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179 Cards in this Set
- Front
- Back
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At what point in time are newborn screening tests are done?
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24-48 hours after birth; in Colorado, a second sample is done in 2 weeks
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What does the term "preventable disease" mean?
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It refers to preventing the morbidity and mortality of a disease, NOT to eliminate the genetic mutation causing the disease
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What does the term "treatable disease" mean?
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it refers to the pharmacologic or dietary program that would prevent all or most morbidity associated with the condition
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What is the only cost-effective population based health intervention in the US?
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Newborn screening
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What is the 5 part public health system of which newborn screening is a component?
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1. screening of newborns
2. follow-up 3. diagnostic testing 4. management of the infant 5. evaluation of all components of the system |
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What are the 4 major categories of the newborn screening program?
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metabolic conditions, endocrine disorders, hemoglobinopathies and hearing loss
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What is the relative positive predictive value of newborn screening tests?
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Low positive predctive value (most positives are false positives in order to not miss anyone that is effected)
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What are the differences between screening tests and diagnostic tests?
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Diagnostic tests: more specific, more complex and expensive, still may be inconclusive
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What is the hidden "sixth" part of the newborn screening public health program?
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Education
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What is the role of the PCP in the newborn screening process?
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I am pretty sure the answer will be "all of the above" since there are about 15 different roles for the PCP
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How many states have government supported funding for newborn screening?
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5; others have a fee $10-$139
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What is the critical period of development?
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a period that is especially responsive to external influences; the individual is vunerable to injury and it corresponds to rapid growth
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What is the sensitive period of development?
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a time when the developing system is more amenable to the acquisition of certain abilities; exposure to things suffices in teaching rather than expending conscious effort to learn
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What are the key developmental domains looked at through the ages?
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Biological
Motor Cognitive Social/emotional and personality Language |
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What terms did Freud coin?
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Id/ego/superego
unconscious Stages of Psychosocial Development Dream interpretation Oedipus Complex |
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What are the stages of psychosexual development?
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Oral (birth - 18/24 months)
Anal (18/24 - 3yrs) Phallic (3-6) Latency (5 yrs - puberty) Genital (puberty to adulthood) |
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What is repression?
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hiding away wishes of the unconscious
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What is displacement?
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symptoms that are hidden in one area appear in another
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What is sublimation?
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using energy from unfulfilled wishes in a constructive way
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What are Piaget's stages of development?
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Sensorimotor (birth - 18/24)
Pre-operational (24 - 7yrs) Concrete operations (7 - 12) Formal operations (12 - adult) |
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Identitiy v. role confusion is a stage of development coined by whom?
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Erickson
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Who is the originator of attachment theory?
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Bowlby
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What is a secure base?
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a relationship with a person that provides comfort and security and enables the child to go away and explore the environment
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At what age range is the peak of stranger anxiety, separation anxiety as well as the development of felt security, trust and mistrust and hierarchy of caregivers?
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7-12 months
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What are the four types of attachment styles?
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Secure
Avoidant Resistant Disorganized |
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Which attachment style is frequently seen in children who have been abused and/or neglected?
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disorganized
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What are the types of adult attachment styles? How does it correlate with their children
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Autonomous = secure
Dismissing = avoidant Preoccupied = resistant Unresolved/disorganized = disorganized |
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What type of parenting styles correspond to what type of children?
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Authoritative = achievers
Authoritarian = irritable, aggressive, low self-esteem Permissive = impulsive, self-centered, frustrated Rejecting/neglecting: low self-esteem, impulsive |
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Who was the developer of Human Ecology Theory
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Bronfenbrenner
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What is gender dysphoria?
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emotional distress associated with incongruity between one's natal sex and gender identity
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What is sexual orientation?
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the emotional and sexual attraction to others of a particular sex, NOT a behavioral definition
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What are some reasons for why heterosexuals engage in homosexual behavior?
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Developmental reasons (adolescence)
Opportunistic motives (delinquents) Situational reasons (prisons) Defense against anxiety |
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What is internalized homophobia?
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hate and negative self judgements about one's own homosexuality
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What is the difference between sexual orientation and sexual preference?
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sexual orientation is an intrinsic personal characteristic; sexual preference implies a behavioral choice
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What is a cross dresser?
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someone who dresses in the clothing of the opposite sex for erotic pleasure, emotional satisfaction or both; says NOTHING about sexual orientatin
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What is a transgenderist?
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Someone who lives in the gender of the opposite sex full-time (alter legal names); generally not interested in sex reassignment surgery
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How many lesbian and gay parents are there in the US?
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1-5 lesbian moms; 1-3 million gay fathers
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Who is a transsexual?
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someone who indergoes hormonal modification of secondary sex characteristics, genital surgeries, and other surgeries in order to permanently live in the gender role of the opposite natal sex
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Which sex "comes out" earlier?
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Men
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What form of therapy results in long term harmful consequences to homosexuals such as severe depression, anxiety disorder, loneliness, etc.
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Reparative/conversion therapy
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What percentage of lesbians do not disclose their sexual orientation when seeking medical care?
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53-72%
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What are the GAPS in end-of-life care?
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Goals of Care
Advanced Directives Psychosocial and spiritual support Symptom management |
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What criteria must be met for a person to be eleigible for hospice services under the MHB?
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1. physician must state that a person's life expectancy is less than 6 months if the dz takes it's natural course.
2. pt must elect to forego further life prolonging therapies |
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T/F: Palliative care increases medical costs and length of stay in a hospital.
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False: PC lowers costs by reducing hospital and ICU length of stay, ER and pharmacy costs
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What percentage of hospice patients have cancer?
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Less than 50%
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What is the median length of stay in hospice?
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3 weeks
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What percentage of all eligible hospice patients are enrolled in hospice care?
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20-30%
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What services are covered by Medicare Hospice Benefits?
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1. Physician, nursing and social work services
2. durable med equipment and supplies 3. meds for symptom control 4. physical and occupational therapies 5. respite 6. bereavement services |
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What is the median length of stay in hospice?
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3 weeks
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What is the difference between a screening test and a diagnostic test?
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Screening identifies those at high risk, has a low PPV in order to be sensitive; diagnostic is more complex and expensive, but should be more sensitive and specific
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What disorders included in the nbs program can be fatal within days if treatment is not initiated?
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Galactosemia, CAH, Maple syrup urine disease
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What disorders included in the nbs program might be asymptomatic early while causing severe brain damage?
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PKU, hypothyroidism
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What is an example of an abnormal screening test leading to more speficic diagnostic tests?
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abnormal metabolite on screening, particular enzyme deficiency on diagnostic
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What are the major categories of disorders screened for at birth?
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metabolic, endocrine, hemoglobinopathies, hearing loss
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Why do most conditions identified at nbs require lifelong management?
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most are diseases without cure
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How are most nbs tests done? What is the exception?
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done with a few drops of blood from heelstick done at 24-48 hrs (repeat at 2 wks for some); exception is hearing loss
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How do the pharmacodynamic actions differ across age groups?
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They don't, for the the most part. Only size adjustments are needed for most drugs
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What properties of drugs change substantially between age groups?
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pharmacokinetics: absorption, excretion, distribution, and metabolism
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When are drug absorption and distribution most variable?
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before age 1, esp first 30 days
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What drugs are examples of the highly variable liver metabolism seen in infants?
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Chloramphenicol (poor clearance - Grey Baby); phenobarbital and caffeine (not metabolized); phenytoin (over-metabolized)
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What is the difference between hepatic metabolism and renal clearance maturation?
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hepatic - postnatal development; renal - postgestational development
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How must loading doses change with age? Maintenance doses?
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loading - not much change; maintenance - dramatic change
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Why must maintenance doses generally be higher in children?
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clearance (either hepatic or renal) is generally more rapid in kids
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Why is it important to monitor drug levels in hepatically eliminated drugs in kids?
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clearance varies widely due to variability in enzyme maturation
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What drugs are high risk factors for altered growth in children?
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psychoactive drugs have modest effect, glucocorticoids are potent growth inhibitors
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Why are tetracyclines contraindicated in kids and pregnant women (after 14 weeks)?
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they are incorporated into growing bone and teeth
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What is Reyes syndrome? What drug may increase the incidence?
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fatty liver with acute encephalopathy, salicylates (esp aspirin)
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What problem exists in the investigation of newer drugs on older populations?
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tested on "well-elderly", not on pts who are older or not healthy -> toxicity occurs due to lack of information
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Why might volume of distribution change in elderly patients?
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overall decreasse in body water, increase in adipose tissue
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What conditions lead to an increase in free concentration of protien-bound drugs in elderly patients? How?
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Marginal nutrition, chronic disease b/c of decreased serum albumin
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What is a safer basis for calculating drug doses in a drug with a narrow therapeutic index?
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dose per surface area (as oppsed to weight mg/kg)
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What differences exist in hepatic metabolism in an elderly patient?
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decrease in hepatic mass and blood flow, decrease in Phase I reactions (oxidation, reduction, hydrolysis)
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What changes occur in renal function in elderly patients?
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decrease in functioning nephrons, decreased GFR, renal plasma flow, tubular secretion
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What drugs may have a change in sensitivity in elderly patients?
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Increased: BDZ, Warfarin, anticholinergics; Decreased: beta-blockers, beta agonists
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Through which pharmacodynamic effect do drugs impair balance and therefore mobility?
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psychomotor retardation, hypotension, vertigo
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Why are elderly patients more susceptible to constipation?
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general decrease in gastric motility with age
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What are some of the ways that drugs can affect continence in older patients?
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anticholinergics -> overflow; alpha-adrenergic antagonists -> stress incontinence; choinergics and diuretics -> urge incontinence; sedatives and hypnotics -> oversedation
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What is the importance of having a separate system (apart from criminal justice) to deal with child welfare?
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because child can't always report against parent. Not as important to prove guilt beyond a reasonable doubt, but very important to remove child from any POTENTIAL harm
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What is the secondary problem with assigning child abuse as a more social than medical problem?
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less money is raised in general for social problems (vs. medical)
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What are the common historical features in abuse cases?
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discrepant history, delay in seeking care, stressed caretaker, behaviour by child triggered assault, caretaker with hx of abuse, social isolation, unrealisitic expectations, increased severity pattern, use of multiple hospitals
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What is the most important part of a medical evaluation of a child you think might be sexually abused?
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history
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How might a child present after sexual abuse?
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sexualized play in developmentally immature children, genereal or direct statements about sexual abuse, Abdominal pain, UTIs, STDs, sleep disturbances, other more general somatic complaints
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What infections are evidence of sexual abuse until proven otherwise?
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GC, syphilis
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What physical exam findings might be present on a child who has been sexually abused?
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hymenal abrasion, anal abrasion
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Why are epidural fractures generally not considered abusive?
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superficial harm, not generally caused by abuse (but it's not impossible)
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What intervention has been shown to decrease the incidence of child abuse?
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Home nurse visits
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What evidence supports the status of child abuse as a health concern (over social)?
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recent studies show increasing evidence of genetic link (MOA, CREB, fosB)
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What must the certifying physician include in the death certificate?
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1. Manner of death (natural, suicide, accidental, homicide, undetermined)
2. Cause of death 3. Mode of death |
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According to the Uniform Determination of Death Act, when must a determination of death be made?
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1. cessation of circulatory or cardiac function, or
2. irreversible cessation of all functions of the entire brain, including the brainstem |
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What are the 5 manners of death?
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natural, suicide, accidental, homicide, undetermined
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What are the 6 determinations and criteria for pronouncing death?
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1. irreversibility
2. coma/unresponsiveness 3. Absence of motor responses to painful stimuli 4. Absence of brain stem reflexes 5. Apnea 6. no electrical activity on EEG |
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What are the 5 reasons for doing an autopsy?
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1. to establish the cause of death and determine any contributing factors
2.discover other information that may be helpful to the family (genetics) 3. Quality assessment? Was a wrong diagnosis made? 4. Add to medical knowledge 5. education for students and residents |
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Who pays for an autopsy if the family requests it?
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the hospital; there is no cost to the family
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What are the 5 steps involved in an autopsy?
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1. review case hisotry
2. external examination 3. examination of body cavities/organs 4. sample all tissues for microexamination 5. special procedures |
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When is rigor mortis at its maximum? How long does it last?
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maximal at 12 hours; lasts for 24-36 hours
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What is livor mortis? How do you know it when you see it?
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settling of the blood into the dependent portions of the body; blood becomes "fixed" at 8-12 hours and the color doesn't shift when the body is moved
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Who can run for the elected position of coroner?
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Anyone who is able to vote
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What are the 5 types of deaths that must be reported to the coroner?
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1. When a physician isn't present at the time of death
2. Deaths that may have been associated with trauma, chemical poisons, infection and contagious disease 3. deaths from surgery/medical procedure 4. deaths occuring within 24 hours of admission 5. unexplained deaths |
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Define aging.
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the natural progressive decline in body function that leads to death
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When does aging begin?
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near the end of the 3rd decade
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What percentage of the US population will be aver 65 years old by 2030?
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20%
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Define life expectancy.
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average age at death
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Define life span.
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greatest possible life expectancy
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Humans cannot live beyond what age?
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110
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Which of the follwing is NOT a change of 'normal aging"?
1. varicose vein 2.significant loss of myelin and white matter 3. atrophy of myocytes 4. Anemia 5. BPH-induced difficuly with micturution |
Anemia
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What are the 6 major diseases that aging individuals are susceptible to?
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Cancer
Generalized atherosclerosis cerebrovacular accidents non-insulin dependent DM Alzheimer's and parkinson's Thromboembolism |
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What is the argument of the Clock Theory of aging?
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the aging process and death are controlled by genes
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What is the argument of the Rust Theory of aging?
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aging results from the accumulation of somatic mutations and oxidative damage in membranes ans macromolecules
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What three genetic diseases are associated with premature aging?
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Progeria
Werner's Syndrome Down's |
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What gene has been associated with longevity in families?
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Sir2 (downregulates p53 and supresses apoptosis)
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What portion of the chromosome gets progressively shorter with each cell division?
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telomeres
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What practice has been shown to increase longevity by 30-35% in many animals?
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caloric restriction -> lowering metabolic rate
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How do you calculate relative risk reduction?
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incidence control - incidence treated/incidence control
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How do you calculate absolute risk reduction?
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incidence control - incidence treated
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What is suffering?
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state of severe distress associated with events that threaten intactness of the person (does not have to relate to pain or actual loss, e.g. anticipatory)
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What's the number one reason people seek dr-assisted suicide?
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fear of loss of control over death
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What is the major determinant of where a patient dies?
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workforce and hospital bed availability
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On average, what percentage of hospice admission prognoses are accurate? By how much are they off?
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only about 20% accuracy, MDs generally overestimate by 5
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What percentage of people report WANTING to die at home?
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90%
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How should you manage symptoms in a patient with advanced illness?
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Understand sx distress, establish pt goals, identify likely cause, treat underlying cause (if possible), symptomatic therapy for relief
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What improvements can be made by treating distressing sxs in a pt with advanced illness?
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Improved quality of life and function
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What are some of the symptomatic interventions for dyspnea?
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moving air, low dose opioids, oxygen only in hypoxemic pts, but NOT BDZ
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What are some of the signs of advanced dementia?
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speaks few words, incontinence, does not recognize family
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How does oral intake normally change as a consequence of the dying process?
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decreases
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Is tube feeding associated with increased survival?
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NO
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How do people with advanced dementia usually die?
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Aspiration-related infection, UTIs and bleeding
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What are some of the risks of initiating PEG?
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fluid retention (esp around lungs) and infection locally
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What are some of the signs of impending death?
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death rattle, loss of sphincter control, decreased resp rate, decreased use of accesory jaw muscles, delirium and decreases consciousness
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During the decreased level of consciousness at the end of life, what should you encourage?
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conversation, assurance (patients awareness > ability to respond)
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What are two common causes of terminal delirium?
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pain and pain meds
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What is Cheyne-Stokes pattern of breathing?
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a few deep, rapid breaths followed by intermittent apnea
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Why do patients develop death rattle at the end of life? What can you do?
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decreased ability to clear secretions, turn them on their side, meds to dry out secretions
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What things can help temper caregiver stress?
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physician empathy, death at home, and hospice involvement
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What are the results of caregiver stress?
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depression, complicated grief, illness, death
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What are some of the normal components of grief?
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disbelief, confusion, numvbness, sadness, fear, anger, guilt, but return to feeling life has meaning, sense of self and ability to participate in other relationships
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At what point might you worry about complicated grief?
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lasts for greater than 6 months of disturbances, and resutls in clinically significant impairment in social and psychologic dunction
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What can you do for someone who shows signs of complicated grief?
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assess for depression, seek skilled assessment, maybe some role for SSRIs
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How is Interprersonal Violence defined?
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violence inflicted by another individual where there is no clearly defined political motive
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What are the subsets of Interpersonal Violence?
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family, Intimate Partner, community
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What define intimate partner violence?
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pattern of assaultive and coercive behaviors that adults or adolescents use against their partners
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What are some examples of intimate partner violence?
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physical, psychological or sexual attacks, economic coercion
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What is the number one cause of death in pregnant women in the U.S.?
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Intimate partner violence!
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What was the lifetime reported incidence of IPV in women in Denver Eds? Incidence in the last year?
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30-50; 28
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What are the risk factors for domestic violence?
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partner separation, alcohol/drug abuse, unemployed assailant, depressed victim; NOT race or socioeconomic status
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What are the clinical clues to domestic violence?
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non-MVC trauma - esp maxillofacial injury & falls, repeated trauma, delayed presentation, unclear mechanism, mental health and non-specific complaints
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Why is it that pregnancy is associated with reporting of domestic violence?
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may be a risk factor, may also be a time when women are more regularly seeking medical care
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What are the reasons that women don't disclose IPV that Drs. Can change?
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women are not asked, they're in denil, they feel that the physician is not interested
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What is the benefit of asking about IPV, even if there is no disclosure?
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it states your values that IPV is not ok
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What are the stages of Change that you might go through with a woman experiencing IPV?
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safety/risk assessment, joint planning (involving legal, shelter, safety of kids), documentation of events, referral to experts
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What seems to determine whether or not the mandated arrest laws work in cases of IPV?
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whether the perp is "invested" in society - i.e. has a job, a reputation, a link to community
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What are the exceptions to confidentialy in IPV?
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IN CO: all acute injuries thought to be due to injury from IPV must be reported to the police
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What are the THREE most common causes of weight loss in old people?
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(in order) depression, GI problems, malignancy
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Which TWO drugs are known to cause dysgeusia (poor taste leading to malnutrition)?
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Lisinopril and Metronidazole
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Which antidepressent should be used in an old person who is already underweight?
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mirtazipine (remeron)
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What steps should be taken for an indwelling Foley catheter infeciton?
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change it and draw cultures from NEW catheter
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What drugs are good for cath infections?
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Ceftriaxone, levofloxacin (broad specturm g- coverage)
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What is the motto for good pressure ulcer care?
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"put anything you want on it except the pateint!"
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What are the characteristics of a stage III pressure ulcer?
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full-thickness skin loss, damage/necrosis of sub-q tissue up to but not through underlying fascia
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What percentage of patients get depression post stroke? What is the treatment?
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30-50% Ritalin
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Between age 65-80, which gender gets more urinary incontinence? After 80?
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women 3x, same
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State the mechanism, symptom, and weakness for the following incontinence disorder: Stress
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weak sphincter/pelvic floor; leakage w/cough, laugh; kegels, estrogen, alpha-agonists, surgery
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State the mechanism, symptom, and weakness for the following incontinence disorder: Urge
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Detrusor hyperreflexia/instability; sudden urge w/large volume leakage; muscle relaxers, avoid irritants, schedule voiding
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State the mechanism, symptom, and weakness for the following incontinence disorder: Overflow
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Obstruction/neurogenic bladder; hesitancy, dribbling, small volume leakage; alpha blockers/finasteride
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State the mechanism, symptom, and weakness for the following incontinence disorder: Functional
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physical/cognative impairment; inability to reach toilet; scheduled voiding/adapt environment
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What is the definition of dementia?
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Memory/cognitive loss associated w/loss of function?
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What percentage of patients with isolated short term memory loss progress to dementa?
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10-15% per year
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What are the most common causes of reversible cognitive impairment?
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Drugs and depression
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What drugs should be used to prevent progression from Mild Cognitive Impairment (MCI) to dementia?
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None - can't stop it!
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What is the most common cause of delirium?
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medications
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What is the prevalence of delirium in elderly post-operative patients?
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10-50%
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Which form of calcium should old people take? Vitamin D? How much of each?
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Calcium citrate (1200-1500mg); D3 (600IU)
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What is the most common vitamin deficiency in old people? What drug makes it worse?
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B12; PPIs
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What drugs should be used to treat community-acquired pneumonia in nursing homes?
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Ceftriaxone or Fluoroquinolone
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What THREE interventions help reduce falls?
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Stop psych meds, home hazard assessment, exercise programs
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What is aricept?
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cholinesterase inhibitor used to treat dementia; expensive and can often be removed near the end without cognitive effects
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What happens to the sensitivity/specificity of mammograms with age? When should they be stopped?
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both increase; 80+ (and otherwise healthy)
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What is the treatment for post-prandial orthostatic hypotension?
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Wait for an hour after meals, coffee before meal, evaluate need for hypertension meds
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How long does it take for statins to have a significant effect?
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1-2 years (don't bother with someone who will die soon)
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What lipid levels support the use of statins in high risk patiens 65-80 yo?
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LDL>130; HDL<50
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