clw 8 Flashcards
HF, hepatitis, liver cirrhosis, asthma, VTE (137 cards)
1
Q
name 3 differential causes of dyspnoea
A
- fluid overload secondary to hfref
- asthma
- pulmonary embolism
- pneumonia
- lung cancer
- MI
- ascites due to liver cirrhosis
2
Q
main sx of fluid overload secondary to HF
A
Orthopnoea - cannot breathe when lying down at night
3
Q
telltale sx of ascites due to liver cirrhosis causing dyspnoea
A
palmar erythema
jaundice, ascites
pruritis
spider angiomata
4
Q
lab results to look out for when liver has issues
A
elevated lft
coagulation tests (PT, aPTT, INR)
5
Q
asthma sx
A
wheezing (auscultation)
SOB
chest tightness
unable to talk in sentences
elevated pulse rate
6
Q
pulmonary embolism s/sx
A
d-dimer
unilateral pitting edema (dvt)
7
Q
ssx of pneumonia
A
fever
cxr lung consolidation
chest pain
8
Q
s/sx of MI
A
chest pains
elevated heart rate
palpitations
diaphoresis (excess sweat)
elevation in cardiac troponin
ST elevation? ECG abnormalities
9
Q
GOT for HF
A
resolve fluid overload (0.5kg weight loss/day)
optimise HF therapy to prevent complications and reduce mortality risk
improve exercise capacity
10
Q
when increasing furosemide for fluid overload episode, how much to increase?
A
double home dose or switch to IV (of same dose)
11
Q
BD dosing for diuretic should not be at night to_
A
prevent need for pt to wake up at night to pee
12
Q
always start with IV for episodes of fluid overload requiring hospitalisation at how much dose?
A
at same IV dose
13
Q
what do beta blockers do
A
decrease HR and cardiac output
14
Q
if patient is hemodynamically unstable, what to do with F4 agents
A
continue but maintain same dose
15
Q
when to hold off SGLT2i
A
before surgery, in acute illness. not for fluid overload
16
Q
what are the agents for HF
A
spironolactone
sglt28
arni/acei
bb
+
diuretic
17
Q
first line for ascites
A
spironolactone, furosemide
18
Q
when to hold use of bb
A
HR low
19
Q
non pharm of HF
A
lose weight
restrict Na (<2g/d) and water (800-1L)
remove K from veg
weigh daily to monitor for fluid issues
cardiac rehab program and exercise
20
Q
what to monitor for diuretic use
A
serum k, Na, Cr
genital infections
21
Q
uses of f4 agents
A
- relieve/reduce sx
- reduce need for admissions
- prolong survival
22
Q
GOT of ascites with liver cirrhosis
A
- managing sx and normalising liver abnormalities
- slowing down disease progression
- preventing complications of liver cirrhosis
23
Q
GOT of viral hep B
A
viral suppression
24
Q
GOT of hep C
A
viral eradication
25
what to do before treating hep b
screen for hiv
26
main side effect of concern for arni/acei
hypotension
27
bb for HF
bisoprolol, carvedilol (but not selective), metoprolol XL
28
how to manage portal htn
propranolol, nadolol, carvedilol
endoscopic variceal ligation (EVL)
29
nonpharm of ascites/cirrhosis
- drain out ascitic fluid
- abstain from alcohol
- salt restriction
- avoid nsaid, acei
*fluid restriction not necessary unless serum Na ≤125mmol/L
30
non pharm hepatitis b
- prevent disease transmission (household contacts shd b vaccinated)
- do not donate blood
- weight loss
- avoid alcohol and smoking
- inform healthcare providers of the condition
31
spironolactone se
gynaecomastia, hyperK
32
how to monitor asthma control
ACT questionnaire
33
why can’t use saba alone
increased risk of exacerbations and hospitalisation
downregulates beta receptors in lungs, reduce responsiveness, affect long term control
34
administration technique for ics-laba
use everyday even if well controlled
wash mouth after using to prevent oral thrush
35
non pharm for asthma / copd
- avoid triggers eg tobacco, allergens
- exercise/breathing exercises
- avoid use of nsaids, bb
- update vaccinations
- remediation of dampness or mould in homes
- dealing with emotional stress
- (copd) nutritional support
36
what is pulmonary rehab prog for copd
patient education, exercise trng, nutritional support, psychosocial support
37
vaccination in copd
pneumococcal: PCV13 and PPSV23
influenza
38
how to monitor asthma
symptoms of exacerbation, frequency of exacerbation and use of inhaler
39
what to always monitor fo HTN drugs
serum creatinine
40
benefit for sglt2i and loops used together
natriuresis effect - kidneys excrete sodium
41
how does liver cirrhosis affect drug distribution
decreased albumin pdtn. affects protein binding and amt of unbound drug
42
how does liver cirrhosis affect cyp enzyme
cyp expression reduced, decreased metabolism of drug, longer half life /elimination of drug
43
what is formula of hepatic extraction ratio
E = 1-F
44
what happens to drug when reduced hepatic blood flow
less drug brought to liver for metabolism, decreased clearance
45
high extraction ratio
>0.7
46
when drug has high extraction ratio, is it perfusion limited? is it sensitive to changes in perfusion or protein binding?
yes. perfusion
47
when drug has low extraction ratio, is it perfusion limited? is it sensitive to changes in perfusion or protein binding?
no, protein binding
48
in cirrhosis, for drugs of high extraction ratio, do you have to reduce initial/maintenance dose?
yes both. affected greatly by extent of metabolism of liver. first past effect evident
maximal plasma concentration and F is increased, elimination is slowed.
49
in cirrhosis, for drugs of low extraction ratio, do you have to reduce initial/maintenance dose?
only maintenance dose. only elimination is slowed
50
what do drugs in bile undergo (2 ways)
1) enterohepatic cycling -reabsorption
2) excreted via feces
51
characteristics of drugs secreted into bile
- polar
- MW > 350g/mol
52
main side effect of statins
hepatic enzymes elevation, myalgia
53
estrogen metabolism
liver
54
obesity: serum albumin?
same
55
obesity: liver blood flow
may increase
56
obesity: cyp3a4? (phase 1)
decrease
57
obesity: gastric emptying
increase
58
obesity: oral F
largely the same
59
renal clearance in obesity
increase then decrease
60
obesity: adipose tissue
increased
61
obesity: gut permeability
increase
62
what protein is increased in obesity
alpha one glycoprotein
63
obesity: cyp2e1 (phase I)
increased
64
phase 2 in obesity
increased glucuronidation and sulfation
65
alpha 1 glycoprotein binds more to acidic or basic drugs?
basic
66
albumin binds more to acidic or basic drugs?
acidic. albumin is basic
67
obesity: cardiac output?
increase
68
obesity related kidney problem
obesity-related glomerulopathy
69
when to use adjusted BW
aminoglycosides dosing. AG is hydrophilic with low Vd
70
dvt wells score? confirm dvt
at least 2 pts
71
if wells score less than 2? conduct d dimer. what does d dimer show?
negative: no dvt
positive: maybe dvt
72
DOACs under crcl_ cannot use
30, switch to enox or warfarin
73
GOT for DVT
prevent extension of embolisation of thrombus (ie escalation to PE)
relieve symptoms
prevent recurrence
74
when starting sglt2i for HF, what should be stopped
IV diuretic
75
which sglt2is are useful in hfref
dapa and empa
76
uses of sglt2i in hfref
- reduces hospitalisation due to new HF
- reduce onset of new HF for ppl with high CVS events
77
what is used as adjunct to bb?
ivabradine
78
how does ivabradine help in hf?
prolong survival, relieve symptoms, prevent admissions
79
if switching from acei to arni, wash out period how long
36h
80
when adding loop diuretics, watch out for what
K/RP (hypokalemia)
maybe give potassium chloride replacement
81
sglt2i watch out for what
euglycemic diabetic ketoacidosis, genitourinary tract infections
82
EDKA symptoms
malaise, vomiting, dyspnea, nausea
83
why do raasi agents cause hyperk
they retain potassium
84
counselling points for BB in HF
1. Some px could take 3-6 months before experiencing an improvement
2. There could be an initial worsening before improvement
3. It is important to measure body weight daily
85
target hr in hfref
below 70
86
when starting sglt2i must make sure SBP_?
>100
87
treatment for chronic hep c
Anti-HCV Nucleoside Agent (NA)- Ribavirin
88
side effects of chronic hep c tx
Haemolytic anaemia
Fatigue
Teratogenic
89
what are useful markers of liver disease
ALP, AST, ALT (GGT alone not useful)
90
features of viral hepatitis
fever, nausea, vomiting, pale stools, jaundice
91
what does liver cirrhosis result in
- portal htn
- varices
- decrease in albumin levels
- impedes portal blood flow
- hepatocellular carcinoma
- encephalopathy (disturbance to brain fx)
92
how does decreased albumin synthesis lead to ascites
changes in intravascular oncotic pressure
93
how does underfilling of circulation lead to ascites
combined with reduced aldosterone metabolism, leads to activation of RAA system
94
GOT of portal hypertension
prevention of bleeding
95
how does cirrhosis affect coagulation
Decreased synthesis of most procoagulant factors as well as naturally occurring
anticoagulants, antithrombin, protein C and S
96
nonalcoholic fatty liver disease risk factors
obesity, diabetes
97
why need to check ascitic fluid
spontaneous bacterial bacterial peritonitis (infection of ascitic fluid)
98
primary prophylaxis for who
- child pugh c small varices
- big varices
99
propranolol therapy goal
resting HR 55-60/min
sbp > 90mmhg
100
in patients with asthma, what is the issue of BB?
beta 2 found in lungs, blocking receptors can increase risk of bronchospasms
101
antibiotic prophylaxis for acute variceal bleed
ceftriaxone, norfloxacine
102
vasoactive agents in portal htn for ?
inhibit splanchnic vasodilation
eg. octreotide, vasopressin, SMT, telipressin
103
secondary prophylaxis of portal htn?
nsbb and chronic evl
104
GOT for hepatic encephalopathy
reduce ammonia blood concentration
105
non pharm for hepatic encephalopathy
diet: protein restriction
supplement with elemental zinc
106
pharm for hepatic enceph
lactulose: lower colonic pH, promotes conversion of ammonia to ammonium for excretion
rifaximin: targets anaerobic bacteria that produce urease which hydrolyzes urea to ammonia in gut
107
non-alcoholic fatty liver (NAFL) vs non-alcoholic steatohepatitis (NASH)
NAFL: no evidence of hepatocellular injury, minimal risk of progression to cirrhosis
NASH: inflammation and hepatocellular injury, may progress to cirrhosis and liver failure
108
GOT of asthma
- reduce need for reliever medication
- avoid troublesome symptoms esp at night
- avoid serious asthma flare-ups
- to achieve good control of
symptoms and maintain normal activity levels
109
benefits of addition of laba to ics
decreases nocturnal asthma, use of rapid-acting b2 agonist and number of exacerbations
110
diagnosing asthma
fev1/fvc is <0.7
111
what is fev1
volume of air exhaled forcefully in first second of maximal expiration
112
fvc
Maximum amount of air
that can be exhaled when
blowing out as fast as
possible, after full
inspiration
113
increase of fev1 after saba to show asthma?
≥12%
114
tcu of asthma
3-6 months after treatment changes; every 1-2 years if stable
115
host risk factors for asthma
Genetic predisposition
* Atopy
* Gender
* Obesity
116
environmental factors for asthma
Indoor allergens
* Outdoor allergens
* Occupational
sensitizers
* Tobacco smoke
* Air Pollution
* Respiratory Infections
* Socioeconomic
factors
* Diet
117
risk factor for exacerbation
* History of ≥1
exacerbations
in the previous
year
* Poor
adherence
* Incorrect
inhaler
technique
* high saba use
118
benefits of low dose ics (in asthma)
– Markedly reduces asthma deaths
– Reduces hospitalizations
and readmissions
– Prevents exacerbations
– Protects against long-term decline in lung function
119
benefit of ics in copd
improve lung fx and oxygenation
shorten length of hospital stay
decrease relapse and treatment failure rates
120
IC steroids monitor for what
osteoporosis, oral thrust, cough, adrenal suppression, HTN, diabetes
121
after an exacerbation, review within
1w
122
consider step down after good control maintained for
3 months
123
MOA of montelukast
- Interfere in the release of leukotriene mediators from mast cells,
eosinophils and basophils
- Reduce symptoms associated with the inflammatory allergic
component of asthma, including swelling of the airway and smooth
muscle constriction
124
adr of montelukast
Headache, nausea
Neuropsychiatric events
125
theophylline
induces SM relaxation via inhibition of phosphodiesterase 3, leading to bronchodilation
126
adr of theophylline
GI: nausea, vomiting
CNS: insomnia, headache, seizures
Cardiac: tachycardia, cardiac flutter
127
emphysema in copd
- Abnormal permanent
enlargement of the airspaces
distal to terminal bronchioles
- Accompanied by destruction
of their walls ± obvious
fibrosis
128
copd primarily due to
exposure to noxious particles or gases
129
risk factors of copd
tobacco smoking
air pollution
occupational exposures
female
age
130
copd clinical presentation
dyspnea, chronic cough, sputum production
wheezing, chest tightness, fatigue, weight loss, anorexia
age>40
131
copd symptoms use what scoring
mMRC or CAT
132
mMRC scale 0-4
0 - least sx; 4 - too breathless to leave house
133
CAT
scale of 0 to 40, >30 is high impact on life
134
GOT for COPD
relieve symptoms, improve exercise tolerance
prevent disease progression and mortality
135
uses of LABA and LAMA in copd
improve lung fx, dyspnea, health status, reduce exacerbation rates
136
long term steroid use can be associated with
risk of pneumonia and mortality
137
over use of abx in copd can lead to
spread of resistant organisms
