Outpatient

Question 1

New AHA blood pressure guidelines

Answer 1

• BP should be treated earlier at 130/80 rather than 140/90
• new categories as below:
  Elevated: Systolic between 120-129 and diastolic less than 80;
  Stage 1: Systolic between 130-139 or diastolic between 80-89;
  Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

Question 2

hypertensive crisis

Answer 2

systolic pressure ≥180 and or diastolic pressure ≥120 mmHg with signs of end organ damage

Question 3

is rate or rhythm control better for afib?

Answer 3

they have the same outcomes, but rate control is easier and there’s less toxicity with drugs.

Question 4

trial assessing rate vs. rhythm control in afib

Answer 4

AFFIRM trial

Question 5

if someone is in afib do they stay in afib?

Answer 5

depends on whether they have paroxysmal or permanent afib

Question 6

which afib group has a higher stroke risk?

Answer 6

paroxysmal (when you go back into sinus you dislodge clot)

Question 7

strategy for rate controlling afib patient

Answer 7

• start with either beta-blocker or CCB if you can’t rate control (you want under 110 according to recent trial) with betablocker (but you don’t want to do this because of high risk of heart block).

Question 8

how to get someone’s INR down from 2.5

Answer 8

hold warfarin at least for a couple days

Question 9

when to bridge afib patient

Answer 9

CHADS-VAS of 5 or higher

Question 10

how often do you need to monitor INR for afib patients?

Answer 10

After starting – every week.
If stable – one month.
If a change is made – every week.

Question 11

dialysis-associated steal syndrome (DASS)

Answer 11

• ischemia (not enough blood flow) resulting from a vascular access device (such as an arteriovenous fistula or synthetic vascular graft–AV fistula) that was installed to provide access for the inflow and outflow of blood during hemodialysis.
• presents as pain distal to fistula + Pallor, Diminished pulses (distal to the fistula), Necrosis

Question 12

other delirium criteria

Answer 12

• Inattention

- change in LOC + disorganized thinking

Question 13

how to manage delirium

Answer 13

• electrolytes, vitals, exam
• UA
• review med list
• consider CThead if anticoagulated
• hydrate, treat constipation, urinary retention
• de-tether, de-line
• reorient, mobilize, sleep/wake cycles

Question 14

dose of haldol to treat agitation

Answer 14

5 mg for crazy guy in ED (0.5 mg or 1 in elderly, MUCH LESS)

Question 15

how to test mental status really briefly

Answer 15

mini-cog

1) have patient repeat back 3 words
2) ask patient to draw a clock including all numbers and place hands at certain time
3) ask patient to repeat three words
- score of 2 or less indicates risk of delirium.

Question 16

drugs to avoid in elderly

Answer 16

anticholinergics
benzos
alphablockers (hypotension)
diuretics (dehydration)
NSAIDs
TCAs (anticholinergic property)
BB's (fatigue)

Question 17

drugs that also affect gut and urine

Answer 17

anticholinergics

Question 18

what is subacute rehab?

Answer 18

• more nursing
• usually coexists with nursing home, but is 2-3 weeks, usually paid by medicare, pt-ot often included, MD stops by every 3 days.

Question 19

when is nursing home appropriate for discharge?

Answer 19

• need long term care, can’t live alone

- paid by medicaid and social security.

Question 20

what is assisted living?

Answer 20

• long-term

- paid out of pocket