test II case studies

Case 38. NG is a 72-year-old male who presents to ED with chest pain that has radiated to his left arm. He explains the chest pain as if an elephant has sat on his chest. States that he has had increased SOB while walking and has been sweating more than normal since the pain began approximately one hour ago. PMH of CVA (2015), HTN, HLD, depression, and PE (2018). Current Medications: aspirin 81 mg PO daily, atorvastatin 40 mg PO daily, lisinopril 20 mg PO daily, sertraline 50 mg PO daily, Xarelto 20 mg PO daily and sildenafil 100 mg daily (last dose 72 hours ago). ED Vitals: HR: 86, BP 86/55, RR 22, Temp: 37.6C Which of the following is a contraindication to nitroglycerin in this patient? a. blood pressure b. pulse c. sildenafil d. stroke Which type of event is NG experiencing? a. unstable angina b. NSTEMI c. STEMI d. unable to determine

a. blood pressure b. NSTEMI we have troponin changes and no ST elevations

Case 7. You receive a "Pharmacist to dose UFH" consult for S.W. Using the attached protocol: a. Determine the initial bolus dose and infusion rate for S.W. (round to nearest 50 units) b. What parameters will you monitor? c. What is S.W.'s therapeutic aPTT goal range?

a. full dose of heparin suggested for DVT/PE (initial bolus= 80 units/kg IV; infusion= 18 units/kg/hr IV; initial rate max. 1,200 units/hr) initial bolus: 5,040 units infusion rate: 1150 units/hr b. obtain CBC panel, aPTT c. 60-85 seconds

Case 10. You are a fourth-year student in your next to last APPE rotation at Gower's pharmacy. You turn your attention to a retirement age gentleman at the counter and greet him with your routine "How may I help you?" He replies "Where ehm, d... d... dizzy pills". The pharmacy tech overhears and asks "have you been to the dentist? Your face is a little droopy." You notice that he is standing oddly to one side. What might you assess to help ascertain what is going on? What actions should you pursue?

F: droopy face A: standing oddly to one side S: impaired speech exhibiting 3 symptoms of what could be an ischemic stroke "Time is Brain": we would want to seek treatment as quickly as possible → CT scan w/o contrast within 20 minutes of arrival (easy to see bleeding) → want to rule out hemorrhage within 45 minutes of arrival → review available labs, final checklist → pharmacy dose/mix r-tPA → obtain informed consent → complete stroke symptom scale again

Case 37. SO, a 64-year-old female is brought to ED by ambulance. She was at a concert when she stated to experience severe, unrelenting substernal chest pain lasting greater than 30 minutes. She also admits to feeling nauseous and anxious. Past medical history of HTN, DM, and chronic stable angina. Her typical angina feels like a crushing pain typically brought on by lifting heavy instruments or walking up-hill and the pain subsides in 5 minutes when she stops or sits down to relax. SO returns from PCI, where a stent was placed to her right carotid artery. She is being ready to discharge. What medication changes should be made to her home medications? HOME MEDS: Aspirin 81 mg PO daily, Metoprolol succinate 50 mg PO daily, Glipizide 5 mg PO BID, Losartan 50 mg PO daily, Simvastatin 10 mg PO daily, SL NTG 0.4 mg PRN chest pain. The provider decides to increase SO's BB for discharge. Which of the following should patient be counseled on for the metoprolol? a. tachycardia b. fatigue c. dry cough d. bleeding

A. keep aspirin 81 mg PO daily B. keep BB the same C. keep the ARB D. dual (adding a P2Y12 inhibitor) Switch to a high-intensity statin (atorvastatin 40 mg PO daily) b. fatigue (lasts a week and with every change, fatigue comes back)

Case 42. MG, 66 yo Hispanic female with a history of T2DM, fibromyalgia, obesity (wt: 260 lbs; BMI: 41), alcohol use disorder, and HTN. Presents to hospital with a DVT that occurred during a 10-hour car trip and is hemodynamically unstable. Medication History: Ibuprofen 200 mg q4-6h PRN, Losartan 50 mg once daily, Duloxetine 60 mg once daily, Metformin 1000 mg BID Vitals: BP- 100/66 mmHg; HR- 101 beats/min; RR- 20 breaths/min; T- 37.2degreesC Labs (baseline): WBC 10.0 x 103 per microliter; Hgb 13.1 g/dL, Hct 36.5%, Platelets 170 x 103 per microliter By day 5 in the hospital the patient seemed to be fully stabilized with plans being made for discharge, but diagnostic tests showed the presence of a new acute thrombosis of the left common femoral vein and a new diagnosis of DVT was made. MG's labs now are as follows: WBC= 9.8 x 103 per microliter; Hgb= 13.2 g/dL; Hct 34.5%; Platelets 83.2 x 103 per microliter. What medication regimen would you recommend for MG now (including dosing and duration/when to discontinue)?

Argatroban • Preferred agent for HIT; also used for PCI • Initial Dose: Argatroban 1 - 2 mcg/kg/min infusion rate titrated to target aPTT • Hepatic Impairment = 0.5 mcg/kg/min • Duration: At least until platelets recover (≥ 150,000/mm3), typically 3 - 6 months Start Argatroban 1-2 mcg/ =118 mcg/min until at least platelets recover typically for 3-6 months

Case 22. P.M. is a 72-year-old man (height 178 cm, weight 116 kg). He visits the ED with the chief concern of several weeks of a "fluttering" feeling in his chest on occasion and now he has some shortness of breath. He thinks the fluttering is nothing; however, is wife insists he have it checked. He takes hydrochlorothiazide for HTN. His vital signs HR 124 beats/minute. All laboratory values are within normal limits (SCr 0.75, K 4.1). An electrocardiogram (ECG) reveals an irregularly irregular rhythm, and a diagnosis of AF is made. What is your initial plan?

CHA2DS2VASc greater than 2 for male patient= first line DOAC metoprolol 25 mg PO BID

Case 9. CJ is a 45-year-old male diagnosed with COVID-19 infection and admitted to your hospital for management of severe COVID-19 symptoms. CJ was started on dexamethasone, high nasal flow canula, and baricitinib. Upon review of the patients medical records, it is found that he does not have a significant past medical history for any comorbidities. Should this patient receive anticoagulation therapy? If yes, what agent and dose would you recommend?

COVID is a risk for clot formation/thrombosis and is indicated for IV anticoagulation. When choosing between UFH and LMWH; look at CrCl and obesity. Would choose Enoxaparin based off CJ's CrCl and he is not obese.

Case 8. K.M. is a 70-year-old female presenting to ED with complaints of chest pain, that was not relieved by 2 tablets of sublingual nitroglycerin. EKG shows ST-segment elevation MI (STEMI). K.M given one more dose of nitroglycerin. Cardiologist recommended to starting enoxaparin prior to transferring the patient to the catheter lab for stent placement. Following stent placement, the patient has uncontrolled bleeding at femoral artery. What would be the most appropriate course of action at this time? a. give protamine 85 mg IV x 1 dose b. give 1 unit of fresh frozen plasma c. give activated prothrombin complex concentrate d. give idarucizumab 2.5 mg IV x 2 doses

a. give protamine 85 mg IV x 1 dose d. idarucizumab is used for reversal of dabigatran

Case 38. NG is a 72-year-old male who presents to ED with chest pain that has radiated to his left arm. He explains the chest pain as if an elephant has sat on his chest. States that he has had increased SOB while walking and has been sweating more than normal since the pain began approximately one hour ago. PMH of CVA (2015), HTN, HLD, depression, and PE (2018). The provider orders tirofiban to be started on this patient. Is this patient a candidate for a glycoprotein IIb/IIIa inhibitor? Which antiplatelet therapy is MOST appropriate for this patient? a. clopidogrel b. prasugrel c. ticagrelor

Patient Qualifies! - risk of thrombosis platelet count is above normal - had PE in 2013 Xarelto and glycoprotein IIb/IIIa inhibitors interact, and properties enhance properties of Xarelto; so just look out for bleeding risk. a. clopidogrel Clopidogrel (not CI with PY12 inhibitor) less bleeding compared with Prasugrel and Ticagrelor and is a prodrug Prasugrel is CI because he has history of stroke (no matter when it occurred)

Case 7. PMH: HTN, DM II, ESRD (on dialysis), recent appendicitis with 5-day hospital admission (3 weeks ago). Home medications: Lisinopril 5 mg PO daily, Lantus 15 units HS, and Oxycodone 5 mg PO every 6 hours as needed for pain. Ultrasound Lower extremities: right DVT S.W. will be initiated on parenteral anticoagulation while he is bridged to a therapeutic warfarin dose. Which parenteral anticoagulant would be most appropriate for him? a. heparin b. enoxaparin c. fondaparinux d. bivalirudin

a. heparin For bridging, we would want to choose IV because it has a quicker onset, and he has active DVT Fondaparinux is CI in CrCl Patient is on dialysis so we can rule out enoxaparin

Case 2. S.W. is a 50 y.o. female presenting to ED with complaints of increasing right calf and leg pain as well as shortness of breath and sharp pain with breathing. Reports that the leg pain started in her calf ~1.5 weeks ago and has progressively worsened. She had attributed this "stiffness" from being stuck in a hospital bed for 4 days after her recent surgery but grew concerned when the pain increased, and her chest pain started. Due to chest pain, initial work-up included EKG and troponin levels. What additional imaging or labs would you look for to confirm or rule out the presence of a DVT and PE?

DVT -Ultrasound of the leg (this is the most definitive test for confirmation of a DVT) -D-dimer? (most helpful in a low likelihood clinical scenario but a positive d-dimer would certainly be consistent with possible thrombus) -Venogram - likely will not see this in clinical practice PE -CT angio - as long as patient doesn't have IV contrast allergy or renal impairment -V/Q scan

Case 9. CJ is a 45-year-old male diagnosed with COVID-19 infection and admitted to your hospital for management of severe COVID-19 symptoms. CJ was started on dexamethasone, high nasal flow canula, and baricitinib. Upon review of the patients medical records, it is found that he does not have a significant past medical history for any comorbidities. What counseling should be recommended for CJ for both enoxaparin and dabigatran?

Enoxaparin: don't push the air bubble out Dabigatran: bleeding risk, GERD, to not crush tablet, take with full glass of water, be aware of P-gp inhbitors/inducers (amiodarone, verapamil)

Case 2. S.W. is a 50 y.o. female presenting to ED with complaints of increasing right calf and leg pain as well as shortness of breath and sharp pain with breathing. Reports that the leg pain started in her calf ~1.5 weeks ago and has progressively worsened. She had attributed this "stiffness" from being stuck in a hospital bed for 4 days after her recent surgery but grew concerned when the pain increased, and her chest pain started. Due to chest pain, initial work-up included EKG and troponin levels. The leg vein ultrasound scan identifies a DVT and CT angio shows a pulmonary embolus. The medical resident has approached you for your recommendation on what anticoagulant should be used to treat S.W.'s DVT/PE. What regimen options do you recommend as first line therapy? What are alternative agents are available?

First Line (in no particular order): -Dabigatran (Pradaxa)→ w/5 days of parenteral AC prior to initiation -Edoxaban →w/5 days of parenteral AC prior to initiation -Rivaroxaban -Apixaban Alternatives: If we do Warfarin, we will have to start parenteral agent (minimum time of 5 days and 2 consecutive INRs in therapeutic range) Potentially LMWH (enoxoparin) although this is typically less convenient and more expensive than oral options and requires self-injection. Used often for initial management but pts are typically transitioned to PO anticoagulant

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. a. Is patient a candidate for Bridging? b. Who would be a candidate for Bridging Therapy? c. Based on the patient's indication, what is his INR goal?

GG does not qualify for bridging (CHADS2VASC= 4 is less than 5) and has not had stroke, MI, or DVT/PE. If score was greater than 5, then we would use a heparin (enoxaparin) and bridge for 5 days and until INR is greater than 2 for two consecutive days. GG's goal is 2-3 99% of the time unless you have a mechanical mitral valve then the goal would be 2.5-3.5 Best practice is INR of 2-3 but in clinical practice will see different goal that includes INR

Case 3. Chest Xray showed was conducted to assess cardiac function and presence of bilateral clots seen in most distal portions of pulmonary arterioles, and patient is diagnosed with isolated subsegmental PE for DG. If the decision is made to treat this patient, what is the best treatment option for him?

Guidelines would say DOAC therapy: Rivaroxaban 15 mg BID then 15 mg daily, or apixaban 10 mg BID for 7 days then 5 mg BID or Dabigatran (pradaxa) 150 mg BID, but due to socioeconomic factors may consider warfarin. Why? Longer half, if patient is prone to missing doses it may be better even if INR may not stay in range. No good answer for these sort of patients, warfarin is also much cheaper. In reality, no good option for this type of patient.

Case 31. 85-year-old female presents to hospital with cough and SOB. Diagnosed with PNA. PMH of Afib, DM, hypothyroidism, HF (EF 45%) and depression. Home meds: digoxin, metformin, glimepiride, atenolol, levothyroxine, warfarin, atorvastatin, citalopram. Hospital meds: levofloxacin, clindamycin, omeprazole Labs: WBC 14, CrCl: 48 mL/min, ECG: Afib, QTc 468 msec, K of 3.6, Mg of 1.8 a. list patients risk factors for QT prolongation. b. what would we recommend for this patient?

a. hypothyroidism, HF, K, Mg, age, diabetic, female, drugs (levofloxacin= KR; citalopram= KR) b. options: - change antibiotic to Ceftraxin + Doxycycline - d/c PPI (no indication of it in hospital) - assess pt. (vitals, BP, pulse, new EKG) - correct electrolytes [Mg and K]: (40 mEq KCl oral x 1; 25 IV MgSO4 IV x 1) Every 10mEq of K ↑ serum K around 0.1 (pt. is currently at 3.6 but we want her at 4)

Case 1. AM is 65 y.o. w/ovarian cancer being treated with chemotherapy reporting to ED from her outpatient oncology clinic. Chief complaint is pain along the length of her left leg with her left calf feeling particularly painful. Additionally, she endorses swelling and warmth of her left leg. HR: 90 bpm RR: 13 breaths/min T: 99.5 °F BP: 135/60 mmHg SpO2 98% (on room air) PMH: ovarian cancer otherwise nothing significant Based on presenting symptoms and patient history, a DVT is expected. Using Wells Scoring Criteria, what is the probability that AM is experiencing a DVT?

High Probability (DVT likely ≥ 2)

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. What dose of Warfarin would you recommend on day 3 of 5 and his INR is at 1.3

His INR is less than or equal to 1.5 so keep at same dose of warfarin 2.5 mg.

Case 28. 65-year-old male presents to the hospital with chest pain. Diagnosed with MI with and EF of 45%. You see him the next day with continued chest pain and the following rhythm. Answer based off of what the prescriber circled. a. what is the rate? b. is it the rhythm regular? c. is the QRS normal? d. what do we do first? e. what is appropriate therapy?

a. rate= (300/1.2) = 250 bpm b. regular rhythm c. wide QRS d. since pt. is experiencing ventricular tachycardia, we need to assess them first. Look at their symptoms, recheck vitals. e. after assessment, pt. has stable BP, so since pt. is post-MI → NSVT (non-sustained ventricular tachycardia) → has LVEF > 35% → asymptomatic → Beta blocker

Case 36. what is the rate?

a. rate= (300/5) = 60 bpm

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. Day 3 INR is at 1.3 and on day 4 INR increased to 1.34

increase to 5 mg of warfarin since INR is less than 1.5

Case 3. DG is a 55 y.o. homeless man with a history of IVDU. PMH: history of atrial fibrillation and HTN. Last was admitted 6 months ago for treatment of endocarditis. HR: 110 bpm (ECG shows patient is in Afib). BP: 118/72 Temp 98 F Tox screen: Positive for amphetamines UA: Unremarkable Troponins: 1 ng/mL D dimer 0.85 (positive) Chest Xray showed was conducted to assess cardiac function and presence of bilateral clots seen in most distal portions of pulmonary arterioles, and patient is diagnosed with isolated subsegmental PE. What do CHEST guidelines recommend for this patient?

Isolated subsegmental PE means PE is in the most distal portion of the pulmonary artery branches. This can carry a high risk for DVT which is why ultrasound to rule out DVT is recommended before making decisions on treatment. It is unclear if anti-coagulation therapy is beneficial in patients with subsegmental PE alone because abnormalities are small and unlikely to have an adverse effect with cardiopulmonary function and tend to resolve without anti-coagulation therapy (estimated that 5 to 10% of all diagnosed PE's are subsegmental, as improvements in tech have increased the rate at which they are identified). In patients with no proximal DVT in the legs who have a low risk of recurrent VTE, clinical surveillance is recommended over anti-coagulation. Anti-coagulation is recommended for patients at high risk of recurrent VTE. Risk factors include patients who are pregnant, have active cancer diagnosis, and no reversible VTE risk factors (i.e. clotting considered unprovoked)

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. Day 5 INR is 1.89. What do we do for the dose?

Keep at 5 mg of warfarin; it is taking longer for GG to reach goal INR and keep Amiodarone in mind

Case 1. AM is 65 y.o. w/ovarian cancer being treated with chemotherapy reporting to ED from her outpatient oncology clinic. Chief complaint is pain along the length of her left leg with her left calf feeling particularly painful. Additionally, she endorses swelling and warmth of her left leg. HR: 90 bpm RR: 13 breaths/min T: 99.5 °F BP: 135/60 mmHg SpO2 98% (on room air) After a compression ultrasound, the leg vein ultrasound scan identifies a DVT. The medical resident has approached you for your recommendation on what anticoagulant should be used to treat A.M.'s DVT. What agent do you recommend as first line therapy and for how long?

LMWH(enoxaparin) or Rivaroxaban since A.M. has ovarian cancer Edoxaban could be an option too but requires 5 days of parenteral anticoagulant first (not considered as bridge therapy because there is no overlap) 6 months of treatment

Amplify Trial Design answered the question of whether there is non-inferiority of Apixaban and Warfarin for VTE treatment in a 6-month randomized double-blind trial and the results were:

Less bleeding with Apixaban and better safety with Apixaban No difference in efficacy between Warfarin and Apixaban

Case 11. You are on your 3rd year IPPE rotation rounding on the med surg unit with your preceptor when a code 'Stroke' is called. You head down to the ER. A 65-year-old man is brought into the ER by his wife 45 minutes after he had a sudden onset of confusion, left sided weakness and dizziness just as they were about to sit down for lunch. SH: smokes 1 pack of cigarettes/day Meds: Amlodipine 5 mg daily and HCTZ 25 mg daily Vitals: BP (145/82), Weight (160 lb) a. What are his non-modifiable risk factors for stroke? b. What are his likely modifiable risk factors for stroke? c. what do we want to rule out?

Non-modifiable Risks: age (> 55 years old) gender (men > Women for morbidity) Family hx not known Modifiable Risks: HTN (145/82 mmHg) → deduced from medications Smoking rule out blood sugar , seizure brain hymot migrain temporat arteritis and hypertensive encephalopathy

Case 32. You are working in the community pharmacy and a 71-year-old female patient presents with nausea and a new prescription ondansetron 4 mg every 6 hours. PMH includes depression, diabetes, and allergies. Home medication include citalopram, metformin, loratadine. Use the diagram to determine the appropriate actions for the ondansetron.

ondansetron= KR for QTc citalopram= KR for QTc 2 KR QTc drugs → contact physician → SBAR

Case 30. BP=132/82 mmHg, RR=18 bpm, QT= 0.32 sec, RR= 0.80 sec Using Bazett's Formula, calculate the QTc interval.

QTc= (0.32 sec/ 0.894 sec) = 0.357 sec 0.357 sec/0.001 sec = 358 ms

Difference Between Unstable Angina, NSTEMI, and STEMI

SYMPTOMS: chest pain, nausea, GI upset, SOB, dyspnea (same for all 3)

Case 3. Should anti-coagulation therapy be given to patients with asymptomatic PE that is incidentally diagnosed?

Suggest the same initial and long-term anti-coagulation therapy recommendations as for patients with symptomatic PE (weak recommendation). Ensure PE is a new finding and ultrasound shows no proximal DVT and assess patient's bleeding risk. For patients with active cancer incidental PE should be treated as a symptomatic PE.

Case 37. Calculate SO TIMI score.

TIMI score= 3 Aspirin use in past 7 days Elevated cardiac biomarkers 3 risk factors for CAD: DM, HTN, family history of CAD Intermediate Risk

T/F; only symptomatic patients receiving optimal rate control should receive anti-arrhythmics.

TRUE

warfarin dosing

pink= 1 mg lilac= 2 mg green= 2.5 mg brown= 3 mg blue= 4 mg orange= 5 mg turquoise= 6 mg yellow= 7.5 mg white= 10 mg

Case 26. Calculate the rate. List the width. What type of arrythmia is this? Regular?

rate= (300/1.4)= 180 bpm regular width= wide ventricular tachycardia since rate is > 100, regular rhythm, wide QRS, and absent T wave

Case 25. Calculate the rate. List the width. What type of arrythmia is this?

rate= (300/1.6) = 188 bpm [1 large box + 3/5 of large box=1.6] width= narrow SVT (super ventricular tachycardia)

Case 11. You are on your 3rd year IPPE rotation rounding on the med surg unit with your preceptor when a code 'Stroke' is called. You head down to the ER. A 65-year-old man is brought into the ER by his wife 45 minutes after he had a sudden onset of confusion, left sided weakness and dizziness just as they were about to sit down for lunch. SH: smokes 1 pack of cigarettes/day Meds: Amlodipine 5 mg daily and HCTZ 25 mg daily Vitals: BP (145/82), Weight (160 lb) a. What labs do you what to be aware of? b. What imaging needs to be performed? c. Assuming that the work up is complete within 1 hours of arrival to the ER is he a candidate for TPA? d. If he is a candidate for TPA what dose does he need? How would you administer it?

a. INR, platelets, aPTT call EMS → CT scan b. CT scan c. yes d. 58.9 mg over an hour

Case 27. Calculate the rate. List the width. What type of arrythmia is this? Regular?

rate= (300/2) =150 bpm irregular width= narrow atrial fibrillation since rate is variable, irregular rhythm, narrow QRS, absent T wave

Case 34. what is the rate?

rate= (300/3.4) = 88 bpm

Case 3. While waiting in the ED, the patient (D.G.) suffered a witnessed seizure and was treated acutely with midazolam. He was consulted by neurology and the decision was made to start the patient on phenytoin. What would be the best choice of anticoagulation for this patient?

Warfarin: dosed based on INR. Use of potent CYP3A4 and PGP inducer is contra-indicated with DOACs. Major interaction with warfarin also but it can be monitored.

Case 29. Calculate the rate. List the width. What type of arrythmia is this?

rate= (300/5)= 60 bpm width= narrow Normal sinus rhythm since rate falls in 60-100 bpm range, we have regular rhythm, narrow QRS, and normal T wave

Case 35. what is the rate?

rate= (300/6) = 50 bpm

Case 33. what is the rate?

rate= (300/9.4) = 32 bpm

Case 2. S.W. is a 50 y.o. female presenting to ED with complaints of increasing right calf and leg pain as well as shortness of breath and sharp pain with breathing. Reports that the leg pain started in her calf ~1.5 weeks ago and has progressively worsened. She had attributed this "stiffness" from being stuck in a hospital bed for 4 days after her recent surgery but grew concerned when the pain increased, and her chest pain started. Due to chest pain, initial work-up included EKG and troponin levels. PMH: HTN, DM II, recent appendicitis w/5 day hospital admission (3 weeks ago) PE: Right calf/Right thigh swelling (R calf 38 cm, L calf 34 cm, R thigh 56 cm, left thigh 52 cm), right leg is warm to touch Based on presenting symptoms and patient history, the medical team is considering a DVT and PE. Using Wells Scoring Criteria, what is the probability that A.M. is experiencing a DVT? PE?

Wells score= 4 High probability (DVT likely) Recently bedridden for greater than 3 days after surgery=1 Calf swelling greater than 3 cm=1 Localized tenderness=1 Entire leg swollen=1 Has 3 signs/symptoms of PE

Case 24. Calculate the rate. List the width. What type of arrythmia is this?

rate= 300/# of boxes b/w R and R so (300/4= 75 bpm) width= wide ventricular tachycardia since rhythm is regular, wide QRS, abnormal T wave, and rate is variable

Case 4. 68 y.o male with metastatic testicular cancer receiving chemotherapy is admitted to medical floor for treatment of atrial fibrillation with rapid ventricular rate (RVR). The patient was not on anti-coagulation prior to admission. He has also neutropenia and anemia, and a history of heart failure with reduced ejection fraction (HFrEF). Labs: Hemoglobin: 6.8 Hematocrit: 23.8 Platelets: 234 SCr: 1.00 (CrCL 90 mL/min) Height: 5'6" Weight: 133 kg What is this patient's PADUA risk score for VTE?

With active cancer, heart failure, and obesity he has a risk score of at least 5. If we add reduced mobility, it would be 7.

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. The patient has no insurance. HT: 170 cm and WT 92 kg Labs: Hemoglobin 12.5%, hematocrit 43.6%, and INR 1.2 Drug Screen: Ethanol 0.18% Provider orders metoprolol 50 mg PO BID and amiodarone drip for rate control. He precedes to place an order for warfarin for the pharmacy to dose. What dose of warfarin would you recommend for this patient?

Would recommend 2.5 mg daily of Warfarin (92kg is not that overweight) Amiodarone interacts with warfarin (increases INR) and aspirin will increase bleeding. There is an alcohol interaction as well and drug screen came back positive for ethanol. Acute alcohol consumption: INR increased Chronic alcohol consumption: INR will actually be lower

Case 7. S.W. on day 3 of the hospital stay the lab calls the floor with a critical lab value. The medical team is concerned that the patient is experiencing heparin-induced thrombocytopenia (HIT). a. Using the 4-T score, what is the probability that his thrombocytopenia is due to HIT? b. The medical team has decided to start S.w. on an alternate anticoagulant whil awaiting the lab assay results to confirm HIT. Which parenteral anticoagulant would be the best option? a. enoxaparin b. fondaparinux c. argatroban d. bivalirudin c. Would you continue warfarin at this time in S.W.?

a. 4-T score tells us the probability of HIT. S.W. has score of 6. b. argatroban S.W. is on dialysis c. d/c warfarin. At 150 K/uL it would be safe to initiate warfarin again. Patient currently is at 45 L/uL.

Case 37. SO a 64-year-old female is brought to ED by ambulance. She was at a concert when she stated to experience severe, unrelenting substernal chest pain lasting greater than 30 minutes. She also admits to feeling nauseous and anxious. She is a band manager with a past medical history of HTN, DM, and chronic stable angina. Her typical angina feels like a crushing pain typically brought on by lifting heavy instruments or walking up-hill and the pain subsides in 5 minutes when she stops or sits down to relax. Which of the patient's following symptoms are consistent with an ACS event? a. Chest pain, nausea, and anxiety b. Chest pain and nausea c. Chest pain d. Chest pain and anxiety

a. Chest pain, nausea, and anxiety

Case 2. S.W. is a 50 y.o. female presenting to ED with complaints of increasing right calf and leg pain as well as shortness of breath and sharp pain with breathing. Reports that the leg pain started in her calf ~1.5 weeks ago and has progressively worsened. She had attributed this "stiffness" from being stuck in a hospital bed for 4 days after her recent surgery but grew concerned when the pain increased, and her chest pain started. Due to chest pain, initial work-up included EKG and troponin levels. CT angio shows a pulmonary embolus. a. DVT/PE provoked or unprovoked? b. If provoked, what actions could have been taken to try and prevent S.W.'s DVT/PE? c. Duration of treatment would you recommend for A.M.?

a. Likely provoked - has major transient risk factors such as prolonged hospitalization and/or immobility (>3 days) and most likely additional immobility at home post-operatively b. Has the most common signs of PE such as chest pain when breathing and shortness of breath. For prevention, recommending compression socks, ambulation and PCD c. 3 months (provoked DVT/PE)

Case 23. AF, 76-year-old female, presents to the ED complaining of heart palpitations and dizziness off and on for the last 3 days but symptoms have been constant for the last several hours. PMH includes HTN (uncontrolled) and COPD. Her medications include HCTZ, albuterol and ADVAIR. She admits to missing several doses per week. Vitals= T:98.9 BP:115/65 P:148 RR:28 PE= Well nourished, uncomfortable appearing female, irregular pulse, lungs bibasilar crackles, slightly obese abdomen, normal BS Tests/Labs= ECG reveals an irregularly irregular rhythm, K 3.8, Mg 2.1, SCr 1.1, O2 Sat 98% What rate control would you recommend? a. Metoprolol IV b. Diltiazem PO c. Digoxin IV d. none of the above

a. Metoprolol IV

Case 5. AG a 72 y.o. female presents to ED with SOB. CT shows bilateral PE. PMH is significant for congestive HF, HTN, upper GI bleed, and GERD. Currently taking furosemide 20 mg PO daily, carvedilol 6. 25 mg PO BID, lisinopril 20 mg PO daily, and omeprazole 40 mg PO daily. If the patient did not have a history of GI bleeding, which of the following be the best treatment option? a. Rivaroxaban 15 mg PO BID x 21 days, followed by rivaroxaban 20 mg PO daily b. Heparin infusion x 5 days, followed by dabigatran 150 mg PO BID c. Warfarin 10 mg PO daily and heparin therapy x 5 days d. Edoxaban 60 mg PO daily

a. Rivaroxaban 15 mg PO BID x 21 days, followed by rivaroxaban 20 mg PO daily Option b requires 5-10 days of parenteral anticoagulation prior to initiation of Dabigatran AE of dabigatran is GERD Option c dose of warfarin is too high for initiation Option d requires 5-10 days of parenteral anticoagulation prior to treatment → we would also want to know AG's CrCl

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. Warfarin 2.5 mg PO was given to the patient last night, the INR this morning was 1.21. what dose of warfarin would recommend for this evening? a.Warfarin 2.5 mg b.Warfarin 5 mg c.Warfarin 7.5 mg d.Warfarin 10 mg

a. Warfarin 2.5 mg It takes about 5 to 7 days to reach full therapeutic effect

Case 4. 68 y.o male with metastatic testicular cancer receiving chemotherapy is admitted to medical floor for treatment of atrial fibrillation with rapid ventricular rate (RVR). The patient was not on anti-coagulation prior to admission. He has also neutropenia and anemia, and a history of heart failure with reduced ejection fraction (HFrEF). Labs: Hemoglobin: 6.8 Hematocrit: 23.8 Platelets: 234 SCr: 1.00 (CrCL 90 mL/min) Height: 5'6" Weight: 133 kg a. Would this patient be a good candidate for VTE prophylaxis per PADUA score? b. What are some non-pharmacologic options for this patient for VTE prophylaxis?

a. Yes, but must take anemia and bleed risk into consideration b. Sequential compression device (Compression stockings or "hose") Ambulation if possible Pneumatic compression device

Case 5. AG a 72 y.o. female presents to ED with SOB. CT shows bilateral PE. PMH is significant for congestive HF, HTN, upper GI bleed, and GERD. Currently taking furosemide 20 mg PO daily, carvedilol 6. 25 mg PO BID, lisinopril 20 mg PO daily, and omeprazole 40 mg PO daily. a. Does AG qualify for an anticoagulant? b. What other indications are there for qualification of use of oral anticoagulants?

a. Yes; AG has bilateral pulmonary embolism, so patient qualifies for oral anticoagulant. b. stroke, Afib, DVT, coagulation disorders (factor V leiden), post op knee replacement, mechanical valves

Case 21: Z.G. is a 61-year-old man with AF, HTN, and hypercholesterolemia. His medications include digoxin 0.125 mg/day, warfarin 5 mg/day, amlodipine 10 mg/day, and pravastatin 20 mg every night. He comes to the clinic today with no complaints except for palpitations and shortness of breath when doing yard work. His vital signs include BP 150/88 mm Hg and HR 85 beats/minute. All laboratory results are within normal limits; his international normalized ratio (INR) is 2.4, and his digoxin concentration is 1.1 ng/dL. INR has been well controlled documented in therapeutic range 70% of time with no previous bleeds. Which is the best option to help with Z.G.'s symptoms? And describe why each answer is correct or incorrect? a. add metoprolol succinate 50 mg/day b. increase digoxin to 0.25 mg/day c. continue current regimen;adivse the patient to avoid activities that cause symptoms d. initiate an amiodarone oral load

a. add metoprolol succinate 50 mg/day

Case 14. A 60-year-old male with hypertension and diabetes mellitus presents to the emergency department with right-sided weakness. The initial blood pressure is 170/90 mmHg. Emergent MRI brain shows a hypertensive bleed. What is the most common location for this type of bleed? a. basal ganglia b. pons c. brainstem d. cerebellum

a. basal ganglia The basal ganglia is comprised of the putamen, globus pallidus, caudate, and thalamus. A major contributing factor for bleeding is reactive hypertension that develops after a cerebrovascular accident in order to ensure adequate cerebral perfusion. This increases the likelihood of arterial rupture.

Case 7. What dose adjustments would you make (based on protocol) in the following scenarios: a. next aPTT comes back at 48 seconds after starting infusion b. next aPTT had been 65 (6 hours later) c. next aPTT had been 115

a. based on bolus, we would increase infusion by 100 units/hr max. is only for initial rate b. no change in infusion c. stop infusion for 30 minutes and change rate of infusion by decreasing 100 units/hour

Case 39. FM is a 58-year-old female who presents to the ED with SOB and sharp shooting pain down her left arm. She states she was out to lunch with friends when she had a sudden felling of "doom" and then couldn't breathe. EMS was called and she was found to have ST-segment elevation on a 12 lead EKG. She was started on MONA therapy on the way to the hospital. When should alteplase be given to this patient? a. within 30 minutes on arrival to the hospital b. within 120 minutes on arrival to the hospital c. within 4 hours from onset of symptoms d. within 12 hours from onset of symptoms What total dose of alteplase should be given to this patient? a. 100 mg b. 107 mg c. 148 mg FM is transferred to a PCI capable hospital after receiving alteplase. Which of the following medications should be initiated? a. aspirin, prasugrel, heparin b. aspirin, clopidogrel, enoxaparin c. aspirin, clopidogrel, bivalirudin d. aspirin, ticagrelor, heparin, tirofiban

a. within 30 minutes on arrival to the hospital goal: ideal is PCI but if can't then within 2 hours, alteplase needs to be given c is for stroke a. 100 mg this is the maximum dose b. aspirin, clopidogrel, enoxaparin prasugrel not given bc of bleed risk d is eliminated

Case 20. An adult patient with normal left ventricular function presents with palpitations. A representative ECG is shown. What is the best initial therapy for this patient? a. Digoxin b. Adenosine c. Verapamil d. Amiodarone

b. Adenosine Short-term management of supraventricular tachycardia (SVT) is best accomplished using adenosine, 6-9 mg IV push. Occasionally, the paroxysmal (PSVT) can restart soon after termination, in which case either a beta-blocker or calcium channel blocker can be initiated, but it will require a second dose of adenosine. Adenosine's site of action is the AV node, where impulse conduction is depressed, leading to tachycardia termination. Since the AV node is a necessary part of the reentry circuit in both forms of PSVT, adenosine works well for both.

Which of the following symptoms would warrant an ACS rule-out in an elderly patient? a. decreased autonomic neuropathy b. altered mental status c. poor appetite d. 3 lb. weight gain overnight

b. altered mental status UTI? polypharmacy? Hepatic encephalopathy? d is incorrect (typically seen in HF patients)

Case 11. You are on your 3rd year IPPE rotation rounding on the med surg unit with your preceptor when a code 'Stroke' is called. You head down to the ER. A 65-year-old man is brought into the ER by his wife 45 minutes after he had a sudden onset of confusion, left sided weakness and dizziness just as they were about to sit down for lunch. SH: smokes 1 pack of cigarettes/day Meds: Amlodipine 5 mg daily and HCTZ 25 mg daily Vitals: BP (145/82), Weight (160 lb) a. Your facility has TNKase on formulary. What dose does he need for stroke? How would you administer it? b. What agent do you recommend for secondary prophylaxis?

b. aspirin 81 mg daily is the most common approach

Case 19. A 6-month-old, weighing 8 kg, is brought to the ER because of poor feeding and listlessness. The infant is breathing spontaneously but is responsive only to pain. Pulses are not palpable. The cardiac monitor reveals a supraventricular tachycardia of 250 beats per minute. What should be done immediately? a. administer verapamil 0.1 mg/kg, slow IV push b. immediate synchronized cardioversion with 4 Joules c. administer digoxin 0.02 mg/kg IV d. immediate defibrillation with 16 Joules

b. immediate synchronized cardioversion with 4 Joules This unstable patient requires immediate cardioversion with a dose of 0.5 to 1 J/kg and, if ineffective, increased to 2 J/kg. c is wrong bc IV digoxin is used to treat supraventricular tachycardia non-emergently, as it may take hours to work. a is wrong bc Verapamil is contraindicated in children under two years of age, as it can cause irreversible cardiovascular collapse due to their low calcium stores. In a patient with a pulse and organized rhythm, synchronized cardioversion is indicated over defibrillation. In synchronized cardioversion, the defibrillator times the shock to coincide with the peak of the QRS complex. This minimizes the potential for R on T phenomenon that can push the patient into ventricular tachycardia, usually polymorphic.

Case 15. A 65-year-old man is brought to the hospital with headache, vomiting, right-sided weakness, loss of speech, and drowsiness. His vital signs show oxygen saturation 98% on room air, respiratory rate 16 breaths/minute, heart rate 67 bpm and regular, blood pressure 220/110 mmHg, and temperature 98.6 F (37 C). On examination, his left pupil is 3 mm and nonreactive. Neurological examination reveals facial weakness on the right side and right-sided hemiplegia. The mental status examination shows confusion and disorientation. A CT scan of the head shows a 4 cm hyper density in the left basal ganglia region. He becomes unconscious within one hour. What is the most likely diagnosis? a. cerebral infarction b. intracerebral hemorrhage c. subarachnoid hemorrhage d. subacute subdural hematoma

b. intracerebral hemorrhage (ICH) presents acutely and deteriorates suddenly, compared to cerebral infarction. The most common etiology of ICH is hypertensive vascular changes. The presentation of hemorrhagic stroke is usually acute and progressing. Cautiously lower the blood pressure to a mean arterial pressure (MAP) less than 130 mmHg, but avoid excessive hypotension. Acute onset headache, vomiting, increases in blood pressure, and the rapidly developing neurological signs are the common clinical manifestations of hemorrhagic stroke. c is wrong bc subarachnoid hemorrhages can cause rapid worsening, but focal deficits will be later in the stage of vasospasm. d is wrong bc subacute subdural hematoma has a gradual presentation.

Case 12. A 68-year-old male with a history of hypertension presents to the emergency department with a sudden onset headache, nausea, vomiting, and dizziness. A CT scan of the head is unremarkable with no intracranial hemorrhage and no acute ischemic lesions seen. He has a non-focal neurologic exam while lying down. As soon as he stands up, he has severe unsteadiness and falls to the floor. He is unable to walk. What is the most appropriate next step in the management of this patient? a. discharge patient w/ an anti-emetic and follow up with his PCP the next day b. order an MRI brain and MR angiogram of the intracranial and neck vessels c. admit him under "observation" w/ a diagnosis of vertigo, w/ neurological evaluation every 8 hours d. perform an urgent lumbar puncture looking for a subarachnoid hemorrhage

b. order an MRI brain and MR angiogram of the intracranial and neck vessels An MRI brain with diffusion-weighted imaging and an MR angiogram are the best way of imaging the posterior fossa and posterior circulation when there is a negative CT. Lumbar puncture is contraindicated in cases where the posterior fossa pressure gradient is likely to be increased, as in ischemic vertebrobasilar stroke. The risk of herniation of the edematous cerebellum in this context is high. This patient should be admitted, with frequent neurological evaluations to observe for mental status changes from obstructive hydrocephalus. However, the best initial step is ordering an MRI brain and MR angiogram.

Case 16. A patient develops a deep venous thrombosis (DVT) and pulmonary embolism and requires heparin. Four days later, she becomes hypotensive, and a CT scan reveals a large retroperitoneal hematoma. After resuscitation with fluids, what is the next step in management? a. stop heparin and observe b. reverse heparin and place a Greenfield filter c. give fresh frozen plasma (FFP) d. surgery to remove the hematoma and the DVT

b. reverse heparin and place a Greenfield filter a greenfield filter is placed in the inferior vena cava under fluoroscopic guidance to prevent venous emboli from entering the pulmonary circulation (captures clots) If the patient has received heparin, reversal with protamine can be attempted. The patient will need a Greenfield filter. d is wrong bc after blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas should not be opened up for exploration.

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. The patient has no insurance. Which of the following drug-drug interactions would lead to considering a higher dose of warfarin at initiation? a.Metronidazole b.Rifampin c.Fluconazole d.Acetaminophen

b.Rifampin Rifampin, a potent CYP3A4 inducer, that decreases INR

Case 7. S.W. is a 50-year-old male presenting to ED with complains of increasing right calf and leg pain as well as SOB and sharp pain with breathing. Reports that leg pain started in his calf ~1.5 weeks ago and has progressively worsened. He had attributed this "stiffness" from being stuck in a hospital bed for 5 days after his recent surgery but grew concerned when the pain increased, and his chest pain started. In reviewing the profile, you see that S.W. did receive VTE prophylaxis with heparin SQ 5,000 units TID post-operatively. Which of the following would be the best therapeutic option to treat this patients DVT? a. Rivaroxaban b. Dabigatran c. Apixaban d. Edoxaban

c. Apixaban patient is on dialysis and has end stage renal disease

Case 5. AG a 72 y.o. female presents to ED with SOB. CT shows bilateral PE. PMH is significant for congestive HF, HTN, upper GI bleed, and GERD. Currently taking furosemide 20 mg PO daily, carvedilol 6. 25 mg PO BID, lisinopril 20 mg PO daily, and omeprazole 40 mg PO daily. Which of the following therapeutic options would be the most appropriate to treat the patients PE? a. Warfarin b. Rivaroxaban c. Apixaban d. Dabigatran

c. Apixaban (Eliquis) Apixaban, a direct facto Xa inhibitor, is indicated for non-valvular atrial fibrillation, DVT/PE treatment and for postoperative DVT prophylaxis (knee and hip replacement) Does NOT require parenteral.

Case 5. AG a 72 y.o. female presents to ED with SOB. CT shows bilateral PE. PMH is significant for congestive HF, HTN, upper GI bleed, and GERD. Currently taking furosemide 20 mg PO daily, carvedilol 6. 25 mg PO BID, lisinopril 20 mg PO daily, and omeprazole 40 mg PO daily. What dose of apixaban should be recommended to this patient? a. Apixaban 5 mg PO BID b. Apixaban 2.5 mg PO BID c. Apixaban 10 mg PO BID x 7 days, then 5 mg PO BID d. More information is needed prior to dosing

c. Apixaban 10 mg PO BID x 7 days, then 5 mg PO BID Option a is for if the pt. had non-valvular atrial fibrillation Option b would be if the pt. was taking it for post-op DVT prophylaxis AG had small GI bleed and want to load during initial acute phase (higher dose to get through acute phase and then go down to typical 5 mg a day) → if AG had multiple GI bleeds, then maybe we wouldn't do a load dose → also AG just had an event (middle box) so we want to treat the DVT with the initial higher dose (10 mg PO BID x 7 days)

A 16-year-old pregnant woman in her third trimester presents to the emergency department with chest pain. A stat EKG shows a heart rate of 72/min, peaked T waves, absence of P waves, and widened QRS complexes. Which of the following is the best initial therapy for this patient? a. 20 cc/kg normal saline IV bolus b. IV insulin-glucose combination c. IV calcium chloride d. Digoxin

c. IV calcium chloride Peaked T waves, shortened QT interval, and widened QRS complex are hallmark signs of hyperkalemia. Severe hyperkalemia can cause life-threatening bradyarrhythmias and even cardiac arrest. Immediate management of hyperkalemia is to administer calcium chloride or calcium gluconate intravenously for its cardioprotective effect. Calcium does not lower serum potassium, and hence, further management includes sodium bicarbonate and glucose/insulin.

A 70-year-old male with a PMH of DM II, dyslipidemia came to ER w/ complaints of palpitation and chest pressure. There is no significant history of heart disease in the family. He smokes one pack/day and occasionally drinks alcohol. EKG showed atrial fibrillation with a rapid ventricular rate. The patient started feeling light-headed and dizzy. The plan was to do cardioversion in ER. At what point in the cardiac cycle is the synchronized cardioversion shock delivered? a. P wave b. S wave c. R wave d. T wave

c. R wave The electrical shock will be timed with the peak of the QRS complex. Once sensing has occurred, the shock will be delivered with the R wave. If patient goes into vfib, the synchronize mode must be turned off. The shock will not be delivered because the monitor is searching for the next R-wave in order to deliver the shock.

Case 39. FM is a 58-year-old female who presents to the ED with SOB and sharp shooting pain down her left arm. She states she was out to lunch with friends when she had a sudden felling of "doom" and then couldn't breathe. EMS was called and she was found to have ST-segment elevation on a 12 lead EKG. She was started on MONA therapy on the way to the hospital. PMH: CHF, HTN, DM II, anxiety, and depression SH: Smokes 1 PPD x 20 year, drinks 3 glasses of wine a week, lives with fiancé FH: Mother CVA age 75, Father DM, HTN, MI aged 45 Home Medications: furosemide 40 mg PO daily, amlodipine 5 mg PO daily, glargine 15 units HS, metformin 500 mg PO BID, sertraline 50 mg PO daily Which type of event is FM experiencing? a. unstable angina b. NSTEMI c. STEMI d. unable to determine Unfortunately, the hospital does not have the capacity to perform PCI. Is FM a candidate for fibrinolytics?

c. STEMI STEMI needs to be treated in the first 6-12 hours!! Waiting for troponin levels to peak is harmful to patient. FM has ST elevation Troponin > 0.03 is high and depends on hospital Candidate

Case 37. SO a 64-year-old female is brought to ED by ambulance. She was at a concert when she stated to experience severe, unrelenting substernal chest pain lasting greater than 30 minutes. She also admits to feeling nauseous and anxious. Past medical history of HTN, DM, and chronic stable angina. Her typical angina feels like a crushing pain typically brought on by lifting heavy instruments or walking up-hill and the pain subsides in 5 minutes when she stops or sits down to relax. SO received a total of 3 SL NTG tablets between backstage at the concert and i the ambulance, IN the ambulance, she was also given 10 mg morphine sulfate IV and placed on 2 L oxygen by nasal cannula. Once in the ED, she was still experiencing severe chest pain and was started on a NTG infusion at 10 mcg/min. What else should SO receive? a. another SL NTG tablet x 1 dose b. amlodipine 10 mg x 1 dose c. aspirin 325 mg x 1 dose d. oxycodone 10 mg x 1 dose

c. aspirin 325 mg x 1 dose during ACS event, use chewable aspirin tablet. rapidly in blood in 10 minutes. 3 doses is max dose of NTG oral started oxygen since we assume that she had less than 92% saturation

A patient with chest pain and shortness of breath is given an aspirin tablet. How should they be instructed to take the tablet? a. place it under their tongue b. hold it in their mouth until it dissolves c. chew the tablet d. swallow the tablet whole

c. chew the tablet Aspirin will be absorbed fastest if chewed. A dose of 160 to 325 mg of aspirin is usually given in for suspected acute coronary syndrome (ACS). In patients with aspirin allergy, clopidogrel can be considered as an alternative.

Case 9. CJ is a 45-year-old male diagnosed with COVID-19 infection and admitted to your hospital for management of severe COVID-19 symptoms. CJ was started on dexamethasone, high nasal flow canula, and baricitinib. Upon review of the patients medical records, it is found that he does not have a significant past medical history for any comorbidities. 5 days into CJ's hospital stay he develops a PE. Patient is currently on enoxaparin 40 mg SC daily. What would be the best treatment option for the patient at this time? a. continue enoxaparin 40 mg sc daily b. d/c enoxaparin 40 mg sc daily, start warfarin 5 mg PO daily c. d/c enoxaparin, start apixaban 10 mg PO BID x 7 days then decrease to apixaban 5 mg PO BID d. bivalirudin 0.75 mg/kg bolus, followed by 1.75 mg/kg/hr infusion

c. d/c enoxaparin, start apixaban 10 mg PO BID x 7 days then decrease to apixaban 5 mg PO BID we could also argue that we change the enoxaparin dose to therapeutic goal while he is in the hospital for his DVT/PE

Case 6. GG a 52 y.o. male presenting to ED due to palpitations and SOB. EKG shows Afib with RVR. PMH of HTN, DMII, transient ischemic attack (TIA) 2 years ago, and seasonal allergies. Currently on metformin 1000 mg PO BID, NPH 15 units sc BID, aspirin 325 mg daily, and loratadine 10 mg daily. The medical provider calculates a CHADS2VASC= 4 and HASBLED =2. After 4 weeks of fluctuating INR's, GG warfarin is as follows: warfarin 5mg: sunday, tuesday, thursday and saturday warfarin 7.5mg: monday, wednesday, friday His INR in clinic today is 3.8; no changes in medications but diet has changed. Which of the following diet changes could result in the INR obtained in clinic? a.Increased spinach b.Increased cheese c.Decreased romaine lettuce d.Decreased rice/tortillas

c. decreased romaine lettuce

Case 9. CJ is a 45-year-old male diagnosed with COVID-19 infection and admitted to your hospital for management of severe COVID-19 symptoms. CJ was started on dexamethasone, high nasal flow canula, and baricitinib. Upon review of the patients medical records, it is found that he does not have a significant past medical history for any comorbidities. After checking with the patient's insurance company for the preferred DOAC, you find out that dabigatran is the preferred drug. At this time the patient has significantly improved, and the patient will most likely be discharged in the next 48 hours. What would be the best course of therapy at this time? a. d/c enoxaparin, start dabigatran 150 mg PO BID b. d/c enoxaparin, start heparin (UFH) 80 units/kg Bolus IV, followed by an infusion of 18 units/kg/hr IV c. increase enoxaparin from 40 mg daily to enoxaparin 85 units sc BID d. fondaparinux 7.5 mg sc daily

c. increase enoxaparin from 40 mg daily to enoxaparin 85 units sc BID We would want to bridge with parenteral anticoagulant (LMWH or UFH) We want to use SC instead of IV a. we would need to do 5-10 days of bridging before starting dabigatran.

Case 13. A 65-year-old man presented to the hospital with a right-sided weakness for two hours. His past medical history reveals that he has been suffering from diabetes mellitus and hypertension for over ten years. On examination, his blood pressure is 170/100 mmHg, heart rate is 92/min, GCS is 15/15, and the respiratory rate is 21/min. He is maintaining his saturation adequately on room air. Neurological examination reveals upgoing planters on the right side and signs of upper motor neuron lesion. A CT scan brain is carried out, which reveals no abnormality. What is the next best step in the management of this patient? a. intravenous tenecteplase b. oral aspirin c. intravenous alteplase d. oral warfarin

c. intravenous alteplase The AHA/ASA recommends intravenous (IV) alteplase for patients who satisfy inclusion criteria and have symptom onset or last known baseline within three hours. Intravenous alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. The first 10% of the dose is given over the first minute as a bolus, and the remainder of the dose is given over the next 60 minutes. The time has been extended to 4.5 hours for selected candidates. A review of the exclusion criteria for thrombolytics should be performed before administering alteplase. According to the Food and Drug Administration, the contraindications to intravenous thrombolysis include active internal bleeding, recent intracranial surgery or serious head trauma, intracranial conditions that may increase the risk of bleeding, bleeding diathesis, severe uncontrolled hypertension, current intracranial hemorrhage, subarachnoid hemorrhage, and a history of a recent stroke.

Case 18. A 55-year-old woman undergoes a hip replacement after a fall. Two days postoperatively she develops sudden shortness of breath and tachycardia. On examination, she is tachypneic with a heart rate of 120/min and blood pressure of 120/57 mmHg. Blood gas analysis reveals a pH of 7.38, PCO2 35 mmHg, PO2 72 mmHg, and bicarbonate of 23 mEq/L. Duplex ultrasound of the lower extremity reveals a large clot in the iliofemoral vein. Which of the following is most likely to be found on a chest radiograph? a. westermark sign b. hamptom hump c. no abnormality d. pleural effusion

c. no abnormality The chest x-ray of a patient with pulmonary embolism is most often normal. The next imaging modality to be ordered after a radiograph is CT pulmonary artery angiography and, in rare cases, ventilation-perfusion scan when a CT is contraindicated. a is wrong bc westmark signs describes the relative area of oligemia or paucity of pulmonary markings on a chest x-ray due to vasoconstriction and decreased blood flow. It is seen in less than 10% of patients. b is wrong bc hampton humps describes wedge-shaped opacity, which is pleural-based with convex medial border representing pulmonary infarction. Pleural effusion accompanies pulmonary infarction in acute and subacute phases. It may be absent in the hyperacute phase or when infarction is close to resolving. If the patient has a history of contrast allergy, a V/Q scan can be substituted when a premedication regimen is inappropriate.

Case 41. A 59-year-old man is brought to the ED with a complaint of chest pain that started two hours ago. The pain is associated with vomiting, nausea, and diaphoresis. The patient has an ongoing history of similar pain that usually resolves with taking rest. However, this time the pain has been constant. There is a strong family history of ischemic heart disease. Which of the following features can best differentiate a non-ST-segment elevation myocardial infarction from unstable angina in this patient? a. description of symptoms b. EKG changes c. troponin elevation d. presence of risk factors

c. troponin elevation NSTEMI and unstable angina may have very similar presentations and findings, with the difference being NSTEMI being diagnosed if troponin elevation is present and unstable angina the diagnosis if troponin is not elevated. In both unstable angina and NSTEMI, ECG is not diagnostic.

Case 7. What dose of warfarin would you start S.W. on today? He is still on UFH. a. none; wait 5 days until therapeutic with heparin b. warfarin 2.5 mg c. warfarin 5 mg d. warfarin 7.5 mg

c. warfarin 5 mg typical starting dose for most patients; also his BMI is normal if patient had liver disease we would consider dose reduction typical INR for pt: 2-3

Case 38. NG is a 72-year-old male who presents to ED with chest pain that has radiated to his left arm. He explains the chest pain as if an elephant has sat on his chest. States that he has had increased SOB while walking and has been sweating more than normal since the pain began approximately one hour ago. PMH of CVA (2015), HTN, HLD, depression, and PE (2018). Current Medications: aspirin 81 mg PO daily, atorvastatin 40 mg PO daily, lisinopril 20 mg PO daily, sertraline 50 mg PO daily, Xarelto 20 mg PO daily and sildenafil 100 mg daily (last dose 72 hours ago). Which of the following anticoagulants should be AVOIDED in this patient? a. Heparin b. Enoxaparin c. Fondaparinux d. Bivalirudin

d. Bivalirudin avoid with PY12 inhibitors because of bleed risk can't use Fondaparinux by itself (parenteral agent): used in combo bc not potent enough on its own; need to renal adjust

Case 43. A 60-year-old female went in for coronary artery bypass grafting, three-vessel bypass and surgery was uncomplicated. Patient was transferred to a cardiac telemetry unit from the intensive care unit on a postoperative day 3 for another 24 hours for close monitoring. Patient has history of mild aortic stenosis, diabetes, and HTN. Around 6 PM, the patient started having chest tightness associated with SOB and dizziness. Vitals showed BP of 80/40 mmHg, pulse 140 per minute, RR 26/minute, and a Temp. of 98.4 F. On examination, the patient was in moderate respiratory distress and bibasilar crackles on auscultation. The patient was lethargic but able to answer all the questions. EKG was done that showed atrial fibrillation with a rapid ventricular rate, no acute ST-T changes. Which of the following is the best next step in the management of this patient? a. Amiodarone b. Defibrillation c. Diltiazem d. Direct current cardioversion

d. Direct current cardioversion Patient developed Afib after coronary artery bypass surgery leading to hemodynamic instability with signs of cardiogenic shock and acute pulmonary edema with impending respiratory failure. All patients with a pulse who has persistent tachyarrhythmia causing clinical or hemodynamic instability (hypotension, acute heart failure, cardiogenic shock, and acute chest pain) should be managed with immediate synchronized direct current cardioversion. b is incorrect bc immediate defibrillation, unlike cardioversion, provides a high-energy shock at a random point in the cardiac cycle (unsynchronized shock) and is indicated in patients with pulseless ventricular tachycardia or ventricular fibrillation and therefore not indicated in this patient. a is incorrect bc Amiodarone is a class III antiarrhythmic drug that is used for acute management of ventricular arrhythmias and maintenance of sinus rhythm in patients with atrial fibrillation. Amiodarone not indicated in hemodynamically unstable patients as it can further worsen hypotension and cause cardiac arrest. c is incorrect bc CCBs such as verapamil and diltiazem are indicated for rate control in stable patients with rapid atrial fibrillation.

Case 44. A 65-year-old woman comes to the ED because of acute onset SOB and coughing up blood for the past 5 hours. She has HTN and type 2 diabetes mellitus. She also has PMH of thrombocytopenia after using an anticoagulant for deep vein thrombosis. On examination, she appears anxious, her pulse is 112 beats/min, and respirations are 24 breaths/min, blood pressure 110/60 mmHg. She has normal breath sounds with no wheezing on auscultation of the chest. Her chest x-ray shows no abnormalities, but her ventilation-perfusion scan shows a small defect in the right middle lobe. The drug most likely to be used for the patient acts on which of the following substances? a. Glycoprotein IIb/IIIa b. Factor VII c. Antithrombin d. Factor Xa

d. Factor Xa rivaroxaban, a direct factor Xa inhibitor, can be used as an anticoagulant for acute PE and also continued for prevention of recurrent venous thromboembolic events - A is incorrect because antiplatelet drugs like abciximab act as glycoprotein IIb/IIIa inhibitor preventing platelet aggregation and are used during PCI. - C is incorrect because Heparin acts by indirectly inactivating thrombin and activated factor X (factor Xa) through binding with antithrombin to enhance its activity and is the initial treatment of choice for most patients with acute PE but given the history of heparin-induced thrombocytopenia in this patient, this drug is contraindicated. -B is incorrect because Warfarin is not the drug of choice for acute PE because the onset of action is typically 24 - 72 hours, and peak therapeutic effect is only seen 5 to 7 days after initiation. Remember that warfarin acts on Factor VII.

Case 40. A 68-year-old male with PMH of HTN, diabetes type 2, and coronary artery disease with prior percutaneous coronary intervention (PCI) and 2 drug-eluting stent placements presented to the ED with heavy retrosternal chest pain started 2 hours ago that lasted for 45 minutes. It started while he was watching TV on the couch. The patient mentioned that the chest pain reminded him of the heart attack he had 2 years ago. EKG was remarkable for normal sinus rhythm, with no ST-T changes. His cardiac markers were negative. BP is 133/79 mmHg, HR is 81 bpm, RR of 14/min, and SpO2 98%. What is the next step in management? a. reassurance and discharge home b. start a long-acting nitrate and discharge the patient home and follow up with cardiology c. admit the patient for serial EKGs every 30 minutes and repeat cardiac biomarker in 8-12 hours from the onset of chest pain d. arrange for urgent cardiac catheterization

d. arrange for urgent cardiac catheterization In this patient, the suspicion for acute coronary syndrome (ACS) is high, and serial ECGs should be performed initially at 15 to 30-minute intervals. An initial ECG should be obtained within ten minutes in these patients. Cardiac biomarkers should be measured in all patients with suspected ACS. Biomarkers should be remeasured eight to 12 hours after chest pain begins if the set obtained within six hours of symptoms was nondiagnostic. Urgent indications for cardiac catheterization are continued pain, cardiogenic shock, severe left ventricular dysfunction, acute mitral regurgitation, new ventricular septal defect, and unstable tachyarrhythmias.

Case 37. SO, a 64-year-old female is brought to ED by ambulance. She was at a concert when she stated to experience severe, unrelenting substernal chest pain lasting greater than 30 minutes. She also admits to feeling nauseous and anxious. Past medical history of HTN, DM, and chronic stable angina. Her typical angina feels like a crushing pain typically brought on by lifting heavy instruments or walking up-hill and the pain subsides in 5 minutes when she stops or sits down to relax. SO was given a total of 3 SL NTG tablets, 10 mg morphine sulfate IV, placed on 2 L of oxygen, started on a NTG infusion at 10 mcg/min and already given aspirin 325 mg x 1 dose. SO's provider decides to proceed with a PCI in the next 48 hours. Which medication should be initiated? a. aspirin, heparin drip, clopidogrel, and tirofiban b. aspirin and enoxaparin sc c. aspirin, heparin drip and prasugrel d. aspirin, enoxaparin sc, ticagrelor

d. aspirin, enoxaparin sc, ticagrelor a. pt. qualifies for GP IIb/IIIa inhibitor (given for increased risk of clot caused by platelet...) pt. is not a high risk clot b. incorrect bc no GP IIb/IIIa inhibitor included c. prasugrel given after a stent bc it is very potent and highest risk of bleed

Case 17. What is the best initial approach for a postmenopausal, obese female with a history of smoking and hormone replacement therapy admitted with left calf pain and decreased sensation? a. lidocaine patch b. start tPA immediately c. start intravenous heparin d. duplex ultrasound

d. duplex ultrasound Compression ultrasonography is the non-invasive approach of choice for the diagnosis of symptomatic patients with the first episode of suspected deep venous thrombosis (DVT). Hormone replacement therapy and smoking history are risk factors for venous thromboembolic disease. If the patient does have a DVT, one option for treatment is to begin unfractionated heparin. Unfractionated heparin can be initiated simultaneously with the oral anticoagulant warfarin. The two medications should overlap several days until anticoagulation with warfarin prolongs the patient's INR to therapeutic levels. Oral factor Xa inhibitors or direct thrombin inhibitors are also options for initial anticoagulation following the diagnosis of DVT.

Case 8. K.M. is a 70-year-old female presenting to ED with complaints of chest pain, that was not relieved by 2 tablets of sublingual nitroglycerin. EKG shows ST-segment elevation MI (STEMI). K.M given one more dose of nitroglycerin. Cardiologist recommended to starting enoxaparin prior to transferring the patient to the catheter lab for stent placement. What would be the appropriate dose of enoxaparin to start the patient on at this time? a. enoxaparin 40 mg sc every 24 hours b. enoxaparin 55 mg sc every 12 hours c. enoxaparin 55 mg sc every 24 hours d. enoxaparin 30 mg bolus PLUS enoxaparin 55 mg sc every 12 hours

d. enoxaparin 30 mg bolus PLUS enoxaparin 55 mg sc every 12 hours a. prophylactic dose b. don't have bolus info. and frequency is not appropriate c. don't have bolus info. and frequency is not appropriate

Case 37. SO, a 64-year-old female is brought to ED by ambulance. She was at a concert when she stated to experience severe, unrelenting substernal chest pain lasting greater than 30 minutes. She also admits to feeling nauseous and anxious. Past medical history of HTN, DM, and chronic stable angina. Her typical angina feels like a crushing pain typically brought on by lifting heavy instruments or walking up-hill and the pain subsides in 5 minutes when she stops or sits down to relax. SO was given a total of 3 SL NTG tablets, 10 mg morphine sulfate IV, placed on 2 L of oxygen, started on a NTG infusion at 10 mcg/min and already given aspirin 325 mg x 1 dose. Which type of ACS is the patient experiencing? a. unstable angina b. STEMI c. NSTEMI d. unable to determine

d. unable to determine We have T-wave inversions and no elevation in troponin. Body has not had enough time to break down troponin and that is an indicator of ischemia. We need to look at serial troponins to determine the ACS event.