Lecture notes in Cardiology

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Med Surg Quick Notes Me d   Su r g   Qui c k   No t e s   Created by SimpleNursing.com Version: 1.0 Simplenursing.com 82% or Higher on Your Next Nursing Test 1 Med Surg Quick Notes Table of Contents 1 Cardiology I Exam Notes ...................................................................................................................................... 8 1.1 Cardiology Terms & Introduction .................................................................................................................. 8 1.2 Pharmacology: Lipid Lowering Drugs........................................................................................................... 8 1.3 Clinical Medicine: Lipids ............................................................................................................................. 10 1.4 Pharmacology: Antihypertensives .............................................................................................................. 13 1.5 Clinical Medicine: Hypertension ................................................................................................................. 16 1.6 Pharmacology: Ischemic Heart Disease .................................................................................................... 18 1.7 Clinical Medicine: Ischemic Heart Disease ................................................................................................ 19 1.8 Pharmacology & Clinical Medicine: Heart Failure ...................................................................................... 24 1.9 Pharmacology & Clinical Medicine: Arrhythmias ........................................................................................ 30 1.10 Clinical Medicine: Cardiovascular Disease Prevention .............................................................................. 31 2 Cardiology II Exam Notes ................................................................................................................................... 32 2.1 Valvular Heart Disease, Infective Endocarditis, and Rheumatic Fever ...................................................... 32 2.2 Vascular Disease ....................................................................................................................................... 37 2.3 Myocardial and Pericardial Disease ........................................................................................................... 41 2.4 Arrhythmias ................................................................................................................................................ 44 3 Dermatology Exam Notes ................................................................................................................................... 46 3.1 Introduction to Dermatology ....................................................................................................................... 46 3.2 Common Bacterial Skin Infections ............................................................................................................. 49 3.3 Fungal and Viral Infections of the Skin ....................................................................................................... 53 3.4 Contact Dermatitis...................................................................................................................................... 56 3.5 Common Inflammatory Dermatoses ........................................................................................................... 58 3.6 Cutaneous Manifestations of Systemic Diseases ...................................................................................... 61 3.7 Acne ........................................................................................................................................................... 65 3.8 Warts .......................................................................................................................................................... 68 3.9 Hair and Nails ............................................................................................................................................ 69 3.10 Human Ectoparasites ................................................................................................................................. 72 4 Emergency Medicine Exam Notes ...................................................................................................................... 75 4.1 Chest Pain Presentations & Cardiac Emergencies .................................................................................... 75 4.2 Infectious Disease Emergencies ................................................................................................................ 81 4.3 Respiratory Emergencies & Airway Management ...................................................................................... 90 4.4 Genitourinary Emergencies ........................................................................................................................ 95 4.5 Acute Abdomen ....................................................................................................................................... 100 4.6 GI Bleed ................................................................................................................................................... 103 4.7 Ocular Emergencies ................................................................................................................................. 107 4.8 Introduction to Point of Care Ultrasound .................................................................................................. 112 5 Emergency Medicine Exam II Notes ................................................................................................................. 115 5.1 Burns ........................................................................................................................................................ 115 5.2 Neurological Emergencies & Head and Spine Trauma ............................................................................ 119 5.3 Pediatric Emergencies ............................................................................................................................. 131 5.4 Shock ....................................................................................................................................................... 135 5.5 Orthopedic Emergencies .......................................................................................................................... 138 Simplenursing.com 82% or Higher on Your Next Nursing Test 2 Med Surg Quick Notes 5.6 Trauma Resuscitation .............................................................................................................................. 141 6 Endocrinology Exam Notes ............................................................................................................................... 144 6.1 Introduction .............................................................................................................................................. 144 6.2 Diabetes Mellitus ...................................................................................................................................... 146 6.3 Diabetes Pharmacology: Oral Agents & Non-Insulin Injectables for Diabetes ......................................... 150 6.4 Insulin Dosing .......................................................................................................................................... 153 6.5 Thyroid ..................................................................................................................................................... 155 6.6 Pituitary Disorders .................................................................................................................................... 163 6.7 Adrenal Disorders .................................................................................................................................... 168 6.8 Disorders of Calcium Metabolism............................................................................................................. 174 6.9 Osteoporosis and Metabolic Bone Disease ............................................................................................. 177 7 ENT Exam Notes .............................................................................................................................................. 178 7.1 Primary Care Otolaryngology ................................................................................................................... 178 7.2 Ophthalmology ......................................................................................................................................... 191 7.3 Common Dental and Oral Mucosal Disorders .......................................................................................... 197 7.4 Oral Cancer and Precancerous Lesions .................................................................................................. 199 8 Gastroenterology Exam Notes .......................................................................................................................... 200 8.1 Approach to the Patient with Gastrointestinal Disease............................................................................. 200 8.2 Diagnostic Methods.................................................................................................................................. 201 8.3 Miscellaneous GI Complaints and Anorectal Disorders ........................................................................... 206 8.4 Colon Cancer ........................................................................................................................................... 209 8.5 GI Bleed ................................................................................................................................................... 211 8.6 Liver Disease ........................................................................................................................................... 213 8.7 Esophageal Disease ................................................................................................................................ 217 8.8 Pancreatic Disease .................................................................................................................................. 221 8.9 Biliary Diseases ....................................................................................................................................... 224 8.10 Infectious Diarrhea ................................................................................................................................... 227 8.11 Inflammatory Bowel Disease .................................................................................................................... 230 8.12 Irritable Bowel Syndrome ......................................................................................................................... 233 8.13 Peptic Ulcer Disease and Gastric Cancer ................................................................................................ 234 9 Gynecology Exam Notes .................................................................................................................................. 237 9.1 Gynecologic Anatomy .............................................................................................................................. 237 9.2 Gynecologic Physiology ........................................................................................................................... 238 9.3 Hormone Studies ..................................................................................................................................... 240 9.4 Gyn Procedures ....................................................................................................................................... 243 9.5 Abnormal Uterine Bleeding, Amenorrhea, and Dysmenorrhea ................................................................ 246 9.6 Sexually Transmitted Infections ............................................................................................................... 248 9.7 Vulvar and Vaginal Disorders ................................................................................................................... 255 9.8 Cervical Disorders .................................................................................................................................... 257 9.9 Gynecologic Pain Disorders and Sexual Dysfunction .............................................................................. 259 9.10 Female Breast Disorders ......................................................................................................................... 261 9.11 Female Breast Cancer ............................................................................................................................. 265 9.12 Contraception ........................................................................................................................................... 267 9.13 Hormone Therapy .................................................................................................................................... 271 Simplenursing.com 82% or Higher on Your Next Nursing Test 3 Med Surg Quick Notes 9.14 Menopause .............................................................................................................................................. 274 9.15 Uterine Disorders ..................................................................................................................................... 276 9.16 Urinary Incontinence ................................................................................................................................ 278 9.17 Induced Abortion and Management of Early Pregnancy Loss ................................................................. 280 9.18 Ovarian Disorders .................................................................................................................................... 282 10 Hematology Exam Notes .................................................................................................................................. 285 10.1 Red Cell Disorders & Neutropenia ........................................................................................................... 285 10.2 Hematologic Malignancies ....................................................................................................................... 294 10.3 Hemostasis: Platelets & Coagulation ...................................................................................................... 300 10.4 Transfusion Medicine ............................................................................................................................... 307 11 Infectious Disease Unit Exam Notes ................................................................................................................. 309 11.1 Pathogens By Site of Infection ................................................................................................................. 309 11.2 Antibiotics ................................................................................................................................................. 309 11.3 Introduction: Principles of Infectious Disease ........................................................................................... 315 11.4 Prevention of Disease .............................................................................................................................. 328 12 Men’s  Health  Exam  Notes ................................................................................................................................ 330 12.1 Male Genitourinary Anatomy .................................................................................................................... 330 12.2 H&P of Male Genitalia, Hernias, Lymphatics, Anus, Rectum, and Prostate ............................................. 332 12.3 Miscellaneous Male Diagnostic Methods ................................................................................................. 334 12.4 Topics  In  Men’s  Health ............................................................................................................................. 334 12.5 Orchitis, Benign Scrotal Disease, and STIs ............................................................................................. 339 12.6 Male Cancers ........................................................................................................................................... 342 13 Microbiology Exam Notes ................................................................................................................................. 345 13.1 Background & Classification .................................................................................................................... 345 13.2 Viruses ..................................................................................................................................................... 345 13.3 Bacteria .................................................................................................................................................... 347 13.4 Fungi: yeasts & molds .............................................................................................................................. 348 13.5 Parasites: protozoa & helminths .............................................................................................................. 349 13.6 Respiratory Pathogens ............................................................................................................................. 350 13.7 Pathogens of Skin, Mucous Membranes, and Bone ................................................................................ 356 13.8 Corynebacterium ...................................................................................................................................... 358 13.9 Gastrointestinal Pathogens ...................................................................................................................... 362 13.10 Genitourinary Pathogens ................................................................................................................. 367 13.11 Pathogens of Sterile Sites ............................................................................................................... 370 13.12 Listeria monocytogenes .................................................................................................................. 372 13.13 Systemic Febrile Syndromes ........................................................................................................... 373 14 Nephrology Exam Notes ................................................................................................................................... 377 14.1 Nephrology Tidbits ................................................................................................................................... 377 14.2 iagnostic Methods: Renal Chemistries, UA, Urine Cultures ..................................................................... 378 14.3 Diagnostic Methods: Urinary Tract Imaging ............................................................................................. 381 14.4 Kidney Physiology .................................................................................................................................... 382 14.5 Salt and Water ......................................................................................................................................... 387 14.6 Nephrolithiasis ......................................................................................................................................... 392 14.7 Acute Renal Failure.................................................................................................................................. 395 Simplenursing.com 82% or Higher on Your Next Nursing Test 4 Med Surg Quick Notes 14.8 Urinary Tract Infections ............................................................................................................................ 397 14.9 Glomerulopathies and Other Renal Diseases .......................................................................................... 399 14.10 Chronic Kidney Disease and Management of Potassium, Calcium, and Phosphorus ..................... 402 15 Neurology Exam Notes ..................................................................................................................................... 408 15.1 Neuroanatomy Review ............................................................................................................................. 408 15.2 Approach to the Neurologic Patient and Diagnostic Methods .................................................................. 413 15.3 Neurogenetics .......................................................................................................................................... 417 15.4 Movement Disorders ................................................................................................................................ 420 15.5 CNS Infections ......................................................................................................................................... 424 15.6 Multiple Sclerosis ..................................................................................................................................... 426 15.7 CNS Neoplasms....................................................................................................................................... 427 15.8 Motor Neuron Diseases, Disorders of Neuromuscular Transmission, and Muscular Dystrophy .............. 430 15.9 Epilepsy and Coma .................................................................................................................................. 435 15.10 Coma ............................................................................................................................................... 441 15.11 Stroke .............................................................................................................................................. 444 15.12 Headache ........................................................................................................................................ 447 15.13 Peripheral Neuropathies .................................................................................................................. 453 16 Oncology Exam Notes ...................................................................................................................................... 461 16.1 Imaging Studies in Oncology ................................................................................................................... 461 16.2 Radiation Therapy .................................................................................................................................... 463 16.3 Chemotherapy ......................................................................................................................................... 465 16.4 Introduction to Medical Oncology ............................................................................................................. 468 16.5 Types of Solid Tumor Malignancies ......................................................................................................... 476 17 Ortho Exam Notes ............................................................................................................................................ 483 17.1 Introduction to Orthopedics ...................................................................................................................... 483 17.2 Cervical Spine .......................................................................................................................................... 487 17.3 Common Shoulder Disorders ................................................................................................................... 490 17.4 Elbow, Wrist, and Hand ............................................................................................................................ 493 17.5 Lumbar Spine ........................................................................................................................................... 500 17.6 The Hip .................................................................................................................................................... 504 17.7 The Knee ................................................................................................................................................. 506 17.8 The Ankle ................................................................................................................................................. 508 17.9 Pharmacology: Management of Musculoskeletal Pain ............................................................................. 511 18 Pulmonology Exam Notes ................................................................................................................................. 514 18.1 Pulmonology H&P .................................................................................................................................... 514 18.2 Physiology Refresher ............................................................................................................................... 514 18.3 Common Pulmonary Symptoms .............................................................................................................. 515 18.4 Pulmonary Imaging .................................................................................................................................. 516 18.5 Sputum Cultures ...................................................................................................................................... 518 18.6 Tuberculin Skin Testing ............................................................................................................................ 518 18.7 Respiratory Tract Infections and Antibiotic Therapy ................................................................................. 519 18.8 Pulmonary Function Testing & Sleep Studies .......................................................................................... 524 18.9 Obstructive Airway Disease and Pharmacologic Therapies ..................................................................... 528 18.10 Interstitial Lung Disease/Diffuse Parenchymal Lung Disease ......................................................... 533 Simplenursing.com 82% or Higher on Your Next Nursing Test 5 Med Surg Quick Notes 18.11 Occupational Lung Disease............................................................................................................. 537 18.12 Venous Thromboembolism.............................................................................................................. 539 18.13 Pulmonary Hypertension ................................................................................................................. 541 18.14 Lung Cancer and Pleural Disease ................................................................................................... 542 18.15 Acute Respiratory Distress Syndrome ............................................................................................. 544 18.16 Cystic Fibrosis ................................................................................................................................. 545 19 Rheumatology Exam Notes .............................................................................................................................. 548 19.1 Introduction to Rheumatic Diseases......................................................................................................... 548 19.2 Common Rheumatological Lab Tests ...................................................................................................... 550 19.3 Rheumatoid Arthritis ................................................................................................................................. 552 19.4 Infectious Arthritis..................................................................................................................................... 557 19.5 The Spondyloarthropathies ...................................................................................................................... 558 19.6 Idiopathic Inflammatory Myopathies ......................................................................................................... 561 19.7 Scleroderma ............................................................................................................................................. 563 19.8 Crystal-Induced Arthritis ........................................................................................................................... 564 19.9 Sarcoidosis and Other Systemic Diseases with Rheumatic Manifestations ............................................. 568 19.10 Systemic Lupus Erythematosus ...................................................................................................... 571 19.11 SLE Treatment and Prognosis ........................................................................................................ 573 19.12 Miscellaneous Rheumatic Diseases ................................................................................................ 574 19.13 Osteoarthritis ................................................................................................................................... 576 20 Surgery Exam I Notes ....................................................................................................................................... 580 20.1 Intro to the OR ......................................................................................................................................... 580 20.2 Casting ..................................................................................................................................................... 585 20.3 Sutures & Knots ....................................................................................................................................... 586 20.4 Bandaging ................................................................................................................................................ 590 20.5 Pre & Post-Op Considerations ................................................................................................................. 590 20.6 Shock & Transfusions .............................................................................................................................. 593 20.7 Gastrointestinal Surgery I ......................................................................................................................... 595 20.8 Gastointestinal Surgery II ......................................................................................................................... 599 20.9 Fluids, Electrolytes, and Acid-Base Regulation ........................................................................................ 602 20.10 Venipuncture  and  IV’s ..................................................................................................................... 606 20.11 Principles of Surgical Infections....................................................................................................... 607 20.12 Surgical Nutrition ............................................................................................................................. 608 21 Surgery Exam II Notes ...................................................................................................................................... 610 21.1 Peripheral Vascular Disease and Other Atherosclerosis .......................................................................... 610 21.2 Suturing Techniques ................................................................................................................................ 613 21.3 Trauma and Care of the Acutely Injured Patient ...................................................................................... 614 21.4 Congenital Heart Disease ........................................................................................................................ 618 21.5 Acquired Heart Disease ........................................................................................................................... 620 21.6 Wound Healing, Sutures, and Wound Closures ....................................................................................... 626 21.7 Neurosurgery ........................................................................................................................................... 629 21.8 Common Office Procedures ..................................................................................................................... 631 21.9 Chest Tube Placement ............................................................................................................................. 633 21.10 Intubation......................................................................................................................................... 633 Simplenursing.com 82% or Higher on Your Next Nursing Test 6 Med Surg Quick Notes 21.11 Orthopedic Surgery ......................................................................................................................... 634 21.12 Non-Small Cell Lung Cancer ........................................................................................................... 635 21.13 Esophageal Cancer ......................................................................................................................... 636 21.14 Transplantation ................................................................................................................................ 637 Simplenursing.com 82% or Higher on Your Next Nursing Test 7 Med Surg Quick Notes 1 Cardiology I Exam Notes 1.1 Cardiology Terms & Introduction  Preload: the 20% of blood remaining in the atria at end of diastole  80% of ventricular filling occurs before atrial kick  increase preload by inspiration or valsalva  Afterload: the volume of blood in the ventricles after atrial contraction  Cardiac output: volume of blood ejected from ventricles in one minute; normally 5 L  increased by increasing HR, contractility, or blood volume (or decreasing resistance)  Stroke volume: volume of blood ejected with each heartbeat  Myocardial contractility: ability of cardiac muscle to shorten with a given load  ejection fraction: a quantification of contractility; EF = SV/EDV  Starling’s  law : stroke volume increases as end diastolic volume increases due to greater stretch put on walls of ventricles  Stenosis: narrowing to forward flow  Regurgitation (insufficiency): backward leakage while valve should be closed  Collaterals: normally nonfunctioning small vessels that interconnect coronary arteries  function when blockage creates upstream pressure, forcing the collaterals open  Heart sounds review o S3 in CHF o S4 in HTN  Coronary vessel dominance: we want to identify which artery perfuses the posterior 1/3 of the interventricular septum: is it the right coronary artery or the left circumflex (or both)?  SA node typically supplied by the right coronary artery, but can also be left circumflex  AV node supplied by whichever is dominant  Coronary artery disease (CAD) (aka coronary heart disease CHD): narrowing of vessels supplying the heart caused by atherosclerosis and/or hardening of the arteries 1.2 Pharmacology: Lipid Lowering Drugs  Statins: act as analogues for liver cholesterol synthesis to inhibit the actions of HMG-CoA reductase → liver upregulates LDL-R to try and draw cholesterol out of circulation  First line medication for lower LDL  Can decrease LDL by 20-60%, decrease TG by 7-30%, and increase HDL by 5-15%  doubling the does results in an additional lowering of LDL by 6%, with HDL increase of 10-15% Simplenursing.com 82% or Higher on Your Next Nursing Test 8 Med Surg Quick Notes  Proven to decrease risk of major cardiovascular events and total mortality, including CAD, MI, stroke, and peripheral vascular disease  Administered at bedtime, when cholesterol synthesis peaks  Kinds:  atorvastatin: CYP3A4 metabolism  lovastatin: CYP3A4 metabolism  pravastatin: less interactions = good choice for someone on many meds, urinary excretion  rosuvastatin: less interactions = good choice for someone on many meds, biliary excretion  simvastatin: CYP3A4 metabolism  Contraindications: pregnancy or potential pregnancy, active or chronic liver disease, concomitant use of CYP3A4 inhibitors  Interactions: amiodarone, cyclosporine, macrolides, protease inhibitors, large amounts of grapefruit juice  Side effects: elevated LFTs, myalgia (no change in CK), myopathy (CK increase), rhabdomyolysis (high CK with organ damage)  Monitor: LFTs (stop statin if increase to 3-5x upper limit of normal) 1.2.1 Drugs to Increase Lipoprotein Lipase Activity  Fibric acid derivatives: stimulate PPARα, a transcription factor that promotes lipid metabolism → increased oxidation of fatty acids and increased metabolism of fatty acids  can reduce LDL by 5-10%, reduce TG by 20-50%, and increase HDL by 10-20%  trials show decrease in major coronary events  kinds: o gemfibrozil: o fenofibrate:  contraindications: severe renal disease, severe hepatic disease  side effects: dyspepsia, gallstones, myopathy  Bile Acid Sequestrants: inhibit bile salt recycling → liver breaks down more cholesterol to make new bile  Add to the LDL-lowering effects of statins  reduces LDL by 15-30%, no effect on TG, mildly helps increase HDL  Cons: requires several doses per day, concomitant drugs must be taken at a different time  Good for persons needing only moderate LDL lowering or women considering pregnancy  Kinds:  cholestyramine:  Contraindications: TG 400 (could increase chance of pancreatitis)  relative: TG 200  Side effects: constipation, GI upset, decreased absorption of other drugs 1.2.2 Drugs to Inhibit Cholesterol Absorption Nicotinic acid (niacin): blocks the breakdown of fats needed for VLDL synthesis → shift in LDL composition from small and dense to larger and more buoyant (less likely to deposit in arteries)  typically used in combination with other lipid-lowering drugs  lowers LDL by 5-25%, lowers TG by 20-50%, and increases HDL by 15-35%  contraindications: chronic liver disease, gout  relative: DM, hyperuricemia, PUD  side effects: flushing (prevent with aspirin before), hyperglycemia, hyperuricemia, GI distreses, hepatotoxicity Ezetimibe: inhibits cholesterol absorption at the brush border of the small intestine  can be used alone to increase LDL by 15-20%, TG decrease by 5-10%, minimal increase of HDL = similar to bile acid sequestrant, but better tolerated  frequently used in combination with statins  contraindications: active liver disease Fish Oil: used to lower TG by 20-50%, with a minor increase in LDL and HDL Simplenursing.com 82% or Higher on Your Next Nursing Test 9 Med Surg Quick Notes  side effects: increased risk of bleeding, diarrhea  prescription brand name is Lovaza 1.3 Clinical Medicine: Lipids 1.3.1 Dyslipidemia  Lipoproteins: cholesterol, triglyceride, and insoluble fat blood transporters  Dyslipidemia: an elevation of plasma cholesterol, triglycerides, or both  primary dyslipidemia: genetic causes o most people with LDL 190 have some genetic component such as:  monogeneic familial hypercholesterolemia:  familial defective apolipoprotein B:  polygenic hypercholesterolemia: o detection of these disorders needs to be done in young adulthood to prevent CAD o usually requires a statin + a bile acid sequestrant to achieve therapeutic goals  secondary dyslipidemia: any non-genetic cause of dyslipidemia o diabetes o hypothyroidism o obstructive liver disease o chronic renal failure o drugs that increase LDL and decrease HDL o diet o sedentary lifestyle  treat these causes first if present, then re-check LDL and establish goal based on isk category  switch to diet low in saturated fat and cholesterol  ingest soluble fiber and plant stanols & sterols  lose weight  increase activity: reduces VLDL & LDL, raises HDL  even as secondary prevention, exercise can reduce total mortality by 20% but  won’t  reduce  chance  of  having  another  nonfatal  MI    dyslipidemia promotes atherosclerosis, with greatest risk on carotid and coronary vasculature 1.3.2 Metabolic Syndrome: It is a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes.  Characteristics: abdominal obesity, atherogenic dyslipidemia, raised blood pressure, insulin resistance, pro-thrombotic state (impaired fibrinolysis and endothelial dysfunction), inflammation, elevated apolipoprotein b  Considered to be the secondary target of overall CAD risk reduction  Clinically identified by presence of 3+ of these factors:  abdominal obesity (waist 40 in for men, 35 in for women)  triglycerides 150  low HDL (men 40, women 50)  BP 130/85  fasting glucose 110  Treatment: weight management, increased activity, treat HTN, therapeutic aspirin, treat elevated triglycerides or low HDL 1.3.3 Diagnostic Methods for Dyslipidemia  Inflammatory markers and lipid levels important for risk factor identification and modification  Labs Simplenursing.com 82% or Higher on Your Next Nursing Test 10 Med Surg Quick Notes  homocysteine: blood amino acid associated with cardiac disease, stroke, and peripheral vascular blockages o lowered by folic acid o can be genetic  lipoprotein A (Lpa): inhibits thrombolysis and enhances LDL retention in arterial walls o -elevation may or may not risk factor for cardiac disease  apolipoprotein B: LDL component  lipid profile: includes total cholesterol, HDL, LDL, triglycerides o total cholesterol and HDL can be measured even if patient was not fasting o if TG are 400, you need to adjust results of LDL level to be accurate: corrected LDL = total cholesterol - HDL - (TG/5)  direct LDL (dLDL): a measure of LDL for nonfasting patients or when TG are 400 or when chylomicrons are present 1.3.4 Screening for Dyslipidemia  Red flag clinical presentations: corneal arcus (cholesterol deposit in cornea) in patient under 40, xanthomas (thickening of tendons due to cholesterol accumulation), xanthelasmas  Lab tests  in patients 20-35 with risk factors (DM, FH, or other cardiovascular risks), get a fasting lipid profile every 5 years o if test is non-fasting, total cholesterol and HDL values are still valid  in patients with no known risk factors, begin screening in men at age 35 and women at age 45 o if lipids are good, continue screening every 5 years  in pediatric patients with high cardiovascular risk (obesity, HTN, FH), get a lipid profile between 2-10 years of age, and every 3-5 years thereafter  For patients without known CAD or CAD equivalents, calculate 10-year risk of developing CHD using Framingham scoring  high risk is known CAD or having a CAD risk equivalent 20% chance of developing CAD o when you would want to set LDL goal 100  moderate risk is having 2+ CAD risk factors 10-20% chance of developing CAD o when you would want to set LDL goal 130  lower risk is having no or one risk factor o when you would want to set LDL goal 190 1.3.5 Treatment of Dyslipidemia ATP III guidelines  Total cholesterol  optimal is 200  200-239 is borderline high  greater than 240 is very high  Triglycerides  less than 150 normal  150-199 borderline high  200-499 high  greater than 500 very high  LDL: the primary target for CAD risk reduction  otherwise healthy individuals: o less than 100 is optimal o 100-129 is near optimal o 130-159 is borderline high o 160-189 is high o greater than 190 is very high  HDL should be 40  Determining a treatment plan for patients Simplenursing.com 82% or Higher on Your Next Nursing Test 11 Med Surg Quick Notes 1. get a fasting lipid profile a. determine patient history of CAD (or risk equivalents) and other high risks for CAD  known CAD puts pt at a 20x greater risk for MI: includes patients with angina, history of cardiovascular procedures  CAD equivalents: o diabetes  if female diabetic, want to increase HDL to 50 o symptomatic carotid artery disease o peripheral arterial disease o abdominal aortic aneurysm  major risk factors: o smoking o hypertension o low HDL ( 40)  low HDL alone is a strong predictor for CAD  low HDL associated with insulin resistance and related risks: high triglycerides, obesity, inactivity  other  causes  of  low  HDL:  smoking,  high  carb  intake,  drugs  such  as  β  blockers,   anabolic steroids, and progesterone o family history of premature CAD (means there is a genetic component) o age (men 55, women 65)  consider other major risk factors for CAD for which targeting will not help the end outcome, although they will modify clinical judgment (???)  obesity: distribution more important than BMI o inactivity: better to be fat and fit than thin and sedentary o impaired fasting glucose o elevated inflammatory markers o homocysteine o thrombotic abnormalities o endothelial dysfunction o elevated triglycerides alone are a risk factor for CAD  contributing factors: obesity, inactivity, smoking, high alcohol, high carbs, disease such as DM, chronic renal failure, and nephrotic syndrome, certain drugs including β  blockers  and  estrogens,  and  genetic  disorders   b. tailor the treatment plan for each patient:  if lipid panel is optimal, encourage them to continue making good choices  for patients without CAD or CAD risk equivalent, but abnormal lipids: o usually, first you will set LDL goal to reach and aim for that  (unless TG are 500, then you want to address that first to prevent pancreatitis)  (extremely low fat diet, weight management, activity, fibric acid derivative or nicotinic acid)  (once this is under control, then address LDL)  if 2+ CAD risks, want to keep LDL under 130  if 0-1 CAD risks, want to keep LDL under 160 o begin with therapeutic lifestyle changes, such as low fat diet, weight management, and increased activity (this includes patients with suspected metabolic syndrome)  try this for 3-6 months o if LDL goal is not met at follow-up with just lifestyle changes, consider meds (statin, bile acid sequestrant, or nicotinic acid)  if 2+ CAD risks with 10-20% calculated risk, start meds with LDL 130  if 2+ CAD risks with 10% calculated risk, start meds with LDL 160  if 0-1 CAD risks, definitely start meds with LDL 190, and maybe sooner  if patient is pediatric, drug therapy should begin if child is at least 8 years old  statins are often first line therapy in peds (adjusted dosing) o follow-up post meds: Simplenursing.com 82% or Higher on Your Next Nursing Test 12 Med Surg Quick Notes  if LDL goal is not met, add higher dose statin or another med (bile acid sequestrant, nicotinic acid)  if LDL goal is met but triglycerides are still elevated, set another goal for all non- HDL cholesterol (should be LDL goal + 30)  add or intensify meds to lower LDL, or add nicotinic acid or fibrate to lower VLDL  for CAD or CAD equivalent patients: start lifestyle changes and meds right away  LDL goal is 100 or 70 if very high risk  for isolated low HDL in CAD or CAD equivalent patients, add nicotinic acid or fibrate  for elderly patients: o know that cholesterol elevates progressively with age o studies show that treating known CAD up to age 75 results in significant reductions in cardiac morbidity and mortality o treating elderly patients without known CAD (primary prevention) does not have much data 1.4 Pharmacology: Antihypertensives 1.4.1 Choosing Pharmacotherapy  Think about the strength of evidence for use of a particular medication  Consider comorbid conditions and compelling indications for more aggressive therapy  Cross-check with current meds being taken  Consider patient insurance and cost of copay Diuretics: increase urine flow by inhibiting ion transport in the kidney Thiazides: inhibit Na and Cl reabsorption in the distal convoluted tubule increased urine volume, decreased blood volume  drugs of choice in the treatment of primary HTN  more effective than loop diuretics unless ClCr 30 (loop diuretics act earlier in the nephron = more time for them to work with reduced nephron functioning)  are Ca sparing = can use in osteoporotic patients  formulations:  chlorthalidone: twice as potent as HCTZ, most evidence  indapamide:  hydrochlorothiazide (HCTZ)  metolazone:  chlorothiazide:  contraindications: anuria, CrCl 30, careful in gout  side effects: hypokalemia, hyperuricemia, hyponatremia, hypercalcemia, hyperglycemia  monitor: electrolytes, BP Loop diuretics: block Na/K/Cl cotransporter in ascending loop of Henle decreased reabsorption of Na and Cl increased urinary excretion, decreased blood volume  more potent Cl reabsorption than thiazides  commonly used to reduce pulmonary edema in CHF  kinds:  furosemide:  bumetanide:  torsemide:  ethacrynic acid:  contraindications: anuria, volume depletion  side effects: hypokalemia, dehydration, orthostatic hypotension, photosensitivity  monitor: electrolytes, BP, volume status Potassium-sparing diuretics: most enhance Na excretion and retain K at the distal convoluted tubule  not very potent alone Simplenursing.com 82% or Higher on Your Next Nursing Test 13 Med Surg Quick Notes  kinds:  spironolactone: inhibits aldosterone R at the distal convoluted tubule o side effects: gynecomastia or hirsutism because it binds nonspecifically to other steroid receptors, hyperkalemia  eplerenone: o side effects: hyperkalemia  monitor: BP, electrolytes, endocrine 1.4.2 Drugs That Interfere with the Renin-Angiotensin System Angiotensin converting enzyme (ACE) inhibitors: prevent conversion of angiotensin I to angiotensin II Na excretion and K retention (by decreasing aldosterone production), decreased vasoconstriction  used in treatment of HTN and CHF  don’t  affect  glucose  levels    ok  to  use  in  renal  pts  that  have  no  renal  function  left  (can’t  hurt  them  any  more)    kinds:  benazepril:  enalapril:  lisinopril:  contraindications: ARF, angioedema, hyperkalemia, pregnancy, bilateral renal artery stenosis  side effects: hyperkalemia, renal failure (so stop if serum Cr increases by 30% or more), hypotension, cough (switch to ARB)  monitor: BP, electrolytes, renal function Angiotensin II receptor blockers (ARBs): interfere with binding of angiotensin to its receptor effects similar to ACE inhibitors  ok  to  use  in  renal  pts  that  have  no  renal  function  left  (can’t  hurt  them  any  more)    kinds:  irbesartan:  losartan:  olmesartan:  valsartan:  contraindications: same as ACE inhibitor  fewer side effects: hyperkalemia, increased SCr, increased BUN, hypotension, syncope  monitor: BP, electrolytes, renal function Aldosterone antagonists: act on tubules to promote Na/Cl excretion and K retention  eplerenone: Direct renin inhibitors (DRIs): blocks conversion of angiotensinogen to angiotensin I  contraindications: renal failure, hyperkalemia  monitor: K, serum Cr 1.4.3 Drugs That Decrease Peripheral Vascular Resistance or Cardiac Output Direct vasodilators  calcium channel blockers (CCBs): inhibit entry of Ca into cells dilation of arteries, decrease in HR decrease in afterload  particularly useful in elderly pts o dihydropyridine CCBs: work at the peripheral vasculature  nifedipine: HTN and angina  amlodipine: HTN and angina  side effects: edema, flushing, headache, reflex tachycardia o non-dihydropyridine CCBs: work at the heart vasculature and act as a negative chronotrope (decrease HR) and negative inotrope (weakens force of contraction) = useful in a-fib  verapamil: HTN, supraventricular tachycardias, unstable angina, chronic angina, vasospastic angina  diltiazem: same as verapamil but no unstable angina Simplenursing.com 82% or Higher on Your Next Nursing Test 14 Med Surg Quick Notes  side effects: constipation, conduction problems o contraindications: heart failure  other direct vasodilators o hydralazine and minoxidil directly relax arterioles o hydralazine + isosorbide used in CHF for ACE/ARB intolerance  mechanism unclear Sympathetic nervous system depressants  α  and  β  blockers:  can’t  acutely  discontinue  because  this  co uld result in acute tachycardia (downregulation of the system) o α-1 blockers: dilate arteries and veins o central  α -2 agonists: used specifically during substance withdrawal or pregnancy  clonidine:  an  α -2 agonist that reduces central sympathetic outflow, but is associated with increased incidence of falls = only use for refractory HTN  methyldopa: drug of choice for HTN in pregnancy (ACEI/ARB not safe) but requires multiple doses per day  cautious use with known CAD  side effects: CNS, orthostasis, peripheral edema  monitor: HR o β  blockers : prevent sympathetic stimulation of the heart decrease HR, decreased contractility, decrease cardiac output, and decrease renin  questionable role in treatment of essential HTN unless pts have heart failure or recent MI  strict  β -1  blockers:  use  for  asthma  or  COPD  pts  (don’t  want  to  block  bronchial   relaxation)  atenolol:  metoprolol:  block at multiple receptors  propranolol:  β -1  and  β -2  labetalol:  β -1,  β -2,  α -1 blocker nd rd  contraindications: 2 or 3 degree heart block, cardiogenic shock  relative contraindications: bradycardia  side effects: weakness, dizziness, bradycardia, sexual dysfunction, dyslipidemia, reduced cardiac output, impotence, exercise intolerance, bronchospasm  can  masks  igns  of  hypoglycemia  (won’t  sw eat)  monitor: BP, HR, glucose Simplenursing.com 82% or Higher on Your Next Nursing Test 15 Med Surg Quick Notes 1.5 Clinical Medicine: Hypertension 1.5.1 Hypertension Background  leading cause of death worldwide  75% of diabetics have HTN  an treatable risk factor for stroke, CHF, peripheral vascular disease, aortic dissection, a-fib, kidney failure, dementia, MI  hypertension has greatest impact on cerebral and renal vasculature  pulse pressures is the difference between systolic and diastolic  diastolic pressures rise natural until age 50 and then decreases progressively, while systolic BP rises throughout life increase in pulse pressure  fatality of HTN is correlated to the pulse pressure  the larger the difference, the greater the risk for fatal MI or stroke  HTN developed before age 50 typically involves systolic and diastolic BPs  HTN developed after age 50 is isolated systolic HTN, due to unavoidable hardening of the large arteries  systolic BP 140 is considered to be a greater cardiovascular risk in this age group than high diastolic BP Resistant hypertension: persistence of BP 140/90 despite treatment (and patient compliance) with full doses or 3 or more different classes of meds (including a diuretic)  could be pseudoresistant hypertension (white coat syndrome): chronic HTN is well controlled outside of the office  inadequate medical regimen for patient: not using appropriate diuretic, renal impairment, inadequate dosing  patient nonadherence or faulty diet: high salt, alcohol, tobacco  exacerbating drugs: cocaine, methamphetamines, NSAIDs, other stimulants, oral contraceptives, EPO, natural licorice, cyclosporine, tacrolimus, herbal products  consider causes of secondary hypertension Primary (essential) hypertension: idiopathic but with known risk factors; 95% of all cases  risk factors affect extracellular fluid volume, heart contractility, or vascular tone:  can have genetic defect for impaired sodium excretion  stress, obesity, drug or substance abuse  variable renin activity  variable sympathetic response  insulin resistance, diabetes  inadequate dietary potassium and calcium  resistant vessels Secondary hypertension: has an identifiable, treatable cause; 5% of all cases, a result of:  chronic renal disease: causes expanded plasma volume with peripheral vasoconstriction  most frequent cause of secondary HTN o and HTN can also cause CKD  85% of CKD pts will develop secondary HTN  would see proteinuria and elevated creatinine  renovascular stenosis: occurs when ill-perfused kidneys (due to atherosclerosis or fibromuscular dysplasia) release a lot of renin vasoconstriction  stenosis due to fibromuscular dysplasia will have a knobbed appearance on cardiac cath  a frequent cause of HNT refractory to treatment  coarctation of the aorta: congenital abnormality causing narrowing of the aorta increased resistance  often accompanies bicuspid aortic valve  or  Turner’s  syndrome    hyperaldosteronism: usually caused by aldosterone-producing tumor or hyperplasia of the adrenals too much Na/K reabsorption water retention Cushing’s  syndrome : pituitary adenoma that produces ACTH lots of cortisol HTN Simplenursing.com 82% or Higher on Your Next Nursing Test 16 Med Surg Quick Notes  pheochromocytoma: adrenal tumor producing catecholamine  typically 35-45 years old, no risk factors for HTN, may feel hot, flushed, anxious, or have a headache  huge problem when undiagnosed because outpouring of catecholamines during a surgical or radiologic procedure can lead to severe hypertensive crisis and death Obstructive sleep apnea: tissues sensing intermittent hypoxia summon renin-angiotensin system to increase BP Hypertensive urgency: severe elevation of blood pressure with no evidence of progressive target organ damage or dysfunction  no raised intracranial pressure  occurs when pts have known HTN but have been noncompliant with meds or diet, or regimen was inadequate  clinical presentation: BPs usually 220/110, with severe headache, SOB, evidence of stable or no target organ damage  need to lower BP slowly over several  hours:  laβlol,  clonidine,  captopril    lowering too much too fast could cause dramatic drop in pressures cerebral hypoperfusion and infarct Hypertensive emergency: acute, severe elevation of BP with evidence of rapidly progressing target organ damage  clinical presentation: BPs usually 220/140, SOB, chest pain, altered mental status, weakness, dysarthria  target organ damage presenting as MI, acute CHF with pulmonary edema, renal failure, encephalopathy, intracranial hemorrhage, eclampsia (with pregnancy), aortic dissection  if seeing papilledema on funduscopic exam, think malignant hypertension o most common in young adults with prior renal disease, black males, pregnancy, or collagen vascular disease  treatment requires immediate and gradual reduction of BP but not to normal parameters, only to 160/110 st  10% decrease in 1 hour followed by 15% decrease in next 3-12 hours  requires use of IV meds: o for vasodilation: sodium nitroprusside, nicardipine, fenoldopam, nitroglycerin, enalaprilat, clevidipine, furosemide o adrenergic  blockers:  laβlol,  esmolol,  phentolamine   1.5.2 Screening for HTN USPSTF strongly recommends screening for all adults, at a minimum of every 2 years 1.5.3 Diagnosing HTN JNC7 HTN guidelines:  Normal BP: 120/80  Pre-HTN: 120/80 - 139/89  HTN stage I: 140/90 - 159/99  HTN stage II: 160/100 HTN = repeatedly elevated pressures 140/90  should be based on 2+ readings that are at least 1 week apart  may want to treat high risk individuals at a lower threshold (130/80)  ex. diabetics, CKD, cardiovascular disease, cerebrovascular disease, LVHs  cautiously treat isolated systolic HTN in the elderly  indapamide +/- perindopril a good route to go  in pregnancy can only use certain meds: methyldopa,  laβlol,  hydralazine,  nifedipine   Assess target organ damage: neurologic, ophthalmic, cardiovascular, renal, vascular  labs: UA for proteinuria, blood chemistry (creatinine, glucose, K, Na), lipid profile, EKG to look for VH Simplenursing.com 82% or Higher on Your Next Nursing Test 17 Med Surg Quick Notes  Assess cardiovascular risk  black patients have greater risk of complications from untreated HTN  Detect rarer, secondary causes of HTN 1.5.4 Management of HTN Lifestyle modification: weight loss and DASH diet has the greatest effect Meds: most single meds will only lower BP by 10-20 points, so pt will probably need multiple  otherwise healthy individuals  prehypertension should start with lifestyle changes  stage I HTN usually start with a thiazide diuretic  stage II HTN 2 drug regimen with one being a thiazide  high cardiovascular disease risk groups require tighter control (BP goal 130/80), and intervention with drugs begins at the prehypertensive stage: CHF, CAD, CKD, DM, post MI, post stroke  classes of anti-HTN meds with additive effect against comorbid diseases o CHF:  diuretic,  β  blocker,  ACE  inhibitor,  ARB,  aldosterone  antagonist   o CAD:  β  blocker,  ACE  inhibitor , Ca channel blocker, diuretic o MI:  β  blocker,  ACE  inhibitor,  aldosterone  antagonist   o diabetics:  β  blocker,  ACE  inhibitor,  diuretic,  ARB   o CKD: ACE inhibitor, ARB o stroke: ACE inhibitor, diuretic 1.6 Pharmacology: Ischemic Heart Disease 1.6.1 CAD Pharmacologic goal is to reduce the myocardial oxygen demand/  β  blockers  reduce  HR  and  contractility    Ca channel blockers reduce systemic vascular resistance and decrease contractility  nitrates cause venous dilation decrease preload decrease oxygen demand  antithrombotics like aspirin prevent clots in the coronary arteries 1.6.2 Antiplatelet Drugs ADP-R antagonists: Kinds:  aspirin:  clopidogrel: ticagrelor:  side effects: dyspnea, brady arrhythmias  preasugrel: Glycoprotein IIb/IIIa-R antagonists: prevent platelet aggregation by blocking the binding of fibrinogen and vWF to the glycoprotein-R on platelet surfaces Kinds:  abciximab: only if PCI planned  side effects: bleeding, thrombocytopenia, allergic reaction, hypotension  eptifibatide: renal dosing available  side effects: bleeding, hypotension  tirofiban: renal dosing available, may be less effective than abciximab during PCI Thrombolytic Drugs: activate plasminogen fibrinolysis Kinds:  alteplase Simplenursing.com 82% or Higher on Your Next Nursing Test 18 Med Surg Quick Notes  reteplase:  tenecteplase: Nitrates: dilate blood vessels to reduce cardiac preload and reduce vessel resistance decreased end diastolic volume decreased stress on myocardial walls decreased oxygen demand by the myocardium Kinds:  isosorbide dinitrate: oral long-acting  isosorbide mononitrate: oral ong-acting  nitroglycerin: PRN or chronic, spray, ointment, patch, paste, or oral  drug of choice for relieving acute coronary spasm causing angina Side effects: headaches, postural hypotension, flushing, dizziness, reflex tachycardia. 1.7 Clinical Medicine: Ischemic Heart Disease 1.7.1 Diagnostic Methods Background for Ischemia Procedures: myocardial ischemia workup 1. first, do a resting EKG a. after that:  normal resting EGK consider doing a stress test (exercise tolerance test): EKG on a treadmill o -keep in mind contraindications for any exercise testing  absolute: acute MI in last 48 hours, refractory unstable angina, arrhythmias causing hemodynamic issues, symptomatic/severe aortic stenosis, uncontrolled/symptomatic CHF, acute PE, acute myocarditis or pericarditis, acute aortic dissection  relative: LCA stenosis, moderate stenotic valvular disease, severe HTN, electrolyte nd rd abnormalities, hypertrophic cardiomyopathy, tachy/brady arrhythmias, 2 or 3 degree AV block o if  patient  can’t  exercise,  consider  doing  a   pharmacologic stress test: agent injected to simulate exercise  dobutamine will stimulate increased cardiac contractility and systemic vasoconstriction  contraindications: BP 180/120, history of v-tach or a-fib, MI in last 3 days, aortic  stenosis,  recent  β  blocker    adenosine and persantine: increase flow in non-diseased coronary arteries = can better visualize blocked areas when using contrast  adenosine contraindications:  COPD,  asthma,  emphysema,  recent  β   blocker, recent theophylline, recent caffeine  persantine contraindications: asthma, emphysema, severe COPD, resting systolic  BP    100,  LCA  disease,  unstable  angina,  acute  MI,  recent  β   blocker, recent theophylline, recent caffeine  hold  the  β  blockers  before  the  test  want  to  be  able  to  achieve  HR    other  drugs  that  can  blunt  BP  or  HR:  digoxin,  β -adrenergic blocking agents, vasodilators  interpretation of stress test:  ST changes without angina 70% chance of significant CAD  ST changes with angina 90% chance of significant CAD  bottom line: the greater the ST changes, the greater the chance of CAD  a systolic BP drop 10 points BAD NEWS BEARS, indicative of severe disease  that  can’t  be  compensated  for  by  ra ising BP  remember that false positives are common on stress tests Simplenursing.com 82% or Higher on Your Next Nursing Test 19 Med Surg Quick Notes o if resting EKG is abnormal do an exercise echo (real exercise or pharmacologically induced) or nuclear stress test or cardiac stress MRI  stress echocardiography: evaluates cardiac blood flow indirectly by assessing effect of exercise on myocardial wall motion  movement interpretation depends on the reader performing the echo  sensitivity and specificity affected by presence of baseline wall movement abnormality, poor imaging windows, adequacy of exercise, and presence of bundle branch blocks  highly specific  nuclear stress test: imaging using radioactive tracers used to look for ischemia and infarcts  highly sensitive  cardiac stress MRI: radiofrequency waves and magnetic fields used to generate detailed images of the heart  adenosine is the only agent used for cardiac MRI  excellent choice for valvular disease, ischemia, aortic abnormalities, congenital abnormalities  costly  contraindications: gunshot wound, shrapnel, metal prosthesis, or other source of metal, obesity, claustrophobia b. if needed cardiac catheterization: gold standard for imaging, utilizes radiation and contrast  can put in stent during same procedure  left heart route goes in through femoral or radial artery o allows for assessment of LV function: EF, left ventricular end diastolic pressure o assessment of aortic & mitral valves o assess for wall movement abnormality or LVH o assessment of coronary anatomy o can allow for imaging of abdominal aorta, renal arteries, iliac arteries  right heart route goes through femoral vein into vena cava o can assess RV pressures & pulmonary HTN o assess for shunts or congenital abnormalities o assess for valvular abnormalities o assess for constrictive or restrictive pericarditis Procedures: STEMI or NSTEMI 1. EKG a. plain-style echocardiography (obviously no exercise with it) or other imaging b. primary percutaneous coronary intervention (aka PCI or angioplasty): mechanically widening obstructed arteries using a stent  can be done during cardiac catheterization c. coronary artery bypass grafting (CABG): arteries or veins harvested from elsewhere in the patient are grafted to areas of blockage to allow blood flow to circumvent the obstructed area Lab monitoring for ACS drug treatment  monitor UFH with PTT  monitor LMWH therapy with anti-factor Xa test  can’t  monit or fondaparinux  if using warfarin, monitor INR Cardiac labs:  creatinine phospokinase (CK): found in skeletal muscle throughout the body  shows up in 1-6 hours, peaks in12, lasts up to 1.5 days Simplenursing.com 82% or Higher on Your Next Nursing Test 20

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