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209 Cards in this Set
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- Back
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5 types of antihyperglycemics?
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Biguanides
Sulfonylureas Thiazolidinediones Alpha-glucosidase inhibitors Meglitinides |
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1 biguanide
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Metformin
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HbA1c reduction of the antihyperglycemics (in general)
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0.5-2%
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Mechanism of metformin (3)
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Suppresses hepatic glucose production and intestinal glucose absorption
Improves insulin sensitivity |
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Most common side effect of metformin
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GI
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When to avoid metformin (4 reasons) and why
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Cr >1.4, decompensated CHF, liver failure, or heavy alcohol use
Risk of lactic acidosis |
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3 sulfonylureas
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Glimepiride
Glipizide Glyburide |
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Mechanism of sulfonylureas
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Increase pancreatic secretion of insulin
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2 thiazolidinediones
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Rosiglitazole
Pioglitazone |
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Mechanism of thiazolidinediones
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Increase sensitivity to insulin
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When to avoid thiazolidinediones?
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NYHA Class III or IV heart failure
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Best adjunctive antihyperglycemic
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Thiazolidinediones
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2 alpha-glucosidase inhibitors
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Acarbose
Miglitol |
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Mechanism of alpha-glucosidase inhibitors
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Decrease postprandial hyperglycemia by reducing GI carb absorption
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When is acarbose contraindicated
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Cirrhosis; always requires liver function monitoring
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2 meglitinides
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Repaglinide
Mateglinide |
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Mechanism of meglitinides
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Increase pancreatic secretion of insulin thru diff glucose-binding site than used by sulonylureas
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Benefit of meglitinides vs. sulfonylureas
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Shorter onset of action/ half life
Greater decrease in postprandial glucose Lower risk for hypoglycemia |
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Best studied oral agent combo (and why)
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Metformin + sulfonylurea (addresses insulin resistance and insulin deficiency)
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Initial insulin dose and how much to increase by
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0.1 U/kg divided into 2 daily doses
Increase at 10% weekly |
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3 additional diabetes therapies
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Pramlintide (synthetic amylin)
Exenatide (incretin mimetic) Sitagliptin (DPP-4 inhibitor) |
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Disadvantage of beta blockers in pts with diabetes
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May mask hypoglycemia
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Disadvantage of thiazide diuretics in pts with diabetes
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May elevated blood glucose levels
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BP goal in diabetics w/ and w/o proteinuria
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<130/80
<125/75 if proteinuria is present |
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4 Rx agents for diabetic neuropathy
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TCAs
Duloxetine Capsaicin cream Antiepileptics (carbamazepine or gabapentin) |
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Medical name for a skin tag
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Acrochordon
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2 removal methods for actinic keratosis
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Liquid nitrogen cryotherapy
5-FU if there are multiple lesions |
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Name for full-thickness epidermal involvement of squamous cell carcinoma?
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Bowen's disease
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4 SCC locations with greatest risk of metastasis
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Hands, lips, temple, vulva
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Rx for tinea (fungal infection)
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Topical antifungals
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Rx for hair/nail fungal infection
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Oral antifungals (ketoconazole, griseofulvin, itraconazole, and terbinafine)
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Where does spinal anesthesia go?
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Subarachnoid space
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Who needs preop ECG?
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Men >40yo
Women >50yo Scheduled for medium to high risk surgery |
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What are METs and what is the commonly used cut-off value?
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Metabolic equivalents (used to measure functional capacity for preop eval)
<4: poor (climb flight of stairs) |
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6 risk factors in the cardiac risk index
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High risk surgery, CAD, CHF, CVA/TIA, IDDM, SKD (Cr >2)
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Ideal HR w/ beta blockers
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50-60
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If pt can't tolerate beta blocker, use
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Clonidine
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Preop CXR needed for which pts
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>50 or history of heart/lung disease going for intermediate or high risk surgery
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What lab test indicates a risk factor for pulm complications?
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Albumin < 3.5
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5 ASA classes
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1: healthy
2: mild systemic disease 3: severe systemic disease 4: severe debilitating/daily systemic disease 5: moribund, prognosis <24hrs irrespective of operation |
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For elective surgery, asthma pts whould be optimized to?
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>80% of their personal best FEV1
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Management of pt on warfarin undergoing high bleeding risk procedure if they have a high thrombotic risk as well?
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D/c warfarin, start heparin when INR subtherapeutic, surgery when INR <1.5, (d/c heparin preop, restart both heparin and warfarin postop)
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3 groups of pts at risk for periop adrenal insufficiency
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Hx of adrenal insufficiency, severe hyperthyroidism, prolonged courses of systemic corticosteroids in last yr
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Steroid regimens for those pts at risk of period adrenal insufficiency
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Minor surgery: give typical dose
Major surgery: 100mg IV hydrocortisone preop, then 50g q 8hrs for 3 days |
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Rx for surgery in pts with mild hyperthyroidism
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Start beta blocker
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Management of pts with severe hyperthyroidism who need elective surgery
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Antithyroid agents, op in 3-8wks
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Management of thyrotoxic pts who need urgent surgery (4)
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Antithyroid meds, beta blockers, stress dose steroids, close monitoring
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4 risks of surgery in pts who are hyperthyroid at time of op
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A fib
Adrenal insufficiency Thyroid storm |
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Benefit of revascularization prior to noncardiac surgery
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None! No reduction in periop cardiac complications
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5 As
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Ask
Advise Assess Assist Arrange |
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How long must a person be quit for the cardiovascular improvements to take effect?
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Immediate
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Likely consequences of nicotine withdrawal
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10lb weight gain
1-3 wks: irritability/restlessness, insomnia, increased coughing, constipation, mild headache, anxiety |
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Dosing for nicotine patch
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21mg for 4 wks, 12mg for 2wks, then 7mg for 2wks
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Side effects of patch
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Local skin reaction, insomnia
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Side effects of nicotine gum
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Mouth sores, dyspepsia
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At what cholesterol levels do patients need lipoprotein analysis?
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>240 or 200-239 with define CHD or 2+ risk factors
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MOA of statins
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HMG CoA reductase inhibitors
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MOA of bile acid resins
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Bind intestinal bile acids
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MOA of niacin (nicotinic acid)
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Decreases liver LDL/VLDL production, inhibits lipolysis, and increases lipoprotein lipase activity
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MOA of fibrates
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Inhibits peripheral lipolysis, decreases liver FFA extraction, and increases clearance and inhibits synthesis of apoB
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MOA of ezetimibe
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Prevents absorption of cholesterol at brush border
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Brand name for ezetimibe
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Zetia
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Rx for diastolic BP >120-130
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Hospitalize
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Back pain in the morning relieved by activity
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Ankylosing spondylitis or inflammation
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Back pain that is worse with sitting, driving, or lifting
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Slipped disc
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Back pain that is worse with standing or walking, relieved by bending/ sitting
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Spinal stenosis
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Most common cause of lower back pain
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Lumbosacral strain (caused by specific episode)
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Impact of nicotine replacement therapy on quit rates
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Doubles success
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2 drugs which can help with smoking cessation
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Bupropion (Zyban/ Wellbutrin)
Varenicline (Chantix) |
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When should bupropion be started, and what is the dose?
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1-2wks before quitting
150mg qd x 3 days, then BID for up to 6mo |
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2 contraindications to bupropion
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Seizures
Eating disorder |
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2 side effects of bupropion
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Insomnia, dry mouth
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Concern with varenicline
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SI/ depression
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2 side effects of varenicline
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Vivid dreams, mild nausea
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3 contraindications to NRT
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Acute MI
Uncontrolled asthma Accelerating HTN |
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Major (and minor) effect of statins
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Decrease LDL (20-60%)
Also increase HDL and decrease TGs |
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Side effects of statins
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Myalgia, liver toxicity, DM, irritability
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Major (and minor) effect of niacin
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Increase HDL (20-25%)
Also decrease LDL and TGs |
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Side effects of niacin
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Flushing, itching, myalgias, gout, glucose intolerance
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Major (and minor) effect of fibrate
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Decrease TGs (35-50%)
Also decrease LDL (though may increase) and increase HDL |
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Side effect of fibrate
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Gallstones, dyspepsia, myalgia/myositis
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Major (and minor) effect of bile acid resins
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Decrease LDL (can increase TGs)
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Side effect of bile acid resins
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Constipation/ GI problems
Decreased absorption of other meds |
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Effect of ezetimibe
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Decrease LDL
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Side effect of ezetimibe
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Liver toxicity
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Treatment of Stage I vs. Stage II HTN
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Both lifestyle intervention, Stage I is 1 drug, Stage 2 needs 2 drugs
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Risk of developing HTN if you have pre-HTN
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70-90%
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Risk of CHD doubles for every increase in BP of how much?
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20/10 (once >125/85)
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Work-up for new onset HTN (5)
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Chem panel, urine (for protein), EKG
Also glucose and lipids to risk stratify |
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First line treatment for HTN (3)
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Thiazides, ACEIs, ARBs
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AA patient and/or has high cholesterol and needs a beta blocker, which to use?
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Labetalol
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What is malignant HTN?
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Severely elevated BP accompanied by end-organ damaage (CHF, renal failure, neuro signs, papilledema, chest pain, ECG changes)
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Rx for malignant HTN
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Reduce MAP by no more than 1/3 using IV nitroglycerin, nitropruside, or labetalol
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Rx for malignant HTN in pregnancy
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IV hydralazine
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Symptoms of migraine
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Photo/sonophobia, N/V, vertigo, dysarthria, tinnitus, diplopia, weakness, ataxia
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Rx for migraines (5)
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Triptan
Ergotamine derivatives NSAIDs Antiemetic Caffeine |
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Prophy for migraines (3 classes)
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TCAs, topamax or depakote, beta blocker
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Which type of headache is often associated with neck stiffness?
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Tension
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Prophy for tension headaches
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TCAs (amitriptyline, doxepin)
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Cluster headaches are more common in
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Males
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Precipitants of cluster headaches
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Nitrates, alcohol, or stress
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Symptoms of cluster headaches
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Unilateral pain w/ conjunctival injection, tearing, rhinorrhea, congestion, ptosis, miosis, eyelid edema, facial sweating
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Rx for cluster headaches (3)
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100% O2
Intranasal lidocaine DHE (IV or IM) or sumatriptan (SQ) |
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Prophy for cluster headaches (shorten cluster period or prevent expected attacks) (4)
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Verapamil
Lithium Timed ergotamine Steroid taper (2nd line) |
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Diet guidelines for weightloss (cal, cal from fat, cal from protein)
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500-1000 kcal/day reduction
<30% from fat >15% from protein |
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3 ways to lower cholesterol
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Reduce saturated fats/ cholesterol
Increase soluble fiber (10-25g/day) Plant stanols, sterols (2g/day) |
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Radiation of lumbosacral strain vs. sciatica
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Lumbosacral strain: low back/ butt/ upper thigh, but not lower leg
Sciatica: down posterior or lateral aspect of leg to foot |
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PEX for lumbosacral sprain
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Local swelling, very TTP
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DDx for sciatica (6)
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Herniated disc (95%)
Spinal stenosis, compression fracture, epidural abscess, vertebral osteo, tumor |
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Other signs and symptoms of sciatica
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Sharp/ burning pain
Paresthesias, numbness Weakness Worse with cough/ valsalva |
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PEX for sciatica
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Numbness/ paresthesia
Calf atrophy, decreased ankle/knee jerk Paraspinal muscle pasm + SLR |
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Rx for lumbosacral strain (3)
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Continue activity
Heat/ warm baths Mild analgesics/ anti-inflammatory |
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When do you get an xray with low back pain?
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When you suspect it is serious
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Potential serious causes of back pain and associated symptoms (7)
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1) Malignancy (>50yo, bone pain unrelieved by rest)
2) Compression fracture (steroids, trauma, postmenopausal woman) 3) Ankylosing spondylitis (limited spinal motion in young male, pain relieved by activity) 4) Chronic oteo (fever/ ESR) 5) Major trauma 6) Major neuro deficits 7) High lumbar or thoracic region pain |
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4 criteria for DM diagnosis
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2 fasting glucose >126
Random glucose > 200 + Sx Postprandial glucose >200 after 75g oral GTT HbA1c > 6.5% |
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Immunizations indicated in DM
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Flu shot, pneumovax
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Shoe care in diabetes
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Break in slowly, alternate shoes daily
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Can you use sulfonylureas in CKD?
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Only 2nd generation (glyburide, glipizide)
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Metformin shouldn't be given within 24hrs of?
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IV contrast
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Effect of metformin on lipids?
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Can lower lipids
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Risks with metaglinides
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Hypoglycemia, pancreatitis, Stevens Johnson, HUS, hepatic dysfunction
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Side effects of ACEIs (5)
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Cough, hypotension, angioedema, hepatotoxicity, loss of taste
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5 indications for ACEI
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CAD, DM, CHF, LV dysfunction, HL
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Which drugs are more effective in African Americans?
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Diuretics and CCBs
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When should you use an ACEI instead of a CCB in African Americans anyway?
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With hypertensive nephropathy (better for preventing renal failure)
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Side effects of beta blockers
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Bradycardia, impotence, worsening CHF, bronhospasm, masks hypoglycemia, increases TG, decreases HDL
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Risk of suddenly d/cing a beta blocker
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MI
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When should the sympathomimetic beta blockers be used?
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Pts w/ symptomatic bradycardia on cardioselective beta blockers
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What are the cardioselective beta blockers? (4)
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Atenolol
Metoprolol Betaxolol |
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What are the sympathomimetic beta blockers (4)
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Carteolol
Penbutolol Pindolol |
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2 alpha/beta blockers
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Carvedilol
Labetalol |
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Risk with alpha/beta blockers (2)
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Orthostatic hypotension
Hepatotoxictiy |
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2 non-dihydropyridine CCBs
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Verapamil
Diltiazem |
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Non-dihydropyridine CCBs are useful in
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Hyperlipidemia
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Dihyropyridines are useful in
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Elderly w/ isolated systolic HTN
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Side effects of non-dihydropyridine CCBs
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Increase MIs in diabetics
Increase CAD, CHF Dizziness, constipation, AV block, bradycardia, lupus rash |
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Side effects of dihydropyridines (3)
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Flushing, tachy, gingival hyperplasia
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Which diuretics should be used for pts with CKD (2)?
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Thiazide or loop diuretic
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Side effects of thiazides (3)?
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Pancreatitis, impotence, gout
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Side effect of loops?
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Metabolic alkalosis
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Side effect of K+-sparing diuretics?
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GI upset
Gynecomastia Nephrolithiasis |
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What serum levels are high with thiazide/ loop diuretics (4)?
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Uric acid
Glucose Cholesterol TGs |
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What serum levels are high just with thiazides?
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Calcium
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What serum levels are low with thiazide/ loop diuretics (3)?
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K+, Na+, Mg2+
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Cardiac exam findings with coronary ischemia
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S4 or S3
Loss of physiologic splitting |
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2 drugs that relieve (not treat) GERD
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Nitrates
CCBs |
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What should be emphasized to patients with somatization, rather than symptoms?
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Function
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What increases the facial pain in acute sinusitis?
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Bending forward
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Sinusitis with teeth pain indicates which sinus is involved?
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Maxillary
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Common bugs in acute sinusitis (4)
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S. pneumoniae, H. influenzae
Also moraxella or anaerobes |
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Rx for acute sinusitis
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Decongestant
Amox or Bactrim If allergic: doxy or azithro |
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How long are chronic sinusitis symptoms present for?
|
2-3 months
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Rx for chronic sinusitis
|
Decongestant
Augmentin x 10days May require surgical drainage or sinus irrigation |
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What is the criteria system for IBS?
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Manning criteria
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2 Manning criteria
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Continuous/recurrent Sx w/ mo of abd pain relieved w/ defecation or associated w/ change in frequency/ consistency of stool
Irregular pattern of disturbed defecation >25% of the time (incl altered frequency, consistency, straining, uregncy, incomplete evac, mucous, distended feeling) |
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Best IBS diet
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High fiber, low fat
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4 IBS meds
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Anxiolytic (buspirone)
Antispasmodic Antidiarrheal (loperamide) Cholestyramine |
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Conjunctivitis with sore throat likely indicates
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Viral (not strep)
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Who needs a rapid strep test?
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Pts w/ 1-2 suggestive symptoms
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What are the 4 suggestive symptoms for strep?
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Tonsillar exudates
Tender cervical adenopathy Fever >101F Pharyngeal erythema, absence of cough |
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5 characteristics that make a UTI complicated
|
Fever
Back pain Elderly Male Catheterized |
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Rx for complicated UTI
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10-14 days fluoroquinolone
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Which UTI pts require hospitalization?
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Rigors, high fever, flank pain, N/V
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Rx for uncomplicated UTI (3 options)
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3 days Bactrim
With sulfa allergy, use cipro or nitrofurantoin |
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Is conjunctivitis usually painful?
|
No
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Laterality of each of the 3 types of conjunctivitis
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Bacterial: unilateral
Viral: unilateral --> bilateral Allergic: bilateral |
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Which type of conjunctivitis usually does not have a foreign body sensation
|
Bacterial
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Which type of conjunctivitis has preauricular adenopathy?
|
Viral
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Most common pathogen in viral conjunctivitis
|
Adenovirus
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3 most common pathogens in bacterial conjunctivitis
|
Pneumococcous, neisseria, staph
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Risk with neisseria conjunctivitis
|
Scars cornea
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Presentation of staph conjunctivitis
|
Chronic, ulcers
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Rx for allergic conjunctivitis
|
Cool compresses, decongestant-antihistamine drops, oral antihistamine
|
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Rx for bacterial conjunctivitis (2)
|
Erythryomycin ophthalmic ointment OR
Polymyxin/trimethoprim drops |
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Average gain in life expectancy from colon cancer screening
|
2-3 months
|
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When to stop cervical cancer screening?
|
65yo
|
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Average gain in life expectancy from cervical caner screening
|
3 mo
|
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Average gain in life expectancy for mammography
|
1mo
|
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PSA is most useful in which age group
|
50-70yo with average risk
45+ with increased risk (AA or FH) |
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Who needs flu vaccine?
|
>50, pregnant in 2nd/3rd trimester, serious medical condition, HCWs, nursing home residents
|
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Who needs pneumovax?
|
>65yo, chronic medical condition (esp asplenia), nursing home reidents
|
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Who needs HBV vaccine?
|
Hemodialysis, HCWs, IVDU, >1 sexual partner in 6mo, STD, MSM, traveler, prison inmate/worker
|
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How many VZV vaccine doses are needed?
|
2 for susceptibles 18+, otherwise only 1 at 1yo
|
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Which vaginitis has usually lasted for weeks to months before presentation?
|
Bacterial vaginosis
|
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Vaginitis with itching odor after urination/intercourse
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BV
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Vaginitis w/ discharge, itching, and burning pain
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Candida
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Vaginitis w/ extreme itching, discharge, and dyspareunia
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Trich
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Gray vs. green/frothy discharge
|
BV vs. trich
|
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Strawberry cervix with vaginitis symptoms can indicate
|
Trich
|
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pH in BV, candida, and trich
|
High in BV and trich (particularly latter)
Normal (4-4.5) in candida |
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Rx for BV
|
Metronidazole (Flagyl) PO 500mg BID
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Rx for candida
|
Diflucan 150mg PO x1 dose or 1wk of Monistat OTC
|
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Rx for Trich
|
Metronidazole 2g PO x1 dose, also treat sexual partner
|
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Thyroid nodule work-up
|
TSH/T4
Thyroid US FNA |
|
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Work-up of thyroid nodule with indeterminate FNA
|
Scintigraphy
|
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Meds that increase risk for osteoporosis (6)
|
Steroids
AEDs Excess thyroid replacement Anticoag Antacids w/ aluminum Cholestyramine |
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Definition of osteopenia
|
T score -2.5 < T < -1.0
|
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Preventive meds for osteoporosis
|
Calcium + Vita D: 500mg BID or TID (Ca best absorbed in doses of 500mg or less)
|
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5 potential treatment options for osteoporosis
|
Bisphosphonates
Raloxifene Estrogen (more prevention) Nasal calcitonin PTH (Teriparatide) |
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Stare and lid lag may indicate
|
Hyperthyroidism
|
|
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Puffy facies and hoarseness may indicate
|
Hypothyroidism
|
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Nail and skin in hyper vs. hypo thyroidism
|
Hyper: warm/moist skin, fine hair, hair loss
Hypo: coarse hair and skin, alopecia |
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Tender goiter + fever, myalgia, recent URI
|
DeQuervain's thyroiditis (subacutre granulomatous thyroiditis)
|
|
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Thyroglobulin levels in thyroiditis
|
Increased
|
|
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Thyroglobulin levels in exogenous hyperthyroidism
|
Decreased (suppressed)
|
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What lab tests are elevated in Hashimoto's?
|
Antithyroglobulin and antimicrosomal Abs
|
|
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Rx for hyperthyroidism
|
PTU
|
|
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Rx for hyperthyroidism in pregnancy
|
Methimazole
|
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Adjunctive therapy for hyperthyroidism (2)
|
Iodides
Beta blockers |
