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Answer: -B- P195 cold remedies have several drug interactions that can cause hypertension and sever bradycardia.
Answer -C- P385 beta-agonist can cause tachycardia and palpitations in some patients.
Answer –D- P593 Insulin with glucose causes the potassium to shift into the cells and lower the serum potassium levels.
4. Only in the afternoon
Answer–C- P605: Metformin IR is 50-60% absorbed during fasting conditions, food decreases the absorption.
Answer –A- P 636: TSH and free T4 determine the effectiveness of Levothyroxine. The thyroid works with a negative feedback system. When a steady state is reached these labs should be checked and the medication should be adjusted to keep the TSH within normal limits.
A) CBC with differential
B) AST, ALT and Alkaline Phosphatase
D) Loop Diuretic
prescribed if one is given?
a) Anytime during the pregnancy, they are safe
b) Never- they are Category D
c) Third trimester- they have no risk
d) First and second trimester- less likey to cause seizure activity in the fetus
Answer: d) Antihistamines should not be given in the third trimester of pregnancy related to the increase potential for seizures in the fetus. (Woo,& Wynne, 2012. p. 424)
a) 50-60 percent absorbed after administration on a empty stomach
b) No hypoglycemic effects
c) It inhibits platelett aggregation
d) It can be used in children as young as 10 years old
Answer: c- Metformins ability to inhibit platelett aggregation makes it a good choice for patients with metabolic syndrome related to their increased risk of cardiovascular symptoms (Woo, & Wynne, 2012p. 605).
a) take every morning
b) Don’t take with grapefruitjuice
c) Take with food
d) Don’t take with dairy products
Answer: b) Do not take with grapefruit juice. Graperuit juice increases blood concentrations of amiodarone by inhibiting the production of N-DEA, the major metabolite of amiodarone (Journal of Clinical Pharmacology, 2000. 49(4))
should they be changed to?
Answer: c) ARB. Also provide renal protection for this population of patients
d. No increase
a. Thyroid hormones are Pregnancy Category A but doses may need to increased during pregnancy between 25-45% because of increased metabolism (p. 635)
a. Take in divided doses.
b. Take as a single dose before the morning meal.
c. Decrease dose until symptoms subside.
b. to decrease the incidence of insomnia a single dose of medication given in the morning is best. Medication should be take before meals to increase absorption (p. 637)
a. Adults 3000mg/d and children 2500 mg/d
b. Adults 3500mg/d and children 3000 mg/d
c. Adults 2550mg/d and children 2000 mg/d
d. Adults 1500mg/d and children 1250 mg/d
c. The maximum dose for metformin is 2550mg/d for adults and and 2000 mg/d in children (p. 607)
a. ACE inhibitors
b. Calcium channel blockers with a diuretic
c. Cardiac glycosides
d. Antiarrhythmics with a diuretic
a. ACE inhibitors are the best choice in threating heart failure when compared to all other medications and combinations of medications (p. 315)
a. Left ventricular heart failure
b. Narrow-angle glaucoma
b. Beta 2 agonist are not recommended in patients with narrow-angle glaucoma (p. 383)
1. A 36-year-old patient presents to the office stating she just found out she was pregnant and does not want to take any medications during her pregnancy. She has been diagnosed with hypothyroidism and started on Levothyroxine. What Pregnancy Category are thyroid hormones?
a. Pregnancy Category A
b. Pregnancy Category B
c. Pregnancy Category C
d. Pregnancy Category D
Correct Answer A: (Woo & Wynne, pg 635) Untreated hypothyroidism during pregnancy may increase the incidence of maternal complications, spontaneous abortion, fetal death, or stillbirth, these outcomes can be avoided by thyroid hormone replace. Thyroid hormones are Pregnancy Category A: replacement is advised for all symptomatic pregnant women. (Drug testing has failed to demonstrate a risk to the fetus in the first trimester of pregnancy; and not evidence of risk in later trimesters).
1. Mr. Adams, a 54-year-old patient, has Ulcerative colitis, which Diabetic medication should he not be prescribed?
Correct Answer C: (Woo & Wynne, pg 625) Patients with severe GI disease should not use these drugs because of their effects on gastric emptying.
1. Brian has Diabetes and hypertension. As a Nurse Practitioner prior to prescribing an Angiotensin-Converting-Enzyme Inhibitor, you need to check evaluate the patient for?
a. Renal function
d. Clotting disorder
Correct Answer A: (Woo & Wynne, pg 307) ACEI should be used cautiously with patients who have impaired renal function especially in older adults. The kidney is the primary organ for excreting ACEI
1. All patients that complain of angina should be taking which drug?
a. Calcium Channel Blockers
c. Beta Adrenergic Blockers
d. Ace Inhibitors
Correct Answer B: (Woo & Wynne, pg 961). All patients with angina should be on aspirin 81 to 325 mg/day. Aspirin is known to be effective for reducing mortality in patients with Coronary artery disease and has been associated with a decrease in nonfatal MI, nonfatal stroke, and vascular death.
1. Janice Monroe, 22 year old female that is 24 weeks pregnant comes to the office for evaluation of her asthma symptoms. As the nurse practitioner you discuss how to monitor her symptoms and prescribe which drug?
b. Montelukast; Singulair
c. Prednisone injection
d. Inhaled corticosteroid: budesonide
Correct Answer D: (Woo & Wynn, pg 1008). Long-term control medication of choice. The inhaled corticosteroid has the most data available in pregnant woman.
1. Mr. Smith, a 67 y/o Caucasian male has recently been diagnosed with hypertension and placed on an ACE inhibitor for the last 4 weeks. He has returned to his practitioner for a follow-up appointment and states that he can’t get rid of his cough. What do you suspect?
a. Mr. Jones is developing a upper respiratory track infection
b. Mr. Jones may be a closet smoker.
c. ACE inhibitors can cause a cough more prominently in Caucasians.
Woo & Wynne,Pg. 309: - C - Coughs are associated more with white individuals than any other race. African Americans and Asians have a higher likelihood of angioedema with ACE inhibitors.
1. What is the underlying cause in about 2/3 of patients with an left ventricular
b. Coronary Heart Disease
Woo & Wynne, Pg. 312 – B – Coronary heart disease is the underlying cause of 2/3 of patients with LV dysfunction. ACE and ARBs heap in treatment of HF leading to CAD.
1. Mrs. Jones has been diagnosed with a severe systolic dysfunction and has an
audible S3 heart sounds. What is the drug of choice for Mrs. Jones?
a. Class 1 Antiarrhythmic
Woo & Wynne, Pg. 333 – C – Although Digoxin is no longer the first-line medication for HF, it is part of the treatment plan for severe systolic dysfunction with S3 heart sounds.
What is considered the “Hallmark of Asthma”
a. Airway Hyperresponsiveness
b. Airflow Obstruction
Woo & Wynne, Pg. 992 – A – Airway hyperresponsiveness is a hallmark of asthma, which leads to wheezing, dyspnea, and chest tightness.
A patient is at home with complaints of an asthma exacerbation. What would be the first line drug to help treat this condition?
a. Inhaled corticosteroid
b. Inhaled beta2 agonist
Woo & Wynne, Pg. 1007 – B – An inhaled beta2 agonist is the first line treatment in acute asthma attack after the patient determines severity.
Metformin is contraindicated in patients with abnormal__________________
b. Blood Glucose levels
c. Creatinine Clearance RateCardiac Enzymes
Metformin is contraindicated in male patient with serum creatinine levels of 1.5 or higher, females with levels of 1.4 or higher, and patients of either gender with abnormal CCr rates.
Insulin is a protein molecule secreted by the _______ cells of the pancreas.
Insulin is a protein molecule secreted by the beta cells of the pancreas. It is crucial to the use of glucose by the cells of the body. Type I diabetes, which accounts for 10 percent of total diabetes, results from an autoimmune destruction of the beta cells of the islet of langerhans of the pancreas, which leads to insulin deficiency and insulin is the primary drug for treating this disorder.
Paroxysmal supraventricular tachycardia is not normally a dangerous arrhythmia unless it is because of ______________________.
In WPW syndrome, a circular pattern may occur between an extra connection with the atria and ventircles that causes an extremely rapid rate. The rate in WPW may be life threatening (Hopkinsmedicine.org, nd).
Angiotensin-converting enzyme inhibitors (ACE Inhibitors) and angiotensin II receptor blockers (ARBs) act on the _____________________ system.
b. Renin-angiotensin-aldosterone (RAA)
d. Central Nervous System
Angiotensin-converting enzyme inhibitors (ACE Inhibitors) and angiotensin II receptor blockers (ARBs) act on the renin-angiotensin-aldosterone (RAA) system, decreasing blood pressure, enhancing oxygenation to the heart, and decreasing remodeling or fibroblast multiplication and thickening of the vessel walls that result in hypertrophy and fibrosis of the heart muscle post myocardial infarction or heart failure.
________________ antiarrhythmics are sodium channel blockers, and work by binding to and blocking the fast sodium channels that are responsible for the rapid depolarization of fast response cardiac action potentials.
a. Class I
b. Class II
c. Class III
d. Class IV
Class I antiarrhythmics are sodium channel blockers, and work by binding to and blocking the fast sodium channels that are responsible for the rapid depolarization of fast response cardiac action potentials. Blocking these channels decreases the slope of phase 0, which also leads to a decrease in the amplitude of the action potential.
Digoxin is a Cardiac Glycoside and its primary use is?
D. Elevated blood pressure
In heart failure it Increase contraction of the heart muscle. In atrial fib, it slows the heart rate
More than half of the patients with Graves' disease experience:
A. ocular symptoms
B. hypothyroid symptoms
C. thyroid storm
Answer: A: Ocular symptoms occur in more than half of the patients with Graves' disease. Pg 1267 Woo & Wynne.
Sulfonylureas potentiate what hormone?
A. Growth hormone
B. Follicle stimulating hormone
C. Thyroid-stimulating hormone
D. Antidiuretic hormone
Lisinopril is an ACE Inhibitor and is often discontinued for this most common side effect.
A. Dry Cough
B. nausea and vomiting
C. GI distress
D. erectile dysfunction
Answer A : Dry "tickle" cough occurs in approximately 15% of patients. Pg 1157, Woo & Wynne.
You are prescribing levothyroxine, when is the best time to take this drug?
A. with breakfast
B. at bedtime
C. afternoon snack
D. 30 minutes before a.m. meal
Answer D: Fasting increases its absorption, pg 631, Woo & Wynne
(1) What combination of drugs has been shown to reduce morbidity and mortality in patients who have suffered a myocardial infarction?
a. Calcium channel blockers, beta blockers, antiplatelet therapy, lipid lowering therapy
b. Diuretics, calcium channel blockers, alpha 1 antagonist, nitrates
c. Ace inhibitors, beta blockers, antiplatelet therapy, lipid lowering therapy
d. Lipid lowering therapy, antiplatelet, alpha 1 agonists, calcium channel blockers
(ANS) According to Woo & Wynne (2012), survivors of acute MI have a risk for subsequent morbidity and mortality that is 1.5 to 15 times greater than the general population. A combination of an ACEI, a beta blocker, antiplatelet and lipid-lowering therapies after MI is appropriate. (p. 312)
(1) Your patient is on reductase inhibitors for the management of cholesterol levels. What lab values are most important to monitor at initiating and continuation of therapy?
c. Serum creatinine
d. Red blood cells
Which medication can lead to the developing of hypothyroidism?
(ANS) Amiodorone inhibits the enzyme that converts T4 to T3 and iodine is a major component of this drug, therefore…patients with underlying predisposition to thyroid disease may develop thyrotoxicosis or hypothyroidism (Woo & Wynne, 2012, p. 339).
(1) A patient calls the office complaining of progressive muscle weakness. After the NP reviews the patients medications, the NP determines is an adverse effect of which medication?
a. Beta blocker
c. Amiodoroned. Atorvastatin
(ANS) For all reductase inhibitors, muscle tenders or pain may indicate a serious problem that may require discontinuance of the drug and should be reported to the healthcare provider immediately (Woo & Wynne, 2012, p. 368).
(1) What are the signs and symptoms of an adverse effect of digoxin in the presence of hypokalemia?
b. Tachycardia disturbances
c. Yellow vision and green halos around light
d. Significant shortness of breath
(ANS) Toxicity is commonly caused by excessive administration of a cardiac glycoside, by too much diuresis resulting in hypokalemia, by concurrent development of renal insufficiency or by administration of drugs that interfere with excretion of digoxin (Woo & Wynne, 2012, p. 329).
When treating a patient with emphysema, which antihypertensive medication should be avoided?
c. Angiotensin-converting enzyme (ACE) inhibitorsCalcium channel blockers
In a patient with emphysema, beta-blockers should be avoided due to the reduction of forced expiratory volume (FEV1) and increased hyperresponsiveness of the airway. Also, when a patient is taking either a high dose of a cardioselective beta-blocker or taking a non-selective beta blocker, the broncodilator response of the beta agonists is inhibited.
1. In an 80 year old Caucasian female with osteoporosis, which medication has favorable effects for the patient?
c. Angiotensin-converting enzyme (ACE) inhibitorsd. Calcium channel blockers
In asthmatic’s lungs, inflammatory changes are controlled by all of the following medications except:
a. Cryomolyn sodium inhaler (Intal)
b. Triamcinolone (Azmacort)
c. Albuterol inhaler (Proventil)
d. Montelukast (Singulair)
1. A 70 year old female was prescribed fluvastatin, an antilipidemic. On her 6 week follow-up visit she complains of dark urine and fatigue. She states that no muscle soreness has been present. What should the APRN consider as the next step in the patient’s plan of care?
a. Urinalysis and urine culture
b. CBC with differential
c. Liver function test
d. Patient needs increase oral fluids and rest
A liver function test should be ordered due to statins having the ability to alter liver function as well as increasing liver enzymes. This may cause the patient to fatigued, weak, or have muscle pains.
1. Jacob is a 16 year old male with a history of type I diabetes. His blood sugars after returning home from school have ranged from 205-225 mg/dL for the past three weeks. Morning dose: 15 units/regular insulin and 30 units/NPH. Evening dose: 20 units/regular insulin and 15 units NPH. Which of the following changes would be the most effective in Jacob’s plan of care?
a. Increase the AM dose of NPH
b. Decrease the PM dose of NPH
c. Increase the AM dose of NPH and regular insulin
d. Decrease the AM dose of NPH and regular insulin
What are the three reasons not to prescribe an ACE inhibitor?
a. Mild heart failure, COPD, MI
b. MI, children, breast feeding
C. Angioedema, pregnancy, bilateral renal stenosis
C. is the correct answer
ACE inhibitors should not be used in bilateral renal stenosis, because of the decrease blood flow that will occur to the kidneys. The stenosis is already causing the decreased perfusion and adding the ACE inhibitor will decrease blood pressure that is needed to perfusion the kidney.
When prescribing ACE inhibitors monitor and educate the patient on the possible side effect of angioedema in the face area such as the tongue, or a voice change may indicate a reversible problem. Approximately 0.2 percent of patients may develop this condition. It can be life threatening (Woo & Wynne, 2012).
What is the most common reason for patient discontinuing use of ACE inhibitors?
a. Weight gain
b. Cramps in legs
D. Dry hacky cough
D is the correct answer.
The most common reason for discontinuing use is the dry hacking cough that can occur with the use of ACE inhibitors. If this occurs, the practitioner may want to switch the patient to an (ARB) angiotensin II receptor blocker. Rash is another common phenomenon that occurs with this class.
A patient with active chest pain should receive long or short acting Nitrates and what route?
a. Long-acting by mouth every 30 minutes
b. short-acting sublingual every 5 minutes
c. Long-acting IV continuous drip
d. short-acting IM injection every hour
The answer is “b”, because Nitrates onset of action is directly linked to the administration route. Sublingual and inhalant routes avoid hepatic first-pass increasing the blood levels. The buccal and transdermal routes do avoid the first-pass effect, but are slower at the onset of actions. Isosorbide is metabolized into active metabolites that accumulate for a longer-term therapy effect. Metabolism of all nitrates leads to glucuronide derivatives, which lead to carbon dioxide excretion by the kidneys and the lungs (Woo & Wynne, 2012, p. 350).
What are three reasons not to give a Nitrate?
a. Head injury, brain hemorrhage, and hypotension
b. COPD, HTN, Renal failure
c. Presence of migraine headaches, Steven Johnson syndrome, and heart failure.
· The answer is “a”, because Nitrates are contraindicated in patients with head trauma or cerebral hemorrhage because vasodilation can increase intracranial pressure.
· Nitrates should be avoided in patients with volume depletion because vasodilation can lead to postural hypotension.
Alpha Glucosidase Inhibitors teaching should include?
a. Take blood sugars at least four times a day
b. Take after each meal
c. Wear a medical alert bracelet indicating the proper carbohydrate for hypoglycemia.
d. Carry crackers with them to use if hypoglycemia occurs
The correct answer is “C”, because If hypoglycemia occurs (use a 8 oz Glass of milk with a lactose tablet). Do not use sucrose, fructose or starches because the inhibitors block the action of these carbohydrates. Wear a medical alert bracelet that indicates the patient is taking a AGI and the source of carbohydrate that needs to be used for hypoglycemia
1. What of the following drugs should the Nurse Practitioner consider as a first line treatment for allergic rhinitis?
B. Medrol Dose Pack
Correct Answer: A. Nasal corticosteroids are “used to manage the inflammatory response associated with seasonal or perennial allergies” (Woo & Wynne, 2012, p. 414). None of the nasal corticosteroids are more preferred than the other; therefore the choice ultimately lies with patient and prescriber preferences.
What is the rational for advising patients not to smoke while taking Theophylline?
A. Taking Theophylline increases the patient’s risk for respiratory side effects
B. Nicotine competes for receptors with Theophylline
C. Theophylline levels may be increased when patients smoke
D. There is an increased risk for cardiovascular side effects
Correct Answer: C. Theophylline levels may be increased when patients smoke and should be closely monitored if patients smoke while taking theophylline. This includes nicotine replacement products such as gum, patches, or lozenges. (Woo & Wynne, 2012).
What is the most common adverse reaction with an antiarrhythmic?
D. Bone Marrow Suppression
Correct Answer: B. Dizziness “is the most common adverse response” with antiarrhythmics (Woo & Wynne, 2012, p. 348). Patients should be taught to use caution when changing positions, driving, or other activities that require mental alertness until safety and tolerability have been established.
All of the following antilipidemics except _____________ affect Warfarin activity.
Correct Answer: A. All antilipidemics except Niacin affect the activity of Warfarin. “Bile acid sequestrants decrease its effect, and the other classes increase its effect” (Woo & Wynne, 2012, p. 361).
1. What is the drug of choice for treatment of gestational diabetes and for women with diabetes who are pregnant or planning to become pregnant?
A. Diet and Exercise
What is the most common serious adverse effect associated with Propylthiouracil PTU and methimazole?
A. Nausea and vomiting
C. Agranulocystosis and aplastic anemia
D. Skin rash
Answer: C. Agranulocytosis and aplastic anemia are serious adverse effects that must be monitored, the practitioner will monitor WBC count and discontinue if any signs of reaction is noted (Woo &b Wynne, 2012)
Patients should be alert that all of the following are indication of hyperglycemia that may precede DKA except:
D. Ketone odor to breath
Answer: A. The signs of hyperglycemia that may precede DKA is polyuria, polydipsia, polyphagia, weight loss and fatigue, vomiting, dehydration, ketone odor to breath, and abdominal pain. Diaphoresis is a symptom of hypoglycemia (Woo & Wynne, 2012).
What is the initial drug therapy for Type II Diabetes?
Answer: D. Metformin is the only drug in the biguanide class that is used clinically as a first-line treatment for Type II diabetes (Woo & Wynne, 2012)
What adverse reaction of ACE Inhibitor therapy listed is the most common and often cited as the reason for discontinuation?
A. Dry, hacking cough
D. Orthostatic hypotension
Answer: A. A dry, hacking cough is noted as the most common adverse effect with ACE inhibitor therapy and noticed within the first week. It is thought that the cough is due to the action of the breakdown of bradykinin as a result of the drug (Woo & Wynne, 2012).
________ are absolutely contraindicated for patients on concurrent MAOI therapy?
A. Oral Decongestants
D. Respiratory inhalants
Answer: D. oral decongestants are contraindicated in concurrent therapy with MAOI therapy because they can result in severe headache, hypertension and hyperpyrexia, and possibly hypertensive crisis (Woo & Wynne, 2012).
The oral maintenance dose of the cardiac glycoside digoxin on an adult atrial fibrillation patient with normal renal function is:
Rationale: The maintenance dose is initiated on young patients and those with normal renal function at 0.25-0.5mg daily. Older individuals with impaired renal function have a maintenance dose of 0.125mg daily. The maintenance dosage for atrial fibrillation with rapid ventricular response or heart failure is 0.063-0.5mg daily (Woo & Wynne, 2012, p. 331-332).
You are caring for a patient that needs an ACE Inhibitor, but has difficulty with swallowing. What ACE Inhibitor would be a good choice for the patient?
Rationale: Ramipril (Altace) capsules can be opened and sprinkled onto applesauce or pudding, or it can be dissolved in apple juice or water with no change in drug effectiveness (Woo & Wynne, 2012, p. 316).
You are caring for a 24 weeks pregnant woman that is in need of long-term control of her asthma. You are going to prescribe an inhaled corticosteroid. Which of the choices below would be best prescribed?
A. Beclomethasone (QVAR)
B. Budesonide (Pulmicort)
C. Flunisolide (AeroBid)
D. Fluticasone (Flovent)
Rationale: Budesonide (Pulmicort) has more available data for use in pregnancy (Woo & Wynne, 2012, p. 1008).
You are caring for Joey, a 4-year-old child that has been diagnosed with asthma. According to the Stepwise approach for managing asthma long-term in children, what should be the first step in managing this child?
A. Medium-dose inhaled corticosteroid (ICS)
B. Low-dose inhaled corticosteroid (ICS)
C. Cromolyn or Montelukast
D. Short acting beta2 agonist (SABA) PRN
Rationale: According to the Stepwise Approach for managing Asthma Long Term in Children, 0-4 Years of Age and 5-11 Years of Age (2007), the first step for managing Joey’s asthma would be a SABA as needed (Woo & Wynne, 2012, p. 1000).
Mr. Ray is a 68-year-old farmer. He is at the clinic today because he has a non-productive cough that he just can’t seem to get to subside and he wants something to help. He has a known medical history of asthma and Parkinson’s. His medications consist of Azilect daily and Advair twice a day. What cough preparation would you prescribe as the primary care provider for Mr. Ray?
Rationale: Antitussives such as dextromethorphan, codeine and benzonatate, should not be used for asthmatic cough, which is not ruled out in Mr. Ray’s case. Antitussives should also NOT be taken concurrently with MAOIs, of which Azilect belongs in this drug class. The best choice within this category of preparations would be guaifenesin for Mr. Ray’s non-productive cough (Woo & Wynne, 2012, p. 439-441).
Two presenting parts
hand/head most common
can deliver vaginally
increased risk for perineal laceration
ischemia, stretching or distention of an organ
- obstruction in biliary system
- ALP(41-133IU/L)= damage or growth, false+ common, can be fractionated into bone or liver
- ALT and AST elevated (or GGT NL=9-85U/L)
- Elevated ALT, AST, AND ALP= obstruction!
- Get abd u/s w contrast
- ERCP: Ele
- Usu <4% of total WBC
- Elevation in number of bands/immature neutrophils
- Occurs in serious bacterial infections, pneumonia, meningitis, septicemia, pyelonephritis, tonsillitis.
-Elevation in total WBC
Absolute neutrophil count (ANC)> 7000n/mm3
- Aka: segs, polys
Appendiceal perforation sx
Sx: marked leukocytosis (TWBC >20-30,000), fever>102F, peritoneal inflammation, sx >244hrs, ill-defined RLQ mass indicative of abscess formation.
C/m: painless frank hematuria
R/f: cigarette smoking, exposure to dyes or heavy metals.
Avg age of dx: 65yo, more men
Abd mass only palpable in advanced dx
Liver enzymes elevation significance
ALT +AST+ALP= obstruction
ALP w/o hi GGT= bone
ALP + GGT= liver (sustained ETOH)
Pancreatic fx tests
Amylase (nl 20-110 U/L)
Lipase (nl <160U/L)
- enzyme release from direct cellular injury: acute pancreatitis (>5x normal), chronic/relapsing pancreatitis s/t ETOH, drugs, viral hepatitis, trauma
- obstruction: biliary tract dx, tumor, drug induced
- plasma proteins: albumin
- protein based clotting factors: prothombin, fibringogen, factors 6-13
- lipids and lipoproteins
- hormone substrate for sex hormones
- bile acids
Markers of liver injury (hepatotoxicity)
AST (Aspartate aminotransferase)
- found in liver and muscle; rises rapidly, clears quickly
- think EXTRAHEPATIC injury (ETOH, statins, tylenol)
ALT (alanine aminotransferase)
- Found almost exclusively in liver
- think INTRAHEPATIC injury (
*Most common cause of abd pain
- Epidemic: Norwalk virus
- Sporadic: Rotaviruses(severe in <5yo), bacterial, amoebic, Adenovirus (adults)
- Chronic: protozoal (giardia-daycare/travel hx), helminth (ascariasis)
- Affects 20-50% of tropical travelers
- E.Coli (70%), salmonella, shigella, amoebic dysentery
- 6 mo post-episode: 18% still have chronic GI sx; 10% will meet Rome crit for IBS
- Pt ed: safe food/drink handling, prophylaxis for pts w/ GERD/IBD,
Tx for e coli gastroenteritis
??? 200mg po tid x 3days
Other Rx: Cipro 500 BID x 7-10 days--covers Shigella
Or Azithromax 1 Gm single dose or 500 qd x 3 or Doxycyline 100 mg po bid x 10 days
Loperamide 4 mg po x single dose; then 2 mg after each loose stool
I- Very faint
II- Quiet but immediately heard
III- Moderately loud without thrill
– About as loud as S1 or S2
IV- Loud with thrill (tremor or
vibration on palpation)
V- Very loud with thrill
VI- Audible without stethoscope
Physiologic split S2
- Sound of lag between aortic then pulmonic valve closing (hear each individually)
- Heard best in pulmonic region
- Split INcreases on pt INspiration
- common in pts<30yo.
Pathologic split S2
Fixed- No change w inspiration (found in uncorrected septal defect)
Paradoxical- Narrows/closes w inspiration (opposite of physiologic S2 split)-- found w delayed aortic closure ie LBBB.
- Heard best in pulmonic area
- Resolves with tx of underlyi
Pathologic S3 heart sound
-Marker of ventricular overload or systolic dysfx (poor contractility)--poor CO
- Heard in early diastole, "hooked on back of S2"
- "Lub dub-dub"
- Low pitch, BELL, might miss w diaphragm
- For dx of HF, correlate w dyspnea, tachycardia, crackles
S4 Heart sound
- Marker of poor diastolic fx (poor relaxation/compliance)
- most often found in poorly controlled HTN or recurrent myocardial ischemia
- Heard late in diastole--"hooked onto front of S1"--presystolic sound
- "dub-lub dub"
- Soft, low pitch (high
Sx of low cardiac output
- HF sx
Sx leading up to AMI (women)
- unusual fatigue
- sleep disturbance
- shortness of breath
Sx during ACS (women)
- Shortness of breath
- unusual fatigue
- diaphoresis (cold sweat)
- chest pain/pressure (30%)
- NO chest discomfort during event (43%)
Acute coronary syndrome in elderly (>75yo)--Presentation
- Neuro sx (syncope, weakness, acute confusion)
- chest pain/pressure (<50%)
**60% of MIs unrecognized in men >85yo!
Low pressure, R-sided venous system
High pressure, L-sided arterial system
-Most of valvular problems come off L heart (mitral, aortic)
Point of Maximum Impulse (PMI)
- Is a palpable sensation of underlying left ventricle
- Normal location: 5th ICS, MCL
- Locate general location w palm of hand--precise location w fingertip
- Norm size= area of nickel
- Sensation= gentle tap by one finger, single impulse
- Indicated increased LV volume
- Unusually forceful, sustained
--> pressure overload, HTN
- Try Left lateral decubitus position
- Consider concomitnt conditions: thick chest wall, obesity, COPD
Radiating Murmur v carotid bruit: differentiation
- Usually softer
- Often UNIlater
- Different sound than in chest
- usu louder
- Same sound and timing as in chest
Etiology of cardiac arrest
- CVD (56%): most common is hypertrophic cardiomyopathy (account for 1/3 of all deaths)
- Blunt trauma(bball)--> structural changes to heart (22%)= cardiac concussion--> induces VF
- Commotio cordis (4%, likely underreported)-- chest blow that inte
Endocarditis: highest risk groups
- hx endocarditis
- prosthetic valve
Dizziness with exertion (etiology)
Decreased cardiac output with exercise
- not enough blood to head when active
- Think cardiac outflow obstruction towards head--Aortic stenosis
**Different from dyspnea (cant breathe) w exertion
Most common murmur in elderly s/t calcification changes!
- Systolic murmur radiating to neck
- Cardiac outflow obstruction-->dizziness on exertion
Hypertrophic cardiomyopathy murmur
- Grade 2/6 midsystolic murmur that INcreases in intensity with position change from supine to standing with Loud S4.
ALERT- cause of sudden death in athletes!
NEED to do squat-stand cardiac exam!!!
HR x SV= CO x PVR
INcrease any part of formula= INcreased BP
Decrease formula= DEcreased BP
Wider pulse pressure= higher PVR
Women <1 drink/day
Men <2 drinks/day
Drink= 12 oz beer, 5oz wine, 1.5oz 80-proof liquor
MOA: low volume Na+ depletion --> decr PVR (modest)
- 10mmHg systolic drop effect
- Dose>25mg/day incr neg impact for hyperlipidemia, glucose control
- Monitor: Na+, Mag, Potassium (all wasted thru urine)
- Ca+ sparing (lower
- Not usually used for HTN
- Just for offloading volume to improve kidney fx
- antagonize beta adrenergic receptors--blunt catecholamine effect (epinephrine)
- "-lol" suffix; B1- 1 heart; B2- 2 lungs
Caution: in COPD, asthma--may worsen airway obstruction sx (even cardioselective BB); heart block w/o pacemaker (rate lowerin
Acute Cardiac Syndrome
-Incl Acute MI, unstable angina
- most often caused by atherosclerosis
- imbalance in ability to supply myocardium with sufficient O2 to meet metabolic needs.
- patterns of sx provocation usu predictable (exertion)
- resolves with rest, NTG
Sx: pressure, pain, tightness, heaviness, suffocation
Dx: 12-lead ECG, exercise/stress ECG. Computed tomography for coronary artery calcification (noninvasive).
- new onset sx at rest or worsening sx with activities that didnt previously provoke sx
- S4 often heard
Creatinine-Kinase MB (CK-MB)
- serum marker for myocardial damage
- level incr within 24-48h; usu returns to normal in ~60hrs (clears quick, not useful for late id of MI)
-regulatory protein of myofibril
-subtypes C, I, and T- I &T released in myocardial damage
- both incr rapidly w/in 12h post-MI; cTnT elevated ~168h, cTnI elevated ~192h
-cTnI- more cardio-specific; sensitive for small-volume myocardial damage. Be
Guidelines for STEMI, NSTEMI, unstable angina managemen
- NTG spray or SL, then parenteral
- Supplemental O2 for cyanotic or resp distress. Pulse ox or arterial blood gas (confirm arterial SaO2>90%)
- Morphine su IV if not immediate relief w NTG, or w pulm congestion or severe agitation present
Acute coronary occlusion
- look for ST elevation >1mm in contiguous leads
Tx: reperfusion therapy w thrombolytics (heparin x >48h), primary percutaneous transluminal coronary angioplasty, or other revascularization.
-Best effect within 6h after chest pain onset. May be he
Absolute C/i to thrombolytics in STEMI:
- Any prior intracranial hemorrhage,
- Known cerebral vascular lesion (AV malformation)
- Known malignant intracranial neoplasm
- ischemic stroke w/in 3mo (exc acute ischemic stroke w/in 3hr)
- Suspected aortic dissection
- active bleeding or b
Relative c/i for thrombolytics in STEMI
- Hx chronic, severe, poorly controlled HTN, Severe HTN on admit (>180/>110)
- Hx prior ischemic stroke >3mo, dementia, known intracranial pathology NOS
- Traumatic/prolonged (>10min) CPR or major surgery (<3wks), Recent (2-4w) internal bleeding
Left Bundle Branch block
- If clinically consistent w MI, begin standard acute MI care
_Should not receive thrombolysis.
- hospitalize on continuous ECG monitorfor rhythm disturbances.
- Serial 12-leads w/ CPK, CK, Troponin measures for myocardial necrosis
- ASA, heparin use--esp in large anterior MI or left ventricular mural thromb
Ongoing care of NSTEMI pt
- reduce LDL <100mg/dl
- in high risk (DM, CAD): LDL <70
- diet, exercise, drug therapy
- S/t altered cardiac fx --> inadequate CO and inability to meet O2 and metabolic demands
- R/f: HTN*, atherosclerosis*, pneumonia (R heart workload), anemia (decr o2-carrying), incr NACL intake (incr circulating volume).
C/m: dyspnea (exertional,
- substantial gain of extracellular fluid (>5L in adults) must occur before peripheral edema manifests
- Hepatojugular reflex/tenderness s/t liver engorgment from elevated R side heart pressures.
- PMI shifts laterally and in dilated cardiomyopath
-relation btw sx and amt of effort for provocation
- goal is lower category
ECG use in HF
-helps ID left atrial enlargement, L ventricular hypertrophy, dysrhythmias consistent with HF, but not specific to dx.
- May also find changes consistent with acute ischemia or MI as cause of HF
How does doxazosin work?
alpha 1 antagonist reversible blocks post synaptic alpha 1 (catecholamines) lowers BP both venous & arteral, relieve outflow obstruction for BPH, works on vascular smooth muscle, pronounced dbp effects.
what is the action and effect of beta blocker?
Mainly Heart with beta 1. blockade of beta 1 receptors at the SA nodeto decrease HR, in artia and ventricle decrease contractility and conduction velocity, AV slows conduction.
what are the adverse reactions of beta blockers?
brady, hypotension, CHF, pulmonary edema, weakness, dizziness, alters carb metabolism which increases BS mask hypoglycemia, dry mouth, GU, impotence, decreased labido,
what happens with rapid withdrawal of a beta blocker?
abrupt withdrawal= life threatening angina, MI, Ventricular arrythmias, death.
what patient teaching should be provided when prescribing clonidine or any centrally acting adrenergic blocker?
take exactly at same time, even not feeling well. missed doses soon as remember unless closer to next dose. don't Dbl. have enough meds. proper application of patch. no cutting. report edema & wt gain 2 lbs in 1 day. know your bp.
continued card for effects and action of beta blockers.
decrease angina, cardiac arrhythmia with rapid. example metoprolol for afib to slow rate. decreased supine & standing BP, reduce orthostatic tachycardia. HTN fall in PVR.
continued beta blocker effect card
renal- beta 1 receptors in juxtaglomerular reduce renin & less angiontensin 2
respiratory- problem with asthmatic pts. causes passive bronchial constriction.
medabolic- beta 2 increased lipids blood sugars.
how to taper beta blockers
1/2 tab every four days. most at risk for s/s are pt taking for angina, CAD, and migraines. low risk pt are HTN and SVT.
What are the adverse effects of beta 1 selective blockers
Hypotension and bradycardia
teach to dangle on side of bed b4 standing. check bp. no exercise I hot temps, take in 2000 in fluid.call dr if hr is <50.
7. What are the adverse effects of a beta 1 selective blocker?
Hypotension, bradycardia, whizzing, difficulty breathing ,dizziness, dry mouth, insomnia, confusion, depression and they mask the symptoms of hypoglycemia it is lost in the beta 1 blocker.
Impotence, Increased GI motility-diarrhea, fatigue, dizziness, depression
Why are beta blockers cautiously prescribed to diabetic pt.
results in impaired insulin release. hyperglycemia. impair recovery from hypoglycemia. may mask s/s of hypoglycemia. ACE are a better choice.
which medication used in the treatment of alzheimer's disease is not an anticholinergic agent.
Aricept = donepezil
What are the agents used to treat.
alzheimers, mg, reversal of non-polarizing neuromuscular blockades, dementia associated with parkinsons
what effect does nicotine have on nicotine receptors?
binds selectively to acetacholinesterase receptors in autonomic ganglia in medulla at neuromuscular junctions and in thr brain.
continued card for nicotine effect on nicotinic receptors.
CV= vasconstriction, ^HR, ^force of ventricular contaction, increases BP & CO. GI= vomiting. CNS= stimulating effect on locus cerulean making the pt alert and improves cognitive preformance. pleasure center is stimulated releasing dopamine.
continued nicotine card.
tolerance develops rapidly lass than an hour. withdrawal can be reduced with lower levels than obtained by smoking w a patch, gum or nasal spray.
what effect is produced with cholinergic blockers.
competitively block actions of acetacholinesterase
CV-^HR reduce PRO interval. Resp- relaxes bronchial muscles and secretions, dry mouth. used preoperative, used for Parkinson tremors and UA incontinence. GU= decrease perastalsis.....
continued card for effects produced with cholinergic blockers.
CNS- (scopalimine) agitation, hallucination, delirim, mild CNS excitation
How do cholinergic blockers manage extrapyramidal symptoms?
the relative excess of cholinergic activity in Parkinsons tremor and extrapyramidal s/s w antipsychotic drugs can be corrected w Muscatine blockade, esp when combined with dopamine.
what is scopalimine commonly administered as a preventative medication.
nausea and vomiting with motion sickness.
Can medications be administered durring pregnancy for myasthenia gravis.
describe each form of the muscarinic agonist.
receptors located in the eye, heart, blood vessels, lung, gi, us bladder, sweat glands. agonist modifies release of ACh from the PNS. five drugs in the group. Michol, carbachol, pilocarpine and bethanechol, methacholine.
what is the pharmacokinetics and pharmacodynamics of muscarinic
what are the adverse effects of coreg
what would you teach a pt about coreg
same reactions a beta blockers. take consistently with or without food.
risk for orthostatic hypotension is greater.
describe the rational drug select of the combined alpha and beta adrenergic antagonist.
these drugs r less likely to effect reduce heart rate and CO. balances to produce reflex vasconstriction. used to reduce progression of CHF and TX L ventricular dysfunction after an MI.
what is the clinical use and dosing of combined alpha beta adrenergic antagonist when treating a patient diagnosed with CHF
less likely to produce significant reduction in heart rate or cardiac output due to the apha blockade predominates.
start coreg at 3.125mg bid for two weeks and reassess.
describe the use and dosing of beta adrenergic antagonist to teatment of migraine headache
propranolol 160 - 200 mg a day. use for 4-6 wks then taper withdrawal.
timolol starting does at 10 mg big w maintenance at 10- 30mg/day.
use 6-8 wks.
atenolol 50-100 mg/day metoprolol 50-100, & nadolol 40 -80 with similar taper as propranolol.
what laboratory test interactions when prescribing propranolol (inderal)
false positive for stress test
continued card for pharmacotheraputics & pharmacodynamics of muscarinic.
carbachol and pilocarpine used to treat glaucoma. pilocarpine comes in a oral form.
labetalol lab test interactions
may metabolite in UA with false positive results of catecholamines, amphetamines
what medication is recommended for pregnant women?
what antihypertensive med is the only one to have a transdermal formulation
which med is proven to manage exertional stress induced angina associated w idiopathic hypertrophic subaortic stenosis
What factors will place the patient at risk for antibiotic resistance
Increasing population, immunocompromised patients increase of invasive medical procedures, increase survival, chronic disease, daycare, overcrowding, travel, use of antibiotics in children under 2 and older than 65, ^ broad spectrum antibiotics use
What factors place the patient at risk for hypersensitivity reactions with penicillins and cephalosporins
cephalosporins and penicillins are beta lactam antibiotics
What are the safest antibiotics to prescribe to a pregnant woman
Amino penicillin, ampicillin, amoxicillin are active against wide range of gram-positive and limited range of gram-negative organisms
What pt teaching will you provide to a pt who is experiencing non infectious diarrhea related to antibiotic administration
If severe diarrhea occurs contact doctor For mild they can use an absorbent anti diarrheal containing Attaapulgite (donnagel) should avoid anti peristaltic agents that will promote the retention of toxins
American College of Cardiology and the aha what are the guidelines related to prophylactic antib prior to dental appointment
The only people who should have prophylactic antibiotic therapy are pt with heart valves, previous endocarditis, congenital heart disease, cardiac transplant, valve regurg who will have tissue or root works
The patient is taking quinolone. what are the most adverse effects. Fluroquinolones include: ciprofloxacin, levofloxacin
Pseudomembranous colitis, Stevens Johnson syndrome, acidosis, renal failure, cardiac dysrhythmia , angina mi, cva
What are the adverse effects related to special populations
Clindamycin is indicated for first line treatment may be harmful or not tolerated. Penicillin age, and genetic factors, due to poor renal elimination in young & old, more prone to drug toxicity. In PG because displase kernicterus & CNS disorders
What lab value should be assesed when administering valacyclovir
BUN and creatinine
What population should not be administered tetracycline and why
Children under 8- will decrease bone growth and permanent discoloration of teeth, enamel hypoplasia. Pregnant women - cross the placenta produces retardation skeletal deformation, staining teeth
What medication will cause pseudotremor cerebri
Tetracycline and minocycline. S/s include ha, blurred vision, bulging of fontanels in infants, DC the drug resolve the problem may be permanent
What patient education related to patient diet should be provided to the patient taking Valacyclovir.
Take with or without food and with a full glass of water at first sign of recurrence
Prior to prescribing metformin, the provider should:
Draw a serum creatinine to assess renal function
Try the patient on insulin
Tell the patient to increase iodine intake
Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions
Draw a serum creatinine to assess renal function
Monitoring a patient with persistent asthma includes:
Monitoring how frequently the patient has a URI during treatment
Monthly in-office spirometry testing
Determining if the patient has increased use of his or her long-acting beta-2-agonist due to exacerbations
Evaluating the patient every 1 to 6 months to determine if the patient needs to step up or down in their therapy
Evaluating the patient every 1 to 6 months to determine if the patient needs to step up or down in their therapy
when should Oselatmivir phosphate be prescribed?
The prevention of influenza in patients aged one year and older who are at high risk for complications from influenza when vaccines are contraindicated or until immunity develops. Not considered a substitute for vaccine
what are the most common drug interactions with lovofloxacin.
Cyclosporin, warfarin, solutions with antacids and magnesium.
What are the most common side effects with levofloxacin
Increase or decrease blood sugars in diabetics photosensitivity dizziness light headed, tenderness and inflammation of tendons, patient should drink a lot of water crystalluria.
What are the recommended doses for treatment of infections with lincosamides.
adults -150 - 300 mg q6 and children p o 8 to 16 mg/d in 3 to 4 equal dosage. For 3 to 5 days drive this is good for dental infection
What is the recommended treatment for H pylori in peptic ulcer disease
A proton pump inhibitor into antibiotics for 14 days, omeprazole clarithromycin, 500 milligrams BID, amoxicillin 1000 milligrams
A patient is administered gentamicin and complains of sudden hearing loss what should the nurse do
Call the doctor stop the antibiotic
What medications interact with linezolid
was developed as a MAOI so any indirect acting sympathomimetics (epi), vaspressors, or dopaminergic, serotonin drugs cause hyperpyrexia & cognitive dysfunction, antidepressants, meperidine, bupronion, buspirone & ssri.
Differentiate between sulfasalazine, mafenide, silver sulfadiazine, and trimethroprim
used to treat ulcerative colitis and RA (R/T it's anti flammatory properties) antibacterial / antiprotozoal.
treats burns to prevent infection
treats burns to prevent infection
used in combo with sulfonamides to treat UTI's
a patient has glucose 6 phosphate dehydrogenase deficiency( G6PD) which antibiotic should not be administered
Sulfonamides are contraindicated 》acute hemolytic anemia r/T increased destruction of RBC 's
What is the course of treatment with doxycycline for the treatment of Lyme disease
Doxy 100 mg bid is the 1st line. duration depends of the s/s. erythema migrants = 14-21 days. mild cardiac involvement 21 days, arthritis = 28 days: isolated facial paralysis = 21-28 days
PO. 125 - 250 mg or powder 250 mg/5ml liquid 500/6ml. poorly absorbed in GI track, rapid action w peak in 1 hr lasts 12h. 1/2 life 4-6 hours adults. 2-3 in kids. exerted feces, prego category B.
2-3 grams/day (30-60 mg/kg/d) divided q8 to q12 hr. kids 10-15 mg/kg q6hr. more dangerous than oral. eliminated 90 % by glomerular filtration. Prego C. more Otoxic w large iv admin. Redman syndrome ( upper body flushing, urticarial, pruritus, rash
what are the adverse effects of Ethambutol.
optic neuritis which is does related. s/s decreased visual
other adverse reactions of ethambutol
GI disturbances, gouty arthritis, transient liver impairment and peripheral neuropathy.
what are the adverse effects of pyrazinamide
hepatotoxicity may appear at any ti me durring therapy. hyperuricemia, gouty arthritis
What is Rifadin prescribed for.
nonmycobacterial infections. prophylactic for close contact of people with meningococcal infections caused my N meningitis
what are the adverse effects of isoniazid (INH).
peripheral neuropathy is most common. Hepatotoxicity, blood, dyscrasias, metabolic acidosis, gynomastia and hypocalcemia related to altered vitamin D metabolism.
what is a nucleoside
Herpes medication like acyclovir,
how should administer the necleoside analogues
oral at first reoccurence. 200 mg five times daily for 10 day. Varicella durring pregnancy. 800mg 5 times daily for 5 days. take with a full glass of water with or without food.
what is the action of necleoside analogues.
a cyclic guano sine derivatives that requires 3 steps 4 activation. converts monophosphate derivative by thr virus thymidine kinase. then to the di and triphosphate. final shep is inhibits viral DNA synthesis.
when prescribing ketoconazole, how should it be administered.
On am empty stomach and to avoid antacids.
what is hypochlorhydria
when the stomach is unable to produce hydrochloric acid.
what lab values should be monitored when administering antifungal agents.
liver funtions, AST, ALT, alkaline phosphate and bilirubin should be monitored before treatment starts, monthly for 3 months.
Identify which antihelmingic is used to treat parasitic worms. Benzimidazoles
benzimidazoles inhibits the formation of worms microtubules, which staves the worms to death.
supresses the development or production of eggs or larve
causes paralysis of the worms.
give examples of penicillins
Cephalosporins info and examples
1st generation-cefazolin, cephalexin, cefadroxil.
2nd generation- loracarbef, cefprozil, cefotan.
3rd generation- cefdinir, Ceftriaxone,
4th generation- cefepine.
inhibit cell wall making. 1st generation active against gram positive cocci, S aureus s epidermis excluding MRSA. 2nd generation- same w klebsiella, proteus and Ecole coverage. 3rd generation same with active against gram negative. enterobacter.
4th generation Cephalosporins
active against gram positive and negative, enterobacter, pseudomonas, (Maxipine)
Fluroquinolones examples and info
older version =cipro, norfloxacin,
newer = genfloxacin, levofloxacin, moxifloxacin. newer ones are refereed to as respiratory Fluroquinolones. treat gram negative, C pneumonia, Ecoli, klebsiella, S aureus, proteus.
macrolides, azalides, and kerolides
oldest, erthromycin, newer, zithromax, latest-telithromycin.
What is the purpose of the inflammatory process?
Prevent infection of injured tissue.
A reduction in the number of LDL receptors on cell surfaces
Antigen-antibody complexes. Activation of the classical pathway begins with the activation of protein C1 and is preceded by formation of a complex between an antigen and an antibody to form an antigen-antibody complex (immune complex)
Increases resistance of cells to insulin. People with type 2 diabetes mellitus suffer from insulin resistance (i.e., their cells have difficulty using insulin). This disease typically occurs among people older than age 40 and, in contrast to type 1diabetes, is seen more commonly among the obese.
Directs leukocytes to the inflamed area
11. If a woman has one affected first-degree relative, her risk of developing breast cancer doubles.
Platelet Activating Factor.The biologic activity of PAF is virtually identical to that of leukotrienes, namely causing endothelial cell retraction to increase vascular permeability, leukocyte adhesion to endothelial cells, and platelet activation.
IL-2. Without IL-2 production, the The cell cannot efficiently mature into a functional helper cell.
Hypersensitivity is an altered immunologic response to an antigen that results in disease or damage to the host.
Type I reactions are mediated by antigen-specific IgE and the products of tissue mast cells. Most common allergies (e.g., pollen allergies) are type I reactions. In addition, most type I reactions occur against environmental antigens and are therefore allergic.
Type I reactions are mediated by antigen-specific IgE and the products of tissue mast cells
Eosinophils. Another important activity of histamine is enhancement of the chemotactic activity of other factors, such as eosinophil chemotactic factor of anaphylaxis (ECF-A), which attracts eosinophils into sites of allergic inflammatory reactions