DQ reply 10 634

Question 1

Breast Cancer Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Why did you select these tests or tools as being appropriate to this scenario? Support your summary and recommended plan with a minimum of two peer-reviewed references in addition to the course materials.

Question 2

Imagine a patient comes into your office with your selected condition or disorder. What elements in the patient history and physical exam would indicate the patient has the selected condition or disorder? Select two differential diagnoses that could be applied to this patient. How did you arrive at the two differential diagnoses? Include history and physical examination findings that would support each of the two alternative diagnoses.

DQ-1

Overactive bladder (OAB) syndrome is a condition with characteristic symptoms of urinary urgency that is usually accompanied by frequency and nocturia, with or without incontinence. It is diagnosed in the absence of urinary tract infection or other pathologies and has a tremendous impact on the quality of life. Although OAB can affect children and young adults, it is most common in patients over 40 years old (Leron, Weintraub, Mastrolia, & Schwarzman, 2018).

The etiology of OAB is not well understood, however, it is thought that the individual’s detrusor muscle becomes more sensitive to cholinergic stimulation leading to increased spontaneous activity. It is also thought that spontaneous bladder contractions during filling results in increased afferent output and consequently increases awareness of bladder filling. In addition, drinking too much alcohol or caffeine, and not drinking enough fluids causes bladder irritation and symptoms of overactivity ((steers, 2012).

Patients with OAB generally present with no clinical signs on examination, so a careful history is essential. It is necessary to rule out other conditions and risk factors that cause incontinence such as diabetes, spinal cord injury, Parkinson's disease, multiple sclerosis, pelvic surgery, obstetric history, dementia, and psychiatric disease. The patient’s current medication lists along with their observations as to what makes the symptoms better or worse also need to be taken into account (Leron et al., 2018).

The physical examination would include a focused examination of the organ systems that may be implicated in urinary incontinence. As the practitioner, I would inspect the abdomen for scars, masses such as uterine fibroids, hernias, and distension of the bladder. I would also perform a neurological exam, screening for upper motor lesions such as Parkinson's disease, and for lower motor lesions such as sacral-nerve root lesions. A direct rectal examination would help determine the anal sphincter tone. Fecal impaction distends the distal sigmoid and rectum, resulting in inadequate detrusor activity and compromised bladder emptying. A vaginal examination may reveal a prolapse of pelvic organs, which would impair bladder emptying and cause urine leakage (Steers, 2012).

 Laboratory tests would include a urine analysis, urinary culture, serum electrolytes, and a CMP to evaluate kidney function. Additional tests would include a cough stress test, which should be negative, and the measurement of postvoid residual, which should be less than 50 ml. Although video-urodynamic studies are the standard for the evaluation of an incontinent patient, they are typically reserved for the evaluation of complex cases of stress urinary incontinence. A bladder diary is also a simple assessment tool to describe bladder habits and patterns related to urination that can also be helpful in determining the frequency, volume, and pattern of voiding (Leron et al., 2018).

 

Leron, E., Weintraub, A. Y., Mastrolia, S. A., & Schwarzman, P. (2018). Overactive Bladder Syndrome: Evaluation and Management. Current urology, 11(3), 117–125. https://doi.org/10.1159/000447205

Steers W. D. (2012). Pathophysiology of overactive bladder and urge urinary incontinence. Reviews in urology, 4 Suppl 4(Suppl 4), S7–S18.

DQ-2

Condylomata acuminate (CA), also known as anogenital warts, the warts are found on the mucosal surfaces of the mouth and vagina, anus, perineum, anus, and genitals (Chang & Welton, 2004; Rosen, 2019). It is the most common viral sexual transmitted disease (STD), even more common than genital herpes (Chang & Welton, 2004). These warts are spread through sexual contact. They are caused by various types of human papilloma virus (Rosen, 2019). It can be spread through physical contact with an affected area (wart) or mucosa (Rosen, 2019). The wart is spread from one labium to the other through autoinoculation (Rosen, 2019). The virus that causes the wart is spread through sexual contact (Rosen, 2019). CA is a manifestation of the human papillomavirus (HPV) (Rosen, 2019). The clinical manifestations of CA include multiple or single, dome-shaped, flat, filiform, cauliflower-shaped, pedunculated, fungating, plaque-like, cerebriform, smooth (on the penile shaft), lobulated, or verrucous (Rosen, 2019). The warts vary in color and it includes hyperpigmented, brown, violaceous, erythematous, skin-colored, or white (Rosen, 2019). The warts are asymptomatic and can also be pruritic (Rosen, 2020). The warts can develop on the cervix, urethra, and anal canal (Rosen, 2020). It can interfere with defecation, cause urethral bleeding and urinary obstruction (Rosen, 2020). The psychological effects include guilt, angst, depression, anxiety, social isolation, and stigmatization over concerns of cancer risk and fertility in the future (Rosen, 2020).

The diagnosis include a thorough health history and physical examination and biopsy of the affected area. If the provider is familiar with the presence and clinical manifestations of CA they can diagnose with a dermatoscope and bright light. If the provider is uncertain about the diagnosis of CA a biopsy (scissor or shave procedure for a sample of the affected area) can be completed and to rule out malignancy a biopsy is beneficial (Rosen, 2019). The need for additional testing is warranted for concomitant internal involvement (anal, vaginal, cervical, and urethral) and other sexually transmitted diseases (gonorrhea, chlamydia) (Rosen, 2019).

The treatments include topical methods (Imiquimod, Podophyllotoxin, Sinecatechins) that are applied by the patient and clinician-administered therapies (cryotherapy, trichloroacetic acid (TCA), surgical removal (excision, electrosurgery, ultrasonic aspiration, laser) (Chang & Welton, 2004; Rosen, 2019). The treatment is dependent on the extent of the area affected, there could be a combination of the patient applied and clinician-administered therapies (Chang & Welton, 2004; Rosen, 2019).

References:

Chang, G. J., & Welton, M. L. (2004). Human papillomavirus, condylomata acuminata, and anal neoplasia. Clinics in colon and rectal surgery, 17(4), 221–230. https://doi.org/10.1055/s-2004-836942

Rosen, T. (2019). Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis. Retrieved from https://www.uptodate.com/contents/condylomata-acuminata-anogenital-warts-in-adults-epidemiology-pathogenesis-clinical-features-and-diagnosis?search=condyloma&source=search_result&selectedTitle=2~124&usage_type=default&display_rank=2

DQ-3

Varicoceles is a common disease in young men and middle-aged men that involves the blood vessels from the testicles (Shuhong & Hongmei, 2020). The veins from the testicles become dilated, and mostly occur without pain or discomfort and usually is ignored (Shuhong & Hongmei, 2020). This dilation comes from dysfunctional valves that create backflow in the testicular veins (Shuhong & Hongmei, 2020). Specifically, the pampiniform venous plexus is the vein system in the testicles that are affected (de los Reyes, Locke & Afshar, 2017). These veins surround the spermatic cord causing vascular sperm dysfunction (Shuhong & Hongmei, 2020). There is a high incidence rate of approximately 15% and also the leading cause of male infertility (Shuhong & Hongmei, 2020).

The disease process itself is usually painless and has little to no discomfort which is the reason it goes undiagnosed most of the time (Shuhong & Hongmei, 2020). Varicoceles are usually discovered by either a general physical exam or when infertility concerns are raised (Shuhong & Hongmei, 2020). However, in approximately 20% -30% of patients, there is discomfort that is localized to the left testicle, left groin, left lower abdomen, and left lower back pain (Shuhong & Hongmei, 2020). There is a 20% incidence rate of varicoceles occurring bilaterally (Shuhong & Hongmei, 2020).

Diagnosis is usually done by physical examination especially with palpation, while the patient is standing (de los Reyes, Locke & Afshar, 2017). There is a grading system associated with varicoceles (de los Reyes, Locke & Afshar, 2017). Grade O is only visible on ultrasound, Grade I is only palpable on Valsalva maneuver, Grade II is palpable with no Valsalva maneuver, and Grade III is visible with no need for palpation (de los Reyes, Locke & Afshar, 2017). Even with a physical examination, an ultrasound is now recommended to help support diagnosis due to the availability of ultrasound (de los Reyes, Locke & Afshar, 2017). This will also help aid in the measurement of blood flow, size of the testicles, and to help rule-in/out testicular torsion as the underlying disease process (de los Reyes, Locke & Afshar, 2017).

There is a small chance that the varicocele is extensive, and extends up into the abdomen (de los Reyes, Locke & Afshar, 2017). If this is discovered on a physical examination, a CT of the pelvis is recommended without contrast to rule-in/out renal involvement such as tumors causing renal vein reflux (de los Reyes, Locke & Afshar, 2017).

Treatment for varicoceles is usually supportive, with supportive underwear or jockstraps (de los Reyes, Locke & Afshar, 2017). If the varicocele is painful or causes infertility, surgical treatment and interventions are recommended (de los Reyes, Locke & Afshar, 2017). Varicocelectomy is performed to restore proper blood flow, and is performed laparoscopically (de los Reyes, Locke & Afshar, 2017).

 

References:

Shuhong Yan, & Hongmei Zhang. (2020). A Comparative Analysis of Nursing Effect between Microscopically Ligation of Varicocele and Traditional Operation. Acta Microscopica, 29(3), 1272–1278. https://eds-b-ebscohost-com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=3&sid=6dcfffe7-15e4-4e0c-bbcd-7203fee55c59%40pdc-v-sessmgr04

de los Reyes, T., Locke, J., & Afshar, K. (2017). Varicoceles in the pediatric population: Diagnosis, treatment, and outcomes. Canadian Urological Association Journal (CUAJ), 1–2 S1, 34. https://doi-org.lopes.idm.oclc.org/10.5489/cuaj.4340