allegra (fexofenadine), 51, 64t
Accessory nerve, 28 Acute tubular necrosis, 295t Allergic conjunctivitis, 80t, 96, 97t
ACCF/AHA stages of heart failure, 125t Acyclovir (Zovirax) Allergic reaction to antibiotics, 87–89
Accolate. See Zafirlukast acute febrile illness, 456 Allergic rhinitis, 95–97, 98f, 98t
Accutane, 54t, 55 aseptic meningitis, 39 Alli, 280
ACD. See Anemia of chronic disease female genitourinary infection, 362t Allopurinol (Aloprim), 211
ACEIs. See Angiotensin converting enzyme herpes zoster, 62 Alogliptin (Nesina), 271t
inhibitors infectious mononucleosis, 102 Aloprim (allopurinol), 211
Acetaminophen male genitourinary infections, 192t ALP. See Alkaline phosphatase
acute bacterial rhinosinusitis, 101 AD. See Alzheimer’s-type dementia Alpha-adrenergic agonists, 321
carpal tunnel syndrome, 222 Adalimumab (Humira), 66, 183, 218t Alpha-beta blockers, 273
fibromyalgia, 242 Adapalene, 54t Alpha blockers, 190–191
headache, 35 Addison’s disease, 289–290 Alpha-fetoprotein (AFP), 469
Achilles tendonitis, 240 Adefovir, 177 Alpha-glucosidase inhibitors, 271t
ACIP. See Advisory Committee on Immunization Adjustable laparoscopic band, 281 Alpha thalassemia minor, 312t, 314
Practices Adrenal insufficiency, 289 Alprazolam (Xanax), 325t, 385t
Aclidium (Pressair), 136t, 141 Adrenocorticotropic hormone (ACTH) Alprostadil (Caverject), 205
Acne medications, 54t Addison’s disease, 289, 290 ALT. See Alanine aminotransferase
Acne neonatorum, 426 Cushing’s syndrome, 291 Altabax (retapamulin), 52
Acne vulgaris, 53–56 Advair, 140t Alvesco (ciclesonide), 136t
ACS. See Acute coronary syndrome Advance directives, 395 Alzheimer’s-type dementia (AD), 387, 392, 393t
505
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506 Index
Amantadine (Symmetrel), 8, 41 Angiotensin receptor blockers (ARBs) ASCVD. See Atherosclerotic cardiovascular
Amaryl (glimepiride), 269, 269t diabetes mellitus, 273 disease
Aminoglycosides, 314t elder patients, 110t Asmanex (mometasone), 131, 135t, 136t
Amiodarone, 126 heart failure, 126 Aspartate aminotransferase (AST), 159t, 178,
Amitiza (lubiprostone), 182 hypertension, 108, 109 322t, 323
Amitriptyline, 62, 385t Angle-closure glaucoma, 82, 376t Aspirin. See also Nonsteroidal anti drugs
Amlodipine, 248, 273 Angular cheilitis, 74 acute coronary syndrome, 121
Amnesteem, 54t Angular stomatitis, 74 acute febrile illness, 455
Amorolfine, 63 Animal-derived desiccated thyroid, 285 anaphylaxis, 317
Amoxicillin Anisocytosis, 311 drug’s half-life, 215, 217
ABRS, 433 Ankle anterior drawer test, 239 giant cell arteritis, 46
acute otitis media, 80t Ankle sprain, 236t, 239 gouty arthritis, 211
AOM, 431, 431t Annular, 48t headache, 35
CAP, 457t Anorexia nervosa (AN), 328 rheumatoid arthritis, 219
duodenal/gastric ulcer, 166t Antabuse (disulfiram), 323 stroke, 44
endocarditis, 116t Anterior epistaxis, 81–82 type 2 DM, 268t, 275
infectious mononucleosis, 103 Anterior uveitis, 82 AST. See Aspartate aminotransferase
Lyme disease, 75 Anthralin (Drithocreme), 65 Astelin, 98t
pregnancy, 476 Anti-CCP. See Antibody to cyclic citrullinated Asthma, 127–137
UTI, 436 peptide assessing asthma control, 134f
Amoxicillin-clavulanate Anti-HBs, 16, 177 children, 440–445, 446t
acute bacterial rhinosinusitis, 101t Anti-HCV, 177 classifying asthma severity, 133f
acute otitis media, 81t, 431t Antibiotic allergy, 87–89 clinical findings, 130t
CAP, 457t Antibody to cyclic citrullinated peptide pharmacologic therapy, 131, 132, 134, 134t,
diverticulitis, 163t (anti-CCP), 218 135–137t, 135t
pregnancy, 476 Anticipatory guidance counseling, 401–405 risk factors for death, 130t
Amphetamine use, 327 Antiepileptic drugs (AEDs) stepwise approach for management, 132f
Ampicillin contraception, 351 symptoms, 130t
endocarditis, 116t fibromyalgia, 242 Asymptomatic bacteriuria, 476
infectious mononucleosis, 103 headache, 36 Atarax (hydroxyzine), 61
Amylase, 187t obesity, 280 Atenolol, 36, 273
ANA. See Antinuclear antibody seizure disorders, 42 Atherosclerotic cardiovascular disease (ASCVD),
Anakinra, 218t Antihistamines, 51 288
Anal fissure, 153–154 acute IgE-mediated hypersensitivity Ativan (lorazepam), 325t
Anaphylaxis, 69, 70t, 316–318 reaction, 64t Atopic dermatitis, 59–61, 426
Anaprox, 35 allergic rhinitis, 96 Atopic diseases, 426
ANC. See Absolute neutrophil count Ménière’s disease, 87 Atorvastatin, 288
Anemia, 307–316 Antinuclear antibody (ANA), 218 Atrial septal defect, 114t, 233t, 451t
anemia of chronic disease (ACD), 309, 316 Antiphospholipid antibodies, 254 Atrophy, 48t
defined, 310 Antipyretics, 454–455 Atrovent. See Ipratropium
folate-deficiency, 308, 312t Antivert, 87 Aubagio (teriflunomide), 40
folic-acid deficiency, 314–315 Antral gastritis, 167t Auditory nerve, 27
hemogram, 310–311, 311t Anxiety, 339–344 Augmentin, 148
inflammatory bowel disease, 182 depression, 332 Autism, 401, 401t
iron-deficiency, 312t, 313 GAD, 341 Avanafil, 205
iron therapy, 313, 313t panic disorder, 341–342 Avandia (rosiglitazone), 270t
overview, 312t psychotropic medications, 325–326t Avelox, 101, 148
pernicious, 308, 312t, 314 PTSD, 343 Avian flu, 6, 415
RDW, 311, 311t AOM. See Acute otitis media Avodart (dutasteride), 191
reticulocyte percentage, 311, 311t Aortic regurgitation (AR), 113t, 232t Avonex, 40
reticulocytosis, 311, 315 Aortic sclerosis, 113t Azactam, 88
thalassemias, 314 Aortic stenosis (AS), 231, 233–234, 451t Azathioprine, 46, 219, 223
vitamin B12, 314t, 315 Apidra, 266t Azelaic acid, 54t, 77
Anemia of chronic disease (ACD), 309, 316 Apley grinding test, 220 Azelastine, 98t
Anginal episode, 119 Apokyn (apomorphine), 41 Azelex, 54t
Angioedema, 317 Apomorphine (Apokyn), 41 Azilect (rasagiline), 41
Angiography Appendicitis, 155–157 Azithromycin
acute coronary syndrome, 121 Apriso (mesalamine), 183 acne vulgaris, 54t
disorders of coagulation, 256 Arava (leflunomide), 219 C. trachomatis infection, 364
peripheral vascular disease, 257–258 ARBs. See Angiotensin receptor blockers CAP, 457t
Angiotensin converting enzyme inhibitors Ardeparin (Normiflo), 253 community-acquired pneumonia, 148
(ACEIs) Arformoterol (Brovana), 141 endocarditis, 116t
ACS, 122 Aricept (donepezil), 392, 393t exudative pharyngitis, 81t
diabetes mellitus, 273 Aristocort, 50t female genitourinary infection, 362t
elder patients, 110t Armour thyroid, 285 male genitourinary infections, 192t, 193t
heart failure, 126 Arteriovenous (AV) malformation syndrome, syphilis, 368t
hypertension, 108, 109 426 AZT (zidovudine), 312t
iron therapy, 313t AS. See Aortic stenosis Aztreonam (Azactam), 88
Raynaud phenomenon, 248 Ascorbic acid, 314, 314t Azulfidine (sulfasalazine), 183
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508 Index
CCBs. See Calcium channel blockers Chest x-ray, 185t duodenal/gastric ulcer, 166t
Cefadroxil (Duricef), 89 Chickenpox, 18–19, 61, 419 endocarditis, 116t
Cefazolin, 116t Childbearing, 463–483. See also Pregnancy exudative pharyngitis, 81t
Cefdinir, 80t, 81t, 431t, 433 Children. See Pediatrics heart failure, 126
Cefepime, 80t Chlamydial infection, 360, 362, 364 pertussis, 461
Cefixime, 196t, 433, 476 Chlamydophila pneumoniae, 147, 148, 149t Claritin (loratadine), 51, 64t, 96
Cefotaxime, 39 Chlor-Trimeton. See Chlorpheniramine Clindamycin
Cefpodoxime Chlorambucil, 223 ABRS, 433
ABRS, 433 Chlordiazepoxide (Librium), 321 acne vulgaris, 54t
allergy risk, 89 Chlorpheniramine (Chlor-Trimeton) AOM, 431t
AOM, 80t, 431t acute IgE-mediated hypersensitivity reaction, endocarditis, 116t
exudative pharyngitis, 81t 64t exudative pharyngitis, 81t
pregnancy, 476 allergic rhinitis, 98t female genitourinary infections, 363t
Cefprozil, 80t, 89 benign prostate hyperplasia, 190 Staphylococcus aureus infection, 73
Ceftazidime, 80t, 89 skin disorders, 51 Clinical Dementia Rating (CDR), 387
Ceftin, 75, 89 Cholecystectomy, 160 Clobetasol propionate, 50t
Ceftriaxone (Rocephin) Cholecystitis, 158 Clonazepam (Klonopin)
acute febrile illness, 456 Cholelithiasis, 158 anxiety, 326t, 342
antibody allergy, 89 Cholesterol levels (children), 406 seizure disorders, 42
AOM, 431t Chronic bacterial prostatitis, 196t, 198–199 Clonidine (Catapres)
bacterial prostatitis, 199 Chronic kidney disease (CKD), 295 alcohol abuse, 321
endocarditis, 116t Chronic lymphocytic thyroiditis, 284–285 menopause, 359
epididymitis, 196, 196t Chronic obstructive pulmonary disease (COPD), opioid withdrawal, 327
female genitourinary infection, 362t 137–142 PTSD, 343
male genitourinary infections, 193t antimicrobial therapy for COPD exacerbations, Clopidogrel (Plavix)
meningitis, 38, 39 143t acute coronary syndrome, 121
older adults, 379 classification of severity of airflow limitation, peripheral vascular disease, 258
pelvic inflammatory disease, 366 139t TIA, 44
syphilis, 202t, 368t combined assessment of COPD, 141t type 2 DM, 268t
Cefuroxime, 89, 431t, 433 GOLD guidelines for pharmacologic therapy, Clostridium tetani, 19, 420
Cefuroxime axetil, 75 139–140t Cluster headache, 32t, 34
Celebrex, 165, 219 medications, 135–137t, 141 CNs. See Cranial nerves
Celecoxib, 165, 219 post-bronchodilator FEV1/FVC ratio, 139 Coalescent, 48t
Celexa. See Citalopram Chronic renal failure, 294 Coarctation of aorta, 452t
Celiac disease, 184–185 Chronic type B gastritis, 167t COC. See Combined oral contraceptives
Celiac sprue, 184 Cialis (tadalafil), 191, 205 Cocaine, 327
Cellcept (mycophenolate), 219 Ciclesonide (Alvesco), 136t Cockcroft-Gault equation, 379
Cellulitis, 71–72, 85 Ciclopirox, 63 Codeine, 385t
Centany, 52 Cilastatin (Primaxin), 88 Coenzyme Q10 (CoQ10), 36
Cephalexin (Keflex), 89, 116t, 476 Cilostazol (Pletal), 258 Cognex (tacrine), 392
Cephalosporins, 89, 436 Cimetidine (Tagamet), 167 Colchicine
Certification exam, 497–503 Cimex lectularius, 75–76 gouty arthritis, 211
multiple-choice questions, 497–499 Cimzia, 183 interaction with vitamin B12, 314t
pacing, 502 Ciprofloxacin pseudogout, 212
studying, 499–500 diverticulosis, 162, 163t Collins’ sign, 158
test anxiety, 500–501 epididymitis, 196, 196t Colonic diverticulosis, 161–163
test day, 501–502 female genitourinary infection, 362t Colony-forming unit (CFU), 298
“test drives,” 502 iron therapy, 313t Colorectal cancer, 160–161
tips/pointers, 502–503 irritable bowel disease, 183 Combined oral contraceptives (COC), 349–351
true/false questions, 499 male genitourinary infections, 192t Combivent Respimat, 139t
Certolizumab, 218t meningitis, 38 Common pathway, 250
Cerumen impaction, 376t otitis externa, 80t, 90 Community-acquired MRSA (CA-MRSA), 72, 73
Cervarix, 414f UTI, 436 Community-acquired pneumonia (CAP),
Cervical cancer screening, 368–369, 370–372t Citalopram (Celexa) 145–150
Cervical radiculopathy, 226 cytochrome P450 isoenzyme inhibition, 337b children, 456–458
Cervical vertebral sprain, 226 depression, 334t IDSA/ATS classification and recommended
Cervicitis, 362t falls, 385t treatment, 150t
Cetirizine (Zyrtec) inflammatory bowel disease, 182t medications, 148, 149
allergic rhinitis, 98t panic disorder, 342 pathogens, 147, 148, 149t
atopic dermatitis, 61 Citracal, 182 risk factors for death, 148
impetigo, 51 CK-MB. See Creatine phosphokinase (CK) Compazine (prochlorperazine), 35
scabies, 64t isoenzyme MB Complete abortion, 483
CFU. See Colony-forming unit CKD. See Chronic kidney disease Complex partial seizure, 43t
Chalazion, 85 Claravis, 54t Compression duplex ultrasound, 251
Chancroid, 191, 192t, 362t Clarinex (desloratadine), 51 Computed tomography (CT). See also Abdominal
Chantix (varenicline), 24 Clarithromycin computed tomography
CHD. See Congenital heart disease CAP, 457t acute coronary syndrome, 119
Cheilosis, 74 community-acquired pneumonia, 148, 149 Addison’s disease, 290
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510 Index
Dilantin. See Phenytoin DRSP. See Drug-resistant S. pneumoniae End-stage renal disease, 294
Diltiazem (Cardizem) Drug holiday, 338 Endocarditis, 115–116, 116t
acute coronary syndrome, 121 Drug-resistant S. pneumoniae (DRSP), 148 Endocrine disorders, 261–291
diabetes mellitus, 273 DTaP vaccine. See Diphtheria and tetanus toxoids Addison’s disease, 289–290
heart failure, 126 and acellular pertussis (DTaP) vaccine Cushing’s syndrome, 290–291
hypertension, 109 DTIs. See Direct thrombin inhibitors DM. See Diabetes mellitus
Dipeptidyl peptidase-4 (DPP-4) inhibitor, Duloxetine (Cymbalta) heatstroke, 276–277
271t depression, 335t hyperlipidemia, 286–288
Diphenhydramine (Benadryl) fibromyalgia, 242 obesity, 277–281
allergic rhinitis, 96, 98t older adults, 343 thyroid disorders, 281–286
benign prostate hyperplasia, 190 osteoarthritis, 214 Endophthalmitis, 83
scabies, 64t pregnancy, 475 Engerix-B0, 12f
skin disorders, 51 sexual dysfunction, 338 Enoxaparin (Lovenox), 253
Diphtheria, 19 Duodenal ulcer, 166t, 168 Entacapone (Comtan), 41
Diphtheria and tetanus, 420–421 Duofilm, 71t Entecavir, 177
Diphtheria and tetanus toxoids and acellular DuoPlant, 71t Enteric-coated iron, 314
pertussis (DTaP) vaccine, 412f, 421 Durable power of attorney, 395 Environmental iodine deficiency, 285
Dipyridamole (Aggrenox), 44, 45 Durable power of attorney for healthcare, 395 Epicondylitis, 208–209
Direct thrombin inhibitors (DTIs), 253 Duricef (cefadroxil), 89 Epididymitis, 195–197
Disease-modifying anti-rheumatic drugs Dust mites, 96 Epididymo-orchitis, 196t
(DMARDs), 218t, 219 Dutasteride (Avodart), 191 Epinephrine, 64t, 318, 341
Disk herniation, 225, 226 Duty of care, 489 Epoetin alfa, 316
Disorders of coagulation, 249–256 DVT, 249–256. See also Disorders of coagulation Epstein-Barr virus, 102
clinical presentation, 252t Dyslipidemia, 405–407 Erectile dysfunction (ED), 204–205
Homans sign, 249, 251, 252t Dysthymia, 333 Ergotamines, 35
INR, 250, 253, 254 Erikson, Erik, 374
LMWH, 253 Ear, nose, and throat problems, 79–103 Erosion, 48t
Virchow triad, 250, 251 acute bacterial rhinosinusitis (ABRS), Erosive gastritis, 167t
warfarin, 253t, 254t, 255t 97–101 Error theory, 374
Wells clinical prediction guide, 252t acute otitis media, 80–81t, 90–92 Erythema toxicum neonatorum, 426
Disulfiram (Antabuse), 323 acute pharyngitis, 81t, 92–95 Erythematotelangiectatic rosacea, 77
Ditropan (oxybutynin), 304, 386 allergic rhinitis, 95–97, 98f, 98t Erythrocyte sedimentation rate (ESR)
Diuretics. See Thiazide diuretics antibiotic allergy, 87–89 gouty arthritis, 211
Divalproex sodium, 36 infectious mononucleosis, 102–103 inflammatory bowel disease, 182
Diverticulosis/diverticulitis, 161–163 Ménière’s disease/syndrome, 85–86 osteoarthritis, 213
Dix-Hallpike test, 86 oral cancer, 87 rheumatoid arthritis, 218
DM. See Diabetes mellitus otitis externa, 80t, 89–90 Erythromycin
DMARDs. See Disease-modifying anti-rheumatic overview, 80–81t acne vulgaris, 54t
drugs Early childhood development, 400–401 C. trachomatis infection, 364
DMPA (Depo-Provera), 352 Eating disorders, 327–329 CAP, 457t
DNR. See Do not resuscitate order ECG. See Electrocardiogram community acquired pneumonia, 148
Do not resuscitate order (DNR), 395 Eclampsia, 478t female genitourinary infection, 362t
Dog bite, 57t Ecstasy (MDMA), 327 heart failure, 126
Domestic violence, 344–345, 479–480 ECT. See Electroconvulsive therapy irritable bowel syndrome, 182
Donepezil (Aricept), 392, 393t Ectopic pregnancy, 481–482, 481t, 482t male genitourinary infections, 192t
Dopamine, 341 Eczema, 426 pertussis, 461
Dopamine agonists, 41 ED. See Erectile dysfunction rosacea, 77
Down syndrome, 469 Edwards syndrome, 469 Erythropoietin, 294, 316
Doxycycline Effexor. See Venlafaxine Escitalopram (Lexapro)
acne vulgaris, 54t Egg allergy, 417t cytochrome P450 isoenzyme inhibition,
acute bacterial rhinosinusitis, 101t Eldepryl, 41 337b
bacterial prostatitis, 199 Elder maltreatment, 380–382 depression, 334t
C. trachomatis infection, 364 Elderly persons. See Older adults panic disorder, 342
CAP, 457t Electrocardiogram (ECG) Esomeprazole (Nexium), 167
community-acquired pneumonia, 148 ACS, 121 Esophageal cancer, 171
epididymitis, 196, 196t heart failure, 125 ESR. See Erythrocyte sedimentation rate
female genitourinary infection, 362t Electroconvulsive therapy (ECT), 393 Estradiol, 359
iron therapy, 313t Electromyography (EMG), 222 Estrogen deficiency, 236, 359
Lyme disease, 75 Elidel (pimecrolimus), 60 Estrogen receptors, 357
male genitourinary infections, 192t, 194t Elimite (permethrin), 64 Estrogen therapy, 358, 358t, 359t
rosacea, 77 Ella, 355 Etanercept (Enbrel), 66, 218t, 227
Staphylococcus aureus infection, 73 Elocon ointment, 50t Ethosuximide, 42
syphilis, 202t, 368t Emergency contraception, 353–355 Evista (raloxifene), 238
DPP-4 inhibitor. See Dipeptidyl peptidase-4 EMG. See Electromyography Excedrin Migraine, 35
(DPP-4) inhibitor Enablex (darifenacin), 304, 386 Excoriation, 48t
DRE. See Digital rectal examination Enalapril, 273 Exelon (rivastigmine), 392, 393t
Drithocreme (anthralin), 65 Enbrel (etanercept), 66 Exenatide (Byetta), 270t
Driving issues (old adults), 387–388 Encephalitis, 36–39 Extavia, 40
Drospirenone, 351 End-of-life decisions, 395 External hordeolum, 85
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Golimumab, 218t pneumococcal immunization, 10f, 11f, 12f, HIT. See Heparin-induced thrombocytopenia
Gonococcal cervicitis, 362t 13–14, 14t HIV. See Human immunodeficiency virus
Gonococcal urethritis, 193t, 362t poliovirus vaccination, 21 H1N1 (swine flu), 6, 415
Gonorrhea, 197–198, 364 preventing disease, 21–23 H5N1 (avian flu), 6, 415
Gout, 211 primary prevention measures, 1–2 Homans sign, 249, 251, 252t
Gouty arthritis, 210–212 recommended immunization schedule, 10–12f, Hordeolum, 84–85
Grade I sprain, 236t 409–414f Hormone therapy (HT), 358–359
Grade II sprain, 236t, 239 secondary prevention principles, 5t Hospital Insurance Program (Medicare Part A), 487
Grade III sprain, 236t, 239 smallpox vaccination, 16–17 Hot flashes, 358, 358t
Grade III systolic heart murmur, 112, 113t tetanus immunization, 10f, 19 HPV. See Human papillomavirus
Grand mal seizure, 43t tobacco use, 23–25 HPV2. See Bivalent HPV vaccine
Grave’s disease, 285 USPSTF recommended preventive services, HPV4. See Quadrivalent HPV vaccine
Griseofulvin, 63 3–4f HPV vaccination. See Human papillomavirus
Group A beta-hemolytic streptococcus, 93 VZV vaccination, 10f, 11f, 17–19 (HPV) vaccination
Group B streptococcus (GBS), 478 zoster vaccination, 10f, 11f, 18 H2RAs. See Histamine2-receptor antagonists
Gynazole-1, 363t Healthcare-associated MRSA (HC-MRSA), 72 HSV-2. See Herpes simplex virus 2
Heart failure (HF), 123–126 HT. See Hormone therapy
H. ducreyi, 191 Heart murmur, 110–116, 449–450, 450–452t HTN. See Hypertension
H. influenzae Heart problems. See Cardiac disorders Humalog, 266t
ABRS, 100t, 101, 433 Heart sounds, 117t Human bite, 58t
AOM, 91, 429t, 430 Heatstroke, 276–277 Human chorionic gonadotropin (hCG), 469
CAP, 147, 148, 149t Helicobacter pylori infection, 165, 166t Human herpesvirus 2 (HHV-2), 192t, 204
H. pylori infection, 165, 166t HELLP syndrome, 478, 478t Human immunodeficiency virus (HIV), 439t
H1 antihistamines, 318t Hemangioma, 426, 427t Human papillomavirus (HPV)
H2 antihistamines, 318t Hemic murmur, 450t cervical cancer, 369
Haemophilus ducreyi, 191 Hemoglobin, 310 genital warts, 193t, 367
Haemophilus influenzae. See H. influenzae Hemoglobin A1c, 266, 267t HPV disease, 203
Haemophilus influenzae type B (Hib) vaccination, Hemoglobin-to-hematocrit ratio, 310 Human papillomavirus (HPV) vaccination, 10f,
10f, 12f, 412–413f Hemogram, 310–311, 311t 11f, 414f
Half-life, 379 Hemorrhagic cystitis, 298 Human rhinovirus, 430
Halobetasol propionate, 50t Hemorrhoids, 154–155 Humira (adalimumab), 66, 183
Haloperidol, 385t HepA vaccine, 414f Humulin N, 266t
Hand-foot-and-mouth disease, 439t Heparin, 253 Humulin R, 266t
Hashimoto’s thyroiditis, 284–285 Heparin-induced thrombocytopenia (HIT), 253 Hydration status, 447, 447t, 448t
HAV. See Hepatitis A virus Hepatic enzyme elevations, 159t, 322t Hydrocodone, 35
Havrix, 12f, 20 Hepatitis. See Viral hepatitis Hydrocortisone, 50t, 135t, 290, 426
HBcAg. See Hepatitis B core antigen Hepatitis A infection, 20, 174, 175t, 176, 421–422 Hydrocortisone butyrate, 50t
HBIG. See Hepatitis B immune globulin Hepatitis A vaccination, 10f, 12f, 20–21, 414f, 422 Hydrocortisone valerate, 50t
HBOT. See Hyperbaric oxygen therapy Hepatitis A virus (HAV), 20–21, 174, 421 Hydroxyzine (Atarax), 61
HBsAb. See Hepatitis B surface antibody Hepatitis B core antigen (HBcAg), 15 Hyoscyamine, 182t
HBsAg. See Hepatitis B surface antigen Hepatitis B immune globulin (HBIG), 14, 16, 177, Hyperbaric oxygen therapy (HBOT), 259
HBV. See Hepatitis B virus 418 Hyperlipidemia, 286–288
HC-MRSA. See Healthcare-associated MRSA Hepatitis B infection, 15, 175t, 176–177, 417–419 Hypertension (HTN), 105–110
hCG. See Human chorionic gonadotropin Hepatitis B surface antibody (HBsAb), 14, 16 blood pressure measurement, 107–108, 108t
HCV. See Hepatitis C virus Hepatitis B surface antigen (HBsAg), 14, 16 children, 405–407
Headache, 28–36 Hepatitis B vaccination, 10f, 12f, 14–16, 412f, 418 lifestyle modification, 109t
helpful observations, 32b Hepatitis B virus (HBV), 15, 176, 418 pregnancy, 477–478
neuroimaging, 33t Hepatitis C infection, 175t, 177 sports participation, 230, 231t
primary/secondary, 31t Hepatitis C virus (HCV), 177 Hyperthyroidism, 283–284t
prophylactic therapy, 35–36 Hepatitis D infection, 176t, 177 Hypertrophic cardiomyopathy, 115, 233t, 234
red flags, 32t Hepatoiminodiacetic acid (HIDA) scan, 160 Hypoglossal nerve, 28
treatment, 34–36 HepB vaccine, 412f Hypogonadism, 449
triggers, 34t Herbal remedies, 343t Hypokalemia, 315, 328
types, 31–32t Herniated disk, 225, 226 Hypoperfusion, 455
Health promotion and disease prevention, 1–25 Herpes simplex virus 2 (HSV-2), 204, 364 Hyposmia, 376t
cancer screening, 23 Herpes zoster, 61–62 Hypotension, 126, 382–383
hepatitis A vaccination, 10f, 12f, 20–21, 414f HF. See Heart failure Hypothyroidism, 283–284t, 286
hepatitis B vaccination, 10f, 12f, 14–16, 412f, HHV-2. See Human herpesvirus 2
418 Hib vaccination. See Haemophilus influenzae Ibandronate (Boniva), 238
Hib vaccination, 10f, 12f type B (Hib) vaccination IBD. See Irritable bowel disease
HPV vaccination, 10f, 11f, 414f Hiberix, 412f IBS. See Irritable bowel syndrome
influenza immunization, 2–8, 10f, 11f, 413f, HIDA scan. See Hepatoiminodiacetic acid IBS-A, 178
416, 416t, 417t (HIDA) scan IBS-C, 178
live attenuated virus vaccines, 18t Histamine2-receptor antagonists (H2RAs) IBS-D, 178
meningococcal vaccination, 10f, 12f, 414f GERD, 170 IBS-M, 178
MMR vaccine, 8–9, 10f, 11f, 408, 414f iron therapy, 313t Ibuprofen
patient education and counseling, 22b older adults, 379 acute bacterial rhinosinusitis, 101
personal immunization contradictions, 15t peptic ulcer disease, 163, 167t drug’s half-life, 215, 217
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514 Index
Index 515
516 Index
Index 517
518 Index
Index 519
SSRI/SNRI-withdrawal syndrome, 338 T3, 284 TIBC. See Total iron-binding capacity
SSRIs. See Selective serotonin reuptake T4, 284 TIG. See Tetanus immunoglobulin
inhibitors Tacrine (Cognex), 392 Tigecycline, 162
St. John’s wort, 343, 343t Tacrolimus (Protopic), 60, 77 Tilade (nedocromil), 136t
ST-elevated myocardial infarction (STEMI), 119, Tadalafil (Cialis), 191, 205 Tindamax (Tinidazole), 193t, 363t
121, 122t Tagamet, 167 Tinel test, 222
Stage 1 Lyme disease, 75 Tamiflu (oseltamivir), 8, 457t Tinidazole (Tindamax), 193t, 363t
Stage 2 Lyme disease, 75 Tamsulosin (Flomax), 190 Tiotropium (Spiriva), 136t, 139t, 140t, 141
Stage 3 Lyme disease, 75 Tasmar (tolcapone), 41 Tissue factor (TF) pathway, 250
Stages of Change Model/Transtheoretical Model Tazarotene, 54t TIV. See Trivalent inactivated vaccine; Trivalent
(TTM), 22 TB. See Tuberculosis influenza vaccine
Standard of care, 489 TBG levels. See Thyroxine-binding globulin TMP-SMX. See Trimethoprim-sulfamethoxazole
Staphylococcus aureus, 72 (TBG) levels TNF-α, 66
Staphylococcus aureus infection, 72–73 TCAs. See Tricyclic antidepressants Tobacco dependence treatment, 24
Stelara (usetekinumab), 66 Td. See Tetanus-diphtheria (Td) vaccine Tobacco use, 23–25
STEMI. See ST-elevated myocardial infarction Tdap. See Tetanus, diphtheria, and acellular Tocilizumab, 218t
Still murmur, 233t, 450t pertussis (Tdap) vaccine Tofacitinib, 218t
STIs (sexually transmitted infections). See Female Tegretol. See Carbamazepine Tolcapone (Tasmar), 41
reproductive and genitourinary systems; Temazepam, 385t Tolterodine (Detrol), 304, 386
Male genitourinary system Temovate, 50t Tonic-clonic seizure, 43t
Strawberry hemangioma, 426 Temporal arteritis, 46 Tophi, 210
Streptococcal impetigo, 52 Tendonitis, 239–240 Topical corticosteroids, 50t. See also
Streptococcus pneumoniae. See S. pneumoniae Tennis elbow, 209, 209t Corticosteroids
Streptococcus pyogenes, 92, 93–95 Tenosynovitis, 240 Topicort, 50t
Streptokinase, 254 Tension-type headache, 31t, 34 Topiramate, 36, 42
Stress-adaptation theory, 374 Terbinafine (Lamisil), 63 Total iron-binding capacity (TIBC), 313
Stress incontinence, 303t Teriflunomide (Aubagio), 40 Total WBC (TWBC), 157
Struvite stones, 305 Teriparatide (Forteo), 238 Toviaz (fesoterodine fumarate), 304, 386
Sturge-Weber syndrome, 426 Tertiary prevention measures, 2 Toxic granulation, 455
Stye, 84–85 Tertiary syphilis, 194t, 202t, 368t Tradjenta (linagliptin), 271t
Subclinical hypothyroidism, 285 Test design and theory. See Certification exam Tramadol (Ultram), 214
Suboxone, 327 Testicular torsion, 200–201 Transient incontinence, 304t
Substance abuse, 319–327 Tetanus, 420 Transient ischemic attack (TIA), 43–45
alcohol abuse, 319–323 Tetanus-diphtheria (Td) vaccine, 11f, 19 Trazodone (Desyrel)
amphetamine use, 327 Tetanus, diphtheria, and acellular pertussis depression, 336t, 337t
cocaine, 327 (Tdap) vaccine, 11f, 19, 412f, 421 PTSD, 343
marijuana, 327 Tetanus immunization, 10f, 19 Trental (pentoxifylline), 258
opioid withdrawal, 326–327 Tetanus immunoglobulin (TIG), 19 Tretinoin, 54t, 71t, 77
psychotropic medications, 325–326t Tetanus infection, 19 Trexall, 219
Sudafed, 98t Tetracycline Triamcinolone (Nasacort), 101, 135t
Sulfacetamide products, 77 acne vulgaris, 54t Triamcinolone acetonide, 50t
Sulfamylon (mafenide acetate), 59 community-acquired pneumonia, 148 Triazolam, 385t
Sulfasalazine (Azulfidine), 183 duodenal/gastric ulcer, 166t Triazolopyridine, 336t
Sulfonylureas (SUs), 269, 269t, 271 iron therapy, 313t Trichloroacetic acid, 193t, 203
Sumatriptan (Imitrex), 34, 35 male genitourinary infections, 194t Trichomoniasis, 193t, 363t
Superficial thrombophlebitis, 251 rosacea, 77 Tricyclic antidepressants (TCAs)
Superior hemorrhoidal veins, 155 syphilis, 202t Alzheimer’s-type dementia (AD), 393t
Supplemental Medical Insurance Program TF pathway. See Tissue factor (TF) pathway depression, 336, 336t, 338
(Medicare Part B), 487 Thalassemia majors, 314 falls, 385t
Support hose, 248 Thalassemia minors, 314 older adults, 380
Suppurative conjunctivitis, 80t Thelarche, 449 panic disorder, 342
Swimmer’s ear (otitis externa), 80t, Theophylline, 137t, 140t, 444, 444f, 446t pregnancy, 475
89–90 Theory of the seasons of life, 374 Trigeminal nerve, 27
Swine bite, 58t Thiazide diuretics Triiodothyronine (T3), 284
Swine flu, 6, 415 elder patients, 110t Trimethoprim-sulfamethoxazole (TMP-SMX)
SWL (shock wave lithotripsy), 306 gouty arthritis, 211 diverticulosis, 162, 163t
Symbicort, 140t heart failure, 126 epididymitis, 196t
Symmetrel (amantadine), 8, 41 hypertension, 108 immediate/delayed reactions, 89
Synalar, 50t Thiazolidinedione (TZD), 270t older adults, 379
Synalar-HP, 50t Third-degree burns, 59 pertussis, 461
Syndrome X, 275 Threatened abortion, 482–483 Staphylococcus aureus infection, 73
Synthroid, 285, 313t Thrombophlebitis, 250 UTI, 298–300, 436
Syphilis, 194t, 201–203, 367–368, 368t Thrombosed external hemorrhoids, 155 Triptans, 35, 475
Systemic corticosteroids, 135t. See also Thyroid disorders, 281–286 Trisomy, 469
Corticosteroids Thyroid hormone, 283 Trivalent cell culture-based inactivated influenza
Systemic lupus erythematosus (SLE), 219 Thyroid stimulating hormone (TSH), 284 vaccine, 7t
Systolic cardiac murmur, 230 Thyroxine-binding globulin (TBG) levels, 284 Trivalent inactivated vaccine (TIV), 7t, 8
Systolic murmurs, 113t TIA, 43–45. See Transient ischemic attack Trivalent influenza vaccine (TIV), 416
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