Case 4: Internal Medicine Flashcards
COPD: Category A
- Sx?
- Risk level?
Less symptomatic: mild or infrequent Sx (i.e. breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) or CAT <10
Low Risk:
-0 to 1 exacerbations in the past year without associated hospitalization
COPD: category A
-tx?
Short-acting bronchodilator OR combo of short-acting beta-agonist and anticholinergic PRN
COPD: category B
- Sx?
- Risk level?
More symptomatic: moderate to severe Sx (ie Pt has to walk more slowly than others of same age due to breathlessness, has to stop to catch breath when walking on level ground or at own pace, OR has more severe breathlessness) or CAT ≥10
Low risk:
0 or 1 exacerbations in the past year without associated hospitalization
COPD: category B
-Tx?
First line: regular tx with a LABA or LAMA. SABA available for symptom control PRN
For persistent Sx: Regular tx with a combo of LAMA + LABA
COPD: Category C
- Sx?
- Risk level?
Less symptomatic:
mild or infrequent Sx (ie breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) or CAT <10
High risk:
≥2 exacerbations per year with 1 or more leading to hospitalization
COPD: Category C
tx?
First choice:
-Regular tx with a LAMA; SABA PRN
For further exacerbations: Regular tx with a LAMA plus LLABA or LABA + ICS
COPD: Category D
- Sx?
- Risk level?
More symptomatic:
mod to severe sx (i.e. Pt has to walk slower than others of same age due to breathlessness, has to stop to catch breath when walking on level ground at own place, or has more severe breathlessness) or CAT ≥10
High risk:
≥2 exacerbations per year with 1 or more leading to hospitalization
COPD: category D
Tx:
first line: regular tx w/ combo of LABA + LAMA. SABA PRN
-LAMA alone if LABA contraindicated
For further exacerbations: Regular tx w/ combo of LAMA + LABA + ICS
If exacerbations cont. despite triple therapy: roflumilast (if chronic bronchitis and FEV1 less than 50%)
mMRC scores:
0-4
mMRC score: Grade 0
Not troubled with breathlessness except with strenuous exercise
mMRC score: Grade 1
Troubled by shortness of breath when hurrying on the level or walking up a slight hill
mMRC score: Grade 2
Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level
mMRC score: Grade 3
Stops for breath after walking about 100 yards or after a few minutes on the level
mMRC score: Grade 4
Too breathless to leave the house or breathless when dressing or undressing
CAT score:
- scaling: 1-5
- 8 item Patient Questionnaire
- Range of CAT scores from 0–40. Higher scores denote a more severe impact of COPD on a patient’s life.
GOLD scoring is based on ______
spirometry
GOLD 1:
Mild. FEV1 ≥ 80 percent predicted
GOLD 2:
moderate. 50 percent ≤ FEV1 <80 percent predicted
GOLD 3: Severe
30 percent ≤ FEV1 <50 percent predicted
GOLD 4:
-very severe
FEV1 <30% percent predicted
When assessing COPD risk in a Pt, choose the HIGHEST risk according to GOLD grade or ________
exacerbation history
Patient Category A
- low risk, less Sx
- GOLD 1-2
- ≤1 exacerbations per yr
- mMRC 0-1
- CAT <10
Patient Category B
- low risk, more Sx
- GOLD: 1-2
- ≤1 exacerbations per yr
- mMRC: ≥2
- CAT: ≥10
Patient category C
- High risk, less Sx
- GOLD 3-4
- ≥2 exacerbations per yr
- mMRC 0-1
- CAT: < 10
Patient Category D
- high risk, more Sx
- GOLD: 3-4
- exacerbations per yr ≥2
- mMRC ≥ 2
- CAT: ≥10
CAD s/p MI
-tx?
- Aspirin-continue
- Beta blocker-continue
- High intensity statin therapy recommended for secondary prevention with all patients ≤75 with CV disease (ACC/AHA recommendations)
- -Atorvastatin (Lipitor) 40-80 mg
- -Rosuvastatin (Crestor) 20-40 mg
Type 2 Diabetes, uncontrolled:
-d/c metformin when CrCl gets below ____
CrCl <30
Type 2 Diabetes, uncontrolled:
Glipizide vs insulin
- Glipizide start with 2.5 mg daily
- Lantus 10 units daily as a starting point
Type 2 Diabetes, uncontrolled:
-Screening?
optho, podiatry, encourage patient to continue daily foot checks.
Type 2 DM uncontrolled:
- recheck A1c in ____
- What else should Diabetic Pts be taking?
- 3 months
- **ACEI
HTN
- Pt On lisinopril
- Expect that with decrease in Lasix, BP may go up
- -Might choose to increase lisinopril
- Return to clinic for BP check
elevated TSH indicates _____
hypothyroidism
Hypothyroidism:
- meds?
- recheck TSH how often?
- Increase dose of Synthroid to 88 mcg PO daily
- Should give without other medications/food
- Recheck TSH in 6-8 weeks
Diuretic therapy:
- Pt may be overdiuresed–> reduce Lazix–>Monitor for worsening s/s on decreased lasix
- Daily weights–> Call for weight gain of ≥3 lbs in 1 day or ≥5 pounds in 1 week
- Low sodium diet–> Refer to RD
Orthostatic hypotension can occur 2/2 _______
overdiuresis
- Decrease Lasix to 20 mg PO daily (or 10 mg PO BID)
- Education
Signs of overdiuresed Pt:
skin– poor turgor
Shriveled appearance
Dizziness
- High mortality associated with orthostatic hypotension
- beta blockers like toprol can also contribute to orthostatic hypotension
What electrolyte imbalances can occur 2/2 overdiuresis?
Labs: electrolyte imbalance–>
Hypernatremia & hypokalemia
**ALWAYS follow up after Lasix is increased
-Decrease Lasix
Recheck BMP in 5-7 days
CKD4 with A2 (moderately increased) albuminuria
- On ACEI
- Referral to nephrology
- Referral to RD
Mild anemia
- Likely anemia of chronic disease
- May want to recheck CBC after Lasix ↓
- Might be slightly worse
Hx tobacco use
- Woohoo she quit!
- Encourage her to stick with it
Stage 4 CKD= CrCl _____
less than 30 ml/min
