MSN 570 Advanced Pathophysiology Leik Review (All Areas Covered)
Pulmonary:
First-line treatment for COPD:
Anticholinergic (Ipratropium/Atrovent) (Tiotropium/Spiriva)
AND/OR
a long acting B2 agonist (LABA) such as Salmeterol/ Formoterol
1st time treatment start with Atrovent and add LABA if poorly controlled.
Second-line treatment for COPD:
Inhaled corticosteroids (mild to moderate)
Systemic/oral corticosteroids “ides” (Pulmicort or Advair)
**The only treatment known to prolong life in COPD patients is supplemental O2 therapy
**Do not use LABA salmeterol/formoterol for rescue treatment**
The only drug class for rescue treatment is the short-acting B2 agonist
(SABA) (Albuterol & Xopenex) COPD/smoker with pneumonia—more
likely to have H flu bacteria
Pneumonia:
Bacterial (CAP)- acute onset, high fever, prod cough, green or rust sputum, lobar infiltrates
#1 Bacteria in CAP is streptococous pneumo #2 is H flu (RUST COLORED or BLOOD tinged )
Atypical- gradual onset, low-grade fever, headache, sore
throat, wheezing, patchy infiltrates #1 Bacteria in atypical
pneumonia is Mycoplasma pneumoniae
Pertussis:
“whooping cough”
Caused by Bordetella pertussis (gram neg)
1st line treatment—Macrolides (Zpack or
Clarithromycin/Biaxin) Antitussives,
mucolytics, rest, hydration, small frequent
meals TDAP
Bronchitis:
,New onset cough, keeping awake at night, low grade fever or mild wheezing
Symptomatic treatment: Increase fluids and rest, stop smoking (DO NOT
PICK ANTIBIOTICS as treatment) Antitussives: Dextromethorphan or
Tessalon Perles
Mucolytic: Guaifenesin
Wheezing: Albuterol inhaler, nebulized tx, or oral steroid Medrol dose pack for severe wheeze
TB:
5mm result:
HIV+
Recent contact with infectious TB cases
Chest x-ray with fibrotic changes consistent
with previous TB disease Any child who had
close contact or had TB symptoms before age
of 5 Immunocompromised patients
10mm result:
Recent immigrants within last 5 years from high-prevalence countries (Latin
Am, Asia, Africa, India, Pacific Island) Child < 4 years or
children/adolescent exposed to high-risk adult
IV drug user, health care worker, homeless
Employee or resident from high-risk setting (jail or nursing home)
15mm result:
Person with no risk factors for TB
**A PPD result may be listed as 9.5mm. If the patient falls under the 10mm group, then it is a
negative result unless the patient has the signs & symp and/or CXR findings suggestive of TB**
**Small children exposed to active TB have a high chance of coming down with the disease**
Asthma:
**Know asthma stages**
-First-line treatment for severe asthmatic exacerbation or respiratory distress: Adrenaline injection
-Peak Expiratory Flow Rate: Based on HAG (Height, Age, Gender)
-All asthmatics need a short-acting for emergencies
-Chronic use of high dose inhaled steroids can cause: osteoporosis, mild growth retardation in
children, glaucoma, cataracts, immune suppression, hypothyalmic-pituitary adrenal suppression
,**Allergic asthma check serum igG refer to allergist for scratch testing**
**Consider eye exams b/c of risk of glaucoma or cataracts**
**Consider bone density testing**
**Consider supplemental calcium with vit D for menopausal or risk of osteoporosis**
Recognize respiratory failure or severe distress: tachypnea, disappearance or lack of wheeze,
accessory muscle use, diaphoresis, and exhaustion
Hematology:
Diagnostic test for Thalassemia and Sickle cell anemia:
Hemoglobin electrophoresis Cheap screening test for
Sickle cell is: Sickledex
Diagnostic test for Iron deficiency anemia is: Iron panel
**Thalassemia vs Iron Deficiency
Anemia lab results** BOTH microcytic/
hypochromic (small and pale)
Iron deficiency anemia: low RBC, high TIBC, high RDW
(random sizes), ferritin level low Thalassemia: ferritin level
is normal to high, RBC normal or high, RDW low (same
size)
-Antacids minimize binding with iron wait 4 hours in between
Order both B12 and folate levels when evaluating MCV greater than 100 (even if no
neurological symptoms)…B12 deficiency can cause neurologic symptoms (tingling or
numbness)
, Food groups for folate deficiency- inadequate dietary intake (over cooked vegetables and low
citrus intake), dark green vegetables, fortified cereals, fresh fruits
Food groups for B12 deficiency- red meat, poultry, eggs,
milk, cheese, fortified cereal Ethnic background may not be
mentioned in a thalassemia problem, or it may be a distractor
RBC cell size may be described in many ways including:
-----MCV less than 80: Microcytic and hypochromic RBCs….small and pale RBCs
-----MCV greater than 100: Macrocytes or macroovalocytes…larger than normal RBCs…RBCs
with enlarged cytoplasms
Pernicious anemia:
is a macrocytic anemia
parietal antibody test and/or the intrinsic factor antibody test are elevated
can result in--B12 deficiency anemia, megaloblastic anemia, or neurologic symptoms
Pharmacology
-Patients with both HTN and osoteoporosis have an extra benefit from thiazides
-Thiazide diuretics reduce calcium excretion by the kidneys and stimulates the osteoblasts which
help build bone
-Patients with serious sulfa allergies should avoid thiazide diuretics (Potassium-sparing diuretics
such as triamterene and amiloride are the alternative options for these patients)
- Chlorthalidone is longer acting and more potent than HCTZ
- When on Potassium Sparing diuretics DO NOT give a potassium supplement. Avoid using salt
substitutes that contain potassium.
- When on Potassium Sparing diuretics be careful with combinations of ACE and ARBs, could
increase potassium levels
- When on Potassium Sparing diuretics avoid with severe renal disease increased risk of hyperkal
ACE/ARBs:
• ACE cough occurs within the first few months of tx. Dry and hacking cough
• 1st line drug for HTN in diabetics (diabetic neuropathy)
• 1st line drug for patients with CKD (proteinuric)
• Avoid using salt substitutes that contain potassium
• Both ACE and ARBs are excreted in breast milk (breastfeeding mothers should avoid
them)
Pulmonary:
First-line treatment for COPD:
Anticholinergic (Ipratropium/Atrovent) (Tiotropium/Spiriva)
AND/OR
a long acting B2 agonist (LABA) such as Salmeterol/ Formoterol
1st time treatment start with Atrovent and add LABA if poorly controlled.
Second-line treatment for COPD:
Inhaled corticosteroids (mild to moderate)
Systemic/oral corticosteroids “ides” (Pulmicort or Advair)
**The only treatment known to prolong life in COPD patients is supplemental O2 therapy
**Do not use LABA salmeterol/formoterol for rescue treatment**
The only drug class for rescue treatment is the short-acting B2 agonist
(SABA) (Albuterol & Xopenex) COPD/smoker with pneumonia—more
likely to have H flu bacteria
Pneumonia:
Bacterial (CAP)- acute onset, high fever, prod cough, green or rust sputum, lobar infiltrates
#1 Bacteria in CAP is streptococous pneumo #2 is H flu (RUST COLORED or BLOOD tinged )
Atypical- gradual onset, low-grade fever, headache, sore
throat, wheezing, patchy infiltrates #1 Bacteria in atypical
pneumonia is Mycoplasma pneumoniae
Pertussis:
“whooping cough”
Caused by Bordetella pertussis (gram neg)
1st line treatment—Macrolides (Zpack or
Clarithromycin/Biaxin) Antitussives,
mucolytics, rest, hydration, small frequent
meals TDAP
Bronchitis:
,New onset cough, keeping awake at night, low grade fever or mild wheezing
Symptomatic treatment: Increase fluids and rest, stop smoking (DO NOT
PICK ANTIBIOTICS as treatment) Antitussives: Dextromethorphan or
Tessalon Perles
Mucolytic: Guaifenesin
Wheezing: Albuterol inhaler, nebulized tx, or oral steroid Medrol dose pack for severe wheeze
TB:
5mm result:
HIV+
Recent contact with infectious TB cases
Chest x-ray with fibrotic changes consistent
with previous TB disease Any child who had
close contact or had TB symptoms before age
of 5 Immunocompromised patients
10mm result:
Recent immigrants within last 5 years from high-prevalence countries (Latin
Am, Asia, Africa, India, Pacific Island) Child < 4 years or
children/adolescent exposed to high-risk adult
IV drug user, health care worker, homeless
Employee or resident from high-risk setting (jail or nursing home)
15mm result:
Person with no risk factors for TB
**A PPD result may be listed as 9.5mm. If the patient falls under the 10mm group, then it is a
negative result unless the patient has the signs & symp and/or CXR findings suggestive of TB**
**Small children exposed to active TB have a high chance of coming down with the disease**
Asthma:
**Know asthma stages**
-First-line treatment for severe asthmatic exacerbation or respiratory distress: Adrenaline injection
-Peak Expiratory Flow Rate: Based on HAG (Height, Age, Gender)
-All asthmatics need a short-acting for emergencies
-Chronic use of high dose inhaled steroids can cause: osteoporosis, mild growth retardation in
children, glaucoma, cataracts, immune suppression, hypothyalmic-pituitary adrenal suppression
,**Allergic asthma check serum igG refer to allergist for scratch testing**
**Consider eye exams b/c of risk of glaucoma or cataracts**
**Consider bone density testing**
**Consider supplemental calcium with vit D for menopausal or risk of osteoporosis**
Recognize respiratory failure or severe distress: tachypnea, disappearance or lack of wheeze,
accessory muscle use, diaphoresis, and exhaustion
Hematology:
Diagnostic test for Thalassemia and Sickle cell anemia:
Hemoglobin electrophoresis Cheap screening test for
Sickle cell is: Sickledex
Diagnostic test for Iron deficiency anemia is: Iron panel
**Thalassemia vs Iron Deficiency
Anemia lab results** BOTH microcytic/
hypochromic (small and pale)
Iron deficiency anemia: low RBC, high TIBC, high RDW
(random sizes), ferritin level low Thalassemia: ferritin level
is normal to high, RBC normal or high, RDW low (same
size)
-Antacids minimize binding with iron wait 4 hours in between
Order both B12 and folate levels when evaluating MCV greater than 100 (even if no
neurological symptoms)…B12 deficiency can cause neurologic symptoms (tingling or
numbness)
, Food groups for folate deficiency- inadequate dietary intake (over cooked vegetables and low
citrus intake), dark green vegetables, fortified cereals, fresh fruits
Food groups for B12 deficiency- red meat, poultry, eggs,
milk, cheese, fortified cereal Ethnic background may not be
mentioned in a thalassemia problem, or it may be a distractor
RBC cell size may be described in many ways including:
-----MCV less than 80: Microcytic and hypochromic RBCs….small and pale RBCs
-----MCV greater than 100: Macrocytes or macroovalocytes…larger than normal RBCs…RBCs
with enlarged cytoplasms
Pernicious anemia:
is a macrocytic anemia
parietal antibody test and/or the intrinsic factor antibody test are elevated
can result in--B12 deficiency anemia, megaloblastic anemia, or neurologic symptoms
Pharmacology
-Patients with both HTN and osoteoporosis have an extra benefit from thiazides
-Thiazide diuretics reduce calcium excretion by the kidneys and stimulates the osteoblasts which
help build bone
-Patients with serious sulfa allergies should avoid thiazide diuretics (Potassium-sparing diuretics
such as triamterene and amiloride are the alternative options for these patients)
- Chlorthalidone is longer acting and more potent than HCTZ
- When on Potassium Sparing diuretics DO NOT give a potassium supplement. Avoid using salt
substitutes that contain potassium.
- When on Potassium Sparing diuretics be careful with combinations of ACE and ARBs, could
increase potassium levels
- When on Potassium Sparing diuretics avoid with severe renal disease increased risk of hyperkal
ACE/ARBs:
• ACE cough occurs within the first few months of tx. Dry and hacking cough
• 1st line drug for HTN in diabetics (diabetic neuropathy)
• 1st line drug for patients with CKD (proteinuric)
• Avoid using salt substitutes that contain potassium
• Both ACE and ARBs are excreted in breast milk (breastfeeding mothers should avoid
them)
