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A 24-year old, otherwise healthy college student presents with c/o cough x 6 weeks. She has tried several OTC cough meds with no improvement. What is the most important information to consider when building your differential diagnoses? Her age Family hex Ineffectiveness of OTC cough medicines Length of time she has been coughing - Correct Answers D) Length of time she has been coughing Why? This information helps you build your dad Acute cough < 3 weeks: bronchitis, sinusitis, PND, exacerbation of COPD/asthma, pneumonia, pulmonary embolism Chronic cough (>8 weeks) GERD and Asthma are most common causes, also consider infection (e.g. pertussis, atypical pneumonia), ACE inhibitors, chronic bronchitis, bronchiectasis, lung ca) According to the CDC, what drug class is considered first-line treatment for pertussis? Sulfonamide Tetracycline Macrolide Beta-lactam - Correct Answers C) Macrolide antibiotic (e.g. Azithromycin, clarithromycin Sulfonamides are second-line
Match the antibiotics with the correct drug class: Sulfonamide Tetracycline Macrolide Beta-lactam Doxycycline Azithromycin Penicillin’s Trimethoprim-Sulfamethoxazole Cephalosporin Clarithromycin - Correct Answers 1. Sulfonamide - Trimethoprim-Sulfamethoxazole (Bactrim)
- Tetracycline - A. Doxycycline
- Macrolide - B & F, Azithromycin and Clarithromycin Beta-lactam - C & E, PCN and cephalosporin’s What are the three most common bugs in community-acquired pneumonia? - Correct Answers Streptococcus pneumonia Mycoplasma pneumonia (atypical pathogen) Chlamydophila pneumonia (atypical pathogen) What is the treatment for CAP caused by Strep pneumonia? - Correct Answers Respiratory quinolone (e.g. Levofloxacin, moxifloxacin, gemifloxacin) OR high-dose amoxicillin OR amoxicillin with clavulanate What antibiotics are avoided in CAP caused by Strep pneumo due to high rates of resistance? - Correct Answers Macrolides
GERD
Pneumonia Tuberculosis Heart Failure - Correct Answers B) Angina C) COPD F) Tuberculosis G) Heart failure How do inhaled anticholinergics work to treat shortness of breath in COPD? They cause bronchodilation in the lungs They block the action of acetylcholine and prevent bronchoconstriction - Correct Answers B) They block the action of acetylcholine and prevent bronchconstriction Name a short-acting inhaled anticholinergic: - Correct Answers Ipratropium (Atrovent) Name a long-acting inhaled anticholinergic: - Correct Answers Tiotropium (Spiriva) How do inhaled betá-agonists work to treat shortness of breath in COPD? They cause bronchodilation in the lungs They block the action of acetylcholine and prevent bronchoconstriction - Correct Answers A) They cause bronchodilation in the lungs What are the only 2 inhaled short-acting beta agonists (SABAs): - Correct Answers Albuterol and levalbuterol Name an inhaled long-acting beta agonists (LABAs): - Correct Answers Salmeterol (Serevent)
What are the side effects associated with anticholinergic medications? - Correct Answers Cognitive impairment, confusion, hallucinations, dry mouth, blurry vision, urinary retention, constipation, tachycardia, acute angle glaucoma "Can't see, can't pee, can't spit, can't shit." Name a inhaled combined short-acting anticholinergic/short-acting beta agonist: - Correct Answers Ipratropium/albuterol (Combivent) Name a inhaled combined long-acting beta-agonist/corticosteroid - Correct Answers Fluticasone/salmeterol (Advair) Fluticasone/vilanterol (Breo) Budesonide/formoterol (Symbicort) Mometasone/frmoterol (Dulera) Name an inhaled steroid: - Correct Answers Fluticasone (Flovent) Budesonide (Pulmicort) Mometasone (Asmanex) Put the following in the correct order for COPD prescribing strategy: Long-acting anticholinergic or LABA, plus rescue med Inhaled corticosteroid +LABA or LA anticholinergic, plus rescue med Short-acting anticholinergic or SABA PRN Inhaled corticosteroid +LABA and/or LA anticholinergic, plus rescue med - Correct Answers C, A, B, D Short-acting anticholinergic or SABA PRN THEN Long-acting anticholinergic or LABA, plus rescue med THEN
Severe persistent asthma - Correct Answers B) Mild persistent asthma A patient with asthma symptoms less than twice a week has Intermittent asthma Mild persistent asthma Moderate persistent asthma Severe persistent asthma - Correct Answers A) Intermittent asthma A patient with asthma symptoms multiple times throughout the day and nighttime awakenings on most nights of the week has Intermittent asthma Mild persistent asthma Moderate persistent asthma Severe persistent asthma - Correct Answers D) Severe persistent asthma What are the most common side effects of long-term inhaled steroid use? Osteoporosis and GERD Cataracts and osteopenia Hyperkalemia and diabetes Hypertension and diabetes - Correct Answers B) Cataracts and osteopenia What medication combination is considered unsafe in a patient with asthma? Fluticasone and albuterol
Mometasone, formoterol, albuterol Budesonide and levalbuterol Salmeterol and levalbuterol Why? - Correct Answers D) Salmeterol and levalbuterol Salmeterol is a long-acting beta agonist. LABAs MUST be combined with an inhaled corticosteroid (e.g. Advair, Breo, Symbicort) A 30-year old male has persistent asthma. What daily medication regimen would be appropriate? Albuterol Low-dose fluticasone, albuterol Medium-dose fluticasone Budseonide, salmeterol, albuterol - Correct Answers C) Medium-dose fluticasone Albuterol alone is used for intermittent asthma Albuterol should not be used daily (if the patient is using their rescue inhaler more than twice a week --> call the PCM!) Mr. Jones, a 45-year old drug and alcohol counselor, smokes 1 PPD and c/o cough, low-grade fever, and night sweats for the last week. His CXR show bilateral hilar nodes. What should you do next? Refer to Pulmonology Order a chest CT with contrast Order a TB skin test Repeat the CXR in 2 weeks - Correct Answers C) Order a TB skin test
If a 19-year old college female diagnosed with community acquired pneumonia was pregnant in her first trimester, how could she be managed? Levofloxacin 750 mg PO daily x 5 days Azithromycin 500 mg on day 1, then 250 mg daily on days 2-5, plus amoxicillin 1000 mg BID Cephalexin 500 mg PO BID x 5 days Doxycyline 100 mg PO BID x 5 days - Correct Answers B) Azithromycin 500 mg on day 1, then 250 mg daily on days 2-5, plus amoxicillin 1000 mg BID Quinolones (e.g. levofloxacin) and tetracyclines (e.g. doxycycline) are teratogenic and should not be given during pregnancy A 63-year old patient w/ COPD c/o a pounding heart after using his inhaler. Which of the following is the least likely culprit? Fluticasone Albuterol Iptratropium Salmeterol - Correct Answers A) Fluticasone Mr. Smith, an 80-year old smoker, has stage II COPD. Based on his medications, what is the most predictable drug-disease interaction? Losartan 50 mg, HCTZ 12.5 mg, Amlodipine 5 mg daily, Tamsulosin (Flomax) 0.8 mg daily, Atorvastatin (Lipitor) 10 mg daily, Albuterol inhaler 2 puffs PRN for SOB, tiotropium (Spiriva) once daily Glaucoma Frequent urination
Anxiety Pruritis Hyperglycemia Fatigue Constipation - Correct Answers G) Constipation Amlodipine (CCB) and tiotropium (short-acting anti-cholinergic) An obese 55-year old woman with a history of moderate persistent asthma has a temperature of 101F, bilateral wheezes, mild shortness of breath, and purulent sputum. Her med list includes: fluticasone/salmeterol BID, albuterol PRN, amlodipine 5 mg, levothyroxine 99 mcg daily, and metformin 1000 mg BID. How should she be managed today? Treat with azithromycin daily for 5 days Treat with ciprofloxacin, nebulized albuterol q4-6 hours PRN for wheezing Treat with oral steroid and nebulized levalbuterol q8 hours PRN Treat with levofloxacin, nebulized albuterol q4-6 PRN for wheezing - Correct Answers D) Treat with levofloxacin, nebulized albuterol q4-6 PRN for wheezing She is more likely to have Strep pneumoniae and should be treated with a quinolone. Ciprofloxacin is not a respiratory quinolone An obese 55-year old woman with a history of moderate persistent asthma has a temperature of 101F, bilateral wheezes, mild shortness of breath, and purulent sputum. Her med list includes: fluticasone/salmeterol BID, albuterol PRN, amlodipine 5 mg, levothyroxine 99 mcg daily, and metformin 1000 mg BID. She is being treated for pneumonia with levofloxacin and nebulized albuterol q4- 6 PRN for wheezing.
-bone marrow disorders (e.g. aplastic anemia)-bone marrow suppression (e.g. chemo) -low levels of erythropoietin (e.g. chronic renal failure) -anemia of inflammation (e.g. malignancy, anemia of chronic disease)
- Increased RBC destruction -inherited disorders (e.g. thalassemia, sickle cell anemia) -malaria -hemolytic anemia (e.g. G6PD deficiency) How do the following conditions affect Hgb/Hct? (e.g. Increase, Decrease, Neutral) COPD: CKD: HTN: DM w/ AIC 14: Aspirin use: Testosterone use: Resident of Denver, CO: Age > 80: - Correct Answers COPD: Increase (tissues are chronically deprived of oxygen) CKD: Decrease HTN: Neutral DM w/ AIC 14: Decrease (poorly controlled disease, strains RBCs and causes them to die early) Aspirin use: Neutral Testosterone use: Increase Resident of Denver, CO: Increase (r/t high altitude) Age > 80: Decreased (bone marrow is not as robust...RBC production is decreased, but DO NOT assume that anemia in an older patient is due to aging!)
Which of the RBC indices tells you about RBC size? What level is normal? What level indicates microcytic (small) RBCs? What level indicates macrocytic (large) RBCs? - Correct Answers Mean Corpuscular Volume (MCV) = Hct/RBC Normal = 80- Microcytic < Macrocytic > Which of the RBC indices tells you about the RBC color? What does a low level tell you about the RBC color? - Correct Answers Mean corpuscular hemoglobin (MCH) Low MCH = hypochromic (pale) RBC Match the lab with the definition Serum iron Serum ferritin Reticulocyte count Peripheral smear A visual description of red blood cells Measure of iron in circulation Indicative of the bone marrow's ability to produce RBCs Measure of iron in storage - Correct Answers 1. Serum Iron - B. Measure of iron in circulation
- Serum ferritin - D. Measure of iron in storage
- Reticulocyte Count - C. Indicative of the bone marrow's ability to produce RBCs Peripheral Smear - A. A visual description of red blood cells When the iron count is HIGH, the TIBC (total iron binding capacity) is _________ - Correct Answers Low
supplementation for another 3-5 months (to replace iron stores) In addition to acanthosis nigricans, which of the following is a risk factor for insulin resistance? Delivery of infant > 9 lbs Severe obesity Age > 65 Sleep Apnea - Correct Answers B) Severe obesity The ADA recommends annual screening for diabetes for patients with a BMI greater than _______ and one ore more risk factors. - Correct Answers 25 The ADA recommends screening for the entire population over the age of _____________ every ____ years if the screening is normal. - Correct Answers 45; 3 Mr.Smith is a 75-year old man with an Ā1C of 8.9%. Which of the following should be the provider's first action? Start metformin Discuss exercise, weight loss Establish an Ā1C goal of < 7% Establish a target Ā1C goal - Correct Answers D) Establish a target Ā1C goal Match the Suggested Ā1C goals for T2DM Patient with T1DM Most pregnant patients Older patients Most adults with T2DM
Ā1C < 7%
Ā1C < 6%
Ā1C < 8%
Ā1C < 6% - Correct Answers A - 2) Patients with T1DM = goal < 6% B - 4) Most pregnant patients = goal <6 % C - 3) Older patients = goal < 8% D - 1) Most adults with T2DM = goal < 7& Mr. Johnson is a 72-year old newly diagnosed Type 2 diabetic. Which of the choices below must be considered prior to starting Metformin in this patient? Select 4. CBC eGFR LFTs Presence of heart failure Presence of binge drinking Use of CCBs Presence of BPH - Correct Answers B) eGFR C) LFTs D) Presence of heart failure E) Presence of binge drinking Mr. Johnson is a 72-year old newly diagnosed Type 2 diabetic. Which of the following characteristics increase the likelihood of lactic acidosis? Select 4. Concurrent use of contrast dye eGFR > 45 Dehydration Presence of heart failure Presence of binge drinking Use of CCBs
35-year old female with newly diagnosed impaired fasting glucose and Ā1C of 5.9% What medication is first-line? What if she is contemplating pregnancy? - Correct Answers 1) Metformin Metformin is OK in pregnancy A 48-year old postmenopausal woman with T2DM diagnosed 6 weeks ago c/o persistent diarrhea with Metformin. Her Ā1C is 9.2% (goal < 7%) What is the primary prescribing strategy? What medication should you avoid in this patient? - Correct Answers 1) Dual therapy (Ā1C > 9%) TZDs (Actos, Avandia) increase the risk of fracture, avoid in postmenopausal women A 77-year old female with newly diagnosed T2DM and Ā1C of 9.5%. What is her Ā1C goal? What occurrence should be avoided if at all possible? What age-related prescribing strategy would you consider in this patient with an Ā1C of 9.5%? - Correct Answers 1) < 8%
- Hypoglycemia
- Monotherapy (older adult patient) A 62-year old male is taking Metformin and has an Ā1C of 7.9% and is on a fixed budget. His Ā1C goal is < 7%. What med class would be your first choice? - Correct Answers 1) Sulfonylurea - lowers Ā1C by 1-2% 27-year old male with lupus has a eGFR of 48 and Ā1C of 7.2%, newly diagnosed with T2DM.
What medication is first choice in this patient? - Correct Answers 1) Metformin (can be given as long as the GFT is > 45, monitor closely) 35-year old obese male with hx of T2DM is on the max dose of Metformin. His Ā1C is 7.6 (goal < 7%). He desires weight loss and is needle-phobic. What medication class should be considered Which med class(es) should be avoided? - Correct Answers 1) SGLT-2 inhibitor (canagliflozin - Invokana, empagliflozin - Jardiance) 2)Sulfonylureas (a/w weight gain) GLP-1, insulin (injectables) 82-year old male with T2DM is currently on max dose of Metformin. His Ā1C is 7.9%. What is your plan at this visit for his Ā1C? - Correct Answers 1) A reasonable Ā1C goal for his age is <8%. Review lifestyle modifications and decrease carb intake A 60-year old mane with T2DM takes Metformin and Glipizide. His Ā1C is 10.2 (goal < 7%). The NP decides to start basal insulin. What should be done with Metformin and glipizide? How much insulin would you start this patient on? - Correct Answers 1) Continue Metformin. STOP glipizide. Start at 0.1-0.2 units/kg/day or 10 units A 50-year old self-employed man drives a bread truck and takes max dose Metformin. He cannot tolerate hypoglycemia. His current Ā1C is 8.0 (goal < 7%). He has limited funds but has an affordable generic co-pay.
