The hormones involved in intermediary metabolism, exclusive of insulin, that can participate in the development of diabetic ketoacidosis (DKA) are epinephrine, glucagon, cortisol, and growth hormone (insulin counter-regulatory hormones). Describe how they participate in the development of DKA.
The APRN tells the patient that the tender points are no longer used to diagnose FM. She suggests that the patient takes the Widespread Pain Index (WPI) and the Symptom Severity Inventory (SSI). The patient asks the APRN what these tests are for. What is the APRN’s best answer?
Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his backyard about a week ago.
Past medical history non-contributory with exception of a severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bullseye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm the diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.
Question:
What is Lyme disease and what patient factors may have increased his risk of developing Lyme disease?
CASE STUDY
A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles’ fracture (distal radius with dorsal displacement of fragments) as well as radiographic evidence of osteoporosis. A closed reduction of the fracture was successful, and she was placed in a posterior splint with an ace bandage wrap and instructed to see an orthopedist for a follow-up.
Question:
What is osteoporosis and how does it develop?
CASE STUDY:
A 32-year-old Caucasian male presents to the office with complaints of back pain, stiffness, especially in the morning, interrupted sleep due to pain, and difficulty in leaning over to tie his shoes. The patient first noticed these symptoms about 6 months ago but attributed them to his weekend basketball team He said he is exhausted due to sleep interruption. He has taken acetaminophen with some relief but says the naproxen seems to be working better.
Married with 2 small children and works as a bank manager. Physical exam: Lungs clear but decreased chest excursion noted as well as decreased range of motion of hips and forward flexion, rotation, and lateral flexion restricted. Spine radiographs in the office revealed a slight kyphosis along with ankylosis at L5-S1. The APRN suspects the patient may have ankylosing spondylitis (AS). The APRN orders laboratory tests including an HLA-B27.
Question:
Why did the APRN order an HLA-B27 lab? How would that lab result assist in understanding what ankylosing spondylitis
CASE STUDY:
A 17-year-old male presents to the clinic with a chief complaint of pain in his right elbow. He says the pain is sharp, especially with pronation and supination. He noticed the pain several weeks ago after his tennis team went to a regional competition. When he rests, the pain seems to go away. The pain is alleviated when he takes Naprosyn. No history of trauma or infection in the elbow. Past medical and social history non He is a junior at the local high school and just started taking tennis lessons 2 months ago and his coach is working with him on his backhand serve. A focused physical exam revealed point tenderness over the lateral epicondylitis and Lateral epicondylitis which increases with pronation and supination. The APRN diagnoses him with lateral epicondylitis and orders a wrist splint to prevent wrist flexion.
Question:
Why did the APRN feel a wrist splint would be helpful? What patient characteristics lead to this diagnosis.
A 32-year-old white female presents to Urgent Care with complaints of blurry vision and “fuzzy thinking” which has been present for the last several weeks. She works as an executive for an insurance company and puts her symptoms down to the stress of preparing the quarterly report.
Today, she noticed that her symptoms were worse and were accompanied by some fine tremors in her hands. She has been having difficulty concentrating and has difficulty voiding. She remembers her eyes were bothering her a few months ago and she went to the optometrist who recommended reading glasses with a small prism to correct double vision. She admits to some weaknesses as well.
No other complaints of fevers, chills, upper respiratory tract infections, or urinary tract infections. Past medical and social history is non-contributory. The physical exam is significant for the 4th cranial nerve palsy. The fundoscopic exam reveals edema of the right optic nerve causing optic neuritis. Positive nystagmus on positional maneuvers.
There are left visual field deficits. There was short-term memory loss with the listing of familiar objects. The APRN tells the patient that she will be referred to a neurologist due to the high index of suspicion for multiple sclerosis (MS).
What is multiple sclerosis and how did it cause the above patient’s symptoms?
Case study:
A 61-year-old male complains of intermittent weakness and muscle fatigue that has progressively worsened over the past month. He was an internationally known extreme mountain climber but now he says he has difficulty in getting his morning paper. Initially, he thought his symptoms of profound leg weakness and fatigue were due to his age and history of injuries from mountain climbing.
Over the past few months, he also reports having noticed “blurriness” when working on his antique train collection or reading for long periods of time. He has developed an intermittent double vision that seems to be worse when reading at bedtime. He also reports an occasional “droopy” eyelid. Past medical and social history Physical exam reveals weakness of right extraocular muscle (EOM) with repetition. There is positive nystagmus and symmetrical upper extremity weakness with fasciculations. Lower extremities within normal limits (WNL). The APRN suspects the patient has myasthenia gravis (MG).
Question:
What is the underlying pathophysiology of Myasthenia gravis?
A 68-year-old man was brought to the emergency department by his family.
During his routine morning walk, he noticed a sudden onset of left facial numbness associated with a dull headache on the right posterior aspect of his head. He was staggering to the right side and feeling unsteady and nauseated, with no vomiting.
He telephoned his wife, who noticed his speech was slow and slurred, but there was no word-finding difficulty. His family immediately took him to the hospital.
There was a history of hypertension, hypercholesterolemia, ischemic heart disease (MI and PCI with a bare-metal stent in 2007), and probable transient ischemic attack (TIA) at the time of cardiac intervention. His medication included atenolol, ramipril, simvastatin, aspirin, and clopidogrel.
Within one hour, the patient’s symptoms had totally resolved. The diagnosis of transient ischemic attack was made, and the patient was discharged to home with instructions to contact his healthcare provider (HCP) for follow-up.
Question:
Why did the patient’s symptoms totally resolve?
An 83-year-old man presents with a history of atrial fibrillation (AF), hypertension, and diabetes.
His daughter, who accompanied the patient, states that yesterday the patient had a period when he could not speak or understand words and that approximately 4 weeks prior he staggered against a wall and was unable to stand unaided because of weakness in his legs. She states that both instances lasted approximately a half-hour. She was unable to persuade her father to go to the emergency room either time.
Today he suffered another episode of right-sided weakness, dysarthria, and difficulty with speech. Past medical history: Hypertension for 15 years, well-controlled; diabetes for the past 10 years, and Medications: Diltiazem CD 300 mg daily; lisinopril 40 mg daily; metformin 500 mg twice daily; aspirin 81 mg daily and atorvastatin 20 mg po qhs.
Social history: reported former smoker with 40 pack-year histories. Alcohol -drinks one beer a day. Denies any other substance abuse. Review of systems: Denies dyspnea, dizziness, or syncope; complains that he cannot move or feel his right arm or leg. Difficulty with speech.
Physical exam: Vitals: height = 70 inches; weight = 185 pounds; body mass index = 26.5; BP = 134/82 mm Hg; heart rate = 88 bpm at rest, irregularly irregular pattern.
HEENT: remarkable for expressive aphasia, eyes with contralateral homonymous hemianopsia.
No loss of sensation but unable to voluntarily move right arm or leg.
The patient was diagnosed with a right middle cerebral artery vascular accident (CVA) secondary to atrial fibrillation (AF)
Question:
How does atrial fibrillation contribute to the development of a CVA?
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