ERRATUM and Corrections
Includes some updates for Maria Codina Leik's Books (Springer Publishing, New York)
1st edition and 2nd edition
Family Nurse Practitioner Certification Intensive Review 
Adult Nurse Practitioner Certification Intensive Review 

Diabetes Mellitus Updates

Diagnosis 
A1c (or HbA1c) of equal or > 6.5% on two or more occassions
Glycated hemoglobin is an average measure of the blood glucose in the previous 3 months. Check the A1c every 3 months (or quarterly), then every 6 months when control achieved. It is a measure of the excess glucose that attaches to the hemoglobin/RBC surface. 

Normal: < 5.7%
Prediabetes: 5.7% to 6.4%
Diabetes: 6.5% or higher

Fasting glucose (equal or > 126 mg/dL) on 2 separate occasions 
2-hour blood glucose equal or > 200mg/dL (OGTT with 75 g glucose load)
and/or  random blood glucose (equal or > 200mg/dL with classic symptoms of diabetes.

Increased Risk for Diabetes (also known as prediabetes)
A1c (HbA1c): a value between 5.7% - 6.4%  
2-hour blood glucose: 140 – 199 mg/dL after 75 g OGTT (Impaired Glucose Tolerance or IGT)
Fasting  blood glucose: 100 – 125 mg/dL (Impaired Fasting Glucose or IFG)

Addison's Disease
Presents with bronze-like skin color (looks like a dark tan) that is especially obvious on the nipples, old scars, etc. Patient will complain of dizziness and weakness. Low serum sodium and high potassium levels. Caused by aldosterone deficiency. 


Mental Health Chapter

Atypical antipsychotics (Zyprexa, Risperdal, Seroquel) 
Increases risk of obesity, type 2 diabetes, and hyperlipidemia. Monitor patients' weight, BMI, waist circumference, fasting blood glucose, and lipid profile.

Do not forget that drugs and new info that was release within the past 6 to 12 months will most likely not be included on the exam. Drug doses are not a big deal on the NP exams, but drug safety issues are. 






WARNING: 
The book is written to review for the ANCC and AANPCP exams so that you can markedly increase your chances of passing your certification exam. It is not written for use on patients in the clinical arena. 




JNC 8 Hypertension Treatment Guidelines

Both the ANCC and the AANPCP exams are now on JNC 8. The list of  official "compelling indications" from JNC 7 is gone. The only two diseases mentioned are diabetes and chronic kidney disease (CKD).  Treatment can be based on race (Black and Non-Black). 

BP goals for all races (including preexisting heart disease, diabetes, CKD) is BP < 140/90 until the AGE OF 60 Years. At age of 60 years or older, the SBP goal is 10 mm Hg higher (< 150/90) EXCEPT for diabetes and chronic kidney disease (CKD). For these two diseases, the BP goal is always < 140/90 (lifetime goal).

What is the goal BP for a hypertensive 60 year old Black male who has no history of diabetes 
and kidney disease?   The goal BP is < 150/90 mm Hg

If the above patient has a diagnosis of diabetes (or CKD), what is the goal BP?
The goal BP is < 140/90 mm Hg (lifetime goal)

What is the preferred antihypertensive drug for a diabetic and/or CKD patient?
ACE inhibitors or ARBs. If poor result, add a thiazide diuretic (eg, chlorthalidone or hydrochlorothiazide)

What  medication is more effective for a patient with hypertension who is of African descent?
​Calcium-channel blockers (CCB) and/or thiazide diuretics

What is the preferred drug for isolated systolic hypertension in an elderly patient?
Either low-dose thiazide diuretic (eg, 12.5 -25 mg/day chlortalidone), or long-acting calcium channel blockers/agonist (eg, long-acting dihidropyridone amlodipine/Norvasc, -pine suffix)
​Source: UptoDate 2016

ACC/AHA Guideline on the Treatment of Blood Cholesterol 
The new hyperlipidemia treatment guidelines is pointing us towards using statins alone in different dosages. The lowest doses are for low intensity treatment, moderate dose for moderate intensity, and the lowest doses are for the low intensity group. It is very specific, it gives you not only the statin dose, but also the preferred statins (such as atrovastatin, rosuvastatin, simvastatin, etc.). Research have shown that combining statins with niacin and fibrates increases the risk of adverse events (liver, muscle breakdown, renal, and drug interactions).

How do I know which statin intensity to "prescribe" a patient? 
It is based on  patient characteristics or "risk factors". Statin intensity doses are determined by presence (or absence) of risk factors and the patient's age group.

For patients who do not have ASCVD (or another form of ASCVD such as hx of MI, CAD, stroke, TIA, PAD, coronary revascularization), you need to calculate the risk. The ASCVD 10-year estimated risk of 7.5% is the cutoff. 
To determine ASCVD risk, use the free ACC/AHA ASCVD risk  estimator tool which is a free app at the Apple store, Google store, or use it directly online (use a search engine to find it). 

According to the ACC and AHA Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk (2013, updated 2014), there are four statin benefit groups. 

Has ASCVD (secondary prevention)
*1. Patients with any form of ASCVD (history of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization)
Younger than 75 yrs: high intensity statin 
Older than 75 yrs (or not candidate for high intensity statin): moderate intensity statin

Does not have ASCVD (primary prevention)
* 2. LDL-C 190 mg/dL or higher:  high intensity statin
3. Diabetics (age 40 to 75 years) with LDL 70-189 mg/dL: moderate intensity statin
4. Without diabetes or ASCVD (age 40 to 75 years) with an estimated 10 -year ASCVD risk of 7.5% or higher: moderate to high intensity statin

Note:
Lack of ASCVD, but adults with 10-year ASCVD risk (between 5% to less than 7.5%), the first line therapy is a heart healthy lifestyle. 

​Statin Intensity Doses
​High Intensity Statins
Atorvastatin (Lipitor)  40 - *80 mg
Rosuvastatin (Crestor) 20 – 40 mg

Moderate Intensity Statins
Atorvastatin 10 -20 mg
Rosuvastatin (Crestor) 5-10 mg
Simvastatin (Zocor) 20-40 mg
Pravastatin (Pravachol)  40-80 mg
Lovastatin (Mevacor)  40 mg

Low Intensity Statins
Simvastatin 10 mg
Pravastatin 10-20 mg
Lovastatin 20 mg
Fluvastatin 20-40 mg




Exam Tip:
I think the best way to study for the test is not to get stuck on specifics. Memorize who gets high-intensity statins. 
There are only two groups (* asterisk by patient group #1 and #2).
The 10-yr ASCVD risk cutoff is 7.5% (age 40-75 yrs).
Egg Allergy and the Flu Vaccine (CDC 2016-2017)

NOTE:  LAIV (FluMist) - CDC does NOT recommend using the LAIV vaccine for 2016-2017 flu season (poor immune response). Use the inactivated flu vaccine injections instead.

After eating eggs or egg-containing foods, does patient experience only hives?
If YES - administer any influenza vaccine formulation appropriate for patient's age and health status.

After eating eggs or egg-containing foods, dose the patient experience other symptoms such as:
Cardiovascular changes (eg; hypotension)
Respiratory distress (eg; wheezing)     ​GI distress (eg; nausea, vomiting)
Reaction requiring epinephrine or requiring medical attention

If  YES - administer in outpatient or inpatient setting under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions (CPR, epinephrine, O2, intubation, etc.).


ERRATUM
Both FNP and AGNP Intensive Certification Review books (2nd ed) are best-sellers and have been published many times since its initial release in 2013. When an error is noted,  it is corrected on the next printing batch. But since it has been reprinted many times, there are older versions out there. 

Endocrine
Somoygi phenomenon is a rebound effect. Due to hypoglycemia early in the morning (about 2 -3 am), the liver secretes glucagon to compensate.  This causes the FBG to become elevated in the morning.  The early am hypoglycemia is caused by evening or bedtime NPH dose too high, skipping snacks, excess physical activity in the afternoon or PM,etc. The "fix" is to eat a carbohydrate snack before bedtime, reduce the intermediate or long-acting insulin dose in the evening, and/or to change the timing of exercise (best to exercise in the morning instead of afternoon/evening).

Dawn phenomenon is physiologic and it occurs in everyone. The body secretes "counter regulatory" hormones such as GH and cortisol in the early am, which causes the FBG to become elevated in the morning. For diabetics, this can cause a problem. The "fix" is to adjust the time (and/or the dose) of the insulin from evening to bedtime, eat fewer carbs in the evening/bedtime, and/or to excercise in the evening (walking).

Antibody Testing (thyroid disease)
Hashimoto Thyroiditis (hypothyroidism) positive for *thyroid peroxidase antibodies (anti-TPO), thyroglobulin antibodies (anti-Tg)
Another name for *thyroid peroxidase antibodies is antimicrosomal antibodies

Graves Disease - thyrotropin (TSH) receptor antibodies or TSH-receptor antibodies (TRAb)

QUESTIONS with corrected answers

19. D) Diuretics (thiazide diuretics)
112. A) Presumptive sign  
162. A) The high vitamin K levels will decrease the bleeding time (or INR goes down). Foods containing vitamin K will decrease the anticoagulation effect of Coumadin (decreases the INR).  Warfarin (Coumadin) is a vitamin K agonist.
191. C) Breastfed infants only require vitamin D supplementation within a few days of birth 
244. B) State legislature has authority to pass the laws (nurse practice act). The BON enforces the laws.
277. D) Elevated creatinine and BUN (EBV does not affect the kidneys).
315. B) Second intercostal space, left sternal border (pulmonic area is best place to auscultate a split S2)
319. B) Basal skin cancer is the most common type of skin cancer. 
338. Can draw a cross at age 4 years. Can ride a bike at age 5 to 6 years.
367. D) Order an AIC level 
372. C) Ranitadine (Zantac) is an H2 blocker, use initially to treat H. pylori negative ulcer instead of starting PPI first.
475. C) Serum folate and B12 level
400. Change question to treatment for a case of uncomplicated chlamydia; answer is C) azithromycin 1 g or doxycline BID x 7 days
But treatment of both gonorrhea and chlamydia is ceftriaxone 250 mg IM plus doxycycline BID x 7 days.
499. See notes above. Somoygi phenomenon is option C) characterized by high fasting BG in morning; Dawn phenomenon is B) physiologic spike...
514. D) Reduction of FEV1 (forced expiratory volume in 1 second) with an increase in  TLC (total lung capacity) and RV (residual volume).





More Notes
Hypertensive Retinopathy: copper wire arterioles, silver wire arterioles, AV nicking
Diabetic Retinopathy: neovascularization, microaneuryms, soft exudates, "dot and blot" hemorrhages

Chest radiographs/xray: you will get a chest film. Memorize right middle lobe pneumonia appearance.  TB chest xray will show cavitations (round black holes) on upper lobes/hila.

Pap/cytology: age less than 21 years, not recommended (even if sexually active, STDs, etc.). Can test for STDs based on sexual history (but no Pap).