Exam 2 Flashcards by Sara Clements

spriometry for gold 1- mild COPD?

Fev1 >80%

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spirometry for gold2- moderate COPD?

Fev1 50-80% predicted

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spirometry for gold 3- severe COPD?

FEV1 30-50% predicted

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spirometry for gold 4- very severe COPD?

fev1< 30% predicted

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short acting bronchodilators for mild (gold 1) COPD?

yes

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which COPD classification? Chronic cough and sputum production, fatigue and SOB

gold 1- mild

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which COPD classification? Increase in symptoms of chronic cough; sputum production, SOB esp with activity

gold 2-moderate

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which COPD classification? Wheezing, difficulty sleeping, the start of COPD exacerbations

gold 2-moderate

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which COPD classification? Further increase in symptoms affecting every day life

gold 3-severe

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which COPD classification? More intense cough and more exacerbations

gold 3-severe

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which COPD classification? Difficulty sleeping, decreased mental status

gold 3-severe

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which COPD classification? Weight loss, morning headaches, breathing takes effort, intense cough

gold 4- very severe

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which COPD classification? Exacerbations may require hospitalizations, delirium, severe infections, increased BP/HR

gold 4- very severe

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when do you start long-acting bronchodilators for COPD?

gold 2-moderate stage

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what meds are preferred over short-acting bronchodilators in moderate COPD?

LABAs or LAMAs

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can you consider LABA/LAMA combo in moderate COPD?

yes

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when can pulmonary rehab start in COPD stage?

gold 1- mild

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what can pulmonary rehab improve?

exercise tolerance and quality of life

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when do you add ICS with COPD?

if there is a history of repeated exacerbations

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do you use long-acting bronchodilators in gold 3 COPD?

yes

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when do you consider ICS with COPD?

patients with frequent exacerbations, especially if eosinophils are elevated

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when do you use PDE4 inhibitors in COPD?

only in severe stage

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drug class? Roflumilast?

PDE-4 inhibitor

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when do you use long-term oxygen therapy for COPD?

if patient has chronic respiratory failure and resting hypoxemia

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quantify resting hypoxemia?

PaO2<= 55 or SpO2 <= 88%

can you consider non-invasive positive pressure ventilation in patients with chronic hypercapnic respiratory failure?

yes

class? Albuterol

short-acting beta 2 agonists

class? Proair HFA

short-acting beta 2 agonists

class? Ventolin HFA

short-acting beta 2 agonists

class? Proventil HFA

short-acting beta 2 agonists

generic name? proair hfa

albuterol

generic name? ventolin hfa

albuterol

generic name? proventil hfa

albuterol

brand name? levalbuterol

xopenex HFA

generic name? xopenex HFA

levalbuterol

class? Levalbuterol

short-acting beta 2 agonists

class? Xopenex HFA

short-acting beta 2 agonists

class? Formoterol

long-acting beta2 agonists

class? Foradil

long-acting beta2 agonists

class? Perforomist

long-acting beta2 agonists

class? Salmeterol

long-acting beta2 agonists

class? Serevent diskus

long-acting beta2 agonists

class? Indacaterol

long-acting beta2 agonists

generic? Foradil

formoterol

generic? Perforomist

formoterol

generic? Serevent diskus

salmeterol

brand name? salmeterol

serevent diskus

generic name? arcapta neohaler

indacaterol

brand name? indacaterol

arcapta neohaler

class? Beclomethasone

inhaled corticosteroids

class? QVAR redihaler

inhaled corticosteroids

class? Budesonide

inhaled corticosteroids

class? Pulmicort flexhaler

inhaled corticosteroids

class? Pulmicort respules

inhaled corticosteroids

class? Fluticasone

inhaled corticosteroids

class? Flovent diskus

inhaled corticosteroids

class? Flovent HFA

inhaled corticosteroids

class? Mometasone

inhaled corticosteroids

class? Asmanex twisthaler

inhaled corticosteroids

generic name? qvar redihaler

beclomethasone

generic name? pulmicort flexhaler?

budesonide

generic name? pulmicort respules

budesonide

generic name? flovent diskus

fluticasone

generic name? flovent HFA

fluticasone

generic name? asmanex twisthaler

mometasone

class? Tiotropium

LAMA

class? Aclidinium

lama

class? Spiriva handihaler

LAMA

class? Spiriva respimat

lama

class? Turdoza pressair

lama

generic name? spiriva handihaler

tiotropium

generic name? spiriva respimat

tiotropium

generic name? turdoza pressair

aclidinium

generic name? foradil certihaler

formoterol/aclidinium

generic name? advair diskus

salmeterol/fluticasone

generic name? trelegy ellipta

vilanterol/umeclidinium/fluticasone

class? Montelukast

leukotriene receptor antagonists

class? Singulair

leukotriene receptor antagonists

generic name? singulair

montelukast

brand name? montelukast

singulair

class? Roflumilast

phosphodiesterase 4 inhibitors

class? Daliresp

phosphodiesterase 4 inhibitors

generic name? daliresp

roflumilast

brand name? roflumilast

daliresp

class? Omalizumab

monoclonal antibodies

class? Xolair

monoclonal antibodies

class? Mepolizumab

monoclonal antibodies

class? Nucala

monoclonal antibodies

class? Reslizumab

monoclonal antibodies

class? Cinqair

monoclonal antibodies

class? Benralizumab

monoclonal antibodies

class? Fasenra

monoclonal antibodies

generic name? xolair

omalizumab

generic name? nucala

mepolizumab

generic name? cinqair

reslizumab

generic name? fasenra

benralizumab

brand name? omalizumab

xolair

brand name? mepolizumab

nucala

brand name? reslizumab

cinqair

brand name? benralizumab

fasenra

laba duration of action?

>= 12 hours

does laba decrease nocturnal asthma?

yes

does laba decrease use of saba?

yes

does laba decrease # exacerbations?

yes

does laba replace saba in asthma?

can ICS decrease sx and use of quick relief meds in asthma?

yes

what is the preferred treatment for persistent asthma at all levels of severity?

inhaled corticosteroids

can ICS be dosed at low/medium/high?

yes

where do you get the most benefit from ICS (re dosage)?

low to medium

are ICS antiinflammatory?

yes

do ICS decrease airway hyperresponsiveness?

yes

do ICS decrease secretions?

yes

when are ICS more effective re intervention w/ asthma?

early intervention

can laba + ics lead to improved lung function in asthma?

yes

can laba + ics decrease asthma symptoms?

yes

can laba + ics decrease saba use?

yes

brand name? fluticasone/salmeterol

advair

brand name? budesonide/formoterol

symbicort

brand name? mometasone/formoterol

dulera

generic name? advair diskus

fluticasone/salmeterol

generic name? symbicort

budesonide/formoterol

generic name? dulera

mometasone/formoterol

what is the goal of asthma education?

encoourage self-management

spirometry with acute asthma exacerbation?

PEFR <50% of predicted normal

failure to respond to a beta2 agonist with asthma exacerbation?

yes

severe coughing or wheezing with asthma exacerbation?

yes

extreme anxiety d/t breathlessness with asthma exacerbation?

yes

gasping for air, sweaty, or cyanotic with asthma exacerbation?

yes

rapid deterioration over a few hours with asthma exacerbation?

yes

severe retractions and nasal flaring with asthma exacerbation?

yes

hunched forward with asthma exacerbation?

yes

what happens to residual volume with status asthmaticus?

increased

what happens to PEFR with status asthmaticus?

decreased

inflammation and constriction of the bronchioles with status asthmaticus?

yes

ventilation-perfusion mismatching with status asthmaticus?

yes

hyperventilation in status asthmaticus leads to what respiratory imbalance?

respiratory alkalosis

do suprasternal retractions suggest severe asthma exacerbation?

yes

do cough, wheezes, chest tightness suggest severe asthma exacerbation?

yes

does accessory muscle use suggest severe asthma exacerbation?

yes

what PEFR suggests severe asthma exacerbation?

PEFR < 50% of personal best or predicted value

what is the initial treatment for severe asthma exacerbation?

inhaled SABA up to three treatments of two puffs of MDI at 60 min intervals or single neb treatment

class of asthma exacerbation? PEFR > 80% predicted or personal best

mild exacerbation

class of asthma exacerbation? PEFR 50-80% predicted or personal best

moderate exacerbation

class of asthma exacerbation? PEFR < 50% predicted value or personal best

severe exacerbation

class of asthma exacerbation? No wheezing or breathlessness

mild exacerbation

class of asthma exacerbation? Responses to beta 2 agonist sustained for 4 hours

mild exacerbation

class of asthma exacerbation? Persistent wheezing/shortness of breath

moderate exacerbation

what should you do re beta 2 agonist with moderate asthma exacerbation?

continue it

what should you add to beta 2 agonist with moderate asthma exacerbation?

add oral glucocorticoid

class of asthma exacerbation? Marked wheezing/SOB

severe exacerbation

what class of meds is first line for acute asthma attack?

short-acting beta 2 agonists

can you use SABAs prophylactically before exercise with asthma?

yes

MOA of sabas?

provides smooth muscle relaxation for bronchodilation

what does an increased need/usage indicate re asthma?

need to change regimen

are anticholinergics indicated for inintial treatment of acute asthma attacks?

are anticholinergics used as a daily controller therapy?

yes

brand name? ipratropium bromide

atrovent

generic name? atrovent

ipratropium bromide

are LTRAs a long-term controlled med re asthma?

yes

are LTRAs effective for acute asthma attacks?

what might LTRAs allow re asthma?

gradual reduction of inhaled corticosteroids

what time of day do you take LTRAs?

at night

are ICS a long-term asthma controller med?

yes

are ICS effective for acute asthma attacks?

when is ICS+laba used for asthma?

long-term controller med for moderate to severe persistent asthma

is ICS+ laba effective for acute asthma attacks?

brand name? fluticasone furorate and vilanterol

breo ellipta

generic name? breo elliptal

fluticasone furorate and vilanterol

what class of drug? Used for long-term treatment of severe persistent asthma that cannot be controlled with other medication classes

systemic corticosteroids

can you use systemic corticosteroids in asthma to establish control when initiating therapy?

yes

can you use systemic corticosteroids in asthma during a period of gradual deterioration?

yes

can you use systemic corticosteroids as a supplement to rescue bronchodilator therapy during acute attacks to prevent late-phase bronchospasm?

yes

are systemic corticosteroids effective for acute asthma attacks?

is controlling symptoms and preventing asthma exacerbations a goal of therapy?

yes

what determines treatment level with asthma management?

treatment is initiated accordin to the patient's highest component of severity

asthma class? Symptoms = 2 days per week

intermittent asthma

asthma class? Nighttime awakening <= 2x/month

intermittent asthma

asthma class? Saba <= 2 days a week

intermittent asthma

asthma class? No interference with normal activity

intermittent asthma

asthma class? Normal fev1 between exacerbations

intermittent asthma

asthma class? Fev1 >80% predicted

intermittent asthma

asthma class? Fev1/fvc normal

intermittent asthma

asthma class? Sx > 2 days/week, but not daily

mild persistent

asthma class? Nighttime awakening 3-4x/month

mild persistent

asthma class? Saba > 2 days per week but not greater than 1x/day

mild persistent

asthma class? Minor limitation/interference with normal activity

mild persistent

asthma class? Fev1 >= 80% predicted; fev1/fvc normal

mild persistent

asthma class? Sx daily

moderate persistent

asthma class? Nighttime awakening > 1x/week, but not nightly

moderate persistent

asthma class? Saba daily

moderate persistent

asthma class? Some limitation/interference with normal activity

moderate persistent

asthma class? Fev1 > 60% predicted

moderate persistent

is fev1/fvc normal with intermittent asthma?

yes

is fev1/fvc normal with mild persistent asthma?

yes

is fev1/fvc normal with moderate persistent asthma?

yes

asthma class? Sx throughout the day

severe persistent

asthma class? Nighttime awakening often 7x/week

severe persistent

asthma class? Saba several times a day

severe persistent

asthma class? Normal activity extremely limited

severe persistent

asthma class? Fev1 < 60% predicted

severe persistent

asthma class? Fev1/fvc reduced > 5%

severe persistent

must there be episodes with sx of airflow obstruction to be present for asthma diagnosis?

yes

must airflow obstruction be at least partially reversible for asthma diagnosis?

yes

how is reversibility defined re asthma?

as a 12% or greater increase in FEV1 after 2 puffs of a SABA have been inhaled

how is asthma diagnosis made?

by demonstrating reversibility of airway obstruction from pre and post-bronchodilator PFTs

what often precedes an acute asthma attack?

infections

how may a CXR look with asthma?

negative or show hyperinflation

what kind of approach to asthma management is required?

aggressive

should you identify factors that exacerbate asthma re management?

yes

should patients monitor pefr daily w/ asthma, including a symptom record?

yes

pft variability with intermittent asthma?

> 20%

pft variability with mid persistent asthma?

20-30%

pft variability with moderate persistent asthma?

> 30%

pft variability with severe persistent asthma?

> 30%

what two diagnoses often accompany a diagnosis of asthma?

allergic rhinitis and atopic dermatitis

condition? A chronic, inflammatory obstructive disease of the airways

asthma

can asthma occur at any age?

yes

what causes wheezing with asthma?

airway spasm

does chest tightness characterize asthma?

yes

does dyspnea/breathlessness characterize asthma?

yes

can asthma s/s remit spontaneously?

yes

can asthma s/s worsen in response to stress or environmental triggers?

yes

can beta blockers trigger asthma?

yes

can aspirin trigger asthma?

yes

what are common precursors to an asthma attack?

upper respiratory infections (esp viral)

condition? A chronic inflammatory disease characterized by reversible hyperreactivity of the bronchi and bronchioles to a variety of stimuli

asthma

what two things does airway inflammation cause with asthma?

bronchial hyperreactivity and airflow limitation

acute bronchoconstriction with asthma?

yes

airway edema with asthma?

yes

mucous plug formation with asthma?

yes

airway narrowing with asthma?

yes

bronchial obstruction with asthma?

yes

is asthma an obstructive pulmonary disease with hypoxia during acute exacerbations?

yes

what happens to residual volume in the lungs with asthma?

increases

what happens to peak expiratory flow rate with asthma?

decreases

what metabolic imbalance happens d/t hyperventilation with asthma?

respiratory alkalosis

hypocapnia due to hyperventilation with asthma?

yes

is there always wheezing with severe obstruction in asthma?

what percentage of asthma patients report that exercise exacerbates their sx?

0.9

what time of day are asthma symptoms usually worse?

at night

can metabisulfites, msg, and dairy trigger asthma?

yes

is airflow limitation reversible with asthma?

yes

is there diurnal variation with asthma?

yes

what is a common feature of asthma?

nocturnal awakening with one or more of these: dyspnea, cough, wheezing

should asthma always be considered with a chronic cough?

yes

what kind of wheezing is most common with mild to moderate persistent asthma?

expiratory wheezing

what happens to the chest with severe persistent asthma?

hyperinflation (increased AP diameter)

what condition frequently coexists with asthma?

allergic rhinitis

asthma- ICS are controller or quick relief?

controller

asthma- LABA are controlled or quick relief?

controller

asthma- LTRAs are controller or quick relief?

controller

asthma- ICS + labas are controller or quick relief?

controller

asthma- methylxanthines are controller or quick relief?

controller

asthma- sabas are controller or quick relief?

quick relief

asthma- anticholinergics are controller or quick relief?

quick relief

asthma- systemic corticosteroids are controller or quick relief?

quick relief

asthma- are immune modulators controller or quick relief?

controller

asthma- GINA step 1

as needed low-dose ICS formoterol

asthma GINA step 2

as needed low-dose ICS- formoterol

asthma- GINA step 3

low dose maintenance ICS- formoterol

asthma- GINA step 4

medium dose maintenance ICS- formoterol

asthma- GINA step 5

add on LAMA; consider high dose ICS formoterol

asthma- NAEPP step 1?

as needed SABA

asthma- NAEPP step 2

daily low dose ICS and as needed SABA OR as needd concomitant ICS and SABA

asthma NAEPP step 3?

daily and as needed combination low dose ICS formoterol

asthma NAEPP step 4

daily and as needed; combination medium dose ICS- formoterol

asthma NAEPP step 5

daily scheduled medium or high dose ICS and other LABA and LAMA and as needed SABA

asthma NAEPP step 6

daily scheduled high dose ICS + LABA+ OCS and as needed SABA

asthma class? Symptoms <= 2 days per week OR <= nights per month; brief exacerbations

mild intermittent

asthma class? PEFR or FEV1 >= 80% predicted; PFT variability after bronchodilator of more than 10%

mild intermittent

asthma class? Symptoms >= 2 times per week, but < 1 time peron day OR < 2 nights per months

mild persistent

asthma class? PEFR or FEV1 >= 80% predicted; PFT variability after bronchodilator of 20-30%

asthma class? Daily symptoms OR more than 3-4 nights per month

moderate persistent

asthma class? PEFR or FEV1 60-80% predicted; PFT variability after bronchodilator greater than 30%

moderate persistent

asthma class? Continuous symptoms OR frequent nighttime symptoms > 1 night per month

severe persistent

asthma class? PEFR or FEV1 less than 60% predicted; PFT variability after bronchodilator greater than 30%

severe

is PEFR used for follow-up for asthma?

yes

class? Selectively stimulate beta 2 adrenergic receptors to cause bronchodilation

short-acting beta 2 agonists

what is the first line treatment for rescue of bronchospasm?

short-acting beta 2 agonists

class? Terbutaline

short-acting beta 2 agonists

class? Salbutamol

short-acting beta 2 agonists

should you avoid MAOIs and TCAs within 14 days of sabas?

short-acting beta 2 agonists

are sabas used for bronchospasm?

yes

class? Aformoterol

long-acting beta2 agonists

class? Formoterol

long-acting beta2 agonists

class? Indacaterol

long-acting beta2 agonists

class? Olodaterol

long-acting beta2 agonists

brand name? aformoterol

brovana

brand name? olodaterol

striverdi respimat

are labas a preferred maintenance med for copd?

yes

are labas a first line therapy for copd?

are labas a rescue med or for bronchospasm?

how do samas work?

causes bronchodilation by blocking muscarinic effects of acetylcholine in the airways

how do lamas work?

causes bronchodilation by blocking muscarinic effects of acetylcholine in the airways

class? Ipratropium

short-acting muscarinic antagonists

brand name? ipratropium

atrovent

generic name? atrovent

ipratropium

class? Glycopyrrolate

long-acting muscarinic antagonists

class? Umeclidinium

long-acting muscarinic antagonists

are lamas used for acute bronchospasm?

class? nonspecific phosphodiesterase inhibitor that produces bronchodilation

methylxanthines

class? Theophyilline

methylxanthines

why are methylxanthines rarely used with COPD?

due to narrow therapeutic window and many drug interactions

is lama + laba used for acute bronchospasm?

is laba + ics + lama used for acute bronchospasm?

does laba + ics + lama cause bronchodilation?

class? Selectively inhibit PD4 in lung tissue and decrease airway inflammation

phosphodiesterase 4 inhibitors

are PDE4 inhibitors used for acute bronchospasm?

what are three common pathogens re COPD exacerbations?

s pneumoniae, h influenzae, m catarrhalis

can doxycycline 100 mg q 12 hours be used for copd exacerbation?

yes

can trimethoprim-sulfamethoxazole 160/800 q 12 hrs be used for copd exacerbations?

yes

can cefpodozime 200 mg q 12 hours be used for copd exacerbations?

yes

can azithromycin pack be used for copd exacerbations?

yes

can amox/clav 875/125 be used for copd exacerbations?

yes

what two vaccines are important for patients with copd?

influenza, pcv 13

how long can you give PO steroids with copd?

10-14 days

condition? Irreversible condition that results in progressive obstruction of airflow

copd

what two diagnoses are involved in copd?

chronic bronchitis, emphysema

condition? A preventable and treatable disease characterized by chronic airflow limitation that is not fully reversible

copd

condition? Partially reversible airflow limitation as well as presence of chronic productive cough

chronic obstructive bronchitis

condition? An abnormal permanent enlargement of the air space distal to the terminal bronchioles

emphysema

condition? The septa of the aleveoli are destroyed and the air spaces are enlarged

emphysema

condition? Prolonged exposure to bronchial irritants (tobacco) leads to goblet cell hyperplasia that leads to increased mucus hypersecretion

chronic bronchitis

chronic cough with copd?

yes

dyspnea with copd?

yes

current or previous tobacco use with copd?

yes

chronic sputum production with copd?

yes

history of exposure to dust/chemicals possible with copd?

yes

barrel chest with copd?

yes

diminished breath sounds with copd?

yes

prolonged expiratory phase and expiratory wheezing with copd?

yes

inspiratory and expiratory wheezing during copd exacerbation?

yes

coarse crackles during copd exacerbation?

yes

is neck vein distention a late finding of copd?

yes

is lower extremity edema a late finding with copd?

yes

is nail clubbing a late sign with copd?

yes

can mental status changes occur with late copd?

yes

spirometry used to dx copd?

yes

why would you do an abg with copd?

to determine hypoxemia and hypercapnia

why would you get a cbc with copd?

eval for anemias

why would you test total protein and albumin with copd?

nutritional status

what is the SF-36 health survey for re copd?

quality of life and need for pulmonary rehab

copd class? 80% or greater fev1, no abnormal signs, cough +- sputum, little or no dyspnea

mild

copd class? b/w 80-50% fev1, breathlessness, cough, variable abnormal signs, hypoxemia possible

moderate

copd class? 30-50% fev1, dyspnea with any exertion or rest; wheeze and cough often prominent

severe

copd class? <30% fev1, lung hyperinflation, peripheral edema, cyanosis, polycythemia, hypoxemia, hypercapnia

very severe

what are the three major goals of copd management?

1) maximize functional capacity; 2) prevent and treat secondary medical complications; 3) improve quality of life by decreasing resp sx

what is the standard therapy for chronic hypoxia?

oxygen therapy

what is the goal of oxygen therapy with copd?

maintain o2 sat >= 90%

what is the max length of oral steroids with copd exacerbation?

10-14 days

what do guidelines recommend in diagnosis of copd to determine severity if dx involves bronchitis and emphysema?

spirometry

may cxr appear normal with copd?

yes

condition? Cxr may show increased lung markings in the lower lobes w/ perilobial thickening

chronic bronchitis

condition? Hyperinflation or a sign of air trapping (low, flat diaphragm and enlarged retrosternal space)

emphysema

what does ics + laba + lama do in copd?

improve lung function

what is a normal BP?

< 120/80

what is an elevated BP?

120-129/<80

what is stage 1 hypertension?

130-139/80-89

what is stage 2 hypertension?

>= 140/90

bp category? 123/62

elevated

bp category? 100/74

normal

bp category? 145/90

stage 2

bp category? 138/83

stage 1

bp category? 160/120

stage 2

bp category? 88/62

normal

bp category? 131/89

stage 1

bp category? 128/77

elevated

bp category? 125/77

elevated

bp category? 135/89

stage 1

bp category? 148/98

stage 2

bp category? 110/70

normal

bp category? 140/95

stage 2

bp category? 132/86

stage 1

bp category? 145/92

stage 2

bp category? 117/78

normal

start med? 32 y/o bp 112/74

start med? 58 y/o, bp 132/86, ascvd risk 8%

start med? 65 y/o, bp 134/88

yes

start med? 41 y/o bp 120/80, diabetes

start med? 48 y/o, 108/72

start med? 54 y/o, bp 140/90, 10 year risk 13%

yes

start med? 18 yo, 110/70, 10 year ascvd risk 9%

start med? 23 yo 130/86, diabetes

start med? 80 yo, 118/78

start med? 72 y/o 150/100, 10 yr ascvd risk 12%

yes

start med? 57 y/o 136/90, diabetes

yes

start med? 71 yo, 140/86

start med? 64 y/o, 122/78

start med? 33 y/o bp 138/86, 10 year ascvd risk 7%

start med? 81 yo, 148/94, known CVD

yes

A black male patient with chronic kidney disease with an average bp of 138/82. what are the two best first-line agents?

acei, arb

A black male patient with a BP of 146/92 (Stage 2 htn) without chronic kidney disease- what are the best two first-line agents?

ccb, thiazide diuretic (e.g., chlorthalidone or hctz)

what two antihypertensive med classes should you not prescribe simultaneously in a primary care setting?

acei and arb

what classes of antihypertensive meds should you avoid for pregnant patients?

acei and arb

what classification of antihypertensives is not considered a 1st line agent for any patient for the treatment of htn?

beta blockers

you have a patient with a diagnosis of isolated, systolic HTN and asthma, migraines, or ischemic disease. What classification should be selected for consideration of stroke prevention?

ccb

you have a patient with dm and htn. Which two classifications should you consider choosing between?

acei and arb

you have a patient with metabolic syndrome and htn. Which three classifications should you consider choosing between?

acei, arb, and ccb

you have a patient with high risk CAD. Which classifications should you consider choosing between for angina?

bb and ccb

you have a patient with high-risk CAD. Which classes should you consider choosing between for asymptomatic atherosclerosis?

acei and ccb

you have a patient with post-MI and htn. What are two options you should consider choosing between?

acei and arb+bb

what is a normal SBP?

< 120

what is a normal DBP?

< 80

what is an elevated SBP?

121-129

what is the DBP in elevated class?

> 80

what is the SBP in stage 1 HTN?

130-139

what is the DBP in stage 1 hypertension?

81-90

what is the SBP in stage 2 hypertension?

>= 140

what is the DBP in stage 2 hypertension?

>= 90

what is the threshold for starting antihtn med with HTN and known CVD or 10-yr ascvd event risk >= 10%?

130/80

what is the threshold for starting antihtn med with no history of CVD and 10 yr ascvd event risk < 10%?

140 systolic

what is the threshold for starting antihtn med for age >= 65 y/o?

130 systolic

what is the threshold for starting anti htn med for patient with diabetes?

130/80

what is the BP goal for heathy patients>= 60 y/o?

<= 150 / <= 90

what is the BP goal for healthy patients < 60 y/o?

<= 140/ <= 90

what is the BP goal for patients with dx of DM or CKD regardless of age?

<= 140/ <= 90

at what point can you diagnose hypertension without further confirmation?

>= 180/110

when should you start bp meds on patients < 60 y/o?

140/90

when should you start bp meds with confirmed htn or 10 year ascvd risk >= 10%?

130/80

when should you start meds on patients with ckd?

140/90

when should you start meds with no history of cvd and ascvd < 10%?

140/90

when should you start meds on patients >= 60 y/o?

150/90

when should you start meds on patients with DM?

130/80

what is the BMI goal for htn?

18.5-24.9

what is the goal for dietary reduction of sodium with htn?

< 2.4 grams

what is the goal for physical activity with htn?

> 30 minutes per day most day of the week

are beta blockers first line for uncomplicated htn?

would you consider bbs with htn + HF?

yes

would you consider bbs with htn + first 2-3 years post-mi?

yes

would you consider bbs with htn + ischemic CVD?

yes

would you consider bbs with htn + migraines?

yes

are CCBs useful for isolated systolic htn?

yes

are CCBs useful for htn with asthma?

yes

are CCBs useful for htn with migraines?

yes

are ccbs useful for htn with ischemic disease?

yes

are ccbs considered for stroke prevention?

yes

what should african american patients use for htn without CKD?

ccbs and thiazides instead of ace-is

what two classes are recommended for initial treatment in all patients with CKD, regardless of ethnic background or DM?

ace-is or ARBS

should aceis and arbs be used together?

how many drugs should be started with stage 2 htn?

two drugs

condition? Bp 180/110 (or higher) with evidence of acute target organ damage

malignant htn

what is the difference between htn urgency and htn emergency?

htn urgency has no target organ damage

does htn urgency show evidence of tod?

does htn emergency show evidence of tod?

yes

how can htn urgency be treated?

with oral agents over 24-48 hours to achieve stabilization

how should htn emergency be managed?

bp reduction in course of hours with oral or IV meds in an inpatient setting

what is the primary goal of HTN treatment?

to attain and maintain goal BP to prevent target organ damage

what is a common and early finding/complication of htn?

left ventricular hypertrophy

can HF be a complication of HTN?

yes

class? Chlorthalidone

thiazide diuretic

class? Hctz

thiazide diuretic

are thiazides a first line therapy to treat htn?

yes

at what creatinine do thiazides become less effective?

> 1.8

which is more potent- loop diuretics or thiazide diuretics?

loop

which are more effective in bp mgmt- loop or thiazide diuretics?

thiazide diuretics

class? Bumetanide

loop diuretic

do loop diuretics likely remain effective in patients with creatinine > 1.8?

yes

class? Spironolactone

aldosterone receptor blocker

is spironolactone a strong antihtn med?

no, weak

class? Block the effects of serum aldosterone and are effective at regulating sodium and water homeostasis to maintain stable intravascular volume

aldosterone receptor blocker

class? Not indicated as 1st line mgmt of htn unless compelling indications present (e.g., ACS, HF)

beta blockers

class? May be used in combo with other anti-htn agents, esp thiazides

beta blockers

are beta blockers a core component for patients with ACS?

yes

are aceis effective for patients with HF?

yes

are aceis effective for patients post-mi?

yes

are aceis effective for patients with renal insufficiency?

yes

are aceis effective for patients with DM w/ nephropathy?

yes

what class is an alternative to aceis in patients who develop a chronic cough 2/2 aceis?

angiotensin receptor blockers

specific class? Amlodipine

dihydropyridine ccb

specific class? Felodipine

dihydropyridine ccb

specific class? Diltiazem

nondihydropyridine ccb

specific class? Verapamil

nondihydropyridine ccb

what are the most potent anti-htn agents routinely utilized?

calcium channel blockers

class? May be useful for treatment of stable angina pectoris, esp dihydropyridines

calcium channel blockers

class? Can be effective in management of angina from coronary artery vasospasm

calcium channel blockers

class? Doxazosin

alpha adrenergic blockers

class? Prazosin

alpha adrenergic blockers

class? Terazosin

alpha adrenergic blockers

are alpha adrenergic blockers a first line agent?

do alpha adrenergic agents alter lipid metabolism by decreasing LDL and VLDL?

yes

class? Hydralazine

direct vasodilator

class? Isosorbide dintrate

direct vasodilator

class? Minoxidil

direct vasodilator

what class of med is good for htn in pregnancy?

direct vasodilators

how can nsaids negate the BP lowering effects of select anti-htn meds?

by increasing sodium retention

what can happen to htn with vasoconstricting meds (e.g., decongestants)?

lead to persistently elevated BP readings

what can excessive ETOH do re: anti htn meds?

prevent them from achieving their full therapeutic effect

what is one of the first manifestations of etoh withdrawal?

bp elevation

what is the key to htn mgmt?

reversal of htn-related disease and prevention of tod

how much can weight reduction lower bp?

5 to 20 mm hg

how mcuh can dash diet lower bp?

2 to 8 mmhg

how much can reduction of dietary sodium to no more than 2.4 g/day reduce bp?

2-8 mmhg

how much can reg physical activity reduce bp?

4-9 mm Hg

how much can moderation of ETOH lower bp?

2 to 4 mmhg

what should you do with patients with elevated sbp up to 129 and dbp up to 80?

adopt healthy lifestyle mods and re-eval in 3-6 months

what is the recommended target sbp for patients with DM?

< 130

what is the recommended target DBP for patients with DM?

< 80

in black patients, initial tx of htn may consist of what?

a ccb or a thiazide

in what population are aceis less effective?

black patients

in patients with ckd, tx should be initiated to lower the bp to what?

sbp < 130 and dbp < 80

what should the initial medication choice be for patients with CKD?

acei or an arb

what are preferred htn meds for patients w/ dm?

acei or arb

what are preferred htn meds for patients with metabolic syndrome?

ace I or arb or ccb

what are the preferred htn meds for ckd?

ace-I or arb

condition? High BP that has no identifiable etiology after a thorough clinical exam excludes possible secondary causes

essential htn

condition? Denotes elevated bp d/t an identifiable condition

secondary htn

condition? A transient risk in BP of patient when in a clinical setting, up to 13%

white coat htn

what is the most likely cause of white coat htn?

anxiety

condition? Htn present during daily life and absent in clinical assessment

masked htn

condition? Encompasses hypertensive urgency/emergency

malignant htn

what is the key to ddx of htn?

determine the underlying etiology of the htn

what is the most common culprit of PAD?

atherosclerosis

is smoking a RF for PAD?

yes

is diabetes a RF for PAD?

yes

is renal insufficiency a RF for PAD?

yes

is obesity a RF for PAD?

yes

what age group is at increased RF PAD?

> 60

is sedentary lifestyle a risk factor for PAD?

yes

what are the five Ps?

pain, pallor, pulselessness, paralysis, paresthesia

pulse 0+?

no pulse

pulse 1+?

thready pulse

pulse 2+?

normal pulse

pulse 3+?

bounding pulse

pulse 4+?

aneurysmal pulse

muscular atrophy with pad?

yes

absent or diminished pulses with pad?

yes

thin, cool, and pale skin with pad?

yes

thick toenails with pad?

yes

delayed wound healing with pad?

yes

reddish-blue dependent extremity with pad?

yes

how is pad diagnosed?

doppler ultrasound flow study

test? The pressure in your ankle is compared to the pressure in your arm to determine how well your blood is flowing

abi

how is the abi calculated?

divide the highest ankle systolic pressure with the highest brachial pressure for the index

what is a normal abi?

> 0.9

what abi indicates a moderate level of disease?

0.6-0.9

what abi indicates severe ischemia?

< 0.5

what is pad treatment focused on?

CV risk modification

what is the primary long-term benefit of antiplatelet agents with pad?

decreased CV events and mortality

arterial or venous? Intermittent claudication, may progress to pain at rest

arterial

arterial or venous? Pale to dependent rubor in color; dull to bright reddish color

arterial

arterial or venous? Skin temp takes on environmental temp, cool

arterial

arterial or venous? Diminished to absent pulses

arterial

arterial or venous? No edema present with isolated disease

arterial

arterial or venous? Skin is shiny w/ hair loss

arterial

arterial or venous? Trophic changes in nails

arterial

arterial or venous? Muscle wasting

arterial

arterial or venous? Wounds occur distally, esp at toes

arterial

arterial or venous? Pain- chronic, dull aching pain which progresses throughout the day

venous

arterial or venous? Normal to cyanotic color

venous

arterial or venous? Normal skin temp

venous

arterial or venous? Edema present, can be pitting, can have weeping of serous fluid

venous

arterial ro venous? Stasis dermatitis with flaky and dry scaly skin

venous

arterial or venous? Can have brownish discoloration

venous

arterial or venous? Fibrosis with narrowing of the lower legs (bottle legs)

venous

arterial or venous? Shallow ulcers on foot and ankle

venous

condition? Formation of a blood clot deep in the circulatory system

dvt

what are is the triad of risk factors for dvt?

venous stasis, vessel injury, hypercoagulability

venous stasis, vessel injury, hypercoagulability- triad for what?

dvt

can dvt be asymptomatic?

yes

condition p/w swelling in affected extremity- usually unilateral?

dct

pain in calf with dvt?

yes

leg cramps, tenderness, soreness w/ dvt?

yes

erythema, pallor, or cyanosis with dvt?

yes

positive homan's sign with dvt?

yes

test? Measurement is a fragmented protein that has a negative predicted value

d dimer

what is the therapeutic range of INR of warfarin?

2 to 3

can dabigatran 150 mg BID be used for DVT?

yes

can apixaban 5 mg BID be used for DVT?

yes

active cancer part of wells criteria for dvt?

yes

paralysis, paresis, or recent cast of Les part of wells criteria for dvt?

yes

is previous dvt part of wells criteria for dvt?

yes

are collateral supericial veins part of wells criteria for dvt?

yes

is entire leg swelling part of wells criteria for dvt?

yes

murmur of what? Harsh systolic murmur, usually crescendo-decrescendo pattern

aortic stenosis

where is aortic stenosis murmur best heard?

2nd right ICS near apex

where does aortic stenosis murmur radiate?

to carotids

what happens to aortic stenosis murmur with standing?

softens

murmur of what? High-pitched blowing diastolic murmur

aortic regurgitation

where is aortic regurgitation murmur best heard?

at 3rd left ics

what may enhance aortic regurgitation murmur?

forced expiration leaning forward

is aortic regurgitation murmur more common in men or women?

men

murmur of what? Soft systolic 50 over 50 murmur

aortic sclerosis

where is aortic sclerosis murmur best heard?

2nd right ICS in aortic valve region

what murmur may precede aortic stenosis?

aortic sclerosis

murmur of what? Middiastolic rumbling murmur, accentuated s1 in early disease

mitral stenosis

where is mitral stenosis murmur best heard?

at apex with bell in left lateral decubitus position

murmur of what? Holosystolic murmur, best heard at apex and radiates to axilla

mitral regurgitation

murmur of what? Midsystolic click followed by late systolic murmur

mitral prolapse

where is mitral prolapse murmur best heard?

at apex

murmur of what? Fixed splitting of s2 during both inspiration and expiration

atrial septal defect

ddx for this? Chest pain anywhere on chest, dull or stabbing pain, usually with hyperventilation or breathlessness, sudden onset, may last <1 min to several days

rule out anxiety

ddx for this? Localized chest pain, may have point tenderness, sharp, continuous or gradual; worse with movement or palpation

rule out costochondritis

ddx for this? Epigastric chest pain, burning after eating, may be a/w hematemesis or tarry stools; sudden onset; usually subsides in 15 to 20 minutes

rule out hiatal hernia and GERD

ddx for this? Lower chest or upper abd chest pain; sharp and severe; agg by eating a heavy meal, bending, or lying down

rule out hiatal hernia and GERD

ddx for this? Chest pain to lateral thorax; severe; may be a/w dyspnea; increased HR, decreased breathsounds, deviated trachea, sudden onset

rule out pneumothorax

ddx for this? Chest pain over lung area; stabbing; may be a/w cyanosis, dyspnea, cough w/ hemoptysis

rule out PE

ddx for this? Retrosternal, upper ABD, or epigastric pain; may radiat to back, neck, shoulders; excruciating, tearing; may be a/w different bp in right and left arms, sudden onset

rule out aortic dissection or pleuritis

ddx for this? Substernal chest pain, may radiate to neck, left arm; sharp and may be a/w friction rub; sudden onset

rule out pericarditis or pleuritis

ddx for this? Pain across chest, may radiate to jaw, neck, back, and arms; pressure, burning, aching, tightness; sob, diaphoresis, weakness, anxiety, nausea, sudden onset; lasts 1/2 to 2 hours

rule out acute MI

ddx for this? Substernal/retrosternal chest pain; may radiate to jaw, neck, arms, back; diffuse, aching, squeezing, pressure, heaviness, usually subsides within 10 minutes

rule out angina

can chest pain be a/w CV problems?

yes

can chest pain be a/w pulmonary problems?

yes

can chest pain be a/w musculoskeletal problems?

yes

can chest pain be a/w neuro problems?

yes

can chest pain be psychogenic?

yes

can chest pain be idiopathic?

yes

localized, fleeting, transient pain that transfers locations in the chest- usually serious?

no, rarely indicates severe heart pathology

condition? Defined as the awareness of the beating of one's own heart

palpitations

can palpitations be benign?

yes

can palpitations be pathological?

yes

what is the most common form of a sustained arrhythmia?

atrial fibrillation

should you check thyroid function with arrhythmia?

yes

should you check serum chemistries with arrhythmia?

yes

should you check h/h with arrhythmia?

yes

why should you check h/h with arrhythmia?

r/o anemia

condition? A loss of consciousness that occurs abruptly as a discrete episode, usually lasts for a short period- only a few minutes

syncope

what is the implied patho with syncope?

decreased cerebral blood flow d/t marked decrease in cardiac output

is syncope usually cardiac in origin?

yes

what is the most common cause of syncope?

vasovagal

is cardiac-related syncope an ominous sign?

yes

what may be the only warning sign of impending sudden cardiac death?

syncopal episode

what are one of the most common cardiac causes of syncope?

cardiac arrhythmias

condition? Lightheadedness, feeling faint, muscular weakness

presyncope

what is the most common origin of presyncope?

CV origin

is vertigo usually caused by decreased cerebral blood flow?

condition? Shortness of breath

dyspnea

is dyspnea a highly subjective complaint?

yes

is dyspnea a sensitive and specific marker for CV disease?

condition? Sob in supine position

orthopnea

condition? Sob that occurs 1-2 hours into sleep

paroxysmal nocturnal dyspnea

can PVD affect both arteries and veins?

yes

when vascular disease is arterial, it is usually the result of what?

atherosclerosis

condition? Accumulation of fatty streaks and fibrosis plaques and high levels of LDLs

atherosclerosis

condition? A general term for elevated concentrations of any or all different types of lipids in the plasma

dyslipidemia

increased lipid levels correlate with an increased r/f what?

acs

what do guidelines recommend considering in patients who do not currently have CVD, but who have a 7.5% or greater risk for stroke or MI?

statin therapy

what is the desirable total cholesterol level?

125 to < 200

what is a borderline high total cholesterol level?

200-239

what is a high total cholesterol level?

>= 240

what is a normal triglyceride level?

< 150

what is a borderline high triglyceride level?

200-239

what is a high triglyceride level?

200-499

what is a very high triglyceride level?

>= 500

what is a low HDL?

< 40

what is a high/optimal/cardioprotective hdl?

> 60

goal ldl for high risk patients (e.g., diabetic)?

< 70

what is the goal ldl for general patients?

< 100

what is a very high ldl?

> 190

what is a high ldl level?

160-189

condition? A heterogeneous metabolic disorder that involves abnormal levels of lipids and lipoproteins that increase risk for atherosclerosis

dyslipidemia

term? The specific type of cholesterol that constitutes the lipid core of atherosclerotic plaque deposits

ldl

term? Removes excess cholesterol from blood vessels and transports it back to the liver through reverse cholesterol transport

hdl

term? Plays a protective role by blocking the oxidation of ldl which in turn inhibits atherogenesis

hdl

how do patients with dld typically present?

without symptoms

term? Yellowish skin deposits of cholesterol

xanthomas

what is the main goal of diagnostic testing for dld?

to adequately characterize the levels of various components of the plasma

can hdl decrease with inactivity?

yes

can alcohol abuse increase TG, HFL, and LDL?

yes

can DM increase TG and TC?

yes

what effect does DM have on HDL?

decrease

does hypothyroidism increase TG and TC?

yes

is a cholesterol-lowering diet recommended for all americans?

yes

what are the three goals of dyslipidemia treatment?

lower elevated LDL, lower elevated TG, raise levels of HDL

how much sat fat is recommended daily?

<7% of total daily calories

what kind of diet has been shown to decrease cholesterol levels?

mediterranean diet

what percentage of total fat is recommended to decrease cholesterol?

20-30% of daily calories

what is the cornerstone of dyslipidemia treatment?

diet

is diet alone often sufficient to decrease cholesterol?

what is the first line drug of choice for DLD?

statins

should these patients be on a statin? Hx of acs, mi, stable/unstable angina, stroke/TIA, PAD, atherosclerosis

yes

should pts with ldl >= 190 be on a statin?

yes

should patients 40-75 y/o with DM be on a statin?

yes

should patients 40-75 y/o with a 10 yr risk CV risk of >= 7.5 % be on a statin?

yes

intensity? Atorvastatin 40-80

high

intensity? Rosuvastatin 20-40 mg

high

by how much can high intensity statin lower ldl?

50% on average

effect of high intensity statin on HDL?

increased

intensity? Atorvastatin 10-20 mg

moderate

intensity? Lovastatin 40-80 mg

moderate

intensity? Pravastatin 40-80 mg

moderate

intensity? Rosuvastatin 5-10 mg

moderate

intensity? Simvastatin 20-40 mg

moderate

by much much can moderate intensity statin lower ldl?

30-50% on average

should patients with active or chronic liver disease be on a statin?

what lab should you check when starting statin?

liver function

men over what age are at increased risk for dyslipidemia?

>= 45 y/o

women over what age are at increased risk for dyslipidemia?

>= 55 y/o

is a family hx of congenital heart disease a risk factor for dyslipidemia?

yes

is cigarette smoking a risk factor for dislipidemia?

yes

is htn a risk factor for dyslipidemia?

yes

is metabolic syndrome a risk factor for dyslipidemia?

yes

is a history of MI a risk factor for dyslipidemia?

yes

is a history of stable/unstable angina a risk factor for dyslipidemia?

yes

what is the bmi goal re dyslipidemia?

18-24.9

term? Used for the disorders of myocardial ischemia

acute coronary syndrome

what are the three traditional types of acs?

nstemi, stemi, and unstable angina

condition? Angina due to myocardial ischemia is newly diagnosed angina or previously dx angina that has changed in pattern, frequency, or severity

unstable angina

what is commonly a forerunner of AMI?

unstable angina

condition? A diagnosed condition of myocardial ischemia that is predictable in pattern and frequency and is controlled w/ medication

stable angina

what patient population is the highest risk group for further coronary events?

patients w/ a previous MI

condition? Broad term, continuum of disorders that arise from coronary artery occlusion

acute coronary syndrome

is stable angina considered a form of acs?

condition? Coronary artery occlusion causes a brief episode of ischemia that is treatable and reversible

stable angina

condition? Coronary artery occlusion causes ischemia with a high risk for MI, which can occur with prolonged ischemia

unstable angina

condition? Atypical form of angina pectoris that occurs as a result of vasospasm of otherwise normal coronary arteries

variant angina

condition? An infarction caused by a nonocclusive thrombus that partially interrupts perfusion of the myocardium and results in an infarction affecting only part of the myocardial wall, rather than full thickness

nstemi

condition? Caused by an occlusive thrombus that leads to a complete transmural MI (infarct of the full thickness of the myocardial wall)

stemi

when can angina pectoris pain frequently occur?

after meals because of the increased oxygen consumption during the meal and greater diversion to splanchnic circulation

can stable angina be relieved by nitro?

yes

condition? Angina-like chest pain lasting > 20 minutes

acute MI

condition? Transient episodes of chest pain r/t activities that increase myocardial oxygen demand

stable angina

how long does stable angina usually last?

3-15 minutes

what two things can relieve stable angina?

rest and/or nitro

condition? More severe chest pain, brought on by less exertion, may occur at rest, prolonged duration

unstable angina

is unstable angina relieved by rest and/or nitro?

is unstable angina relieved by morphine?

yes

condition? Chest pain episodes unrelated to activities that increase myocardial oxygen demand

variant angina

when does variant angina often occur?

during sleep, early morning hours

which angina? Pain intensifies quickly and lasts longer than with stable angina

variant angina

which angina may subside with exercise?

variant angina

which is the high-sensitivity cardiac troponin?

troponin I

when do tropinin I levels rise?

within the first 2-4 hours

how long do troponin I levels stay elevated?

7-10 days

when do CKMB levels rise after an MI?

within 4-8 hours

is myoglobin specific for heart muscle death?

is leukocytosis a nonspecific indicator of myocardial injury?

yes

what is the goal of ACS management?

promptly diagnose and treat the underlying etiology of myocardial ischemia

which angina? Harbinger of more severe cardiac ischemia

unstable angina

which angina? Ischemia chest pain relieved by nitro and rest

stable angina

what is the duration of chronic anginal pain episodes?

3-5 minutes

what meds can be added to regimen after chest pain Is relieved?

a beta blocker and/or long-acting nitrate

med class? Decrease myocardial oxygen demand by interfering with effects of sympathetic nervous system on beta 1 receptors of the heart

beta blockers

med class? may be added to a beta blocker to increase myocardial oxygen supply through coronary artery vasodilation

long-acting nitrates

what is the pharmacologic treatment of ACS directed at?

the dissolution of the thrombus that is causing obstruction of blood flow

what is the goal of MI management?

to salvage the ischemic myocardium before it becomes necrotic by reperfusing the area asap, then it shifts to preventing future Mis

when should aspirin be given relative to MI symptom onset?

within 70 minutes

what dose of aspirin should be given for its antiplatelet effects with MI?

162-325

what effects does nitro have during MI?

decreases preload and coronary artery vasospasm

when are thrombolytic agents most effective in an MI?

when given in the early course of an MI

when is the best therapeutic effect of thrombolytic agents in MI?

within first 3 hours (ideally 30 min) of symptom onset

what has been shown to be more effective than thombolysis for stemi if dne within 90 min?

immediate coronary angiography and primary PCI

effect of bb on myocardial oxygen demand?

decreased

effect of bb on myocardial wall stress?

decreased

effect of bb on arrhythmogenic effects of catecholamines?

antagonizing these effects

mod/nonmod rf heart disease? Male gender

nonmodifiable

non/nonmod rf heart disease? Increasing age

nonmodifiable

non/nonmod rf heart disease? Family hx cad

nonmodifiable

non/nonmod rf heart disease? African american, hispanic, indigenous descent

nonmodifiable

mod/nonmod rf heart disease? Hypertension

modifiable

mod/nonmod rf heart disease? Smoking

modifiable

mod/nonmod rf heart disease? Excess etoh use

modifiable

mod/nonmod rf heart disease? Sedentary lifestyle

modifiable

mod/nonmod rf heart disease? Unhealthy diet

modifiable

mod/nonmod rf heart disease? Hyperlipidemia

modifiable

mod/nonmod rf heart disease? Estrogen replacement therapy

modifiable

what range of bp is modifiable risk factor for heart disease?

> 140 and/or >= 90

is dm a contributing factor to heart disease?

yes

is obesity a contributing factor to heart disease?

yes

is stress a contributing factor to heart disease?

yes

if heart disease is left untreated, what is the usual presenting symptom?

exertional angina

when is a stress test contraindicated?

in the presence of known acute cvd (heart cannot respond to increased oxygen demand)

what is the origin of most URIs?

viral

condition? A life-threatening, rapidly progressive cellulitis of the epiglottis that may cause complete airway obstruction

acute epiglottitis

condition? Should be suspected when odynophagia seems severe compared with findings; dyspnea, drooling, and stridor

acute epiglottitis

condition? Aprupt onset w/ fever, chills, malaise, myalgia, headache, nasal stuffiness, sore throat, sometimes nausea; nonproductive cough early in illness, fever up to 103

influenza

management of influenza?

generally symptomatic

is mucopurulent rhinitis that accompanies the common cold an indication for antimicrobial treatment?

condition? An acute inflammation of the lung parenchyma, usually infectious in origin

pneumonia

condition? Lung tissue typically becomes consolidated as the alveoli fill with exudate

pneumonia

condition? Gas exchange may be impaired as blood is shunted around nonfunctional alveoli

pneumonia

which pneumonia? Occurs outside the hospital or is diagnosed within 2 days after hospitalization

community-acquired pneumonia

what organism is responsible for 70% of all cases of bacterial pneumonia?

streptococcus pneumoniae

condition? An infection of the alveoli, distal airways, and interstitium of the lungs and is predominately a parenchymal disease

pneumonia

condition? The spongy consistency of the lung tissue fills with fluid and several lineages of white blood cells infiltrate depending on the infective agent involved

pneumonia

term? The area of pneumonia, typically dull to percussion on physical exam

consolidative focus

is m catarrhalis common with CAP?

yes

is h influenzae common with CAP?

yes

what is the most common cause of CAP?

s pneumoniae

is s pneumoniae gram positive or gram negative?

gram positive

is h influenzae gram positive or gram negative?

gram negative

what is the second most common cause of CAP?

h influenzae

is legionella pneumophilia gram positive or gram negative?

gram negative

what percentage of adult cases of CAP are caused by viral infections?

5 to 15 percent

most viral infections (re pneumonia) are limited to where?

the upper respiratory symptoms

can influenza cause a primary viral pneumonia?

yes

condition? Also known as primary atypical pneumonia or walking pneumonia

mycoplasma pneumonia

condition? Characterized by a sudden onset of fever, cough, chest pain, and fatigue

pneumonia

bacterial or viral pneumonia? A productive cough

more likely bacterial

pts with what condition produce sputum with rusty coloration?

pneumococcala pneumonia

what kind of chest pain with pneumonia?

pleuritic

is myalgia a common complaint with pneumonia?

yes

condition? Gradual onset of a day 'hacking' cough, fever, and prominent constitutional symptoms

atypical pneumonia

splinting with pneumonia?

yes

chills with pneumonia?

yes

myalgia with pneumonia?

yes

crackles with pneumonia?

yes

dullness on percussion with pneumonia?

yes

bronchophony with pneumonia?

yes

egophony with pneumonia?

yes

whispered pectoriloquy with pneumonia?

yes

pleural friction rub with severe consoludation?

yes

what are the most common presenting symptoms of covid?

cough, fever, fatigue, dyspnea

condition? Acutely ill patient who c/o chest pain and demonstrates respiratory splinting on one side of the thorax

pneumonia

what may be the only abnormal findings with penumonia?

crackles and dullness to percussion

term? Increased resonance of voice sounds on auscultation

egophony

term? Increased volume or persistent loudness of the patient's voice throughout the lung fields and especially toward the periphery

bronchophony

term? Increased loudness of whispering on auscultation

whispered pectoriloquy

term? Tubular or hollow breah sounds over the large airways

bronchial breath sounds

what are the three most helpful tests in the initial establishment of a pneumonia diagnosis?

CXR, leukocyte count, gram stain of sputum

what test is used to determine if pneumonia is bacterial or viral?

cxr

lobar infiltrates strongly suggest a bacterial or viral pneumonia?

bacterial

condition? Will show dense homogeneous shadows involving one or more lobes on cxr

bacterial pneumonia

diffuse interstitial infiltrates on cxr suggest what?

viral or mycoplasma pneumonia

what complication occurs in approx one-third of pneumococcal pneumonia patients?

pleural effusion

what test do you use to r/o pleural effusion in pneumonia?

cxr

can a cbc help distinguish viral from bacterial pneumonia?

yes

total WBC counds > what suggest bacterial infection?

> 15,000

which is more valuable- sputum culture or a gram stain?

gram stain

acute bacterial pneumonia should be differentiated from what condition?

acute bacterial bronchitis

do acute bacterial pneumonia and acute bacterial bronchitis both produce a fever and productive cough?

yes

pneumonia or bronchitis? Patient will have clear lung sounds except for a few scattered rhonchi and possibly tubular sounds

bronchitis

pneumonia or bronchitis? Patient will likely have crackles, abnormal breath sounds, and dullness to percussion

pneumonia

what is the initial task in managing pneumonia?

determine if they can be treated outpatient or whether need hospitalization

cool? Criteria to determine the severity of CAP

curb-65

what does the curb-65 take into account?

confusion, BUN, RR, SBP, and age

what represents the mainstay of treatment for patients with suspected or confirmed pneumonia?

antimicrobial therapy

analgesics for chest pain and myalgia with pneumonia?

yes

antipyretics to control fever with pneumonia?

yes

increased fluid intake for pneumonia?

yes

what is the recommended fluid intake for patient with pneumonia?

at least 3 L over 24 hours

WHAT may be indicated in pneumonia to decrease sputum viscosity and clear airways if a productive cough is present

expectorants

before starting treatment for pneumonia, must determine what?

whether the patient has had recent antibiotic therapy and any coexisting diseases

empiric choices for CAP if no comorbidities no risk factors for MRSA or pseudomonas?

monotherapy with amoxicillin or doxycycline or macrolide antibiotic

empiric choices for CAP if have comorbidities?

combination therapy with amoxicillin/clav or cephalosporin AND macrolide or doxycycline OR monotherapy with respiratory fluoroquinolone

is m tuberulosis aerobic or anaerobic?

aerobic

condition? Onset is insidious, with symptoms of anorexia, fatigue, digestive disturbances, slow weight loss, irregular menses, and lack of stamina

tuberculosis

condition? Low-grade elevation of temp that appears in the afternoon

tuberculosis

condition? Characterized mainly by a productive cough, purulent sputum, and repeated occurrences of coryza-like symptoms with rhinorrhea and nasal congestion

pulmonary tb

condition? Cough progresses slowly over weeks or months to become more frequent and a/w production of mucoid or mucopurulent sputum

tuberculosis

rhonchi, crackles, wheezing, and bronchial breath sounds with tb?

yes

what is the most accurate and widely used method for TB testing?

mantoux tuberculin skin test

how long for tb test reaction to develop?

48 to 72 hours

what is the measurement for a positive TST in healthy people?

> 15 mm

what is the main goal of tb therapy?

eliminate all tubercule bacilli from the patient while avoiding the development of clinically significant drug resistance

what is the current minimum acceptable duration for treatment with culture-positive tb?

6 months

the initial phase of a 6-month regimen should consist of a 2-month course of what drugs?

isoniazid, rifampin, pyrazinamide, and ethambutol

should TB be drugs be taken with food or on an empty stomach?

empty stomach

which tb drug can cause peripheral neuropathy?

isoniazid

for how long are tb patients considered to be infectious after starting drug therapy?

2 to 3 weeks

condition? Condition in which cardiac output is insufficient to meet the body's metabolic demands

heart failure

condition? A constellation of clinical manifestations that result from the heart's inability to pump adequate amounds of blood to meet the oxygen demands of peripheral tissues

heart failure

condition? Involves a number of complex pathophysiological changes that are progressive

heart failure

type of hf? Can result from a dysfunctional ventricle that is unable to eject an adequate amount of blood

systolic dysfunction

type of hf? The inability of the ventricle to fill with a sufficient amount of blood

diastolic dysfunction

what are the most common underlying causes of hf?

ischemic heart disease and longstanding htn

what condition causes diminished coronary perfusion of the myocardium that weakens the strength of contractility of the ventricles?

ischemic heart disease

what condition creates excess mechanical stress on the ventricles, resulting in the structural changes of myocardial hypertrophy and left ventricular dilation?

hypertension

myocardial remodeline with heart failure?

yes

another name for systolic heart failure?

reduced LVEF

another name for diastolic heart failure?

preserved LEVF

which hf? Diminished ejection of blood from a weakened ventricle cannot pump sufficient blood volume forward into the arterial system, which results in decreased cardiac output and a hypoperfusion of end organs

systolic dysfunction

what is the most common type of heart failure?

left-sided heart failure

what is the most common cause of left-sided heart failure?

longstanding hypertension

which hf? Systemic hypertension increases resistance against the left ventricle, thereby increasing workload

left-sided heart failure

condition? Exertional dyspnea, cough, orthopnea, PND, crackles, and elevated pulmonary capillary wedge pressure

left-sided heart failure

what is a normal EF?

55 to 70

what type of hf dysfunction? An abnormality of filling, distensibility, or relaxation of the ventricles

diastolic dysfunction

what is the most common cause of right-sided heart failure?

as a result of LVF due to inadequate cardiac output into the systemic circulation

NYHA class? Patients with asymptomatic HF

NYHA class? Patients with HF symptoms with significant exertion

NYHA class? Patients with HF sx with marked limitation of physical activity

III

NYHA class? Patients with HF sx at rest

orthopnea is worse in what position with HF?

left lateral decubitus

why do hf patients breate easier w/ HOB elevated?

this position reduces preload (by decreasing venous return)

what happens to degree of dyspnea as HF progresses?

increases

condition? Breathlessness, dyspnea on exertion, pallor of extremities, distended peripheral veins

heart failure

lab value? Secreted in response to the atrial stretch that occurs in HF due to increased hydrostatic pressure within the atria

ANP

lab value? It is abundant in the heart and rapidly rises in the bloodstream in the presence of HF

BNP

in patients w/ dyspnea, what blood test can be used to rule out HF, as it is highly sensitive and unlikely to be normal in the presence of HF?

BNP

what lab test is a useful indicator of the degree of HF?

BNP

is BNP specific to HF?

can a patient have a normal cxr with HF?

yes

what might a cxr show with hf?

altered cardiac silhouette, pulmonary venous congestion

what ECG findings are common with HFrEF?

LVH or LBBB

what test is useful to measure intracardiac pressures?

right-heart catheterization

what medication are indicated for all patients with LV systolic dysfunction (unless specific contraindications)?

ace inhibitors

what meds are called the "cornerstone of HF therapy"?

ace inhibitors

what may be the sole therapy for a HF patient with fatigue and mild DOE?

ace inhibitors

what medications have been shown to decrease mortality in HF by counteracting many of the neurohumoral changes that affect the SNS and effect fluid balance via the RAAS system?

ace inhibitors

what med class can be used for patients that do not tolerate ace inhibitors?

ARBs

what does the sympathetic nervous system cause in HF?

arterial vasoconstriction and an increased heart rate

medication? Bb and alpha1 blocker that will slow heart rate and limit peripheral arterial vasoconstriction, thereby decreasing the force of afterload against the ventricles and in turn, the work of the heart

carvedilol

should regular exercise be encouraged for all patients with stable HF?

yes

what is the sodium restriction for patients with hf?

2g/day or less

should limitation of fluid intake be advised with hf?

yes

what are the weight parameters that should be reported by patients with HF?

3 or more lbs in 24 hours or 5+ pounds within one week

acetylcholine

effect of smoking on myocardial oxygen consumption?

increased

effect of smoking on heart rate?

increased

effect of smoking on systemic vascular resistance?

increased

effect of smoking on myocardial inotropic activity?

decreased

does smoking cause coronary artery vasospasm?

yes

effect of smoking on mucociliary clearance?

decreased

does smoking cause cough and bronchospasm?

yes

nicotine dependence is related to what?

the amount and duration of smoking

when do nicotine withdrawal symptoms start?

within a few hours

when do nicotine withdrawal symptoms peak?

48 to 72 hours

when do nicotine withdrawal symptoms resolve?

within 3 to 4 weeks

what should you do when you identify a patient as a smoker?

advise them of the need to quit

what are the five stages of behavioral change?

precontemplation, contemplation, preparation, action, and maintenance

which stage? Smokers in this stage have no desire to quit in the next 6 to 12 months

precontemplation stage

which stage? smokers in this stage are seriously thinking about and expressing interest in quitting, but are not yet ready

contemplation stage

which stage? Smokers are serious about quitting and have taken the initial steps toward cessation

preparation stage

which stage? Smoker quits smoking

action stage

which stage? Smoker has abstained from cigarettes for 6 months

maintenane stage

what med is an antidepressant and smoking deterrent?

bupropion

when should bupropion be started relative to patient's diesired quit date?

1 to 2 weeks before

what is the dosage for bupropion?

150 mg per day x 3 days, then 150 mg BID

medication? A nicotininc acetylcholine receptor partial agonist

varenicline (chantix)

chantix dosing?

0.5 mg daily x 3 days, 0.5 mg BID x 4 days, then 1 mg BID x 12 weeks

what modality has the most potential to assist in smoking cessation?

inhaler

term? subjective sensation of uncomfortable or difficult breathing

dyspnea

what is the majority dyspnea due to?

cardiopulmonary issues

what kind of virus causes influenza?

orthomyxovirus

how long can you take decongestants?

only 3 days

what is the window for antivirals with influenza?

48 hours

condition? Common clinical diagnosis usually described as an acute infection of the lower respiratory tract manifeste by a cough with or without sputum production that lasts for up to 3 weeks

acute bronchitis

is bronchitis an objective diagnosis?

no, subjective

can any diagnostic test differentiate between acute bronchitis and the common cold?

is smoking a risk factor for acute bronchitis?

yes

is alcohol a risk factor for acute bronchitis?

yes

is malignancy a risk factor for acute bronchitis?

yes

is history of splenectomy a risk factor for acute bronchitis?

yes

is HIV positive status a risk factor for acute bronchitis?

yes

what percentage of acute bronchitis cases are caused by viruses?

90 percent

can influenza A and B cause acute bronchitis?

yes

can parainfluenza cause acute bronchitis?

yes

can RSV cause acute bronchitis?

yes

bacteria are responsible for what percentage of acute bronchitis?

less than 10%

can mycoplasma pneumoniae cause acute bronchitis?

yes

can chlamydophila pneumonia cause acute bronchitis?

yes

can bordetella pertussis cause acute bronchitis?

yes

are labs indicated for acute bronchitis?

is chest x-ray indicated for acute bronchitis?

condition? An acute infection of the lung parenchyma

community-acquired pneumonia

condition? Impairment in gas exchange resulting from exudate that fill the alveoli in response to a pathogen

community-acquired pneumonia

how does a consolidative focus present?

dullness

how are pathogens spread with CAP?

aerosolization

what is the most common cause of bacterial pneumonia?

s pneumoniae

do older adults always present typically with pneumonia?

lobe infiltrates strongly indicate what?

bacterial pneumonia

what kind of chest xray should be ordered?

AP and lateral

acute bacterial bronchitis-- what breath sounds?

clear breath sounds with scattered rhonchi

comorbidities or abx within last 3 months or risk factors for drug resistant strep pneumoniae---- does this dictate treatment selection?

yes

is respiratory rate > 30 part of the curb 65 score?

yes

is sbp <90 or dbp =60 part of curb 65 score?

yes

is age > 65 y/o part of curb 65 score?

yes

is confusion part of curb 65 score?

yes

is bun > 19 part of curb 65 score?

yes

which curb 65 score? Low risk, consider home treatment

0-1

which curb 65 score? Short inpatient hospitalization or closely supervised outpatient treatment

which curb 65 score? Severe pneumonia; hospitalize and consider admission to intensive care

3 to 4

one dose of ppsv 23 is recommended for what age group?

19 to 63 (w chronic medical conditions or cigarette smoking)

compromised immune systems should receive one dose of what vaccine?

pcv 13 followed ppsc 20 8 weeks later then other doeses 5 years later

what is the most common cause of non-small cell lung cancer?

adenocarcinoma

adenocarcinoma is non-small cell or small cell lung cancer?

non-small cell

where do many adenocarcinomas present?

peripherally

where do adenocarcinomas most frequently arise?

in areas of previous pulmonary parenchymal damage?

which type of lung cancer is less closely a/w smoking than other types?

adenocarcinoma

what is the second most common type of non-small cell lung cancer?

squamous cell

is squamous cell non-small cell cancer associated with smoking?

yes, strongly

where can squamous cell lung cancer occur usually?

most occur centrally

can squamous cell lung cancer produce bronchial obstruction?

yes

which type of lung cancer tends to ulcerate and cause bleeding?

squamous cell

condition? Primary infection results in alveolar macrophages that phagocytose and contain the bacteria

tuberculosis

condition? Macrophages release inflammatory mediators, including TNF which contribute to fever, anorexia, and weight loss

tuberculosis

condition? Macrophages and other inflammatory mediators wall off the mycobacterium by forming granulomas

tuberculosis

can latent TB spread to others?

is latent TB infectious?

will PPD be positive with latent TB?

yes

what is the most common clinical form of TB?

reactivation TB

when does reactivation TB occur?

during times of lowered immunity

although TB is primarily a disease of the lungs, what percentage of new TB cases are extrapulmonary?

20 percent

what are the three most common sites of extrapulmonary TB?

GU, bone, lymph nodes

extrapulmonary TB is more common in what patient population?

HIV-positive

is latent TB symptomatic?

is latent TB asymptomatic?

yes

PPD may be negative in what percentage of patients with malnutrition and debility?

20 percent

HIV patients with a low CD4 cell counts have what percentage of false negative PPD?

0.5

how many sputums for AFB do you need?

three

what is the TB vaccine?

BCG vaccine (Bacille Calmette-Guerin) vaccine

will anyone who receives the BCG vaccine have a positive PPD?

yes

what is the treatment of latent TB?

INH 5 mg/kg daily (max 300 mg) x 9 months and pyridoxine (vitamin B6) 50 mg daily

what labs should be checked pretreatment for TB?

LFTs (and periodic monitoring)

what does the treatment of active TB depend on?

HIV status and whether the pt is infected with multi-drug resistant TB

what are the four core medications to treat TB?

INH, ethambutol, rifampin, and pyrazinamide

condition? A very rapidly growing tumor that usually metastasizes to distant tissue while the tumor is quite small

small-cell lung cancer

is adenocarcinoma a small-cell lung cancer?

is adenocarcinoma a non-small cell lung cancer?

yes

is squamous cell lung cancer a small cell lung cancer?

is squamous cell lung cancer a non-small cell lung cancer?

yes

what causes the majority of lung cancer cases?

smoking

the risk of lung cancer does WHAT with the duration of smoking?

increases

small cell lung cancer accounts for what percentage of all lung cancers?

15 percent

where does SCLC typically develop?

around a main bronchus

smoking results in SCLC or NSCLC more?

small-cell lung cancer

which is more aggressive SCLC or NSCLC?

small-cell lung cancer

non-small cell lung cancers comprise what percentage of all primary lung carcinomas?

non-small cell lung cancers

what is the second most common lung cancer?

squamous cell carcinoma

is squamous cell carcinoma more common in men or women?

men

squamous cell carcinoma occurs almost entirely in whom?

smokers

what is the most prevalent form of lung cancer in both sexes and nonsmokers?

adenocarcinoma

where do adenocarcinomas arise from?

bronchial epithelium and lung scars or fibrous tissues

what portion of the lung do adenocarcinomas arise from?

peripheral portion of the lungs

are adenocarcinomas usually fast-growing?

where do adenocarcinomas usually metastasize to?

brain, liver, bone, adrenal glands

what is the least common type of lung cancer?

large-cell carcinoma

what is another name for large-cell carcinoma?

undifferentiated carcinoma

do large cell carcinomas grow rapidly?

yes

what do the clinical manifestations of lung cancer depend on?

location of tumor and extent of the spread

what percentage of lung cancer patients are asymptomatic at the time of diagnosis?

25 percent

the most common signs and symptoms of lung cancer, local-regional disease are described as what?

ambiguous and insidious

condition? Cough, sputum production, dyspnea, chest pain, hemoptysis, wheezing, postobstructive pneumonia, pleural effusions

condition? A temporary pause in breathing during sleep that lasts at least 10 seconds

sleep apnea

for a confirmed diagnosis, how many times an hour must breathing pause for sleep apnea?

five times an hour

what are the three patterns of sleep apnea?

central, obstructive, mixed

when does central sleep apnea occur?

when both airflow and respiratory efforts are absent

what does each type of apnea result in?

progressive asphyxiation until an arousal from sleep occurs (with a subsequent restoration of upper airway patency and airflow)

condition? A period of hypoventilation (Decreased airflow) defined as a 50% reduction in thoracoabdominal movements, with a 4% decrease in oxygen saturation lasting at least 10 seconds during sleep

sleep hypopnea

condition? Present when the respiratory drive is intact, but the upper airway intermittently becomes obstructed during sleep

osa/hypopnea

what measure is used to define and quantify the severity of OSA?

apnea-hypopnea index

how is the AHI calculated?

by dividing the total number of events by the total sleep time in hours

what defines an event re AHI calculation?

the number of apnea episodes plus the number of hypopnea episodes

term? The AHI plus the average number of snoring-related arousals per hour

respiratory disturbance index

in the absence of comorbid factors, what value of AHI or RDI confirms OSA dx?

>= 15

if comorbid factors are present, what AHI/RDI confirms OSA dx?

>= 5 and < 14

in general, as the AHI increases, so does what?

the severity of symptoms

when may OSA become clinically significant re the AHI?

> 15

is sleep-disordered breathing an independent risk factor for HTN?

yes

are cardiac arrhythmias associated with OSA?

yes

is atrial fibrillation a/w OSA?

yes

do people with sleep apnea have a higher risk of dying from sudden cardiac arrest?

yes

is OSA more prevalent in patients with CHF?

yes

can OSA cause mild pulmonary hypertension?

yes

do patients with sleep apnea have both day and nighttime symptoms?

yes

what is the single most important presenting symptom of sleep apnea?

hypersomnolence

define hypersomnolence?

uncontrollable sleepiness

condition? Characterized by loud snoring that is repeatedly interrupted by episodes of complete upper airway obstruction and resolves with temporary arousal

obstructive sleep apnea

what are the two features of OSA snoring?

loud and habitual

does hypercarbia happen with OSA?

yes

upper body obesity a/w osa?

yes

increased neck size a/w osa?

yes

crowded oropharynx a/w osa?

yes

Exam 2 Flashcards

(1053 cards)