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NCC Board Prep > CH3: Primary Care > Flashcards

CH3: Primary Care Flashcards

1
Q

what is “primary prevention”

A

delivery of healthcare services that focuses on PREVENTING disease from occurring

examples: immunizations, health promotion counseling

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2
Q

what is “secondary prevention”

A

delivery of healthcare services that focuses on EARLY DETECTION of disease states as well as interventions that will LIMIT the severity and morbidity

examples: identification of risk factors, screening tests, counseling and education

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3
Q

what is “tertiary prevention”

A

delivery of healthcare services that focuses on RESTORING OPTIMAL FUNCTION, improving health status, and limiting long-term disability AFTER the diagnosis of disease

examples: treatment of disease, rehab

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4
Q

what is “health screening”

A

laboratory or other tests conducted on asymptomatic individuals routinely for the early detection of health problems

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5
Q

health screening is an example of _______ prevention

A

secondary prevention

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6
Q

colorectal cancer screening ages for average risk, recommendations per the ACS

A

adults 45yo and older should undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam (e.g., colonoscopy)

adults in good health with life expectancy >10 years should continue screening through age 75yo

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7
Q

for colorectal cancer screening – more frequent testing and starting at a younger age is recommended for those with risk factors, including:

A
  • inflammatory bowel disease (IBD)
  • personal or family history of colon polyps or CRC
  • known or suspected Lynch Syndrome (hereditary nonpolyposis colon cancer)
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8
Q

Lynch Syndrome, aka….

A

hereditary nonpolyposis colon cancer

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9
Q

available stool-based tests for colorectal cancer screening (3)

A

Fecal Occult Blood Tests (FOBTs)

  1. guaiac fecal occult blood test (gFOBT) (annual)
  2. fecal immunochemical test (FIT) (annual, superior to guaiac based FOBT)

Stool DNA-Fecal Immunochemical Test
3. stool DNA test (Q3 years)

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10
Q

What is the guaiac fecal occult blood test for CRC screening

A

multiple-stool sample collected at-home that detects hidden blood in the stool

recommended to complete ANNUALLY for screening

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11
Q

What is the stool DNA test for CRC screening

A

single-sample collected at-home that detects (1) DNA from cancer, (2) polyp cells, or (3) blood in stool.

recommended to complete Q3 YEARS for screening

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12
Q

What is the fecal immunochemical test for CRC screening

A

single-sample, collected at home, tests for blood in stool. more sensitive than gFOBT

recommended to complete ANNUALLY for screening

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13
Q

available structural (visual) screening tests for CRC (3)

A
  1. colonoscopy (generally Q10 years)
  2. flexible sigmoidoscopy (generally Q5 years)
  3. CT colonography (generally Q5 years)
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14
Q

Clinical Breast Examination (CBE) recommendations for breast cancer screening, per ACS

A

NOT recommended among average-risk females at any age

Average risk = no personal history of breast cancer, no suspected or confirmed genetic mutation known to increase breast cancer risk, and no previous radiation therapy to the chest

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15
Q

Clinical Breast Examination (CBE) recommendations for breast cancer screening, per ACOG

A

Offer every 1-3 years for pts age 25-39yo, and annually after 40yo

Offer in the context of shared, informed decision making approach that recognizes there is uncertainty of any additional benefit and harms of CBE in folks who are already getting on-schedule screening mammograms

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16
Q

Clinical Breast Examination (CBE) recommendations for breast cancer screening, per USPSTF

A

Insufficient evidence to assess the balance of benefits and harms of CBE if the pt is also being screened with mammograms (Grade I)

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17
Q

Mammogram recommendations for breast cancer screening, per ACS

A

Yearly beginning at age 45yo for average risk pts. Offer to start between ages 40-45yo.

Can transition to every other year (biennially) after age 55yo, or can continue annually, per patient preference.

No definitive age at which to discontinue screening - base shared-decision making on patient’s health status and whether they would elect for breast cancer treatment if diagnosed

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18
Q

Mammogram recommendations for breast cancer screening, per ACOG

A

Offer to start anytime between ages 40-49yo. No later than 50yo.

Both annual and biennial (every other year) intervals are acceptable, per patient preference

No definitive age at which to discontinue screening - base shared-decision making on patient’s health status and whether they would elect for breast cancer treatment if diagnosed

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19
Q

Mammogram recommendations for breast cancer screening, per USPSTF

A

Biennial (every other year) from ages 50-74yo (Grade B evidence).

Insufficient evidence to assess the balance of benefits and harms in patients 75yo and older (Grade I)

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20
Q

Breast self awareness (BSA) recommendations for breast cancer screening, per ACS and ACOG

A

Educate females 20yo and older about BSA and when to seek further evaluation. Encourage patient to know the normal appearance and feel of their own breast so they can be alert to any changes.

No systematic or regular technique or self-examination

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21
Q

Pap test recommendations for cervical cancer screening <21yo, per ACS

A

<21yo, screening is not recommended

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22
Q

Pap test recommendations for cervical cancer screening <21yo, per ACOG

A

<21yo, screening is not recommended EXCEPT if they have HIV, begin screening within 1 year after starts to have sexual activity and no later than age 21yo

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23
Q

Pap test recommendations for cervical cancer screening <21yo, per USPSTF

A

<21yo, screening is not recommended

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24
Q

Pap test recommendations for cervical cancer screening 21-29yo, per ACS

A

cytology alone Q3 years

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25
Q

Pap test recommendations for cervical cancer screening 21-29yo, per ACOG

A

cytology alone Q3 years

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26
Q

Pap test recommendations for cervical cancer screening 21-29yo, per USPSTF

A

cytology alone Q3 years

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27
Q

Pap test recommendations for cervical cancer screening 31-65yo, per ACS

A

cytology + HPV co-testing Q5 years (preferred), or

cytology alone Q3 years (acceptable)

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28
Q

Pap test recommendations for cervical cancer screening, 31-65yo, per ACOG

A

cytology + HPV co-testing Q5 years (preferred), or cytology alone Q3 years (acceptable)

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29
Q

Pap test recommendations for cervical cancer screening, 31-65yo, per USPSTF

A

cytology + HPV co-testing Q5 years (preferred), or cytology alone Q3 years (acceptable), or HPV testing alone Q5 years (acceptable)

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30
Q

Pap test recommendations for cervical cancer screening >65yo, per ACS

A

Stop screening age 65+ if adequate prior negative screening results

Adequate prior negative = 3 consecutive negative cytology results, OR 2 consecutive negative co-testing results within the previous 10 years and the most recent of which was within the past 5 years

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31
Q

Pap test recommendations for cervical cancer screening >65yo, per ACOG

A

Stop screening age 65+ if adequate prior negative screening results

Adequate prior negative = 3 consecutive negative cytology results, OR 2 consecutive negative co-testing results within the previous 10 years and the most recent of which was within the past 5 years

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32
Q

Pap test recommendations for cervical cancer screening >65yo, per ACOG

A

Stop screening age 65+ if adequate prior negative screening results

Adequate prior negative = 3 consecutive negative cytology results, OR 2 consecutive negative co-testing results within the previous 10 years and the most recent of which was within the past 5 years

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33
Q

Once cervical cancer screening has stopped (at 65yo) with adequate prior history, are there any circumstances in which screening should resume again?

A

No - do not resume screening if adequate prior history even if they report having a new sexual partner

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34
Q

If a patient has a history of cervical intraepithelial neoplasia ____ (CIN___) or higher, pap test screening for cervical cancer should continue for _____ years after spontaneous regression or treatment

A

CIN 2 or greater, continue screening for 20 years

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35
Q

Pap test recommendations for cancer screening in patient at any age who had a total hysterectomy (cervix removed)

A

No further screening is needed unless they had a history of CIN2, CIN3, adenocarcinoma in situ, or cervical cancer at any time in the past 20 years

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36
Q

Lung cancer screening recommendations per USPSTF and ACS

A

Screen individuals ages 55-74yo (USPSTF says up to 80yo) who are in fairly good health and have risk factors for lung cancer

Risk factors: 30+ pack-year smoking history and still smoking, or quit within the last 15 years

Screening method: Low-dose CT scan (LDCT) ANNUALLY

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37
Q

Testicular cancer screening recommendations per USPSTF and ACS

A

clinical or self-testicular examinations for testicular cancer screening are NOT recommended by ACS or USPSTF

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38
Q

Prostate cancer screening recommendations per USPSTF

A

For men ages 55-69yo, the decision to undergo periodic PSA (prostate-specific antigen) screening is based on shared-decision making and risk factors such as family history, race/ethnicity, other medical conditions, and the client’s values

USPSTF recommends against PSA-based screening for males 70yo and older

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39
Q

Prostate cancer screening recommendations per ACS

A

Shared decision making conversations about the risks and benefits should begin at 50yo, and earlier for African American males or those with a family history of prostate cancer that was diagnosed before 65yo

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40
Q

Diabetes screening recommendations per ADA, average healthy adult

A

Average healthy person –> screen with HgbA1c (or 2-hr 75g OGTT) every 3 years starting at age 45yo

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41
Q

Diabetes screening should be more frequent or start at a younger age for those with the following risk factors:

A
  • overweight (BMI >25)
  • obesity (BMI >30)
  • hypertension
  • dyslipidemia
  • cardiovascular disease
  • physical inactivity
  • PCOS
  • DM in a first-degree relative
  • not caucasian
  • history of GDM
  • baby weigh >9lbs at birth
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42
Q

Diabetes screening recommendations for patient with history of gestational diabetes (GDM), per ADA

A

Lifelong screening at least every 3 years

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43
Q

cardiovascular disease (CVD) risk factors for females (6)

A
  • age 55yo or older
  • family history of premature CAD (<55 in male relative, <65 in female relative)
  • smokes cigarettes
  • HTN
  • low HDL (<40)
  • diabetes
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44
Q

Blood pressure screening recommendations, per USPSTF (2015)

A
  • Screen all adults ages 18-39yo with a normal BP (<135/85) who have no other risk factors every 3-5 years
  • Screen all adults 40yo and older, and those who are younger but at increased risk for HTN, annually

Risk factors include:

  • high-normal BP (130-139/85-89)
  • overweight or obese
  • African American
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45
Q

Hyperlipidemia/Dyslipidemia screening recommendations, per USPSTF

A
  • periodic assessment of CVD risk factors should occur from ages 40-75yo and should include measurement of total cholesterol, LDL, and HDL
  • there is insufficient evidence that screening for dyslipidemia before age 40yo has a positive or negative effect on long term cardiovascular outcomes
  • USPSTF states that every 5 years is reasonable, but there is no firm recommendation on interval
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46
Q

USPSTF referral recommendations for adults with BMI of 30 or above (obese)

A

refer to intensive, multicomponent behavioral interventions

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47
Q

Characteristics of the most successful interventions for weight loss in obese individuals

A

intensive behavioral interventions with multiple sessions over 1-2 years including a support or maintenance phase

interventions should be tailored with attention to social, environmental, and individual factors

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48
Q

Who meets criteria for weight-loss surgery (2)

A
  • individuals with BMI 40 or higher (extremely obese)

- individuals with BMI 35 or higher who have other high-risk comorbidities (e.g., HTN, DM)

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49
Q

Osteoporosis screening recommendations from the National Osteoporosis Foundation (NOF)

A
  • screen all females 65yo and older for osteoporosis or osteopenia with a bone mineral density (BMD) test
  • screen folks younger than 65yo if they have risk factors associated with an increased fracture risk

Risk factors:

  • low BMI
  • history of a fragility fracture
  • smoking
  • alcohol >3 drinks/day
  • family history of hip fracture or osteoporosis
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50
Q

Risk factors for low bone density that might warrant earlier screening with DEXA (5)

A
  • low BMI
  • history of a fragility fracture
  • smoking
  • alcohol >3 drinks/day
  • family history of hip fracture or osteoporosis
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51
Q

According to the CDC and USPSTF, who should be screened for Hepatitis C

A
  • screen all individuals born between 1945 and 1965 one time
  • screen other folks based on risk factors

risk factors include:

  • current injection or intranasal drug use
  • blood transfusion before 1992
  • long-term hemodialysis
  • born to a mother with hepatitis C virus (HCV)
  • receipt of an unregulated tattoo
  • other percutaneous exposures
  • HIV infection
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52
Q

Screen all individuals for hepatitis C who were born between…..

A

1945-1965

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53
Q

Screen all individuals for hepatitis C who received a blood transfusion prior to….

A

1992

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54
Q

Biochemical (lab) measurements to assess nutritional status (5)

A
  • CBC (hgb/hct)
  • lipids
  • serum albumin
  • serum glucose
  • serum folate
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55
Q

Healthy eating recommendations include limiting calories from added sugars and saturated fats to about ___% of intake

A

10% each

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56
Q

Healthy eating recommendations including limiting sodium intake to less than _____ per day

A

2300mg (1 tsp)

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57
Q

Healthy eating recommendations include limiting alcohol intake to ….

A
  • up to 1 drink/day for women
  • up to 2 drinks/day for men

1 drink = 12 oz beer, 5 oz wine, 1.5oz hard liquor

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58
Q

Per healthy eating recommendations, 1 drink is equivalent to how much beer, wine, liquor

A

12 oz beer
5 oz wine
1.5 oz liquor

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59
Q

Calcium recommendations for women, per Institute of Medicine (IOM)

A
  • 14-18yo: 1300mg/day
  • 19-50yo: 1000mg/day
  • 51yo and older: 1200mg/day
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60
Q

Vitamin D recommendations for women, per Institute of Medicine (IOM)

A
  • 14-70yo: 600IU/day

- 71yo and older: 800IU/day

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61
Q

Calcium recommendations for women, per NOF

A
  • 18-50yo: 1000mg/day

- 51yo and older: 1200mg/day

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62
Q

Vitamin D recommendations for women, per NOF

A
  • 18-50yo: 400-800 IU/day

- 51yo and older: 1000 IU/day

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63
Q

Good sources of calcium

A
  • milk
  • yogurt
  • cheese
  • soybeans
  • tofu
  • canned sardines
  • salmon with edible bones
  • fortified cereals
  • fortified orange juice
  • supplements
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64
Q

Good sources of vitamin D

A
  • regular exposure to direct sunlight
  • fortified milk
  • egg yolks
  • saltwater fish
  • liver
  • supplements
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65
Q

Folate recommendations for women of childbearing age

A

0.4mg folic acid/day

If history of infant with neural tube defect, recommend 4mg folic acid/day starting at least 1 month before trying to conceive and continuing through the first 2-3 months of gestation

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66
Q

Good sources of folic acid

A
  • beans
  • leafy green vegetables
  • citrus
  • fortified cereals
  • most MVIs contains 0.4mg folic acid
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67
Q

Iron recommendations for non-pregnant women

A
  • 14-18yo: 15mg/dL per day
  • 19-50yo: 18mg/dL per day
  • 51yo and older: 8mg/dL per day
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68
Q

Good sources of iron

A
  • meat
  • fish
  • poultry
  • fortified cereals
  • dried fruits
  • dark green vegetables
  • supplements
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69
Q

Nutrients to be concerned about deficiencies for vegetarian patients (5)

A
  • protein
  • calcium
  • iron
  • vitamin B12
  • vitamin D
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70
Q

Who is at increased risk for vitamin D deficiency (6)

A
  • > 59yo
  • dark skin
  • live in northern areas (less sun)
  • overweight or obese
  • milk allergy or lactose intolerance
  • digestive diseases such as Crohn’s or celiac
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71
Q

Benefits of physical activity with strong evidence to support

A
  • lowers risk for heart disease, stroke, HTN, HLD
  • lowers risk for DM, metabolic syndrome, overweight/obesity
  • lowers risk for colon and breast cancers
  • improves cardiovascular and muscular fitness
  • reduces depression
  • improves cognitive function in older adults
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72
Q

Physical activity recommendations, per USDHHS

A
  • engage in at least 150-300 minutes of moderate-intensity aerobic physical activity per week, OR 75-150 minutes of vigorous intensity aerobic exercise
  • engage in muscle-strengthening activities of moderate or high intensity of all major muscle groups 2 or more days of the week
  • include bone-strengthening activity in the exercise regimen
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73
Q

What are examples of “moderate intensity” aerobic exercise

A
  • exercises that achieve 50-60% of max HR (where max HR is 220 minus age)
  • examples include brisk walking, running, bicycling, jumping rope, or swimming
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74
Q

What are examples of muscle-strengthening activities

A
  • weight lifting
  • elastic resistance bands
  • using body weight for resistance (i.e., push ups, climbing)
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75
Q

What are examples of bone-strengthening activities

A
  • running
  • brisk walking
  • weight training
  • tennis
  • dancing
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76
Q

When does substance use become a substance use disorder?

A

when there is continued use of a substance despite the existence of use-related health problems

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77
Q

The severity of a substance use disorder is based on the number of criteria met of the following (4):

A
  • loss of control over use
  • impact on social function
  • risky use
  • development of tolerance or dependence
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78
Q

% prevalence of smoking in general adult women population

A

13.5% (highest in those ages 25-44yo)

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79
Q

% prevalence of smoking e-cigarettes in female high school students

A

10%

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80
Q

5As for smoking cessation

A
  • ASK about tobacco use
  • ADVISE to quit smoking
  • ASSESS willingness/readiness to quit
  • ASSIST in quit attempt (quit smoking meds, counseling)
  • ARRANGE follow-up
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81
Q

Forms of NRT

A

gum, patches, lozenges, inhalers, nasal spray

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82
Q

How does NRT help folks quit smoking

A

helps to reduce the physical withdrawal symptoms and cravings that occur with smoking cessation or reduction

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83
Q

Common side effects of NRT

A
  • local skin reaction with the patch
  • mouth and throat irritation with lozenges, gum, or inhaler
  • hiccups with gum or lozenges
  • nasal irritation
  • headache
  • dizziness or nausea
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84
Q

Contraindications to use of NRT

A
  • serious cardiac arrhythmias
  • severe angina
  • recent MI
  • concurrent smoking (THIS IS NOT TRUE!!!!)
  • pregnancy (THIS IS ALSO NOT TRUE)
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85
Q

Considerations for use of NRT in pregnancy and breastfeeding

A
  • per book, this is a contraindication – however, per medical literature, the benefits of quitting smoking greatly outweigh the risks of NRT AND NRT is safer in pregnancy than are cigarettes
  • can use during breastfeeding but recommend avoid use within 1 hr of breastfeeding
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86
Q

How does bupropion sustained release (Zyban) help folks quit smoking

A

reduces cravings, exact MOA is unknown but is thought to work on the brain pathways involved in nicotine addiction and withdrawal
- class: norepinephrine-dopamine reuptake inhibitor (NDRI)

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87
Q

Common side effects of bupropion sustained release (Zyban)

A
  • dry mouth
  • insomnia
  • nausea
  • skin rash
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88
Q

Contraindications for bupropion sustained release (Zyban) for smoking cessation

A
  • seizure disorder
  • eating disorder
  • use of an MAOI
  • concomitant use of other forms of bupropion (e.g., Wellbutrin for depression)
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89
Q

Considerations regarding the use of bupropion sustained release (Zyban) for smoking cessation during pregnancy and lactation

A
  • data from animal studies and epidemiological studies of women exposed to bupropion in the first trimester do NOT show an increased risk of congenital malformation overall (per book) - risk for congenital heart defects inconclusive (per Epocrates)
  • it is transmitted through breastmilk but there is insufficient evidence to evaluate its safety for the infant (per book) - concern for neonatal seizures (per Epocrates)
  • overall, consider use during pregnancy only if the potential benefit justifies the potential risk to the fetus or neonate
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90
Q

Recommendations for timing of use and duration of bupropion sustained release (Zyban) for smoking cessation

A
  • recommend to start the medication 1-2 weeks before planned quit date
  • recommended duration of therapy is 6 months (even if quit)
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91
Q

How does varenicline (Chantix) help folks quit smoking

A
  • reduces withdrawal symptoms
  • blocks the effect of nicotine if an individual does resume smoking
  • class: nicotinic acetylcholine receptor partial agonist
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92
Q

Common side effects of varenicline (Chantix) for smoking cessation

A
  • nausea
  • changes in dreams
  • constipation, gas
  • vomiting
  • neuropsychiatric symptoms, including suicidal ideation
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93
Q

Contraindications to use of varenicline (Chantix) for smoking cessation

A
  • use caution in individuals with psychiatric disorders

- renal impairment

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94
Q

Considerations for the use of varenicline (Chantix) for smoking cessation during pregnancy and lactation

A

data from animal studies and epidemiological studies of women exposed to bupropion in the first trimester do NOT show an increased risk of congenital malformation overall (per book)

  • it is transmitted through breastmilk but there is insufficient evidence to evaluate its safety for the infant (per book)
  • overall, consider use during pregnancy only if the potential benefit justifies the potential risk to the fetus or neonate
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95
Q

Recommendations for timing of use and duration of varenicline (Chantix) for smoking cessation

A
  • initiate medication around 1 week before planned quit date
  • okay to use alongside NRT but may increase side effects
  • discontinue and report if experience agitation, depression, or suicidal ideation
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96
Q

% prevalence of females who use any alcohol, and of reproductive age females

A

46% general population females

53% reproductive age females non pregnant

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97
Q

% prevalence of binge drinking in reproductive age females

A

18%

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98
Q

% prevalence of pregnant women who continue to drink alcohol during pregnancy, and the percent of these who report binge drinking

A

11%, 1/3 of which report binge drinking

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99
Q

General definition of binge drinking

A

females = 4 or more drinks on one occasion and within a couple hours

males = 5 or more drinks on one occasion and within a couple hours

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100
Q

Counseling regarding alcohol use in pregnancy

A

there is no safe amount, type, or time to drink alcohol during pregnancy. alcohol is a known teratogen. use during pregnancy is one of the major preventable causes of birth defects and developmental disabilities

to avoid fetal alcohol exposure before pt knows they are pregnant, encourage those who are trying to conceive

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101
Q

most frequently used illicit drug in the USA

A

marijuana (legal in some states for medical and/or recreational use)

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102
Q

Who and how often should be screened for substance use disorders

A

screen all individuals annually at wellness visits, initial prenatal visits, and other visits as indicated

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103
Q

SBIRT intervention for substance use disorders

A
  • Screening
  • Brief Intervention (using motivational interviewing)
  • Referral to Treatment
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104
Q

the “one key question” designed for clinicians to screen individuals on pregnancy intention

A

“would you like to become pregnant in the next year?”

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105
Q

PATH questions for reproductive life planning

A
  • Pregnancy/Parenthood Attitudes (do you think you might like to have [more] children at some point?)
  • Timing (when do you think that might be?)
  • How important (how important is it to you to prevent pregnancy [until then]?)
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106
Q

Goals of preconception care (5)

A
  • reproductive life planning and the provision of contraception as desired
  • health promotion and disease prevention to optimize maternal and fetal health in any future pregnancy
  • identification and management of existing chronic medical conditions to optimize disease control and maternal health
  • identification of any complications during previous pregnancies and implementation of interventions to reduce risk in future pregnancies
  • identification of any social, cultural, or structural barriers to health care and the implementation of interventions to increase access to needed resources
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107
Q

Genetic carrier screening and counseling are ideally performed when?

A
  • prior to pregnancy

whenever the patient wants

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108
Q

All pts considering pregnancy should be offered carrier screening for (2)

A
  • cystic fibrosis

- spinal muscular atrophy

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109
Q

All pts considering pregnancy with an abnormality on their CBC should be offered screening for (2)

A
  • thalassemias

- hemoglobinopathies

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110
Q

Relevant conditions for identification/risk reduction in preconception counseling that we have vaccines for (6)

A
  • rubella
  • varicella, chickenpox
  • hepatitis B
  • HPV
  • tdap
  • influenza
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111
Q

Intimate partner violence more commonly affects [older vs. younger] women

A

younger women

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112
Q

USPSTF recommends screening all women ages ___ to ____ for intimate partner violence

A

14-46yo

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113
Q

(3) screener tools available for identifying intimate partner violence

A
  • HITS (Hurt, Insult, Threaten, Scream)
  • HARK (Humiliation, Afraid, Rape, Kick)
  • WAST (Woman Abuse Screen Tool)
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114
Q

Risk factors for elder abuse (3)

A
  • isolation/lack of social support
  • functional impairment
  • poor physical health
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115
Q

Signs/symptoms of possible elder abuse

A
  • depression
  • agitation
  • becoming withdrawn
  • weight loss for no apparent reason
  • unexplained bruises or injuries
  • burn scars
  • unkempt appearance (unwashed hair, dirty clothes)
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116
Q

Risk factors for infant abuse and neglect

A
  • immaturity of the parent(s) (e.g., adolescent parents are higher risk)
  • isolation/lack of social support system
  • parent was rejected or abused as a child
  • emotional instability
  • lack of knowledge about development and care of children
  • low self-esteem
  • stressful situations (e.g., IPV, poverty, unemployment)
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117
Q

Difference in definition between sex “drive” and sex “motivation”

A

sex drive = biological component of desire, based on neuroendocrine mechanisms

sex motivation = intrapsychic and interpersonal component, influenced by quality of relationship, emotional/psychological health, past sexual history, cultural and religious values

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118
Q

Linear model of sexual response (Master’s & Johnson, 1966)

A

model was considered to apply to males and females

  1. excitement = sensory stimulation leads to vasocongestion
  2. plateau = increased vasocongestion and pelvic floor muscle tension
  3. orgasm = widespread genitopelvic muscle contraction
  4. resolution = return to nonstimulated state
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119
Q

Nonlinear model of sexual response (Basson, 2000)

A

model focuses on women

  • emotional intimacy and physical satisfaction, not necessarily orgasm, may be the goal
  • recognizes female sexual motivation is complex and not an innate physiologic phenomenon
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120
Q

What does the PLISSIT model for addressing sexual concerns as generalists stand for

A
  • Permission giving
  • Limited Information
  • Specific Suggestions
  • Intensive Therapy
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121
Q

CDC guidelines for routine chlamydia and gonorrhea screening

A
  • routine annual screening for sexually active pts <25yo
  • routine annual screening for sexually active pts >25yo who have additional risk factors
  • all pregnant patients at first prenatal visit and repeat in third trimester if risk factors

risk factors = new sex partner, multiple sex partners, sex partner has multiple partners, exchanging sex for money or drugs

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122
Q

CDC guidelines for routine HIV screening

A
  • one time screen for all individuals 13-64yo
  • screen all pregnant individuals at first prenatal visit and repeat in third trimester if risk factors
  • younger and older adults outside of these age ranges who are at increased risk of infections should also be screened
  • repeat screens based on risk factors
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123
Q

Counseling regarding safer rex practices for prevention of STIs and HIV should be based on….

A

behaviors and risk factors (NOT on sexual orientation or gender identity)

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124
Q

“safe” sex, per this book

A

all unprotected sexual activities when both partners are monogamous and known by testing to be free of HIV and other STIs

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125
Q

“low but potential risk” sex, per this book

A
  • all sexual activities when both partners are monogamous but have not been tested for HIV or other STIs (…arguably, multiple partners who have ALL been tested for STIs and are negative would be safer - no???)
  • intact skin (no lesions in areas of contact)
  • use of latex or plastic condom or barrier device for oral, vaginal, and anal intercourse
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126
Q

“unsafe in absence of mutual monogamy and STI/HIV testing of both partners” sex, per this book

A
  • blood contact of any kind
  • oral, vaginal, or anal intercourse without a latex or plastic condom or barrier
  • shared sex toys
  • digital penetration of vagina or anus
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127
Q

There are vaccines for hepatitis (2), but not for (1)

A

vaccines = hepatitis A, B

no vaccine = hepatitis C

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128
Q

What is the schedule for doses of Hepatitis B vaccination

A

three-dose series, at baseline, 1 month, and 6 month follow-up

*if the three-dose series is interrupted, the series does not need to be restarted. Give second dose as soon as possible and third dose at least 8 weeks later

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129
Q

High risk groups for Hepatitis B (ensure immunity/vaccination status)

A
  • multiple sex partners
  • MSM
  • household contacts or sexual partners of individual with known HBV infection
  • injection drug use
  • health care workers
  • inmates in long-term correctional institutions
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130
Q

Recommendations for influenza vaccine

A
  • recommended annually for all individuals ages 6mos and older, including pregnant folks
  • administration of the inactivated flu vaccine (IM injection) is considered safe at any stage of pregnancy and during lactation
  • the live attenuated influenza vaccine is given intranasally and should only be used in healthy, non-pregnant adults between 2-49yo
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131
Q

Considerations for the influenza vaccine during pregnancy and breastfeeding

A

administration of the inactivated flu vaccine (IM injection) is considered safe at any stage of pregnancy and during lactation

intranasal flu vaccine is a live attenuated virus and is contraindicated in pregnancy and breastfeeding

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132
Q

(2) types of pneumococcus vaccines

A
  • pneumococcal conjugate 13-valent vaccine (PCV13; Prevnar 13)
  • pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23)
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133
Q

Pneumonia vaccine recommendations for ALL immunocompetent individuals 65yo and older

A

PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23), one time, for all immunocompetent adults ages 65yo and older

Should be given at least 1 year apart.

If the individual has not yet had either vaccine, start with PCV13

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134
Q

the PCV13 (Prevnar 13) vaccine is recommended for adults younger than 65yo with the following conditions: (4)

A
  • immunocompromising conditions (e.g., HIV)
  • functional or anatomic asplenia
  • cerebrospinal fluid leaks
  • cochlear implants
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135
Q

the PPSV23 (Pneumovax 23) vaccine is recommended for adults younger than 65yo with the following conditions:

A
  • chronic illness (e.g., T2DM)
  • smoke cigarettes
  • resident of long-term care facility or nursing home
  • otherwise candidates for early PCV13 (Prevnar 13) vaccination (e.g., immunocompromised, transplant recipient)
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136
Q

65yo pt presents for annual. They had the PPSV 23 (Pneumovax 23) vaccine at age 45yo when they were diagnosed with T2DM. They are wondering if they still need the pneumonia vaccine - “the one for old people”?

A

Yes, if PPSV23 (Pneumovax 23) is administered before age 65yo, administer another dose at age 65 and at least 5 years after the first dose was given

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137
Q

Considerations for rubella vaccination in pregnancy and lactation

A
  • live vaccine –> NOT safe in pregnancy. Wait 4 weeks after administration before trying to become pregnant
  • YES may be given to breastfeeding folks postpartum
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138
Q

General recommendations for the rubella vaccine in adults

A

vaccination against rubella (MMR) is recommended for all non-pregnant folks of childbearing age who lack documented laboratory evidence of immunity or prior immunization after 1 year of age

  • documentation of provider-diagnosed rubella infection is not considered evidence of immunity, must draw titers
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139
Q

Contraindications to receiving the rubella vaccine (MMR)

A
  • pregnancy
  • known severe immunodeficiency
  • HIV with AIDS
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140
Q

General recommendations for Tdap/Td vaccines

A
  • recommend three-dose vaccination series including a Tdap dose for adults with unknown or incomplete history of primary Td vaccination
  • recommend one dose of Tdap for all adults who have not previously received Tdap
  • Recommend one dose of Tdap vaccine for pregnant folks during each pregnancy regardless of the number of years since prior Td or Tdap vaccination
  • Booster Td vaccination is recommended every 1- years for adults
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141
Q

What does Tdap vaccine protect against?

A

tetanus, diptheria, acellular pertussis

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142
Q

Considerations for Tdap vaccination in pregnancy and breastfeeding

A
  • safe
  • recommend one dose of Tdap each pregnancy, regardless of last dose, to protect the infant in first few months of life when high risk exists for severe illness or death from pertussis
  • ideal timing: between 27-36 weeks EGA (ideally closer to 27 weeks)
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143
Q

General recommendations for varicella vaccine

A
  • given as a two-dose series 4-8 weeks apart
  • recommended for all NON-pregnant adolescents and adults without evidence of immunity
  • pregnant folks should be assessed for immunity and if not immune, given the first dose of the vaccine upon completion or termination of pregnancy and the second dose 4-8 weeks later
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144
Q

Considerations for varicella vaccine in pregnancy and lactation

A
  • live vaccine - NOT safe in pregnancy (advise not to become pregnant for 4 weeks after receiving)
  • YES can be given during breastfeeding
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145
Q

Contraindications to receipt of varicella vaccine

A

(same as for rubella, another live vaccine)

  • pregnancy
  • known severe immunodeficiency
  • HIV with AIDS
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146
Q

General recommendations for herpes zoster (shingles) vaccine

A
  • two-dose series recombinant zoster vaccine (RZV) 2-6 months apart
  • recommended for individuals 50yo and older regardless of their previous history of herpes zoster (shingles) or previously received live-virus shingles vaccine (ZVL’; Zostavax)
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147
Q

68yo pt presents for annual. They previously received the Zostavax vaccine at age 50, but they have heard about a new shingles vaccine. What is your recommendation?

A

Yes, should receive Shingrix (RZV) vaccine at 50yo and older regardless of previous history of shingles and/or receipt of the old live-virus vaccine (Zostavax)

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148
Q

Contraindications to receipt of herpes zoster (shingles; Shingrix) vaccine

A

(even though it is NOT a live attenuated virus, it is still contraindicated in these populations…. likely because it is new and there is not much research?)

  • pregnancy
  • known severe immunodeficiency
  • HIV with AIDS
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149
Q

General recommendations for Hepatitis A vaccine

A
  • two-dose series, at least 6 months apart (hepatitis A alone) OR three-dose combination Hepatitis A/B vaccine at baseline, 1 month, and 6 months
  • recommended for all individuals who live in or are traveling to countries with high levels of Hepatitis A infection, MSM, folks who use illicit drugs (both injection or non-injection), those with occupational exposure risks (e.g., handles food), individuals with chronic liver disease or clotting factor disorders
  • however, identification of a risk factor is not required – any individual who wants protection from hepatitis A may receive
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150
Q

Contraindications to Hepatitis B vaccine in adults

A

none, other than allergy to any components

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151
Q

Contraindications to influenza IM vaccine in adults

A
  • allergy to any components (e.g., egg allergy)

- history of guillain-barre (relative contraindication)

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152
Q

Contraindications to pneumonia vaccines in adults

A

none, other than allergy to any components

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153
Q

Contraindications to hepatitis A vaccine in adults

A

none, other than allergy to any components

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154
Q

Contraindications to HPV vaccine in adolescents and adults

A

none, other than allergy to any components

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155
Q

General recommendations for HPV vaccine (Gardasil)

A
  • 9vHPV (Gardasil 9) recommended routinely for all individuals 11-12 yo. However, may be given as young as 9yo and as old as 45yo
  • anyone younger than 15yo can receive a 2-dose series with the second dose 6-12 months after the first
  • 15yo and older is a three-dose series at baseline, 2 months, and 6 months follow-up
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156
Q

What does the HPV vaccine (Gardasil 9) cover

A

the nine-valent HPV vaccine (9vHPV; Gardasil 9) targets 9 types of HPV total:

  • types 16 and 18, which cause 66% of all cervical cancers
  • types 6 and 11, which cause most anogenital warts
  • and 5 additional types, altogether protecting against 90% of HPV-associated cancers
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157
Q

Gardasil 9 protects against ___% of all HPV-associated cancers

A

90%

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158
Q

26yo F presents to establish care with a new OBGYN. She is sexually active. Previously diagnosed with HPV on a pap test. She has not received the HPV vaccine (Gardasil) in the past and is wondering if she still needs it now that she already had HPV

A

yes, still recommended. Individuals already infected with one or more HPV types will still receive protection against the types not yet acquired

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159
Q

Considerations for HPV vaccine (Gardasil 9) in pregnancy and lactation

A
  • NOT recommended in pregnancy (is not live, so this is probably just because we don’t have data?). Recommend delay receipt until after pregnancy
  • YES safe during breastfeeding
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160
Q

General recommendations for meningococcal vaccine

A
  • initial vaccination recommended at age 11 or 12 as a one-time dose
  • booster vaccine is recommended at age 16yo, and a booster is not needed if the initial vaccine was at age 16yo or older
  • recommended specifically for all first-year college students living in dormitories if they were not previously vaccinated at age 16yo and older, military recruits, individuals with anatomic or functional asplenia, or those traveling to regions where meningococcal disease is common
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161
Q

Contraindications to meningococcal vaccination in adults

A

none, other than allergy to any components

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162
Q

General considerations regarding immunizations during pregnancy and lactation, overall

A
  • Live attenuated virus vaccines should NOT be given during pregnancy. Examples include: nasal flu, varicella, MMR. Herpes zoster should also not be given during pregnancy, however, it is not a live-attenuated vaccine. All of these CAN be given during breastfeeding, however, the IM flu is recommended over the nasal flu
  • Inactivated virus vaccines, bacterial vaccines, toxoids, and tetanus immunoglobulins MAY be given during pregnancy, but only if indicated. Consider waiting until after completion of pregnancy if not time-sensitive
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163
Q

Routine screening recommendations for vision, per American Academy of Ophthalmology

A

Recommends screening by an ophthalmologist for visual acuity and glaucoma on the following schedule:

  • Q3-5 years for African Americans ages 20-39yo
  • Q2-4 years for those ages 40-64yo regardless of race
  • Q1-2 years for those ages 65yo + regardless of race
  • annually for folks with diabetes, regardless of age
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164
Q

Routine dental screening recommendations, per American Dental Association

A

recommends all adults have routine dental care and preventive services, including oral cancer screening, at least annually

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165
Q

JNC 8 definition of hypertension

A

SBP 140 or greater
DBP 90 or greater
based on the average of two or more properly measured BP readings on each of two or more office visits or while on antihypertensive medications

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166
Q

ACC and AHA 2017 definitions of high blood pressure

A
  • normal BP = <120/<80
  • elevated BP = 120-129/<80
  • stage I HTN = 130-139/80-89
  • stage II HTN = 140+/90+
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167
Q

(3) objectives of documenting hypertension

A
  1. to identify any secondary causes (and eliminate)
  2. to assess for target organ damage (eyes, brain, blood vessels, heart, kidneys)
  3. to identify other concomitant risk factors or disorders that may define prognosis and guide therapy (e.g., smoking, diabetes)
168
Q

primary end organs of damage with chronic HTN (5)

A
  • eyes (retinopathy)
  • brain (TIA, stroke, alzheimers)
  • blood vessels (PVD)
  • heart (CAD, CHF, MI)
  • kidneys (CKD)
169
Q

Other cardiovascular risk factors or concomitant conditions that may define the prognosis and guide therapy for HTN (8)

A
  • smoking cigarettes
  • obesity (BMI 30+)
  • physical inactivity
  • dyslipidemia
  • diabetes mellitus
  • microalbuminuria or eGFR <60 mL/min
  • 55+yo males, 65+yo females
  • family history of premature CVD (<55yo males, <65yo females)
170
Q

% of HTN cases that are primary or “essential”

A

90-95%

171
Q

% of HTN cases that are secondary

A

5-10%

172
Q

% prevalence of HTN among US adults

A

45%

173
Q

% prevalence of HTN among postmenopausal US women

A

75%

174
Q

Menopause is associated with a ____x [increase vs. decrease] in risk for HTN

A

2x increase in risk

175
Q

prevalence of HTN is highest among which racial/ethnic group of US women

A

non-Hispanic Black (56%)

176
Q

Pt presents for problem visit. They meet criteria for HTN which is a new diagnosis. CC: palpitations, tremor, and sweating. You suspect…..

A

secondary HTN, s/t pheochromocytoma

177
Q

Pt presents for problem visit. They meet criteria for HTN which is a new diagnosis. CC: weight gain. You note truncal obesity and purple striae. You suspect….

A

secondary HTN, s/t Cushing’s syndrome

178
Q

Pt presents for problem visit. They meet criteria for HTN which is a new diagnosis. CC: weakness and muscle cramps. You suspect….

A

primary aldosteronism

179
Q

Pt presents for annual. They meet criteria for HTN which is a new diagnosis. They are asymptomatic. On physical exam, you note renal artery bruit. You suspect….

A

secondary HTN, s/t renal artery stenosis

180
Q

Pt presents for annual. They meet criteria for HTN which is a new diagnosis. They are asymptomatic. On physical exam, you note delayed or absent femoral pulses and decreased blood pressure in the lower extremities. You suspect….

A

secondary HTN, s/t coarctation of the aorta

181
Q

Secondary causes of HTN

A
  • obstructive sleep apnea
  • CKD
  • primary aldosteronism
  • renovascular disease (e.g., renal artery stenosis)
  • chronic steroid therapy
  • Cushing’s syndrome
  • pheochromocytoma
  • coarctation of the aorta
  • thyroid or parathyroid disease
  • drug-related (e.g., drug abuse with cocaine or stimulants, alcohol, combination OCPs, OTC cold-remedies)
182
Q

Recommended initial lab tests when pt presents with new diagnosis of HTN (5)

A
  • UA
  • CBC
  • BMP (blood glucose for diabetes, potassium for aldosteronism, creatinine for renal disease)
  • lipids
  • ECG
183
Q

Pt presents for annual. They meet criteria for HTN which is a new diagnosis. They are asymptomatic. On initial labs, you note hypokalemia. You suspect….

A

secondary HTN, s/t primary aldosteronism

184
Q

Optional lab tests to consider including when pt presents with new diagnosis of HTN

A
  • urinary albumin excretion, or albumin/creatinine ratio
  • TSH
  • IV pyelogram to r/o renovascular disease
  • 24-hr urine to test for metanephrines and catecholamines to r/o pheochromocytoma
  • chest radiograph to r/o cardiomegaly and coarctation of the aorta
  • echocardiogram to detect LVH
185
Q

When should you start lifestyle therapy vs. medication for a new diagnosis of HTN?

A

lifestyle modifications recommended for elevated BP and stage I HTN (120-139/80-89) AND calculated 10-yr ASCVD risk <10%. Trial for 3-6 months and then recheck BP.

start a medication right away for those with stage II HTN (140+/90+) or those with stage I HTN (130-139/80-89) who have >10% 10-yr ASCVD risk or comorbid CVD, diabetes, or CKD.

186
Q

Lifestyle modifications recommended in HTN (6)

A
  • weight reduction/maintain “ideal body weight”
  • dietary choices - DASH diet, Mediterranean diet, plant-based diets (rich in fruits vegetables and low-fat dairy products while reducing saturated fats and total fat)
  • reduce dietary sodium (aim to reduce by at least 1000mg/day, for no more than 1500mg/day)
  • increase physical activity, aerobic, at least 40 min/day most days of the week
  • limit alcohol, no more than 1 drink/day
  • smoking cessation
187
Q

(4) first line medication classes for HTN

A
  • thiazide diuretic (e.g., hydrochlorothiazide)
  • calcium channel blocker (e.g., amlodipine)
  • ACE inhibitor (e.g., lisinopril)
  • ARB (e.g., valsartan)
188
Q

Pt presents for annual. PMH significant for T2DM. BP today is 135/85, which is newly elevated. What is your initial plan?

A

LABS: CBC, BMP, A1c, lipids, UA, ECG

TREATMENT: start 1 antihypertensive medication (thiazide diuretic, CCB, ACE, or ARB). Recommend lifestyle changes. Follow-up in 1 month to assess adherence and response to treatment.

189
Q

Pt presents for HTN follow-up. PMH significant for T2DM and HTN which was diagnosed at his last visit 1 month ago. At that time, you started them on an ACE inhibitor. BP today still not at goal <130/80. What is your next steps?

A
  • consider increase in dose of current therapy
  • consider addition of another class (CCB, thiazide)
  • reinforce lifestyle changes
  • follow-up monthly until control is achieved, then Q6 months
190
Q

Pt presents for establish care. They haven’t been to see a provider for many years. Only PMH they remember is HTN, but they are not taking any BP medications. BP today is 150/92. What is your initial plan?

A

LABS: CBC, BMP, A1c, lipids, UA

TREATMENT: start with 2 antihypertensive medications from two different classes. Recommend lifestyle changes. Follow-up in 1 month to assess adherence and response to therapy.

191
Q

key considerations for reproductive-age women with HTN

A
  • uncontrolled chronic HTN can lead to increased risks for maternal, fetal, and neonatal morbidity and mortality
  • ACE inhibitors and ARBs are contraindicated in pregnancy
  • contraceptives that contain estrogen are contraindicated in folks with uncontrolled HTN or vascular disease. They are also not recommended even if adequately controlled, unless no other method is available or acceptable to patient
  • LARCs and progestin-only pills are best options for contraception
192
Q

Hypertensive crisis BP

A

> 180/120

193
Q

THIAZIDE DIURETICS FOR HTN

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/precautions
  • pregnancy/lactation
A
  • EXAMPLES: hydrochlorothiazide, chlorthalidone
  • MOA: inhibits sodium reabsorption from the distal renal tubules&raquo_space; reduced sodium results in decreased vascular tone
  • SIDE EFFECTS: hypotension, orthostatic hypotension, volume depletion, hypokalemia and other electrolyte disturbances, hyperglycemia, worsening kidney function, transient hyperlipidemia
  • INTERACTIONS: enhances the effects of other antihypertensives, may decrease efficacy of oral sulfonylureas (glyburide, glipizide) and insulin, NSAIDs may reduce the effect of thiazides and increase the risk of acute renal failure
  • CONTRAINDICATIONS/CAUTIONS: sulfa allergy, use caution in impaired renal function, diabetes, h/o gout, and those at risk for hypotension (e.g., elderly)
  • PREGNANCY/LACTATION: second-line treatment during pregnancy (safe), risks are related to theoretical potential for intravascular volume depletion and electrolyte abnormalities
194
Q

BETA BLOCKERS FOR HTN

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/precautions
  • pregnancy/lactation
A
  • EXAMPLES: propanolol, atenolol, labetalol
  • MOA: inhibits sympathetic stimulation of the heart, reduces sympathetic outflow to peripheral vasculature, blocks renin release from the kidneys
  • SIDE EFFECTS: bronchospasm, bradycardia, hypotension, heart failure, may mask symptoms of hypoglycemia, insomnia, fatigue, decreased exercise tolerance
  • INTERACTIONS: additive effect with other antihypertensives and alcohol, alters the effectiveness of hypoglycemic drugs
  • CONTRAINDICATIONS/CAUTIONS: asthma, AV block, heart failure, use caution in diabetes and older adults
  • PREGNANCY/LACTATION: may be considered as initial treatment for pregnant folks with HTN (safe), low concentrations of labetalol and propanolol are found in breast milk but there are high concentrations of atenolol
195
Q

CALCIUM CHANNEL BLOCKERS FOR HTN

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/precautions
  • pregnancy/lactation
A
  • EXAMPLES: nifedipine (Procardia), diltiazem (Cardizem), verapamil
  • MOA: blocks influx of calcium through transmembrane calcium channels that trigger smooth muscle contraction; results in prolonged vascular smooth muscle relaxation
  • SIDE EFFECTS: dizziness, hypotension, headache, GI upset, peripheral edema, heart failure **side effects are less common with sustained-release forms
  • INTERACTIONS: additive effect with other antihypertensives and alcohol, risk of digoxin and lithium toxicities when used togehter
  • CONTRAINDICATIONS/CAUTIONS: heart failure, AV block, significant peripheral edema. may worsen GERD
  • PREGNANCY/LACTATION: nifedipine may be considered if needed for initial treatment of pregnant folks with chronic HTN (safe)
196
Q

ACE INHIBITORS FOR HTN

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/precautions
  • pregnancy/lactation
A
  • EXAMPLES: captopril, enalapril, lisinopril, ramipril
  • MOA: inhibits angiotensin-converting enzyme which prevents the conversion of angiotensin I to angiotensin II, thereby enhancing vasodilation
  • SIDE EFFECTS: cough, hypotension, rash, angioedema
  • INTERACTIONS: additive effect with other antihypertensive agents and alcohol, increased risk for renal toxicity with NSAIDs, increased risk for hyperkalemia with potassium-sparing diuretics
  • CONTRAINDICATIONS/CAUTIONS: angioedema, bilateral renal artery stenosis, hyperkelamia
  • PREGNANCY/LACTATION: not safe, associated with fetal anomalies
197
Q

ARBs FOR HTN

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/precautions
  • pregnancy/lactation
A
  • EXAMPLES: losartan (Cozaar), valsartan (Diovan)
  • MOA: block the binding of angiotensin II to the receptor, thereby enhancing vasodilation
  • SIDE EFFECTS: similar to ACE inhibitors, but not as likely to cause a cough and less likely to cause angioedema
  • INTERACTIONS: (same as ACE inhibitors)
  • CONTAINDICATIONS/CAUTIONS: same as ACE inhibitors with the exception of angioedema
  • PREGNANCY/LACTATION: not safe, associated with fetal anomalies, same as ACE inhibitors
198
Q

Heart murmurs are commonly associated with these (2) dynamics/MOAs

A

regurgitation, stenosis

199
Q

Pathologic heart murmurs are indicative of _____ or ____ disease, for example….

A

heart or valvular disease

examples: rheumatic heart disease, aortic or pulmonary stenosis, atrial-septal defect, mitral valve prolapse

200
Q

How common are innocent or functional heart murmurs

A

50-70% of children and up to 50% of adults at some time

201
Q

characteristics of heart murmur that suggest it is functional, or innocent

A
  • no additional physical findings except the murmur
  • soft (grade 1 or 2), medium pitch
  • systolic
  • heard bent when the patient is supine
  • disappears with standing or straining
  • increases with increased cardiac output (e.g., exercise, fever)
202
Q

characteristic of heart murmur that it is pathologic

A
  • diastolic
  • pansystolic
  • any murmur above grade 3
  • intensifies with exercise or Valsalva maneuver
  • mid- or late-systolic click (associated with mitral valve prolapse)
  • cyanosis
  • jugular vein distention
  • hepatomegaly
  • pedal edema
  • diminished femoral pulses or unequal blood pressure in the left and right arms
  • associated with chest pain, DOE, orthopnea, cough or wheeze, or paroxysmal nocturnal dyspnea
203
Q

Diagnostic evaluation of suspected pathologic heart murmur

A
  • echocardiography will confirm the severity and location of clinically-detected lesions
  • chest radiograph can be used to confirm cardiac enlargement
  • CBC (r/o anemia), TSH (r/o thyroid dz)
  • stress electrocardiogram or cardiac catheterization as indicated
204
Q

27yo pt presents for annual. No significant PMH. No medications. No symptoms today, she wants her flu shot. On physical exam, found to have a grade 1/6 systolic murmur. Next step…….

A

low-grade, asymptomatic systolic murmur with a low-risk history can be assumed innocent and followed-up at next visit

205
Q

It is important to consider preventing _________ for folks with valvular heart disease, prosthetic heart valves, or other cardiac structural abnormalities during medical procedures (e.g., dental, upper respiratory, GI, and GU procedures)

A

preventing bacterial endocarditis

rx: amoxicillin PO 2g 1hr before the procedure

206
Q

Bacterial endocarditis prophylaxis prescription

A

amoxicillin PO 2g 1 hr before the procedure

207
Q

What is a “thrombosis” vs. “embolus”

A

thrombosis = blood clot that forms abnormally within a blood vessel

embolus = blood clot that breaks free from its site of formation

208
Q

what is “thrombophilia”

A

tendency to develop thrombosis from either acquired or inherited causes, or both

209
Q

what is superficial phlebitis

A

inflammation of the superficial veins as a result of local trauma, venous stasis, or infection

210
Q

what is “virchow’s triad”

A

triad of conditions increasing risk for blood clot

  1. endothelial damage (e.g., s/t trauma)
  2. stasis (e.g., s/t immobility)
  3. hypercoagulability (e.g., s/t protein C or S deficiency, malignancy)
211
Q

% risk of DVT embolizing to pulmonary circulation

A

40% risk when thigh vein is involved

risk is minimal when only calf veins are involved

212
Q

superficial thromboses usually occur in….

A

varicose veins

213
Q

Most common acquired risk factors for a DVT

A
  • recent surgery
  • immobilization and/or venous stasis
  • trauma or fracture
  • malignancy
  • pregnancy, early postpartum
  • combination OCPs
  • congestive heart failure, recent MI
  • h/o prior blood clot
  • obesity
  • inflammatory diseases
  • antiphospholipid syndrome
  • smoking
214
Q

Most common inherited risk factors for a DVT

A
  • factor V leiden
  • protein C deficiency
  • protein S deficiency
  • prothrombin gene mutation
  • homocysteine abnormalities
  • antithrombin gene deficiency
215
Q

Symptoms suggestive of superficial phlebitis

A

localized area of edema, erythema, and tenderness over a SUPERFICIAL vein

216
Q

Symptoms suggestive of DVT

A
  • acute onset of unilateral leg pain, most commonly in the calf
  • leg edema
  • up to 50% will have no symptoms
217
Q

Symptoms suggestive of PE

A
  • cyanosis
  • diminished breath sounds over the involved area
  • tachypnea
  • cough with hemoptysis
  • tachycardia
  • fever
218
Q

Diagnostic evaluation of suspected superficial phlebitis

A

usually none needed; clinical diagnosis

219
Q

Diagnostic evaluation of suspected DVT

A

In summary: Doppler US and/or plasma D-dimer initial tests&raquo_space; if inconclusive, contrast venography&raquo_space; follow-up with testing for inherited or acquired thrombophilias

  • duplex (Doppler) US is the best initial test when the probability of DVT is intermediate-high for it has good sensitivity and specificity in symptomatic patients. A negative test in an individual with intermediate to high probability of a DVT requires further testing
  • plasma D-dimer enzyme-linked immunoassay (ELISA) will be elevated in 95-98% of DVTs. Therefore, most useful in ruling OUT DVT since a negative test makes DVT unlikely). In contrast, positive results are supportive but not diagnostic because it could be an number of other causes
  • contrast venography , which is best used when clinical findings suggestive of DVT are not confirmed on the initial US
  • test for other inherited or acquired anticoagulation deficiencies (Protein C, protein S, antithrombin, prothrombin gene mutation, antiphospholipid antibodies, factor V Leiden)
220
Q

Diagnostic evaluation of suspected PE (5)

A
  • ventilation/perfusion (VQ) lung scan
  • arterial blood gasses (ABG)
  • ECG and chest radiograph
  • plasma d-dimer ELISA
  • pulmonary angiogram
221
Q

Management of superficial phlebitis

A

elevate legs, compression with an ace wrap, NSAIDs for pain

222
Q

Patient education points to prevent blood clot in those at high risk

A
  • during prolonged confined travel: support stockings, plenty of fluids, passive intermittent contraction of calf muscles, rest breaks to walk, stretch, exercise the legs
  • may consider a low-dose aspirin on long travels
  • do not smoke
  • do not use estrogen-containing OCPs
223
Q

The main reason we care about dyslipidemia is because it is a risk factor for the development of…..

A

coronary heart disease

224
Q

Criteria for Elevated LDL-C

A

> 130mg/dL

  • optimal: <100
  • near optimal: 100-129
  • borderline high: 130-159
  • high: 160-189
  • very high: >190
225
Q

Criteria for Elevated triglycerides

A

> 200 mg/dL

  • normal: <150
  • borderline high: 150-199
  • high: 200-499
  • very high: >500
226
Q

Criteria for Low HDL-C

A

<40 mg/dL

227
Q

Criteria for metabolic syndrome

A

any (3) of the following:

  • abdominal obesity and/or waist circumference >35 inches in females, >40 inches in males
  • triglycerides >150 mg/dL
  • HDL <50 in females, <40 in males
  • BP 130/85 or higher
  • fasting glucose 110 mg/dL or higher
228
Q

(3) drug classes that can increase cholesterol

A

beta blocks, corticosteroids, thiazide diuretics

229
Q

prevalence of dyslipidemia in adult women in the US

A

> 50%

230
Q

(3) physical exam findings that may be associated with dyslipidemia

A
  • corneal arcus: thin, grayish-white arc or circle near the edge of the cornea
  • xanthomas: slightly raised, yellow-ish, well-circumscribed plaques along the nasal portion of the eyelids
  • central obesity
231
Q

Criteria for elevated total cholesterol

A

> 200 mg/dL

  • desirable: <200
  • borderline high: 200-239
  • high: >240
232
Q

the treatment for dyslipidemia is driven by…..

A

risk for coronary heart disease events

233
Q

Framingham Risk Tool criteria for CHD risk

A
  • CHD or CHD risk equivalents (diabetes, PVD, abdominal aortic aneurysm, symptomatic carotid artery disease) = >20% 10-yr risk
  • 2+ risk factors (smoking, HTN, low HDL, age, family hx of premature CHD) without diagnosed CHD or CHD risk equivalents = <20% 10-yr risk
  • 0 or 1 risk factors = <10% 10-yr risk
234
Q

Dietary modifications for lowering LDL cholesterol, per the AHA (4)

A
  • reduce saturated fats to no more than 5-6% of total calories
  • reduce trans fats to less than 1% of calories
  • emphasize fruits, vegetables, whole grains, low-fat dairy, poultry, fish, andnuts
  • limit red meats and sugary foods/beverages
235
Q

Lifestyle modifications for treatment of dyslipidemia

A
  • QUIT SMOKING!
  • weight loss if overweight or obese with goal BMI <25 and/or initial weight-loss goal of 5-10% of current weight
  • moderate-intensity exercise for 30 min/day most days of the week (walking counts!)
  • dietary modifications
236
Q

In folks with dyslipidemia, how do you decide whether to start with lifestyle vs. medication therapy first?

A

lifestyle start = without clinical coronary heart disease, no h/o diabetes, ages 40-75yo, LDL <190 and estimated CVD event risk of <7.5%

medication start: LDL >190, h/o diagnosed CHD or diabetes, 10-yr CHD risk >7.5%, patient preference

237
Q

(4) factors to discuss in shared-decision-making of starting a statin in pt with dyslipidemia

A
  • lipid lab values (borderline high vs. very high)
  • presence of coronary heart disease or diabetes
  • estimated 10-year ASCVD risk
  • patient preference regarding benefits, risks, side effects, drug-drug interactions
238
Q

First line medication class for LDL reduction in adults

A

Statins (HMG-CoA reductase inhibitors)

239
Q

MOA Statins

A

inhibits HMG-CoA reductase, an enzyme that controls cholesterol biosynthesis in cells

Statins are effective in decreasing LDL-C, moderately effective in increasing HDL-C, and moderately effective in decreasing triglycerides

240
Q

Contraindications/cautions for the use of statins

A

contraindications = severe liver disease, pregnancy, lactation

cautions = myopathy, with risk increased if they are also on a fibrate or niacin

241
Q

Considerations for the use of statins in pregnancy and lactation

A

not safe! not safe in pregnancy or lactation

242
Q

Medication options for the treatment of dyslipidemia

A
  • statins (HMG-CoA reductase inhibitors) = first line
  • ezetimibe (Zetia) = second line
  • there is no high-quality evidence to support fibrates, nicotinic acid, bile acid sequestrants, and omega-3 fatty acids but they may be considered
243
Q

High intensity statin therapy lowers LDL-C by __% on average, vs. low and moderate intensity statins

A

high intensity = >50% reduction
moderate intensity = 30-50% reduction
low intensity = <30% reduction

244
Q

(2) prescriptions that represent HIGH INTENSITY statin therapy

A
  • atorvastatin (Lipitor) 40-80mg PO QD

- rosuvastatin (Crestor) 20-40mg PO QD

245
Q

(5) prescriptions that represent MODERATE INTENSITY statin therapy

A
  • atorvastatin (Lipitor) 10-20mg PO QD
  • rosuvastatin (Crestor) 5-10mg PO QD
  • simvastatin (Zocor) 20-40mg PO QD
  • pravastatin (Pravachol) 40-80mg PO QD
  • lovastatin (Mevacor) 40mg PO QD
246
Q

(3) prescriptions that represent LOW INTENSITY statin therapy

A
  • simvastatin (Zocor) 10mg PO QD
  • pravastatin (Pravachol) 10-20mg PO QD
  • lovastatin (Mevacor) 20mg PO QD
247
Q

Define “coronary heart disease”

A

atherosclerotic changes to the coronary vasculature. this causes decreased blood flow through the coronary arteries due to partial obstruction or vasospasm

atherosclerosis develops with the formation of fatty streaks, fibrous plaques, and complicated lesions that narrow the lumen of the coronary arteries

248
Q

What is “angina pectoris”

A

myocardial ischemia secondary to inability of the coronary arteries to supply oxygenated blood to meet the myocardial oxygen demands

249
Q

What is “acute coronary syndrome”

A

when an atherosclerotic plaque ruptures, may cause thrombus formation that impedes or completely occludes the coronary lumen

2 types: unstable angina, acute myocardial infarction

250
Q

(2) types of acute coronary syndrome

A
  • acute MI

- unstable angina

251
Q

leading cause of death for women in the US

A

coronary heart disease

252
Q

Symptoms of chronic stable angina pectoris

A

clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arm that is precipitated by exertion and relieved by rest or nitroglycerin

stable angina has predictable frequency, severity, duration, and provocation – exercise

this pattern remains the same, unless there is an acceleration of the disease progress

253
Q

Symptoms of acute coronary syndromes

A
  • chest pain described as pressure, heaviness, squeezing, crushing, aching
  • pain typically involves the sternum and/or epigastrum
  • pain may radiate to the shoulder, arm, jaw, neck, or back
  • may be associated with nausea, vomiting, diaphoresis, or dyspnea
254
Q

Diagnostic evaluation of coronary heart disease

A

In summary: ECG and consider labs (troponins, myoglobin)&raquo_space; Stress tests (exercise/treadmill, medication, nuclear)&raquo_space; coronary angiography

  • ECG = changes will depend on the location of vessel(s) involved, amount of myocardium involved, and the duration of ischemia. ST-segment depression and symmetric T wave inversion in affected leads may occur during an acute episode of chronic stable angina. ACS may demonstrate ST segment elevation
  • stress tests (exercise, pharmacologic, or nuclear) = will demonstrate ischemic changes or angina during the test. myocardial perfusion imaging aka nuclear stress test is used to confirm and assess extent and location of coronary artery disease
  • coronary angiography is the definitive test for coronary artery disease (uses dye and CT/radiographs)
  • lab tests involving myocardial markers = may include troponin I and T (high sensitivity and specificity, become elevated within 3-4 hours of an event and remain elevated for as long as 7-14 days after an event), and myoglobin (not as specific as troponins, released within 1-3 hours of myocardial cell injury and normalizes in 24 hours)
255
Q

Management of acute coronary syndromes

A

requires revascularization procedures which may include:

  • percutaneous transluminal coronary angioplasty (PTCA) via the femoral artery
  • coronary artery bypass graft (CABG)
256
Q

Medication classes for angina/CHD

A
  • aspirin 81-325 mg/day inhibits platelet aggregation, primary prevention
  • sublingual nitroglycerin 0.4mg PRN for symptomatic relief of anginal episodes
  • beta blocks are the preferred initial therapy, decrease myocardial demand by decreasing HR, systolic BP, and contractility
  • calcium channel blockers (long-acting) promote peripheral arterial vasodilation thereby reducing oxygen demand by decreasing afterload, and they also decrease coronary vasospasm
  • long-acting nitrates (isosorbide dinitrate, nitropaste, nitropatches) cause venous dilation, which decreases venous return to the heart and leads to modest arterial vasodilation resulting in decreased myocardial oxygen demand
  • make sure to treatment comorbid HTN, diabetes, dyslipidemia, and tobacco use
257
Q

What is allergic rhinitis

A

inflammation of the mucous membranes of the nose in response to contact with certain allergies, triggering the production of immunoglobulin E (IgE) antibodies&raquo_space; histamine release&raquo_space; subsequent edema, itching, discharge, and sneezing

eyes, ears, sinuses, and throat can also be involved

affects 10-20% of adults and typically onsets between ages 10-20yo

258
Q

seasonal vs. perennial allergic rhinitis are usually due to….

A

seasonal = pollens/allergens including trees, grasses, ragweed, hay fever

perennial = usually related to dust mites, mold, cockroaches, and animal dander

259
Q

symptoms suggestive of allergic rhinitis

A

nasal congestion, clear rhinorrhea, sneezing, pruritis of nose/throat/eyes, sore throat and cough from post-nasal drip

260
Q

physical exam findings suggestive of allergic rhinitis

A
  • nasal mucosa is pale, boggy
  • rhinorrhea is thin and clear
  • nasal crease = horizontal crease across the lower bridge of the nose caused by repeated upper rubbing of the tip of the nose with palm of hand
  • injected conjunctiva and tearing
  • allergic shiners aka dark discoloration beneath both eyes
261
Q

what is “rhinitis medicamentosa”

A

“rebound rhinitis”

rhinitis caused by excessive topical use of of intranasal vasoconstrictors including decongestants or cocaine

262
Q

diagnostic evaluation of suspected allergic rhinitis

A
  • usually none are needed, clinical diagnosis
  • skin tests to determine specific allergens are the gold standard for diagnosis
  • serum allergy tests can be considered, including radioallergosorbent test (RAST) which measures amount of specific IgE to individual allergens correlating with the allergic sensitivity to that substance …. can be used to determine specific IgE to a number of different allergens at one time, but is expensive and not as sensitive as skin tesitng
263
Q

Non-pharm and pharm measures for the treatment of allergic rhinitis

A

non pharm:

  • allergen avoidance (especially the bedroom)
  • vaccuum, dusting, remove carpeting, feather pillows, and stuffed animals
  • reduce exposure to pets
  • air conditioning and air filters

pharm classes:

  • antihistamines (first line)&raquo_space; good for itching, sneezing, rhinorrhea (with minimal effect on congestion)
  • decongestants&raquo_space; can be used alone or in combination of antihistamines, best for nasal congestion specifically
  • topical nasal corticosteroids&raquo_space; increasingly becoming first line given their effectiveness, however, they have a slow onset of action and are maximally effective if used as a maintenance therapy
  • mast cell stabilizers/intranasal cromolyns&raquo_space; effective for prophylaxis, not acute, as they have no direct anti-inflammatory or antihistamine effects
  • montelukast (leukotriene receptor antagonist)&raquo_space; reduces inflammation
264
Q

First line medication for allergic rhinitis

A

antihistamines

and, increasingly, intranasal corticosteroids given their effectiveness

265
Q

ANTIHISTAMINES FOR ALLERGIC RHINITIS

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/cautions
  • pregnancy/lactation
A

-EXAMPLES:
++ FIRST GEN: diphenhydramine (Benadryl), meclizine
++ SECOND GEN: loratidine (Claritin), fexofenadine (Allergra), cetirizine (Zyrtec)
++MISC: azelastine Hcl (Astelin) intranasal

-MOA: blocks the action of histamine,
++FIRST-GEN also has anticholinergic properties
++ AZELASTINE specifically inhibits histamine release from mast cells

-SIDE EFFECTS: second gen has less sedative effects
++ FIRST GEN: dry mucous membranes, blurred vision, drowsiness (anticholinergic effects)
++ AZELASTINE specifically can cause bitter taste, somnolence, and headache

  • INTERACTIONS: additive CNS depressant effects with alcohol, sedatives, anti-anxiety agents, barbiturates, MOAIs and TCAs
  • CONTRAINDICATIONS/CAUTIONS: avoid first-gen use in the elderly as the sedative effect may cause adverse effects on cognition and balance. caution in patients with renal or hepatic dysfunction.
  • PREGNANCY/LACTATION: diphenhydramine is the antihistamine of choice during pregnancy, safe, there are no fetal malformations associated with its use. Not recommended during lactation as can cause neonatal sedation. there is limited to no data on the second generation antihistamines in pregnancy and lactation
266
Q

antihistamine of choice during pregnancy

A

diphenhydramine (Benadryl)

267
Q

DECONGESTANTS FOR ALLERGIC RHINITIS

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/cautions
  • pregnancy/lactation
A
  • EXAMPLES: pseudoephedrine (Sudafed), phenylephrine (Sudafed PE)
  • MOA: alpha-adrenergic agonist&raquo_space; vasoconstriction in nose reduces engorgement of the nasal mucosa
  • SIDE EFFECTS: increases HR, BP, CNS stimulation
  • INTERACTIONS: can cause hypertensive crisis when taken with MAOIs
  • CONTRAINDICATIONS/CAUTIONS: contraindicated in those with severe HTN, CVD, or MAOIs
  • PREGNANCY/LACTATION: there is some evidence of association between first-trimester use of pseudoephedrine and risk of infrequent specific birth defects . no controlled human data on use of phenylephrine during pregnancy
268
Q

CORTICOSTEROIDS FOR ALLERGIC RHINITIS

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/cautions
  • pregnancy/lactation
A
  • EXAMPLES: budesonide (Symbicort, Rhinocourt)
  • MOA: anti-inflammatory effects, but the therapeutic benefit is not immediate
  • SIDE EFFECTS: local irritation, epistaxis, headache, there is minimal systemic absorption at the recommended doses
  • INTERACTIONS: effects CYP450
  • CONTRAINDICATIONS/CAUTIONS: not for relief of acute bronchospasm, avoid with Cushing’s syndrome
  • PREGNANCY/LACTATION: very little of nasal corticosteroid is absorbed systemically, okay to use generally
269
Q

MAST CELL STABILIZERS FOR ALLERGIC RHINITIS

  • examples
  • MOA
  • side effects
  • interactions
  • contraindications/cautions
  • pregnancy/lactation
A
  • EXAMPLE: cromolyn (NasalCrom)
  • MOA: prevents degranulation of mast cells and thus the release of histamine; a prophylactic drug
  • SIDE EFFECTS: local reactions including burning, stinging, and sneezing
  • INTERACTIONS: None
  • CONTRAINDICATIONS/CAUTIONS: none
  • PREGNANCY/LACTATION: available data suggests no association with fetal toxicity or teratogenicity
270
Q

what is conjunctivitis and its most common (3) types

A

umbrella term for a group of conditions presenting as inflammation of the conjunctiva

conjunctiva = loose connective tissue that covers the surface of the eyeball (bulbar conjunctiva) and reflects back upon itself to form the inner layer of the eyelid (palpebral conjunctiva)

TYPES:

  1. viral
  2. bacterial
  3. allergic
271
Q

what is viral conjunctivitis, cause, symptoms

A

inflammation of the conjunctiva, most commonly caused by adenovirus. may also be caused by herpes simplex and hrepes zoster viruses

symptoms: mild discomfort, sensation of scratchy grit in eye, acute onset, may be unilateral or bilateral, water discharge, preauricular adenitis, may be associated with a recent URI

272
Q

what is bacterial conjunctivitis, cause, symptoms

A

inflammation of the conjunctiva, most commonly caused by staphylococci, streptococci, chlamydia, or gonorrhea

symptoms: mild discomfort, sensation of scratchy grit in eye, acute onset, starts in one eye and spreads to the other, discharge is mucopurulent, eyelids are matted together upon awakening

273
Q

what is allergic conjunctivitis, cause, symptoms

A

inflammation of the conjunctiva, most commonly caused by type I IgE-mediated hypersensitivity reaction to small airborne particles including pollen, animal dander, or dust

symptoms: mild discomfort, bilateral, sensation of eye itching, tearing, redness, may have mild eyelid swelling, discharge is clear and watery or stringy and mucoid, personal or family history of atopic conditions

274
Q

most common eye complaint in primary care

A

conjunctivitis

275
Q

recommended management for viral conjunctivitis

A

anticipatory guidance that these are self-limited. can use cold compresses and eye lubricants (e.g., liquid tears) for comfort

recommend discarding opened makeup, replace all contact lenses, cases, and opened solutions. avoid sharing linens to prevent transmission. frequent handwashing.

276
Q

recommended management for bacterial conjunctivitis

A

broad-spectrum topical antibiotic such as erythromycin, polymixin B/trimethoprim x 5-7 days

if gonococcal or chlamydial, will need systemic antibiotics

recommend discarding opened makeup, replace all contact lenses, cases, and opened solutions. avoid sharing linens to prevent transmission. frequent handwashing.

277
Q

recommended management for allergic conjunctivitis

A
  • remove known allergens or triggers
  • short-term treatments for acute episodes may include dual tx: topical antihistamines (e.g., Neo-Syneprhine) and vasoconstrictors (Clear Eyes)
  • long-term therapy for seasonal or perennial allergic conjunctivitis can include topical anthistamine plus a mast cell stabilizer, OR combination oral antihistamine and mast cell stabilizer (olopatadine Hcl, bepotastine)
  • topical NSAIDs: ketorolac (Acular)
278
Q

Pts with suspected bacterial conjunctivitis should show improvement within _____ of treatment, otherwise should be referred

A

48 hours of appropriate treatment

279
Q

% of squamous cell carcinomas that occur at the site of a previous actinic keratosis

A

60%

280
Q

Physical exam findings in asthm

A
  • hyperresonance to percussion
  • wheezing
  • prolonged expiratory phase
  • diminished breath sounds
  • tachypnea
  • dyspnea
281
Q

Characteristics of mild persistent asthma

A
  • daytime symptoms more than 2x weekly, but less than daily
  • nocturnal symptoms 3-4x per month
  • use of a SABA >2 days per week but less than daily and not more than 1x per day
  • two or more exacerbations requiring oral corticosteroids in the last year
  • mild interference with normal activity
  • FEV1 >80% predicted (normal FEV1/FVC ratio for age between exacerbations)
282
Q

% of those with latent (asymptomatic) TB who will progress to active infection

A

10%

283
Q

5-mm or greater skin reaction on a PPD test is considered positive for…..

A
  • HIV positive
  • immunocompromised
  • have abnormal chest radiograph findings consistent with healed TB lesions
  • close contact with known TB-infected person
284
Q

Symptoms of active TB

A
  • night sweats
  • fever
  • malaise
  • weakness
  • anorexia and weight loss
  • productive cough
  • hemoptysis
  • chest pain
  • dyspnea
285
Q

Warn patients about this possible side effect of sumatriptan

A

may initially cause tightness of the throat/chest, flushing, numbness, tingling, and dizziness

side effect usually abates within a few minutes and is not a contraindication for future use

286
Q

Reasons for neurological evaluation of headaches

A
  • new type of headache occurring in individual >50yo
  • sudden onset of the worst headache ever experienced
  • headaches increasing in frequency or severity
  • headache initiated by exertion
  • focal neuro symptoms that persist after the headache onset
  • headache s/t head trauma
287
Q

Non-pharm recommendations for lower back pain

A
  • continuation of daily activities (no bedrest)
  • local application of heat
  • warm baths
  • PT for strength and conditioning
  • low stress aerobic exercise (walking, biking, swimming)
288
Q

Characteristics of osteoarthritis

A
  • asymmetrical involvement
  • aggravated by joint movement and relieved by rest
  • decreased ROM to affected joints
  • joint crepitus with movement
  • minimal joint warmth without erythema
  • enlargement of the distal and proximal interphalangeal joints
289
Q

A herniated disc is characterized by ______ pain

A

radicular

290
Q

Most common disc ruptures/herniated discs involve these (2) nerve roots

A

L5

S1

291
Q

Criteria for recommending a rapid strep antigen test

A

adult with pharyngitis (sore throat) who meets 2 or more of the following:

  • tonsillar exudates
  • tender anterior cervical lymphadenopathy
  • fever
  • NO cough
292
Q

PrEP is contraindicated with individuals with severe renal impairment. Folks on PrEP should have kidney function tests repeated every….

A

Q6 months while on therapy

293
Q

How is response to ART therapy monitored in HIV positive individuals

A

HIV RNA levels, which are useful for predicting progression of disease by indicating viral load and are used to monitor ART therapy

294
Q

Most opportunistic infections (e.g., PCP pneumonia) occur in HIV-infected individuals with a CD4 count of less than….

A

<200 cells/mm3

295
Q

Significance of PCP pneumonia in someone with known HIV infection

A

PCP pneumonia is a major AIDS-defining illness (pneumocystic pnuemonia, a fungal infection)

296
Q

Racial/ethnic groups at elevated risk for SLE (2)

A 
African American (1 in 250)
Hispanic/Latinx (100 in 100,000)

[compared to Caucasian women 12-39 per 100,000)

297
Q

Criteria for the diagnosis of SLE, per American College of Rheumatologists 2005

A

Must meet 4/11 criteria

  • malar rash (erythematous, flat or raised rash over the malar eminences)
  • discoid rash (erythematous raised patches with scaling)
  • photosensitivity
  • oral ulcers
  • arthritis involving 2 or more peripheral joints
  • serositis (e.g., pleuritis, pericarditis, peritonitis)
  • renal disorder involving proteinuria or cellular casts
  • neurological disorder involving seizures or psychosis
  • hematologic disorder (e.g., hemolytic anemia, leukopenia, thrombocytopenia)
  • positive ANA test (antinuclear antibodies)
  • positive other immunologic test (e.g., anti-dsDNA [anti-double-stranded DNA), anti-Smith (anti-Sm), LE (lupus erythematosus) cell preparation, or false-positive syphilis serology)
298
Q

What is the single lab test that is most important for the diagnosis of SLE

A

ANA = antinuclear antibodies

positive in 95% of cases

299
Q

Diagnostic evaluation of suspected SLE

A
  • ANA (antinuclear antibodies)
  • anti-dsDNA (anti double stranded DNA)
  • anti-Sm (anti-Smith)
  • LE cell prep (lupus erythematosus cell prep)
  • VDRL test (false-positive syphilis test)
  • antiphospholipid antibodies (anticardiolipin IgG or IgM or lupus anticoagulant – 30-50% of individuals with lupus have positive antiphospholipid antibodies)
  • CBC to assess for anemia, leukopenia, lymphopenia, or thrombocytopenia
  • serum creatinine to assess kidney function
  • UA to determine presence of hematuria, cellular casts, and proteinuria
300
Q

Medical management for SLE

A

treatment is generally symptomatic and variable

  • NSAIDs for fever, joint pain, serositis
  • low dose topical corticosteroids for skin rashes
  • oral or IV glucocorticoids (steroids) for major organ involvement
  • hydroxychloroquine (Plaquenil), an antimalarial drug that can decrease flares and organ involvement with long-term use
301
Q

Considerations for the use of hydrochloroquine for folks with SLE in pregnancy

A

can continue to use during pregnancy, try to use the lowest therapeutic dose possible

302
Q

commonly comorbid blood disorder in folks with SLE

A

antiphospholipid antibody syndrome (30-50%)

blood clotting risk

303
Q

SLE diagnosis is what category for the Medical Eligibility Criteria for COCs

A

category 4 (contraindicated)

304
Q

Anticipatory guidance: pregnancy outcomes are best when the patient with SLE has met which (2) criteria before pregnancy

A
  • symptoms in remission for at least 6 months before pregnancy
  • renal function is normal
305
Q

Anemia, per WHO criteria

A

Hgb <12 g/dL for females

Hgb <13 for males

306
Q

Pathophysiology of otitis media infection s/t a viral URI

A

eustachian tube dysfunction secondary to a URI (often viral) or allergies causes edema and congestion in the middle ear that impedes the flow of ear secretions. Accumulation of secretions promotes the growth of pathogens, including bacteria

307
Q

When are antibiotics indicated for the treatment of acute bacterial rhinosinusitis (ARBS)

A

if symptoms are present for 10 or more days after the onset of URI symptoms OR if symptoms first improve and then worsen again within 10 days

308
Q

Classic triad of symptoms for mononucleosis

A
  • fever
  • sore throat
  • swollen lymph nodes (especially anterior and posterior cervical chain)
309
Q

What might you see on CBC with diff in someone with mononucleosis

A

CBC may show a lymphocytic leukocytosis, with 10% of cells being atypical

310
Q

Age range for highest mononucleosis prevalence

A

10-30yo, with peak in those 15-19yo

311
Q

Most common cause of bright red painless bleeding per rectum

A

internal hemorrhoids

internal hemorrhoids originate above the anorectal line, are covered by non-sensitive rectal mucosa, and are usually painless

312
Q

Two medications that might be useful for someone with IBS-constipation

A
  • fiber supplement

- lubiprostone

313
Q

% of duodenal ulcers caused by H. pylori

A

90-95%

314
Q

% of gastric ulcers caused by H. pylori

A

70-80%

315
Q

% prevalence of H. pylori in the general population

A

5-10%

316
Q

Diagnostic evaluation of suspected peptic ulcer disease (PUD)

A
  • stool for fecal occult blood
  • serologic test for H. pylori (stool or urea breath can be used to test for cure)
  • CBC with diff
  • mucosal biopsy can be considered for select populations or no improvement with treatment
317
Q

Who should be considered for a mucosal biopsy in those with suspected peptic ulcer disease (PUD)

A
  • age >50yo
  • alarm symptoms
  • family history of gastric cancer
  • no improvement with treatment
318
Q

Methods of testing for H. pylori

A

SEROLOGIC
- enzyme-linked immunosorbent assay (ELISA) to detect immunoglobulin G (IgG) H. pylori antibodies will indicate current or past infection

STOOL
- stool antigen test with revert to negative within 5 days to a few months after eradication of the organism

BREATH
- urea breath test detects the presence or absence of infection

ENDOSCOPY
- endoscopic evaluation with/without mucosal biopsy

319
Q

Lab test that signifies immunity against Hepatitis B

A

HBV surface ANTIBODY test, aka anti-HBs

320
Q

What is HbsAg

A

Hepatitis B Virus Surface Antigen

When positive, indicates an acute or chronic infection and that the person is infectious

321
Q

Lab tests that signifies infectivity with Hepatitis B

A

HBV surface ANTIGEN, aka HbsAg

HBV e ANTIGEN (highly infectious)

322
Q

What is anti-Hbs

A

Hepatitis B Virus Surface Antibody

When positive, indicates immunity due to prior infection or to vaccination

323
Q

What is anti-HBc

A

Hepatitis B Virus Core Antibodies

When positive, indicates acute or chronic infection at some point and these will persist for life

324
Q

What is IgM anti-HBV

A

Hepatitis B Virus Core IgM Antibody

When positive, indicates an acute infection, will return to normal in 4-6 months

325
Q

What is HBV DNA

A

Will be positive in acute and chronic infection

326
Q

What is IgM anti-HAV

A

Hepatitis A Virus IgM Antibodies

When positive, indicates a current or recent infection. Will return to negative in 6 months

327
Q

What is IgG anti-HAV

A

Hepatitis A Virus IgG Antibodies

When positive, indicates immunity due to prior infection or vaccination

328
Q

What is the lab that demonstrates active infection with Hepatitis A

A

IgM anti-HAV

329
Q

What is the lab that demonstrates immunity against Hepatitis A

A

IgG anti-HAV

330
Q

What is anti-HCV

A

Hepatitis C Antibodies

When positive, indicates a current or resolved infection, as this persists positive for life

331
Q

What is HCV RNA

A

Lab test that confirms current Hepatitis C infection, and persists with chronic infection

332
Q

What is the lab test that demonstrates active HCV infection

A

HCV RNA

333
Q

What is the lab test that demonstrates HCV immunity

A

anti-HCV

334
Q

most common type of gallstones

A

cholesterol

335
Q

% of gallstones composed of cholesterol

A

85-95%

336
Q

Best initial imagining for suspected gallstones

A

US, which has 95% sensitivity for detecting stones in the gallbladder

337
Q

US has ___% sensitivity for diagnosing stones in the gallbladder

A

95% sensitivity

338
Q

Which hepatitis most commonly turns into chronic infection and is the most common reason for liver transplantation

A

Hepatitis C

339
Q

% of hepatitis C infection that becomes chronic hepatitis

A

80%

340
Q

% of hepatitis C infection that will become cirrhosis or hepatocellular carcinoma

A

20-30%

341
Q

Management recommendations for acute cholecystitis

A

hospitalization and early cholecystectomy once stable

342
Q

What characteristics of a patient with suspected GERD would warrant referral for further diagnostic evaluation with GI specialist

A
  • symptoms are chronic and refractory to therapy
  • esophageal complications are suspected
  • dysphagia
  • weight loss
  • evidence of GI bleeding
343
Q

Fasting plasma glucose diagnostic of T2DM

A

> or = 126 mg/dL

344
Q

2-hr postprandial glucose diagnostic of T2DM

A

> or = 200 mg/dL

345
Q

random glucose diagnostic of T2DM

A

> or = 200 mg/dL

346
Q

HbA1c diagnostic of T2DM

A

> or = 6.5%

347
Q

Most common causative agent for traveler’s diarrhea

A

escheria coli (E. Coli)

The most common causative agent for traveler’s diarrhea is E. coli. If the patient does not have bloody stools or a fever, and symptoms are self-limiting, no stool evaluation or antibiotic treatment is needed

348
Q

Management of traveler’s diarrhea

A

<2 days, self-limiting, no fever, no blood in stool = fluids, no anti-diarrheals, supportive care

fever, bloody stool, not resolving, severe = stool studies for parasites/ova and treat with antibiotics

349
Q

MOA of ezetimibe (Zetia) for HLD

A

inhibits cholesterol absorption

350
Q

% of hyperthyroidism cases caused by Grave’s disease

A

90%

351
Q

Most common cause of hyperthyroidism

A

Graves Disease (90%)

352
Q

What is Grave’s disease

A

autoimmune condition characterized by excess synthesis and secretion of thyroid hormone caused by antibodies that stimulate the TSH receptors

353
Q

% of patients with Grave’s disease treated with radioactive iodine who will develop long-term hypothyroidism

A

70% of patients by ten years

354
Q

When starting someone on levothyroxine for a new diagnosis of hypothyroidism, how often should TSH be measured and drug levels adjusted until control is acheived?

A

Q6 weeks

levothyroxine has a half-life of 6 days and reaches steady state slowly

355
Q

Most common skin cancer

A

basal cell carcinoma (75%)

356
Q

% of all skin cancers that are basal cell carcinoma

A

75%

357
Q

Common precipitating factors for vaso-occlusive sickle cell crisis (6)

A
  • infection
  • stress (physical or emotional)
  • blood loss
  • pregnancy
  • surgery
  • high altitudes
358
Q

tinea unguium refers to fungal infection of the…..

A

nails (fingernails or more commonly toenails)

359
Q

% of folks with hepatitis B infection who will develop chronic hepatitis

A

10%

360
Q

% of neonates infected with hepatitis B at birth who will develop chronic hepatitis

A

90%

361
Q

chronic hepatitis increases the risk of these (2) sequelae

A
  • cirrhosis

- cancer (hepatocellular carcinoma)

362
Q

Acute constipation, recommend first line treatment with….

A

saline laxatives (e.g., milk of magnesia)

saline laxatives draw water into the intestinal lumen, causing the fecal mass to soften and swell. This stretches the intestinal lumen and stimulates peristalsis

363
Q

Medication class of milk of magnesia

A

saline/osmotic laxative

364
Q

CURB-65 Criteria for Hospitalization in Pneumonia

A

hospitalize if 2 or more of the following …

  • Confusion
  • Uremia (BUN >19 mg/dL)
  • Respiratory rate >30
  • Blood pressure <90 SBP or 60 DBP
  • 65yo or older
365
Q

First line treatment for community-acquired pneumonia

A

empiric antibiotic therapy, whether its viral or bacterial!!!

with an advanced-generation macrolide = AZITHROMYCIN

With risk factors for drug-resistant strep pneumonia (DRSP), first line is a respiratory fluoroquinolone

366
Q

(3) respiratory fluoroquinolones

A

levofloxacin, moxifloxacin, gemifloxacin

367
Q

Pt presents with new onset HTN and an abdominal bruit. Suspect –

A

renal artery stenosis

368
Q

ACEs and ARBs are contraindicated in pregnancy due to the risk for causing…..

A

fetal anomalies

369
Q

Physical exam findings suggestive of anorexia nervosa

A
  • emaciation
  • dry skin
  • fine body hair (lanugo)
  • muscle wasting
  • peripheral edema
  • bradycardia
  • arrhythmias
  • hypotension
  • delayed sexual maturation
  • stress fractures
370
Q

(3) most common locations for psoriasis lesions

A

knees, elbows, scalp

371
Q

Treatment goal for an individual with HLD and clinically manifest CHD or a CHD-equivalent (e.g., T2DM) is….

A

LDL-C <100 mg/dL

372
Q

Lab findings of iron-deficiency anemia (in terms of MCV, MCHC, RDW, ferritin, and reticulocytes)

A
  • low MCV (<80, microcytic)
  • low MCHC (hypochromic)
  • increased RDW (>15%)
  • low serum ferritin (low iron stores)
  • low reticulocyte count

Also….
- high TIBC (high total iron binding capacity, because not very much is bound)

373
Q

Medication class: Naloxone

A

opioid antagonist

used to reverse the physical effects of an opioid overdose&raquo_space; reverses CNS and respiratory depression

374
Q

(3) classes of medications that can cause dyslipidemia

A

corticosteroids, thiazide diuretics, beta blockers

375
Q

Mid or late-systolic click is usually caused by…..

A

mitral valve prolapse

376
Q

Innocent physiologic heart murmurs will [increase vs. disappear] with Valsalva maneuvers

A

disappear

If a murmur increases with straining/Valsalva, that is more concerning

377
Q

Most common cause of bacterial community-acquired pneumonia

A

streptococcus pneumoniae

378
Q

First line treatments (2) for asthma in pregnancy

A
  • SABAs (albuterol)

- inhaled corticosteroid BUDESONIDE

379
Q

Asthma exacerbations in pregnancy cause risk for…. (3)

A
  • perinatal mortality
  • preterm birth
  • low birth weight infants
380
Q

Criteria for the diagnosis of Rheumatoid Arthritis, per the American College of Rheumatology

A

Total score needed 6/10 in 4 categories (A-D)

A = JOINT INVOLVEMENT
- based on the number and size of joints with clinical synovitis (stiffness, swelling)

B = SEROLOGY
- based on serum Rheumatoid Factor (RF), and anti-citrullinated protein antibody (ACPA)

C = ACUTE PHASE REACTANTS
- based on normal or abnormal CRP (C reactive protein) and/or ESR (erythrocyte sedimentation rate)

D = DURATION OF SYMPTOMS
- based on duration of 6 or more weeks

381
Q

(3) medication classes used for migraine prophylaxis

A
  • beta blockers (propanolol, timolol)
  • calcium channel blockers
  • antiepileptic agents
382
Q

who is a candidate for migraine prophylaxis medications

A
  • > 2 severe headaches pre month
  • acute medication tx >2x per week
  • unable to tolerate abortive agents
383
Q

Preferred therapy for the long-term management of Rheumatoid Arthritis

A

DMARDs (most commonly methotrexate, hydrochloroquine is another option)

384
Q

Clinical presentation for mononucleosis

A
  • tonsillar enlargement with exudate
  • palatal petechiae (junction of hard and soft palate)
  • lymphadenopathy, especially posterior cervical chain
  • fever
  • hepatomegaly
  • splenomegaly
  • lymphocytic leukocytosis with atypical lymphocytes on CBC
385
Q

Common locations for eczema (atopic dermatitis)

A
  • face
  • wrists
  • hands
  • arms
  • knees
  • genitals
386
Q

All folks considering pregnancy should be offered genetic carrier screening for (2)

A
  • cystic fibrosis

- spinal muscular atrophy

387
Q

Normal MCV range

A

80-100 fL

388
Q

(4) conditions causing a macrocytic anemia

A
  • folate deficiency
  • vitamin B12 deficiency (pernicious anemia)
  • liver disease
  • hypothyroidism
389
Q

Pharmacological treatment is considered for the treatment/prevention of osteoporosis in post-menopausal females who meet any of the following criteria:

A
  • h/o hip or vertebral fracture
  • T score of -2.5 or less at the femoral neck or spine (with secondary causes r/o)
  • T score between -1 and -2.5 at femoral neck or spine with a 10-yr probability of HIP fracture >3%
  • 10-yr probability of any major osteoporotic fracture of > or =20%
390
Q

True or false: Vertebral fracture is consistent with the diagnosis of osteoporosis independent of BMD results

A

true

391
Q

For whom should you consider adding on VFA (vertebral fracture assessment) imaging to a DXA scan?

A
  • female 70yo+ with T score at or below -1.0
  • female ages 65-69yo with T score at or below -1.5
  • post-menopausal females with low trauma fracture during adulthood
  • historical height loss of 4cm or more
  • prospective height loss of 2cm or more (measured?)
  • recent or ongoing long-term glucocorticoid therapy
392
Q

Patient instructions with prescription of a bisphosphonate

A
  • take medication with 8oz water
  • take first thing in the morning on an empty stomach
  • take at least 30 minutes before any beverage, food, or medication
  • avoid lying down for at least 30 minutes and until the first food of the day is eaten
393
Q

(3) DSM-5 criteria for anorexia nervosa

A
  • restriction of intake in relation to requirements
  • intense fear of gaining weight and/or persistent behaviors that interfere with weight gain
  • disturbed body image
394
Q

Elevated lab value that may indicate heavy or chronic alcohol use

A

GGT

GGT is an enzyme that is very sensitive for diseases of the liver and gall bladder, but not very specific

395
Q

% of sexual assault survivors with PTSD

A

30-65%

396
Q

PTSD is persistent anxiety lasting more than _____ following a traumatic event

A

> 1 month

397
Q

one of the following (2) criteria are REQUIRED for any DSM-5 diagnosis of MDD, along with a constellation of other comorbid symptoms

A
  • loss of interest or pleasure in usual activities
  • sad or depressed mood
  • must be present most of the day, every day
398
Q

Women with uncomplicated diabetes of less than ______ duration can use ANY of the birth control methods

A

<20 years

399
Q

Risk factors for suicide in an individual with MDD

A
  • sense of hopelessness
  • substance abuse
  • family h/o substance abuse
  • prior suicide attempt
  • family h/o suicide attempt
  • living alone
  • medical illness
  • advanced age
  • male gender
400
Q

What is agoraphobia

A

anxiety disorder that includes avoidance of places or situations in which leaving suddenly may be difficult in the event that the individual has a panic attack

401
Q

What is the most common type of anxiety disorder

A

specific phobia (25%)

followed by… social phobia (13%), PTSD (12% in women), GAD (5%), and panic disorder (3.5%)

402
Q

Typical age of onset for bulimia nervosa

A

late adolescence to early adulthood

403
Q

Impulsive behaviors such as shop-lifting, alcohol and drug abuse, and unsafe sexual behaviors are characteristic of this eating disorder

A

bulimia nervosa

404
Q

Common side effects of SSRIs

A
  • anxiety
  • insomnia or hypersomnia
  • headache
  • nausea
  • anorexia
  • sexual dysfunction
405
Q

Physiologic dependence on a substance is defined as (2)

A
  • characteristic withdrawal symptoms or the use of the substance to avoid withdrawal, and/or…
  • tolerance in which markedly increased amounts of the substance are needed to achieve intoxication or the desired effect
406
Q

MOA of metformin

A

class = biguanide

works by:

  • decreasing hepatic glucose production
  • decreasing intestinal absorption of glucose
  • increasing peripheral glucose uptake and utilization
407
Q

Severe exacerbations of asthma relate to a peak flow of…..

A

peak flow <60%

normal = 80-100%

408
Q

Severe exacerbations of asthma should be treated with …..

A

short course of oral steroids x5-10 days

409
Q

HPV vaccine schedule >15yo

A

baseline, 2 months post-baseline, 6 months post-baseline

410
Q

Live attenuated virus vaccines, examples (4)

A
  • MMR (measles, mumps, rubella)
  • varicella
  • zoster (Zostavax — Shingrix is not)
  • intranasal flu (LAIV)
411
Q

USPSTF recommendations for mammograms

A

biennial ages 50-74yo

412
Q

Risk factors for Hepatitis C

A
  • born between 1945-1965
  • received a blood transfusion before 1992
  • current injection or intranasal drug use
  • long-term hemodialysis
  • born to mother with HCV infection
  • receipt of unregulated tattoo
  • other percutaneous exposures
  • HIV infection
413
Q

Risk factors for increased fracture risk that may warrant BMD screening earlier than 65yo but POST-menopausally

A
  • low BMI
  • h/o low-trauma fracture
  • smoking
  • alcohol intake > or = 3 drinks/day
  • family history of hip fracture or osteoporosis
414
Q

Expected symptoms and physical exam findings in someone with interstitial cystitis (painful bladder syndrome)

A
  • unpleasant sensation (pain, pressure or discomfort) perceived to be localized to the urinary bladder
  • > 6 weeks in duration
  • absence of infection
  • lower abdominal pain that may become worse with sexual intercourse and relieved somewhat with urination
  • mild suprapubic tenderness
  • tenderness along the anterior vaginal wall and urethra
415
Q

(2) anticholinergic medications for the treatment of urge urinary incontinence

A 
oxybutynin chloride (Ditropan)
tolterodine tartrate (Detrol)
416
Q

Management of urge urinary incontinence

A
  • bladder retraining with scheduled voiding
  • biofeedback
  • Kegel exercises
  • avoid bladder irritants
  • anticholinergic medications (e.g., oxybutynin, tolterodine)
417
Q

Prophylaxis regimen for recurrent UTIs after sex

A

nitrofurantoin (Macrobid) single dose after sex

NCC Board Prep (10 decks)

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