Clinical Theraputics Exam II flashcards.txt

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Clinical Theraputics Exam II flashcards.txt
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  1. A 60 year old presents with vertigo, tinnitus and hearing loss he states that this has happened to him before and the last time the sensation lasted 3 hours what should be on the differential diagnosis?
    • A: Acoustic neruoma
    • B: Vestibular neuritis
    • C: Meniere's disease
    • D: all of the above
  2. D: all of the above
  3. An hearing loss that is gradual and continuous, associated with vertigo and possibly tinnitus
    Aucoustic neuroma
  4. A hearing loss that lasts severl days usually following an URI with vertigo and tinnitus
    Vestibular neuritis
  5. What non-ear specific problem would you be worried about in an older patient with ringing in the ear, vertigo and falling?
    Vascular insufficency
  6. Idiopathic diagnosis of the inner ear that is characterized by recurrent spontaneous attacks of vertigo, tinnitus, fluctuating hearing impairment and aural fullness
    Meniere's Disease
  7. What Medications do you use to treat Meniere's disease?
    • Diazapem, Meclizine (antivert), Phenergan (to treat the vertigo)
    • Triamterene/hydrochlorothiazide- diuretics to decrease fluid in the ear
  8. True of False you can treat Meniere's disease surgically
    True
  9. What medication would you use to treat vertigo in a Meniere's patient
    Phenergan
  10. What class of medications would you use to treat the underlying eitiology of meniere's?
    Diuretics
  11. A patient brings in their one year old child and states that the patient has been irritable and fussy. Pt's temperature is 38.5 C (101.3) there is redness around the TM but the TM is still mobile how would you treat?
    • A. Amoxicillin
    • B. amoxicillin + clavulunate
    • C. watchful waiting
    • D. topical antibiotics
  12. C. Watchful Waiting
  13. What are 3 things needed for the diagnosis of acute otitis media?
  14. 1. a history of acute onset of signs and symptoms
    • 2. The presense of middle ear effusion
    • 3. signs and symptoms of middle ear inflammation
  15. What 4 things indicate the pressence of a middle ear effusion?
    • Bulging of the tympanic membrane
    • limited or absent mobility of the tympanic membrane
    • air fluid level behind the tympanic membrane
    • otorrhea
  16. Give 2 signs or symptoms of middle ear inflammation
    • 1. distinct erythema of the tympanic membrane
    • 2. distinct otalgia (discomfort clearly referable to the ears that results in interference with or precludes activity or sleep)
  17. For a child with suspected AOM less than 6 months old will you treat with antibiotics for an uncertain diagnosis?
    yes
  18. With a patient age 6 months to 2 years whom you suspect has an AOM how will you treat?
    It depends!!!!! Antibacterial therapy for severe illness (to modify sever otalgia or fever = to or above 39 degrees C) Otherwise Observation for non severe illness (fever less than 39 degrees C and mild otalgia)
  19. A 10 year old presents to you with acute onset of left ear pain febrile at 39 degrees C and bulging TM that does not move with pneumatoscope the patient has no known drug allergies what would you perscribe?
    Amoxicillin
  20. A 10 year old patient that presented to you with a 39 degree C fever red bulging TM comes back to you after 2 days of being on Amoxicillin what are your next steps?
    Confirm the original diagnosis, change the antibiotic, start a different antibiotic, tell the parent to bring the child back soon to check the progress
  21. What is the first line treatment for acute otitis media?
    Amoxicillin
  22. When treating AOM if amoxicillin fails or the infection is sever what would you perscribe?
    Amoxicillin/clavulanate (augmentin)
  23. You diagnose a 10 year old with severe acute otitis media. The child is allergic to penicilin, but did not have hives or anaphylaxis with the penicillin what would you perscribe?
    Cefuroxime, cefproxoime or cefdinir
  24. You diagnose a 5 year old with severe acute otitis media and the child is allergic to penicillin with a history of uticaria and anaphylaxis with the drug. What would you perscribe this patient?
    azithromycin of clarithromycin
  25. Is it appropriot to give a patient with AOM pain medication?
    Yes ibuprofen or acetaminophen but not asprin
  26. What common OTC drug can cause tinnitus at higher or prolonged doses?
    Asprin
  27. A 22 year old presents complaining of left ear pain the patient is afebrile on physical exam and you see an erythematous TM that has limited movement the patient has no known drug allergies what would you give this patient?
    If ear pain not bad watchful waiting or if ear pain is bad amoxicillin there is no difference in treating kids and adults with AOM
  28. A 28 year old presents with pain to his right ear, he denies trauma and is afebrile, physical examination is unremarkable (non erythematous TM with movement with valsalva) what do you diagnose?
    Otalgia
  29. A 16 year old presents with itchy minimal painful right ear he swims for his high school, on physical exam you note minimal tenderness on pushing on the tragus and you notice some debri with no edema in the canal what would you do to treat?
    Gently clean and dry the ear canal
  30. Pt presents with painful right ear. On PE the canal of the ear is swollen, TM can not be visualized because of the swelling. What would you treat this patient with?
    Topical antibiotics, systemic antibiotics and a wick
  31. How would you treat a mild OE?
    gentle cleaning of the canal and topical drying agents
  32. How would you treat moderate OE with a visible TM?
    Topical antibiotics
  33. How would you treat severe OE with no visible TM?
    Topical antibiotics and systemic` antibiotics and a wick
  34. Non-antibiotic treatment for OE
    Acidifying agents: acetic acid with aluminum acetate (domeboro otic) or acetic acid with hydrocortisone (vosol HC)
  35. What otic` antibiotic should you NEVER use if you cannot visualize the TM?
    Neomycin containing meds (cortisporin otic)
  36. What are some Topical antibiotics that you can use for OE?
    • ciprofloxacin otic
    • oxafloxacin otic
    • polymyxin B + neomycin + hydrocortisone
    • Dicloxacillin
    • Bactrim
    • Augmentin
  37. What is the number one risk factor for the development of COPD?
    Cigarette smoking
  38. What are the characteristic symptoms of COPD?
    • chronic and progressive dsypnea cough and sputum production
    • as disease progresses can develop reduced exercise capacity, fatigue, dyspnea on exertion and cor pulmonale
  39. What are some physical exam findings that are characteristic of COPD?
    wheezing, hyperresonance (from air trapping), diminished breath sounds, use of accessory muscles, pursed lip breating, elevated JVP, hepatomegaly, peripheral edema
  40. COPD findings on chest CXR
    • hyperinflated lungs
    • flattened diaphragms
    • bullae
    • hyperlucency in severe emphysema
  41. What is the recommended treatment for all patients with COPD?
    SABA prn, influenza and pnumococcal vaccinations, smoking cessation
  42. True or False inhailed corticosteroids don't work ask well for COPD patients as they do for asthmatics
    True
  43. What treatment plan would you choose for mild COPD FEV1 > or =80% predicted?
    Short acting bronchodilator
  44. What treatment plan would you choose for a moderate COPD patient FEV1 50% < FEV1 < 80% perdicted with or without symptoms?
    Add regular treatment with LABA, add rehab
  45. What treatment plan would you choose for a severe COPD patient 30% < FEV1 < 50% ?
    Add ICS to albuterol, LABA and rehab with exacerbations
  46. What treatment plan would you choose for a VERY Severe COPD patient with an FEV1/FVC of less than 30% or chronic respiratory failure?>
    Albuterol, ICS, Rehab, LABA, LTOT and possible surgery
  47. What are the general treatment options for COPD?
    • Bronchodialators
    • Inhailed corticosteroids
    • systemic corticosteroids
    • oxygen therapy
    • surgery
    • rehabilitation therapy
  48. Name a short acting beta 2 agonist ( bronchodilator)
    albuterol
  49. Name a long acting B2 agonist (bronchodilator)
    salmeterol, formeterol, arformeterol
  50. What are the side effects of long acting beta 2 agonists?
    Muscle tremor, tachycardia, palpitations, hypokalemia
  51. Name an anticholinergic
    Ipratropium bromide, tiotropium bromide
  52. In COPD anticholinergics may be (less effective? or more effective?) than beta 2 agonists?
    the same as or more effective
  53. What are the side effects of anticholinergics?
    bitter taste after ipratropium, caution in prostatic hypertrophy, glaucoma
  54. Name a combination inhaled ICS and LABA
    Fluticasone/salmeterol or budesonide/formoterol
  55. Name a combination anticholinergic and SABA
    albuterol and ipatropium
  56. Name a methylxanthine
    theophylline, aminophyllin
  57. What is the MOA of methyxanthines
    phosphodiesterase inhibitors
  58. What are the side effects/ drawbacks to using methyxanthines?
    • Narrow theraputic window
    • SE: major cardiac events such as arrythmias and seizures
  59. When would you use systemic steroids for a chronic COPD patient?
    With acute exacerbation ONLY
  60. True or False inhailed corticosteroids have a significant effect on the disease process of COPD
    False
  61. Does thophylline work better for an Asthma patient or a COPD patient?
    COPD
  62. Why do you use an inhaled corticosteroid in a COPD patient?
    they upregulate B2 receptors for more effective B2 agonist use, they decrease the number of exacerbations especially in patients with FEV1<50% of predicted
  63. Name 3 smoking cessation medications
    Nicotine replacement, Bupropion, Chantix (varenicline)
  64. Nicotine Replacement
    • gum lozenges, patches, nasal sprays
    • efficacy primarily results from preventing withdrawl
    • efficacy improved with counseling and motivational therapy
  65. Bupropion
    • enhances both noradrenergic and dopaminergic neurotransmission via uptake inhibition
    • quit day one week after treatment
    • black box warning
    • contraindicated in: sz d/o, anorexia, bulimia, MAO inhibitors
  66. Chantix
    • Interacts with the ACh receptors so that when you smoke you dont get any positive chemical enforcement
    • start one week before quit day
    • Black box warning: mood and behavioral changes and suicide ideation
    • caution in cardiovascular disease which remember is VERY common in COPD patients BE CAREFUL!
  67. What are the benifits of Long Term Oxygen Therapy for a COPD patient?
    • improves survival, exercise, sleep and cognitive performance
    • reverses hypoxemi and prevents hypoxia
    • reverses secondary polysythemia, improves cardiac function during rest and exercise
  68. What are some indications for putting a COPD patient on LTOT
    hypoxia, HTN, cor pulmonale, edema from right heart failure, impaired mental status
  69. What are 3 types of surgery that can be done for COPD?
    Bullectomy, Lung volume reduction surgery, Lung transplantation
  70. What are some symptoms of an acute COPD exacerbation?
    • progressive hypoxemia which causes: tachypnea, tachycardia, systemic htn, cyanosis, change in mental status
    • pt will be sitting up and forward with pursed lip exhalation, accesory muscle use and diaphoreis
  71. What is the treatment progression for a patient with an acute COPD exacerbation?
    • Oxygen
    • Beta 2 agonists and anticholinergics (nebulizer) often in combination
    • corticosteroids sytemically
    • antibotics if there are signs of infection
    • assisted ventillation if needed
    • (EKG with chest pain)
    • admission if the signs and symptoms are bad enough
  72. COPD patients in acute exacerbation with respiratory fatigue, worsening of respiratory acidosis, or deteriorating mental status should be treated with ___
    Assisted ventilation
  73. What are some contraindications for assisted ventilation for a COPD patient (3)
    Obtunded, Facial surgery, morbidly obese
  74. What are some tests you would order if you suspected a patient had an acute exacerbation of COPD?
    ABG, CBC, BMP, EKG, CXR, close monitoring
  75. What are the contraindications for noninvasive positive pressure ventilation?
    uncooperative or obtunded patient, patients who cannot clear secretions, pts with recent facial or gastroesophageal surgery, burns, hemodynamically not stable
  76. What are some signs and symptoms associated with PE?
    shortness of breath, tachypnea, hypoxemia, chest pain, fever (if there is infarction), tachycardia, pertinent history of coagulation or long sitting periods or surgery or OTCs
  77. You suspect your patient has a PE. You decide to touch the chest to see if their chest pain was reproducible and it is, does this change your diagnosis? how?
    GOOD! most likely not a PE reproducible chest pain suggests costochondritis
  78. What are the two most common symptoms of PE?
    shortness of breath and chest pain
  79. What are the risk factors for PE?
    • Hypercoagulability: malignancy, pregnancy, estrogen, coagulopathies
    • Venous stasis: bed rest for more than 48 hours, immobility secondary to cast, recent hospitalization, long distance travel
    • Venous injury: recent surgery, recent trauma
  80. What is the test of choice for a PE?
    CT angiogram
  81. What will falsely elevate d-dimer with a patient who you suspect has PE?
    pregnancy, malignancy, sepsis etc.
  82. Why would you order a D-dimer?
    if you suspect a PE it can rule PE out but not definitivly diagnose a PE
  83. How would you handle a patient who you have a high suspiction of PE?
    CT angiogram or treat
  84. How would you handle a patient who you have a low suspicion of PE?
    if all the PERC criteria are met no D-dimer is nesissary if they are not perform a D-dimer and if it is positive then do a VQ scan or a CT angio
  85. What lab tests can you order to indicate the presense of a PE?
    • BMP
    • D-dimer
    • EKG
    • Severe distress do an arterial blood gass
  86. What are 3 possible treatments for PE
    Unfractionated heparin, low molecular weight heparin, fibrinolytic therapy
  87. Unfractionated heparin
    • used to treat PE
    • binds to antithromin and accelerates its activty thus preventing extension of thromus, short half life if pt has to undergoe surgery, contraindicated in active hemorrhage and/or recent brain hemorrahage
  88. Low molecular weight heparins
    • Used to Treat PE
    • greater bioavalibility, more predictable response than unfractionated, longer half life
    • enoxaparin and dalteparin
  89. Fibrinolytic therapy
    • alteplase
    • used for PE tx
    • contraindications: intracranial neoplasm, previous hemorrhagic stroke, ishemic CVA in past year, active internal bleeding or suspected aortic dissection
  90. __ occurs when air enters the potential space between the visceral and parietal pleura
    pneumothorax
  91. What are the symptoms of pneumothorax?
    chest pain, dyspnea, often tachycardia
  92. what are some physical exam findings that are sugestive of pneumothorax?
    decreased breath sounds, decreased tactile fremitus, hyperresonnance
  93. What will you see on CXR in a patient with a pneumothorax?
    visualization of the visceral pleural line with an overlying radiolucent area without vascular or lung markings between the visceral pleural line and chest wall
  94. what are 4 causes of pneumothorax?
    • Primary spontaneous- absence of underlying lung disease
    • Secondary spontaneous- underlying lung disease
    • Iatrogenic
    • trauma
  95. What treatment would you choose for a very small pneumothorax?
    watchful waiting with oxygen
  96. What would you do for a small to medium sized pneumothorax?
    simple needle aspiration
  97. What would you do for a bad pneumothoraxy or one with secondary complications??
    Chest tube
  98. What are some symptoms of a tension pneumothorax?
    hypotension, tachycardia, diaphoresis, trachial deviation, distended neck veins, cardiovascular collapse
  99. What are the symptoms of Asthma?
    Cough, chest tightness, wheezing, quiet chest, acute respiratory distress, noctournal coughing, exercise induced, atopy, couging at night
  100. Mild intermittent Asthma
    • 2 or less attacks per week, lung function or PEF 80% or greater than predicted FEV1/FVC normal, Nighttime symptoms 2x or less per month,
    • Treatment: SABA
  101. Mild persistent Asthma
    • more than 2 attacks per week but less than one per day, FEV or PEF = or less than 80%, nighttime symptoms more than 2x montly
    • Treatment: SABA + Low dose ICS or alternative
  102. Moderate persistent Asthma
    • Daily symptoms and daily use of SABA, FEV1>60% to <80% predicted, Exacerbations affect activity, night time exacerbations 1x per week, FEV1/FVC reduced 5%,
    • Treatment: low dose ICS + LABA or medium dose ICS
  103. Severe persistent Asthma
    Continual symptoms that limit physical activity, Frequent exacerbations and frequent nighttime symptoms
  104. When would you use a methacoline challenge to diagnose asthma?
    In patients with exercised induced asthma and someone who cannot perform spirometry
  105. what two tests can you do to confirm a diagnosis of asthma?
    Methacholine challenge, and Bronchodialator response to short acting bronchodialator
  106. What percentages of change would you suspect in an asthmatic for spirometry (bronchodialator)/bronchial provocation testing ?
    Improvement of >12% or a decrease >20%
  107. What are the side effects of a SABA?
    nervousness tremor tachycarida palpatations and headache
  108. what are some side effects of inhailed corticosteroids for asthma?
    hoarsness and candidiasis
  109. When do you use systemic corticosteroids for an asthma patients?
    in acute exacerbations, use the lowest dose possible
  110. what are some side effects of systemic corticosteroids?
    hypertension diabetes mellitus, osteoporosis, HPA supression, caution tachyphylaxis
  111. When do you use an Antileukotriene for asthma?
    when you are trying to cut down on steroid use
  112. How do antileukotrienes modify the course of disease in asthma?
    work on leukotriene receptors in the respiratory tract producing: bronchodialation, decrease microvascular leakage, increase eosinophilc inflammation
  113. Name an antileukotriene
    • montelukast singulair
    • zariflukast accolate
  114. Name an immunomodulator druge used to treat asthma
    omalizumab
  115. Omalizumab
    • immunomodulator used to treat asthma
    • block antibody that neutralizes circulating IgE and inhibits IgE mediated reactions
    • decreases number of exacerbations in those patients with severe asthma
    • treatment is suitable for highly selective patiens who are not controlled with maximal doses of inhailer therapy, very expensive
    • have an IgE within a specified range
  116. Pt has been on SABA prn however she has been using her inhailer several times per week what would you do first?
    • A: Check environment
    • B: Put her on high dose ICS
    • C: put her on LABA
    • D: start her on theophylline
    • A: Check environment
  117. Your patient with mild asthma has been using her SABA multiple time per week and denies any environmental changes recently or any new exacerbating factors, you decide that she is poorly controlled what do you do next?
    • A: add low dose ICS
    • B. Add high dose ICS
    • C. add LABA
    • D. Add albuterol
    • A. Add low dose ICS
  118. Pt is on albuterol prn and low dose ICS having night time symptoms greater than one time per week, using inhailer daily what would your next step after checking environment, adherence and co-morbidities?
    • A: Add a LABA
    • B: Increase ICS to medium dose
    • C. add oral steroids
    • D. A or B
    • D. A or B
  119. Your patient is having an acute asthma exacerbation, they come into the ER with wheezing and shortness of breath. You do a PEF, pulse ox and CXR, What will you give them via nebulizer?
    Albuterol and possibly oxygen
  120. What are the steps for treating mild, moderate and severe asthma exacerbations?
    • Mild- albuterol, PEF before and after treatment, pulse ox and possibly CXR
    • Moderate- all of the above plus albuterol or combivent via nebulizer, and prednisone d/c home after normal pulse ox with walk tests
    • Severe- albuterol or combivent nebulizer, magnesium, solumedrol, reevaluate, and/or admit (usually admit with severe wheezing, inability to talk in full sentances, inability to walk)
    • Very severe- Respiratory distress- intubate
  121. Symptoms of pneumonia
    productive/nonproductive cough, dyspnea, fever, pleuritic chest pain, tachycardia, tachypnea
  122. Physical exam findings of pneumonia
    • alveolar fluid (inspiratory rales, consolidation)
    • Bronchial breath sounds
    • Pleural effusion (dullness)
    • bronchial congestion (rhonchi and wheezing)
  123. What are the 4 types of pneumonia (classified by setting)?
    CAP, HAP, VAP, HCAP
  124. You have a patient with pneumonia who you are treating outpatient who is mildly ill, has no cardiopulmonary disese or other modifying factors what do you choose to treat with?
    Azithromycin or clarithromycin
  125. You have an patient with pneumonia who you are treating outpatietn who is stable with comorbidities what would you treat with?
    Floroquinolone (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
  126. Floroquinolones (moxifloxacin and levovloxacin) are contraindicated with what?
    pregnancy
  127. You have a patient with pneumonia who you are treating as an outpatient who has had a course of antibiotics in the past three months how do you treat this person?
    Floroquinolones (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
  128. What are the criteria for curb 65?
    • Confusion, BUN > 19 mg/dL, Systolic pressure of <90 or diastolic <60, Respiratory rate 30 or greater, age 65 or older
    • each of these factors earns you one point
  129. 1 or 2 points on a CURB 65 how would you manage?
    Short in patient hospitalization or closely supervised outpatient care
  130. 0 points on CURB 65 how would you manage?
    Low risk consider outpatient treatment
  131. 3 or 4 or 5 on Curb65 how would you manage?
    hospitalization and consider ICU admission
  132. A 62 year old male presents with fever, cough, chillls x3 days. He has well controlled DM and HTN but otherwise healthy. RR 24 BP 130/70, HR76 no signs of confusion WBC 23,000 BUN 14 where should the patient be treated? Bonus what should the patient be treated with?
    Out patient therapy (according to CURB65) and with Levofloxacin or moxifloxacin because he has comorbidities
  133. First line treatment of a patient that has no comorbidities that has CAP and is going to be treated outpatient is ?
    • Azithromycin
    • Note: you can also use erythromycin but it has a worse side effect profile and can cause C.diff
  134. 16 year old male presents with fever, cough, and 15 pounds of weight loss in 3 months. He recently returned from Ghanna doing missionary work. On chest X-ray he has a consolidated apical mass in his right upper lung apical region what is the most likely Dx?
    TB
  135. A PPD test induration of 5 or more millimeters is considered positive in...
    • HIV in fected persons
    • a recent contact of a person with TB disease
    • persons with fibrotic changes on chest radiograph consistent with prior TB
    • Pts with organ transplants
    • persons who are immunosurppressed
  136. A PPD test induration of 10 or more millimeters is considered positive in
    • recent immigrants
    • Injection drug users
    • Residents and employees of high-risk congregate settings
    • mycobacteiology laboratory personel
    • persons with clinical conditions that place them at high risk
    • children under 4yo
    • infants, children, and adolescents exposed to adults in high risk categories
  137. A PPD test with induration of 15 or more mm is considered positive in
    any person, including people with no known risk factors for TB, however targeted skin testing programs should only be conducted among high-risk groups
  138. What are some symptoms of TB?
    • many cases are asymptomatic, fever, shortness of breath, cough,
    • post primary TB- productive cough, night sweats, anorexia
    • Other signs and symptoms of disese depend on location such as abdominal pain
  139. What is the preferred Tx for treatment of latent TB (for both HIV positive and HIV negative)?
    Isoniazide for 9 months taken either daily or twice weekly
  140. What should all suspected latent TB patients get before starting treatment?
    CXR
  141. For patients who in whom active TB is proved or strongly suspected what is your choice for initial treatment?
    Isoniazid, rifampin, pyazinamide and ethambutol (initial phase) Then a continuation phase of 4 months on just two
  142. What must all patients baseline tests should you get on all patients before starting initial TB therapy?
    LFTs, CBCs, HIV, etc
  143. After initial TB treatment what are subsequent treatments based on?
    initial chest x ray, smear results, CD4 count
  144. Adverse effects of Isoniazide (INH)
    • asymptomatic elevation of aminotransferases discontinue if they become 5x the upper limit or symptomatic
    • Clinical hepatitis
    • Peripheral neuropathy- recommend pyridoxine supplementation in pts that have increased for this secondary to other conditions
  145. What monitoring do you need if you have a patient on Isoniazide?
    routine monitoring not necessary. however pts who have preexisting liver disesae or had abnormal liver function baseline lfts should be monitored monthly monitor serum concentratiosn of drugs that have interactions (phenytoin)
  146. INH
    • Isoniazide
    • first line treatment for all forms of TB caused by organisms known or presurmed to be susceptible to the drug. inhibits cytrochrome p450 system therefore significant drug interations
  147. Rifampin (RIF)
    • First line agent for treatmetn of all forms of TB caused by organisms with known or presumed sensitivity to the drug
    • Inducer of cytochrome P450 system; interferes with NRT and PI (rifambutin is used as a substitute for RIF patietns recieveing any drug having unacceptable interactions with RIF)
  148. If a patient is on a drug that is not compatable with Rifampin what do you use instead?
    Rifambutin
  149. What are the adverse effects of Rifampin?
    • Cutaneous reactions with or without rash
    • GI
    • Hepatoxicity
    • Orange discolorations of bodily fluids
  150. Which TB drug causes Red urine?
    Rifampin
  151. Pyrazinamide
    first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
  152. What do you have to monitor on a patient who is on pyrazinamide and rifampin for the treatment of latent TB?
    liver disease
  153. What are the adverse effects of Pyrazinamide?
    Hepatotoxicity, GI symptoms, polyarthralgias, asymptomatic hyperuricemia, photodermatitis
  154. Ethambutol
    • first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
    • Not recommended in children whose visual actuity can not be monitored
  155. Which TB drug is contraindicated for children whose visual acuity cannot be monitored?
    Ethambutol
  156. What are the side effects of Ethambutol?
    Retrobulbar neuritis- manifested as decreased visual acuity or decreased red-green color discrimination
  157. What monitoring do you have to have with the use of Ethambutol?
    baseline visual acuity test and testing of color discrimination. Pts asked montly about vision and instructed to contact a physician if they experience any change in their vision. Montly testing of vision and color vision discrimination for patients taking doses of 15-25mg/kg or recieving the drug more than twice a month or a patient with renal insufficency
  158. An induration of 10 or more mm on TST would be positive for
    • A. pts with no risk factors
    • B. IVDU
    • C. children under 4
    • D. male over 65
    • B. IVDU
  159. Pt is on a TB treatment regimin, you did a color discrimination test before treatment what drug is he on?
    • A. Streptomycin
    • B. pyrazinamide
    • C. Ethambutol
    • D. Rifambutin
    • C. Ethambutol
  160. You are going to start a patient on Rifampin in addition to telling them about skin rx, GI upset you would tell them about what?
    • A. Possible visual changes
    • B. Productive cough
    • C. Orange discoloration of body fluids
    • D. Insomnia
    • C. Orange discoloration of body fluids
  161. What is the preferred drug for LTBI?
    INH
  162. What are the symptoms of Influenza?
    Fever, chills, malaise, headache, myalgias
  163. What is the treatment for influenza?
    • Supportive treatment, Zanamivir (shortens by 2 days and can be taken prophylactically), Oseltamivir
    • Vaccinations
  164. You have a patient with flu like symptoms fever, chills malaise, headache and myalgias, as a good PA you ask them if they have nuchal ridgidity. what are you ruling out by asking them this?
    Meningitis
  165. What are the most common pathogens of Epiglottitis?
    Haemophillis influenza, group A strep, S. pneumo
  166. Who presents more acutely with epiglottitis kids or adults?
    Kids
  167. What are the symptoms of Epiglottitis?
    Abrupt onset of fever, drooling, muffled voice, inspiratory retractions, stridor, pts present sitting up and leaning forward
  168. How do adult patients with epiglottitis present?>
    1-2 day history of worsening dysphagia, odynophagia and dyspnea especially in the supine position
  169. You inspect the larynx of a patient with worsening dysphagia and see a cherry red swolen eppiglottis what do you Dx
    Epiglottitis
  170. True or false the incidence of epiglottitis is increasing
    False the incidence of epiglottitis is actually decreasing secondary to immunizations
  171. What is the primary clinical concern in Epiglottitis?
    protection of the airway
  172. what would you perscribe a patient with Epiglottitis?
    • Cefuroxime, cefotaxime, ceftriaxone
    • Rifampin to PCN allergic patients
  173. Epiglottitis will show what important sign on X-ray
    Thumb sign
  174. "Thumb Sign" on X ray
    Epiglotittis
  175. Infectious process that is characterized by a bark like or brassy like cough
    Croup
  176. In addition to cough croup may be associated with what other respiratory symptoms?
    Hoarsness, inspiratory stridor, respiratory distress
  177. What is the most common cause of stridor after neonatal period? (6mo to 3yr)
    Viral croup (laryngotracheobronchitis)
  178. What is the most common cause of viral croup?
    parainfluenza virus
  179. 1-5 day prodrome consisting of cough coryza and rhinorrhea followed by a 3-4 day barking type cough that is worse at night
    Croup
  180. Is stridor from croup greater on inspiration or expiration?
    Inspiration (it is also not affected by position or with increased crying or agitation)
  181. True or false increased costal retractions and tachypnea are some symptoms of Croup
    True
  182. Steeple sign
    Croup
  183. How would you treat moderate to severe croup?
    Nebulized racemic epinephrine and dexamethasone
  184. How would you treat severe croup for whom intubation is being considered?
    Heliox
  185. What is the most common respiratory infection in children under 2 y.o.?
    Bronchiolitis
  186. What is the most common pathogen of Bronchiolitis
    RSV
  187. Inflammation, edema and necrosis of epithelial cells lining small airways increased mucous production and bronchospasm with a nasal wash positive for RSV would indicate what?
    Bronchiolitis
  188. What are some symptoms of bronchiolitis?
    • presentation can be minimal to respiratory distress, usually begins with a prodrome of upper respiratory infection first sign is rhinorrhea, followed by increaseing respiratory effort and wheezing, fever inconsistent
    • rhinitis, tachypnea, wheezing, cough, crackles, uses of accessory muscles and/or nasal flaring
  189. You 1 year old patient with a respiratory infection and a mild fever. Upon chest auscultaion you note wheezing and some crackles. you also note the child is breathing quickly. What do you diagnose?
    Bronchiolitis
  190. What are three important signs of SEVERE bronchiolitis?
    Tachypnea >70bpm, listlessness, apneic spells
  191. What are the treatments for Bronchiolitis?
    • use of bronchodialators- is controversial
    • Use of racemic epinephrine- controversial as well
    • IV fluids and supplemental oxygen are indicated
  192. What is the most important step in preventing nosocomial spred of RSV?
    hand washing! especially with alcohol based rubs
  193. What prophylaxis is recommended of bronchiolitis?
    Plavizumab
  194. Who should get prophylaxis for bronchiolitis?
    • children under 2 years old with chronic lung disease who have required medical treatment in the preceeding 6 months before the start of RSB season
    • Children younger than 2 years old who have cyanotic or complicated congenital heart disease
    • infants younger than 6 months that were born at 29-32 weeks gestation
    • Infants younger than 6 months born between 32 and 35 weeks gestation and have two or more risk factors (siblings, daycare, neuromuscular disease, congenital abnormality of the airways)
  195. ATP III recommends that a ___ profile be obtained at least once every 5 years beginning at the age of ___
    Lipoprotein, 20y.o.
  196. ATP recommends that patients with ____ or ___ equivalents have a lipid pannel every 1 year or less
    CHD, CHD risk equivalents
  197. ATP III recommends patients with two or more risk factors get screened every ___ years or less
    2
  198. 0-1 risk factos on the ATP III recommends that a patient get a lipid profile every ___ years or less
    5
  199. What are the 3 components of a lipid pannel?
    LDL, HDL, VLDL
  200. What is total cholesterol?
    LDL+VLDL+HDL
  201. What is LDL equal to?
    TC-TG/(5-HDL)
  202. If the triglyceride level is over 400mg then you need to get a separate what?
    LDL
  203. What is an optimal LDL?
    100-129
  204. What is a Borderline high LDL?
    130-159
  205. what is a High LDL?
    160-189
  206. What is a very high LDL?
    190 or more
  207. What is a good TC level?
    less than 200
  208. What is a Borderline high TC level?
    200-239
  209. what is a high TC level?
    240 or more
  210. For a patient with CHD or CHD risk equivalents what is their goal LDL?
    less than 100 mg/dL
  211. According to ATP III for a patient with 2+ risk factors, goal LDL is what?
    less than 130
  212. According to ATP III patients with 0-1 risk factors have a goal LDL of what?
    less than 160
  213. What is a good HDL?
    40 or less
  214. What is a high HDL?
    60 or more
  215. What are some secondary causes of hyperlipidemia?
    • CRF
    • Nephrotic syndrome
    • obstructive liver disease
    • DM
    • Hypothyroid
    • Medications: protease inhibitors, anabolic steroids, corticosteroids, thiazides
  216. What would be the next step to take with a hyperlipidemia patient after you rule out all the secondary causes?
    Determine lipoprotein levels, ID prescence of clinical atherosclerotic dz, determine presence of major risk factors for CHD other than LDL, assess the 10 year CHD risk factor, determine the risk category
  217. Name 5 vascular diseases that you should look for in a hyperlipidemia patient
    • clinical CHD
    • Symptomatic carotid artery disease
    • PAD
    • AAA
    • DM
  218. What are the 5 ATP risk factors?
    • cigarette smoking
    • HTN or on HTN meds
    • Low HDL less than 40
    • Family Hx of premature CHD (CHD in male first degree relatives under 55yrs, CHD in female first degree relatives under 65)
    • Age (men 45 or older, women 55 or older)
  219. Patients with a 10 year CHD risk factor of >___ % are considered CHD equivalents
    20
  220. Patients with CHD equivalents should be treated as agressively as...
    patients with CHD
  221. CHD and CHD risk equivalents have an LDL goal of what?
    less than 100
  222. Multiple (2+) risk factor patients have an LDL goal of what?
    under 130
  223. Patients with 0-1 risk factors have an LDL goal of what?
    less than 160
  224. If the patient has a TG of greater than 150 and an HDL of less than 40 then the diagnosis is ____
    atherogenic dyslipidemia (look for metabolic syndrome in these patients)
  225. What is a normal triglyceride level?
    less than 150
  226. what is a borderline high triglyceride level?
    150-199
  227. what is a high triglyceride level?
    200-499
  228. what is a very high triglyceride level?
    over 500
  229. What is non HDL equal to?
    VLDL + LDL
  230. If a patient has CHD or CHD risk equivalents then their LDL goal is ___ and their non HDL goal is ___
    less than 100, less than 130
  231. if a patient has multiple (2 or more) risk factors and a 10 yr risk of 20% then their LDL goal is ___ and their HDL goal is ___
    less than 130 and less than 160
  232. If a patient has 0-1 risk factors then their LDL goal is __ and their non HDL goal is __
    160, 190
  233. Which cholesterol is always first priority in treatment?
    LDL
  234. If goal LDL is achieved but non HDL remains high what should you add?
    high dose of statin or statin + niacin or fibrate
  235. If triglycerides are greater than 500 then your first piority is to prevent what? what would you perscribe?
    prevent pancreatitis, perscribe fibrate or niacin
  236. What is metabolic syndrome?
    • Abdominal obesity men waist circumf. (greater than 102 cm or greater than 40 inches) for women (greater than 88 cm or 35 inches)
    • Triglycerides of 150 or more
    • HDL in men of less than 40 and in women of less than 50
    • Blood pressure of 130 or >/85 or >
    • Fasting glucose of 110 or more
  237. What are some causes of low HDL?
    increase in serum triglycerides, overweight obesity, physical inactivity, high carbohydrate intake, DM II, genetic factors, certain drugs
  238. A low ___ as in less than 40 is associated with an indcrease in the risk of ___
    HDL, CHD
  239. What are 3 lifestyle changes you can suggest to your patient to help them lower their cholesterol?
    • Wt control
    • Increased physical activity
    • Dietary changes - decreased intake of saturated fats and cholesterol and increased intake of plant sterols and fiber
  240. How long do you give the patient to make life style changes?
    3-6 months
  241. What are the 4 major classes of drugs used to control cholesterol?
    • Statins (HMG CoA reductase inhibitors)
    • Bile acid sequestrants
    • Nicotinic acid (Niacin)
    • fibrinic acid derivatives (Fibrates)
  242. What is the most effective set of drugs for lowering cholesterol?
    Statins
  243. What is the first line drugs used to lower LDL?
    Statins
  244. What drugs would you want to use for children with heterozygous familial hypercholesterolemia?
    Statins
  245. What drug do you use for children under 8 with heterozygous familial hypercholesterolemia?
    pravastatin
  246. What do you use for children 11 and older who have heterozygous familial hypercholesterolemia?
    Atorvastatin, lovastatin, simvastatin
  247. What are some contraindications to statin use?
    active or chronic liver disease and pregnancy
  248. What drugs can you not take with statins?
    cyclosporine, macrolides, antifungals, and cytochrome p450 inhibitors
  249. What are some side effects of Statins?
    Increase LFTs by 3X, myopathy, increased CK, non specific aches or joint pains, good to get a baseline LFT before starting therapy, possible rhabdomyolysis
  250. What is the MOA of statins?
    inhibit HMG CoA reductase which is the rate limiting step in cholesterol biosynthesis
  251. Name a bile acid sequestrant (resin)
    Cholestyramin, colestipol, colesevelam
  252. True or False Bile acid sequestrants work to lower all types of cholesterol
    False they have no effect on triglycerides
  253. What is the primary side effect with Bile acid sequestrants?
    GI upset; bloating, cramping, fullness, nausea, flatulance
  254. Which class of Cholesterol drugs is perscribed mainly to add to the effects of other drugs particularly the statins?
    Bile acid sequestrants
  255. What is the MOA of bile acid sequestrants?
    binds to intestinal bile acids
  256. What is the drug of choice for lowering cholesterol in patients planning to get pregnant?
    Bile acid sequestrants
  257. What affect doe bile acid resins have on other drugs?
    they decrease the other drugs absorbtion, so you must take other drugs 1 hour prior or 4 hours after (except for colesevelam)
  258. Are bile acid sequestrants salf for use in younger patients?
    yes
  259. What is the most effective lipid lowering drug for raising HDL levels???
    Niacin (Nicotinic acid)
  260. What are the contraindications for Niacin?
    liver disease, peptic ulcer disease, pregnancy
  261. What are the side effects of niacin?
    flushing, hyperglycemia, hyperuricemia, GI distress, hepatotoxicity
  262. What should you monitor for a patient on niacin?
    LFTs at baseline, fsting glucose, uric acid
  263. When do you use Niacin?
    In patients with atherogenic dyslipidemia who do not have a substancial increase in LDL and in combination with other medications
  264. What are 3 recommendations for the use of Fibric Acid derivatives
    • 1. to decrease the risk of pancreatitis in patients with very high triglycerides
    • 2. in patients with low levels of LDL and atherogenic dyslipidemia
    • 3. Combination with statins who have elevated LDL and atherogenic dyslipidemia
  265. MOA of fibric acid derivatives
    unclear mechanism but inhibit tryglyceride synthesis and stimulate catabolism of triglyceride rich lipoproteins
  266. What are the side effects of Fibric acid derivatives
    GI distress, rash, increase LFT
  267. What are the drug interactions with Fibric acid derivatives?
    Will affect levels of coumadin, monitor INR for increased risk of bleeding
  268. Ezetimibe should not be used in patients with ____
    liver disease
  269. MOA of ezetimibe
    inhibits cholesterol absorbtion
  270. Do not use Ezetimibe with what other drugs (3)
    Cyclosporines, bile acid resins, fibrates
  271. Can Ezentimibe be used with statins?
    yes it is used with statins to lower LDL
  272. What is an OTC treatment for dyslipidemia?
    Omega fatty acids, Fish oil

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