Exam #01 Flashcards
Put the following tasks in the proper order for providing patient-centered pharmacy care:
a. Develop a patient specific evidence-based pharmacy care plan and discuss with other health professionals if necessary.
b. collect information to identify an actual or potential medication therapy problem
c. set therapeutic goals
d. document plan in writing
e. collect additional data to monitor therapy in order to determine outcomes of care plan
b, c, a, d, e
As a pharmacist what is the first data that you want to review for a patient?
Medication list
This type of data is directly observed or measured?
objective data
This type of data represents information provided by the patient and or caregiver and cannot be directly observed or measured?
subjective data
What can excessive doses of Digoxin cause?
bradycardia
What component of Augmentin is a common allergy for many patients?
amoxicillin
What common side effect is seen with all ACE inhibitors?
dry cough
Is doxycycline an appropriate treatment to treat Lyme disease in a pregnant woman?
No, doxycycline is to teratogenic
What common side effect is seen in cold medication that contains phenylephrine?
increases BP
State the normal vital signs
HR 60-100 beats/min
Respiratory rate 12-18 respirations/min
BP 120/80 (systolic/diastolic)
Temperature 96.4-99.1F (35.8-37.3C)
State the BMI ranges for a normal, overweight, and obese patient
BMI
Normal 18-25
Overweight 25-29.9
Obese >=30
If you were dosing a medication based on ideal body weight, what weight would you use for a woman that weighs 105 lbs whose IBW is 110 lbs?
Actual body weight of 105 lbs
State the reference ranges for everything included in the BMP
Na 135 - 145 mEq/L K 3.5 - 5 mEq/L Cl 95 - 105 mEq/L CO2 22 - 28 mEq/L BUN 8 - 20 mg/dL Cr 0.6 - 1.2 mg/dL Glucose 70 - 100 mg/dL
What are 3 common causes of hyponatremia?
- abnormal sodium loss (usually from inadequate replacement)
- syndrom of inappropriate antidiuretic hormone (SIADH)
- hypervolemia (CHF) - edema in lower extremities
Name 2 common causes of hypernatremia?
- excessive sodium replacement
2. retention of sodium usually as a result of an endocrine problem i.e. hyperaldosteronism or Cushing’s Syndrome
Drugs that cause nephrogenic Diabetes Insipidus would have what effect on a patient’s sodium levels?
patient would become hypernatremic
Alkalosis would result in what potassium imbalance? Acidosis would result in what potassium imbalance?
alkalosis - hypokalemia
acidosis - hyperkalemia
True or False - renal dysfunction or renal failure is a common cause of hyperkalemia?
True
Why would a patient that experience blunt force trauma to the body (crush injury) be hyperkalemic?
excessive cell destruction releases K+ from the ICF to the ECF
What K+ imbalance can ACE inhibitors commonly cause?
hyperkalemia - ACE inhibitors stop angiotensin I –> angiotensin 2 which prevents the signal from getting to the adrenal gland and releasing aldosterone. Aldosterone causes, among other things, secretion of K+ so if this function is blocked, this would result in hyperkalemia
What does the total CO2 concentration in a BMP primarily reflect?
HCO3 (bicarbonate)
If a patient presents with a high CO2 in their BMP, is the patient acidotic or alkolotic?
Alkolotic when CO2 high (really HCO3)
Acidotic when CO2 low (really HCO3)
A diabetic patient is admitted in ketoacidosis and has the following BMP laboratory results: low sodium, normal potassium, high glucose, and low carbon dioxide. Explain why Na+ and CO2 levels are low. Why is K+ at normal level?
Na is low because of osmotic diuresis (lots of glucose in the blood makes the body urinate causing sodium and potassium loss)
CO2 (really HCO3) is low because patient is acidotic (ketoacidosis)
K+ at NL because of acidosis
What is the major reservoir for Ca+ in the body?
bones
What percent of calcium in the ECF is bound to plasma proteins? Which plasma protein does Ca primarily bind to?
40% bound to protein
albumin
What percent of Ca+ is unbound (ionized and active free Ca)?
45-55%
What is the reference range for total calcium?
What is the reference range for albumin?
Calcium 8.5 - 10.5 mg/dL
Albumin 3.5 - 5
When would you use the corrected calcium equation?
If a patient has a low Ca level AND a low albumin level, use the corrected calcium equation. If the patient only has low albumin and normal calcium levels, no need to use corrected calcium level equation, just need to correct albumin level
Name (5) common causes of hypocalcemia (3 drugs, 2 other)
- malabsorption of calcium (typically from a Vit D deficiency arising from dietary, renal dysfunction, or liver dysfunction)
- hypoparathyroidism
- Loop diuretics
- Calcitonin (promotes bone formation)
- Oral phosphorous
How does vitamin D play a role in calcium absorption and where does the liver and kidney fit into this equation?
The active form of vitamin D, calcitriol, enhances calcium absorption in the intestine. The liver converts cholecalciferol (Vit D3) into calcidiol, a vitamin D intermediate. The kidneys convert part of calcidiol into the biologically active form of vitamin D, calcitriol
Name (2) common causes of hypercalcemia and (2) medications that can cause hypercalcemia?
- malignancy (bone cancer invading bone, breaking it down and releasing Ca)
- hyperparathyroidism (more PTH released, acts to increase Ca concentration in blood)
- Thiazide diuretics
- Vitamin D toxicity (supplements)
True or False - renal failure is a common cause of hyperphosphatemia? Why or why not?
True because the kidneys are responsible for excreting phosphate
Name (1) common OTC medication that can cause hypophosphatemia? (1) that can cause hyperphosphatemia?
- Phosphate binding antacids can cause hypophosphatemia
2. Phosphate containing enemas can cause hyperphosphatemia
What are (2) common causes of hypomagnesemia?
- Dietary
2. Toxemia of pregnancy
True or False - It is possible to correct hypokalemia or hypocalcemia even if Mg levels are off?
False - Mg must be corrected and in normal range before any corrections to K or Ca can be made (because Mg involved in absorption of both)
Name (4) causes of hyperuricemia?
- Decreased renal excretion (from renal dysfunction or thiazide diuretics)
- Excessive production (chemotherapy, neoplasia - abnormal growth of cells)
- Gout
- Thiazide diuretics
What is the end product of protein metabolism?
uric acid
True or False - uric acid is excreted unchanged by the kidney?
True
Name (3) medications associated with hyperglycemia?
- Diuretics (mostly thiazides)
- Glucocorticoids (steroids)
- Estrogen and estrogen containing oral contraceptives
If a patient presented with HT and gout, would a thiazide diuretic be an appropriate medication to treat the HT?
No, thiazide diuretics can cause hyperuricemia and since this patient already has hyperuricemia (gout), this would exacerbate the problem
Name (5) common causes of hyperglycemia?
- DM
- Stress (extreme like being admitted to ICU)
- Pancreatitis
- Infections
- Pregnancy
Explain the criteria for diagnosing diabetes (include fasting plasma glucose, symptoms of hyperglycemia, random plasma glucose)?
Patient may have diabetes if…
- fasting plasma glucose is >126 mg/dL (fasting plasma glucose drawn at least 8 hrs after last meal)
- random plasma glucose >= 200 mg/dL AND symptoms of hyperglycemia
Symptoms of hyperglycemia are polyuria, polydipsia (excessive thirst), and unexplained weight loss
A patient with impaired fasting glucose (IFG) can be considered pre-diabetic. What is the reference range of glucose for a patient with IFG? Will this patient develop DM?
IFG 100 - 125 mg/dL
Patient may not develop DM, but they should be monitored. No drug therapy is required at this point
During the 120 day lifespan of RBC, glucose is irreversibly bound to hemoglobin in proporation to the average serum glucose. What test monitors this and what is the criteria for diagnosing DM?
Test - HbA1C (glycosylated hemoglobin)
DM >= 6.5%
(goal for DM patients is
What blood test would be given to assess acid/base balance (acidosis/alkalosis) and acute changes of pulmonary function (asthma, COPD)?
Arterial Blood Gas
What are the (4) components of the arterial blood gas? Which component is most important clinically?
- pH
- PaCO2 (most important clinically)
- PaO2
- HCO3
Pa = partial pressure
True or False - PaCO2 from ABG test is a true measure of CO2 (and not a measure of HCO3)?
True
Give the reference ranges for arterial blood gas components?
- pH 7.35 - 7.45
- Pa CO2 35 - 45 mm Hg
- Pa O2 90 - 100 mm Hg
- HCO3 22 - 26 mEq/L
What is the serum anion gap used for?
Use to identify the cause of metabolic acidosis in a patient
What is the serum anion gap equation?
What is the reference range for serum anion gap?
Na - (Cl + HCO3)
Normal 3 - 11 mEq/L
When identifying an acid/base abnormality using a patients ABG test, what components do you review first?
pH & CO2 - then review HCO3 levels and determine if any compensation is occuring
Which liver test measures substances synthesized or metabolized by the liver?
Liver function test
Which liver enzyme is present in both liver and heart tissue? When is this enzyme released?
AST (Aspartate Aminotransferase)
AST released after cell damage
Which liver enzyme is present in the liver and more specific for liver disease than AST? When would you see an increased concentration of this liver enzyme in a patient?
ALT (Alanine Aminotransferase)
Increased after acute injury
Which liver enzyme has the highest concentration in bone and biliary tract and physiologically increased in growing children and during the 3rd trimester of pregnancy?
ALP (Alkaline Phosphatase)
Which test reflects the enzymes released from hepatic cells as a result of cell damage?
Liver enzyme test
Which liver enzyme is a microsomal enzyme, is present in the liver, pancreas, and kidney and is elevated by drugs that induce microsomal enzymes like phenobarbital carbamazepine, and phenytoin?
GGT (Gamma-glutamyl Transferase)
Why would a liver enzyme test not be useful in properly assessing the status of liver disease in a patient?
Liver enzyme tests reflect the enzymes which are released as a result of cell damage. Once a patient’s liver is fibrotic, there are fewer cells left to be destroyed and fewer enzymes would be released. A patient’s liver enzyme test may even improve despite worsening liver function
What are (3) common causes of elevated ALP?
PRIMARILY RELATED TO BONE DISEASES
- Biliary tract disease (cholestasis - obstruction in biliary tract or metabolic (bile formation) - general stress on the liver
- Bone diseases (phosphorous stored in bone, bone diseases breakdown bone and release phosphorous, ALP is responsible for removing phosphate groups so more would be released in this case)
- Long-term use of phenytoin or phenobarbitol (due to effects on metabolism of vitamin D)
Which liver enzyme is a sensitive indicator of alcohol abuse and/or alcohol induced liver disease?
GGT (Gamma-glutamyl Transferase)
The concentration of this enzyme increases with alcohol consumption
Biliary obstruction and cholecystitis are associated with an increased concentration of which liver enzymes?
GGT (Gamma-glutamyl Transferase) and ALP
What type of bilirubin gets sent to the liver for metabolism? (Bilirubin is the breakdown product of heme from hemoglobin in RBCs)
Unconjugated bilirubin
If a patient’s liver function test indicates an elevated total bilirubin with elevated indirect bilirubin (unconjugated), what is the possible diagnosis?
- Patient may have excessive hemolysis of RBCs (possibly from a drug)
- Patient may have liver disease
If a patient’s liver function test indicates an elevated total bilirubin with elevated direct (conjugated) bilirubin (unconjugated), what is the possible diagnosis?
Cholestatic disease. Something must be wrong with the bile duct (obstruction) because the indirect bilirubin is getting to the liver to be metabolized, but cannot be secreted through the bile duct into the duodenum
What is another name for unconjugated bilirubin?
Indirect bilirubin
What is another name for conjugated bilirubin?
Direct bilirubin (bilirubin is metabolized in the liver to conjugated bilirubin)
Which bilirubin can be directly measured?
Conjugated (direct) bilirubin can be directly measured.
What comprises the total bilirubin?
Total bilirubin = direct + indirect bilirubin
True or False - both conjugated and unconjugated bilirubin may be elevated in hepatitis?
True
What comprises the total bilirubin? What is the NL?
Total bilirubin = direct + indirect bilirubin
NL 0.1 - 1.0 mg/dL
Name (5) common conditions associated with LOW albumin concentrations?
- Hepatic disease (liver dysfunction)
- Hemorrhage
- Malnutrition
- Burns (cell destruction)
- Nephrosis (renal protein wasting)
Why would albumin be an important parameter to monitor in a patient who is being treated with phenytoin?
Phenytoin is a highly protein bound drug and therefore its effects are dependent on the concentration of albumin. (low albumin levels = increased drug effect)
Assess liver enzyme and liver function tests for a patient with Hepatocellular Disease? ALT/AST GGT ALP Total Bilirubin Direct Bilirubin Indirect Bilirubin
Hepatocellular Disease
ALT/AST HIGH GGT NL ALP NL Total Bilirubin HIGH Direct Bilirubin NL Indirect Bilirubin HIGH
Assess liver enzyme and liver function tests for a patient with Cholestatic Disease? ALT/AST GGT ALP Total Bilirubin Direct Bilirubin Indirect Bilirubin
Cholestatic Disease
ALT/AST NL GGT HIGH ALP HIGH Total Bilirubin HIGH Direct Bilirubin HIGH Indirect Bilirubin NL
Assess liver enzyme and liver function tests for a patient with Hemolytic Disease? ALT/AST GGT ALP Total Bilirubin Direct Bilirubin Indirect Bilirubin
Hemolytic Disease
ALT/AST NL GGT NL ALP NL Total Bilirubin HIGH Direct Bilirubin NL Indirect Bilirubin HIGH
Assess liver enzyme and liver function tests for a patient with Bone Disease? ALT/AST GGT ALP Total Bilirubin Direct Bilirubin Indirect Bilirubin
Bone Disease
ALT/AST NL GGT NL ALP HIGH Total Bilirubin NL Direct Bilirubin NL Indirect Bilirubin NL
What is the average lifespan of a WBC?
1 - 2 days
Which WBC constitutes 40-70% of the WBC differential?
Neutrophils
What are bands? What % of Neutrophils do they represent?
Bands are immature neutrophils and they represent 3-5% of all neutrophils.
Explain “shift to the left”
A “shift to the left” indicates an increased percentage of bands (immature neutrophils) and is typically indicative of infection or inflammation
What is neutropenia? How is neutropenia expressed quantitatively?
An abnormally low number of neutrophils. The degree of neutropenia is expressed as the absolute neutrophil count (ANC)
Define neutropenia in terms of number of neutrophils?
Neutropenia < 2,000/mm^3
True or False - your risk of infection is considered low if you have > 1,000 neutrophils/mm^3
True
Which WBC constitutes 20-40% of the WBC differential?
Lymphocytes
What is an increase in lymphocyte percentage indicative of?
viral infections and lymphomas
Which WBC constitutes 0 - 8% of the WBC differential?
Eosinophils
Which WBC would you see an increase in during an allergic reaction or parasitic infestation?
Eosinophils
What is the main function of the kidney?
Maintain homeostasis by balancing electrolytes and fluid status using filtration, secretion, and reabsorption
Is filtration an active or passive process?
Passive, it does NOT require energy
Is secretion an active or passive process?
Active, requires energy
Is reabsorption an active or passive process?
Active, requires energy
In general, what diffuses across the glomerular capsule during the filtration process?
- Water
2. Small MW ions (<60 kdA)
In general, what diffuses across the glomerular capsule during the filtration process? Where does filtration process occur?
- Water
- Small MW ions (<60 kdA)
Filtration occurs at the proximal convoluted tubule
If large molecules such as proteins, RBCs, or glucose are found in the urine, what is this indicative of?
Kidney damage
What (5) components comprise the kidney nephron?
- glomerulus
- proximal tubule
- loop of Henle
- distal tubule
- collecting duct
Through what blood vessel is blood delivered to the glomerulus?
Afferent arteriole
What is the role of vasopressin at the collecting ducts?
In states of volume depletion, vasopressin is released from the posterior pituitary gland which triggers the body to hold onto water and produce an more concentrated urine
Define the equation for Rate of Excretion?
Rate of excretion = rate of filtration + rate of secretion - rate of reabsorption
What is the main job of the proximal convoluted tubule?
Reabsorption. Reabsorbs 90% of what’s filtered including H2O, glucose, aa, electrolytes
Which limb of the Loop of Henle impermeable to water?
ascending limb
Most drugs are small enough (<60kDa) to be freely filtered at the glomerulus. Give (2) exceptions.
- large proteins (albumin/RBC)
2. drugs bound to plasma proteins
Normal CO is ~5L/min. What % of CO is directed to the kidneys?
20-25% or about 1.2L/min
What is the normal GFR?
120 - 130 ml/min
How many liters of urine do the kidneys excrete per day?
1.5 L
What (5) components of urinalysis chemical composition are reviewed for detection of kidney disease? What physical composition is analyzed?
CHEMICAL
- pH
- Specific gravity (SG)
- Glucose
- Ketones
- Urobilinogen and bilirubin
PHYSICAL
protein or albumin
When reviewing a patient’s urinalysis, what is a normal pH of urine?
Normal pH of urine: 4.5-7.8
What results would you expect with SG of a urinalysis for a patient with DM?
You would expect the SG to be higher than normal since heavy molecules like glucose increase SG
When performing a urinalysis for detection of kidney disease, what does the detection of urobilinogen and bilirubin in the urine signify?
Liver disease - if liver’s function is impaired or when biliary drainage is blocked, some direct bilirubin leaks out of the hepatocytes and into the urine
What does the presence of epithelial cells in urine usually indicate?
contamination
Name (2) situations in which a false positive is given for a urinalysis?
- UTI - WBC in urine
2. Just ran a marathon - RBC in urine
Name the (3) labs used to detect kidney disease?
- Urinalysis
- BUN
- Scr
True or False - the Dip and read test component of a urinalysis can indicate the presence of protein and blood, and measure pH AND be used as a diagnostic?
False - the Dip and read test does measure presence of protein and blood and measures pH but CANNOT be used as a diagnostic (meaning you can’t determine if you have kidney disease just from this test)
What does a bright orange urine color indicate the presence of? What does a bright yellow urine color indicate the presence of?
Bright orange - supplements
Bright yellow - vitamin B
What would the effect of decreased blood flow to the kidneys (dehydration, bleeding, vomiting) have on BUN?
Urea follows water so in conditions of hypovolemia or decreased GFR the body holds on to water and BUN increases
Amino acids are metabolized to ammonia and are subsequently converted in the liver to form what?
Urea
Give an example of (2) endogenous substances that are not reabsorbed and instead concentrated in the urine?
- urea
2. creatinine
This marker of kidney function is a product of muscle breakdown and is directly dependent on muscle mass?
creatinine
True or False - with declining renal function comes declining filtration?
True
True or False - factors that affect BUN are solely related to kidney function?
False!
Why would using Scr as an absolute marker of kidney function in calculated equations, overestimate GFR by 10-20% in early stages of chronic kidney disease?
Only 80-90% of creatinine is eliminated by glomerular filtration. Therefore, 10-20% of creatinine isn’t being filtered at all (instead it’s being secreted into the lumen to be eliminated in urine) so using the Scr assumes the kidney is filtering 100% of creatinine, but in reality it’s only filtering 80-90%, overestimating GFR by 10-20%
This term is defined as the volume of plasma filtered across the glomerulus per unit time
Glomerular filtration rate (GFR)
What (2) filtration markers that are 100% filtered are the gold standard for measurement of GFR but not practical because of their extensive processes?
- inulin
2. iothalamate iohexol
True of False - Creatinine Clearance (CrCl) is a good estimate of GFR in stable subjects?
True - stable meaning steady, not necessarily normal
Cockcroft-Gault (CG) equation can overestimate renal function in two types of patients, what are they?
- Obese patients
2. patients with muscle wasting
When should you use ABW in the CG equation?
When BMI > 30 kg/m^2
What effect do the following factors have on Scr?
- Age
- Sex
- Diet (vegetarian, cooked meats)
- Body habitus (muscular, malnutrition, obesity)
- Medications
- Age decreases Scr (reduction in creatinine generation)
- Female gender decreases Scr
- Diet: vegetarian decreases Scr, cooked meats increases Scr
- Body Habitus: muscular increases Scr, Malnutrition decreases Scr, obesity has no effect on Scr (since excess mass is fat, not muscle)
- Medication increasesScr (reduced tubular secretion)
What class of drugs is indicated for early stage renal disease and can delay progression to end stage renal disease by decreasing proteinuria and preserve renal function?
ACE inhibitors
What does BUN measure?
BUN measures the amount of nitrogen that comes from the waste product, urea
24 hours urine collection may be required to estimate CrCl in which (6) conditions?
- extremes of age/body size
- malnutrition or obesity
- people who lost limbs (para/quad)
- vegetarian diet
- pregnancy
- rapidly changing kidney function
True or False - if a medication has a renal elimination of >30% than you would need to adjust the dose of the medication?
True
What is blood flow to the kidney determined by?
Cardiac output (CO)
True or False: >99% of the glomerular filtrate is reabsorbed back into the bloodstream?
True
When blood glucose is >180 glycosuria would be present. Why?
Because the reabsorption is saturated and excess glucose spills into urine
Ketones are a breakdown of what? Ketones are seen in patients in what three conditions?
fat
- DM
- anorexia
- dieting (Atkins)
Name (5) risk factors associated with Acute Kidney Injury (AKI)
- older age
- infection (sepsis)
- nephrotoxic medications
- dehydration
- overdiuresis
