Case Files-FM Flashcards
52 y.o. man comes to office for routine physical
New pt…no comorbidities, no meds, no smoking
BP 127/82, ht: 5,7 weighs 190. No abnormalities.
-What screening tests for cardiovascular dz?
-What screening tests for cancer?
-What immunizations?
52, here for annual physical
CVS: screen for HTN (BO), lipids, U/S for AAA men -65-75 who has ever smoked
Cancer: fecal occult blood testing, flexible sigmoidoscopy, colonoscopy or contrast barium enema for colorectal cancer. Prostate cancer- not determined whether for/against
IMMUNIZATIONS-
1.Tdap (if never had one or if over ten years since he had Td vaccine or if he needs booster protection against pertussis
2. Influenza annually
Primary Prevention
u will intervene before the dz develops; you identify and manage risks - using statins to reduce LDL or removing colon polyps before they become cancerous.
Secondary Prevention
reduces or prevents exacerbation of the current disease (using statins after you had an M.I.
Who should be screened for lipid disorders?
men and women 45
young adults >20 with risk factors
Is U/S screening of AAA for women recommended?
NO
Who should be screened for colorectal cancer?
men and women >50 via
- FOBT of three consecutive bowel movements - ANNUAL
- Flexible sigmoidoscopy with/without occult blood testing-EVERY 3-5 yrs
- Colonoscopy-EVERY 10 yrs
Who should be screened for prostate cancer?
men over 75 via PSA and DRE. There is no recommendation for men younger than that
What other cancer should be screen out?
Lung cancer, thyroud and oral caner
Obesity
screening for obesity by measuring BMI and promoting behavioral intervenions
- Do we screen every obese person for T2DM?
- No, only adults with HTN and HLD
What other things are screen for?
Depression, Tobacco, Alcohol abuse
Immunizations
Tdap - q10 yrs or booster if waning immunity
Flu vaccine- age 6mos and up
Hep B- those higher risk of exposure (health care workers, MSM,
Hep A-liver dz, clotting factor problems, IV drug users, travelers
Varicella-those who never had Chicken pox or at risk
Meningococcal-dorm rooms, military recruits, no spleen, travelers
Managing stable COPD-Stage 1
Encourage quit smoking
Appropriate Flu and pneumococcal vaccines
–>Inhaled short-acting bronchodilators (albuterol, beta-agonists, Ipatropium-anticholinergics)
Managing stable COPD-Stage 2
add+ Long acting bronchodilators (Salmeterol), Tiotropium, oral Methylxanthines (less common)
Managing stable COPD-Stage 3, 4
add inhaled STEROIDS (Fluticasone, Triamcinolone)
add oxygen if hypoxemia (Sao2
Managing COPD exacerbation
short-acting bronchodilators, systemic steroids prednisolone 10-14 days).
case: 68 y.o. smoker with COPD has PFT showing FEV1 of 40% with frequent exacerbations of COPD. His SaO2 by pulse ox is 91%. Which is most appropriate?
inhaled Fluticasone BID, inhaled tiotropium BID, inhaled albuterol as needed
Gout Flare up (knee joint)
Dx: joint aspiration to exclude infection or to reveal crystals-negatively birefringement crystals
Tx: NSAID, colchicine
Factors causing gout–Thiazide diuretics, alcohol consumption , red meat
Rheumatoid Arthritis
morning stiffness, involvement of hands, symmetric arthritis, positive serology[anti-CCP, RF], eleveated acute phase reactants, duration of symptoms >6 weeks,
TX: DMARDS (Methotrexate)
Tx of Allergic Rhinitis
- Antihistamines-cheap, available OTC
eg. Benadryl,
Side effects are anticholinergic (dry eyes, dry mouth, urine retention
2nd gen antihistamines (Loratidine, Fexofenadine, Zyrtec do not penetrate the CNS. - Decongestants…constrict the nasal mucosa, reducing its volume
- Corticosteroid nasal spray
- Leukotriene inhibitors….for maintainance for persistent asthma
- Oral steroids-inhibit cell mediated immunity
- Desensitization therapy
When do you try desensitization therapy?
- patients who have refractory symptoms despite adequate medical therapy
- Test for antigens that person is allergic to and then keep injecting them with diluted amounts of antigen in effort to eventually reduce the patient’s inflammatory response to the antigen
Which therapy would and asthmatic with allergies get?
Monteleukast!
Which therapy is best for a driver or forklift operator?
FEXOFENADINE
Talking about quitting smoking-the 5 As
Ask- @ each visit about tobacco use Advise-to quit Assess-willingness to quit (how do they feel about quitting) Assist-counseling Arrange-follow up and support
Drugs to Quit Smoking
Nicotine replacement
Non-nicotine- Bupropion and Verenacline
Buproprion
Blocks NE/Dopamine
- do not give to people with eating disorders, seizures or MAOI (antidepressant) use in the past 2 weeks
- can be used alone or IN COMBO with nicotine-based treatments
Verenicline
Nicotinic receptor partial agonist
Side effects: Neuropsychiatric disorders, suicidal thoughts and abnormal dreams
do not give to anyone with a psych hx
-NOT FOR COMBINATION
Which of the two drugs can be used for pregnant patients patients?
both Bupropion and Verenacline
Woman’s Cardiovascular Health
18 and older- HTN
45 and older- HLD screening]
postmenopausal women taking hormone replacement (estrogen alone or estrogen/progesterone combo) have higher risks of cardiovascular dz [stroke, heart dz or venous thromboembolism]
Breast Cancer Screening (Mammograms)
USPSTF- after age 50, screening every 2 yrs (Level B) - under 50, could be individualized (take into acct benefits and harms)
ACOG- varies for under age 50, but definitely screen every 1 to 2 years
Cervical Cancer Screening/Pap Smears - when do you start?
@ age 21 or three years after first sexual encounter; come back 1 yr or at least 3 normal before going longer
Amer Cancer Society-recommends annual pap smears until age 30 then every 2-3 years after that
-HPV vaccine for age 9-26
USPSTF: If you had a hysterectomy, then you don’t need cervical cancer screening- don’t do a pap smear
-if you have a cervix then you continue to have pap smears
ACS: stop screening @ age 70 if after 3 consecutive positive and no abnormal in ten years
Screening for Osteoporosis
-done by measuring bone density (T-score)
osteoporosis if T-socre is below -2.5
osteopenia if T-score is -1 to -2.5
DXA scan after age 65 and in women >60 if they have high risk of osteo fractures
how much calcium and Vit D
1200mg Calcium
400-800mg Vit D
weight braring and muscle strengthening
Meds: Bisphosphanates: alendronate, risedronate, Calcitonin, Estrogen, PTH, SERM (Raloxifene)
Screening for Domestic Violence
Reporting is mandatory ‘
USPSTF finds no evidence for or against screening for Domestic Violence or that it affects outcomes. So you don’t have to do it.
Musculoskeletal Injuries
Ankle sprains- due to inversion of ankle that is plantar flexed. The AnterioTaloFibular(ATFL) Ligament form the lateral ankle is most often damaged in ankle spraing
Grade 1 Sprain is STRETCHING of the ATFL,which causes pain and swelling. Patient can bear weight
Grade 2-partial tear of ATF and stretching of CFL, causing more pain, swelling and bruising- Non-weight bearing
GRADE 3-complete tear of ligament
Ottowa Ankle rules tells u to get plain XRAY if
- it applies to
1) nonpregnant adults who don’t have painful injuries
2) pts w. normal mental status
3) must be done within 10d of injury - so like a volleyball player who sprains her ankle
bony tenderness of the posterior edge or tip of the distal 6cm of either medial or lateral malleolus
OR
If patient is unable to bear weight immediately or when examined
Ottowa Rule Foot XRAY should be performed when
bony tenderness over
- navicular bone (medial midfoot)
- fifth metatarsal (lateral midfoot)
- unable to bear weight
0ttowa Knee XRAY Rules on pts with one of 5 criteria:
1) age 55 and older
2) isolated patella tenderness
3) tender head of fibula
4) inability to flex knee to 90 degrees
5) inability to bear weight for four steps immediately an din the exam room, regardless of limping
Management of sprains/ strains
P-PROTECTION from further injury R-Range of motion exercises start 48-72h after injury I-Ice to reduce swelling and pain C-Compression E-elevation to reduce edema \+add NSAIDs for pain
The most common cause of persistently stiff joints is inadequate rehab
Malignant Melanoma
seen before but enlarging–>completely excised with 2-3mm
margins
Larger lesions–>BIOPSY. If >5mm go to plastic surgeon to excise completely.
Observe 1yr
What kind of biopsy do you give for raised lesions?
shave biopsy
What kind of biopsy do you give for flat lesions lesions?
punch biopsy or elliptical excision
Prognosis in Melanoma/Breslow measurement
Melanomas
Most common type of melanoma to both genders?
Most aggressive and second most common?
Most common type found in elderly (70s) usually in chronic sun-damaged face, ears, arms, upper trunk; usually found in Hawaii?
Most common in Asians and African Americans?
Superficial spreading
Nodular melanoma- grows quickly and is invasive
Lentigo maligna
Acral Lentiginous Melanoma
