Correct Answer:
decreased TSH and increased T3 &T4
What labs are used to diagnose thyroid problems?
Correct Answer:
Free and total T3
Free and total T4
TSH
Anti-TPO
Confirm diabetes diagnosis prior to treatment
Correct Answer:
fasting plasma glucose greater than or equal to 126, A random plasma
glucose of greater than or equal to 200 plus symptoms of diabetes, an oral
glucose tolerance test of two hours, plasma glucose of greater than or equal
to 200, or a hemoglobin A1c, a 6.5 or higher (on two occasions)
A1c general goal
Correct Answer:
<7%
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<\/a><\/figure>\n\n\n\nWhat labs are used to diagnose thyroid problems?
Free and total T3
Free and total T4
TSH
Anti-TPO<\/p>\n\n\n\n
Hypothyroidism labs
increased TSH, decreased T3 &T4<\/p>\n\n\n\n
hyperthyroidism labs
decreased TSH and increased T3 &T4<\/p>\n\n\n\n
When to recheck labs after starting levothyroxine?
6-8 weeks or after dose change, then 12 months once stabilized<\/p>\n\n\n\n
S\/S hypothyroidism
pale, puffy, and expressionless face, cold and dry skin, brittle hair\/hair loss, low heart rate and body temperature, lethargy, fatigue, cold intolerance, mental status changes, thyroid enlargement<\/p>\n\n\n\n
Think “hypo low and slow”<\/p>\n\n\n\n
S\/S hyperthyroidism
strong and rapid heart rate, dysrhythmias, angina, nervousness, insomnia, rapid thought flow and speech, muscle weakness\/atrophy, increased metabolic rate (increased heat production, increased body temperature, heat intolerance), warm\/moist skin, increased appetite, weight loss despite increased caloric intake<\/p>\n\n\n\n
think “hyper as in fast”<\/p>\n\n\n\n
result of not treating hypothyroidism during pregnancy
permanent neuropsychological deficits in the child. First trimester: fetus unable to produce their own thyroid hormones. Fetal thyroid gland is fully functional in the second trimester.<\/p>\n\n\n\n
Medication to treat SYMPTOMS of hyperthyroidism
beta blocker (decrease HR)
non-radioactive iodine<\/p>\n\n\n\n
How to take levothyroxine with food?
take on an empty stomach in the morning, 30-60 minutes before breakfast<\/p>\n\n\n\n
Supplement\/drug interactions with levothyroxine
antacids, iron, calcium<\/p>\n\n\n\n
Confirm diabetes diagnosis prior to treatment
fasting plasma glucose greater than or equal to 126, A random plasma glucose of greater than or equal to 200 plus symptoms of diabetes, an oral glucose tolerance test of two hours, plasma glucose of greater than or equal to 200, or a hemoglobin A1c, a 6.5 or higher (on two occasions)<\/p>\n\n\n\n
A1c general goal
<7%<\/p>\n\n\n\n
Older adult A1c goal
<8%<\/p>\n\n\n\n
When should insulin be considered?
For patients with an A1c >10%, a fasting blood glucose >300 or are markedly symptomatic<\/p>\n\n\n\n
At what interval should A1c be rechecked?
2-4 times a year (every 3 months) until A1c drops to 7% and at least every 6 months there after<\/p>\n\n\n\n
action of insulin
regulation of glucose metabolism. Insulin promotes glucose and amino acid uptake into muscle and adipose tissues, and other tissues except brain and liver. It also has an anabolic role in stimulating glycogen, fatty acid, and protein synthesis<\/p>\n\n\n\n
First, it stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and potassium. Second, insulin promotes synthesis of complex organic molecules. Under the influence of insulin and other factors, glucose is converted into glycogen, amino acids are assembled into proteins, and fatty acids are incorporated into triglycerides<\/p>\n\n\n\n
Pioglitazone (TZD) contraindications
do not give to patients with heart failure or history of bladder cancer<\/p>\n\n\n\n
GLP-1
glucagon-like peptide-1 receptor agonist<\/p>\n\n\n\n
ending in -glutide\/tide
ex. semaglutide<\/p>\n\n\n\n
TZD
Thiazolidinedione’s<\/p>\n\n\n\n
end in -ones
ex. glitazones<\/p>\n\n\n\n
DPP4-1
Dipeptidyl Peptidase-4 inhibitors<\/p>\n\n\n\n
end in -gliptin
ex. gliptins<\/p>\n\n\n\n
SGLT2i
sodium-glucose contransporter 2 inhibitors<\/p>\n\n\n\n
end in-flozin<\/p>\n\n\n\n
Which drug class should be considered for diabetes prior to insulin
metformin<\/p>\n\n\n\n
Ratio of basal insulin to rapid acting insulin in total daily dose of insulin?
50%<\/p>\n\n\n\n
Which diabetic medications come with concern to hypoglycemia?
Amylin Analogues, Insulin, Meglitinides, Sulfonylureas (think these medications AIMS cause hypoglycemia)<\/p>\n\n\n\n
Treatment of thyroid storm?
K iodine or strong iodine solution to suppress thyroid release and methimazole to suppress thyroid synthesis<\/p>\n\n\n\n
Preferred treatment is PTU<\/p>\n\n\n\n
SGLT2i
increase glucose secretion via the urine by inhibiting SLGT in the kidney tubules, decreasing glucose levels and inducing weight loss by caloric loss through the urine<\/p>\n\n\n\n
higher chance of UTI<\/p>\n\n\n\n
DPP-4i
Enhance the activity of incretins and thereby increase insulin release, reduce glucagon release, and decrease glucose production by the liver<\/p>\n\n\n\n
TZD
decreases insulin resistance and increase glucose uptake by muscle and adipose tissue, decrease glucose production by the liver<\/p>\n\n\n\n
contraindicated in patients with heart failure<\/p>\n\n\n\n
A newly pregnant mother shows understanding of hypothyroidism in pregnant women by stating
Increase dose up to 50% starting in weeks 4-8 and levels off at week 16
It can cause neurophysiological damage such as IQ, mental development, derangement of growth<\/p>\n\n\n\n
Biguanide mechanism of action
decreases glucose production by the liver
ex. metformin (used for PCOS too)<\/p>\n\n\n\n
Metformin contraindicated
renal insufficiency d\/t risk of lactic acidosis
HF<\/p>\n\n\n\n
A female patient is taking canagliflozin comes in with a UTI and 6 months ago had a fungal infection. What are the next steps?
-flozin (SGlT2i)
dc and change medications<\/p>\n\n\n\n
Methylxanthines- risk for toxicity
Smokers require higher doses. Smoking increases clearance so if you stop smoking levels will rise to toxic levels.
Heart disease and liver disease require lower doses.
Initial doses are based on weight and age
Methylxanthines should be used cautiously in patients that have an untreated seizure disorder or peptic ulcer disease. Overdose\/toxicity can cause severe dysrhythmias and convulsions. To manage toxicity, discontinue medication use, and administer activated charcoal plus a cathartic. Have IV lidocaine or amiodarone and IV benzodiazepines on hand if the patient is in the hospital.
Older patients are at much higher risk for toxicity when taking methylxanthines.<\/p>\n\n\n\n
Asthma and COPD – manage with a BLANK as needed
SABA<\/p>\n\n\n\n
sulfonylureas MOA
Promote insulin secretion by the pancreas
stimulate beta cells of the pancreas to secrete more insulin.
Stimulates insulin release from pancreatic islet-will only work in DM2.
increased risk of hypoglycemic events
Do not use it in pregnancy and breastfeeding<\/p>\n\n\n\n
examples: Glimepiride (Amaryl)
Glyburide (DiaBeta; Micronase)
Glipizide (Glucotrol)<\/p>\n\n\n\n
end in -ide<\/p>\n\n\n\n
GLP-1 MOA
increase in insulin production and inhibit postprandial glucagon release and increase satiety.
Suppress appetite\/ stimulate weight loss
Augment effects of incretin hormone GLP-1
Can also cause pancreatitis so monitor amylase and lipase
Use caution if a patient has a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2.<\/p>\n\n\n\n
1st line treatment for diabetes
lifestyle changes and metformin<\/p>\n\n\n\n
Insulin dose calculation
step 1: Calculate TDD by using 0.6 units\/kg\/day
step 2: calculate mealtime carbs by dividing 500 for rapid acting or 450 for regular by TDD
step 3: round
step 4: ratio
step 5: for a 50g carb meal divide 50 by ratio number for insulin coverage number<\/p>\n\n\n\n
A patient wakes up at night a few times a week, has been using his SABA daily, and has been experiencing symptoms daily, and states he cannot make it up flight of stairs without trouble breathing. What is his severity of his asthma symptoms and what step should be considered?
Moderate persistent asthma
Step 3- not well controlled, SABA PRN, low dose IGC and LABA OR medium dose IGC<\/p>\n\n\n\n
When should roflumilast be indicated for a COPD patient?
reserved for severe cases of COPD with a primary component of chronic bronchitis<\/p>\n\n\n\n
A patient has been SOB\/wheezing 2 days a week with nighttime awakenings two times a month, and has had one exacerbation in the last year. She is currently using a SABA and low dose IGC. What are next steps? Is it well controlled?
Well controlled, re-evaluate 1-6 months. Consider stepping down if well controlled for 3 months.
Intermittent asthma<\/p>\n\n\n\n
For asthma, a LABA has been prescribed, what other medication must a LABA be used with?
combine with glucocorticoid<\/p>\n\n\n\n
Benefits of using ICS
very effective, safer than systemic, usually minor adverse reactions<\/p>\n\n\n\n
Examples of SABA drugs
or bronchodilators\/short acting
Albuterol
Levalbuterol
isoproterenol
terbutaline sulphate<\/p>\n\n\n\n
Why is it important to know the frequency a patient is using their SABA?
SABA use is a marker of inadequate asthma control<\/p>\n\n\n\n
Patient instructions\/education for SABA
Using a spacer with a one-way valve may improve results
Assess peak expiratory flow daily and compare personal best
Counsel patients to keep record of these assessments along with symptom frequency and symptom intensity, nighttime awakenings, effect on normal activity, and SABA use
Inform patients who are using inhalers that two are needed and an interval of at least 1 minute in between<\/p>\n\n\n\n
LABA examples
salmeterol
formoterol
oldaterol<\/p>\n\n\n\n
LABA use in COPD
preferred over SABA for stable COPD
long term control<\/p>\n\n\n\n
ICS examples
Budesonide
Fluticasone Propionate<\/p>\n\n\n\n
At what point should an oral steroid be prescribed?
moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD<\/p>\n\n\n\n
only can be prescribed when symptoms cannot be controlled with safer medications (ICS, inhaled SABA\/LABA)<\/p>\n\n\n\n
risk of toxicity increases with duration of use<\/p>\n\n\n\n
Bupropion recommended length of treatment
decrease use after 12 weeks<\/p>\n\n\n\n
Wellbutrin contraindications
can cause neuro psychiatric effects such as mood changes, erratic behavior, and suicidal thoughts. use cautiously in patients with seizures, cocaine abuse, anorexia, and psychiatric disease. drug interactions are MAOI, other bupropion drugs.<\/p>\n\n\n\n
Nicotine patch patient education
applied once a day to non hairy areas, patch should be changed daily and the site should not be reused for 1 week<\/p>\n\n\n\n
steady level of nicotine<\/p>\n\n\n\n
Nicotine gum patient education
chew slowly and intermittently for approximately 30 minutes, rapid chewing can release too much nicotine at one time resulting in nausea, throat irritation, and hiccups. food can decrease nicotine absorption so do not eat while chewing or 15 minutes before<\/p>\n\n\n\n
bad taste<\/p>\n\n\n\n
Nicotine nasal spray patient education
fastest delivery and highest nicotine level<\/p>\n\n\n\n
most irritating, mucous membranes thin<\/p>\n\n\n\n
How does nicotine replacement work
Decrease nicotine craving and symptoms of withdrawal<\/p>\n\n\n\n
ex\/nicotine patch, gum or nasal spray, lozenges<\/p>\n\n\n\n
What constitutes drug resistant TB
Multi-drug resistant TB (MDR-TB): resistant to isoniazid and rifampin (2 most effective anti-TB drugs)<\/p>\n\n\n\n
XDR-TB (most severe form of MDR-TB) is resistant to isoniazid, rifampin, all fluoroquinolones, and at least one of the injectable second line anti-TB drugs (amikacin or capreomycin)<\/p>\n\n\n\n
Treatment of TB in a pregnant person, what all should be included?
rifabutin is the safest anti-TB drug for use during pregnancy
per CDC, benefit justifies risk for isoniazid, rifampin, and pyrazinamide
ethambutol is known to cause teratogenesis in animal studies and eye abnormalities in children; benefit must outweigh risk in order to use<\/p>\n\n\n\n
if a mother is taking isoniazid and rifampin, can she breastfeed?
Yes- any other durg you would have to weigh benefit vs risk<\/p>\n\n\n\n
Isoniazid use
is a drug that can be used to prevent TB in people that have been exposed.<\/p>\n\n\n\n
example of decongestant
beclomethasone diproprante, budesonide, fluticasone, triamcinolone<\/p>\n\n\n\n
Which drug class has no significant drug interactions
Expectorants (ex. guaifenesin)
help clear out mucous<\/p>\n\n\n\n
H2 receptor antagonists examples
Ending -tidine
Cimetidine, ranitidine, famotidine (pepcid), nizatidine (axid)<\/p>\n\n\n\n
Which H2 receptor antagonist is most likely to interact due to CYP450 enzyme system?
Cimetidine interacts with CYP system so check with pt if they are taking warfarin, phenytoin, theophylline, lidocaine<\/p>\n\n\n\n
Associated vitamin and\/or mineral deficiencies w\/ PPI’s
Hypomagnesemia (check mg levels periodically especially in elderly)
get enough calcium and vit D
contraindicated in those with hypocalcemia due to increased risk for bone fractures
Decreased absorption of calcium, magnesium, and vitamin B12<\/p>\n\n\n\n
How to treat moderate to severe GERD?
PPI’s (protein pump inhibitors) – most effective for inhibiting acid secretion
ending in -prazole<\/p>\n\n\n\n
mild treatment of GERD
H2RAs<\/p>\n\n\n\n
least effective for GERD
antacids<\/p>\n\n\n\n
What medication for GERD to avoid in older adults and why?
Ranitidine and Cimetidine (H2) can cause mental status change in older adults due to interactions with medications due to the CYP450 system.<\/p>\n\n\n\n
Treating GERD during pregnancy\/Which cytoprotective agents would be used
misoprostol (Cytotec) is contraindicated (teratogenic effects)<\/p>\n\n\n\n
sucralfate (Carafate) action is topical – no precautions or contraindications for pregnancy<\/p>\n\n\n\n
When to test for h. Pylori
If lifestyle modification and OTC antacids or H2 Blockers are ineffective<\/p>\n\n\n\n
How to treat h. Pylori
Start PPI (continue 8-12 weeks to promote healing) and abx for 10-14 days<\/p>\n\n\n\n
Triple therapy for H. pylori
PPI, clarithromycin (500mg), amoxicillin(1gm) or metronidazole (500mg)<\/p>\n\n\n\n
Lifestyle modifications to support ulcer healing (PUD)
five or six small meals a day
stop smoking
aspirin and NSAIDS should be avoided
avoid alcohol<\/p>\n\n\n\n
Which one contraindicated (anti-diarrheal) in children during or after chickenpox
Pepto Bismol- Due to risk of Reye’s Syndrome<\/p>\n\n\n\n
Which one (anti-diarrheal) associated with gray\/black stools and black tongue
Pepto Bismol- Expected, and does not indicated GI bleed<\/p>\n\n\n\n
Lifestyle modifications to suggest prior to treatment (for constipation)
increasing fiber in diet and fluids
mild exercise especially after meals can improve bowel function<\/p>\n\n\n\n
Risks of laxatives during pregnancy
can induce labor<\/p>\n\n\n\n
Preferred treatment during breastfeeding (constipation)
Senna (Senokot)<\/p>\n\n\n\n
Psyllium (bulk-forming laxative)
How it works
swell in water to form a viscous solution or gel, thereby softening the fecal mass and increasing its bulk. Fecal volume may be further enlarged by growth of colonic bacteria, which can utilize these materials as nutrients. Transit through the intestine is hastened because swelling of the fecal mass stretches the intestinal wall and thereby stimulates peristalsis.<\/p>\n\n\n\n
What to assess for if psyllium doesn’t produce a bowel movement?
fecal impaction<\/p>\n\n\n\n
What can be helpful to aid in diagnosis and treatment of IBS
a diary<\/p>\n\n\n\n
Who should receive the Tdap vaccine?
Immunocompromised, cancer, HIV, high-dose glucocorticoid, pregnancy<\/p>\n\n\n\n
True contraindication for DTaP or Tdap vaccine.
history of anaphylactic reaction or encephalopathy within 7 days of vaccine<\/p>\n\n\n\n
varicella contraindications
pregnancy, cancers like leukemia or lymphoma, hypersensitivity to neomycin or gelatin<\/p>\n\n\n\n
Hepatitis B virus (HBV) vaccine (one of safest vaccines) contraindications
Anyone who has prior anaphylactic reaction to baker yeasts of Hep B itself<\/p>\n\n\n\n
example of Attenuated vaccine
measles, mumps, and rubella (MMR) vaccine and the varicella (chickenpox) vaccine, flumist, rotavirus, varicella zoster<\/p>\n\n\n\n
example of live virus vaccine
Measles, mumps, and rubella virus vaccine (MMR)
Measles, mumps, and rubella, and varicella virus vaccine (MMRV)
Varicella virus vaccine
Influenza vaccine (live)
Rotavirus vaccine<\/p>\n\n\n\n
example of toxoid vaccine
Dtap, tetanus<\/p>\n\n\n\n
example of Inactive viral antigen vaccine
Poliovirus vaccine, inactivated (IPV, Salk vaccine)
Hepatitis A vaccine (HepA)
Hepatitis B vaccine (HepB)
Influenza vaccine<\/p>\n\n\n\n
herd immunity (community)
The resistance to an infectious organism because a large group of people is immune to the infectious organism through immunization\/vaccine. Herd or Community immunity is contingent on the likelihood individuals are prone to the infection will encounter the infected person. For example, most of the people in the community are immune to an infectious disease, which means everyone does not need immunity to prevent the spread of the infection.<\/p>\n\n\n\n
active immunity
When the immune system produces antibodies in response to an antigen by the vaccine, or by the infection itself. For example, if a person who has never had hepatitis B contracts hepatitis B and recovers from it, that person becomes immune to hepatitis B because of the immune system’s antibody response to the hepatitis B virus<\/p>\n\n\n\n
passive immunity
The immunity that occurs naturally. This type of immunity is passed on when an antibody is produced in another host. For example, immunity is passed on from a mother to her infant or by artificial administration of antibody-containing formulations.<\/p>\n\n\n\n
define vaccine
preparation containing whole or fractioned microorganisms, which cause recipients immune system to manufacture antibodies directed against the microbe<\/p>\n\n\n\n
Post exposure prophylaxis for suspected rabies bite
1 mL dose IM on days 0,3,7,and 14<\/p>\n\n\n\n
Who can receive attenuated influenza vaccine (FluMist)?
Individuals >2 yo and less than 50, non-pregnant, and not immunocompromised<\/p>\n\n\n\n
How to treat gastroparesis (which your stomach can’t empty itself of food in a normal fashion. Symptoms include heartburn, nausea, vomiting, and feeling full quickly when eating)
Prokinetic=Metoclopramide(Reglan)<\/p>\n\n\n\n
Black box warning associated with treatment (Reglan)
Can cause Tardive Dyskinesia, risk increased with length of treatment. Should discontinue at 12 weeks or if the patient develops movement disorder<\/p>\n\n\n\n
Metronidazole – Patient teaching needed
Metronidazole (Flagyl) is very effective against sensitive strains of H. pylori. Unfortunately, more than 40% of strains are now resistant. The most common side effects are nausea and headache. A disulfiram-like reaction can occur if metronidazole is used with alcohol; hence alcohol must be avoided. Metronidazole should not be taken during pregnancy.<\/p>\n\n\n\n
Patient teaching for ciprofloxacin for traveler’s diarrhea
non-pregnant adults
Finish full dose of antibiotics
cipro can cause serious side effects (txt not normally recommeded)
Use the drug if symptoms develop and are severe or do not improve in a few days.<\/p>\n\n\n\n
Intermittent asthma symptoms and SABA use
2 days\/week of less
2 times a month nighttime awakening
SABA use- 2 days\/week or less<\/p>\n\n\n\n
Mild Persistent symptoms and SABA use
more than 2 days\/week but less than daily
3-4 times\/month nighttime awakenings
More than 2 days\/week but less than daily<\/p>\n\n\n\n
Moderate Persistent symptoms and SABA use
Daily symptoms
More than once a week\/but less than daily nighttime awakening
Daily SABA use<\/p>\n\n\n\n
Severe asthma symptoms and SABA use
Several times daily
nighttime awakening: often nightly
SABA use several times a day<\/p>\n\n\n\n
Benefits of use of SABA
“rescue medication”
abort an ongoing attack\/acute symptoms, but not for prolonged prophylaxis<\/p>\n\n\n\n
Benefits of use of LABA
long term control, fixed schedule<\/p>\n\n\n\n
Mechanism of action of decongestants
Decongestants act on the nasal cavity to shrink engorged mucous membranes and decrease stuffiness. There are three separate groups of nasal decongestants: adrenergics (sympathomimetics), anticholinergics (parasympatholytics), and selected topical corticosteroids (intranasal steroids). Nasal steroids are aimed at the inflammatory response elicited by invading organisms (viruses and bacteria) or other antigens<\/p>\n\n\n\n
mechanism of action of expectorant
Expectorants work to encourage the expectoration (i.e., coughing up and spitting out) of excessive mucus in the respiratory tract. They work to break down and thin secretions for easier expectoration<\/p>\n\n\n\n
patient teaching for ciprofloxacin for traveler’s diarrhea
cipro can cause serious side effects (txt not normally recommeded), use the drug if symptoms develop and are severe or do not improve in a few days
non-pregnant adults<\/p>\n\n\n\n
Patient teaching and assessments for post vaccine side effects
Local reactions: discomfort, swelling, erythema at injection site
Fever is common
Very rare but severe effects include anaphylaxis (e.g., in response to measles, mumps, and rubella virus vaccine); acute encephalopathy (caused by diphtheria and tetanus toxoids and pertussis vaccine); and vaccine-associated paralytic poliomyelitis (caused by oral poliovirus vaccine).
immunocompromised children are at special risk from live vaccines
in the absence of an adequate immune response, the viruses or bacteria in these normally safe vaccines are able to multiply in profusion, thereby causing serious infection.
live vaccines should generally be avoided in children who are severely immunosuppressed (congenital immunodeficiency, human immunodeficiency virus (HIV) infection, leukemia, lymphoma, generalized malignancy, and therapy with radiation, cytotoxic anticancer drugs, and high-dose glucocorticoids)<\/p>\n\n\n\n
Symptoms of PPI short use risk?
hypomagnesium – muscle cramps, tremors, cramps, and palpitations<\/p>\n\n\n\n