GI disorders, Urinary Tract Disorders Flashcards
1
Q
constipation is a symptom rather than a disease
-functional
-structural
-hypothyroidism
-neurologic
-celiac disease
-medications
-pregnancy
A
-functional: low fiber diet, motility disorders, sedentary lifestyle, dehydration
-medications: laxative overuse, anticholinergics, opioids, iron supplements
-more common in elderly adults
2
Q
constipation is defined as less than ___ BMs per week
A
less than 3 BMS per week
3
Q
diagnostic tests/findings only indicated with “red flags” including:
A
- abdominal pain, N/V
- weight loss
- melena, rectal bleeding
- rectal pain
- fever
- new onset older than age 50
4
Q
treatment
-non pharm and pharm
A
non pharm: increase activity, increase fluids, high-fiber diet
pharm:
1. bulk-forming agents like psyllium husk- used to PREVENT constipation; do NOT use if signs of fecal impaction or obstruction; plan time for defecation
- stool softeners- docusate sodium (Colace)
-lowers surface tension, allows water to penetrate stool
-for patients with hard stools/straining - Osmotic laxatives- sorbitol, lactulose
- saline laxatives- magnesium hydroxide/milk of magnesia
-draw water into intestinal lumen; treats acute constipation - chloride channel activator- Lubiprostone
-GI motility enhancer
5
Q
diarrhea also a symptom rather than a disease
-more than ___ stools/day
-defined as (acute vs chronic)
A
loose, watery stools three or more times a day
acute: less than 1 to 2 weeks duration
chronic: more than 3 weeks
6
Q
T/F diagnostic tests/findings are not usually indicated for symptoms lasting less than 72 hours unless asx with bloody diarrhea or patient appears ill
A
true
BUT if persistent: stool eval, HIV testing, CBC, electrolytes, TSH (low in hyperthyroidism)
7
Q
pharm
a. antimotility agents
b. antisecretory agents
c. antibiotics
A
a. antimotility agents: loperamide (Imodium)
-safe in pregnancy
b. antisecretory agents bismuth subsalicylate (Pepto-Bismol)
-NOT rec in pregnancy
c. antibiotics
-only when pathogen is identifiable
8
Q
hemorrhoid symptoms
-internal
-external
-managements
A
-internal: painless, bright red bleeding with defecation
-external: protrude when straining, blue, shiny masses if thrombosed (refer immediately)
-MNGMT: sitz bath, witch hazel pads, topical anesthetic, avoid straining with stool softeners (Colace)
9
Q
Irritable bowel syndrome (IBS)
-abdominal pain
-changes associated with…
-subgroup identifications (constipation IBS, diarrhea IBS, mixed/alternating IBS)
A
chronic condition; recurrent abdominal pain or discomfort at least 3 days per month in previous 3 months
associated with two or more of the following
a. improvement with defecation
b. onset associated with change in stool frequency
c. onset associated with change in stool form
one or more of the following symptoms on at least 25% of occasions:
1. abnormal stool frequency- less than 3 times per week or more than 3 times per day
2. abnormal stool forms (lumpy/hard vs loose)
3. abnormal stool passage
4. bloating, feelings of abdominal distension
5. paassage of mucus
10
Q
T/F diagnostic tests for IBS is not indicated for patients younger than 50 years old who meet above criteria, have normal exam, or lack of symptoms
A
TRUE
-colonoscopy if patient > 50, weight loss, anemia, evidence of GI bleeding
11
Q
important education for patients with IBS
A
reassurance of benign nature of disease!!!
-decrease caffeine, alcohol, fatty foods, gas-forming foods
-increase fiber in diet
-stress management, relaxation techniques
-regular physical activity
-probiotics
12
Q
treatment of. IBS should be guided by patient’s symptoms
a. pain predominant
b. diarrhea predominant
c. constipation predominant
A
a. pain predominant
1. antispasmodic/anticholinergics:
2. tricyclic antidepressants
b. diarrhea predominant
1. Loperamide (Imodium), diphenoxyalate (Lomotil)
c. constipation predominant
1. fiber supplements: psyllium
2. osmotic laxative- lactulose, sorbitol
13
Q
IBS referral is required…
A
in those older than 50, weight loss, suggestive of GI bleeding
14
Q
Appendicits
-incidence
-symptoms
-physical findings: McBurneys, Psoas, Rovsing’s, obturator
A
-pain begins in epigastrum or periumbilical area then localizes to RLQ after several hours
-anorexia, N/V
-sense of constipation
-fever: 99-100
-tenderness localized to McBurney’s point (pain worsened and localized with cough)
-absent bowel sounds
-positive psoas sign: pain with flexion of hip against resistance or hyperextension
-positive Rovsing’s sign- RLQ pain elicited when LLQ is deeply palpated and pressure is released
-positive obturator sign: pain with passive internal rotation of flexed right hip/knee
Referral for immediate surgery
15
Q
what should be ruled out when appendicitis is suspected?
A
ectopic pregnancy! pregnancy test
16
Q
Peptic Ulcer Disease definition/etiology
A
-chronic mucosal ulcerative disorder involving the upper GI tract; too much acid and pepsin production for gastric and duodenal mucosa to protect itself
-H. pylori is established causative factor
-NSAID-related ulcers are more likely to be GASTRIC
17
Q
symptoms of PUD
-how long after eating?
A
-burning or deep epigastric pain that occurs 1 to 3 hours after meals; relieved by ingestion of food or antacids
-pain commonly causes early-morning waking
-cluster of symptoms lasting a few weeks followed by symptom-free periods
GASTRIC: food may make it worse
18
Q
diagnostic test includes serologic testing for H pylori
A
- serologic test: ELISA detects IgG antibodies; indicates current or past infection
- stool antigen test- reverts to negative within 5 days
- urea breath test- detects active infection
19
Q
PUD management
-non pharm
A
-avoid ASA and NSAIDs
-smoking cessation
-decrease alcohol intake
-use stress management
NO FUN!!!
20
Q
PUD pharm management
1. when disease is NOT due to H. pylori
- ulcers caused by H. pylori
A
- NOT h pylori:
-Histamine 2 Receptor Antagonists- Ranitidine (Zantac)
-PPI: omeprazole (Prilosec)
^^both can alter absorption of other drugs - ulcers caused by H. pylori
-PPI triple therapy: PPI, amoxicillin, clarithromycin
-Bismuth quadruple therapy: bismuth subsalicylate, metronidazole, tetracycline, PPI
21
Q
Viral hepatitis defintions
A
group of systemic infections involving the liver with common clinical manifestations caused by different viruses with distinctive patterns
22
Q
- Hepatitis A virus (HAV)
-spread via
A
a. oral-fecal route by person to person contact or eating/drinking contaminated food or water; spreads readily in households and daycare
b. self-limited; no carrier state or chronic-liver disease2.
23
Q
- Hepatitis B Virus (HBV)
-spread via
A
a. transmitted via percutaneous or mucosal contact with infectious blood or body fluids (saliva, vaginal secretions, semen) by parenteral, sexual, PERINATAL exposure
b. spectrum of illness: asymptomatic to acute illness
c. 10% of people infected as adults and 90% infected as neonates become chronic carriers
24
Q
- Hepatitis C Virus (HCV)
-spread vis
A
-IVDU, infected blood through transfusion prior to 1992, much less frequently through sex, occupational, perinatal exposure
-acute disease often mild in adults; asymptomatic in chilren
-80% of infected individuals develop chronic hepatitis, with 20-30% eventually developing cirrhosis
25
4. Hepatitis D Virus (HCD)
-which other hepatitis is needed for this to replicate?
-needs HBV to replicate
-also spread via percutaneous or mucosal exposure to infectious blood as a co-infection with HBV
-suspect superinfection with HDV in patient who presents with fulminant hepatitis and chronic HBV
26
5. hepatitis E virus
-spread via
oral fecal route!! just like hep A
-endemic in developing countries
-more common in children and young adults
27
symptoms- all viral types produce very similar syndromes; severity can vary
1. phase 1- incubation
2. phase 2- pre-icteric (prodromal)
3. phase 3- icteric
4. phase 4- convalescence
1. phase 1- incubation
-asymptomatic lasting weeks to months
2. phase 2- pre-icteric (prodromal)
-three to 10 days in length
-malaise, fatigue, anorexia, nausea, vomiting, skin rash, flulike aches, headache, skin rash, change in sense of smell or taste; aversion to cigarettes
3. phase 3- icteric
-one to four weeks in length
-RUQ pain, dark-colored urine, clay-colored stools
-jaundice of skin, sclera, nail beds
4. phase 4- convalescence
-may last weeks to months
-chronic disease may develop in certain types
-Hep B, C, D may be fatal; HEV has 10-20% mortality rate in pregnant women
28
physical findings in in hepatitis
-what organs are affected?
1. rash- maculopapular and urticarial lesion
2. low grade fever
3. slight jaundice, yellow sclera
4. hepatomegaly
5. splenomegaly
29
diagnostic tests for hepatitis include (3)
1. viral serologies
2. urinalysis- + for protein, bilirubin
3. LFTS with marked elevations
30
HAV igM antibody vs IgG antibody
IgM: positive, current or recent infection, resolves in 6 months
IgG: positive; indicates immunity due to prior infection or vaccination
31
HBV
-surface antigen (HBsAg)
-surface antibody (anti-HBs)
-HBV core antibody (anti-HBc)
-HBV core IgM antibody
-HBV e antigen
-HBV DNA
-HBV surface antigen (HBsAg): positive; acute and chronic infection, indicates person is INFECTIOUS
-HBV surface antibody: positive; immune due to prior infection or vaccination
-HBV core antibody (anti-HBs): positive; acute and chronic infection, persists for life
-HBV core IgM antibody (IgM anti-HBV): positive; acute infection; resolves in 4-6 months
-HBV e antigen: positive; acute infection, highly INFECTIOUS
-HBV DNA: positive; acute and chronic infection
32
HCV antibody (anti-HCV)
HCV RNA
HCV antibody (anti-HCV): positive; current or resolved infection, persists for life
HCV RNA: positive confirms current infections, persists with chronic infection
33
HDV antibody
HDV IgM antibody
HDV antibody: positive with positive HBV surface antigen, current or past HBV/HDV coinfection or superinfection
HDV IgM antibody: positive; positive HBV surface antigen, current or past HBV/HDV coinfection or superinfection; negative: resolved HDV infection
34
non pharm management/patient education regarding hepatitis
a. activity as tolerated; avoid strenuous activity or contact sports
b. hydration
c. maintain adequate caloric intake and balanced diet
d. d/c all meds but essential
e. avoid alcohol (obvi)
-careful disposal of infected waste, SCRUPULOUS hand-washing and food handling, safer sex practices, avoid blood contamination (DO NOT SHARE toothbrushes, razors, needles)
35
hepatitis prevention
a. hep A
b. hep B
1. HAV
-immune globulin rec for travelers going to countries for longer than 6 months where HAVs endemic
2. HBV
-hep b immune globulin: give as prophylaxis to infants born to HBsAg positive women; give within 14 days of sexual exposure
36
cholecystitis definition and etiology
acute or chronic distention and inflammation of gallbladder, commonly r/t obstruction of cystic or bile ducts by gallstones (cholesterol, mostly) --> results in inflammation
37
risk factors for cholecystitis (5)
-female gender
-advanced age
-obesity
-pregnancy
-rapid weight loss
38
symptoms of cholecystitis
-RUQ epigastrium pain that is severe, steady, localized
-more common at night
-pain typically sudden and may last 3 hours; may be accompanied by N/V
39
acute cholecystitis
-physical findings: Murphy's sign
1. fever
2. Murphy's sign: inspiratory arrest secondary to pain during deep palpation of right subcostal region
40
what diagnostic technique can we use for acute cholecystitis that has a 95% sensitivity?
-labs
ultrasound!!!
95% sensitivity for detecting stones in the gallbladder
labs: r/o pregnancy, CBC with left shift, LFTS elevated serum bili, pancreatic enzymes: increased amylase and lipase
41
T/F elective cholecystectomy is recommended for most patients with symptomatic gallstones
true
42
GERD
-repeated movement of gastric contents from the stomach into the esophagus
-when esophagus is repeatedly exposed to refluxed material for prolonged periods of time, inflammation of esophagus can occur
43
diagnostic evaluation if symptoms are chronic or refractory to therapy or if esophageal complications are suspected....
a. endoscopy: useful for diagnosis of esophagitis, stricture, Barrett's esophagus; indicated with: dysphagia, unplanned weight loss, evidence of GI bleeding or iron deficiency anemia, screen for Barretts if 10 years or more of GERD symptoms
44
management of GERD
-non pharm
-pharm
NON PHARM
-weight loss if obese
-smoking cessation
-elevate HOV
-avoid recumbency 3 hours after eating if symptoms worsen when supine
-reduce fat to no more than 30% of calories
-reduce consumption of alcohol, chocolate, colas, coffee, peppermint, citrus juice, tomato products
PHARM
-commercially available antacids are useful for mild, infrequent
-h2 receptor antagonists
-PPIS (acid suppressant): most effective agents for healing esophagitis and preventing complications
45
Lower Urinary Tract infections
1. cystitis
2. urethritis
1. cystitis: infection of the bladder
-usually caused by ascending infection; 50% of women will develop cystitis in their lifetime
2. urethritis: infection or inflammation of distal urethra
-asx with chalmydia, gonorrhea
46
acute cystitis symptoms
-abrupt onset
-dysuria
-frequent urination
-urgent urination
-suprapubic pain
-cloudy, malodorous urine
47
diagnostic tests/findings for cystitis include...
-colony count criteria
urine culture and sensitivity: clean catch-midstream
10^5 is traditional criteria but in symptomatic patients can use 10^3 or 10^4
48
uncomplicated cystitis treatment for non pregnant individuals
1. trimethoprim-sulfamethoxazole (TMP/SMX) orally for 3 days (160/800 mg tablet BID x 3 days)
2. nitrofurantoin orally for 5 days (Macrobid 100 mg BID 5 days)
49
recurrent UTI: at least two culture-proven symptomatic uncomplicated acute cystitis episodes in 6 month period or 3 episodes within 1 year in which symptom resolution occurred between culture proven events
-management
a. retest and retreat- culture confirmation is important
b. use same medications as for uncomplicated cystitis up to 7 days
c. consider 6-12 month prophylaxis regimen if two infections in past 6 months/3 in 1 year: TMP/SMX, nitrofurantoin, cephalexin. 3x/week or weekly
d. if related to coitus, consider single dose regiment after sex: TMP/SMX, nitrofurantoin
50
what should be considered apart of management in postmenopausal women with vaginal atrophy and cystitis?
vaginal estrogen!
vaginal atrophy increases risk for UTI
51
acute pyelonephritis
-definition
-risk factors
infection of renal pelvis and kidney
risk factors: frequent sexual intercourse, cystitis in last 12 months, stress incontinence
52
symptoms of pyelnoephritis
-fever
-chills
-dysuria
-frequent urination
-urgency
-n/V
FLANK or abdominal pain
-hematuria (gross)
physical: unilateral or bilateral costovertebral angle tenderness, fever
53
treatment of pyelonephritis
1. oral fluroquinolone: 7 day regimen
2. test of cure with urine culture
3. hospitalize if severe illness, pregnancy, immunocompromised, no improvement within 48 to 72 hours
54
Urolithiasis aka..
renal or ureteral stones/calculi that can cause urinary tract obstruction
may be r/t gout, chronic UTI
55
how do we diagnose urolithiasis?
non-contrast CT scan is gold standard for dgx
56
urinary incontinence
1. stress
2. urge
3. mixed
4. overactive bladder
1. stress: leakage during increased abdominal pressure, sneezing, coughing, exercise
-r/t pelvic floor support
2. urge: precedes urgency to pee; difficulty controlling once flow begins
3. mixed: combination of stress and urge
4. overactive bladder: sense of urgency with or without incontinence
57
management of incontinence
-rule out any identified transient causes for incontinence- DIAP-PERS
Delirium
infection
atrophic vaginitis
pharm/medications
Psychological
Excessive urine output (hyperglycemia)
Retention
Stool impaction
58
interstitial cystitis (IC)/Painful bladder syndrome
-diagnostic test
unpleasant sensation (pain, pressure, discomfort) perceived to be r/t urinary bladder; greater than 6 week duration, absence of infection
-frequency/volume diary
-urinalysis
-postvoid residual
TX: avoid foods that trigger symptoms, PT, bladder retraining
59
pharm interventions for IC/painful bladder
-oral medications
1. pentosane polysulfate sodium (elmiron)
-FDA approved, may take up to 6 months to show effects
2. histamine blockers
c. tricyclic antidepressants
60
Anemias :)
definition of anemia is a hemoglobin...
(men vs women)
Hgb < 12 in women, < 13 in men
61
anemia classification
1. microcytic anemia
2. macrocytic anemia
3. normocytic anemia
1. microcytic anemia (MCV < 80): iron deficiency anemia, thalassemia trait
2. macrocytic anemia (MCV > 100): vitamin B12 deficiency, folate deficiency, liver disease, hypothyroidism
3. normocytic anemia (MCV 80-100)
62
a. iron deficiency anemia
-characteristics
-sxs
microcytic, hypochomic
-slow, persistent blood loss
-inadequate dietary intake of iron-rich foods
-pregnancy
*most common
SX: asymptomatic unless severe, fatigue, dyspnea on exertion, HA
PHYSICAL: spoon shaped/brittle nails, tachycardia
63
b. anemia of chronic disease
-CBC results
-SX
-normochromic, normocytic
-hypo proliferation anemia asx with underlying chronic disorders such as infections, inflammatory disorders
-decreased RBC lifespan
SX: fatigue, weakness, exertional dyspnea
64
c. vitamin B12 deficiency anemia
-CBC results
-SX, onset?
-macrocytic, megaloblastic, normochromic
-vitamin B12 deficiency alters DNA synthesis of RBCs
-develops s/t lack of intrinsic factor
-SX: none at first, then insidious onset
-dyspnea, fatigue, palpitations, GI disturbances (anorexia, bloating, diarrhea), sore tongue, loss of taste and smell, neuro: peripheral paresthesia, ataxia
PHYSICAL: smooth, beefy-red tongue, pale skin
65
d. folate-deficiency anemia
megaloblastic, macrocytic, normochromic (same as vitamin B12 deficiency)
-increased demand in pregnancy, malabsorption syndromes, inadequate intake (alcoholics, elderly)
-sx are similar to vitamin B12 minute neurologic
PHYSICAL: pallor, brittle nails, tachycardia
66
e. sickle cell anemia
-characterized by...
SX
-characterized by sickle-shaped RBCs
-an autosomal recessive genetic disorder
SX: vaso-occlusive crisis: malaise, chills, pain (esp. in bones, abdomen, chest), headaches, difficulty walking
(often precipitated by infection, stress, blood loss, pregnancy)
67
what is the single most useful test for diagnosing iron deficiency anemia?
-how do we treat IDA
ferritin levels (<10)
TX:
non pharm: increase iron in diet, check Hgb 3-4 weeks after initiating treatment; monitor q 3 months until stable
pharm: ferrous sulfate (can d/c when serum ferritin > 50)
-take iron with meals to alleviate GI distress; take with orange juice or vitamin C to improve absorption
68
vitamin b12
-cbc findings
-TX (pharm)
-megaloblastic, macrocytic (MCV > 100)
-RBCs of varying size and shape
-serum methylmalonic acid and homocysteine levels elevated
TX:
a. vitamin B12/cyanocobalamin: IM dose daily for 1 week, then weekly until Hct is normal, then monthly for life
69
sickle cells
-CBC findings
TX
-Hgb 7-9; Hct 20-30%
-mild leukocytosis (12,000-15000)
-irreversibly sickled cells on peripheral smear
TX
-maintained continuously on folic acid supplementation
during crisis: hydration and adequate oxygenation, analgesics for pain control
Education:
70
Folate deficiency anemia TX
-nonpharm
-pharm
nonpharm: increased dietary sources of folic acid: legumes, leafy greens, fruits
pharm: folic acid
71
stages of HIV infection
a. acute HIV infection/seroconversion
b. clinical latency
c. AIDS
a. acute HIV infection/seroconversion: 6-12 weeks but can take up to 6 months; highly contagious
SX: flu like 2-4 weeks after inoculation, fever, diarrhea, oral lesions on palate, muscle/joint pain, rash lasting 2-4 weeks- but is self limited
b. clinical latency: HIV remains active but reproduces at very low levels; without antiviral therapy: last up to decade or more and remain contagious; with antiviral therapy: may remain in this stage for several decades with undetectable viral load and low risk for transmitting disease; SX: viral load goes up and CD4 cells go down; may begin to have: fever, night sweats, anorexia, weight loss, fatigue
c. AIDS: CD4 cell count less than 200, opportunistic infections
72
HIV transmission includes
sexual contact, sharing needles, blood transfusions, babies born to HIV infected mothers
73
initial laboratory tests for women with established HIV infection
1. quantitative plasma HIV RNA
2. CD4 count
-others?
1. quantitative plasma HIV RNA: useful for predicting progression of disease by indicating viral load
2. CD4 count: indicative of immune status; normal is 800 to 1050
other: CBC, serology for hep A, B, C, CMP (creatinine, BUN, urinalysis) , TB test if indicated, serology for CMB, syphilis, varicella
74
pharm therapy for HIV infection
a. antiretroviral therapy for HIV suppression
1. highly active antiretroviral therapy (HARRT): combining three or four drugs is the standard of care for tx of HIV infection to minimize development of drug resistance
2. goal is to reduce HIV RNA to undetectable levels (< 500 copies/mL)
75
b. antiretroviral drug classes:
1. nucleoside reverse transcriptase inhibitors (NRTIs)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTIS)
3. protease inhibitors
4. integrase stand transfer inhibitors
5. chemokine receptor antagonists
NRTIS; stall virus replication by providing a faulty version of building blocks needed for HIV to make copies of itself
76
HIV patient education
-immunization
-lifestyle modifications
-safer sexual practices
1. maintain immunizations
-hep B and A
-pneumococcal vaccine (repeat in 5 years)
-influenza annually
-tdap, booster every 10 years
-HPV vaccin
-Live vaccine contraindicated if CD4 count < 200
2. stop tobacco, alcohol
3. nutritious diet
4. adherence to medication
77
PrEP: preexposure prophylaxis for HIV
-what is it
-who is it available to?
-pregnancy considerations
-combo of two antiretrovirals: tenofovir and Truvada taken once daily
-reduces transmission by 92%
-available to HIV negative but increased risk of exposure to HIV
-OK to take in pregnancy
NOTE: must take consistently to be effective, takes 20 days of taking it to be effective; follow up every 3 months
78
Systemic lupus erythematosus (SLE)
definition and etiology
chronic, inflammatory, multisystem disorder of the immune system characterized by period of remission and exacerbation; course of disease unpredictable and highly variable
-etiology: autoimmune (abnormal immune response creates antibodies to normal tissue)
79
criteria for diagnosis of SLE
four of the following eleven criteria to diagnosis:
1. malar rash ("butterfly" rash)
2. discoid rash
3. photosensitivity
4. oral ulcers
5. arthritis involving two or more peripheral joints
6. serositis- pleuritis, pericarditis, or peritonitis
7. renal disorder involving proteinuria
8. nerologic disorder involving seizures or psychoses
9. hematologic disorders- hemolytic anemia, leukopenia, thrombocytopenia
10. positive antinuclear antibody (ANA) test
11. positive other immunologic test- anti double stranded DNA (anti-dsDNA), anti-Smith, LE cell prep
80
symptoms/physical findings of SLE
-fever, fatigue, arthralgia, photosensitivity, HA, seizures
-malar rash, discoid rash, alopecia, mucosal ulcers, pericarditis
81
diagnostic tests/findings
1. ANA
2. Anti-dsDNA
3. CBC
-others?
1. ANA positive in 95% of cases
2. anti-dsDNA, anti-Sm, LE cell prep, false-positive VDRL test
3. CBC- anemia, thrombocytopenia
4. serum creatinine to assess kidney function
5. urinalysis (proteinuria)
6. antiphospholipid antibodies (30-50% + in SLE)
82
non pharm and pharm management of SLE
-patient education
1. nonpharm: moderate physical activity, adequate rest to avoid fatigue, protection from direct sunlight, proper diet (vitamin d and calcium)
2. pharm:
-treatment is symptomatic
-NSAIDS: fever, joint pain
-tropical corticosteroids: low dose for skin lesions
HYDROXYCHLOROQUINE (Plaquenil): may help treat lupus rashes and joint symptoms; may decrease flares (can be continued at lowest dose in pregnancy)
83
contraception in women with SLE
-category 3
-category 4
-LARC options are typically first line: IUD, Nexplanon
-COC's: are category 4
-POP's alternative for women with SLE that cannot have estrogen
84
when are pregnancy outcomes the best for moms with SLE?
when mother has been in remission for at least 6 months prior to pregnancy and has NORMAL RENAL function
85
women with SLE in pregnancy are at an increased risk for...
premature delivery, spontaneous abortion, IU fetal death, IUGR, gHTN, VTE, pp hemorrhage
-exacerbation of symptoms may also occur in pregnancy
86
SLE patient education
-avoidance of surgery, dental procedures when symptoms present
-live vaccines not advisable
-vitamin D supplementation
87
Rheumatoid arthritis
-definition
chronic multisystem disease characterized by SYMMETRICAL joint inflammation, loss of normal synovial joint anatomy and mobility, pain
88
RA criteria
-6/10 needed in four categories:
1. joint involvement
2. serology
3. acute-phase reactant
4. duration of symptoms
1. joint involvement: score 0-5 depends on number and size of joints with clinical synovitis (stiffness, swelling)
2. serology: score 0-3 dependent on -, +, and level of rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA)
3. acute-phase reactant: score 0-1 depends on normal/abnormal C-reactive protein (CRP) and/or erythrocytes sedimentation rate (ESR)
4. duration of symptoms- score 0-1, with 1 point if has had symptoms for 6 or more weeks
89
suspected etiology of RA includes... (3)
1. autoimmune
2. genetic predisposition
3. environmental factors may act as triggers
90
symptoms of RA
SYMMETRICAL JOINT INVOLVEMENT
1. morning stiffness in joints lasting > 1 hour
2. joint pain, constant or recurring; insidious development over weeks to months
3. joint warmth and redness; functional impairment
4. fatigue, weakness, anorexia, low grade fever, malaise
PHYSICAL FINDINGS
-soft tissue swelling in metacrapophalangeal (MCP) and proximal interphalangeal (PIP) joints; usually symmetric
-limited ROM in affected joint
91
diagnostic tests/findings
1. RF
2. Anti-citrullinated protein antibody
3. erythrocyte sedimentation rate
4. radiography
1. RF: + in 70-80% of patients with RA, but not specific to RA
2. Anti-citrullinated protein antibody: higher specificity than RF; present in 40% of people with negative RF
3. erythrocyte sedimentation rate: may be elevated
4. radiography: joint erosion, narrowing of joint space
92
Pharm management of RA
-DMARS
a. Disease-modifying anti-rheumatic drugs (nonbiologic): METHOTREXATE
-slow disease progression but no analgesic effect
-CI during pregnancy
b. DMARS- biologic: Infliximab (Remicade)
c. NSAIDs: use for short-term therapy until DMARDs take effect
93
Diabetes
type 1
type 2
type 1: absolute insulin deficiency
type 2: combination of resistance to insulin action and inadequate compensatory insulin response
94
T/F diabetes can also be caused by metabolic syndrome
true! metabolic syndrome is. group of metabolic components that can lead to CVD: abdominal obesity, insulin resistance, elevated triglycerides and low HDL, HTN, pro-inflammatory state
95
complications of diabetes
a. macrovascular
b. microvascular
MACRO: CAD, MI, peripheral vascular disease, intestinal ischemia
MICRO: retinopathy, nephropathy, peripheral neuropathy (paresthesia), autonomic neuropathy (gastroparesis and sexual dysfunction)
96
T/F there is a three to fourfold increase in prevalence of depression in patients with diaebtes
TRUE
doesn't matter which type
97
type 1 etiology
autoimmune destruction of pancreatic beta cells that produce insulin
98
type 2 etiology
impaired insulin secretion, peripheral insulin resistance, and increased hepatic glucose production
typically in >45, overweight, sedentary, family hx
native American, Hispanics, AA at risk
99
GDM etiology
function of hormonal/metabolic demands of pregnancy
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symptoms of diabetes
"classic symptoms"- the three P's
polyuria, polydipsia, polyphagia
weight loss, fatigue and or weakness, persistent vaginal candidiasis, vision changes, type 2 often asymptomatic in early stage
physical findings
type 1: thin, decreased weight
type 2: overweight, obese, HTN
advanced disease: slow healing skin infections/ulcerations, retinopathy, glaucoma, diminished peripheral pulses
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CRITERIA DGX OF DIABETES TYPE 1 OR 2
-four ways: FPG, OGTT, HgbA1c, random plasma glucose
1. fasting plasma glucose: 126 or greater; fasting defined as no caloric intake for at least 8 hours
2. OGTT- value of 200 or greater in the 2 hour sample; using 75g glucose test
3. Hemoglobin A1c > 6.5%
4. Random plasma glucose: 200 or greater with classic symptoms of hyperglycemia
MUST BE CONFIRMED ON SUBSEQUENT DAY- unless patient also has classic symptoms of hyperglycemia
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criteria for diagnosis of prediabetes
-IFG
-IGT
-HbA1c
-IFG: fasting plasma glucose between 100-125
-IGT: results of oral glucose tolerance test of 144-199 in 2 hour sample
-HbA1c: 5.7%-6.4%
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criteria for screening asymptomatic adults
-age
-other factors?
-anyone older than 45 years old at 3 year intervals
-earlier in adults who are overweight or obese with one or more additional risk factor: physical inactivity, family hx diabetes, high risk ethnic population, infant > 9 lbs, HTN, HDL cholesterol of 35 or less, triglycerides 250 or more, CVD, HbA1c 5.7% or >, PCOS
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nonpharm management of diabetes
-annual screenings
-vaccinations
-diet
-aerobic exercise
-smoking cessation
-refer T2DM at time of dgx, T1 within 3-5 years for eye exam; annually thereafter
-comprehensive foot exam, including Semmes-Weinstein monofilament, tuning fork
-annual influenza; pneumococcal vaccine
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recommended blood glucose, blood pressure, and lipid goals for most adults with diabetes
-HbA1c
-preprandial plasma glucose
-peak postprandial plasma glucose (1-2 hours after meal)
-blood pressure
-lipids
-HbA1c: <7%
-preprandial plasma glucose: 80-130
-peak postprandial plasma glucose (1-2 hours after meal): < 180
-blood pressure: < 140/90 (10 year risk for ASCVD less than 15%); < 130/80 (10 year risk for ASCVD less greater than 15%)
-lipids: LDL-C less than 100
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pharm
-insulin (Type 1 DM, may be combined with oral medications for T2DM if needed)
INSULIN
1. rapid active: aspart (NovoLog), lispro (Humalog): onset in 10-30 minutes, peaks in 30-3 hours, last 3-5 hours
2. short acting: regular (Humulin R): onset in 30-60 minutes, peaks in 1-5 hours, lasts 6-8 hours
3. intermediate acting: NPH: onset 1-2 hour, peaks in 4-12 hours, lasts 14-24 hours,
4. long acting: determir, glargine: onset 1-2 hours, peak: constant (no peak), duration: 24 hours
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pharm
-oral agents (type 2 diabetes):
1. biguanides (metformin)
2. sulfonylureas (glipizide, glyburide)
3. Dipeptidyle peptidase-4 inhibitors (sitagliptin)
4. glucagon-like peptide 1 (GLP-1) receptor agonists/incretin mimetic (exenatide, liraglutide)
5. alpha-glucosiddase inhibitors
6. Meglitinides: repaglinide
7. Thiazolidinedones: pioglitazone
-may consider managing with diet and exercise first; if glucose intolerance persists: begin oral agent
1. biguanides (metformin): decreases hepatic glucose production and intestinal absorption of glucose; increases peripheral glucose uptake and utilization
***preferred initial treatment for T2DM
2. sulfonylureas (glipizide, glyburide): stimulates insulin secretion from pancreatic beta cells
3. Dipeptidyle peptidase-4 inhibitors (sitagliptin): inhibits degradation of incretin GLP-1 with increase of insulin release from pancreas
4. glucagon-like peptide 1 (GLP-1) receptor
agonists/incretin mimetic (exenatide, liraglutide): binds to GLP-1 receptor stimulated production/secretion of insulin
5. alpha-glucosiddase inhibitors: delays absorption of carbs
6. Meglitinides: repaglinide: stimulates insulin release from pancrease
7. Thiazolidinedones: pioglitazone: improves insulin sensitivity, glucose uptake in muscles and adipose tissue
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how often are initial treatment and subsequent treatment changes assessed?
every 2-3 months for oral agents in T2DM
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contraceptive counseling in diabetic patients
-whats CI?
COCs CI if diabetes with nephropathy, retinopathy, neuropathy, or longer than 20 years duration
DMPA not recommended (weight gain)
LARC methods probably best
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hypoglycemia
-s/sx (mild, moderate, severe)
-side effect of insulin or oral medications for diabetes, skipped or delayed meals or snacks, increased physical activity
-mild: hunger, weakness, shakiness
-moderate: increased irritability, inability to complete tasks
-severe: confusion, drowsiness, progression to unconscious
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management of hypoglycemia
-take simple carb: 4 ounces fruit juice, 5-6 pieces hard candy, tablespoon honey
-test blood glucose in 10-15 minutes (<60: take more simple carbs)
-administration of subq glucagon if patient unable to swallow
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hyperglycemia s/sx, management
cause: insulin deficiency precipitated by acute illness, injury, infection, lack of adherence to meds
early sxs: increased thirst, frequent urination, HA, blurred vision, difficulty concentratin
diabetic ketoacidosis: fruity breath, abdominal pain, N/V, dehydration
^^Med EMERGENCY
