Case Files 1-6 (C) Flashcards
Screening tests for cardiovascular conditions
- Blood pressure measurement (HTN)
- Lipid measurement (dyslipidemia)
Recommendations for:
Influenza vaccine
Tetanus vaccine
Annually and every 10 years, respectively
Intervention designed to prevent a disease before it occurs
Primary prevention
Examples:
Statin medication to reduce LDL in order to lower the risk of CAD
Removal of colon polyps to prevent the development of colon cancer
Intervention intended to reduce the recurrence or exacerbation of a disease
Secondary prevention
Example:
Use of a statin medication after a person has had a MI
Criteria for effective screening
- Disease should be of high enough prevalence to make the effort worthwhile
- Time frame during which the person is asymptomatic, but during which the disease/risk factor can be identified
- Available test that sufficient sensitivity and specificity, is cost-efective, and is acceptable to patients
- Must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality
Gold standard for clinical preventive medicine
USPSTF
(United States Preventive Services Task Force)
USPSTF grades
A: offer/provide this service
B: offer/provide this service
C: offer/provide only if there are other considerations that support offering/providing
D: discourage use of this service
I: insufficient evidence
When should screening begin for lipid disorders?
Level A:
Men >35
Women >45
Level B:
Adults >20 who are at increased risk for cardiovascular disease
Screening recommendation for abdominal aortic aneurysm
Level B for men 65-75 who have smoked at any point
Level C (no recommendation) for men who have never smoked
Level D for women, regardless of smoking status
Screening for colorectal cancer
Men and women older than 50
FOBT annually, sigmoidoscopy every 3-5 years, and colonoscopy every 10 years
*An abnormal FOBT or sigmoidoscopy leads to the performance of a colonoscopy
Tdap recommendation
All adults between 19 and 65 should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis
Pneumococcal polysaccharide vaccination
Recommended as a single dose for all adults >65
*Recommended at a younger age for adults who are alcoholics/smokers, have chronic cardiovascular/pulmonary/renal/heptic disease, diabetes, an immunodeficiency, or who are functionally asplenic
62M with recently diagnosed emphysema presents to your office for a routine exam. He has not had any immunizations in more than 10 years. Which immunizations would be most appropriate for this individual?
Tdap
Pneumococcal (d/t chronic lung disease)
Influenza
Two most common causes of dyspnea and wheezing in adults
- COPD
- Asthma
Presents earlier in life, may or may not be associated with cigarette smoking, and is characterized by episodic exacerbations with return to relatively normal baseline lung functioning
Asthma
Presents in midlife or later, is usually the result of a long history of smoking, and is a slowly progressive disorder in which measured pulmonary functioning never returns to normal.
COPD
Mainstays of medical therapy for both asthma and COPD
- Oxygen
- Bronchodilators
- Steroids
Cough and sputum production on most days for at least 3 months during at least 2 consecutive years
Chronic bronchitis
Shortness of breath caused by the enlargement of respiratory bronchioles and alveoli (destruction of lung tissue and elastin)
Emphysema
Pink puffer: pink from polycythemia (2/2 chronic hypoxia), enlarged chest b/c lungs cannot deflate, and puffing because slow breaths = less obstruction
A rare cause of COPD that should be considered when emphysema develops at younger ages (<45), especially in nonsmokers
α1-antitrypsin deficiency
Pathologic changes in COPD
Mucous gland hypertrophy with hypersecretion, ciliary dysfunction, destruction of lung parenchyma, and airway remodeling
By the time dyspnea develops, lung function has been reduced by about half and the COPD has been present for years
Barrel Chest + Distant Heart Sounds
COPD
A result of hyperinflation of the lungs
FVC and FEV1 in COPD
Both the FVC and FEV1 are reduced, but the ratio of FEV1 to FVC is less than 0.7
*Reversibility is defined as an increase in FEV1 of greater than 12% or 200 mL
- Mild: FEV1 > 80*
- Moderate: FEV1 50-80*
- Severe: FEV1 30-50*
- Very Severe: FEV1 < 30*
Treatment for:
Mild COPD (FEV1 >80%)
Moderate COPD (FEV1 50-80%)
Severe COPD (FEV1 30-50%)
Very severe COPD (FEV1 <30%)
Mild: short-acting bronchodilators
Moderate: long-acting bronchodilators
Severe: inhaled steroids
Very severe: long-term oxygen therapy and consider surgical interventions
Albuterol
Ipratropium
Short-acting bronchodilators for Stage I COPD
Albuterol = β2-agonist
Ipratropium = anticholinergic
Inhaled medications are preferred over oral
Salmeterol
Tiotropium
Long-acting bronchodilator for Stage II COPD
Salmeterol = inhaled β2-agonist
Tiotropium = inhaled anticholinergic
Fluticasone
Triamcinolone
Mometasone
Inhaled steroids for Stage III COPD
They do not affect the rate of decline of lung function, but do reduce the frequency of exacerbations. Long-term treatment with oral steroids is not recommended (use inhaled).
Should also consider when seeing a patient with suspected acute exacerbation of COPD
Pulmonary embolism
CHF
MI
*Systemic steroids shorten the course of exacerbation and may reduce the risk of relapse (40 mg prednisolone for 10-14 days is recommended)
59M with a known history of COPD presents with worsening dyspnea. On exam he is afebrile. His breath sounds are decreased bilaterally. He is noted to have JVD and 2+ pitting edema of the lower extremities. What is the most likely cause of his increasing dyspnea?
Cor pulmonale
AKA right heart failure due to chronically elevated pressures in the pulmonary circulation
45M presents with sudden onset of monoarticular joint pain. The first diagnosis that needs to be excluded is…
Infected Joint
Cartilage can be destroyed within the first 24 hrs of infection
Most gout attacks occur between the ages of ___ and ___ in men, with a later onset in postmenopausal women (___ -___ years of age)
30-50 men
50-70 women
Exacerbating factor for gout (anything that may induce hyperuricemia):
-Alcohol, trauma, surgery, large meals (high in purines such as red meat, liver, or seafood), thiazide diuretics
Joint Aspirate:
WBC 2000-60,000 w/ <90% neutrophils
vs
WBC 100,000 w/ >90% neutrophils
Crystal-induced
(must culture to rule out a coexisting infection)
Septic Joint
Monosodium Urate (MSU) Crystals
Gout
Needles and strong negative birefringence
Rod-shaped, rhomboid, weakly positive
Calcium pyrophosphate dehydrate
Seen by electron microscopy, cytoplasmic inclusion that are nonbirefringent
Calcium hydroxyapatite
Bipyramidal appearance, strongly positive birefringence; seen mostly in end-stage renal disease patients
Calcium oxalate
Condition of excess uric acid leading to deposition of MSU crystals in joints
Gouty Arthritis
Crystal analysis: rod-shaped, rhomboid, weakly positive birefringent
Pseudogout: calcium pyrophosphate dehyrdate crystals
Podagra
Classic presentation of gout (swelling and pain, accompanied by erythema and warmth, involving the metatarsophalangeal joint of the first toe)
What will the uric acid levels be during an acute attack of Gout?
Normal or low (likely as a result of the existing deposition of the urate crystals)
Uric acid levels are useful in monitoring hypouricemic therapy between attacks
An infection involving one joint is usually…
Chronic monarticular or 2-3 joints…
More than 3 joints…
1 joint = bacterial (usually knee, hip, or shoulder)
chronic or 2-3 = fungi of mycobacteria
acute polyarticular (more than 3) = endocarditis or disseminated gonoccal infection
Rheumatoid arthritis patients are predisposed to what type of joint infections?
Staph aureus
Due to chronic inflammation + steroids
HIV positive patients think H influenza
IV drug users think Pseudomonas
How does ROM differ between patients with septic joint vs patients with cellulitis?
septic = very limited ROM
cellulitis/bursitis/osteomyelitis = maintained ROM
What lab tests may be abnormal in a patient with RA?
+ RF and anti-CCP
↑ ESR and CRP
Anemia, Thrombocytosis, and low Albumin
*the level of hypoalbuminemia usually correlates with the severity of the disease; anti-CCP is more specific than RF; a positive anti-CCP may precede the clinical manifestation of disease by many years
A 44-year-old woman has a 5-month history of malaise and stiff hands in the morning that improve as the day goes by. She notes that both hands are involved at the wrists. Initial lab tests show an elevated ESR and high positive anti-CCP. Which treatment is most likely to lead to the best long-term disease outcome for this patient?
Methotrexate (DMARD)
Would alter the natural history of the disease rather than just treating the symptoms
A 52-year-old man complains of bilateral knee pain for about 1 year. He is noted to have a BMI of 40. Other than weight loss, what is the best initial therapy?
Ibuprofen (NSAID)
A 35-year-old man with HTN presents with the sudden onset of right big toe pain. What medication was he taking that predisposed him to this condition and how would you treat it?
HCTZ (used to treat HTN) can increase the risk of gouty arthritis.
Treat with Colchicine.
Indications for ultrasound in pregnancy
According to ACOG, an ultrasound is not mandatory in routine, low-risk prenatal care
Indicated for: uncertain gestational age, size/date discrepancies, vaginal bleeding, multiple gestations, or other high-risk situations
Laboratory studies recommended at the initial prenatal visit
CBC
HBsAg
HIV testing
Syphilis screening with RPR
UA and UCx
Rubella antibody
Bloody type and Rh status w/ antibody screen
Pap smear
Cervical swab for gonorrhea and Chlamydia
Risk to the pregnancy based on the radiation exposure from dental x-rays
Risk for the baby is increased once the radiation exposure is greater than 5 rad; the radiation exposure from routine dental x-rays is 0.00017 rad
Optimal time for the trisomy screen
10-13 weeks: nuchal transluceny + serum hCG and PAPP-A
16-18 weeks: triple (ACG, hCG, estriol) or quadruple (triple + inhibin-A)
For low-risk women, what is recommended to reduce the risk of neural tube defects?
400 to 800 μG of folic acid daily
*Women with DM or epilepsy should take 1 mg and a woman who has had a child with a NT defect should take 4 mg
Naegele’s rule
To determine EDD, subtract 3 months from LMP and add 7 days
When should heart tones be obtainable using a handheld Doppler fetoscope?
10 weeks
When should RhoGAM be given?
1 dose at 28 weeks gestation or within 72 hours of trauma, complication, procedure, or delivery
*Antibody screen: Lewis lives, Kell kills, Duffy dies
What is the most common cause of a false-positive serum screen (i.e., false-positive trisomy screen)
Incorrect gestational age dating
Triple screen has a sensitivity of 65-69% and a specificity of 95%
*Although the risk for trisomy 21 increases with maternal age, an estimated 75% of affected fetuses are born to mothers younger than age 35 at time of delivery
When should mother’s be screened for gestational diabetes?
24-28 weeks with a 1-hour 50-g glucose challenge
(a value above 140 mg/dL is considered abnormal, and a value of 200 mg/dL is generally diagnostic)
If 1-hour is positive, then do 3-hour 100-g glucose challenge
A 28-year-old woman with a history of epilepsy presents for a preconception consultation visit. What is the most important advice to give this patient?
She should receive 1 mg of folic acid supplementation daily to help prevent neural tube defects
A 28-year-old G1P0 woman at 16 weeks’ gestation is noted to be Rh negative. What is the most appropriate next step for this patient?
Indirect Coombs test (antibody screen)
If the antibody screen is negative, there is no isoimmunization, and RhoGAM is given at 28 weeks’ gestation and again at delivery if the baby is confirmed as Rh positive
Reduction or loss of vision in one eye from lack of use
Amblyopia
The most common cause of amblyopia
Strabismus (aka Ocular misalignment)
How is failure to thrive defined?
Weight below the 3rd or 5th percentile for age
OR
Decelerations of growth that have crossed two major growth percentiles in a short period of time
What two tests do all states require for newborns?
Testing for phenylketonuria (PKU) and congenital hypothyroidism
Early treatment can prevent the development of profound mental retardation
Most common cause of anemia in children
Iron deficiency (kid who drinks a lot of cow’s milk)
↓H&H, ↓ferritin, ↑TIBC
Treat with oral ferrous salts
Presence of red reflexes
Helps to rule out the possibility of congenital cataracts and retinoblastoma
How to test for strabismus?
Asymmetric light reflex
Cover-uncover test (child focuses on an object with both eyes and the examiner covers one eye. Strabismus is suggested when the uncovered eye deviates to focus on the object)
Leading cause of death in children older than age 1 year
Accidents and injuries (all states now require car seats)
A child should sit in a rear-facing car seat until they are both 1 year old and weigh at least 20 lbs
A child may use a booster-type seat when they weigh more than 40 lbs
Leading cause of death of infants younger than 1 year
Sudden Infant Death Syndrome (SIDS)
Ways to reduce risk: sleep on back with nothing else in the crib and pacifiers
Inflammation of the nasal passages caused by allergic reaction to airborne substances
Allergic Rhinitis
Perennial vs Seasonal vs Occupational
*Response to treatment with antihistamines supports the diagnosis of allergic rhinitis
Common PE findings in a patient with allergic rhintis
Allergic shiners (dark circles around the eyes)
Allergic salute (horizontal crease across the lower half of the nose)
Thin and water nasal secretions
Swollen/boggy, pale nasal turbinates
Dennie-Morgan lines (prominent creases below the inferior eyelid)
Cobblestoning of the posterior pharynx
Diphenhydramine
Chlorpheniramine
Hydroxyzine
First-generation anti-histamines
Side effects include sedation and the anticholinergic effects (dry mouth, dry eyes, blurred vision, and urinary retention)
Loratadine
Desloratadine
Fexofenadine
Cetirizine
Second-generation antihistamines (look for -dine)
Much less penetration into the CNS, resulting in a lower incidence of sedation as a side effect (except for cetirizine). They also have fewer anticholinergic effects.
Pseudoephedrine
Decongestant (α-adrenoreceptor agonist)
Constrict blood vessels in the nasal mucosa and reduce the overall volume of the mucosa
Side effects: tachycardia, tremors, insomnia, and rebound hyperemia/worsening of symptoms (with chronic use)
First-line therapy for the long-term management of mild-moderate persistent symptoms of allergic rhinitis
Corticosteroid nasal sprays (eg, Flonase)
Reach maximal effectiveness after 2-4 weeks of use
Zafirlukast
Montelukast
Zileuton
Leukotriene inhibitors
Indicated for both allergic rhinitis and for maintenance therapy for persistent asthma
Why are oral corticosteroid reserved only for severe allergies?
Suppression of the HPA axis and hyperglycemia
Long-term use can lead to peptic ulcer formation, increased susceptibility to infection, poor wound healing, and the reduciton of bone density
The most commonly isolated organisms in bacterial conjunctivitis are…
Staph, Strep, Haemophilus, Moraxella, and Pseudo
*Epidemic keratoconjunctivitis (pink eye) is highly contagious and spread by person-to-person contact or fomites (most common cause is adenovirus)
A 30-year-old man has both mild persistent asthma and chronic environmental allergies. Which medication is indicated for the management of both conditions?
Oral montelukast (leukotriene modifier)
