ANCC 2 FINAL PAPER QUESTIONS AND COMPLETE SOLUTIONS
✔✔Duodenal ulcer - ✔✔abdominal pain described as burning, gnawing pain about 2-3 h
PC. Relief with foods, antacids. Awakening at 1-2AM with symptoms
Objective: tender at epigastrium, LUQ, slightly hyperactive bowel sounds
✔✔Hepatitis A - ✔✔fecal contaminated water
sxs: clay colored stools, dark colored urne, joint pains, nausea, fever, maliase
7
Incubation-28 days
✔✔Hepatitis C - ✔✔most commonly transmitted from sharing of needles, blood
transmission
More horizontal> vertical transmission
Needle sharing, tattooing, piercing (not through birth)
✔✔Hepatitis B...when mom is HBsAB positive or when anyone is exposed - ✔✔Give
hep B immunization and hepatitis B immune globulin to the newborn
contra- allergy to baker's yeast**
Vaccination of hep B- prevents Hep D
ALL PREGNANT WOMEN NEED SCREENING
get it if CD4 count >200 or health care worker
2 doses (1 year and 4-6 yrs) or 2 shots 4-8 weeks apart for older
✔✔Hepatitis Lab values - ✔✔HBsAG- positive Hep B surface antigen in acute and
chronic
Ant-HBc
IgM anti-HBc- positive in acute infection ONLY
Anti-HBs- protection, been exposed
Anti-HAV- has had hep A in the past (two doses, 6 months apart)
Anti-HCV and HCV RNA- hep C is positive
AST should be (0-40) elevated 56
ALT should be (0-40) elevated 98
Increase in Bilirubin (degradation of heme)- cause jaundice, urobilinogen-found in urine
sample causing "cola-looking" pee
✔✔Antimicrobial resistance preferred for CAP/S. pneumoniae - ✔✔Recent use within 3
months, age >65, exposure to children, medical comorbidites
,Can use Macrolides (azithro*-QT prolong, clarith-CYP inter, eryth)- risk for CV
problems- QT prolongation and increased risk of CV death (5-7 days)
Preferred with risk for DRSP: high dose amox with macrolide, respiratory fluroquin
(moxi, levo, gemi)- tendon rupture risk
Previously health, no recent in 3 months- Macrolide or doxy
Comorbidities, COPD, DM- respiratory fluro (moxi, gemi, **levo) or advanced macrolide
azithro plus beta-lactam such as HD amox
DEATH TO PNEUMONIA_- due to renal insuffiency
✔✔Drug resistance - ✔✔s.pnemonae- alteration in protein binding sites
h.influenza- beta lactamase production
cause of resistance- longer course, lower dosage, broader spectum
RF: antimicrobial therapy in the previous 3 months, exposure to children in day care,
age older than 65
✔✔Likely causative organisms in CAP include - ✔✔S. pneumoniae and select
respiratory viruses
✔✔COPD old man with CAP - ✔✔Give levo 5 days
7 day course of clarithomycin (macrolides)- no doesnt cover DRSP and its a CYP
inhibitor
Amox-Clav- doesn't treat atypicals
Cefpodoxime- doesn't treat atypicals
✔✔CURB-65 - ✔✔BUN greater than 19
RR greater than 30
BP <90/60
Age >65
Score <1 = outpatient, >1 = inpatient
✔✔Most common pathogen implicated in acute bronchitis - ✔✔Respiratory virus
give person relief from the cough
Atrovent/albuterol, prednisone 3-5 days (gets rid of lower airway inflammation)
small percentage bacterial- then prescribe macrolide or tetracycline
,Tx- Anticholinergics for uncomplicated bronchitis
✔✔Asthma - ✔✔Core defect chronic airway inflammation
Spirometry is needed to make dx of asthma- FEV1
Peak flow is used to monitor asthma
inhaled corticosteroids- stop release of at least 8 inflammation mediators (only 20% of
the dose of the inhaled cort. is systemically absorbed
Visit frequency- well controlled-3-6 months, not well controlled 2-6weeks
SABA- albuterol (can't relieve inflammation, just bronchospasm
✔✔PCPs are not well-versed in - ✔✔Inhaled corticosteroids and SSRIs
✔✔Anticholinergics for asthma (Muscarinic antagonists) - ✔✔Atrovent/ipratropium
bromide- short acting
Spiriva/tiotropium bromide- long acting
used in COPD, for prevention of bronchospasm
✔✔Asthma/COPD - ✔✔PE: Hyperresonance, decreased tactile fremitus, wheeze
(expiratory first, inspiratory later), low/flattened diaphragms, increased AP diameter
For asthma flares- give 5 day course of oral prednisone (don't give injectables!)
COPD- high pressure on right side of heart can result in afib, chronic obstruction
(FEV1:FVC <0.70 post bronchodilator confirms persistent airflow limitation
oxygen therapy- >15 hours
** consider CXR only with fever and/or low SaO2 to help rule out concomitant
pneumonia
-Best course for flare--> Doxy with a short course oral corticosteroid
✔✔Alpha-1 Antitrypsin Deficiency screening - ✔✔perform when COPD develops in
patients of caucasian decent under 45 years with a strong family hx of COPD
✔✔Hemoglobin A1c - ✔✔<6% goal with no CVD (newly dx 26 y/o with DM2)
<8%- fragile elders with life expectancy <5 years (don't want hypoglycemia)
2x/year check A1c, 4x/year if not meeting glycemic goals
✔✔Metformin - ✔✔Anticipated A1C reduction with intensified use= 1-2%
With radiocontrast use, surgery, omit for the day of and >48 h post
, contra with CHF
✔✔DMT2 care consideration - ✔✔A- Aspirin
B-Blood pressure control
C- Cholesterol, statin use and creatinine-check value
D-Diet, Dental care
E-exercise, eye exam
F-Foot examination
G-Goals
✔✔JN8 guidelines- HTN/Dyslipidemia - ✔✔Age>60 goal <150/90
Age<60 goal <140/90
DM no CKD goal <140/90
CKD with or w/o DM <140/90
Non-black- thiazide, ACE/ARB, CCB (no ACE with ARB)
Black- thiazide, CCB
CKD- ACEi, ARB
wait a month...another month...4 months- introduce BB and aldosterone
young patient typically has his or her blood pressure checked every two years.
✔✔Aldosterone Antagonist- Spironolactone - ✔✔Hyperkalemia risk
Gynecomastia risk with prolonged use***
Treat it with danazol**, nonaromatizable androgens, testosterone
✔✔Statin therapy - ✔✔>7 .5 estimated 10 y ASCVD risk use mod-high intensity
DMT1/2 with high LDL use high intensity
HIgh intensity- LDL goes by 1/2
Atorvastatin- 40-80mg
Rosuvastatin- 20-40mg
Moderate- LDL goes by 1/3
Low- LDL goes down by 1/4
Statins- LDL lowering effect
Fish oil- can't switch too only can decrease TG
LDL goal for >60 male with DM and hx of ACS 2 years ago- <70
✔✔Duodenal ulcer - ✔✔abdominal pain described as burning, gnawing pain about 2-3 h
PC. Relief with foods, antacids. Awakening at 1-2AM with symptoms
Objective: tender at epigastrium, LUQ, slightly hyperactive bowel sounds
✔✔Hepatitis A - ✔✔fecal contaminated water
sxs: clay colored stools, dark colored urne, joint pains, nausea, fever, maliase
7
Incubation-28 days
✔✔Hepatitis C - ✔✔most commonly transmitted from sharing of needles, blood
transmission
More horizontal> vertical transmission
Needle sharing, tattooing, piercing (not through birth)
✔✔Hepatitis B...when mom is HBsAB positive or when anyone is exposed - ✔✔Give
hep B immunization and hepatitis B immune globulin to the newborn
contra- allergy to baker's yeast**
Vaccination of hep B- prevents Hep D
ALL PREGNANT WOMEN NEED SCREENING
get it if CD4 count >200 or health care worker
2 doses (1 year and 4-6 yrs) or 2 shots 4-8 weeks apart for older
✔✔Hepatitis Lab values - ✔✔HBsAG- positive Hep B surface antigen in acute and
chronic
Ant-HBc
IgM anti-HBc- positive in acute infection ONLY
Anti-HBs- protection, been exposed
Anti-HAV- has had hep A in the past (two doses, 6 months apart)
Anti-HCV and HCV RNA- hep C is positive
AST should be (0-40) elevated 56
ALT should be (0-40) elevated 98
Increase in Bilirubin (degradation of heme)- cause jaundice, urobilinogen-found in urine
sample causing "cola-looking" pee
✔✔Antimicrobial resistance preferred for CAP/S. pneumoniae - ✔✔Recent use within 3
months, age >65, exposure to children, medical comorbidites
,Can use Macrolides (azithro*-QT prolong, clarith-CYP inter, eryth)- risk for CV
problems- QT prolongation and increased risk of CV death (5-7 days)
Preferred with risk for DRSP: high dose amox with macrolide, respiratory fluroquin
(moxi, levo, gemi)- tendon rupture risk
Previously health, no recent in 3 months- Macrolide or doxy
Comorbidities, COPD, DM- respiratory fluro (moxi, gemi, **levo) or advanced macrolide
azithro plus beta-lactam such as HD amox
DEATH TO PNEUMONIA_- due to renal insuffiency
✔✔Drug resistance - ✔✔s.pnemonae- alteration in protein binding sites
h.influenza- beta lactamase production
cause of resistance- longer course, lower dosage, broader spectum
RF: antimicrobial therapy in the previous 3 months, exposure to children in day care,
age older than 65
✔✔Likely causative organisms in CAP include - ✔✔S. pneumoniae and select
respiratory viruses
✔✔COPD old man with CAP - ✔✔Give levo 5 days
7 day course of clarithomycin (macrolides)- no doesnt cover DRSP and its a CYP
inhibitor
Amox-Clav- doesn't treat atypicals
Cefpodoxime- doesn't treat atypicals
✔✔CURB-65 - ✔✔BUN greater than 19
RR greater than 30
BP <90/60
Age >65
Score <1 = outpatient, >1 = inpatient
✔✔Most common pathogen implicated in acute bronchitis - ✔✔Respiratory virus
give person relief from the cough
Atrovent/albuterol, prednisone 3-5 days (gets rid of lower airway inflammation)
small percentage bacterial- then prescribe macrolide or tetracycline
,Tx- Anticholinergics for uncomplicated bronchitis
✔✔Asthma - ✔✔Core defect chronic airway inflammation
Spirometry is needed to make dx of asthma- FEV1
Peak flow is used to monitor asthma
inhaled corticosteroids- stop release of at least 8 inflammation mediators (only 20% of
the dose of the inhaled cort. is systemically absorbed
Visit frequency- well controlled-3-6 months, not well controlled 2-6weeks
SABA- albuterol (can't relieve inflammation, just bronchospasm
✔✔PCPs are not well-versed in - ✔✔Inhaled corticosteroids and SSRIs
✔✔Anticholinergics for asthma (Muscarinic antagonists) - ✔✔Atrovent/ipratropium
bromide- short acting
Spiriva/tiotropium bromide- long acting
used in COPD, for prevention of bronchospasm
✔✔Asthma/COPD - ✔✔PE: Hyperresonance, decreased tactile fremitus, wheeze
(expiratory first, inspiratory later), low/flattened diaphragms, increased AP diameter
For asthma flares- give 5 day course of oral prednisone (don't give injectables!)
COPD- high pressure on right side of heart can result in afib, chronic obstruction
(FEV1:FVC <0.70 post bronchodilator confirms persistent airflow limitation
oxygen therapy- >15 hours
** consider CXR only with fever and/or low SaO2 to help rule out concomitant
pneumonia
-Best course for flare--> Doxy with a short course oral corticosteroid
✔✔Alpha-1 Antitrypsin Deficiency screening - ✔✔perform when COPD develops in
patients of caucasian decent under 45 years with a strong family hx of COPD
✔✔Hemoglobin A1c - ✔✔<6% goal with no CVD (newly dx 26 y/o with DM2)
<8%- fragile elders with life expectancy <5 years (don't want hypoglycemia)
2x/year check A1c, 4x/year if not meeting glycemic goals
✔✔Metformin - ✔✔Anticipated A1C reduction with intensified use= 1-2%
With radiocontrast use, surgery, omit for the day of and >48 h post
, contra with CHF
✔✔DMT2 care consideration - ✔✔A- Aspirin
B-Blood pressure control
C- Cholesterol, statin use and creatinine-check value
D-Diet, Dental care
E-exercise, eye exam
F-Foot examination
G-Goals
✔✔JN8 guidelines- HTN/Dyslipidemia - ✔✔Age>60 goal <150/90
Age<60 goal <140/90
DM no CKD goal <140/90
CKD with or w/o DM <140/90
Non-black- thiazide, ACE/ARB, CCB (no ACE with ARB)
Black- thiazide, CCB
CKD- ACEi, ARB
wait a month...another month...4 months- introduce BB and aldosterone
young patient typically has his or her blood pressure checked every two years.
✔✔Aldosterone Antagonist- Spironolactone - ✔✔Hyperkalemia risk
Gynecomastia risk with prolonged use***
Treat it with danazol**, nonaromatizable androgens, testosterone
✔✔Statin therapy - ✔✔>7 .5 estimated 10 y ASCVD risk use mod-high intensity
DMT1/2 with high LDL use high intensity
HIgh intensity- LDL goes by 1/2
Atorvastatin- 40-80mg
Rosuvastatin- 20-40mg
Moderate- LDL goes by 1/3
Low- LDL goes down by 1/4
Statins- LDL lowering effect
Fish oil- can't switch too only can decrease TG
LDL goal for >60 male with DM and hx of ACS 2 years ago- <70
