Clinical Questions Flashcards
If you were in code blue and had another one go off, what would you do?
I would first assess the current situation and the current code I am at right now. If I am the only pharamcist there and needed in the action then I would stay. However, if there is another pharamcist there and I am not needed and the other place needed people I would go to that one.
A patient comes in with hypotension. What do you do?
Is this in an outpatient or inpatient setting?
Inpatient? I would lay the patient or sit the patient down so they do not fall. Then I would assess to see what could be causing the hypotension: dehydration, medication history (eg. meds that can cause hypotension: antihypertensive drugs/ diuretics, is the patient preg?, anemia?, blood loss?, May need to get EKG to rule out heart or valve malformation that may cause bradycardia.
- For treatment?: fluids/ blood (if they loss blood) - fluid: 1 L over 30 mins, compression stocking … if they realy need med: midodrine 2.5-10 mg PO q8hr
You have a patient who has been on Lovenox and Warfarin for 5 days already. The patient is still subtherapeutic. What do you do?
..Wut.. they were on both at the same time?? Ok if it’s just bridging.. then ok. I would ask the patient how they are taking the medication/ to see if they are compliance and doing it correctly. Also, I would obtain an INR to see where they are at and make adjustments that way/ see what dose they are taking right now. increase by 25%
Hypokalemia - patient has K = 3 (normal 3.6 to 5.2 mmol/L), what do you do? When to start IV drip?
Mild to moderate (mild: 3 to 3.4 mmol/L, moderate: 2.5 to 3 mmol/L) hypokalemia is typically treated with oral potassium supplements. Providing 60 to 80 mmol/day in divided doses over days to weeks is usually sufficient -> Lexicomp 10 to 20 mEq 2 to 4 times daily.
If the patient has severe hypokalemia (less than 2.5) or have symptoms (including: N/V, muscle cramps, cardiac dysrhythmias - EKG: T-wave flattening, ST depression and the appearance of a U wave
This is when we would initiate IV potassium
Patient is taking Fluoxetine, birth control pills, St John’s Wort and has an amox Rx - do you fill it?
I would have to double check with Lexicomp for interactions, however, based on my knowledge, there are no interactions and I would fill the amox as they patient needs it for infection. Additionally I would advise the patient against using St. Johns Wort as this medication is known for having a lot of drug-drug interaction
The following medications require renal dosage adjustments
Allopurinol (Zyloprim)
Lithium (Lithobid)
Acyclovir (Valtrex)
Amantadine (Symmetrel)
Fexofenadine (Allegra)
Gabapentin (Neurontin)
Metoclopramide (Reglan)
Ranitidine (Zantac)
Rivaroxaban (Xarelto)
Alot of abx:
Cephalexin (Keflex)
Amoxicillin (Amoxil)
Cefuroxime (Ceftin)
Ciprofloxacin (Cipro)
Clarithromycin (Biaxin)
Levofloxacin (Levaquin)
Nitrofurantoin (Macrobid)
Piperacillin/Tazobactam (Zosyn)
Tetracycline (Sumycin)
Trimethoprim/Sulfamethoxazole (Bactrim)
Antibiotics:
Gentamicin
Vancomycin
Ciprofloxacin
Cardiovascular Medications:
Enalapril
Lisinopril
Atenolol
Digoxin
Pain Medications:
Morphine
Oxycodone
Gabapentin
Anticoagulants:
Warfarin
Diuretics:
Furosemide
Hydrochlorothiazide
Antivirals:
Acyclovir
Immunosuppressants:
Tacrolimus
Cyclosporine
Antidiabetic Medications:
Metformin
Antiarrhythmics:
Amiodarone
Opioid Analgesics:
Morphine
Oxycodone
What are 5 drugs to avoid in the elderly - Dr. Beers’ criteria.
Ketorolac
Amitriptyline
omeprazole
lorazapam
Diphenhydramine
Fluoxetine
ASA
Bupropion
atropine
What factors effect prothrombin time?
- Liver Function: Liver diseases can impair the synthesis of clotting factors, affecting PT
- Vitamin K status: Vitamin K is a necessary component in factors II, VII, IX, and X. A deficiency in vitamin K will lead to a decrease in these factors and prolong PT.
- Warfarin Therapy (VKA) : KA therapy inhibits factors II, VII, IX, and X and causes a prolonged PT.
-
Antiphospholipid antibodies/ other genetics factor **
- Drug-Drug interaction**: Medication Interactions:
Drugs that interact with anticoagulants, such as certain antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs), can affect PT. Monitoring is necessary to adjust anticoagulant dosages accordingly.
Can you give me the pros & cons for using a PTT vs. factor 10a to monitor heparin use?
PTT (Activated Partial Thromboplastin Time):
Pros:
Widely Used: PTT is a widely available and established test used for monitoring heparin therapy.
Cost-Effective: PTT testing is generally less expensive compared to anti-factor Xa assays.
Effect on Intrinsic Pathway: PTT primarily reflects the activity of heparin on the intrinsic coagulation pathway.
Cons:
Variable Sensitivity: PTT can have variable sensitivity to heparin, making it less reliable for predicting the anticoagulant effect.
Influence of Other Factors: PTT results can be affected by various factors such as liver disease, vitamin K deficiency, and lupus anticoagulant presence, potentially leading to inaccurate readings.
Laboratory Variability: Different laboratories may use different reagents and methods, leading to variability in PTT results.
Anti-Factor Xa Assay:
Pros:
Specific for Heparin: Anti-factor Xa assays are specific to heparin, providing a more direct measurement of heparin’s anticoagulant effect.
Less Affected by Other Factors: Anti-factor Xa assays are less influenced by factors like liver disease or lupus anticoagulant, providing a more accurate representation of heparin activity.
Precise Monitoring in Specific Patient Populations: Anti-factor Xa assays are particularly useful for monitoring heparin therapy in specific patient populations, such as those with obesity or renal dysfunction, where PTT may be less reliable.
Cons:
Availability: Anti-factor Xa assays may not be as widely available in all laboratories compared to PTT.
Cost: Generally, anti-factor Xa assays can be more expensive than PTT testing.
Standardization Issues: There may be challenges in standardizing anti-factor Xa assays across different laboratories, leading to potential variability in results.
The choice between PTT and anti-factor Xa assay depends on factors such as institutional practices, patient characteristics, and the specific clinical context. Individualized patient management and close collaboration with healthcare professionals are essential for effective anticoagulation therapy.
What can cause QT prolongation other than drugs?
- Electrolyte Imbalances: Abnormal levels of electrolytes, particularly low potassium (hypokalemia) or low magnesium (hypomagnesemia), can disrupt the normal electrical activity of the heart and lead to QT prolongation
- Other comorbiditity :left ventricular hyperthrophy, heart failure, myocardial ischaemia, hypertension, diabetes mellitus, increased thyroid hormone concentrations, elevated serum cholesterol, high body mass index, slow heart rate
- Gender: female
- Age (older)
HTN - 4 lifestyle modifications; goal BP values in the general population vs. DM patient.
- Reduce sodium intake: 2-1.5 grams per day
- Limit alcohol consumption
- Exercise: 150 minutes (two hours and 30 minutes) per week of moderate-intensity physical activity
- Quit smoking
- Maintain a healthy weight: ideal BMI is in the 18.5 to 24.9
Goals:
general population: 140/90???
Diabetes patient: 130/80 mm Hg
Heart Failure - What is it? drugs, treatments?
Heart failure is a chronic and progressive condition in which the heart is unable to pump blood efficiently, leading to inadequate perfusion of tissues and organs. It can result from various cardiovascular diseases that impair the heart’s ability to fill with or eject blood. Heart failure is a serious condition that requires ongoing management and can significantly impact a person’s quality of life.
Pathophysiology of Heart Failure:
- Impaired Contractility: The heart muscle may become weakened and unable to contract effectively, reducing its ability to pump blood.
- Increased Afterload: Conditions such as hypertension can increase the workload on the heart, leading to a thickening of the heart muscle and further compromising its pumping ability.
- Myocardial Infarction: Heart attacks can cause damage to the heart muscle, reducing its overall function and contributing to heart failure.
- Ventricular Remodeling: The heart undergoes structural changes, including enlargement of the chambers and alterations in the shape of the heart muscle, as it tries to compensate for reduced pumping efficiency.
Signs and Symptoms of Heart Failure:
- Shortness of Breath (Dyspnea): Often worsens with physical activity or when lying down.
- Fatigue and Weakness: Due to reduced cardiac output and inadequate tissue perfusion.
- Fluid Retention (Edema): Swelling in the legs, ankles, and sometimes the abdomen due to fluid buildup.
- Persistent Coughing: Especially at night, may be accompanied by frothy or pink-tinged sputum.
- Rapid or Irregular Heartbeat (Arrhythmias): Resulting from changes in the heart’s electrical conduction system.
TREATMENT:
ACE inhibitors (lisinopril)
angiotensin-2 receptor blockers (ARBs - losartan)
beta blockers - (cardioselective: metoprolol succ., bisoprolol, atenolol)
mineralocorticoid receptor antagonists (Spironolactone and eplerenone)
diuretics (furosemide, bumetanide, metolazone)
ivabradine
sacubitril valsartan AKA Entresto
hydralazine with nitrate
digoxin - rate control
SGLT2 inhibitors (empagliflozin, canagliflozin)
Counsel a patient on Warfarin
Can I tell you a bit more about this medication? Warfarin or Coumadin (which is the brand name) is a blood thinner, or anticoagulant. This means it slows down your body’s ability to make blood clots/ helps dissolves the current clot we have going on right now. You will take the medication as indicated by the doctor/ on the bottle - Take warfarin at the same time every day. It is best to take it in the evening. If you happen to miss or skip a dose please take it as soon as you remember to do so- however, if it’s closer to the time of your next dose, skip that dose all together and just continue on with your next dose the next day - make sure not to double up.
While you’re on warfarin, you need to get your blood tested often. These blood tests are called INRs. They tell your provider how well the medicine is working. You must get blood tests the whole time you’re
taking warfarin. Your INR goal is 2-3. If your INR is too high, you have a higher chance of bleeding. If your INR is too low, you have a higher chance of getting a
blood clot. Diet can change how your INR looks, The best thing you can do is stay consistent in what you eat. This means you should eat your normal diet. Do not change your diet suddenly.
If you need to go to a dentist or if you’re getting a medical procedure, tell your doctor or dentist that you are on warfarin. Tell them when you are scheduling the appointment or the procedure so they know ahead of time. The doctors may need to hold your warfarin.
And just some side effects with the medication to me on the lookout for = bruising, you’re bleeding more than usual from a cut or wound, heavier period (if patient is a women), bleeding in your urine or stool. And if you have any of the more severe side effects like blood in your urine or stool (will look dark/ black tarry), if you are throwing up blood, or if you fall and hit your head or have any changes in your vision please call 911.
Please reach out if you have any questions, thank you so much! What questions do you have? ok I know we went over a lot of information, and I want to make sure we give you all of the most inportant information! So we’re gonna do a little quiz! How do you take warfarin?, what are some side effect to be on the look out for?
Written questions asking you to match the infectious organism with the antibiotic of choice.
KNOW BUG AND DRUG CHART
CAP Cases: drugs/ organisms/ coverage!
