NRNP 6566 WEEK 3 KNOWLEDGE
CHECK
Question 1
Mrs. Franklin is a 68-year-old woman with long-standing, persistent AF being managed
with rhythm control on dofetilide. She also has type 2 diabetes mellitus (T2DM),
hypertension, and a myocardial infarction 3 years ago.
What is her CHADS2 and CHA2DS2-VASc score? How would you interpret those scores in
deciding on treatment for Mrs. Franklin?
Correct
Answer:
CHADS2 score=2 (HTN, T2DM)
A score of greater than 2 is considered high risk for stroke.
CHA2DS2-VASc score=5 (age >65, female, HTN, T2DM, coronary artery
disease [CAD])
A score of greater than 2 is considered high risk for stroke.
Many patients are hesitant to begin anticoagulation due to the expense and
inconvenience. However, after understanding that a 4% annual risk for stroke
(if the CHA2DS2-VASc Score is 4) equates to 40% risk over 10 years, patients
are more willing to comply.
Question 2
A 58-year-old male complains of a galloping heart rate and shortness of breath. Vital
signs are BP 110/74, P 156, RR 22 Oxygen sat is 96%. Continuous EKG monitoring
identifies periods of sinus tachycardia as well as episodes of atrial fibrillation. Laboratory
results for this patient show:
Hemoglobin 13.3 g/dl
Hematocrit 39%
WBC 8.7
Platelets 172,000
Sodium 140
Potassium 3.7
TSH 0.0 mIU/L
T4 3 mg/dl
T3 6.6 pg/ml
What is your working diagnosis and what two initial medications would you prescribe for
this patient?
, Correct
Answer:
The low TSH combined with the high T4 and T3 are indicative of
hyperthyroidism. A common side effect of the hypermetabolic state is atrial
fibrillation. Two medications that should be considered for initial treatment are
beta blockers and anti-thyroid drugs.
Beta blockers offer quick relief symptoms of hyperthyroidism, such as
tachycardia, palpitations, heat intolerance, and nervousness. Nonselective
beta blockers, such as propranolol, are preferred because they have a more
direct effect on hypermetabolism. Start propranolol at 10 to 20 mg every 6
hours and titrate upward until symptoms are controlled. Once the T4 and T3
have normalized, the propranolol can be tapered off.
Methimazole is the drug of choice in nonpregnant patients because of its lower
cost, longer half-life, and lower incidence of hematologic side effects. Start the
medication at 15 to 30 mg per day. Monthly free T4 and T3 levels should be
obtained and methimazole adjusted to reach an euthyroid state.
Maintenance doses may be lower (5–10 mg daily).
Question 3
A 63-year-old female has been successfully cardioverted and is now on amiodarone for
rhythm maintenance. The patient is on the following medications:
Warfarin 10 mg po daily
Lisinopril 20 mg po daily
Amiodarone 400 mg po daily
Prilosec 20 mg po daily
Digoxin 4250 mcg po daily
What interactions are possible and how would you monitor and adjust for them.
Correct
Answer:
Amiodarone is known to interact with warfarin and digoxin. Digoxin levels may
increase 30–50% when taken with amiodarone. Amiodarone increases digoxin
concentrations by inhibiting the P-glycoprotein (P-gp) mediated transport that
facilitates the elimination of digoxin from the body. The greater the
concentration of amiodarone the greater the increase in serum digoxin
levels.
Patient’s digoxin levels should be closely monitored, and dosing should be
decreased to account for this effect.
Amiodarone is a potent inhibitor of the enzymes that metabolize warfarin.
Decreased metabolism of warfarin leads to higher plasma concentration levels
and increased risk of bleeding. Warfarin doses should be decreased, and
frequent INR monitoring is indicated when initiating amiodarone treatment.
CHECK
Question 1
Mrs. Franklin is a 68-year-old woman with long-standing, persistent AF being managed
with rhythm control on dofetilide. She also has type 2 diabetes mellitus (T2DM),
hypertension, and a myocardial infarction 3 years ago.
What is her CHADS2 and CHA2DS2-VASc score? How would you interpret those scores in
deciding on treatment for Mrs. Franklin?
Correct
Answer:
CHADS2 score=2 (HTN, T2DM)
A score of greater than 2 is considered high risk for stroke.
CHA2DS2-VASc score=5 (age >65, female, HTN, T2DM, coronary artery
disease [CAD])
A score of greater than 2 is considered high risk for stroke.
Many patients are hesitant to begin anticoagulation due to the expense and
inconvenience. However, after understanding that a 4% annual risk for stroke
(if the CHA2DS2-VASc Score is 4) equates to 40% risk over 10 years, patients
are more willing to comply.
Question 2
A 58-year-old male complains of a galloping heart rate and shortness of breath. Vital
signs are BP 110/74, P 156, RR 22 Oxygen sat is 96%. Continuous EKG monitoring
identifies periods of sinus tachycardia as well as episodes of atrial fibrillation. Laboratory
results for this patient show:
Hemoglobin 13.3 g/dl
Hematocrit 39%
WBC 8.7
Platelets 172,000
Sodium 140
Potassium 3.7
TSH 0.0 mIU/L
T4 3 mg/dl
T3 6.6 pg/ml
What is your working diagnosis and what two initial medications would you prescribe for
this patient?
, Correct
Answer:
The low TSH combined with the high T4 and T3 are indicative of
hyperthyroidism. A common side effect of the hypermetabolic state is atrial
fibrillation. Two medications that should be considered for initial treatment are
beta blockers and anti-thyroid drugs.
Beta blockers offer quick relief symptoms of hyperthyroidism, such as
tachycardia, palpitations, heat intolerance, and nervousness. Nonselective
beta blockers, such as propranolol, are preferred because they have a more
direct effect on hypermetabolism. Start propranolol at 10 to 20 mg every 6
hours and titrate upward until symptoms are controlled. Once the T4 and T3
have normalized, the propranolol can be tapered off.
Methimazole is the drug of choice in nonpregnant patients because of its lower
cost, longer half-life, and lower incidence of hematologic side effects. Start the
medication at 15 to 30 mg per day. Monthly free T4 and T3 levels should be
obtained and methimazole adjusted to reach an euthyroid state.
Maintenance doses may be lower (5–10 mg daily).
Question 3
A 63-year-old female has been successfully cardioverted and is now on amiodarone for
rhythm maintenance. The patient is on the following medications:
Warfarin 10 mg po daily
Lisinopril 20 mg po daily
Amiodarone 400 mg po daily
Prilosec 20 mg po daily
Digoxin 4250 mcg po daily
What interactions are possible and how would you monitor and adjust for them.
Correct
Answer:
Amiodarone is known to interact with warfarin and digoxin. Digoxin levels may
increase 30–50% when taken with amiodarone. Amiodarone increases digoxin
concentrations by inhibiting the P-glycoprotein (P-gp) mediated transport that
facilitates the elimination of digoxin from the body. The greater the
concentration of amiodarone the greater the increase in serum digoxin
levels.
Patient’s digoxin levels should be closely monitored, and dosing should be
decreased to account for this effect.
Amiodarone is a potent inhibitor of the enzymes that metabolize warfarin.
Decreased metabolism of warfarin leads to higher plasma concentration levels
and increased risk of bleeding. Warfarin doses should be decreased, and
frequent INR monitoring is indicated when initiating amiodarone treatment.
