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253 Cards in this Set
- Front
- Back
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definition of anxiety
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-an unpleasant and overriding mental tension
-has no apparent cause -accompanied by physical distress -disrupts ADLs -feeling of dread -somatic signs indicative of a hyperactive autonomic nervous system -different from fear which has a known cause |
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An anxiety disorder disrupts daily life when a person.....
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-feel anxious all the time
-feel anxious for no apparent reason -stops every day activities to avoid discomfort -may be immobilizing |
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what is a misconception of anxiety as a normal emotion?
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miconception that people can overcome their disordered symptoms through sheer will power
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Name 5 types of Anxiety disorders
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1. Generalized Anxiety disorder (GAD)
2. Panic Disorder (PD) 3. Post Traumatic Stress Disorder (PTSD) 4. Obsessive-Compulsive Disorder (OCD) 5. Social phobias (SB) |
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where can you find the criteria for diagnosing mood disorders?
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DSM IV TR
Diagnostic and Statistical Manual of Mental Disorders |
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what is the epidemiology of anxiety disorders?
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-most common disorder in the US
-19% of US populations has an anxiety disorder -onset is from late childhood to adulthood -family links to prevalence -80-90% concordance with monozygatic twins -more common in women |
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The age of onset for Anxiety disorders is usually before ____ years old?
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30 years old
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what is secondary to mental illness that results in more patients being seen in primary care settings?
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Somatotization Disorder-- a psychiatric diagnosis applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin
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in the central nervous system, what are major mediators of symptoms of anxiety disorders ?
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norepinephrine
serotonin dopaimine other corticotropin-releasing factors |
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what other mental illness is associated with anxiety?
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depression
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what are some physical signs of anxiety?
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sweaty palms, restlessness or a feeling of being "edgy", distractibility, excessive ongoing worry and tension, unrealistic view of problems, irritability, muscle tension, headaches, sweating, difficulty concentrating, nausea, urinary frequency, tiredness, trouble falling or staying asleep, trembling, being easily startled
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what is a important question regarding safety that you must always ask a patient with an anxiety disorder?
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- Suicidal ideation should be assessed by asking about passive thoughts of suicide, desires to be dead, thoughts of harming self, or plans to harm self.
(Homicidal ideation is uncommon) |
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what type of question should you avoid when speaking to a pt?
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Negative questions
example: "You're not thinking about killing yourself? right?" |
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what are serious sequelae of anxiety disorders?
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suicide risk
alcohol or chemical dependency sexual dysfunction vulnerability to physical illness |
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Generalized Anxiety disorder (GAD)
definition symptoms |
-excessive anxiety and worry about a number of events x6 months
-associated with 3 of the following symptoms *restlessness or feeling on edge *easily fatigued *difficulty concentrating *irritability *muscle tension *sleep disturbance |
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Panic Disorder (PD)
definition symptoms |
-recurrent unexpected panic attacks characterized by 4 symptoms
-palpitations, sweating, trembling or shaking, SOB, feeling of choking, chest pain or discomfort, nausea, abdominal distress, feeling dizzy, light headed or faint, fear of losing control or going crazy, fear of dying, numbness or tingling, chills or hot flashes, persistent concerns of future attacks, worry about the meaning of or consequences of attacks (heart attack, stroke), significant change in behavior related to attacks, + or - agoraphobia |
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Obsessive Compulsive Disorder (OCD)
defintion symptoms |
Obsession: recurrent persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate. (Example: contamination, sexual images, repeated doubts)
Compulsions: repetitive behaviors or mental acts whose goal is to prevent or reduce anxiety and distress. (example: handwashing, counting) |
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special tests for the cervical neck
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1) distraction test: pull neck up- shows how effective traction might be in relieving pain. Relieves pain caused by narrowing of neural foramen
2) Compression test: press down on head while sitting/standing. Increase in pain, note dermatome distribution. May reproduce pain, referred arm pain. |
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red flags for neck pain
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hx of difficulty walking
lower extremity or trunk symptoms bowel/bladder dysfunction fever, chills, unexplained wt loss, immunosupression, cancer, or IVdrug use |
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red flags in low back pain
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hx cancer, nocturnal pain, wt loss, fever, chills, night sweats, age <15 or >50, neuro deficits (decreased motor/sensory innervation), urinary and fecal incontinence
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physical exam of L4
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-foot inversion
-patellar reflex sensation to medial aspect of foot and ankle |
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physical exam of L5
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-flex toe
-sensation to middle of foot |
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physical exam of S1
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-foot eversion
-achilles tendon reflex -sensation to lateral aspect of foot |
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spondylosis
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degenerative joint disease affecting the vertebrae and invertebral disc
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spondylolysis
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fracture in pars interarticularis
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spondylolisthesis
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displacement of one vertebra on another
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shoulder muscles involved in external rotation
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infraspinatus
teres minor |
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shoulder muscles involved in internal rotation
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subscapularis
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special test to evaluate rotator cuff tear, specifically a supraspinatus tear?
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Drop-arm test
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special test to evaluate subacromial impingement
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Neer's sign
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special test to evaluate supraspinatus tendon impingement
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Hawkin's test
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Adhesive capsulitis
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"frozen shoulder"
-loss of passive/active ROM -2nd to previous shoulder injury -due to lack of use -requires physical therapy -severe cases may need anesth for manipulation |
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scaphoid fracture
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-load to the dorsiflexed wrist as in fall onto outstretched hand
-pain, swollen wrist -snuffbox tenderness -high frequency of nonunion and avascular necrosis -order scaphoid series -immobilize cast |
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DeQuervain's Tenosynovitis
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overuse injury- "new mom"
inflammation of extensor pollicis brevis and abductor pollicis longus tendons -special test: finkelstein's test |
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carpal tunnel syndrome
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median nerve compression
aching hand and arm nocturnal or AM paresthesias "shaking" to obtain relief tests: phalen's-both wrists maximally flexed for 1 min tilen's-tap on median nerve |
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Trigger Finger
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-stenosing flexor tenosynovitis
-painful snap, lock, or pop -palpate nodule as digit flexed or extended |
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Flexor Tenosynovitis
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-tendon sheath infection usually due to puncture wound
-bacterial skin flora -surg emergency!! see ortho! Cardinal s/s: uniform swelling of finger, sensitivity along tendon sheath, pain on passive extension, finger held in flexion |
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Patrick's test
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FAbER- flexion, abduction, external rotation
evaluation of sacro-iliac joint dysfunction + if there is pain at hip or sacral joint or if leg cannot lower to the point of being parallel to opposite leg |
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Valgus Test
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apply medial stress, checking MCL stability
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Varus Test
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apply lateral stress, checking LCL stability
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Anterior Drawer test
Lachman test |
Test of ACL
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Posterior Drawer test
Posterior Sag |
Test of PCL
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Apley Compression Test
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-used to assess meniscal injury
-pt prone with knee flex 90 deg - apply a downward compressive force through the lower leg while laterally rotating the lower leg. +Pain indicate an injury |
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Thessaly Test
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used to assess menical injury
-pt standing single-leg (on affected leg) -knee bent 5 deg, rotate 3 times -repeat at 20 deg +pain indicate injury |
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McMurray test
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- used to assess meniscal injury
Patient lies supine Knee flexed to 45 degrees and Hip flexed to 45 degrees Examiner braces lower leg One hand holds ankle and other hand holds knee Medial meniscus assessment Assess for pain on palpation Palpate medial joint line with knee flexed Assess for "click" suggesting meniscus relocation Apply valgus stress to flexed knee Externally rotate leg (toes point outward) Slowly extend the knee while still in valgus Lateral meniscus Repeat above with varus stress and internal rotation +pain and pop/click indicate injury |
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Thomas Test
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-test for flexion contracture of the iliopsoas muscle (hip)
- patient supine on the exam table Flex the hip and knee on the side NOT being tested, and have the patient hold their knee against their chest.The non-flexed leg is examined A positive test result occurs if this leg raises off the table, indicating a flexion contracture of the iliopsoas muscle. |
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Ober's Test
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used to identify contracture of the iliotibial band.
During the test the patient lies on his/her side with the unaffected leg on bottom and bent and the affected leg on top and straight. The examiner places a stabilizing hand on the patient's upper iliac crest and then lifts the straight upper leg, extends it at the hip and slowly lowers it behind the bottom leg, allowing it to adduct below. The test result is positive if the patient can't adduct pass anatomic neutral. |
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Patellar Apprehension w/lateral movement
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evaluation of patella subluxation or dislocation
-Patient lies supine -Knee flexed to 30 degrees or Knee in full extension -Examiner applies pressure from medial patella -Patella forced laterally by medial pressure -Patient tightens quadriceps muscle -Positive test is painful -Patient may refuse to do this in anticipation of pain |
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when is knee inspiration indicated?
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when you suspect
-infection -crystal arthropathy (gout) -tense effusion causing symptoms |
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noble's test
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-test for iliotibial syndrome
-Patient lies supine -Examiner's thumb over lateral epicondyle (knee) -Patient repeatedly flexes and extends knee +Pain injury |
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Agoraphobia
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form of anxiety d.o
fear of being in a place or situation from which escape might be difficult or embarrasing or in which help may not be available in case of a panic attack |
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Social Phobias
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-marked and persistent fear of 1 or more social or performance situations in which the person is concerned about negative evaluation by others
(public speaking, initiating or maintaining conversations) |
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Xanax (Alprazolam)
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-benzodiazepine, fast-acting
-short term relief of mild-mod anxiety -also used for panic/depression -highly addictive |
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Klonopin (Clonazepam)
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-anticonvulsant benzodiazepine
-primarily for seizure d.o. -also used for panic, anxiety, depression -slow acting, less addictive |
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BuSpar
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-anti-anxiety Azaspirone
-some properties of Benzodiazepine -for generalized anxiety d.o. |
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Benzodiazepines
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-highly effective against panic d.o., generalized d.o., and social phobias
-drowsy effect -symptoms of withdrawal when d/c'd -start low dose then increase gradually -prescribed for short periods (2-4 wks) -dose must be tapered, should not stop taking suddenly |
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Beta blockers
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-block the fight or flight response
-limited to social anxiety in performance situations |
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SSRIs
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-start at low dose
-typical effects noted at week 3-4 -6-8 weeks is full trial -if no desired response, increase dose -if s/e are serious or response not obtained by 12 wk, switch to another SSRI |
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Major Depressive D.O
how long must pt have symptoms for diagnosis? |
2 weeks
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PTSD
how long must pt have symptoms for diagnosis? |
1 month
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Bipolar I and II
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condition in which depressive phases alternate with periods of mania (type 1) or hypomania (type 2) for a period of 2 weeks or more
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Dysthmia disorder
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chronic, milder mood disturbance in which a person reports a low mood almost daily for 2 yrs
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Cyclothymic disorder
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chronic, milder mood disturbance in which a person reports a hypomanic mood almost daily for 2 yrs
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Monoamine oxidase inhibitors (MAOIs)
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antidepressant drugs
-may be used for smoking cessation Education- restrict ingestion of tyramine foods MAOIs is only used when other antidepressant drugs do not work because it its potentially lethal dietary and drug interactions. |
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Tricyclic Antidepressants (TCAs)
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-antidepressants
-lethal in overdose -s/e: arrythmias, anti-cholinergic effects |
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Side effects of SSRIs
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nausea, sexual dysfunction, h/a, sedation, sweating
(s/e go way after 2 weeks) |
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Serotonin Syndrome
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-medical emergency!
-it is a drug reaction resulting from the over-stimulation of serotonin receptors -symptoms: hyperactivity, mental confusion, agitation, shivery, sweating, lack of coordination, seizure, diarrhea |
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what drug is used to augment SSRIs and helps to reduce sexual side effects?
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Wellbutrin- antidepressant
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medications to use to augment SSRIs for sleep issues
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-trazadone (keep you asleep)
-ambien (get you to sleep) |
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An increase of _____mmHg in Systolic BP doubles the risk for fatal MI.
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20mmg Hg
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Risk Factors of HTN
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-Race- enhanced renal Na absorption in 57% of African Americans
-Increased alcohol intake -Obesity -Physical inactivity -Dyslipidemia -Salt intake -Personality traits -Metabolic syndrome |
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Complications of HTN
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Premature Cardiovascular Disease
Heart failure Left Ventricular Hypertrophy Stroke Cerebral hemorrhage Renal Disease Retinopathy Erectile dysfunction |
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Stage 1 Hypertension
Stage 2 Hypertension |
Stage 1 HTN:
SBP 140-159 DBP 90-99 Stage 2 HTN SBP >160 DBP >100 |
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initial drug therapy for HTN
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Thiazide-type diuretics
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JNC7 recommendations state that if BP is > ___/___ above goal, therapy should be with 2 agents, one shold be thaizide-type diuretic.
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BP > 20/10 above goal
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Define Primary HTN
Define Secondary HTN |
Primary: 95% of cases. No known cause. Also known as essential or idiopathic. Most persons with HTN are considered primary until diagnostic screen shows otherwise.
Secondary: is caused by altered hemodynamics associated with primary disease such as arteriosclerosis |
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Define Isolated systolic HTN
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systolic ≥160 accompanied by a normal diastolic ≤90. Most common in elderly. Manifested by an increased Cardiac Output or rigidity of aorta (# 1 cause), or both. Rarely, can be seen with abnormal openings in heart, thyrotoxic crisis, Paget’s disease of bone, and thiamin deficiency
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Medications that are associated with increased BP
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NSAIDS
Corticosteroids Sympathomimetics Methylxanthines (theophylline and caffeine) Cyclosporine Erythropoietin Cocaine Nicotine Phencyclidene (PCP) |
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what is JNC7's recommended sodium intake per day?
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< 2.4 grams of sodium per day
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Compelling indications for individual drug classes
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heart failure
post MI High CVD risk Diabetes Chronic kidney disease Recurrent stroke prevention |
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Clinical Manifestations of End Organ Damage
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Heart disease
Renal insufficiency CNS dysfunction (CVA, TIA, Stroke) Impaired vision (Retinopathy) Impaired mobility Vascular occlusion or edema |
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Physical Examination of a pt with HTN should include:
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-BP with verification in both arms
-Examination of the optic fundi -Auscultation for bruits -Examination of thyroid gland, JVD, and carotid bruits -examination of the heart and lungs -Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation -Palpation of the lower extremities for edema and pulses -Neurological assessment |
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Office BP measurement
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Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.
BP should be taken manually! |
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24 hour Ambulatory BP monitoring
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*Gold Standard*
-Indicated for evaluation of “white-coat” HTN. -Must have an absence of EOD. -Absence of 10–20% BP decrease during sleep may indicate increased CVD risk. -BP every 15 minutes for 24 hrs |
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Self-Measurement of BP
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Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.
-home measurement of > 135/85 mmHg is considered HTN |
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what are laboratory tests use for the evaluation of HTN?
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Electrocardiogram
Urinalysis Blood glucose Hematocrit Serum potassium, creatinine, GFR, and calcium Lipid profile TSH |
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when do we treat for HTN?
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-evidence of end organ damage
-average of 140/90 BPs on 2 different occasions -average of 130/80 in patients with DM or renal disease |
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what are lifestyle modifications for treatment of HTN?
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Moderate sodium reduction
Weight loss Decrease in alcohol intake Aerobic exercise Smoking cessation Patient Education Healthy diet patterns |
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what are 1st, 2nd, and 3rd line drugs used for treatment of HTN?
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-First line- low dose thiazide-like diuretics
-Second line – add one of the following: Beta-blocker Ace inhibitor Ace receptor blocker Calcium channel blocker -Third line-Add another second line drug Direct vasodilator (hydralazine) or alpha blocker |
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HTN: Thiazide Diuretics
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-First line, alone or in combination
-Useful in black and elderly patients -Inexpensive -Loop diuretics preferable for edema and heart failure -Associated with sexual dysfunction in males -May precipitate gout -caution with renal sufficiency -possible hypokalema/hyponatremia -periodic BMP needed |
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HTN:Beta Blockers
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-Indicated in pts with previous MI
-Useful in HTN with resting tachycardia -May be used in diastolic/systolic heart failure -*Pts with ischemic heart disease must be warned not to stop abruptly, may result in accelerated angina, MI, and death* -Nonselective B-1 associated with elevated glucose, insulin resistance, reduced HDL, and elevated TG -useful for migraine and anxiety |
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Side effects and contraindications of Beta blockers for HTN
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associated with Bradycardia, impaired circulation in extremities, depression
Contraindications: Asthma COPD Severe peripheral vascular disease Raynaud’s phenomenon Bradycardia Second or 3rd degree heart block Diabetic patients prone to hypoglycemia |
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HTN: Alpha 1 Blockers
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-Not for first line treatment
-Improve lipid profile (Decrease LDL and triglycerids, Increase HDL) -May cause dizziness, headache, weakness- Orthostatic hypotension -Consider for older men with BPH |
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HTN: Angiotensin Coverting Enzyme Inhibitors (ACE Inhibitors)
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-Work well with thiazide diuretics
-Hypovolemia triggers release of renin -Counters potential hypokalemia -Indicated for post MI, heart failure, diabetes, chronic renal disease -Side effect dry hacking cough -Contraindications Angioedema Pregnancy Hyperkalemia Renal artery stenosis |
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HTN: Angiotension Receptor Blockers (ARB)
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-No evidence that ARB is better than ACE
-If patient coughs with ACE switch to ARB -Occasionally used together - contraindicated in pregnancy |
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HTN: Direct Renin Inhibitors
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-approved by FDA in 2007
-Aliskirin comparable to other agents -contraindicated in pregnancy |
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HTN: Calcium Channel Blockers
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-Not typically for routine first line use
-Work well in isolated elevated systolic HTN -Work well in pts with DM and hyperlipidemia -increase efficacy in blacks -May worsen heart failure -Associated with leg edema -Caution if combined with beta blocker or digoxin -Contraindicated in patients with EF<40% |
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HTN Vasodilators
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-Second or third line
-Used in combination therapy -TID – QID dosing -Transdermal may need cosultation! |
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Goals of Treatment of HTN
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--Prevent End-Organ Damage
Heart Failure Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy |
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Causes of Secondary HTN
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Primary Renal Disease
Renal Vascular Disease Oral Contraceptives Pheochromocytoma Primary Hyperaldosteronism Endocrine disorders Sleep apnea Coarctation of the aorta |
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when would you suspect Secondary HTN?
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Severe, refractory HTN
Creatinine >1.5mg/dL* Onset of age prior to puberty Sudden acute rise if previously stable Acute rise in creatinine after starting ACE or ARB* Moderate to severe HTN with diffuse atheroscerosis* Abdominal bruit* No family history of HTN *supect RAS or primary renal disease |
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Malignant HTN
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-Life-threatening emergency
-Generally >180/120 -Retinal hemorrhages, exudates, and papilledema (symptomatic) -May be nephroscerosis -Often occurs in long time severe hypertensive pts that have discontinued their medication -May have underlying RAS -Rapidly lower systolic to 100-105 IV preferred |
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Urgent HTN
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-May be >180/120
-But no signs of end organ damage -Pt asymptomatic -Often occurs in long time severe hypertensive pts that have discontinued their medication -Do not want to lower as rapidly (2-3 hours) -Rest, quiet -Reinitiate medications, may add diuretic -Initiate traditional regimens -Close follow up |
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Causes of Resistant HTN
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-Improper BP measurement
-Excess sodium intake -Inadequate diuretic therapy -Medication Inadequate doses Drug actions and interactions (NSAIDs, illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN |
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General followup guidelines for HTN
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1.Initial diagnosis:
2. within 2 weeks of new medications- Labs if indicated (ACE inhibitors) 3. then at 3 months, 4. then at 6 months, 5. then every 6 months |
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causes of secondary dyslipidemia
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-Diabetes
-Hypothyroidism -Obstructive liver disease -Chronic renal failure -Drugs that raise LDL cholesterol and lower HDL cholesterol (progestins, protease inhibitors, thiazide diuretics, anabolic steroids, and corticosteroids, atypical antispychotics) |
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C-reactive Protein
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-marker of systemic inflammation
-high risk >3.0mg/L -strong predictor of future coronary events -universal screening not recommended |
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Homocysteine
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-Sulfur containing amino acid that may cause vascular damage by increasing intracellular oxidation stress in endothelial cells.
-Independent risk factor for CVD -Primary atherogenic and prothrombotic properties -High concentrations may be reduced by folic acid (1mg), either alone or in combination with B6 and B12 -Significant increase in CVD risk is observed above 13-15μmol/L -Routine screening not recommended |
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CVD Risk Equivalents
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-Peripheral artery disease
-Abdominal aortic aneurysm -Symptomatic carotid artery disease -Diabetes -Multiple risk factors that confer a 10 year risk for CHD >20% **if pt has any of these then AUTOMATICALLY in HIGH RISK category** |
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What are the risk factors (exclusive of LDL) that modify LDL goals?
(these are the things you count up to decide if you need to figure out the Framingham risk) |
-Smoking
-Hypertension or on med -Low HDL (<40mg/dL) -Family history of premature CVD (male <55, female <65) -Age (men ≥ 45, women ≥ 55) -HDL > 60mg/dL is a negative risk factor and removes one risk factor from the total count |
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1st step before calculating risk level for CVD
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an accurate lipid panel
must be fasting 9-12 hrs |
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what is the LDL goal?
High Risk CVD or CVD risk equivalents (10 yr risk > 20%) |
LDL 100
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what is the LDL goal?
Moderately High Risk 2+ Risk factors (10 year risk 10-20%) |
LDL < 130
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what is the LDL goal?
Moderate Risk 2+ risk factors (10 year risk < 10%) |
LDL <130
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what is the LDL goal?
Lower Risk 0-1 risk factor |
LDL < 160
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what level LDL do you consider medication for high risk category?
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LDL >100
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what level LDL do you consider medication for moderately high risk?
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LDL > 100
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what level LDL do you consider medication for moderate risk?
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LDL > 160
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what level LDL do you consider medication for lower risk?
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LDL > 160
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what are therapeutic lifestyle changes in LDL-lowering therapy?
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Saturated fats <7% of total calories
Dietary cholesterol <200 mg per day Viscous (soluble) fiber (10–25 g per day)- lowers LDL Weight reduction Increased physical activity |
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HMG CoA Reductase Inhibitors (STATINS)
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-Reduce LDL 18–55% & TG 7–30%
-Raise HDL 5–15% -Major side effects: Myopathy; Rhabdomyolysis →renal failure; Increased liver enzymes -Contraindications: active liver disease; pregnancy |
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Bile Acid Sequestrants
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-Reduce LDL 25%
-Raise HDL-C negligable -May increase TG (10%) -Side effects:GI distress/constipation; Decreased absorption of other drugs Take 1 hour before or 4 hours after -Contraindications: Raised TG (especially >400 mg/dL) |
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Nicotinic Acid (Niacin)
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-Lowers LDL 20-40%
-Lowers TG 45-50% -Raises HDL 15–30% -Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity -Contraindications: liver disease, severe gout, peptic ulcer |
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Fibric Acids
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-Lower LDL 10% (with normal TG)
-May raise LDL (with high TG) -Lower TG 30-35% -Raise HDL-C 10% (25% of HDL<35) -Side effects: dyspepsia, gallstones, myopathy -Contraindications: Severe renal or hepatic disease |
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Cholesterol Absorption Inhibitor
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-Use in combination with statin
-Reduces LDL and apoB lipoprotein -Contraindicated in patients with liver disease -Category C, not recommended for nursing mothers -Potentiated by fibrates, gemfibrozil and cyclosporine -SE: diarrhea, abdominal pain, increased LFT’s |
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Omega 3 Fatty Acids
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Include: - а - linolenic acid
-flaxseed, nuts, soy and plant-based oils such as canola and soybean oils, and cold-water fish and fish oils. -Inhibit synthesis of VLDL in the liver -Lower TG by 20 – 30% -Side Effects:GI upset; Bleeding; Low to moderate risk of worsening glycemia; Oily stools; Odor -Lovaza 1g (4 po q day): Indicated for severe hypertrigyceridemia (>500) -May raise LDL -85% active omega 3 (OTC 30-50%) |
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Management of Low HDL Cholesterol
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-LDL cholesterol is primary target of therapy
-Weight reduction and increased physical activity (if the metabolic syndrome is present) -TG secondary target of therapy (if triglycerides >200 mg/dL) -Consider nicotinic acid or fibrates in isolated low HDL (for patients with CHD or CHD risk equivalents) |
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Management of Elevated Triglycerides
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-Goal of therapy: prevent acute pancreatitis
-Very low fat diets (<15% of caloric intake) -Triglyceride-lowering drug usually required (fibrate or nicotinic acid) -Reduce triglycerides before LDL lowering -If TG > than 400 then LDL cannot be accurately calculated |
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Management of High LDL
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-statins
-statins + bile acid sequestrants -statins + bile acid seqestrants + nicotinic acid |
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General Features of Metabolic Syndrom
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Atherogenic dyslipidemia
Elevated triglycerides Increased small LDL particles Low HDL cholesterol Elevated plasma glucose Prothrombotic state Proinflammatory state Ancanthosis nigrans warrants TSH, fasting glucose, and lipid panel |
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Criteria that constitutes diagnosis of metabolic syndrome
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1) Abdominal obesity (102 cm in men, 88 cm in women)
2) Elevated triglycerides 150 mg/dL Or drug treatment for elevated TG 3) Low HDL (40 mg/dL in men or 50 mg/dL in women OR Drug treatment for reduced HDL 4) Elevated BP 130 mmHg systolic BP or 85 mmHg diastolic BP OR Drug treatment for hypertension 5) Elevated fasting glucose ≥100 mg/dL or Drug treatment for elevated glucose *3 of 5 makes the diagnosis |
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what is the incubation period of Hepatitis A ?
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inhubation is average 30 days (2-6wks)
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when is Hepatitis A contagious?
|
during incubation period (2-6 wks)
1 week after appearance of jaundice |
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what is the time frame that the Hepatitis A virus is shed in stool?
|
2-3 weeks before AND 1 week after onset of jaundice
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what are risk factors of HAV?
|
-Poor sanitation
-International travel (15% of cases in US) -Mexico and Central/South America -Sexual and household contact with infected person (10% of cases) -Homosexual activity in men (9% of cases) -Food or water born out breaks (7% of cases) -Child or employee in daycare (4% of cases) -IV drug use (3% of cases) |
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Clinical Manifestations of HAV?
|
Fatigue
Malaise Nausea and vomiting Anorexia Fever Right upper abdominal pain Dark urine Acholic stools- white stools Jaundice- in 70% of symptomatic pts, peaks in 2 weeks Pruritis Hepatomegaly- in 80% of symptomatic pts |
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how do you diagnose HAV?
|
serum IgM anti-HAV
(remains positive for 4-6 mo) ALT and AST > 1000IU/dl elevated alkaline phosphatase elevated total and direct bilirubin |
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how do you confer immunity to HAV?
|
IgG anti-HAV
reamains detectable for decades |
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how do you treat HAV?
|
-supportive care
-aggressive if fulminate infection -85% full recovery in 3 months -rare fatalities associated with chronic hepatitis and advanced age |
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who gets vaccinated with HAV vaccination?
|
-Chronic liver disease
-Men who have sex with men -Those with close personal contact (eg, household contact or regular babysitting) with an international adoptee from a country of high or intermediate endemicity during the first 60 days following arrival of the adoptee in the United States -Travelers to countries with high or intermediate endemicity -Those who use illegal drugs -Those wishing to be vaccinated -HIV -Routine and recommended childhood vaccination since 2006 |
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patient education for HAV
|
-Handwashing
-Thoroughly cook foods -Don’t drink the water in endemic areas -Vaccinate when indicated |
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Patients with Hepatitis B are at risk for developing what diseases?
|
15-40% of pts with HBV are at risk for developing cirrhosis and
hepatocellular carcinoma (HCC). 30-50% of HCC in HBV pts occurs in absence of cirrhosis HBV patients require lifelong monitoring |
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what is the incubation period for HBV?
|
4-6 weeks
|
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how is HBV transmitted?
|
-Blood and body fluids
-Perinatal: infection rate among infants born to HBeAg pos mothers is as high as 90%, and 90% become chronic -Transfusion -Sexual -Percutaneous -Nosocomial: most commonly transmitted blood borne virus in health care setting -Organ transplantation |
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what are risk factors for HBV?
|
-Sexual exposure
-Heterosexual 39% new cases in US -Homosexual men 24% new cases in US -Multiple sex partners -IV drug use- 16% new cases in US -Nosocomial infections |
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what are clinical manifestations of HBV?
|
*only 30% get sick
Fatigue and malaise during prodromal period N/V, anorexia Fever Right upper abdominal pain Dark urine Acholic stools Jaundice may last 1-3 months Pruritis Hepatomegaly Fulminant hepatic failure in 0.1-0.5% |
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how do you diagnose Acute HBV?
|
HBsAg Hepatitis B surface antigen is the serum marker for HBV infection
(appears 1-10 weeks after exposure) pts who recover from HBV becomes undetectable after 4-6 mo |
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How do you manage Acute HBV?
|
-supportive care
-GI consult -admission for fulminate or decompensatory hepatitis |
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how do you confer immunity of HBV?
|
clearance of antigen HBsAg and appearance of antibody HBsAb
>95% of immunocompetent pts with symptomatic HBV recover spontaneously |
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What is chronic HBV?
how do you manage pts with chronic HBV? |
persistance of antigen HbSAg for more than 6 months
Refer Out! Managed by GI/Hepatology Chronic HBV pts need long term follow up |
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Progression from acute to chronic hepatitis B is determined primarily by _____?
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age at infection
-90 % for a perinatally acquired infection -20-50% for infections between the age of one and five years -< 5% for an adult-acquired infection |
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what population do we screen for Chronic HBV?
|
Those born in areas of high and intermediate prevalence rates:
South Asia Africa South Pacific Islands European Mediterranean Eastern Europe The Arctic *if seronegative should be vaccinated seroconversion- development of an antibody response to an infection of vaccine, measured in serum |
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what high risk population group do we screen for chronic HBV?
|
-Household and sexual contacts of HBsAg pos persons*
-IV drug use (past and present)* -Multiple partners or history of STD* -Men who have sex with men* -Inmates* -Chronically elevated AST/ALT* -HCV or HIV* -Renal dialysis* -All pregnant women *if seronegative should be vaccinated |
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Therapy for Chronic HBV
|
decison to initiate antivirals based on:
--E antigen status (HBeAg) --ALT --Viral load (HBV DNA) Therapy: nucleoside/nucleotide analogs & alpha interferon |
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What are the therapeutic goals for HBV?
|
-Suppress HBV replication
*Loss of HBsAg *Seroconversion to HBeAg neg -Decrease HBV DNA to undetectable level -Normalize ALT -Improve liver histology |
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Patient Education for HBV
|
-Have sexual contacts vaccinated
-Use barrier protection during intercourse if not immune -Not share toothbrushes or razor blades -Cover open cuts and scratches -Clean blood spills with detergent or bleach -Participate in all activities including contact sports -Not be excluded from school or daycare -Not be prohibited from sharing food, utensils, or kissing |
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HBV vaccine
|
-95% conversion rate to HBsAb > 10mIU/mL
-Routine testing to confirm seroconversion not necessary unless Health care workers; Hemodialysis; or Others with repeated exposure |
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Modes of transmission for HCV
|
IV drug use (60-80% of users in US)
Blood transfusion Iatrogenic Occupational exposure Recreational Sex (low prevalence) Body piercings Shared toothbrush/razor Vertical transmission (5%) |
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Acute HCV manifestations
|
similar to HAV and HBV
60-70% have no history of acute phase |
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how do you manage acute HCV?
|
-Supportive in acute HCV
-Refer to GI/hepatology -Admission for fulminate hepatitis or decompensation |
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How do you diagnose Acute HCV?
|
HCV-RNA
-indicative of viral load -detectable 1-2 wks after exposure -takes 8 weeks to detect antibody 15-40% will clear virus during acute phase |
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what is chronic HCV?
|
positive HCV antibody (anti-HCV) > 6 months
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signs and symptoms of chronic HCV
|
-often asymptomatic
Weight loss Myalgias / arthrlagias Fatigue Insomnia Abdominal discomfort Anorexia Nausea / diarrhea Depression |
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management of chronic HCV
|
managed by GI/hepatology
Treatment dictated by many factors: -Genotype (1-6) -Liver biopsy -Co-morbidities -Pts wishes -Prognosis -Treatment can be debilitating 24-48 weeks of Pegylated alpha interferon plus ribavirin -Contraindicated in major uncontrolled depressive illness |
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What population should receive HCV testing?
|
-IV drug use even once in 1969
-Persons with HIV -Pts with hemophilia who received clotting factors prior to 1987 -Ever been on hemodialysis -Unexplained aminotransferase levels -Prior recipients of transfusions or organ transplants -Pts who received blood prior to July 1992 -Organ transplant prior to July 1992 -Children of HCV infected mothers -Needle stick injuries -sexual partners of HCV infected persons (prevalence low) |
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Patient Education on Chronic HCV
|
-Avoid sharing toothbrushes and razors
-Cover wounds -Stop injecting drugs -Alcohol promotes progression of HCV -Screening for varicies and HCC |
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What is the role of a primary care provider with patients with hepatitis?
|
-Educate patient
-Understand issues related to HBV and HCV and what happens if you or the patient drops the ball -Advocate for the patient -Understand issues related to successful treatment -Manage side effects when necessary -Supportive medications: Antidepressants, CSFs, vaccinations |
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what is AIDS?
|
AIDS is a CD4 count below 200/mm3 and/or
A broad spectrum of opportunistic infections, malignancies, and nonspecific syndromes |
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|
what is the time frame from HIV infection to 1st complication?
|
8 years
progression to death is 1 more year |
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what is advanced HIV
|
Cd4 count below 50mm
|
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what is the clinical presentation of acute HIV?
|
begins as a prodrome of mono or flu-like illness characterized by sore throat, fever, lymphadenopathy, headache and rash
A minority may present with aseptic meningitis, bell’s palsy or peripheral neuropathy |
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|
Examples of early symptomatic HIV
|
Thrush Vaginal candidiasis
Oral hairy leukoplakia Herpes zoster involving two episodes or more than one dermatome Peripheral neuropathy Bacillary angiomatosis Cervical dysplasia Cervical carcinoma in situ Constitutional symptoms such as fever (38.5°C) or diarrhea for more than one month Idiopathic thrombocytopenic purpura Pelvic inflammatory disease, especially if complicated by a tubo-ovarian abscess Listeriosis |
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Conditions that define AIDS
|
P. carinii pneumonia — 42.6%
Esophageal candidiasis - 15.0% Wasting — 10.7 % Kaposi's sarcoma — 10.7 % Disseminated M. avium infection — 4.8 % Tuberculosis — 4.5 % Cytomegalovirus disease — 3.7 % HIV-associated dementia — 3.6 % |
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Who do you test for HIV?
|
-Required – i.e. the military or a blood bank
-The patient asks for it because they are concerned -The patient is at high risk -You suspect infection -Pregnant women (you don't need to randomly screen people who are not considered to be at risk) |
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Kaposi Sarcoma Lesions
|
-Affects skin and oral mucosa
-initial presentation is usually in the form of pink, purple or red macules or papules -Can progress to large tumors |
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Oral Candidiasis in HIV
|
painful white papules, plaques, and erosions on palate
-A potassium hydroxide preparation show budding yeasts |
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Oral Hairy Leukoplakia
|
-white plaques in mouth
-white vertically oriented corrugated plaques on the side of the tongue |
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|
what are USPSTF recommendations on who we should screen for HIV?
|
-all pregnant women
-Men who have sex with men after 1975 -Men or women who have had unprotected sex with multiple partners -Past/present IV drug users -Prostitutes/Sex with prostitutes -Past or present partners were HIV infected, bi-sexual or iv drug users -Treated for STDs -Blood transfusion between 1975 and 1985 -Anyone who asks for a test |
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|
what are the 2 diagnostic tests that confirm HIV?
|
-Enzyme Linked Immunosorbent Assay (ELISA)
-Western Blot |
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|
ELISA
|
-The screening test
-Has a very high sensitivity -A negative ELISA excludes chronic infection -Rate of false positives in low-risk population is significant -A positive ELISA will automatically warrant a reflexive Western Blot |
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|
Western Blot
|
-99% specificity and sensitivity
-Identifies the presence of discrete antibodies to HIV and provides one of three outcomes: Positive, negative, or indeterminate -A positive test definitively diagnoses chronic infection -A negative test excludes chronic infection -A Western Blot can be indeterminate Infected with HIV-2 (rare in the US) -Immediately infected called primary HIV (PHI) and not producing antibodies -An indeterminate test can be a false positive |
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|
when do you suspect HIV?
|
Unusual infections
Weight loss Unusual skin lesions Opportunistic infections |
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|
what is the management of a patient with HIV/AIDS?
|
-Not NP business
-Highly Active Antiretroviral therapy (HAART) -Preventing and treating opportunistic infections -Immunizations -Management of co-morbid diseases |
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|
prognosis of HIV is based on what?
|
dependent on ability to get on and faithfully remain on HAART (highly active antiretroviral therapy)
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|
In order for a tick to give you lyme disease, how long does the tick need to be present on skin?
|
24-48 hrs
Only 1% to 3% of tick bites result in lyme disease |
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|
Clinical manifestations of Lyme Disease
|
-Usually within 1 week to 1 month, the classic “erythema migrans” rash appears in 80% of patients
-It appears at the site of the bite -Large circular rash that is at least 2 inches in diameter with central clearing -Expands rapidly; Lasts 1-2 weeks -Referred to as ““Bull's-eye” rash Can be necrotic in center Often confused as “spider bites” |
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|
what is the serologic testing for lyme disease?
|
-Used only to support diagnosis, not make it or exclude it
-Use when patient has no rash, but you suspect diagnosis -ELISA (also called “titers”) High rate of false positives. Confirm with Western Blot -People immunized with lyme immunization are positive -5% of population has antibodies to this ELISA -Can be difficult to diagnose serologically due to slow immune response -Culturing of lesions or skin biopsy can give a definitive diagnosis |
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|
symptoms of Lyme Disease- early disease
|
Fatigue
Arthraglias/myalgias Headaches Conjunctivitis Lymphadenopathy Fevers Stiff neck Flu-like illness without sore throat, rhinnorhea or cough |
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treatment of early Lyme Disease
|
-Doxycycline 100mg bid for 14 days (not for kids or pregnant women)
-Amoxicillin 500mg tid for 14 days -Can use erythromycin for allergic patients |
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|
symptoms of early disseminated Lyme Disease
|
-Multiple skin lesions
-More constitutional symptoms -Neurologic symptoms (Usually at 1-2 months after bite; Bell’s palsy; Peripheral neuropathy; Encephalitis/meningitis -Cardiac changes – nonspecific st-t wave changes -Arthralgias that can poly or monoarticular -Can develop a chronic arthritis |
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|
You can treat lyme disease empirically with what?
|
Doxycycline 200mg PO x1 dose
You can treat if pt was bitten by tick but no symptoms and unsure |
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|
How do you treat early disseminated lyme disease?
|
*Consult with Infectious Disease*
-Neurological disease and Cardiac disease--High dose IV penicillin; Ceftriaxone and cefotaxime -Isolated facial nerve palsy Oral doxycycline |
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|
symptoms of late persistent lyme disease
|
-Also called chronic disease
-Characterized by chronic joint pain -Can also cause chronic neuropathies -Cognitive defects -Confusion -Fibromyalgia |
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|
How do you treat late persistent lyme disease?
|
-Largely the same as with early disseminated
-IV antibiotics for neurologic disease PO Doxycycline without neuro symptoms -Treat the arthritis appropriately -May get large effusions -Treat the pain with NSAIDS and acetaminophen |
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|
what are associated symptoms of infectious diarrhea?
|
fever, chills, nausea, vomiting
|
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|
what is acute diarrhea?
|
-defined as lasting less than 2 weeks
-Usually lasts only a few days and identification of specific causative agents is not warranted -Usually associated with headaches, fevers, malaise -Lasts 24-96 hours -Treatment is supportive – hydration, bland diet, rest |
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|
E.Coli infected Diarrhea
|
-Common
-Contaminated meats, undercooked -Also person to person -Toxin causes mild to life-threatening symptoms -Can cause hemorrhagic colitis -Begins with crampy pain followed within hours by watery diarrhea that progresses to grossly bloody stools -Children and elderly get the sickest |
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|
Treatment of diarrhea
|
Treat with antibiotics if diarrhea is from E. Coli, Traveller's Diarrhea, or diarrhea lasting more than 2 weeks
-Rehydrate- Water, Gatorade, Flat cola, IV for severe cases -Bismuth (Pepto-Bismol) for mild cases -Immodium--Probably shouldn’t be used in severe bacterial diarrheas because they prolong the course |
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|
when do you use antibiotics to treat diarrhea?
|
-Most diarrheas are self-limiting
-Antibiotics don’t really help much -Quinolones (Ciprofloxacin, levofloxacin) for really sick people -Can cause an antibiotic related diarrhea -Best used with acutely ill patients, positive stool cultures or evidence of a bacterial infection |
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|
what is the work up for Diarrhea?
|
work up is done for pts who are ill or diarrhea > 2 weeks
CBC Stool analysis/gross examination Stool culture Stool for C. difficile Stool for Ova and Parasite |
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|
management of chronic diarrhea
|
send to GI but do work up labs first!
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|
|
Herpes Zoster manifestations
|
-Begins with a prodrome of pain, itching, burning preceding rash by 3-5 days
-Is localized to a dermatome -Is unilateral -May have mild constitutional symptoms like malaise, fever, and headache -Results ultimately in a rash and neuritis |
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|
complication of herpes zoster opthalmicus
|
acute retinal necrosis
send to opthalmology now! |
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|
Treatment of Herpes Zoster
|
-Best effects if used within 72 hours of symptoms
-Goals: Decrease pain Decrease viral shedding Rapid healing of skin lesions Reduce the likelihood of complications like post-herpetic neuralgia -Acyclovir, Valcyclovir, Famcyclovir -Can consider steroids in the elderly |
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|
Patient education regarding Herpes Zoster
|
-Pain my exist beyond rash and be severe
-Prepare them for the possibility of post herpetic neuralgia -Remind them to keep their rash away from babies while it is in the vesicular phase |
|
|
what is post-herpetic neuralgia?
|
-Onset increases with age
-Pain, and/or paresthesias (tingling, pricking, or numbness), pruritis, motor neuropathies that extends beyond the course of the skin disease -Can last months or become chronic -May require pain clinic intervention, long-term opioid use -Trycyclic antidepressants, gabapentin, pregabalin |
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|
Zoster Vaccination
|
-In individuals over 60, a live, attenuated varicella vaccine decreased the incidence of zoster by 50%
-In those who had the disease, the course was shorter and less painful -It decreased the incidence of post-herpetic neuralgia by 67% -Recommendation is to vaccinate those greater than age 60 |
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|
the most common bacterial cause of community acquired pneumonia (CAP)
|
streptococcus pneumonia
|
|
|
most common viral causes of community acquired pneumonia?
|
Influenza
Adenovirus Parainfluenza Respiratory Syncytial Virus Human Metapneumavirus |
|
|
what are symptoms of pneumonia?
|
Cough
Fever Pleuritic chest pain Dyspnea Sputum Nausea, vomiting, diarrhea Mental status changes |
|
|
what would you see on physical exam in a patient with pneumonia?
|
-Febrile ~ 80%, frequently absent in older adults
-RR >24 ~ 45-70% -Tachycardia -Rales in most patients -WBC 15,000-30,000 (labs are optional and not recommended in the healthy) |
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|
how do you diagnose pneumonia?
|
Consolidation on chest x-ray is considered the gold standard for diagnosis.
(A radiologic diagnosis of pneumonia will require serial films until the pneumonia is cleared) Gram stain and sputum cultures can be considered in patients who are sicker, elderly, or have other considerations like recent travel, failure to improve. |
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|
when would you consider gram stain and sputum cultures for pneumonia?
|
-Empiric treatment will account for over 95% of the common pathogens.
-Consider culture and gram stain for: Admissions Treatment failure Alcohol abuse COPD -Urine antigens may be useful in those who can not cough up a good sample |
|
|
what is the CURB-65 score?
|
-Confusion (based upon a specific mental test or disorientation to person, place, or time)
-Urea blood urea nitrogen >19mg/dL -Respiratory rate >30 -[BP] (systolic <90 mmHg or diastolic <60 mmHg), -Age >65 years *0 to 1 of the above, treat outpatient. 2 or more admit |
|
|
what is the treatment for pneumonia?
without comorbidities? with comorbidities? |
-No comorbidities:
Azithromycin Clarithromycin Doxycycline -Comborbidities: Respiratory fluoroquinolones-- Gatifloxacin, levofloxacin, moxifloxacin |
|
|
what is the usual time course of pneumonia?
|
In healthy individuals, improvement seen and fever resolved in 1-3 days; sometimes up to 1 week, Mycoplasma up to 2 weeks.
|
|
|
who will have a poor prognosis for pneumonia?
|
age extremes, positive blood cultures, low WBC, presence of associated disease, immunosuppression, respiratory failure, inappropriate antecedent antibiotics, delayed treatment >8 hours
|
|
|
how do you prevent pneumonia?
|
-Reduce risk factors
-Avoid indiscriminate use of antibiotics during minor viral infections -Annual influenza vaccine -Pneumovax -Isolation of active cases |
|
|
who gets the pneumovax?
|
-1 dose for all over 65
-2 doses for all under 65 with: Chronic pulmonary disease Chronic cardiac disease Type II DM Chronic liver disease Alcoholism Immunocompromised |
|
|
antibiotics is not indicated for acute bronchitis, except for what bacteria?
|
pertussis
|
|
|
what are causes of acute bronchitis?
|
influenza A and B
Parainfluenza coronavirus (types 1-3) Rhinovirus respiratory syncytial virus human metapneumovirus |
|
|
what are symptoms of acute bronchitis?
|
*Fever rare
(If fever and constitutional symptoms, consider influenza, pneumonia) -Cough – usually worse in the morning, >5 days, +/- productive +/- purulence -Post nasal drip -Rhonchi that clear after cough |
|
|
how do you treat acute bronchitis?
|
Treat the cough
NSAIDS Acetaminophen Decongestants Dextromethorphan |
|
|
who can you treat with antibiotics for acute bronchitis?
what antibiotics do you use? |
-Comorbidities
-Patients over 65 with acute cough and two or more of the following, or patients over 80 with one or more of the following: -Admission to hospital in the previous year -Type 1 or type 2 diabetes -History of congestive heart failure -Current use of oral glucocorticoids Amoxicillin Doxycycline TMP-SMX |
|
|
signs and symptoms of influenza
|
Abrupt onset
Fever Headache Myalgia and arthralgia Malaise Usually improves in 2 to 5 days |
|
|
what are complications of influenza?
|
-Influenza (viral) pneumonia
-Secondary bacterial pneumonia 25% of deaths S. pneumoniae or S. aureaus MRSA -Rhabdomyolysis -Encephalitis -Pericarditis |
|
|
symptoms of primary influenza (viral) pneumonia
|
Fevers, dyspnea, Cyanosis
Happens when the flu virus enters the lung *rare, high mortality |
|
|
Secondary Bacterial Pneumonia
|
*complication of influenza
-Usually Strep Pneumoniae -Community acquired MRSA can have high mortality -Initially fever and respiratory symptoms -Some initial improvement Then dyspnea, cough, high fevers, sputum, and infiltrates on plain films -ACUTE |
|
|
symptoms that help to diagnose influenza
|
48 hours of fever and cough have a positive predictive value of 79%
In adults >65 yoa, fever, chills, malaise Sneezing makes diagnosis less likely |
|
|
Lab testing to diagnose influenza
|
-Rapid antigen tests
10 to 30 minutes Low sensitivity (40 to 60%) -Polymerase Chair Reaction (RT-PCR) Most sensitive Takes longer -Viral culture Washes, swabs, sputum culture 48 to 72 hours Not used for acute management |
|
|
Management of uncomplicated flu
|
Antivirals if within 30 hours
Tylenol Supportive Rest, fluids Usually resolves in two to five days Illness may last a week Can be very fatigued for several weeks –called postinfluenza asthenia |
|
|
antivirals for influenza
|
NEURAMINIDASE INHIBITORS
Influenza A&B, H5N1 –Can shorten course by 2-3 days –zanamivir (Relenza) -oral inhalation (H1N1) –oseltamivir (Tamiflu) -tablet or powder (H1N1 resistant) -Amantadines rarely used |
|
|
Flu Vaccine
|
-Vaccine made each year in an attempt to respond to the virus strains likely to cause an epidemic
-2010 recommended for all people 6 months and older -Two preparations each year: IM, Flu mist |
|
|
signs and symptoms of tuberculosis
|
Fever
Night sweats Cough Hemoptysis Scanty nonpurulent sputum Weight loss Pleuritic chest pain SOB |
|
|
risk factors of Tuberculosis
|
-For infection: Urban, homeless, minority, migrant workers; institutional
-For disease: HIV; recent infection; IV drug abuse |
|
|
what are medical conditions that increase risk of tuberculosis?
|
-HIV
-Recent infection TB within past two years -Chest x-ray positive -Diabetes -Immunocompromised -CA Head and neck -End Stage Renal Disease |
|
|
positive PPD
|
- > 5 mm - positive if HIV infection (or suspected), immunosuppressed, exposed household contact, clinical evidence of active or old disease on chest x-ray
- > 10 mm - positive if other risk factor or < 4 years old - > 15 mm - positive if older than 4 years and no risk factors |
|
|
treatment for inactive TB
|
INH x12 months
|
|
|
treatment for active TB
|
For active disease:
Multidrug Directly observed therapy (DOT) recommended for ALL patients and mandatory for unreliable patients If HIV infected: Separate regimen and longer treatment |
|
|
what is the followup plan for TB patients?
|
-During preventive therapy - monthly visits
monitor for hepatitis and neuropathy, > 35 or symptoms, check LFT’s, modify drugs if needed -During TB therapy - sputum culture monthly If culture positive after 2 months of therapy, reassess drug sensitivity -CXR at 3 months and at completion of therapy |
|
|
when is a TB patient non-contagious?
|
Not infectious if: favorable clinical response after 2-3 weeks of therapy and 3 AFB smears are negative.
|
|
|
who is predisposed to asthma?
|
--Allergies (most significant factor)-- Environmental, Occupational
--Medications/Drug induced --Hormonal changes |
|
|
Inhaled Beta 2 agonists
|
Most effective for:
-acute bronchospasm -prevention of exercise-induced asthma -PRN use |
|
|
Oral Beta 2 agonists
|
-Not first line
-Less effective -More side-effects -Slower onset Extended-release useful for: -people unable to use inhaler correctly -nocturnal asthma -very young or very elderly |
|
|
Long acting Beta 2 agonists
|
-Salmeterol
-slow onset -Not for acute bronchospasm -Also needs short acting Beta2 -BID Salmeterol + inhaled corticosteroids (may really help nocturnal asthma) -Salmeterol + fluticasone (Advair®) |
|
|
Inhaled Corticosteroids
|
-decrease inflammation
-decrease bronchial hyper-responsiveness -Use lowest dose possible -Adverse effects: *? slowing of linear growth (dose dependent) *monitor growth through age 12.. *HPO axis suppression, skin thinning, osteoporosis, glaucoma/cataract possible at high doses |
|
|
Cromolyn & Nedocromil
|
-Inhibit mast cell degranulation
-decrease airway hyper-responsiveness -No bronchodilator activity -USE ONLY FOR PROPHYLAXIS -15-30 minutes prior to exercise or exposure -not as effective as beta2-agonist -decrease systemic toxicity |
|
|
Methylzanthines
|
-Theophylline
-Slower onset than Beta2’s -not helpful in acute bronchospasm -decrease symptom frequency and severity -particularly good for nocturnal asthma -Can decrease IC requirements -Narrow therapeutic range -watch serum levels closely |
|
|
Leukotriene Modifiers
|
-Leukotriene’s: products of arachidonic acid metabolism causing Eosinophil migration,
Mucus and edema, Bronchoconstriction. -Montelukast & Zafirlukast: Receptor antagonists -Zileuton: Inhibits leukotriene synthesis |
|
|
Ipratropium bromide
|
-Inhaled anticholinergic
-Pulmonary cholinergic nerves cause Bronchoconstriction -Ipratropium relieves bronchospasm in chronic bronchitis & COPD -Atrovent (alone) -Combivent (combined w/ albuterol) -Not approved for use in Asthma (may be good for people w/ COPD + Asthma) |
|
|
COPD encompasses what diseases?
|
Chronic Bronchitis
Asthma Cystic fibrosis Bronchiectasis Emphysema |
|
|
cardinal signs of chronic bronchitis
|
-increased sputum volume
-increased sputum purulence -increased intermittent dyspnea other s/s: cough, frequent infections, pedal edema, cyanosis, wheezing, weight gain, diminished breath sounds, RR>25/min |
|
|
S/S of emphysema
|
-minimal cough
-scant suptum -dyspnea -often significant weight loss |
