Tetralogy of Fallot (TOF) is a congenital heart defect which is classically understood to involve four anatomical abnormalities of the heart (although only three of them are always present). It is the most common cyanotic heart defect and the most common cause of blue baby syndrome.TOF is usually a right-to-left shunt, in which higher resistance to right ventricular outflow results in more severe cyanosis symptoms.
These defects, which affect the structure of the heart, cause oxygen-poor blood to flow out of the heart and to the rest of the body. Infants and children with tetralogy of Fallot usually have blue-tinged skin because their blood doesn't carry enough oxygen.
Tetralogy of Fallot is often diagnosed during infancy or soon after. However, tetralogy of Fallot might not be detected until later in life, depending on the severity of the defects and symptoms.
With early diagnosis followed by appropriate surgical treatment, most children who have tetralogy of Fallot live relatively normal lives, though they'll need regular medical care and might have restrictions on exercise.
Signs and Symptoms
Tetralogy of Fallot symptoms vary, depending on the extent of obstruction of blood flow out of the right ventricle and into the lungs. Signs and symptoms may include:
A bluish coloration of the skin caused by blood low in oxygen (cyanosis)
Shortness of breath and rapid breathing, especially during feeding or exercise
Loss of consciousness (fainting)
Clubbing of fingers and toes — an abnormal, rounded shape of the nail bed
Poor weight gain
Tiring easily during play or exercise
Irritability
Prolonged crying
A heart murmur
Tet spells
Sometimes, babies who have tetralogy of Fallot will suddenly develop deep blue skin, nails and lips after crying or feeding, or when agitated. These episodes are called tet spells and are caused by a rapid drop in the amount of oxygen in the blood. Tet spells are most common in young infants, around 2 to 4 months old. Toddlers or older children might instinctively squat when they're short of breath. Squatting increases blood flow to the lungs.
Causes
Tetralogy of Fallot occurs during fetal growth, when the baby's heart is developing. While factors such as poor maternal nutrition, viral illness or genetic disorders might increase the risk of this condition, in most cases the cause of tetralogy of Fallot is unknown.
The four abnormalities that make up the tetralogy of Fallot include:
Pulmonary valve stenosis. Pulmonary valve stenosis is a narrowing of the pulmonary valve — the valve that separates the lower right chamber of the heart (right ventricle) from the main blood vessel leading to the lungs (pulmonary artery).Narrowing (constriction) of the pulmonary valve reduces blood flow to the lungs. The narrowing might also affect the muscle beneath the pulmonary valve.
Ventricular septal defect. A ventricular septal defect is a hole in the wall that separates the two lower chambers of the heart — the left and right ventricle. The hole allows deoxygenated blood in the right ventricle — blood that has circulated through the body and is returning to the lungs to replenish its oxygen supply — to flow into the left ventricle and mix with oxygenated blood fresh from the lungs. Blood from the left ventricle also flows back to the right ventricle in an inefficient manner. This ability for blood to flow through the ventricular septal defect reduces the supply of oxygenated blood to the body and eventually can weaken the heart.
Overriding aorta. Normally the aorta — the main artery leading out to the body — branches off the left ventricle. In tetralogy of Fallot, the aorta is shifted slightly to the right and lies directly above the ventricular septal defect. In this position the aorta receives blood from both the right and left ventricles, mixing the oxygen-poor blood from the right ventricle with the oxygen-rich blood from the left ventricle.
Right ventricular hypertrophy. When the heart's pumping action is overworked, it causes the muscular wall of the right ventricle to thicken. Over time this might cause the heart to stiffen, become weak and eventually fail.
Some babies who have tetralogy of Fallot may have other heart defects, such as a hole between their heart's upper chambers (atrial septal defect).
Risk Factors
While the exact cause of tetralogy of Fallot is unknown, various factors might increase the risk of a baby being born with this condition. These risk factors include:
A viral illness during pregnancy, such as rubella (German measles)
Alcoholism during pregnancy
Poor nutrition during pregnancy
A mother older than age 40
A parent who has tetralogy of Fallot
The presence of Down syndrome or DiGeorge syndrome
Diagnosis
Tests may include:
Echocardiography - Echocardiograms use high-pitched sound waves to produce an image of the heart. Sound waves bounce off your baby's heart and produce moving images that can be viewed on a video screen. This test is generally used to diagnose tetralogy of Fallot. It allows your baby's doctor to determine if there is a ventricular septal defect and where it's located, if the structure of the pulmonary valve and pulmonary artery is normal, if the right ventricle is functioning properly, and if the aorta is positioned properly. This test can also help your baby's doctors to plan treatment for your baby's condition.
Electrocardiogram - An electrocardiogram records the electrical activity in the heart each time it contracts. During this procedure, patches with wires (electrodes) are placed on your baby's chest, wrists and ankles. The electrodes measure electrical activity, which is recorded on paper.This test helps determine if your baby's right ventricle is enlarged (right ventricular hypertrophy), if your baby's right atrium is enlarged and if the heart rhythm is regular.
Chest X-ray - A chest X-ray can show the structure of your baby's heart and lungs. A common sign of tetralogy of Fallot on an X-ray is a "boot-shaped" heart, because the right ventricle is enlarged.
Oxygen level measurement (pulse oximetry) - This test uses a small sensor that can be placed on a finger or toe to measure the amount of oxygen in your baby's blood.
Cardiac catheterization - Doctors may use this test to evaluate the structure of the heart and plan surgical treatment. During this procedure, your baby's doctor inserts a thin, flexible tube (catheter) into an artery or vein in your baby's arm, groin or neck and threads it up to his or her heart. Your baby's doctor injects a dye through the catheter to make your baby's heart structures visible on X-ray pictures. Cardiac catheterization also measures pressure and oxygen levels in the chambers of the heart and in the blood vessels.
Treatments
Surgery is the only effective treatment for tetralogy of Fallot. Surgical options include intracardiac repair or a temporary procedure that uses a shunt. However, most babies and older children have intracardiac repair.
Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. The liver carries out several necessary functions, including detoxifying harmful substances in your body, cleaning your blood and making vital nutrients.
Cirrhosis occurs in response to damage to your liver. Each time your liver is injured, it tries to repair itself. In the process, scar tissue forms. As cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function.
Decompensated cirrhosis is the term used to describe the development of specific complications resulting from the changes brought on by cirrhosis. Decompensated cirrhosis is life-threatening.
The liver damage done by cirrhosis generally can't be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.
Signs and Symptoms
Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and symptoms do occur, they may include:
Fatigue
Bleeding easily
Bruising easily
Itchy skin
Yellow discoloration in the skin and eyes (jaundice)
Fluid accumulation in your abdomen (ascites)
Loss of appetite
Nausea
Swelling in your legs
Weight loss
Confusion, drowsiness and slurred speech (hepatic encephalopathy)
Spiderlike blood vessels on your skin
Redness in the palms of the hands
Testicular atrophy in men
Breast enlargement in men
Causes
A wide range of diseases and conditions can damage the liver and lead to cirrhosis. The most common causes are:
Chronic alcohol abuse
Chronic viral hepatitis (hepatitis B and C)
Fat accumulating in the liver (nonalcoholic fatty liver disease)
Other possible causes include:
Iron buildup in the body (hemochromatosis)
Cystic fibrosis
Copper accumulated in the liver (Wilson's disease)
Poorly formed bile ducts (biliary atresia)
Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
Genetic digestive disorder (Alagille syndrome)
Liver disease caused by your body's immune system (autoimmune hepatitis)
Destruction of the bile ducts (primary biliary cirrhosis)
Hardening and scarring of the bile ducts (primary sclerosing cholangitis)
Infection such schistosomiasis
Medications such as methotrexate
Complications
High blood pressure in the veins that supply the liver (portal hypertension).Cirrhosis slows the normal flow of blood through the liver, thus increasing pressure in the vein that brings blood from the intestines and spleen to the liver.
Swelling in the legs and abdomen. Portal hypertension can cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). Edema and ascites also may result from the inability of the liver to make enough of certain blood proteins, such as albumin.
Enlargement of the spleen (splenomegaly). Portal hypertension can also cause changes to the spleen. Decreased white blood cells and platelets in your blood can be a sign of cirrhosis with portal hypertension.
Bleeding. Portal hypertension can cause blood to be redirected to smaller veins, causing them to increase in size and become varices. Strained by the extra load, these smaller veins can burst, causing serious bleeding. Life-threatening bleeding most commonly occurs when veins in the lower esophagus (esophageal varices) or stomach (gastric varices) rupture. If the liver can't make enough clotting factors, this also can contribute to continued bleeding. Bacterial infections are a frequent trigger for bleeding.
Infections. If you have cirrhosis, your body may have difficulty fighting infections. Ascites can lead to spontaneous bacterial peritonitis, a serious infection.
Malnutrition. Cirrhosis may make it more difficult for your body to process nutrients, leading to weakness and weight loss.
Buildup of toxins in the brain (hepatic encephalopathy). A liver damaged by cirrhosis isn't able to clear toxins from the blood as well as a healthy liver can. These toxins can then build up in the brain and cause mental confusion and difficulty concentrating. Hepatic encephalopathy symptoms may range from fatigue and mild impairment in cognition to unresponsiveness or coma.
Jaundice. Jaundice occurs when the diseased liver doesn't remove enough bilirubin, a blood waste product, from your blood. Jaundice causes yellowing of the skin and whites of the eyes and darkening of urine.
Bone disease. Some people with cirrhosis lose bone strength and are at greater risk of fractures.
Increased risk of liver cancer. A large proportion of people who develop liver cancer that forms within the liver itself have cirrhosis.
Acute-on-chronic liver failure. Some people end up experiencing multiorgan failure. Researchers now believe this is a distinct complication in some people who have cirrhosis, but they don't fully understand its causes.
Treatments
Treatment for cirrhosis depends on the cause and extent of your liver damage. The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis.
Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It's also your brain's main source of fuel.
If diabetes is detected, no matter what type, it means you have too much glucose in your blood, although the causes may differ. Too much glucose can lead to serious health problems.
Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes conditions include prediabetes — when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes — and gestational diabetes, which occurs during pregnancy but may resolve after the baby is delivered.
To understand diabetes, first you must understand how glucose is normally processed in the body.
How Insulin Works
Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas).
The pancreas secretes insulin into the bloodstream.
The insulin circulates, enabling sugar to enter your cells.
Insulin lowers the amount of sugar in your bloodstream.
As your blood sugar level drops, so does the secretion of insulin from your pancreas.
The Role Of Glucose
Glucose — a sugar — is a source of energy for the cells that make up muscles and other tissues.
Glucose comes from two major sources: food and your liver.
Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
Your liver stores and makes glucose.
When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range
Signs and Symptoms
Some of the signs and symptoms of type 1 and type 2 diabetes are:
Increased thirst
Frequent urination
Extreme hunger
Unexplained weight loss
Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin)
Fatigue
Irritability
Blurred vision
Slow-healing sores
Frequent infections, such as gums or skin infections and vaginal infections
Causes
Causes of type 1 diabetes
The exact cause of type 1 diabetes is unknown. What is known is that your immune system — which normally fights harmful bacteria or viruses — attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.
Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what many of those factors are is still unclear.
Causes of Prediabetes and type 2 diabetes
In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream.
Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of type 2 diabetes. Being overweight is strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight.
Causes of gestational diabetes
During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin.
Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your cells and too much stays in your blood, resulting in gestational diabetes.
Risk Factors
Risk factors for type 1 diabetes
Although the exact cause of type 1 diabetes is unknown, factors that may signal an increased risk include:
Family history - Your risk increases if a parent or sibling has type 1 diabetes.
Environmental factors - Circumstances such as exposure to a viral illness likely play some role in type 1 diabetes.
The presence of damaging immune system cells (auto-antibodies) - Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes auto-antibodies. If you have these auto-antibodies, you have an increased risk of developing type 1 diabetes. But not everyone who has these auto-antibodies develops diabetes.
Dietary factors - These include low vitamin D consumption, early exposure to cow's milk or cow's milk formula, and exposure to cereals before 4 months of age. None of these factors has been shown to directly cause type 1 diabetes.
Geography - Certain countries, such as Finland and Sweden, have higher rates of type 1 diabetes.
Risk factors for Prediabetes and type 2 diabetes
Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and others don't. It's clear that certain factors increase the risk, however, including:
Weight - The more fatty tissue you have, the more resistant your cells become to insulin.
Inactivity - The less active you are, the greater your risk. Physical activity helps you control your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
Family history - Your risk increases if a parent or sibling has type 2 diabetes.
Race - Although it's unclear why, people of certain races — including blacks, Hispanics, American Indians and Asian-Americans — are at higher risk.
Age - Your risk increases as you get older. This may be because you tend to exercise less, lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing dramatically among children, adolescents and younger adults.
Gestational diabetes - If you developed gestational diabetes when you were pregnant, your risk of developing prediabetes and type 2 diabetes later increases. If you gave birth to a baby weighing more than 9 pounds (4 kilograms), you're also at risk of type 2 diabetes.
Polycystic ovary syndrome - For women, having polycystic ovary syndrome — a common condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.
High blood pressure - Having blood pressure over 140/90 millimeters of mercury (mm Hg) is linked to an increased risk of type 2 diabetes.
Abnormal cholesterol and triglyceride levels - If you have low levels of high-density lipoprotein (HDL), or "good," cholesterol, your risk of type 2 diabetes is higher. Triglycerides are another type of fat carried in the blood. People with high levels of triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know what your cholesterol and triglyceride levels are.
Risk factors for gestational diabetes
Any pregnant woman can develop gestational diabetes, but some women are at greater risk than are others. Risk factors for gestational diabetes include:
Age - Women older than age 25 are at increased risk.
Family or personal history - Your risk increases if you have prediabetes — a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You're also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.
Weight - Being overweight before pregnancy increases your risk.
Race - For reasons that aren't clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.
Complications
Long-term complications of diabetes develop gradually. The longer you have diabetes — and the less controlled your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening. Possible complications include:
Cardiovascular disease - Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you are more likely to have heart disease or stroke.
Nerve damage (neuropathy) - Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in your legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.
Kidney damage (nephropathy) - The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant.
Eye damage (retinopathy) - Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
Foot damage - Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can develop serious infections, which often heal poorly. These infections may ultimately require toe, foot or leg amputation.
Skin conditions - Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
Hearing impairment - Hearing problems are more common in people with diabetes.
Alzheimer's disease - Type 2 diabetes may increase the risk of Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears to be. Although there are theories as to how these disorders might be connected, none has yet been proved.
Complications of gestational diabetes
Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby.
Complications in your baby can occur as a result of gestational diabetes, including:
Excess growth - Extra glucose can cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth.
Low blood sugar - Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
Type 2 diabetes later in life - Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
Death - Untreated gestational diabetes can result in a baby's death either before or shortly after birth.
Complications in the mother can also occur as a result of gestational diabetes, including:
Preeclampsia - This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
Subsequent gestational diabetes - Once you've had gestational diabetes in one pregnancy, you're more likely to have it again with the next pregnancy. You're also more likely to develop diabetes — typically type 2 diabetes — as you get older.
Tests and Diagnosis
The ADA recommends that the following people be screened for diabetes:
Anyone with a body mass index higher than 25, regardless of age, who has additional risk factors, such as high blood pressure, a sedentary lifestyle, a history of polycystic ovary syndrome, having delivered a baby who weighed more than 9 pounds, a history of diabetes in pregnancy, high cholesterol levels, a history of heart disease, and having a close relative with diabetes.
Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, to be screened every three years thereafter.
Tests for type 1 and type 2 diabetes and prediabetes
Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes. Below 5.7 is considered normal.
If the A1C test results aren't consistent, the test isn't available, or if you have certain conditions that can make the A1C test inaccurate — such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:
Random blood sugar test - A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL) or higher suggests diabetes.
Fasting blood sugar test - A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
Oral glucose tolerance test - For this test, you fast overnight, and the fasting blood sugar level is measured. Then you drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.
If type 1 diabetes is suspected, your urine will be tested to look for the presence of a byproduct produced when muscle and fat tissue are used for energy when the body doesn't have enough insulin to use the available glucose (ketones). Your doctor will also likely run a test to see if you have the destructive immune system cells associated with type 1 diabetes called auto-antibodies.
Tests for gestational diabetes
Your doctor may use the following screening tests:
Initial glucose challenge test - You'll begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level. A blood sugar level below 140 mg/dL (7.2 to 7.8 mmol/L) is usually considered normal on a glucose challenge test, although this may vary at specific clinics or labs. If your blood sugar level is higher than normal, it only means you have a higher risk of gestational diabetes. Your doctor will order a follow-up test to determine if you have gestational diabetes.
Follow-up glucose tolerance testing - For the follow-up test, you'll be asked to fast overnight and then have your fasting blood sugar level measured. Then you'll drink another sweet solution — this one containing a higher concentration of glucose — and your blood sugar level will be checked every hour for a period of three hours. If at least two of the blood sugar readings are higher than the normal values established for each of the three hours of the test, you'll be diagnosed with gestational diabetes.
Treatments
Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral medications may play a role in your treatment. Eating a healthy diet, maintaining a healthy weight and participating in regular activity also are important factors in managing diabetes.
Treatments for all types of diabetes
An important part of managing diabetes — as well as your overall health — is maintaining a healthy weight through a healthy diet and exercise plan:
Healthy eating - Contrary to popular perception, there's no specific diabetes diet. You'll need to center your diet on more fruits, vegetables and whole grains — foods that are high in nutrition and fiber and low in fat and calories — and cut down on animal products, refined carbohydrates and sweets. In fact, it's the best eating plan for the entire family. Sugary foods are OK once in a while, as long as they're counted as part of your meal plan. Yet understanding what and how much to eat can be a challenge. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle. This will likely include carbohydrate counting, especially if you have type 1 diabetes.
Physical activity - Everyone needs regular aerobic exercise, and people who have diabetes are no exception. Exercise lowers your blood sugar level by moving sugar into your cells, where it's used for energy. Exercise also increases your sensitivity to insulin, which means your body needs less insulin to transport sugar to your cells. Get your doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. What's most important is making physical activity part of your daily routine. Aim for at least 30 minutes or more of aerobic exercise most days of the week. If you haven't been active for a while, start slowly and build up gradually.
Treatments for type 1 and type 2 diabetes
Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent blood sugar checks, and carbohydrate counting. Treatment of type 2 diabetes primarily involves monitoring of your blood sugar, along with diabetes medications, insulin or both.
Monitoring your blood sugar
Insulin
Oral or other medications - Metformin (Glucophage, Glumetza, others) is generally the first medication prescribed for type 2 diabetes.
Transplantation - In some people who have type 1 diabetes, a pancreas transplant may be an option. Islet transplants are being studied as well. With a successful pancreas transplant, you would no longer need insulin therapy. But transplants aren't always successful — and these procedures pose serious risks. You need a lifetime of immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection, organ injury and cancer. Because the side effects can be more dangerous than the diabetes, transplants are usually reserved for people whose diabetes can't be controlled or those who also need a kidney transplant.
Bariatric surgery - Although it is not specifically considered a treatment for type 2 diabetes, people with type 2 diabetes who also have a body mass index higher than 35 may benefit from this type of surgery. People who've undergone gastric bypass have seen significant improvements in their blood sugar levels. However, this procedure's long-term risks and benefits for type 2 diabetes aren't yet known.
Pericarditis is swelling and irritation of the pericardium, the thin sac-like membrane surrounding your heart. Pericarditis often causes chest pain and sometimes other symptoms. The sharp chest pain associated with pericarditis occurs when the irritated layers of the pericardium rub against each other. Pericarditis usually begins suddenly but doesn't last long (acute). When symptoms develop more gradually or persist, pericarditis is considered chronic. Most cases are mild and usually improve on their own. Treatment for more-severe cases may include medications and, rarely, surgery. Early diagnosis and treatment may help to reduce the risk of long-term complications from pericarditis.
Signs and Symptoms
Acute pericarditis usually lasts less than a few weeks. Chronic recurrent pericarditis has two types, including the incessant type which occurs within six weeks of weaning medical treatment for an acute episode, and the intermittent type which occurs after six weeks.
If you have acute pericarditis, the most common symptom is sharp, stabbing chest pain behind the breastbone or in the left side of your chest. However, some people with acute pericarditis describe their chest pain as dull, achy or pressure-like instead, and of varying intensity.
The pain of acute pericarditis may travel into your left shoulder and neck. It often intensifies when you cough, lie down or inhale deeply. Sitting up and leaning forward can often ease the pain. At times, it may be difficult to distinguish pericardial pain from the pain that occurs with a heart attack.
Chronic pericarditis is usually associated with chronic inflammation and may result in fluid around the heart (pericardial effusion). The most common symptom of chronic pericarditis is chest pain.
Depending on the type, signs and symptoms of pericarditis may include some or all of the following:
Sharp, piercing chest pain over the center or left side of the chest
Shortness of breath when reclining
Heart palpitations
Low-grade fever
An overall sense of weakness, fatigue or feeling sick
Cough
Abdominal or leg swelling
Causes
Under normal circumstances, the two-layered pericardial sac that surrounds your heart contains a small amount of lubricating fluid. In pericarditis, the sac becomes inflamed and the resulting friction from the inflamed sac leads to chest pain.
The cause of pericarditis is often hard to determine. In most cases, doctors either are unable to determine a cause (idiopathic) or suspect a viral infection.
Pericarditis can also develop shortly after a major heart attack, due to the irritation of the underlying damaged heart muscle. In addition, a delayed form of pericarditis may occur weeks after a heart attack or heart surgery. This delayed pericarditis is known as Dressler's syndrome. Many experts believe Dressler's syndrome is due to a mistaken inflammatory response by the body to its own tissues (autoimmune response) — in this case, the heart and pericardium.
Other causes of pericarditis include:
Systemic inflammatory disorders. These may include lupus and rheumatoid arthritis.
Trauma. Injury to your heart or chest may occur as a result of a motor vehicle or other accident.
Other health disorders. These may include kidney failure, AIDS, tuberculosis and cancer.
Certain medications. Some medications can cause pericarditis, although this is unusual.
Complications
Constrictive pericarditis. Although uncommon, some people with pericarditis, particularly those with long-term inflammation and chronic recurrences, can develop permanent thickening, scarring and contraction of the pericardium.
In these people, the pericardium loses much of its elasticity and resembles a rigid case that's tight around the heart, which keeps the heart from working properly. This condition is called constrictive pericarditis and often leads to severe swelling of the legs and abdomen, as well as shortness of breath.
Diagnosis
Electrocardiogram (ECG)
Chest X-ray
Computerized tomography (CT)
Cardiac magnetic resonance imaging (MRI)
Treatment
Severe cases may require one or more of the following:
pericardiocentesis to treat pericardial effusion/tamponade
antibiotics to treat tuberculosis or other bacterial causes.
steroids are used in acute pericarditis but are not favored because they increase the chance of recurrent pericarditis.
in rare cases, surgery
in cases of constrictive pericarditis, pericardiectomy
High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease.
Blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure.
You can have high blood pressure (hypertension) for years without any symptoms. Even without symptoms, damage to blood vessels and your heart continues and can be detected. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke.
High blood pressure generally develops over many years, and it affects nearly everyone eventually. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.
Signs and Symptoms
A few people with high blood pressure may have headaches, shortness of breath or nosebleeds, but these signs and symptoms aren't specific and usually don't occur until high blood pressure has reached a severe or life-threatening stage.
Causes
Primary (Essential) Hypertension
For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years.
Secondary Hypertension
Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:
Obstructive sleep apnea
Kidney problems
Adrenal gland tumors
Thyroid problems
Certain defects in blood vessels you're born with (congenital)
Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
Illegal drugs, such as cocaine and amphetamines
Alcohol abuse or chronic alcohol use
Risk Factors
High blood pressure has many risk factors, including:
Age - The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
Race - High blood pressure is particularly common among blacks, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in blacks.
Family history - High blood pressure tends to run in families.
Being overweight or obese - The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
Not being physically active - People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
Using tobacco - Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow, increasing your blood pressure. Secondhand smoke also can increase your blood pressure.
Too much salt (sodium) in your diet - Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
Too little potassium in your diet - Potassium helps balance the amount of sodium in your cells. If you don't get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
Too little vitamin D in your diet - It's uncertain if having too little vitamin D in your diet can lead to high blood pressure. Vitamin D may affect an enzyme produced by your kidneys that affects your blood pressure.
Drinking too much alcohol - Over time, heavy drinking can damage your heart. Having more than two drinks a day for men and more than one drink a day for women may affect your blood pressure. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
Stress - High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco or drinking alcohol, you may only increase problems with high blood pressure.
Certain chronic conditions - Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes and sleep apnea.
Complications
Heart attack or stroke - High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
Aneurysm - Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
Heart failure - To pump blood against the higher pressure in your vessels, your heart muscle thickens. Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body's needs, which can lead to heart failure.
Weakened and narrowed blood vessels in your kidneys - This can prevent these organs from functioning normally.
Thickened, narrowed or torn blood vessels in the eyes - This can result in vision loss.
Metabolic syndrome - This syndrome is a cluster of disorders of your body's metabolism, including increased waist circumference; high triglycerides; low high-density lipoprotein (HDL) cholesterol, the "good" cholesterol; high blood pressure; and high insulin levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
Trouble with memory or understanding - Uncontrolled high blood pressure may also affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people with high blood pressure.
Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, occurs when blood flow stops to a part of the heart causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Often it is in the center or left side of the chest and lasts for more than a few minutes. The discomfort may occasionally feel like heartburn. Other symptoms may include shortness of breath, nausea, feeling faint, a cold sweat, or feeling tired. About 30% of people have atypical symptoms, with women more likely than men to present atypically. Among those over 75 years old, about 5% have had an MI with little or no history of symptoms. An MI may cause heart failure, an irregular heartbeat, or cardiac arrest.
Signs and Symptoms
While the classic symptoms of a heart attack are chest pain and shortness of breath, the symptoms can be quite varied. The most common symptoms of a heart attack include:
pressure or tightness in the chest
pain in the chest, back, jaw, and other areas of the upper body that lasts more than a few minutes or that goes away and comes back
shortness of breath
sweating
nausea
vomiting
anxiety
a cough
dizziness
a fast heart rate
It’s important to note that not all people who have heart attacks experience the same symptoms or the same severity of symptoms. Chest pain is the most commonly reported symptom among both women and men. However, women are more likely than men to have:
shortness of breath
jaw pain
upper back pain
lightheadedness
nausea
vomiting
Causes
Atherosclerosis
Coronary occlusion secondary to vasculitis
Ventricular hypertrophy (eg, left ventricular hypertrophy, hypertrophic cardiomyopathy)
Coronary artery emboli, secondary to cholesterol, air, or the products of sepsis
Coronary trauma
Primary coronary vasospasm (variant angina)
Drug use (eg, cocaine, amphetamines, ephedrine)
Arteritis
Coronary anomalies, including aneurysms of coronary arteries
Factors that increase oxygen requirement, such as heavy exertion, fever, or hyperthyroidism
Factors that decrease oxygen delivery, such as hypoxemia of severe anemia
Aortic dissection, with retrograde involvement of the coronary arteries
Risk Factors
High Blood Pressure
You’re at greater risk for heart attack if you have high blood pressure. Normal blood pressure is below 120/80 mm Hg (millimeters of mercury) depending on your age. As the numbers increase, so does your risk of developing heart problems. Having high blood pressure damages your arteries and accelerates the buildup of plaque.
High Cholesterol Levels
Having high levels of cholesterol in your blood puts you at risk for acute myocardial infarction. You may be able to lower your cholesterol by making changes to your diet or by taking certain medications called statins.
High Triglyceride Levels
High triglyceride levels also increase your risk for having a heart attack. Triglycerides are a type of fat that clog up your arteries. Triglycerides from the food you eat travel through your blood until they’re stored in your body, typically in your fat cells. However, some triglycerides may remain in your arteries and contribute to the buildup of plaque.
Diabetes and High Blood Sugar Levels
Diabetes is a condition that causes blood sugar, or glucose, levels to rise. High blood sugar levels can damage blood vessels and eventually lead to coronary artery disease. This is a serious health condition that can trigger heart attacks in some people.
Obesity
Your chances of having a heart attack are higher if you’re very overweight. Obesity is associated with various conditions that increase the risk of heart attack, including:
diabetes
high blood pressure
high cholesterol levels
high triglyceride levels
Smoking
Smoking tobacco products increases your risk for heart attack. It may also lead to other cardiovascular conditions and diseases.
Age
The risk of having a heart attack increases with age. Men are at a higher risk of a heart attack after age 45, and women are at a higher risk of a heart attack after age 55.
Family History
You’re more likely to have a heart attack if you have a family history of early heart disease. Your risk is especially high if you have male family members who developed heart disease before age 55 or if you have female family members who developed heart disease before age 65.
Other factors that can increase your risk for heart attack include:
stress
a lack of exercise
the use of certain illegal drugs, including cocaine and amphetamines
a history of preeclampsia, or high blood pressure during pregnancy
Diagnosis
A combination of the following
Chest pain
ECG reveals ST segment elevation, ischemia
Elevated Troponins
Stress Test
Cardiac catheterization
Echocardiogram
Treatment
Blood thinners, such as aspirin, are often used to break up blood clots and improve blood flow through narrowed arteries.
Thrombolytics are often used to dissolve clots.
Antiplatelet drugs, such as clopidogrel, can be used to prevent new clots from forming and existing clots from growing.
Nitroglycerin can be used to widen your blood vessels.
Beta-blockers lower your blood pressure and relax your heart muscle. This can help limit the severity of damage to your heart.
ACE inhibitors can also be used to lower blood pressure and decrease stress on the heart.
Pain relievers may be used to reduce any discomfort you may feel.
The Gastrointestinal section of the PCCN Certification will encompass a very small portion of the PCCN exam. This particular section will have approximately 5 to 8 questions on the exam. Although that is a very small portion in comparison to everything else on the exam, it is imperative that you get all of these questions correct. If you are able to answer all of the GI questions correct, you will have some latitude when answering other parts of the exam. In this article we will cover the Gastrointestinal outline of the PCCN exam, a broad overview of GI anatomy and physiology, and cover some GI practice questions.
Gastrointestinal Outline
Acute Abdominal Trauma
Acute GI Hemorrhage
Acute Abdomen
GI Surgeries
Hepatic Failure/Coma
Pancreatitis
Gastro-esophageal Reflux
GI Anatomy & Physiology
The human GI tract is an organ system responsible for transporting and digesting food, absorbing nutrients, and expelling waste. The GI tract consists of the stomach, and is divided into the upper and lower GI tracts and the small and large intestines. The GI tract includes all structures between the mouth and the anus, forming a continuous passageway that includes the main organs of digestion, namely the stomach, small intestine, and large intestine. The whole human GI tract is about 30 feet long at autopsy. It is considerably shorter in the living body because the intestines, which are tubes of smooth muscle tissue, maintaining a constant muscle tone.
Pancreatitis
The pancreas is a large gland behind the stomach and next to the small intestine. The pancreas does two things: it releases powerful digestive enzymes into the small intestine to aid the digestion of food, and it releases the hormones insulin and glucagon into the bloodstream. These hormones help the body control how it uses food for energy.
Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas. There are two forms of pancreatitis; acute and chronic.
Acute pancreatitis is a sudden inflammation that lasts for a short time. It may range from mild discomfort to a severe life threatening illness. Most people with acute pancreatitis recover completely after getting the right treatment. In severe cases, acute pancreatitis can result in bleeding into the gland, serious tissue damage, infection, and cyst formation.
Chronic pancreatitis is long lasting inflammation of the pancreas. it most often happens after an episode of acute pancreatitis. Heavy alcohol consumption is another big cause.
Signs and Symptoms
Upper abdominal pain that radiates to the back; aggravated by eating, especially foods high in fat
Swollen and tender abdomen
Nausea and vomiting
Fever
Increased heart rate
Pancreatitis Etiology
Gallstones or heavy alcohol use
Medications, infections, trauma
Metabolic disorders and surgery
Treatment of Pancreatitis
Treat the s/s
IV fluids and pain meds
PCCN GI Sample Questions
1) Vasopressin may be used in the patients with GI bleeding. What is the mechanism of action of Vasopressin?
A) Increases mesenteric blood flow to reduce ischemia
B) Decreases portal venous blood flow to decrease bleeding
C) Causes sodium and water retention to replace volume
D) Blocks H2 receptors to inhibit hydrochloric acid secretion
2) A 39 y/o male is admitted with a history of chronic liver failure and ETOH abuse. He has ascites and severe peripheral edema. He is anorexic, vomiting, hypokalemic, and now has developed metabolic alkalosis. Which of the following would not be included in this patient's management?
A) Diuretics
B) Potassium supplements
C) Antiemetics
D) Diet high in protein
3) A 52 y/o male patient with acute pancreatitis develops agitation, fine tremors, and tachycardia about 48 hours after admission. Which of the following is the most likely cause of these signs and symptoms?
A) Pancreatic pseudocyst
B) Hypoglycemia
C) Alcohol withdrawal
D) Pancreatic abscess
PCCN GI Practice Questions Answer with Rationale
1) Correct Answer - B) Decreases portal venous blood flow to decrease bleeding
Rationale - Vasopressin slows blood loss by constricting the splanchnic arteriolar bed and decreasing portal venous pressure.
2) Correct Answer - A) Diuretics
Rationale - Diuretics would contribute to metabolic alkalosis and hypokalemia and would deplete the vascular bed rather than the third spaces.
3) Correct Answer - C) Alcohol withdrawal
Rationale - Alcoholism is a common cause of acute pancreatitis, and alcohol withdrawal is a complication that must be closely observed for within the first 24 - 72 hours after onset of abstinence.
Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe. In most cases, heart problems cause pulmonary edema. But fluid can accumulate for other reasons, including pneumonia, exposure to certain toxins and medications, trauma to the chest wall, and exercising or living at high elevations.
Pulmonary edema that develops suddenly (acute pulmonary edema) is a medical emergency requiring immediate care. Although pulmonary edema can sometimes prove fatal, the outlook improves when you receive prompt treatment for pulmonary edema along with treatment for the underlying problem. Treatment for pulmonary edema varies depending on the cause but generally includes supplemental oxygen and medications.
Signs and Symptoms
Sudden (acute) Pulmonary Edema Symptoms
Extreme SOB of difficulty breathing (dyspnea) that worsens when lying down
A feeling of suffocating or drowning
Wheezing or gasping for breath
Anxiety, restlessness or a sense of apprehension
Blood tinged frothy sputum
Chest pain and palpitations
Long-term (chronic) Pulmonary Edema Symptoms
Having more SOB than normal when physically active
Difficulty breathing with exertion
Difficulty breathing when lying flat
Wheezing
Awakening at night with a breathless feeling relieved by sitting up
Rapid weight gain when pulmonary edema develops
Swelling in your lower extremities
Fatigue
High Altitude Pulmonary Edema Symptoms
Shortness of breath after exertion, which progresses to SOB at rest
Cough, fever, and chest discomfort
Difficulty walking uphill
Blood tinged sputum, palpitations
Headaches
Causes
Cardiogenic Pulmonary Edema
Cardiogenic pulmonary edema is a type of pulmonary edema caused by increased pressures in the heart. This condition usually occurs when the diseased or overworked left ventricle isn't able to pump out enough of the blood it receives from your lungs (CHF). As a result, pressure increases inside the left atrium and then in the veins and capillaries in your lungs, causing fluid to be pushed through the capillary walls into the air sacs. Medical conditions that can cause the left ventricle to become weak and fail includes
Coronary artery disease
Cardiomyopathy
Heart valve problems
Hypertension
Noncardiogenic Pulmonary Edema
Pulmonary edema that isn't caused by increased pressures in your heart is called noncardiogenic pulmonary edema. In this condition, fluid may leak from the capillaries in your lung's air sacs because the capillaries themselves become ore permeable or leaky, even without the buildup of back pressure from your heart. Some factors that can cause noncardiogenic pulmonary edema includes:
ARDS
High altitudes
Nervous system conditions
Adverse drug reactions
Pulmonary embolism
Viral infections
Lung injury
Exposure to certain toxins
Smoke inhalation
Near drowning
Complications
Lower extremity and abdominal swelling
Pleural effusion
Congestion and swelling of the Liver
Treatment
Preload reducers such as Lasix, Nitroglycerin, Procardia
A ruptured eardrum — or perforated tympanic membrane as it's medically known — is a hole or tear in your eardrum, the thin tissue that separates your ear canal from your middle ear. A ruptured eardrum can result in hearing loss. A ruptured eardrum can also make your middle ear vulnerable to infections or injury. A ruptured eardrum usually heals within a few weeks without treatment. Sometimes, however, a ruptured eardrum requires a procedure or surgical repair to heal.
Signs and Symptoms
Signs and symptoms of a ruptured eardrum may include:
Ear pain that may subside quickly
Clear, pus-filled or bloody drainage from your ear
Hearing loss
Ringing in your ear (tinnitus)
Spinning sensation (vertigo)
Nausea or vomiting that can result from vertigo
Causes
Causes of a ruptured, or perforated, eardrum may include:
Middle ear infection (otitis media). A middle ear infection often results in the accumulation of fluids in your middle ear. Pressure from these fluids can cause the eardrum to rupture.
Barotrauma. Barotrauma is stress exerted on your eardrum when the air pressure in your middle ear and the air pressure in the environment are out of balance. If the pressure is severe, your eardrum can rupture. Barotrauma is also called airplane ear because it's most often caused by air pressure changes associated with air travel. Other events that can cause sudden changes in pressure — and possibly a ruptured eardrum — include scuba diving and a direct blow to the ear, such as the impact of an automobile air bag.
Loud sounds or blasts (acoustic trauma). A loud sound or blast, as from an explosion or gunshot — essentially an overpowering sound wave — can cause a tear in your eardrum.
Foreign objects in your ear. Small objects, such as a cotton swab or hairpin, can puncture or tear the eardrum.
Severe head trauma. Severe injury, such as skull fracture, may cause the dislocation or damage to middle and inner ear structures, including your eardrum.
Complications
Your eardrum (tympanic membrane) has two primary roles:
Hearing. When sound waves strike it, your eardrum vibrates — the first step by which structures of your middle and inner ears translate sound waves into nerve impulses.
Protection. Your eardrum also acts as a barrier, protecting your middle ear from water, bacteria and other foreign substances.
If your eardrum ruptures, complications can occur while your eardrum is healing or if it fails to heal. Possible complications include:
Hearing loss. Usually, hearing loss is temporary, lasting only until the tear or hole in your eardrum has healed. The size and location of the tear can affect the degree of hearing loss.
Middle ear infection (otitis media). A perforated eardrum can allow bacteria to enter your ear. If a perforated eardrum doesn't heal or isn't repaired, you may be vulnerable to ongoing (chronic) infections that can cause permanent hearing loss.
Middle ear cyst (cholesteatoma). A cholesteatoma is a cyst in your middle ear composed of skin cells and other debris. Ear canal debris normally travels to your outer ear with the help of ear-protecting earwax. If your eardrum is ruptured, the skin debris can pass into your middle ear and form a cyst. A cholesteatoma provides a friendly environment for bacteria and contains proteins that can damage bones of your middle ear.
Diagnosis
Laboratory tests. If there's discharge from your ear, your doctor may order a laboratory test or culture to detect a bacterial infection of your middle ear.
Tuning fork evaluation. Tuning forks are two-pronged, metal instruments that produce sounds when struck. Simple tests with tuning forks can help your doctor detect hearing loss. A tuning fork evaluation may also reveal whether hearing loss is caused by damage to the vibrating parts of your middle ear (including your eardrum), damage to sensors or nerves of your inner ear, or damage to both.
Tympanometry. A tympanometer uses a device inserted into your ear canal that measures the response of your eardrum to slight changes in air pressure. Certain patterns of response can indicate a perforated eardrum.
Audiology exam. If other hearing tests are inconclusive, your doctor may order an audiology exam, a series of strictly calibrated tests conducted in a soundproof booth that measure how well you hear sounds at different volumes and pitches.
Treatment
Most perforated eardrums heal without treatment within a few weeks. Your doctor may prescribe antibiotic drops if there's evidence of infection. If the tear or hole in your eardrum doesn't heal by itself, treatment will involve procedures to close the perforation. These may include:
Eardrum patch. If the tear or hole in your eardrum doesn't close on its own, an ENT specialist may seal it with a patch. With this office procedure, your ENT may apply a chemical to the edges of the tear to stimulate growth and then apply a patch over the hole. The procedure may need to be repeated more than once before the hole closes.
Surgery. If a patch doesn't result in proper healing or your ENT determines that the tear isn't likely to heal with a patch, he or she may recommend surgery. The most common surgical procedure is called tympanoplasty. Your surgeon grafts a tiny patch of your own tissue to close the hole in the eardrum. This procedure is done on an outpatient basis, meaning you can usually go home the same day unless medical anesthesia conditions require a longer hospital stay.
The Neurology portion of the PCCN exam will include roughly 20 questions or more. This is a fairly large portion of the exam. It is very important that you have a really good grasp on the particular section of the exam. The Cardiac, Pulmonary, and Neurology is the bulk of the PCCN exam. In this article, we will cover some of the content on the Neurology portion of the PCCN exam, Neurology Anatomy and Physiology, AV Malformation Overview and some of the PCCN Neurology practice questions that we have embedded in our PCCN Online Course and PCCN Question Bank.
PCCN Neurology Exam Outline
Aneurysm, AV Malformation
Encephalopathy
Head Trauma, Skull Fractures
Intracranial/Intraventricular Hemorrhage
Neurologic Infectious Diseases
Seizure Disorders, Stroke
Neurology Anatomy and Physiology
The nervous system is the part of an animal's body that coordinates its voluntary and involuntary actions and transmits signals to and from different parts of its body. The nervous system consists of 2 main parts; the central nervous system and the peripheral nervous system. The CNS contains the brain and spinal cord. The PNS consists mainly of nerves, which are enclosed bundles of the long fibers or axons, that connect the CNS to every other part of the body.
The autonomic nervous system is divided into the sympathetic (SNS) and parasympathetic nervous systems (PSNS). The SNS is activated in cases of emergencies to mobilize energy, while the PSNS is activated when organisms are in a related state. The enteric nervous system functions to control the gastrointestinal system. Both autonomic and enteric nervous systems function involuntarily. Nerves that exit from the cranium are called cranial nerves while those exiting from the spinal cord are called spinal nerves.
PCCN Neurology Exam Practice Questions
1) A patient with a traumatic brain injury (TBI) has just been admitted after resuscitation in the emergency room department. Which of the following initial studies should the nurse anticipate in this patient?
A) Magnetic resonance imaging (MRI) of the brain
B) Computed tomography (CT) scan of the head
C) Lumbar puncture (LP)
D) Cerebral angiography
2) A patient presents with new-onset seizures. Diagnostic imaging reveals a 4 cm right posterior frontal arteriovenous malformation. In planning this patient's nursing care needs, which of the following conditions should the nurse anticipate?
A) Left-sided weakness
B) Receptive aphasia
C) Left homonymous hemianopsia
D) Sensory deficits on the right face and arm
3) A patient admitted last night with subarachnoid hemorrhage returned from the operating room 4 hours ago following aneurysm clipping. On admission, the patient was assessed as a Hunt and Hess Grade II. The patient now appears to be stuporous with significant left hemiparesis. The nurse should
A) Note that this is consistent with the Hunt and Hess appraisal at admission
B) Contact the neurosurgeon to communicate the examination findings
C) Adjust IV infusion rate because the aneurysm may have rebleed
D) Prepare for ventriculostomy insertion by the physician so hydrocephalus can be treated.
4) During report, the nurse is told that a patient with an intracranial hemorrhage has GCS values of 3 - 3 - 4. Evaluation of the patient's progress is based on the nurse's knowledge that this patient
A) Opens his eyes when spoke to
B) Follows simple commands
C) Makes no attempt to remove noxious stimuli
D) Makes no attempt to vocalize
5) A 25 y/o admitted patient has a generalized tonic clonic seizure. After the seizure has subsided, the nurse expects the patient to exhibit which of the following as a characteristic behavior after a seizure?
A) Restlessness
B) Lethargy
C) Automatisms
D) Incontinence
PCCN Neurology Exam - Sample Questions Answer with Rationale
1) Correct Answer - B) Computed tomography (CT) scan of the head
Rationale - CT scan of the head is useful for looking at bone and blood and is the best imaging study to view most intracranial processes, including trauma, intracerebral hemorrhage, and hydrocephalus.
2) Correct Answer - A) Left-sided weakness
Rationale - The location of the AVM suggests which deficit the nurse needs to anticipate. A lesion in the right frontal area would be expected to affect voluntary motor control on the left side of the body. Comprehension of spoken language.
3) Correct Answer - B) Contact the neurosurgeon to communicate the examination findings
Rationale - The patient is now a Hunt and Hess Grade IV, a substantial deterioration compared to the initial Grade II (Grades range from I to V, with Grade I identifying alert patients with mild headache and stiff neck and Grade V identifying patients in coma. The most appropriate action would be to notify the neurosurgeon, who may request a head CT scan or angiography.
4) Correct Answer - A) Opens his eyes when spoke to
Rationale - The GCS is an internationally recognized standardized assessment tool that evaluates level of consciousness, the most sensitive indicator of cerebral function. The patient's best responses in three areas, eye opening, motor response, and verbal response.
5) Correct Answer - B) Lethargy
Rationale - Typical postictal behavior includes confusion, lethargy, HA, and somnolence. The patient will usually sleep for an extended period following a seizure.
