NR511 Final Exam Study Guide
NR511 Final Exam Study Guide
Topics:
o Common M/S disorders
o Common spine disorders
o Metabolic disorders
o Endocrine
... [Show More] disorders
o Wounds, lacerations & bites
o Common hematological disorders
o Common male GU disorders
o Testicular disorders
Chapters + lectures:
Wk 5:
o Chapter 52: Common Musculoskeletal Complaints
o Chapter 53: Spinal Disorders
o Chapter 54: Soft-Tissue Disorders
o Lectures
o Hollier
o DE
Wk6:
o Chapter 57: Glandular Disorders (p. 880-897 only)
o Chapter 59: Metabolic Disorders
o Chapter 73: Common Injuries (p.1210-1223 only) 1212-1213 table 73.1
o Review thyroid lecture again
o Lectures
o Hollier
o DE
Wk7:
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NR511 Final Exam Study Guide
o Chapter 46: Nocturia in Men (p. 682) & Testicular Pain (p. 685)
o Chapter 49: Prostate Disorders
o Chapter 50: Penile & Testicular Disorders
o Chapter 61: Hematological Disorders
o Lectures
o Hollier
o DE
Completion of study guide: IIII
1. Signs and
symptoms and
management of
musculoskeletal
sprains/strains/dislocations
Signs and symptoms and management of musculoskeletal sprains/strains/dislocations
Sprains: stretching or tearing of ligaments that occurs when a joint is forced beyond its normal
anatomical range
First degree- stretching of ligamentous fibers
Second degree- partial tear of part of the ligament with pain and swelling
Third degree- complete ligamentous separation
Sprain- sudden injury or fall that caused acute pain and swelling that got worse over a few
hours, redness and bruising, active and passive ROM decreased. Radiography to rule out fx.
Strain: muscle injury caused by excessive tensile stress placed on a muscle that results in
stiffness and decreased function
-effects muscle or tendon that connects a muscle to a bone, complain of “pulled
muscle,” severe cases cause inflammation, swelling, weakness and loss of function-surgery may
be needed
Management: PRICE (protect, rest, ice, compression, elevation), limitation of activity, physical
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NR511 Final Exam Study Guide
therapy, NSAIDS, referral to ortho
Dislocation- complete separation of 2 bones that form a joint
Very painful and cause immobility, need immediate medical attention
Referral to orthopedics for possible surgery or reduction with application of cast or splint.
four cardinal signs of inflammation (erythema, warmth, pain, or swelling) -SPEW
2. Signs and symptoms and
management of spinal
disorders (spondylosis,
stenosis, etc.)
Cervical Spondylosis- neck stiffness, mild aching discomfort with activity. Pain and limited ROM
occur with lateral rotation and lateral flexion of the neck toward the affected side. Weakness
shoulder abduction- C5. Bicep weakness- C6. Tricep weakness-C7.Myelopathy- leg weakness,
gait disturbance, balance problems, difficulty performing fine motor tasks, loss of bowel and
bladder. Treatment- cervical traction, PT, pain relievers. Surgery for Myelopathy.
Low back pain-Tenderness and decreased range of motion. Positive straight leg test. TreatmentNSAIDS, muscle relaxants, opioids, surgical, self-care, spinal manipulation
Stenosis-pseudoclaudication causing radicular pain in the calves, buttocks, and upper thighs of
one or both legs. Symptoms progress from a proximal to distal direction. Walking or prolonged
standing causes pain and weakness in buttocks and legs. Stooping over helps relieve pain.
Positive Romberg. Reflexes diminished. With bowel or bladder symptoms, sphincter tone may
be decreased
Management- surgical decompression. NSAIDS, folic acid, vitamin b12. PT-flexing the
spine.Bicycling.
Intermittent use of NSAIDs may be helpful, as well as folic acid or vitamin B12 supplementation
in some cases depending on results of laboratory tests.
Management revolves around physical therapy or an exercise program that focuses on flexing
the spine. Flexion of the spine increases intraspinal volume. Bicycling is one exercise that is
done with the spine in flexion. Improving abdominal muscle tone lifts the pelvis anteriorly and
flexes the lumbar spine. Reduction of intra-abdominal fat is critical to achieving the objective.
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NR511 Final Exam Study Guide
Thus, weight loss may be pivotal. Lumbar flexion exercises increase spinal canal volume.
Examples include exercise on all fours, arching the back, or in the fetal position. Exercises that
extend the spine should be avoided (swayback).
3. Recognition and
immediate management of
cauda equina syndrome
Immediate management of cauda equina syndrome. (P. 829)
Cauda equina syndrome is a medical EMERGENCY and requires immediate decompression.
If Cauda equina is confirmed, surgical lumbar decompression is necessary to halt neurological
deterioration unless surgery is contraindicated for other medical reasons.
*Rational on Davis Edge question: Low back pain accompanied by acute onset of urinary
retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, loss of
sensation in the buttocks and perineum, and motor weakness in the lower extremities is a red
flag for cauda equina syndrome or severe neurologic compromise. Perianal numbness.
Cauda equina compression is characterized by bilateral lower extremity weakness, anesthesia,
or paresthesia of the perineum and buttocks (saddle anesthesia). There may or may not be
bowel or bladder incontinence or bladder retention. When there is neurologic deficit affecting
the bowel or bladder, these changes may not be reversed with surgical decompression,
4. Maneuvers and
expected findings with
joint pain (knee, shoulder,
wrist, etc.)
Neck pain-Spurling’s.
Shoulder pain-Apley scratch test(reaching the scapula). Internal and external flexion. Internal
and external abduction. Pain with abduction= early supraspinatus tendinitis and subacromial
bursitis=early rotator cuff injuries. Wrist and hand-allen’s test= radial and ulnar arteries.
Phalens test=median nerve compression.
Tinel’s sign assess for compression neuropathy – tapping over nerve.
Finkelsteins test- de Quervains disease. Thumb between finger and point.
Knee Pain= Mcmurray, apprehension sign, bulge sign, inspect/palpate to assess effusion.
Lachman, drawer sign – ACL,
Thumb test - PCL
MCL, LCL test are valgus and varus
Tennis elbow cup coffee cup sign
CTS-NSAIDs not effective
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NR511 Final Exam Study Guide
Achillies rupture – Thompson test
5. Initial assessment of
FOOSH injury in correlation
to anatomical location of
radial head bone Lisa
Callahan
FOOSH - Falling On an Out Stretched Hand. After falling on an outstretched hand patients
present after trauma with pain and swelling in the distal forearm or wrist. Numbness may be
present if the medial nerve is affected. The mechanism of injury will often provide important
clues to the diagnosis. The examination begins with gentle palpation to locate the area of point
tenderness and includes a thorough neurovascular assessment. A radiograph of the wrist
(including an oblique view) may be necessary to rule out fracture. Common fractures are the
Colles fracture of the distal radius and the navicular (scaphoid) fracture of the anatomical
snuffbox. It is not unusual to have a navicular fracture missed on radiography, so an orthopedic
referral should be provided when the presenting complaint is pain and trauma to the soft-tissue
area of the anatomical snuffbox. Scaphoid injury.
6. Assessment and
management of Myofascial
pain
Trigger points within a muscle. Common cause of nonarticular rheumatic pain. Injections at the
trigger point with saline, an anesthetic, or corticosteroid, dry needling, muscle relaxant
tizanidine, NSAIDS, or cyclooxygenases-2 inhibitors. Tricyclic antidepressants.
7. Health promotion
activities to prevent sport
related musculoskeletal
injuries
Protection may refer to preventing the injury from occurring or making it less severe by wearing
protective gear, such as helmets, wrist pads, and kneepads. Maintain adequate hydration and
proper diet while playing sports. Stretch before the activity. Stop when you are injured, do not
“tough it out”.
8. Osteopenia Osteopenia:
• Osteopenia Is the precursor to osteoporosis. Osteopenia is categorized by the level of Tscores in relation to the results of a dual-energy x-ray absorptiometry scan or (DXA Scan),
which measures the mineral content of bone. A T-score ranging from -1 to -2.5 would be
classified as osteopenia.
Pathophysiology:
• It occurs secondary to uncoupling of osteoclast-osteoblast activity, resulting in a
quantitative decrease in bone mass. Peak bone mass is typically achieved by males and females
just prior to, or early-on in the 3rd decade of life.
• Beyond age 30, bone resorption gradually becomes favored as dynamic bone
remodeling continues into later decades of life.
• Histologic specimens demonstrate markedly thinned trabeculae, decreased osteon size,
and enlarged haversian and marrow spaces.
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NR511 Final Exam Study Guide
Osteopenia Prevention:
• Certain habits can accelerate the process such as:
o Smoking – prevents calcium uptake
o Not getting enough calcium and vitamin D
o Drinking too much ETOH
o Use of certain medications (i.e.: corticosteroids and anticonvulsants)
o Not getting enough weight-bearing exercise (at least 30 mins on most days). If your feet
touch the ground during an exercise, it’s probably weight bearing. Running and walking are
weight bearing. Swimming and biking are not – non-weight bearing
o Falls
• Women are more likely to have low bone density than men, but it’s no longer viewed as
solely a women’s condition.
• Approx. a third of white and Asian men over age 50 are affected.
• Percentages for Hispanics (23%) and blacks (19%) are lower, but still sizable.
Current National Osteoporosis Foundation (NOF) recommends testing for:
• Women 65 and older
• Postmenopausal women younger than 65 who have one or more risk factors, which
include being thin
• Postmenopausal women who have had a fracture
• For men: testing is done more on a case-by-case basis.
Osteopenia Treatment:
Can be treated with exercise and nutrition or with medications.
• If T-score is under -2, need to ensure you are doing regular weight-bearing exercise, and
getting enough vitamin D and dietary calcium.
• If T-score is closer to -2.5, a medication may be considered to keep bones strong.
• Bisphosphonates are most commonly prescribed medication class for treatment to
prevent/reduce reabsorption of bone.
Prolonged use has been linked with 2 major clinical side effects: osteonecrosis of the jaw (ONJ)
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NR511 Final Exam Study Guide
and the atypical subtrochanteric femur fracture. DE quiz question.
• ONJ is rare and is associated with IV forms and not oral forms of the medication. Tx
entails immediately stopping the offending agent.
• Atypical femur fractures also are rare but have significant associated morbidity, and
clinicians are cautioned against the chronic, uninterrupted bisphosphonate use beyond 3 to 5
years or in situations when pts report mild thigh discomfort while undergoing tx.
• The core treatment options for osteopenic patients involve early education on how to
achieve and maintain healthy bone mass levels and extensive education and counseling on the
relevant social, environmental, and lifestyle risk factors that compromise bone health.
General consensus favors pharmacologic treatment in a patient with spine or hip fractures in
addition to a documented low BMD. Treatment recommendations vary for other nonvertebral
fractures and include the following:
• The National Osteoporosis Society (NOS) recommends starting treatment in all
postmenopausal women with a history of any fragility fracture
• The National Osteoporosis Foundation (NOF) recommends performing DXA scans on
patients sustaining nonvertebral fragility fractures, and the decision to treat or not with
pharmacotherapy is based on the patient’s t-score; patients considered to be osteopenic (tscore between -1 and -2.5) are not started on drugs.
Pharmacotherapy agents work through either anti-resorptive or anabolic means.
Bisphosphonates are the most commonly prescribed medication class. These drugs are divided
into non-nitrogen and nitrogen-containing compounds. The latter are considered first-line
therapy. The nitrogen-containing compounds inhibit farnesyl pyrophosphate synthase and
ultimately inhibit osteoclast resorption and induce osteocyte apoptosis. Common agents
include:
• Alendronate may reduce the rate of hip, spine, and wrist fractures by 50%
• Risedronate may reduce vertebral and nonvertebral fractures by 40% over three years
• IV zoledronic acid reduces the rate of spine fractures by 70% and hip fractures by 40%
over three years
Other Medication Classes
• Conjugated estrogen-progestin hormone replacement (HRT)
• Estrogen-only replacement (ERT)
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NR511 Final Exam Study Guide
• Salmon calcitonin (Miacalcin, Fortical)
• Selective estrogen receptor modulators (Raloxifene) - Raloxifene is an agonist to
estrogen receptors on bone and reduces osteoclast resorption
• Anabolic (Teriparatide) - Teriparatide is a recombinant form of parathyroid hormone
(PTH) that stimulates osteoblasts to produce more bone. Teriparatide is now FDA approved
for osteoporosis treatment in males and females
• RANKL inhibitors (Denosumab) - Denosumab is a monoclonal Ig2 that targets RANKL and
inhibits its ability to bind to RANK and results in the inhibition of osteoclast activation
• The t-score is measured in standard deviations and reflects the difference between the
patient's measured BMD and the mean value of BMD in healthy, young, matched controls (30-
year-old women). By definition, a normal BMD measurement is within one standard deviation
of the young adult mean. The WHO defines t-scores between -1 and -2.5 as osteopenic and
scores below -2.5 as osteoporotic. Greater than -2.5 means osteoporosis.
The z-score is also measured in standard deviations, but the z-score is compared to a healthy,
age-matched control group. The z-score is most clinically relevant when obtaining a DXA scan in
younger patients when secondary osteoporosis is being considered. A z-score less than -1.5
warrants a comprehensive secondary osteoporosis workup.
• Standard laboratory workup includes checking calcium, phosphorus, albumin, alkaline
phosphatase, liver function tests, creatinine (serum and urine), 25 hydroxyvitamin D, TSH and
free T4, and intact PTH levels. Males should have a free testosterone level checked to rule out
hypogonadism.
• The WHO created a fracture risk assessment tool (FRAX score) to predict the 10-year risk
of sustaining a hip or other major osteoporotic fracture. These other major fragility fractures
include fractures of the spine, wrist, forearm, or humerus. The assessment includes 12
questions weighted by the relative risk associated with a future fragility fracture event.
Assessment includes age, sex, personal history of fracture, low BMI, oral steroid use, secondary
osteoporosis, parental history of hip fracture, smoking status and alcohol intake. In addition,
optional BMD measurement values can be included from a prior DXA scan (if available) to
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NR511 Final Exam Study Guide
provide a more comprehensive score report.
Obesity is a predisposing factor, as is osteoporosis
9. Assessment and
management of gout
Persons from the United States, the Pacific Islands, and countries with abundant lifestyles have
an increased incidence of gout. Gout is more prevalent in African American men. The increased
incidence of gout in older adults has been associated with an increased use of diuretics – HCTZ
DEQ. Patients with gout may experience an acute attack with rapid fluctuations of serum urate
levels. Surgery, dehydration, binge alcohol consumption, emotional stress, infections, diuretics,
and uricosuric drugs can all cause rapid fluctuations in serum urate levels. Causes of primary
gout include idiopathic inborn errors of purine metabolism, decreased renal clearance of uric
acid, and specific enzymatic defects such those resulting in Lesch-Nyhan syndrome and glycogen
storage disease. Secondary causes of gout include other disease processes and medications,
such as thiazide diuretics, that result in an overproduction or underexcretion of uric acid. The
patient will present during an acute attack with pain, tenderness, erythema, and swelling of the
affected joints. the joint most frequently affected is the first metatarsophalangeal joint of the
great (big) toe; however, the midfoot, knees, fingers, wrists, and elbows may also be affected.
The typical presentation is excruciating pain that awakens the patient at night. Patients often
describe the pain as throbbing, crushing, and pulsating. The pain is not relieved by rest or
positional changes and prevents weight-bearing on the affected limb. Often the patient cannot
tolerate anything coming in contact with the affected joint—even bed clothing touching the
limb can be extremely painful.
The clinical presentation and medical history findings are often sufficient to diagnose gout. A
definitive diagnosis is only made with identification of sodium urate crystals in the aspirated
fluid from affected joints. The goals of clinical management are to terminate an acute attack,
prevent future attacks, normalize hyperuricemia, and prevent potential complications of urate
deposits. Management of gout includes pharmacological treatment of acute attacks and longterm medical and pharmacological treatment of hyperuricemia. Acute management of gout
includes generalized rest, elevation and immobilization of affected joints, and pharmacological
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NR511 Final Exam Study Guide
treatment. The initial medication of choice for acute gout attacks is an NSAID. Colchicine is an
effective medication to terminate an acute attack of gout if administered within 36 hours of the
initial onset of symptoms. Corticosteroids can provide dramatic systematic relief and can be
administered orally, intramuscularly, or intra-articularly. The long-term management of gout
includes pharmacological agents, dietary modifications, activity evaluation, and education
regarding the prevention of gout. Patients with extensive or large tophi may benefit from
surgical excision of these lesions. Physical activity must be restricted during an acute gout
attack, and bedrest should be maintained for 24 hours following an acute attack. The joint
should be immobilized; if a lower extremity is involved, no weight-bearing should be allowed
during the acute attack. During intercritical periods, physical therapy may be indicated to
maintain or improve function. Hot compresses may promote comfort after an acute attack but
should not be instituted until the acute pain subsides, usually 24 to 72 hours after the initiation
of therapy. The patient should apply heat for 20 minutes two to three times daily through the
use of moist heating pads, warm showers and baths, or moist towels heated in a microwave.
Relief may also be obtained using ice packs during an acute attack. Patients should be instructed
to apply packs for only 10 to 20 minutes sessions at a time to avoid thermal damage to the skin;
ice packs should be discontinued if pain is not relieved. Long-term management includes dietary
moderation of purine-containing foods (limited to no more than one to two servings of purinerich foods per day), moderating alcohol intake, maintaining weight, and sufficient physical
activity to maintain joint mobility during quiescent periods between gout flares.
10. Medication
management for acute vs.
chronic gout
Acute-rest, elevation and immobilization. NSAIDS, colchicine (onset of symptoms less than 36
hours), and corticosteroids. Avoid aspirin. Avoid excessive alcohol. Avoid purine-rich foods.
Chronic- uric acid secretion <1,000 mg/24 hrs: probenecid. Uric acid secretion >1,000mg/24 hrs:
allopurinol. Colchcine.
11. Dietary restrictions for
gout
Restrict purine foods, (Examples • All meats and seafoods (especially organ meats such as liver,
kidneys, and sweetbreads [thymus, pancreas]) • Meat extracts and gravies • Yeast and yeast
extracts (brewer’s and baker’s) • Beer and alcoholic beverages • Beans, peas, lentils, oatmeal,
spinach, asparagus, cauliflower, and mushrooms • Mussels and scallops • Anchovies, herring,
and sardines • Trout, haddock, mackerel, and tuna
12. Signs and symptoms Hyperthyroidism: inverse (low TSH, High T4) [Show Less]