Clin Med Lab Final New stuff Flashcards
signs from Hx indicative of PAD
`1.Pt can walk discrete distance prior to pain
- Sitting helps
- Pain resumes with activity again
- Pain in legs with reclining in chair
- Advil does not help
- PMH (smoking, obese, HLD, etc.)
Physical Exam findings in PAD (5)
- Diminished pulses
- Smooth hairless legs that are cooler to touch
- Thickened toenails
- Color changes
- Buerger test
Buerger Test (2 parts)
- Elevate legs 45 degrees for 2 min.
Pallor indicates poor perfusion/ischemia - Next, patient sits up and hangs their legs over the edge of the bed
Color should return to the legs
Skin generally becomes blue then red
Arterial disease that affects the peripheral vasculature, most commonly from atherosclerosis
PAD
Clinical SSx of PAD (10)
Asymptomatic Intermittent claudication Atypical pain Pain at rest Nonhealing wounds Ulcers Gangrene Thin, hairless/shiny skin Cool skin Blue toe syndrome
Exertional leg pain that classically occurs after a certain distance of walking
Resolves with rest
Claudication
Buttock & Hip Claudication is indicative of
Aortoiliac Dz
Aching, may have weakness of thigh or hip with walking. Diminished pulses in 1 or both groins
Aortoiliac Dz
claudication + absent or diminished femoral pulses + ED
Leriche syndrome
Thigh Claudication
Common femoral artery
Claudication of Calf: Upper 2/3
Superficial Femoral Artery
Claudication of Calf: Lower 1/3
Popliteal artery
Foot Claudication vessel involved
Tibial & Peroneal artery
6 P’s of Acute Limb Ischemia
Pulseless Paralysis Perishingly cold Paresthesias Pallor Pain
Tx of Acute Limb Ischemia (2)
Start heparin & revascularization
STAT
How to measure ABI?
NL?
Dx of PAD?
Dx of calcified vessels?
Ratio of the ankle systolic blood pressure
divided by
the brachial systolic pressure
0.91-1.3
PAD <0.9
calcified vessels >1.3
What do you measure PAD arterial extent with?
Doppler probe
an _____ ___________ _________ gives the most objective evidence of how much someone is functionally limited by PAD
Exercise treadmill test
Might be considered in patients with atypical pain & a normal ABI
Performed in a vascular lab
Exercise treadmill test
An ABI that ↓ ____% after exercise is diagnostic of arterial obstruction
20
Vascular imaging:
initial study?
Gold standard?
Ideal?
initial: CTA
Gold standard: conventional angiography
Do both at same time in limb ischemia
PAD Tx? (3 courses)
- Risk factor modification
Smoking cessation, control DM and HTN, lose weight - Antithrombotic therapy long-term
ASA or Clopidogrel (Plavix) - Lipid-lowering therapy with at least a moderate intensity statin
Irrespective of LDL cholesterol level
Claudication Tx? (3)
Initial?
Rx? (1) and contraindication
Surg? (2)
- Initial: supervised exercise program
- Cilostazol (Pletal)
Contraindicated in ANY patients with CHF (↓survival). Patients with CAD have ↑ risk of angina & MI
3.Revascularization
For life threatening ischemia –or-
Patients with significant/disabling symptoms unresponsive to lifestyle modifications & medication
Stenting or bypass
What Rx is Contraindicated in ANY patients with CHF (↓survival)
Cilostazol
S/E of Cilostazol
s/e: headache, diarrhea, infection, rhinitis
A/N Foot Ulcers:
Location?
A: Toe Joints
N: Plantar Surface
A/N Foot Ulcers:
Appearance?
A: Irregular margins
Pale or necrotic base
N: ‘punched out’
Red base
A/N Foot Ulcers:
Ulcers w/in callus?
A: rare
N: yes
A/N Foot Ulcers:
Pain?
A: yes
N: No
A/N Foot Ulcers:
Deformity?
A: No
N: Often
A/N Foot Ulcers:
Skin Changes
A: Shiny, taunt
N: Waxy or shiny, poss pitting edema
A/N Foot Ulcers:
Reflexes?
A: present
N: absent
___ is a strong predictor of adverse CV outcomes (CHF risk equivalent)
PAD
PMH & P/E Predictors of progression to acute limb ischemia? (3)
- DM
- , ↑pack year smoking hx
- Lower ABI
Asssessment & Plan PAD
How to fix:
- PAD ->
- Type 2 Diabetes with CKD3b->
- HTN ->
- HLD ->
- Hypothyroidism->
- Tobacco use ->
- Obesity ->
Wells Pretest Probability for DVT (10)
HANG IN THERE!
- CA tx in last 6mo
- Paralysis/paresthesia or cast of BLE (stasis)
- Bedridden for 3d in last 4wks
OR
major surg in last 12wks. - Vein tenderness
- Swelling of ENTIRE leg
- UNILATERAL calf swelling >3cm
- UNILATERAL pitting edema
- prior DVT
- Collateral veins (compensation)
- Any other Dx makes more sense
Pretest Probability for DVT
D-dimer?
U/S?
Low->
Moderate->
High->
low: 0pts
D-dimer:
if NL-DONE
if (+)- U/S
Moderate: 1-2pts
HIGH SENSITIVITY D-dimer:
if NL-DONE
if (+)- U/S
High: 3-8pts (50-75%)
NO D-DIMER
DO U/S!
Wells Pretest probability for PE (7)
- DVT sx
- PE likely Dx
- Bedrest ≥3d
OR Surg in 4wks - Previous PE/DVT
- Hemoptysis (SOB pts)
- CA Tx in 6mo
- HR >100
Pretest Probability for PE (using Wells)
D-dimer?
CTPA?
Low->
Intermediate->
High->
Low: <2pts
Apply PERC
1. if pt fulfills ALL PERC-> DONE (NO D-dimer/CTA)
2. if 1 is not fulfilled-> D-Dimer
if D-dimer (+)-> CTPA
Intermediate: 2-6pts
D-dimer:
(+)-> CTPA
(-)-> DONE
High >6pts
DO CTPA
No need for D-Dimer!!
PERC (8)
- Age <50
- HR <100
- O2 Sat ≥95%
- No hemoptysis
- No estrogen use
- No prior DVT/PE
- No UNILATERAL leg swelling
- No surg/trauma req admission in 4wks
Key things that can cause an ↑ D-dimer
Surg Trauma NL pregnancy Sickle Cell Dz w/ vasoclusive episode ↑ age Afib CHF/CVD infection/sepsis/inflamm MI/CVA Acute limb ischemia preeclampsia thrombolytic agents AV malformations Liver/Renal dz
Test that is SENSITIVE and SPECIFIC for PE Dx
CTPA (with contrast)
Proximal DVT locations (3)
Popliteal v.
Femoral v.
Iliac v.
Distal DVT locations
Anterior tibial v.
Posterior tibial v.
Peroneal v.
Massive PE Dx
HEMODYNAMICALLY UNSTABLE
SBP <90
Massive PE Tx (3)
- Vasopressors/ clear evidence of shock
- IV fluids
- Reperfusion therapy
a. systemic thrombolysis
b. embolectomy
RV dysfunction & borderline BP is a __ PE?
Submassive PE
Reperfusion therapy for hemodynamically unstable PE pts (2)
- TPA
-for hemodynamically unstable - Embolectomy
- for failure of TPA
OR
-contraindication for TPA (saddle PE)
No identifiable provoking factor for DVT/PE is a ____ ___?
Unprovoked VTE
ok people, lets start the workup
identifiable provoking factor/event is a ___ ___?
Provoked DVT
provoking factors for DVT
- surg
- admisison
- C-section
- pregnant
- ESTROGEN!
- reduced mobility (stasis)
Persistent risk factors:
Inherited v. acquired (5)
inherited (genetic)
Acquired (CA)
- malignancy
- Factor V
- prothrombin gene mutation
- gene mutation
- anatomic risk factors
- chronic dz (IBD)
Common Rx that cause provoked DVT
- estrogens
- OCP’s
- Testosterone
- Tamoxifen
- Steroids
Tx w/anticoagulants (2 chocies)
Which one needs a Heparin (Lovenox) bridge?
- Coumadin
(needs a Lovenox bridge until INR 2-3 for 24hrs) - NOACs- Eliquis, Pradaxa, Xarelto, Savaysa
DVT Tx Bridging w/Heparin (lovenox).
What indiacations?
How long to bridge?
Indication: Warfarin (Coumadin)
Bridge until INR measured 2.0-3.0 for 24hrs straight.
Warfarin, NOACs & Reversal Agents
Warfarin- Vit K
NOAC’s
- Pradaxa (Praxibind)
- Savaysa (Andexxa)
- Eliquis (Andexxa)
- Xarelto (Andexxa)
“SEX with ANDEXXA”
NOAC vs Coumadin
good vs bad
Dont need to bridge NOACs w/ Lovenox
Starting doses are HIGHER (loading dose)
Minimum length of time to anticoagulate in VTE Pt
3months
Can go longer if needed
Average 3-6mo
DVT when to initiate anticoags:
Proximal?
Distal?
Contraindications?
Proximal: no contraindications
Distal: Symptomatic w/no contraindications
Conraindications: active bleed, platelets <50k, prior intracranial hemorrhage
Highest risk of VTE occurence (time frame)
1-2yrs after 1st event
Pts w/ ____ ____have rates of VTE ocurence of 15-20%/yr
benefit from what prophylactically?
Active Cancer
Benefit from anticoags prophylactically
High recurrence risk VTE pts (4)
INDEFINITELY ANTICOAG THEM!
- RECURRENT PROXIMAL DVT &/or Symptomatic PE (w/o identifiable risk factors)
- Any VTE associated w/Active Cancer w/o provoking event
- FIRST EPISODE PROXIMAL DVT/Symptomatic PE (w/o identifiable risk factor
Intermediate recurrence risk VTE pts (3)
SHARED DECISION MAKING FOR ANTICOAGS
- First VTE WITH persistent NONMALIGNANT risk factor
- First episode VTE 2/2 transient MINOR risk factor
- Recurrent VTE provoked by transient or persistent malignant risk factor
Low Recurrence VTE risk
indefinite coags NOT recommended
1st episode VTE w/transient major risk factor
IVC filters main point
Prevent embolization of a lower extremity clot to the lung
IVC filters for pts with ____ ____ and _____who have an _____ _______ to anticoagulants
(ACUTE) PROXIMAL DVT/PE
ABSOLUTE CONTRAINDICATION
T/F: IVC plus anticoagulants has benefit
False
No benefit
common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways
COPD
Chronic PRODUCTIVE cough
present 3mo x2 successive years
COPD
Abnormal enlargement of terminal air spaces
Accompanied by destruction of airspace walls WITHOUT FIBROSIS
Emphysema
2 scales for rating severity of COPD
CAT scale
mMRC scale
Combined COPD Assessment Steps (3)
1. How symptomatic are they: less Sx: mMRC <2 or CAT <10 more Sx mMRC >2 or CAT >10 (take worse of the 2 scales) 2. Spirometry reading 3. Amt of exacerbations in past yr.
COPD management most important principle (2)
STOP SMOKING
use O2 if indicated
COPD mgmt other principles (4)
- Influenza vaccine
- Pneumococcal vaccine
(>65yo or <65yo w/FEV1 <40% predicted) - Exercise program
- pt education
Group A COPD Tx
preferred?
SABA or SAMA
SABA>SAMA
SABA (2)
dosage
Albuterol (Proair-red box, Proventil, Ventolin)
Neb: 2.5mg inhaled Q6hr
Levalbuterol (Xopenex)
Neb: 0.63mcg/3mL Q8hr
albuterol s/e
tremors, jittery, tachycardia
SAMA (1)
dosage
Ipatropium (Atrovent)
Neb: 500mcg inhaled Q6-8hrs
Group B Tx
(SABA)+
LABA or LAMA
Combo SABA + SAMA
Duoneb
Combo beta agonist and anticholinergic
Ipratroprium + albuterol
Neb: Duoneb: 1 vial Q4H
All COPD PT GROUPS should habe this as a rescue med:
SABA- Albuterol
LABA
which does she want us to know?
AFORMOTEROL (BROVANA)
15mcg inhaled neb BID
LAMA
Which one does she want us to know?
TIOTROPIUM (SPIRIVA)
handihaler: 1 capsule (18mcg) QD
Respimat: 2.5 mcg/act 2 inhalations QD
What pt education needed for LABA/LAMA
QD use.
Need to use RESCUE INHALER (SABA) if dyspnic
Group C Tx
what does prof P. prefer?
ICS + LABA
or
LAMA alone
Prof prefers LAMA alone. No steroid-> no immunosuppression-> no PNA risk
Inhaled ICS + LABA (4)
which one does she want us to know?
FLUTICASONE/ SALMETEROL (ADVAIR)
250mcg/50mcg
Rx:
strength-
How much is in the pill
ie. Ibuprofen
200mg/1 pill
Rx:
Dosage-
How many pills
ie. Ibuprofen
600mg=3pills
Rx:
Sig->
Dosage
Route
Frequency
How long
Rx:
Disp->
Total Quantity to dispense (spell out too)
Things that affect med dosing:
Age Wt Hepatic Funct Renal Funct Wt Other Rx (↑ # Rx=↑ risk adverse rxns) i.e Coumadin ↑ w/ABX
what bronchodilator is controversial for the amount of s/e, LOW therapeudic window, and Rx interactions
Theophylline
Indications for long-term O2 use:
1. daily
16 h/d
Resting arterial PO2 (PaO2) ≤ 55 mm Hg, or pulse oxygen saturation (SpO2) ≤ 88%
OR
PaO2 ≤ 59 mm Hg or SpO2 ≤ 89%, concurrent with cor pulmonale, right heart failure, or erythrocytosis (hematocrit > 55%)
Indications for long-term O2 use:
2. Nocturnal Use
PaO2 ≤ 55 mm Hg or SpO2 ≤ 88% during sleep
OR
Decrease in PaO2 > 10 mm Hg or in SpO2 > 5% during sleep with symptoms or signs of nocturnal hypoxemia such as disrupted sleep, morning headaches, impaired cognitive function or insomnia
Indications for Long-term O2 use:
3. w/exertion
Decrease in PaO2 ≤ 55 mm Hg or in SpO2 ≤ 88% during exercise
How many physicians must certify that a pt has <6mo to live?
2
T/F Patient (or family) must sign, choosing Hospice over curative treatment
True
T/F Eligibility for hospice does not depend on disease process responsible for decline
false. it does
What 3 paramerters must be met to qualify for hospice based on a respiratory issue?
- Disabling dyspnea at rest, poorly or unresponsive to bronchodilators *
- Progression of disease, as evidenced by: increasing visits to the ER, increasing hospitalizations, or increasing physician visits *
- Hypoxemia at rest on room air: pO2 ≤55 mmHg, O2sat ≤88% or hypercapnia pCO2≥50 mmHg *
How to initiate a hospice conversation (8) key poitns
- Establish the medical facts
- Pick a private place for a conversation, ensure family/friends who want to attend can be there
- Assess understanding (of patient and family) of prognosis
- Define the patient’s goals
- Identify needs for care
- Introduce Hospice and dispel any myths
- Respond to emotions
- Recommend Hospice and make referral
T/F: PAs are permitted to provide, manage, and have hospice services reimbursed by Medicare
T/F: PAs in this capacity can establish and review a hospice patient’s plan of care
true
what can’t PA’s & NP’s do in hospice?
- Only a physician or medical director may certify terminal illness
- Only a medical director may admit a patient to hospice
- PAs can’t take the position of the physician
What can NP’s do that PA’s cant in hospice?
Face-to-face encounter prior to recertification for hospice care to determine continued eligibility
Some signs of the dying process:
Weakness, fatigue, and functional decline
Decreased oral intake & impaired swallowing
Diminished blood perfusion
Tachycardia, hypotension, peripheral cooling, cyanosis, mottling of the skin, loss of peripheral pulses
Neurologic changes:
Decreasing consciousness leading to coma and death –or-
Terminal restlessness/delirium: confusion, restlessness, agitation, day/night reversal
Breathing changes: periods of apnea, Cheyne Stokes breathing, accumulation of upper airway secretions with a “death rattle”
Excretion changes: loss of sphincter control (urine/stool) & decreased urine output
Inability to close eyes
2 best drugs for hospice?
- Morphine
Helps with pain and dyspnea
Available in an oral elixir (Roxanol) that is absorbed through MM
Normal starting dose: Roxanol 20 mg/ml 5 mg (0.25 ml) PO/SL Q4H prn pain/dyspnea - Ativan
Helpful for anxiety (often associated with dyspnea) and terminal restlessness
Also available in a liquid form that can be absorbed through MM
Normal starting dose: Ativan 2 mg/ml 0.5 mg (0.25 ml) PO/SL Q4-6H prn anxiety/terminal restlessness
T/F: haldol is good for nausea in hospice?
true
Nursing orders for hospice
Minimize vitals Least restrictive diet Bowel care Good attention to mouth care Lines Dyspnea
