NR601 / NR 601 Midterm Review Week 1, 2, 3, 4 (New, 2022/2023): Chamberlain College, Study Guides, Projects, Research of Nursing

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NR I 601 IMidterm IReview IWeeks I 1 - 4 INotes: CGA

• Purpose: IPhysical Ihealth Iis Ir/t Ipsychosocial Ifunctional Iability Iand Isafe Ienvironment. o helps Iin Idx Iconditions Iand Iimprove Ioutcomes o identifyIpotential Ipreventable Iconditions o patient-centered Icare
• Most Ibeneficial Ifor Ithe Ivulnerable, Iolder Iadults Ibut Ishould Ibe Icompleted Ifor Iall Iolder Iadults.
• Domains: IPhysical Ihealth, Ifunctional Ihealth, Ipsychological Ihealth, Isocioenvironmental Isupport I& Iquality Iof Ilife Imeasures. o Physical Ihealth ▪ Medical Ihistory, IPE I(abnormals-differentials), IROS, Idiagnostics, ▪ Nutritional Iassessment- - Assessment Itool: Imini Inutritional Iassessment Iinstrument - Food Idiary - Phys Iassessment Iwith Imeasurements - Biochemical Imarkers ▪ Medication Ireview I(Beers Icriteria) ▪ Functional Ihealth- Igoal Iis Ito Iimprove Ifunction Iand Iprevent Idecline ▪ ADLs- IKatz IADLs Iscale ▪ IADLs- ILawton I& IBrody IScale Ifor IIADLs ▪ Ask Ipatients Ito Idemonstrate Ior Iexplain Ihow Ithey Icomplete Iadls ▪ Psychological Ihealth I(cognition Iand Imood) ▪ DSM- 5 I(delirium Ivs Icognitive Iimpairment) ▪ MMSE ▪ CDT, Iword Irecall ▪ Mini-Cog ▪ SLUMS ▪ Confusion IAssessment IMethod I(CAM) ▪ Geriatric IDepression IScale- IPHQ- 9 ▪ HOPE, IFICA, ISPIRIT ▪ Socioenvironmental ▪ Social Inetwork/support ▪ Social Iisolation Iassessment I(lubben Isocial Inetwork Iscale) ▪ Living Isituation I(housing, Itransportation ▪ Environmental I( Iutilities, Iheat, Iwater) ▪ Economic I(income, Iassets, Iafford Imeds Iand Ihealthcare) ▪ Quality Iof Ilife Imedical Ioutcomes Istudy ▪ Physical/social Iconditions ▪ Personal Iresources ▪ Preference Iof Icare I(advance Idirective) Age Irelated Ichanges: IPhysiological ▪ Skin- ▪ decrease Idermal Ithickness/elasticity I= ISBD Irisk

▪ Decrease Ivascularity= Iless Isweat, Iodor, Iheat Iloss= Ialtered Itemp Iregulation, Irisk Iof Iheat Istroke, Ichange Iin Ifluid Ineeds ▪ Resp: decreased Ivital Icapacity I= Idecreased Igas Iexchange Iprocesses ▪ Cilia Iatrophy=increase Iinfection Irisk ▪ Decreased Iresp Imuscle Istrength=risk Ifor Iatelectasis o CVD: o GI: ▪ fibrosis Ito Iheart Ivalves= Ireduced ISV, ICO= Idecreased Istress Iresponses ▪ Fibroclastic ISA Inode Ithickens= Islower IHR=increased Iarrhythmias ▪ Decreased Ibaroreceptors Isensitivity=decreased Isense Ito Ibp Ichanges I= Imore Ifalls, Iinjuries o liver Ismaller=decreased Istorage ▪ Decreased Imuscle Itone=altered Imotility ▪ Decreased Imetabolism=need Ifor Iless Icalories Lab Iresults: Inormal Ilevels Ivary Iwith Iage, Isex, Irace I (don’t Iassume Iabn Ilab Iresult Iis Ipart Iof Iaging Iprocesses) o Decreased ICrCl, IGFR: Inephrotoxic Idrugs ▪ Digoxin ▪ H2 Iblockers ▪ Lithium ▪ Water-soluble Iatb- Iceftriaxone, Ipiperacillin, Igentamycin, Ivanco ▪ Review Ipage I 1285 Itable(Dunphy) Atypical IPresentations Acute Iabd Iillness Vague Isx, Iacute Iconfusion, Iconstipation, mild Idiscomfort, Itachypnea, Depression Anorexia, Ivague Iabd Icramps, Inew Iconstipation, Iagitation, Iinsomnia, Ilack Iof sadness Hyperthyroidism Apathetic Ithyrotoxicosis- Ifatigue, Iweak, Iwt Iloss I(not Igain), Ipalpitations, tachycardia, Inew Iafib Ionset, I HF Iif Iundx Hypothyroidism Confusion, Iagitation, Icardiac Imanifestations, Inew Ianorexia, Iwt Iloss, arthralgia Malignancy New/worse Iback Ipain I 2 nd^ Ito Imets Iform Islow Igrowing Ibreast Imasses Ior Isilent Ibowel Imasses Jaundice-GB Idisease MI No Ichest Ipain, Ifatigue, Inausea, Idecreased Ifunction Iand Icognition, Iclassic: Idyspnea, Iepigastric Ipain, Iweakness, Inv, Ihx Iof Icardiac Ifailure Higher Iin Ifemales: Inon-Q-wave IMI Infectious Idisease Low Igrade Ifever Ior Inone, Imalaise, Isepsis: Iw/o Ileukocytosis Ior Ifever Falls, Inew Iconfusion, Ior IAMS

Decreased Ifunction, Ianorexia Peptic Iulcer Dyspepsia, Iearly Isatiety IPainless, Ibloodless Istool INew Iconfusion Tachycardia, Ihypotension Pna Mild Icough Iwithout Icopious Isputum, Ino Ifever Ior Imild, Iconfusion Tachycardia, Itachypnea, Ianorexia, malaise Pulmonary Iedema Lack Iof Iparoxysmal Inocturnal Idyspnea, IInsidious Ionset Iof Idecreased Ifunction, appetite, Ifluids, Iconfusion TB Hepatosplenamegaly, Iabn Iliver Itests, anemia UTI No Ior Imild Ifever, Iworse Icognition, dizziness, Ianorexia, Ifatigue, Iweakness Geriatric ISyndromes- Imultifactorial: Isx Iseen Iin Ielderly Ithat Iare Ir/t Icombo Iof Idiseases o SPICES I(assessment Itool) o Sleep Idisturbance o Problems Ieating Ior Ifeeding o Incontinence o Confusion o Evidence Iof Ifalls o SBD Categories Iof IAging o 65 - 74 = Iyoung Iold o I 75 - 84 = Iold o 85 - older = Ioldest Causes Iof Idelirium o Drugs o Electrolyte Iimbalance o Lack Iof Idrugs I(w/d, Iuncontrolled Ipain) o Infection o Reduced Isensory Iinput I(vision/hearing) o Intracranial I(CVA, ISDH) o Urine Iretention, Iimpaction o Myocardial/pulmonary Iconditions Exercise Iin IOlder IAdults- Irecommended Imoderate- Iintensity Iaerobics I30min Ix5 Idays Ia Iweek, Ior Ivigorous Iintensity Iaerobic I 20 Imin Ix I 3 Idays Ia Iweek( Ican Ibe Iintermittent Ithroughout Ithe Iday) o Barriers Ito Iexercise

o Lack Iof Itime o Perceived Ineed Ifor Iequip o Disability Ior Ifunction Ilimitation o Unsafe Ineighborhood/weather Iconditions o Depression/lack Iof Imotivation/sig Ilife Ievent o High IBMI o Don’t Iknow Iwhat Ito Ido ➢ Facilitators o Social Inetworks o Positive Iself Iworth o Motivation Ito Ido Iit o Good Ihealth o Good Icontact Iwith Iprescriber o Reg, Ischeduled Iprograms] o Happy Iwith Iprogram o Insurance Iincentive o Improved Imobility/health ➢ Contraindications o Unstable Iangina o Uncompensated IHF o Severe Ianemia o Uncontrolled IBG o Unstable Iaortic Ianeurysm o Uncontrolled IHTN/tachycardia o Severe Idehydration Ior Iheat Istroke o Low Io2 Isat Exercises Ifor Isleep o Tai-chi, Iwalking, Iaquatherapy, Ibiking I( Iassess Ibalance Iand Ifall Irisk I 1 st) IExercise Ifor Iflexibility: o To Imaintain Iflexabilty, Iperform Iexercises I 10 Imin Ix I 2 Idays Ia Iweek Exercises Ifor Iother Idx: Review Itable Ion Ipage I 21 I(Kennedy) Screenings Ibefore Iexercise: o Cardiac: Istress Itest Ibefore Ibeginning Ivigorous Iexercises o Parkinsons, Iosteoporosis, Idementia: IAssess Ibalance Iand Irisk Ifor Ifalls o DM: Iproper Ishoe Ifit/insulin Ireduction o Fibromyalgia: Imay Ihave Iincreased Ipain Iinitially Beers ICriteria:

• American IGeriatric ISociety
• Purpose: IImprove Imedication Iselection; Iavoid Idangerous Imedications.
• Tailored Ifro I 65 Iyears I& Iolder Iin Iall Isettings Iexcept Ihospice I& Ipalliative Icare.
• Stresses Iimportance Iof Ideprescribing Ito Iavoid Ipolypharmacy I& IADRS
• Look Iat Ithese Ilists Ion Ithe IBeers Icriteria IEx: IDon’t Igive IBenadryl I(antihistamines) Ihttps://agsjournals-onlinelibrary-wiley- Icom.chamberlainuniversity.idm.oclc.org/doi/full/10.1111/jgs. Health IPromotion:
• Vaccines: ITetanus, IDiphtheria, IPneumococcal I& IInfluenza I(Know Ivaccine Ischedules)
• Colorectal IScreening: I 50 - 75 Iyr Iold
• Breast ICancer IScreening: IBiennial Iscreening Ifor Iwomen Iages I 50 - 74
• Smoking ICessation
• Aerobic IExercise I& IStrength ITraining I(Want Ito Ispecialize Ito Ipatient!! IWhat Ikind Iof Iexercises Ifor Iwhat Idisease Iprocesses Ishould Iyour Ipatient Ido?)
• HIV Itesting- I 15 - 65 Iyr Iold Iand Ihigh Irisk
• AAA Iscreening- Imen I 65 - 75 Iwho Ihave Iever Ismoked
• Tobacco Iuse- Irecommend Icessation Ito Iall
• Depression- Iall Iadults, Ipregnant, Ipostpartum
• Abnormal Iglucose Iscreenings- I 40 - 70 Iyr Iolds Iwith Iobesity
• Low Idose Istatin Iuse I 40 - 75 Iyr Iolds Iwith: o Risk Ifactors- IHLD, IHTM, IDM o 10 Iyr ICVD Irisk Ifactor I10% Ior Ihigher
• Low Idose IASA Iuse Iprevention Iof ICVD I 60 - 69 Iyrs- Iindividual Ibasis Idecision
• One Itime Iscreening Ifor IAAA- Imen I 65 - 75 Iw/smoking Ihx
• Obesity- Iall Iadults
• Mammogram- Ievery I 2 Iyrs I 50 - 74 Iyr Iolds
• Osteoporosis Iscreening- Iwomen I 65 Ior Iolder, Iand Iyounger Ipopulations Iw/risk
• Depression: Iall Iadults Iwith Iroutine Iscreenings Iat Ieach Isubsequent Ivisit Irecommended Travel Irisks o Thromboembolic Ievents: Ilong Iflight, Ilow Ihumidity, Ilow Io2, Icramped Iseats o Altitude Iillness: Icardiac Iand Icerebrovascular Ifunctions o High Iheat/humidity: Iincreased Irisk Ifor Idehydration, Iheat Istroke/exhaustion o CNS Ichanges: Iincreased Ianxiety, Ijet Ilag, Ilonger Idelays

o Immune Isystem: Iincreased Irisk Ifor Iinfections o Bladder Idysfunction: Ilong Iwaits Ifor Ibathroom Istops o Vision/hearing Iimpairments: Iincreased Ifall Iand Isafety Irisks Polypharmacy ➢ Definitions: o Many IRXs o 5 Ior Imore IRXs o Prescribing Ipotentially Iinappropriate Imeds I(Beers Icriteria) ➢ Polypharmacy: Iprimary Ipredictor Ifor IADRs o 10% IER Ivisits, I17% Iadmissions ➢ Causes o Multiple Iproviders o Lack Iof Icommunication Ib/w Iproviders o Clinical Iinertia: Ifailure Ito Iadvance Idose Iof Idrug Ito Ireach Itherapeutic Idose Ilevel o Prescribing Iunnecessary Idrugs o Not Ievaluating Itrue Icause Iof ICC I(as Ipossible IADR Ifrom Iother Idrug) Ibefore Iadding Imore IRX Ileads Ito Icascade Iof Iunavoidable Ievents ➢ Screening Itools Ifor Ipolypharmacy: o STOPP/START Itool o BEERS Icriteria- Ilist Iof Ipotentially Iinappropriate Imeds I(PIM) Ithat Ishould Ibe Iavoided Iin Ielderly I(except Ipalliative Ior Ihospice Icare) o Medication IAppropriateness Iindex Icriteria I(MAI)- Iused Iwith IBeers Ito Idetermine Ibenefit Ivs Irisk Ianalysis ➢ Prevention Istrategies o medication Ireview/reconciliations Iat Ivisits o brown Ibag Itechnique Ifor Ielderly o parasimonious Iprescribing o quick IHFU Ito Iassess Iand Ireview Imedications o thorough Ipatient Ieducation- Iexpired Idrugs, Iside Ieffects, Iadverse Ireactions, Iprovide Inew Imed Ilist Iat Ieach Ivisit Iand Iinstruct Ipt Ito Idestroy Iold Ilist o communicate Iwith Iother Iproviders o slowly Ideprescribe Iinclude Ipatient/family Ipreferences Iwhen Idoing Ithis. o Week I 2 COPD o progressive IObstructive Idisease Inot Ifully Ireversible o due Ito Iairflow Ilimitations=hyperreactivity Iof Iairways o involves Iboth Ilung Iparenchyma I(emphysema) Iand Ibronchioles I(chronic Ibronchiolitis) o Exacerbations Iand Icomorbidities Idetermines Iseverity o Hyperinflation Iof Ilungs

S/Sx o Cardinal Isx= Ichronic/progressive Idyspnea, Ichronic Icough Iwith Ior Iwithout Isputum Iproduction o Other= Iwheezing, Ichest Itightness, Idecreased Iactivity Itolerance I, Ifatigue, Iwt Iloss, Irecurrent Ilower Iresp Iinfections o Increased Ianterioposterior Idiameter Iof Ithorax, Iuse Iof Iaccessory Imuscles, Iprolonged Iexpiration, Ihyperresonance Ion Ipercussion, Idecreased Iheart/lung Isounds, Itachypnea, INVD Iwith Iexpiration, Iruddy Icyanotic Icolor, Iclubbed Inail Ibeds Risk Ifactors o SMOKING o Aging- Ihigh Iin I 65 - 75 Iyr Iold I(usually Idx Ib/w I 40 - 50 Iyr Iold) o Recurrent Iinfections o Repeated Ichemicals/gases/irritants Iexposures o Long Iterm Iasthma o Alpha I 1 Iantitrypsin Ideficiency I(less Ithan I 45 Iyrs Iold Inonsmokers Iw/ Iclinical Iemphysema, Ifamily Ihx Iof ICOPD Iyoung Iage Diagnosis: o GOLD Istandard I – Ispirometry Should Ibe Idone Iin Isymptomatic Ipatients Ionly o DX Icriteria: INot Ifully Ireversible Iif: IFEV1/FVC I – Iless Ithan I0.70 Iand I FEV1- Iless Ithan I 80 % o CXR: Inot Iused Ito Idx ICOPD; Ican Ir/o Iother Idx: ICHF, Ipna, Icardiomegaly, IPF Management Iof ICOPD: o Smoking Icessation o Flu Ivaccine Iannually o PNA I(,PPSV I13, IPPSV I23) Iage I 65 Iand Iolder I(or Ihigh Irisk I 19 - 64 Iyrs)- Ishould Ibe Iadministered Ione Iyear Iapart o Reduce Irisk Ifactor Iexposures o Person-centered Iand Ishared Idecision- Imaking Imanagement Iplan o Pulm Irehab o O2 Iuse- Iincreases Isurvival Iif Iused I 15 Ihours/day I(use Icaution Ito Idecrease Irisk Iof Iwill Ito Ibreathe) o O2 Icriteria: IPaO2 I=55 Ior Ihigher, IO2 Isat I=88% Iwith/without Ihypercapnia I 2 Ix Iin I 3 Iweeks

Medications Igoals: o reduce Isymptoms, o reduce Iexacerbations Irisk Iand Iseverity, o improve Iexercise Iand Ioverall IQOL/health COPD Iexacerbations- Iacute Iworsening Iof Iresp Isx Ithat Irequire Iadded Itx o Usually IOccurs Iafter IURI o Mild: ISABA Ionly o Moderate: ISABA Iand Ioral Icorticosteroids o Severe: IER/hospital I(acute Iresp Ifailure) o COPD Iaction Iplans Iimperative Ito Ireduce Irisks Iof Ifuture Iexacerbations IPharmacological ITx- ICOPD DRUG ICLASS MOA RX SABA- Bronchodilation: Irelaxes Ismooth Albuterol end Iin I “terol” muscles Iin Iairway. Levoalbuterol rescue Imed**** Onset- Irapid pirbuterol Q I 4 - 6 Ihrs LABA End Iin I “terol” IMaintenance Itx Bronchodilation: Irelaxes Ismooth Iresp Imuscles Onset: I 10 - 20 Imin Salmeterol IFormoterol IQ I 12 Ihrs DAILY ILABAs: Iindacaterol I(Arcapta) olodaterol I(Striverdi IRespirmat) Inhaled Ianticholinergics /Iantimuscarinic I “SAMA” Ends Iin I “tropium” IUsed Iin Iacute Iand Imaintenance Caution Iin Iglaucoma Ipt, IBPH, Ibladder Ineck Iobstruction, Iallergy Ito Iatropine IAnticholinergic ISE Cant Isee ICant Ipee ICant Ispit Cant Ishit Blocks Ibronchoconstriction Iof Iacetylcholine Ipratropium IQ I 6 - 8 Ihrs Inhaled Ianticholinergics Prevents Ibronchoconstriction, Tiotropium I(Spiriva) LAMA causes Isome Ibronchodilation Umeclidinium I(Incruse IEllipta) “tropium” Q I 24 Ihours Maintenance Itx

Caution Iin Iglaucoma Ipt, IBPH, Ibladder Ineck Iobstruction, Iallergy Ito Iatropine IAnticholinergic ISE Cant Isee ICant Ipee ICant Ispit Cant Ishit Combo ILABA Iwith IICS ISuffix I “one” Ior I “ide” FEV1 I<60% Best Iin Icombo Iwith bronchodilators Improved Ibronchodilation- Ireduces Iinflammation Budesonide/formoterol I(Symbicort) IFluticasone/salmeterol I(Advair) IVilanterol/fluticasone (Breo IEllipta) Systemic Isteroids Short Iterm Iuse Ifor Iacute Iexacerbations Anti-inflammatory Iactions Prednisone Methylxanthines Risk Ifor Itoxicity IDrug Iinteractions Toxic IADR Oral IBronchodilator theophylline Asthma:

• Chronic,Iinflammatory, Iobstructive Idisease
• Intrinsic I(stress) Ior Iextrinsic I(environmental)
• Pathophysiology: IREVERSIBLE Ihyperreactivity Iof Ibronchi I& Ibronchioles Ito Ia Ivariety Iof Istimuli Sx: o Wheezing, Isob, Icough I(worse Iat Inight I), Ichest Itightness o Air Ihunger o May Ioccur Iwith IURI, Iweather Ichanges, Ienvironment Iallergens, Istress Ior Iemotional Ireactions o May Ibe Iexacerbated Iwith INSAIDs, IASA, Ibeta Iblockers Dx Icriteria: o Spirometry/PFT- IFEV1 Iand IFEV1/FVC Iratio o Reversible Iairway Idx Iif I12% Ior Igreater Iimprovement Ipost Ibronchodilator I(differentiates Iasthma Ifrom ICOPD) o If Ispirometry Inormal- Irecommend Imethacholine Ichallenge Itest ISEVERITY IAND ITX: Intermittent Mild Ipersistent (^) Moderate persistent Severe persistent

Sx < I 2 Idays Iwk Ior INighttime <2x/month

2 Idys/wk, Inot Idaily Noc- I 3 - 4 Ix month Daily Isx Noc: I1x Iwk, Inot Inightly Sx Ithroughout Iday: Noc: I7x Iweek PRN Iinhaler Iuse

SABA IPRN I< I 2

dys/wk

SABA IPRN I>

dys/wk I(not Idaily Iand Inot Imore Ithan Ione time Idaily) SABA Idaily SABA: Iseveral Itimes Ia Iday FEV1 I>80% PFT Ivariable: 20%

FEV1 I>80%

PFT Ivariable: 20 - 30%

FEV1 I>60-80%

PFT Ivariable:

30%

FEV1 I>60%

PFT Ivariable:

30% FEV1/FVC- normal

FEV1/FVC-

normal

FEV1/FVC-

reduced I5%

FEV1/FVC-

reduced I5% Treatment Iplan SABA IPRN Low Idose IICS+ ISABA IPRN Or LTRA I(singulair Ior IXolair) Low Idose IICS+LABA Ior Medium Idose IICS SABA- Ino Imore than I 3 - 4x Iday Medium Idose IICS+LABA Ior Medium Idose IICS I+LTRA SABA- Ino Imore than I4x Iday Interstitial ILung Idisease:

o affects Icell Isurfaces Iof Ialveolar Iwalls, Isatellite Istructures Iof Ilungs, Iand Ibronchioles o inflammation Iand I “fibrosis Iof Ilower Iresp Itract o diffuse Iparenchymal Ilung Idisease o honeycomb Ilung- Iworsened Iopacities Ion ICXR Ias Idisease Iprogresses o CXR: Iground Iglass Ior Ihazy Iappearance Iin Iearly Idisease o Pulmonary Iinfiltrates- o nodular I(granulomatosis Idiseases Iand Ihypersensitive Ipna o , Ireticular I(fibrosis Idiseases), Ior o reticulonodular Sx ▪ dyspnea Ion Iexertion Idue Ito Ino Iother Idx ▪ nonproductive Icough ▪ fatigue Iin Ithe Iabsence Iof Idyspnea ▪ dry Icough Iw/o Iresp Isx ▪ fever, Iwt Iloss, ▪ abn Icxr Iin Iabsence Iof Isx ▪ incidental Iabn IPFTs IPF ▪ alveolitis Ito Iinflammation Ito Ifibrosis Iof Ithe Ilungs ▪ SX: Idyspnea, Icough, Ifatigue, Icrackles I(Velcro), Iclubbing, Itachypnea, Iabn IPFT ▪ Tx: Ino Icurative Imeds Bronchiolitis Iobliterans Iorganizing Ipna I(BOOP) ▪ Masses Iof Igranulation Itissue Iin Ithe Ismall Iairway Ilumens ▪ SX: Icough, Iflu-like Isx, Iinspiratory Icrackles, Iexp Isqueaks, ▪ CXR: Ipatchy Ialveolar Iinfiltrates Iwith Iground-glass Iappearance ▪ TX: Icorticosteroids Systemic ILupus IErythematosus ▪ Chronic, Imultisystem Iinflammation Iof Iconnective Itissue Iof Iskin Ijoints, Ipleura, Ipericardium, Ikidneys, Iheme Isystem, ICNS ▪ Pulm ISX: Ipleuritis Iwith Ior Iw/o Ieffusion, Ipulm IHTN, Ipulm Ithromboembolism ▪ TX: IBenlysta, INSAIDs, Icorticosteroids, Ihydroxychloroquine, Imethotrexate, ICytotoxan RA ▪ Chronic Isystemic Idisease; Irecurrent Iinflammation Iof Idisarthrodial Ijoints ▪ Pulm Isx: Iabn IPFTs Iwith Ireduced Idiffusing Icapacity, Ipulm Inodules, IBOOP, Ipleuritis Iw Ior Iw/o Ieffusion ▪ TX: INSAIDs, ICOX- 2 Iinhibitors, Imethotrexate, ITNF Iantagonists(Remicade, IEnbrel, Ihumira, ICimzia), INon ITNF Iantagonists I(Orencia, IRituxan) Progressive Isystemic Isclerosis I(Schleroderma) ▪ Connective Itissue Idisorder Iof Ifibrotic, Idegenerative Iand Iinflammation Iin Iskin, Ivessels, Iskeletal Imuscle, Iand Iinternal Iorgans

▪ Pulm ISx: Idyspnea, Ibibasilar Icrackles, Ireduced Ilung Icompliance, Iabn IPFT, Irecurrent Iaspiration Ipna ▪ CXR: Ipulm Ifibrosis, Iplueral Ithickening ▪ TX: Iantifibrotic Iagents I(Cuprimine),immunosuppressants I(Imuran, Imethotrexate Lymphamatoid Igranulomatosis ▪ Systemic Idisease Iof Iangiocentric Ilymphoid Igranulomatous Ivasculitis Iin Ilungs, Ikidneys, Iskin ▪ Pulm Isx: Icough, Idyspnea ▪ CXR: Imultiple Ibil Iill Idefined Ior Inodular Idensities ▪ TX: ICytotoxan, Icorticosteroids, Ichemotherapy Allergic IAngiitis Iand Igranulomatosis I(Churg-Stross ISyndrome) ▪ Rare Idisorder; Inecrotizing Iangiitis Iof Ilungs, Iheart, Iskin, ICNS ▪ Pulm Isx: Iallergic Ihx, Iasthma ▪ CXR: Ipatchy Idensities Ito Ilarge Ibilateral Inodular Iinfiltrates Sarcoidosis ▪ Multisystem Isyndrome Iof Iunknown Ietiology, Iaffects Ilungs ▪ Pulm Isx: IPFT-restrictive Ipattern Iand Ismall Ilung Ivolumes ▪ CXR: Ihilar Ilymphadenopathy Hypersensitivity Ipneumonitis ▪ Caused Iby Iinhalation Iof Iorganic Idusts ▪ Pulm Isx: Iresp/systemix Isx Idev I 4 - 6 Ihr Iafter Iexposure I(dyspnea, Icough, Ifever, Ichills, Imalaise) Ithese Isx Iabate Iin I 12 Ihours Ibut Ireappear Iwith Ieach Ire-exposure. IInspiratory Icrackles Ibases ▪ CXR; I, Idiffuse Ialveolar Ifilling Ianda Ivariable Iinterstitial Istreaks, Iabn IPFT

• Chronic IBronchitis ITx: IIrritants Ilead Ito Iinflammation Ilead Ito Imucus Ilead Ito Idecreased Ilung Ifunction. o Irritants: IRemoving Ilung Iirritants I(smoking, Ipollution, Icoal, Iasbestos, Iallergens) Iis Iimportant Ifor Ichronic Ibronchitis o Inflammation: IBronchodilator Iopens Iairway Iback Iup. IB2 Iagonist I(beta Ireceptors Iin Iheart, Ieyes, Iand Ilungs). IAnti-cholinergics Iare Ianother Ibronchodilator, Iopen Ilumen Iof Iairway Iso Ilung Ican Ibe Iless Iinflamed. o Steroids/Leukotriene Iinhibitors Itarget Ithe Icascade Iof Iinflammation. IStops Ithe Iinflammation Iat Ithe Iroot. ILT Iis Ithe Ilast Istep, Isteroids Istop Iit Iearlier Iin Ithe Icascade. o Mucus: IWe Ido Inot Itreat Iwith Isuppressants Ibecause Iwe Iwant Ipt Ito Icough Ithe Imucus Iup. o Lung IFunction: IHave Ito Ibe Icareful Iwith Igiving IO2. ICO2 Icontrols Ibreathing Idrive Iin Ipeople Iwith Ihealthy Ilungs. IIn Ichronic Ibronchitis, ICO2 Ilevels Iare Ihigh, Ibut Idon’t Isignal Ipatient Ito Ibreath Ibut Iinstead IO2 Icontrols Ibreathing Idrive. IIf Iwe Igive Iextra IO2, Iwe Ican Ishut Ioff Itheir Ibreathing Idrive Iand Istop Ibreathing.
• Emphysema ITx: ISTOP ISMOKING. o Chronic ITreatment: IBronchodilators Iopen Iup Iairway. IB2 Iagonists I(Albuterol) IAnticholingergics I(- Iopium) ILeukotriene Iinhibitors Ihelp Ithe Idisease Ifrom Igetting Iworse. o Acute ITreatment: IAntibiotics
• Oxygen Ishown Ito Idecrease Imortality.
• Labs: ICBC I(evaluate Ieosinophil Ilevel) I& IAlpha I 1 Iantitrypsin Ilevels

CAP

• Patho: IAcute Iinflammation Iof Ilung Iparenchyma; Iusually Iinfectious
• 70 - 80% Iof Icases Iare Ipeople Iover Iage I60.
• S. Ipneumonia- Igram I+ I(40%) IMOST ICOMMON- IDEADLY
• H. Iinfluenza- Igram Ineg I(2nd^ Imost Icommon)
• Legionella- Igram Ineg
• Staph Iaureus: I 2 - 9%, Ioccurs Iin Ihealthy Iindividual Is/p Iinfluenza, Ior Ielderly Iwith IDM, ICRF, Ilung ICA
• Mycoplasma: Iatypical; Iwalking Ipna; Imore Iprevalent Iin Iclose Iproximity Ipopulation Igroups
• Chlamydia Ipna: Igram Ineg-adult Ionset Iasthma Iprior Ito Idx SX: o Lower Ilobes Imostly Iaffected o Sudden Ifever, Icough, Ichest Ipain, Ifatigue o Pneumococcal: Irust Icolored Isputum o Myalgia Iin Icalf Iand Ithighs o Chest Ipain Iwith Isplinting Ion Ione Iside o Crackles, Idull Ipercussion o Sx Iof Iconsolidation: Iegophony, Ibronchophony Dx Icriteria: ▪ CXR- o determines Iviral Ivs Ibacterial o rules Iout Ipleural Ieffusion o cavities Imay Ibe Ipresent Iindication Iof Ispecific Itypes Iof Ibacteria ▪ CBC o Indicate Iif Ihospitalization Iis Ineeded I(WBC I>15000- Ibacterial ▪ Pneumococcal Iurinary Iantigen Itest o Detects IS. Ipneumoniae Iprotein Iwithin I 15 Iminutes o Helps Ito Idetermine Iatb Itx Tx: ▪ CURB- I 65 Icriteria-determines Iseverity Iand Ineed Ifor Ihosp. o Confusion o BUN I>7ml/L o Resp Irate- Ialkalosis o BP I(systolic)- I< ▪ Antibiotics- Iuncomplicated ICAP o Azithromycin, Idoxy o With Icomorbidities: Iresp Iquinolone(Levaquin) Ior IIM/IV IRocephin Ior ICeftin I+macrolide o MRSA; Ivanco Ior Izyvox OSA:
• Temporary Ipause Iin Ibreathing Ifor Iat Ileast I 10 Isecs Iin Iduration Iat Ileast I5x/hr Sx:
• Night Iand Idaytime Isleepiness I(hypersomnolence)
• Morning Ih/a(hypercapnia)
• Neuropsychological Idisturbance(falling Iasleep Iwhile Idoing Ipurposeful Iactivity)

• Decreased Iconcentration, Iambition, Iincreased Imemory Iloss
• Irritable Iand Imoody
• Decreased Ilibido Risk Ifactors: ▪ Obesity ▪ Increased Ineck Isize I(collar Isize I>17) ▪ Tonsillar Ihypertrophy ▪ Enlarged Isoft Ipalate Iand Itongue ▪ Retrognathia Iand Imicrognathnia
• Anatomical IRFs: ISeptal Ideviation, Imacrognathia I(enlarged I), Itonsil Ihypertrophy, Iobesity
• Avoid Ialcohol, Isedatives I(alters IREM Isleep), Iand Inarcotics
• Complications: ICardiac Idysrhythmias I(A. Ifib)
• SE: IHypersomnolence Iresulting Iin IHA
• Alcohol DX: Stanford ISleepiness IScore I(SSS): ➢ records Idegree Iof Isleepiness Iexperienced Iby Ipatient Iat Ia Igiven Itime ➢ if Ibelow Ia I 3 Iwhen Ialertness Ishould Ibe Ipresent- Isleep Ideficit Iindicated IEpworth ISleepiness IScale I(ESS) ➢ measures Ipatients Itendency Ito Ifall Iasleep Iduring I 8 Inonstimulating Iexercises ➢ 10 Ior Ihigher: Iabnormal Definitive Itest Ifor IDx: Overnight Ipolysomnogram Week I 3 Anxiety Excessive Iworrying Ithat Iis Idifficult Ito Icontrol Iand Iinterferes Iwith Idaily Ilife. ICommon Iin Iolder Iadults Unrecognized Iand Iundertreated IFemales Imore Ithan Imen Prevalence: Iunknown Ibut Ihigher Ithan Irecognized I(15-50%) I 3 - 14% Iolder Iadults Iwith Idx I 50 - 90% Ihave Ianother Imental Iillness Ialong Iwith IGAD- Imost Ioften Idepression DSM- 5 Icriteria- Isx Ifor Iat Ileast I 6 Imonths ▪ GAD o Dx: Iexcessive Ianxiety, Idifficult Icontrolling Iworrying Iwith Irestlessness, Ipalpitations, Isweating, Idyspnea, Ieasily Ifatigued, Idifficult Iconcentrating, Iirritability, Imuscle Itension, Idifficult Ifalling/staying Iasleep I(must Ihave Iat Ileast I 3 Iof Iassociated Isx) o Anxiety Idue Ito Imedical Iproblem o Anxiety Inot Iotherwise Ispecified

o Substance Iinduced Ianxiety o Acute Istress Ireaction Id/o o PTSD o Panic Idisorder- Iless Icommon Iin Ielders S/SX ▪ Impending Idoom Ifeeling ▪ Trembling ▪ Breathlessness, ▪ Tachycardia ▪ Impaired Imemory Iand Iattention ▪ Older: Iconstipation, Inausea, Isleep Idisturbance, Iworry Iabout Ihealth, Ifinances Risk Ifactors ▪ Poor Iphysical Ihealth ▪ Financial Istressors ▪ Loss Iof Isignificant Iother ▪ Fear Iof Idisability ▪ Sleep Idisturbances ▪ Poor Isocial Isupport Isystems Tx: ▪ Mild: ISSRI I(lexapro, IZoloft, I(caution Iw/ Icitalopram- Iprolonged IQT Iinterval) ▪ Moderate:Buspar Ior Igabapentin Iif ISSRI Ifailed ▪ Severe: ISSRI I+ Ishort Iterm IBenzo ▪ Nonpharm: ICBT, Iexercise, Irelaxation Itraining, Imusic Unipolar IDepression o Pervasive Ifeeling Iof Isadness Ior Ia Ilack Iof Iinterest Ior Ipleasure Iin Ipreviously IEnjoyed Iactivities o Single Ior Irecurrent Iepisodes o Geriatric: IMDD, Ivascular Idepression, Idysthymia, Idepression Ir/t Ito Idementia, Ibipolar, Iexecutive Idysfunction o Not Ipart Iof Iaging Iprocess, Iwomen Imore Ithan Imen o Prevalence: I 3 - 4x Imore Iin Inursing Ihomes o I Community Iliving: I 2 - 4% o I ALF: I 13 - 24% o I LTC: I 12 - 20% Unipolar IDepression ISx: ▪ Affect/Mood o Sadness o Anhedonia o Apathy o Helplessness o Hopelessness o Worthlessness Iand Iloneliness

▪ Cognition o Ambivalence o Uncertainty o Cant Iconcentrate o Confusion o Poor Imemory o Slow Ispeech o Self Icriticism o Poor Iself Iesteem o Psychosis: Ihallucinations, Idelusion, Iillusions ▪ Physiological o Sleep, Iappetite, Ienergy Idisturbance o Wt Ichange o Constipation o Pain, Ih/a o Decreased Ilibido o Sexual Inonresponsiveness o Exaggerated Iconcerns Iover Ibody Ifunction ▪ Behavior o Psychomotor Iretardation o Agitation o Poor Ipersonal Ihygiene o Tearful o Social Iw/d IRisk IFactors o Family Ior Iother Ilosses, Iautonomy, Iprivacy, Isocial Inetwork, Imove Ito INH o Illness: IDM, Icancer, Iparkinsons, IAD, ICVA, IOSA, ICOPD, Ianemia, ICVD o Alcohol/substance Iabuse, Ifamily Ihx, Igenetics o Prevalence Iof Idepression Iis I 3 - 4x Imore Iin Inursing Ihome Iresidents o May Ipresent Iwith Ic/o Ipain Idue Ito Iconcerns Iof Isocial Istigma o CBT o Medications: Ianxiolytics, Isedatives, Iantipsychotics, Ibeta Iblockers, IH2 Iblockers, Inarcotic Ipain Imeds, Isteroids Unipolar IDiagnostic Icriteria IDSM- 5 ➢ Sustained Idisruptive Iand Ipervasive Idepressed Imood Ior Iloss Iof Iinterest Iwith I 5 Ior Imore Ifor Iat Ileast I 4 Iweeks o Depressed Imood Ireported o Obsessive Iworry o Appetite Iand Isig Iwt Ichange o Sleep Ipattern Ichange- Iinsomnia, Iwaking Iearlier, Iinability Ito Ifall Iback Ito Isleep) o Psychomotor Iagitation o Fatigue Ior Ino Ienergy o Hopelessness

o Feeling Iof Iworthlessness/excessive Iguilt o Diminished Iconcentration, Iindecisiveness o SI ➢ Older Iadults Iinclude: o Lack Iof Iemotions o Excessive Iconcern Iover Ibody Ifunctions o Seeking Ireassurance Iand Isupport o Isolation Ior Iw/d o Decline Iin IADLs o Irritable, Ifearless, Iagitation, Ianxiety ➢ Labs: ICBC, ITSH, IB- 12 ➢ Assessments o PHQ- 9 o BDI o GDS Medication: ➢ Review Imedications Iand Ieliminate Ipossible Icontributing Ito Idepression ➢ 1 st^ Iline Imed Itx: ISSRI I(start Ilow, Igo Islow) Bipolar IDepression ➢ BP I1: Iat Ileast Ione Imanic Iepisode ➢ BP III: Iat Ileast Ione Iprevious Iepisode Iof Imajor Idepression Iand Iat Ileast Ione Ihypomanic Iepisode ➢ Cyclothymic: Imilder Imood Ialteration Iover Ia Iperiod Iof Itime ➢ Unspecified: Isx Icause Iclinical Iimpairment Ibut I don’t Imeet Idx Icriteria Ifor Iany Iof Ithe Iabove I 3 Sx: o Elevated Imood Iof Ieuphoria Ior Iirritability o Dysphoria I(depression Iand/or Iirritability) o Rapid Imood Icycling Bipolar IDepression IDSM- 5 - I must Ihave Iincreased Ienergy Iwith Ithese Isx: I DIGFAST o Distractibility o Insomnia o Grandiosity o Flight Iof Iideas o Activities I(hyperactive) o Speech I(rapid) o Thoughtlessness I(impulsive) Diagnostic Icriteria: o MDQ I(useful Ibut Inot Ispecific Ifor Ielders) o GDS o CBC, ICMP, ITSH, IRPR, IHIV, IEKG, Itox Iscreen, IUDS o MMSE

Medication: I 1 st^ Iline I(lowest Idose)

• Lithium Iand Ivalproic Iacid I(mood Istabilizers)
• Quetiapine Iand Iolanzapine I(antipsychotics) Metabolic Iside Ieffects ➢ Lithium: Ibaseline Irenal,cardiac, Ithyroid Ifunction Ibefore Ibeginning. o Levels Iaffected Iby INSAIDs, Ithiazide Ior Iloop Idiuretics, IACEi o Monitor Ilithium Ilevels: ▪ Adverse Ieffects: Ihypothyroidism, Iwt Igain, Icognitive, Irenal Iimpairment, ➢ Valproic Iacid: o Monitor Idrug Ilevels, ILFT, ICBC o Adverse Ieffects: Iwt Igain, Ihepatoxicity, Ipancreatitis, Ithrombocytopenia ➢ Antipsychotics o Monitor Iwt, Iglucose, Iand IQT Iinterval Iprolongation o Increased Imortality Iin Iolder Iadults Sleep IWake IDisorders Diagnostic Ioverlay Iof Iconditions Ithat Iaffect Inormal Isleep
• Insomnia- Imost Icommon
• OSA
• Substance/medication Iinduced
• RLS Underlying Imedical Icauses:
• Pain
• Fibromyalgia
• Dementia, Idelirium
• GERD
• Pulm Iconditions Icausing Isob
• Thyroid
• Obesity
• Pregnancy
• Med Iside Ieffect Underlying Ipsychological Icauses: o MDD o GAD o Manic o Psychosis o Traumatic Ievents Iprecipitate Iacute Iinsomnia o PTSD o Poor Isleep Ihygiene o OSA, IRLS Insomnia Complex Icommon Isleep Idisorder

Difficulty Ifalling Iasleep Ior Istaying Iasleep I25% Igeriatrics Prevalence Iin Ielderly: I50% Iage I 65 Ior Iolder I, Irespiratory Iconditions Iincrease Irisk

• Staying Iasleep Iis Imost Icommon Icomplaint
• Melatonin I(Start Iout Ion Ilow Idose)
• Avoid Iantihistamines
• Educate Ion Iproper Isleep Ihygiene
• Can Ibe Iearly Isign Iof Imental Iillness Insomnia ISx:
• Report Iof Inot Isleeping
• Daytime Isleepiness Iexcessive
• Loud Isnoring I(OSA)
• Restless Ilegs
• Difficulty Ifalling Iasleep Iand Istaying Iasleep
• Irritability
• Impaired Iconcentration
• Nonrefreshing Isleep Diagnostic Icriteria: ➢ Medical: o History Iand IPhysical Iexam o Falls, o MMSE o Sleep Ihx ➢ Psychiatric: o MMSE o GAD o Depression o Alcohol Iabuse Chronic Iinsomnia: ➢ 1 st^ Iline Itx: Icomplete Imed Iand Ipsych Ihx ➢ ESS Ior ISSS Isleep Iscale Ito Iidentify Iaspect Iof Iproblem ➢ Sleep Idiary ➢ CBT Iand Iinstructed Isleep Ihygiene Itogether Medication: I All Ion Ithe IBeers IList ➢ Sleep Ionset: Itemazepam I(Restoril), Izaleplon I(Sonata), Iramelteon I(Rozarem) ➢ Sleep Ionset Iand Imaintenance: Ieszopiclone I(Lunesta) ➢ Sleep Imaintenance: Izolpidem I(ambien), ➢ Belsomra ➢ Silenor I(not Imore Ithan I6mg) ➢ Melatonin ➢ Trazadone I(off Ilabel Iuse) ➢ Benzo I(not Irecommended)

WEEK I 4

➢ Sx Iand Istructural Iremodeling Iof Iarticular Icartilage Iwith Iinflammation Iof Isynovitis Iand Iligament ➢ Unknow Ietiology ➢ Age Irelated Ichanges Iin Icartilage Ileads Ito Iremodeling Iresponse Iof Imatrix ➢ Common Iover I45, Iwomen Imore Ithan Imen Factors: ▪ Age ▪ Obesity ▪ Previous Ijoint Iinjury ▪ Prior Isurgeries ▪ Occupation ▪ Prolonged Isports Ithat Iinvolve Iwt Ibearing Ijoints ▪ Low Ibone Idensity ▪ Family Ihx ▪ Uric Iacid Iacromegaly- Igout, Ipseudogout Sx:

• Morning Istiffness I(less Ithan I 30 Iminutes) I “gel I phenomenon”
• Stiffness Ithat Iimproves Iwith Iactivity Ior Imuscle Ispasms
• Persistent Ijoint Ipain
• Bourchards Inodes I(nontender Inodules IPIP Ijoints)
• Heberdens Inodes I(nontender Iat IDIP Ijoints Iof Ihands Iand Ifeet)
• CMC Ijoint Iof Ithumb
• Women: Ierosive IOA- Ired Itender Ijoints IPIP Iand IDIP Ithat Ilead Ito Ijoint Ierosion, Ideformity Iand Iankylosis
• Knee: ICrepitus Igrinding Isensation. I “lock Iand I buckling”, I Baker’s Icysts Iposterior Ipopliteal
• Cervical: IParathesia Iin Iarms Ithat Iimproves Iwith Imovement
• Lumboscacral/Hip: ILow Iback Iand Ibuttocks Ipain
• Shoulders: Icrepitus, Idecreased IROM, Itender Iwith Ipalpation
• Foot: Ihallux Ivalgus Ideformity I(bunion) DX: o Physical Iexam Iand IH&P o Xrays Iuseful Ifor: o Hip Idx o Disease Iseverity o Baseline Istatus Ito Icompare Ito Ifuture Ixrays o Screen Ifor Iother Ibones Iand Ijoint Idiseases Iif Isevere Ipain Iand Iaffecting Isleep o Bilateral Istanding I 2 Iview Ixrays: o Asymmetrical Ijoint Ispace Inarrowing Ir/t Iloss Iof Icartilage o subchondral Icyst Iformation o subchondral Ibony Isclerosis ➢ Asymmetrical Ijoints Iof Ihands, Iknees, Ihips, Ispine Iare Icommon

OA:

o I osteophytosis I(bone Ispurs) ➢ MRI o Detect Icartilage, Iligament, Itendon Idamage I(spinal Istenosis) ➢ Arthrocentesis o Completed Iwith Ijoint Ieffusions o r/o Iinfection Iand Icrystalline Idisease I(gout Iand Icalcium Ipyrophosphate Icrystals) o normal Iresult- Iclear Iviscous Ifluid Iwith I<2000 Iwbc Tx: Iaimed Iat Icontrolling Ipain, Imaximizing Ifunction, Iminimize Idisability ➢ 1 st^ Iline: I nonpharmacological: Iexercise/ Itherapy ➢ Pharmacological: IAcetaminophen Medication Imanagement ➢ Hand: o Topical Icapsaicin o Topical INSAIDs o Oral INSAIDs I(not Iin I 75 Ior Iover) o Tramadol ➢ Knee: o Tylenol o Oral INSAIDs o Topical INSAIDs o Tramadol o Corticosteroid Iinjections ➢ Hip: o Obesity Imanagement o Oral INSAIDs o PT o Intra-articular Isteroid Iinjections o Assess/tx Ifor Idepression, Ianxiety, Ietc ➢ Other Imeds: o Gabapentin o SSRI o TCA ➢ Ortho Ior Ipain Ispecialist Ireferral RA Ivs IOA:

• RA Igoal Ito Idecrease Iinflammation
• RA Isxs Ipain I>60 Imins; Iulnar Ideviation, Iswan-neck Ideformity, Isymmetrical Iloss Iof Ifunction; Ijoint Isubluxations I(autoimmune)
• RA Itx: INSAIDs I& IDMARDs; IRA Ilabs: IRF I& Ianti-CCP
• OA Isxs: Iasymmetrical, IBouchard’s I& IHerbeden’s INodes; Imorning Istiffness I<30 Imins
• OA Id/t Irepetitive Imicrotrauma I(d/t Ioveruse)
• OA Itx: IAcetaminophen; IOA Ilabs ICBC
• OA IRF: IObesity Osteoporosis I – IDEXA IScan I 65 Iyears Iold

Generalized Iskeletal Idisorder Icaused Iby Ibone Imineralization Iand Ilow Ibone Imass Idensity, IincreasingIrisk Ifor Ifx I(usually Iat Ihip Ior Ivertebra) Risk IFactors:

• Smoking, Ietoh Sx Iof Iosteoporosis: o No Iclinical Isx Iuntil Ifx o May Ihave Igradual Iupper/midthoracic Iback Ipain Iwith Iactivity Ior Iprolonged Isitting/standing Ithat Iis Irelieved Iwhen Ilaying Idown Objective:
• Vertebral Icompression Ifx: Isudden Isevere Ipain Iwith Ifocal Ipoint Itenderness Iwhere Ifx Iis
• Microfractures Iof Ivertebral Ispine: IDorsal Ikyphosis I (dowager’s Ihump) Icausing Iht Iloss
• As Ikyphosis Iworsens- Idecreased Ilung Ivolumes Iresult Iin Imore Iresp Icomplaints
• Most Icommon Ipresentation: IBONE IFX IDEXA Iresults DX RESULTs Normal BMD Iwithin I 1 ISD Iof Iyoung Iadult Ireference mean Osteopenia- Iless Ithan Inormal IBMD Ibut Iless severe BMD I>1 ISD Ibelow Iyoung Iadult Ireference mean I(21) Osteoporosis- BMD I> I2.5 ISD Ibelow Iyoung Iadult Ireference mean I(22.5) Osteoporosis I(severe) BMD I>2.5 ISD Ibelow Iyoung Iadult Iref IAND presence Iof Iosteoporotic Ifx Medication IManagement IGOAL- Ipain Imanagement ▪ First Iline: IBisphonates Ix I 5 Iyears I( INo IDEXA Iduring Itx o Alendronate I(Fosamax)- Iweekly o Risedronate I(Actonel)-weekly

o Ibanodronate I(Bonvia)- Imonthly o Zoledronic Iacid I(Reclast)- IIV Iannually o Forteo- Iinjection Iannually o Denosumab I(Prolia) Iinjection Ievery I 6 Imonths ▪ Calcium I 500 - 1200mg Idaily ▪ Vit ID I 800 - 1000 Iunits Idaily RA Chronic Iprogressive Isystemic Iinflammatory Idisease Iaffecting Isynovial IjointsIWomen Imore Ithan Imen Symmetrical Ipolyarthritis Sx: ➢ Subjective: o Malaise o General Idiffuse Iarthritis o Wt Iloss, Ianorexia o Low Igrade Ifever o Morning Ijoint Istiffness Iand Iswelling Ithat Iimproves Ias Iday Iprogresses(>60MIN) o Progressive Idisease: Irecurrent Ipain, Iswelling Iin Ismall Iand Ilarge Iperipheral Ijoints Ilead Ito Ilow Iactivity, Iworsening Ipain Iand Iimmobility ➢ Objective: o Symmetrical Iperipheral Ipolyarthritis Iand Imorning Istiffness o PIP, IMCP Ijoints Iof Ihands Iand Iwrists Ipainful Ito Ipalpation, Iedematous, Ilimited IROM o ULNAR IDEVIATION o Advanced Idisease: IBoutinneire Ideformity Iof Ifingers I (PIP Inonreducible Iflexion I hyperextension Iof I DIP) o Advanced: Iswan Ineck Ideformity(PIP Ihyperextended Iand IDIP Iconstant Iflexion) o Severe: Iarthritis Imutilans- Icomplete Iloss Iof Ijoint Ispace,shortening Iand Imalpositioning Iof Ifingers, Ialmost Icomplete ISYMMETRICAL Iloss Iof Ifunction Diagnostics ➢ Anti-CCP- Ihigher Isensitivity Iand Ispecificity ➢ RF ➢ ESR ➢ CRP ➢ Xrays: Inecessary Ito Icheck Ifor Iearly Isx Iof Ierosions Iindicating Ia Ineed Ifor Iaggressive Itx o Soft I I I I I I I I I I I tissue I I I I I I I I I I I I I Iswelling I o I Symmetrical Ijoint Ispace InarrowingI o I Joint Isubluxations ➢ CBC: o normochromic, Inormocytic Ianemia, o mild Ileukocytosis o thrombocytosis Tx IGOAL: IDECREASE IINFLAMMATION

➢ 1 st^ Iline Itx: Nonpharmacological o Therapies IPT/OT o Heat/cold Icompresses o Exercise I(isometric) I(low Iresistant Iaerobics) o Rest o Assistive Idevices, Icanes, Iwalker, Isplint o Meditation o Wt Iloss ➢ Drugs: o Tylenol Ior Icapsaicin Igel o NSAIDS- IASA I(if Iliver, Iplatelet, Irenal, Iand Ihgb Iok), Itake Iwith I8oz Imilk Ior Iwater o 6Corticosteroids- Iprednisone I(short Iterm Iless Ithan I 6 Imonths) o DMARDS- Istart Iwithin I 3 Imonths Iof Idisease Ionset ▪ Hydroxychloroquine I(Plaquenil ▪ Cyclosporine- Ionly Iused Iif Imethotrexate Ifailed ▪ Methotrexate I(Rheumatrex)- ▪ Adalimumab I(Humira)- Imod Ito Isevere IRA I( Ican Ibe Igiven Iwith Imethotrexate) ▪ Etanercept I(Enbrel) ▪ Infliximab I(Remicade)- Imust Ibe Igiven Iwith Imethotrexate o Review Ipage I 1007 Iin IDunphy

ASTHMA

Intermittent Mild Ipersistent Moderate Ipersistent Severe Ipersistent Sx < I 2 Idays Ia Iweek Ior INighttime I- <2x/month

2 Idays/week, Inot Idaily Noc- I 3 - 4 Ix Imonth Daily Isx, Ibut Inot Icontinual Noc: I> I1x Iweek, Inot Inightly Affects Isleep I& Iactivity Sx Ithroughout Iday, IContinuous. Noc: I7x Iweek Ifrequently IAffects IActivity PRN inhaler Iuse

SABA IPRN I< I 2

days/week

SABA IPRN I>2

days/week I(not Idaily Iand Inot Imore Ithan 3 - 4 Itimes Idaily) SABA Idaily (no Imore Ithan I 3 - 4 Itimes Ia Iday) SABA: Iseveral Itimes Ia Iday (no Imore Ithan I 3 - 4 Itimes Ia Iday) FEV1 I>80% PFT Ivariable: I20% INormal IPeak IExpiratory Iflow Ibetween exacerbations

FEV1 I>80%

PFT Ivariable: I 20 - 30%

FEV1 I>60-80%

PFT Ivariable: I>30%

FEV1 I>60%

PFT Ivariable:

30% FEV1/FVC-normal FEV1/FVC- normal FEV1/FVC- Ireduced I5% FEV1/FVC- Ireduced 5%

Treatment Iplan

SABA IPRN

No Idaily Imeds Step Iup Iif Inot Icontrolled. IStep Idown Iif Icontrolled Ifor I 3 Imonths Low Idose IICS+ ISABA IPRN Or LTRA I(singulair Ior IXolair) Low Idose IICS+LABA IOR Medium Idose IICS ISABA- Ino Imore Ithan I 3 - I4x Iday Medium Idose IICS+LABA OR Medium Idose IICS +LTRA SABA- Ino Imore Ithan I4x Iday

• Consider steroids