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438 Cards in this Set
- Front
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__ million people in US with diabetes
__ undiagnosed more common in men or women |
20 million in 2005
6 million (50% get diagnosed once complications develop...esp cardiovascular) men |
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diabetes accounts for __% of the health budget
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5-10%
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__% of diabetes is type 1
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5-10%
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metabolic syndrome
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any 3 of the following...
BP > 130/85 fasting BG > 110 waist > 40''M or 35''F male LDL <40, female <50 TG > 150 |
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in pregnancy, glucose requirement increases, esp during __ trimester (as __ levels increase)
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3rd
human placental lactogen) |
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when to do diabetes testing
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age >45, especially if BMI >25, then every 3 years if normal
younger if BMI >25 + additional risk factors like: -inactive -hx GDM -1st degree relative -high risk group -htn |
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A1c of __ = diabetes
A1c of __ = pre-DM |
>6.5 but must be repeated on another day
5.7-6.4 but must be repeated on another day |
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FPG is taken when patient has not eaten for at least __ hours
DM = FPG > pre-DM aka impaired fasting glucose = FPG > |
8
126 (but must be repeated another day) 100 (but must be repeated another day) |
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DM = OGTT (75g then 2 hrs) >
pre-DM aka IGT = OGTT > |
200
140 |
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random glucose > __ AND __ = DM
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200
sx like polyuria, polydipsia, unexplained weight loss (does NOT need to be repeated) |
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principles in confirming DM diagnosis
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use same test that you first used
unless you have 2 different tests that both confirm DM, then you don't have to repeat on subsequent day if, say, A1C is DM but FPG is not, repeat the A1C to confirm DM dx |
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what children should be tested for DM
minimum age of kid how often should they be tested |
weight >85th %ile
BMI >85th %ile weight >120% ideal + 2 of the following: -family history -race -htn, PCOS, dyslipidemia, etc -maternal GDM kid should be >10 yo test every 2 years FPG preferred |
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women with GDM should be screened for DM __ weeks postpartum
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6-12 weeks
and then again later |
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Weight loss and regular exercise can reduce the risk of diabetes by almost __%
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50%
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for run of the mill pre-diabetes, what do you do?
how often do you follow up? |
make them lose 5-10% of weight and exercise
follow up annually |
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for what pre-diabetics do you stave off with drugs? which drugs?
how often should they be followed up? with what? |
**IFG + IGT** + one of:
-age <60 -BMI >35 -first degree relative -elevated triglycerides -HTN -A1C >6 metformin...glitazones have not been shown to be cost effective every 6 months with A1C (if they're not on metformin, follow annually) |
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what labs do you need for new diabetic
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A1c
fasting lipid profile microalbuminuria (type 1 >5 years or any type 2) Cr TSH for Type 1 UA for ketones, protein, sediment |
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when diabetics are sick, they should check sugars every...
check __ every 4 hours and drink lots of ___ call doctor if they cannot |
2-4 hours
ketones non-caffeinated fluids hold fluids or carbs down for >6 hours, can't eat regular food for 1 day, develop intractable heavy vomiting |
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if blood glucose is < __ you should eat ___
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70
1/2 cup of any fruit juice 1/2 cup of regular soft drink 1 cup of milk 5 or 6 pieces of hard candy 1 or 2 teaspoons of sugar/honey 2 or 3 glucose tablets |
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risk factors for depression in diabetics is:
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age <65
prior depression unmarried poor physical health female |
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DSME stands for
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diabetes self-management education
(reimbursed by medicare and medicaid) |
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when to do fingersticks if you are not on insulin and: are a new DM, recently changed therapy, or are outside target range
what if you are in target range? what if you are taking insulin with boluses what if you are just taking basal insulin |
before breakfast
before main meal 2 hr after start of main meal 3x/day every 3rd day 4 times/day: before bkfst, mid morning, mid afternoon, mid evening fasting glucose daily, other intermittently |
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testing A1C is not useful in patients who...
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have hemolytic disease
blood loss hemoglobinopathies |
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DM A1C goals
DM pre-meal goals DM post-prandial goal |
<7%, but as close to 6 as possible without risking hypoglycemia
90-130 <180 (these are all according to American Diabetes Association) |
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MNT stands for ___
it can reduce A1C by __% in new DM2 or by __% in 4+ year DM2s |
medical nutrition therapy
2 1 (focuses on weight management, carb counting, reduced fat) |
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__g of carbs = "1 carbohydrate choice"
how many choices do you get per meal if goal is weight loss what if you want to maintain weight? what if you're very active |
15
2-3 for women, 3-4 for men 3-4 for women, 4-5 for men 4-5 for women, 4-6 for men |
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total fat should be only __% of the calories in a DM diet
fiber rich foods, like __ are encouraged if they choose to drink alcohol, women should limit to __, men to __ |
25-35%
fruits, vegetables, whole grains, legumes 1 drink per day, 2 drinks per day |
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moderate intensity aerobic exercise
vigorous exercise how much of each do you want what kind of resistance training do you need? |
50-70% max heart rate
>70% max heart rate 150 min moderate / week (over 3 days) OR 90 min vigorous / week (over 3 days) 3 sets of 8-10 reps (where you can't do more than that)...3x/week get an EKG first if their risk of coronary event is >10% in 10 years |
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__ most increases insulin sensitivity in an overweight diabetic?
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metformin (more than insulin or sulfonylureas)
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acarbose MOA
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alpha glucosidase inhibitor that delays glucose absorption
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secretagogues
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sulfonylureas
meglitinide d-Phenylalanine |
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secretagogues are useful for insulin __
side effects relative contraindications |
deficiency
hypoglycemia weight gain GI complaints rare skin rxn, photosensitivity renal disease (except repaglinide and nateglinide) |
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sulfonylurea MOA
A1C can decrease by as much as what happens when they stop doing the trick dosing |
Sulfonylureas bind to a sulfonylurea receptors on the β-cells which stimulate insulin secretion or sensitize the β-cells to the presence of glucose
2.3% ADD insulin once daily |
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repaglinide dosing
renal insufficiency? |
before each meal and with bedtime snacks (flexibility to skip a dose if you skip a meal --> prevent hypogycemia)...but have to take several times a day to be effective
okay |
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rapaglinide is a
nateglinide is a which is faster acting |
meglitinide
d-phenylalanine nateglinide/d-phenylalanine |
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types of insulin sensitizers
good for insulin resistance and those with |
biguanides
thiazelidinediones cholesterol issues |
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biguanides example
MOA |
metformin
decrease gluconeogenesis by liver, increase uptake by muscles enhance basal metabolic rate |
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metformin can decrease A1C by __%
most effective dose contraindications side effects |
2% (and decrease fasting glucose by 60)
can stabilize weight, reduce cholesterol levels, reduce MI risk 2000 mg QD (start with 500 at dinner) Cr >1.4-1.5 liver disease pulmonary disease cardiac issues hold before surgery or contrast dye study flatulence, diarrhea, nausea, and a metallic taste. |
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Thiazolidinediones example
MOA side effects contraindications |
rosiglitazone and pioglitazone
insulin sensitizing effect on the peroxisome proliferator-activated nuclear receptors in liver cells, adipose tissue, and muscle weight gain, anemia, edema Class III or IV heart failure (rosiglitazone could give you an MI or kill you) pregnancy LIVER disease (AST >2.5x normal) |
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Alpha-glucosidase inhibitors (e.g. ___) delay disaccharide and complex carbohydrate absorption in the ___
these agents are best for patients with contraindications |
acarbose
miglitol small intestine and allow it to occur instead in the large intestine and colon. elevated 2hr PP, whether due to resistance or deficiency liver disease pregnancy must given with every meal reduces A1C by 0.5-1% if combined with other orals or insulin (if get hypo with the combo, take milk b/c it has not effect on lactose) side effects diarrhea and flatulence must start low and slow can cause elevation of liver enzymes |
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first line oral DM agents
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metformin (esp if obese)
maaaaybe thiazalidinediones use secretagogue if you think they have pancreatic dysfunction |
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__% of patients on monotherapy for DM will eventually require another
what do you do |
50% after 3 years
sensitizer + secretagogue or 2 sensitizers |
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when might you do combination oral agents as first line DM management (ie before MNT trial)
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if A1C is >9
or >8 after MNT is tried |
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with insulin __% should be basal and __% boluses
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50
50 |
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__% of DM2 pts require insulin
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50
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bolus insulin - rapid
bolus insulin - fast acting |
lispro (humalog)
aspart (novalog) regular (humulin R, novolin R) (might be better for people who snack) |
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basal insulin long acting
basal intermediate acting extended intermediate |
glargine (cannot be mixed in syringe with other types)
NPH (humulin L, novolin L) Lente ultralente |
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when do you take rapid acting insulin
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15 minutes before meal
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basic insulin regimens
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rapid acting + NPH (including pen)
regular + NPH (including pen) orals (day) + NPH (night) orals (day) + glargine (night) latter two if high fasting glucose |
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starting dose of glargine
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10 U
can increase 2-5 U every 4-7 days until fasting is <140 |
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starting dose of insulin in basic regimen
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0.3-0.5 U/kg/day
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basic insulin regimens are inflexible and risk
advanced regimens (RAs + NPH or RAs + glargine) require |
hypoglycemia
more injections, more monitoring |
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most patient will ultimately require __ U/kg/day
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1-2
(start with 0.4-0.5 U/kg/day) |
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Insulin dosage should always be adjusted for hypoglycemia first. If all self monitored glucose levels are greater than 200 mg/dL, then the total daily dose of insulin should be increased by ___ U/kg
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0.1
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The target glucose level for rapid-acting insulin is achieved when the 2 hour post meal glucose level is within ___ mg of the pre meal glucose level
Patients can also be taught to administer insulin sliding scales in the event of unexpected high glucose levels. |
20 – 40
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side effects of injected insulin
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lipodystrophy (hypertrophy in men, atrophy in women)...change injection sites
local skin reactions such as itching, redness, discomfort...usually resolve in 6 weeks...try antihistamines allergies - urticaria or anaphylaxis...usually in peeps with PCN allergy or atopic dermatitis...also if uses insulin intermittently...desensitization therapies available |
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new DM medications
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1. exenatide - incretin mimetic agent
mimicking the effects of glucagon-like peptide-1 nausea, vomiting, diarrhea, hypoglycemia in conjunction with metformin and/or sulfonylurea 2. Sitagliptin - dipeptidyl peptidase-4 (DPP-4) inhibitor inhibits incretin breakdown advantage of not really risking hypoglycemia contraindicated in DM1 or renal impairment |
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The major cause of mortality in diabetic patients is
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cardiovascular disease
(also of morbidity and costs) |
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diabetic with BP __ should be on meds + MNT and exercise
BP __ should get lifestyle modification trial for 3 months, and if not target, ACEi or ARB |
>140/90
130-139/80-89 |
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in DM, if ACEi or ARB doesn't reach goal, you can add
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diuretics, beta blocker, calcium channel blocker
should do orthostatics to assess for autonomic dysfunction |
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in hypertension and macroalbuminuria, __ is nephroprotective
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ARB
(for micro, ACEi or ARB) |
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in DM, screen for HLD how often
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every year, or every other year if LDL <100, HDL >50, TG <150
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lipid goals for DM without cardiovascular disease
WITH cardiovascular disease HDL and TG goals for all |
<100 - if over 40, initiate statin to reduce by 30-40% regardless of baseline LDL...if under age 40, consider statin only if they have other risk factors
<70 - and all pts should be on statin to reduce LDL 30-40% regardless of baseline >40M, >50F, <150 fibrates may be a good option...combination therapies may be necessary but have not yet been shown to reduce CV risk |
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when to put diabetic on aspirin
when to add clopidogrel |
1. if have add'l CV risk factors, like age >40, htn, family history, smoking, HLD
or as secondary prevention if history of CVD people <30 yo have not been studied, and <21 is contraindicated 2. if severe and progressive CVD |
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when do you give a diabetic an ACEi
if they had prior MI or are about to undergo surgery, you should add |
if >55, +/- HTN, if they have other risk factors for CVD
beta-blocker to reduce mortality |
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t/f metformin is contraindicated in acute decompensated CHF
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t
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In those with any degree of chronic kidney disease or macroalbuminuria, protein intake should be reduced to recommended daily allowance of ___
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0.8 g / kg.
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for diabetics, you should be screened for microalbuminuria every __, and get creatinine measured every __
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year
year |
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if you use ACEi or ARB or diuretics in diabetic patient, you should check
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serum K
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consider referring diabetic to renal specialist if GFR falls below
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60
(or if management of HTN or hyperkalemia becomes difficult) *P.S. diabetic nephropathy should be reserved for bx proven...the cause of CKD should be fully investigated and not assumed to be diabetic |
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diabetic retinopathy risk can be reduced by
what affect does aspirin have? |
glycemic and HTN control
*aspirin does not affect the retinopathy in any way! |
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women who are diabetic and THEN get pregnant should get eye exam...
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at start of pregnancy and then repeats throughout
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insensitive diabetic feet should be inspected every __ months
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3-6
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neuropathic pain can be managed with
can treat gastroparesis with |
gabapentin, TCAs, NERIs, 5-hydroxytriptamine
metoclopramide |
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risk of amputation or ulcers is greatest in diabetics have had DM >__ years, are __, have poor glucose control, and have other complications of DM
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10
male |
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all diabetics should get a lifetime __ vaccination
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pneumococcal
and then again at 65, and then 5 years therafter |
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top 10 causes of death in US
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1. heart disease
2. cancer 3. stroke 4. COPD 5. accidents 6. diabetes 7. alzheimers 8. influenza/pneumonia 9. nephritis, nephrotic syndrome, nephrosis 10. septicemia 11. suicide |
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causes of death in 35-44 cohort
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1. accidents***
2. cancer 3. heart diseases 4. suicide*** 5. HIV/AIDS*** 6. assault/homicide*** 7. cirrhosis*** 8. cerebrovascular disease 9. diabetes 10. flu/pneumonia heart, cancer, and diabetes are common to this group and older cohort |
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causes of death in 65+ cohort
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1. heart diseases
2. cancer 3. stroke 4. COPD 5. alzheimer's 6. diabetes 7. flu/pneumonia 8. kidney stuff 9. accidents 10. septicemia COPD, renal, alzheimer's, and septicemia are not really prevalent in younger group |
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causes of death for men of all ages
women |
1. heart disease
2. cancer 3. accidents*** 4. stroke 5. COPD 6. diabetes 7. flu/pneumonia 8. suicide*** 9. kidney 10. alzhemer's 1. heart disease 2. cancer 3. stroke 4. COPD 5. alzheimer's*** 6. accidents 7. diabetes 8. flu/pneumonia 9. nephritis 10. septicemia |
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in blacks, homicide is #__ cause of death. AIDS is #__
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6
9 diabetes is higher, flu/pneumonia and alzheimer's aren't in the top 10 |
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in latino's, the #__ cause of death is cirrhosis
the #__ is homicide |
6
7 *hispanic as an ethnicity should be interpreted with caution...very heterogenous group |
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in native americans, the #_ cause of death is cirrhosis
#__ is suicide |
6
8 |
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in asians, the #__ cause of death is alzheimer's
__# is suicide |
10
8 |
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infant mortality is highest in this race
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blacks
(low utilization of preventive care) |
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the vast majority of leading causes of death are __
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preventable
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__% of americans live with at least 1 chronic condition
__% of all deaths are attributed to a chronic disease medical care costs of people with chronic diseases account for more than __% of the $2 trillion dollars Americans spend each year on medical care costs |
almost 50%
70% 75% |
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__% of our GDP is spent on health care
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16%
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$__ billion is spent on CVD
$__ billion in direct costs related to physical inactivity $__ are direct and indirect costs of smoking heart disease and stroke? cancer obesity hospitalizations for pregnancy related complications before delivery diabetes |
300
75 75 448 billion 89 billion 117 billion 1 billion 174 billion |
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Nearly __% of Medicare expenditures are spent on interventions during the final year of life
only __% of expenditures is on prevention |
25%
2-3% |
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A mammogram every 2 years for women aged 50–69 costs only about $9,000 per year of life saved
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$9,000
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For each $1 spent on school-based HIV, other STD, and pregnancy prevention programs, about $__ is saved on medical and social costs
Every $1 spent on preconception care programs for women with diabetes can reduce health costs by up to $__ by preventing expensive complications in both mothers and babies For each $1 spent on water fluoridation, $__ is saved in dental restorative treatment costs. |
$2.65
$5.19 $38 |
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The most cost-effective of all clinical preventive services is smoking cessation. Implementing proven clinical smoking cessation interventions would cost an estimated $___ for each year of life saved. Physician counseling is a low cost activity that saves billions of dollars in health care costs.
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2,587
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Public health efforts in the early part of the 20th century resulted in a reduced death rate of __% for typhoid and diphtheria; __% for infectious diarrhea, and __% for whooping cough and measles
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97
92 91 Modern examples include cigarette taxes, anti-smoking laws in public areas, and banning the use of trans-fats in cooking food. |
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aspirin does not prevent strokes in __
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men
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aspirin does not prevent CAD events in __
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women
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WHO principles of screening
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The condition should be an important health problem.
There should be a treatment for the condition. Facilities for diagnosis and treatment should be available. There should be a latent (asx) stage of the disease. There should be a test or examination for the condition. The test should be acceptable to the population. The natural history of the disease should be adequately understood. There should be an agreed policy on whom to treat. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. Case-finding should be a continuous process, not just a "once and for all" project, in step with the natural history and prevalence of disease, and needs of the population. screening test should also have a high sensitivity |
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when not to screen:
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The service benefits no or very few people in the target population
The service has no or little effect in the target population The condition has low prevalence in the target population The screening is “unfocused” (ordering a “Chem 12” rather than just a “Basic Metabolic Panel” may pick up more abnormalities that may not be medically significant). The service causes net harm in the target population. There is uncertain balance of benefits and harms. |
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genetics of hereditary hemochromatosis
should you screen asx individuals? |
C282Y homozygote at the HFE locus
no - early detection offers no benefit over clinically-detected people |
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USPSTF recommends breast cancer screening at age ___, then every __ years
insufficient evidence to assess risks vs benefits after age __ |
50 (grade B)
2 (grade C) 75 (grade I) also insufficient evidence about whether MRI and digital mammography are better |
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behavior change falls into 3 categories
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Reduction or elimination of destructive behaviors (e.g., smoking)
Promotion of healthier lifestyles (e.g., healthier food choices) Adherence to medical regimens (e.g., taking medications as directed) |
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stages of behavioral change
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1. pre-contemplative
2. contemplative 3. preparation/determination 4. action 5. maintenance 6. relapse |
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For optimal comprehension and compliance, patient education material should be written at a __ or lower reading level, preferably including pictures and illustrations.
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6th grade
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5 A's of smoking cessation
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1. ask
2. advise 3. assess 4. assist 5. arrange |
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how do you assist patient in quitting smoking
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Set a quit date.
Request encouragement from family and friends. Anticipate triggers and cues to smoking. (should follow up within a week of set quit date, then a month) Suggest changes to the environment (i.e., throw away cigarettes, lighters, and ashtrays; vacuum car and home; avoid other smokers and alcohol). |
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nicotine gum increases chance of success by
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2x
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chantix is __
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varenicline
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screening for intimate partner violence is much more effective...
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if a person asks (rather than a form...7% vs 30%)
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The number of new cases of a target disorder in the average population identified during a specified time period
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incidence
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The total number of cases of the target disorder in the population at a given time (including new and previously diagnosed cases). Usually expressed as a percentage of the population
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prevalence
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technically, life expectancy means
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the expected time remaining to live
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1 QALY =
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one year of perfect health-life expectancy
(if the health is less than perfect for that year, that is <1 QALY) |
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specificity
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true negative / (false positive + true negative)
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positive predictive value
negative predictive value |
true positive / (true positive + false positive)
true negative / (true negative + false negative) |
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A test is __ if it is consistent within itself and across time
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reliable
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___ refers to the degree to which the test actually measures what it claims to measure
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validity
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pretest probability =
|
prevalence
(increases the PPV of a test) |
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posttest probability of a positive test
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Number of people with disease / Number of people with a positive test
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posttest probability of a negative test
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Number of people with disease / Number of people with a negative test
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how to calculate number needed to treat
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inverse of absolute risk reduction
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calculate relative risk reduction
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(experimental event rate - control event rate) / control event rate
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calculate relative risk
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experimental event rate / control event rate
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odds ratio is used in RCT or retrospective case-control
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retrospective case-control
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NNT will __ as either the likelihood of the outcome increases or as the benefit of treatment increases
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decrease
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4 questions to ask when looking at a paper about screening
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Is there randomized control trial evidence that early diagnosis really leads to improved survival or quality of life or both?
Are the early diagnosed patients willing partners in the treatment strategy? How do benefits and harms compare in different people and with different screening strategies? Do the frequency and severity of the target disorder warrant the degree of effort and expenditure? |
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grade A recommendation
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high certainty that net benefit is substantial
offer it! |
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grade B recommendation
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high certainty that net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
offer it! |
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grade C recommendation
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The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.
only offer if other considerations for that patient support |
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grade D recommendation
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The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
discourages the use of the service |
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grade I recommendation
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The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
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recommend screening for Chlamydia infection for all sexually active non-pregnant young women aged __ and younger and for older non-pregnant women who are at increased risk (Grade A)
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24
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Among men and women, increased prevalence rates for ___ are also found in incarcerated populations, military recruits, and patients at public sexually transmitted infection clinics
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chlamydia
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grade __ evidence for routine counseling of all patients in the primary care setting to reduce driving while under the influence of alcohol or riding with drivers who are alcohol-impaired
|
I
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grade __ evidence for routine serological screening for HSV in asymptomatic adolescents and adults
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D
(recommend against it) |
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grade __ evidence for behavioral counseling in primary care settings to promote physical activity
|
I
(variable quality of counseling) |
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screening recommendations can come from 4 different bodies that you should be aware of
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1. specialty centered
2. disease centered 3. payer centered 4. prevention centered* *least biased |
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CTF (___) is convened by
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community task force
CDC assess prevention strategies targeted at the community and population level. Interventions that are considered include environmental improvements, health policy, education, service delivery and system improvements. The recommendations can be implemented in schools, work places, or an entire community. |
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principles of community oriented primary care
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Define the community – Identify the targeted population by collecting relevant demographic, historical, political, cultural, and economic data. Although there are several limitations to the data, some of this information may come from the U.S. Census Bureau – or from local or state agencies.
Identify the health problem – Identify the health needs of the target population. This is done by reviewing local and national databases for socioeconomic, demographic, and morbidity and mortality rates. Health issues in the target population that are out of proportion to the national distribution should be benchmarked. One example of this data is the New York Department of Health’s “My Community’s Health” website. Prioritize health needs - Conduct neighborhood surveys and focus groups to allow the community to participate in the “community diagnosis” and which health issues need prioritizing. Implement appropriate interventions to address the health needs – Involve community members in implementing the intervention. This may involve training community members in specific skills such as health educators or the formation of partnerships with existing community agencies and resources (e.g., Alianza Dominicana in Washington Heights, Asociacion Tepayac in Manhattan, Native American Tribal Councils at the Indian Health Service sites, etc.). Interventions can be healthy school menus, worksite injury prevention programs, or recreational park clean-up efforts. Evaluate the impact of intervention(s) – Maintain ongoing surveillance, evaluation, and assessment of the outcomes of the COPC program. Modify future intervention(s) based upon evaluation and reassess outcomes. **community involvement and participation are essential |
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African Americans, Native Americans, Latinos, and Asian Americans have higher incidence of chronic diseases, higher morbidity and mortality rates, and inferior health outcomes as compared to whites
what are some reasons for disparity |
rovider – patient communication issues (language, culture, health literacy barriers)
Conscious or unconscious provider discrimination Institutional racism Individual and community mistrust of the medical establishment Lack of financial resources Health insurance issues: no health insurance or underinsurance (insurance with high deductibles or co-pays or lacking in coverage breadth) Lack of regular source of care Legal obstacles (for example, undocumented persons barred from health benefits or entitlements) Structural or system obstacles (unable to secure transportation or prolonged periods in the waiting room) Fractured health care delivery system and financing Scarcity of health providers especially primary care physicians Lack of a diverse health care force (one that is reflective of the diversity of the American public) Disadvantaged populations are less represented in political arenas and have less health advocacy |
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|
__% of the uninsured were employed uninsured and were members of families with at least one working adult
|
83
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|
insured get __% more hospital services than uninsured
|
90
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|
there are __er rates of smoking, alcohol, and drug use in LGBT populations than in their heterosexual counterparts
|
higher
|
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vulnerable populations (demographic, geographic, or economic characteristics place them at a health disadvantage)
|
elderly, disabled, homeless, and immigrant population
|
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reasons why primary care increase leads to health increase
|
Greater access to needed services
Better quality of care A greater focus on prevention Early management of health problems Cumulative effect of the main primary care delivery characteristics Role of primary care in reducing unnecessary and potentially harmful specialist care |
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Patients with HIV, renal disease, and asplenia need a second PPV vaccination after
|
5 years.
|
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screening for AAA
|
male
>65 smoked >100 cigarettes in life |
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grade _ recommendation for screening for oral cancer
|
I
|
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recommendations for screening for asx carotid dz
screening for COPD with spirometry |
D (against)
D (against) |
|
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risk factors for LDL disease (cardiovascular risk factors)
|
smoking
HTN >140/90 low HDL (<40) family hx of premature CHD (M<55, women <65) men >45, women >55 *note: HDL >60 counts as a negative risk factor |
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Elevated ___ is the major cause of coronary heart disease
|
LDL cholesterol
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According to ATP III, in all adults age __ or older, a ___ hour fasting lipoprotein profile (total cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and triglyceride (TG) should be performed once every __ years
The USPSTF strongly recommends screening men aged __ and older for lipid disorders. The USPSTF recommends screening men aged __ for lipid disorders if they are at increased risk for coronary heart disease. The USPSTF strongly recommends screening women aged __ and older for lipid disorders if they are at increased risk for coronary heart disease. The USPSTF recommends screening women aged ___ for lipid disorders if they are at increased risk for coronary heart disease. their recommended screening interval is... |
20
9-12 5 35 20-35 45 20-45 probably every 5 years, shorter if at risk, longer if not at risk and consistently normal |
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LDL optimal level
near optimal borderline high high very high |
<100
100-129 130-159 160-189 >190 |
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desirable total cholesterol
borderline high high |
<200
200-239 >240 |
|
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low HDL
high HDL |
<40
>60 |
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CAD equivalents
|
DM
AAA PAD sx carotid artery dz framingham >20 |
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if CHD risk factors are 2+, you must then stratify risk by
|
Framingham score...
<10 10-20 >20% (CHD equivalent) the risk is risk of developing CAD or event in 10 years |
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LDL goal if CHD or equivalent
when do you initiate lifestyle changes level at which to consider drug therapy |
<100
>100 >130 (drug optional at 100-130) |
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LDL goal if 2+ RFs but <20% risk
when to initiate lifestyle therapy (3 month trial) when to consider drug therapy |
<130
>130 >130 if risk is 10-20% >160 if risk is <10% |
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LDL goal if 0-1 RFs
when to initiate lifestyle therapy (3 month trial) when to consider drug therapy |
<160
>160 >190 |
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what is the lifestyle change for LDL lowering
|
saturated fats <7% of calories
cholesterol <200 mg/day polyunsaturated up to 10% monounsaturated up to 20% of calories consider increased soluble fiber and plant sterols weight loss exercise |
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statins can lower LDL by __%
(can also affect...) side effects absolute contraindications avoid... proven effects |
55%
(can also raise HDL 5-15% and lower TGs 30%) myopathy increased LFTs active or chronic liver disease mixing with grapefruit juice Reduced major coronary events, CHD deaths, need for coronary procedures, stroke, and total mortality |
|
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bile acid sequestrants can lower LDL...can also change...
side effects e.g. contraindications proven effects |
up to 30%
increase HDL a little bit TG - no change or increase! GI distress decreased absorption of other drugs cholestyramine TG>400 reduced coronary events, CHD deaths |
|
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nicotinic acid can lower LDL...can also change...
side effects contraindications proven effects |
up to 25%
increase HDL up to 35%! lower TGs up to 50%! flushing hyperglycemia gout upper GI distress hepatotoxicity absolute: chronic liver disease, severe gout relative: diabetes, PUD reduced coronary events, possibility reduced mortality |
|
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fibrates can lower LDL
side effects contraindications proven effects |
20% (or may increase them if high TG)
can incr HDL 20% can lower TG 50% dyspepsia gallstones myopathy unexplained CHD deaths severe renal disease severe liver disease reduced coronary events |
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Ezetimibe...what is it
NEJM found that... |
lipid-lowering drug that selectively inhibits intestinal absorption of cholesterol...used in conjunction with statin or used alone if statin is not tolerated
interestingly, NEJM found that it didn't change intima media thickness in familial hypercholesterolemia |
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what about omega 3s for CHD risk
|
can reduce risk for major coronary events in persons with established CHD (secondary prevention)
|
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how do you progress therapy for LDL lowering
|
first is lifestyle
then first line drug is low-dose statin increase statin or add another agent (though there is insufficient evidence that these are better than statin alone at reducing LDL or events) |
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___ed soluble fiber in the diet is part of the recommendations.
|
increased
|
|
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t/f: The total fat consumed is a primary target for TLC
|
no
A diet low in saturated fat, transfatty acids, and cholesterol and that contains soy protein and plant sterols/stanols can be just as effective as a statin at decreasing serum total cholesterol and LDL levels |
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T/F: A diet low in saturated fat, transfatty acids, and cholesterol and that contains soy protein and plant sterols/stanols can be just as effective as a statin at decreasing serum total cholesterol and LDL levels
|
t
|
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Substitution of low-fiber carbohydrates for saturated fatty acids can __ HDL and ___ triglycerides
|
decrease
increase |
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For every 1% increase in calories from saturated fatty acids as a percent of total energy, serum LDL rises about __
|
2%
|
|
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Substitution of low-fiber carbohydrates for saturated fatty acids can __ HDL and ___ triglycerides
|
decrease
increase |
|
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For every 1% increase in calories from saturated fatty acids as a percent of total energy, serum LDL rises about __
|
2%
|
|
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in patients with CAD or equivalent do you do TLC for 3 months and then try drugs?
|
no, you should try drugs and TLC simultaneously
for all other risk categories, try 3 months of TLC alone first |
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how do you diagnose HTN
|
at least two elevated measurements, one in each arm, should be made on 2 or more visits
patient should not be acutely ill |
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why do you check HTN in both arms
|
rule out coarctation of the aorta??
or other aorta anomaly |
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in coarctation of the aorta, BP would be high in __ arm and low in __ arm
|
right
left ??? |
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USPSTF recommends high blood pressure screening in health individuals should begin at age __ and older
JNC 7 recommends screening every __ in persons with blood pressure less than 120/80 mm Hg and every __ with systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 90 mm Hg. |
18
2 years year |
|
|
proper BP measurement
If the cuff is too small, the blood pressure reading may be erroneously __ |
seated quietly for 5 minutes
in a CHAIR (not exam table) feet on floor arm supported at heart level bladder of cuff should wrap around 80% of arm high in order to diagnose HTN you have to have a measurement in each arm on 2 separate visits (4 measurements) |
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|
HTN prevalence in US
normotensive people have a __% chance of developing HTN over lifetime |
50 million
90% |
|
|
the relationship of BP to __ is continuous, consistent, and independent
|
CVD
|
|
|
t/f: the greater the BP, the higher the risk of MI, CHF, renal disease, stroke
|
T
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|
|
the most common primary diagnosis in america
|
HTN
|
|
|
JNC 7 recommendations are regarding
|
BP
|
|
|
evaluation of pt with HTN has 3 objectives
|
To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affects prognosis and guides treatment.
To reveal identifiable causes of high blood pressure (secondary hypertension) To assess the presence or absence of target organ damage and cardiovascular disease. |
|
|
focused history for HTN as per JNC7proper initial physical examination for a patient with new hypertension as per JNC 7
|
1. already have HTN? duration? (>10 yrs likely to have end organ damage)
2. PVD? (end organ damage) 3. CHF sx? (end organ damage) 4. Diabetes? (metabolic syndrome) 5. CVD? (end organ damage) 6. renal disease? (end organ damage) 7. cholesterol issues? (metabolic syndrome) 8. FHx of premature MI or stroke (M<55, F<65...8x higher risk of CVD or death) 9. FHx of diabetes (risk of diabetes) 10. FHx of cholesterol 11. Meds (OTCs, amphetamines, thyroid meds, steroids, certain anti-depressants, pseudoephedrine, NSAIDs, herbals, appetite suppressants may elevate BP) 12. alcohol and drug history (alcohol >2 drinks men >1 drink women, cocaine, ketamine) 13. diet history 14. psychosocial stressors (stress releases angiotensin II and norepi, also makes adherence more difficult) |
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|
what meds may elevate BP
|
OCPs, amphetamines, thyroid meds, steroids, pseudoephedrine, appetite suppressants, NSAIDs, herbals
also alcohol, cocaine, ketamine |
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|
proper initial physical examination for a patient with new hypertension as per JNC 7
|
1. BP in each arm 2 min apart
2. BMI 3. fundoscopic exam 4. carotid bruits? 5. thyroid? 6. auscultate heart 7. check PMI 8. abdominal bruits? 9. assess peripheral veins (diabetes, PVD) 10. LE edema 11. neuro exam (get a baseline) |
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|
stage II HTN
|
systolic >160
OR diastolic >100 (change in JNC7 was designation of pre-hypertension to identify those individuals in whom early intervention by adoption of healthy lifestyles could reduce BP, decrease the rate of progression of BP to hypertensive levels with age, or prevent hypertension entirely...also stage 2 HTN and stage 3 HTN were combined b/c they're managed similarly) |
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|
labs/diagnostics for new dx HTN
|
-EKG
-UA (proteinuria = end organ damage, glucosuria = undx diabetes) -blood glucose -hematocrit (anemia makes MI/stroke more likely, underlying cause must be found and addressed) -serum K (baseline before meds, and to r/o cushings, hyperaldo) -serum Cr (end organ damage, also as baseline before meds) -serum Ca (One-third of patients with hyperparathyroidism and hypertension can be attributed to renal parenchymal damage due to nephrolithiasis. Increased calcium levels can also have a direct vasoconstrictive effect) -fasting lipid panel -urinary albumin excretion or albumin/creatinine ratio (OPTIONAL) |
|
|
identifiable causes of secondary HTN
|
-OSA
-drug-induced or related causes -CKD -primary aldosteronism -renovascular disease -steroid therapy, cushing's syndrome -pheochromocytoma -coarctation -thyroid or parathyroid disease |
|
|
essential hypertension, which makes up ___ of the hypertension in the United States
|
95 – 99%
|
|
|
Hypertensive Emergency
malignant hypertension Hypertensive Urgency |
marked hypertension with evidence of end-organ damage that requires immediate blood pressure control
marked hypertension with papilledema, retinal hemorrhages or exudates and is considered a subset of a hypertensive emergency marked hypertension that requires blood pressure control within hours but without evidence of end-organ damage. |
|
|
pre-hypertension tx
|
lifestyle modifications
(drugs if compelling indications like CKD, or diabetes for goal <130/80) |
|
|
stage 1 HTN tx
|
thiazide diuretics for most (might add another from below if not optimal)
may consider ACEi, ARB, BB, CCB or combination (plus lifestyle modifications) |
|
|
stage 2 HTN tx
|
2 drug combo for most
usually thiazide + ACEi/ARB/BB/CCB combo pill like HCTZ-atenolol or HCTZ-lisinopril is a nice option (plus lifestyle modifications) (be careful if their at risk for orthostatic hypotension...elderly, diabetics, paraplegics; also, if there is a side effect you won't know which it's from if they start at the same time) |
|
|
why are lifestyle modifications important for HTN
|
Reduce blood pressure
Enhance anti-hypertensive drug efficacy Decrease cardiovascular risks |
|
|
how much can each of the following drop your blood pressure:
a. weight loss b. DASH eating plan (fruits, vegetables, lowfat dairy, reduced saturated and total fat) c. dietary sodium reduction (no more than 2.4 g Na or 6 g NaCl) d. physical activity e. moderation of alcohol consumption |
a. 5-20 / 10 kg
b. 8-14 c. 2-8 d. 4-9 e. 2-4 |
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|
why are thiazides preferred?
|
1. shown to have best reduction in morbidity and mortality wrt HTN
2. known benefits and side effect profiles with 70+ years of data 3. quite inexpensive ($5 for a month) |
|
|
"Compelling Indications" for Individual Drug Classes for HTN:
1. CHF 2. MI 3. high CAD risk 4. diabetes 5. CKD 6. recurrent stroke |
1. thiaz, BB, ACEI/ARB, ALDO ANT (should not be titrated high)
2. BB, ACEI, ALDO ANT 3. thiaz, BB, ACE, CCB 4. thiaz, BB, ACE, ARB, CCB 5. ACEi, ARB 6. thiaz, ACEi |
|
|
T/F: Beta blockers in diabetics mask hypoglycemia
|
F
|
|
|
dosing HTN meds
|
start at starting dose
titrate up until you achieve control or maximum dose of the drug if maxed out on one drug, start at starting dose another and titrate up prn (most patients will require two or more meds) |
|
|
what determines maximum dose of anti-HTN med
|
a) manufacturer or FDA regulations
b) dose at which patient has side effects c) dose at which patient prefers not to take it **must document in notes why a given dose was max for them |
|
|
nicotine __es BP and ...
|
increases
reduce the efficacy of anti-hypertensives |
|
|
after starting drug therapy for HTN, you should see them again q__
serum K and Cr should be monitored __x per year after BP is stable, follow up q__ |
month (until BP goal is reached)
*more frequently if stage 2 or complicated pt 1-2 3-6 months *consider periodically rechecking cholesterol, glucose |
|
|
thiazide diuretics:
May be a problem in __ patients Studies have shown that doses above __mg a day of HCTZ (hydrochlorothiazide) does not decrease BP or morbidity and mortality watch levels of __ avoid in __ patients may slow __ in osteoporosis start at lower doses in elderly who may be very sensitive |
urine incontinent (or elderly who may become that)
25 Na (hyponatremia) gout demineralization |
|
|
loop diuretics:
monitor electrolytes and __ start at lower doses in the elderly |
Cr
|
|
|
beta blockers:
check initial ___ you don’t have to avoid in ___ excellent for use in (4) usually avoided in patients with __ and 3rd degree heart block |
EKG and pulse
diabetic patients tachyarrhythmias / fibrillation, migraines, essential tremor, and perioperative hypertension asthma |
|
|
this anti-hypertensive is avoided in patients with 3rd degree heart block
|
BB
|
|
|
ACEi:
monitor ___, ___, and ___ great for renal protection...reduces ___...first line in diabetes and renal disease shown to have direct ___ remodeling effects a rise of up to __ above baseline in creatinine is acceptable ACE inhibitor cough is common in 15 – 20% of patients due to __ production __ is a serious side effect to monitor in patients avoid in pregnant women as they are Category _ drugs |
potassium (hyperkalemia)
sodium (hyponatremia) elevated creatinine levels microalbuminuria heart 35% bradykinin angioedema C |
|
|
ARBs:
reduces ___ shown to have ___ remodeling effects avoid in pregnant patients as they are Category __ drugs less ___ production |
microalbuminuria and macroalbuminuria
heart C bradykinin |
|
|
CCBs:
may be useful in ___ often causes __ side effect (15-30% depending on different studies) short acting calcium channel blockers are contraindicated for use in essential hypertension and ___ |
Raynaud's syndrome
certaing arrhythmias leg edema hypertensive urgencies or emergencies |
|
|
aldosterone antagonists:
may cause __ low dose aldosterone antagonists reduce morbidity and mortality in __ patients but increase __ at higher doses |
hyperkalemia
(avoid in patients with K ≥ 5 prior to starting meds) CHF sudden death |
|
|
__ class of drugs:
*no proven decrease in morbidity and mortality demonstrated in research studies *not mentioned in JNC 7 algorithm for treatment of essential hypertension *only useful as adjunct in hard to control blood pressure |
alpha blockers
(may be useful in prostatism but should not be used as a first line anti-hypertensive in patients with BPH) |
|
|
JNC7 definition of resistant HTN
causes of apparent resistant htn |
failure to reach goal blood pressure in patients who are adhering to full doses of an approximate three drug regimen that includes a diuretic
-improper BP measurement -excess sodium intake -inadequate diuretic therapy -inadequate doses of meds -herbals, OTC remedies -drug interactions -excess alcohol -secondary HTN |
|
|
do you refer a pt with resistant htn to a specialist?
|
well, should see if the cause is something like salty diet which would be better served by nutrition counseling
some PCPs try a 4th antihypertensive before referring to specialist might send to specialist if you're seeing end organ damage like CHF or nephropathy |
|
|
why are women a special population in htn
what if they're reproductive age? what do you do if they're on OCP? |
under researched
less likely to know they have htn less medically treated less under control no ACEi/ARB trial of d/c OCP and see if HTN goes away |
|
|
women on OCPs should have their blood pressure assessed every __
|
6 months
|
|
|
BP control rates are lowest in __.
Prevalence, severity, and impact of hypertension is increased in ___ |
mexicans and natives
African Americans |
|
|
___ are 2 - 4 x more likely to develop angioedema from ACE Inhibitors than other groups
|
African Americans
|
|
|
African Americans demonstrate somewhat reduced BP responses to monotherapy with __ compared to ___
|
BBs, ACE inhibitors/ARBs
diuretics or CCBs (These differences are usually eliminated by adding adequate doses of a diuretic) (Furthermore, BB, ACE inhibitors, and ARBS still reduce morbidity and mortality from hypertension in African Americans (renal protection, cardio-protection) separately from the BP levels) |
|
|
T/F: An elderly person starts at lower doses but ends up on as much blood pressure medication as a younger person to control their hypertension.
|
T
|
|
|
__% of those over 65 have HTN
|
2/3
(and they have the lowest rates of control) |
|
|
T/F the majority of patients with HTN will require 2+ drugs
|
T
|
|
|
____ is one of the most common conditions seen by primary care physicians second only to ____
|
Depression
hypertension |
|
|
point prevalence of depression in the outpatient primary care setting is between ___, and the point prevalence in the inpatient setting is __. Large scale studies have suggested that __ of men will suffer an episode of major depression at one point in their lives, while the percentage for women is more on the order of ___
|
5-9%
15% 7 – 12% 20-25% |
|
|
Over __ the people who experience an episode of major depression are at risk for a relapse and recurrence
peak onset |
half
20-30 |
|
|
In one study, __% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint
|
69
Unlike patients with depression in psychiatric inpatient or outpatient care settings, persons suffering from depression in primary care settings often present as “undifferentiated” patients. |
|
|
__ percent of patients with severe mood disorders die from suicide. In one study among older patients who committed suicide, __ visited their primary care physician on the same day as their suicide
|
15%
20% |
|
|
T/F: Depressed patients have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide
|
T
|
|
|
Deficiencies in ___ have all been hypothesized as contributing to depression. Over activity in other neurotransmitters including ___ (with lack of diurnal variation) has also been proposed to contribute to depression.
|
serotonin, norepinephrine, dopamine, GABA, and peptide neurotransmitters (somastatin, thyroid-related hormones, and brain derived neurotrophic factors)
substance P, and acetylcholine, and elevated serum cortisol |
|
|
The first degree relatives of a patient with recurrent major depression have a __ times higher risk of depression themselves as compared to the general population
|
1.5-3
|
|
|
First degree relatives of patients with bipolar disorder have an estimated __% lifetime prevalence of bipolar disorder, which is __ times higher than the general population
|
12
10 |
|
|
__% of children with one parent with a mood disorder will develop a mood disorder themselves, and that increases to __% if both parents are affected
|
27%
50-75% |
|
|
The higher the number of somatic complaints that a patient has, the higher the risk that they may have a
|
mood disorder
The higher the number of somatic complaints that a patient has, the higher the risk that they may have a mood disorder |
|
|
when to think about screening for depression
|
Personal previous history of depression or bipolar disorder
First-degree biologic relative with history of depression or bipolar disorders Patients with chronic diseases Obesity Chronic pain (e.g., backache, headache) Impoverished home environment Financial strain Experiencing major life changes Pregnant or postpartum Socially isolated Multiple vague and unexplained symptoms (e.g., gastrointestinal, cardiovascular, neurological) Fatigue or sleep disturbance Substance abuse (e.g., alcohol or drugs) Loss of interest in sexual activity Elderly age |
|
|
Several studies suggest that in primary care settings, lack of improvement in depression is more related to ___, not
|
inadequate treatment
insufficient case identification |
|
|
The United States Preventive Services Task Force recommends “screening adults for depression in
does the USPSTF recommend one screening test over another |
clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up
no |
|
|
Recurrent depression screening these patients may be the most useful
|
a history of depression,
unexplained somatic symptoms, substance abuse, chronic pain, or co-morbid psychological conditions |
|
|
PHQ-2 depression screen questions
|
"Over the past 2 weeks, have you been bothered by...
-feeling down, depressed, or hopeless -little interest or pleasure in doing things" If either of those is "yes", do a PHQ-9 (score >10 has sensitivity and specificity >88% and |
|
|
pts with melancholic depression must have 3 of the following sx
|
1. diurnal variation (depressive symptoms worse in the morning)
2. pervasive and irremedial depressed mood 3. significant weight loss or anorexia 4. psychomotor agitation or retardation 5. excessive or inappropriate guilt 6. early morning awakening |
|
|
Depressed patients that have psychotic features such as hallucinations and delusions are at very high risk for ...
|
suicide (even if they deny SI)
|
|
|
depression with atypical features has to have at least 2 of:
this type of depression responds less to... |
1. hypersomnia
2. leaden paralysis 3. overeating or weight gain 4. rejection hypersensitivity (even when they are not acutely depressed TCAs |
|
|
what is "mild to moderate depression"
|
no set criteria, but probably:
2-4 of the SIGECAPS for most day over 2 weeks (or 5-9 on PHQ9 scale) |
|
|
medical conditions that can cause depression
|
cancer (brain, pancreatic)
stroke heart disease (MI, HF) endocrine disorders (thyroid, diabetes) neurological diseases (dementia, MS, epilepsy) gastrointestinal diseases (IBD, IBS, cirrhosis) rheumatologic diseases (lupus, RA) severe anemia sleep apnea infectious (syphilis, HIV, hepatitis) Cushing's pulmonary This depression is independent of the psychological impact of the stress of the illness, and is patho-physiologically related to the underlying condition. |
|
|
T/F: The presence of a chronic medical illness alone is the most prevalent risk factor for developing depression.
|
F
|
|
|
prescription meds that can cause depression
|
reserpine, propanolol
anticholinergics steroids oral contraceptives psychotropic medications antineoplastic drugs |
|
|
T/F: dysthymic disorder is less responsive to pharmacotherapy
|
T
more chronic and unremitting |
|
|
in children and adolescents, dysthymic disorder requires dura
|
1 year
|
|
|
for dysthymic, you must be depressed for 2 years (with no more than a __ break) plus have
|
2 month
2 of the following: eating disturbance sleep disturbance poor concentration hopelessness low self-esteem low energy |
|
|
bereavement shouldn't last more than
pathologic symptoms |
2 months
Pathologic symptoms include thoughts of death beyond the wish to be with the lost loved one excessive guilt an overwhelming new sense of worthlessness severe psychomotor retardation hallucinations (other than transiently hearing the voice or seeing the image of the loved one) the inability to perform usual tasks and obligations |
|
|
tx for seasonal affective d/o
|
psychotherapy
antidepressants lights |
|
|
adjustment disorder dx (specifically, timeline)
tx |
depressed mood is diagnosed when the patient has depressive symptoms or complaints within **3 months** of an identifiable psychosocial stressor...The stressor causes depressed symptoms that do not meet the criteria for major depression or dysthymic disorder
psychotherapy (rather than drugs) |
|
|
risk of SSRI's in 3rd trimester
usually lasts no longer than |
"poor neonatal adaptation" -- irritability, tachypnea, hypoglycemia, thermal instability, and a week or absent cry but is usually mild and transient
2 weeks (occurs in 2/1000) |
|
|
agents of choice for depression in pregnancy
which to watch out for |
SSRI (fluoxetine) or TCA
paroxetine can cause cardiac malformations (risk increases as you go along with pregnancy) the mood stabilizers valproate, dilantin, carbamazepine are teratogenic -first line should be psychotherapy, unless they have h/o of MDD, bipolar, SA, psychotic disorders should probably continue their meds |
|
|
The risk-benefit decision about whether to start antidepressants in a breastfeeding woman is based on
|
the severity of the depression and the need for pharmacotherapy, rather than any known risks to the infant.
|
|
|
post partum depression typically occurs within
|
1 month
|
|
|
baby blues can begin __ and is usually over by __
|
24 hours of delivery
10 days |
|
|
Risk factors for depression in elderly persons include a history of depression, chronic medical illness, ___ sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events
|
female
|
|
|
Patients who are elderly when their first depressive episode occurs have a relatively __ likelihood of developing recurring chronic depression
|
high
|
|
|
The long term prognosis for the elderly suffering from depression
|
good with tx
|
|
|
elderly pt with insomnia, anorexia, and fatigue
|
may need SSRI
(pseudodementia may also be mistaken for dementia) |
|
|
potential difference between pseudodementia and dementia
|
patients suffering from pseudodementia will exhibit profound concern about their impaired cognitive function, in contrast with patients with a diagnosis of dementia, who may tend to minimize their disability
|
|
|
pts with pseudodementia may need pharmacotherapy plus...
|
ECT
|
|
|
in pseudodementia, agnosia, dysphasia, apraxia are usually
|
absent
|
|
|
in pseudodementia vs dementia, which will say "Don't know" vs near answers
|
pseudodementia = don't know
|
|
|
minimum duration of manic episode
must also have |
1 week
3 of the following: distractibility increased goal-directed activity grandiosity flight of ideas activities that are risky sleep disturbances talks fast *cause severe impairment or hospitalization, or have psychotic features |
|
|
hypomanic episode must last at least
|
4 days
no psychotic features |
|
|
what to do for a patient with SI and a plan
|
emergency room!
|
|
|
for a patient with SI, should you Emphasize that suicidal feelings worsen with stress, but is a treatable condition?
should you highlight that suicide causes family members and friends great pain that lasts for years? |
yes
yes |
|
|
which is more lethal in overdose, SSRI or TCAs?
|
TCAs
|
|
|
only antidepressant found to be effective in children and adolescents
|
fluoxetine
escitalopram can also be used in adolescents |
|
|
do antidepressants make patients more suicidal?
|
no evidence
though it may give them more energy to act The average risk of suicide in general was 4% with antidepressants and 2% on placebo |
|
|
how to assess the safety of a depressed patient
|
Presence of suicidal or homicidal ideation or plans
Access to a means for suicide and the lethality of the means (e.g. access to handguns) Presence of psychotic symptoms (e.g. command hallucinations or delusions) Severe anxiety Concurrent alcohol or substance use History of previous attempts Family history of suicide Recent exposure to another person who committed suicide |
|
|
depression requiring psych referral
|
mania
suicidal psychotic chronic recurrent refractory can't take care of self need for ECT cardiac disease that requires TCAs |
|
|
benefits of anti-depressants may take how long
|
2-4 weeks
Emphasize the need to seek early treatment and intervention if symptoms arise to prevent a full-blown exacerbatio |
|
|
depression tx has 3 phases:
what is the tx? |
1. Acute phase: remission is induced (min 6-8 weeks)
2. Continuation phase: remission is preserved and relapse prevented (16-20 weeks) 3. Maintenance Phase: Susceptible patients are protected against recurrence or relapse of subsequent major depressive episodes (duration varies with frequency and severity of previous episodes) __________________ Acute phase: drugs or psychotherapy + drugs...see them back in 1-2 weeks after starting meds Patients with depression and psychotic symptoms, catatonia, or severe impairment may be considered for combination therapy with antidepressants, antipsychotics, and / or electroconvulsive therapy (ECT) ______________________ continuation phase : same dose ______________________ maintenance phase: same dose, cognitive behavioral therapy and interpersonal therapy decrease to once a month, while psychodynamic psychotherapy maintains the same previous frequency |
|
|
tx of mild to moderate depression
|
drugs alone OR
talk therapy alone OR combo The frequency of monitoring in the acute phase of pharmacotherapy is from once a week to multiple times a week Clinical features that may suggest that antidepressant medication is preferred over other modalities are a positive response to prior antidepressant treatment, significant sleep and appetite disturbance, severity of symptoms, or anticipation by the physician that maintenance therapy will be needed Clinical features that suggest the use of psychotherapy are the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities |
|
|
The degree of an “adequate response” to treatment of depression has been loosely defined as non response = ___, partial response = ___, partial remission = ___, remission = ___
if they are not fully responding, you should... if there's still not moderate improvement after 4-8 months of that, you should... |
decrease in baseline symptoms of 25% or less
26 – 49% decrease in baseline symptoms 50% or greater decrease in baseline symptoms with residual symptoms remission is the complete absence of symptoms) increase the dose reassess of the diagnosis, medication regimen and / or psychotherapy, adherence, substance or alcohol use |
|
|
minimum duration of antidepressant therapy
|
6 months
|
|
|
T/F most patients with MDE will have another at some point
issues to consider regarding maintenance therapy |
true - 50-85%
severity of episodes (e.g., suicidal ideation or attempts, psychotic symptoms, functional impairment); risk of recurrence (e.g., residual symptoms between episodes, number of recurrent episodes); comorbid conditions; side effects experienced with continuous treatment; or patient preference |
|
|
how do you d/c maintenance therapy for depression
|
taper over several weeks to monitor for emerging sx
short acting meds need a longer taper if you don't taper slowly, what look like reemergence symptoms may just be rebound |
|
|
T/F: Antidepressant medications’ effectiveness is generally comparable across classes and within classes of medications
|
T
differ in SE profiles, DDIs, cost |
|
|
The dual action reuptake inhibitors __ and __ are generally regarded as ___ agents
|
venlafaxine and bupropion
second line |
|
|
Tricyclics and other mixed or dual action inhibitors are ___ line
|
third
and MAOI’s (monoamine oxidase inhibitors) are usually medications of last resort |
|
|
Titration of the antidepressant drug to therapeutic levels is done over the initial __ of treatment.
|
weeks
(elderly get half the starting dose of normal adult) |
|
|
least anti-cholinergic TCA
however it causes a lot of |
amitriptyline
sedation also moderate hypotension, moderate weight gain |
|
|
main side effects of SSRIs
|
sexual dysfunction
GI insomnia mild weight gain |
|
|
nortriptyline is a
|
NRI
|
|
|
TCAs and NRIs may be more effective in
contraindicated in patients with |
severe depression
melancholic depression depression with physical features or pain cardiac problems, esp conduction, b/c they can cause conduction delay contraindicated for BPH, urinary retention, closed angle glaucoma |
|
|
duloxetine and paroxetine are also effective in treating
duloxetine is a |
diabetic neuropathy and chronic pain
serotonin-NE reuptake inhibitor |
|
|
bupropion inhibits
|
NE and dopamine
less nausea, somnolence, sexual side effects |
|
|
MAOIs may be more effective for depression with
|
extreme fatigue, sensitivity to rejection, or troubled relationships
but have to have low tyramine diet to prevent hypertensive crisis |
|
|
mirtazapine (antidepressant) blocks ...
sig side effect |
alpha 2 – adrenergic, serotonin, histamine receptors
sig weight gain and quite sedating |
|
|
if a patient fails SSRI, try
if they have a partial response to one medication, if pt has depression with psychotic features |
a different class
try adding a second to augment can add antipsychotic to antidepressant |
|
|
SSRIs and TCAs may initially __ anxiety. This can be avoided by
|
worsen
starting at lower doses and titrating up more slowly. |
|
|
___ should not be used as the primary pharmacologic agent in any patient with major depression and anxiety disorders.
|
benzos
they can improve antidepressant response, but can cause sedation, memory loss, and dependence and withdrawal syndromes (should also be very cautious with elderly) |
|
|
The combination of CBT and antidepressants has been shown to effectively manage ___ depression and for __ with depression. CBT has been shown to reduce relapse rates and effectively manage residual symptoms.
|
severe or chronic
adolescents (CBT focuses on present) |
|
|
3 stages of interpersonal therapy
|
assessment
practice termination doesn't have formal homework focuses on present |
|
|
problem solving therapy is particularly effective in the tx of
|
older adults
does involve homework can be group and/or individual relatively cheap |
|
|
Remission rates with ECT are around __ percent in severe major depressive disorder, with maximal response usually after ___
ECT is the first line treatment when there is |
60-80
3 weeks severe depression with psychotic features psychomotor retardation resistance to medications Suicidal patients and pregnant patients may also have rapid benefits from ECT ECT consists of 6 – 12 treatments (2 to 3 times a week) ostictal confusion, retrograde and anterograde memory impairment usually improves in a few days. usually adjuvant tx with antidepressants etc |
|
|
St. John's wort + this antidepressant is bad...also bad with...
does SJW work for depresson? |
MAOi
HAART b/c it weakens the cocktail no |
|
|
The prognosis for depression recovery is __ in young and old patients, although remission may ___ older patients
|
equal
take longer to achieve in |
|
|
The main factor associated with the development of acute paronychia
|
direct or indirect trauma to the cuticle or nail fold
This enables pathogens to inoculate the nail, resulting in infection (paronychia = inflammation of the folds of tissue surrounding the nail of a toe or finger) |
|
|
Treatment options for acute paronychia include
|
warm compresses
topical antibiotics +/- steroids oral antibiotics surgical I&D for severe cases |
|
|
Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to
tx |
irritants and allergens
broad spectrum topical antifungal + corticosteroid |
|
|
In recalcitrant chronic paronychia, en bloc excision of the proximal nail fold is an option
|
en bloc excision of proximal nail fold
Alternatively, an eponychial marsupialization, with or without nail removal, may be performed. |
|
|
___ constitute approximately 80 percent of all nonmelanoma skin cancers
|
Basal cell carcinoma
|
|
|
basaloid carcinoma arises in sites such as the
|
prostate, pancreas, lung, cervix, salivary gland, thymus, and anal canal.
|
|
|
immunosuppression predisposes to what skin cancer?
|
basal cell
|
|
|
for what conditions do you use low potency topical steroids
high potency |
dermatitis of face, eyes, diaper
intertrigo, perianal inflammation lichen planus, resistant atopic dermatitis, alopecia, discoid lupus, hyperkeratotic eczema, nummular eczema, severe hand eczema, poison ivy, lichen sclerosus (non vulva), psoriasis |
|
|
topical steroids have limited use for
ultra high dose topical steroids should not be used for more than __ weeks continuously |
melasma, chronic idiopathic urticaria, and alopecia areata
3 -- taper down, then at least 1 steroid free week |
|
|
for topical steroids, 1 hand sized area uses __ fingertip units
usually shouldn't apply more than __ times per day |
0.5
1-2 |
|
|
Psoriasis is a __cell–mediated autoimmune disease, but certain __ and __ are well-known risk factors
incidence about __% have an affected relative |
T
medications and infections up to 4.8% 30% |
|
|
mainstays of psoriasis therapy
|
Steroids and vitamin D derivatives (e.g., calcipotriene)
combination is better than either alone |
|
|
Patients with psoriasis involving more than __ of their skin or those not responding to topical therapy are candidates for __
|
20%
light therapy, traditional systemic therapy (methotrexate, cyclosporine, oral retinoids), or systemic treatment with immunomodulatory drugs such as alefacept, efalizumab, and etanercept |
|
|
most patients with psoriasis eventually develop __ involvement
may be complicated by increased incidence of __ |
nail (onycholysis, pitting, etc)
nonmelanoma skin cancer, lymphoma also arthritis |
|
|
Telogen effluvium
|
handfuls of hair loss
|
|
|
Androgenetic alopecia
tx |
one of the most common forms of hair loss, usually has a specific pattern of temporal-frontal loss in men and central thinning in women
topical minoxidil (rogaine) to treat men and women, with the addition of finasteride for men |
|
|
Exclamation-point hairs
Mid-shaft, fractured hairs |
alopecia areata (diffuse is alopecia totalis)
systemic disease, tinea capitis, stress |
|
|
in alopecia areata, Spontaneous recovery usually occurs within ___, with hair in areas of regrowth often being pigmented differently
tx |
six to 12 months
immunomodulating agents (can be topical) and biologic response modifiers, intralesional steroid injections if patchy prognosis is not as good if it persists longer than one year, started before puberty, or worsens recurrence rate is 30% and usually affects initial area of involvement |
|
|
__% of nonmelanoma skin cancer is SCC
risk of metastasis is ___ |
20%
much higher than BCC (lungs, liver, brain, skin, and bone) |
|
|
The principal precursor of cutaneous squamous-cell
carcinoma is highest risk lesions are on __ and __ tx |
actinic keratosis
more easily felt than seen...scaly lip and ears curettage, excision, or cryosurgery can eliminate up to 90 percent of local tumors |
|
|
tx of mild or moderate comedones
|
opical retinoids, benzoyl peroxide, sulfacetamide, and azelaic acid are effective in patients with mild or moderate comedones
|
|
|
tx of mild to moderate inflammatory acne or mixed acne
|
topical clinda or erythro
|
|
|
tx of moderate to severe inflammatory acne
|
6 months oral doxy, tetra, erythro, mino
low dose OCP |
|
|
seborrheic dermatitis usually affects these areas
__ can cause flare-ups are the scales greasy or dry? may cause mild to marked erythema of the An uncommon generalized form in infants may be linked to tx |
scalp (dandruff), central face, anterior chest...infants in first 3 months or adults 30-60
stress greasy nasolabial fold immunodeficiencies topical antifungals, low-potency steroids, now new topical calcineurin inhibitors (tacrolimus), tar shampoo, etc |
|
|
is rosacea acute or chronic
features |
chronic, sometimes progressive
central facial erythema, symmetric flushing, stinging, phymatous changes, papules and pustules, telangiectasias...may be erythematous (harder to treat) or papulopustular (easier to treat) |
|
|
tx for mild rosacea
tx of moderate papulopustular rosacea ocular involvement referral to specialist is necessary for |
topical metronidazole
sufacetamide azelaic acid oral tetracyclines + topical agents (e.g. metronidazole) same as above ophtho complications, phymatous changes, recalcitrant rosacea |
|
|
atopic dermatitis...chronic?
usually affects... tx |
yes
children aggressive emollients antihistamines for itching topical steroids for flares (topical tacrolimus as second line, and should NOT be used in those under 2) Rarely, systemic agents (e.g., cyclosporine, interferon gamma-1b, oral corticosteroids) may be considered in adults. |
|
|
ophtho referral for red eye is needed if
|
severe pain not relieved by topical anesthetics
herpes recent ocular surgery topical steroids needed vision loss copious purulent discharge corneal involvement distorted pupil recurrent infections traumatic injury |
|
|
what do viral and allergic conjunctivitis have in common
what different |
watery or serous discharge
allergic is more itchy |
|
|
focal eye hyperemia
|
episcleritis
|
|
|
bacterial conjunctivitis most common pathogens in kids
adults |
strep, h. flu
staph |
|
|
Dandruff-like scaling on eyelashes,
missing or misdirected eyelashes, swollen eyelids, secondary changes in conjunctiva and cornea leading to conjunctivitis |
blepharitis
|
|
|
intensely hyperemic
conjunctiva, perilimbal sparing, and watery discharge |
viral conjunctivitis
|
|
|
blepharitis can be associated with
treatment |
rosacea
eyelid massage warm compresses eyelid hygiene topical abx if they don't respond |
|
|
most common bacterial isolates from the middle ear fluid of children with acute otitis media
|
strep
H. flu moraxella |
|
|
Antibiotics for otitis media are recommended in all children younger than __, or children between __ and __ if the diagnosis is certain, or if severe infection
if resistant to amox, can give could also give a single parenteral dose of hearing test is recommended if persistent effusion for more than |
6 months
6 months to 2 years macrolides, cephalosporin, clinda ceftriaxone 3 months |
|
|
sources of secondary otalgia (otalgia + usually normal ear exam)
tx options include Patients who ___ are at higher risk for ear pain that needs evaluation |
TMJ
pharyngitis dental disease cervical spine arthritis symptomatic tx without a clear diagnosis imaging ENT consult smoke drink alcohol have diabetes (malignant otitis externa) are >50 cardiac RFs (MI) further workup includes MRI, fiberoptic nasolaryngoscopy, ESR (r/o giant cell arteritis) |
|
|
use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media
distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk, and 3) manage the child with OME who is not at risk with watchful waiting for __ from the date of effusion onset (if known) or diagnosis (if onset is unknown). |
pneumatic otoscopy
3 months |
|
|
SURVEILLANCE: CHILDREN WITH PERSISTENT
OME WHO ARE NOT AT RISK SHOULD BE REEXAMINED AT ___ UNTIL THE EFFUSION IS NO LONGER PRESENT, SIGNIFICANT HEARING LOSS IS IDENTIFIED, OR STRUCTURAL ABNORMALITIES OF THE EARDRUM OR MIDDLE EAR ARE SUSPECTED |
3- TO 6-MONTH INTERVALS
|
|
|
most common type of rhinitis
|
allergic rhinitis (seasonal, perennial, occupational)
allergy testing is not necessary in most cases, just ambiguous or complicated ones |
|
|
most common non-allergic rhinitis
others |
acute viral rhinitis
vasomotor hormonal drug-induced structural occupational (irritant) rhinitis medicamentosa non-allergic with eosinophilia |
|
|
tx for allergic rhinitis
|
intranasal steroids
second line: antihistamines decongestants cromolyn leukotriene antagonists *Evidence does not support the use of mite-proof impermeable covers, air filtration systems, or delayed exposure to solid foods in infancy |
|
|
With the exception of __, second-generation antihistamines are less likely to cause sedation and impair performance.
|
cetirizine
|
|
|
allergic rhinitis usually develops at what age
|
<20
|
|
|
___ is generally considered the gold standard for diagnosis of ABRS
other signs most common pathogens tx |
sinus puncture with aspiration of purulent secretions gold standard
purulent discharge, maxillary tooth or facial pain (usually unilateral), worsening of symptoms after initial improvement strep, h. flu...moraxella, staph amoxicillin, augmentin --> fluoro |
|
|
sx viral pharyngitis
|
cough
coryza diarrhea |
|
|
tx strep throat if penicillin allergy
|
erythromycin, first generation ceph
|
|
|
In patients with sinus infection, acute bacterial rhinosinusitis should be diagnosed and treated with antibiotics only if symptoms have not improved after __ days or have worsened afte __
|
10
5-7 days |
|
|
tx acute bronchitis in otherwise healthy adults
|
no abx!
|
|
|
when to treat nonspecific cough illness with abx
|
if lasts >14 days, evaluate for pneumonia
pertussis reported to health authoritis chlamydia and m. pneumonia can present in kids older than 5 |
|
|
tx c. pneumoniae or m. pneumoniae
|
macrolides
|
|
|
manifestations of vitamin D deficiency
|
symmetric low back pain
proximal muscle weakness muscle aches throbbing bone pain with pressure over sternum or tibia |
|
|
In persons with vitamin D deficiency, treatment may include ___ at ___ per week for eight weeks
After vitamin D levels normalize, experts recommend maintenance dosages of ___ (vitamin D3) at 800 to 1,000 IU per day from dietary and supplemental sources |
oral ergocalciferol
50,000 IU cholecalciferol |
|
|
kids should get __ U vit D per day
adults... |
400
700-800 |
|
|
vit D deficiency is diagnosed by
|
25-hydroxyvitamin D level <20
|
|
|
Fractures caused by osteoporosis affect 1 in __ women and 1 in __ men over the age of 50
|
2
5 |
|
|
subclinical thyroid disease
incidence of sub~ hypo? hyper? |
abnormal TSH +
normal free T4 or T3 5% 2% |
|
|
There is good evidence that subclinical __thyroidism is associated with progression to overt disease
treat |
hypo
no...little evidence |
|
|
TSH level greater than 10 μU per mL have a higher incidence of elevated __
|
LDL
|
|
|
A serum thyroid-stimulating hormone level of less than __ μU per mL is associated with progression to overt hyperthyroidism as well as ___. There is __ evidence that early treatment alters the clinical course.
|
0.1
atrial fibrillation, reduced bone mineral density, and cardiac dysfunction little |
|
|
find a palpable thyroid nodule, what do you do?
then what? ablation by radioactive iodine is done for |
get TFTs
if euthyroid --> FNA (U/S guided) if non-euthyroid or histology is unclear --> radionuclide scan post-op malignancy if metastasis or residual |
|
|
after surgery for malignant thyroid, what do you do
|
thyroxine suppression (which is not done for benign nodules)
radioactive iodine ablation if mets or residual |
|
|
who's more likely to have thyroid cancer, men or women?
|
men
|
|
|
what do you do with a "hot" thyroid nodule
|
surgery or radioactive ablation
|
|
|
if patient with nodule is thyrotoxic, what is order of action
|
radionuclide scan
if hot --> surgery/ablate if cold --> FNA |
|
|
what if FNA for nodule is benign?
what if it is just suspicious? |
repeat in 6 months
get a frozen section |
|
|
you suspect costochondritis, but when should you get EKG (+ possibly CXR)
|
age >35
hx CAD cardiopulmonary symptoms |
|
|
predictors of poor outcome in RA
|
high ESR or CRP
+RF lower SES early radiologic changes early involvement of many joints |
|
|
RA is __er during pregnancy
|
better
(decreased risk with OCPs too) |
|
|
RA has stiffness during
|
morning
|
|
|
Joint destruction in rheumatoid arthritis begins within __ of symptom onset
|
a few weeks
|
|
|
after RA diagnosis, begin treatment with ___
if sx not adequately controlled |
DMARDs (reverse pyramid)
for mild: -hydroxychloroquine -sulfasalazine -minocycline for severe: -methotrexate if not controlled: leflunomide azathioprine combo with methotrexate with all of above: NSAIDs or salicylates (RA patients are very sensitive to GI side effects though) |
|
|
RA patients should get radiographs every __
those on methotrexate should get labs (CBC, AST, albumin, Cr) every ___ |
year
2 months (q2 weeks in the beginning) |
|
|
diet supplements that have been shown effective for OA
|
glucosamine (most common), chondroitin sulfate
S-adenosylmethionine may reduce pain but high costs and product quality issues limit its use |
|
|
after childbirth, you can begin with __ contraception immediately
for the other kind, wait __ if breast feeding, __ if not |
progesterone
6 weeks to 6 months 3 weeks |
|
|
when during the cycle can you insert an IUD
|
anytime, assuming the woman isn't pregnant
|
|
|
features of ankylosin spondylitis
|
morning stiffness
improvement with exercise younger age alternating buttock pain awakening in 2nd half of the night |
|
|
when to get MRI for suspected herniated disc
|
symptoms >1 month
|
|
|
for pts with acute back pain, should they stay active?
|
yes
minimize bed rest use heat or ice take NSAIDs |
|
|
Patients who present with spontaneous onset of wrist pain, who have a vague or distant history of trauma, or whose activities consist of repetitive loading could be suffering from
|
carpal bone non-union or avascular necrosis
|
|
|
for ankle injury, semirigid supports or elastic bandages?
immobilize or strengthening exercises |
semirigid
exercises |
|
|
adhesive capsulitis can be associated with
features |
diabetes
thyroid disorders diffuse shoulder pain restricted passive ROM |
|
|
painful cross-body adduction test
|
AC osteoarthritis
(also superior shoulder pain) |
|
|
rotator cuff injury has pain at ___ or with ___
|
night
overhead activity |
|
|
hx of shoulder trauma and <40 yo?
>40 yo? |
subluxation/instability
rotator cuff |
|
|
chronic shoulder pain is > __
eval |
6 months
all should get radiograph |
|
|
tx of chronic shoulder pain
if sx continue after __ of treatment, go to ortho |
activity modifications
analgesics if still sx --> PT +/- injections (GH joint needs fluoroscopy) 6-12 wks |
|
|
weight lifting associated with this shoulder injury
|
weight lifting
|
|
|
indications for knee radiographs
|
isolated tenderness at patella
tenderness at head of fibula inability to bear weight can't flex knee to 90 degrees age >55 |
|
|
A history of knee locking episodes suggests a
|
meniscal tear
(also slow effusion 24-36 hours) |
|
|
a history of popping in the knee suggests
|
ligamentous tear
(also rapid effusion 2 hours) |
|
|
teenage girl who presents with "giving way" episodes of the knee
|
patellar subluxation
|
|
|
teenage __ who presents with anterior knee pain localized to the tibial tuberosity is likely to have
|
boy
tibial apophysitis (Osgood Schlatter) usually for months, worse with squatting, walking up and down stairs, jumping |
|
|
teenage boy with knee pain walking down stairs
|
patellar tendonitis
(jumper's knee) |
|
|
in SCFE, pain is elicited with
|
passive internal rotation or extension of the affected hip.
|
|
|
Pes anserine bursitis is pain at
|
medial knee
(overuse syndrome) |
|
|
Baker's cyst
|
popliteal cyst
|
|
|
tx chlamydia
|
azithro
|
|
|
tx gonorrhea
|
ceftriaxone
|
|
|
tx trichomoniasis
|
metronidazole
|
|
|
tx Lymphogranuloma Venereum (nontender papule that may ulcerate)
|
doxy
|
|
|
all pregnanct women should be screened for
those at risk should be screened for |
HepB
HIV syphilis GCCT |
|
|
The USPSTF recommends that all sexually active women younger than __ years be considered at increased risk of chlamydia and gonorrhea
|
25
|
|
|
Men at increased risk should be screened for
|
HIV, syphilis
|
|
|
chlamydia, gonorrhea, HIV,
and syphilis screening for women who engage in high-risk sexual behavior, i.e. |
multiple current partners
new partner sex under influence inconsistent use of condoms sex for money |
|
|
2nd leading cause of UTI
|
staph saprophyticus
|
|
|
alternative, or in some cases preferred, tx for uncomplicated UTI
|
cipro
|
|
|
most common species in prostatitis
|
e. coli
|
|
|
Meniere's disease assoc with vertigo +
|
hearing loss, tinnitus, or aural fullness caused by increased volume of endolymph in the
semicircular canals |
|
|
constant vertigo lasting weeks
without improvement vertigo lasting days |
psychogenic
acute (viral) vestibular neuronitis -- recent URI |
|
|
acute labyrinthitis is due to
|
bacterial or viral infection
|
|
|
resolution of nystagmus with fixation is typical of __ vertigo
imbalance is worse with ___ vertigo nausea/vomiting worse with hearing loss with |
peripheral
central peripheral peripheral |
|
|
Vertiginous migraine headaches generally improve with
|
dietary changes
a tricyclic antidepressant a beta blocker or calcium channel blocker |
|
|
Vertigo associated with anxiety usually responds to
|
SSRI
|
|
|
Ménière’s disease often responds to
|
low salt diet
diuretics |
|
|
tx acute vestibular neuronitis
|
vestibular suppressant medications (meclizine, lorazepam, dimenhydrinate, amitriptyline)
and vestibular exercises |
|
|
sx in meniere's disease last for
|
hours
|
|
|
how do you know if pt has a migraine
|
at least 4 features of POUNDING:
Pulsatile 4-72 hOurs Unilateral Nausea vomiting Disabling intensity |
|
|
when should you get neuroimaging, besides if thunderclap headache
|
headache with vomiting
aura exertion or valsalva aggravates abnormal neuro exam |
|
|
cluster headache features
tx ppx |
unilateral, excruciating, conjunctival injection, lacrimation, congestion or rhinorrhea, eyelid edema (can be acute or chronic)...men get in their 20s, women at 60
oxygen sumitriptan ?stereotactic electrodes verapamil avoiding alcohol, smoke Episodic cluster headache is defined as at least two cluster periods lasting seven to 365 days and separated by pain-free remission periods of one month or longer. Chronic attacks recur over more than one year without remission or with remission lasting less than one month. Called “suicide headache” because of its severity and “alarm clock” headache because of its periodicity, cluster headache is characterized by unilateral excruciating pain (a hot-poker or stabbing sensation) in the ocular, frontal, or temporal areas. |
|
|
migraine ppx
|
propranolol
timolol amitriptyline divalproex topiramate (fair effectiveness of naproxen, gabapentin, botox) |
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first choice for prevention of recurrent stroke
what if they can't tolerate it? |
aspirin (but the combination of dipyridamole and aspirin should be considered for many patients because of its superior effectiveness in two clinical trials)
clopidogrel (warfarin or aspirin/plavix should NOT be used) |
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what's better, carotid stenting or CEA
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CEA
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what about aspirin for someone with uncontrolled htn to prevent recurrent stroke?
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nooo
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In patients with respiratory symptoms, particularly dyspnea, __ should be performed to diagnose airflow obstruction
|
spirometry
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Treatment for stable chronic obstructive pulmonary disease (COPD) should be reserved for patients who have __ and___ predicted, as documented by spirometry.
what is the tx? Clinicians should prescribe oxygen therapy in patients with COPD and resting hypoxemia (PaO2 < __) hould consider prescribing pulmonary rehabilitation in symptomatic individuals with COPD who have an FEV1 less than __% predicted |
respiratory symptoms
FEV1 less than 60% 1 of the following: LABA long-acting inhaled anticholinergic inhaled corticosteroid 55 50 |
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what step should you start someone on if intermittent asthma? mild? moderate? severe?
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step 1
step 2 step 3 step 3 or step 4 |
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asthma class wrt daytime symptoms
night awakenings limitations |
<2 days per week
>2 days per week daily throughout the day <2 per month 3-4 per month every week many days per week none minor some extreme |
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medium dose ICS and LABA is step _
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4
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tx CAP
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macrolides
doxy fluoroquinolones if special reason (failed other abx, significant comorbidities, recently had abx, etc...levoflox, moxiflox) (empirically) |
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rate control for new onset Afib
what about DC cardioversion vs pharmacologic? |
atenolol, metoprolol,
diltiazem, and verapamil (digoxin only helps at rest, and is 2nd line) either is fine |
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if patients are sx and want rhythm control, use __
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amiodarone, disopyramide, propafenone, sotalol
(ps patients who are converted to sinus rhythm should not be on rhythm maintenance meds) |
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use __ perioperatively for patients with cardiac risk factors
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beta blockers
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major perioperative cardiac clinica predictors
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Unstable angina
Recent MI (within 30 days) Decompensated CHF Significant arrhythmias Severe valvular disease |
