Feb 23, 2024 NURS 6501 Knowledge Check Women’s and Men’s Health, Infections, and Hematologic Disorders
NURS 6501 Knowledge Check Women’s and Men’s Health, Infections, and Hematologic Disorders
NURS 6501 Knowledge Check Women’s and Men’s Health, Infections, and Hematologic Disorders
Scenario 3: Syphilis
A 37-year-old male comes to the clinic with a complaint of a “sore on my penis” that has been there for 5 days. He says it burns and leaked a little fluid. He denies any other symptoms. Past medical history noncontributory.
SH: Bartender and he states he often “hooks up” with some of the patrons, both male and female after work. He does not always use condoms.
PE: WNL except for a lesion on the lateral side of the penis adjacent to the glans. The area is indurated with a small round raised lesion. The APRN orders laboratory tests, but feels the patient has syphilis.
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Question:
1. What are the 4 stages of syphilis
Your Answer:
Syphilis progresses through four distinct stages, each characterized by specific symptoms and clinical manifestations:
Primary Stage: This stage begins with the appearance of a painless sore called a chancre at the site of infection, typically within 3 weeks after exposure. The sore is firm, round, and often goes unnoticed. It can last for a few weeks and eventually heals on its own. The chancre is highly contagious and contains the bacterium Treponema pallidum.
Secondary Stage: After the chancre heals, the secondary stage emerges, usually a few weeks to a few months later. Symptoms during this stage can vary widely and may include a skin rash, mucous membrane lesions (e.g., in the mouth or genitals), fever, fatigue, sore throat, and muscle aches. The rash is typically non-itchy, red or brown, and may appear on the palms and soles. These symptoms can come and go over several weeks.
Latent Stage: This stage is characterized by the absence of visible symptoms. Syphilis remains present in the body, but there are no outward signs or symptoms. Latent syphilis is further categorized into early latent (within a year of initial infection) and late latent (more than a year after initial infection). During this stage, the infection can still be transmitted to others through sexual contact.
Tertiary Stage: If left untreated, syphilis can progress to the tertiary stage, which can occur years after the initial infection. Tertiary syphilis is rare due to the widespread use of antibiotics. However, it can lead to severe and potentially life-threatening complications, such as damage to the heart, blood vessels, brain, nerves, and other organs. Neurological complications can lead to significant disability.
Scenario 1: Polycystic Ovarian Syndrome (PCOS) A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted. Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management. Question 1. What is the pathogenesis of PCOS? Selected Answer: Polycystic Ovary Syndrome (PCOS) has an underlying genetic component that causes irregular ovulation, increased androgens, and ovaries with polycystic characteristics (McCance & Huether, 2019). Glucose intolerance and insulin resistance increase androgen secretion via the ovaries’ supportive structures and reduce sex-hormone-binding globulin (McCance & Huether, 2019). Elevated leptin levels act on the hypothalamus interfering with hormone production. Follicular growth and apoptosis alterations influence the absence of ovulation, creating inappropriate functioning of FSH and LH. Cortical thickening increases subcortical stroma, and hyperplasia occurs (McCance & Huether, 2019) Polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to release eggs regularly. other factors that may contribute to the development of PCOS include: Excess insulin. Insulin is the hormone produced in the pancreas that allows cells to use sugar, your body’s primary energy supply. If your cells become resistant to the action of insulin, then your blood sugar levels can rise, and your body might produce more insulin. Excess insulin might increase androgen production, causing difficulty with ovulation. Low-grade inflammation. This term describes white blood cells’ production of substances to fight infection. Research has shown that women with PCOS have a type of low-grade inflammation that stimulates polycystic ovaries to produce androgens, leading to heart and blood vessel problems. Excess androgen. The ovaries produce abnormally high androgen levels, resulting in hirsutism and acne. Early diagnosis of PCOS and treatment and weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease. Complications of PCOS can include: Infertility, Gestational diabetes or pregnancy-induced high blood pressure, miscarriage or premature birth, Nonalcoholic steatohepatitis, Metabolic syndrome including high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels that significantly increase your risk of cardiovascular disease, Type 2 diabetes or prediabetes, Sleep apnea, Depression, anxiety and eating disorders, Abnormal uterine bleeding, and cancer of the uterine lining (endometrial cancer). It is important to note that these complications are more severe in overweight women. Correct Answer: The pathogenesis of PCOS has been linked to altered luteinizing hormone (LH) action, insulin resistance, and a possible predisposition to hyperandrogenism. One theory maintains that underlying insulin resistance exacerbates hyperandrogenism by suppressing synthesis of sex hormone–binding globulin and increasing adrenal and ovarian synthesis of androgens, thereby increasing androgen levels. These androgens then lead to irregular menses and physical manifestations of hyperandrogenism. The hyperandrogenic state is a cardinal feature of PCOS but glucose intolerance/insulin resistance and hyperinsulinemia often run parallel to and markedly aggravate the hyperandrogenic state, thus contributing to the severity of signs and symptoms of PCOS. Response Feedback: [None Given]
Question 2
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Scenario 1: Polycystic Ovarian Syndrome (PCOS) A 29-year-old female presents to the clinic with a complaint of hirsutism and irregular menses. She describes irregular and infrequent menses (five or six per year) since menarche at 11 years of age. She began to develop dark, coarse facial hair when she was 13 years of age, but her parents did not seek treatment or medical opinion at that time. The symptoms worsened after she gained weight in college. She got married 3 years ago and has been trying to get pregnant for the last 2 years without success. Height 66 inches and weight 198. BMI 32 kg.m2. Moderate hirsutism without virilization noted. Laboratory data reveal CMP within normal limits (WNL), CBC with manual differential (WNL), TSH 0.9 IU/L SI units (normal 0.4-4.0 IU/L SI units), a total testosterone of 65 ng/dl (normal 2.4-47 ng/dl), and glycated hemoglobin level of 6.1% (normal value ≤5.6%). Based on this information, the APRN diagnoses the patient with polycystic ovarian syndrome (PCOS) and refers her to the Women’s Health APRN for further workup and management. Question How does PCOS affect a woman’s fertility or infertility? Selected Answer: PCOS is the leading cause of infertility in women (McCance & Huether, 2019). Infertility results from alterations in androgen production, follicular disturbances, and an absence of ovulation. In other words, PCOS negatively impacts fertility because women with the condition do not ovulate or release an egg each month due to an overproduction of estrogen by the ovaries. Correct Answer: Ovulation problems are usually the primary cause of infertility in women with PCOS. Ovulation may not occur due to an increase in testosterone production or © 2020 Walden University 2 because follicles on the ovaries do not mature. Due to unbalanced hormones, ovulation and menstruation can be irregular. A hyperandrogenic state is a cardinal feature in the pathogenesis of PCOS. Excessive androgens affect follicular growth, and insulin affects follicular decline by suppressing apoptosis and enabling follicle to persist. There is dysfunction in ovarian follicle development. Inappropriate gonadotropin secretion triggers the beginning of a vicious cycle that perpetuates anovulation Response Feedback: [None Given]
The case study concerns a 60-year-old man with complaints of urinary frequency and incontinence that started after having chemo and radiotherapy three years ago to treat prostate cancer. The patient is more worried about his low back and hip pain that started roughly one month ago, which he thought was caused by lifting heavy boxes. Lab results show a normal urinalysis and CBC, and PSA of 7.2. The prostate is enlarged and nodular on DRE. The purpose of this assignment is to discuss prostatitis as it relates to the patient case.
Why prostatitis and infection happen and causes of a systemic reaction.
Prostatitis occurs due to inflammation of the prostate gland. Bacterial prostatitis mainly occurs with urethritis or a lower urinary tract infection (UTI). It is commonly caused by Enterobacter, Escherichia coli, Group D streptococci, and Proteus (Pirola et al., 2019). The microbes reach the prostate through the urethra or bloodstream. The patient presents with symptoms of chronic bacterial prostatitis like urinary frequency and incontinence. This could have been caused by the inoculation of bacteria during therapy or microorganisms from a lower UTI spreading to the prostate (Pirola et al., 2019).
Furthermore, chronic prostatitis manifests with pain in and around the penis, testicles, anal area, lower abdomen, and lower back. It also presents with an enlarged or tender prostate on digital rectal examination (DRE). Therefore, the patient’s low back and hip pain, as well as findings of an enlarged, nodular prostate, can be pointed to chronic prostatitis.
Benign prostatic hyperplasia (BPH) is a risk factor for prostatitis. The patient’s history of prostate cancer can be attributed to chronic bacterial prostatitis. The bacteria may have been inoculated to the prostate during the chemotherapy and radiotherapy. The patient has an elevated PSA level of 7.2 and an enlarged nodular prostate, which can be attributed to prostate cancer (McCance & Huether, 2019). Furthermore, the patient’s mild degenerative changes in the spine and cystic mass near the spine can be due to metastatic spinal cord compression (MSCC). MSCC occurs when cancer cells spread from the prostate and grow in or near the spine, pressing on the spinal cord (Patnaik et al., 2020).
A systemic reaction occurs in a patient with prostatitis when the causative organisms enter the circulation through the lymphatic or blood system and cause infection to other body organs. This results in systemic symptoms like fever, chills, malaise, tachycardia, tachypnea, and myalgia.
Conclusion
The patient has symptoms consistent with chronic bacterial prostatitis, like urinary frequency and incontinence. Chemotherapy may have caused prostatitis when pathogens are inoculated into the bladder. Besides, the patient has symptoms consistent with prostate cancer, like an enlarged, nodular prostate and elevated PSA levels. The degenerative changes and cystic mass near the spine are likely due to the spread of cancer cells from the prostate. A systemic reaction can occur when causative organisms migrate from the prostate to the circulation.
References
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier
Patnaik, S., Turner, J., Inaparthy, P., & Kieffer, W. K. (2020). Metastatic spinal cord compression. British journal of hospital medicine (London, England : 2005), 81(4), 1–10. https://doi.org/10.12968/hmed.2019.0399
Pirola, G. M., Verdacchi, T., Rosadi, S., Annino, F., & De Angelis, M. (2019). Chronic prostatitis: current treatment options. Research and reports in urology, 11, 165–174. https://doi.org/10.2147/RRU.S194679
Week 9 Discussion Main Post
Many patients who present for medical treatment of acute illness have multiple comorbidities that require consideration. The focus of this post is a 68-year-old male patient who presents with acute community-acquired pneumonia (CAP). Medical history includes Type II diabetes, hypertension (HTN), hyperlipidemia, and chronic obstructive pulmonary disease (COPD).
Current Drug Therapy
The patient’s current drug therapy includes Metformin 500 mg twice a day, glipizide 10 mg once daily, lisinopril 10 mg once a day, hydrochlorothiazide 20mg once a day, simvastatin 40mg once a day, albuterol inhaler two puffs every four to six hours as needed for wheezing or shortness of breath, tiotropium inhaler two puffs (18 mcg) once daily. He is receiving ceftriaxone 1 Gm IV daily and azithromycin 500mg IV daily for the treatment of community-acquired pneumonia and is improving after three days of this therapy.
Metformin is an antihyperglycemic medication used in conjunction with diet and exercise to control blood glucose levels in diabetic patients. This drug should be held for 48 hours when radioactive dye is used for diagnostic testing to prevent damage to the kidneys. Mechanisms of action include increased insulin sensitivity, decreased glucose secretion and decreased glucose absorption. Metformin does not cause hypoglycemia. Glipizide is a blood glucose lowering drug classified as a sulfonylurea drug used to control blood glucose levels in diabetic patients who do not achieve adequate control with diet, exercise, and metformin. Glipizide works by stimulating insulin production and secretion in pancreatic beta cells and its action is dependent on functioning pancreatic beta cells. Patients taking glipizide are at risk of hypoglycemia and should be educated on signs and symptoms of hypoglycemia.
The patient is taking lisinopril and hydrochlorothiazide for blood pressure control. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that works to lower blood pressure and protect diabetic patients from renal disease and is also cardio protective. Hydrochlorothiazide is a diuretic and antihypertensive medication whose mechanism of action is not fully understood. It works in the distal tubule to enhance the secretion of sodium and chloride. It is not metabolized but is excreted by the kidneys and requires dosage adjustments in cases of renal impairment. Patients taking hydrochlorothiazide should be monitored for fluid and electrolyte imbalances.
Simvastatin is a statin drug that acts to lower the risk of coronary heart disease by lowering cholesterol and triglyceride levels in high-risk patients. Patient should avoid grapefruit while taking this medication. Dosing adjustments should be considered in patients with decreased renal function. Simvastatin interacts with several medications and prescribing providers must check drug-drug interactions when prescribing to avoid risk of rhabdomyolysis (Food and Drug Administration [FDA] & Merck Sharp & Dohme Corp [Merck & Co, Inc.], 2012).
The patient is taking tiotropium inhaled powder which is a long-acting muscarinic antagonist (LAMA) that works to prevent bronchospasm in patients diagnosed with COPD. This anticholinergic drug should not be used for rescue when the patient is experiencing shortness of breath. This patient uses an albuterol inhaler as needed for rescue when he is experiencing shortness of breath or wheezing. Albuterol is a short-acting beta agonist (SABA) that works immediately to relieve bronchospasm and is used only as needed.
Anti-infective Therapy for CAP
Ceftriaxone and azithromycin are being given intravenously to treat community acquired pneumonia (CAP). Ceftriaxone is a broad spectrum, third generation cephalosporin antibiotic used to treat bacterial infections in the lower respiratory tract. It works by inhibiting bacterial cell wall synthesis which results in a weak cell wall, bacterial cell lysis, and death. Ceftriaxone is mixed in 50 ml of D5W and should be administered over 30 minutes for four to fourteen days. Compatibility with other IV solutions is a concern, and this drug should be checked for compatibility if other IV solutions are being used particularly calcium which is not compatible with ceftriaxone. Onset is immediate when ceftriaxone is administered IV and peak is within two hours. The half-life of the drug is six to nine hours, and it is excreted primarily by the kidneys. Altered dosing is required in patients with moderate to severe renal impairment. Adverse reactions include life threatening anaphylaxis in patients with allergies to cephtriaxone. Less severe reactions include rash, fever, nausea, pain at injection site. Ceftriaxone is generally well tolerated. Patients taking broad spectrum antibiotics may develop diarrhea related to clostridium difficile (Roche Pharmaceuticals, 1997).
Azithromycin is a broad-spectrum macrolide antibiotic and is indicated for treatment of CAP and prolonged, severe, exacerbation of COPD not responsive to LAMA, or LABA medications (Rosenthal & Burchum, 2019, p. 579). It works by inhibiting bacterial protein synthesis and should be used for at least two to five days of therapy in treatment of CAP. Absorption is primarily from the small intestine and azithromycin distributes readily into most body tissues and fluid. It is primarily eliminated in bile. The peak plasma concentration is within one hour of IV administration and the half life of the drug is approximately eight hours. Adverse reactions include gastrointestinal (GI) upset, prolonged QT interval and risk of torsades de pointes, sudden cardiac death, anaphylaxis, hepatotoxicity, and clostridium difficile associated diarrhea. Azithromycin should not be taken by patients taking class IA or class III antidysrhythmic drugs or CYP3A4 inhibitors. Taking this medication with food has been shown to decrease GI upset (Rosenthal & Burchum, 2019, p. 679).
Current Therapy
The patient is experiencing nausea, vomiting, and is not tolerating his diet. Glipizide should be discontinued, and capillary blood glucose testing ordered before meals and at bedtime. Low dose sliding scale Humalog insulin will be used to control blood glucose levels until patient is eating well. This will help protect the patient from hypoglycemic occurrences. In making decisions about which antibiotic should be used to treat bacterial infections, Choosing Wisely guidelines provide expert recommendations (Choosing Wisely, 2021). CAP is commonly caused by staphylococcus aureus, Mycoplasma, H. influenza and S. pneumoniae. Recommended treatments include penicillin G, penicillin V and amoxicillin. If the strain is determined to be resistant, cephalosporin or ampicillin is recommended. Since this patient has an allergy to penicillin the recommended drug is azithromycin. Cephalosporin drugs are safe to use in patients with penicillin allergies if the reaction is mild. Ceftriaxone is used to treat gram negative bacteria. This combination of antibiotics may have been chosen by the clinician because of the severity of the infection and the need to treat before the pathogen is identified in culture. Once the culture and sensitivity results are back from the lab, decisions will need to be made as how therapy should be continued to produce the best patient outcome (Rosenthal & Burchum, 2019). Since our patient is on day three of treatment, culture results should be available.
Conclusion
Clinical knowledge and guidance are imperative in preventing poor patient outcomes and bacterial resistance to drugs when treating infections. Renal function, hepatic function, allergies and their severity, and patient comorbidities must be considered. When selecting antibiotics, one must consider the infecting organism and host factors to ensure the best patient outcomes.
References
Choosing Wisely. (2021). Learning Resources. Retrieved April 29, 2022, from https://www.choosingwisely.org/choosing-wisely-learning-network/cwln-resources/
Food and Drug Administration & Bristol-Myers Squibb Co. (2011). Glucophage (metformin hydrochloride). Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020357s037s039,021202s021s023lbl.pdf
Food and Drug Administration & Merck Sharp & Dohme Corp. (2012). Zocor (Simvastatin). Food and Drug Administration.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019766s085lbl.pdf
Food and Drug Administration & Mylan Pharmaceuticals Inc. (2011). Hydrochlorothiazide. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/040735s004,040770s003lbl.pdf
Food and Drug Administration & Roerig Division of Pfizer. (2011). Glipizide. FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017783s021lbl.pdf
Roche Pharmaceuticals. (1997). Cephtriaxone. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/0550585s063lbl.pdf
Rosenthal, L. D., & Burchum, J. R. (2019). Lehneś Pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.
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