What is the major difference between varicose veins and atherosclerosis

 

What is the major difference between varicose veins and atherosclerosis?

Vessels that are affected

 

Pt has had poorly controlled HTN >10yrs. Indicate the most likely position of his PMI.

c. 5th ICS left of MCL

 

43yo hispanic male has audible diastolic murmur best heard at the mitral point. No audible click. He has been monitored for 2yrs. What is the most likely murmur?

d. Mitral stenosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What are PFTs?

Group of tests that provide quantifiable measurement of lung function, used to dx resp abnormalities or assess progression/resolution of lung dz.

 

What is FEV1?

Forced Expiratory Volume in 1 second (80-120%)

 

What is FVC?

Forced Vital Capacity (80-120%)

 

What is normal FEV1/FVC ratio?

<0.7 (70%)

 

What is GOLD 1 criteria?

Mild

 

FEV1 >/= 80% predicted

What is GOLD 2 criteria?

 

Moderate

FEV1 50-79% predicted

 

What is GOLD 3 criteria?

Severe

FEV1 30-49% predicted

 

What is GOLD 4 criteria?

Very severe

FEV1 <30% predicted

 

What are the signal symptoms of COPD?

Dyspnea

 

Chronic cough w/sputum

Decreased activity tolerance

Wheezing

 

What are characteristics of COPD?

Common, preventable, treatable.

 

Characterized by persistent airflow limitation.

 

Usually progressive, associated with enhanced chronic inflammatory response in airways and lungs to noxious particles/gases

 

Airway fibrosis, luminal plugs, airway inflammation, increased airway resistance, small airway dz.

 

Decreased elastic recoil of alveoli.

 

What are risk factors for COPD?

Smoking (increasing w/number of pack years)

Second hand smoke

Environmental pollution (endotoxins, coal dust, mineral dust)

 

What is seen on phys exam in COPD?

May be normal in early states

 

As severity progresses: lung hyperinflation, decreased breath sounds, wheezes at bases, distant heart tones (b/c of hyperinflation, so S1/S2 sounds off in distance), accessory muscle use, pursed lip breathing, increased expiratory phase, neck vein distention.

 

How is COPD diagnosed?

Spirometry is gold standard (pre and post bronchodilator).

Irreversible airflow limitation is hallmark.

 

How is COPD treated?

Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo.

 

What is the MOA of beta agonists?

Stimulates beta-2-adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways.

 

What is the MOA of anticholinergics?

Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation.

 

Why are long-acting beta agonists prescribed for COPD?

They are for moderate airflow limitation.

They relieve symptoms, increase exercise tolerance, reduce number of exacerbations, improve QOL.

 

What are some non pulmonary diagnoses that result in COPD-type symptoms?

CHF

 

What are some Hyperventilation syndrome

Panic attacks

Vocal cord dysfunction

Obstructive sleep apnea

Aspergillosis

Chronic fatigue syndrome

 

What are signal symptoms of asthma?

Wheezing

Shortness of breath

Cough (esp at night)

Chest tightness

 

What is chronic bronchitis?

Daily chronic cough w/increased sputum for at least 3 consecutive months in at least 2 consecutive years.

 

Usually worse on wakening.

 

May or may not be associated with COPD.

 

What is emphysema?

Characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles.

 

Chronic inflammation/remodeling, trapping air, hindering effective O2/CO2 exchange (all due to inflammatory mediators infiltrating airways).

 

What are signal symptoms of ischemic heart dz?

Chest pain

Chest tightness

Chest discomfort

 

What is ischemic heart dz?

Imbalance between supply and demand for blood flow to myocardium

 

What are signal symptoms of lung CA?

Cough

Dyspnea

Wt loss

Anorexia

Hemoptysis

 

What is lung CA?

Malignant neoplasm originating in parenchyma of lung/airways

 

What are signal symptoms of MI?

Prolonged CP (>20min duration)

SOB

Confusion

Weakness

Worsening HF

 

What is an MI?

Necrosis of heart tissue caused by lack of blood and O2 supply to the heart

 

What are signal symptoms of pneumonia?

Fever

Chills

Hypothermia

New cough w/or w/out sputum

Chest discomfort or dyspnea

Fatigue

HA

Some older adults will be asymptomatic but may experience falls/confusion

 

What is community acquired pneumonia?

Acute lower resp tract infection of lung parenchyma.

Can be bacterial or viral.

Bacterial is most common in older adults.

 

What are signal symptoms of a PE?

Dyspnea

CP on inspiration

Anxiety

Presentation is variable

Symptoms nonspecific

Some asymptomatic

 

What is PE description?

Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site.

 

What are signal symptoms of tuberculosis?

Initially asymptomatic

Later: productive, prolonged cough

Fatigue

Low-grade fever

Night sweats

Poor appetite

Hemoptysis

Wt loss

 

Fever/sweats are less common in elderly

 

Symptoms in elderly are often attributed to other comorbidities

 

What is tuberculosis?

Chronic, necrotizing infection caused by slow-growing acid-fast bacillus (Mycobacterium tuberculosis).

 

Most common cause of death related to infectious dz worldwide.

 

What are signal symptoms of valvular heart dz?

Asymptomatic in early stages

Fatigue

Exertional dyspnea

What is valvular heart dz?

Damage to valve(s) of the heart, causing cardiac dysfunction.

 

Most prevalent types in elderly: calcific and degenerative aortic valve dz

What is aortic stenosis?

Abnormal narrowing of aortic valve orifice

 

What is aortic regurgitation?

Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole

 

What is mitral stenosis?

Abnormal narrowing of mitral valve orifice

 

What is mitral regurgitation?

Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve

 

What is mitral valve prolapse?

Mitral regurgitation associated with bulging of one or both mitral valve leaflets into L atrium during ventricular systole

 

What are most common causes of VHD in elderly?

Age-related degenerative calcifications

Myxomatous degeneration

Papillary muscle dysfunction

Infective endocarditis

Rheumatic dz

 

What happens in valvular regurgitation?

Portion of the ejected blood leaks back into the upstream cardiac chamber

 

What happens in valvular stenosis?

Usually results in elevated pressures in the chamber upstream from the stenosis

 

What are signal symptoms of URI?

Nasal congestion

Rhinorrhea/mucopurulent discharge

Sore throat

Cough

HA

Malaise

 

What is a URI?

Most frequently called the common cold

Usually caused by virus

Results in nasal passage inflammation

Most are self-limiting, accompanied by minor complaints

Included in URI dx: acute laryngitis, acute rhinosinusitis, acute pharyngitis

 

What are signal symptoms of restrictive lung dz?

Rapid, shallow respirations

Dyspnea

Decreased activity tolerance

Easily fatigued

Nonproductive, irritating cough provoked by deep breathing/exertion

 

What is restrictive lung dz?

Heterogenous group of disorders that share common abnormal ventilatory function.

Characterized by small tidal volume, rapid rate.

Hallmark restrictive pattern is decreased lung volm, esp. total lung capacity and vital capacity.

 

What is the purpose of functional assessment of the elderly?

Discovers the ability to care for themselves on a daily bases

 

What can ongoing pain be linked to in the elderly?

Depression

Decreased socialization

Sleep disturbance

Impaired cognitive function

 

Is chronic pain a normal sign of aging?

No

 

What is polypharmacy?

Broad definition, but basically too many medications for what is going on with the patient, the use of multiple pharmacies/providers.

 

What is Stage A of HF?

At high risk for heart failure but w/out structural changes/symptoms

What is Stage B HF?

Structural heart dz but w/out s/s of HF (still “at risk” for HF)

 

What is Stage C HF?

Structural heart dz w/prior or current s/s of HF (actually have HF)

 

What is Stage D HF?

Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.)

 

What are treatment goals for Stage A HF?

Heart-healthy lifestyle

Prevent vascular, coronary dz

Prevent LV structural abnormalities

 

What are drugs used in Stage A HF?

ACEi or ARB in appropriate pt’s for vascular dz or DM

Statins as appropriate

 

What are treatment goals for Stage B HF?

Prevent HF symptoms

Prevent further cardiac remodeling

 

What are drugs used in Stage B HF?

ACEi or ARB as appropriate

Beta blockers as appropriate

 

In selected pt’s:

ICD

Revascularization/valvular surgery as appropriate

 

What are goals of Stage C HFpEF?

Control symptoms

Improve HRQOL

Prevent hospitalization

Prevent mortality

ID comorbidities

 

What is treatment for Stage C HFpEF?

Diuresis to relieve s/s congestion

Follow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.)

 

What are treatment goals for Stage C HFrEF?

Control symptoms

Pt education

Prevent hospitalization

Prevent mortality

 

What are drugs used in Stage C HFrEF?

Diuretics for fluid retention

ACEi or ARB

BB

Aldosterone antagonists

 

Drugs in selected pts:

Hydralazine/isosorbide dinitrate

ACEi and ARB

Digitalis

 

Procedures in selected pts:

CRT

ICD

Revascularization/valvular surgery as appropriate

 

What are treatment goals in Stage D HF?

Control symptoms

Improve HRQOL

Reduce hospital readmissions

Establish pt’s end-of-life goals

 

What are options for Stage D HF?

Advanced care measures

Heart transplant

Chronic inotropes

Temporary or permanent MCS

Experimental surgery/drugs

Palliative care, hospice

ICD deactivation

 

What is the normal BNP level?

<100pg/mL (indicates HF is unlikely)

 

What is normal BP?

<120/80

 

What is “elevated” BP?

120-129/<80

 

What is Stage 1 HTN?

130-139 OR 80-89

 

What is Stage 2 HTN?

>/= 140 or >/= 90

 

What is recommended BP for DM?

<130/80

 

What is recommended BP for CKD?

<130/80

 

How should HTN be managed?

Stage 2 and up should be given consideration for pharm treatment.

Others can wait for lifestyle modification.

 

What is first-line meds for non-black HTN population (including those w/DM)?

Thiazide, CCB, ACEi, or ARB, either alone or in combo

 

What is the med guideline for ASCVD for those </= 75yo?

High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)

 

What is the med guideline for ASCVD for those >75yo?

Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mg BID)

 

What is the guideline for meds for LDL >/= 190?

High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)

 

What is the med guideline for ASCVD for 40-75yo w/DM?

Their 10yr risk is >7.5%, so high intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)

 

What is the med guideline for LDL 70-189?

Their 10yr risk is <7.5%, so moderate intensity statin (atorvastatin/Lipitor 10mg, rosuvastatin/Crestor 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mgBID)

 

What is the ASCVD med guideline for 40-75yo w/out ASCVD or DM?

Their 10yr risk is >7.5%, so moderate to high intensity statin

 

The meds listed in Beers Criteria are not absolutely contraindicated in elderly.

True

 

The BC recommendations are graded as high, medium, low to assist w/decision making.

True

 

The BC list includes dosage adjustments for kidney impairment.

True

 

The BC list includes drug to drug interactions to avoid.

True

 

Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts.

True

 

What vaccination is recommended for people traveling to countries where dz is common?

Hep A

 

How is Hep A vax given?

Two doses: initial at least 4wks before departure, second dose 6-12mo later.

 

When is Hep B vax recommended?

High-risk people (IV drug users, persons w/multiple partners)

 

How is Hep B vax given?

Initial dose

1mo later: 2nd dose

4-6mo after 2nd: 3rd dose

 

When is Zostavax recommended?

Anyone over 60yo, given as single dose

 

Can people who have had prior episode of zoster be vaccinated?

Yes

 

When is flu vax recommended?

Annually for all adults >50yo

 

When should DTaP be given?

Once in a lifetime for all adults, then Td booster every 10yrs.

 

When is pneumococcal vax recommended?

Once for 65yo and older

Younger adults w/severe chronic health conditions

 

 

 

 

What is primary prevention?

Activities to prevent occurrence of dz or adverse health condition, including mental health.

 

What is osteoporosis?

Skeletal disorder characterized by impaired bone strength that predisposes to increased risk of fracture.

 

Can occur from not only bone loss but also from failure earlier in life to make sufficient bone.

 

Primary: due to aging (increased bone resorption/reduced new bone formation)

Secondary: consequence of underlying medical condition/drug

What are s/s of osteoporosis?

Sometimes not seen until fracture sustained spontaneously or after minimal trauma, usually in thoracic/lumbar vertebrae, hip, wrist, humerus, pelvis.

 

With each fracture, risk of another increases exponentially.

 

Loss of height, kyphosis development.

 

XR: bones appear osteopenic (at least 30% loss in bone mass); spine shows loss of horizontal vertebral trabeculae, accentuating end plates, producing biconcave “codfish” vertebrae; maybe compression fracture.

What are diagnostic tests for osteoporosis?

XR

DEXA (screen all women >65yo, hip/spine; test earlier if major risk factors present; repeat every 3-5yrs depending on degree)

 

What is T-score of -2.5 or lower indicative of?

Osteoporosis

 

What is a T-score of -1.0 to -2.5 indicative of?

Osteopenia

 

What is a T-score of -1.0 or higher indicative of?

Normal bone density

 

What is a Z-score of <-1.5 indicative of?

Secondary cause of osteoporosis

 

What are the risk factors for osteoporosis?

Previous fracture

Advanced age

Low body wt/BMI

Maternal h/o fracture

Current smoking

Physical inactivity

Excessive exercise resulting in amenorrhea

Poor lifetime intake of calcium

Endocrine disorders

GI dz

Chronic systemic illnesses

Nutritional deficiencies

Meds (steroids, anticonvulsants, thyroid hormone, SSRI, aromatase inhibitors for breast CA)

Alcoholism

 

What is the treatment for osteoporosis?

Aim to prevent those that are at risk

Combine diet, exercise, meds

Dietary Ca/vit D

Wt-bearing/strength exercises

Bisphosphonates

Selective estrogen receptor modulators

Calcitonin

PTH

Denosumab

Fall prevention

 

How does chronic pain differ from acute pain?