0 Family Medicine: 1, 2, 3

Front 1

What are the factors associated with increased breast cancer risk?

Back 1

Family History of BrCa in first degree relative (mother or sister)
Menarche before 12, menopause after 45 (prolonged exposure to estrogen)
Genetic Predisposition (BRCA1/2 mutations)
Advanced age
Female Sex
Increased Breast Density
Advanced age at first pregnancy
Therapeutic radiation
Obesity

Front 2

Exposure to what chemical increases risk of breast cancer?

Back 2

Diethylstilbestrol

Front 3

What factors are associated with DECREASED breast cancer rates?

Back 3

Pregnancy at early age
Late menarche, early menopause
High parity
SERMs, NSAIDs, ASA (possibly)

Front 4

What are the USPTF and ACS guidelines for self and clinical breast exams?

Back 4

USPTF does not recommend breast self-exams.
ACS recommends women know how breasts normally feel and that they report any change to physician. Should start in 20s.

ACS recommends clinical breast exam q3 years for women in 20s-30s, and qyear for women 40+

Front 5

What factors are associated with INCREASED cervical cancer risk?

Back 5

Early onset of intercourse
Greater number of lifetime sexual partners
Diethylstilbestrol exposure (DES)
Cigarette smoking (4x inc'd risk)
Immunosuppression

Front 6

What are the two types of HPV vaccines? Which serotypes are they protective against?

Back 6

Gardasil: serotypes 6, 11, 16, 18--prevents cervical cancer and genital warts (approved for women ages 9 to 26)

Cervarix: seroryptes 16, 18, 31, 45--prevents cervical cancer (approved for women ages 10-25)

Front 7

How many shots are in the HPV vaccine series? Who should receive them?

Back 7

Series of 3 shots; recommended for females ages 11 through 18

Routine vaccination before sexual debut or shortly thereafter is important to achieve optimal effectiveness

Front 8

What defines menopause?
Average age?
When do smokers enter menopause?

Back 8

Missed period for 12 straight months
Usually around 51 (range 40-60)
Smokers tend to go through menopause few years earlier

Front 9

What defines perimenopause? How long does it last?
Symptoms?

Back 9

Lasts 2-8 years; hallmark = menstrual irregularity

Syx: Hot flashes, vaginal dryness, change in libido, or mood swings

Abnormal syx that are concerning: periods coming very close together, heavy bleeding/spotting, periods lasting more than a week

Front 10

What are the risk factors for osteoporosis?

Back 10

Low estrogen states (early menopause--before 45; prolonged premenopausal amenorrhea, low weigh/BMI)
Lack of physical activity
Inadequate Ca2+ intake
FMH osteoporosis
Hx previous osteoporotic fractures
DEMENTIA
CIGARETTE SMOKING
CAUCASIAN RACE

Front 11

What is the effect of obesity on osteoporosis risk?

Back 11

BMI >30 associated with high estrogen level and can be protective against menopausal syx and osteoporosis

Front 12

What are the USPTF guidelines for screening for osteoporosis?

Back 12

DEXA in all women 65+ as well as women 60-64 with inc'd fracture risk

Front 13

What are the guidelines for Td vs Tdap immunizations?

Back 13

Td every 10 years
Tdap (tetanus, diphtheria, acellular pertussis) for adults 19-64 who have not received Tdap previously

Front 14

Which fingers are used during breast exam?

Back 14

Middle three fingers, use finger pads; use varied pressure

Front 15

Mammograms:
Specific benefit of detection of cancer (when compared to self breast exam)
Sensitivity
When during menstruation is the procedure least tender?

Back 15

mammograms detect cancer 1-2 years before may be felt by self-exam
Sensitivity is 60-90%
Tenderness is minimized about a week after menstruation

Front 16

When is routine mammography indicated?

Back 16

For women at avg risk, between ages of 40-50, decision for obtaining mammogram should be individualized
Women under 40 with known BRCA mutation

As long as a woman is in good health and would be candidate for BrCa treatment, she should continue to be screened with mammography.

Calculating woman's breast cancer risk using Gail criteria can also help.

Front 17

When should pap smears be performed? How often?

When can pap smears be discontinued?

Back 17

At 21 years of age, every 2 years until 29
Every 3 years between 30 and 65 (unless are high risk, ex: immunocompromised, HIV poz, hx CIN 2/3/cancer, exposure to DES in utero)

Women between 65 and 70 with 3 or more normal Pap tests within last 10 years may choose to stop cervical cancer screening.
Women who have undergone total hysterectomy for benign reasons do not require cervical cancer screening.

Front 18

In interpreting a pap smear:
ASC vs LSIL vs HSIL

Back 18

Atypical Squamous Cells: Some abnl cells seen, may be due to infection or irritation, may be pre-cancerous

LSIL: May progress to high grade lesion but most regress

HSIL: Considered significant precancerous lesion

Front 19

Which breast exam findings are associated with malignancy?

Back 19

single, hard, immobile lesion of 2cm or larger with irregular borders

Front 20

What are the follow-up steps for a cystic breast lump vs a solid breast lump?
What technique allows for differentiation of cysts from solid lumps?

Back 20

If cystic-->aspirate and send for cytology
If solid-->mammogram

Ultrasound helps tell difference from cyst and solid

Front 21

How can postmenopausal women prevent osteoporosis?

Back 21

1200-1500 mg Calcium and 800 IU Vitamin D qd

Calcium tables may be combined with vitamin D in form of cholecalciferol

Calcium supplementation of anything greater than 500 mg should be taken in divided doses for maximum absorption

Front 22

What is the RISE mnemonic for preventive exam?

Back 22

Identify RISK factors for serious medical conditions
Update IMMUNIZATIONS
Order appropriate SCREENING tests
EDUCATE pts re: living healthy lifestyle and reducing risk of dz

Front 23

Screening should be considered for conditions that are _________________.

Back 23

Treatable and important

Front 24

Why should a screening test be able to detect disease during latent phase?

How does this affect prevalence?

Back 24

If detect disease during latent phase (before patient becomes symptomatic) should lead to more timely treatment, positively affecting the outcome of the disease

Since pts without syx are being screened, overall prevalence of condition will be low

Front 25

What test qualities make a good screening test?

Back 25

High sensitivity (identify most or all potential cases)
High specificity (label incorrectly as few cases as possible)

Front 26

What are the modifiable and non-modifiable risk factors for heart disease?

Back 26

Modifiable:
Sedentary lifestyle
Tobacco use
Excess EtOH
Stress
Poor diet
Obesity
(these factors may contribute to dev't of BP, elevated lipids, diabetes)

Non--modifiable:
Older age
Male gender
FMH

Front 27

What are the 3 C's of addiction?

Back 27

Compulsion
lack of CONTROL
CONTINUED use despite adverse consequences

Front 28

What are the four stages of behavior change experienced by smokers?

Back 28

Pre-contemplative: not aware of need to change or not interested in changing behavior

Contemplative: Currently interested in changing behavior

Active: Currently making a behavior change

Relapse: Attempted behavior change, no longer making change

Front 29

What are the cardiovascular protective effects of moderate alcohol consumption?

Back 29

Small increase in HDL; may also contain other chemicals that act as anti-oxidants or inhibit PLT aggregation

Front 30

What should a brief nutrition history include?

Back 30

Number of meals/snacks eaten in 24-hour period
Dining-out habits
Frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy, desserts

If initial history indicates poor diet, perform:
24 hour dietary recall (ask about each meal separately; include snacks, beverages, portion sizes)

Front 31

How is BMI calculated?
Ranges?

Back 31

BMI = weight in kg/height in m^2

Normal: 18-25
Overweight: 25-30
Obese: 30+
Very Obese: 35-40
Morbidly obese: 40+

Front 32

What physical exam findings are associated with dyslipidemia and atherosclerosis?

Back 32

Arcus corneus
Acanthosis nigricans
Xanthelasmas

Front 33

What is the ABCDE of suspicious lesions?

Back 33

Asymmetry
Border Irregularity
Color non-uniform
Diameter >6 mm
Evolution or change over time

Front 34

What are the USPTF and ACS guidelines for PSA screening?

Back 34

USPTF recommends against PSA screening
ACA recommends testing at 50+ after discussion with pt

Front 35

What are the potential benefits and harms of PSA screening?

Back 35

benefits:
Prolonged life from early detection and tx of CaP
Psychological reassurance of negative screen or of detecting cancer at treatable stage

Harms:
Pain and discomfort a/w prostate biopsy
Psychological f/x of false-positive test results
Complications (including erectile dysfunction, urinary incontinence, bowel dysfn, death) from tx of prostate cancer that may not have ever caused syx if left undetected

Front 36

Other than colonoscopy what are the available methods of screening for colon cancer? How often?

Back 36

Annual testing of three stools for blood and flexible sigmoidoscopy every 5 years

Double-contrast enemas every 5 years

CT colography (virtual colonoscopy) is still experimental

Front 37

What is the USPSTF guideline for lung cancer screening?

Back 37

USPSTF found fair evidence that screening (with CT, CXR, sputum cytology) can detect lung cancer at an earlier stage, but found poor evidence that this decreases mortality.

Because of invasive nature of testing and possibility of high number of FP tests, there is potential for significant harm in screening.

Front 38

What labs should be ordered to assess risk for diabetes and cardiovascular disease?

Back 38

Glucose, lipid panel; ideally done fasting

Front 39

What do you tell a patient who is attempting to quit smoking for the 4th time?

Back 39

Most smokers quit multiple times before being truly successful

Front 40

What drug, other than Chantix, is useful in enhancing tobacco quit success rate?

Back 40

bupropion: start one week before quit date

Front 41

What is the protocol for initial management of obesity, hyperlipidemia, elevated blood pressure, and elevated glucose?

Back 41

Educate patient about inc'd CV and cerebrovascular risk
Obtain stress test
Intitiate 81 mg qd
F/U in one month
Repeat fasting lipid panel in 3 months, initiate medications if necessary
Counsel to reduce calories consumed and increase exercise

Front 42

Calculation for target heart rate range during exercise.

Back 42

THR = (220-age) x 0.7-0.8

Front 43

What is the Borg rating of perceived exertion scale (6-20)?

Where should a patient want to be during exercise?

Back 43

6: No exertion
7: Extremely light
9: Very light (easy walking slowly at comfortable pace)
11: Light
13: Somewhat hard (quiet an effort; feel tired but can continue)
17: Very hard; strenuous, fatigued
19: Extremely hard, cannot continue for long at this pace
20: Maximum effort

Patients should aim for 12-14

Front 44

Follow-up protocol of tubular adenoma with low-grade dysplasia on colonoscopy.

Back 44

Repeat colonoscopy in 5-10 years

Front 45

Hypothyroidism:
Diagnostic test
Treatment

Back 45

MAY BE A/W DEPRESSION

Diagnosed by TSH
Treat with T3 (Triiodothyroxine) and/or T4 (Thyroxine)

Once TSH levels return to normal range, depression syx often subside

Front 46

What diseases can manifest with depression?

Back 46

Hypothyroidism
Parkinson's (often an early feature, preceding motor problems)
Dementia (often difficult to differentiate from depression)

Front 47

What screening tests are used for dementia? What does each entail?

Back 47

Mini-cog:
1. instruct pt to repeat apple,w atch penny
2. Administer clock drawing test
3. Ask pt to repeat three items previously named
99% sensitivity, 93% specificity

Mini-mental:
Examines orientation, memory, attention, as well as ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape
Sensitivity 91%, specificity, 92%

Front 48

What are the diagnostic criteria for major depressive disorder?

Back 48

5 of SIGECAPS for at least 2 months:

Sleep: insomnia or hypersomnia nearly qd
Interest, loss of: Anhedonia
Guilt: feelings of worthlessness or excessive or inappropriate guilt (may be delusional) nearly qd
Energy (dec'd)
Concentration (dec'd); indecisiveness
Appetite (inc or dec)
Psychomotor agitation/retardation; observable by others, not merely subjective feelings of being slowed down or restless
Suicidal ideation: recurrent thoughts of death (not just feat of dying), recurrent suicidal ideation without specific plan, or suicide attempt or specific plan for committing suicide

Front 49

How can major depressive disorder be discerned from bereavement?

Back 49

-If 5 of SIGECAPS last longer than 2 months after loss

-If following syx present:
Guilt about things other than actions taken or not taken at time of death
Thoughts of death other than feeling that he or she would be better off dead or should have died with deceased person
Morbid preoccupation with worthlessness
Marked psychomotor retardation
Prolonged and marked fnal impairment
Hallucinatory experiences other than hearing voice of or seeing image of deceased person

Front 50

What is the effect of ethnicity on:
-diagnosis of depression
-presentation of depression
-rates of depression

Back 50

-Depression ID'd less frequently in Hispanics and AAs than in whites
-Hispanics more frequently present with somatic complaints such as myalgias or fatigue rather than mood-complaints
-US born Hispanics experience depression at similar rates to other ethnic groups (note: rates of depression in immigrant Hispanics up to 50% lower than US born Hispanics)

Hispanics and other minorities less likely to receive adequate therapies

Front 51

What factors increase a patient's likelihood of completing a suicide attempt?

Back 51

White male (white females more likely to attempt, however)
Previous attempted suicide

Front 52

What factors increase an ELDERLY patient's likelihood of suicide attempt?

Back 52

Widow(er)s
Live alone, perceive health status to be poor
Reduced sleep quality, lack confidant

Note drug overdose is most common means of suicide in elderly

Front 53

Citalopram:
Drug Class

Back 53

SSRI (block reuptake of 5HT)

Front 54

Fluoxetine:
Drug Class

Back 54

SSRI (blocks reuptake of 5HT)

Front 55

Fluvoxamine:
Drug Class

Back 55

SSRI

Front 56

Paroxetine:
Drug Class

Back 56

SSRI

Front 57

Sertraline:
Drug Class

Back 57

SSRI

Front 58

Escitalopram:
Drug Class

Back 58

SSRI

Front 59

Venlafaxine:
Drug Class

Back 59

5HT and NE reuptake inhibitor

Front 60

Bupropion:
Drug Class

Back 60

NE and DA reuptake inhibitor

Front 61

Nefazodone:
Drug Class

Back 61

5HT ANTAGONIST and REUPTAKE inhibitor

Front 62

Trazodone:
Drug Class

Back 62

5HT antagonist and reuptake inhibitor

Front 63

Mirtazapine:
Drug Class

Back 63

NE and 5HT antagonist, antihistaminic effects

Front 64

Duloxatine:
Drug Class

Back 64

Serotonin and NE reuptake inhibitor

Front 65

Nortryptyline:
Drug Class

Back 65

NE/5HT reuptake inhibitor (TCA)

Front 66

Amitriptyline:
Drug Class

Back 66

NE/5HT reuptake inhibitor (TCA)

Front 67

Clomipramine:
Drug Class

Back 67

NE/5HT reuptake inhibitor (TCA)

Front 68

Doxepin:
Drug Class

Back 68

NE/5HT reuptake inhibitor (TCA)

Front 69

Phenelzine:
Drug Class

Back 69

Blocks pre-synaptic catabolism of NE and 5HT (MAOI; rarely used today)

Front 70

Tranylcypromine:
Drug Class

Back 70

Blocks pre-synaptic catabolism of NE and 5HT (MAOI; rarely used today)

Front 71

SSRI/SNRI side effects

Back 71

HA
Drowsiness, insomnia
Nausea, diarrhea
Hyponatremia due to SIADH
Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, death)
Inc'd risk GI bleed
Inc'd risk falls in elderly (possible AE on bone density)

Front 72

TCA side effects

Back 72

Cardiac arrhythmias

Front 73

What are the most common causes of insomnia in the elderly?

Back 73

Noise, uncomfortable bedding
Drugs/alcohol/caffeine
Sleep apnea
Restless leg syndrome
Jet lag, shift work
GERD
Pain, pruritus
Hyperthyroidism

Front 74

What is the USPSTF recommendation for depression screening?

Back 74

Screen all adults for depression, but esp pts with chronic dz like DM as they are at high risk

Front 75

What blood work is appropriate for causes of insomnia, fatigue, and depression?

Back 75

CMP: screen for electrolyte, renal, hepatic problems
TSH: r/o hypothy
CBC: check for anemia, vitamin deficiencies
ESR: test for rheum dz
EKG if pt using drugs that might alter cardiac conductivity, e.g., TCAs

Front 76

What behavioral treatments are available for insomnia?

Back 76

CBT-I involving:
Sleep restriction tx: most effective; tell pts to spend amount of time in bed that he/she spends sleeping, not awake+sleep. Time in bed gradually inc'd in 15-20 min increments as sleep efficiency increases

Sleep compression tx: dec time in bed gradually to match total sleep time rather than making immediate change

Front 77

What is the pregnancy rating for SSRIs?

Back 77

Category C (animal reproduction studies have shown AE on fetus; no adequate studies in humans, but potential benefits may warrant use of drug in pregnant women)

Front 78

This SSRI has an unusually long half-life (2 to 4 days) with effects lasting for weeks after d/c.

Back 78

Fluoxetine

Front 79

This SSRI is approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders.

Back 79

Sertraline

Front 80

This SSRI has the most GI side effects.

Back 80

Sertraline

Front 81

This SSRI has the best anti-anxiety effects.

Back 81

Paroxetine

Front 82

This SSRI is associated with significant weight gain, impotence, sedation, and constipation.

Back 82

Paroxetine

Front 83

This SSRI has an extremely short half-life and may likely cause antidepressant discontinuation syndrome.

Back 83

Paroxetine

Front 84

This SSRI is very useful in OCD.

Back 84

Fluvoxamine

Front 85

This SSRI is associated with greater frequency of emesis.

Back 85

Fluvoxamine

Front 86

This SSRI is approved specifically for generalized anxiety disorder.

Back 86

Escitalopram

Front 87

Treatment plan of Major Depressive Disorder.

Back 87

For first episode, take SSRI/SNRI for 9-12 months; stopping sooner is higher risk for recurrence

Recurrent episodes of depression tx'd for 2-3 years

Consider continuous therapy for those with multiple recurrences and in the elderly

Allow 4-6 weeks before medication effective, but follow-up in 2 weeks to monitor side effects

Front 88

What treatments for mild to moderate depression are equally effective as psychotropic medications?

Back 88

Cognitive behavior therapy (focuses on changing dysfnl thought patterns that perpetuate depression)
Interpersonal therapy (focuses on grief, interpersonal disputes/deficits)
Exercise--both aerobic and weight bearing

Front 89

Describe scale for assessing severity of whether patient seriously considering suicide.

Back 89

SAD PERSONS
Sex (male)
Age (<19 or >45)
Depression, diagnosis of
Previous attempts
EtOH or other substance abuse
Rational thinking impaired (psychosis, delusions, hallucinations)
Social supports lacking
Organized plan for suicide
No significant other
Sickness (physical illness)

Assign 1 pt for each:
If 7-10: hospitalization warranted
If 4-6: Outpt tx appropriate