What is the major difference between varicose veins and atherosclerosis?
What is the major difference between varicose veins and atherosclerosis?
Vessels that are affected
Pt has had poorly controlled HTN >10yrs. Indicate the most likely position of his PMI.
c. 5th ICS left of MCL
43yo hispanic male has audible diastolic murmur best heard at the mitral point. No audible click. He has been monitored for 2yrs. What is the most likely murmur?
d. Mitral stenosis
What are PFTs?
Group of tests that provide quantifiable measurement of lung function, used to dx resp abnormalities or assess progression/resolution of lung dz.
What is FEV1?
Forced Expiratory Volume in 1 second (80-120%)
What is FVC?
Forced Vital Capacity (80-120%)
What is normal FEV1/FVC ratio?
<0.7 (70%)
What is GOLD 1 criteria?
Mild
FEV1 >/= 80% predicted
What is GOLD 2 criteria?
Moderate
FEV1 50-79% predicted
What is GOLD 3 criteria?
Severe
FEV1 30-49% predicted
What is GOLD 4 criteria?
Very severe
FEV1 <30% predicted
What are the signal symptoms of COPD?
Dyspnea
Chronic cough w/sputum
Decreased activity tolerance
Wheezing
What are characteristics of COPD?
Common, preventable, treatable.
Characterized by persistent airflow limitation.
Usually progressive, associated with enhanced chronic inflammatory response in airways and lungs to noxious particles/gases
Airway fibrosis, luminal plugs, airway inflammation, increased airway resistance, small airway dz.
Decreased elastic recoil of alveoli.
What are risk factors for COPD?
Smoking (increasing w/number of pack years)
Second hand smoke
Environmental pollution (endotoxins, coal dust, mineral dust)
What is seen on phys exam in COPD?
May be normal in early states
As severity progresses: lung hyperinflation, decreased breath sounds, wheezes at bases, distant heart tones (b/c of hyperinflation, so S1/S2 sounds off in distance), accessory muscle use, pursed lip breathing, increased expiratory phase, neck vein distention.
How is COPD diagnosed?
Spirometry is gold standard (pre and post bronchodilator).
Irreversible airflow limitation is hallmark.
How is COPD treated?
Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo.
What is the MOA of beta agonists?
Stimulates beta-2-adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways.
What is the MOA of anticholinergics?
Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation.
Why are long-acting beta agonists prescribed for COPD?
They are for moderate airflow limitation.
They relieve symptoms, increase exercise tolerance, reduce number of exacerbations, improve QOL.
What are some non pulmonary diagnoses that result in COPD-type symptoms?
CHF
What are some Hyperventilation syndrome
Panic attacks
Vocal cord dysfunction
Obstructive sleep apnea
Aspergillosis
Chronic fatigue syndrome
What are signal symptoms of asthma?
Wheezing
Shortness of breath
Cough (esp at night)
Chest tightness
What is chronic bronchitis?
Daily chronic cough w/increased sputum for at least 3 consecutive months in at least 2 consecutive years.
Usually worse on wakening.
May or may not be associated with COPD.
What is emphysema?
Characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles.
Chronic inflammation/remodeling, trapping air, hindering effective O2/CO2 exchange (all due to inflammatory mediators infiltrating airways).
What are signal symptoms of ischemic heart dz?
Chest pain
Chest tightness
Chest discomfort
What is ischemic heart dz?
Imbalance between supply and demand for blood flow to myocardium
What are signal symptoms of lung CA?
Cough
Dyspnea
Wt loss
Anorexia
Hemoptysis
What is lung CA?
Malignant neoplasm originating in parenchyma of lung/airways
What are signal symptoms of MI?
Prolonged CP (>20min duration)
SOB
Confusion
Weakness
Worsening HF
What is an MI?
Necrosis of heart tissue caused by lack of blood and O2 supply to the heart
What are signal symptoms of pneumonia?
Fever
Chills
Hypothermia
New cough w/or w/out sputum
Chest discomfort or dyspnea
Fatigue
HA
Some older adults will be asymptomatic but may experience falls/confusion
What is community acquired pneumonia?
Acute lower resp tract infection of lung parenchyma.
Can be bacterial or viral.
Bacterial is most common in older adults.
What are signal symptoms of a PE?
Dyspnea
CP on inspiration
Anxiety
Presentation is variable
Symptoms nonspecific
Some asymptomatic
What is PE description?
Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site.
What are signal symptoms of tuberculosis?
Initially asymptomatic
Later: productive, prolonged cough
Fatigue
Low-grade fever
Night sweats
Poor appetite
Hemoptysis
Wt loss
Fever/sweats are less common in elderly
Symptoms in elderly are often attributed to other comorbidities
What is tuberculosis?
Chronic, necrotizing infection caused by slow-growing acid-fast bacillus (Mycobacterium tuberculosis).
Most common cause of death related to infectious dz worldwide.
What are signal symptoms of valvular heart dz?
Asymptomatic in early stages
Fatigue
Exertional dyspnea
What is valvular heart dz?
Damage to valve(s) of the heart, causing cardiac dysfunction.
Most prevalent types in elderly: calcific and degenerative aortic valve dz
What is aortic stenosis?
Abnormal narrowing of aortic valve orifice
What is aortic regurgitation?
Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole
What is mitral stenosis?
Abnormal narrowing of mitral valve orifice
What is mitral regurgitation?
Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve
What is mitral valve prolapse?
Mitral regurgitation associated with bulging of one or both mitral valve leaflets into L atrium during ventricular systole
What are most common causes of VHD in elderly?
Age-related degenerative calcifications
Myxomatous degeneration
Papillary muscle dysfunction
Infective endocarditis
Rheumatic dz
What happens in valvular regurgitation?
Portion of the ejected blood leaks back into the upstream cardiac chamber
What happens in valvular stenosis?
Usually results in elevated pressures in the chamber upstream from the stenosis
What are signal symptoms of URI?
Nasal congestion
Rhinorrhea/mucopurulent discharge
Sore throat
Cough
HA
Malaise
What is a URI?
Most frequently called the common cold
Usually caused by virus
Results in nasal passage inflammation
Most are self-limiting, accompanied by minor complaints
Included in URI dx: acute laryngitis, acute rhinosinusitis, acute pharyngitis
What are signal symptoms of restrictive lung dz?
Rapid, shallow respirations
Dyspnea
Decreased activity tolerance
Easily fatigued
Nonproductive, irritating cough provoked by deep breathing/exertion
What is restrictive lung dz?
Heterogenous group of disorders that share common abnormal ventilatory function.
Characterized by small tidal volume, rapid rate.
Hallmark restrictive pattern is decreased lung volm, esp. total lung capacity and vital capacity.
What is the purpose of functional assessment of the elderly?
Discovers the ability to care for themselves on a daily bases
What can ongoing pain be linked to in the elderly?
Depression
Decreased socialization
Sleep disturbance
Impaired cognitive function
Is chronic pain a normal sign of aging?
No
What is polypharmacy?
Broad definition, but basically too many medications for what is going on with the patient, the use of multiple pharmacies/providers.
What is Stage A of HF?
At high risk for heart failure but w/out structural changes/symptoms
What is Stage B HF?
Structural heart dz but w/out s/s of HF (still “at risk” for HF)
What is Stage C HF?
Structural heart dz w/prior or current s/s of HF (actually have HF)
What is Stage D HF?
Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.)
What are treatment goals for Stage A HF?
Heart-healthy lifestyle
Prevent vascular, coronary dz
Prevent LV structural abnormalities
What are drugs used in Stage A HF?
ACEi or ARB in appropriate pt’s for vascular dz or DM
Statins as appropriate
What are treatment goals for Stage B HF?
Prevent HF symptoms
Prevent further cardiac remodeling
What are drugs used in Stage B HF?
ACEi or ARB as appropriate
Beta blockers as appropriate
In selected pt’s:
ICD
Revascularization/valvular surgery as appropriate
What are goals of Stage C HFpEF?
Control symptoms
Improve HRQOL
Prevent hospitalization
Prevent mortality
ID comorbidities
What is treatment for Stage C HFpEF?
Diuresis to relieve s/s congestion
Follow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.)
What are treatment goals for Stage C HFrEF?
Control symptoms
Pt education
Prevent hospitalization
Prevent mortality
What are drugs used in Stage C HFrEF?
Diuretics for fluid retention
ACEi or ARB
BB
Aldosterone antagonists
Drugs in selected pts:
Hydralazine/isosorbide dinitrate
ACEi and ARB
Digitalis
Procedures in selected pts:
CRT
ICD
Revascularization/valvular surgery as appropriate
What are treatment goals in Stage D HF?
Control symptoms
Improve HRQOL
Reduce hospital readmissions
Establish pt’s end-of-life goals
What are options for Stage D HF?
Advanced care measures
Heart transplant
Chronic inotropes
Temporary or permanent MCS
Experimental surgery/drugs
Palliative care, hospice
ICD deactivation
What is the normal BNP level?
<100pg/mL (indicates HF is unlikely)
What is normal BP?
<120/80
What is “elevated” BP?
120-129/<80
What is Stage 1 HTN?
130-139 OR 80-89
What is Stage 2 HTN?
>/= 140 or >/= 90
What is recommended BP for DM?
<130/80
What is recommended BP for CKD?
<130/80
How should HTN be managed?
Stage 2 and up should be given consideration for pharm treatment.
Others can wait for lifestyle modification.
What is first-line meds for non-black HTN population (including those w/DM)?
Thiazide, CCB, ACEi, or ARB, either alone or in combo
What is the med guideline for ASCVD for those </= 75yo?
High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)
What is the med guideline for ASCVD for those >75yo?
Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mg BID)
What is the guideline for meds for LDL >/= 190?
High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)
What is the med guideline for ASCVD for 40-75yo w/DM?
Their 10yr risk is >7.5%, so high intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)
What is the med guideline for LDL 70-189?
Their 10yr risk is <7.5%, so moderate intensity statin (atorvastatin/Lipitor 10mg, rosuvastatin/Crestor 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mgBID)
What is the ASCVD med guideline for 40-75yo w/out ASCVD or DM?
Their 10yr risk is >7.5%, so moderate to high intensity statin
The meds listed in Beers Criteria are not absolutely contraindicated in elderly.
True
The BC recommendations are graded as high, medium, low to assist w/decision making.
True
The BC list includes dosage adjustments for kidney impairment.
True
The BC list includes drug to drug interactions to avoid.
True
Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts.
True
What vaccination is recommended for people traveling to countries where dz is common?
Hep A
How is Hep A vax given?
Two doses: initial at least 4wks before departure, second dose 6-12mo later.
When is Hep B vax recommended?
High-risk people (IV drug users, persons w/multiple partners)
How is Hep B vax given?
Initial dose
1mo later: 2nd dose
4-6mo after 2nd: 3rd dose
When is Zostavax recommended?
Anyone over 60yo, given as single dose
Can people who have had prior episode of zoster be vaccinated?
Yes
When is flu vax recommended?
Annually for all adults >50yo
When should DTaP be given?
Once in a lifetime for all adults, then Td booster every 10yrs.
When is pneumococcal vax recommended?
Once for 65yo and older
Younger adults w/severe chronic health conditions
What is primary prevention?
Activities to prevent occurrence of dz or adverse health condition, including mental health.
What is osteoporosis?
Skeletal disorder characterized by impaired bone strength that predisposes to increased risk of fracture.
Can occur from not only bone loss but also from failure earlier in life to make sufficient bone.
Primary: due to aging (increased bone resorption/reduced new bone formation)
Secondary: consequence of underlying medical condition/drug
What are s/s of osteoporosis?
Sometimes not seen until fracture sustained spontaneously or after minimal trauma, usually in thoracic/lumbar vertebrae, hip, wrist, humerus, pelvis.
With each fracture, risk of another increases exponentially.
Loss of height, kyphosis development.
XR: bones appear osteopenic (at least 30% loss in bone mass); spine shows loss of horizontal vertebral trabeculae, accentuating end plates, producing biconcave “codfish” vertebrae; maybe compression fracture.
What are diagnostic tests for osteoporosis?
XR
DEXA (screen all women >65yo, hip/spine; test earlier if major risk factors present; repeat every 3-5yrs depending on degree)
What is T-score of -2.5 or lower indicative of?
Osteoporosis
What is a T-score of -1.0 to -2.5 indicative of?
Osteopenia
What is a T-score of -1.0 or higher indicative of?
Normal bone density
What is a Z-score of <-1.5 indicative of?
Secondary cause of osteoporosis
What are the risk factors for osteoporosis?
Previous fracture
Advanced age
Low body wt/BMI
Maternal h/o fracture
Current smoking
Physical inactivity
Excessive exercise resulting in amenorrhea
Poor lifetime intake of calcium
Endocrine disorders
GI dz
Chronic systemic illnesses
Nutritional deficiencies
Meds (steroids, anticonvulsants, thyroid hormone, SSRI, aromatase inhibitors for breast CA)
Alcoholism
What is the treatment for osteoporosis?
Aim to prevent those that are at risk
Combine diet, exercise, meds
Dietary Ca/vit D
Wt-bearing/strength exercises
Bisphosphonates
Selective estrogen receptor modulators
Calcitonin
PTH
Denosumab
Fall prevention
How does chronic pain differ from acute pain?
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