Joy's NP 2

  1. What are the different cholesterol levels risk stages?
    Image Upload 1
  2. What are the management guidelines for Angina?
    • Reduction of risk factors when possible
    • Manage diet-decrease fats, unsaturated fats
    • Low dose coated ASA
    • Common pharmacotherapy
    •     Nitrates, beta blockers, CCB
    • Optimizing lipid panel with ASCVD risk chart – statin therapy
    • Initiate drug therapy
  3. What are the indications and medication for Statin therapy?
    Image Upload 2
  4. What are the signs and symptoms of Myocardial infarct/ACS?
    • 1/3 of pts give a hx of alteration in typical anginal pain
    • Most infarcts occur at rest: pain similar to angina but more severe
    • Nitro has little effect
    • Cold sweat; weakness, impending doom, apprehension, light headedness, Syncope, dyspnea, cough, N/V
  5. MI/ACS

    List physical exam findings
    • Physical findings
    • Dysrhythmia very common
    • S4 very common, pulmonary crackles
    • Wheezing, tachycardia
    • Low grade fever during first 48hrs
  6. MI/ACS Labs and diagnostics
    • Lab/diagnostics
    • ECG changes- Peaked T waves, ST elevation, Q wave development
    •    Lead 1, aVL or V5-6= lateral
    •    Lead 2, 3, aVL = inferior
    •    V leads or V3 and V4 = anterior
    •    V1 and V2 = septal
    •    Tall R waves = posterior
    • Elevated cardiac enzymes
    • ECHO for bed side assessment of wall motion and EF
    • Leukocytosis 10,000 to 20,000 on second day
  7. What is the management for MI/ACS?
    • ASA 325 table to chew
    • NTG SL q5mins X3
    • 02 therapy, IV @KVO 3 PIVs
    • 12 lead EKG and cardiac monitor
    • Morphine 2-4mg IVP
    • Lasix if pulmonary edema 40mg IVP
    • Metoprolol 5mg X3 @ 2min intervals, then 50mg PO q6hrs 15min after last IV dose, if not contraindicated
    • ACE inhibitor most beneficial when patient has failure or a large infarct to help prevent ventricular remodeling
    • Heparin vs low molecular weight heparin (Lovenox 1mg/kg), monitor therapeutic coagulation values
  8. What are the normal coagulation values?
    • INR = 0.8 to 1.2 sec
    • Activated coagulation time (ACT)= 70 to 120sec
    • APTT= 28-38sec
    • PT= 11 to 16sec
    • PTT= 60 to 90sec
  9. What are the therapeutic coagulation values for MI/ACS?
    INR: MI: 2.5 to 3.5 X normal – Coumadin: 2 to 3

    ACT: 150 to 190 or >300sec post PTCA/sent

    aPTT: 1.5 to 2.5 X normal

    PT: 1.5 to 2.5 X normal

    PTT: 1.5 to 2.5 X normal
  10. What are the indications for pharmacologic revascularization of MI/AC?


    What would be the contraindication?
    • Indication for pharmacologic revascularization
    •    Unrelieved CP (>30mins and <6hrs) WITH
    •    ST segment elevation >0.1 mV in two or more contiguous leads

    • Contraindication
    •    Active bleeding or risk thereof, including abnormal coagulation values
  11. Superficial Thrombosis

    Signs and symptoms
    Physical Exam findings
    • SS: Sudden onset of pain
    • Phy Exam: Localized heat and erythema, low grade temp
    • Lab: None
    • MGMT: Elevation of extremity, warm compresses, non-steroidal agents, D/C oral contraceptive
  12. Deep Thrombosis

    Signs and symptoms
    Physical Exam findings
    • Sudden onset of pain, pain or tenderness while walking, dull ache or tight feeling
    • Edema distal to occlusion, low grade temp, skin may be cool to touch
    • Ultrasound, D dimer, venography
    • Bed rest with leg elevation until tenderness subsides, Lovenox 1mg/kg q12 or heparin infusion for 7 to 10 days, Coumadin for 12 weeks
  13. Peripheral Vascular Disease 

    Signs and symptoms
    Physical Exam findings
    • S/S: C/O calf pain, cold/numbness to extremities, progresses to pain at rest
    • Physical: Shiny/hairless skin, cyanosis, pallor, ulcerations, reduced pulses
    • Lab/Dx: Doppler U/S to evaluate flow, ABI, Xrays may show calcification, arteriography – most definitive test
    • Mgmt: Smoking cessation, exercise, weight reduction, mngt or DM and hyperlipidemia, angioplasty, bypass surgery, amputation
    •     Pharmacotherapy for symptom relief - Pentoxifylline (Trental), Cilostazol (Pletal)
  14. Chronic Venous Insufficiency  

    Signs and symptoms
    Physical Exam findings
    • Aching of the LE relieved by elevation, edema after prolonged standing, night cramps of the LE
    • Trophic changes with brownish discoloration, stasis ulcers, LE edema, dermatitis may be common, cool to touch
    • Nonspecifically diagnostics of CVI, R/O edema due to heart failure and other causes
    • Bed rest with legs elevated to decrease edema, heavy duty elastic support stockings, weight reduction for obese, treat dermatitis or ulcers as indicated
    •     Acute weeping dermatitis- wet compresses, 0.5% hydrocortisone cream after compresses, abx if bacterial infection
  15. Pericarditis
    Signs and symptoms
    Physical findings
    • Viruses most common cause, post MI, Renal failure, Endocarditis, drug or trauma induced, TB, septicemia
    • Very localized retrosternal/precordial chest pain, pleuritic in nature
    •     Pain increased by deep inspiration, coughing, swallowing, pain relieved by sitting forward, SOB 2/2 pain
    • Pericardial friction rub, fever may be present depending on underlying cause
  16. Pericarditis Lab, diagnostics
    • . Lab, diagnostics
    • ST segment elevation in all leads with return to normal in a few days
    • Depression of PR segment highly indicative
    • ESR elevation, positive BC if bacterial, CBC
    • ECHO to confirm presence of pericardial fluid or other abnormalities
  17. Pericarditis

    • Management
    • NSAIDs are mainstay of tx- Ibuprofen 400-600q6-8hrs
    • Indomethacin (Indocin) 25-50mg q8hrs for 2 weeks
    • Corticosteroids are indicated only when there is total failure of high dose NSAIDS over several weeks and with relapsing pericarditis
    •     Dexamethasone 4mg IV may relieve pain in a few hrs
    •     Prednisone 60mg daily, then tapered
    • ABX in cases of bacterial infection
    • Codeine 15-60 mg PO QID for pain
    • Monitor for tamponade
  18. Endocarditis
    Signs and symptoms
    Physical findings
    • Infection of endothelial surface of the heart, usually caused by bacteria, known valvular disease recent dental work, genitourinary instruments, surgery of resp tract, HD IV catheters
    • Fever and malaise, Night sweats and weight loss, General sick feeling
    • Murmur often present, medium to high fever, Osler’s nodes: painful, red nodules in the distal phalanges, petechiale, purpura, pallor
    •     Splinter hemorrhages: linear, subungal splinter-appearing
    •     Janeway lesions: small macules on the palms and soles
    •     Roth spots: small retinal infarcts
  19. Endocarditis 
    Lab, diagnostics
    • WBC may be normal or elevated but there is always a shift with bands
    • ECHO for valvular damage
    • Blood cultures for causative organism
    •     3 separate cultures at 3 separate sites in 1 hr
    • ESR always elevated
  20. Endocarditis management
    • Hold abx until cultures are confirmed in stable and not acutely ill or cardiac failure
    • In unstable patients empiric abx should be initiated
    •     PCN G 2million units IV q4
    •     Nafcillin (Unipen) 2 g IV q4
    •     Vanco- used for PCN-resistant strep and MRSA
  21. What are some Gerontology considerations for cardiovascular physiologic changes?
    • Arterial walls thicken and stiffen-resulting in decreased compliance
    • The heart becomes stiffer and increase in size related to LV and arterial hypertrophy
    • Sclerosis of valves
    • Maximum HR decrease, resting HR and CO are unaffected
    • Baroreceptors that monitor BP become less sensitive
    • Circulatory changes with diminished blood flow
    • Loss of pacemaker cells with increased AV conduction time
    • Arteriosclerosis and atherosclerosis
  22. Gerontology Considerations


    What are some Cardiovascular physical findings and/or results?
    • Hypertension: increased risk for CVA, MI, and renal failure
    • Heart murmurs are common
    • Decrease cardiac reserve (may lead to orthostatic hypotension or syncope
    • Overall diminished peripheral pulses and cool extremities
    • Dysrhythmias
  23. What disorder can be ruled out using the Cosyntropin stimulation test?
    Diabetes Insipidus
    Adrenal insufficiency
    Adrenal insufficiency


    • Cosyntropin is a lab/diagnostic for Addison’s disease
    • In healthy individuals, the cortisol level should increase above 18-20 µg/dl within 60 minutes on a 250 mg cosyntropin stimulation test.
    • In Addison's disease, both the cortisol and aldosteronelevels are low, and the cortisol will not rise during the cosyntropin stimulation test
  24. You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness?
    Thyroxin index


    • Lab/diagnostics for Hypothyroidism
    • TSH usually elevated
    • T3 and T4 decreased
    • T3 not reliable test and T4 can also be normal in Hypothyroidism
  25. For the past few months, 29 year old Janine has been gaining weight while experiencing amenorrhea and increasingly severe acne. She has gained more than 20 pounds, and you note that she is carrying her weight around the midline, w/BL purplish striae across both flanks. You suspect Cushing’s syndrome. Which of the following findings would not contribute to a Dx?
    Urine free cortisol = 360 μg/day (>50 is abnormal)
    WBC 19
    After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol
    . After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol (In Cushings, pituitary does not respond to dexamethasone)
  26. Which of the following is not a criteria of Metabolic Syndrome?
    BP > 140/90
    Waist >40 inches
    TG >150
    HDL < 40
    • BP > 140/90 (it’s ≥130/85)
    • Waist > 40men >35women
    • BP > 130/85
    • TG > 150
    • FBG> 100
    • HDL< 40men <50women
  27. What is the treatment if a patient is hypotensive with Addison’s?
    IVF (D5NS) should be treatment of choice. Vasopressors are usually ineffective


    • Inpatient management of Addison
    •     Hydrocortisone 100-300mg IV initially with NS;
    •     Replace volume with D5NS at 500cc/hr X4hrs and then taper per condition
    •     Treat underlying causes
  28. 23 yo F presents with DKA. ABD pH 7.3, glucose 520, BP 90/65, HR 120 and confused. Which of the following are not included in the initial management of DKA?
    Isotonic fluids,
    insulin infusion,
    sodium bicarb
    supportive care?
    Sodium bicarb is only indicated for DKA if pH <7.1


    • DKA management
    • Isotonic fluids (NS) at least 1L in first hr then 500cc/hr
    • If glucose > 500 use ½ NS after first hr (as water deficits exceeds sodium loss)
    • Glucose < 250 change to D5 ½ NS to prevent hypoglycemia
    • Regular insulin
    • Correct sever acidosis (pH<7.1) with bicarb gtt (44-48 mEq in 900ml ½ NS until pH>7.1 Do not treat hyperkalemia
  29. Which of the following is contraindicated for a patient receiving a renal angiogram?
    Beta blocker
    Alpha blocker
    Calcium channel blocker
    Ace Inhibitor
    Ace Inhibitor


    Ace inhibitors may cause cough, rash, taste disturbances, hyperkalemia, renal impairment etc
  30. Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe?
    ASA (young with no risk factors/history)

    • Coumadin (would be used in old-65 with + RF/Hx)
  31. Which of the following lipid panels shows 3 out of 4 abnormal values?
    TC 205, LDL 150, HDL 30, TG 300
    TC 150, LDL 99, HDL 35, TG 145
    TC 102, LDL 50, HDL 60, TG 102
    TC 180, LDL 136, HDL 25, TG 160
    • TC 180, LDL 136, HDL 25, TG 160
    • TC<200
    • TG<150
    • LDL<130 <100 <70
    • HDL>50
  32. A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage?
    Stage III


    Class 3 indicates marked limitations of physical activity but comfortable at rest.
  33. Temporal Arteritis
    • Inflamed or damaged temporal arteries can be linked to autoimmune response
    •     Also, known as giant cell arteritis
    • Double vision, loss of vision in one eye, throbbing HA, fatigue, weakness, loss of appetite, jaw pain, fever, unintentional weight loss
    • CBC, liver fx test, ESR, CRP, U/S, biopsy of the suspected artery to make a definitive diagnosis,
    • Blindness, development of aneurysms, stroke, eye muscle weakness
    • No cure, goal of tx is to minimize tissue damage
    •     If suspected treatment with steroids should begin immediately
  34. 62 yo M presents with angina after his daily walk.  Lipid panel reveals LDL 250, HDL 25, chol 350 and triglycerides 250. You prescribe niacin. How would you explain the mechanism of action to the pt?
    Niacin lowers LDL and increases HDL
  35. Peptic Ulcer Disease

    Signs and Symptoms
    Physical findings
    • Causes: pylori, NSAIDs, ASA, and glucocorticoids
    • S/S: Gnawing epigastric pain,

    -    Duodenal – relief of pain with eating

    • -    Gastric – pain worsens with eating
    • Physical findings: Mild epigastric tenderness

    •          -     GI bleeding- melena, hematemesis or coffee emesis
    • Lab/Dx: endoscopy after 8-12 weeks of tx, H. pylori testing
  36. Peptic Ulcer Disease

    Out-patient management
    • Acid-antisecretory agents
    •     H2 Receptor Antagonists –Zantac
    •     Proton Pump Inhibitors – protonic
    • Mucosal Protective Agents
    •      Give 2hrs apart from other meds
    •     Sucralfate, pepto-bismol
    • pylori eradication therapy- 2 abx +PPI or bismuth
    •      Flagyl, clarithromycin, amoxicillin
  37. Peptic Ulcer Disease

    In patient management
    • IV access- fluid/blood products
    • Baseline labs- CBC, PT/PTT, BMP
    • O2
    • Endoscopy; GI angiography
    • Foley cath
    • NPO/Nasogastric tube for lavage
    • Upright or decubitus films-show free air in 75% cases
    • Monitor abdomen- quiet, rigid with rebound tenderness
    • IV H2 blockers
    • If coagulopathy present, give FFP
    • If thrombocytopenia (<50,000) exist, transfuse platelets
    • GI/surgical evaluation
  38. GERD

    • Incompetent lower esophageal sphincter, delayed gastric emptying
    • Retrosternal burning, belching, dysphagia, hiccoughs, may be relieved by sitting up, antacids, water or food
    • EGD to rule out cancer, Barrett’s esophagus, peptic ulcer
  39. mgmt GERD
    • Non-pharm
    •     Elevate head of bed, avoid alcohol, stop smoking
    •     Avoid spices caffeine, and peppermint
    • Med
    •     Antacids PRN,
    •     H2 blockers, PPI,
    • GI/surgical consult PRN
  40. Hepatitis
    Hep A
    Hep B
    Hep C
    • Hep A
    • Contaminated water and food
    • Blood and stool are infectious during 2-6 week
    • Hep B
    • Present in serum, saliva, semen, and vaginal
    • Transmitted via blood & blood products sexual activity, and mother-fetus
    • Hep C
    • Source of infection uncertain Traditionally associated with blood transfusion/ IV drug use
  41. Hepatitis
    Signs and symptoms
    • Signs and symptoms
    •     Pre-icteric- fatigue, malaise, anorexia, N/V, HA
    •     Icteric- weight loss, jaundice, pruritus, RUQ pain, clay colored stool, dark urine
    •       Low grade fever, hepatosplenomegaly
    • Lab/diagnostic
    •   WBC-low to normal
    •   U/A- Proteinuria, bilirubinuria
    •   Elevated AST and ALT (500-2000)
    •   LDH, bilirubin, AKP, and PT normal or slightly elevated
  42. Hepatitis A, B, and C serology test interpretation
    • Hepatitis A
    • Active Hep A = Anti-HAV, IgM
    • Recovered Hep A = Anti-HAV, IgG
    • Hepatitis B
    • Active Hep B = HBsAg, HBeAg , Anti-HBc, IgM
    • Chronic Hep B = HBsAg, Anti-HBc, Anti-HBe, IgM, IgG
    • Recovered Hep B = Anti-HBc, Anti-HBsAg
    • Hepatitis C
    • Acute Hep C = Anti-HCV, HCV RNA
    • Chronic Hep C = Anti-HCV, HCV RNA
  43. Management of Hepatitis
    • Generally supportive; rest during active phase
    • Increased fluids to 3000 to 4000 ml/day
    • Avoid alcohol or other drugs detoxified by the liver
    • No/low protein diet
    • Oxazepam (Serax) if sedation is necessary
    • Vitamin K for prolonged PT (>15 sec)
    • Lactulose 30ml orally or rectally for elevated ammonia levels: Hepatic encephalopathy
  44. Diverticulitis
    Signs and symptoms
    Physical findings
    • LLQ pain, constipation or loose stool, N/V
    • Low grade fever, LLQ tenderness,
    •     Patients with free perforation present with a more dramatic picture and peritoneal signs
    • Leukocytosis, Elevated ESR, stool heme,
    •     Sigmoidoscopy shows inflamed mucosa
    •     May consider CT scan to evaluate abscess
    •     Plain abd films for evidence of free air
  45. In-Patient management of Diverticulitis
    • NPO dependent upon condition
    • IV fluids to maintain hydration
    • IV abx – flagyl, Cipro, ceftazidime, clindamycin, ampicillin
    • If significant GI bleeding present, treat like PUD Surgical consultation
  46. Cholecystitis

    Signs and symptoms
    Physical findings
    • Precipitated by large or fatty food, sever pain epigastric/RUQ
    • Physical findings
    •     Murphys sign deep pain under right rib cage
    •     RUQ tenderness to palpation
    •     Muscle guarding and rebound pain
    •     Fever
    • Lab/diagnostic
    •     WBC 12-15000
    •     Elevated bili, ALT, AST, LDH, AKP Amylase
    •     Pain films show gallstones, HIDA scan, U/S gold standard
  47. Cholecystitis management
    • Pain management
    • NGT for gastric decompression
    • Maintain NPO
    • Crystalloid solutions
    • IV abx, broad spectrum such as PCN
    • Surgical consultation for lap choley
  48. Acute Pancreatitis

    Signs and symptoms
    Physical findings
    Lab diagnostics
    • Gallbladder disease, heavy alcohol use, hypercalemia
    • Abrupt onset worsened by walking and lying supine
    •     Pain improved by sitting and leaning forward
    •     Pain radiates to the back
    •     N/V, weakness, sweating, anxiety
    • Under abd tender to palpation, distended abd, absent BS
    •     Grey Turner’s sign- flank discoloration
    •     Cullen’s sign- umbilical discoloration
    • Elevated WBC, hyperglycemia, LDH & AST, amylase and lipase, BUN and coagulation,
    •     Hypocalcemia- levels <7 watch for chvostek & trousseau’s sign
    •     Elevated C-reactive protein suggest necrosis, CT
  49. Acute Pancreatitis management
    • Prognostic signs at admission GWGLA HBCABE
    • Greater than 55yrs   George Washington Got Lazy After He Broke C_A_B_E
    •     WBC>16000
    •     Glucose >200
    •     LDH>350
    •     AST>250
    • Prognostic signs during first 48hrs
    •     Hct drop of >10
    •     BUN increase >5
    •     Calcium <8
    •     Arterial 02<60
    •     Base deficit>4
    •     Estimated fluid sequestration >6,000
    • Bed rest, NPO, IV volume repletion, NG suction, pain control
    • Once pt is pain free and has BS, may start clear diet
  50. Bowel Obstruction
    Signs and symptoms
    Physical findings
    • Cramping periumbilical pain initially, later becomes constant and diffuse, vomiting within mins
    • Minimal distention (proximal), pronounced abd distention (distal), high pitched, tinkling BS, unable to pass stool/gas
    • Elevated WBCs and values consistent with dehydration,
    •     Plain films show dilated loops of bowel and air-fluid levels
    •       Horizontal pattern in SBO
    •       Frame pattern in LBO
  51. Management of Bowel Obstruction
    • Fluid resuscitation
    • NGT suction
    • Broad spectrum abx
    • Surgical intervention in all cases of complete obstruction
    • In partial obstruction, may treat medically
Card Set
Joy's NP 2
2nd joys np