FNP I Final Review Powerpoint Questions

HTN
● What is the difference between HTN and White Coat HTN?
○ White coat HTN is when the patient is hypertensive in the office setting, but normotensive
outside of the office setting. Recommend home blood pressure monitoring before prescribing
anti-hypertensives and consider 24-hour ambulatory monitoring.
HLD
● What are the causes of hyperlipidemia?
○ Primary
■ Genetics
■ Genetic mutation (single gene); Heterozygous
■ Chol levels are usually 2-3x the normal LDL levels
● in adults, > 190 and in children, > 160
■ Prevalence is 1:200
■ Usually don't require genetic testing unless uncertainty in dx
○ Secondary
■ Lifestyle: diet high in saturated fat (affects mostly the LDL), exercise, ETOH (biggest

m
er as
effect on HDL - can have a positive effect on HDL unless excessive intake; will also

co
increase triglyceride levels), smoking, obesity

eH w
■ Chronic diseases: DM, hypothyroidism, nephrotic syndrome (lowers HDL), menopause

o.
(accelerate increase of LDL in year following menopause), obstructive liver disease, CRF
rs e
■ Drugs: anabolic steroids and HIV drugs can cause low HDL; progestins, synthetic
ou urc
steroids, glucocorticoids, amiodarone or protease inhibitors, and thiazides (high doses)
can cause increased LDL
● How would you work a patient up for these causes?
o

○ UA (proteinuria)
aC s

○ TSH
vi y re

○ LFTs
○ HgbA1c and fasting blood glucose
● What medication and at what dose would you start a patient on with hyperlipidemia?
○ Statins remain 1st line therapy
ed d

○ Pts with DM do not need a ASCVD - they just get started on a moderate dose statin
ar stu

○ Someone 40 - 75 yrs who isn't being tx'ed for hyperlipidemia, do 10 yrs ASCVD risk. If > 7.5%
then TREAT; if 5 - 7.5% then consider treat w/ moderate dose statins.
○ Pediatrics - Lifestyle modification first; Then start LOW and titrate SLOW unlike w/ adults who
is

have high LDL or have ASCVD risk > 7.5% where you would start with high dose statin.
○ Elderly - Start with a moderate dose statin therapy for secondary prevention (pt who has known
Th

heart disease and elevated cholesterol levels) instead of a high dose statin.
● How would you treat a patient with hypertriglyceridemia?
○ Drugs Affecting Lipoprotein Metabolism -
sh

■ Fibric Acid (Gemfibrozil, fenofibrate, etc) Indicated for ppl w/ severe

hypertriglyceridemia > 500.
■ Long Chain Omega 3 Fatty Acids - At 4 gm / day, trigs can be lowered 45%; will also
have an effect on LDL and can raise HDL.
○ Statins
■ Lower trigs by 7-30%
○ Nicotinic Acid
■ Lowers trigs by 7-30%
This study source was downloaded by 100000829216747 from CourseHero.com on 08-09-2021 23:09:01 GMT -05:00
1

https://www.coursehero.com/file/41163075/FNP-I-Final-Review-Questionsdocx/
 ● Diet changes for a person with hypertriglyceridemia?
○ Decrease ETOH
● Diet changes for a person with elevated LDL?
○ Decreased intake of cholesterol and/or trans fatty acids. Decreased intake of animal products
and red meat.
● Diet changes for a person with low HDL
○ Increased intake of vegetables, fruits, low fat dairy products, whole grains, fish, poultry, beans,
non-tropical vegetable oils, and nuts. Avoidance of red meat, sugary drinks, and sweets. Limit
sodium intake and intake of saturated and trans fat.
● What if a patient has both elevated cholesterol and triglycerides?
○ For hypertriglyceridemia, add fenofibrate, niacin, or omega-3 fatty acid to medication regimen,
along with statin therapy
● What are the non-pharm options for treatment?
○ Lose weight if obese or overweight (maintain health BMI)
○ Healthier diet with more fruits and vegetables and less red meat and animal products. Limit
saturated and trans fat to less than 5-6% of calories. Limit sodium to 2,400 mg/day.
○ Less ETOH consumption or no ETOH consumption
○ Start exercise program (moderate-vigorous aerobic activity, atleast 40 minutes, 2-4 times a
week)

m
○ Tobacco cessation

er as
● Understand the side effects of statins, from mild to severe

co
○ Statins - mainstay; no evidence that combo/monotherapy with other meds effective in decreasing

eH w
ASCVD risk

o.
○ **Do not add gemfibrozil to statin therapy; increased risk of myositis/rhabdomyolysis
rs e
○ Statins - headache, rash, fatigue, myalgia, myositis → rhabdomyolysis,
ou urc
elevated liver enzymes/liver dysfunction, increased risk of DM
○ Bile acid sequestrants - can interfere with absorption of other meds; constipation,
bloating/fullness, flatulence, nausea; contraindicated if triglycerides >300
o

○ Nicotinic acid - flushing sensation; may be reduced by taking 325 mg ASA prior to taking med;
low compliance with multiple doses/day; check uric acid - may elevate, peptic ulcers, GI
aC s
vi y re

disturbances
○ Fibric acids - may increase LDL; well tolerated, work especially for triglycerides >500;
contraindicated if GFR <30, GI disturbances, cholelithiasis, hepatitis
○ Cholesterol absorption inhibitors - check liver function, discontinue if ALT elevated >3x
ed d

baseline; diarrhea, arthralgia, rhabdomyolysis, hepatitis, pancreatitis, thrombocytopenia

ar stu

○ Long chain omega 3 FA - 2-4 gram/daily to be effective; nausea, dyspepsia, rash, increased
bleeding time, elevated fasting BG, unpleasant aftertaste
● Be aware of drug interactions with statins - which drugs can particularly have a serious
interaction with statins.
is

○ Do NOT add gemfibrozil (Lopid) to statin therapy due to increased risk of myocitis and
Th

rhabdomyelitis.
○ Other medications that interact with statins and increase patient’s risk for
myopathy/rhabomylosis include Macrolides, Itraconazole, Gemfibrozil, Cyclsporine, Niacin, and
Danazol.
sh

● What would be your physical and lab findings if a patient has a side effect of a statin?
○ Muscle aches and weakness
○ Elevated CK
○ ***CPK is preferred test in patients presenting with muscle signs/symptoms, because CPK is
more sensitive and specific than other labs***
● Myopathy vs Rhabdo
○ Myalgia
■ Muscle aches or weakness WITHOUT elevated CK

This study source was downloaded by 100000829216747 from CourseHero.com on 08-09-2021 23:09:01 GMT -05:00
2

https://www.coursehero.com/file/41163075/FNP-I-Final-Review-Questionsdocx/
 ■ Least severe and most common presentation
■ Patients can be reassured and remain on statin therapy
○ Myositis
■ Myalgia or weakness WITH elevated CK < 10 times upper level normal (ULN)
■ Statin should be discontinued
■ Once statin is discontinued, CK will return to normal and there is no long-term adverse
effects
■ Statin therapy should be reinitiated once CK levels return to normal
○ Rhabdomyolysis
■ Muscle symptoms with VERY HIGH (>10 times ULN), increased serum Creatinine, and
myoglobinuria
■ Most severe and least common presentation
■ May lead to renal failure
■ Risk from statins is < 0.5%
■ Present with urinary myoglobin and renal insufficiency
■ CK and myoglobin is released into the circulation
■ More common in patients on combination therapy, especially in patients on statin and
gemfibrozil
● How would you evaluate?
○ To evaluate for adverse muscle symptoms related to statins, check CK, LFT’s, Creatinine

m
er as
(serum), and do a urinalysis (check for urinary myoglobin and renal insufficiency).
○ Some patients may have a mild CK elevation that is unrelated to statin therapy.

co
eH w
○ Mild elevations of CK can occur following exercise, especially in patients who run.
○ Mild elevations of CK are also common in patients who experience blunt force trauma or muscle

o.
cramping, so always evaluate patients for secondary causes of muscle symptoms.
rs e
● What would you do? Stop it, change it, change the dose?
ou urc
○ Discontinue the statin until symptoms can be evaluated and until the cause of symptoms can be
determined.
○ If muscle symptoms, or elevated CK do not resolve after 2 months off of statin, consider other
o

causes of muscle symptoms.

aC s

○ If muscle symptoms resolve and no contraindications exist, restart the patient on the same or
vi y re

lower dose of original statin to establish a causal relationship

○ If causal relationship exists, discontinue original statin and use lower dose of another statin
○ Once low dose of statin is tolerated, gradually increase the dose as tolerated to the maximum
tolerated dose
ed d

○ If persistent muscle symptoms are unrelated to statin therapy or the predisposing condition has
ar stu

been treated, resume statin therapy at original dose

● Evaluation and management
Diabetes
● Understand the pathophysiology of Type 2 Diabetes
is

● Physiologically how type 2 DM changes over time and what can affect the changes
Th

● What is the diagnostic criteria for pre-diabetes

○ Impaired fasting glucose (IFG) result of 100-125 mg/dl
○ Impaired glucose tolerance (IGT) result of greater than/equal to 140, 2 hours after glucose drink
and < 199 mg/dl
sh

○ A1C of 5.7-6.4%
● What are the indications of pre-diabetes in history, physical and lab results
● What are your management options for patients dx’d with pre-diabetes (when if ever would you
decide to start meds? What lifestyle changes would you recommend?)
○ Diet should be well balanced and consist of complex carbohydrates
○ Consider having patient see a dietician

This study source was downloaded by 100000829216747 from CourseHero.com on 08-09-2021 23:09:01 GMT -05:00
3

https://www.coursehero.com/file/41163075/FNP-I-Final-Review-Questionsdocx/
 ○Patients should exercise, if they don’t currently. Patients may say that their job is exercise, but
the definition of exercise is above/beyond their daily activity. Patients should exercise 5 times a
week for 30-40 minutes as their goal
○ Patients should lose weight and set realistic goals, such as 10% of their body weight over the
next 6 months
○ Patients should control their blood pressure and lipids
○ Therapeutic Drugs
■ Metformin is the medication of choice for pre-diabetes
■ Consider drug therapy after giving the patient atleast three months to make lifestyle
modifications
■ After three months, repeat the patient’s blood work to see how their values have
changed
■ If patient isn’t doing well after three months of lifestyle modifications (A1C or fasting
glucose is worse), add a medication.
■ Medications can be considered right away, without three month trial of lifestyle
modifications, if when you initially diagnose the patient with pre-diabetes, their FBS is
120 or higher (close to being full blown diabetic)
● When should you start pre-conceptual counseling
○ All women of childbearing age (at puberty) and even before that

m
○ Do it at every well visit due to the rate of unplanned pregnancies being so high

er as
○ Pre-conceptual care in women with diabetes appears to reduce the risk of morbidities in infants

co
● What are the goals of pre-conceptual counseling in a diabetic patient

eH w
○ Educate patient on the risks of having diabetes and becoming pregnant, which include

o.
spontaneous abortion, fetal anomalies, fetal demise, pre-eclampsia, macrosomnia, pre-natal
rs e
hypoglycemia, and an increased risk of the baby having diabetes.
ou urc
○ Inform patient that major medical malformations remain the leading cause of mortality and
serious morbidity in infants born to mothers with diabetes (either type 1 or type 2)
○ Inform patients that the goal is to keep their A1C as “normal as possible.” For a healthy woman
o

who is contemplating becoming pregnant, the more their A1C is controlled, the less their risk of
aC s

complications in the pregnancy.

vi y re

○ Inform patient that statins, ACEs, ARBs, and non-insulin therapies are contraindicated in
pregnancy, so if they are on these drugs and don’t want to be pregnant, they should be on a
contraceptive and use it 100% of the time they are sexually active. If planning a pregnancy, and
on these drugs, refer patient to an OB and/or endocrinologist to discuss their options.
ed d

● Diagnosis Criteria - what is the diagnostic criteria to diagnose a patient w/ diabetes?

ar stu

○ You have three choices: (What results would you expect to dx someone w/ DM?)
■ Fasting plasma glucose (second best option)
● More sensitive than hemoglobin A1C, but less sensitive than glucose tolerance
test.
is

● Make sure the patient is truly fasting for 8 hours before lab draw (only allowed to
Th

have water and black coffee when fasting for labs)

● Normal: < 100
● Pre-Diabetic: 100-125
● Diabetic: > 126
sh

■ Hemaglobin A1C (third best option)

● Not great for detecting pre-diabetes, but good for detecting diabetes
● Need elevated blood sugars for over 3 months to get accurate A1C, which
patients might not have with pre-diabetes
● There are also genetic variations with hemoglobin A1C (in African Americans,
Asians, and Mediterranean heritage). Patients with these genetic variations do
not have accurate hemoglobin A1Cs.

This study source was downloaded by 100000829216747 from CourseHero.com on 08-09-2021 23:09:01 GMT -05:00
4

https://www.coursehero.com/file/41163075/FNP-I-Final-Review-Questionsdocx/
 ●
Patients’ A1C can also be inaccurate if they have hemoglobin abnormalities, such
as liver or kidney disease, iron deficiency anemia, or any condition that affects
RBC turnover/count will affect A1C
■ Glucose tolerance test (BEST OPTION*)
● The most accurate test for detecting pre-diabetes and diabetes
● Give the patient a 75 gram carbohydrate load, then test their plasma glucose in 2
hours
● Not diabetic: < 140
● Pre-diabetic: >140- <199
● Full blown diabetes: > 200
● Evaluation - pertinent aspects of the history, ROS (s/s of complications of DM, what would they
exhibit?)
● Management
○ When to start a medication
○ What med would you consider starting
■ Metformin
○ When would you change medications and what would you change to?
■
○ What if a patient also has HTN?

m
○ Goal of treatment

er as
■ Who should strive for tight control vs loose control?
● Management

co
eH w
○ Are there special concerns in managing children with diabetes versus adults - growth
and development, self esteem issues etc.

o.
■ In children, there’s a more rapid progression decline in beta cell function, which means
rs e
children will need insulin sooner than if they were diagnosed with type 2 diabetes as an
ou urc
adult. This also means that in children, there is an accelerated development of
complications.
■ With children, there are complex psychosocial/cultural considerations, which make it
o

harder to get lifestyle changes going. Need to work with the schools and parents, and
aC s

possibly get social workers involved.

vi y re

■ 6% of pediatric patients with diabetes may present with DKA. DKA doesn’t mean the
patient is automatically type 1 diabetic.
■ There are only two medication options for children, which are Metformin and Insulin. All
other hypoglycemics have not been approved for use in children.
ed d
ar stu
is
Th
sh

This study source was downloaded by 100000829216747 from CourseHero.com on 08-09-2021 23:09:01 GMT -05:00
5

https://www.coursehero.com/file/41163075/FNP-I-Final-Review-Questionsdocx/
Powered by TCPDF (www.tcpdf.org)