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NR 508 Final Exam Study Guide
Cardiovascular management:
- Know Initial treatment choices for HTN 1 st^ line options: ACE Inhibitors OR ARB, Calcium Channel Blocker, thiazides Black people 1st^ line: CCB and/or thiazides preferred (better outcomes) CKD (regardless of ethnicity): ACE Inhibitor OR ARB (but not together) For someone with gout: thiazides increase uric acid (Do NOT use); CCBs and Losartan (but not other ACEIs decrease the risk) ALL other antihypertensives are 2nd line Could consider BB if indicated for a comorbidity (eg arrhythmia, tremor, need for migraine prophylaxis) but no longer considered 1st^ line
- Diuretics: Loop diuretics; Thiazide-type diuretics; Potassium-Sparing Diuretics The loop diuretics inhibit sodium reabsorption in the ascending loop of Henle. These drugs are short-acting and cause a large natriuresis. The thiazide-type diuretics act on the distal renal tubule to inhibit sodium reabsorption. Their effect is generally longer- lasting, and they cause less brisk diuresis. Both classes increase potassium excretion. The potassium-sparing diuretics include aldosterone antagonists and agents like amiloride that inhibit excretion of potassium distally. These agents are weak diuretics, often used in combination with thiazides to reduce potassium loss. Diuretics may also be used as adjunct therapy for disease processes in which the treatment itself may contribute to fluid retention—for example, use of some CCBs and antiarrhythmics. Spironolactone blocks the mineral corticosteroid receptor that aldosterone binds to; *Aldosteronism. It is also useful in ventricular remodeling and decreasing the inflammatory cascade that can occur in the days following an MI. Amiloride's potassium-sparing characteristics are used to counter any chronic potassium losses that cannot be reliably corrected with diet or supplements. Uses Diuretics are first-line therapy in the treatment of HF & HTN through their reduction in ECF volume. Ones most commonly used in primary care are the distal tubular (thiazides and aldosterone antagonists) & loop diuretics.
Side effects All - hypokalemia, arrhythmia, metabolic alkalosis, fatigue, postural hypotension, hyperlipidemia K+-sparing - hyperkalemia, gynecomastia, peptic ulcer Thiazides - hyperglycemia & hypercalcemia Loop- hypocalcemia Drug Interactions All diruetics- a) digoxin (hypokalemia/toxicity risk); b) NSAIDs (reduce diuresis), c) lithium (toxicity risk), d) corticosteroids (enhance hypokalemia), e) anti-diabetic drugs (decrease anti-diabetic levels) Thiazides & Beta blockers increase hyperglycemia/ hyperlipidemia Loops & aminoglycosides cause ototoxicity & nephrotoxicity Spironolactone – Aldactone Furosemide-Lasix Metolazone- Zaroxolyn Hctz- Apo-Hydro; Aquazide; BPZide; Dichlotride; Esidrex; Hydrochlorot; Hydrodiuril; HydroSaluric; Microzide; Oretic Amiloride (Midamor) Triamterene (Dyrenium)
- Preferred diuretic with renal impairment Loop diuretics are the best Tx for renal impairment generally (GFR <30); Amiloride is contraindicated in diabetic neuropathy patients, pts c a BUN > 30 or a creatinine
1.5mg. Metolazone is the only thiazide effective in stage 3 or 4 CKD. Potassium sparing diuretics are absolutely contraindicated in patients with severe renal impairment.
- Post diuretic sodium retention Loop diuretics cause a post-effect, a compensatory sodium-retention process that begins as the diuretic action wanes. The effect of loop diuretics dissipates rapidly, after which the kidneys immediately begin to reabsorb sodium and nullify the diuretic effect. This process is called post-diuretic sodium chloride retention. If sodium chloride intake is high and the half-life of the diuretic is short (as with a loop diuretic), post-diuretic sodium chloride retention compensates entirely for the sodium loss.^7 Therefore, sodium restriction is important when a patient is taking loop diuretics.
bronchospastic disease. For a patient with COPD or asthma, a cardio selective BB can be used, although still with caution since there is still some, but less, risk of bronchospasm. Digoxin: may be added by cardiologist since not first-line tx any longer (3rd now). Used for LV dysfunction or EF <40 while on an ACE and beta- blocker. Diuretics: use loop first. Can use thiazide and a potassium sparing, or can add a potassium sparing to a loop. K+ sparing are not strong enough alone but can be used c loop or thiazide. Spironolactone & Eplerenone Calcium channel blockers- should be avoided. It is okay to use amlodipine, a long-acting dihydropyridine, for Tx of comorbid HTN and/or angina c CHF. **BUT NEVER IN SYSTOLIC DYSFUNCTION - thats for digoxin. If already started, do not d/c. First-line therapy in treating CHF is with ACEIs, depending on the stage of failure. Drugs are often introduced in combinations. The role of diuretics is supplemental and only part of a treatment regimen. The most effective class for this indication is the loop diuretics. Torsemide is a very good long-acting loop diuretic that is especially useful in HF management. Loop diuretics are effective in moderate to severe disease and can be used when Ccr is less than 25 mL/min. Indapamide is also indicated for edema associated with HF and is effective with these low Ccr levels. Thiazide diuretics may be used to treat the edema associated with mild HF, corticosteroid and estrogen therapy, premenstrual syndrome, and limited renal dysfunction. They are not useful if the Ccr is less than 25 mL/min. Among the thiazides, hydrochlorothiazide and chlorthalidone are the first choices for this indication. Intermittent dosing may be advantageous and reduce the incidence of adverse reactions. With premenstrual syndrome, the drug should be taken 3 to 5 days before menstruation and discontinued when menstruation begins. Frequent dosage adjustments may be necessary in edematous patients. Neuro/Psych:
- Know migraine management and prophylactics (see migraine lecture) Dark quiet room/sleep, NSAID (1st^ for kids always), Triptans, Ergot Alkaloids, Caffeine like Excedrin Migraine, Sedatives in the emergency setting, and antiemetics Reglan and Compazine. Triptans (sumatriptan/imitrex, zolmatriptan/zomig, rizatriptan/maxalt) nasal, oral, subq use no more than 2d/week due to rebound potential Contraindicated in recent use of MAOIs, ergots, SSRIs, CVD, CAD, TIA/Stroke, HTN, pregnancy, brainstem migraines. Naratriptan has been used in children age 12-17.
Ergots (ergotamine tartrate/cafergot) not used often, expensive nasal, oral, rectal, IM, IV, sublingual Contraindicated in recent use of triptans, CVD, CAD, TIA, HTN, pregnancy/lactation May cause severe n/v DHE IM or Intranasal Unlikely rebound potential Contraindicated in pregnancy, CAD, PVD, HTN, severe renal/liver dysfunction. Premedicated c antiemitic Migraine prevention beta blockers (metoprolol, propranolol, timolol) o first line Tx (Propanolol ok for children 0.5-1mg/kg/day divided BID and increased q 3-4 days to 2-4 mg/kg/day.
- 2-3 months for effect- decrease frequency & severity by 50% -A/E- drowsiness, exercise intolerance, depression -CI-CHF, asthma anticonvulsants (valproate, topiramate) effective but major A/E o Valproate S/E- dizziness, platelet dysfunction, hair loss, hepatoxic, teratogenic o Topiramate S/E- cognitive dysfunction, wt loss, renal stones CCBs (Verapamil); o C/I in pregnancy, lactation, children, Parkinson’s, depression o May be first-line for pts c HTN who cannot take a beta blocker. Serotonin Antagonist (Methysergide) o S/E retroperitoneal fibrosis o Pts should be drug free 3-4 week p q6monts of tx o C/I in pregnancy, CAD, CVD, impaired renal or liver function, and HTN Botox (inhibits aCE release from nerve endings (avoid if facial nerve disorder/hypersensitivity); adults only. Herbal migraine management Butter bur root. It should be PA free or could result in liver damage Feverfew (Tanacetum parthenium) - Action: Antiinflammatory effects Uses: migraine prevention Interactions: Anticoagulants, antiplatelet drugs, aspirin. Alternative therapies that have been described in the evidence-based literature include feverfew, riboflavin, magnesium, and CoQ
- What drugs can cause serotonin syndrome? SSRIs , SNRIs, tramadol, MOAIs, St. John’s Wort. S/S include: N/D, chills, sweating, hyperthermia, hypertension, myoclonic jerking, tremor, agitation, ataxia, disorientation, confusion, disorientation.
Dextroamphetamine/amphetamine combo xr; Dexmethylphenidate; methlydphenidate xr versions.
- Nonstimulant alternatives: Strattera/ atomoxetine Nuvigil/provigil Clonidine derivatives eg guanfacine (intuniv)- these tend to be most effective in younger boys with hyperactivity symptoms and can be helpful with insomnia Buproprion (wellbutrin) (it is an off-label use) – consider in adolescent who also has depressive symptoms or touret’s; young boys
- Know the treatment of Alzheimer’s and the education behind the medication management of the disease. Use mini mental exam and montreal exam for mental cognition assessment along c family input; teach family tx may or may not help; try different meds until one works better; half-life of Aricept is 3-7 days. Side effects won’t disappear in a day. First line Tx: Donepezil (Aricept) try first; any stage o Take in evening before bed, unless nightmares or sleep distubances, then take am Galantamine ER (Razadyne) mild to mod Rivastigmine (Exelon) mild to moderate Helps to slow progression of disease and improves function Adjunct Tx: NMDA inhibitor such as Memantine or Namenda Reach the max dose, hold for 6 months then add NMDA inhibitor Added as 2nd^ line tx for mod to severe disease
- Parkinson Disease: Drugs including Try to use a dopamine agonist such as bromocriptine, pergolide, pramipexole, or porinirole first for mild to moderate parkinson’s. As symptoms worsen, introduce Levodopa. Combos of Levodopa and Carbidopa, amantadine or carbidopa/levodopa/selegiline may provide improve response time and possible slow progression/deterioration. Levodopa/carbidopa (Sinemet) – monotherapy or adjunctive; most effective therapy for slowness, stiffness, tremor; can cause dyskinesias (abnormal movements); protein impairs levodopa effects; levodopa can activate malignant skin tumors
Benztropine – this is an anticholinergic that can be used to treat tremor in younger patients with PD; it can also be used to treat excessive drooling; anticholinergics can cause confusion, hallucinations, dry mouth, blurred vision and urinary retention (anticholinergic adverse effects more commonly a problem for older patients) MAOI/anticholenergics (eg selegiline, rasagiline) moderate effect; monotherapy delays need for dopas; delays for slowness, stiffness therapy; adjunctive as well for motor fluctuations – wearing off phenomena Amantadine – not the most effective but can be tried as adjunctive therapy for classic PD sx of slowness, stiffness and tremor; adjunct to dopas x slow, stiff & tremor, or if decreased dopa dose needed Pramipexole – this is a dopamine agonist and can be used as mono or adjunctive therapy for classic PD sx. Apomorphine – used for late stage PD as an adjunctive therapy for wearing off symptoms Wearing off phenomena- patients who take levodopa for several years may experience a wearing off. May need either a levodopa combo CR like Sinemet CR or require a drug holiday to restore effectiveness.
- Depression medications including Follow APA guidelines found on their website. First line treatments are SSRIs, SNRIs, NDRIs (bupriopion) Second line treatments: SNRIs, NDRIs, TCAs Third line treatments: SARIs, MAOIs SSRIs o FLU like symptoms for abrupt w/d. o Sexual dysfunction 50% o Increased effects c certain populations like geriatric and drugs o Increased risk of SUICIDE, especially in teens b/c depression is not fully treated but now they have the energy to carry out plan o Serotinin Syndrome: can be fatal, aggravated/caused by other drugs that increase serotonin such as meperidine, tramadol, st johns wort, dextromethorphan, and other decongestants, linezolid, MAOIs, lithium. Diarrhea, diaphoresis, tachycardia, HTN, dilated pupils, loss of muscle control/twitching, muscle rigidity, HA, shivering, mental status changes. SEVERE/Fatal: High-fever, irregular rhythm, and AMS. FEVER sky high o Fluoxetine (Prozac) 10-80 mg/day only SSRI that doesn’t have w/d s/s due to long half-life. Approved for children age 7 and older for MDD OCD Most drug interactions among class Highest sex dysfunction o Fluvoxamine (2 week flu - long 1/2 life)
SSRIs category C, avoid Paxil Nortriptyline and Imipramine category D Severe depression during pregnancy use fluoxetine and sertraline SNRI Pristiq (desvenlfaxine-Postpartum)
- Side effects of antipsychotics What is the side effect of antipsychotics that can lead to abnormal rhythmic movements? How should this be managed? Extrapymridial Symptoms (EPS): EPS are among the troublesome s/e associated c antipsychotics and increase risk of noncompliance. Include pseudoparkinsonian s/s (shuffling, pill-rolling, cog-wheeling, tremors, drooling, rigidity), akathisia (restlessness), dystonia (involuntary painful movements), and tardive dyskinesia (involuntary buccolingual movements, difficulty speaking, and swallowing- may not be reversible. Managed/Tx with antiparkinson, antihistamine, and anticholinergic drugs (IE Benadryl & reglan/Pepcid) Other Side Effects: Neuroleptic malignant syndrome (NMS), characterized by fever up to 107 degrees, tachycardia, diaphoresis, rigidity, stupor, or coma, and acute renal failure. Serentil (Mesoridazine Besylate): Typical (old-school) antipsychotic Black box warning: Reserve and use only in schizophrenics who fail other reasonable treatments. Causes Prolonged QT c interval and risk for Torsades, VT, and Sudden Death. Clozaril (Clozapine) Atypical antipychotic approved for tx of schizophrenia Black Box Warnings: o Monitor weekly CBC with differential per manufacturer. The manufacturer maintains a confidential register (800-448-5938); patients must be enrolled and have a baseline white blood cell (WBC) count and absolute neutrophil (ANC) count before initiation of therapy. Treatment should not be initiated if the baseline WBC is <3500/mm3 or ANC is <2000/mm3. Issue of weekly supplies of the drug is dependent on the results of the weekly white blood cell count; the results are sent to the national registry via forms supplied by the manufacturer. If after 6 months of weekly monitoring, the WBC has continuously remained ≥3500/mm3 and the ANC has remained ≥2000/mm3, the monitoring of blood counts through the registry may be reduced to every 2 weeks for 6 months. If acceptable WBC and ANC counts (WBC ≥3500/mm3 and ANC ≥2000/mm3) have been maintained during the second 6 months of continuous therapy, WBC and ANC may then be monitored every 4 weeks starting at the end of the 12 months and thereafter.
o Seizures (dose related and pt who are prone to seizures) o Myocarditis (associated c fatal myocarditis, highest risk 1st^ month) o Other adverse CardioRespiratory Effects Orthostatic hypotension w/ or w/o syncope that has led to cardiac arrest, may occur c rapid dose titrated. Increased mortality in elderly patients with dementia type psychosis. Use when failure to other schizo drugs have not worked. Side effects of carbamazepine (Tegretol) and lab monitoring Metabolized in liver & is autoinductive (creates its own metabolism) May be nontherapeutic due to its own metabolism, even c good compliance Induces metabolism of many CYP450 enzymes Blackbox warning Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) in Chinese pts. Should be screened for HLA-B*1502 prior to beginning Tegretol Potential to cause blood dyscrasias, some potentially lethal. Can lead to Decreased WBC, can depress bone marrow and lead to leukopenia, thrombocytopenia, agranulocytosis, and aplastic anemia. Other side effects: Hepatic injury impaired thyroid function, Drowsiness, dizziness, blurred vision, ataxia, nausea, vomiting, dry mouth, diplopia, and HA., abd pain, somnolence, fatigue, tremor, dyspepsia, hyponatremia, anticholinergic (mild but caution for intraocular pressure), aplastic anemia, Rash, Stevens- Johnson, confusion, hypersensitivity/photosensitivity, leukopenia Grapefruit interaction due to CPY Decreases effect of Beta blockers, succinimides, valproic acid, warfarin, haloperidol, doxycycline, and muscle relaxants. Baseline labs should include baseline & periodic LFTs (d/c c hepatic injury) CBC/UA - baseline then Q3MO x 1 yr (d/c x wbc <2500) TSH Chem 14 (includes liver function tests) Know first line treatment for generalized seizure management (eg Dilantin) not adjunct therapies The hydantoins: phenytoin (Dilantin), Ethotoin (Peganone), and fosphenytoin (Cerebryx) are THE first line txs drugs for seizures (partial complex and tonic- clonic). They are the least sedating drugs used to treat seizures, too. Phenytoin is the most commonly used. Avoid use in pts c hepatic or renal disease; Ethotoin is contraindicated for renal and hepatic disease or hematologic disorders.
- Evaluation of incontinence – initial steps A focused history with a careful physical examination is essential for determining the cause of incontinence. Transient or reversible causes should be ruled out. A bladder diary is a helpful diagnostic tool that reveals toileting habits, fluid intake, and leakage episodes. Urinalysis and postvoid residual are essential laboratory tests. Further evaluation by specialists may involve urodynamic and imaging tests.
- Meds for erectile dysfunction know which have a quick onset of action. – which has quickest onset: tadalafil (Cialis), sildenafil (Viagra), avanafil (Stendra) or vardenafil (Levitra)? Tadalafil (Cialis): Tadalafil may assist men with ED to have an erection in response to sexual stimulation for up to 36 hours after a single dose. Can also work quickly. Sildenafil (Viagra): Initial dose 50 mg Take 1 dose as needed 1–4 hours before sexual activity, up to once daily. Avanafil (Stendra): works in about 15 minutes: The quickest. Or the “First Man Standing” Vardenafil (Levitra): Initial dose 10 mg Take 1 dose as needed 1–4 hours before sexual activity, up to once daily. ***should be taken on an empty stomach, as high-fat meals or alcohol will delay absorption. Tadalafil absorption is not affected by food or alcohol. Sildenafil has the longest safety record of the three
- Why should we avoid use of chronic nitrofurantoin in older adults? (See Geriatric lecture) Peripheral neuropathy, pulmonary and hepatic toxicity (Beer’s Criteria); avoid long-term use; avoid in CrCl<60. Endocrine:
- Know the treatment and labs for Hyperthyroid and Hypothyroid (know normal TSH and T4 labs as well as pattern seen with hypo vs hyperthyroidism) Hypothyroidism : TSH increased in primary; Total T4 is decreased (secondary low; low) Levothyroxine (Synthroid®, Levoxyl®, Levo-T®); Desiccated thyroid (Armour thyroid®, thyroid) is obtained from hog, sheep, or beef sources. It is a mixture of both T 3 and T 4 hormone; L-thyronine (Cytomel®) is pure T 3 ; Liotrix (Thyrolar®) is mixture of T 4 : T 3 in a ratio of 4:1 (the ratio of naturally produced thyroid hormone). S/S: Cold intolerance, weight gain despite decreased appetite, hoarseness and lowering of the voice pitch, decreased sweating, decreased sweating easy fatigability, dry brittle and sparse hair, thinning of the lateral aspects of the eyebrows, puffy faces, large tongue, edematous eyelids, goiter in primary hypothyroidism, cardiac enlargement, poor heart sounds, precordial pain, low output failure, dyspnea, constipation, further exposure to allergen makes it worse, menorrhagia, dysmenorrhea, broad hands and feet, pretibial myxedema, cold and dry skin, brittle yellowish nails, muscle pain and weakness, paresthesia, delayed deep tendon reflexes, emotional instability, depression, lethargy, decreased energy, increased sleep requirements, mental sluggishness. Hyperthyroidism : Total T4 increased; TSH: normal (0.4-4.8) or LOW Medications: Propylthiouricil (PTU) and methimazole (Tapazole). Secondary: Iodides, lithium, beta blockers: The calcium channel blockers (diltiazem or verapamil) can be used as an alternative for those who have contraindications to the beta-blockers. Radioactive iodine treatment represents the most cost-effective choice for the treatment of hyperthyroidism, but it almost always causes permanent hypothyroidism in the months to years that follow. Pregnancy and breastfeeding should be avoided for 6 to 12 months following the therapy. Surgery represents the third treatment option for patients with hyperthyroidism. It provides rapid and permanent treatment, but like RAI treatment, it is often associated with hypothyroidism. S/S Heat intolerance, weight loss despite increased appetite, increased sweating, thinning of hair, fine texture, prominence of the eyes, lid lag, lid retraction, can proceed to visual acuity loss, soft diffusely enlarged goiter w/ or w/o bruit, palpitations, increased HR,
generation sulfynlureas (Glipizide), nonsulfonylurea secretagogues (nateglinide /Starlix), alpha-Glucosidase inhibitors (acarbose /Precose)
- Vitamin deficiency associated w Metformin: Vitamin B
- Side effects of Metformin: GI upset, nvd, chills, wt loss, dyspnea, lactic acidosis, metallic taste
- Acarbose MOA & side effects: MOA- must be taken with food.....inhibits pancreatic a-amylase and membrane bound intestinal a-glucoside hydrolysis enzymes.... prevent the breakdown of complex starches to glucose. Side effects: flatulence, diarrhea, abdominal pain warning-carcinogenic x renal tumors; contraindicated- dka, cirrhosis, IBS, intestinal obstructions
- MOA and side effects of canaglifozin Sodium-glucose transport inhibitor type 2 (sglt-2) inhibits renal glucose reabsorbtion From our discussion board gluscouria = Canaglifozin is working Side effects: side effects- increased risk of foot amputations, uti's, diuresis, hypotension, increased ldl, adverse cardiac events, dka, reduced bone density **ENT:
- Know the treatment for Otitis Media and Otitis Externa** Otitis Media: Top 3 causes: S. pneumonia, Nontypable H. Influenza, M. Catarrhalis (same for acute sinusitis) Less frequent strep A Viral causes: RSV, Adenovirus, influenza PCN resistant S. Pneumoniae is increasing Tympanic membrane red or yellow, swollen, and fluid-filled
Moderate to severe bulging Ear pain Drainage/blood Presence of fluid First-line TX Analgesics: NSAIDS, APAP, topical benzocaine drops Amoxicillin 80-90mg/kg/day divided BID 5-10 days o High dose amoxicillin is needed to cover S. pneumoniae o Probiotics and yogurt may help to decrease diarrhea/C-diff overgrowth Alternatives: Augmentin (first choice if recent amox use), cefuroxime, cefdinir, cefpodoxime, ceftriaxone IM. If PCN allergy-TMP/SMX (but S. pneumoniae resistance); azithromycin 30mg/kg/one dose; clindamycin. If no improvement in 2-3 days, suggest resistance to antibacterial therapy change to Amox/Clav, Ceftriaxone IM x 3 days, clindamycin and consider referral to specialist for tubes. Complications include: hearing loss, Chronic effusion, Mastoiditis, meningitis> intracranial extension, cholesteatoma suspect if recurrent foul- smelling otorrhea Infection with current tubes in places Treat c quinolone otic drops. Otitis Externa Tx Cipro drops (fluoroquinolone) c a Corticosteroid Analgesics
2. Preferred medication for impetigo (honey,crusted skin lesions)? What are the recommended therapies if the impetigo is in a limited area vs more extensive? Keflex or dicloxacillin is the first choice. Clindaymycin, Bactrim, and doxycycline if MRSA is suspected If PCN allergy use: erythromycin (macrolide) or azithrymycin or clindamycin Mupirocin (Bactroban) may also be applied topically for mild lesions, not systemic.
Infants and children, including adolescents, need supplementation with 400 IU of vitamin D daily. Women of childbearing age who may become pregnant need 400 mcg/day of folic acid. Pregnant women need 600 mcg/day of folic acid, a multivitamin/mineral supplement, 27 mg/day of iron (60 mg/d if patient is anemic), and vitamin B12 if the patient is vegan or lacto-ovo-vegetarian. Older adults over age 50 need vitamin B12 2.4 mcg/day and need to ensure adequate intake of vitamin D and calcium. Patients at risk for suboptimal vitamin D levels (older patients, patients with dark skin, patients who are not exposed to sufficient sunlight) should consume vitamin D–fortified foods and/or supplements. Vitamin B6 deficiency may be drug-induced by use of isoniazid (INH), cycloserine, or hydrazine, or caused by a diet that is deficient in vitamin B6–containing foods (fortified cereals, potatoes, bananas, meat). Pyridoxine (vitamin B6) 25 mg/day should be added to the regimen for pregnant patients to decrease the incidence of peripheral neuropathy associated with INH (American Thoracic Society, 2003). Vitamin B2, also known as riboflavin, is a water-soluble vitamin. Riboflavin deficiency is rare but may be seen in alcoholics, anorexic patients, and those with lactose intolerance who cannot drink milk or consume other dairy products. Omega 3-1 gm to treat autism and ADHD. Maintaining calcium balance involves a complex relationship between adequate intake of calcium and vitamin D and endocrine system function. Populations at risk for calcium deficiency include postmenopausal women, amenorrheic women, women with female athlete triad, patients with lactose intolerance who cannot tolerate dairy products, and vegans. Folate deficiency occurs in times of increased demand, such as occurs in pregnancy and lactation, or when loss increases (malabsorption, alcohol abuse, dialysis, liver disease).
- What vitamin deficiency is common with chronic alcohol abuse? B2 riboflavin, folic acid, B1 thiamine
- What iron deficiency is associated with overconsumption of milk in toddlers? What is the screening test that should be ordered? Iron deficient-anemia; test c ferritin level
- What side effect can occur with salt substitutes? hyperkalemia
- Vitamins a vegetarian may require b12, protein, iron, calcium, vitamin D, vitamin B12, and omega-3 fatty acids
- How to prevent osteoporosis Calcium, Vit D, sunlight, wt bearing exercise; walking
- Cimetidine (Tagament) has many adverse effects and C/I (theophylline, phenytoin, warfarin) Smoking cessation:
- How to taper nicotine nasal spray useful for patients with severe cravings and wants immediate relief. Fastest nicotine delivery, most closely resembles nicotine effects of smoking. highest potential for prolonging addiction. use 1-2 doses per waking hour for 3-6 months, consider taper period by halving number of doses per week. pg785. Also 1-2 0.5 mg sprays each nostril/hour. Do not exceed 5 sprays/ hour or 40/sprays day. gradually reduce rate over 6-8 weeks ID:
- Tx of Rocky Mountain Spotted Fever? What to do if patient fails oral therapy? doxycycline 100 mg po bid × 7 days chloramphenicol 50 mg/kg/day IV q6h × 7 days
- Know the indications for the use of Vancomycin and MOA serious or life-threatening staph or strep. The primary care use x pseudomembranous colitis caused by C. difficile. It is given in oral form when treatment with metronidazole is contraindicated or ineffective. Prevents synthesis of the bacterial cell wall by blocking peptidoglycan strand formation.
- Know the mechanism of action of Cephalosporins causes bacterial cell death by binding to the bacterial cell wall membrane & attaches to the gut well.
- What class is erythromycin? macrolide Analgesia:
- Know the side effects of Acetaminophen nausea, stomach pain, loss of appetite, itching, rash, headache, dark urine, clay-colored stools, or jaundice (yellowing of skin or eyes).
- Know the signs of Acetaminophen toxicity First 24 hours: n/v, diaphoresis, pallor and anorexia. 24 to 72 hours: clinically improved, AST, ALT, bilirubin, and prothrombin begin to rise. 72 to 96 hours: Peak hepatoxicity, jaundice, confusion, AST of 10,000 not unusual. 4 to 14 days: Death or recovery. Pts who survive (rare) enter recovery phase. Tx is Oral N-acetylcysteine Acute hepatic necrosis occurs in doses of 10-15grams Doses above 25 grams are usually fatal
- NSAID side effects; use of topical NSAIDs
