Management Flashcards
Acute COPD exacerbation
Cardinal sx:
- Increased SOB
- Increased cough (frequency or severity)
- Sputum (change in color or volume)
Dx
CXR > hyperinflation
ABG > hypoxia or CO2 retention
Tx
O2 goal 88% - 92%
Inhaled bronchodilators (SABA) or SAMA
Systemic glucocorticoids (40 mg prednisolone 10-14 days)
Antibiotics if at least 2 sx
Noninvasive pos pressure vent if ventilatory failure progressing to intubation if CI or failed
CI: medical instability, inability to protect airway, upper airway obstruction
5 A’s of smoking cessation
- Ask each visit about tobacco use
- Advise to quit (risks of smoking)
- Assess willingness to quit
- Assist to quit-counseling, pharmacologic tx, motivational interviewing
- Arrange followup
Asymptomatic Microscopic Hematuria
- R/o reversible causes of hematuria (UTI, exercise, urologic procedure) through hx
-get RF (smoking, benzenes, dyes, hx of hematuria, analgesic abuse, pelvic radiation, older than age 40).
Pee SAC: P=Phenacetin S=Smoking A=Aniline dyes. C=Cyclophosphamide (causes hemorrhagic cystitis). - Repeat urinalysis. In every first time microscopic hematuria, always follow up with a repeat at a 6 week interval before doing anything else.
- -if less than 3 RBCs > repeat 3 times at 6 week intervals > if consistently less than 3 give pt reassurance
* dipstick is nonspecific for microscopic hematuria so always confirm with a urinary sediment (direct examination of sediment) bc myoglobin looks like blood on dipstick - -if more than 3 RBCs go right to workup. r/o infection with urine culture if has sx .
- if source found, repeat UA 6 weeks after resolution of agent - assess renal fx (BMP and GFR) > if abnormal nephrology referral or proteinuria, red cell casts,dysmorphic RBCs = glomerular bleeding
- If ALL negative proceed to
- CT urography (upper urinary tract)
- Cystoscopy (lower urinary tract) to r/o RCC or transitional carcinoma - If all still negative, UA with microscopy annually for 2 consecutive years. For those with two consecutively negative results, workup can be stopped.
30-40% of gross hematuria = cancer
5% of microscopic = cancer
Thyroid nodules
incidence of malignancy in solitary nodules is 5-6% (higher in children, hx of head or neck radiation, fam hx of cancer, age >60)
- Thyroid fx testing
- Ultrasound (gives size, cancer characteristics like irregular margins, microcalfications, solid nodule).
3.If functional adenoma unlikely cancer, must follow-up with radioactive iodine uptake study > radioactive ablation or surgery (skip if pregnant)
- Nodules greater than 1 cm with normal or elevated TSH require biopsy (fine needle aspiration)! *if cytology is follicular then you need surgery for further evaluation (follicular of undetermined significance)
- papillary, medullary, anaplastic can be accurately diagnosed with FNA
- if less than 1 cm, repeat ultrasound in 6 months is indicated
5. Get thyroidectomy followed by radioactive ablation - if pregnant do after delivery of child
Work-up and management of MI
- Initial labs
- CBC
- electrolytes
- BUN/Cr
- PTT/PT/INR
- troponins/CK/CK-MB: every 6-10 hrs 3x - CXR and EKG
- Give MONA
- morphine
- oxygen
- IV nitroglycerin (if no sildenafil use or hypotension)
- aspirin 325
- also beta blocker (unless cocaine is suspected)
- heparin (reduce risk of subsequent MI): 48 hrs or until angiography is performed
- GPIIb/IIIa - if PCI or unstable angina
- ACE inhibs: reduce mortality within 24 hrs
- clopidogrel if aspirin not tolerated
- atropine if unstable bradycardia
- furosemide if pulmonary edema (if no hypotension)
- no evidence for CCB’s (short acting dihydroperidines are actually contraindicated bc increase mortality)
- aspirin, nitro, beta blockers, statins useful for secondary prevention of MI with onset of acute coronary syndrome
4. Continuous tele monitoring
- Get PCI!!!
Fibrinolysis — The 2013 American College of Cardiology Foundation/American Heart Association recommends the use of fibrinolytic therapy in patients with symptom onset within 12 hours who cannot receive primary percutaneous coronary intervention within 120 minutes of first medical contact - Unstable angina: If asymptomatic after 48 hrs of drug therapy > stress test if positive > angiography (controversy regarding when)
Management of stable Angina
- Beta Blockers (1st line)
- CCBs*
- nitrate
- low dose aspirin and; statin for prevention of Ischemia
- Ace inhibitor only if comorbid conditions
Risk stratification is most important!
EKG, stress testing, echocardiogram
- In patients with stable coronary artery disease, left ventricular ejection fraction is the strongest predictor of long-term survival
Prophylaxis of endocarditis
prophylaxis to prevent bacterial endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for high-risk patients with 1. prosthetic valves, 2. previous history of endocarditis, 3. unrepaired cyanotic congenital heart disease (CHD) or CHD repaired with prosthetic material 4. for cardiac transplant recipients who develop valvular disease.
When is neuroimaging indicated in tinnitis
Tinnitus that is bilateral and not bothersome can be treated conservatively with
cognitive-behavioral therapy,
sound therapy, and, if appropriate, hearing aids.
Indicated with:
Pulsatile tinnitus,
unilateral tinnitus,
or tinnitus associated with asymmetric hearing loss is more likely to be associated with a pathologic cause.
Management of IBS
Alarm sxs: fever, anemia, hematochezia, bloody diarrhea, family hx of colon cancer/celiac/IBS
Initial: -CBC -colon cancer screening (If diarrhea/mixed subset) -CRP -IgA tissue transglutaminase antibody
Tx:
PAIN————————
1. Dicyclomine: prescription medication that relieves muscle spasms in the gastrointestinal tract through an apparent mechanism of nonselective smooth muscle relaxation, and that presents a range of anticholinergic side effects
- TCA’s, SSRI: if pain more frequent and severe w/o big concern for constipation or diarrhea.
- Probiotics
- Peppermint oil
Constipation predominant——————-
- Soluble fiber
- Polyethylene glycol (osmotic load)
Diarrhea predominant——————-
1. Loperamide (imodium): opiod agonist thats slows gut motility and doesnt crosss BBB
2: Rifaximin: an abx that is gut specific bacteriostatic > for nonconstipation IBS
Adjunct to: -exercise -diet modification -psychological support ———————————- AAfP This patient has diarrhea-predominant irritable bowel syndrome (IBS). There are many treatments available, with varying degrees of evidence. SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS. Polyethylene glycol is a treatment for constipation and would not help this patient. Acupuncture has not been shown to be superior to sham acupuncture in improving IBS symptoms. Neomycin has been shown to improve symptoms in constipation-predominant IBS but would not be helpful in diarrhea-predominant IBS. SOLUBLE fiber such as psyllium improves symptoms and decreases abdominal pain scores in patients with IBS.
Prevention of preeclampsia
A 2013 update from the American College of Obstetricians and Gynecologists on hypertension in
pregnancy summarizes the evidence regarding prevention of preeclampsia.
The only medication with evidence to support its routine use is aspirin at dosages of 60–80 mg daily.
In a high-risk population, defined as women with a history of preeclampsia in two or more pregnancies or a history of preeclampsia with delivery at <34 weeks, the risk of preeclampsia is sufficiently high to justify the use
of aspirin, with a number needed to treat of 50 to prevent one case of preeclampsia.
Statin use
whom statin therapy is beneficial:
(1) individuals with clinical atherosclerotic cardiovascular disease (ASCVD)
-ACS
-stable angina
-CABG
-stroke, TIA
-PAD
<75 yrs old: high intensity
>75 yrs old: moderate intensity
2) those with primary
elevations of LDL-C >190 mg/dL
High intensity statin -all ages
3) For patients age 40–75
with diabetes, an LDL-C level of over 70 mg/dL, and no clinical ASCVD, a moderate-intensity statin is recommended.
For patients age 40–75
with diabetes, an LDL-C level of over 70 mg/dl and ASCVD risk >7.5% = a high-intensity statin is recommended.
4) For patients age 40–75 without clinical ASCVD or diabetes, an LDL-C level of 70–189 mg/dL, and an estimated 10-year ASCVD risk >7.5%. = moderate to high intensity statin
Pharmacologic tx of lupus
According to the American College of Rheumatology criteria, this patient has systemic lupus erythematosus, with photosensitivity, arthritis, a positive antinuclear antibody test, and a positive anti–double-stranded DNA test.
Hydroxychloroquine reduces arthritis pain in lupus patients (SOR A) and is the preferred initial treatment for lupus arthritis. Cyclosporine and azathioprine are indicated for severe lupus or lupus nephritis.
Mycophenolate is indicated for refractory lupus or lupus nephritis
Rituximab is indicated for severe refractory lupus.
Hb threshold for transfusion
In otherwise healthy stable patients with upper gastrointestinal bleeding, a transfusion of red cells is recommended when the hemoglobin level falls below 7.0 g/dL.
In hypotensive patients with severe bleeding, a blood transfusion before the hemoglobin level reaches 7.0 g/dL is needed to prevent significant decreases below this level that would occur with just fluid resuscitation.
In hemodynamically stable patients with known cardiovascular disease and significant upper gastrointestinal bleeding, 8.0 g/dL should be the threshold for a blood transfusion.
Management of acute angle glaucoma
For an acute primary angle-closure attack, initial management involves prompt administration of pressure-lowering eye drops. A possible regimen would be one drop each, one minute apart, of [21]:
●0.5% timolol maleate;
●1% apraclonidine; and
●2% pilocarpine
We also suggest giving the patient 500 mg of oral or intravenous (IV) acetazolamide. The eye pressure should be checked 30 to 60 minutes after giving pressure-lowering drops and acetazolamide. If the eye pressure is still significantly elevated, the same drops could be given again, but the patient should also be examined immediately by an ophthalmologist. Systemic medications other than acetazolamide (such as IV mannitol) should be administered under the guidance of an ophthalmologist, since angle-closure should be confirmed before they are given.
If medical treatment is successful in reducing IOP, as is most often the case, corneal edema and eye pain will typically lessen or resolve. Once the attack is broken, the treatment of choice is a peripheral iridotomy. If laser peripheral iridotomy fails to remain patent, or the cornea is too cloudy to visualize the iris, surgical peripheral iridectomy may be necessary.
COPD inhaler therapy
Pulmonary rehabilitation is recommended for patients in groups B, C, and D.
Those in group A should receive a short-acting anticholinergic or short-acting beta2 agonist for mild intermittent symptoms.
For patients in group B, long-acting anticholinergics or long-acting beta2 agonists should be added.
Patients in group C or D are at high risk of exacerbations and should receive a long-acting anticholinergic or a combination of an inhaled corticosteroid and a long-acting beta2 agonist. For patients whose symptoms are not controlled with one of these regimens,
triple therapy with an inhaled corticosteroid, long-acting beta2 agonist, and long acting anticholinergic should
be considered. Prophylactic antibiotics and oral corticosteroids are not recommended for prevention of COPD exacerbations. Continuous oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD.
Group A: SABA or SAMA
Group B: LABA OR LAMA
Group C: LAMA and LABA
Group D: > LAMA, LABA, ICS
