2: 55-year-old man annual exam Flashcards

1
Q

metabolic syndrome

A

characterized by abdominal obesity, dyslipidemia, hypertension, and insulin resistance with or without impaired glucose tolerance.

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2
Q

RISE Mnemonic for Preventive Visits

A

Risk factors: Identify risk factors for serious medical conditions during history and physical exam. Immunizations: Provide recommended

immunizations/chemoprophylaxis.

Screening tests: Order appropriate screening tests.

Education: Educate patients on ways to live healthier while reducing risks for disease.

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3
Q

Most Frequent Causes of Death for a 55-Year-Old Male in the U.S.

A
malignant neoplasm
heart disease
unintentional injury (accident) 
diabetes mellitus
chronic lung disease 
chronic liver disease 
cirrhosis
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4
Q

Many risk factors have been independently associated with cardiovascular disease (CVD) including:

A
sedentary lifestyle 
stress
premature family history 
excess alcohol use
and many more (e.g. obesity, poor diet, low selenium levels, high homocysteine levels, etc.)
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5
Q

Most of a person’s risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a patient’s risk category from that determined by the major risk factors.

A

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every four to six years in adults age 20 to 79 who are free from ASCVD.

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6
Q

Effects of moderate alcohol intake:

A

The best-known effect of moderate alcohol intake is a small increase in HDL cholesterol. However, regular physical activity is another effective way to raise HDL cholesterol, and niacin can be prescribed to raise it to a greater degree. Alcohol or some substances such as resveratrol found in alcoholic beverages may prevent platelets in the blood from sticking together. That may reduce clot formation and reduce the risk of heart attack or stroke. (Aspirin may help reduce blood clotting in a similar way.) How alcohol or wine affects cardiovascular risk merits further research, but right now the American Heart Association does not recommend drinking wine or any other form of alcohol to gain these potential benefits.

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7
Q

Effects of red wine:

A

Over the past several decades, many studies have been published about how drinking alcohol may be associated with reduced mortality due to heart disease in some populations. Some researchers have suggested that the benefit may be due to wine, especially red wine. Others are examining the potential benefits of components in red wine such as flavonoids and other antioxidants in reducing heart disease risk. The linkage reported in many of these studies may be due to other lifestyle factors rather than alcohol. Such factors may include increased physical activity, and a diet high in fruits and vegetables and lower in saturated fats. No direct comparison trials have been done to determine the specific effect of wine or other alcohol on the risk of developing heart disease or stroke.

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8
Q

Effects with certain chronic diseases

A

Patients with heart failure, cardiomyopathy, diabetes, hypertension, arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol ingestion.

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9
Q

Relevant immunization recommendations:

A

Influenza is recommended annually.

Current recommendations recommend substituting a one-time dose of Tdap for Td booster (tetanus and diphtheria) for ages 11 to 64 to provide additional pertussis protection, then boost with Td every 10 years.

One dose of zoster vaccine is recommended when patients turn 60.

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10
Q

Immunocompromising conditions:

A

Live vaccines, like zoster (also MMR, OPV, and Varicella), should not be administered to immunocompromised patients, their close contacts, or to pregnant women.

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11
Q

The USPSTF grades each recommendation according to one of five classifications:

A

A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net
benefit is substantial.

B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net benefit is fair or fair certainty that the net benefit is moderate - substantial.

C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved; net benefit is small. However there may be occasions that warrant provision of this service in a patient.

D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits, or harms outweigh benefits.

I: There is insufficient evidence to recommend for or against the service.

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12
Q

United States Preventive Services Task Force Screening Recommendations for a 55-Year- Old Asymptomatic Man Who Smokes

A

“A” or “B” screening recommendations include:
Colorectal cancer
Obesity
Diabetes mellitus
Lipid disorders
Tobacco use
Hypertension
Alcohol misuse
Lung cancer screening: only recommended under certain circumstances. Annual screening for lung cancer with low-dose computed tomography is recommended in adults ages 55 to 80 years who have a 30 pack- year smoking history and currently smoke or have quit within the past 15 years. In this case, Mr. Reynolds has been smoking for 5 years, so lung cancer screening would not be indicated
Hepatitis C virus infection: screen in persons at high risk for infection. Offer one-time screening for HCV infection to adults born between 1945 and 1965.
Depression

Note: One of the USPSTF depression screening recommendations is Grade B, another is Grade C.

Grade B: Screen adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.

Grade C: Do not routinely screening adults for depression when staff-assisted depression care supports are not in
place. There may be considerations that support screening for depression in an individual patient.

Screen for depression with two questions:

  1. Over the past two weeks, have you ever felt down, depressed, or hopeless?
  2. Over the past two weeks, have you felt little interest or pleasure in doing things?

“D” (not recommended) screening recommendations include:
Bacteriuria, bladder cancer, pancreatic cancer, testicular cancer, spirometry for COPD, genital herpes, gonorrhea, hemochromatosis, and hepatitis B.
Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important to consider other factors, including family history, travel history, sexual history, etc.

“I” screening recommendations include:
Prevention of motor vehicle injuries with seatbelt use and avoiding driving under the influence of alcohol; family and intimate partner violence screening; illicit drug use; and skin cancer screening.
Depending upon the patient population, additional screening receiving an “I” recommendation are: screening for glaucoma; lung cancer screening; oral cancer screening; and thyroid disease screening.

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13
Q

Prostate Cancer Screening Recommendations

A

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA-based screening in average-risk males results in little or no reduction in prostate-cancer-related deaths and is associated with harms related to tests, procedures, and treatment of the condition, some of which may be unnecessary.

Other organizations, such as the American Cancer Society (ACS) and the American Urology Association (AUA) recommended that men ages 55 to 69 thinking about having prostate cancer screening should make informed decisions based on available information, discussion with their doctor, and their own views on the benefits and side effects of prostate cancer screening and treatment.

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14
Q

PSA Screening: Benefits and Harms

A

The potential benefit of PSA screening is that it may lead to prolonged life from early detection and treatment of prostate cancer. In addition to the potential benefit of early detection of malignant prostate cancer, some men may receive psychological reassurance that they probably do not have prostate cancer or they have probably caught it early so it can be treated.

A potential harm of PSA screening is serious complication (such as erectile dysfunction, urinary incontinence, bowel dysfunction) or even death from treatment of a prostate cancer that would not have caused symptoms if left undetected during his lifetime. Another potential harm is pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.

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15
Q

Colon Cancer Screening Options

A

The USPSTF recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years using:

fecal occult blood testing
sigmoidoscopy
colonoscopy

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16
Q

Indications for Exercise Stress Testing

A

Asymptomatic male patients over 45 years of age with one or more risk factors (hypercholesterolemia, hypertension, smoking, or family history of premature coronary artery disease) may obtain useful prognostic information from exercise testing.

17
Q

Diet Recommendations to Lower Heart Disease Risk

A

The American Heart Association recommends eating fish twice a week. Eating more fatty fish like mackerel, lake trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk.

Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower heart disease risk.

Unfortunately, studies are showing that vitamins C, E, and folic acid do not reduce heart attacks or strokes.

18
Q

Lifestyle Change Counseling

A

Three Cs of Addiction:

  1. Compulsion to use
  2. Lack of Control
  3. Continued use despite adverse consequences

The Five A’s of Counseling for Behavior Change:

  • -Ask or Address the behavior needing change.
  • -Assess for interest in behavior change.
  • -Advise on methods to change behavior.
  • -Assist with motivation to change behavior.
  • -Arrange for follow-up

Stages of Behavior Change:

  • -Pre-contemplative: Not aware of need to change or not interested in changing behavior.
  • -Contemplative: Currently interested in changing behavior.
  • -Active: Currently making a behavior change.
  • -Relapse: Attempted behavior change but no longer making the change.
19
Q

Screening for Alcohol Misuse: CAGE Questions

A

Have you ever:

  1. felt the need to Cut down your drinking?
  2. felt Annoyed by criticism of your drinking? 3. had Guilty feelings about drinking?
  3. taken a morning Eye-opener?

The CAGE question has been validated as a useful tool in conjunction with quantifying the amount of alcohol being used. When positive answers to any of the CAGE questions are received, further probing questions regarding other effects of alcohol are indicated to help determine whether a problem with alcohol use exists.

20
Q

Gathering a Complete Nutrition History

A

Dietary choices can affect a patient’s risk for coronary heart disease, diabetes, some cancers, and stroke. Thus, nutrition assessment is a critical aspect of the preventive routine exam.

There are many ways to gather a nutrition history. A brief history should include the number of meals and snacks eaten in a 24-hour period; dining-out habits; as well as frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy products, and desserts. Nutrients missing in the diet are equally important as those eaten in excess.

When this initial history indicates a poor diet or there are medical indications for a more complete diet history, use of one or more of the following methods is indicated.

21
Q

24-hour Dietary Recalls:

A

Ask about each meal separately. Be sure to include snacks and beverages as well as portion sizes. WAVE is a pocket card tool designed to encourage dialogue about the patient’s “Weight, Activity, Variety and Excess.” Based on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of servings from the Food Guide Pyramid (Variety) and whether he or she is eating too much fat, salt, sugar, and calories (Excess) recommended in the Dietary Guidelines for Americans. The card also lists counseling tips to aid the practitioner in setting dietary goals with the patient.

22
Q

Food Frequency Questionnaire:

A

Usually covers food intake over the period of a month. Often used in combination with the 24-hour recall, it is the quickest way to determine nutritional deficiencies and excesses. Rapid Eating and Activity assessment for Patients (REAP) is a brief validated questionnaire that assesses diet related to the Food Guide Pyramid and the 2000 U.S. Dietary Guidelines. REAP includes questions to assess intake of whole grains; calcium-rich foods; fruits and vegetables; fat; saturated fat and cholesterol; sugary beverages and foods; sodium; alcoholic beverages; and physical activity. REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and how willing the patient is to make changes to eat healthier. Patients can either fill out the instrument in the waiting room or have it sent home to complete before their appointment. The REAP Physician Key includes sections on patients at risk, further evaluation and treatment as well as counseling points/further information for each major dietary area.

23
Q

Signs of Dyslipidemia and Atherosclerosis

A

Changes associated with dyslipidemia:
Corneal arcus, xanthelasmas, acanthosis nigricans

Changes associated with atherosclerosis:
Decreased peripheral pulses, carotid bruit

24
Q

The ABCDE of Suspicious Skin Lesions

A
Asymmetry
Border irregularity
Color non-uniform
Diameter > 6 mm
Evolution or change over time
25
Q

Smoking Interventions

A

Most smokers quit multiple times before being truly successful. It is helpful to view tobacco abuse as a chronic disease and continue to work with smokers who relapse.

The annual quit rate for smokers without any medical interventions is about 2% to 3% per year.

Interventions that improve quit rates:
1. Quit rates are highest when patients are engaged in a group setting.
2. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 to 3 times the placebo quit rate.
3. When combined with medication, a series of one-on-one counseling sessions (as in a physician’s office)
enhances quit rates.
4. Providing practical problem-solving skills, assistance with social supports, and use of relaxation/breathing techniques can increase quit rates.

Choosing medication to assist with smoking cessation:
Many physicians prefer prescribing bupropion to help smokers quit. Due to side effects, varenicline is often reserved for those that have failed bupropion or if a patient specifically requests it.

26
Q

Smoking Cessation Strategies

A

When a patient is ready to quit smoking:
1. Set a quit date
2. Give instructions for taking bupropion
–Start one week before the quit date with one pill a day for the first three days, then increase to one pill twice a day, morning and evening.
–After another four days, stop smoking and continue on the pills twice a day.
–Add nicotine gum for bad cravings, if needed.
–After about two months on the pills, gradually stop.
3. Provide other smoking cessation resources
1-800-QUIT NOW
www.smokefree.gov

Note: According to studies, it is easier to quit smoking if you do so with a partner!

27
Q

Weight Loss Counseling

A
  1. Target a realistic weight goal.
  2. Reduce calories consumed and increase calories burned.
  3. Eliminate soft drinks; drink water instead.
  4. Eat five servings of fruits and vegetables.
  5. Meet with a dietitian.
28
Q

Target heart rate calculation:

A

THR = (220 - age) * 0.7-0.8

There is a fairly good correlation between THR and perceived exertion, so after measuring for THR with exercise several times, patients can rely on perceived exertion to gauge their level of exercise.

Using the Borg perceived level of exertion scale, patients should exercise to a level of 12 to 14 (on a scale of 6-20)

The U.S. Department of Health and Human Services recommends that men participate in at least 150 minutes of moderate-intensity aerobic exercise per week, as well as muscle strengthening at least twice per week.

29
Q

Managing High Risk for ASCVD Event

A

Appropriate steps to manage high risk for an ASCVD event include: starting aspirin and begining a moderate-to high-intensity statin.

An exercise stress test can be considered to further evaluate for the presence of coronary atherosclerosis in a high-risk man, particularly if he were planning to begin a vigorous exercise program. If he had symptoms of coronary artery disease, further evaluation with stress testing would be indicated.

HS CRP is a minor risk factor for ASCVD, which might be helpful if there was clinical uncertainty after assessing risk using the Pooled Cohort Equations. Similarly, EBCT may help stratify those at intermediate risk.

30
Q

Approach to ECG Interpretation

A
  1. Examine rate, PR interval, QRS, duration, and QT interval.
  2. Look for abnormalities in P waves.
  3. Assess axis, R wave progression, presence of Q waves, and level of voltage.
  4. Look for ST depression or elevation and inverted T waves.
31
Q

ECG Changes That Suggest Coronary Artery Disease

A

Horizontal ST segment depression or downsloping ST segment
Suggests cardiac ischemia

Convex ST segment elevation
Suggests acute myocardial injury

Q waves that are greater than 25% of succeeding R wave and greater than 0.04 seconds
Indicate infarction

32
Q

Other ECG changes:

A

U waves are abnormal when greater than 1.5 mm in any lead, and are associated with bradycardia, electrolyte imbalance such as hypokalemia, hypercalcemia or hypomagnesemia, drug effect (digitalis, quinidine, procainamide), CNS disease, hyperthyroidism, left ventricular hypertrophy or mitral valve prolapse.

A short PR interval is seen in arrhythmias such as Wolff-Parkinson-White, AV junctional rhythm with retrograde P wave conduction, or Lown-Ganong-Levine.