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Case Files Flashcards

1
Q

Examples of primary prevention

A

Prevent disease; immunization, public health education, exercise/stress management, removal of polyp to prevent colon cancer

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2
Q

Examples of secondary prevention

A

Early detection of disease; mammography for breast cancer, eye exams for glaucoma

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3
Q

Examples of tertiary prevention

A

Therapeutic and rehabilitative measures; medications, rehabilitation programs for stroke patients, chronic pain management

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4
Q

What is needed for a effective screening of disease or health conditions? (6)

A

High enough prevalence, time frame during which a person is asymptomatic but RF or disease can be identified, sensitive> specific, cost effective, acceptable to patients, and there is an intervention that can be made during the asymptomatic period

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5
Q

USPSTF

A

United States Preventive Services Task Force; gold standard for screenings

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6
Q

Level A recommendation from USPSTF

A

There is high certainty that the net benefit of the intervention is substantial; offer or provide this service

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7
Q

Level B recommendation from USPSTF

A

There is high certainty that the net benefit of the intervention is moderate or moderate certainty that it is moderate to substantial; offer or provide this service

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8
Q

Level C recommendation from USPSTF

A

There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that there is no net benefit or harm; offer or provide the service only if there are other considerations that support offering or providing for the individual

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9
Q

Level D recommendation from USPSTF

A

There is moderate or high certainty that there is no net benefit or that the harms outweigh the benefits; discourage use of this service

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10
Q

Level I recommendation from USPSTF

A

There is insufficient evidence or the available evidence is of such poor quality that the balance of benefits and harms cannot be weighed and recommendations for or against the service cannot be made; if the service is offered patients should understand the uncertainty about the balance of benefits and harms

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11
Q

Level A cardiovascular screenings (3)

A
  • HTN screening with blood pressure in patients >18 y/o
  • Lipid disorders screening; non-fasting total cholesterol+HDL or fasting LDLs in men >35 and women >45
  • Myocardial infarction prevention; daily aspirin in men 45-79 y/o
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12
Q

Level B cardiovascular screenings (2)

A
  • Lipid disorders screening; patients with increased risk >20 y/o
  • AAA ultrasonography in men 65-75 y/o who have ever smoked
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13
Q

Level C cardiovascular screenings (1)

A

AAA screening for men who have never smoked

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14
Q

Level D cardiovascular screenings (2)

A
  • AAA screening for women who have never smoked

- Coronary artery disease screening in adults; routine ECG, exercise stress testing, CT scanning for coronary calcium

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15
Q

Level I cardiovascular screenings (3)

A
  • Coronary artery disease screening for adults at higher risk for coronary events
  • Peripheral artery disease and coronary artery disease screening in patients with ankle-brachial index (ABI)
  • Carotid artery stenosis screening in asymptomatic patients
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16
Q

Level A cancer screenings (1)

A
  • Colorectal cancer in men/women >50
    • Colonoscopy every 10 years
    • Flexible sigmoidoscopy every 3-5 years with or without occult blood testing
    • FOBT using guaiac cards on three consecutive bowel movements collected at home annually
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17
Q

Level B cancer screenings (1)

A

-Lung cancer in men/women 50-80 y/o with a >/= 30 year pack history who continue to smoke or who quit

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18
Q

Level D cancer screenings (3)

A
  • Testicular and pancreatic cancer in asymptomatic adults
  • Routine CXR for lung cancer
  • Prostate cancer screening using digital rectal exam or PSA
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19
Q

Level I cancer screenings (1)

A

-Bladder cancer screening in asymptomatic individuals

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20
Q

Level A other health conditions screenings (1)

A

-Tobacco cessation screening and counseling

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21
Q

Level B other health conditions screenings (4)

A
  • Alcohol misuse screening and counseling
  • Obesity screening using BMI; if >30, patients should be offered/referred for intensive multi-component behavioral intervention
  • DM2 screening for patient switch HTN or HLD
  • Depression screening IF there are mechanisms in place for accurate diagnosis, treatment and follow-up
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22
Q

Level I other health conditions screenings (2)

A
  • DM2 screening in asymptomatic adults

- Thyroid disease screening in asymptomatic individuals

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23
Q

Who should receive a Tdap shot/booster?

A
  • 19-65 y/o patients should receive booster Tdap instead of scheduled dose of Td due to increasing number of pertussis nationwide
  • Adults who have never received Tdap or have not received Td booster within the last 10 years
  • People who need increased protection against pertussis (healthcare workers, child care providers, or those having contact with infants
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24
Q

Who should receive the influenza vaccine?

A

Everyone >6 months old annually

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25
Q

Who should receive the pneumococcal polysaccharide (PPSV-23) and Pneumococcal conjugate (PCV-13) vaccine?

A
  • All adults >65 y/o
  • Previously unvaccinated adults younger than 65 in the presence of other immunocompromising or certain chronic medical conditions
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26
Q

Who should receive the hepatitis B vaccine? (7)

A
  • Health care workers
  • Those exposed to blood or blood care products
  • Dialysis patients
  • IV drug users
  • Individuals with multiple sexual partners
  • Men who have sex with men
  • Patients with diabetes
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27
Q

Who should receive the hepatitis A vaccine? (6)

A
  • Chronic liver disease
  • Patient using clotting factors
  • Occupational exposure to hepatitis A virus
  • IV drug users
  • Men who have sex with men
  • Travelers to endemic regions
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28
Q

Who should receive the varicella vaccine?

A
  • Those with no reliable history of immunization or disease
  • Seronegative for varicella immunity
  • Those at risk for exposure to virus
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29
Q

Who should receive the menigococcal vaccine?

A
  • College dormatory residents
  • Military recruits
  • Patients with certain complement deficiencies
  • Functional or anatomic asplenia
  • Travelers to endemic regions
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30
Q

Is counseling on exercise recommended? What are the benefits of exercising?

A
  • There are inconsistent results on whether counseling improves patient compliance but the benefits are clear and should be promoted
  • Exercising reduces the risk of cardiovascular disease, diabetes, obesity, and overall mortality
  • Even moderate amounts (walking 30 mins most days) has positive effects on health
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31
Q

What is the leading cause of morbidity and mortality among adults and how can we prevent it?

A
  • Motor vehicle accidents

- Counsel patients to wear seat belt

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32
Q

What routine blood tests and XRs are done at AHM visits?

A

There are no routine blood tests or XRs

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33
Q

What is the appropriate treatment of a COPD/dyspnea exacerbation?

A

Antibiotics, bronchodilators, systemic corticosteriods

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34
Q

What interventions can reduce the number of COPD exacerbations?

A

Smoking cessation, long-acting bronchodilator, inhaled corticosteriod, influenza and pneumococcal polysaccharide vaccination

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35
Q

Define chronic bronchitis

A

cough and sputum production on most days for at least 3 months during at least 2 years

36
Q

Define emphysema

A

SOB caused by the enlargement of respiratory bronchioles and alveoli by destruction of lung tissue

37
Q

What is the third leading cause of death in the US and what percent of adults does it affect?

A

COPD, 5%

38
Q

Define COPD

A

Airway obstruction that is not fully reversible, is usually progressive, and is associated with chronic bronchitis, emphysema or both

39
Q

What etiologies are associated with COPD?

A
  • Smoking
  • Secondhand smoke
  • Occupational exposure to dusts (mining, cotton, silica, plastics)
  • Chemicals
  • Fumes (welding, heavy metals)
40
Q

alpha1-antitrypsin deficiency

A

A rare cause of COPD more common in Caucasians that should be considered when emphysema develops at younger ages (

41
Q

Pathological changes in COPD

A

-Mucus gland hypertrophy with hypersecretion, ciliary dysfunction, destruction of the lung parenchyma, and airway remodeling resulting in narrowing of the airways, causing a fixed airway obstruction, poor mucous clearance, cough, wheezing, and dyspnea

42
Q

What is the initial symptom and primary presenting symptom of COPD

A

Cough is the initial symptom and dyspnea is the primary presenting symptom

43
Q

What is the lung function as measured by the FEV1 in patients who have COPD when dyspnea develops

A

FEV1 has been reduced by half and the COPD has been present for years

44
Q

What is the DDX for dyspnea?

A

CHF, COPD, asthma, interstitial lung disease, pneumonia, and psychogenic disturbances (anxiety)

45
Q

What does the physical exam of a patient with mild-moderate COPD look like?

A

If they are not having an exacerbation they look normal

46
Q

What does the physical exam of a patient with severe COPD look like?

A

Patients will develop “barrel chests” or increased AP diameter, distant heart and breathe sounds due to hyperinflation of lungs, expiratory wheezes with a prolonged expiratory phase of respiration

47
Q

Describe the CXR in patients with COPD

A

CXR in patients with COPD are typically normal until the disease is advances; in severe cases, hyperinflation of the lungs with an increased PA diameter and flattening of the diaphragm may be seen
-Bullae or areas of pulmonary parenchymal destruction may also be seen

48
Q

What is the primary diagnostic rest of lung function?

A

Spirometry

49
Q

What is the ratio of FVC: FEV1 in normal lungs

A

> 0.7

50
Q

Reversibility of COPD is defined as what?

A

an increase in FEV1 of greater than 12% or 200 mL

51
Q

Why should we encourage COPD patients to quit smoking?

A

Although smoking cessation does not result in significant improvement in pulmonary function, smoking cessation does reduce the risk of further deterioration to that of a nonsmoker

52
Q

Define Stage 0 COPD

A

At risk; cough, sputum production, normal spirometry
-vaccines and address risk factors (exposure to tobacco smoke, occupational dust/chemicals or smoke form home cooking/heating fuel)

53
Q

Define Stage 1 COPD

A

Mild COPD; FEV1/FVC 80%
With or without symptoms
-Treat with short acting bronchodilators B2 agonists albuterol and anticholinergic ipratropium

54
Q

Define Stage 2 COPD

A

Moderate COPD; FEV1/FVC

55
Q

Define Stage 3 COPD

A

Severe COPD; FEV1/FVC

56
Q

Define Stage 3 COPD

A

Very severe COPD; FEV1/FVC

57
Q

Is prophylactic antibiotic use recommended for patients with COPD?

A

-While it is used to decrease the number of COPD exacerbations for a few years, there is no decrease in mortality and the risk of antibiotic resistance makes this a controversial issue

58
Q

When should Oxygen therapy by given for COPD patients

A
  • With Stage IV COPD

- PaO2

59
Q

What is the only intervention that has been shown to decrease mortality in severe COPD patients?

A

Oxygen therapy for >15 hours a day

60
Q

What is the definition and clinical presentation of a patient with an acute COPD exacerbation?

A
  • Defined as a change in respiratory function causing worsening of symptoms which leads to a change in medication
  • Present with a change in sputum color or amount, wheezing, cough, and increased dyspnea
61
Q

What is the DDX for acute COPD exacerbation

A

Pulmonary embolism, CHF, MI, pneumonia, pneumothorax, pleural effusion

62
Q

What medical history questions should you ask a patient who is having an acute COPD exacerbation?

A
  • number of previous episodes and hospitalizations
  • other chronic conditions
  • current tx regime
  • history of intubation/mechanical ventilation
  • duration and new symptoms
63
Q

What physical exam findings are present with severe exacerbations of COPD

A

use of respiratory muscles, worsening or new cyanosis, unstable BO adn HR, AMS, and peripheral edema.
-Oxygen should be given with a target saturation of 88-92% or PaO2 levels at about 60mmHg

64
Q

How do you treat a patient with an acute exacerbation of COPD

A
  • SA bronchodilator
  • Systemic corticosteriods shorten the course of the exacerbation and may reduce the risk of relapse (40mg pf prednisone for 10-14 days)
  • If patient has increased amounts or purlent sputum, a culture should be performed
65
Q

What are the most common bacteria implicated in acute COPD exacerbations? What are the most severe

A
  • Most common are Pneumococcus, Haemophilus influenzae, and Moraxella cararrhalis
  • Most severe are Klebsiella, pseudomonas
66
Q

What is the first dx that needs to be excluded when a patient presents with sudden onset monoarticular joint pain?

A

Infected joint; exclusion of infectious etiology is paramount as cartilage can be destroyed within the first 24 hours of infection

67
Q

How does a joint become infected?

A

-septic by blood inoculation, by contiguous infection (such as from bone or soft tissue), or from direct inoculation from trauma or surgery

68
Q

What age group and ethnicity does gout usually affect?

What are other risk factors for gout?

A
  • African americans
  • Men 30-50 y/o
  • Postmenopausal women 50-70 y/o
  • RF: trauma, surgery, or a large meal (especially one high in purines such as red meat, liver, nuts or seafood) induces hyperuricemia
69
Q

What pharmacological agents increase the risk of gout?

A
  • Thiazide diuretics may induce hyperuricemia by increasing urinary urate reabsorption
  • Look diuretics and chemotherapeutic agents
70
Q

How do you dx gout?

A

-The examination of a joint aspirate is essential dor dx; the gross appearance of fluid is not very specific as both a septic aspirate and a heavily condensed crystal-induced arthritis may have a thick, yellowish/chalky appearance

71
Q

What crystals may be see on examination of joint aspirate under polarizing microscopy?

A
  • To dx crysal induced arthritis, polarizing microscopy must reveal monosidum urate (MSU) crystals which will look like needles and have a strongly negative birefriengence.
  • Other crystals are calcium pyrophosphate dehydrate (CPPD), calcium hydroxypatite, and calcium oxalate
72
Q

What do calcium pyrophosphate dehydrate (CPPD) crystals look like under microscopy?

A

ROd-shaped, rhomboid, weakly positive birefringence

73
Q

What do calcium hydroxyapatite crystals look like?

A

Seen by electron microscopy, cytoplasmic inclusions that are nonbirefringent

74
Q

What do calcium oxalate crystals look like under microscopy?

A

Bipyramidal appearance, strongly positive birefringence; seen mostly in end-stage renal disease patients

75
Q

What is the WBC count of joint aspirate in crystal induced arthritis?

A

average 2,000 to 60,000uL with less than 90% neutrophils while a septic joint will have an average of 100,000 WBC/ul (25,000-250,000 cells) with more than 90% neutrophils; aspirate that has been determined to be crystal induced must also be cultured to rule out coexisting infection

76
Q

Condition of excess uric acid leading to deposition of MSU crystals in joints

A

Gouty arthritis

77
Q

Condition of joint pain and inflammation due to calcium pyrophosphate dehydrate crystals in joints which can be diagnosed by noting rod-shaped, rhomboid, weakly positive birefringence by crystal analysis

A

Pseudogout

78
Q

DDX for nontraumatic swollen joint

A

gout (or any crystal-induced arthritis), infectious arthritis, osteoarthritis, and rheumatoid arthritis; for acute monoarticular arthritis in adults, the most common causes include trauma, crystals, and infection

79
Q

What are the four stages of gout?

A
  1. Asymptomatic tissue deposition ofcrystals
  2. Acute gout flares
  3. Intercritical segments (occurring after an acute flare, but before the next flare)
  4. Chronic gout (symptoms of chronic arthritis and/or tophi
80
Q

Classically, a gout attack involves the ____ which is called ___ but it may involve any joint in the body

A
  • metatarsophalangeal joint of the first toe

- podagra

81
Q

What is gout’s first episode usually confused with and describe the uric acid levels during an acute attack

A
  • Cellulitis
  • During an acute attack, the serum uric acid level may be normal or even low, likely as a result of teh existing deposition of the urate crystals
82
Q

Describe radiographic changes in patients with gout

A

Radiographs may show cystic changes in the joint surface with punched out lesions and soft tissue calcification. These findings are nonspecific and are also seen in osteoarthritis and rheumatoid arthritis

83
Q

What are the three ways in which microorganisms can infect joints

A
  1. Direct penetration (surgery, bite, trauma)
  2. Hematogenous spread from a distant infection
  3. Extension from a nearby infected joint
84
Q

What tests should be obtained in the case of acute polyarticular arthritis?

A

Arthrocentesis with examination of synovial fluid, a blood culture, gram stain and culture, CBC, ESR

85
Q

What are some of the risk factors for infectious arthritis?

A

Alcoholism, malignancy, DM, hemodialysis, immunodeficiency,

Family Medicine (1 decks)

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