Internal Medicine 14: 18-Year-Old Female For Pre-College

You will complete the Aquifer case, Internal Medicine 14: 18-year-old female for pre-college physical, focusing on the “Revisit three months later” for this assignment.

After completing the Aquifer case, you will present the case and supporting evidence in a PowerPoint presentation with the following components:

  • Slide 1: Title, Student Name, Course, Date
  • Slide 2: Summary or synopsis of Judy Pham’s case
  • Slide 3: HPI
  • Slide 4: Medical History
  • Slide 5: Family History
  • Slide 6: Social History
  • Slide 7: ROS
  • Slide 8: Examination
  • Slide 9: Labs (In-house)
  • Slide 10: Primary Diagnosis and 3 Differential Diagnoses – ranked in priority

Primary Diagnosis should be supported by data in the patient’s history, exam, and lab results.

  • Slide 11: Management Plan: medication (dose, route, frequency), non-medication treatment, tests ordered, education, follow-up/referral.
  • Slide 12-16: An evaluation of 5 evidence-based articles applicable to Ms. Pham’s case: evaluate 1 article per slide.
  1. Include title, author, and year of article
  2. Brief summary/purpose of the study
  3. How did the study support Ms. Pham’s case?

Course texts will not count as a scholarly source. If using data from websites you must go back to the literature source for the information; no secondary sources are allowed, e.g. Medscape, UptoDate, etc.

  • Slide 17: Reference List                                                                                                                                                                                                                                                                                                                                                                                                                                           
  • You will submit the PowerPoint presentation in the Submissions Area by the due date assigned. Name your Case Study Presentation SU_NSG6430_W7_A2_lastname_firstinitial.docV

    Internal Medicine 14: 18-year-old woman for pre-college physical

    User: Ariana Amini

    Email: aamini@gwu.edu

    Date: November 11, 2019 2:19AM

    Learning Objectives

    The student should be able to:

    Obtain a history that differentiates among etiologies of dysuria.

    Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.

    Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep, and KOH stain.

    Describe current recommendations for cervical cancer screening.

    Discuss safe sexual practices and efficacy of common methods of contraception.

    Knowledge

    Adolescent Interview – Safety

    Violence

    The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape and

    school violence are all common. In many urban communities, up to one in four students report carrying a weapon to school. Family violence and

    dating violence cross all economic and social boundaries.

    Injuries

    For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is

    important to address use of a seat belt and bike helmets with every adolescent.

    Even though you address the safety issues most prevalent in the patient’s community first, do not skip any part of the history based on assumptions

    about the patient’s ethnic background or economic status.

    Recommended Vaccinations for Adolescents and Teenagers

    MMR

    MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the

    case of pregnant women. Pregnant women should not be vaccinated with MMR because of a risk of fetal transmission since it is a

    live virus vaccine.

    Hepatitis B Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and hepatic carcinoma. The

    series of three injections is recommended for adolescents if they did not receive them when younger.

    Meningococcal

    The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12 years during the

    routine preadolescent immunization visit with a booster dose at age 16 and is recommended for all previously unvaccinated

    adolescents aged 11-18 years.

    Human

    papillomavirus

    There are two different human papillomavirus vaccines available. They vary by the number of strains of HPV they protects against,

    ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and women

    9-26 years old.

    The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or 12 years of age.

    ACIP also recommends vaccination in males ages 13 through 21 who have not been vaccinated previously or who have not

    completed the three-dose series. ACIP states that males aged 22 through 26 years may be vaccinated, but does not recommend

    routine vaccination in this age group.

    Tetanus,

    diphtheria,

    acellular

    pertussis

    The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria and pertussis. It contains acellular

    pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that caused high fever and neurologic

    symptoms when given to older children and adults. Tdap, which was licensed in 2005, is the first vaccine for adolescents and adults

    that protects against all three diseases.

    Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred timing between 11

    and 12 years. If a patient has received a Td booster, then waiting at least five years between Td and Tdap is encouraged because

    the incidence of side effects is lower.

    The exception to this rule is the case of type III hypersensitivity reactions. Type III hypersensitivity reactions (Arthus reactions), which

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    are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of tetanus toxoid or

    diphtheria toxoid-containing vaccines. These reactions are characterized by severe pain, swelling, and sometimes necrosis at the

    injection site and occur between 4 and 12 hours following vaccination. It is recommended that patients who have had such a type III

    hypersensitivity reaction avoid receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.

    Varicella

    The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had chickenpox or have

    not received the vaccine.

    Varicella was added to the list of standard childhood vaccines in 1995. Two doses are required, with the first administered at 12-15

    months of age and the second at 4-6 years of age. There is also a combination measles, mumps, rubella, and varicella vaccine

    (MMRV) available.

    Influenza

    The influenza vaccine is recommended for everyone who is at least age six months. It is usually administered in September through

    December when the influenza season is imminent.

    The H1N1 strain, or “swine” influenza, the predominant strain circulating in the U.S. over the past several years, has high rates of

    morbidity and mortality among children and adolescents.

    Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.

    Haemophilus

    influenzae type

    b

    Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in infants and young

    children, but it is not recommended after the age of five years.

    When a Pelvic Examination Is Indicated

    Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65. There is recent

    evidence that screening for cervical cancer in women less than 21 years of age leads to procedures and more harm than benefit. The frequency of

    cervical cancer screening with the Papanicolaou (Pap) test for immunocompetent individuals with previously normal tests is once every three years

    or, for women ages 30 to 65 years, screening with a combination of cytology and human papillomavirus (HPV) testing every five years.

    STI Screening Recommendations

    Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.

    Test results for some STIs such as gonorrhea must be reported to the public health department.

    Most Common Causes of Cystitis

    E. coli causes a majority of all cases of uncomplicated urinary tract infections.

    Other common organisms include Staphylococcus saprophyticus, Klebsiella pneumonia, and Proteus mirabilis.

    Differentiating Cystitis from Pyelonephritis

    It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

    Cystitis Pyelonephritis

    Clinical

    manifestations

    dysuria, frequency, urgency,

    suprapubic pain, and/or

    hematuria

    may or may not have symptoms of cystitis together with fever (> 38ºC) and other systemic

    symptoms such as, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting

    Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)

    Treatment

    short-course antibiotic therapy

    (three days);

    hospitalization usually not

    required

    at least seven days of treatment;

    hospitalization may be required

    Dysuria in Males

    Disease Presentation Diagnosis

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    UTI and

    cystitis

    Isolated acute cystitis is rare in males because their longer urethra hinders

    bacteria from reaching the bladder, and prostatic fluid has antibacterial

    properties.

    Most males with acute cystitis have functional or anatomic abnormalities, and

    need further evaluation.

    Symptoms of lower and upper tract infections are the same in males and

    females.

    Midstream culture and sensitivity of the urine

    Urethritis

    Usually sexually transmitted gonococcal and/or chlamydia infection.

    Gonococcal urethritis is more likely in males with acute symptoms and

    purulent urethral discharge.

    Chlamydia is likely when dysuria is present alone or with minimal discharge.

    Males with chlamydia infection may be asymptomatic.

    Recommended that patients be treated presumptively for both gonorrhea and

    chlamydia, pending results.

    Herpes simplex virus is a rare cause of urethritis, but may be suggested by

    the history of penile lesions.

    Diagnosis can be made on a gram stain of

    a urethral swab.

    Leukocytes and gram-negative

    intracellular diplococci confirm the

    diagnosis of gonorrhea.

    White cells without organisms suggest

    non-gonococcal urethritis (NGU) which is

    usually chlamydia but can also be

    Trichomonas vaginalis.

    Because many outpatient offices are not

    equipped to do gram stains, NAAT testing

    of the urethra or urine is becoming the

    preferred diagnostic test for gonorrhea

    and chlamydia.

    Prostatitis

    Acute prostatitis

    Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy,

    and is caused by gram-negative rods (Enterobacteriaceae, Pseudomonas,

    Proteus), gram-positive organisms (Enterococcus, S. aureus), and sexually

    transmitted agents such as Neisseria gonorrhoeae and Chlamydia

    trachomatis.

    Prostate is edematous and very tender on digital rectal examination.

    Chronic prostatitis

    Characterized by lower urinary tract symptoms, perineal discomfort, pain with

    ejaculation, and occasionally deep pelvic pain that radiates to the back. The

    symptoms are often subtle and sometimes may be absent, and the physical

    exam may be normal.

    This diagnosis should be considered in men with recurrent UTIs without risk

    factors.

    Diagnosis can be difficult to make and may

    require submitting urine specimens gathered

    following prostatic massage for microscopic

    urinalysis and culture.

    Epididymitis

    Patients with epididymitis present with dysuria, frequency, urgency, and

    unilateral testicular pain.

    Fever and rigors may be present and there may be redness and tenderness

    of the entire affected testicle.

    Testicular torsion should be considered in all cases, especially when the

    patient is an adolescent and the onset is sudden.

    Epididymitis in men < 35 years is usually caused by Chlamydia trachomatis

    or Neisseria gonorrhoeae; in those > 35, enteric gram-negative rods

    (Escherichia coli) are the most common causes.

    If the diagnosis is questionable, color duplex

    doppler scanning should be obtained

    immediately.

    Factors that Contribute to Complicated Urinary Tract Infections

    Hospital-acquired Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing

    infections with antibiotic-resistant organisms that are found in the hospital environment.

    Pregnant Urinary tract infections in pregnant females can progress to and can induce preterm labor so are thus considered complicated.

    Urinary catheter or

    recent

    instrumentation

    Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they

    introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial

    growth.

    Immunosuppressed Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated

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    or recently treated

    with antibiotics

    infections.

    Anatomic or

    functional

    abnormalities of the

    urinary tract

    Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial

    growth and causing complicated infections.

    Male

    Urinary tract infections in men are complicated because they are commonly associated with bladder outlet obstruction,

    instrumentation, or other urologic abnormalities. However, a small number of adult men can develop uncomplicated UTIs. Risk

    factors associated with these infections are homosexuality, intercourse with a urinary tract-infected female partner, and lack of

    circumcision.

    Birth Control Options

    Percentage of women experiencing an unintended pregnancy within the first year of use: United States

    Method Typical use Perfect use

    No method 85 85

    Spermicides 29 18

    Withdrawal 27 4

    Fertility awareness-based methods 25

    Standard days method 5

    Two day method 4

    Ovulation method 3

    Sponge

    Parous women 32 20

    Nulliparous women 16 9

    Diaphragm 16 6

    Condom

    Female (Reality) 21 5

    Male 15 2

    Combined pill and progestogen-only pill 8 0.3

    Evra patch 8 0.3

    NuvaRing 8 0.3

    Depo-Provera 3 0.3

    Combined injectable (Lunelle) 3 0.05

    IUD

    ParaGard (copper T) 0.8 0.6

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    Mirena (LNG-IUS) 0.2 0.2

    Implanon 0.05 0.05

    Female sterilization 0.5 0.5

    Male sterilization 0.15 0.10

    Adapted from WHO Medical eligibility criteria for contraceptive use (2009)

    Male latex condoms: when correctly used with each episode of intercourse, are the best protection against sexually transmitted infections.

    IUDs: can be considered for women at low risk of acquiring sexually transmitted infections, since sexually transmitted infections may require

    removal of the IUD. Women with a history of PID can safely use the IUD with appropriate counseling. IUDs can be used as long as the woman

    is not planning a pregnancy for at least one year, since attempting a pregnancy would require IUD removal. Women who have never been

    pregnant can safely use the IUD.

    Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the risk of pregnancy by at

    least 75%.

    Management

    First-Line Empiric Therapy for Cystitis

    In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.

    In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a poor choice for

    empiric therapy.

    In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%. Therefore, these

    have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these antibiotics vary by geographic

    region and can exceed 20% in some areas.

    Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas resistance rates

    exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant resistant organisms (sometimes referred

    to as “collateral damage”). Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are

    not eligible to receive recommended first-line agents.

    Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there are less data with these agents.

    The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate,

    2nd-generation cephalosporins (cefaclor), 3rd-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances 1st-generation

    cephalosporins (cephalexin and cefadroxil).

    In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug-

    drug interactions, recent antibiotic use, and renal function, among others.

    Recommended Dosing and Duration for Cystitis Therapy

    Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has similar efficacy to

    that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other recommended first-line agents have

    different recommended durations. See the table below for recommended durations of first-line agents.

    First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.

    Drug Dose and interval Duration

    Trimethoprim-sulfamethoxazole 160/800 mg q 12 hours 3 days

    Nitrofurantoin monohydrate macrocrystals 100 mg q 12 hours 5 days

    Fosfomycin trometamol 3 gm in a single dose 1 dose

    Recommended Therapy for Pyelonephritis

    In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic urinalysis. Definitive

    antibiotic choice should be based on the results of the urine culture.

    For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the local resistance rates

    are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be

    given for pyelonephritis.

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    Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism

    is known to be susceptible. Two-week regimens are generally advised when using trimethoprim-sulfamethoxazole. If trimethoprim-sulfamethoxazole

    is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be

    given before starting the course of trimethoprim-sulfamethoxazole.

    Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained.

    Who Should Be Hospitalized For Pyelonephritis

    Patients who cannot maintain oral hydration or cannot take oral medicines should be hospitalized, as should those who have social

    circumstances or other factors that hinder adherence to therapy.

    Patients who appear septic, who are hemodynamically unstable and who have any complicating factors should also be hospitalized.

    In many cases, people with diabetes should be hospitalized for parenteral therapy because they have worse outcomes, and diabetics have an

    increased risk of complications such as emphysematous pyelonephritis or abscess.

    Pregnant women should be hospitalized because pyelonephritis is associated with an increased incidence of fetal complications and

    premature delivery.

    Preventing Recurrent UTIs

    1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis and urine culture.

    Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical irritation, or urethritis.

    2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating infections. These

    predisposing factors should be treated if present.

    3. In patients without predisposing factors, some physicians attempt behavioral and lifestyle modification. Because sexual activity is associated

    with recurrent infections, doctors often recommend that women void before and after sexual intercourse. This, and advice to wipe “front to

    back,” increase fluid intake (including cranberry juice), and avoid full bladders, have not been proven to reduce the recurrence of infection, but

    they are benign maneuvers, and still make sense to many clinicians.

    4. For post-menopausal women, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection.

    5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at least two in six

    months, antibiotic prophylaxis may be considered.

    Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do not differ

    significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than continuous prophylaxis with

    similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise, patient-initiated treatment upon developing

    symptoms can represent a cost-effective management strategy if infections are not severe and not frequent.

    The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns of the patient’s

    prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by observation for reinfection.

    Recommended Chlamydia Therapy

    First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline 100 mg twice daily . The

    one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin are considered alternative treatment agents

    and require seven days of therapy.

    Studies

    Cervical Cancer Screening Guidelines

    Age Recommendation

    Under

    21 Women under the age of 21 should not be tested, regardless of sexual activity.

    21-29 Women between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique. HPV testing

    should not be used in this age range unless it is prompted by an abnormal Pap result.

    30-65 There are three options for screening women between the ages of 30 to 65: 1. “Co-testing” with the Pap test and a high-risk HPV test every

    five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years.

    Over

    65

    Women older than 65 who have had negative Pap tests are unlikely to have abnormal Pap tests with repeat testing so should no longer be

    screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing continues after the age of 65.

    Women in the following groups should be screened yearly:

    those with HIV infection

    those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids)

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    those with diethylstilbestrol (DES) exposure before birth

    HPV vaccines target only certain genotypes of HPV. The 9-valent Gardasil-9 includes 7 genotypes that cause cervical cancer (types 16, 18, 31, 33,

    45, 52 and 58) and 2 genotypes that most commonly cause genital warts (types 6 and 11), the quadrivalent Gardasil includes the most common

    genotypes to cause cervical cancer (types 16 and 18) and the 2 genotypes that most commonly cause genital warts (types 6 and 11). But recipients

    of either vaccine are still at risk of developing cervical cancer. Therefore, they should receive age-appropriate screening as discussed above.

    However, they are at a decreased risk because types 16 and 18 are the cause of cervical cancer in a majority of cases.

    Liquid-based cytology is a method where cervical cells are suspended in a vial of liquid preservative instead of spread from a brush and spatula onto

    a glass slide. There are fewer unsatisfactory specimens with liquid Paps, and testing for HPV can be done on fluid from the vial, if warranted.

    However, there are more false-positive results with liquid Pap, which can result in needless referrals for colposcopy.

    Recommended Pelvic Exam Tests in the Setting of Suspected STIs

    Nucleic acid amplification testing

    (NAAT) for N. gonorrhea and C.

    trachomatis

    The best way to test for chlamydia and gonorrhea during a pelvic exam is nucleic acid amplification testing

    (NAAT) for N. gonorrhea and C. trachomatis. NAAT is a sensitive and specific assay and has replaced

    culture methods. It can be used on urine specimens as well.

    Microscopic examination of slide

    with drop of vaginal discharge and

    potassium hydroxide

    The potassium hydroxide slide is used to visualize budding yeast and hyphae that are seen with candida

    vaginal infections.

    Microscopic examination of slide

    with drop of vaginal discharge and

    normal saline

    The saline-prepped or “wet mount” slide allows for diagnosis of Trichomonas and bacterial vaginosis.

    Smelling a slide with a drop of

    vaginal discharge and potassium

    hydroxide

    Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test. The production

    of a fishy odor indicates a positive test. A positive whiff-amine test is seen in bacterial vaginosis.

    Tests not indicated:

    Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of Neisseria

    gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid testing.

    Smelling a slide with normal saline is not useful.

    What to Look for on Wet Mount Slides

    In the case of trichomoniasis, wet mount slides reveal trichomonads, which are flagellated protozoans. The treatment is a single dose of 2

    grams of metronidazole.

    Clue cells can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of a vaginal

    discharge in women of childbearing age, is a condition characterized by reduced numbers of normal vaginal lactobacilli and overgrowth of

    other vaginal bacteria. Clue cells are epithelial cells entirely covered with these bacteria giving the perimeter a “furlike” appearance. The

    treatment of BV is a course of metronidazole 500 mg twice daily for seven days.

    It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis, and atrophic

    vaginitis.

    Diagnostic Tests for Cystitis

    Microscopic urinalysis

    Pyuria, defined as at least two to five leukocytes per high-powered field in a spun urine specimen, is present in almost all women with cystitis, and

    evaluation of midstream urine for white blood cells is the most valuable lab test for urinary tract infection. If white cells are not present in the urine, an

    alternative diagnosis should be considered.

    Urine dip stick

    In ambulatory settings, urine dipstick testing has largely replaced microscopy to confirm the diagnosis of urinary tract infection (UTI), because it is

    cheaper, faster and more convenient. Dipsticks detect the presence of leukocyte esterase and nitrite and have comparable accuracy to microscopic

    urinalysis in the diagnosis of cystitis. However, they may be negative in low-colony count infections (less than 104 colonies/mL). Therefore, patients

    should also have a microscopic urinalysis performed.

    Tests not indicated for diagnosis of cystitis

    Microscopic evaluation of the urine for bacteriuria is generally not recommended for acute cystitis because bacteria in low quantities (less

    than 104 colonies/mL) are difficult to find, even with gram stain.

    Urine culture is not cost-effective and not necessary in women with cystitis, because the causative organisms and antibiotic sensitivities are

    predictable, and the results of the culture are not immediately available. There are certain situations when obtaining a urine culture is useful,

    such as in patients with refractory symptoms or those with history of urinary tract infections with antibiotic-resistant organisms.

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    Indications for Imaging or Urologic Evaluation in a Patient with a UTI

    Imaging studies and urologic referral are not indicated in the routine evaluation of young women with cystitis or pyelonephritis because they rarely

    uncover abnormalities that require treatment. However, in certain groups, further evaluation is recommended to exclude anatomic abnormalities and

    complications of pyelonephritis.

    Isolation of Proteus can be associated with urologic (struvite) stones so may require imaging, especially in patients with recurrent or refractory

    infections despite adequate antibiotic treatment.

    Recurrent pyelonephritis should prompt imaging to rule out nephrolithiasis or other urologic anomalies.

    Patients with pyelonephritis who remain febrile and show no clinical improvement within 72 hours on appropriate antibiotic therapy should

    have imaging to rule out obstruction or renal or perinephric abscesses. The presence of these complications often requires drainage and

    longer courses of antibiotics.

    Patients with suspected abnormality of the urinary tract.

    CT scan or renal ultrasound is recommended as a first step to rule out nephrolithiasis or obstruction prior to urologic evaluation in these

    circumstances.

    Urologic evaluation, including cystoscopy, should also be performed in those with persistent hematuria after infection has been eradicated.

    Clinical Reasoning

    Differential of Dysuria, Urinary Frequency, and Hematuria

    Most Likely Diagnoses

    Gonorrhea

    Several sexually transmitted infections, such as chlamydia, gonorrhea, trichomoniasis, and herpes simplex virus can cause

    urethritis and dysuria similar to that seen here.

    Symptoms that occur gradually over several weeks are more likely with a sexually transmitted urethritis.

    Cystitis

    Cystitis is an inflammation of the bladder caused most commonly by bacterial infection.

    A non-specific term often used interchangeably with cystitis is “urinary tract infection”. Urinary tract infection can denote

    infection of any portion of the urinary tract including the kidneys (pyelonephritis) or urethra (urethritis).

    Hematuria, urinary frequency, and dysuria are all common features of cystitis.

    Urinary frequency and dysuria can also be seen with urethritis, but hematuria is rarely seen with that condition. The

    presence of hematuria points to cystitis rather than urethritis in this patient.

    Note that fever is not seen with cystitis. When fever is present in the setting of urinary symptoms, pyelonephritis should be

    considered.

    Pelvic

    inflammatory

    disease

    Pelvic inflammatory disease, often called PID, is the name for a spectrum of disorders of the upper female genital tract,

    including endometritis, tubo-ovarian abscess and salpingitis.

    Often sexually transmitted infections are the source of PID, which can lead to infertility if not treated.

    Women with PID may have subtle symptoms, and physical exam findings of cervical motion tenderness, and uterine or

    adnexal tenderness are important diagnostic features of PID.

    In addition to vaginal discharge, abdominal and pelvic pain are common in PID-more so than with the other diagnoses.

    Fever is variably present in PID, and is more likely in severe cases.

    Less Likely Diagnoses

    Pyelonephritis

    Pyelonephritis is an infection of the kidney, or upper urinary tract.

    Dysuria may be present, but is rarely the only symptom.

    Symptoms that suggest the diagnosis of pyelonephritis are flank pain, fever, chills, nausea, vomiting, and prostration none of

    which are present here.

    Fever is usually present with pyelonephritis, but not always, so a lack of fever argues against this diagnosis.

    Candidiasis

    Candidiasis is an often-neglected cause of dysuria, and is perceived as pain or burning when urine comes in contact with an

    inflamed perineum or labia.

    A vaginal yeast infection may cause inflammation of the perineum and the urethral orifice, called “vaginitis” that leads to

    dysuria. This so-called “external dysuria” is most common with candida and trichomonas vaginitis, but is also present in

    patients with genital ulcers from herpes simplex, and in irritant vaginitis from soaps, hygiene products, condoms, and

    spermicides.

    Urinary frequency, urgency or hematuria are symptoms related to the bladder and urethra. When present, they speak against

    © 2019 Aquifer 8/9

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    the diagnosis of vaginitis.

    Bacterial

    vaginosis

    Bacterial vaginosis is a condition marked increased malodorous vaginal discharge.

    It is caused by an imbalance of naturally occurring vaginal flora.

    It is not an inflammatory condition, therefore pain and burning are rarely seen.

    Sexual activity is a risk factor for bacterial vaginosis, but there is no clear evidence that it is transmitted sexually.

    Interstitial

    cystitis

    Interstitial cystitis, also known as painful bladder syndrome, is a chronic pain syndrome characterized by frequency, urgency

    and dysuria.

    However, it is less likely to present with hematuria and is less likely to have such an acute onset.

    Nephrolithiasis Although nephrolithiasis can cause hematuria, it usually does not present with dysuria or urinary frequency.

    References

    Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women.

    Cochrane Database Syst Rev. 2004;(3):CD001209.

    Goldring J, Rosen D. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21:64.

    Gupta K, Hooton TM, Naber KG, Wullt B, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and

    pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious

    Diseases. Clin Infect Dis 2011;52:e103-20. DOI: 10.1093/cid/ciq257.

    Gupta K, Hooton TM, Roberts PL, Stamm WE. Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med

    2007;167:2207-12. DOI: 10.1001/archinte.167.20.2207.

    Hooton TM. Recurrent urinary tract infection in women. Int J Antimicrob Agents 2001;17(4):259-68.

    Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. Recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm

    Rep. 2011;60(2):1-60.

    Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for cervical cancer: a decision analysis for the U.S. Preventive Services Task Force.

    https://www.ncbi.nlm.nih.gov/books/NBK92546/. Agency for Healthcare Research and Quality, Publication No. 11-05157-EF-1. Published May 2011.

    Accessed August 21, 2019.

    Qaseem A, Snow V, Shekelle P, Hopkins R Jr, et al. Screening for HIV in health care settings: a guidance statement from the American College of

    Physicians and HIV Medicine Association. Ann Intern Med. 2009 Jan 20;150(2):125-31. DOI: 10.7326/0003-4819-150-2-200901200-00300.

    U.S. Preventive Services Task Force. Final Recommendation Statement: Cervical Cancer: Screening.

    https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2. Accessed August 21,

    2019.

    WHO Medical eligibility criteria for contraceptive use. 2009.

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Lab: Stickleback Evolution

Complete all the activities in this lab instruction packet: Lab 4: Stickleback Evolution, Part 2.  Work through the instruction packet step by step. Record your results in the worksheet as you progress through this instruction packet.

For any sections that request that you “take notes”, the notes should be in your own words summarizing information learned. You should not copy and paste information from the Internet including media and resources accessed in this lab. Directly copying and pasting information is considered plagiarism in this course.

Lab 4: Stickleback Evolution, Part 2

 

General Instructions

 

Be sure to read the general instructions from the Lessons portion of the class prior to completing this packet.

 

Remember, you are to upload this packet with your quiz for the week!

 

Background

In this experiment, you will analyze the pelvic structures of stickleback fish collected from two lakes around Cook Inlet, Alaska, to determine whether there are significant differences between the two populations. You will then use your data and information about the lakes to draw conclusions about the possible environmental factors affecting the evolution of pelvis morphology.

 

 

Specific Lab Instructions

 

Name:

Date:

 

Return to: The Virtual Stickleback Evolution Lab

Link: https://media.hhmi.org/biointeractive/vlabs/stickleback2/index.html?_ga=2.222191320.1578381481.1524156496-368479012.1521089692

 

You are going to perform Experiment 2 for the Stickleback lab this week.

 

Begin with Tutorial 2. When you are comfortable scoring a pelvis in fossil fish, you may move on (Note: it is a little more difficult in fossils than live fish, so you may want to spend a little time here).

 

1. What score would you assign to a fossil specimen that has only one pelvic spine visible?

2. A stickleback fossil may show no signs of pelvic structures. What are possible sources of error associated with scoring the pelvis of such a fossil as “absent”?

 

When you feel you have mastered scoring fossils, you may move on to Experiment 2.

1. In your own words describe the overall objective of Experiment 2 and explain what the data you collect will allow you to estimate.

 

2. What is one type of information that researchers can gain from studying fossils that they cannot obtain from living populations?

 

Lab 4: Stickleback Evolution, Part 2

 

Page 1 of 9

Begin the experiment in the window on the left. Complete Part 1: Preparing Fossils (click on the bench to get started).

 

3. You will collect data on pelvic structures using fossils from rock layers 2 and 5. Approximately how many years of deposition separate these two layers?

 

4. Which layer is older, 2 or 5? Explain your answer.

 

 

 

Complete Part 2 of the lab in the window on the left.

Score Your Fossils

 

 

5. Based on the pelvic phenotypes you measured, do the fossils in layer 2 differ from those in layer 5? Explain how.

 

6. After your collect data for the pelvic phenotype in layers 2 and 5, add your totals, and submit. As in lab 3, you may use the graph feature in the program as it works fine, or you can create your own Excel graph. Insert a screenshot here.

7. How do your data compare to those collected by Dr. Bell and colleagues?

 

8. Take the quiz. What can be inferred about the presence or absence of predatory fish when the Truckee Formation was a lake? Describe the evidence.

 

9. After completing the quiz, click on Experiment 2 Analysis.

10.

11. Complete the tables below as you perform the rate calculations. (The link to the instructions is very helpful.)

Sample Layer Number of Fish with a Complete Pelvis Total Number of Fish Sampled Relative Frequency of Complete Pelvis Trait in Population Sampled
1

2

3

4

5

6

 

Time Decrease in Percentage of Complete Pelvis Trait per Thousand Years (Rate of Change)
First 3,000 years (Layer 1 to Layer 2)

Next 3,000 years (Layer 2 to Layer 3)

Next 3,000 years (Layer 3 to Layer 4)

Next 3,000 years (Layer 4 to Layer 5)

Next 3,000 years (Layer 5 to Layer 6)

Total 15,000 years (Layer 1 to Layer 6)

 

 

1. What does it mean when the rate of change is a negative number?

 

2. Complete the Analysis Quiz.

3. Describe the trend in the data over time.

 

4. Why is it important to calculate the rate of change over time?

 

5.

6. In what way is the change in the complete pelvis phenotype in the fossils from the Nevada lakebed similar to what might have occurred in Bear Paw Lake from Experiment 1?

 

 

 

 

Adapted from: Brokaw, A. (2013). Stickleback Evolution Virtual Lab. HHMI Biointeractive Teaching Materials.

 
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Biology Experiement Homework2

Transcription and Translation – Introduction

Be sure that you have read over our online lecture this unit on DNA and read pp 177 to 181 in your book before starting. DNA can be a complex concept to grasp, and there is a lot of terminology to keep straight. These first two exercises will focus on transcription and translation, the two processes responsible for taking the information embedded in our DNA and using it to create a protein.

There are segments in our DNA called genes that code for the proteins needed to carry out cellular functions. These genes are a sequence of nucleotides; adenine (A), thymine (T), cytosine (C) and guanine (G) and the specific sequence of these nucleotides is what conveys the information needed to produce a given protein. In humans, the smallest gene is 252 nucleotides long, whereas the largest is more than 2 million nucleotides long! The genetic code is used to decipher the sequence of nucleotides into a sequence of amino acids. The code uses a series of three-nucleotide sequences called codons. Each different codon codes for an amino acid and it is this specific sequence of amino acids that determines what protein is formed.

DNA is found in our nucleus, yet our proteins are synthesized in the cytoplasm. A gene must first be transcribed into a form that can leave the nucleus. Transcription is the process in which a sequence of DNA used to synthesize a complementary strand of messenger RNA (mRNA). This mRNA acts a template and is used to translate the original DNA sequence into a protein, based on the information in its codons and the Genetic Code.

For example, the DNA sequence ATG-CGT-TAG-CGT-ATTC would be transcribed into the mRNA sequence UAC-GCA-AUC-GCA-UAA. Then, using Fig 10.11 on p 180 in your book, you can determine that this mRNA would be translated into the amino acid sequence Tyrosine-Alanine-Isoleucine-Alanine-Stop.

In Exercise 1, you will have the opportunity to demonstrate your understanding of transcription and translation. You will be using the following website; be sure that you are able to access and use the site:

University of Utah. No date. Transcription and Translation

http://learn.genetics.utah.edu/content/molecules/transcribe/ (Links to an external site.)

In Exercise 2, you will apply what you learned in Exercise 1 and evaluate the effect that different types of mutations have on the outcome of transcription and translation. You’ll want to review these mutations on pp 186-187 of your book and in our online lecture on DNA before starting. You will be using the following website; be sure that you are able to access and use the site:

McGraw Hill. No date. Virtual Lab: DNA and Genes

http://www.glencoe.com/sites/common_assets/advanced_placement/mader10e/virtual_labs_2K8/labs/BL_04/index.html  (Links to an external site.)

Finally, in Exercise 3, you will complete a series of calculations to determine the probability of a mutation occurring within a gene that results in a change in protein structure.

UNIT 5 EXPERIMENT ANSWER SHEET Please submit to the UNIT 5 Experiment SUBMISSION LINK no later than Sunday midnight.

SUMMARY OF ACTIVITIES FOR UNIT 1 EXPERIMENT ASSIGNMENT

· Experiment 5 Exercise 1 – Transcription and Translation

· Experiment 5 Exercise 2 – Translation and Mutations

· Experiment 5 Exercise 3 – Mutation Rates

 

Experiment 5 Exercise 1: Transcription and Translation

This exercise will ensure that you have a good understanding of the processes of transcription and translation. To get started, go to the following website:

University of Utah. No date. Transcription and Translation

http://learn.genetics.utah.edu/content/molecules/transcribe/

 

Procedure

A. Read over the information on the first screen and click on the click here to begin to proceed.

B. On the next screen transcribe the give DNA strand.

Table 1. Transcription of the DNA sequence (1.5 pts).

RNA                                            

 

C. Once you have finished transcribing the DNA, you will then translate the RNA sequence. Follow the instructions on the screen.

Table 2. Translation (1.5 pts)

  Codon Amino Acid
Codon 1    
Codon 2    
Codon 3    
Codon 4    
Codon 5    
Codon 6    

 

 

Experiment 5 Exercise 2: Translation and Mutations

Now that you know how to transcribe DNA and translate the mRNA message, let’s take a look at the different types of mutations that might disrupt this process. Review pp 186-187 in your book before beginning. In this exercise you will need to use the following website:

McGraw Hill. No date. Virtual Lab: DNA and Genes http://www.glencoe.com/sites/common_assets/advanced_placement/mader10e/virtual_labs_2K8/labs/BL_04/index.html

Read over the information in the Mutation Guide and close it when you are done. Note that there are several pages; you will need to click on Next to proceed through the Guide. If you want to review this material, you can click on the Mutation Guide button. You are going to run a series of simulations in which an mRNA sequence and its corresponding amino acid sequence is provided. You will be told what type of mutation you will you apply (= Mutation Rule) and you will have to determine the new, mutated mRNA and the resulting protein sequence.

Procedure

A. Click on the Mutate button to get started.

B. Find the Mutation Rule (lower left corner) and enter it into Table 3 below (see the Example provided).

C. Drag the appropriate nucleotides to build the new, Mutated mRNA sequence. If you make a mistake building the new mRNA sequence, drag the correct nucleotide and place it on top of the incorrect one (you cannot actually remove a nucleotide).

D. Once you have generated your Mutated mRNA sequence, you now need to build your Mutated amino acid sequence by matching the appropriate amino acid with each codon. Click on Genetic Code Chart to see the code or you can use Figure 10.11 on p 160 in your book.

NOTE: If you add a STOP codon, do NOT add any more amino acids after it!

 

E. Once you have finished, click on the Check button. If you are correct, then continue with Step F. If you had errors, you will have to Reset the simulation and start over with Step A. Here is what the results look like for the example provided:

F. When you have been successful, enter the Original mRNA sequence and the Original amino acid sequence in the Table below. Then enter the Mutated mRNA and Mutated protein sequence.

G. Click on Reset and repeat Steps A through F four more times so that you end up with FIVE replicates. Do not reuse the same Mutation Rule and do not use the rule used in the example (“the 4th A becomes a C”). If you get the same Mutation rule twice, Reset the simulation and run again.

Do NOT use the same Mutation rule as shown in the example and do NOT use the same Mutation Rule twice!

Table 3. Mutation rules, mRNA sequences and amino acid sequences (10 pts).

Rep Mutation Rule and Sequences
E

X

A

M

P

L

E

Mutation rule: The 4th A becomes a C
  Original mRNA sequence AUG CAC ACG GUG CGA GGG AGU CUG
  Original amino acid sequence Met (Start) – His – Thr – Val – Arg – Gly – Ser – Leu
  Mutated mRNA sequence AUG CAC ACG GUG CGC GGG AGU CUG
  Mutated amino acid sequence Met (Start) – His – Thr – Val – Arg – Gly – Ser – Leu
  Consequence Substitution appears to have had no effect; Arg Arg
1 Mutation rule:
  Original mRNA sequence  
  Original amino acid sequence  
  Mutated mRNA sequence  
  Mutated amino acid sequence  
  Consequence  
2 Mutation rule:
  Original mRNA sequence  
  Original amino acid sequence  
  Mutated mRNA sequence  
  Mutated amino acid sequence  
  Consequence  
3 Mutation rule:
  Original mRNA sequence  
  Original amino acid sequence  
  Mutated mRNA sequence  
  Mutated amino acid sequence  
  Consequence  
4 Mutation rule:
  Original mRNA sequence  
  Original amino acid sequence  
  Mutated mRNA sequence  
  Mutated amino acid sequence  
  Consequence  
5 Mutation rule:
  Original mRNA sequence  
  Original amino acid sequence  
  Mutated mRNA sequence  
  Mutated amino acid sequence  
  Consequence  

 

Questions

1. What is a silent mutation? Did you see any examples of this in your mutations above? If so, which mutation rule(s) generated it? Cite your sources (2 pts).

 

2. What is a missense mutation and how does it differ from a nonsense mutation? Did you see examples of either of these types of mutation and if so, which mutation rule(s) generated it? Cite your sources (2 pts).

3. What is a frame-shift mutation and why are they so damaging? Did you see any examples of this in your mutations above? If so, which mutation rule(s) generated it? Cite your sources (2 pts).

 

4. Find a genetic disorder that develops as a result of one of the types of genetic mutations we have examined in this exercise. Identify the disorder and briefly describe the mutation responsible. Cite your sources (3 pts).

 

 

Experiment 5 Exercise 3: Mutation Rates

We learned in our second exercise that not all mutations have an observable effect. Yet the risk of a mutation being damaging is fairly significant, so it is important to understand the probability of them occurring. In this exercise, we are going to calculate the probability of a mutational event within a gene. You are given the necessary information below to complete the calculations. Do not let them overwhelm you; this is simple math, so think things through.

Assume that:

· there are approximately 3,000,000,000 base pairs in the mammalian genome (genes constitute only a small portion of this total)

· there are approximately 10,000 genes in the mammalian genome

· a single gene averages about 10,000 base pairs in size

 

Questions

1. Based on the assumptions above, in the mammalian genome, how many total base pairs are in all the mammalian genes? Show your math (2 pts).

2. What percentage (%) of the total genome does this represent? Show your math (2 pts).

 

3. What is the chance (%) that a random mutation will occur in any given gene? Show your math (2 pts).

 

4. Only 1 out of 3 mutations that occur in a gene result in a change to the protein structure. What is the probability that a random mutation will change the structure of a protein? Show your math (2 pts).

 

UNIT 1 Experiment Grading Rubric

Component Expectation Points
Experiment 5 Exercise 1 Demonstrates an understanding of the process of transcription and translation (Table 1 and 2). 3 pts
Experiment 5 Exercise 2 Correctly implements the proper mutation and transcribes the mRNA correctly (Table 3). 10 pts
  Demonstrates an understanding of the different types of mutations and their consequences (Questions 1-4). 9 pts
Experiment 5 Exercise 3 Correctly calculates the necessary information (Questions 1-4). 8 pts
TOTAL   30 pts

 

 

 

1. Explain the four roles that DNA plays in cells? How are these roles influenced by DNA’s structure? Be sure you demonstrate your understanding of DNA’s structure in your answer.

 

Citation(s):

 

2. Match the terms with the most suitable description.     _____ genetic code             a.  Examples of RNA processing     _____ promoter                   b. Sequence of three nucleotides that code for an amino acid.     _____ exon                          c. Location on DNA where RNA polymerase attaches.     _____ intron                        d. Sequence of three nucleotides that is complementary to a codon triplet.     _____ anticodon                  e. Portion of a gene that is excised from the RNA transcript.      _____ codon                        f.  Rules that convert a nucleotide sequence into a protein.     _____ cap and tail               g. Parts of a gene that are expressed.

3. Briefly explain the differences among messenger RNA, transfer RNA and ribosomal RNA in terms of the roles they play in transcription and translation and where they are found in the cell.

 

Citation(s):

 

4. Using the genetic code table (Fig 10.11 on p 180), take the following DNA sequence and complete the following. Note that the mRNA is generated from the complementary DNA strand.                                           T A C C C C A T G T A A C A T A C C A C T

Complementary DNA strand _______________________________________________

mRNA strand ___________________________________________________________

Amino acid sequence _____________________________________________________

 

5. Part of the coding sequence of a gene produces an mRNA sequence of  A U G A A G G C U C C U C C A A G C G G C

What is the DNA sequence __________________________________________________

What is the amino acid sequence _____________________________________________

6. Review pp 178-185 in your book and view the following animation. Then complete the following table. You may need to watch it the video more than once to catch the details.

Genome British Columbia. Gene Expression. 2007. Web. 25 July 2016. https://www.youtube.com/watch?v=OEWOZS_JTgk (Links to an external site.) undefined

Question Transcription Translation
What is it, in brief?    
Where does it occur in the cell?    
What is the product?    
Describe how the product is modified to reach its final form.    

Citation(s):

 

Updated April 2015

 
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Case 6-1: An Adolescent Couple with HIV

Discussion Post

—Word Count Is Your Discretion for All Questions Except Question 6 750 Words Minimum!!!

—MLA Format

— Cite All Sources

— Due 2pm American/ New York Time

— 2/14/18

**Read Case Study 1 Attached & Answer Question 1**

Case 6-1: An Adolescent Couple with HIV

Question 1: “You are the nurse in the clinic on the day Alexa finds out she has HIV. She remains in the clinic for more than an hour with you while you try to support and console her. You have had formal HIV counseling training, so you apply your skills as you communicate with her. Several weeks later, after Alexia is more composed and has had time to think more about her situation, she drops by the clinic and wants to talk with you on a more personal basis. She needs comforting. What approaches will you use with Alexa? Please explore how to use and apply the nursing ethical competencies to help Alexa. Be specific with your approaches and rationales. You can approach this issue keeping in mind the three key ethical principles of autonomy, beneficience and nonmaleficense as they relate to your nursing interventions.

** Read Case Study 2 Attached & Answer Question 2 **

Question 2: CBRT Case Study Attached. Use article to answer questions below

1. Phosgene exposure causes inflammation and pulmonary edema that is deleterious to the function of the lungs. (a) What are the three physical factors that influence pulmonary ventilation? How would each of these factors be affected by inflammation and edema?

2. After exposure to phosgene gas, the partial pressures of both O2 and CO2 would be altered in the blood and tissues, because the mechanism for moving these gases in and out of the body has been compromised. After severe exposure to phosgene, what would you expect to find if you measured the partial pressure of oxygen (PO2) and carbon dioxide (PCO2) in the alveoli, the blood plasma, and the cells of the tissues?

3. The transport of oxygen and carbon dioxide in the blood is critical for survival. The victims with the most severe symptoms would need mechanical ventilation to overcome the inability of their respiratory systems to maintain normal blood levels of oxygen and carbon dioxide. Phosgene gas would reduce the amount of oxygen available for transport to the tissues. In addition, the metabolic waste product carbon dioxide is transported by three mechanisms back to the alveoli in the blood. Here carbon dioxide crosses the respiratory membrane, driven by a pressure gradient that favors its exit via the lungs during exhalation. By knowing which mechanism transports the most CO2, predict what would happen to the blood pH if the CO2 level dramatically increased?

** Read Below & Answer Question 3**

Question 3: Give a brief description of Botox & briefly describes how it affects the nervous system and action potential conduction. You should have a minimum of 2 academically appropriate resources.

** Read Below & Answer Question 4 I Attached Chapters**

Question 4: Please read Controversy 13 in your text, about Childhood Obesity and Early Chronic Diseases. As with many public health concerns, there is a controversy around personal responsibility and environmental influence. This conflict is further complicated when it involves children. Discuss what individuals, groups, or agencies you think are responsible for addressing childhood obesity? Please propose two to three solutions to address this concern and provide evidence to support your ideas.

** Read Below & Answer Question 5**

Question 5: Please read the following scenario and submit a report with a response to each of the associated questions. Cite sources in APA style.

Mini Case Study of Betsy’s Bones

Betsy is a 72-year-old retired teacher who lives alone. She used to love gardening, but since moving to a condo, doesn’t get much time outside, and spends most of her days reading or talking on the phone. She presents to her doctor complaining of right leg pain and muscle weakness. Her laboratory results showed deficient vitamin D and reduced bone density, and a diet recall included:

• Breakfast: two hard-boiled eggs, 1 whole grapefruit with 1 tsp sugar, 12 oz. black coffee

• Lunch: cucumber sandwich (made with a ½ cup of sliced cucumber, 2 slices white bread, and 1 T mayonnaise), 1 oz. potato chips, 16 oz. unsweetened iced tea

• Dinner: pasta (1 c.) with meatless marinara sauce (1/2 c.), small white roll, 1 glass red wine, fun-size Milky Way.

Betsy is 5’4” and weighs 126# (57kg). She says she loves to cook, but since it’s just her, she usually just prepares something quick and easy. Every Sunday she goes to church and to the grocery store, but otherwise, she doesn’t leave the house much.

1. Estimate how much protein Betsy is getting. How much does she need? Is her intake adequate? What recommendations do you have regarding Betsy’s protein intake?

2. What about Betsy’ fluid intake? Is she getting enough water? What are potential consequences of not taking in enough fluid?

3. Her doctor recommended a vitamin D supplement. What other ways can Betsy improve her vitamin D status? List some foods that are good sources of vitamin D.

4. Betsy’s mom had osteoporosis and she’s concerned about developing it too. What steps can Betsy take to maintain her bone health? Are there specific nutrients other than vitamin D and calcium that are important to bone health?

5. Why is vitamin D deficiency more common in the elderly?

** Read Below & Answer Question 6**

Question 1: You are required to post 750-word summary of a personal response to a attached article (MATERNAL-FETAL CONFLICT). The summary should reflect self-awareness and critical thinking regarding why you chose both the article and the subject matter. Validate your opinion with references to the code of ethics. Articles and references used in researching the topic summary must be cited using proper APA format.

* Provide some background describing it and why it is timely and worth consideration.

* What are the pro and con arguments about the problem? Refer to ethical concepts, theories and principles in your book.

* What is your position on this problem and why? How do you think it could be resolved?

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** View the Video Below & Answer Question 7**

https://www.youtube.com/watch?v=gE4ef0yQZRU&feature=youtu.be

Question 7: Reflection: After viewing the “Unusual Support Group” material, why is it that infection rates went up AFTER better sanitation? If Polio had infected the human population for centuries and only a small percentage has long-lasting damage, why were we so determined to “fight” this infection and eradicate it?

 
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