Test 3 Flashcards
1
Q
If a cough in acute bronchitis lasts more than 14 days, then consider
A
pertussis
2
Q
Usual duration of cough with acute bronchitis
A
1-3 weeks
3
Q
s/s of acute bronchitis
A
cough with or without sputum, low grade fever, wheezes/rhonchi
4
Q
Diagnostic for acute bronchitis
A
usually based on history and exam
5
Q
This does not necessarily indicate a bacterial cause in acute bronchitis
A
purulent sputum
6
Q
treatment for acute bronchitis
A
antitussive therapy for nighttime cough, NSAIDs, ipratropium inhaler
7
Q
3 changes in asthma
A
bronchoconstriction, hyperresponsiveness, and inflammation
8
Q
Restrictive disease is when
A
alveoli cannot be filled
9
Q
obstructive disease is when
A
air cannot get out
10
Q
factors that can exacerbate asthma
A
GERD, atopy
11
Q
Exercise induced asthma is when symptoms begin
A
5-10 min after completing exercise and resolve in 1-4 horus
12
Q
severe rhinorrhea, sneezing, N/V, and airway obstruction that occurs in those 20-30s.
A
aspirin-induced asthma
13
Q
hallmark symptoms of asthma
A
wheezing, dyspnea, cough, and sputum production
14
Q
Diagnosis for asthma is with
A
peak flow meters and spirometry
15
Q
Between asthma attacks, sputum is usually ___; during an asthma attack, the sputum may be ____ even with an absence of infection
A
clear; yellow or green
16
Q
Asthma is diagnosed with a FEV1 of ___ and a ____ FEV1/FVC ratio that improves with bronchodilator therapy.
A
less than 80%; reduced
17
Q
In intermittent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
A
less than 2 days/week;
less than twice a month;
less than 2 days a week;
normal.
18
Q
In mild persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
A
more than 2 days a week;
3-4 times a month;
more than 2 days a week but not daily;
Greater than 80%
19
Q
In moderate persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
A
Daily;
More than once a week but not nightly;
Daily;
60-80%
20
Q
In severe persistent asthma, the symptoms occur ____; nighttime awakenings occur _____; SABA use is _______; and FEV1 is _____.
A
throughout the day;
every night;
several times a day;
less than 60%
21
Q
Normal FEV1/FVC is
A
70-80%
22
Q
FVC is forced expiratory volume and can help indicate
A
restrictive disease if less than 80%
23
Q
FEV1 is max volume expired in 1 second and can help indicate
A
obstructive disease if less than 70%
24
Q
Step 1 of asthma approach
A
SABA PRN
25
Step 2 of asthma approach
low dose ICS + SABA PRN
26
Step 3 of asthma approach
low dose ICS + LABA + SABA PRN
27
Step 4 of asthma approach
medium dose ICS + LABA + SABA PRN
28
Step 5 of asthma approach
high dose ICS + LABA + SABA PRN
29
Step 6 of asthma approach
High dose ICS + LABA + oral steroid
30
SABA can be used up to ____ treatments at ____ minute intervals
3; 20
31
Use of SABA more than _____ days a week indicate inadequate control
2
32
common LABA
salmetrol and formoterol
33
Combined LABA + ICS drugs
fluticasone/salmeterol (Advair);
| bedesonide/formoterol (Symbicort)
34
LABAs are usually only indicated for those older than
12
35
Can be used as alternatives to those with asthma who do not tolerate SABAs.
anticholinergics
36
short acting anticholinergic
ipratropium (Atrovent) 2-3 puffs every 6 hours
37
combined anticholinergic and beta 2 agonist
ipratropium/albuterol (Combivent)
38
For acute asthma exacerbations, you can tell the patient to continue SABA use to
every 3-4 hours for next 24-48 hours
39
used for prophylaxis for mild to moderate asthma
cromolyn
40
why theophylline has limited use
narrow therapeutic range, side effects same as caffeine
41
education for use of inhalers
slowly inhale, hold breath for 4-10 seconds, breath out through pursed lips. wait 1 min in between puffs.
42
This score in asthma control test means asthma is not well controlled
less than 19
43
f/u when stepping up or down in asthma therapy
in 4-6 weeks
44
improvement in occupational asthma after cessation of exposure is typically
gradual and reaches a plateau 2 years after
45
difference b/t cardiac and noncardiac chest pain characteristics
cardiac chest pain is pressure, noncardiac chest pain is stabbing and sharp
46
Chest pain that localizes to a small area of the chest suggests
pleural or chest wall involvement.
47
noncardiac chest pain has onset that is
abrupt
48
for those less than 40, this can r/o cardiac disease for chest pain
ECG
49
for those older than 40, this can be done r/o cardiac disease for chest pain
stress test, cardiac enzymes, heart cath
50
Musculoskeletal chest pain characteristics
persistent; aggravated by movement or breathing; can be reproduced by touch.
51
Pleuritic or pneumothorax chest pain characteristics
stabbing or shooting pain that is aggravated by breathing, coughing, sneezing
52
seen in young tall, thin men ages 30-40 who smoke and have no history of lung disease.
primary spontaneous pneumothorax
53
those with GERD related chest pain can be given
trial of twice daily high dose PPI for 1-2 months
54
acute cough lasts
less than 3 weeks
55
subacute cough lasts
3-8 weeks
56
chronic cough lasts
more than 8 weeks
57
most coughs are caused by
viral URI
58
common causes of subacute cough
asthma or sinusitis
59
postinfectious cough usually lasts
longer than 8 weeks after viral infection and resolves on its own
60
common causes of chronic cough
asthma, GERD
61
ACEI cough resolves in
1-4 weeks after cessation
62
characteristics of psychogenic cough
barking cough that doesn't occur at night
63
First step in treating chronic cough
anithistamines, nasal steroids, Atrovent x 2 weeks
64
Second step in treating chronic cough
spirometry to check for asthma
65
Third step in treating chronic cough
Trial of high-dose PPI to treat for GERD
66
Fourth step in treating chronic cough
Chest xray
67
characterized as a dry, nocturnal cough and associated with a drop in morning peak flows
cough-variant asthma
68
methacholine test
bronchoconstrictor, incrementally given. Positive if there's a 20% drop in FEV1.
69
COPD is categorized as
chronic bronchitis and emphysema
70
chronic bronchitis is characterized by a persistent cough for
3 consecutive months for 2 consecutive years.
71
destruction of the alveolar walls leading to expiratory airway collapse
emphysema
72
risk factors for COPD
smoking, recurrent respiratory infections, recurrent sinus infections, nasal polyps
73
COPD can cause this complication
cor pulmonale (right ventricular hypertrophy)
74
S/S of COPD
dyspnea on exertion, increase AP diameter of chest, prolonged expirations
75
With inspiration in those with COPD, there is a _____movement of the rib cage and _____ movement of the abd wall.
decreased; increased
76
Diagnosis of COPD
spirometry with FEV1/FVC
77
Stage I COPD
FEV1 > 80%
78
Stage II COPD
FEV1 50-80% with SOB on exertion
79
Stage III COPD
FEV1 30-50% with increased SOB and repeated exacerbations
80
Stage IV COPD
FEV1 less than 30% with impaired quality of life
81
Those with COPD may show this on labs
polycythemia d/t hypoxemia
82
standard Medicare criteria for home O2 is
PA02 less than 55 mg and o2 sat less than 88%
83
All patients with COPD should be prescribed with a
short acting bronchodilator as needed.
84
Those with Stage II-III COPD should have a
long acting bronchodilator (anticholinergic is preferred) + short acting bronchodilator
85
Those with Stage III-IV COPD should have a
long acting bronchodilator + ICS + short acting bronchodilator
86
Recommended first line therapy for COPD
ipratropium (atrovent) as needed + tiotropium (Spiriva) 1 inhalation daily
87
beclomethasone (QVAR)
inhaled corticosteroids
88
budesomide (Pulmicort)
inhaled corticosteroids
89
fluticasone propionate (Flovent)
inhaled corticosteroids
90
education about ICS
must be used regularly, rinse mouth after use
91
Inhaled bronchodilators relieve _____, and corticosteroids reduce ________.
bronchospasm; inflammation
92
if ICS is used in COPD, then recheck FEV1 in
3-4 weeks to see if the FEV1 improves
93
those with COPD should be educated about
pulmonary rehab, weight loss, smoking cessation
94
paradoxical breathing seen in severe dyspnea
chest wall rises and abd moves inward
95
Diagnostics for dyspnea
Chest xray, spirometry, V/Q scan to r/o PE, ECG/Echo, H&H to r/o anemia
96
most common causes of hemoptysis
bronchitis, lung cancer, PNA, TB
97
diagnostics for hemoptysis
sputum culture, CBC, coags, chest xray
98
hemoptysis from the GI tract is usually
coffee-ground, acidic
99
Urgent evaluation is needed if hemoptysis is more than
50 mL of blood loss in the past 24 hours
100
The most common causes of acute dyspnea
asthma, bronchitis, pneumothorax, PNA, PE
101
Repetitive upper airway narrowing or closure, which occurs during sleep
sleep apnea
102
diagnosis for sleep apnea
polysomnography (PSG)
103
s/s of sleep apnea
snoring, nocturnal gasping/choking, nocturia
104
There is evidence that untreated OSA is a cause
systolic hypertension.
105
most common signs of nicotine withdrawal
dysphoria and difficulty thinking
106
during precontemplation change of smoking cessation
advise patient to quit but do not pursue smoking cessation
107
when the patient shows awareness of smoking problem
contemplation
108
when the patient says they have to do something about their smoking
determination stage
109
important to provide intervention steps for smoking cessation during this stage
determination stage
110
when the patient actually stops smoking
action phase; make sure a f/u appt is set
111
Nicotine replacement therapy should be cautiously used in those with
cardiovascular disease
112
these types of nicotine replacements should be used for 8 weeks and gradually tapered
gum, patches, and nasal spray
113
buproprion for smoking cessation should NOT be prescribed in those with
eating or seizure disorders
114
most common side effect os buproprion
insomnia
115
dosing for buproprion
start with 150 mg daily x 3 days, then increase to bid;
| start 1-2 weeks before quit date
116
Chantix can be started
1 week before quit date
117
common side effect of Chantix
nausea, high risk of hostile behavior
118
characterized by upper respiratory symptoms followed by lower respiratory infection with inflammation
bronchiolitis
119
bronchiolitis occurs in
children less than 2
120
most common cause of bronchiolitis
RSV
121
risk factors for bronchiolitis
prematurity, congenital heart disease
122
s/s of bronchiolitis
starts off with upper URI symptoms (runny nose) for 1-3 days, then fever & cough occur.
123
course of bronchiolitis
self-limited and resolves in 28 days
124
treatment for nonsevere bronchiolitis
bulb suction, fluids
125
NOT recommended for nonsevere bronchiolitis
bronchodilators, glucocorticoid
126
Cystic Fibrosis is a
autosomal recessive
127
usual presenting symptoms in cystic fibrosis
pulmonary infections, pancreatic insufficiency, elevated sweat chloride levels.
128
cystic fibrosis is caused by a mutation in the
CFTR protein
129
complications of CF in adulthood
spontaneous pneumothorax and hemoptysis
130
diagnosis of cystic fibrosis
newborn screening (IRT and DNA assay), if positive then diagnosis is confirmed with sweat chloride testing > 6 mmol/L
131
atbx recommended for those with CF
azithromycin
132
Many patients with CF show improvement with
bronchodilators
133
foreign body aspiration occurs in those
less than 3
134
commonly aspirated products
peanuts, nuts, seeds, popcorn, pieces of toys
135
Most aspirated foreign bodies are located in the
bronchi
136
S/S of bronchial foreign body aspiration
coughing/wheezing, hemoptysis, dyspnea, fever, decreased breath sounds
137
problem with choking episode is
it is usually self-limited followed by an asymptomatic period
138
complication of foreign body aspiration
pneumonia
139
why chest xray is not always diagnostic in foreign body aspiration
most objects are radiolucent and are not detected on xray
140
best diagnostic tool for foreign body aspiration
bronchoscopy
141
Hard and/or round foods should not be offered to children younger than
four years old
142
cause of croup
parainfluenza virus type 1
143
age group for croup
3 months to 3 years old
144
anatomic sign of croup seen on chest xray
steeple sign of the trachea
145
s/s of croup
initially starts with congestion;
| progresses to fever, hoarsness, barking cough, stridor
146
diagnosis for croup
usually based on history and PE
147
trx for mild croup
humidity mist, fluids, antipyretics, dexamethasone
148
trx for moderate to severe croup
referral to ER
149
most common type of lung cancer
non-small cell lung cancer
150
most effective screening tool for lung cancer
low-dose helical CT
151
most common symptom of lung cancer
cough, hemoptysis
152
staging of non-small cell lung cancer
size of tumor, regional lymph node involvement, degree of metastasis
153
problem with lung cancer
already advanced to later stages by time of diagnosis.
154
total volume in the pleural space is
20 mL
155
Most common causes of pleural effusion
CHF, pneumonia, cancer
156
s/s of pleural effusion
pleuritic sharp, unilateral chest pain, nonproductive cough, dyspnea
157
physical findings in pleural effusion
dullness to percussion, absent tactile fremitus, egophony (E to A change), pleural friction rub
158
why chest xrays aren't always diagnostic for pleural effusion
can only detect effusion greater than 500 mL
159
best diagnostic tool for pleural effusion
Chest US or CT
160
inflammation of the pleura
pleurisy
161
sharp or stabbing that is exacerbated by coughing, deep breathing, sneezing.
pleuritic chest pain
162
drugs associated with pleurisy
nitrofurantoin, methotrexate, amiodarone, beta blockers
163
may be described as a “stitch on the side”
pleurisy
164
physical exam with pleurisy
pt will lie on affected side, tenderness on palpation, pleural friction rub
165
pleural friction rub in pleurisy is only heard when
patient take a deep breath
166
treatment for pleurisy
thoracentesis, NSAIDs
167
typical pneumonia is caused by
streptococcus pneumonia
168
atypical pneumonia is caused by
influenza virus, mycoplasma pneumonia
169
more likely to acquire atypical pneumnoia
young adults
170
community acquired pneumonia is caused by
Streptococcus pneumoniae (gram +) and H. influenza (gram negative)
171
pneumonia in those with COPD, alcoholics, and diabetics is mostly caused by
Moraxella catarrhalis
172
outpatient trx of pneumonia
macrolide
173
outpatient trx of pneumonia in those with heart/lung disease, liver disease, or DM
fluoroquinolone + macrolide
174
not recommended for diagnosis of PNA in the outpatient setting
sputum culture; usually diagnosed through chest xray
175
s/s of pneumonia in elderly
lethargy, decreased appetitie, AMS
176
secondary pneumothorax is caused by
COPD, SLE, sarcoidosis, asthma
177
tension pneumothorax is caused by
mechanical ventilation or CPR
178
pneumothorax results when there is a loss of
negative pressure in the pleural space
179
s/s of pneumothorax
sudden sharp pain, dyspnea, cough
180
tension pneumothorax is a
medical emergency
181
diagnosis of pneumothorax
chest xray, ultrasound
182
treatment for asymptomatic pneumothorax
none, resolution in 7-14 days
183
treatment for primary pneumothorax
needle aspiration
184
treatment for secondary pneumothorax
chest tube
185
primary pneumothorax is
recurrent, refer to pulmonologist
186
pulmonary arterial hypertension results in
high pulmonary vascular resistance and right ventricular hypertrophy (cor pulmonale)
187
PAH is a PA pressure greater than
25 mmHg
188
common causes of PAH
hypoxia
189
s/s of PAH
asymptomatic until it becomes severe;
| angina, cough, hemoptysis
190
usual time of onset of symptoms for PAH
insidious onset of 2 years
191
signs of right ventricular failure (JVD, hepatomegaly, ascites) is often seen with
PAH
192
diagnostic for PAH
doppler Echo, ECG
193
treatment for PAH
CCB, tadalafil;
oxygen;
CPAP
194
Multisystem, inflammatory, granulomatous disease of unknown origin that commonly affects young and middle-aged adults age 20-45
sarcoidosis
195
Presentation of sarcoidosis
asymptomatic with abnormal chest xray;
| dry cough, dypsnea, chest pain, fever
196
other involvements with sarcoidosis
ocular and skin lesions
197
complication of sarcoidosis
pulmonary fibrosis
198
treatment for asymptomatic sarcoidosis
none; NSAIDs, steroids
199
treatment with stage III-IV sarcoidosis
immunosuppression, steroids
200
f/u with sarcoidosis
recurrence is common
201
sudden infant death syndrome occurs mostly in those less than
1 years of age
202
risk factors for SIDS
maternal smoking, low birth weight, preterm labor, prone sleeping, soft bedding, bed-sharing, overheating
203
protective measures for SIDS
pacifier, room-sharing, breastfeeding, fan use
204
multidrug resistance is growing for TB in these drugs
rifampin and isoniazid
205
TB infection occurs when the inhaled particles reach the
alveoli
206
Most cases of TB are
asymptomatic and identified through positive skin test
207
s/s of TB
fatigue, weight loss, night sweats, cough, hemoptysis, low grade fever
208
A person with TB will react positively to the skin test ____ after infection.
2-8 weeks
209
PPD skin test
induration is measured in 48-72 hours. Should be recorded by mm of induration
210
factors that cause false negative PPD result
age > 45, simultaneous live vaccination, infection
211
factors that can cause a false positive resolve
BCG vaccine
212
two step testing for TB
if negative, give second test 1-3 weeks later
213
Positive if induration in greater than 5 mm in those with
HIV, close contacts with TB
214
Positive if induration in greater than 10 mm in those with
immigrants, high risk facilities (prison, LTC, hospital, homeless), chronic disease (DM, renal failure, children less than 4)
215
Positive if induration in greater than 15 mm in those with
no known risk factor for TB
216
Must be done with every TB case
reported to local health department.
217
preventative therapy for those with latent TB
INH for 9 months
218
complication of INH
hepatitis
219
cause of Type 1 Diabetes
autoimmune destruction of beta cells in the pancreas resulting in insulinopenia
220
Type II diabetes causes
insulin resistance
221
s/s of type 2 diabetes
polyuria, polyphagia, polydipsia, blurred vision, fatigue
222
ADA criteria for diagnosis of diabetes
A1C > 6.5%;
FPG > 126 mg/dL;
2-hour OGTT with 75 g > 200 mg/dL;
random plasma glucose > 200 mg/dL
223
benefits of exercise in diabetes
increases glucose uptake in skeletal muscles and improves insulin sensitivity
224
Step 1 of DM management
lifestyle modifications, begin metformin
225
Step 2 of DM management
add either basal insulin (most effective) or sulfonyurea (least expensive)
226
Step 3 of DM management
if Hgb persists > 7%, increase insulin
227
goal of type 2 DM management is to keep
A1C
228
Early morning hyperglycemia is controlled by _____
basal insulin
229
post-meal glucose spikes are controlled by _____
prandial insulin.
230
onset of rapid acting insulin (Novolog, Humalog)
10-20 min
231
peak of rapid acting insulin (Novolog, Humalog)
1-3 hours
232
duration of rapid acting insulin (Novolog, Humalog)
3-5 hours
233
onset of short acting insulin (Regular & Humalin R)
30-60 min
234
peak of of short acting insulin (Regular & Humalin R)
2-4 hours
235
duration of short acting insulin (Regular & Humalin R)
5-8 hours
236
onset of intermediate acting insulin (NPH)
1-2 hours
237
peak of of intermediate acting insulin (NPH)
2-12 hours
238
duration of intermediate acting insulin (NPH)
24 hours
239
onset of long acting insulin (Levemir, Lantus)
90 min
240
duration of long acting insulin (Levemir, Lantus)
24 hours
241
Long acting insulin is
peakless
242
MOA of metformin
suppresses hepatic glucose production
243
Goal is to keep premeal insulin between
80-130 mg/dL
244
Pramlintide (Symlin)
SQ pen given before meals along with insulin
245
MOA of sulfonyurea
stimulate insulin secretion
246
education with sulfonyureas
take with meals
247
medication that can cause hypoglycemia
sulfonyureas
248
act in the small intestine, delaying the digestion of polysaccharides which leads to lower postprandial glucose levels.
alpha glucosidase inhibitors
249
with alpha glucosidase inhibitors, the med must be taken wtih
the first bite of a meal that contains carbs
250
f/u care for Diabetes
A1c every 3 months;
lipid panel annually;
urine microalbumin annually
251
thiazolidinediones (Actos) is contraindicated in
those with CHF as they cause edema
252
release insulin and decrease glucagon levels by slowing the inactivation of incretin hormones.
DPP4 inhibitors (Januvia)
253
hypoglycemia is blood sugar less than
70 mg/dL
254
hyperglycemia is blood sugar greater than
180 mg/dL
255
education on sick days with diabetics
check blood sugar every 4 hours;
drink 8 oz of sodium rich fluid every hour;
continue meds even if not eating
256
provides the earliest indication of renal damage from diabetes
microalbumin
257
Once microalbuminuria is confirmed in those with diabetes, then
start an ACEI or ARB
258
types of neuropathy with diabetes
peripheral, gastroparesis, neurogenic bladder, sexual dysfunction, orthostatic hypotension
259
All pregnant women are screened for GM at
24- 28 weeks
260
Diagnosis for GM is made if OGTT with 75 g is
fasting > 92;
1-hour > 180;
2-hour > 153
261
If lifestyle modifications fail, then this can be added for diabetes prevention
metformin
262
Meds that can be used during pregnancy
insulin, glyburide, metformin
263
complications of GM
macrosomnia, hypoglycemia, PIH, polyhdramnios, preterm labor
264
These types of insulin have a reduced risk of hypoglycemia
rapid acting and long acting insulin
265
these can mask the signs of hypoglycemia
alcohol and beta blockers
266
trx for mild to moderate hypoglycemia
15-20 g of carb/sugar
267
DKA is characterized as
hyperglycemia, ketonuria, and anion gap metabolic acidosis
268
s/s of DKA
abdominal pain, N/V, Kussmaul respirations, fruity odor
269
Labs in DKA
glucose less than 800 mg/dL;
high potassium;
elevated anion gap
270
a rapid urine dipstick that can determine serum ketone levels to explain the high anion gap in DKA
Nitroprusside
271
treatment for DKA
Isotonic fluids, correct K+ first, IV insulin
272
SQ insulin in DKA can be started when anion gap is
less than 12
273
HHNK is seen in
type 2 diabetics and elderly
274
DKA is seen in
type 1 diabetics and young
275
S/S of HHNK
gradual signs of polyuria and polydipsia, altered mental status
276
labs in HHNK
```
glucose > 1000 mg/dL;
high osmolality;
hyponatremia;
NO ketones in urine;
pH > 7.30
```
277
most common cause of HHNK and DKA
stopping insulin and dehydration
278
metabolic syndrome is characterized as
abdominal obesity, hyperglycemia, high triglycerides, low HDL, HTN, inflammatory state
279
labs values in metabolic syndrome
triglyceride > 150;
HDL 130/85;
fasting glucose > 100
280
risk factors for metabolic syndrome
family hx, obesity, abd fat, physical inactivity
281
Metabolic syndrome places the patient in a ____ state.
prothrombic
282
Diagnostic of metabolic syndrome
microalbuminuria;
| fasting insulin > 10
283
acanthosis nigricans is seen in
metabolic syndrome
284
treatment for metabolic syndrome
antihypertensives, statins, ASA therapy, metformin
285
hemoptysis from the respiratory tract is
bright red/pink, frothy, alkaline pH
286
primary diagnostic tool for TB
sputum specimen
287
compared to albuterol, levalbuterol has ___ with a lower dose
greater bronchodilation
288
caution with prescribing this antibiotic with theophylline
macrolide
289
name a 3rd of 4th generation fluoroquinolone
levaquin
290
a short acting bronchodilator is effective for
4 hours
291
hyperresonnance on percussion is seen in those with
asthma
292
what pathogen is found in an acute exacerbation of chronic bronchitis
H. influenza
293
in cystic fibrosis, which vitamins are not well absorbed
fat soluble: A, D, E, K
294
GI problem in those with cystic fibrosis
meconium ileus
295
a problem seen after mechanical ventilation in a neonate
bronchopulmonary dysplasia (BPD)
296
symptoms of BPD resolve by
age 3
297
abtx for a 78 year old with community acquire PNA and COPD
amoxicillin and macrolide
298
a risk factor for pneumonia death
renal insufficiency
299
is someone with latent TB contagious?
No
300
s/s of somogyi effect
excessive hunger, weight gain, hyperglycemia
301
action to trx somogyi effect
decrease evening insulin, check blood sugar at 2 am
