Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer.
So if you're ready, let's jump right in.
Margaret Fitzgerald: Joseph is a 14-year-old, generally well, and up-to-date with health maintenance who presents for a sick visit stating, “My stomach's not been right for about the past four days.” The illness began with a 36-hour of gradual onset nausea, vomiting, and loose stools; and he reports that, quote, “I'm not sure how many times I threw up or had diarrhea.” Close quote.
He last vomited 24 hours ago and his last stool was about four hours ago and reported it as yellow- brown in color without any blood. He's been tolerating clear liquids for about the past 24 hours and voided a small amount about two hours ago. He states he feels, quote, “A little bit hungry and I'm afraid to eat or I might throw up again. I still feel a little bit sick.”
Close quote. Joseph reports that he's on his high school wrestling team and that for the past week, one guy after another has had the same thing. Vital signs are within normal limits and he denies dizziness with position change from supine to sit or stand. His mucous membranes are slightly dry and he has intact skin turgor; and mild diffuse, abdominal tenderness without rebound, with the working diagnosis of viral gastroenteritis.
Which of the following two clinical actions should be taken? A: Obtain stool for culture and sensitivity. B: Order a chem panel. C: Provide information about a slowly progressive diet as tolerated. D: Prescribe an antiemetic. And the correct answers are C: Provide information about a slowly progressive diet as tolerated and D: Prescribe an antiemetic. Where should you start?
Figure out what kind of a question this is. Now, this is an interesting question, because the choices really would be more information gathering, like getting the stool culture, getting a chem profile. So, that actually would be more assessment. Or with choices of C or D, the correct answer is what we're being told is, ‘Hey, go ahead and treat this young man and he's ready for intervention.’
And it's really telling us, by C and D being the correct choices, that he really does not need any more assessment done. So, with that in mind, let's take a look at some background information. Viral gastroenteritis is caused by select, disease-specific organisms with norovirus far and away being the most common. The vast majority of episodes, as we see here, will be seen in an otherwise healthy person who’s been sick for a number of days, who reports that they've also been in contact with a number of people with similar signs and symptoms.
Please note, when you're taking boards, every word in the stem or the story of the question is important. And this history, that multiple members of his wrestling team have come down with this same signs and symptoms over the last number of days, is consistent with a viral pathogen that's highly contagious. Most of the time with viral gastroenteritis, the very acute stage is fairly self-limiting.
One to two days in duration. And this is really what we hear in Joseph's history, that he was really very sick to his stomach, with both upper and lower GI symptoms for about 36 hours. But what’s equally as important, is that we walk away from the history with he hasn't vomited now for 24 hours. His stool was about four hours ago.
Looks like that hyper-acute stage with lots of vomiting and lots of stooling is behind him. However, now we often talk about viral gastroenteritis as a fairly short-term illness, where virtually everybody makes a full recovery. People often say that they have a few days worth of lingering GI symptoms, and this is what he's telling us. He's telling us that he's finally hungry.
It's probably the first time he's been hungry in a few days, but he still feels a little sick to his stomach and he’s a little bit worried about eating because he doesn't want to throw up again. There are no alarm findings on Joseph’s exam and it looks like he could be drinking more fluid since he has slightly dry mucous membranes, but non-deranged vital signs, intact skin turgor.
And I'm not at all surprised that he has some diffuse abdominal tenderness without rebound, as viral gastroenteritis hits literally the entire GI tract. But, the tenderness is usually quite mild. There is no rebound there. So, the question asked us, then what are we going to do next? We're also given two options. Keep in mind on the NP boards, there are no all of the above.
No, none of the above or no choose as many as many as you want type of questions. If you are to choose more than one answer, you'll be told how many answers to choose. And usually the maximum is two choices. But again, you're going to be told how many of your choosing. And of course, the computer will not let you choose all of the above or anything along those lines.
If this is a question with a single correct answer, you can only tick off one correct answer. If it's a question that says two correct answers, you will be allowed to do that second answer. The other point I want to make is there is no partial credit on the boards. Either you get the question 100% right or it's considered 100% wrong.
And you have to keep in mind that Joseph is clearly getting better, that he's young. Otherwise healthy teen, who is recovering from a defined episodic. You might be tempted to say, ‘Yeah, but how do we know this is actually viral gastroenteritis? How do we know Joseph doesn't have something more seriously wrong with him?’
Well, if the question says he has viral gastroenteritis, ‘Have a nice day.’ That's it. That's the diagnosis. And what you have to do is simply assume all the information you're given on a question is, in fact, truthful. The real point of this question is getting you to think in the mindset of treating someone in the outpatient setting who at baseline is healthy and is recovering from an episodic illness.
Viral gastroenteritis is a diagnosis made clinically, typically with no additional studies needed. With all that in mind, let's take a look at the question again. Joseph is a 14-year-old, generally well, and up-to-date with health maintenance who presents for a sick visit stating, “My stomach's not been right for the past four days.” As the illness began with the 36 hour, gradual onset nausea, vomiting and loose stools, Joseph’s reporting quote, “I'm not sure how many times I threw up or had diarrhea.”
Close quote. He last vomited 24 hours ago, and his last stool was four hours ago, reported as yellow-brown in color, small amount, and without blood. He's been tolerating clear liquids for the past 24 hours. And voided a small amount about two hours ago. He stated, “I’m a little bit hungry but I'm afraid to eat or I might throw up again. I still feel a little bit in my stomach.”
Joseph reports that he’s on his high school wrestling team and that for the past week one guy after another has had this same thing. Vital signs are within normal limits and he denies dizziness with position change from supine to sit or stand. His mucous membranes are slightly dry with intact skin turgor and mild, diffuse abdominal tenderness without rigor. With a working diagnosis of viral gastroenteritis, which of the following two clinical actions should be taken? A: Obtain a stool culture and sensitivity.
This is incorrect. The stool culture and sensitivity is not indicated in a person who appears to be recovering from viral gastroenteritis. Stool cultures are sometimes done for protracted diarrhea, even in what looks like it could have started with viral gastroenteritis or when there is a thought that it could be a more serious infection going on. And as you transition from the acute care setting to thinking like a primary care provider, you might reflect on the fact that in the inpatient setting, when a person starts to stool or presents with stooling, there are stool cultures obtained and that is because in the inpatient setting, people will have diarrheal diseases for myriad of reasons and you generally do need to get to the bottom of it.
But in the outpatient setting, otherwise young, healthy adult like us, stool cultures are not indicated in viral gastroenteritis. B: Order a chem panel. So, that would include electrolytes, BUN, creatinine, and a number of other studies. This is also incorrect. Take a look at the information we're being given about Joseph. He recently urinated, which is one of the best predictors of hydration status in the outpatient setting.
He has good skin turgor and he hasn't vomited in a whole day. And what he's really telling you is, ‘I'm starting to get hungry.’ That's a recovery finding in viral gastroenteritis. But, he still feels like his stomach is a little bit off, probably has some mild nausea. Might not be drinking as much as he should because we see that his mucous membranes are a bit dry.
And remember, he was no doubt mild-to-moderately dehydrated during the hours that he had all this stooling and vomiting going on. But, he is getting better. Whenever you go to order a diagnostic test, you'd have to ask yourself the question, ‘What am I trying to answer with the results of this test?’ And in this scenario, there's no particular reason to think that Joseph would have any abnormality in his chem panel. Ordering it would be a waste of resources and you will have to wait for the results to come back.
It's simply not implicated. Remember the adage, ‘Never do a test that doesn't contribute to your diagnosis or your treatment plan.’ Option C, one of our correct options, provide information about a slowly progressive diet as tolerated. And he's telling you he's afraid to eat because he still feels a little bit sick to his stomach. Give him advice on what he can eat.
And a lot of this advice is simply common sense. Try to avoid fatty foods that sit heavily in the stomach. Take more to simple, easy-to-digest foods, including white rice, toast, crackers, broth-based soups. Usually the advice is given to avoid dairy, although there's some controversy about that. But what is observed frequently is that when dairy is introduced to the diet, in a person recovering from viral gastroenteritis, due to a temporary lactase deficiency caused by the viral gastroenteritis, sometimes ingesting dairy will trigger diarrhea.
But if he feels like having a piece of toast with some butter and that appeals to him, a small amount of dairy is usually not problematic. In fact, yogurt would actually be helpful in this situation. So, we're going to give him some simple diet advice. Option D, our other correct answer, prescribe an antiemetic. And I'll be candid, it's probably not necessary that you give him an antiemetic, but it is there as an option and we have to choose two.
So, we're going to go with it. But, we also need to listen to this kid and what he's telling you is he’s afraid to eat because, “I feel sick to my stomach.” So, the use of it by the 5-HT3 antagonist such as Zofran or even, I do this sometimes in this clinical situation, an antihistamine-based antiemetic that is available OTC, in a product like Dramamine, is simply enough to calm the stomach down.
So, now the person feels more comfortable eating. In all likelihood, any residual nausea that he has is going to be gone in a day or two. And this is not an alarm finding, but it's a very common finding in a person recovering from viral gastroenteritis. Key takeaway: as you transition from the mindset of an acute care health provider to a primary care provider, where you being educated in the family or a child care or primary care roles, keep in mind that many of the conditions we treat on the outpatient setting are diagnosed clinically, where no additional laboratory findings or imaging are needed.
And quite often with these self-limiting episodic diseases such as viral gastroenteritis, in particular in a younger, healthier person as we have here, what we do for intervention is both common sense and science-based. Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit FHEA.com.