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Block 2 Family Med Flashcards

1
Q

When seeing a patient for a general physical, what mnemonic can be used to remember the important components?

A 
RISE
R: Risk factors for disease identified in Hx and Physical
I: Immunizations
S: Screening Tests
E: Education
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2
Q

What are the most common causes of death in a 55 y/o male in the USA?

A 
Heart disease
Cancer
Chronic lung disease
Accidents
Stroke
Alzheimer's
Diabetes
Influenza and Pneumonia
Kidney disease
Suicide
(These are stats for all adults in USA)
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3
Q

How are Selenium and Homocysteine associated with CVD?

A

Low Selenium and High homocysteine are associated with increased risk for CVD

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4
Q

What are some Sx of ASCVD that should be asked for during an H&P?

A

Claudication and Angina with exercise as both can be signs of atherosclerosis

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5
Q

What is the only drug class recommended by the AHA and ACC?

A

HMG Co-A Reductase inhibitors

Statins

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6
Q

What are the 4 indications for statin use?

A

1: Individuals with clinical ASCVD (ACS, Stroke or TIA, PVD)–High intensity statins
2: Pt’s 40-75 y/o q DM (consider outside this age range based on risk and preference)–Moderate intensity statins unless risk greater than 7.5%
3: Pt’s over 21 y/o q LDL above 190 (generally genetic condition)–High intensity statin
4: Pt’s 40-75 q 10 year risk above 7.5%–Moderate or High intensity statin

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7
Q

Trade name for Atorvastatin?

A

Lipitor

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8
Q

Trade name for Rosuvastatin?

A

Crestor

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9
Q

Trade name for Simvastatin?

A

Zocor

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10
Q

Trade name for Pravastatin?

A

Pravachol

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11
Q

Trade name for Lovastatin?

A

Mevacor, Altoprev

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12
Q

Trade name for Fluvastatin?

A

Lescol

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13
Q

Trade name for Pitavastatin?

A

Livalo

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14
Q

What are the high-intensity statins?

A

Lipitor 40-80mg

Crestor 20-40mg

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15
Q

What are the moderate intensity statins?

A

Lipitor 10-20mg
Crestor 5-10mg
Other statins at their higher dose

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16
Q

What are the major risk factors for ASCVD?

A

Age: worse with age
Gender: ASCVD is the leading cause of death in men and women, but the age-related increase in risk begins 10 years earlier in men than in women (over 45 for men, over 55 for women)
HTN: regardless of how well it is controlled
Systolic BP: most recent value is a risk factor alone used in several predictive formulas
Cholesterol: High total and low HDL lead to increased risk
DM: High risk
Smoking: Single greatest environmental factor

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17
Q

What are some other risk factors for ASCVD that can be considered beyond the major ones?

A

Family Hx: first degree relative having premature CVD (less than age 55 for men and 65 for women)
HS-CRP: highly sensitive c-reactive protein
Coronary artery calcium: CT scan of arteries provides a score
ABI: ankle brachial index very helpful to identify peripheral vascular disease, abnormal when less than 0.9

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18
Q

What is the new risk calculator for cholesterol that came out with the new 2013 guidelines?

A

Pooled Cohort Equations

Replaces the Framingham Risk Score which drew conclusions from a study of one town of white individuals in the 1950’s

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19
Q

How can you increase HDL?

A

Exercise
Quit smoking
Olive oil
Avoid trans fats (they increase LDL and lower HDL, found in shortening, fried foods, and margarin)
Drugs: niacin, gemfibrozil, simvastatin, rosuvastatin
Drugs specific to increasing HDL have not been shown to decrease heart attacks

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20
Q

According to Mayo clinic, what are the at risk and desirable levels for HDL?

A

Men: at risk less than 40, desirable above 60
Women: at risk less than 50, desirable above 60

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21
Q

What are the three C’s of addiction?

A

Compulsion to use
Lack of control
Continued use despite adverse consequences

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22
Q

What are the 5 A’s to help counsel behavior change?

A 
Ask or Address the behavior needing change
Assess interest to change
Advise methods to change
Assist with motivation
Arrange follow-up
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23
Q

What is the annual quit rate for smokers without medical help?

A

2-3% per year

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24
Q

How do smoking quit rates change when oral medications are used vs placebo?

A

The quit rate of patients on the medications were 1.5-3X higher than placebo

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25
Q

What oral medications are used to quit smoking?

A

Bupropion (Wellbutrin) is often the first-line agent

Varenicline (Chantix) is used second because of higher side effects

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26
Q

How much alcohol should a person be drinking on a daily basis?

A

Recommended to not exceed 1 per day for women and 2 for men

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27
Q

What are the effects of moderate alcohol use?

A

Slight increase in HDL

Potential to prevent clotting

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28
Q

What does the AHA recommend as far as the heart benefits of drinking alcohol?

A

It does not currently recommend any form of alcohol in order to get the benefits for the heart.
One reason is that you cannot predict who will have difficulty with alcohol dependance and it is therefore better to not encourage anyone to start drinking.

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29
Q

What has research shown as far as the health benefits of red wine daily?

A

Some studies have shown a decrease in mortality due to heart conditions in those drinking wine. However, it is unclear whether this benefit is truly from the alcohol, or if it is from flavonoids and other antioxidants or from other lifestyle factors like diet and exercise.
There is no clear conclusive evidence that wine is a positive thing for the heart.

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30
Q

What chronic diseases can be affected by alcohol use?

A 
Heart failure
Cardiomyopathy
Diabetes
HTN
Arrhythmia
Obesity
Hypertriglyceridemia
Individuals on certain meds
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31
Q

What are the CAGE questions used to screen for alcohol dependence issues?

A

Have you ever felt the need to Cut down on your drinking?
Have you ever felt Annoyed by criticisms of your drinking?
Have you ever had Guilty feelings about your drinking?
Have you ever taken an Eye Opener?

If Yes to any of above, further questions are warranted to further determine dependence. Also, need to get an accurate estimate of amount ingested.

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32
Q

When screening for intimate partner violence, what is the SAFE protocol of questions?

A

(Safety) Do you feel safe in your relationship?
(Afraid) Have you ever been in a relationship where you have been hurt, injured, or afraid?
(Friends) Are your friends and family aware that you have been hurt? Could you tell someone and would they be able to give you support?
(Emergency Plan) Do you have an emergency plan and a safe place to go and the resources you need in case of an emergency?

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33
Q

What are the ranges/categories of BMI?

A 
18.5-24.9 Normal
25-29.9 Overweight
30-34.9 Obese
35-39.9 Very Obese
40+ Morbid or extreme obesity
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34
Q

What are some clinical signs of dislipidemia and atherosclerosis?

A

Dislipidemia: corneal arcus, xanthelasmas, acanthosis nigricans
Atherosclerosis: decreased peripheral pulses, carotid bruits

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35
Q

What are the characteristics to look for when screening for skin cancer?

A 
ABCDE
A: Asymmetry
B: Irregular border
C: Non-uniform color
D: Diameter over 6mm
E: Evolution, or change with time
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36
Q

What are the live vaccines and who should they not be given to?

A

Zoster, MMR, OPV, Varicella

Not given to immune compromised or individuals around them, or pregnant women

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37
Q

What are recommendations for Zoster vaccine?

A

One dose to individuals over age 60

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38
Q

How can a test with a high sensitivity and specificity have a low PPV?

A

There will be more false positives the less prevalent a disease is. Remember this because a test with a sensitivity of 98% and specificity of 95% can still only have a PPV of 16% because of low prevalence of the disease.

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39
Q

What are 2 questions that can be used to screen for depression?

A

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

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40
Q

What is the USPSTF stance on PSA screening for prostate cancer?

A

They recommend against it.

Other organizations recommend making an informed decision that is personal.

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41
Q

What are some preliminary studies showing about number needed to treat as far as death prevention in prostate screening and treatment?

A

To prevent 1 death at 11 years out, you would need to screen over 1,000 people and treat 37 cases of cancer.

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42
Q

What is the most common precancer in terms of the skin?

A

Actinic Keratosis

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43
Q

How many people will develop skin cancer over their lifetime?

A

40-50%

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44
Q

What is the most common form of skin cancer?

A

Basal Cell Carcinoma

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45
Q

What skin cancer is the least common, but accounts for the most deaths?

A

Melanoma

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46
Q

How often should lipids be tested in an unsymptomatic patient to screen for ASCVD?

A

Every 4-6 years for all patients over 21

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47
Q

Which lipids are affected by fasting vs fed state?

A

Triglycerides will be high in the fed state, otherwise total cholesterol, HDL, LDL do not vary much

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48
Q

According to the USPSTF, what are the indications for DM screening in an unsymptomatic patient?

A

Screening can be performed in patients with BP over 135/80

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49
Q

According to the ADA, who should be screened for DM?

A

Patients over 45 with one or more additional risk factor

50
Q

Indications for cardiac stress testing

A

Male over 45 with risk factors:

High Chol., HTN, smoker, family Hx of premature heart disease

51
Q

What does a horizontal ST segment or downsloping ST segment indicate?

A

Suggests cardiac ischemia

52
Q

What does convex ST segment elevation indicate?

A

Acute myocardial injury

53
Q

What does an abnormal Q wave look like and indicate?

A

Greater than 25% of succeeding R wave and greater than 1 box or 0.04 seconds
Indicates infarction

54
Q

What is a U wave and what can it mean?

A

The wave between the T and P waves

Assoc. with: bradycardia, low K+ or Mg+, high Ca2+, drug effects, hyperthyroid, LVH, and mitral prolapse

55
Q

When would you see a short PR interval?

A

Wolf-Parkinson-White

AV junctional rhythm with retrograde P wave conduction

56
Q

What is a smoking cessation regimen with use of bupropion?

A

Start pills 1 week before quit date
Take 1 pill per day for three days, then two per day for 4 days
Stop smoking all at once
Use nicotine gum for cravings
After 2 months, slowly come off the medication

57
Q

What kind of diet can significantly lower lipids?

A

Low-carb

58
Q

When might bariatric surgery be indicated for weight-loss?

A

Patients with BMI> 35 with complications from obesity and have failed diet and lifestyle interventions

59
Q

What should a preventive visit include?

A

Comprehensive H&P
Anticipatory guidance and risk factor identification and intervention
Ordering of immunizations, labs, diagnostic tests
Addressing insignificant problems

60
Q

What is the peak HR and target HR for an individual trying to exercise to lose weight?

A

Peak: 220-age
THR: (220-age) x 0.7-0.8

61
Q

What dietary recommendations lower Heart Disease risk?

A

Eating fatty fish 2 x per week: mackerel, lake trout, salmon, sardines, albacore tuna
These provide Omega-3’s
Also, the oils from tofu, soybeans, canola, walnuts, flax seed can also help lower risk

62
Q

What are Sx of prostate cancer?

A 
Urinary frequency
Urinary urgency
Incomplete urinary emptying
Hematuria
Back pain
Weight loss
63
Q

What is the leading cause of death in patients with diabetes? What is their incidence rate for this compared to the general population?

A

Cardiovascular disease including cerebrovascular disease
Diabetics are 2-4 times more likely to have these conditions
Having DM is equivalent in risk as having a previous MI

64
Q

What is the most common cause of new cases of blindness in working age adults?

A

Diabetes

In the first 5 years after Dx with DMII, up to 40% will have retinal damage

65
Q

What is the most common cause of end stage renal disease?

A

Diabetes

66
Q

How can hypothyroidism complicate DM care?

A

Hypothyroidism can lead to fatigue, depression, dyslipidemia

67
Q

What are two acute decompensation states for DM type I and II?

A

DMI: classically has DKA
DMII: can also cause DKA if the insulin deficiency is great enough, more commonly they develop HHS (Hyperosmolar Hyperglycemic State)

68
Q

What are the mortality rates between HHS and DKA in DM?

A

HHS: 15% ave, up to 20-30% with severe infection
DKA: 2% in less than 65y, up to 22% over 65y

69
Q

What are the defining features of HHS?

A

Significant dehydration (up to 9L low on fluids, fluid replacement is key Tx)
No acidosis present
Plasma glucose often over 600
Ketones absent or only mildly elevated because there is enough insulin to suppress production

70
Q

What can precipitate HHS in DMII?

A

Infections like pneumonia and UTI combined with decreased fluid intake most common
MI, Stroke, PE can also do it

71
Q

How do the ADA and USPSTF differ in recommendations for DM screening?

A

ADA: over 45 in asymptomatic adults or, if BMI over 25 and have additional risk factor

USPSTF: patients with sustained BP over 135/80 whether controlled or not

72
Q

What is the most effective treatment strategy for pre-diabetics?

A

Education and coaching on diet and exercise. These patients had a 58% reduction in risk as compared to those only given info on diet and exercise and given metformin who only had a 31% decrease in risk.

73
Q

How many people in US have DM vs pre-DM?

A

26 Million have it with many undiagnosed

57 Million are pre-DM

74
Q

What is the hallmark of proliferative retinopathy?

A

Neovascularization because hypoxia and ischemia are driving it

75
Q

What should a diabetic foot exam consist of?

A

Test for loss of protective sensation: vibration, pin-prick, achilles reflex
Assess pulses in the foot as decreased flow is strongest risk factor for delayed ulcer healing and eventual foot amputation
Visual inspection: hair loss and temp change are indications of vascular insufficiency, look for breaks in the skin from accidents or poor footwear, look for pressure calluses and bony deformities that are precursors to ulceration

76
Q

What are the reasons for ordering lab tests in follow-up diabetic care?

A

1) Monitor control
2) Assess end-organ damage
3) Monitor SE’s of Tx
4) Look for management complications

77
Q

How often should A1c be checked in a diabetic?

A

If well controlled, 2x per year

If changing therapy or poor control, 4x per year

78
Q

How is nephropathy monitored in DM?

A

Spot urine albumin/creatinine ratio for microalbumin

Serum creatinine and GFR to monitor chronic kidney disease

79
Q

What are some side effects of metformin?

A

Renal insufficiency

Decreased B12 levels

80
Q

When is TSH screening indicated in relation to diabetes?

A

Type I DM
Newly diagnosed dyslipidemia
Women over 50 as part of comprehensive DM labs

81
Q

What is the most important modifiable cause of premature death?

A

Smoking

82
Q

What are the 4 agents recommended to lower BP?

A

ACE
ARB
Ca channel blocker
Thiazide diuretic

It is no longer a recommendation to preferentially pick an ACE or ARB over the others in DM patients.

In blacks patients, a Ca channel blocker or thiazide should be used.

In all patients with CKD, an ACE or ARB should be used.

Beta and alpha blockers are no longer considered first-line options for HTN.

83
Q

What diet has been shown to help prevent CVD?

A

Mediterranean diet
All patients should be recommended this diet: veggies, fresh fruits, whole grains, lean meats, legumes, tree nuts, non-tropical vegetable oil, avoid sweets and red meats

84
Q

What dietary guidelines should be given to help lower LDL?

A

Limit saturated fat intake: animal fats from meat & dairy, coconut and palm oil

Limit trans fat: partially hydrogenated oils, oil from frying, vegetable shortening, pre-packaged baked goods and chips

85
Q

How should dyslipidemia be managed in a DM patient?

A

Age 40-75 with LDL 70-189: moderate intensity statin
Age 40-75 with 10 year risk of CVD over 7.5%: high intensity statin
Age under 40 or over 75 should be considered on individual basis
Over 21 with LDL over 190 should have statin regardless of DM status
Lifestyle changes for everyone: lose weight, exercise, eat less fat

86
Q

Aspirin and DM

A

ADA: baby aspirin given to PT’s q DM and previous Hx of CVD as secondary preventive measure, given as primary preventive measure in DM patients with increased risk such as men over 50 and women over 60

USPSTF: weigh risks and benefits for men 45-79 and women 55-79 in regard to CVD and stroke and gastric hemorrhage

87
Q

Name 3 sulfonylureas

A

Glyburide, Glipizide (2nd gen)

Glimepiride (3rd gen)

88
Q

What is Actos?

A

Pioglitazone

Thiazolidinedione

89
Q

What is Avandia?

A

Rosiglitazone

Thiazolidinedione

90
Q 
Describe the Thiazolidinediones:
Drugs
MOA
When used
SE's
A

-glitazones (Actos, Avandia)
MOA: cause changes in gene expression leading to increased uptake of FFA’s into adipose so other cells are more dependent on carb use for energy, affects PPAR gamma nuclear receptor
Use: PT’s who can’t tolerate metformin or sulfonylureas
SE: increased heart failure, edema, bone fractures

91
Q

What is Starlix?

A

Nateglinide

Meglitinide

92
Q

What is Prandin?

A

Repaglinide

Meglitinide

93
Q

Describe Meglitinides:
Drugs
MOA
SE’s

A

-glinides (Starlix, Prandin)
MOA: similar to sulfonylureas, binds ATP-dependent K+ channels in beta cells causing depolarization and opening of Ca++ channels which leads to increased insulin release
SE: weight gain, hypoglycemia

94
Q

What is Byetta?

A

Exanetide
GLP-1 analog
Given sub-Q

95
Q

What is Victoza?

A

Liraglutide
GLP-1 analog
Given sub-Q

96
Q

What is Trulicity?

A

Dulaglutide

GLP-1 analog

97
Q

Describe the GLP-1 analogs:
Drugs
MOA
SE’s

A

-tides (Byetta, Victoza, Trulicity)
MOA: incretin mimetics, stimulate insulin release and decrease glucagon release and slows gastric emptying, works same pathway as DPP-4 inhibitors but considered to be more potent
SE: considered less likely to cause hypoglycemia than insulin secretagogues like sulfonylureas and meglitinides,

98
Q

What is Januvia?

A

Sitagliptin

DPP-4 inhibitor

99
Q

What is Onglyza?

A

Saxagliptin

DPP-4 inhibitor

100
Q

What is Tradjenta?

A

Linagliptin

DPP-4 inhibitor

101
Q

Describe the DPP-4 inhibitors:
Drugs
MOA
SE’s

A

-gliptins (Januvia, Onglyza)
MOA: prevents breakdown of GLP-1 causing increased insulin release, decreased glucagon, decreased gastric emptying
SE: HA, nausea, heart failure, hypersensitivity, joint pain

102
Q

When should DM patients be referred for ophthalmology evaluation?

A

DM type 1: 5 years after Dx and yearly

Type 2: at time of Dx and every year thereafter

103
Q

What molecules are released by stress that lead to HTN?

A

Norepinephrine and Angiotensin II

104
Q

How does PVD change the toenails?

A

Decreased blood to the extremities leads to thick nails and loss of hair

105
Q

What is an abdominal panniculus?

A

Overhanging flap of skin and fat

106
Q

How are electrolytes affected by Thiazides?

A

Can cause hyponatremia

107
Q

What is the cheapest and among the most effective antihypertensive agents and what doses are most effective at reducing negative outcomes?

A

Thiazide diuretics, about $4.30 per month

Lower doses of the drug are more effective than higher doses

108
Q

What are the first and second best prognostic factors for death in all people?

A

1) Age: the older you are, the more likely you are to die

2) Left Ventricular Hypertrophy

109
Q

How do ACE’s and ARB’a affect serum potassium?

A

Can cause hyperkalemia

110
Q

What HTN meds can affect serum creatinine and how?

A

ACE, ARB, Diuretics can elevate serum creatinine

111
Q

What is the most effective lifestyle modification for lowering BP?

A

Weight loss
Second is DASH eating plan
Third is Sodium reduction
Fourth is exercise

112
Q

Special considerations for Thiazide diuretics

A

May exacerbate urinary incontinence or cause it
Doses above 25mg don’t improve morbidity or mortality
Monitor for hyponatremia
Avoid in gout patients
Start at lower doses in elderly
May slow demineralization of bones

113
Q

Special considerations for Beta blockers

A

Check initial EKG and pulse
Not necessary to avoid in diabetics as masking hypoglycemic events appears to not be true
Good in tachyarrhythmias and fibrillations, migraines, essential tremor, perioperative HTN
Avoid in asthma and 3rd degree heart block

114
Q

Special considerations with ACEI’s

A 
Monitor K+, Na+, Creatinine levels
Renal protective
Reduces microalbuminuria
First line agent in DM and kidney disease
Has direct heart remodeling effects
Up to a 35% rise in serum creatinine is acceptable after starting therapy
Cough and angioedema are common
Avoid in pregnancy
115
Q

Special considerations for ARB’s

A

Reduces micro and macroalbuminuria
Heart remodeling effects
Avoid in pregnancy
Less bradykinin production

116
Q

Special considerations for Ca channel blockers

A

Can be useful in Raynaud’s
Can help some arrhythmias
Often causes leg edema
Short acting blockers are CI in essential HTN and HTN urgency and emergency

117
Q

Special considerations for loop diuretics

A

Monitor electrolytes and creatinine

Start at low doses in the elderly

118
Q

Special considerations for aldosterone antagonists and K+ sparing diuretics

A

Can cause hyperkalemia

Low doses reduce morbidity and mortality in CHF but higher doses increase risk of sudden death

119
Q

Special considerations for alpha blockers in HTN

A

Not shown to reduce morbidity or mortality
Not included in recommended medications
Only used for hard to control patients as adjunct therapy

120
Q

What group of people is at an increased risk of angioedema from an ACE?

A

African Americans are 2-4 times more likely

This is why they are preferentially started on thiazides or CCBs first unless they have kidney disease

Rotations (11 decks)

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