Clin Med Lab Final New stuff Flashcards
1
Q
signs from Hx indicative of PAD
A
`1.Pt can walk discrete distance prior to pain
- Sitting helps
- Pain resumes with activity again
- Pain in legs with reclining in chair
- Advil does not help
- PMH (smoking, obese, HLD, etc.)
2
Q
Physical Exam findings in PAD (5)
A
- Diminished pulses
- Smooth hairless legs that are cooler to touch
- Thickened toenails
- Color changes
- Buerger test
3
Q
Buerger Test (2 parts)
A
- Elevate legs 45 degrees for 2 min.
Pallor indicates poor perfusion/ischemia - Next, patient sits up and hangs their legs over the edge of the bed
Color should return to the legs
Skin generally becomes blue then red
4
Q
Arterial disease that affects the peripheral vasculature, most commonly from atherosclerosis
A
PAD
5
Q
Clinical SSx of PAD (10)
A
Asymptomatic Intermittent claudication Atypical pain Pain at rest Nonhealing wounds Ulcers Gangrene Thin, hairless/shiny skin Cool skin Blue toe syndrome
6
Q
Exertional leg pain that classically occurs after a certain distance of walking
Resolves with rest
A
Claudication
7
Q
Buttock & Hip Claudication is indicative of
A
Aortoiliac Dz
8
Q
Aching, may have weakness of thigh or hip with walking. Diminished pulses in 1 or both groins
A
Aortoiliac Dz
9
Q
claudication + absent or diminished femoral pulses + ED
A
Leriche syndrome
10
Q
Thigh Claudication
A
Common femoral artery
11
Q
Claudication of Calf: Upper 2/3
A
Superficial Femoral Artery
12
Q
Claudication of Calf: Lower 1/3
A
Popliteal artery
13
Q
Foot Claudication vessel involved
A
Tibial & Peroneal artery
14
Q
6 P’s of Acute Limb Ischemia
A
Pulseless Paralysis Perishingly cold Paresthesias Pallor Pain
15
Q
Tx of Acute Limb Ischemia (2)
A
Start heparin & revascularization
STAT
16
Q
How to measure ABI?
NL?
Dx of PAD?
Dx of calcified vessels?
A
Ratio of the ankle systolic blood pressure
divided by
the brachial systolic pressure
0.91-1.3
PAD <0.9
calcified vessels >1.3
17
Q
What do you measure PAD arterial extent with?
A
Doppler probe
18
Q
an _____ ___________ _________ gives the most objective evidence of how much someone is functionally limited by PAD
A
Exercise treadmill test
19
Q
Might be considered in patients with atypical pain & a normal ABI
Performed in a vascular lab
A
Exercise treadmill test
20
Q
An ABI that ↓ ____% after exercise is diagnostic of arterial obstruction
A
20
21
Q
Vascular imaging:
initial study?
Gold standard?
Ideal?
A
initial: CTA
Gold standard: conventional angiography
Do both at same time in limb ischemia
22
Q
PAD Tx? (3 courses)
A
- Risk factor modification
Smoking cessation, control DM and HTN, lose weight - Antithrombotic therapy long-term
ASA or Clopidogrel (Plavix) - Lipid-lowering therapy with at least a moderate intensity statin
Irrespective of LDL cholesterol level
23
Q
Claudication Tx? (3)
Initial?
Rx? (1) and contraindication
Surg? (2)
A
- Initial: supervised exercise program
- Cilostazol (Pletal)
Contraindicated in ANY patients with CHF (↓survival). Patients with CAD have ↑ risk of angina & MI
3.Revascularization
For life threatening ischemia –or-
Patients with significant/disabling symptoms unresponsive to lifestyle modifications & medication
Stenting or bypass
24
Q
What Rx is Contraindicated in ANY patients with CHF (↓survival)
A
Cilostazol
25
S/E of Cilostazol
s/e: headache, diarrhea, infection, rhinitis
26
A/N Foot Ulcers:
Location?
A: Toe Joints
N: Plantar Surface
27
A/N Foot Ulcers:
Appearance?
A: Irregular margins
Pale or necrotic base
N: 'punched out'
Red base
28
A/N Foot Ulcers:
| Ulcers w/in callus?
A: rare
N: yes
29
A/N Foot Ulcers:
| Pain?
A: yes
N: No
30
A/N Foot Ulcers:
| Deformity?
A: No
N: Often
31
A/N Foot Ulcers:
| Skin Changes
A: Shiny, taunt
N: Waxy or shiny, poss pitting edema
32
A/N Foot Ulcers:
| Reflexes?
A: present
N: absent
33
___ is a strong predictor of adverse CV outcomes (CHF risk equivalent)
PAD
34
PMH & P/E Predictors of progression to acute limb ischemia? (3)
1. DM
2. , ↑pack year smoking hx
3. Lower ABI
35
Asssessment & Plan PAD
How to fix:
1. PAD ->
2. Type 2 Diabetes with CKD3b->
3. HTN ->
4. HLD ->
5. Hypothyroidism->
6. Tobacco use ->
7. Obesity ->
36
Wells Pretest Probability for DVT (10)
| HANG IN THERE!
1. CA tx in last 6mo
2. Paralysis/paresthesia or cast of BLE (stasis)
3. Bedridden for 3d in last 4wks
OR
major surg in last 12wks.
4. Vein tenderness
5. Swelling of ENTIRE leg
6. UNILATERAL calf swelling >3cm
7. UNILATERAL pitting edema
8. prior DVT
9. Collateral veins (compensation)
10. Any other Dx makes more sense
37
Pretest Probability for DVT
D-dimer?
U/S?
Low->
Moderate->
High->
low: 0pts
D-dimer:
if NL-DONE
if (+)- U/S
Moderate: 1-2pts
HIGH SENSITIVITY D-dimer:
if NL-DONE
if (+)- U/S
High: 3-8pts (50-75%)
NO D-DIMER
DO U/S!
38
Wells Pretest probability for PE (7)
1. DVT sx
2. PE likely Dx
3. Bedrest ≥3d
OR Surg in 4wks
4. Previous PE/DVT
5. Hemoptysis (SOB pts)
6. CA Tx in 6mo
7. HR >100
39
Pretest Probability for PE (using Wells)
D-dimer?
CTPA?
Low->
Intermediate->
High->
```
Low: <2pts
Apply PERC
1. if pt fulfills ALL PERC-> DONE (NO D-dimer/CTA)
2. if 1 is not fulfilled-> D-Dimer
if D-dimer (+)-> CTPA
```
Intermediate: 2-6pts
D-dimer:
(+)-> CTPA
(-)-> DONE
High >6pts
DO CTPA
No need for D-Dimer!!
40
PERC (8)
1. Age <50
2. HR <100
3. O2 Sat ≥95%
4. No hemoptysis
5. No estrogen use
6. No prior DVT/PE
7. No UNILATERAL leg swelling
8. No surg/trauma req admission in 4wks
41
Key things that can cause an ↑ D-dimer
```
Surg
Trauma
NL pregnancy
Sickle Cell Dz w/ vasoclusive episode
↑ age
Afib
CHF/CVD
infection/sepsis/inflamm
MI/CVA
Acute limb ischemia
preeclampsia
thrombolytic agents
AV malformations
Liver/Renal dz
```
42
Test that is SENSITIVE and SPECIFIC for PE Dx
CTPA (with contrast)
43
Proximal DVT locations (3)
Popliteal v.
Femoral v.
Iliac v.
44
Distal DVT locations
Anterior tibial v.
Posterior tibial v.
Peroneal v.
45
Massive PE Dx
HEMODYNAMICALLY UNSTABLE
SBP <90
46
Massive PE Tx (3)
1. Vasopressors/ clear evidence of shock
2. IV fluids
3. Reperfusion therapy
a. systemic thrombolysis
b. embolectomy
47
RV dysfunction & borderline BP is a __ PE?
Submassive PE
48
Reperfusion therapy for hemodynamically unstable PE pts (2)
1. TPA
-for hemodynamically unstable
2. Embolectomy
- for failure of TPA
OR
-contraindication for TPA (saddle PE)
49
No identifiable provoking factor for DVT/PE is a ____ ___?
Unprovoked VTE
ok people, lets start the workup
50
identifiable provoking factor/event is a ___ ___?
Provoked DVT
51
provoking factors for DVT
1. surg
2. admisison
3. C-section
4. pregnant
5. ESTROGEN!
6. reduced mobility (stasis)
52
Persistent risk factors:
| Inherited v. acquired (5)
inherited (genetic)
Acquired (CA)
1. malignancy
2. Factor V
3. prothrombin gene mutation
4. gene mutation
5. anatomic risk factors
6. chronic dz (IBD)
53
Common Rx that cause provoked DVT
1. estrogens
2. OCP's
3. Testosterone
4. Tamoxifen
5. Steroids
54
Tx w/anticoagulants (2 chocies)
| Which one needs a Heparin (Lovenox) bridge?
1. Coumadin
(needs a Lovenox bridge until INR 2-3 for 24hrs)
2. NOACs- Eliquis, Pradaxa, Xarelto, Savaysa
55
DVT Tx Bridging w/Heparin (lovenox).
What indiacations?
How long to bridge?
Indication: Warfarin (Coumadin)
Bridge until INR measured 2.0-3.0 for 24hrs straight.
56
Warfarin, NOACs & Reversal Agents
Warfarin- Vit K
NOAC's
1. Pradaxa (Praxibind)
2. Savaysa (Andexxa)
3. Eliquis (Andexxa)
4. Xarelto (Andexxa)
"SEX with ANDEXXA"
57
NOAC vs Coumadin
| good vs bad
Dont need to bridge NOACs w/ Lovenox
Starting doses are HIGHER (loading dose)
58
Minimum length of time to anticoagulate in VTE Pt
3months
Can go longer if needed
Average 3-6mo
59
DVT when to initiate anticoags:
Proximal?
Distal?
Contraindications?
Proximal: no contraindications
Distal: Symptomatic w/no contraindications
Conraindications: active bleed, platelets <50k, prior intracranial hemorrhage
60
Highest risk of VTE occurence (time frame)
1-2yrs after 1st event
61
Pts w/ ____ ____have rates of VTE ocurence of 15-20%/yr
benefit from what prophylactically?
Active Cancer
Benefit from anticoags prophylactically
62
High recurrence risk VTE pts (4)
| INDEFINITELY ANTICOAG THEM!
1. RECURRENT PROXIMAL DVT &/or Symptomatic PE (w/o identifiable risk factors)
2. Any VTE associated w/Active Cancer w/o provoking event
3. FIRST EPISODE PROXIMAL DVT/Symptomatic PE (w/o identifiable risk factor
63
Intermediate recurrence risk VTE pts (3)
| SHARED DECISION MAKING FOR ANTICOAGS
1. First VTE WITH persistent NONMALIGNANT risk factor
2. First episode VTE 2/2 transient MINOR risk factor
3. Recurrent VTE provoked by transient or persistent malignant risk factor
64
Low Recurrence VTE risk
indefinite coags NOT recommended
1st episode VTE w/transient major risk factor
65
IVC filters main point
Prevent embolization of a lower extremity clot to the lung
66
IVC filters for pts with ____ ____ and _____who have an _____ _______ to anticoagulants
(ACUTE) PROXIMAL DVT/PE
ABSOLUTE CONTRAINDICATION
67
T/F: IVC plus anticoagulants has benefit
False
| No benefit
68
common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways
COPD
69
Chronic PRODUCTIVE cough
| present 3mo x2 successive years
COPD
70
Abnormal enlargement of terminal air spaces
| Accompanied by destruction of airspace walls WITHOUT FIBROSIS
Emphysema
71
2 scales for rating severity of COPD
CAT scale
| mMRC scale
72
Combined COPD Assessment Steps (3)
```
1. How symptomatic are they:
less Sx:
mMRC <2 or CAT <10
more Sx
mMRC >2 or CAT >10
(take worse of the 2 scales)
2. Spirometry reading
3. Amt of exacerbations in past yr.
```
73
COPD management most important principle (2)
STOP SMOKING
| use O2 if indicated
74
COPD mgmt other principles (4)
1. Influenza vaccine
2. Pneumococcal vaccine
(>65yo or <65yo w/FEV1 <40% predicted)
3. Exercise program
4. pt education
75
Group A COPD Tx
| preferred?
SABA or SAMA
| SABA>SAMA
76
SABA (2)
| dosage
Albuterol (Proair-red box, Proventil, Ventolin)
Neb: 2.5mg inhaled Q6hr
Levalbuterol (Xopenex)
Neb: 0.63mcg/3mL Q8hr
77
albuterol s/e
tremors, jittery, tachycardia
78
SAMA (1)
| dosage
Ipatropium (Atrovent)
| Neb: 500mcg inhaled Q6-8hrs
79
Group B Tx
(SABA)+
| LABA or LAMA
80
Combo SABA + SAMA
Duoneb
Combo beta agonist and anticholinergic
Ipratroprium + albuterol
Neb: Duoneb: 1 vial Q4H
81
All COPD PT GROUPS should habe this as a rescue med:
SABA- Albuterol
82
LABA
| which does she want us to know?
AFORMOTEROL (BROVANA)
| 15mcg inhaled neb BID
83
LAMA
| Which one does she want us to know?
TIOTROPIUM (SPIRIVA)
handihaler: 1 capsule (18mcg) QD
Respimat: 2.5 mcg/act 2 inhalations QD
84
What pt education needed for LABA/LAMA
QD use.
| Need to use RESCUE INHALER (SABA) if dyspnic
85
Group C Tx
what does prof P. prefer?
ICS + LABA
or
LAMA alone
Prof prefers LAMA alone. No steroid-> no immunosuppression-> no PNA risk
86
Inhaled ICS + LABA (4)
| which one does she want us to know?
FLUTICASONE/ SALMETEROL (ADVAIR)
| 250mcg/50mcg
87
Rx:
| strength-
How much is in the pill
ie. Ibuprofen
200mg/1 pill
88
Rx:
| Dosage-
How many pills
ie. Ibuprofen
600mg=3pills
89
Rx:
| Sig->
Dosage
Route
Frequency
How long
90
Rx:
| Disp->
Total Quantity to dispense (spell out too)
91
Things that affect med dosing:
```
Age
Wt
Hepatic Funct
Renal Funct
Wt
Other Rx (↑ # Rx=↑ risk adverse rxns) i.e Coumadin ↑ w/ABX
```
92
what bronchodilator is controversial for the amount of s/e, LOW therapeudic window, and Rx interactions
Theophylline
93
Indications for long-term O2 use:
| 1. daily
16 h/d
Resting arterial PO2 (PaO2) ≤ 55 mm Hg, or pulse oxygen saturation (SpO2) ≤ 88%
OR
PaO2 ≤ 59 mm Hg or SpO2 ≤ 89%, concurrent with cor pulmonale, right heart failure, or erythrocytosis (hematocrit > 55%)
94
Indications for long-term O2 use:
| 2. Nocturnal Use
PaO2 ≤ 55 mm Hg or SpO2 ≤ 88% during sleep
OR
Decrease in PaO2 > 10 mm Hg or in SpO2 > 5% during sleep with symptoms or signs of nocturnal hypoxemia such as disrupted sleep, morning headaches, impaired cognitive function or insomnia
95
Indications for Long-term O2 use:
| 3. w/exertion
Decrease in PaO2 ≤ 55 mm Hg or in SpO2 ≤ 88% during exercise
96
How many physicians must certify that a pt has <6mo to live?
2
97
T/F Patient (or family) must sign, choosing Hospice over curative treatment
True
98
T/F Eligibility for hospice does not depend on disease process responsible for decline
false. it does
99
What 3 paramerters must be met to qualify for hospice based on a respiratory issue?
1. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators *
2. Progression of disease, as evidenced by: increasing visits to the ER, increasing hospitalizations, or increasing physician visits *
3. Hypoxemia at rest on room air: pO2 ≤55 mmHg, O2sat ≤88% or hypercapnia pCO2≥50 mmHg *
100
How to initiate a hospice conversation (8) key poitns
1. Establish the medical facts
2. Pick a private place for a conversation, ensure family/friends who want to attend can be there
3. Assess understanding (of patient and family) of prognosis
4. Define the patient’s goals
5. Identify needs for care
6. Introduce Hospice and dispel any myths
7. Respond to emotions
8. Recommend Hospice and make referral
101
T/F: PAs are permitted to provide, manage, and have hospice services reimbursed by Medicare
T/F: PAs in this capacity can establish and review a hospice patient’s plan of care
true
102
what can't PA's & NP's do in hospice?
1. Only a physician or medical director may certify terminal illness
2. Only a medical director may admit a patient to hospice
3. PAs can’t take the position of the physician
103
What can NP's do that PA's cant in hospice?
Face-to-face encounter prior to recertification for hospice care to determine continued eligibility
104
Some signs of the dying process:
Weakness, fatigue, and functional decline
Decreased oral intake & impaired swallowing
Diminished blood perfusion
Tachycardia, hypotension, peripheral cooling, cyanosis, mottling of the skin, loss of peripheral pulses
Neurologic changes:
Decreasing consciousness leading to coma and death –or-
Terminal restlessness/delirium: confusion, restlessness, agitation, day/night reversal
Breathing changes: periods of apnea, Cheyne Stokes breathing, accumulation of upper airway secretions with a “death rattle”
Excretion changes: loss of sphincter control (urine/stool) & decreased urine output
Inability to close eyes
105
2 best drugs for hospice?
1. Morphine
Helps with pain and dyspnea
Available in an oral elixir (Roxanol) that is absorbed through MM
Normal starting dose: Roxanol 20 mg/ml 5 mg (0.25 ml) PO/SL Q4H prn pain/dyspnea
2. Ativan
Helpful for anxiety (often associated with dyspnea) and terminal restlessness
Also available in a liquid form that can be absorbed through MM
Normal starting dose: Ativan 2 mg/ml 0.5 mg (0.25 ml) PO/SL Q4-6H prn anxiety/terminal restlessness
106
T/F: haldol is good for nausea in hospice?
true
107
Nursing orders for hospice
```
Minimize vitals
Least restrictive diet
Bowel care
Good attention to mouth care
Lines
Dyspnea
```
