Understanding Different Types of Atrial Fibrillation and Pain Management, Exams of Nursing

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ICP EXAM 2, ICP Exam 2 Prescription Writing, Pain Management, Nutrition, Exercise, Gender Affirming Care- Guaranteed Success What is Interstitial Lung Disease (ILD)? - Correct answer *Umbrella term* for heterogeneous group of disorders, characterized by *varying* patterns of *lung inflammation* and *fibrosis* The term arises from the *histological* appearance that the *interstitial* is abnormal, although the alveoli, airways, blood vessels, and pleura are often altered as well ILD arises from - Correct answer identified cause or idiopathic *3 MC*: sarcoidosis cryptogenic organizing pneumonia idiopathic many causes of ILD - connective tissue diseases, treatment-related or drug-induced diseases, primary and idiopathic diseases, occupational and environmental diseases, inorganic disease, etc. what are some classifications of ILD? - Correct answer Connective Tissue Diseases Treatment-Related or Drug-Induced Diseases Primary and Idiopathic Diseases Occupational and Environmental Diseases Inorganic Organic Bird breeder's/Farmer's lung some ILDs are more common in women, such as - Correct answer those resulting from *autoimmune* diseases, also known as *connective tissue disorders* occupational exposure causes of ILD are more common in - Correct answer men Most ILDs occur in people older than? - Correct answer 50 yrs of age what are some common identifiable risk factors for ILD? - Correct answer environmental exposures such as down, mold, silicone, and asbestos reactions to drugs such as chemotherapeutic agents, tyrosine kinase inhibitors, amiodarone, and nitrofurantoin radiation therapy connective tissue disease including rheumatoid arthritis, scleroderma, and myositis pathologic acid reflux both tobacco and drug use some have increased genetic susceptibility Concerning PE Findings for ILD? - Correct answer shortness of breath (especially with exertion) cough (dry) tachypnea bibasilar end-inspiratory dry crackles pulmonary hypertension cyanosis clubbing ILD Hallmarks: - Correct answer *restriction* of lung volumes and reduced diffusing capacity demonstrated by pulmonary function tests potentially reversible unless fibrosis, once fibrosis occurs, restrictive patterns are IRREVERSIBLE Diffusion abnormalities can result from - Correct answer loss of functional capillaries from fibrosis - desquamative interstitial pneumonia - pulmonary alveolar proteinosis Interstitial fibrosis - usual interstitial pneumonia - nonspecific interstitial pneumonia (fibrosing NSIP) Interstitial Inflammation - nonspecific interstitial pneumonia (cellular NSIP) - lymphocytic interstitial pneumonia - hypersensitivity pneumonitis ILD Imaging Studies may show what? - Correct answer CXR may appear normal or show opacities (often in *reticular pattern*) *High* resolution CT (HRCT) is necessary to evaluate the radiographic pattern of lung injury - consolidation - ground glass opacity - reticulation - traction bronchiectasis - fibrosis - air trapping - cysts - may identify pulmonary artery enlargements with pulmonary hypertension What can echo show with ILD? - Correct answer cardiac size and function screen for pulmonary hypertension ILD with an identifiable cause, what is one of the first things you do? - Correct answer identify the cause and get rid of it patient education prevent further damage No pharmacologic Therapy of ILD - Correct answer Avoidance of tobacco and occupational exposures *Mainstay* is to identify the cause of the lung injury and completely avoid it, e.g., discontinue offending drugs or remove environmental exposures Avoidance alone may be sufficient to reverse acute and sub acute inflammation Pharmacologic Therapy of ILD depends on what? - Correct answer The type of ILD Essential to try and classify the type in order to appropriately treat Steroids and immunosuppression should be avoided in idiopathic pulmonary fibrosis; they are an important part of treatment for hypersensitivity pneumonitis though For patients with acute or sub acute inflammation demonstrated by consolidation or ground glass opacity in HRCT, what should we treat with? - Correct answer immunosuppression with steroids or steroid-sparing agents, such as mofetil mycophenolate and azathioprine, could *expedite* improvement while steroids often cause rapid improvement, their multiple side effects may limit their prolonged use Patients being treated for ILD should be closely monitored with what to assess ILD trajectory? - Correct answer PFTs If there is improvement or stabilization after 4 to 12 wk of steroids, the dose should be tapered If an ILD patient's condition declines as steroids are weaned, starting _________ or ___________ for maintenance may allow steroid tapering - Correct answer mofetil mycophenolate azathioprine if patients are at high risk for steroid-induced side effects, mofetil mycophenolate or azathioprine monotherapy could be considered from the beginning Nintedanib and ILD - Correct answer a tyrosine kinase inhibitor with ant fibrotic and anti-inflammatory properties could be considered as monotherapy or added to immunosuppression in scleroderma- associated ILD When working up ILD, it's important to take a thorough history regarding - Correct answer tobacco and prior drug use prior meds workplace and environmental exposures pets review of symptoms, including s/sexes of underlying connective tissue ds What are some meds that can cause pulmonary fibrosis? - Correct answer a lot of meds can contribute antibiotics - nitrofurantoin (macro bid) - more likely if on chronically amiodarone what was the reason for this woman's ILD? - Correct answer her prior radiation likely contributed she had a history of chemo and radiation which can cause radiation fibrosis may have shown signs and symptoms but provider didn't notice before it became irreversible What is HTN? - Correct answer Elevated: Defined as systolic BP between 120 and 129 mm Hg or diastolic BP < 80 mm Hg Can be further divided into stage 1 and stage 2 Stage 1 HTN - Correct answer 130 - 139 systolic 80 - 89 diastolic Stage 2 HTN - Correct answer > 140 > 90 How do you make the diagnosis of HTN? - Correct answer Accurate measurements and average of > 2 readings on *> 2* occasions HTN Potential Etiologies - Correct answer Essential (primary) HTN (85%) Drug induced or drug related (5%) - NSAIDs - oral contraceptives - corticosteroids Renal HTN (5%) - renal parenchymal disease (3%) - endovascular HTN (RVH) (< 2%) Endocrine (< 2%) - primary aldosterone’s (at least 5%) - pheochromocytoma (0.2%) - cushing syndrome and long-term steroid therapy (0.2%) Any drugs, OTC, or prescription to think about? - Correct answer Amphetamines, cocaine, illicit drugs Decongestants Anything that will cause vasoconstriction NSAIDs, OCPs, CS (esp long term) pertinent history to get from pt with HTN - Correct answer age of onset of HTN previous antihypertensive therapy family history of HTN, stroke, CV disease diet, salt intake, caffeine, alcohol, drugs (e.g., oral contraceptives, NSAIDs, decongestants, steroids) occupation, lifestyle, pain, socioeconomic status, psychologic factors other cardiovascular risk factors: hyperlipidemia, obesity, diabetes mellitus Symptoms of secondary HTN - Correct answer headache, palpitations, excessive perspiration (possible pheochromocytoma) weakness, polyuria (consider hyperaldosteronism) claudication of lower extremities (seen with coarctation of aorta) loud snorting, daytime somnolence, morning confusion (may warrant eval for sleep apnea) Important lifestyle questions? Certain dietary questions? - Correct answer Vegan diet Even vegan substitutes can be very high in sodium and other supplements that aren't as healthy as people may think Read labels Exercise habits important He does aerobic exercise 5x a week DASH diet Ask about occupation, stressors, home happiness and safety What are some common recommendations on changing or adding HTN medications? - Correct answer Chlorthalidone 50 mg was very high; can cause repercussions It's better for pts unresponsive to therapy to be started on combo therapy at lower doses (can eventually raise) Thiazide diuretics tend to work well with AAs Protect the kidneys!! What are first line medications for HTN? - Correct answer Thiazides ACE-Is ARBs ARNIs CCBs (non-dihydroipyridines) BBs not first line Why would you get an echo in a chronic HTN pt? - Correct answer assess for typical findings of long-standing HTN LVH Ejection fraction, assess for regurg that she may not have seen or heard on exam Not necessarily needed for this case consider strain, hypertrophy When may a diagnosis of hypertension be established if pt not previously seen? - Correct answer > 180/110 or evidence of end organ damage General Clues to consider for when to consider screen for secondary HTN - Correct answer severe or resistant HTN an acute rise in BP developing in pt with previous stable BP age less than 30 yr, nonobese, non-black with no family history sudden onset or accelerated hypertension age of onset before puberty; if above is suspected, additional tests for secondary HTN should be done including renin, aldosterone, cortisol levels, 24-hr urine metanephrines, and serum catecholamines *PE should include searching for secondary causes, and sequelae of hypertension* What are some components of the PE that should inform you about secondary causes, and sequelae of hypertension? - Correct answer examine skin for the presence of cafe-au-laity spots (neurofibromatosis), uremic appearance (renal failure), and lilaceous striate (Cushing syndrome) perform careful fundoscopic examination; check for papilledema, retinal exudates, hemorrhages, arterial narrowing, arteriovenous compression examine neck for carotid bruits, distended neck veins, and enlarged thyroid gland perform extensive cardiopulmonary examination: check for a laterally displaced point of maximal intensity, an S3 and S4, and valvular mumurs palpate abdomen for renal masses (pheochromocytoma, polycystic kidneys), and auscultate for bruit over the aorta and renal arteries examine arterial pulses (dilated or absent femoral pulses and BP greater in upper extremities than lower extremities suggest aortic coarctation) look for truncal obesity (cushing syndrome) and pedal edema (congestive heart failure) Routine Lab Tests before HTN - Correct answer Urinalysis with microscopic evaluation; for signs of glomerulonephropathy Basic methabolic panel and calcium; for signs of kidney damage, hypokalemia (primary aldosteronism and Cushing syndrome), hypercalcemia (hyperparathyroid) Complete bood count Screening for coexisting diseases that may adversely affect prognosis; hemoglobin A1c or fasting glucose level, serum lipid panel Options tests include measurement of urinary albumin or albumin/creatine ratio serum creatinine (and estimated glomerular filtration rate) in HTN - Correct answer assessment of renal function Initiate antihypertensive drug therapy with 2 first-line agents of different classes for adults with stage 2 HTN and BP more than ____________________ mmHg higher than their target - Correct answer 20/10 patients with diabetes mellitus and CKD are considered high risk for - Correct answer HTN what are preferred initial anti-hypertensive agents for general non-Black population? - Correct answer thiazide-type diuretics ACEIs ARBs CCBs ACEs and ARBs are preferred initial agents in diabetics and those with *chronic kidney disease* what are the preferred initial anti-hypertensive agents for Black population? - Correct answer thiazide-type diuretics or CCBs what can improve medication compliance - Correct answer once a day dosing also consider cost, metabolic and subjective side effects, DDIs what's a concern with BBs and DM? - Correct answer can mask hypoglycemia symptoms what's the mainstay treatment of hypertensive urgencies? - Correct answer clonidine how to treat fibromuscular dysplasia? other causes of renovascular HTN? - Correct answer percutaneous transluminal renal angioplasty (young fibromuscular dysplasia patients refractory to medical therapy) BBs, ACEIs, diuretics (often in combo with ace inhibitors) treatment of HTN in pregnancy - Correct answer methyldopa hydralazine labetalol nifedipine Hypertensive emergencies occur when the BP elevation is - Correct answer > 180 mmHg systolic and/or > 120 mm Hg diastolic WITH evidence of new or progressive organ dysfunction *requires rapid lowering of BP to prevent end-organ damage* Hypertensive urgencies occur when the BP elevation is - Correct answer not a thing ignore Ferri's only worry if HTN AND SIGNS AND SYMPTOMS OF END ORGAN DAMAGE most clinicians suggest lowering the BP to < 160 mm Hg/ < 100 mm Hg or to a level no more than 30% lower than the patient's baseline BP IV meds preferred in emergencies for pts with HTN, every ______________ mmHg increase *doubles* the risk of cardiovascular events - Correct answer 20/10 IF BP is greater than _________ mmHg above goal, therapy should be initiated with two drugs - Correct answer 20/10 Resistant HTN - Correct answer HTN is considered resistant if the BP *cannot be reduced* below target levels in pts who are compliant with an optimal triple-drug regimen that includes a diuretic terms refractory and resistant used interchangeably causes include pseudohypertension, measurement artifact, medication nonadherence, volume overload, and secondary HTN What are some potential concerns in gramma who "fell out"? - Correct answer TIA Head injury, bleed Seizure Why shouldn't you do a CT if you suspect a TIA? - Correct answer won't see anything with TIA What should you ask about medications in pts presenting with confusion, syncope, etc.? - Correct answer want to know what they are side effects any new? recent changes? able to manage the medications? any assistants with meds? independent still (able to manage their own BP)? Heart Block Risk Factors - Correct answer BMI Diabetic HTN BB use not on CCB for rate control Hyperkalemia slow rate of firing from sinus node inappropriately fast pacemaker for ventricle iatrogenic: anesthesia, inotrope infusion, ventricular pacing, radiofrequency ablation of slow pathway, digoxin toxicity sinus node disease, ischemia, hyperkalemia, overactive vagal drive complete heart block: progressive fibrosis of the His-Purkinje system, medications, Lyme disease What is AV dissociation? - Correct answer lack of association between the atria and the ventricles or independent function of the atria and ventricles umbrella rather than a diagnosis may occur in the setting of Bradycardia rhythms, complete heart block, as well as tachycardia rhythms Cannon A waves - Correct answer Third degree heart block if the right atrium contracts against a *closed tricuspid valve* during ventricular systole may be seen in the jugular vein what is mitral regurgitation? - Correct answer *retrograde* blood flow into the left atrium resulting from any part of an incompetent mitral valve apparatus this condition may cause LV failure, as well as increased left atrial and pulmonary pressures leading to pulmonary hypertension and right-sided heart failure mitral regurg is a _______ valvular abnormality occurring in about 10% of the population - Correct answer common Heart sounds on PE of mitral regurg - Correct answer diminished S1 as valve leaflets fail to coapt properly widely split S2 as A2 occurs earlier because of decreased LV ejection time (blood flowing back) presence of an S3 as a result of increased flow into a dilated LV caused by severe MR with systolic impairment Mitral Regurg Heart Murmur - Correct answer *Holosystolic, high-pitched "blowing" murmur* most easily audible at *apex* with radiation to base, *left axilla*, or back true or false there is good correlation between the intensity of the systolic murmur and the degree of regurgitation - Correct answer false what suggests severe MR? - Correct answer an early to mid-diastolic rumble (pseudomitral stenosis) acute MR murmur may be short and unimpressive Some causes of Primary MR - Correct answer idiopathic myxomatous degeneration of the mitral valve, mitral valve prolapse (most common cause of MR in *industrialized* countries) papillary muscle dysfunction or rupture (typically as a result of an inferior wall myocardial infarction) ruptured chordae tendinae infective endocarditis calcified mitral valve annulus rheumatic valvulitis (may be combined) with mitral stenosis; common in developing countries) systemic lupus erythematosus (Libman-Sacks endocarditis) drugs: fenfluramine, dexfenfluramine, pergolide, cabergoline congenital cleft valve ischemic MR due to papillary muscle dysfunction from multivessel coronary artery disease (CAD) What are some causes of Secondary MR? - Correct answer hypertrophic cardiomyopathy LV dilation (e.g., secondary to dilated cardiomyopathy) Patients with symptomatic MR may present with the following - Correct answer symptoms suggestive of heart failure (fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema) hemoptysis (caused by pulm HTN) atrial fibrillation chronic secondary mitral regurgitation - Correct answer functional, remodeling of the ventricle and atrium cardiomyopathy, dilated cardiomyopathy, chronic a-fib could lead to chronic secondary left atrium increased, hypertrophied chronic afib, cardiomyopathy, dilated cardiomyopathy can contribute to hypertrophy MR Risk Factors - Correct answer age HTN DM daily alcohol use valvular disease Diagnostic workup for MR - Correct answer echocardiography ECG chest radiograph cardiac cath is sometimes needed to confirm severity of the disease what is the initial imaging modality of choice for mitral regurg? - Correct answer TTE TEE is performed if insufficient or discordant info obtained from TTE findings include *dilated* left atrium, hyperdynamic left ventricle, erratic motion of the leaflet in patients with ruptured chordae tendineae, and color flow Doppler with evidence of MR *most important aspect of the echo is the quantification of severity of MR* what are risk factors for afib? and MR? - Correct answer age HTN diabetes hyperlipidemia overweight underlying valvular disease common in elderly what is seen on echo for mitral regurg? - Correct answer dilated left atrium (atrial enlargement) hyperdynamic left ventricle erratic motion of the leaflet in patients with ruptured chordae tendineae color flow doppler with evidence off MR need to quantify severity possible pulmonary congestion what is often seen on ECG with MR? - Correct answer left atrial enlargement LV hypertrophy atrial fibrillation Early-persistent AF: AF that has been continuous for longer than 7 days but fewer than 3 months Long-standing persistent AF: AF that persisted for longer than 1 yr, either because cardioversion has failed or because cardioversion has not been attempted Permanent A-Fib - Correct answer when pt and physician decided to stop pursuing restoring sinus rhythm lone atrial fibrillation (LAF) - Correct answer generally refers to AF in younger patients without clinical or echocardiographic evidence of cardiopulmonary disease, diabetes, or hypertension nonvalvular a-fib - Correct answer a-fib in the absence of moderate-to-severe mitral stenosis or in the presence of a mechanical heart valve secondary A-Fib - Correct answer occurs in the setting of a primary condition that may be the cause of the AF, such as acute myocardial infarction, cardiac surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary embolism, pneumonia, or other acute disease considered separately bc AF is less likely to recur once the precipitating condition has resolved silent A-Fib - Correct answer asymptomatic AF diagnosed by an ECG or rhythm strip A-Fib Epidemiology - Correct answer increases with age, from 2% in adults < 65 to 9% of those > 65 years old significantly higher in *men* more common in *caucasians* what is the most common and dreaded complication of AF? - Correct answer stroke due to thromboembolism risk of stroke is not solely due to AF, changes in the endothelium and elevated markers of inflammation that may contribute to thrombosis are found in pts with AF what are some causes of A-Fib? - Correct answer *Extracardiac factors*: hypertension, obesity, sleep apnea, hyperthyroidism, alcohol/drugs Atrial tachycardia remodeling *Atrial structural abnormalities*: fibrosis, dilation, ischemia, infiltration, hypertrophy Inflammation oxidative stress RAAS activation Autonomic nervous system activation *Atrial electrical abnormalities*: increased heterogeneity, decreased conduction, decreased action potential duration/refractoriness, increased automaticity, abnormal intracellular calcium handling *Genetic variants*: channelopathy, cardiomyopathy electrolytes, systemi c stress, medications/toxins, endocrine issues, etc. A-Fib Presentation - Correct answer palpitations, dizziness, or light-headedness fatigue, weakness, or impaired exercise tolerance angina dyspnea some pts are asymptomatic cardiac auscultation revealing *irregularly irregular* rhythm thromboembolic phenomenon such as stroke what is the most frequent change in AF - Correct answer loss of atrial muscle mass and atrial fibrosis fibrillation is presumed to be caused by multiple wandering wavelets, usually originating from the pulmonary veins If COPD is the cause of A-fib, what should the tx be? - Correct answer B-blocker Diltiazem Verapamil If LV dysfunction or HF are the cause of A-fib, what should the tx be? - Correct answer B-blocker Digoxin If hypertension or HFpEF are the cause of A-fib, what should the tx be? - Correct answer B-blocker Diltiazem Verapamil If no other CV disease is found to be the cause of A-fib, how still would we treat? - Correct answer B-blocker Diltiazem Verapamil A-Fib Labs - Correct answer Thyroid-stimulating hormone, free T4 Serum electrolytes Toxicity screen CBC count (looking for anemia, infection) Renal and hepatic function tests D-dimer/CT scan of chest pulmonary embolism protocol (if the pt has risk factors to merit a pulmonary embolism workup) A-Fib Workup - Correct answer diagnosis, determination of etiology, and classification history and physical exam, ECG, TTE, case-specific lab work to rule out secondary AF A-Fib Imaging Studies - Correct answer ECG -absence of P waves - fibrillatory or F waves at the isoelectric baseline with varying amplitude, morphology, and intervals - irregular ventricular rate Echo to rule out structural heart disease CXR TTE to eval for left atrial thrombus (particularly in left atrium appendage) CT and MRI in pts with positive d-dimer can also do 6 min walk test, sleep study, holter monitor, electrophysiologic study What is Peripheral Arterial Disease (PAD)? - Correct answer refers to atherosclerotic, inflammatory, occlusive, and aneurysmal diseases involving the noncerebral and noncoronary arteries it's essentially CAD in the peripheral body decreased blood flow to certain area and having those signs/symptoms; muscle strain needling oxygen - presents with *claudication symptoms* metabolic demand not being made How does PAD typically present? - Correct answer claudication symptoms PAD Prevalence - Correct answer equal in men and women *increases with age* esp > 40 claudications more likely to be present in males Risk Factors for PAD - Correct answer smoking diabetes HTN hypercholesterolemia pts at increased risk of PAD include those > 65 yr, those aged 50 to 64 yr with risk factors of atherosclerosis, those < 50 yr with diabetes and an additional risk factor, as well as those individuals with known atherosclerotic disease in another vascular bed patients with newly diagnosed PAD are _____________ times more likely to die within the next 10 years than when compared with patients without PAD - Correct answer 6 PAD Presentation - Correct answer 20 - 50% asymptomatic 10 - 35% intermittent claudication, defined as aching pain, cramping, weakness, numbness, or heaviness of the leg induced by exercise, relieved by rest 1 - 2% critical limb ischemia, defined as chronic (> 2 wk) rest pain, or tissue loss with nonhealing ulceration, necrosis, or gangrene 40 - 50% atypical symptoms involving the calf, thigh or buttock acute limb ischemia (ALI) 14/100,000 individuals _________ is 3x more likely to lead to PAD than CAD - Correct answer Smoking What is Buerger's test? - Correct answer Pt lying recumbent Raise leg to approximately a 45 degree angle directly up and examine the color of the leg; it will be pale when raised due to a lack of blood distribution; gravity and pressure can't be overcome in the leg when leg is put back down, rush of blood from arterial flow that occurs and gravity and will now see the skin turn red Arterial bruits in PAD? - Correct answer good to listen to the abdominal vessels, including femoral when suspecting PAD tend to worry about aorta-iliac ABI - Correct answer ankle brachial index get systolic in arm and leg and see if there is a discrepancy and what the ratio of the discrepancy is and if there's lower blood flow to lower leg how is ABI calculated? - Correct answer ABI of each leg is calcualted by dividing the highest dorsalis pedis or posterior tibial systolic blood pressure by the highest systolic brachial pressure obtained from either the right or left arm PAD is a risk factor specifically for what really bad thing - Correct answer abdominal aortic aneurysm (AAA) what are concerning ABI values? - Correct answer < 0.9 is *diagnostic* < 0.4 is severe Acute limb ischemia - Correct answer *acute* (< 2 wk) onset of symptoms due to severe perfusion of the extremities, and further categorized into the following: - viable - threatened - irreversible Viable limb ischemia - Correct answer no sensory or muscle weakness with audible doppler pulses Threatened limb ischemia - Correct answer mild to moderate sensory or motor loss; inaudible arterial doppler Irreversible limb ischemia - Correct answer severe sensory loss and muscle weakness; inaudible arterial doppler - claudication can be categorized using the Rutherford and Fontaine classification symptoms PAD is primarily the result of - Correct answer atherosclerotic narrowing of the arterial lumen that results in impaired blood flow to the lower-extremity tissues PAD Physical Exam Findings - Correct answer diminished pulses and/or cool skin temp of lower extremities bruits heard over the distal aorta, iliac, or femoral arteries change in skin color - dependent rubor - livedo reticularis, or a mottle reticulated vascular pattern - trophic changes of hair loss, brittle nails, and muscle atrophy What are some other PE findings of PAD? - Correct answer diminished pulses and/or cool skin temp of lower extremities bruits heard over the distal aorta, iliac, or femoral arteries (femoral bruit is an independent marker for ischemic cardiac events) changes in skin color: - dependent rubor in critical limb ischemia - livedo reticularis, or a mottled reticulated vascular pattern that appears lacelike - trophic changes of hair loss, brittle nails, and muscle atrophy PAD Workup - Correct answer Thorough history, including symptoms regarding walking impairment, claudication, ischemic rest pain, or nonhealing wounds in patients > 70 yr or those > 50 yr with a history of smoking and./or diabetes what lab studies should be done for PAD? - Correct answer lipid profile hemoglobin A1c d-dimer C-reactive protein/ESR what is pulse volume recording (PVR)? - Correct answer measure volume of limb flow per pulse in different segments of the limb (e.g., thigh, calf, ankle, metatarsal, and toes) segmental limb pressures can be useful IV necrosis, gangrene Why does exercise work for PAD? - Correct answer encouraging metabolic demand, helps to create collateral blood flow to go around the clot and provide circulation Treatment goal for PAD - Correct answer focus on CV risk factor reduction to decrease mortality and morbidity as well as improve limb-related symptoms ALL PTS SHOULD RECEIVE ANTI-PLATELET THERAPY LIKE ASPIRIN what should be given for cholesterol in PAD pts - Correct answer statin therapy pts with atherosclerotic PAD receive high-intensity statin therapy in order to lower risk of CV events regardless of baseline cholesterol values revascularization in PAD - Correct answer higher morbiditiy with surgery greater reinterventions in the percutaneous approach reasonable for pts with lifestyle-limiting claudication with inadequate response to guideline-directed medical therapy multidisciplinary approach individuals with claudication symptoms who have signficant functional disabiltiy that is vocational or lfiestyle limiting unresponsive to exercise or pharmacotherapy autogenous vein graft is superior to prosthetic graft iliac or femoropopliteal disease with long segments; multifocal segments, etc percutaneous/endovascular treatment - Correct answer vocational or lifestyle-limiting disability significant aortoiliac or femoropopliteal disease durability of endovascular is greater in iliac and proximal (including proximal popliteal) artery than in the femoropopliteal segment revascularization for acute limb ischemia - Correct answer management approach is dependent on whether limb is viable, threatened or irreversible if absence of sensation and movement, urgent surgery heparin should be given to all; direct thrombin is pt has history of HIT catheter-based thrombolysis is effective with salvageable limb amputation in pts with irreversible damage pharmacologic therapy for PAD - Correct answer cilostazol (100 mg BID), a phosphodiesterase inhibitor (PDE-3) that enables pain-free and maximal walking distance; reduces platelet aggregation and causes vasodilation - contraindicated in pts with HF Arterial vs Venous Ulcer - Correct answer arterial: toes or foot, irregular, cool and cyanotic, severe with decreased sensation, absent peripheral pulses venous: malleolus or metatarsal, exudate and irregular shape, warm, mild severity, pulses present What is endocarditis? - Correct answer an infection of the endocardial surface of the heart or mural endocardium Modified Duke Criteria - Correct answer Infective Endocarditis Major: 2 positive blood cultures, Echo (vegetation, perforation), new valvular regurgitation Minor: Predisposing condition (abnormal valves, IVDA, indwelling catheters), Fever, Vascular/Embolic phenomena, Immunologic phenomina (osler, roth, +RF), 1 pos blood culture, echo not meeting major criteria (worsening murmur) Diagnostic: - 2 major - 1 major & 3 minor - 5 minor Endocarditis in Injection Drug Users - Correct answer often involving S. aureus or Pseudomonas aeruginosa with variation that may be geographically influenced; tricuspid or multiple valvular involvement; high mortality rate of 50% to 60% Epidemiology of Endocarditis - Correct answer Female > male 45 to 65 yr females: often < 35 yr old male: 45 to 65 yr old dental work can be a *risk factor* for endocarditis age has shifted *> 65* now because more individuals are getting dialysis, prosthetic heart valves, indwelling cardiac devices, previous rheumatic fever (not as common now with antibiotics and tx methods) What types of bacteria tend to be involved in endocarditis? - Correct answer staph aureus, streptococci, enterococci 30% are staph aureus Most likely staph aureus or Pseudomonas with IV drug use can get fungal endocarditis from candida less frequent: HACEK bacteria (mostly colonize in oropharynx) bacteremia Acute endocarditis - Correct answer usually caused by staph aureus, streptococcus pyogenes, s pneumo, and neisseria organisms classic presentation of high fever, positive blood cultures, vascular and immunologic phenomenon Subacute endocarditis - Correct answer usually caused by Viridans streptococci in the rpesence of valvular pathology; less toxic, often indolent presentation with lower fevers, night sweats, fatigue Endocarditis in Injection Drug Users - Correct answer often involves s. aureus or p. aeruginosis iwth variation that may be geographically influences; tricuspid or multiple valcular involvement high mortality rate of 50% to 60% prosthetic valve endocarditis (early vs late - Correct answer *early*: caused by s. aureus (leading cause of PVE) within 2 mo of valve replacement - other organisms include s. epidermidis - gram-negative bacilli, diphtheroids, candida organisms *late*: typically develops > 60 days after valvular replacement; involved organisms similar to early prosthetic valve endocardititis - Viridans streptococci, enterococci, group D enterococci Nosocomial Endocarditis - Correct answer secondary to IV catheters, total parenteral nutrition lines, pacemakers; coagulase-negative staphylococci, S. aureus, and strep most common Osler Nodes vs Janeway Lesions - Correct answer Osler nodes: tender raised lesions on finger or toe pads Janeway lesions: small erythematous lesion on palm or sole ___________ is the leading cause of native or prosthetic valve infection - Correct answer staphylococcal infection Endocarditis Risk Factors - Correct answer poor dental hygiene long-term hemodialysis diabetes mellitus HIV infection mitral valve prolapse Why should CT surgery be contacted for endocarditis? - Correct answer prosthetic heart valves signs of heart failures embolism sepsis pictures surgery doesn't usually come in to clean out vegetations Endocarditis Tx - Correct answer 4 - 6 weeks IV antibiotic after blood cultures come back negative echo important for initial management - most likely going to get a transthoracic, but transesophageal is better sensitivity and specificity for vegetations or to see better on an implanted device What is the anticoagulation controversy in endocarditis? - Correct answer there's an increased risk of bleeding bc you can get microhemorrhages if you have emboli and septic endocarditis, but prosthetic heart valve patients tend to also get endocarditis but they're also the ones who need anticoagulation so do you coagulate or not Endocarditis Workup - Correct answer History and physical exam Apply modified duke criteria blood cultures: three sets in first 24 hr CBC ESR, CRP RF U/A Serologies and PCR? Echo: TTE or TEE ECG Endocarditis Lab Findings - Correct answer blood cultures: *three sets* in first 24 hr more culturing if pt has received prior antibiotic CBC (anemia possibly present, subacute) WBC (leukocytosis is higher in acute endocarditis) ESR and C-reactive protein (elevated) Positive rheumatoid factor (subacute endocarditis) Proteinuria, hematuria, RBC casts Serologies or PCR for more unusual pathogens (B. henselae, C. burnetii, etc.) Treatment for endocarditis is influenced by - Correct answer the type of organism/possible etiology usually begin with broad spectrum *Vancomycin* as empiric antibiotic and tailor it when blood cultures come back could add gentamicin to cover enterococci some would've given ceftriaxone as well good to do vanc + other drugs nafcillin + gentamicin or cefazolin for native valve endocarditis MSSA vanc for MRSA ampicillin-sulbactam + gentamicin or vancomycin in culture-negative valve endocarditis ceftriaxone or ampicillin-sulbactam or cipro for HACEK organisms what is a concern with vancomycin use - Correct answer should be infused over at least 1 h to reduce the risk of histamine-release "red man" syndrome if someone with endocarditis needs a dental procedure, what do we do? - Correct answer they need prophylaxis a previous episode of endocarditis increases the risk of recurrent endocarditis associated with transient bacteremia from dental procedures streptococcus viridians tends to be what kind of flora - Correct answer oral/dental Acute vs Subacute Endocarditis - Correct answer Acute = Staph, more virulent, infects normal valves, sudden onset of heart murmur Subacute = others, less virulent, infects pre-existing valvulopathy, prexisting heart murmur -> worsening of existing If you get endocarditis blood cultures back and they result in strep bovis? - Correct answer colon cancer ACS Algorithm - Correct answer Nitro x3, O2, ASA, Beta blocker (MONA) what is a myocardial infarction - Correct answer characterized by symptoms of myocardial ischemia, persistent ECG changes, and release of biomarkers of myocardial necrosis resulting from insufficient supply of oxygenated blood to an area of the heart classified as ST-segment elevation MI (STEMI) non-ST-segment elevation MI (NSTEMI) what is ACS? - Correct answer acute coronary syndrome refers to acute myocardial ischemia without myocardial necrosis (unstable angina) and myocardial necrosis and infarction (NSTEMI and STEMI) criteria for diagnosing MI (NSTEMI and STEMI) - Correct answer detection of the rise and/or fall of cardiac biomarker values (preferably cardiac troponin with at least one value *above the 99th* percentile upper reference limit with at least one of the following: 1. symptoms of ischemia 2. development of pathologic Q waves in the ECg elevated biomarkers 2 anginal episodes in past 24 hrs presence of risk factors for CAD EKG findings age > 65 prior coronary stenosis > 50% what if you can't do PCI right away? - Correct answer Heparin is an option Lovenox is an option also if not getting immediate PCI Dual antiplatelet therapy can be done: Brilinta or Plavix in addition to her aspirin Continue DAP for 12 months MI Presentation - Correct answer history of substernal pressure type chest pain that radiated to the neck, lower jaw, left arm, or mid-back lasting 20 min or more not completely relieved by sublingual nitroglycerin nausea/vomiting are atypical symptoms elderly may present with dizziness or syncope skin may be diaphoretic and exhibit pallor rales may be present at the bases of lungs apical systolic murmur caused by mitral regurg from papillary muscle dysfunction S3 or S4 may be present edema, shock exam may even be normal common MI etiology - Correct answer coronary atherosclerosis and plaque rupture coronary artery spasm coronary embolism periarteritis and other coronary artery inflammatory diseases dissection into coronary arteries (aneurysmal or iatrogenic or spontaneous) anomalous origin of coronary artery, esp interarterial (aorta and pulmonary artery) course of coronary artery hypercoagulable states, increased blood viscosity MI with normal coronaries (younger pts, cocaine addicts) What are some patients that may have an atypical ACS presentation? What are some of those atypical signs and symptoms? - Correct answer elephant on my chest, pouring sweat, etc epigastric pain, nausea and vomiting SOB sense of indigestion referred pain sometimes symptoms can seem minor women, diabetics, elderly patients MI Workup - Correct answer EKG *within 10 minutes* - can do at 5- and 10- minute intervals or as needed to assess Cardiac troponin levels (cardiac-specific troponin T and cardiac-specific troponin I) - rise relatively early after muscle damage (3 to 6 hr) - peak at 12 - 16 hr - may be present for several days aftre - preferred marker for *myocardial necrosis* CK-MB isoenzyme can be done if troponin levels unavailable Imaging studies such as CXR, CT, TTE TIMI or GRACE risk scores Thrombolysis in Myocardial Infarction (TIMI) risk score (STEMI) - Correct answer 30- day outcomes the higher the score, the higher the 30-day mortality variables based on historic, exam, and presentation Global Registry of Acute Coronary Events (STEMI) - Correct answer 6-mo outcomes variables based on historic, exam, and presentation for NSTEMI, looks at in hospital outcomes Thrombolysis in Myocardial Infarction (TIMI) risk score (NSTEMI) - Correct answer 14- day outcome age presence of > 3 risk factors for CAD known CAD (coronary artery stenosis > 50%) aspirin use in the past 7 days > 2 episodes of > 0.05 mV positive cardiac enzymes *each variable is worth one point* A risk score of 6 to 7 on TIMI for NSTEMI patients carries what prognosis? - Correct answer estimated major acute coronary event (MACE) rate of 41% during 14 days of post-MI HEART SCORE - Correct answer Even before HEART SCORE, what do we do? - Correct answer monitor EKGs, monitor patient in ED for a while; EKG every 15 - 30 min Catch changes EARLY repeat ECG esp if change in status, return in chest pain, etc. If considering discharge, definitely need to make sure stable first Nonpharmacologic Tx of MI - Correct answer limit patient's activity; bed rest with bedside commode for initial 12 to 24 hr; if pt remains stabile, gradually increase why should an UFH infusion not exceed 48 hr after PCI? - Correct answer HIT what does nitroglycerin do? - Correct answer increase oxygen supply by reducing coronary vasospasm and decrease oxygen consumption by reducing ventricular preload patients with ongoing ischemic discomfort should receive sublingual nitroglycerin every 5 min for a total of *3 doses* , after which an assessment should be made about the need for IV nitro who should not be given nitroglycerin - Correct answer pts with BP < 90 mmHg or > 30 mmHg below baseline or severe bradycardia (< 50 bpm) tachycardia (> 100 bpm) or suspected RV infarction or phosphodiesterase inhibitor for ED within last 24 hr (48 hr for taladafil) oral BBs should be initiated in the first 24 hr in pts with MI who do not have what? - Correct answer signs of HF evidence of low-output state sinus tachycardia increased risk for cardiogenic shock (also start ACEI) what are some other post-MI goals? for diabetics? LDL? BP? - Correct answer LDL < 70 A1C around 7% BP around 130/80 AV block and bradyarrhythmias in the setting of inferior wall MI are usually _________ and _____________ require long-term pacing - Correct answer transient do not require usually resolve within 2 to 4 weeks of symptom onset Risk Factors for GI Ulcers - Correct answer NSAID use Diet (greasy or spicy food) Smoking Alcohol use Family history Stress H. pylori What are some clues for an upper GI bleed? - Correct answer epigastric pain associated with eating FOBT + melena (darker red stool) hematochezia (BRISK upper GI bleed) Low H & H (numbers may not be impacted right away) fatigue What are some anemia exam findings? - Correct answer pale conjunctiva pale oral mucosa (extreme anemia) general pallor orthostatics unstable VS What are some sources of lower GI bleeds? - Correct answer CA IBD Diverticular bleed Fissure Hemorrhoid What is the most common cause of UGI? - Correct answer *Peptic Ulcer Disease (PUD)* accounts for 40 - 50% of the cases Of those, majority is secondary to duodenal ulcers (30%) What may PUD be associated with? - Correct answer H. Pylori NSAIDs Stress-related mucosal disease UGIB accounts for ____% of all acute gastrointestinal (GI) bleeding cases - Correct answer 75 What are two important aspects of history for UGI? - Correct answer detailed social history regarding alcohol use directly ask about NSAIDs, antiplatelet drugs, aspirin, or anticoagulants Diagnostic Clues for Upper GI Bleeds - Correct answer FOBT + (not a great test - can have false negatives) Rectal exam (blood in stool) H & H, low MCV BUN:Cr > 30 (seen only in upper GI bleed d/t blood being ingested) What diagnostic tests need to be done for suspected GI bleed? - Correct answer endoscopy within 12 hours esp for higher risk patients (def want by 24 hrs if possible after resuscitative efforts and for admission to optimized hemodynamic parameters and other medical problems) H & H should be checked every 3 hours; monitor pt Consult GI Rockall Score - Correct answer designed to predict rebleeding and mortality includes age, comorbidities, presence of shock, and endoscopic stigmata Two or fewer points is considered low risk Six or more have a rebleeding rate of 15% and mortality of 39% increased pressure of blockage - increase inflammation and necrosis of region --> perforation or fistula to adjacent organ, obstruction some say it can have an inflammation that's similar to IBS/IBD or both (based on histologic findings of granulomas, infiltrating leukocytes, etc.) doesn't have to do with nuts, seeds, popcorn Diverticulitis Presentation - Correct answer Left lower quadrant (LLQ) pain Often relieved by defecation Can cause muscle spasm, guarding, rigidity, and rebound tenderness predominantly affecting the LLQ Exacerbated by movement Fever Absence of vomiting > 50 yr History of one or more episodes Diverticular disease is believed to be secondary to - Correct answer low intake of dietary fiber Common histologic findings of diverticular disease - Correct answer Granulomas Infiltrating lymphocytes TNF Histamine Matrix Metalloproteinases Similar to IBS, IBD, or both Diverticulitis Labs - Correct answer Leukocytosis with left shift Microcytic anemia can be present in patients with chronic bleeding from diverticular disease; MCV may be elevated in acute secondary to reticulocytosis Urinalysis Pregnancy test for women of child-bearing age Electrolytes and liver enzymes CRP levels of 50 mg/L or greater is common Why is colonoscopy avoided during acute diverticulitis? - Correct answer risk of perforation can generally be performed *after 6 wk* to rule out the presence of cancer and IBD Does diverticulitis require imaging? - Correct answer if clinical features are highly suggestive of diverticulitis, imaging studies are generally not necessary what is the preferred imaging to use to diagnose acute diverticulitis? - Correct answer A CT scan of the abdomen with IV and luminal contrast typical findings are thickening of the bowel wall, fistulas, or abscess formation CT may also reveal other processes Hinchey Classification - Correct answer 0 and Ia indicate uncomplicated diverticulitis Ib pericolic or mesenteric abscess in proximity to the primary inflammatory process II intraabdominal abscess distant from primary inflammatory process or pelvic/retroperitoneal abscess III generalized purulent peritonitis IV generalized fecal peritonitis Nonpharmacologic Tx of Diverticular Disease - Correct answer Increase in dietary fiber intake Regular exercise Oral diet of clear liquids NPO and IV hydration in severe Emergent surgery required for perforation, peritonitis, or uncontrolled sepsis Mild to Moderate Diverticulitis Pt Tx? - Correct answer in-patient: single-agent therapy with ertapenem 1 mg IV every 24 hr, ticarcillin-clavulinic acid 200 to 300 mg/kg per day divided doses every 6 hr, or moxifloxacin 400 mg IV every 24 hr for 4 to 7 days combination therapy of cefazolin (1 - 2 mg every 8 hr) or levofloxacin (750 mg every 24 hr) plus metronidazole (500 mg every 8 hr) is also effective Severe Complicated Diverticulitis - Correct answer Imipenem-cilastatin 500 mg IV q 6h or Piperacillin-tazobactam 4.5 g IV 1 8h or Meropenem 1 g IV q 8hr or Doripenem 500 mg IV q 8hr *Cefepime 2 g IV q 8h or ciprofloxacin 400 mg IV q 12h each in combination with metroniaazole 500 mg IV q 8hr* Surgical Tx of Diverticulitis - Correct answer Peritonitis: colonic resection with Hartmann pouch is *procedure of choice* Inability to exclude carcinoma (10 - 20% are found to subsequently have carcinoma of the colon) *Consisting of resection of involved areas and reanastomosis (if feasible)*; diverting colostomy with reanastomosis is performed when infection has been controlled (in general) What is a common concern with FQs? - Correct answer Achilles *tendinitis* (tendinopathy in general) Why is diet counseling important in diverticulitis? - Correct answer one of the risk factors is the "Western Diet": low fiber, high fat, lots of red meat add more fiber, more fruits and vegetables pts can eat soft/bland foods at home if they're feeling better or up to it What are reasons to admit diverticulitis pts to the hospital? - Correct answer Comorbidities (DM, peripheral neuropathy, CKD) - high risk of deteriorating Had not eaten anything; wasn't getting adequate fluids (needed IVF) Mostly just risk factors + severity Weight loss Fatigue Pallor (IDA) Angular cheilitis, aphthous ulcers, atopicdermatitis, and *dermatitis herpetiformis* What may be seen in children and infants with celiac disease? - Correct answer weight loss dyspepsia short stature failure to thrive what are the 3 common celiac symptoms in adults? - Correct answer weight loss fatigue diarrhea What are some atypical forms of celiac disease that are increasingly being recognized? - Correct answer osteoporosis short stature anemia infertility neurologic problems If your patient has celiac disease, what should you do with family members? - Correct answer depends on if they are symptomatic or not findings are inconclusive on whether first degree relatives should be screened if they are asymptomatic education is an important aspect of treatment if family starts to get symptomatic, they should be tested How can a celiac patient be monitored to ensure treatment compliance? - Correct answer Anti-TTG IgA antibody test to see if they are adhering to the diet Would expect it to look higher if not adhering, the levels would be increased Check again pretty soon after initial diagnosis bc dietary changes need to be adhered to 3 month follow up; if they feel good then after that may only check once a year or every couple of years or so Levels should normalize over time as pt is avoiding gluten; the test will look like they don't have celiac disease at all (same with small intestine biopsy) can monitor serial antigliadin or antiendomysial antibody tests can be used to monitor the pt's adherence to a gluten-free diet Why may it be good to refer a pt with newly diagnosed celiac disease to a registered dietician? - Correct answer educate pt on foods they're allowed to eat gluten is in a lot of foods in western diets adjusting can be hard, getting calories and nutrients you need while still eating the foods that you enjoy; huge lifestyle change If you were to screen a patient with celiac's disease first degree relative, like their daughter, and she is negative, what does that mean? - Correct answer not completely ruled out she still make get celiac disease later in life check again if she gets associated s/sxs What would you do if you eliminate gluten from the diet and the pt still has celiac disease symptoms? What is the next course of action for refractory disease? - Correct answer possible to try corticosteroids there are people who have a complete gluten free diet and steroids and don't have relief some immunomodulators can be used such as Azathioprine Celiac Disease vs Celiac Allergy - Correct answer difference between disease and allergy and intolerance/sensitivity Is celiac disease very prevalent? - Correct answer no only in about 0.5% - 1% of the population Where does celiac disease primarily impact? - Correct answer the upper small intestine manifested by infiltration of the lamina propria and the epithelium with chronic inflammatory cells and villous atrophy Probably cause(s) of ecchymoses and petechiae - Correct answer Vitamin K deficiency Rarely, thrombocytopenia Probable cause of edema - Correct answer Hypoproteinemia Probable cause of dermatitis herpetiformis - Correct answer Epidermal (type 3) tTG autoimmunity Probable cause(s) of Follicular hyperkeratosis and dermatitis - Correct answer Vitamin A malabsorption, vitamin B complex malabsorption Probable Cause(s) of Amenorrhea - Correct answer Malnutrition Hypothalamic-pituitary Immune dysfunction Probable cause(s) of secondary hyperparathyroidism - Correct answer Calcium and/or Vitamin D malabsorption with hypocalcemia Probable cause(s) of Anemia - Correct answer Iron Foalte Vitamin B12 or Pyridoxine deficiency Probable cause of Thrombocytosis, Howell-Jolly Bodies - Correct answer Hyposplenism Probable cause(s) of Atrophy - Correct answer malnutrition due to malabsorption Probable cause(s) of Tetany - Correct answer calcium vitamin D and/or 50 - 80 y/o men = women specific and nonspecifc gene variants are associated with UC infection with what gives you an 8 - 10x higher risk of developing UC the following year? - Correct answer nontyphoid salmonella or campylobacter How do UC patients often present? - Correct answer *acute* onset of bloody diarrhea accompanied by *tenesmus*, *fever*, and *dehydration* 40% of adults have proctitis 40% have left-sided colitis 20% have pancolitis May have periods of spontaneous remission and frequent relapses What should you do when you suspect UC? - Correct answer sigmoidoscopy and biopsy (colonoscopy) colonoscopy to diagnose presence of mucosal inflammation; typical endoscopic findings in UC are areas of continuous friable mucosa; diffuse, uniform erythema replacing the usual mucosa vascular pattern; and pseudopolyps transition from abnormal to normal tends to be abrupt crypt abscesses and atrophy, mucin depletion, basal plasmacytosis, basal lymphoid aggregates, increased lamina propria cellularity, and Paneth cell metaplasia may be present UC Laboratory Findings - Correct answer Anemia and *High* ESR (in severe colitis) are common Potassium, magnesium, calcium and albumin may be decreased Antineutrophil cytoplasmic antibodies (ANCA) with a perinuclear staining pattern (pANCA) can be found in > 45% of patients *Calprotectin* is a protein that is measured in feces as a marker of intestinal mucosa leukocyte activity that may be useful for screening of patients with suspected IBD Fecal lactoferrin is a *sensitive* marker of intestinal inflammation Stool examination for ova and parasites, stool culture, and testing for C diff toxin and E. coli O157:H7 may be useful what may be seen on a barium enema in UC? - Correct answer lead pipe sign (loss of haustra) UC Scoring Tools - Correct answer different scoring tools moderate is 4 - 6 categorized according to # bowel movements, abdominal pain, and ESR What are some non GI manifestations of UC? - Correct answer there is a really long list on Ferri's liver disease sclerosing cholangitis uveitis episcleritis arthritis erythema nodosum aphthous stomatitis iron deficiency anemia other arthritic or autoimmune conditions what are some things you can tell a patient with newly diagnosed UC? - Correct answer this is something you will have for the rest of your life common to have relapses 66% achieve remission with therapy 88% of those retain remission Some will require colectomy Once you relapse, you are likely to have more relapses UC Tx - Correct answer Mild UC: rectal 5-ASA (mesalamine enema and suppository) Mild-Moderate: can also do oral + rectal 5-ASA Moderate - Severe: can also do glucocorticoids Severe: infliximab and TNF inhibitors or surgery Surgery for UC - Correct answer is *curative* total proctocolectomy with ielal pouch anal anastamosis --> curative UC and Cancer - Correct answer these patients are at risk for colon cancer and should be screened *earlier* and more often 10 - 20% will develop cancer within 10 yrs of disease onset what are some important lifestyle modifications with UC? - Correct answer maintain diet with fiber and lower saturated fats during flares tobacco is a big trigger so smoking cessation is important UC Treatment (Jordan) - Correct answer Mesalamine: asacol and lialda lialda released same way and is once a day dosing and asacol is like 4 times a day Ischemic Colitis - Correct answer occurs in *older adults* *sudden* onset often *painful* usually resolves *spontaneously* in several days segmental splenic flexure and sigmoid most commonly affected mucosal necrosis with ghost cells congestion with rbcs fibrosis (chronic disease) Microscopic Colitis - Correct answer *watery* diarrhea normal-appearing mucosa radiologic features usually normal positive blood cultures in 50% of cases, typically with enteric gram-negatie aerobes (e.g., Escherichia coli, Klebsiella pneumonia), enterococci, or anaerobes Cholangitis vs Cholecystitis - Correct answer cholangitis: biliary tract infection secondary to obstruction cholecystitis: gallbladder (cystic) duct infection secondary to obstruction --> differs bc there is positive Murphy's sign (inflammation and pain of the gallbladder) Cholangitis Imaging - Correct answer *Ultrasound*: allows visualization of the gallbladder and bile ducts to differentiate extrahepatic obstruction from intrahepatic cholestasis - insensitive but specific for visualization of common duct stones *CT scan*: less accurate for gallstones - more sensitive than ultrasound for visualization of the distal part of the common bile duct - allows better definition of neoplasm *ERCP*: confirms obstruction and its level - allows collection of specimens for culture and cytology - indicated for diagnosis if ultrasound and CT scan are inconclusive - may be indicated in therapy cholangitis complications - Correct answer bacteremia (50%) septic shock hepatic abscess pancreatitis When is a situation in which you would do MRCP? - Correct answer when CBD dilated, and you DON'T see a stone (MIGHT BE A TUMOR) before digging around with an ERCP and irritating things before MRCP: magnetic resonance cholangiopancreatography If you see jaundice, what do you expect bilirubin levels to be? - Correct answer Bili around 4 (definitely > 2) What is the cholestatic pattern of LFTs in cholangitis? - Correct answer Cholangitis: increased Alk Phos (more than ALT/AST) Increased WBC Increased Bili Increased (or normal) Lipase How long until cholecystectomy in cholangitis? - Correct answer ERCP and Abx initially Once levels have calmed down, cholecystectomy in 72 hours or so Can do ERCP (below the obstruction) for decompression or PTC (above the obstruction) Broad spectrum antibiotics, usually prescribe a third gen cephalorsporin as well what is a risk after getting ERCP? - Correct answer pancreatitis if complicated ERCP, give prophylaxis abx to prevent pancreatitis Where else may jaundice be seen/where can you check in a pt presenting with cholangitis? - Correct answer scleral icterus sublingual what is the dispo of cholangitis pts? - Correct answer admit to ICU or hospital (in this case, it was ICU b/c pt also had sepsis, pancreatitis, and pre-renal AKI) consult interventional radiology and GI surgery emergent ERCP and cholecystectomy 2 large bore IVs Bed monitor NPO, Zofran IV Can do ketorolac for acute pain or consider low dose fentanyl In hypoalbuminemia and hypoproteinemia, can give IV albumin get cultures before antibiotics!! Monitor Cr and CBC in AKI, fluid maintenance education what may be associated with cholangitis? - Correct answer recent biliary tract surgery with secondary stenosis tumor iatrogenic after ERCP or PTC *primary sclerosing cholangitis* (PSC) (association with UC, as well) HIV-associated sclerosing cholangitis Biliary decompression - Correct answer may be urgent in severeily ill pts or those unresponsive to medical therapy within 12 to 24 hr may also be performed semielectively options: - ERCP with or without sphincterotomy or placement of a draining stent - percutaneous transhepatic biliary drainage for the acutely ill pt who is a surgical candidate - endoscopic ultrasound-guided biliary drainage - surgical exploration what are the key abx for cholangitis - Correct answer carbapenems pip/tazo ampicillin-sulbactam ticarcillin-clavulanate cholangitis prognosis - Correct answer excellent with *definitive surgical therapy*, otherwise relapses are common can be life-threatening if untreated antibiotics alone will *not* resolve cholangitis in the presence of biliary obstruction; high intrabiliary pressures prevent antibiotic delivery decompression and drainage of the biliary tract to alleviate the obstruction with antimicrobial therapy is the *therapy of choice* What is gastroparesis? - Correct answer decreased GI motility and delayed gastric emptying acute hyperglycemia has been found to have effects on the *gastric sensory and motor* functions causing *altered* gastric electrical activity; can result in *relaxation* of the proximal stomach and *decreased pressure* in the antrum and pylorus - all of these processes can lead to slower gastric emptying What is a succussion splash? - Correct answer Gas and fluid in obstructed organ. Put stethoscope on abdomen while shaking patient side to side. Sloshing--> distension of stomach or colon free fluid or air hear when ausculating the abdomen near the stomach Why can patients with gastroparesis better tolerate fluids? - Correct answer liquids can more easily go through than solids How to rule out mechanical obstruction in gastroparesis? what are some imaging options? - Correct answer Upper GI endoscopy is *first line* CT enterography vs MRI may also be done to rule out mechanical obstruction from a small-bowel mass Barium follow-through if CT or MRI unavailable Food retained after overnight fasting can be suggestive of gastroparesis Scintigraphic gastric emptying should be cone as a confirmatory test after mechanical obstruction has been ruled out (doesn't have to be done though) What will GI do for gastroparesis diagnostics? - Correct answer nuclear gastric emptying scintigraphy at 1 hr 2 hrs and 4 hrs; can grade them based on severity as indicated by the test its the simplest and most cost-effective test documenting the presence of delayed gastric emptying and assessing its severity is best done by measuring the delay in gastric emptying of solids patient is asked to ingest a standard, low-fat meal what is the step-wise approach of diagnostic testing for gastroparesis - Correct answer 1) upper endoscopy initially 2) CT vs MR enterography to rule out SBO 3) gastric emptying scintigraphy test (specialist does) what is a gastric emptying scintigraphy test? - Correct answer 1. it is the simplest and most cost effective test 2. documenting the presence of delayed gastric emptying and assessing its severity is best done by measuring the delay in gastric emptying of solids 3. patient is asked to ingest a standard, low-fat meal 4. abnormal gastric emptying is defined as *> 10% gastric retention of solid food at 4h* and *> 60%* at 2 hr - C breath test can also be used to measure gastric emptying (not as sensitive) is diabetic gastroparesis progressive? - Correct answer no treatment is aimed primarily at alleviated patient symptoms and correcting exacerbating factors what is key to gastroparesis workup? - Correct answer thorough history and physical exam want to know blood sugar history and other diabetic symptoms that may be present all medications that can delay gastric emptying should be stopped before a formal workup Gastroparesis Labs - Correct answer Hemoglobin A1C TSH Total protein/albumin Hemoglobin Vitamin B12 Antinuclear antibody titers No specific labs are needed to confirm the diagnosis, but they can help to arrive at the diagnosis Gastroparesis Nonpharmacologic Tx - Correct answer oral nutrition is *preferred* diet should include small meals that are low in fiber (low-residue) and fat avoidance of carbonated beverages is recommended because these can lead to symptoms of bloating alcohol and tobacco smoking should also be stopped because these also delay gastric emptying for patients with severe disease, a feeding jejunostomy tube may be considered a successful trial of a nasojejunal feeding tube should precede placement optimize glucose and electrolyte levels Acute General Tx of Gastroparesis - Correct answer Metoclopramide and erythromycin are both available IV and in liquid form, which makes med administration, tolerance, and efficacy more acceptable if pt symptoms are severe Antiemetic agents are also important in acute settings such as promethazine, odansetron, reglan, etc What is important to get before starting a pt on reglan (anti-emetic meds) - Correct answer get an EKG concern for QT prolongation dyskinesias Metoclopramide should be limited use for how long? - Correct answer no more than 12 weeks unless the benefits outweigh the risks SEs are restlessness, anxiety, QT prolongation, and extrapyramidal effects such as dystonia and tardive dyskinesia Erythromycin - Correct answer is limited to *4 wk* because longer use leads to *tachyphylaxis*; similar effect is seen with the higher dose (250 mg) vs a lower dose (40 mg) used for acute gastroparesis attacks; consider if she failed reglan What is a concern with regular marijuana use? - Correct answer cyclical vomiting; cannabis hyperemesis syndrome (can't rule out until 6 months off of it; symptoms can get better with a hot shower) What diabetic med is associated with gastroparesis? - Correct answer GLP-1s What is traveler's diarrhea (TD)? How do the pt's present? - Correct answer when people travel from resource-rich to resource-pour countries presents typically when they *first arrive* (within first week of traveling or first 10 days) Traveler's Diarrhea Workup - Correct answer Most cases are *self-limiting* and do not require workup, and are treated symptomatically without regard to etiologic agent In pts with diarrhea, fever, and colitic symptoms (bloody stools, cramping), a stool culture should be obtained to look for specific bacterial pathogens - stool culture *x 3* for bacterial pathogens - stool for ova and parasites to protozoans - blood cultures in pts with systemic illness to rule out Salmonella spp What approach can you take to appendicitis without exposing the patient to radiation? - Correct answer lower abdominal U/S often labeled as "nondiagnostic study bc the appendix could not be visualized" by the radiologist but it's still a good starting point apparently if you're trying not to expose them to a bunch of radiation theoretically if an appendix is inflamed enough, you should see it on U/S, but if you don't see it and it's not super high on your differential, you can probably r/o appendicitis can also bring them back in the next day for another eval to see if it's worsening or getting better What are some imaging/lab/diagnostic studies that could be done for traveler diarrhea? - Correct answer C. diff test U/A to check hydration; look at specific gravity (want to avoid dehydration bc patient is losing so much fluid) Look at mucus membranes and BUN/Cr ratio on BMP to further assess hydration status Stool culture is controversial bc it may not necessarily change tx plan How do we tx Traveler's Diarrhea? - Correct answer HYDRATE - fluids!! No anti-motility agents for campylobacter (imodium can prolong course in infectious diarrhea) - abx only if bloody stools or persistent high fever, or lasts longer than 7 days (minimizes sx by 1.3 days so not super helpful) Antisecretory agents such as bismuth subsalicylate (pepto-bismol) or Loperamide Antibiotics are warranted only for moderate to severe diarrhea; can reduce duration of diarrhea by 1 to 2 days What are antibiotic choices for traveler diarrhea? - Correct answer Azithromycin: the preferred antibiotic for empiric treatment of moderate to severe TD - dose of 1 g PO single dose for women - children get 10 mg/kg daily dose for 3 days - particularly effective for quinolone-resistant Campylobacter infections Ceftriaxone is an option for kids: 50 mg/IV once daily x 3 days Ciprofloxacin 500 mg bid for 1 to 3 days Levaquin 500 mg/day for 1 to 3 days Fluoroquinolones are effective agents for bacterial causes of TD, but resistance is increasing - can't use in children under 15 or in pregnant women Rifamycin is now FDA approved for noninvasive strains of E. Coli Rifaximin: 200 mg PO tid for 3 days for children age > 12 and adults is effective for afebrile, noncolitic diarrhea such as ETEC; doesn't tx Salmonella, Shigella, or Campylobacter Remember though widespread use of antibiotics has led to resistance When should a person with traveler's diarrhea patients return to the ED? - Correct answer acute abdominal pain worsens diarrhea for significantly longer than 7 days recent onset of bloody stool continuous high fever follow up with PCP to make sure everything's back in equilibrium Where should you look for some preventative recommendations and counseling? - Correct answer go to CDC website for where you're traveling make sure eating food that's well-prepared, well-heated drink bottled water or fluids don't eat the peels of fruits and vegetables if they have diarrhea --> can prescribe abx (with guideliens on when to take) oral rehydration packets - azithro and cipro (historically go-to) are still go-to options Traveler's Diarrhea Differential - Correct answer Appendicitis Hepatitis IBS C.diff Who should be considered for antibiotic prophylaxis? - Correct answer certain groups of people such as those with underlying illness, athletes, and politicians for up to 2 to 3 weeks Ciprofloxacin 250 to 500 mg/day is effective in preventing 90% of TD Rifaximin is dosed daily has been shown to help prevent TD for U.S., travelers to Mexico, but not as effective as ciprofloxacin bismuth (pepto bismol) 4x daily (be aware of interactions with anticoagulants, black tongue, black stool) what is the most frequent cause of long lasting TD? - Correct answer Giardia (most frequently identified parasite in North America!) Metoprolol Succinate Indications - Correct answer Trade: Toprol XL Indications: HTN, angina, HF associated risk reduction - NYHA Class II - IV HF pts with reduced EF, Migraine headache prophy Metoprolol Drug Class - Correct answer beta blockers, selective Metoprolol Contraindications - Correct answer Taper dose over 1 - 2 weeks to D/C Do not crush or chew Tab may be cut in half May increase weekly Hepatic impairment - start with low doses and titrate gradually Risk of hypersensitivity Sinus bradycardia; HR < 45 bpm (MI use) Sick sinus syndrome (pts w/o pacemaker) AV block, 2nd - 3rd degree (pts w/o pacemaker) AV block w/ PR interval > 0.24 sec (MI use) HF, decompensated HF, moderate-severe (MI use) SBP < 100 (MI use) Cardiogenic shock Pheochromocytoma (beta blocker monotherapy use) Brilinta Serious and Common Reactions - Correct answer Severe SEs: Bleeding, severe Syncope Bradyarrythmia AV block Hypersensitivity rxn TTP Central sleep apnea Common rxns: Dyspnea Bleeding Cr elevated Nausea Dizziness Diarrhea Brilinta DDIs - Correct answer CYP3A4 substrate P-gp substrate CYP3A4 inhibitor, weak ENT1 inhibitor P-gp inhibitor, weak Affected by delayed gastric emptying Antiplatelet Bradycardia Delays AV conduction Brilinta Pregnancy Class - Correct answer C Bivalirudin Indications - Correct answer Trade: Angiomax, Angiox, Bivalirudin Novaplus Indications: anticoagulation, direct thrombin inhibitor Bivalirudin Therapeutic Class - Correct answer anticoagulant, direct thrombin inhibitor Bivalirudin MOA, PK/PD - Correct answer MOA: directly, reversibly inhibits thrombin PK/PD: Urine excretion Half-life is 25 min. 34 min (GFR 30 - 59), 57 min (GFR 10 - 29), 3.5h (dialysis) Metabolism: plasma Bivalirudin Contraindications/Cautions - Correct answer Hypersensitivity to drug/class/component Bleeding, active major Caution: elderly pts Caution: CrCl < 30 Caution: bleeding risk Caution: brachytherapy Serious Reactions: Bleeding, severe Hemorrhage Thrombosis Thrombocytopenia Cardiac tamponade Bradycardia, severe Hypersensitivity rxn Anaphylaxis Common Rxns: Bleeding Back pain Pain Nausea Hypotension Headache Injection site pain Insomnia HTN Vomiting Pelvic pain Anxiety Bradycardia Dyspepsia Abdominal pain Fever Nervousness Urinary retention INR incr. Bivalirudin DDIs - Correct answer other anticoagulants Bivalirudin Pregnancy Class - Correct answer B Unfractionated Heparin Indications - Correct answer Trade: Hepflush-10, PosiFlush Heparin Indications: thromboembolism prophylaxis, thromboembolism treatment, PCI, acute coronary syndrome adjunct tx, anticoag for cardiopulmonary bypass Unfractionated Heparin Therapeutic Class - Correct answer anticoagulation Unfractionated Heparin MOA, PK/PD - Correct answer MOA: acts at multiple sites in coagulation process; binds to antithrombin III, catalyzing inactivation of thrombin and other clotting factors PK/PD: Liver metabolism, reticuloendothelial system; CYP450: unknown Excretion: urine Half-life: 0.5 - 2 hr Unfractionated Heparin Contraindications/Cautions/Precautions - Correct answer Contraindications/Precautions: Hypersensitivity to drug/class/components Hypersensitivity to pork product Hypersensitivity to corn (dextrose-containing form) Hypersensitivity to sulfites (dextrose-containing form) IM use Thrombocytopenia, severe HIT tx HITT hx Thrombocytopenia hx, pentosan polysulfate-induced Hemorrhage Bleeding, active (expect pts with DIC) Pts unable to monitor levels (full-dose use) Long-term use (peds pts) Neonates (benzyl alcohol-containing INJ forms) Caution: pregnancy (benzyl alcohol-containing INJ forms) Caution: breastfeeding (benzyl-alcohol-containing INJ forms) Caution: patients > 60 yo, esp females Caution: hepatic dz Caution: renal dz, sevre Caution: DM Caution: HTN, severe Caution: metabolic acidosis Caution: bleeding risk Caution: heparin resistance risk Caution: hyperkalemia risk Caution: surgery, recent major Caution: lumbar puncture, recent Caution: spinal anesthesia use, recent Serious reactions: Hemorrhage Adrenal hemorrhage Ovarian hemorrhage Dizziness Flushing Urinary hesitancy Urinary retention Abdominal distention Nausea Vomiting Heat intolerance Impaired body temperature regulation Restlessness Tremor Fatigue Injection site pain Rash Delirium Libido decr. Impotence Atropine DDIs - Correct answer Affects growth hormone diagnostic test results Anticholinergic effects Tachycardia Atropine Pregnancy Class - Correct answer C Weigh risks/benefits Coumadin Indications - Correct answer Trade: Jantoven, Coumadin bran discontinued in US market; now Warfarin Indications: DVT/PE prophylaxis, postpartum, thromboembolism/stroke prophylaxis, LV thrombus, VTE prophylaxis, atrial fibrillation/flutter, VTE prophylaxis, orthopedic surgery, ischemic stroke Warfarin Therapeutic Class - Correct answer anticoagulant Warfarin MOA, PK/PD - Correct answer MOA: Inhibits vitamin K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S) PK/PD: Metabolism: liver; CYP450: 1A2, 2C8, 2C9 (primary), 2C18, 2C19, 3A4 substrate Excretion: urine 92% (minimal unchanged), bile Half-life: 20 - 60h (anticoagulant effect) Info: half-life highly variable based on rate of clotting factor catabolism Warfarin BBW - Correct answer major or fatal bleeding; more likely during first month of tx; risk factors including high intensity anticoagulation (INR > 4.0), pts 65 yo and older, highly variable INR, GI bleeding hx, HTN, cerebrovascular dz, anemia, malignancy, trauma, renal impairment, genetic factors, concomitant drugs and long warfarin tx duration; regularly monitor INR for all patients; more frequent INR monitoring, careful dose adjustment, shorter tx duration may benefit high-risk pts; drugs, dietary changes affect INR levels during tx; monitor INR more frequently when starting, stopping, or dose adjusting other drugs, including herbals; instruct pts on bleeding prevention, reporting s/sxs Warfarin Serious and Common Rxns - Correct answer Serious Reactions: Hemorrhage Skin necrosis Tissue necrosis Gangrene Cholesterol embolism Purple toes syndrome Hypersensitivity rxn Anaphylaxis Cholestatic jaundice Hepatitis Vasculitis Tracheobronchial calcification Anemia Syncope Calciphylaxis Acute kidney injury (renally impaired pts or renal dz hx) Common Reactions: Bleeding Ecchymosis Abd cramps Abd pain Nausea Vomiting Diarrhea Abd distention Flatulence Fatigue Malaise Lethargy Asthenia Headache Dizziness Taste changes Pruritus Edema Dermatitis Rash Urticaria Fever Cold intolerance Paresthesia Alopecia Warfarin - Correct answer CYP1A2 substrate CYP2C9 substrate CYP3A4 substrate Anticoagulant Binds to anion exchange resin/polymer Binds to polyvalent cations Gastric pH sensitive GI flora-dependent vitamin K production Monitor INR more frequently when starting, adjusting, or stopping other drugs, incl. Short-term therapies, OTC drugs, herbal supplements; drug interaction mechanisms do not always predict anticoagulation effects due to high inter- and intra- patient variability Warfarin Pregnancy Class - Correct answer X Contraindicated during pregnancy unless pt with mechanical heart valve, then weigh risk/benefit Risk of fetal harm, incl. Intrauterine growth restriction, teratogenicity, and fetal death (based on animal data) Cyclophosphamide - Correct answer Trade: Cytoxan Indications: Lymphoma, multiple myeloma, leukemia, solid tumors, axillary node positive breast Ca adjuvant tx, CML allogeneic HSCT condition tx Cyclophosphamide Therapeutic Class - Correct answer Alkylating agents, nitrogen mustards, DMARDs, conventional Cyclophosphamide MOA, PK/PD - Correct answer MOA: alkylates and crosslinks DNA PK/PD: Metabolism for cyclophosphamide is primarily liver; CYP450: 2A6, AB6 (primary), 2C9, 2C18, 2C19, 3A4, 3A5 substrate; prodrug converted to active metabolites; for active metabolites: oxidation, beta-elimination; CYP450: none Urine excretion primarily (10 - 20% unchanged Bile 4% Half-life 3 - 12 hr Digoxin MOA, PK/PD - Correct answer MOA: inhibits sodium-potassium ATPase PK/PD: Metabolism: liver 16z%; CYP450: unknown Urine excretion (50 - 70% unchanged) Half-life: 1.5 - 2 days 3.5 - 5 days if anuria Digoxin Contraindications/Cautions/Precautions - Correct answer Contraindications/Precautions/SEs: Hypersensitivity to drug/class/components Ventricular fibrillation Myocarditis MI, acute Caution: elderly pts Caution: hypokalemia Caution: hypercalcemia Caution: hypomagnesemia Caution: hypocalcemia Caution: renal impairment Caution: WPW syndrome Caution: sinus node dz Caution: bradycardia Caution: AV block Caution: IHSS Caution: cardiomyopathy Caution: amyloid heart dz Caution: Cor pulmonale, acute Caution: pericarditis, constrictive Caution: thyroid dz Serious Reactions: AV block Bradycardia, severe Ventricular arrhythmia Thrombocytopenia Delirium Hallucinations Intestinal ischemia Hemorrhagic intestinal necrosis Common Reactions: Dizziness Headache Diarrhea Nausea Vomiting Abdominal pain Anorexia Weakness Bradycardia Palpitations Ventricular ectopy Tachycardia Visual disturbance Confusion Apathy Depression Anxiety Mental disturbance Gynecomastia Rash Digoxin DDIs - Correct answer P-gp substrate Affected by delayed gastric emptying Binds to anion exchange resin/polymer Binds to polyvalent cations Bradycardia Delays atrioventricular conduction Hypercalcemia Hypokalemia Hypomagnesemia Shortens QT interval Monitor digoxin levels more frequently when starting, adjusting, or stopping other drugs, incl. short-term therapies, OTC drugs, and/or herbal supplements Monitor electrolytes more frequently with concomitant drugs, OTC drugs, and/or herbal supplements that may lead to electrolyte abnormalities, resulting in potential incr. Risk of digoxin toxicity, cardiac arrhythmias Digoxin Pregnancy Class - Correct answer C May be used during pregnancy; risk of fetal harm not expected based on limited human data May use while breastfeeding Diltiazem Indications - Correct answer Trade: Cardizem Indications: ACLS/PALS/NALS; angina, chronic stable; angina, vasospastic; HTN; atrial fibrillation/flutter; PSVT conversion Diltiazem Therapeutic Class - Correct answer antianginals, antiarrhythmics, oral; antiarrhythmics, parenteral; calcium channel blockers, non-dihydropyridines Diltiazem MOA, PK/PD - Correct answer MOA: inhibits calcium ion influx into vascular smooth muscle and myocardium, relaxing smooth muscle, decreasing peripheral vascular resistance, dilating coronary arteries and prolonging AV node refractory class (class IV antiarrhythmic) PK/PD: Extensive liver metabolism; CYP450: 3A4 substrate; info: active metabolite Excretion: bile, urine (2 - 4% unchanged) Half-life: 3 - 9 hr Diltiazem Contraindications/Cautions - Correct answer Contraindications/Precautions/SEs: Hypersensitivity to drug/class/components Sick sinus syndrome (pts without pacemaker) AV block, 2nd - 3rd degree (pts w/o pacemaker) SBP < 90 Acute MI with pulmonary congestion Atrial fibrillation (IV use in pts with accessory bypass tract) Atrial flutter (IV use in pts with accessory bypass tract) Ventricular tachycardia (IV use) Caution: hepatic impairment Caution: cardiac conduction defect Caution: heart failure Caution: left ventricular dysfunction Serious Reactions: Bradycardia AV block Arrhythmia Hypotension, severe Syncope Heart failure Hepatic injury, acute Hypersensitivity rxn Stevens-Johnson syndrome Toxic epidermal necrolysis Erythema multiforme Exfoliative dermatitis Acute generalized exanthematous pustulosis Common Reactions: Peripheral edema Headache Nausea Dizziness