Exam 2 Flashcards
Risk factors for hypertension
Age (>65)
Male
African American
Obesity
FHx
ETOH
Sedentary
Smoking
Stress
Diet
Secondary hypertension causes
Cushings
Coarctation of aorta
Pheochromocytoma
Hyperaldosteronism
Renovascular HTN
OSA
Description of “resistant” HTN
Uncontrolled HTN despite 3-drug max regimen
How to treat a patient with resistant HTN
Referral to a cardiologist and look at secondary causes
Differential diagnosis for HTN
OSA, Drug-induced, CKD, Thyroid/Parathyroid
What is the recommendation of when to start HTN medications according to JNCB
For most ages and co-morbidities: > 140/90
If >60years: >150/90
What is the preferred antihypertensive for Black people?
TTD or CCB
Examples of TTDs
HCTZ, Chlorthalidone
Examples of CCBs
Amlodipine
Felodipine
Diltiazem
Verapamil
Examples of ARBs
Losartan
Olmesartan
Valsartan
Examples of ACEIs
Lisinopril
Enalapril
When would you treat a black patient with an ACE or ARB?
If they have co-morbid CKD; this is true for all races
Diabetics should also be monitored closely for which disease?
HLD
Criteria for metabolic syndrome
Abdominal obesity
Elevated triglycerides
Low HDL
HTN
Elevated fasting glucose
Total cholesterol desired level
<200 mg/dL
Triglyceride level
<150 mg/dL
HDL level
W: >45
M: >40
LDL Level
<100
Non-modifiable RFs for CAD
Males
Increased age
FHx
African American
Define stable angina
angina that is typically triggered by exertion and relieved with rest
Define unstable angina
angina that persists even at rest
Define Variant angina
Also known as Prinzmetal’s; coronary artery spasm
Differential Dx for ACS
PE
AAA Dissection
Tension Pneumo
Cardiac tamponade
Esophageal rupture
GERD
Sx of acute MI
Substernal compression (pressure, tight, heavy)
Indigestion
Epigastric pain
Radiating pain
Dyspnea
N/V
Diaphoresis
S&S of Afib
Chest pain
JVD
Crackles
S3
Rapid HR
Dizziness
SOB
Lightheaded
Tx for heart failure
ACEI
ARB
Beta Blocker
Entresto (sacubitril & valsartan)
Diuretics
S&S of Stage 4 HF
Sx at rest:
Ankle edema
JVD
Crackles
S3
Hepatojugular reflux
Pleural effusion
Paraoxysmal nocturnal dyspnea
S&S of Stage 3 HF
Sx w/ moderate exertion:
Fatigue
Dyspnea on exertion
Pulmonary congestion on CXR
Cardiomegaly
DDx for syncope
Arrhythmia
PE
Vasovagal
CVA
Seizure
Rx factors for PAD
Smoking
Obesity
Sedentary
HTN
HLD
DM
Rx factors for PVD
Coagulation abnormalities
Abdomen/pelvic surgery
Estrogen/oral contraceptives
Pregnancy
Obesity
HF
Advanced cancer
S&S of PAD
Intermittent leg pain that increases w/ exertion
9 Ps: Pain, Pulselessness, Pallor, Paresthesia, Paralysis, Poikilothermia (cool)
Pharmacological treatment for PAD
ASA (antiplatelet)
If can’t tolerate ASA than clopidogrel (Plavix)
+ Statin
Dx for PAD
-Doppler ultrasound flow study which will estimate the ABI (Normal is > 0.9, < 0.5 = severe)
-Arteriogram if consult with vascular surgeon
Pt education for PAD
-Walk for 30 minutes at least 3-4 times/wk
-Ulcers/lesions need immediate care
-Avoid tight dressings/stockings
-Keep legs dependent to improve blood flow
What is the diagnostic test of choice for patients with DVT?
compression ultrasonography of the femoral and popliteal pulses (Do this immediately if Well’s score is moderate or high; if Well’s score is low, D-Dimer first)
What would a low risk Well’s score and negative D-Dimer indicate?
No DVT present
What is Virchow’s triad?
Describes Rx factors for DVT
Venuous Stasis
Vessel Injury
Hypercoagulability
Tx for Chronic venuous insufficiency
Light exercise
Compression stockings
Weight loss
Elevation of legs several times/day for 30+ minutes
Difference between PAD & PVD
PAD- Intermittent claudication, No edema, no pulse or decreased pulse, round smooth sores on toes and feed, black/eschar color or dusky color
PVD- Dull, achy pain, lower leg edema, pulse present, Sores with irregular borders on ankles, yellow slough or ruddy skin
S&S of PE
SOB, Tachypnea, Tachycardia, low fever, chest pain
Wells Probability scoring
High if > 6
Moderate if 2-6
Low if <2
Most likely pathogens for CAP
S. Pneumoniae
Pnuemococcal pneumonia
Staph aureus
Mycoplasma pneumonia
H. influenzae
Tx for CAP for patient w/o comorbidities
Azithromycin, Clarithromycin, or doxycycline
Tx for CAP for patient with comorbidities
Respiratory fluroquinolone (-floxacin) OR a beta lactam (PCN) WITH a macrolide (azithromycin)
Tx for CAP for patient with recent ABX
Respiratory fluoroquinolone OR macrolide + high dose amoxicillin/augmentin
CURB-65 scoring
0-1: Low risk, home treatment
2: Short inpatient or closely monitored outpatient
3-4: sever pneumonia; hospitalize, maybe ICU
What is CURB-65?
An easy to remember tool to determine severity of CAP
What does CURB-65 test?
C- Confusion
U- BUN (>19 is +)
R- Respiratory Rate (>30 is +)
B- BP (SBP <90, DBP 60 is +)
Age- >65 is +
F/U for patients with CAP
For outpatients: contact within 24-48 hours of treatment start, follow up visit 1 week after, and follow up 4-6 weeks after
CXR if symptoms not improving
Diagnostics for CAP
CXR
Gram stain of sputum
Leukocyte count
S&S of HLD
Carotid bruit
Corneal arcus
Yellowish skin deposits (also known as Xanthelasma (on eyelids)
Pharmacological Tx of HLD
Statins
Statin + CCB
Ezetimibe
Niacin
What is the single most important sign of OSA?
Hypersomnolence (uncontrollable sleepiness)
When should you test for OSA?
When hypersomnolence and snoring are both present and/or new diagnosis of hypertension
Diagnostic tools for OSA
-Subjective assessments of sleepiness including Stanford Sleepiness Score and Epworth Sleepiness Scale
-Sleep study- overnight polysonogram
DDx for OSA
Narcoloepsy, depression, Hypothyroidism, Seizure, drugs or alcohol use
Define mild persistent asthma
symptoms more than 2 days per week but not daily; PEF or FEV1 60-80% predicted; PFT variability = 20-30%
Define moderate persistent asthma
symptoms daily but not continual; nighttime sx more than once a week; PEF or FEV1 60-80% predicted; PFT variability >30%
Define severe persistent asthma
Continueous daily symptoms and frequent nighttime symptoms with activity limitations and frequent exacerbations; PEF or FEV1 <60% predicted; PFT variability >30%
How do you interpret PFTs?
Measure pre-bronchodilator and postbronchodilater function tests such as spirometer and diffusing capacity to determine the response; result is % change
What is FEV1 and what does it measure?
Forced expiratory volume in 1 second; reversibility is defined as 10% or greater increase in the FEV1 after two puffs of a short-acting beta-agonist
What often precedes an asthma attack?
infections
Tx for intermittent asthma
SABA PRN less than twice per week
Tx for mild persistent asthma
Low dose ICS, SABA PRN, not to exceed three to four times per day
Treatment for moderate persistent asthma
Daily low-dose ICS plus LABA; SABA PRN
Tx for severe persistent asthma
Medium-dose ICS plus LABA and SABA PRN 3-4 times daily; consider short course of systemic corticosteroids
Step-up from severe persistent asthma
High dose ICS plus LABA, SABA, short course systemic corticosteroids
Management of asthma
-Remove triggers
-Step up to the next step if control is not achieved
-Step down if controlled for 3 months
Patient education for asthma
-Basic facts
-How to use inhalers
-How to recognize early symptoms of attack
-Role of medications
-Avoidance measures for asthma triggers
-Importance of pneumococcal and annual influenza vaccines
-Stress proper use of medications and adherence to regiment
Stages of severity for COPD
Mild: FEV >80% predicted
Moderate: FEV1 50-80%
Severe: FEV1 30-50%
Very severe: FEV1 <30%
Tx for Very severe COPD
PDI4 inhibitor, roflumilast (Dalirespt) and azithromycine (Zithromax)
Tx for mild COPD
short acting or long acting bronchodilator
Tx for moderate COPD
a long-acting muscarinic antagonist (LAMA) or LAMA+LABA or LABA+ICS
What is the first line therapy for COPD?
SABA (Albuterol, proventil Ventolin)
What is the goal of therapy for COPD?
to prevent bronchospam with long-acting bronchodilators and to use a SABA as a rescue medication to alleviate acute episodes of bronchospasm
What are LABA medications used for?
for maintenance therapy to prevent acute bronchospastic episodes (not first line)
Examples of ICS
beclomethasone, budesonide (pulmicort), or fluticasone (Flovent)
Examples of comination medications used to treat COPD
Advair: salmeterol + fluticasone; Symbicort (formoterol plus budesonide)
When would a PDE4 inhibitor (roflumilast/daliresp) be indicated for COPD?
For patients with COPD and bronchitis who have exacerbations
When are xanthines (theophylline) used for the treatment of COPD?
as a fourth-line drug if other drugs fail to prove effective; they have a narrow therapeutic index and interact with many drugs
What could be caused by long term uncontrolled HTN?
Target organ damage: CVA, HF, Pulmonary edema, MI, Acute Renal failure
When should pharmacologic treatment be initiated in a patient with HTN and DMII?
140/90 or higher
Follow-up for HTN after starting therapy
One month: if target pressure still is not reached, increase dose or start a second medication
A patient with CKD and HTN should receive which medications?
ACE inhibitor or ARB initially or as add-on therapy
