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213 Cards in this Set
- Front
- Back
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Incontinence: Primary Prevention
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1) adequate fluid intake
2) Responding to urge to void (normally occurs at 150 mL in bladder) in timely manner. |
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Incontinence: Secondary Prevention
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1) Screening all pts during annual exam would provide early identification
2) Attitude of provider should be that is not a normal part of aging |
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Incontinence: Tertiary Prevention
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1) Treatment goal: begin treatment before sequela of depression, social withdrawl, avoidance of sexual intimacy, UTIs occur
2) Treatment dependent on type of incontinence Kegels Avoid bladder irritants: e.g. etoh, caffeine Incontinence undergarments/pads Urge Incontinence- Muscle relaxants- anticholinergics (oxybutynin, Detrol, Enablex, Vesicare)- causes dry mouth Estrogen bladder cream - NOT PO- increases circulation and normal consistency and normal mucosa of vaginal vault. surgical removal of obstruction Urethral insert or Pessary. STRESS INCONTINCE. -alpha adrenergics agonists e.g. ephedrine -OTC OTC oxytol -Consder surgery OVERFLOW -surgical removal of obstruction -intermittent cath or short term indwelling catheter FUNCTIONAL INCONTINENCE -evaluation medication for improved mentation for tx. STRESS OR URGE INCONTINENCE -bladder retraining; voiding every 1-2 hours, then increase by 15 minutes every week |
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Highest correlation of incontinence in women is....
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parity.
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What is the key for treating incontinence
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Evaluate the CAUSE as incontinence is a symptom, not a disease
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UTI are infection of the urinary tract where the urine culture demonstrates either
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> 10 to the fifth (100,000) (colony forming units/ml without symptoms
however 10 to the 2nd (100) colony forming units is acceptable if pt is symptomatic. |
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Understand the difference between bacteremia and the different types of UTIs (complicated v uncomplicated): COMPLICATED UTI
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UPPER UTI
Involve UTIs involve ureters kidneys -flank or back pain -fever, chills, malaise -nausea, vomiting, not uncommon -anorexia. |
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Understand the difference between bacteremia and the different types of UTIs (complicated v uncomplicated): UNCOMPLICATED UTI
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LOWER UTI
involves bladder urethra and/or the prostate 1-3 hx frequency, urgency, burning with urination may have pressure sensation over bladder may have sensation of not emptying bladder prostatitis yields pain in scrotom, pelvis, perineum, and with orgasm. ***avoid massaging prostate as may lead to bacteremia. Assessment findings: Hematuria Leukocyte esterase (breakdown of WBC) Nitrites (breakdown of bacteria) Suprapubic discomfort |
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Understand the difference between bacteremia and the different types of UTIs (complicated v uncomplicated): BACTEREMIA
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100 colony forming units in an asymptotic person.
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UTI: Primary Prevention
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-cranberry juice
-obviously then, voiding within 1 hour of intercourse will reduce bacteruia. -avoid wearing tight clothing e.g. tights jeans or pantyhose, tampon, or sanitary napkin use. -avoid bladder irritants such as coffee and etoh -avoid local irritants such as bubble bath and perineal deodorant "feminine deodorant" **** MANY of the standard teaching points for prevention of UTI are NOT supported by studies -wipe front to back -voiding more frequently -related to masturbation -wear cotton underwear -adequate fluid intake seems logical, but no evidence of value for reducing UTI |
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UTI: Secondary Prevention
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None (only do when symptomatic)
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UTI: Teritary Prevention
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bactrim DS
-alternatres for urological pathogens- Macrobi or most of the fluorquinolones e.g. Cipro but this family is very expensive with higher side effects. Pyridium: urological anesthetic- starts within 2 hours. use for 3 days max. Colors urine, sweat, tears (caution contact wearers.) |
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Difference between STD and UTI
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more likely to be STD if symptoms
-evolve over 1-2 weeks -are accompanied by vaginal symptoms (e.g. dysparunia, vaginal drainage) -OR penile symptoms e.g. urethral drainage *****USUALLY DON'T HAVE URGENCY AS SYMPTOM WITH DYSURIA (THIS IS A BLADDER SYMPTOM) |
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When should you do a urine culture and sensitivity
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ONLY IF COMPLICATED
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When do you recheck UTI
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perform a urine dip in 2 weeks to ensure resolution hematuria, etc.
Recurrent or relapsing infections, and non-resolution of hematuria require a workup for underlying anatomic abnormality. |
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Pt with pylenephritis, recurrent infection, or any males with UTI follow up....
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need to return in 10-14 days for a urine dip and reculture. If infection not controlled, refer to urologist.
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Breast Cancer: Primary Prevention
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Avoid estrogen supplements postmenopausal.
Tamoxifen is effective to reduce breast cancer risk in high risk women, however, there is an increased risk of endometrial cancer, stroke, PE, and DVT iwth use. Although no authority lists these are primary prevention, there have been well established association with breast cancer and: non parity, sedentary lifestyle, high fat diet, non-breastfeeding, obesity, ETOH excess. |
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Breast Cancer: Secondary Prevention
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ACS no longer recommends "baseline" mammography at 35 years. RECOMMENDEDATION FOR SCREENING EVERY 1-2 YEARS STARTS AT AGE 40 UNLESS COMPELLING REASON FOR EARLIER DUE e.g. HIGH FAMILY RISK.
SBE q month removed as secondary CBE q 3 years (20-39 years) 1-2 years (40-69 years) 2-3 years (65-85 years) |
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Breast Cancer: Tertiary Prevention
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Tamoxifen
Chemo/Radiation Mammogram (continued followed up on regular basis) -Ultrasound -Surgery -BSE q month -Periodic exams depending on extent of disease and treatment -Annual mammograms (follow up- treatment) |
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breast mass: what to do
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recheck
mammography or ultraound |
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mastalgia
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mass?
evaluate difference sources unilateral consider breast cancer |
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When to refer out breast cancer
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after screening shows breast cancer
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Suspicious nipple discharge should be
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sent for cytology in addition to steps for suspicious lesions
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suspicious breast lesions should lead to these intevention
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mammogram
and surgical referral for consideration for biopsy. |
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*****A negative mammogram
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DOES NOT RULE OUT BREAST CANCER
FOR SCREENING (SOMEBODY WITH NO MASS) false negative rate of 10-15 years false positive rate for 15-20 years. |
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Management suspicious mammograms
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Requires follow up
Ultrasound, if not clearly identified as cystic then -Needle biopsy ***If negative, cancer has NOT been ruled out - if positive for cancer, needs: OPEN BIOPSY -incisional- part of lesion or excisional-lesion excised and examined; or -core needle biopsy under flouroscopy, which is positive requires; definitive surgery and staging. |
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Cervical Cancer: Primary Prevention
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Condoms
Postponement of first intercourse until 20+ (sensitivity of squamous collumnar junction) Few sexual partners Avoidance of risk for HPV and chlamydia infections Smoking avoidance Since 2005-vaccine development approved by FDA -Guardail for 6, 11, 16, 18 (HPV and genital warts) -Cerverix for 16, 18 (HPV) |
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Cervical Cancer: Secondary Prevention
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Start screening at age 21
Pap smears q 2 years until 30 Pap smears q 5 years after 30 exit from screening at age 65 |
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Cervical Cancer: Tertiary Prevention
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Referral to gynecologist and oncologist or oncologist gynecologist for stating and treatment palns
may need cystoscopy, sigmoidoscopy or BE, CT or MRI abd, lymphangiography. During chemo and radiation, nutritional and skin support measures needed. |
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Follow up for cervical cancer
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Pap every 3 months X 2 years
Paps every 6 months for 3-5 years Paps annually after 5th year follow up |
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Define Atypical squamous cells (ASC)
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The cervix and vagina are lined by cells called squamous cells
name given to squamous cells on a Pap test (also called a Pap smear or cervical cytology) that do not have a normal appearance but are not clearly precancerous |
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Define: Low-grade squamous intraepithelial lesions (LSIL)
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on a Pap test are cells that appear slightly abnormal.
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Cervical cancer screening is recommended starting at age
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21
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Women who have ASC or LSIL on a Pap test require
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further testing because some women with these findings have a precancerous lesion of the cervix
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two options for women with an ASC-US Pap test who are ages 25 or older
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1) Test for human papillomavirus (HPV) infection. This is the preferred follow-up for ASC-US in women 25 and older
Use of testing for high-risk HPV gives important information about whether a woman with an ASC-US Pap test is at risk of cervical cancer. Women who test negative for HPV are not likely to have cervical precancer. These women should have a repeat Pap test and HPV testing in three years. In most cases, the ASC-US resolves during this time. 2) Repeat the Pap test in one year. If this test is normal, the woman can return to regular screening. If an abnormality is found, then a colposcopy should be done. |
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HPV testing is not a usual part of screening for cervical cancer for women ages
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21 to 24. This is because HPV infection is common in young women, but often goes away and usually does not cause cervical precancer or cancer
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For women 21-24 years of age with an ASC-US Pap test, there are two options:
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1) Repeat the Pap test in one year.
2) Another option is to do an HPV test. If the HPV test is negative, the woman can return to regular screening |
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LOW-GRADE SQUAMOUS LESION (LSIL)
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An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent
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LSIL Pap test is evaluated differently depending upon age. For women ages 25 or older, follow-up depends upon
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the results of human papillomavirus (HPV) testing:
1) Women who test positive for HPV or who have not been tested for HPV should have colposcopy 2) Women who test negative for HPV can be followed-up with a Pap test and HPV test in one year |
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LSIL pap test evaluation for women ages 21-24
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As noted above, HPV testing is not a usual part of screening for cervical cancer for women ages 21 to 24. For these women, an LSIL Pap test should be followed-up with another Pap test in one year.
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High-grade squamous intraepithelial lesion (HSIL)
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the name given to squamous cells on a Pap test (also called a Pap smear or cervical cytology) that appear abnormal and signal an increased risk of squamous cervical cancer.
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HSIL refers to
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moderate to severe changes in the cells of the cervix. The risk that these abnormalities reflect precancerous changes is as high as 71 percent and the risk of cervical cancer is as high as 7 percent
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For most women with HSIL on Pap test, follow-up is
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a colposcopy. Colposcopy is an examination of the cervix using a type of microscope, which is done in the clinician’s office. Colposcopy is discussed in a separate topic
In some cases, the clinician will advise immediate treatment at the same visit, with a loop electrosurgical excision procedure (also called a LEEP or LLETZ). This is a biopsy of the cervix that removes the area of the cervix (called the transformation zone) where precancers and cancers usually develop. This provides a larger amount of tissue to analyze for precancer or cancer and also treats cancer or precancer if either is present. Immediate treatment is not an option for women ages 21 to 24 because even high-grade lesions often go away without treatment in young women and there are concerns that treatment may increase the risk of complications in a future pregnancy. |
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Bacterial Vaginosis treatment
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Metronidazole 500 mg PO BID X 7 days (cheap but vomiting with alcohol) or
Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days (expensive) OR Clindamycin cream 2 % one full applicator (5 g) intravaginally at bedtime for 7 days. (safest but most expensive) |
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Uncomplicated Gonococcal infection of the cervix , urethra, and rectum: treatment
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To maximize compliance with recommended therapies, medications for gonoccocal infections should be dispensed on site.
Recommended regimens -Ceftriaxone 250 mg IM in a single dose OR IF NOT AN OPTION Cefixime 400 mg PO in a single dose OR Single dose injectable cephalosporin regimens PLUS azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days. |
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Uncomplicated Gonococcal infection of the pharynx: treatment
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Ceftriaxone 250 mg IM in a single dose
PLUS Azithromycin 1 gram orally in a single dose OR Doxycline 100 mg orally BID X 7 days. |
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Bacterial Vagonosis: Primary prevention
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X
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Bacterial Vaginosis: Secondary prevention
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X
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Bacterical Vaginosis: Tertiray prevention
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X
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Uncomplicated Gonococcal infection: Primary
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x
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Uncomplicated Gonococcal infection: Seconday
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x
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Uncomplicated Gonococcal infection: Tertiary
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x
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Why is ovarian cancer the deadliest of all gynecological cancers?
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symptoms are vague and overlapping
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Ovarian risk factors
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1) genetic predisposition-one or more first degree relatives has a history or ovarian cancer
2) family ovarian cancer syndromes 3) reproductive factors-nullparity or delayed childbearing, early menarche, late menopause > 50 years of age 4) fertility drugs 5) obesity >50% risk 6) Hx of breast cancer 7) talcum powder to perineum (long time use) contain asbestos 8) estrogen therapy. |
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Ovarian Cancer: Primary Prevention
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Decreased risk has been associated with:
Birth control pills Breast feeding Bilateral tubal ligation, hysterectomy, oopherectomy Avoidance of drugs which stimulate ovulation e.g. fertility drugs; talc; high fat diet. Avoidance estrogen postmenopausally |
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Ovarian Cancer: Secondary Prevention
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No screening has been found to be effective including: CA-125, transvaginal US, or pelvic exam
Early identification of high risk women: Those with site-specific familial ovarian ca - 2+ first degree relatives Those with breast-ovarian ca syndrome with -clusters of breast or ovarian cancers among first and second degree relatives However, these tests would likely increase laparotomies, and laparoscopies without finding new ovarian cancers. Higher risk associated with BRCA 1 and BRCA2 Causes 10% of ovarian ca cases Not yet recommended but bilat oopherectomy decreases risk gyne cancers in those with genetic mutations |
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Ovarian Cancer: Tertiary Prevention
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Despite aggressive treatments including surgery, chemotherapy, and radiation therapy, death rates remain high.
Causes more deaths than cervical and endometrial cancers combined Almost all ovarian cancers require surgery for: TAH with BSO Abdominal cytology “washings” Omentectomy Diaphragm sampling Selective lymphadenectomy Primary cytoreduction (debulking) with a goal of residual <2cm Bowel surgery, splenectomy if needed for cytoreduction. Consider follow-up surgery after chemotherapy |
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Ovarian Cancer: Management
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Almost all ovarian cancers require surgery for:
TAH with BSO Abdominal cytology “washings” Omentectomy Diaphragm sampling Selective lymphadenectomy Primary cytoreduction (debulking) with a goal of residual <2cm Bowel surgery, splenectomy if needed for cytoreduction. Consider follow-up surgery after chemotherapy |
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Follow up for Ovarian Cancer
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Physical exams with pelvic q3mo x 2y
q4mo for third year q6mo forever Ca-125 q visit Yearly Pap |
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Prostate Cancer: Risk factors
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Age: Chances increase after age 50. >70% of all prostate cancers are diagnosed in men > age 65.
Race: Occurs 60% more often in African Americans than in Whites; and they are more likely to be diagnosed at an advanced stage. It occurs less frequently in Asians than whites and Hispanics. Nationality: Prosate CA is most common in North America and Northwestern Europe. |
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Prostate Cancer: Primary Prevention
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(Non-malleable: age, FH (9%), AA, higher testosterone)
Some association of risk with: high fat diet, reduced intake of fruits/vegetables, and of Omega-3 fatty acids |
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Prostate Cancer: Secondary Prevention
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ACS recommends screeening by PSA and DRE to men 50y and older who have life expectancy of at least 10 years.
Men with BRCA1 genetic mutation have 3x risk of those without for prostate ca. Risk becomes 8% by age 70 No recommendation for BRCA1 screening. |
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Secondary prevention- PSAs
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Issues
Normal PSA found in >20% patients with prostate ca Only 20% of patients with PSA 4-10ug/ml have prostate cancer Confirm elevated PSA several weeks later to avoid unnecessary advanced testing of prostate (Ferri, 2012) Serum-free PSA may solve some problems with PSA as higher free PSA is found in men with BPH and higher protein-bound PSA levels found in men with prostate ca |
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Controversy with PSA
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Controversy over PSA exists because of: “while both digital rectal exam and PSA have demonstrated reasonable performance characteristics (sensitivity, specificity, positive predictive value) for prostate cancer, the lack of evidence that screening and treatment affects ultimate population morbidity or mortality has led to many organizations to eschew screening.”
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Prostate Cancer: Tertiary Prevention
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For early tumors, no compelling difference in survival between radical prostatectomy, external beam radiation therapy, brachytherapy, and surveillance.
Individualized treatment plan advised with discussion of side effects. Cost-Benefit ratios. Younger men without co-morbidities are more likely candidates for treatment as they are more likely to die of prostate cancer than older men or those with co-morbidities (NCI, 2011) “Radical prostatectomy is a surgical procedure to remove the entire prostate gland and nearby tissues. Sometimes lymph nodes in the pelvic area (the lower part of the abdomen, located between the hip bones) are also removed. Radical prostatectomy may be performed using a technique called nerve-sparing surgery that may prevent damage to the nerves needed for an erection. However, nerve-sparing surgery is not always possible. Radiation therapy involves the delivery of radiation to the prostate. Radiation therapy is usually administered in an outpatient setting using an external beam of radiation. Radiation can also be delivered in a technique known as brachytherapy, which involves implanting radioactive seeds directly into, or very close to, the tumor using a needle. Patients with high-risk prostate cancer are candidates for adding hormonal therapy to standard radiation therapy. Active Surveillance (watchful waiting) may be an option recommended for patients with early-stage prostate cancer, particularly those who have low-grade tumors with only a small amount of cancer seen in the biopsy specimen. These patients have regular examinations, PSA tests, and, sometimes, scheduled biopsies. If there is evidence of cancer growth, active treatment may be recommended. Older patients and those with serious medical problems may also be good candidates for active surveillance.” Treatment dependent upon: Stage of tumor Patient’s life expectancy Health status and co-morbidities Patient’s preference Radical prostatectomy, radiation or hormone therapy? Radical prostatectomy usually done on pts with localized prostate cancer and life expectancy >10years Radiation, external beam or implant, is alternative if pt with poor surgical candidate or high-grade malignancy Radiation therapy and hormone therapy (DES, LHRH analogs, antiandrogens, or bilateral oorchiectomy) may be best for pt with advanced disease and life expectancy <10 y All three choices for pts with regional metastatic disease with >10 year life expectancy. Antiandrogens with GnRH (gonadotropic-releasing hormone) agonist for metastatic prostate cancer (Ferri, 2011) |
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PSA:
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Normal values <4 ng/ml.
Levels > 10.0 ng/ml indicate a high probability of prostate cancer (67%). The PSA is limited by a lack of specificity between 4.0 -10.0 ng/ml. Levels can be elevated in patients with BPH and prostatitis. |
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PSA level can be affected by:
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BPH
Prostatitis UTIs Normal increase with advancing age. Ejaculation can temporarily increase levels (abstain 2 days before testing). Proscar, Propecia, or Avodart may falsely lower levels. Herbal preparations may mask an elevated level (Saw Palmetto). |
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Confirm PSA how soon after one elevated
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several weeks later
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The PSA level can be monitored
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after the diagnosis of cancer to help determine if the treatments were successful.
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Percent-Free PSA:
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Indicates how much PSA circulates free compared to the total PSA level. Biopsies may be recommended for levels 25% or less.
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Age Specific PSA Ranges:
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PSA levels are normally higher in older than younger men, even in the absence of cancer. Some doctors suggest comparing PSA results with results from other men of the same age
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PSA Density:
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Used for men with large prostate glands. Higher densities indicates a greater likelihood of cancer.
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PSA Velocity:
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The change in PSA values over time. A high velocity suggests cancer may be present and a biopsy should be considered. Should be measured over a minimum of 18 months.
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Distinction between BPH and ca
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not possible by H&P alone
you have to do diagnostic testing Transrectal Ultrasound (TRUS) Most commonly used during a prostate biopsy. Can be used to measure the size of the prostate gland. Prostate Biopsy: The gold standard for diagnosis is the prostate biopsy. However, MAY STILL MISS CANCER! Several narrow needles are inserted through the wall of the rectum into the prostate glad using TRUS for guidance. Each needle removes a tissue sample (6-13 samples). Causes only a brief stinging sensation because it is done with a biopsy gun which inserts and removes the needles in a fraction of a second |
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Follow up for prostate cancer
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q3-6 mo exam, PSA x 1 year,
then q6mos for second year, then yearly if stable. CXR and bone scan annually |
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NB: 20-25% of normal PSAs have prostate cancer found due to abnormal DRE!)
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NB: 20-25% of normal PSAs have prostate cancer found due to abnormal DRE!)
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IF PSA >10ng/ml
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Transrectal US with biopsy confirms diagnosis
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Prostate Cancer Treatment Options
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Radiation Therapy
External Beam Radiation Therapy (EBRT), usually 5 days per week for 7-8 weeks. Painless. Three Dimensional Conformal Radiation Therapy (3DCRT) uses computers to precisely map and deliver radiation to the prostate. Intensity Modulated Radiation Therapy (IMRT) more advanced than 3DCRT. Brachytherapy: radioactive pellets placed directly into the prostate. Cryosurgery Used to treat localized prostate cancer by freezing the prostate. Side effects include: hematuria, soreness, impotence. Urinary incontinence is rare. Hormone (Androgen Deprivation Therapy) Used to make prostate cancers shrink or grow more slowly. Used as 1st line if surgery or radiation is not an option. Also used as an addition to radiation therapy or before surgery or radiation to make treatment more effective. Other Hormone therapy Orchiectomy (not popular), Medical castration preferred. Luteinizing hormone releasing hormone (LHRH) analogs (Lupron, Zoladex, Trelstar) to lower testosterone levels. LHRH antagonists: lowers testosterone levels more quickly (Plenaxis). Antiandrogens: block the body’s ability to use androgens. (Eulexin, Casodex). |
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“Active Aging”
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Fries has conducted a
longitudinal study over the past 30 years and found those who are physically active have the ability to ‘compress morbidity’ to a shorter timeframe in their lives AND live longer. • With active health comes easier social interactions and less depression/anxiety |
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Alcohol abuse is defined as the consumption of
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of 14 or more drinks/wk for MEN or >4 drinks on one
occasion. Definition for women is approximately ½ of male’s |
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Substance Abuse: Primary Prevention
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Treat anxiety/depression
Council high risk patients on stress management |
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Substance Abuse: Secondary Prevention
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– No screening, but look for high risk patients
– CAGE tool (originally for etoh abuse, adaptable for drugs) • Cut down • Annoyed by criticism • Guilty • Eye opener needed |
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Substance Abuse: Tertiary Prevention
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Pharmacological
• Antidepressants during withdrawal: SSRI’s • IM or IV Thiamine for DTs (may occur 2-7 d after withdrawal and lasts for 1-3 days) • Lorezepam or other benzodiazipines for DT treatment (15% mortality if not treated) • Chronic treatment (potentiates symptoms of nausea, dizziness, +/or drowsiness): Disulfiram • Also narcotic antagonists: Narcan 50mg po qd or Nalmefene 10-40mg qd • Monitoring and treatment for other related disorders: pancreatitis, GI bleed, • Non-pharmacological & complimentary tx • Ensure safety during abstinence • Monitor for depression exacerbation • AA for pt • Adult children of alcoholics • Al-Anon or Al-A-Teen • Salvation Army Rehab centers – low cost in- or out-pt care • Good nutrition: Need adequate Thiamine (primarily deficient), Folate, niacin, riboflavin, minerals, protein (deficiencies seen in etoh abuse) • Counseling |
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CAGE tool
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(originally for etoh abuse, adaptable
for drugs) • Cut down • Annoyed by criticism • Guilty • Eye opener needed |
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What is the most specific lab test for alcohol use
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GGT
enzymes that breakdowns alcohol. not on liver panel (has to be ordered separately) |
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Define: Depression
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At least 5 symptoms present
nearly all the time in the past at least 2 weeks simultaneously: (DSM5; APA, 2013) – Depressed mood – Diminished interest, pleasure, energy, self-worth, ability to think and concentrate – Altered sleep pattern – Altered appetite – Altered level of psychomotor activity |
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Depression: Primary Prevention
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None identified
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Depression: Secondary Prevention
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Screen adult patients
not recommended, FYI, for adolescents or children! |
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Depression: Tertiary Prevention
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Cognitive, behavioral, medical management
SSRI’s: 6-12 months or longer (60-65% effective) – Consider continuous prophylactic tx if >3 lifetime episodes Antidepressant drugs represent a first line of treatment for moderate or severe depression For mild depression, other therapeutic strategies can be considered before antidepressant drugs The use of drugs is recommended for those patients with mild depression and a history of moderate or severe episodes of depression The use of drugs is recommended for mild depression when other medical illnesses or associated comorbidity may be present It is advisable to set up an appointment within 15 days for any patient with depression who does not receive pharmacological treatment” • Non-pharmacological & complimentary tx – Counseling support (40-50% effective) – Physical activity – Nutritional support – Sleep support – Etoh withdrawal if indicated – Close monitoring of treatment and medications |
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Comparative Efficacy of Drugs : depression
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“Selective serotonin reuptake inhibitors (SSRIs) are recommended as drugs of first choice in the treatment of major depression
In the event that an SSRI drug is not well-tolerated due to the appearance of adverse effects, it should be switched to another drug of same group An SSRI should be prescribed for patients who may receive treatment with any tricyclic antidepressant (TCA) and who do not tolerate it TCAs are an alternative to SSRIs if a patient has not tolerated at least two drugs from this group or is allergic to them New drugs could be used in the event of intolerance to SSRIs, thereby using the profile of their adverse effects as a guideline Specific patient profiles could warrant different drugs, thereby using the adverse effects rather than their efficacy as a guideline Venlafaxine should be considered as a second line of treatment in patients with major depression Before starting antidepression treatment, a healthcare professional should adequately inform the patient about the expected benefits; the frequent, infrequent, and patient-specific side effects that could arise, in both the short and the long-term; and especially about the duration of the treatment It is especially advisable to inform about a possible delay in the therapeutic effect of antidepressants Patients receiving antidepressant drug treatment must be closely monitored, at least during the first 4 weeks All patients who show moderate major depression and who are treated with antidepressant drugs must be assessed again before 15 days after initiating treatment All patients who show severe major depression and who receive outpatient treatment with antidepressant drugs must be assessed again before 8 days after initiating treatment” |
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All patients who show moderate major depression and who are treated with antidepressant drugs must be
assessed again before |
15 days after initiating treatment
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All patients who show severe major depression and who receive outpatient treatment with antidepressant
drugs must be assessed again before |
8 days after initiating treatment”
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Depression: Assess and manage suicide risk
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ASK about suicide ideation or thoughts of hurting oneself
• Include questions about previous self-harm • In patients with a high risk of suicide, seek frequent, additional support and to assess sending them urgently to a mental health specialist. • Hospitalization if high risk |
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Depression: Screening tools
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• Zung self-assessment depression scale
• Becks depression inventory • General health questionnaire • Center for epidemiologic study depression scale (CES-D) • Two key questions re mood and ahedonia – Over the past 2 weeks, have you felt down, depressed, or hopeless? – Over the past 2 weeks, have you felt little interest or pleasure in doing things? |
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“pseudodementia”
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Most common presentation in older adults is “pseudodementia” of depression with rapid decline cognitive fn – more rapid than e.g. Alzheimer's
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Anxiety
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• Wide ranging from mild situational anxiety to panic attacks.
Most commonly manifested |
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Generalized Anxiety Disorder
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is characterized by anxiety, fear and worry most of the time for at least 6 months.
Symptoms must be accompanied by at least 3 somatic symptoms e.g. – Restlessness – Irritability – Insomnia or inability to fall to sleep – Fatigue |
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Generalized Anxiety Disorder: Primary Prevention
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None controllable identified
– Seen less frequently with good health, active lifestyle, low-moderate stressor, intact families – Heredity plays a role 30% of diagnoses |
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Generalized Anxiety Disorder: Secondary Prevention
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– Early identification by screening at risk
individuals with every clinic visit |
|
|
Generalized Anxiety Disorder: Tertiary Prevention
|
Medical/cognitive/behavioral management
Pharmacological – Non-benzodiazepine anti-anxiety meds e.g. Buspar (buspirone) • No tolerance or abuse potential – major advantage over benzodiazepines – SSRI’s and venlafaxine effective with GAD – Sedating antidepressants e.g. Trazadone, Elavil are effective short-term in relieving insomnia • Non-pharmacological & complimentary tx – Behavioral therapy: stress reduction, relaxation training, biofeedback – Cognitive counseling (probably more effective than medications alone) – Family support – Etoh withdrawal if applicable – Nutritional support – Close monitoring of treatment and medications |
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Delirium
|
Characterized
by a sudden onset of Confusion that lasts over hours or days |
|
|
Delirium: Primary Prevention
|
Avoid medications known to promote delirium in
older adults if possible |
|
|
Delirium: Secondary Prevention
|
No screening for delirium
|
|
|
Delirium: Tertiary Prevention
|
Aimed at eliminating or reducing causative factors.
Pharmacological – NB: Neuroleptics, though prescribed often for dementia have demonstrated limited efficacy, only use with serious problems e.g. psychotic symptoms, serious emotional distress, or danger from behavior disturbances (Mayo, 2012) – Rule of thumb with all meds for delirium: “START LOW, GO SLOW! – Medication treatment should be short-term – Withdraw medications associated with delirium – Effectively treat all medical problems – Ensure adequate nutrition/oxygenation – Treat any identified metabolic dysfunctions Non-pharmacological & complimentary tx – Non-drug interventions considered along with medication interventions (Mayo, 2012) • Reality orientation e.g. clocks, calendars, pictures of family members • Behavioral intervention e.g. Sleep promotion • Occupational activities • Environmental modification e.g. Avoid over-stimulating environment • Validation therapy e.g. Continuity of care providers • Reminiscence e.g. Family visits and support • Sensory stimulation e.g. glasses and hearing aids in for appropriate reception of stimuli |
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Delirium
|
Inability to concentrate on new stimuli
Disorganized thinking At least 2 of these • Lowered LOC • Perceptual disturbances • Disturbed sleep • Change in activity level • Disorientation to time, place, or person • Memory dysfunctions – Short onset, with variation over day (typically worse at night) – No evidence or assumption of organic cause of disorder |
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|
Delirium: at risk people
|
Older adults
• Severely ill: e.g. head trauma, sepsis • Chronic brain dysfunction • CNS medications e.g. narcotics, sedatives, anticholinergics • Other medical conditions: liver disease with hypoalbuminemia • Psychiatric co-morbidities • Aesthesia • Sleep deprivation |
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Hyperlipidemia: define
|
an elevation in lipid transport proteins in blood with
elevation in cholesterol, triglycerides, or both after a 9-12h fast |
|
|
Hyperlidemia: Primary Prevention
|
“Step 1 diet:
• <300mg/d dietary cholesterol and 8-10% calories from saturated fats. • Consume 2 servings of fish, especially those relatively high in omega-3 fatty-acids (eg, salmon, trout, and herring) at least twice weekly. – Children and pregnant women should follow Food and Drug Administration (FDA) guidelines for avoiding mercury-contaminated fish (eg, shark, swordfish, king mackerel, and tilefish). • Limit intake of saturated fat, trans fat, and cholesterol by choosing lean meats, vegetable alternatives, and fat-free (skim) and low-fat (1% fat) dairy products and minimize intake of partially hydrogenated fats. • Minimize intake of beverages and foods with added sugars. To consume no more than 2300 mg of sodium daily, choose and prepare foods with little or no salt. Middle-aged and older adults, African Americans, and those with hypertension should consume no more than 1500 mg of sodium daily. • Limit alcohol intake to not more than 1 drink per day for women and 2 drinks per day for men (1 drink = 12 oz of beer, 4 oz of wine, 1.5 oz of 80-proof distilled spirits, or 1 oz of 100- proof spirits). • Maintenance of weight in desired range |
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Hyperlipidema: Secondary Prevention
|
-Fasting cholesterol panel q 5y after age 20 in absence of disease
– ‘According to AHA, measurement of lipid parameters, including lipoproteins, apolipoproteins, particle size, and density, beyond a standard fasting lipid profile is not recommended |
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Hyperlipidemia: Teritary Prevention
|
Treatment of elevated LDL or triglyceridemia with
• Medications • TLC: total lifestyle changes: – Diet: Low cholesterol, low fat, high fiber – Exercise – specify intensity, frequency, and duration in prescriptions – Wt management – Stress management |
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|
Risk factors that influence tx of elevated LDL
|
CAD or a CAD risk equivalent:
– Carotid artery disease – Peripheral arterial disease – AAA – Diabetes is a CAD risk equivalent!!!!! – Risk factor combination that incur a risk for CAD mortality >20% in 10 years. • Major risk factors: – Smoking – Hypertension or taking antihypertensive agent – Low HDL (<40mg/dl) – FH premature CAD (M<55y, F<65y) – Age: M>45, W>55 (ATPIII, 2002, 2010) |
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What is a CAD risk equivalant
|
Diabetes
Peripheral arterial disease AAA |
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|
Management: Hypertriglyceridemia
|
– If Triglycerides (TG) >500mg/dl –treat this abnormality first due to risk of pancreatitis
• Total Lifestyle Change (TLC) plus fibric acids ( or nicotinic acid – When TG <500 • turn to LDL lowering therapy – If TG 200-299 after LDL goal met • consider adding fibrate or nicotinic acid |
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|
Management: Low HDL
|
-- First reach LDL goal
– Then intensify diet/activity, wt management – Add fibrate or nicotinic acid in CAD |
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|
Management elevated LDL
|
Pharmacological
– HMG CoA reductase inhibitors (statins): (e.g. Lipitor, Prevachol) can cause myopathy and increase LFTs. Avoid with cyclosporin, macrolides, many antifungal agents and P450 inhibitors • LDL –18-55% • HDL +5-15% • TG -7-30% – Intestinal absorptive blockers (e.g. Ezetimibe Zedia) – can cause abd pain and diarrhea – higher caution LFTs with HMG CoA reductase inhibitors • LDL -18% – Bile acid sequestrants (e.g. Questran): can cause GI distress, decrease absorption other drugs. Avoid with TG>400 (or >200) • LDL -15-30% • HDL +3-5% • TG no change – Nicotinic acid (e.g. Niaspan): can cause flushing, hyperglycemia, hyperuricemia, GI distress, hepatotoxicity. Avoid with liver disease, gout, consider avoid in diabetes. • LDL -15-25% • HDL +15-35% • TG -20-50% Fibric acids (e.g. TriCor): can cause myopathy and GI distress. Avoid with severe renal or hepatic disease. • LDL -5-20% but may increase in those with high TG ! • HDL -10-20% • TG -20-50% – ASA for CAD or equivalent, men >40, and women>50. • Study data described that women only over 65 benefited from CVD risk reduction, but did have greater reduction in risk from ischemic stroke than men Non-pharmacological & complimentary High fiber diet – Step 2 diet: <200mg/d dietary cholesterol and <7% calories from saturated fats – Physical activity – Weight management – Aggressive lifestyle changes in diabetics due to high risk CAD (ADA, 2006) – Identify and treat metabolic syndrome • Elevated FBS of >110, but <126mg/dl • Associated with elevated triglyceridemia, abd obesity, low HDL, elevated BP |
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|
Step 2 diet
|
<200mg/d dietary cholesterol and <7% calories from
saturated fats |
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|
LDL GOAL: High risk: CHD1 or CHD risk equivalents
|
<100 mg/dL (optional goal: <70 mg/dL)
|
|
|
LDL GOAL: Moderately high risk: 2+ risk factors
|
<130 mg/dL
|
|
|
LDL GOAL: Lower risk: 0-1 risk factor
|
<160 mg/dL
|
|
|
Coronary heart disease (CHD) includes history of
|
MI, unstable angina, stable angina,
coronary artery procedures, or evidence of clinically significant myocardial ischemia. |
|
|
CHD risk equivalents include
|
noncoronary forms of atherosclerotic disease (PAD, AAA, and CAD [transient ischemic attacks or stroke of carotid origin or >50% obstruction of a carotid
artery]), diabetes |
|
|
CHD Risk factors include
|
smoking,
HTN or on antihypertensive medication), low HDL (<40 mg/dL), FH premature CHD (CHD in male first-degree relative <55 years of age; CHD in female first-degree relative <65 years of age), and age (men >45 years; women >55 years). |
|
|
When LDL-lowering drug therapy is employed, it is advised that intensity of therapy be
sufficient to achieve at least a |
30% to 40% reduction in LDL-C levels.
|
|
|
When to recheck lipid panel after initiation of TLC for elevated LDL
|
Initially fu in 6 weeks for fasting panel to check effect of TLC
|
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|
What to do if not at LDL goal after 6 weeks of initiating TLC
|
IF not at goal at 6 weeks, intensify TLC, consider referral to
dietician |
|
|
When to follow up for LDL after intensifying TLC and considering referral to dietician?
|
6 weeks
|
|
|
What to do if not at LDL goal after 6 weeks of intensifying TLC and considering referral to dietician
|
If still not at goal in 6 further weeks, consider treat with meds
|
|
|
When to follow up after starting medication management for goal LDL
|
4-6 months
|
|
|
What to do if not at LDL goal after 4-6 months after starting medication management
|
– If not at goal in 4-6 months of med tx, consider increase med, add second agent, refer to dietician, consider lipid clinic, workup for metabolic syndrome
|
|
|
How often do you check LDL after initiation of medication
|
FU q 4-6 months until goal
|
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|
LFTs and Statins
|
Check LFTs if statin no longer done since Feb, 2012:
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|
Hypertension: define
|
elevated systolic bp >140 and/or elevated diastolic bp >90mmHg OR taking antihypertensive meds.
– These numbers are 130 and 80, respectively for patients with diabetes |
|
|
• Starting at 115/75 mmHg, CVD risk doubles with
each increment of |
20/10 mmHg throughout the BP range.
|
|
|
HTN: Primary Prevention
|
-Weight control (esp. avoid obesity and associated Type II diabetes [T2Diabetes]),
– Smoking cessation – Manage hyperlipidemia – Physical activity – Manage microalbuminuria |
|
|
HTN: Secondary Prevention
|
-Screen all adults q 1 year if bp 130-9 or 85-9
– Screen all adults q 2 years if bp <130 or <85 – Reconfirm bp 140-159 or 90-99 (stage I) within 2 months to diagnose with htn – Evaluate all pts with bps >160 or >100 (stage II) – *NB need to be able to identify stages for determining tx. |
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|
HTN: Tertiary Prevention
|
Lifestyle changes
• Pharmacological – Most pts will require >2 agents to control BP – If BP >20/10mmHg greater than BP goal, consider starting pt on 2 agents initially – Thiazide diuretics advocated for initial tx due to reduced morbidity and mortality and low cost – either alone or with another agent (JNC7, 2003). – ACE, ca agonists, α1 blockers, and α-β blockers effective and indicated in certain co-morbidities. – Consider cost, SE, drug interactions Non-pharmacological & complimentary • Smoking cessation and smokeless tobacco cessation • Etoh avoidance or reduction • Diet for wt control, sodium reduction • 1200mg/d Ca from dairy products (DASH: full diet for pts available on line at: www.nhlbi.gov), adequate Mg and K • Exercise • Wt management • Stress management • ASA • Avoidance of ephedrine (in some “herbal” wt loss products), pseudophedrine, caffeine, NSAIDS, steroids |
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|
What are – Non-malleable risks of HTN
|
• W>65, M>55,
• FH of CVD W<65, M<55 |
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|
What is considered pre hypertension
|
120-139/80-89
|
|
|
treatment of bp 120-139/80-89
|
lifestyle modifications
|
|
|
What is Stage one HTN
|
140-159/90-99
|
|
|
Treatment of BP of 140-159/90-99
|
Stage one HTN
Life style modications Thiazide diuretics for most May consider ACE, ARB, BB, CCB or combination |
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|
What is Stage two HTN
|
>160/>100
|
|
|
Treatment of BP of >160/>100
|
Lifestyle changes
Two drug combination - Thiazide diuretic and ACE or ARB or BB or CCB |
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|
CAD: definition
|
Atherosclerotic disease of the coronary arteries
|
|
|
Most COMMON cause of morbidity and mortality in US
|
CAD
|
|
|
Most common manifestation of CAD is
|
angina
|
|
|
Risk factors for CAD
|
HTN
Smoking Elevated cholesterol Diabetes |
|
|
CAD: Primary Prevention
|
Diet
– Low cholesterol – Balanced in folate levels • Wt control • Physical activity • Control diabetes, hyperlipidemia, Htn, • Smoking avoidance • No- or moderate-etoh intake • Avoid cocaine |
|
|
CAD: Secondary Prevention
|
High cardiac risk patients should be screened with
stress EKG before initiating vigorous exercise program, NOT moderate intensity (ACC/AHA, 2012) – Rapid CT scans for calcium deposits in coronary vessels not supported for screening. – Routine CRP not recommended |
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|
CAD: Tertiary Prevention
|
– TLC plus medical treatment
Pharmaco Chronic Angina -non ISA- beta blockers (first line) -long acting nitrates Vasospastic angina: cardioselective beta blockers, the beta1-blockers (e.g. Tenormin and Lopressor) or long acting ca channel blockers – Microvascular angina associated with diabetes: ACE • Non-pharmacological & complimentary – Lifestyle Heart Trial found dramatic lifestyle changes of vegetarian diet with stress management, and support, along with other TLC methods showed a regression of CAD without hyperlipidemia meds after 5 y. These participants had a 50% reduction in coronary events (Ornish, 1998) – Diet: low cholesterol, wt controlling – Exercise – closely monitored after coronary event in order to progress safely in cardiac rehab setting – Also in setting, social support connections available – Social support in community – Smoking cessation – Manage hyperlipidemia, obesity, diabetes, htn, other disorders |
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|
Angina: define
|
substernal chest pain or pressure 30 sec
to 30 minutes, non-pleuritic, often accompanied by SOB, nausea, diaphoresis and paresthesias |
|
|
Angina: Types
|
– Unstable or Acute: sudden and new onset cp.
Unresolved LAD disease associated with 75% risk of MI – Chronic stable: e.g. exercise induced imbalance from long standing, >50% plaque in coronary arteries – Prinzmetal’s: often seen with normal coronary arteries, caused by vasospasm – Microvascular: associated with insulin resistance with Atherosclerotic changes in microvasculature. |
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|
Pharmaco: Chronic Angina
|
-non ISA- beta blockers (first line) (ISA means intrinsic
sympathomimetic activity) Tenormin, Lopressor -long acting nitrates |
|
|
Pharmaco: Vasospastic angina
|
cardioselective beta blockers,
the beta1-blockers (e.g. Tenormin and Lopressor) or long acting ca channel blockers |
|
|
Microvascular angina associated with diabetes:
|
ACE
|
|
|
ß blockers
|
• Negative ionotrope
• Decrease 02 demand • Decrease nor-epi effects on HR and contractility. • Non-ISA (e.g. Tenormin, Lopressor) agents are first line after MI due to decreased mortality. (ISA means intrinsic sympathomimetic activity) • BCAPs (ß blocker cholesterol lowering asymptomatic plaque study) found greater reduction in athrosclerotic carotid plaques when treated with statin and beta blocker than statin alone. |
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|
Calcium-channel blockers: CCB divided into 2 groups by effects
|
Dihydropyridines
Non-Dihydropyridines |
|
|
Calcium-channel blockers: Dihydropyridines
|
(e.g. nifedipine, nicardipine, and nimodipine), which
are predominantly vasodilators and generally have neutral or increased effects on vascular permeability • Because the dihydropyridines have very weak effects on the SA node and AV junction, there is an increase in heart rate due to the increase in sympathetic tone • Any weak direct negative inotropic effect of the drug is overwhelmed by the strong reflex sympatheticresponse |
|
|
Calcium-channel blockers: Non-Dihydropyridines
|
(e.g. verapamil and diltiazem) which reduce
vascular permeability and effect cardiac contractility and conduction Diltiazem (an NDP) shown to decrease mortality after MI. – Long acting agents (verapamil, nifedipine, nicardipine, bepridil, and diltiazem) are recommended for vasospastic angina |
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|
MI – STEMI : definition
|
- Acute ischemic necrosis of the myocardium due to compromise in the coronary
circulation • An important cause of non-accidental sudden death - 25% patients of AMI die. |
|
|
Risk factors for MI
|
Unstable angina
– Coronary vasospasms – Atherosclerosis risk factors - HTN, DM, Hyperlipidemia, Smoking. – Embolus – Collagen vascular diseases – Coronary anatomic anomalies – Cocaine abuse |
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|
Heart failure: definition
|
Complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the ability of the ventricles to fill with or eject blood. |
|
|
Leading cause of hospitalizations in patients older than 65
yrs. |
Heart failure
|
|
|
Heart Failure: Primary Prevention
|
--Diet
– Exercise – Weight Management – Control of HTN, Diabetes,etc – Smoking Cessation – Limit etoh consumption |
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|
Heart Failure: Secondary Prevention
|
– No screening for HF
|
|
|
Heart Failure: Teritary Prevention
|
-Disease management
• CAD • Chronic hypertension • Arrhythmia • Heart valve disease • Cardiomyopathy • Congenital heart defects – Reduce Risk Factors • Alcohol and drug abuse – Use of cardiotoxic medication • Based on Class and symptoms – 1 – Primary prevention and treat risk factors – 2 - add ACE/ARB and Beta blocker if not already taking – 3 – add Diuretics, Dignoxin, Nitrates, Hydralazine • Consider Biventricular Pacing and Implantable Defibrillator – 4 – Hospice, Heart Transplant, Chronic Inotropes (Dobutamine clinic), Permanent pump (LVAD) • Individualized management – necessary to address multiple health and QOL concerns. • Non-pharmacological & complimentary – Moderate regular physical activity – Na+ intake • 2-3g/d in mild-mod HF • <2g/d severe HF – Smoking cessation – Maintain appropriate body wt. – Etoh intake • No more than 2oz or 2drinks per day • No etoh if alcoholic cardiomyopathy |
|
|
BNP
|
- Marker of ventricular dysfunction
• Cardiac neurohormone secreted from the ventricles in an increasing amount in response to abnormal pressure overload and increasing volume • Levels increase according to progressive worsening of CHF • Level over 100 is indicative of CHF |
|
|
HF: Class I
|
no symptoms
|
|
|
HF: Class II
|
Symptoms with moderate activity
|
|
|
HF: Class IIIa
|
Symptoms with ordinary activity
|
|
|
HF: Class IIIb
|
Symptoms with minimal activity
|
|
|
HF: Class IV
|
Symptoms at rest with no activity
|
|
|
Key medication treatments HF
|
Diuretics
• Spironolactone • ACE inhibitors • Beta Blockers • Digitalis • Natrecor (NESIRITIDE) –IV medication for TX of CHF –Therapeutic peptide that acts as a vasodilator –Given as a bolus followed by a continuous drip –Can cause hypotension –Use caution when administering with other diuretics |
|
|
Diuretics: HF
|
– Increase urine sodium excretion
– Decrease clinical S&S of fluid retention – Goal of tx: obtain/maintain optimal dry wt – Spironalactone * Improves survival • K+ sparing diuretic • Used in combination with loop for maximal excretion • Used in HF to reduce aldosterone levels • SE: – hyperkalemia – esp in combination with ACE – Gynecomastia/breast tenderness |
|
|
ACE Inhibitors: HF
|
– Reduce circulating angiotensin II levels
– Decrease afterload and preload – Decreased sympathetic tone allows for increased systolic emptying (increased CO) – SE: Important to obtain baseline labs: Lytes, BUN, creat. – Retest 1-2wk after start and periodically with up-titration. • Hypotension • Renal dysfunction - Hyperkalemia |
|
|
Angiotensin receptor blockers (ARBs) : HF
|
– Consider if pt unable to tolerate ACE due to SE:
angioedema or intractable cough – SE: Same baseline and FU labs as ACE • Hypotension • Worsening renal fn • Hyperkalemia |
|
|
Beta Blockers: HF
|
– Inhibit adverse effects of SNS in HF pt i.e. break cycle of HF leading to neurohormonal activation (which leads to worsening HF)
– Marked suppression of renin is possible mechanism of action for beta blockers. – SE: • Fluid retention • Fatigue • Bradycardia/heart block • hypotension |
|
|
Positive ionotropes : HF
|
Digoxin
– Increases contractility, slows HR – In mild-mod HF – Improves clinical sx – QOL – Exercise tolerance – Little effect on mortality – Modest reduction in combined risk of death and hospitalization – Usual dose: 0.125 – 0.25mg qd – Use cautiously in pts taking – Quinidine – Verapamil – Amiodarone – Spironalactone – SE: - Arrhythmias – GI distress – Visual disturbances – Milranone or Dobutamine • Infusions used often in decompensated Class IV HF when oral meds fail to provide clinical sx relief – Neseritide • An effective vasodilator and some degree of diuretic fn • Clinical trials demonstrate less SE than Dobutamine • Alleviates clinical sx quickly |
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|
Anemias: define
|
a reduction in Hg or Hct below normal
|
|
|
Anemia Males
|
Hg<13g/dl (14-18) or Hct <38% (45-52)
|
|
|
Anemia Females
|
Hg<12g/dl (12-16) or Hct <35% (36-48)
|
|
|
Anemia: Primary Prevention
|
Nutrition: diet rich in iron, B vitamins – especially
B12 and folate |
|
|
Anemia: Secondary Prevention
|
Screen high risk individual adults:
• Pregnant women (USPTF, 2011) • Not recommended by USPTF, but do consider in females aged 11-19 in this age due to high rate of iron deficiency. – Moderate to heavy menses – Chronic wt loss – Nutritional deficiencies – Heavy athletic activity |
|
|
Anemia: Tertiary Prevention
|
--Management by cause of disorder.
– Anemia is an indicator of a health problem, provider must find cause of disorder. |
|
|
• Normocytic anemias
|
MCV 80-100fl
40% of micro- or macro-cytic anemias present early as normocytic • RDW and peripheral blood smears ‘unmask’ this anemia – Acute blood loss (should have high Retic ct) – RBC underproduction (with low Retic ct) • Marrow failure e.g. leukemia, aplastic anemia, drugs • Systemic disease e.g. malignancies, chronic infection |
|
|
• Microcytic anemias
|
MCV <80fl
Iron deficiency anemia either from excess loss or inadequate intake – Thalassemias – Lead poisoning – Anemia of inflammation (used to be called of chronic disease) |
|
|
Macrocytic anemias
|
MCV >100fl
– Megablastic • Folate deficiencies e.g pregnancy, etoh abuse, poor diet, sprue, enteropathy, anticonvulsants • Vit B12 deficiency (PERNICIOUS) e.g. gastrectomy, strict vegetarian (no animal products), tapeworm, H pylori infection, autoimmune diseases (Ferri, 2010) – Non-megablastic • Etoh abuse • Myelodysplasias • Liver disease • Hypothyroidism • Aplastic anemia • Myeloma • Cytotoxic drugs |
|
|
Symtomotology : Normocytic
|
Depends on severity of anemia and severity and
type of underlying illness – Requires a thorough H&P, retic count • If retic count elevated, draw LDH, indirect bilirubin, serum haptoglobin, and direct Coombs • If retic count low or normal, draw TSH, Bun and creatinine, LFTs – If normal levels of above, draw serum ferritin, RBC RDW (RDW changes early in anemia, often before MCV. Measures variability of RBC size and can help id mixed anemias especially with a peripheral blood smear) |
|
|
Symtomotology : Microcytic
|
– Depends on severity and rate of progress
– May be asymptomatic – May include classic sx of fatigue, HA, palpitations, exercise intolerance, cold intolerance, sob – And extend to postural vertigo, palpitations, weakness, exhaustion – Thalasemia diagnosed by peripheral blood smear with presence of poikilocytosis, anisocytosis, target cells and basophilic stippling – HG electrophoresis confirms Thalasemia which needs a hematologist – Ferritin level indicates if adequate stored iron; TIBC and serum iron assist with dx – Also look for causes especially seen in iron deficiency: GI bleeding- upper or lower; consider malignancies – Prolonged depletion of iron can lead to signs of glossitis, skin pallor, pallor conjunctiva, mucous membranes, brittle and moon shaped nails, tachycardia, systolic murmurs. |
|
|
Symtomotology : Macrocytic
|
*NB: macrocytosis without anemia is an important warning sign of underlying pathology – work up as in anemia
– Classic neuro signs of megablastic anemia • Paresthesias in fingers and legs • GI symptoms of glossitis and stomatitis • Folate deficit may present as cognitive changes “megaloblastic madness” • Ataxia, loss of sensation or vibratory or position sense. – Hemolysis of RBC may cause jaundice and pallor resulting from release of bilirubin – Retic count helps in distinguishing if megaloblastic • If retic normal or low, need to check cobalamine and folate levels • If cobalamine is decreased, do a Shilling test (urine test of B12) |
|
|
Anemia workup low MCV < 80
|
Microcytic
Check ferritin (iron deficiency) Check hg electrophoresis (thalessemia) Check lead if at risk (lead poisoning) Check for chronic illness (Anemia of chronic disease) |
|
|
Anemia workup MCV 80-100
|
Normocytic
Tricky because 40% are actually microcytic or macrocytic anemias Check retic count LOW- bone marrow failure, or systemic disease HIGH- acute blood loss. |
|
|
Anemia workup MCV >100
|
Macrocytic
Check folate, vitamin b12 (megablastic) Various disorders (nonmegablastic) |
|
|
Management: Microcytic anemia
|
• If iron deficiency
– Replace with daily iron po with food and Vit C source – Retic count should respond in 1 week – Hg should improve by 1gm/dl in 1 month – Ferritin level should be normal in 4-6 mos, tx can be d/c • If ACD (anemia of chronic disease) tx underlyng cause • If thalasemia – refer to hematologist |
|
|
Management: Normocytic anemia
|
Tx dependent on underlying cause, e.g.
– If acute bleed – referral and transfer to ER – If malignancy or bone marrow depression – refer to hematologist/oncologist emergently – If mixed anemia, treat underlying disorder |
|
|
Management: Macrocytic anemia
|
• Don’t treat for low folate until cobalamine checked as well.
Untreated cobalamine deficit may lead to permanent neuro damage • Cobalamine deficit: Vitamin B12 injections qwk x 4-6 weeks, then qmo IM or intranasal qwk indefinitely (except in Leber’s disease where tx associated w optic atrophy). Monitor K levels due to early erythropoisis depletion of K • High dose oral B12 may be useful too (Level B recommendation AAFP, 2011) • Folic acid deficit: Folate replacement 1mg/d • Retic count should respond by elevation in 1 week |
|
|
• Non-pharmacological & complimentary : treatment for anemias
|
– Dietary instruction in
• Foods high in iron if iron deficiency • Foods high in folate if folic acid deficit • Foods high in Vit B12 if cobalamine deficit – Etoh avoidance, AA if contributor to disorder – Instructions about gradual improvement rather than spontaneous resolution of symptoms – Avoid overexertion during recovery |
|
|
What is the term for angina without provocation and typically occurring at rest?
|
Prinzmetal or variant angina
|
|
|
A 65-year-old patient is at your clinic, with history of Vasospastic angina and when reviewing his medications, what medication would you expect as part of his treatment plan for Vasospastic angina.
a. Diuretic, Lasix 20 mg, PO, QD b. Potassium chloride, 20 MEQ, PO, QD c. Calcium Channel Blocker, verapamil, 80 mg, PO, TID d. Nitrates, Nitroglycerin 0.04 mg, SL, Q5min apart PRN for CP e. Both C & D f. None of the above |
c. Calcium Channel Blocker, verapamil, 80 mg, PO, TID
d. Nitrates, Nitroglycerin 0.04 mg, SL, Q5min apart PRN for CP e. Both C & D************* |
|
|
What is NOT a 1st line therapy for the management of Metabolic Syndrome?
a. Weight reduction b. Treat lipid and non-lipid risk factors (atherogenic dyslipidemia) c. Treatment of diabetes d. Increased physical activity |
c. Treatment of diabetes
Answer=c, not a 1st line treatment. Diabetes is a CHD equivalent and warrants a more intense treatment plan. |
|
|
Name 3 criteria for the diagnosis of Metabolic Syndrome:
|
§ WAIST CIRCUMFERENCE of
>40 inches men >35 inches women § HIGH-DENSITY LIPROPROTEIN (HDL) < 40 mg/dL in men < 50 mg/dL in women § TRIGLYCERIDE LEVEL OF 150 mg/dL or higher § BLOOD PRESSURE HIGHER THAN 130/85 § FASTING SERUM GLUCOSE OF 110 MG/dL or higher |
|
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What can be causes for HDL to be low (< 40)?
a. genetics, anti depressant medications, smoking b. uncontrolled diabetes, high carbohydrate diet, smoking c. anabolic steroids, inactivity, being male d. none of the above. |
b. uncontrolled diabetes, high carbohydrate diet, smoking
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A patient wants to raise their HDL level without medication, which is the best plan?
a. weight lifting and high protein diet and OTC niacin b. treadmill for 10 minutes a day , eating more fish and no ETOH c. lose weight, stop smoking , add soluble fiber to diet twice daily d. increase monounsaturated fats in diet, no ETOH and weight lifting |
c. lose weight, stop smoking , add soluble fiber to diet twice daily
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1.) All of the following ACCEPT which could be used as Differentials in diagnosing a gero patient that presents with confusion
a. Incontinence b. UTI c. Pneumonia d. intestinal obstruction e. all of the above |
a. Incontinence
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2.) Which of the following would be the appropriate when performing a physical exam to determine confusion in a gero patient?
a.) Comprehensive cardiorespiratory exam b.) Focal neurologic signs usually absent c.) Formal mini mental state exam d.) all of the above |
d.) all of the above
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Metabolic syndrom is diagnosed by the following:
a. Obesity, hypertension, insulin resistance, and low high density lipoprotein b. Hypertension, low high density lipoprotein, central obesity, and insulin resistance c. High triglycerides, low high density lipoprotein, diabetes mellitus, and hypertension d. Obesity, Low triglycerides, insulin resistance and hypertension |
b. Hypertension, low high density lipoprotein, central obesity, and insulin resistance
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Iron deficiency Anemia is best diagnosed by:
a. Low Hgb, Low Plt, Low RDW b. Low Hgb, Normal MCV, Low Reticulocytes c. Elevated RDW, elevated MCV, and Low Ferritin d. Low MCV and Elevated RDW, and Low Hgb e. Low Hgb, Elevated RDW and Low Ferritin |
e. Low Hgb, Elevated RDW and Low Ferritin
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. Regarding obesity which of the following is false.
a) The medical rationale for weight loss in obese subjects is that obesity is associated with a significant increase in mortality and many health risks including type 2 diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. b) Selection of treatment for overweight subjects is based upon an initial risk assessment. c) All patients who are overweight (BMI ≥25 kg/m2) or obese (BMI ≥30 kg/m2) should receive counseling on diet, lifestyle, and goals for weight management. d) For individuals with a BMI >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have failed to achieve weight loss goals through diet and exercise alone, bariatric surgery should be recommended. |
d) For individuals with a BMI >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have failed to achieve weight loss goals through diet and exercise alone, bariatric surgery should be recommended.
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According to a Nurses’ Health Study, after adjustment for age, smoking, exercise level and dietary factors, of all sedentary behaviors, 2 hours increments of which the following actives appears to be the most predictive of obesity risk
a. Prolonged television watching b. Prolonged desk work c. Reading for extended amount of time d. Driving for extended distances |
a. Prolonged television watching
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A 62 year-old Hispanic male presents to clinic with complaints of ‘bloating’ and LE edema. His only history is HTN and CAD. He is a current smoker and drinks 4 ETOH beverages 3-4 days a week. On exam, his abdomen is distended and he has a positive hepatojugular reflex. Bilateral LE with 2 + pitting edema noted. The most likely differential diagnosis is:'
Alcoholic liver disease Congestive heart failure Bowel obstruction None of the above |
Congestive heart failure
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An 68 year old woman with a history of HTN, NIDDM and hyperlipidemia presents for follow up after a hospitalization for newly diagnosed CHF. Her current medications include Lipitor 40mg QD, Lisinopril 20mg PO QD, Lasix 40mg PO QD, and Atenolol 50 mg PO QD. Her BP is 129/78, HR 71, RR 16, Oxygen Sat 98%, her ECG shows NSR with right left axis deviation, eGFR is 50%, and a recent echocardiogram reveals and EF of 35%. The best choice for medication adjustment is:
A. Increase Atenolol to 100mg QD B. Start Amiodarone 100mg PD QD C. Digoxin 0.125 mg PO QD D. Cardizem CD 120 mg PO QD |
C. Digoxin 0.125 mg PO QD
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What type of medication would decrease LDL by 20-60%
a. Cholesterol absorption inhibitors b. Beta Blocker c. HMG-CoA inhibitor D. Diuretic |
c. HMG-CoA inhibitor
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What type of Live style management will decrease LDL
a. Weight management b. Low fat, low cholesterol diet and high fiber diet c. Stress management d. Smoking |
d. Smoking
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