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Visual Changes 561 A few weeks after the visit described above, you receive a phone call from Marion's friend, who calls the clinic with news that Marion experienced a brief episode of slurred speech and right‐sided weakness that lasted a few minutes. These symp-toms occurred about 30 minutes ago. What is your priority recommendation? Her friend reports that Marion is feeling fine now but she is frightened. What is your advice? You advise Marion to seek immediate evaluation in the emergency room. Her symptoms are con-sistent with a transient ischemic attack (TIA) (a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction) but cannot be dif-ferentiated from a stroke without neurovascular imaging. The most common symptoms of brain ischemia include sudden weakness or numbness on one side (face, arm, or leg), trouble speaking or slurred speech, trouble walking (due to sudden unexplained dizziness, loss of coordination, or sudden “drop” attack and fall), or trouble seeing (sudden loss of visual field, sudden monocular or binocular vision loss, blurred vision, or diplopia). Headaches, tinnitus, and hearing loss may accompany vertebrobasilar insufficiency. The inherent uncertainty of classifying ischemic stroke as being distinct from a TIA is a result of the inadequacy of the diagnostic workup in some cases to visualize the occluded artery or localize the source of the embolism (Powers et al., 2018). However, due to their shared physiological mechanisms, both TIA and ischemic stroke patients should have an evaluation sufficient to exclude high‐risk modifiable conditions such as carotid stenosis or AF as the cause of ischemic symptoms (Powers et al., 2018). The ABCD 2 clinical risk prediction score has been shown to predict stroke risk and should be used in the early period following stroke to determine risk (Wardlaw, 2015). However, the ABCD 2 does not reliably discriminate those at low and high risk of early recurrent stroke, identify patients with carotid stenosis or AF needing urgent intervention, or streamline clinic workload (Wardlaw, 2015). What diagnostic evaluation should be completed? A diagnostic evaluation will differentiate stroke mimics (SMs), which are nonvascular conditions that can produce symptoms that resemble an acute stroke (Viela, 2017) constitute a large percentage of acute stroke admissions to hospitals. The most common SMs include Bell's palsy, conversion disorders, seizures and postictal paralysis or toxic‐metabolic disturbances such as brain tumors, infections, and migraine (Viela, 2017). If her symptoms included a loss of vision, visual field, or other acute vision changes, ocular neuropathy or intraocular pathology may be included in the differential diagnosis (Viela, 2017). If Marion's clinical presentation demonstrated a score of 1 or 2 on the ABCD 2, she would be con-sidered low risk in the initial emergency department evaluation, and subsequently she would be referred back to her primary care provider for further evaluation. A neurology consult is recom-mended to effectively plan and implement a comprehensive and cost‐effective workup that includes appropriate neurovascular imaging. A head CT is generally performed in the emergency room, and as such an MRI of the head is recommended for outpatient diagnosis and treatment. Doppler ultrasound, transcranial ultrasound, cardiac echo, EKG, MR angiography, or CT angiog-raphy can detect carotid cardiac abnormalities or vascular pathology. If symptoms recur, a tele-medicine network may be indicated to ensure a timely treatment (Powers 2018). What education is needed? Marion will need to learn the importance of phrases such as “Time is brain” that signify the emergent nature of accessing care because antithrombolytic agents (if indicated) must be given emergently within the first 3 to 4. 5 hours after the onset of symptoms for optimal effect. Patients and family members are taught to recognize the signs of a “brain attack” or stroke, using the mnemonic FAST. F (Face)—Ask the person to smile. Does one side of the face dr oop? A (Arms)—Ask the person to raise both arms. Does one arm drift downwar d?
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562 Resolutions S (Speech)—Ask the person to r epeat a simple sentence. Are the words slurred or is there difficulty repeating the sentence corr ectly? T (T ime)—If the person has any one of these symptoms, they should activate EMS (call 911) and go to the hospital immediately. Emergency personnel will want to know the last known symptom‐free time, since duration of symptoms is an important parameter in calculating the risk/benefit of various treatment options. A family member or friend should travel to the hospital, if possible, to provide information. Other symptoms of stroke include trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance or coordination, or sudden severe headache with no known cause. What is the management plan? Acute/initial inpatient management includes appropriate brain imaging; airway and breathing support; blood pressure, temperature, and glycemic regulation; in tandem with antithrombotic medication as indicated (Powers et al., 2018). The nurse practitioner plays a critical role in partnering with the patient and interprofessional health care team to facilitate risk factor reduction, to reduce the likelihood of secondary strokes, and disability, as well as vascular dementia. Therefore, it will be critical to follow the latest American Heart Association guidelines and recommendations for mitigating future stroke risk, such as management of Marion's hypertension, and assessing and treating potential hyperlipidemia, diabetes mellitus, or atrial fibrillation. Antiplatelet therapy or an anticoagulant is recommended for secondary prevention of noncardioembolic, ischemic stroke, as dictated by a patient's comorbid conditions (Powers et al., 2018). Anticoagulation may be preferred for treatment in lieu of antiplate-let therapy for patients with atrial fibrillation. Older adults are at higher risk of bleeding from antiplatelet and/or anticoagulation therapy, and the risk‐to‐benefit ratio needs to be evaluated for each patient, guided by the latest available evidence. Physician consultation and collaboration is recommended. Age alone is not a contraindication to anticoagulant therapy, and there is evidence of undertreatment in high‐risk older adults (Powers et al., 2018). If she is hospitalized, mechanical thrombectomy using a stent retriever may be selected for Marion if she meets all established cri-teria (Powers, 2018). Screening for dysphagia will be performed, and blood pressure, blood sugar, temperature, and nutrition will be closely monitored. If Marion was admitted to the hospital, upon discharge, she may be transferred to a rehabilita-tion center following her hospital course, either for inpatient or ambulatory care treatment as indi-cated by her condition. What are some of the most important domains of nursing assessment and management (physical, psychological) during these first few hours after symp-toms? In the early post‐stroke period? As systems of care evolve in response to health care reform efforts, post‐acute care and rehabilita-tion are considered a costly area of care to be trimmed, without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depres-sion, loss of autonomy, and reduced functional independence (Weinstein et al., 2016). Goals in the early post‐stroke period are to restore maximal function and to assist with emotional and physical adjustment during the rehabilitation period. Skillful nursing assessment, care, education, and monitoring are needed in collaboration with the interdisciplinary team, the patient, and the family. The goals of care include maintaining or improving mobility and speech (if impaired), self‐care, swallowing, bladder control, bowel function, sexual function, emotional adjustment, and family coping. Instructing formal and informal caregivers is an important nursing role in order to prevent injury (e. g., shoulder dislocation), avoidable complications (choking, aspiration, fecal impaction), and frustration related to unrealistic expectations and unmet needs for adaptive equipment, tech-nologies, or assistance. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts (Weinstein et al., 2016).
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Visual Changes 563 REFERENCES AND RESOURCES Abe, R., Diniz‐Filho, A., Costa, V., Gracitelli, C., Baig, S., & Medeiros, F. (2016). The impact of location of pro-gressive visual field loss on longitudinal changes in quality of life of patients with glaucoma. Ophthalmology, 123(3), 552-557. Carlson, C., Merel, S., & Yukawa, M. (2015). Geriatric syndromes and geriatric assessment for the generalist. Medical Clinics of North America 99(2), 263-279. Garcia‐Layana, A., Cabrerea‐Lopez, F., Garcia‐Arumi, J., Arias‐Barquet, L., & Ruiz‐Moreno, J. (2017). Early and intermediate age‐related macular degeneration: Update and clinical review, Clinical Interventions in Aging, 12, 1579-1587. Golan, S., Rabina, G., Kurtz, S., & Leibovitch, I. (2016). The prevalence of glaucoma in patients undergoing surgery for eyelid entropion or ectropion. Clinical Interventions in Aging, 11, 1429-1432. Hanna, K., Hepworth, L., & Rowe, R. (2016). Screening methods for post stroke visual impairment: A systematic review. Disability Rehabilitation, 39(25), 2531-2543. Miller, C. (2019). Nursing for wellness in older adults (8th ed., pp. 337-362 & 419-434). Philadelphia: Wolters Kluwer. Pioro, M. (2018). Primary care vasculitis, polymyalgia rheumatica and giant cell arteritis. Primary Care: Clinics in Office Practice, 45(2), 305-323. Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., . . . American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110. doi:10. 1161/STR. 0000000000000158 Revicki, D. A., Rentz, A. M., Harnam, N., Thomas, V. S., & Lanzetta, P. (2010). Reliability and validity of the National Eye Institute Visual Function Questionnaire‐25 in patients with age‐related macular degenera-tion. Investigative Ophthalmology & Visual Science, 51(2), 712-717. Su, D., Greenberg, A., Simonson, J., Teng, C., Liebmann, J., Ritch, R., & Park, S. (2016). Efficacy of the Amsler Grid Test in evaluating glaucomatous central visual field Defects. Ophthalmology, 123(4), 737-743. Viela, P. (2017). Acute stroke differential diagnosis: Stroke mimics. European Journal of Radiology, 96, 133-144. Vujosevic, S., Toma, C., Villani, E., Gatti, V., Brambilla, M., Muraca, A., . . . De Cilla, S. (2019). Early detection of microvascular changes in patients with diabetes mellitus without and with diabetic retinopathy: Comparison between different swept‐source OCT‐A instruments. Journal of Diabetes Research, 19. https:// doi. org/10. 1155/2019/2547216 Wardlaw, J. M., Brazzelli, M., Chappell, F. M., Miranda, H., Shuler, K., Sanderock, P. A. G., & Dennis, M. S. (2015). ABCD 2 score and secondary stroke prevention. Neurology, 85(4). https://doi. org/10. 1212/ WNL. 0000000000001780 Weinstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., . . . Zorowitz, R. D. (2016). Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association, Stroke, 47(6), e98-e169.
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565 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 6 Back Pain RESOLUTION What are the most likely differential diagnoses in this case and why? Vertebral compression fracture (VCF): A late midlife woman who presents with a chief complaint of acute onset of upper midback pain that limits active range of motion and deep breathing and radiates to her lower chest and abdomen prompts the clinician to consider several differential diagnoses. The most common differential that accounts for this constellation of symptoms is vertebral compression fracture (VCF) due to osteo-porosis (OP). This is a common presentation of OP as bone loss does not cause any pain or symp-toms until a fracture occurs (Bethel, 2019; Camachoet al., 2016; Cosman et al., 2014). However, several other differentials may mimic some symptoms of VCFs or exacerbate these symptoms and must be carefully explored; these include back strain, atypical angina, and costochondritis. Less common differentials that the clinician will consider given Mary's history include an RA flare and extra‐articular pulmonary RA manifestations. VCFs commonly occur with usual activities when the spine is hyperextended or flexed as the vertebral bones are weakened due to bone loss and the anterior or posterior edges of the bones are crushed with the pressure of the flexion or extension of the spinal column. About two‐thirds of patients who experience VCFs do not have significant pain. These patients may present with height loss or kyphosis. VCFs change the vertebral bone to a wedge shape instead of a square shape and lead to the classic forward‐bent posture seen in patients with kyphosis of the spine. OP often pres-ents with a fracture because there are no symptoms associated with bone loss until an actual frac-ture occurs. This is why early screening is advocated (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). OP is diagnosed with a comprehensive history and physical exam, selected laboratory testing, and central bone density measurement such as dual‐energy absorptiometry (DXA). Mary's DXA revealed a T‐score of-2. 6 at her lower spine,-2. 0 at her hip, and-1. 7 for her combined hip. Her FRAX ® 10‐year fracture risk at the hip was reported as 3. 0%; and for any major OP fracture, it was reported as 22. 0%. Her physical examination findings are consistent with thoracic VCFs. Her labo-ratory testing revealed a normal fasting serum calcium and 24‐hour urinary calcium and a serum 25‐OH‐D of 20 ng/m L, suggesting nutritional insufficiency. Finally, her spine films revealed stage 1 VCFs at T7 and T8 (20-25% deformity).
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566 Resolutions The history and physical examination and laboratory tests are done to evaluate the possible presence of secondary OP. Secondary OP is present when a disease process or medication causes bone loss that results in OP. Mary is at risk for secondary OP because she has a high‐risk disease (RA) and has needed to take high‐risk medications (oral steroids) for many years (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). Since her need for daily steroids continued for many years, it is highly likely that her OP is secondary, at least in part, due to steroid use. The rate of bone loss also normally increases signifi-cantly in women during the early postmenopausal years (bone loss of up to 5% per year can occur); thus it is likely that Mary's OP is also partly primary and due to her postmenopausal status. Other musculoskeletal causes: Musculoskeletal causes of back or chest‐wall pain that are unrelated to OP must also be considered. Such differentials would include back strain and costochondritis. Mary's physical examination findings of pain upon movement and tenderness with chest‐wall compression support each of these differentials. Back strain is the more likely of these differentials because of the history of physical activity that precipitated the onset of Mary's pain. Costochondritis is less likely as it tends to develop over time with overuse and inflammation as opposed to acute injury. However, neither of these differentials is supported by the physical examination finding of vertebral tenderness; this finding is more indicative of VCF. Angina: Angina is an important differential that Mary's clinician cannot afford to miss. Mary is at increased risk for cardiovascular disease due both to her RA and to her age. Although cardiac manifestations of RA can occur; they are not common. RA is, however, associated with an increased risk for cardiovascular disease (Jagpal & Navarro‐Millan, 2018). Women are more likely to develop cardiovascular disease as they age, with postmenopausal women having an equal or greater risk for cardiovascular disease than men of the same age cohort (Jagpal & Navarro‐Millan, 2018). While women do experience typical angina symptoms, angina often presents atypically among women with fatigue, neck pain, nausea, and shortness of breath. Women are less likely than men to present with acute infarction; rather, they have symptoms over a longer period of time and at rest. As women age, the likelihood that they will present with more typical angina symptoms increases (Maas, 2017). In Mary's case, she has not described symptoms of atypical angina such as nausea or prolonged fatigue; rather, she stated that she usually awakes refreshed and well rested. Additionally, her pain is the posterior chest rather than the anterior chest, an acute onset related to a specific activity, radiates to her lower chest and abdomen, and is exacerbated with chest‐wall palpation—all findings that suggest VCF more strongly than angina‐related chest pain. RA Flare: Given Mary's history of RA, her clinician would also likely consider an RA flare and extra‐articular pulmonary RA manifestations as possible, yet less likely, causes of her pain. RA flares tend to pre-sent with increased symptoms in previously affected joints such as the metacarpal phalangeal (MCP) and proximal interphalangeal (PIP) joints in the hands. As the disease progresses, other joints may be affected such as the elbows or wrists; ankles, knees, or hips; shoulders; and cervical spine (such as C1 and C2) (Smith, 2018). In Mary's presentation, she describes this pain as distinct from her usual morning stiffness associated with RA and does not associate it with the many RA flares that she has experienced in the past. Additionally, RA is not likely to affect other areas of the spine (Smith, 2018), and Mary's symptoms are specifically centered in the T7-T8 region by both her history and her physical examination. Extra‐articular pulmonary RA manifestations are even less likely. Pericardial effusions related to RA are normally asymptomatic. Pulmonary manifestations may include asymptomatic pleural effusions and are more commonly seen among men (Smith, 2018). Similarly, lung nodules caused by RA are also more common in men. These pulmonary man-ifestations do not present with acute onset upper back pain.
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Back Pain 567 Which diagnostic tests are required in this case and why? Diagnostic testing is needed to diagnose both osteoporosis (OP) and vertebral compression fractures (VCFs). 1. EKG: Obtaining an EKG would be prudent for a 63‐year‐old woman who presented with either typical or atypical angina symptoms. However, an EKG is not useful in verifying OP or VCFs, and may not accurately identify myocardial distress. 2. CPKs: Obtaining CPKs would be prudent for a 63‐year‐old woman who presented with typical or atypical angina symptoms or who presented with myalgias such as are sometimes seen with statins. However, CPKs are not used to verify OP or VCFs. 3. Fasting lipid panel, fasting blood glucose, and hemoglobin A1C (Hg A1c) level: While these tests would be useful to determine cardiovascular disease and diabetes risk profiles and might be appro-priate if Mary has not been screened recently, these tests will not assist with verifying OP or VCFs. 4. CBC, ESR, and CRP: A CBC is drawn to evaluate the number and types of cells present in a serum sample. Anemia of chronic disease is a common finding with RA. A CBC is also useful to assess in patients suspected of having OP to rule out secondary causes of bone loss and to determine overall health status (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). ESR and CRP are nonspecific markers for inflammation and are indicative of disease activity with RA; however, they are not highly specific and will be elevated with other inflammatory processes as well (Smith, 2018). 5. LFTs, BUN/cr eatinine, e GFR, phosphorous: These tests are often measured to assess general health and are appropriate to test in Mary to evaluate for secondary causes of OP. Knowing her liver and kidney function status may be important when determining whether to use pharmacotherapeutics to manage her OP and VCFs. 6. TSH: Obtaining a TSH level is appropriate to evaluate for secondary causes of OP despite the fact that Mary does not describe symptoms consistent with thyroid abnormality. 7. Fasting serum calcium, 24‐hour urinary calcium, and ser um 25‐OH‐D (vitamin D): These tests are done to identify calcium and vitamin D levels. This data is important for any patient sus-pected of OP, as low calcium levels may suggest underlying pathology or secondary OP and must be rectified prior to starting any antiresorptive medication (Bethel, 2019; Camachoet al., 2016; Cosman et al., 2014). Similarly, low vitamin D levels (below 30 ng/m L) need to be corrected (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). Adequate vitamin D is needed both for normal bone resorption processes and for calcium absorption. 8. Spine films: Spine films can be used to diagnose VCFs. In patients with greater than 30% bone loss, OP can be seen on radiological examination. However, X‐ray is not used to diagnose OP. Patients with bone loss identified on X‐ray are referred for DXA. 9. DXA with FRAX®: DXA is considered the gold standard for the diagnosis of OP (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). Results are provided that include both T‐scores and Z‐scores; and, since early 2009, most reports also include the 10‐year risk probability for hip and major OP fractures identified by the FRAX ® algorithm. T‐scores identify how the patient's bone density compares to that of a normal young adult of the same gender. The Z‐score identifies how the patient's bone density compares to others of the same age and gender. Both T‐scores and Z‐scores are reported as standard deviations, with 0 indicating an exact match. Since they are standard deviations, a normal T‐score is-1 to +1. Low bone mass, or osteopenia, is identified with T‐scores of-1 to-2. 5; and osteoporosis is identified with T‐scores below-2. 5. Severe OP is identified with T‐scores below-2. 5 in the presence of fragility fracture(s) (World Health Organization [WHO], 1994). Low trauma fractures (formerly called fragility fractures) are those that occur with low trauma or a fall from standing height or less (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). FRAX ® is an individualized algorithm that identifies the probability of fracture over the next 10 years based on the patient's height, weight, and bone density raw score and the presence or absence of 11 additional risk factors such as smoking, history of RA,
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568 Resolutions steroid use, and parental history of hip fracture (WHO, 2007a, 2007b). FRAX® is used to assist with determining whether a specific patient would benefit from the use of pharmacotherapeutics to prevent fracture and thus is used for patients who have not previously been treated with medication. Analyses were done on the U. S. population to evaluate the cost of fracture and pharmacotherapy. These analyses revealed that it is cost effective to treat those with a 10‐year risk of hip fracture of above 3% or a 10‐year risk of major OP fracture of above 20% (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). It is important to note that a diagnosis of OP is not made based on DXA results alone. All patients, even those with a T‐score of below-2. 5, require a detailed history and physical examination with selected laboratory evaluations to identify any secondary causes of OP that can be treated and to determine safety in using possible pharma-cotherapeutic agents (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). What is the plan of treatment? Mary and her clinician need to address both of her diagnoses. She has documented VCFs identified by X‐ray as well as OP identified by DXA. The plan for her pain management for the VCFs will be of a more short‐term nature, while OP management will be long term. Self‐management lifestyle changes: Mary will initially need to avoid activities that increase her pain. She needs to understand that it may take 3 months before she is fully healed and that a return to activity as soon as possible is important. It will be important for her to see the physical therapist for pain modalities early on, as well as for strength-ening exercises for her upper midback and body mechanics retraining later to prevent further injury. For OP management, she will need to adjust her activity and intake of vitamin D and calcium. Mary needs to increase her activity and ensure that it includes both resistance and weight‐bearing activities each day. These activities will serve to increase osteoblast activity and thus strengthen bone. Mary also needs to assure daily intake of vitamin D of 800-1000 IU and calcium of 1200 mg (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). This level of vitamin D intake is enough to rectify her vitamin D deficiency within about a 3‐month period. Since most people cannot achieve the recommended daily intake of vitamin D and calcium through diet alone, it is likely that Mary will require ongoing calcium and vitamin D supplementation, even after her vitamin D levels are normalized. Many different supplement brands and types are available. Calcium citrate is less con-stipating than calcium carbonate and can be taken with or without meals. Calcium carbonate must be taken with meals, as an acid environment is needed for it to be absorbed. Calcium carbonate would not be an appropriate option for Mary if she uses antacids of any kind. Both calcium car-bonate and calcium citrate are also available as a combination tablet with vitamin D. Mary also needs to implement a fall prevention program (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). This is not because she is at an increased risk for falls simply due to her OP; it is more that the likelihood of fracture caused by a fall is increased significantly due to her OP. Mary's clinician will advise her to look around at home and remove any loose rugs or cords that she might fall or trip on. She will need to assure adequate lighting in case she needs to get up at night, again to lessen the risk of a fall. Similarly, she will need to ensure removal of snow, ice, or wet leaves and uncluttered walkways around her home to reduce the risk of a fall. Complementary and alternative medicine therapies: Mary may be interested in light massage therapy or acupuncture for pain management. While nei-ther of these therapies will increase bone strength, each may help to reduce her pain while the VCFs are healing. Continuing with these therapies may increase her tolerance for exercise later as well. Other relaxation therapies that may be beneficial include yoga, aromatherapy, and meditation. Yoga should not be initiated until the VCFs have healed and will need to be modified to avoid any forward bending (flexion) of the spine. Research results evaluating the use of soy to improve bone strength have been contradictory; some demonstrate a benefit, while others show none. A meta‐analysis that reviewed randomized, controlled trials did not find overall support for the use of soy to prevent bone loss (Zheng, Lee, & Chun, 2018).
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Back Pain 569 Pharmacotherapeutics: Pharmacotherapeutic agents for both Mary's VCF pain and management of her OP are reasonable. Her pain may be adequately managed by consistent use of acetaminophen, dosed at 1000 mg by mouth every 6 hours, or in combination with a nonsteroidal anti‐inflammatory drug (NSAID). If an NSAID is used, she must be cautioned to take it with food to reduce the likelihood of developing gastrointestinal irritation as a side effect, especially if she is prescribed a bisphosphonate for her OP. If acetaminophen or a combination of acetaminophen and NSAIDs is ineffective, then acet-aminophen combined with a narcotic analgesic, such as acetaminophen with codeine, may be tried. A return to usual activity as soon as possible is the goal. Mary meets the criteria established by both the National Osteoporosis Foundation (NOF) and the American Association of Clinical Endocrinologists (AACE) for pharmacotherapeutic treatment of her OP (Camacho et al., 2016; Cosmanet al., 2014). Both organizations recommend initiating medication therapy in individuals with documented OP, which Mary has. In fact, Mary meets the diagnostic criteria established by the WHO for severe osteoporosis, because she has a spine T‐score of-2. 5 on DXA plus fragility or low‐trauma fractures (VCFs) (WHO, 1994). Even if Mary's DXA scores had not indicated OP and she did not have VCFs, her clinician would still consider pharmacotherapeutic therapy for her, as her FRAX ® 10‐year risk for major OP fracture was above the cutoff of 20. 0%. This suggests that it would be cost effective, based on U. S. population calculations, to treat Mary with medications for OP (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). The purpose of pharmacotherapy for OP is to reduce fracture incidence and its related sequelae. Several different effective medications for OP management are currently available in the United States and approved by the FDA, including bisphosphonates, calcitonin, estrogen agonist/antagonists, hor-mone therapy (estrogen or estrogen‐progestin therapy), a RANK‐ligand inhibitor, and parathyroid hormone (see Table 10. 6. 1). These medications can be categorized into two groups: antiresorptive or anabolic. Antiresorptive agents increase bone strength by inhibiting the function of the osteoclasts and include bisphosphonates, calcitonin, estrogen agonist/antagonists (which were previously known as selective estrogen receptor modulators [SERMs]), and hormone therapy (HT, estrogen or estrogen‐progestin therapy). Denosumab is also in this category and increases bone density by binding with RANK‐ligand, which ultimately inhibits osteoclast formation and function. Anabolic agents stimulate bone formation by increasing osteoblast activity and include one agent—teriparatide. For Mary, selecting an agent will focus on identifying an effective therapy that is acceptable to her, does not interfere with her current medications, and has a reasonable side‐effect profile. Because she has established OP, she needs a medication that is approved for OP treatment. This means that hormone therapy is not an appropriate option. If Mary had osteopenia and was also experiencing significant menopause‐related symptoms, then HT or estrogen + bazedoxifene (Duavee ®) might be a good option (e Pocrates, updated daily; North American Menopause Society, 2014). Bisphosphonates are frequently identified as first‐line options for OP. Several different med-ications are now available in this class with varied frequency of dosing and varied routes of administration. Some are also available in generic formulation, which can significantly reduce cost. A precise procedure for taking oral bisphosphonates must be followed to reduce the risk of esoph-ageal irritation. Other rare side effects are also possible (see Table 10. 6. 1). If Mary starts with a bisphosphonate and is unable to follow the oral medication regimen or has a low bone‐density response, she might have better adherence with an injectable bisphosphonate or denosumab. Denosumab is also identified as a first‐line option. If Mary was at high risk for breast cancer, raloxi-fene might be a better option for her. Calcitonin is sometimes used for the pain associated with VCFs and might be considered for Mary. However, other OP medications have better fracture pre-vention data and Mary's pain will likely be well managed with analgesics instead. Teriparatide or abaloparatide are unlikely options for Mary as these are generally reserved for use in patients who do not respond to first‐line medication options. Poor adherence to OP medication is a significant problem. Therefore, it is important that Mary is an active participant in deciding which medication to use. She is much more likely to continue with the medication if it is taken on a schedule that
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570 Resolutions T able 10. 6. 1. Prescription Agents for Osteoporosis Management. Medication FDA‐Approved Use and Dose Considerations Alendronate (Fosamax) PMO prevention—5 mg by mouth daily or 35 mg by mouth weekly. SIO—5 mg by mouth daily or 10 mg by mouth daily if postmenopausal and off estrogen PMO and MOP treatment—10 mg by mouth daily or 70 mg by mouth weekly. Take oral doses first thing in the morning on an empty stomach with 8‐oz glass of plain water; remain upright and take no other food or drink for at least 30 minutes. Take oral doses 2 hours before antacids/calcium. Caution with oral forms if upper gastrointestinal disease, clinical association with dysphagia, esophagitis, or ulceration. Beneficial effects may last for years after medication is discontinued. Alendronate + cholecalciferol (Fosamax plus D)PMO and MOP treatment—70 mg plus 2800 IU Vitamin D 3 or 70 mg plus 5600 IU vitamin D3 in combined tablet by mouth weekly. Fosamax plus D—combined bisphosphonate and vitamin D 3 in a single tablet taken weekly. Actonel with calcium—blister pack for 28‐day use, provides Actonel in 1 tablet taken on day 1 and calcium in other 6 tablets taken days 2-7, repeated sequence over 4 weeks. Risedronate (Actonel) PMO prevention or treatment— 5 mg by mouth daily, 35 mg by mouth weekly, 75 mg by mouth 2 consecutive days each month, or 150 mg by mouth monthly. SIO—5 mg by mouth daily. MOP—35 mg by mouth weekly. IV ibandronate and zoledronic acid are not associated with gastrointestinal side effects or limitations on timing dose around food, water, calcium, or medication intake. Hypocalcemia must be corrected prior to use. Ibandronate (Boniva) PMO prevention or treatment— 2. 5 mg by mouth daily or 150 mg by mouth monthly. PMO treatment—3 mg IV every 3 months. Subtrochanteric fracture is an extremely rare event that has been associated with bisphosphonate use. Advise patients that the risk of this extremely rare event is far less than the risks associated with hip fracture and encourage them to take their prescribed bisphosphonates consistently. Zoledronic acid (Reclast)PMO prevention—5 mg IV every 2 years. PMO, MOP, and SIO treatment— 5 mg IV yearly. Calcitonin (Miacalcin, generic nasal spray)PMO treatment—200 IU intranasal spray daily (generic) or 100 IU subcutaneously 3 times each week (Miacalcin). Usually administered as nasal spray. Alternate nares for nasal spray. Most often used for analgesic effect on acute pain due to vertebral compression fractures. Denosumab (Prolia, Xgeva)PMO treatment—60 mg injection (subcutaneous) every 6 months. Denosumab is for those with multiple risks for fracture, with osteoporotic fracture history, and who have not responded to other treatments. Requires administration by a health care professional. Use may be associated with ONJ, oversuppression of bone turnover, skin infections, and dermatologic conditions. Individuals with a latex allergy should not handle gray needle cover. Hypocalcemia must be corrected prior to use. Estrogen (e. g., Alora, Climara, Estrace, Menest, Menostar, Premarin, Vivelle Dot)PMO prevention—doses and routes vary. Also effective in alleviating most symptoms related to menopause (even Menostar, which has a very low dose and was shown to effectively reduce severity and frequency of hot flashes). Estrogen + Bazedoxifene (Duavee)PMO prevention Also effective in alleviating most symptoms related to menopause.
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Back Pain 571 works for her life. This may mean daily or nondaily oral medications, or possibly infrequent office visits for injectable medications. Ensuring insurance coverage of her selection is also crucial. What are the plans for referral and follow‐up care? Referral to physical therapy initially for pain modalities and later for strengthening exercises and body mechanics training is appropriate. If Mary does not respond to routine pain management strategies or if her DXA T‐scores continue to fall, then referral to a specialist may be indicated. Consultation with an OP specialist may be warranted if she is not responding to therapy. A pain specialist or ongoing physical therapy may help to alleviate her pain. Some patients with VCFs require referral for surgical intervention, such as kyphoplasty or vertebroplasty, to relieve pain and preserve function. Kyphoplasty (a balloon is inserted into the vertebral space, is inflated to straighten the vertebral bones, and is then replaced with a cement‐like substance) is performed under local anesthesia so pain and function can be monitored throughout the procedure. Vertebroplasty is similar and was the precursor to kyphoplasty. Vertebroplasty is usually per-formed by interventional radiologists and involves injection of a cement‐like substance into the fractured vertebrae. If effective, pain relief is almost immediate after either procedure. In addition to reevaluating Mary's ability to follow the management plan including both medi-cations and self‐management strategies at every visit, a follow‐up DXA scan will be ordered for about 1-2 years to evaluate the efficacy of Mary's management strategies (Bethel, 2019; Camacho et al., 2016; Cosman et al., 2014). It will be repeated every 1-2 years until her results are stable. If her T‐scores do not improve after a few years, her clinician might consider changing the pharmaco-therapeutic agent to an alternate class or consider referral to an OP specialist. What health education should be provided for this patient? While OP is not wholly reversible, slowing bone loss with the described self‐management strategies is crucial to reducing the impact of the disease and preventing future fractures. It is important for Mary to understand that she has a lifelong challenge ahead of her to retain her current bone strength and hopefully build upon it. This can only be successful with a combined management plan that includes self‐management lifestyle strategies—such as regular exercise, adequate calcium and vitamin D intake, and careful monitoring of her RA—and consistent use of her OP medications. Medication FDA‐Approved Use and Dose Considerations Estrogen‐Progestin combination products (e. g., Activella, Climara, Climara Pro, Femhrt, Prefest, Premphase, Prempro)PMO prevention—doses and routes vary. Available in several forms (e. g., pills, patch, ring, cream, gel). Use for 2-3 years immediately following menopause may provide some beneficial effects on bone health after discontinuation. Raloxifene (Evista) PMO prevention or treatment— 60 mg by mouth daily. May cause hot flashes. Not recommended if taking ET or EPT. Also approved for prevention of breast cancer in women at high risk for invasive breast cancer. Teriparatide [recombinant human PTH 1-34] (Forteo) Abaloparatide (Tymlos)PMO, MOP, and SIO treatment (high fracture risk)—20 mcg subcutaneously daily. (A teriparatide patch for osteoporosis is under investigation. )Reserved for use after failure of first‐line agents. Most effective when used sequentially following bisphosphonate. PMO = postmenopausal osteoporosis; SIO = steroid‐induced osteoporosis; MOP = male osteoporosis. Source: e Pocrates (updated daily); Bethel (2019); Camacho et al. (2016); Cosman et al. (2014). Table 10. 6. 1. (Continued)
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572 Resolutions What demographic characteristics might affect this case? Several of the medications available for OP treatment and prevention only carry FDA approval for use in postmenopausal women, so agent selection options would be narrowed (see Table 10. 6. 1). Does the patient's psychosocial history impact how you might treat her? If Mary were under 40, a more aggressive search for other secondary causes of OP would be appro-priate. Any conditions identified would then need to be managed to reduce bone loss. Additionally, most of the medications available for OP treatment and prevention do not carry FDA approval for use in premenopausal women, so agent selection options would be narrowed (see Table 10. 6. 1). Consideration of Mary's psychosocial history is important when developing a management plan with her. Consideration of Mary's health care insurance coverage of medications, physical therapy, and DXA evaluations is important. Many insurance companies dictate which pharmacotherapeutic agents are covered. Similarly, most companies have rules governing the frequency of covered DXA testing and the length of physical therapy treatments. These issues are taken into account when deciding on a management plan with Mary so that financial barriers to the cost of medications, follow‐up DXA testing, or PT do not become barriers to her ability to follow the agreed upon plan. Are there any standardized guidelines that should be used to treat this case? If so, what are they? Both the National Osteoporosis Foundation and the American Association of Clinical Endocrinologists have published guidelines for osteoporosis prevention, identification, and management (Camacho et al., 2016; Cosman et al., 2014). REFERENCES Bethel, M. (2019). Osteoporosis. e Medicine, Med Scape. Accessed September 27, 2019. Available at: https:// emedicine. medscape. com/article/330598‐overview. Camacho, P. M., Petak, S. M., Binkley, N., Clarke, B. L., Harris, S. T., Hurley, D. L., . . . Watts, N. B. (2016). American Association of Clinical Endocrinologists and American College of Endocrinology clinical prac-tice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2016. Endocrine Practice, 22(Suppl. 4), 1-42. https://journals. aace. com/doi/pdf/10. 4158/EP161435. GL Cosman, F., de Beur, S. J., Le Boff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., & Lindsay, R. (2014). Clinician's guide to prevention and treatment of osteoporosis. Osteoporosis International, Online (August 2014), 1-25. file:///C:/Users/ima00001/Downloads/Clinicians‐Guide. pdf e Pocrates. (Updated daily). Computerized pharmacology and prescribing reference [Mobile application soft-ware]. Retrieved from http://www. epocrates. com Jagpal, A., & Navarro‐Millan, I. (2018). Cardiovascular co‐morbidity in patients with rheumatoid arthritis: A narrative review of risk factors, cardiovascular risk assessment and treatment. BMC Rheumatology, 2, article no. 10. https://bmcrheumatol. biomedcentral. com/articles/10. 1186/s41927‐018‐0014‐y Maas, A. H. E. M. (2017). The clinical presentation of “angina pectoris” in women. E‐Journal of Cardiology Practice, 15(3). https://www. escardio. org/Journals/E‐Journal‐of‐Cardiology‐Practice/Volume‐15/The‐ clinical‐presentation‐of‐angina‐pectoris‐in‐women. North American Menopause Society (NAMS). (2014). Menopause practice: A clinician's guide (5th ed. ). Mayfield Heights, OH: Author. Smith, H. R. (2018). Rheumatoid arthritis. e Medicine. Medscape. Accessed July 30, 2019. Available at: https:// emedicine. medscape. com/article/331715‐overview World Health Organization. (1994). Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical report series. Geneva: Author. World Health Organization. (2007a). WHO FRAX Technical Report. Retrieved June 6, 2008, from http://www. shef. ac. uk/FRAX/ World Health Organization. (2007b). WHO scientific group on the assessment of osteoporosis at the primary health care level: Summary meeting report. Geneva, Switzerland: Author. Zheng, X., Lee, S‐K., & Chun, O. K. (2018). Soy isoflavones and osteoporotic bone loss: A review with an emphasis on modulation of bone remodeling. Journal of Medical Food, 191(1), 1-14. doi:10. 1089/ jmf. 2015. 0045. https://www. ncbi. nlm. nih. gov/pmc/articles/PMC4717511/pdf/jmf. 2015. 0045. pdf
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573 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 7 Acute Joint Pain RESOLUTION What is the most likely diagnosis and why? Acute gouty arthritis: The location of the joint pain in the first metatarsophalangeal (MTP) joint, redness, swelling, warmth, and tenderness to light touch are all consistent with an acute gout flare. Other factors that make this the most likely diagnosis include Rami's male sex, history of hypertension, lack of known injury, unilateral presentation, and absence of fevers/chills. What are possible differential diagnoses? See Table 10. 7. 1. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? When suspecting gout the most important diagnosis to rule out is septic arthritis, as they have sim-ilar presentations. If there is concern for septic arthritis a joint aspiration with synovial fluid anal-ysis should be performed. The presence of monosodium urate (MSU) crystals in the joint fluid confirms the presence of gout; the presence of bacteria and white blood cells in the joint fluid con-firms septic arthritis. If the risk for septic arthritis is low and a joint aspiration cannot be easily obtained other diagnostics including joint X‐ray, CBC and serum uric acid levels can help to make the diagnosis. Of note, an elevated serum uric acid level lends support to the diagnosis of gout but is not diagnostic. Interestingly, serum uric acid levels can be normal during acute gout flares. Renal function should be checked to help guide treatment choice as several of the treatment options for gout are contraindicated in renal insufficiency. What is the plan of treatment? There are several options to consider when treating an acute gout flare. The need to start treatment as soon as possible after a flare occurs should be discussed. The choice of pharmacologic agent is mostly dependent on the patient's other comorbidities as one is not superior to the other in clinical trials. Options include: NSAIDs: High‐dose NSAIDs, such as naproxen or indomethacin, ar e effective in the management of gout. Common contraindications to NSAID use include renal insufficiency,
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574 Resolutions T able 10. 7. 1. Differential Diagnoses. Condition Signs and Symptoms Sprain/strain Acute pain and swelling following an injury. Decreased range of motion, possibly with ecchymosis. Pertinent negatives: redness, fever, warmth. Septic arthritis Acute monoarticular joint pain with associated redness, swelling, and warmth; Significantly decreased range of motion; often accompanied by fever, chills. Hip and knee joints are the most commonly affected. Osteoarthritis Insidious, progressive joint pain and stiffness; worse upon first arising and after significant activity; generally relieved by rest; welling and crepitus may be present; generally not symmetrical. Rheumatoid arthritis Insidious onset over weeks or months; often bilateral, symmetrical joint pain with associated swelling, aching, and morning stiffness lasting over an hour; associated systemic symptoms such as weakness, weight loss, malaise, fatigue, and loss of appetite are often present. history of gastrointestinal bleeding/peptic ulcer disease, and prior bariatric surgery. The con-comitant use of a proton pump inhibitor (PPI) with an NSAID could be considered to help minimize the risk of stomach upset and perforation. Given that Rami has stomach upset with ibuprofen, other treatment options should be considered. Colchicine: This medication is most effective if started within 24 hours of an acute gout flar e. Some patients may be on colchicine for prevention of acute gout episodes. Patients with renal or hepatic dysfunction should not use colchicine. A common side effect is diarrhea. Oral corticosteroids: Oral ster oids are recommended for patients with contraindications to NSAIDs and/or colchicine; however, they should be used with caution in patients with a concurrent infection or history of diabetes mellitus. Corticosteroids can also be administered intraarticularly after a joint aspiration. In addition to pharmacotherapy, icing and elevation may help relieve symptoms. Are there any modifiable risk factors or medications Rami is taking that could contribute to this diagnosis? Alcohol use is a risk factor for the development of gout. Discussing with Rami the reduction of his nightly alcohol intake would be recommended. Thiazide diuretics are also associated with an increased risk of gout. Consider changing Rami's chlorthalidone to an alternate blood pressure medication. There is some evidence that use of the angiotensin receptor blocker losartan can help decrease uric acid levels. What are the plans for referral and follow‐up care? Should Rami require a joint aspiration, referral to a provider able to perform this procedure and analyze the joint fluid is appropriate. In cases of refractory gout symptoms, referral to rheuma-tology may be appropriate. Follow‐up within 1-2 days is recommended if there is no improvement in symptoms. What health education should be provided to Rami at this visit? Several lifestyle changes can be made for Rami. Consumption of meat, seafood, alcohol, and sugar‐sweetened beverages and foods containing high‐fructose corn syrup can contribute to the development of gout and the incidence of acute attacks. Education around limiting these foods and beverages is recommended. Weight loss can also be beneficial for preventing future attacks. Reiterating the importance of starting treatment as soon as possible in future attacks would also be beneficial.
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Acute Joint Pain 575 What if Rami had uncontrolled diabetes mellitus? How would this affect the treatment plan? It would be important to avoid the use of oral corticosteroid if possible in patients with diabetes. Rami recovers from his current symptoms but comes in again in 4 months with a similar problem. What should be done for him at this visit? Rami would require treatment for his acute gout attack; however, he now meets criteria for initia-tion of urate‐lowering therapy (ULT). ULT is not recommended after the first gout attack or in patients with infrequent attacks. In patients with more frequent attacks or evidence of tophaceous deposits on exam or X‐ray, the initiation of ULT is recommended. The most common medication used for ULT is allopurinol 100-300 mg daily. When starting ULT, patients may experience an increased number of gout flares. In order to prevent this, prophylaxis with either NSAIDs or col-chicine is recommended along with ULT for the first 6 months, assuming no contraindications. The goal for ULT is to titrate the serum uric acid level to <6 mg/d L. REFERENCES AND RESOURCES Qaseem, A., Mc Lean, R. M., Starkey, M., & Forciea, M. A. (2017). Diagnosis of acute gout: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(1), 52-57. Qaseem, A., Harris, R. P., & Forciea, M. A. (2017). Management of acute and recurrent gout: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(1), 58-68. Schlesinger, N. (2017). Gout. In T. M. Buttaro, J. Trybulski, P. Polgar‐Bailey, & J. Sandberg‐Cook (Eds. ), Primary care: A collaborative practice (5th ed., pp. 928-932). St. Louis: Elsevier.
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577 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 8 Itching and Soreness RESOLUTION What is the most likely differential diagnosis and why? Aside from cherry angiomas and seborrheic keratoses, Rosa has no visible entry wound or lesions. She has no papules, vesicles, urticaria, redness, or swelling in the affected area. The absence of a rash, lesion, inflammation, or visible insect bite makes bug bites, contact dermatitis, and seborrheic dermatitis unlikely. The initial small, red papule associated with scabies may be difficult to see, but it is often accompanied by small linear burrows that assist in diagnosis. Scabies often appears in areas such as the finger webs, axillary or subgluteal folds, and/or flexor (wrists) or extensor (elbows and knees) surfaces of the joints. This condition is intensely pruritic, especially at night (Raffi, Suresh, & Butler, 2019). Rosa's irritation and tenderness are not consistent with scabies. Xerosis and systemic diseases may contribute to pruritus (as described earlier), but they do not explain the localized sensory symptoms. Medication side effects should always be considered in the differential diagnosis of new symp-toms in the elderly. Medications may precipitate changes in mental status, falls, or functional decline. Older adults experience adverse drug effects more often due to polypharmacy, drug inter-actions, and age‐related changes in pharmacokinetics and pharmacodynamics. Dermatologic side effects of medicines may result in maculopapular rashes, photosensitivity, or desquamation. Toxic epidermal necrosis (TEN) and Stevens-Johnson Syndrome (SJS) are rare, life‐threatening condi-tions that may appear within weeks to months of starting a new medicine. (There are also non‐medication‐related causes. ) These syndromes may present with skin pain and other systemic symptoms prior to evolution of the characteristic skin lesions (Schneider & Cohen, 2017). Allopurinol is one of the medicines that may precipitate this reaction, but Rosa has been taking this medicine for some time. She has no suspicious eye or mucous‐membrane findings and has not had any pro-dromal flu‐like symptoms. Musculoskeletal pain may also be associated with medications. Rosa is taking alendronate; cases of serious bone, joint, or muscle pain have been reported with the use of bisphosphonates (U. S. Food and Drug Administration, 2018). Pain begins days to months after beginning therapy and typically begins locally but spreads and may become severe, interfering with daily activities. Rosa's pattern of symptoms and her findings on examination suggest a distinctly different etiology for her discomfort, but it would not be unreasonable for the clinician to hold the next dose of alendronate pending confirmation of the diagnosis.
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578 Resolutions Rosa's history of osteoporosis suggests an increased risk of fracture. The nurse practitioner would know that thoracic discomfort and tenderness may be consistent with a rib fracture, which can occur with little or no trauma in older adults with osteoporosis. Fracture would be suspected if Rosa's pain was aggravated by inspiration or if point tenderness was found on palpation when she took a deep breath. Rosa's corticosteroid therapy increases her risk for osteoporosis, skin changes (thinning and easier bruising), high blood sugar, and other effects. Rosa's history of polymyalgia rheumatica (PMR) may result in symptoms such as aching, stiff-ness (worse in the morning and late at night), and weakness in the upper arms, thighs, neck, or lower back, but PMR is not associated with itching or significant tenderness on palpation. Note: Older adults with PMR should be educated to notify their clinician immediately if they have vision changes or headache, since PMR can be associated with a serious condition in the elderly called giant cell arteritis (GCA), also known as temporal arteritis. Early recognition and treatment of GCA may prevent permanent blindness and other serious sequelae (Resnick & Gershowitz, 2019). Nostalgia paresthetica is an underdiagnosed condition characterized by pruritis in the mid-scapular region associated with pain or sensory symptoms. It may or may not include a hypo‐ or hyperpigmented macule. It may be associated with intervertebral disc or nerve impingement and is more common in women; mean age of onset is 50-60 years. Symptoms may last 2-3 years (Howard, Sahhar, Andrews, Bergman, & Gin, 2018). Rosa has no prior history of a similar rash. She did have chickenpox in childhood and has no history of receiving the herpes zoster vaccine. Risk factors for varicella zoster virus (VZV) reactiva-tion include older age and immunosuppression (Schmader, 2016). You suspect shingles based on the acute onset and neurosensory symptoms in a dermatomal pattern. Your suspicions are con-firmed when Rosa returns several days later with a weeping rash along the T5 dermatome associ-ated with a sharp stinging sensation. You find a mixture of erythematous papules and vesicles. Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? Herpes zoster is a clinical diagnosis based on dermatomal‐pattern vesicular rash with neurosen-sory symptoms. Diagnostic tests are not needed unless there is diagnostic uncertainty or possible disseminated disease in an immunocompromised individual. Viral identification by PCR or fluorescent antibody testing may be helpful in those cases (Saguil, Kane & Mercado, 2017). An ESR may be used to assess inflammation related to PMR, but it is not as useful in the context of an acute dermatologic condition. Chemistry profiles may identify systemic disease but are not warranted by dermatologic symptoms alone. Skin scrapings and microscopy are useful for scabies identification. What is the management plan? The management plan has three main goals: to treat the presenting disease or condition, to prevent negative sequelae and excess disability, and to promote comfort. Antiviral therapy is recommended within the first 72 hours after onset of rash to lessen acute discomfort and reduce symptom dura-tion (O'Connor & Paauw, 2013; Schmader, 2016). While there is insufficient evidence to support benefit after 72 hours, this may still be considered if new lesions are still emerging or in cases of ophthalmic involvement. Research is mixed on whether antiviral therapy reduces the risk of postherpetic neuralgia (PHN), a painful complication of shingles. The two greatest risk factors for PHN are older age and severity of acute symptoms (i. e., pain and rash). Acyclovir, famciclovir, and varaciclovir are the currently available antiviral agents. They differ in cost, dosing frequency, and efficacy in treating acute and postherpetic neuralgia. The most common side effects of these agents are nausea, vomiting, diarrhea, and headache. Patients with disseminated lesions and/or impaired immune competence (e. g., patients with HIV, and malignancies) should be referred to a specialist. Facial lesions or paralysis should prompt an assessment of the ear canals for involvement. If the VZV affects the facial nerve (Ramsay Hunt syndrome), it may cause facial paralysis, intense ear pain, hearing loss, dizziness, tinnitus, or loss
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Itching and Soreness 579 of balance. Patients with facial or trigeminal nerve involvement or lesions in the ears or near the eyes should be referred. Ocular zoster is an emergency that may result in permanent vision loss, and patients should be immediately referred to an ophthalmologist. The American Dermatology Association recommends using cool wet cloths, cool baths, or ice packs for comfort (American Association of Dermatology, 2019). When not using these, the area should be kept clean and dry, covered with nonstick, sterile bandages. Calamine lotion may be applied to the rash and blisters to reduce itching. Colloidal oatmeal baths are also used for symp-tomatic relief and loose, cotton clothing may improve comfort. The varicella zoster virus (VZV) can spread from a person with active shingles and cause chick-enpox in someone who is not immune to the disease. Contact with fluids from the rash blisters poses risk of transmission. Until all lesions are crusted over, the individual should avoid contact with pregnant women and persons who are not immune to chickenpox. Airborne precautions are recommended in cases of disseminated zoster (Centers for Disease Control, 2018). Pain management is a key component of care. Corticosteroids do not prevent or shorten PHN but may be used to reduce acute pain. Acetaminophen and nonsteroidal anti‐inflammatory drugs (NSAIDS) are used for generalized pain relief in acute zoster. NSAIDs pose greater risks for older adults (Wehling, 2014) and, if prescribed, should be used in the lowest dosage and for the shortest time necessary. Tricyclic antidepressants (TCAs) and anticonvulsants such as gabapentin and pre-gabalin are used to treat the neuropathic pain of PHN (John & Canaday, 2017). Topical lidocaine is a well‐tolerated option for PHN and some patients may also receive benefit from capsaicin, but the burning sensation may not be tolerable, and some patients are adverse to touch and all topical therapies. Nonpharmacologic strategies for pain management and/or stress reduction include progressive muscle relaxation, meditation, guided imagery, deep breathing, physical exercise, and distraction. Nutritional assessment and counseling are key strategies to support immunologic competence. Frequent follow‐up and evaluation of pain relief and psychosocial well‐being are essential. Stress management techniques and psychosocial interventions may be indicated. PHN‐related pain may decrease quality of life and may result in depression, decreased activity level, decreased appetite, impaired sleep, decreased function, and social isolation. Some older adults may use alcohol or other substances to obtain symptom relief. Are any referrals appropriate at this time? Referral to an ophthalmologist is essential to prevent vision loss related to herpes zoster opthal-mica (HZO), a prodrome of headache, malaise, and fever followed by unilateral pain in the eye, forehead, or top of head and conjunctivitis (Conceicao, 2018; John & Canaday, 2017). Referral to a pain specialist is indicated for severe or persistent pain. Cognitive‐behavior modi-fication, biofeedback, and relaxation training may be used, as well as nerve blocks. Referral to a mental health professional for assessment and counseling may also be indicated. Which of the clinical findings are consistent with normal aging changes? Aging is associated with changes in cellular structure and function resulting in changes in skin dry-ness, fragility, atrophy, and decreased elasticity (Resnick & Gershowitz, 2019). Aging skin is more susceptible to wrinkling, uneven tearing, and purpura (purplish discolorations caused by extrava-sation of blood into the tissues after minor trauma). Benign lesions such as seborrheic keratoses (yellow, light tan, brown, or brown‐black scaly or waxy growths) and cherry angiomas (tiny, bright‐red papules) are more common in older adults. Many skin changes are related to environmental factors including air quality and chronic sun exposure over the life course, contributing to accelerated skin aging, dryness, and increased risk for premalignant (e. g., actinic keratoses) or malignant skin growths (including basal cell and squamous cell carcinomas and malignant melanomas). Genetic factors and lifestyle habits contribute to het-erogeneity in dermatologic changes in older adults.
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580 Resolutions Some of Rosa's dermatologic findings may be attributed to normal, age‐related interactions with genetic factors (e. g., the cherry angiomas and seborrheic keratoses); and her new complaint of pruritus (itching) may stem in part from xerosis (dry, cracked, or rough skin, which occurs more commonly in cold, low‐humidity environments and in older age); but neither aging nor xerosis provides a sufficient explanation for her sensory symptoms and tenderness to touch. The nurse practitioner needs to pursue a more comprehensive assessment and diagnostic approach. What are the most common causes of pruritus (itching) in older adults? What are the risks and benefits of antihistamine therapy for pruritus, such as diphenhydra-mine (Benadryl©)? Itching may be associated with dermatologic conditions (xerosis, scabies, urticaria insect bites), neuropathic conditions (herpes zoster or postherpetic neuralgia, neuropathic syndromes), systemic disease (cholestasis, kidney disease, malignancies, thyroid disease), and psychiatric conditions (obsessive‐compulsive disorders, somatization disorders) (Nowak & Yeung, 2017). Dry, rough skin (xerosis), especially over the lower legs, is a common skin finding in older adults, occurring in more than 50% of elderly patients (Berger, Shive & Harper, 2013). Medication side effects are another common cause of pruritis, particularly with thiazide diuretics and calcium channel blockers, as well as photosensitizing medications (Berger et al., 2013). Older adults with contact dermatitis, eczema, psoriasis, folliculitis, and infestation may also pre-sent with itching as the primary complaint. In scabies, the severity of the itching is usually out of proportion to the skin appearance. If these dermatoses have been ruled out and pruritis persists, metabolic and systemic causes must be considered. Pruritis is a common symptom associated with pre‐ and postherpetic disease in shingles (Valdes‐ Rodriguez, Stull & Yosipovitch, 2015). Systemic conditions associated with pruritus include renal disease, liver disease, thyroid disease, endocrine disease, hematologic disease, infectious disease, autoimmune disease, and cancer (Chinniah & Gupta, 2014; Fazio & Yosipovitch, 2019). These con-ditions typically cause generalized, rather than limited, pruritus. Moses (2003) provides a diagnos-tically useful pictorial chart, organizing likely causes of pruritis by body location. Dry skin is treated by avoiding or reducing exposure to aggravating agents (e. g., harsh deter-gents and alkaline soaps; chemicals including chlorine; and long, hot baths or soaks) and treating liberally with emollients applied to moist skin, immediately after bathing, to seal in moisture (Kirkland‐Kyhn, Zaratkiewicz, Teleten & Young, 2018). Urea‐based products, glycerin, and petro-latum products are often used to maintain moisture and scaling may be treated with keratolytics that contain alpha hydroxy or lactic acid (Fazio & Yosipovitch, 2019; Kirkland‐Kyhn et al., 2018). Humidification of dry environments may be helpful. Diphenhydramine is appropriate for emergency allergic reactions, but is not recommended for routine use in older adults as a hypnotic or antipruritic, due to the risk of confusion and sedation. Diphenhydramine is one of the medications listed in the American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (American Geriatrics Society 2019 Criteria Update Expert Panel, 2019). The published Beers criteria include an explicit list of medications that are best avoided in older adults or must be used with caution due to increased risk for delirium, falls, or increased mortality. If new lesions continue to appear after 1 week, what additional considerations should be addressed? Patients with new lesions appearing after 1 week may have underlying conditions that impair immune function and should be referred for more extensive evaluation. Which specific vaccines' dates of administration should be included in immunization documentation for older adults? In addition to the standard recommendations for all adults, the Centers for Disease Control (CDC, 2018) recommends the following vaccines for adults age 65 and older: influenza (inactivated or
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Itching and Soreness 581 recombinant), tetanus and diphtheria booster, zoster recombinant (2 doses) or zoster live (1 dose), pneumococcal conjugate (PCV13), and pneumococcal polysaccharide (PPSV23). The recombinant zoster vaccine (Shingrix) is recommended by the Advisory Committee on Immunization Practices (ACIP) as the preferred vaccine because it is more than 90% effective at preventing shingles and PHN, but Zostavax ® may be used if the patient is allergic to Shingrix. Shingrix should be given even if the older adult has had shingles, received Zostavax in the past or is not certain whether they have had chickenpox (CDC, 2018). When an older adult presents with new symptoms, accurate diagnosis facilitates appro-priate treatment to prevent further health and functional decline. List two additional ques-tions the practitioner should consider to guide clinical care. How can excess disability be prevented? While early and recognition and treatment with antivirals may prevent or mitigate the severity of PHN, these strategies are not always effective. The best opportunity to prevent pain and disability is vaccination with Shingrix. Education in primary care and community health settings is critical to make older adults aware of the need for prompt evaluation and treatment. How can comfort (physical, psychosocial, and spiritual) be enhanced, beginning immediately? How can suffering be reduced? By correcting any myths or unfounded fears, alleviating uncertainty, enhancing a sense of control and participation in self‐care, and providing reassurance, as well as using nonpharmacologic and pharmacologic comfort measures. REFERENCES AND RESOURCES American Association of Dermatology. (2015). Tips for treating shingles. Available at: https://www. aad. org/ media/news‐releases/dermatologists‐share‐tips‐for‐treating‐shingles American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi:10. 1111/jgs. 15767. Berger, T. G., Shive, M., & Harper, G. M. (2013). Pruritus in the older patient: A clinical review. JAMA, 310(22), 2443-2450. doi:10. 1001/jama. 2013. 282023 Centers for Disease Control. (2018). What everyone should know about shingles vaccine (Shingrix). Available at: https://www. cdc. gov/vaccines/vpd/shingles/public/shingrix/index. html Chinniah, N., & Gupta, M. (2014). Pruritus in the elderly: A guide to assessment and management. Australian Family Physician, 43(10), 710-713. Retrieved from https://search‐ebscohost‐com. libraryproxy. quinnipiac. edu/login. aspx?direct=true&db=ccm&AN=109680891&site=ehost‐live&scope=site Conceicao, V. (2018). Prevention and management of shingles and associated complications. Journal of Community Nursing, 32(6), 40-43. Dodiuk‐Gad, R. P., Chung, W. H., Valeyrie‐Allanore, L., & Shear, N. H. (2015). Stevens-Johnson syndrome and toxic epidermal necrolysis: An update. American Journal of Clinical Dermatology, 16, 475-493. https://doi. org/10. 1007/s40257‐015‐0158‐0 Fazio, S., & Yosipovitch, G. (2019). Pruritus: Etiology and patient evaluation. In R. P. Dellavalle & J. Callen (Eds)., Up To Date. Waltham, MA: Up To Date Inc. https://www. uptodate. com (Accessed October 6, 2019). Howard, M., Sahhar, L., Andrews, F., Bergman, R., & Gin, D. (2018). Notalgia paresthetica: A review for der-matologists. International Journal of Dermatology, 57(4), 388-392. doi:10. 1111/ijd. 13853 John, A. R., & Canaday, D. H. (2017). Herpes zoster in the older adult. Infectious Disease Clinics of North America, 31(4), 811-826. doi:S0891‐5520(17)30070‐3 [pii] Kirkland‐Kyhn, H., Zaratkiewicz, S., Teleten, O., & Young, H. M. (2018). Caring for aging skin: Preventing and managing skin problems in older adults. American Journal of Nursing, 118(2), 60-63. doi: 10. 1097/01. NAJ. 0000530249. 91452. 4e.
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582 Resolutions Moses S. (2003). Pruritus. American Family Physician, 68(6), 1135-1012. Retrieved from https://search‐ ebscohost‐com. libraryproxy. quinnipiac. edu/login. aspx?direct=true&db=ccm&AN=106707867&site=eh ost‐live&scope=site Nowak, D. A., & Yeung, J. (2017). Diagnosis and treatment of pruritus. Canadian Family Physician Medecin De Famille Canadien, 63(12), 918-924. doi:63/12/918 [pii] O'Connor, K. M., & Paauw, D. S. (2013). Herpes zoster. Medical Clinics of North America, 97(4), 503-522. https:// doi‐org. libraryproxy. quinnipiac. edu/10. 1016/j. mcna. 2013. 02. 002 Raffi, J., Suresh, R., & Butler, D. C. (2019). Review of scabies in the elderly. Dermatology and Therapy, 9, 623-630. https://doi. org/10. 1007/s13555‐019‐00325‐2 Resnick, B., & Gershowitz (Eds. ). (2019). Geriatric nursing review syllabus (6th ed. ). American Geriatric Society. Saguil, A., Kane, S., Mercado, M., & Lauters, R. (2017). Herpes zoster and postherpetic neuralgia: Prevention and management. American Family Physician, 96(10), 656-663 Schneider, J. A., & Cohen, P. R. (2017). Stevens-Johnson syndrome and toxic epidermal necrolysis: A concise review with a comprehensive summary of therapeutic interventions emphasizing supportive measures. Advances in Therapy, 34(6), 1235-1244. doi:10. 1007/s12325‐017‐0530‐y Schmader, K. (2016). Herpes zoster. Clinics in Geriatric Medicine, 32(3), 539-553. https://doi‐org. libraryproxy. quinnipiac. edu/10. 1016/j. cger. 2016. 02. 011 U. S. Food and Drug Administration. (2018). FDA drug safety communication: Safety update for osteoporosis drugs, bisphosphonates, and atypical fractures. Available at: https://www. fda. gov/drugs/drug‐safety‐and‐availability/fda‐drug‐safety‐communication‐safety‐update‐osteoporosis‐drugs‐bisphosphonates‐and‐atypical Valdes‐Rodriguez, R., Stull, C., & Yosipovitch, G. (2015). Chronic pruritus in the elderly: Pathophysiology, Diagnosis and Management. Drugs & Aging, 32(3), 201-215. doi:10. 1007/s40266‐015‐0246‐0. Wehling, M. (2014). Non‐steroidal anti‐inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: Management and mitigation of risks and adverse effects. European Journal of Clinical Pharmacology, 70(10), 1159-1172. doi:10. 1007/s00228‐014‐1734‐6
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583 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 9 Knee Pain RESOLUTION What is the most likely differential diagnosis and why? Osteoarthritis (OA): Obesity, age, and a previous history of an active lifestyle can contribute to OA. People with OA usually have symptoms that occur with activity or shortly after embarking on activity. Stairs can present a particular problem. OA is most often unilateral but can be polyarticular and symmetric. Sharon did not experience any popping, twisting, clicking, or giving way, so ligamental strains and tears are less likely. She denies experiencing a tick bite, but it is important to remember that one does not always remember a bite or being outdoors and may still have Lyme disease. However, Lyme disease typically presents with unilateral knee pain and swelling. A Lyme titer might be a good test to include in the diagnostics for this case just to rule out the possibility. Gout and pseudo-gout typically include acute onset of severe pain accompanied by erythema and warmth. They are most often unilateral. Patellofemoral syndrome is most common in teens and young adults. Anterior knee pain is the most common complaint. Difficulty with stairs is a symptom with difficulty going down stairs typ-ically more severe than going up stairs. Sitting for prolonged periods causes pain that is relieved with walking, and a sense of joint locking instability is common. Rheumatoid arthritis (RA) is typ-ically symmetric and may appear in later life, so Sharon should be questioned regarding morning stiffness, other joint pain and swelling, and fatigue, especially since she has a positive family his-tory for RA. If Sharon experienced unilateral knee pain with an acute onset specific to the area just inferior and medial to the patella (classic location), she would most likely have anserine bursitis. Which diagnostic studies should be considered to assist with or confirm the diagnosis? It is important to determine whether the pain is acute or chronic and whether the patient's activity level or ability to move or function has changed because of the pain. Ask the patient to point to the part of the knee causing her pain. Knee pain can be a sign of systemic disease so a thorough history and diagnostic testing are necessary depending on presentation. A rheumatoid factor, Lyme titer, and a CCP as well as an ESR should be included in the lab work for Sharon. Further, Sharon may be osteoporotic and should therefore receive a DEXA scan if she
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584 Resolutions hasn't had one in the past year or 2. Sharon should have X‐rays of the knees if these have not pre-viously been done or if they have not been done for a long time. An ultrasound is necessary if an effusion is suspected. An MRI is appropriate if a soft tissue injury is suspected. In addition to lab-work this visit (Lyme titer, rheumatoid factor, CCP, ESR, vitamin D), Sharon should have a CBC, CMP, and TSH, as her blood pressure is elevated and she is fatigued. These tests could be delayed, for insurance reimbursement purposes, until she returns to the office for a complete physical. At that time, the clinician should order a mammogram, colonoscopy, and DEXA scan, and also should include a pelvic exam. What should be the plan of treatment? Clearly, Sharon needs a physical to determine her overall health status and to evaluate her health maintenance. She should be advised to lose weight, exercise, and begin taking calcium and vitamin D, if deficient. Sharon's blood pressure is elevated during this visit. She should be encour-aged to check her blood pressure at home every day for 3 weeks and return for a follow‐up visit. She should be educated about symptoms of hypertension and red flags associated with potential complications and when to report them. She should be counseled to eat a low‐sodium diet. In addition, Sharon should decrease weight bearing while her knees are causing her pain. Swimming in a heated pool is a good alternative. She should avoid kneeling and try to do less housework, if possible. Plan to see Sharon back to discuss the imaging and lab results and to per-form her physical and pelvic exams. Lifestyle changes are the first‐line treatment. However, oral and topical NSAIDs, intra‐articular steroid injections, capsaicin, and braces may be helpful. Surgery is a final option. Acetaminophen is not recommended. What should be the plan for health maintenance testing for this patient? Sharon should see the dermatologist annually to assess and treat any suspicious skin lesions. If the primary care clinician observes any suspicious lesions between these annual visits, the patient should see the dermatologist sooner. Sharon should also have a colonoscopy if she has not had one or if the last one was 5 or more years ago depending on the findings at that time. She should also have annual mammograms. Sharon should have a DEXA scan to look for osteoporosis or osteope-nia. In addition, she should have basic laboratory screening including CBC, LFTs, CMP, and a lipid panel. Does this patient need gynecological care and treatment at this time? Sharon is a widow and is not engaged in sexual activity; however, she and her nurse practi-tioner should jointly discuss the advisability of a pelvic exam to check for abnormalities. The vaginal dryness is probably due to atrophy and should be examined. Sharon may want and/or require treatment. The American Cancer Society recommends Pap test screening until age 65 years for a healthy patient who has not had an abnormal test fort 10 years (https://www. cancer. org/cancer/cervical‐cancer/prevention‐and‐early‐detection/cervical‐cancer‐screening‐guidelines. html). What is the plan for referrals and follow‐up? No referrals are needed at this time. However, if treatment fails, then an orthopedic and/or a rheu-matologic referral should be considered. Sharon can be treated with NSAIDs to begin with, and diclofenac gel can be used to rub into her knees. Alternation of ice and heat may also help. If swell-ing increases and limits her mobility, corticoid injections into the knee should be considered. Synvisc injections are also possible treatments. Finally, total knee replacements may need to be considered in the future if her symptoms worsen.
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Knee Pain 585 REFERENCES AND RESOURCES American Cancer Society. (2018, May 30). American Cancer Society guideline for colorectal cancer screening. https:// www. cancer. org/cancer/colon‐rectal‐cancer/detection‐diagnosis‐staging/acs‐recommendations. html Cameron, D. J., Johnson, L. B., & Maloney, E. L. (2014). Evidence assessments and guideline recommendations in Lyme disease: The clinical management of known tick bytes, erythema migrans rashes and persistent disease. Expert Review of Anti‐Infective Therapy, 12(9), 1103-1135. https://www. ilads. org/patient‐care/ ilads‐treatment‐guidelines Deveza, L. A., Bennell, K., Hunter, D., & Curtis, M. R. (2019). Osteoarthritis. Up To Ddate. Mayo Clinic. (2018, April 21). Pseudogout. https://www. mayoclinic. org/diseases‐conditions/pseudogout/ symptoms‐causes/syc‐20376983 National Osteoporosis Foundation. (n. d. ). https://www. nof. org O'Dell, J. R. (2007). Rheumatoid arthritis: The disease—diagnosis and clinical features. In J. Imboden, D. Hellmann, & J. Stone (Eds. ), Current diagnosis & treatment: Rheumatology (2nd ed., pp. 161-169). New York: Mc Graw Hill‐Lange.
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587 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the top three differential diagnoses in this case and why? 1. Heat‐related illness (classic heat stroke vs. heat exhaustion) 2. Neurological condition (e. g., str oke, meningitis, encephalitis) 3. Infection (systemic or central nervous system) Which diagnostic tests are required in this case and why? 1. MRI or CT to assess for central nervous system causes of altered mental status 2. Blood and urine cultures with urinalysis to r ule out systemic and urinary tract infection 3. Laboratory studies: CBC to assess for increased WBC Serum electr olytes to assess for abnormalities, particularly sodium BUN, creatinine to assess for acute kidney injury Liver enzymes to assess for heat‐induced liver injury Coagulation panel (PT, PTT, INR) to assess for heat‐induced liver injury and disseminated intravascular coagulation What are the concerns at this point? Given Judith's risk factors and her current neurological and cardiovascular status, the etiology of hyperthermia is unclear. However, heat stroke, which is a medical emergency that can lead to mul-tisystem organ failure and death, cannot be ruled out. It is important to note that the temperature reported by the EMTs at the scene was an oral temperature and therefore corresponds to a higher core temperature. Efforts to decrease her core temperature should be the priority to prevent further deterioration while other diagnoses are investigated. The elderly are particularly vulnerable to heat‐related illnesses (HRIs), such as heat exhaustion and heat stroke. List the symptoms and treatment associated with each condition. Heat‐related illnesses (HRIs) are the most common cause of weather‐related deaths in the United States. Older adults, those living with chronic illness, pregnant women, and prepubertal children Case 10. 10 Hyperther mia and Mental Status Changes in the Elderly
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588 Resolutions are particularly at risk for developing an HRI. These are classified as mild (heat edema, heat rash, and muscle cramping), moderate (syncope, heat exhaustion), and severe (heat stroke). There are two types of heat stroke—exertional hyperthermia and nonexertional (classic heat stroke) hyper-thermia, both of which are life‐threatening, medical emergencies. 1. Heat exhaustion Symptoms: Thirst (late sign in the elderly), headache, fatigue, tachycardia, weakness, ataxia, syncope, nausea, vomiting, diarrhea, cold/clammy skin, core temperature 101-104o F Tr eatment: Remove from heat, rest in supine position, evaporative cooling, oral/IV rehydration. 2. Heat stroke Symptoms: Alter ed mental status (confusion, delirium, seizures, coma, tachycardia, tachy-pnea, hypotension, pulmonary crackles, oliguria, core temperature 104o F or greater. Tr eatment: Rapid cooling to below 102o F, using conductive or evaporative cooling tech-niques (infusion of cool fluids, application of ice packs or wet gauze with fanning). These are better tolerated in the elderly as compared to cold water immersion. NOTE: Antipyretics should not be used to treat heatstroke. Identify six risk factors that Judith has for developing heatstroke. 1. Age 2. Gender 3. Socioeconomic status 4. Chronic medical condition (car diovascular disease) 5. Social isolation 6. Medicationsa. Lasix: Dehydration b. Beta‐blockers: Reduced cardiac output decr eases blood flow to skin, limiting the shunting of warm blood to periphery, which impairs cooling Identify three physical assessment findings from the case that support a diagnosis of heatstroke. It should be noted that heatstroke is diagnosed clinically, and there is no diagnostic test that can confirm it. However, in the face of hyperthermia, neurological symptoms, and recent exposure to hot weather, heatstroke should be considered. In this case, Judith presented with: 1. Hyperthermia 2. Confusion and restlessness 3. Hemodynamic indicators (tachycardia, tachypnea, hypotension) Identify and explain three elements from the patient's history that support a diag-nosis of heat stroke. 1. No air conditioning in the home in the context of a heatwave. 2. EMT's report of neur ological status upon arrival to the home. 3. Documented oral temperature in the home. Of note, a PO temperatur e of 103. 3°F is particularly concerning because it correlates with a core temperature greater than 104°F. What is the differential diagnosis for heatstroke? Meningitis, encephalitis, epilepsy, drug intoxication, severe dehydration, and metabolic syn-dromes such as neuroleptic malignant syndrome and thyroid storm. Alternative diagnoses should be considered only after ruling out heatstroke since a delay in treatment increases mor-bidity and mortality.
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Hyperthermia and Mental Status Changes in the Elderly 589 What is the plan of treatment? Send Judith to the emergency room by ambulance. 1. Rapid cooling in the emer gency room to below 102°F, using convective or evaporative cooling techniques (infusion of cool fluids, application of ice packs or wet gauze with fanning). These are better tolerated in the elderly as compared to cold water immersion. The longer hyper-thermia persists, the greater chance of complications related to the underlying systemic inflammatory response triggered. 2. Hospital admission for supportive care and continued monitoring for pr ompt recognition of complications including: acute respiratory distress syndrome, rhabdomyolysis, compartment syndrome, liver dysfunction, acute renal failure, disseminated intravascular coagulopathy, and electrolyte abnormalities NOTE: Antipyretics should not be used to treat heatstroke. What are the plans for referral and follow‐up care? Home health care services: ° Nursing to continue patient education and to provide car e as required based on her clinical status at the time of discharge. ° Occupational therapy (OT) to assess Judith's home environment for safety. ° Physical therapy as needed. Referral to local community agency to determine if local cooling centers are available during periods of heat wave and to determine pr ocess for accessing (i. e., transportation). What health education should be provided to this patient? Education about heat and health and home environment Heat‐related pr evention measures ° Stay indoors during between 10 a. m. and 4 p. m. when it is the hottest. ° Ensure that shades ar e on windows and draw during periods when sun is most intense. ° Wear a hat and light clothing when going outside. ° Take cool showers. ° Drink plenty of cool liquids before you feel thirsty (check with your doctor to see what amount is appr opriate). ° Do not use the oven to cook on very hot days. ° Note: The r esearch on the use of fans for cooling in the elderly, while limited, is equivocal. Some studies suggest that the use of electric fans impedes heat loss at high ambient temper-atures while others suggest fans contribute to heat loss. If the ambient temperature is hotter than the core temperature of an individual, the use of a fan can lead to an increase in core temperature, particularly on hot, dry days above 95 o F. Worrisome signs and symptoms ° Dizziness or fainting ° Nausea or vomiting ° Headache ° Rapid breathing ° Rapid heart rate ° Extreme thirst ° Decreased urination and dark urine What to do if you experience symptoms ° If outside, move to a cool place immediately and drink cool liquids. ° If inside, call 911.
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590 Resolutions What demographic characteristics might affect this case? Age Gender Social isolation/lives alone Low socioeconomic status Does the patient's psychosocial history impact how you might treat her? The patient's psychosocial history is important in the treatment plan since social isolation is a con-cern for Judith. Addressing the need for social services with additional services such as social work involvement are important considerations. How does Judith's living in an urban area impact her risk for heatstroke? Living in an urban area is an additional risk for heatstroke, particularly for vulnerable populations. Urban heat islands are a risk for heatstroke, particularly for the elderly. The urban heat island refers to a city or metropolitan area that experiences significantly higher temperatures than rural areas. Because urban areas have areas with asphalt and concrete, temperatures are significantly higher than rural areas with greenspace. Asphalt absorbs the sun's rays because of its dark color and both asphalt and concrete retain heat at higher temperatures than green areas. Buildings also reflect heat, which then leads to higher temperatures. Are there any standardized guidelines that should be used to treat this case? If so, what are they? Canadian Guidelines on Heat Stress and Health: Retrieved from https://www. canada. ca/en/ health‐canada/services/environmental‐workplace‐health/reports‐publications/climate‐change‐health/extreme‐heat‐events‐guidelines‐technical‐guide‐health‐care‐workers. html REFERENCES AND RESOURCES Epstein, Y., & Yanovich, R. (2019). Heatstroke. New England Journal of Medicine, 380(25), 2449-2459. doi:10. 1056/ NEJMra1810762 Gaudio, F. G., & Grissom, C. K. (2016). Cooling methods in heat stroke. Journal of Emergency Medicine, 50(4), 607-616. doi:10. 1016/j. jemermed. 2015. 09. 014 Gauer, R., & Meyers, B. K. (2019). Heat‐related illnesses. American Family Physician, 99(8), 482-489. Gupta, S., Carmichael, C., Simpson, C., Clarke, M. J., Allen, C., Gao, Y., . . . Murray, V. (2012). Electric fans for reducing adverse health impacts in heatwaves. Cochrane Database of Systematic Reviews, 7, CD009888. doi:10. 1002/14651858. CD009888. pub2 Lemery, J., & Auerbach, P. (2017). Enviromedics: The impact on climate change on human health. London: Rowman & Littlefield. Luber, G., & Mc Geehin, M. (2008). Climate change and extreme heat events. American Journal of Preventative Medicine, 35(5), 429-435. doi:10. 1016/j. amepre. 2008. 08. 021 Mechem, C. C. (2019). Severe nonexertional hyperthermia (classic heat stroke) in adults. Up To Date. Retrieved from: www. uptodate. com Wald, A. (2019). Emergency department visits and costs for heat‐related illness due to extreme heat or heat waves in the United States: An integrated review. Nursing Economic$, 37(1), 35-48. Water, Air, and Climate Change Bureau, Health Environments and Consumer Safety Branch. (2011). Extreme heat events guidelines: Technical guide for health care workers. Retrieved from: www. healthcanada. gc. ca
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The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 5919 month visit, 29-31, 295-296 12 month visit, 25-27, 293-294 AAA see abdominal aortic aneurysm abdominal aortic aneurysm (AAA), 475abdominal pain cholecystitis, 155-156, 431-432constipation, 67-69, 321-323preschool children, 67-69, 321-323with weight gain, 191-193, 471-473women's health, 155-156, 431-432 abdominal radiographs, 321abdominal ultrasound, 405ABG see arterial blood gas ABI see ankle brachial index ACE inhibitors, 476ACS see acute coronary syndromeacute coronary syndrome (ACS), 205-206, 487-489acute cystitis, 157-158, 433-434acute gouty arthritis, 273-274, 573-575acute myocardial infarction, Dressler's syndrome, 486acute sinus infections, 211-212, 495-497ADHD see attention deficit hyperactivity disorderadjustment disorder with anxiety, 529with depressed mood, 229-230, 515-517 adolescents, 111-131, 365-402 anxiety, 372, 397aspirin, 317birth control decision‐making, 123-124, 387-393chlamydia, 125-126, 395-396confidentiality, 368contraception, 123-124, 373, 378, 384, 387-393, 397-398counseling, 368drug use, 113-114, 365-370eating disorders, 371, 372-375excessive exercise, 371-372female athlete triad, 372, 374knee pain, 129-131, 399-402Lyme disease, 129-131, 399-402major depressive disorder, 365malabsorption, 372malnutrition, 372menstrual cramps, 119-120, 377-381mental health, 113-114, 365-370missed periods, 121-122, 191-193, 383-385, 471-473 pregnancy, 383-385primary dysmenorrhea, 119-120, 377-381sad mood, 229-230, 515-517school attendance, 113, 365-366school phobia, 365-366sexual history, 5P approach, 125sexual identity, 127-128, 397-398sleep problems, 113, 366, 367thyroid disorders, 366, 372vaginal discharge, 125-126, 395-396vitamin deficiencies, 374weight loss, 115-117, 371-375 adverse drug effects, older adults, 540, 546, 577, 580akathisia, 546alarms for bedwetting, 312albuterol, 342alcohol and pregnancy, 403allergic conjunctivitis, 334allergic rhinitis, 211-212, 495-497 Index
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592 Index allergies amoxicillin, 310 anaphylaxis, 103-105, 357-361desensitization, 361food, 103-105, 351, 357-361older adults, 580peanuts, 103-105, 357-361penicillin, 56, 310, 338 allopurinol, 575, 577Am B see amphotericin BAmerican Urological Association symptom index, 455 amitriptyline, 444amoxicillin, 45 allergies, 310Lyme disease, 401-402otitis media, 309-310peptic ulcers, 472sore throat, 338 amoxicillin‐clavulanate impetigo, 328otitis media, 310 amphotericin B (Am B), 492amputations, phantom limb pain, 223-224, 511-512anabolic agents, 569anaphylaxis Epi Pens, 359-360peanut allergy, 103-105, 357-361symptoms, 360younger siblings, 360-361 angina, 566ankle brachial index (ABI), 475anorectal manometry, 321anorexia nervosa, 371antacids, 482antibiotics burns, 317impetigo, 328Lyme disease, 400nonpuerperal breast abscess, 424otitis media, 309-310penile lesions, 326peptic ulcers, 471-472urinary tract infections, 433see also individual pharmaceuticals. . . antibody screening celiac disease, 351-353, 507first trimester bleeding, 405systemic lupus erythematosus, 440 anticholinergic agents bedwetting, 312delirium, 546 antidepressants breastfeeding, 527demographic factors, 536depression disorders, 522fibromyalgia, 444post‐traumatic stress disorder, 535 antiemetics for migraine with aura, 436antimicrobials burns, 317see also antibiotics anti‐nuclear antibodies (ANA), 399, 440antiphospholipid syndrome (APL), 440antiplatelet therapy, 476antipsychotics, 546antiresorptive agents, 569anti‐tissue transglutaminase 2 (anti‐t TG) antibodies, 351-353, 507 anxiety, 239-240, 529-531 adjustment disorder with, 529and forgetfulness, 247-249, 539-541generalized, 529health education, 530sexual identity, 397substance/medication‐induced, 529substance use disorder, 459, 461, 463-464tremors, 551weight loss in adolescents, 372 APL see antiphospholipid syndromeappetite in infants, 25-35, 293-299arm pain, school‐aged children, 95-96, 345-346arterial blood gas (ABG) chronic obstructive pulmonary disease, 479pulmonary screening, 185 arterial ulcers, 468, 477arthritis adolescents, 129-131, 399-402osteo, 277-278, 583-585rheumatoid, 225-226, 513-514, 566 aspirin, contraindications, 317assessment of suicide risk, 366, 369, 520-522, 534-535asthma, 93-94, 341-343, 403attention deficit hyperactivity disorder (ADHD), 459, 461, 463-464 autoimmune disorders, 399azithromycin chlamydia, 395otitis media, 310sore throat, 338 bacitracin burns, 317penile lesions, 326 back pain, 267-271, 565-572bacterial infections balanoposthitis, 325chlamydia, 125-126, 395-396conjunctivitis, 83-84, 333, 334-335epididymitis, 181-182, 455-458
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Index 593 foot ulcer, 467 impetigo, 77-78, 327-329, 328pelvic pain, 417penile lesions, 325sore throat, 85-87, 337-338 bacterial vaginosis, 420Bactrim, urinary tract infections, 433balanoposthitis, 71-73, 325-326bedwetting, preschool children, 57-59, 311-313behavior changes in older adults, 251-254, 543-550benign prostatic hyperplasia (BPH), 455benzodiazepines, night terrors, 348beta chorionic gonadotropin (beta h CG) first trimester bleeding, 405pelvic pain, 417 binge‐eating, 371bipolar depression, 229-230, 515-517birth control confidentiality, 389, 391-392contraindications, 390decision‐making, 123-124, 387-393follow‐up care, 391health education, 391initiation, 389-390migraine, 437options, 388-389, 388-390polycystic ovary syndrome, 472preconception planning, 404side effects, 390-391standardized guidelines, 392see also contraception bisphosphonates, 569blastomycoses dermatitidis (BD), 207-208, 491-492bleeding in first trimester, 137-138, 405-406blood pressure migraine, 160, 437morning headaches, 209-210, 493-494older adults, 549 blood type screening, 405blood urea nitrogen (BUN) failure to thrive, 297systemic lupus erythematosus, 440 BMI see Body Mass Index Body Mass Index (BMI), 363-364, 372bone mineral density oral contraceptive pills, 373osteoporosis, 267-271, 565-572 Borrelia burgdorferi, 400BPH see benign prostatic hyperplasiabreakthrough varicella zoster virus, 79-81, 331-332breastfeeding, 29-31, 295-296, 526-527breasts, nonpuerperal abscesses, 149-150, 423-425breathing difficulties, 197-198, 479-480brief interventions, 369bronchiolitis, 15-17, 289-290, 303bronchodilators, 342bulimia nervosa, 371bullous impetigo, 328bullying, 398buprenorphine, 462burning pain epigastric after meals, 199-200, 481-483legs, 195-196, 475-478 burns Lund and Browder charts, 316preschool children, 61-62, 315-318rule of nines chart, 316 CAD see coronary artery diseasecalcium channel blockers (CCB), 493CAM see complementary and alternative medicine therapies; Confusion Assessment Method candidiasis balanoposthitis, 325pharyngitis, 337vaginal, 147-148, 419-421 cardiovascular screening exams, 3-5, 283-284caregivers anaphylaxis education, 359-361see also parents caries, preschool children, 63-65, 319-320cariostatic foods, 320carpal tunnel syndrome (CTS), 217-219, 503-506cataracts, 560CBC see complete blood count CD see celiac diseasecefadroxil, 338cefdinir, 310cefoxitin, 418cefpodoxime, 310ceftriaxone, 418celecoxib, 379celiac disease (CD), 101-102, 221-222, 321, 351-356, 508-510 autoantibodies, 351-353differential diagnosis, 507-509nutrition, 355referrals, 355-356vitamin deficiencies, 352 cephalexin nonpuerperal breast abscess, 424sore throat, 338 cephalosporin antibiotics impetigo, 328nonpuerperal breast abscess, 424otitis media, 310pelvic pain, 418sore throat, 338 cerebrovascular accident (CVA), 546-547cervical radiculopathy, 503-504cheerleaders, 115-116, 371-375
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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594 Index chest pain with dyspnea without radiation, 201-203, 485-486 radiating, 205-206, 487-489 chest X‐rays (CXR) for infant cough, 303chickenpox, 79-81, 331-332child abuse, 95-96, 345-346Childhelp National Child Abuse Hotline, 345chlamydia, 125-126, 395-396, 420 pelvic pain, 417testicular pain, 453 chlamydial pneumonia, 289cholescintigraphy, 431cholesterol screening, 363chronic diarrhea, 221-222, 507-510chronic kidney disease (CKD), 213-215, 499-500, 499-501chronic obstructive pulmonary disease (COPD), 197-198, 479-480, 500 Cimetidine, 471, 482, 546citalopram, 540clarithromycin otitis media, 310peptic ulcers, 472sore throat, 338 classic impetigo, 328CLI see critical limb ischemiaclindamycin impetigo, 328nonpuerperal breast abscess, 424sore throat, 338 clinical opiate withdrawal scale (COWS), 460clonidine, 462cognition delirium, 251-254, 543-549dementia, 544forgetfulness, 247-249, 539-541 cognitive behavioral therapy (CBT) anxiety, 530depression, 521, 523fibromyalgia, 443 colchicine, 574Columbia-Suicide Severity Rating Scale (C‐SSRS), 366, 369, 520-522, 534-535 combined hormonal contraceptives contraindications, 390initiation, 389side effects, 391 commercial insurance, confidentiality issues, 368common cold, 495-496complementary and alternative medicine therapies (CAM) perimenopausal period, 410vertebral compression fracture, 568 complete blood count (CBC) failure to thrive, 297first trimester bleeding, 405foot ulcer, 467infant cough, 303menstrual cramps, 377oxygenation, 289secondary hypogonadism, 449sexual assault, 427systemic lupus erythematosus, 440 condoms, health education, 395confidentiality adolescents, 368, 389, 391-392contraceptives, 389, 391-392drug use, 368 confusion delirium, 251-254, 543-550with fatigue and weight loss, 213-215, 499-501 Confusion Assessment Method (CAM), 544conjunctivitis allergic, 334bacterial, 83-84, 333, 334-335contact lenses, 335viral, 83-84, 333-335 constipation and delirium, 546infants, 29-31, 295-296preschool children, 67-69, 321-323prevalence, 323scheduled toileting, 322 constitutional growth delay, 298contact lenses, conjunctivitis, 335contraception adolescents, 123-124, 373, 378, 384, 387-393, 397-398birth control decision‐making, 123-124, 387-393contraindications, 390emergency, 384, 389, 390health education, 385initiation, 389-390migraine, 437options, 388-389polycystic ovary syndrome, 472side effects, 390-391smoking, 387 contraindications aspirin, 317contraceptives, 390 COPD see chronic obstructive pulmonary diseasecoronary artery disease (CAD) chronic obstructive pulmonary disease, 480diabetes, 494 cotinine, 423cough asthma, 93-94, 341-343infants, 41-43, 303-304persistent with joint tenderness, 207-208, 491-492school‐aged children, 93-94, 341-343 counseling adolescents, 368cognitive behavioral therapy, 443, 521, 523, 530spontaneous abortion, 406
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 595 COWS see clinical opiate withdrawal scale C‐reactive protein (CRP), 399, 440creatine levels, systemic lupus erythematosus, 440creatinine test, failure to thrive, 297critical limb ischemia (CLI), 475-477Crohn's disease, 321croup, 41-43, 303-304CRP see C‐reactive protein CTS see carpal tunnel syndrome CT scans head trauma, 307migraines, 436strangulation, 428 CVA see cerebrovascular accident CXR see chest X‐rays Cymbalta (Duloxetine), 444, 540 dark field microscopy, 325 DDVAP see desmopressin acetate vasopressindeamidated gliadin peptide, 351-353decision‐making, birth control, 123-124, 387-393deep partial‐thickness burns, 315deep vein thrombosis (DVT), 487delirium, 251-254, 543-550dementia, 500 and delirium, 544 demographic patterns antidepressant usage, 536balanoposthitis, 326child abuse, 346depression, 517, 520, 523failure to thrive, 298-299Lyme disease, 401night terrors, 348-349nutrition, 293-294oral hygiene, 320postpartum depression, 526trauma disorders, 536-537 Denosumab, 569dental caries, preschool children, 63-65, 319-320depot medroxyprogesterone acetate (DMPA), 384 contraindications, 390initiation, 389side effects, 391 depression adjustment disorder, 229-230, 515-517adolescents, 365bipolar, 229-230, 515-517demographic patterns, 517, 520, 523fibromyalgia, 444health education, 522-523hypothyroidism, 520medications, 522night sweats, 408older adults, 500postpartum, 235-237, 525-527preconception planning, 403self‐harm, 520, 522-523sexual identity, 397standardized tests, 369substance use disorder, 459, 461, 463-464 desensitiziation, food allergies, 361desmopressin acetate vasopressin (DDVAP), 312development failure to thrive, 33-35, 297-299infants, 33-35, 297-299small for gestational age, 525 dexamethasone, croup, 303DFA testing see direct fluorescent antigen testingdiabetes coronary artery disease, 494fatigue, 175-177, 259-262, 449-451, 555-557foot ulcers, 187-190, 467-469and gout, 575hormone therapy, 413and hypertension, 494older adults, 259-262, 555-557peripheral artery disease, 475-477vaginal candidiasis, 421 diabetic peripheral neuropathy (DPN), 247-249, 539-541 Diagnostic and Statistical Manual 5th edition (DSM‐5) psychotropic depression medicines, 522substance use disorder, 460Z codes, 534 diarrhea chronic, 221-222, 507-510infants, 45-47, 305-306 dicloxacillin impetigo, 328nonpuerperal breast abscess, 424 differential diagnosis, celiac disease, 507-509difficulty breathing anaphylaxis, 103, 360asthma, 341-343school‐aged children, 93-94, 103, 341-343 digital rectal exams, 321diphenhydramine, 580direct fluorescent antigen (DFA) testing, 331discoid lupus, 441disrupted sleep, adolescents, 113, 366, 367disruptive behavior, 89-91, 339-340DMPA see depot medroxyprogesterone acetatedomestic violence, 241, 520, 534-535doppler fetal heart tones, first trimester bleeding, 405doppler studies, testicular pain, 453doxycycline chlamydia, 395Lyme disease, 400pelvic pain, 418 DPN see diabetic peripheral neuropathy Dressler's syndrome, 486
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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596 Index drug use adolescents, 113-114, 365-370 confidentiality, 368health education, 367-368intravenous, 465-466substance use disorder, 185-186, 459-466 dry skin, older adults, 580DSM‐5 see Diagnostic and Statistical Manual 5th editiondual‐energy absorptiometry (DXA), 565, 567Duloxetine diabetic peripheral neuropathy, 540fibromyalgia, 444 DVT see deep vein thrombosis DXA see dual‐energy absorptiometrydysmenorrhea adolescents, 119-120, 377-381primary, 377 dyspnea, with chest pain, 201-203, 485-486 earache, preschool children, 55-56, 309-310 ear, nose, and throat (ENT) referrals, sore throat, 338echocardiography, pericarditis, 486eczema, food allergies, 358EEG see electroencephalograms Effexor (venlafaxine), fibromyalgia, 444electrocardiograms (ECG), 487electroencephalograms (EEG), 347electrolyte imbalance, 297ELISA tests, Lyme disease, 399emergency contraception, 384, 389, 390endocrine disorders hyperthyroidism, 169-171, 372, 445-447, 447hypothyroidism, 366, 407, 447, 520night sweats, 407-408 endometriosis, 378endomysium antibodies, 351-353ENT see ear, nose, and throatentrapment, median nerve, 503, 505enuresis, 57-59, 311-313EOB see explanation of benefitseosinophhilia, 287epididymitis, 181-182, 455-458epigastric pain, burning, after meals, 199-200, 481-483epiglottitis, 303Epi Pens, 359-360Epstein‐Barr virus (EBV), 337erectile dysfunction, 175-177, 449-451erythema toxicum, 11-13, 287-288erythrocyte sedimentation rate (ESR), 399-400 foot ulcer, 467systemic lupus erythematosus, 440 escitalopram, 522ESPGHN see European Society for Pediatric Gastroenterology, Hepatology, and Nutrition ESR see erythrocyte sedimentation rateessential tremor, 255-257, 551-553European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHN), 352-353 exacerbation therapy, 342-343excessive consumption of milk, 293-294exercise excessive, 371-372intolerance, 107-108, 363-364 expedited partner therapy, 396explanation of benefits (EOB), 368externalizing behaviors, 89-91, 339-340, 537eyes conjunctivitis, 83-84, 333-335visual changes, 263-265, 559-563 facial pain, 211-212, 495-497failure to thrive (FTT), infants, 33-35, 297-299falls from height, 49-51, 307-308familial factors celiac disease, 354oppositional defiant disorder, 90, 339see also parents family planning, 387FAST, 561-562fatigue with confusion and weight loss, 213-215, 499-501with joint pain, 161-163, 439-442secondary hypogonadism, 175-177, 449-451systemic lupus erythematosus, 161-163, 439-442and trauma, 241-243, 533-537with weight gain, 259-262, 555-557 female athlete triad, 372, 374fertility testing, 404fetal alcohol syndrome, 297fever intermittent with earache, 55-56, 309-310mild, with breast redness and swelling, 149-150, 423-425 rashes with, 79-81, 331-332 fibromyalgia (FM), 165-167, 443-444first‐degree burns, 315first trimester bleeding, 137-138, 405-406fluoxetine, 522FM see fibromyalgiafolic acid supplementation, 404follicle stimulating hormone (FSH), 449food allergies, 103-105, 351, 357-361 desensitiziation, 361eczema, 358peanuts, 103-105, 357-361symptoms, 360younger siblings, 360-361 foot ulcers, 187-190, 467-469foreskin lesions, 71-73, 325-326forgetfulness, 247-249, 539-541
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Index 597 formula milk, 29, 295-296 foster care, 298-299FSH see follicle stimulating hormone FTT see failure to thrivefull‐thickness burns, 315fungal infections balanoposthitis, 325blastomycoses dermatitidis, 207-208, 491-492potassium hydroxide test, 331 gabapentin diabetic peripheral neuropathy, 540fibromyalgia, 444 GABHS see group A beta‐hemolytic streptococci GAD‐7 scores, 529-530gastric tumors, 431gastrin levels, 431gastroenteritis chronic diarrhea, 221-222, 508-510inflammatory bowel disease, 508, 509irritable bowel syndrome, 351, 508, 509neonates, 291viral, 45-47, 305-306, 509see also celiac disease gastroesophageal reflux disease (GERD), 199-200, 291, 481-483 gastrointestinal complaints celiac disease, 101-102, 351-356school‐aged children, 101-102, 351-356see also gastroenteritis GCS see Glasgow Coma Scalegeneral adult health, 183-226, 459-514 acute coronary syndrome, 205-206, 487-489acute sinus infections, 211-212, 495-497blastomycoses dermatitidis, 207-208, 491-492breathing difficulties, 197-198, 479-480burning leg pain, 195-196, 475-478carpal tunnel syndrome, 217-219, 503-506celiac disease, 221-222, 508-510chest pain with dyspnea without radiation, 201-202, 485-486radiating, 205-206, 487-489 chronic diarrhea, 221-222, 507-510chronic obstructive pulmonary disease, 197-198, 479-480 epigastric pain after meals199‐200, 481-483facial pain, 211-212, 495-497foot ulcers, 187-190, 467-469gastroesophageal reflux disease, 199-200, 481-483hand numbness, 217-219, 503-506hypertension, 209-210, 493-494intractable pain, 223-224, 511-512morning headaches, 209-210, 493-494opioid dependency, 185-186, 459-466peptic ulcers, 191-193, 471-473pericarditis, 201-202, 485-486peripheral artery disease, 195-196, 475-478persistent cough and joint tenderness, 207-208, 491-492phantom limb pain, 223-224, 511-512polycystic ovary syndrome, 191-193, 471-473rheumatoid arthritis, 225-226, 513-514substance use disorder, 185-186, 459-466third‐stage chronic kidney disease, 213-215, 499-501weight gain with abdominal pain, 191-193, 471-473wrist pain and swelling, 225-226, 513-514 generalized anxiety disorder, 529, 534GERD see Gastroesophageal reflux diseasegiant cell arteritis, 560gingivitis in preschool children, 63-65, 319-320Glasgow Coma Scale (GCS), 307glomerular filtration rate (GFR), 499gluten, 351-356gonorrhea, 420 pelvic pain, 417testicular pain, 453 gout, 273-274, 467, 573-575Gram staining foot ulcer, 467impetigo, 328penile lesions, 325 group A beta‐hemolytic streptococci (GABHS), 85-87, 337-338 growth constitutional delay, 298failure to thrive, 33-35, 297-299infants, 33-35, 297-299 guideline‐directed medical therapy (GDMT), peripheral artery disease, 476 gums, gingivitis, 63-65, 319-320 H2 blockers, 482 Haldol, 546hand burns, 61-62, 316-317hand numbness, 217-219, 503-506headaches hypertension, 209-210, 493-494migraine with aura, 159-160, 435-437morning, 209-210, 493-494 head trauma, infants, 49-51, 307-308health education acute coronary syndrome, 488-489adolescent weight loss, 374anxiety, 530birth control, 391candida infections, 420-421chronic obstructive pulmonary disease, 480depression, 522-523diabetic foot ulcers, 468drug use, 367-368essential tremor, 552
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598 Index gout, 574 heat stroke, 589hypertension, 493menstrual cramps, 380mild cognitive impairment, 540osteoporosis, 571pelvic pain, 418perimenopausal period, 412-413pneumonia, 548self‐harm, 522-523sexual assault, 429sexually transmitted infections, 395strokes, 561-562substance use disorder, 463tick‐bourne illnesses, 400-401visual changes, 560 heartburn see gastroesophageal reflux diseaseheart murmur, infants, 37-39, 301-302hearts acute coronary syndrome, 205-206, 487-489neonatal screening, 3-5, 283-284patent ductus arteriosus, 283-284pericarditis, 201-202, 485-486Still's murmur, 37-39, 301-302 heat exhaustion, 588heat‐related illnesses (HRIs), 279-280, 587-590heat stroke, 279-280, 588-590hepatic iminodiacetic acid (HIDA) scan, 431herpes genitalis, 420herpes simplex virus, 331herpes zoster in older adults, 275-276, 577-582HIDA see hepatic iminodiacetic acid Hirschsprung disease, 321hives, anaphylaxis, 103HIV risk post‐exposure prophylaxis, 427-429sexual assault, 427-429sexually transmitted infections, 396 honey‐colored crusts, impetigo, 77-78, 327-328hormone therapy (HT) diabetes, 413hypertension, 413osteoporosis, 569perimenopausal period, 411-414secondary hypogonadism, 450 hospitalization failure to thrive, 298heat stroke, 589Lyme disease, 402pelvic pain, 417-418pericarditis, 485-486 hot flushes, night sweats, 139-143, 407-415HRIs see heat‐related illnesseshydrogen breath test, 305hydronephrosis, 433hydroxychloroquine, 441hygiene, sleep, 348hypertension hormone therapy, 413migraine, 160, 437morning headaches, 209-210, 493-494peripheral artery disease, 475-476 hyperthermia with mental status changes, 279-280, 587-590 hyperthyroidism, 169-171, 372, 445-447, 447hypogonadism, 175-177, 449-451hypomania, 515hypotension, orthostatic, 549hypothyroidism, 366, 407, 447, 520 IBD see inflammatory bowel disease IBS see irritable bowel syndromeibuprofen, menstrual cramps, 379ID Migraine screen, 436Ig E mediated food allergies, 103-105, 357-361Ig G Western blot tests, 399Ig M Western blot tests, 399imipramine, 312immunocompromised patients sore throat, 337varicella zoster virus, 322 immunosupression, systemic lupus erythematosus, 441impetigo, 77-78, 327-329implants, contraceptive, 384, 389-390, 391indomethacin, 486infants, 23-51, 293-308 aspirin, 317breastfeeding, 29-31, 295-296cough, 41-43, 303-304failure to thrive, 33-35, 297-299falls from height, 49-51, 307-308growth, 33-35, 297-299head trauma, 49-51, 307-308heart murmur, 37-39, 301-302maternal postpartum depression, 235-237, 525-527nutrition, 25-35, 293-299viral gastroenteritis, 45-47, 305-306 infertility, 404, 472-473inflammatory bowel disease (IBD), 508, 509initiation of birth‐control, 389-390injecting drug users, 465-466injectionable contraception adolescents, 384initiation, 389side effects, 391smoking, 387 inpatient treatment failure to thrive, 298Lyme disease, 402health education (cont'd)
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 599 pelvic pain, 417-418 pericarditis, 485-486 insomnia, 169-171, 445-447insulinoma, 431insulin resistance test, 363see also diabetes insurance and confidentiality, 368intermittent claudication, 475-476intermittent fever with earache, 55-56, 309-310interstitial cystitis, 433intractable pain, phantom limbs, 223-224, 511-512intrauterine devices (IUDs), 384, 388 contraindications, 390initiation, 389polycystic ovary syndrome, 472side effects, 390-391 intravenous drug use, 465-466iron deficiency anemia in infants, 29-31, 295-296iron‐fortified formula, 295-296irregular menses, 191-193, 471-473irritable bowel syndrome (IBS), 351, 508, 509ischemic stroke, 561-562itching older adults, 275-276, 577-582vaginal, 147-148, 419-421 IUDs see intrauterine devices joint pain with fatigue, 161-163, 439-442 knees of adolescents, 129-131, 399-402systemic lupus erythematosus, 161-163, 439-442 joint tenderness and persistent cough, 207-208, 491-492 kidneys, ureters, and bladders (KUB) X‐rays, 311knee pain adolescents, 129-131, 399-402older adults, 277-278, 583-585 KOH see potassium hydroxide KUB X‐rays see kidneys, ureters, and bladders X‐rays lactic acid dehydrogenase (LDH) test, 399 lactose tolerance tests, 305lansoprazole, 472LARCs see long‐acting reversible contraceptiveslaryngotracheobronchitis see croup LDH see lactic acid dehydrogenaselead screening, 339LEAP study see Learning Early About Peanut study Learning Early About Peanut (LEAP) study, 360left arm pain, school‐aged children, 95-96, 345-346legs burning pain, 195-196, 475-478knee painadolescents, 129-131, 399-402older adults, 277-278, 583-585 lesbian, gay, bisexual, transgender, queer (LGBTQ) groups, 127-128, 397-398 lesions, on penis, 71-73, 325-326Lewy body dementia, 544LFTS see liver function tests LH see luteinizing hormonelipid profiles, 363liver function tests (LFTs), pre post‐exposure prophylaxis, 427 long‐acting reversible contraceptives (LARCs), 384 contraindications, 390initiation, 389 loss of weight, adolescents, 115-117, 371-375lower respiratory infections (LRIs), older adults, 548lower urinary tract symptoms (LUTS), 455-456low‐grade fever, with rash, 79-81, 331-332Lund and Browder burn charts, 316lungs bronchiolitis, 15-17, 289-290chlamydial pneumonia, 289chronic obstructive pulmonary disease, 197-198, 479-480pneumonia, 251-254, 289, 543-550pulmonary screening exams, 7-9, 285-286transient tachypnea of the newborn, 285-286 lupus, 161-163, 439-442luteinizing hormone (LH), hypogonadism, 449LUTS see lower urinary tract symptoms Lyme disease, 129-131, 331, 399-402 antibiotics, 400demographic patterns, 401diagnosis, 399-400hospitalization, 402school‐aged children, 401-402standardized guidelines, 401vs. osteoarthritis, 583 Lyrica, 444 macrolides, impetigo, 328 macular degeneration, 560maculopapular rashes, varicella zoster virus, 332magnetic resonance imaging (MRI) forgetfulness, 539migraines, 436 major depressive disorder (MDD), 229-230, 515-517 adolescents, 365and forgetfulness, 539health education, 522-523medication, 522standardized tests, 369and trauma, 533-534 malabsorption, adolescents, 372male sexual dysfunction, 175-177, 449-451malnutrition, adolescents, 372
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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600 Index mania, 515 marijuana usage, 367-368maternal postpartum depression, 235-237, 525-527MCI see mild cognitive impairment MDD see major depressive disorder MDI see metered dose inhalermedian nerve entrapment, 217-219, 503, 505mefenamic acid, 379menopause see perimenopausal periodmen's health, 173-182, 449-458 acute coronary syndrome, 487-489epididymitis, 181-182, 455-458fatigue, 175-177, 449-451maternal postpartum depression, 526prostate changes, 181-182, 455-458secondary hypogonadism, 175-177, 449-451testicular pain, 179-180, 453-454trauma, 537urinary tract infections, 434 menstrual cramps, adolescents, 119-120, 377-381mental health, 227-243, 515-537 adjustment disorder with depressed mood, 229-230, 515-517 adolescents, 113, 366-369anxiety, 239-240, 529-531domestic violence, 241, 520, 534-535forgetfulness, 247-249, 539-541major depressive disorder, 229-230, 515-517more than depression, 231-233, 519-524postpartum depression, 235-237, 525-527sad mood, 229-230, 515-517self‐harm, 520, 522-523sexual identity, 397-398standardized tests, 369substance use disorder, 459, 461, 463-464, 463-465suicide risk assessment, 366, 369, 520-522, 535trauma, 241-243, 533-537 mental status changes, with hyperthermia, 279-280, 587-590 metabolic panels fatigue, 449sexual assault, 427 metered dose inhaler (MDI), 342methadone, 461, 462-463methicillin‐resistant Staphylococcus aureus (MRSA), impetigo, 327-328 methotrexate, 441metronidazole pelvic pain, 418peptic ulcers, 472 MI see myocardial infarctionmigraines with aura, 159-160, 435-437vs sinusitis, 497 mild cognitive impairment (MCI), 247-249, 539-541mild fever, with breast redness and swelling, 149-150, 423-425 milk excessive consumption, 293-294formulas, 29, 295-296 Milnacipran (Savella), 444mini‐pill see progestin‐only pillminocycline, 441missed periods, adolescents, 121-122, 191-193, 383-385, 471-473 morning headaches, 209-210, 493-494motivational interviewing, 369mouth see oral health MRI see magnetic resonance imaging MRSA see methicillin‐resistant Staphylococcus aureusmupirocin, 328Murphy's sign, 156, 431-432muscle tenderness, fibromyalgia, 165-167, 443-444myocardial infarction (MI) Dressler's syndrome, 486non‐ST elevation, 205-206, 487-489 naltrexone, 463naproxen, 379nasopharyngeal swabs, neonates, 289Neisseria gonorrhea, 420 pelvic pain, 417testicular pain, 453 neomycin, 317neonates, 1-21, 283-292 aspirin, 317bronchiolitis, 15-17, 289-290cardiovascular screening, 3-5, 283-284nutrition and weight, 19-21, 291-292overfeeding, 19-21, 291-292oxygenation, 15-17, 289-290pulmonary screening, 7-9, 285-286skin screening exams, 11-13, 287-288transient tachypnea, 7-9, 285-286 neurobiology of depression, 523Neurontin, 444Nexplenon contraindications, 390initiation, 389side effects, 391 nightmares, school‐aged children, 97-99, 347-349night sweats, 139-143, 407-415 depression, 408endocrine disorders, 407-408hormone therapy, 411-414and menopause, 407-414prescription options, 410-413selective serotonin reuptake inhibitors, 411-412 night terrors, 97-99, 347-349nipple piercing, 423nitrofurantoin, 433
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 601 nocturnal leg pain, 195-196, 475-478 nonallergic rhinitis with eosinophilia syndrome (NARES), 495 nonorganic failure to thrive, 33-35, 297-299nonproductive cough asthma, 93-94, 341-343chronic obstructive pulmonary disease, 197-198, 479-480 nonpuerperal breast abscess, 149-150, 423-425non‐ST elevation myocardial infarction (NSTEMI), 205-206, 487-489 nonsteroidal anti‐inflammatory drugs (NSAIDs) gingivitis and caries, 320gout, 573-574Lyme disease, 400menstrual cramps, 378-379patent ductus arteriosus, 283-284systemic lupus erythematosus, 440-441vertebral compression fractures, 569 Non‐Suicidal Self‐Injury Assessment Tool (NSSI‐AT), 520, 534 normal pressure hydrocephalus (NPH), 546-547NPH see normal pressure hydrocephalus NSAIDS see nonsteroidal anti‐inflammatory drugs NSSI‐AT see Non‐Suicidal Self‐Injury Assessment Tool NSTEMI see non‐ST elevation myocardial infarctionnumbness in hands, 217-219, 503-506nutrition adolescent weight loss, 371-372, 374breastfeeding, 29-31, 295-296celiac disease, 355constipation, 295-296depression, 523failure to thrive, 33-35, 297-299infants, 25-35, 293-299iron deficiency anemia in infants, 295-296neonates, 19-21, 291-292oral health, 320 OA see osteoarthritisobesity, school‐aged children, 107-109, 363-364obstructive sleep apnea (OSA), 493, 500ODD see oppositional defiant disorder OGTT see oral glucose tolerance testolder adults, 245-280, 539-590 acute joint pain, 273-274, 573-575allergies, 580back pain, 267-271, 565-572behavior changes, 251-254, 543-550chronic kidney disease, 213-215, 499-501delirium, 251-254, 543-550dementia, 500depression, 500, 523diabetes, 259-262, 555-557dry skin, 580essential tremor, 255-257, 551-553forgetfulness, 247-249, 539-541gout, 273-274, 573-575herpes zoster, 275-276, 577-582hyperthermia and mental status changes, 279-280, 587-590itching and soreness, 275-276, 577-582knee pain, 277-278, 583-585lower respiratory infections, 548orthostatic hypotension, 549osteoarthritis, 277-278, 583-585osteoporosis, 267-271, 565-572pneumonia, 251-254, 543-550polypharmacy, 540stroke, 561-562tremors, 255-257, 551-553vaccinations, 580-581vertebral compression fracture, 267-271, 565-572visual changes, 263-265, 559-563weight gain and fatigue, 259-262, 555-557 omeprazole, 471, 482, 546OP see osteoporosisopiates buprenorphine, 462clonidine, 462intravenous administration, 465-466methadone, 461, 462-463naltrexone, 463overdose, 460-461, 463use disorder, 185-186, 459-466withdrawal, 459, 460 opioid use disorder (OUD) see opiatesoppositional defiant disorder (ODD), 89-91, 339-340oral antibiotics impetigo, 328see also individual pharmaceuticals. . . oral antifungals, candidiasis, 419-420oral contraceptive pills (OCPs) birth control, 388bone mineral density, 373contraindications, 390initiation, 389-390menstrual cramps, 378migraine, 437polycystic ovary syndrome, 472preconception planning, 404side effects, 391smoking, 387 oral corticosteroids, gout, 574oral desensitization, food allergies, 361oral glucose tolerance test (OGTT), 363oral hygiene cariostatic foods, 320demographic patterns, 320preschool children, 63-65, 319-320toothache, 63-65, 319-320 oral steroids, 342organic failure to thrive, 298orthostatic hypotension, 549
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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602 Index OSA see obstructive sleep apnea osteoarthritis (OA), 277-278, 583-585osteomyelitis, 467, 469osteoporosis (OP), 267-271, 565-572 health education, 571pharmacotherapeutics, 269-271referrals, 571 otitis media, 55-56, 309-310OUD (opioid use disorder) see opiatesoverdose, opiates, 460-461, 463overfeeding, neonates, 19-21, 291-292over‐the‐counter (OTC) antifungals, 419-420oxybutynin chloride, bedwetting, 312oxygenation, neonates, 15-17, 289-290, 303oxygen therapy, croup, 303 PAD see peripheral artery disease pain back, 267-271, 565-572chest with dyspnea without radiation, 201-203, 485-486radiating, 205-206, 487-489 knees adolescents, 129-131, 399-402older adults, 277-278, 583-585 phantom limb, 223-224, 511-512radiating, 205-206, 487-489vertebral compression fractures, 267-271, 565-572wrists, with swelling, 225-226, 513-514 pain reduction burns, 317migraine with aura, 436 parasomnias, 97-99, 347-349parathyroid hormone, 569parents anaphylaxis education, 359-361celiac disease, 354depression risk, 520domestic violence, 241, 534-535oppositional defiant disorder, 90, 339postpartum depression, 235-237, 525-527 Parkinson's disease (PD), 546, 551partial thickness burns, 61-62, 315-318parvovirus, 441patellofemoral syndrome, 583patent ductus arteriosus (PDA), 3-5, 283-284, 301Patient Health Questionnaire‐9 (PHQ‐9), 369, 460, 520, 534PCOS see polycystic ovary syndrome PCR see polymerase chain reaction PD see Parkinson's disease PDA see patent ductus arteriosus PE see pulmonary embolism #peanut allergy, 103-105, 357-361 Epi Pens, 359-360younger siblings, 360-361pelvic inflammatory disease (PID), 145-146, 417-418pelvic pain, 145-146, 417-418penicillin allergies, 56, 310, 338sore throat, 338 penis erectile dysfunction, 175-177, 449-451lesions, 71-73, 325-326 PEP see post‐exposure prophylaxispeptic ulcers, 191-193, 471-473pericarditis, 201-202, 485-486perimenopausal period, 406 complementary and alternative medicine, 410health education, 412-413hormone therapy, 411-414night sweats, 139-143, 407-415selective serotonin reuptake inhibitors, 411-412vasomotor symptoms, 410-412 periodontitis, 319periods cramps, 119-120, 377-381irregular, 191-193, 471-473missed, 121-122, 383-385 peripheral artery disease (PAD), 195-196, 475-478persistent cough, and joint tenderness, 207-208, 491-492phantom limb pain (PLP), 223-224, 511-512pharyngitis, 337phenazopyridine, 433phimosis, 326PHN see postherpetic neuralgiaphysical abuse domestic violence, 241, 520, 534-535school‐aged children, 95-96, 345-346 PID see pelvic inflammatory disease Plaquenil (hydroxychloroquine), 441PLP see phantom limb pain PNE see primary nocturnal enuresispneumonia chlamydial, 289older adults, 251-254, 543-550 polycystic ovary syndrome (PCOS), 191-193, 471-473polyethylene glycol (PEG), 322polymerase chain reaction (PCR), 331polypharmacy, 540polysomnography, 347post‐exposure prophylaxis (PEP), HIV, 427-429postherpetic neuralgia (PHN), 578postpartum depression, 235-237, 525-527post‐stroke period, 562post‐traumatic stress disorder (PTSD), 241-243, 533-537potassium hydroxide (KOH) smear test, 331poverty, failure to thrive, 298-299preconception planning, 135-136, 403-404, 473prednisolone, 342prednisone, 441
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 603 pregabalin, 444 pregnancy adolescents, 383-385first trimester bleeding, 137-138, 405-406migraine medications, 436polycystic ovary syndrome, 472-473preconception planning, 135-136, 403-404urinary tract infections, 434 pregnancy testing, 383, 388premature births, 3-5, 283-284preschool children, 53-73, 309-326 abdominal pain, 67-69, 321-323aspirin, 317balanoposthitis, 71-73, 325-326bedwetting, 57-59, 311-313burns, 61-62, 315-318constipation, 67-69, 321-323dental caries, 63-65, 319-320earache, 55-56, 309-310gingivitis, 63-65, 319-320oral hygiene, 63-65, 319-320otitis media, 55-56, 309-310penile lesions, 71-73, 325-326scheduled toileting, 322toothache, 63-65, 319-320 prevalence preschool constipation, 323systemic lupus erythematosus, 439testicular malignancy, 453 primary dysmenorrhea, 119-120, 377-381primary hypogonadism, 449primary nocturnal enuresis (PNE), 311progesterone levels, first trimester bleeding, 405progestin‐only pill (mini‐pill), 390 side effects, 391 prolactin levels, 449pronator syndrome, 217-219, 503, 505prostate cancer, 456prostate changes, 181-182, 455-458proton pump inhibitors (PPI), 471, 482, 546pruritis, older adults, 577-582PSA test, 456pseudomonal keratitis, 335PTSD see post‐traumatic stress disorderpulmonary embolism (PE), 487pulmonary screening exams, 7-9, 285-286pyelonephritis, 433, 434 RA see rheumatoid arthritis radiating chest pain, 205-206, 487-489RANK‐ligand inhibitors, 569rapid strep test, 337rashes with fever, 79-81, 331-332impetigo, 77-78, 327-329neonates, 11-13, 287-288older adults, 580without fever, 77-78, 327-329 receeding gums, 63-65, 319-320red eye, 83-84, 333-335redness, breasts, 149-150, 423-425RED‐S see relative energy deficiency in sportsreferrals acute coronary syndrome, 488blastomycoses dermatitidis, 492chronic obstructive pulmonary disease, 480diabetic foot ulcers, 468-469drug use, adolescent, 368, 369forgetfulness, 540osteoporosis, 571pericarditis, 486peripheral artery disease, 475, 476post‐traumatic stress disorder, 536substance use disorder, 464, 465vertebral compression fractures, 571 reflux see gastroesophageal reflux diseaserelative energy deficiency in sports (RED‐S), 372, 374, 375repetitive transcranial magnetic stimulation (r TMS), 512respiratory distress chronic obstructive pulmonary disease, 197-198, 479-480 transient tachypnea of the newborn, 7-9, 285-286 respiratory syncytial virus (RSV), 15-17, 289-290Reye syndrome, 317Rhesus screening, first trimester bleeding, 405rheumatoid arthritis (RA), 225-226, 513-514, 566rhinosinusitis, 211-212, 495-497right upper quadrant (RUQ) tenderness, 155-156, 431-432rotavirus, 305-306RSV see respiratory syncytial virusr TMS see repetitive transcranial magnetic stimulationrule of nines burn chart, 316RUQ see right upper quadrant sad mood, 229-230, 515-517 SAMHSA see Substance Abuse and Mental Health Services Administration Savella (Milnacipran), 444SBIRT see Screening, Brief Intervention and Referral for Treatment scabies, 577, 580scheduled toileting, 322school‐aged children, 75-109, 327-364 abuse, 95-96, 345-346aspirin, 317asthma, 93-94, 341-343breakthrough varicella zoster virus, 79-81, 331-332celiac disease, 101-102, 351-356conjunctivitis, 83-84, 333-335cough and difficulty breathing, 93-94, 341-343
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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604 Index depression, 523 disruptive behavior, 89-91, 339-340food allergies, 103-105, 351, 357-361gastrointestinal complaints, 101-102, 351-356impetigo, 77-78, 327-329left arm pain, 95-96, 345-346Lyme disease, 401-402nightmares, 97-99, 347-349obesity, 107-109, 363-364rash with fever, 79-81, 331-332rash without fever, 77-78, 327-329self‐harm, 523sore throat, 85-87, 337-338 school attendance adolescents, 113, 365-366anaphylaxis risk, 358-359celiac disease, 355conjunctivitis, 335impetigo, 329menstrual cramps, 379 school‐based health centers (SBHC) depression, 231-233, 519-524drug use, 113-114, 365-370major depressive disorder, 113menstrual cramps, 119-120, 377-381school phobia, 113-114self‐harm, 231-233, 519-524suicide risk assessment, 366, 369trauma, 241-243, 533-537weight loss, 115-117, 371-555 school phobia, 365-366Screening, Brief Intervention and Referral for Treatment (SBIRT), 369, 459-460 secondary hypogonadism, 175-177, 449-451second‐degree burns, 61-62, 315-318selective serotonin reuptake inhibitors (SSRIs) depression, 522fibromyalgia, 444perimenopausal period, 411-412post‐traumatic stress disorder, 535, 536side effects, 522 self‐injurious behavior (SIB), 520, 522-523, 535serotonin norepinephrin reuptake inhibitors (SNRIs), 411-412serum creatine, systemic lupus erythematosus, 440SES see socioeconomic statussexual assault, 151-153, 427-429sexual assault response teams (SARTs), 428sexual desire disorders, 407-408, 450sexual history, 5p approach, 125sexual identity, adolescents, 127-128, 397-398sexually transmitted infections adolescents, 121, 377, 378, 383expedited partner therapy, 396health education, 395HIV risk, 396pelvic pain, 417preconception planning, 403-404testicular pain, 453vaginal discharge, 125-126, 395-396 short‐acting beta 2‐agonists, 342 SIB see self‐injurious behaviorsiblings, food allergies, 360-361side effects contraception, 390-391itching and soreness, 577-578selective serotonin reuptake inhibitors, 522 sinus infections acute, 211-212, 495-497vs migraines, 497 skin screening exams, 11-13, 287-288sleep adolescents, 113, 366, 367and depression, 521, 523fibromyalgia, 165, 443hygiene, 348, 443, 521, 523, 535, 536night terrors, 97-99, 347-349 sleep apnea, obstructive, 500slow‐wave sleep (SWS), 347small for gestational age (SGA), 525smoking acute coronary syndrome, 488chronic obstructive pulmonary disease, 197-198, 479-480cotinine concentration, 423hormonal contraceptives, 387hypertension, 209-210, 493-494migraine, 437peripheral artery disease, 475-476and pregnancy, 403 SMs see stroke mimics SNAP food stamps, 293-294socioeconomic status (SES) failure to thrive, 298-299nutrition, 293-294 sore throat, school‐aged children, 85-87, 337-338spinal cord injury, hand numbness, 217-219, 503-504spirochete infections, penile lesions, 325spontaneous inevitable abortion, 137-138, 405-406SSRIs see selective serotonin reuptake inhibitorsstandardized guidelines adolescent birth control, 392adolescent drug use, 369diabetic foot ulcers, 468female athlete triad, 372, 374Lyme disease, 401major depressive disorder, 369pelvic pain, 418pericarditis, 486sexual assault, 429substance use disorder, 465school‐aged children (cont'd)
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 605 Staphylococcus aureus, 77-78, 327-329 balanoposthitis, 325-326 statins, peripheral artery disease, 476steroids, oral, 342Stevens-Johnson Syndrome (SJS), 577STI see sexually transmitted infection Still's murmur, 37-39, 301-302stool tests, 305, 321strangulation, 152, 427-429strep test, sore throat, 337Streptococcus balanoposthitis, 325-326nonpuerperal breast abscess, 423-424pyogenes, 77-78, 327-329 stressor‐related disorder, 533stroke, 561-562stroke mimics (SMs), 561Substance Abuse and Mental Health Services Administration (SAMHSA) tool, 459 substance/medication‐induced anxiety disorder, 529substance use disorder (SUD), 185-186, 459-466 buprenorphine, 462clonidine, 462diagnostic tests, 459-460health promotion, 463intravenous administration, 465-466mental health, 459, 461, 463-464, 463-465methadone, 461, 462-463naltrexone, 463opioids, 459-466opioid withdrawal, 459, 460referrals, 464, 465standardized guidelines, 465 suicide risk assessment, 366, 369, 520-522, 535Sunday start method, 389superficial burns, 315superficial partial‐thickness burns, 315superimposed delirium, 544suspected child abuse, 345-346swelling breasts, 149-150, 423-425wrists, 225-226, 513-514 SWS see slow‐wave sleepsynovial fluid, testing, 399-400systemic lupus erythematosus (SLE), 161-163, 439-442 TBI see toe brachial index; traumatic brain injury TBSA see total body surface areatemporal arteritis, 560tender abdomen, celiac disease, 101-102, 351-356testicular malignancy, 453testicular pain, 179-180, 453-454testosterone testing, 449testosterone therapy, 450thenar atrophy, 505third‐degree burns, 315third‐stage chronic kidney disease, 213-215, 499-501thyroid disorders adolescents, 366, 372comparison, 447insomnia, 169-171, 445-447night sweats, 407 thyroid panels, 366thyroid storm, 446TIA see transient ischemic attacktimpanic membrane (TM), otitis media, 56, 309TM see timpanic membranetoddlers, 53-73, 309-326 abdominal pain, 67-69, 321-323aspirin, 317balanoposthitis, 71-73, 325-326bedwetting, 57-59, 311-313burns, 61-62, 315-318constipation, 67-69, 321-323dental caries, 63-65, 319-320earache, 55-56, 309-310gingivitis, 63-65, 319-320otitis media, 55-56, 309-310penile lesions, 71-73, 325-326scheduled toileting, 322toothache, 63-65, 319-320 toe brachial index (TBI), 475toothache in preschool children, 63-65, 319-320Topamax (topiramate), fibromyalgia, 444topical antibiotics, impetigo, 328topical antifungals, candidiasis, 419-420topical antimicrobials burns, 317penile lesions, 326 torsion, testicular, 453total body surface area (TBSA) of burns, 316toxic epidermal necrosis (TEN), 577toxicology drug screening, 366polypharmacy, 540sexual assault, 427 transferrin saturation, 449transient ischemic attack (TIA), 561-562transient tachypnea of the newborn (TTN), 7-9, 285-286 transvaginal ultrasound first trimester bleeding, 405pelvic pain, 417 trauma demographic patterns, 536-537and domestic violence, 534and mental health, 241-243, 533-537testicular, 454 trauma‐informed care, 535-536
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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606 Index traumatic brain injury (TBI), infants, 49-51, 307-308 tree nuts, 103-105, 357-361tremors, 255-257, 551-553Treponema pallidum, 325, 417trichomonas, 420TTN see transient tachypnea of the newborn Tzanck smear, 331 ulcers arterial, 468, 477 feet, 187-190, 467-469venous, 468, 477 ULT see urate‐lowering therapyultrasound abdominal pain, 431breast redness and swelling, 423first trimester bleeding, 405pelvic pain, 417 unspecified trauma‐related disorder, 533upper respiratory infections (URI) in neonates, 15-17, 289-290 urate‐lowering therapy (ULT), 575URI see upper respiratory infectionsurinalysis bedwetting, 312failure to thrive, 297fatigue, 449penile lesions, 325sexual assault, 428 urinary frequency, 157-158, 181-182, 433-434, 455-458 urinary tract infections (UTI), 157-158, 311, 420, 433-434, 456 urine nucleic acid amplification test (urine NAAT), 428urine pregnancy tests, 383, 388UTI see urinary tract infections vaccinations for older adults, 580-581 vaginal discharge, 125-126, 395-396vaginal itching, 147-148, 419-421varicella zoster virus (VZV), 578 breakthrough, 79-81, 331-332 vasomotor symptoms in perimenopausal period, 410-412 VCF see vertebral compression fracture VCUG see voiding cystourethrographyvenlafaxine, fibromyalgia, 444venous ulcers, 468, 477ventricular septal defect (VSD), 301vertebral compression fracture (VCF), 267-271, 565-572viral infections bronchiolitis, 15-17, 289-290conjunctivitis, 333-335gastroenteritis, 45-47, 305-306herpes simplex, 331sore throat, 337varicella zoster breakthrough, 79-81, 331-332 visual changes, 263-265, 559-563vitamin deficiencies adolescents, 374celiac disease, 352osteoporosis, 568systemic lupus erythematosus, 440 voiding cystourethrography (VCUG), 311VSD see ventricular septal defect VZV see varicella zoster virus WBC see white blood cell weight adolescents, 115-117, 371Body Mass Index, 363-364, 372failure to thrive, 33-35, 297-299gain with abdominal pain, 191-193, 471-473and fatigue, 259-262, 555-557 infants, 25-35, 293-299loss adolescents, 115-117, 371with confusion and fatigue, 213-215, 499-501 malabsorption, 372malnutrition, 372neonates, 19-21, 291-292obesity, 107-109, 363-364school‐aged children, 107-109, 363-364 “well child” visits 9 months, 29-31, 295-29612 months, 25-27, 293-294 Western blot testing, Lyme disease, 399white blood cell (WBC) count diarrhea, 305joint pains, 399-400oxygenation, 289 withdrawal from opiates, 459, 460Women, Infants, and Children (WIC) program, 293-294, 296 women's health, 133-171, 403-447 abdominal pain, 155-156, 431-432acute coronary syndrome, 489breast swelling and redness, 149-150, 423-425candidiasis, vaginal, 147-148, 419-421cholecystitis, 155-156, 431-432fatigue with joint pain, 161-163, 439-442fibromyalgia, 165-167, 443-444first trimester bleeding, 137-138, 405-406headaches, 159-160, 435-437hormone therapy, 411-414insomnia, 169-171, 445-447migraine with aura, 159-160, 435-437muscle tenderness, 165-167, 443-444night sweats, 139-143, 407-415
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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Index 607 pelvic pain, 145-146, 417-418 polycystic ovary syndrome, 191-193, 471-473postpartum depression, 235-237, 525-527preconception planning, 135-136, 403-404sexual assault, 151-153, 427-429sexual desire disorders, 407-408spontaneous abortion, 137-138, 405-406systemic lupus erythematosus, 161-163, 439-442trauma, 241-243, 533-537urinary frequency, 157-158, 433-434urinary tract infections, 157-158, 433-434vaginal itching, 147-148, 419-421 Wright stain, 287wrist swelling with pain, 225-226, 513-514
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Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
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