Topic 1
A 12-year-old pediatric patient checks into the Peds ED where you are working as an NP. The mother endorses 3 days of coughing, mild nasal congestion, and increased work of breathing. Mother states patient has needed albuterol for in the past but does not have any diagnosed medical problems. On exam patient has the following vitals: HR 120, RR 32, BP 118/90, O2 93%, T 99.8. The patient has moderate intercostal retractions and bilateral inspiratory and expiratory wheezes.
What disease process do your suspect? What diagnostic tests will you order and why?
Asthma
Acceptable answers:
-Viral swabs to look for the source of exacerbation
-Chest x-ray to rule in/out pneumonia and any structural abnormalities
-None, if the mother agrees; sounds like a straightforward asthma exacerbation and unlikely that testing will change the plan of care
You are working in a primary care as an FNP and see a new 21-year-old female patient with chief complaint of fatigue. The patient notes that her menstrual periods have been heavier than usual around the same time her fatigue started.
What are your differential diagnoses?
Acceptable answers: iron deficiency anemia, pregnancy with threatened abortion, endometriosis, hemorrhagic ovarian cyst, etc
You are working an an NP at a primary care clinic. You see a 35-year-old patient who expresses concern with trouble losing weight. The patient states she has increased her exercise and decreased her caloric intake but does not seem to be losing any weight.
What are your differential diagnoses?
Hypothyroidism
Other acceptable answers to include: pregnancy, diabetes, stress, sleep deprivation, etc
A 12-year-old pediatric patient checks into the Peds ED where you are working as an NP. The mother endorses 3 days of coughing, mild nasal congestion, and increased work of breathing. Mother states patient has needed albuterol for in the past but does not have any diagnosed medical problems. On exam patient has the following vitals: HR 120, RR 32, BP 118/90, O2 93%, T 99.8. The patient has moderate intercostal retractions and bilateral inspiratory and expiratory wheezes.
What will you do for this patient right now?
Order breathing treatments
-Acceptable answers: albuterol, duonebs (albuterol and ipratropium), 1-3 of either one and reassess
Order steroids
-Acceptable answers: 0.6mg/kg decadron, 2mg/kg prednisolone (note: if using prednisolone must send pt home with a script for remaining days)
You are working in a primary care as an FNP and see a new 21-year-old female patient with chief complaint of fatigue. The patient notes that her menstrual periods have been heavier than usual around the same time her fatigue started. You diagnose her with iron deficiency anemia and start her on oral iron replacement.
What education can you give her to help increase absorption? What side effects should she look out for? What should she do if she experiences these side effects?
Increase absorption: take in the morning before eating breakfast or drinking coffee/tea, take with orange juice or other sources of vitamin C, wait for 30min-1 hour after taking to eat
Side effects: nausea, vomiting, constipation, green/black stools
Experiencing side effects: take with food, do not take with vitamin C, take stool softener, increase hydration, follow up with NP to potentially change dosing schedule/dose/medication
You are working an an NP at a primary care clinic. You see a 35-year-old patient who expresses concern with trouble losing weight. You suspect hypothyroidism.
What other symptoms/signs do you assess for?
Acceptable answers: fatigue, cold intolerance, constipation, hair loss, dry skin muscle aches, goiter (later sign), etc
You are working as a Pediatric NP and you have a follow-up with a 12-year old patient who was seen at a Peds ER a few days ago with suspected new-onset asthma.
The mother wants to know the pathophysiology of asthma. What do you tell her?
Complete answer should include:
You are working in a primary care as an FNP and see a new 21-year-old female patient with chief complaint of fatigue. The patient notes that her menstrual periods have been heavier than usual around the same time her fatigue started.
What labs will you order today? What values do you expect to be abnormal?
Acceptable answers: CBC (possible low hgb, hct, rbc), iron panel (possible low serum iron, transferrin, ferritin; possible high TIBC)
You are working an an NP at a primary care clinic. You see a 35-year-old patient who expresses concern with trouble losing weight. You suspect hypothyroidism.
What labs do you order today? Why? What values do you expect to be abnormal?
Thyroid panel: TSH (high), T3 (low/normal), T4 (low)
Acceptable: Thyroid Antibodies (TPOAb/TgAb): High, if the cause is Hashimoto’s disease
Note: There is an argument to be made for just ordering a TSH
You are working as a Pediatric NP and you have a follow-up with a 12-year old patient who was seen at a Peds ER a few days ago with suspected new-onset asthma.
What test will you order to formally diagnose the asthma and what results will confirm it? When will you send this patient for testing?
Pulmonary function tests/Spirometry
-FEV1 and PEFR are less than 80% of predicted, and improve 12+% with a bronchodilator
After their exacerbation is resolved so you can get a good baseline
You are working in a primary care as an FNP and see a new 21-year-old female patient with chief complaint of fatigue. The patient notes that her menstrual periods have been heavier than usual around the same time her fatigue started. The patient's workup reveals iron deficiency anemia.
After prescribing oral iron replacement, when will you recheck bloodwork? Why? What is the soonest and the longest you should wait? What will influence your decision?
Acceptable answers: 1-3 months, to allow iron/hemoglobin stores time to replenish
Soonest: 4 weeks. Longest: Usually 3 months
Influences: how low values are, what medication prescribed, clinical signs of anemia, concerns for noncompliance, patient preference
You are working an an NP at a primary care clinic. You see a 35-year-old patient who expresses concern with trouble losing weight. You suspect hypothyroidism.
You order a thyroid panel and get the following results:
-TSH: low
-T3: high
-T4: high
What do these labs mean? What is your next step? Why?
The patient has hyperthyroidism; they must have something else going on that is causing the weight retention
Refer the patient to endocrinology
Hyperthyroidism is not normally managed in primary care
You are working as a Pediatric NP and you have a follow-up with a 12-year old patient who was seen at a Peds ER a few days ago with suspected new-onset asthma. You order the appropriate diagnostic test and confirm the patient has asthma.
What education will you give the patient and their family today. (Hint: include triggers, medication that you will prescribe today, and how to use medication, and guidelines for stepping up and down)
Acceptable answers:
Triggers: dust, pollen, cold, infection, pet dander, exercise, smoke, etc
Medication prescribed today: Albuterol or Symbicort prn wheezing/shortness of breath
How to use: Shake inhaler well for 5–10 seconds, remove the cap, and breathe out completely. Place the mouthpiece between your teeth and seal your lips around it. Press the canister once while breathing in slowly and deeply, then hold your breath for 10 seconds
Step Up/Step Down: Step up when symptoms are not controlled, step down when symptoms are well controlled for 3+ months.
Sample Step Up/Down:
1: SABA PRN
2: low dose ICS
3: low dose-ICS + LABA/medium ICS
4: Medium ICS + LABA
5: High ICS + LABA
6: High ICS + LABA + oral steroid
Note: Symbicort can also be alone for every step, 1-2 puffs 1-2 times per day depending on step
You are working in a primary care as an FNP and see a new 21-year-old female patient with chief complaint of fatigue. The patient notes that her menstrual periods have been heavier than usual around the same time her fatigue started. The patient's workup reveals iron deficiency anemia.
What medication will you prescribe for the patient today (include dose)? What if they have concerns about cost? What if they suffer from constipation? What if they really do not want to take a medication and prefer to address to issue "naturally"?
Acceptable medications to prescribe: ferrous sulfate 325mg po D-TID, ferrous gluconate 240-324mg po D-QID, ferrous fumarate 360mg po D
Concerns about cost: ferrous sulfate is the cheapest option (usually under $15 for 100 tablets)
What if they suffer from constipation: consider ferrous gluconate or ferrous fumarate over ferrous sulfate. Increase hydration/fiber/etc. Consider stool softener
Does not want medication: consider iron-rich foods such as red meat, spinach, raisins, salmon, etc, depending on how low levels are and clinical signs of deficiency. Educate patient that if levels do not come up with diet they will then need medication.
You are working an an NP at a primary care clinic. You see a 35-year-old patient who expresses concern with trouble losing weight. You order diagnostic testing and confirm hypothyroidism.
What will you prescribe the patient today (include dose)? What education will you give them? What if they are Jewish and refuse to eat pork? When will the follow up/what will influence the time frame? What will you do if the follow-up labs are minimally changed?
Prescribe: Levothyroxine; usually 1.6 mcg/kg/day
Education: Take first thing in the morning on an empty stomach with water, take at the same time every day, avoid antacids/iron for 4 hours, etc
Jewish: educate that levothyroxine is a synthetic hormone and unlike Desiccated Thyroid Extract (Armour Thyroid or NP Thyroid), it does not contain pork
Follow up: 4-6 weeks, depending on levels, clinical signs, patient preference, suspicion for noncompliance
Labs are minimally changes: increase dose by 12.5-25mcg daily