CH3: Primary Care Flashcards
what is “primary prevention”
delivery of healthcare services that focuses on PREVENTING disease from occurring
examples: immunizations, health promotion counseling
what is “secondary prevention”
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
what is “tertiary prevention”
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
what is “health screening”
laboratory or other tests conducted on asymptomatic individuals routinely for the early detection of health problems
health screening is an example of _______ prevention
secondary prevention
colorectal cancer screening ages for average risk, recommendations per the ACS
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
for colorectal cancer screening – more frequent testing and starting at a younger age is recommended for those with risk factors, including:
- inflammatory bowel disease (IBD)
- personal or family history of colon polyps or CRC
- known or suspected Lynch Syndrome (hereditary nonpolyposis colon cancer)
Lynch Syndrome, aka….
hereditary nonpolyposis colon cancer
available stool-based tests for colorectal cancer screening (3)
Fecal Occult Blood Tests (FOBTs)
- guaiac fecal occult blood test (gFOBT) (annual)
- fecal immunochemical test (FIT) (annual, superior to guaiac based FOBT)
Stool DNA-Fecal Immunochemical Test
3. stool DNA test (Q3 years)
What is the guaiac fecal occult blood test for CRC screening
multiple-stool sample collected at-home that detects hidden blood in the stool
recommended to complete ANNUALLY for screening
What is the stool DNA test for CRC screening
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
What is the fecal immunochemical test for CRC screening
single-sample, collected at home, tests for blood in stool. more sensitive than gFOBT
recommended to complete ANNUALLY for screening
available structural (visual) screening tests for CRC (3)
- colonoscopy (generally Q10 years)
- flexible sigmoidoscopy (generally Q5 years)
- CT colonography (generally Q5 years)
Clinical Breast Examination (CBE) recommendations for breast cancer screening, per ACS
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
Clinical Breast Examination (CBE) recommendations for breast cancer screening, per ACOG
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
Clinical Breast Examination (CBE) recommendations for breast cancer screening, per USPSTF
Insufficient evidence to assess the balance of benefits and harms of CBE if the pt is also being screened with mammograms (Grade I)
Mammogram recommendations for breast cancer screening, per ACS
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
Mammogram recommendations for breast cancer screening, per ACOG
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
Mammogram recommendations for breast cancer screening, per USPSTF
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)
Breast self awareness (BSA) recommendations for breast cancer screening, per ACS and ACOG
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
Pap test recommendations for cervical cancer screening <21yo, per ACS
<21yo, screening is not recommended
Pap test recommendations for cervical cancer screening <21yo, per ACOG
<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
Pap test recommendations for cervical cancer screening <21yo, per USPSTF
<21yo, screening is not recommended
Pap test recommendations for cervical cancer screening 21-29yo, per ACS
cytology alone Q3 years
Pap test recommendations for cervical cancer screening 21-29yo, per ACOG
cytology alone Q3 years
Pap test recommendations for cervical cancer screening 21-29yo, per USPSTF
cytology alone Q3 years
Pap test recommendations for cervical cancer screening 31-65yo, per ACS
cytology + HPV co-testing Q5 years (preferred), or
cytology alone Q3 years (acceptable)
Pap test recommendations for cervical cancer screening, 31-65yo, per ACOG
cytology + HPV co-testing Q5 years (preferred), or cytology alone Q3 years (acceptable)
Pap test recommendations for cervical cancer screening, 31-65yo, per USPSTF
cytology + HPV co-testing Q5 years (preferred), or cytology alone Q3 years (acceptable), or HPV testing alone Q5 years (acceptable)
Pap test recommendations for cervical cancer screening >65yo, per ACS
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
Pap test recommendations for cervical cancer screening >65yo, per ACOG
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
Pap test recommendations for cervical cancer screening >65yo, per ACOG
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
Once cervical cancer screening has stopped (at 65yo) with adequate prior history, are there any circumstances in which screening should resume again?
No - do not resume screening if adequate prior history even if they report having a new sexual partner
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
CIN 2 or greater, continue screening for 20 years
Pap test recommendations for cancer screening in patient at any age who had a total hysterectomy (cervix removed)
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
Lung cancer screening recommendations per USPSTF and ACS
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
Testicular cancer screening recommendations per USPSTF and ACS
clinical or self-testicular examinations for testicular cancer screening are NOT recommended by ACS or USPSTF
Prostate cancer screening recommendations per USPSTF
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
Prostate cancer screening recommendations per ACS
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
Diabetes screening recommendations per ADA, average healthy adult
Average healthy person –> screen with HgbA1c (or 2-hr 75g OGTT) every 3 years starting at age 45yo
Diabetes screening should be more frequent or start at a younger age for those with the following risk factors:
- 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
Diabetes screening recommendations for patient with history of gestational diabetes (GDM), per ADA
Lifelong screening at least every 3 years
cardiovascular disease (CVD) risk factors for females (6)
- age 55yo or older
- family history of premature CAD (<55 in male relative, <65 in female relative)
- smokes cigarettes
- HTN
- low HDL (<40)
- diabetes
Blood pressure screening recommendations, per USPSTF (2015)
- 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
Hyperlipidemia/Dyslipidemia screening recommendations, per USPSTF
- 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
USPSTF referral recommendations for adults with BMI of 30 or above (obese)
refer to intensive, multicomponent behavioral interventions
Characteristics of the most successful interventions for weight loss in obese individuals
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
Who meets criteria for weight-loss surgery (2)
- individuals with BMI 40 or higher (extremely obese)
- individuals with BMI 35 or higher who have other high-risk comorbidities (e.g., HTN, DM)
Osteoporosis screening recommendations from the National Osteoporosis Foundation (NOF)
- 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
Risk factors for low bone density that might warrant earlier screening with DEXA (5)
- low BMI
- history of a fragility fracture
- smoking
- alcohol >3 drinks/day
- family history of hip fracture or osteoporosis
According to the CDC and USPSTF, who should be screened for Hepatitis C
- 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
Screen all individuals for hepatitis C who were born between…..
1945-1965
Screen all individuals for hepatitis C who received a blood transfusion prior to….
1992
Biochemical (lab) measurements to assess nutritional status (5)
- CBC (hgb/hct)
- lipids
- serum albumin
- serum glucose
- serum folate
Healthy eating recommendations include limiting calories from added sugars and saturated fats to about ___% of intake
10% each
Healthy eating recommendations including limiting sodium intake to less than _____ per day
2300mg (1 tsp)
Healthy eating recommendations include limiting alcohol intake to ….
- 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
Per healthy eating recommendations, 1 drink is equivalent to how much beer, wine, liquor
12 oz beer
5 oz wine
1.5 oz liquor
Calcium recommendations for women, per Institute of Medicine (IOM)
- 14-18yo: 1300mg/day
- 19-50yo: 1000mg/day
- 51yo and older: 1200mg/day
Vitamin D recommendations for women, per Institute of Medicine (IOM)
- 14-70yo: 600IU/day
- 71yo and older: 800IU/day
Calcium recommendations for women, per NOF
- 18-50yo: 1000mg/day
- 51yo and older: 1200mg/day
Vitamin D recommendations for women, per NOF
- 18-50yo: 400-800 IU/day
- 51yo and older: 1000 IU/day
Good sources of calcium
- milk
- yogurt
- cheese
- soybeans
- tofu
- canned sardines
- salmon with edible bones
- fortified cereals
- fortified orange juice
- supplements
Good sources of vitamin D
- regular exposure to direct sunlight
- fortified milk
- egg yolks
- saltwater fish
- liver
- supplements
Folate recommendations for women of childbearing age
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
Good sources of folic acid
- beans
- leafy green vegetables
- citrus
- fortified cereals
- most MVIs contains 0.4mg folic acid
Iron recommendations for non-pregnant women
- 14-18yo: 15mg/dL per day
- 19-50yo: 18mg/dL per day
- 51yo and older: 8mg/dL per day
Good sources of iron
- meat
- fish
- poultry
- fortified cereals
- dried fruits
- dark green vegetables
- supplements
Nutrients to be concerned about deficiencies for vegetarian patients (5)
- protein
- calcium
- iron
- vitamin B12
- vitamin D
Who is at increased risk for vitamin D deficiency (6)
- > 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
Benefits of physical activity with strong evidence to support
- 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
Physical activity recommendations, per USDHHS
- 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
What are examples of “moderate intensity” aerobic exercise
- 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
What are examples of muscle-strengthening activities
- weight lifting
- elastic resistance bands
- using body weight for resistance (i.e., push ups, climbing)
What are examples of bone-strengthening activities
- running
- brisk walking
- weight training
- tennis
- dancing
When does substance use become a substance use disorder?
when there is continued use of a substance despite the existence of use-related health problems
The severity of a substance use disorder is based on the number of criteria met of the following (4):
- loss of control over use
- impact on social function
- risky use
- development of tolerance or dependence
% prevalence of smoking in general adult women population
13.5% (highest in those ages 25-44yo)
% prevalence of smoking e-cigarettes in female high school students
10%
5As for smoking cessation
- ASK about tobacco use
- ADVISE to quit smoking
- ASSESS willingness/readiness to quit
- ASSIST in quit attempt (quit smoking meds, counseling)
- ARRANGE follow-up
Forms of NRT
gum, patches, lozenges, inhalers, nasal spray
How does NRT help folks quit smoking
helps to reduce the physical withdrawal symptoms and cravings that occur with smoking cessation or reduction
Common side effects of NRT
- 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
Contraindications to use of NRT
- serious cardiac arrhythmias
- severe angina
- recent MI
- concurrent smoking (THIS IS NOT TRUE!!!!)
- pregnancy (THIS IS ALSO NOT TRUE)
Considerations for use of NRT in pregnancy and breastfeeding
- 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
How does bupropion sustained release (Zyban) help folks quit smoking
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)
Common side effects of bupropion sustained release (Zyban)
- dry mouth
- insomnia
- nausea
- skin rash
Contraindications for bupropion sustained release (Zyban) for smoking cessation
- seizure disorder
- eating disorder
- use of an MAOI
- concomitant use of other forms of bupropion (e.g., Wellbutrin for depression)
Considerations regarding the use of bupropion sustained release (Zyban) for smoking cessation during pregnancy and lactation
- 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
Recommendations for timing of use and duration of bupropion sustained release (Zyban) for smoking cessation
- recommend to start the medication 1-2 weeks before planned quit date
- recommended duration of therapy is 6 months (even if quit)
How does varenicline (Chantix) help folks quit smoking
- reduces withdrawal symptoms
- blocks the effect of nicotine if an individual does resume smoking
- class: nicotinic acetylcholine receptor partial agonist
Common side effects of varenicline (Chantix) for smoking cessation
- nausea
- changes in dreams
- constipation, gas
- vomiting
- neuropsychiatric symptoms, including suicidal ideation
Contraindications to use of varenicline (Chantix) for smoking cessation
- use caution in individuals with psychiatric disorders
- renal impairment
Considerations for the use of varenicline (Chantix) for smoking cessation during pregnancy and lactation
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
Recommendations for timing of use and duration of varenicline (Chantix) for smoking cessation
- 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
% prevalence of females who use any alcohol, and of reproductive age females
46% general population females
53% reproductive age females non pregnant
% prevalence of binge drinking in reproductive age females
18%
% prevalence of pregnant women who continue to drink alcohol during pregnancy, and the percent of these who report binge drinking
11%, 1/3 of which report binge drinking
General definition of binge drinking
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
Counseling regarding alcohol use in pregnancy
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
most frequently used illicit drug in the USA
marijuana (legal in some states for medical and/or recreational use)
Who and how often should be screened for substance use disorders
screen all individuals annually at wellness visits, initial prenatal visits, and other visits as indicated
SBIRT intervention for substance use disorders
- Screening
- Brief Intervention (using motivational interviewing)
- Referral to Treatment
the “one key question” designed for clinicians to screen individuals on pregnancy intention
“would you like to become pregnant in the next year?”
PATH questions for reproductive life planning
- 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]?)
Goals of preconception care (5)
- 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
Genetic carrier screening and counseling are ideally performed when?
- prior to pregnancy
whenever the patient wants
All pts considering pregnancy should be offered carrier screening for (2)
- cystic fibrosis
- spinal muscular atrophy
All pts considering pregnancy with an abnormality on their CBC should be offered screening for (2)
- thalassemias
- hemoglobinopathies
Relevant conditions for identification/risk reduction in preconception counseling that we have vaccines for (6)
- rubella
- varicella, chickenpox
- hepatitis B
- HPV
- tdap
- influenza
Intimate partner violence more commonly affects [older vs. younger] women
younger women
USPSTF recommends screening all women ages ___ to ____ for intimate partner violence
14-46yo
(3) screener tools available for identifying intimate partner violence
- HITS (Hurt, Insult, Threaten, Scream)
- HARK (Humiliation, Afraid, Rape, Kick)
- WAST (Woman Abuse Screen Tool)
Risk factors for elder abuse (3)
- isolation/lack of social support
- functional impairment
- poor physical health
Signs/symptoms of possible elder abuse
- depression
- agitation
- becoming withdrawn
- weight loss for no apparent reason
- unexplained bruises or injuries
- burn scars
- unkempt appearance (unwashed hair, dirty clothes)
Risk factors for infant abuse and neglect
- 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)
Difference in definition between sex “drive” and sex “motivation”
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
Linear model of sexual response (Master’s & Johnson, 1966)
model was considered to apply to males and females
- excitement = sensory stimulation leads to vasocongestion
- plateau = increased vasocongestion and pelvic floor muscle tension
- orgasm = widespread genitopelvic muscle contraction
- resolution = return to nonstimulated state
Nonlinear model of sexual response (Basson, 2000)
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
What does the PLISSIT model for addressing sexual concerns as generalists stand for
- Permission giving
- Limited Information
- Specific Suggestions
- Intensive Therapy
CDC guidelines for routine chlamydia and gonorrhea screening
- 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
CDC guidelines for routine HIV screening
- 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
Counseling regarding safer rex practices for prevention of STIs and HIV should be based on….
behaviors and risk factors (NOT on sexual orientation or gender identity)
“safe” sex, per this book
all unprotected sexual activities when both partners are monogamous and known by testing to be free of HIV and other STIs
“low but potential risk” sex, per this book
- 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
“unsafe in absence of mutual monogamy and STI/HIV testing of both partners” sex, per this book
- 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
There are vaccines for hepatitis (2), but not for (1)
vaccines = hepatitis A, B
no vaccine = hepatitis C
What is the schedule for doses of Hepatitis B vaccination
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
High risk groups for Hepatitis B (ensure immunity/vaccination status)
- 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
Recommendations for influenza vaccine
- 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
Considerations for the influenza vaccine during pregnancy and breastfeeding
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
(2) types of pneumococcus vaccines
- pneumococcal conjugate 13-valent vaccine (PCV13; Prevnar 13)
- pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23)
Pneumonia vaccine recommendations for ALL immunocompetent individuals 65yo and older
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
the PCV13 (Prevnar 13) vaccine is recommended for adults younger than 65yo with the following conditions: (4)
- immunocompromising conditions (e.g., HIV)
- functional or anatomic asplenia
- cerebrospinal fluid leaks
- cochlear implants
the PPSV23 (Pneumovax 23) vaccine is recommended for adults younger than 65yo with the following conditions:
- 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)
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”?
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
Considerations for rubella vaccination in pregnancy and lactation
- live vaccine –> NOT safe in pregnancy. Wait 4 weeks after administration before trying to become pregnant
- YES may be given to breastfeeding folks postpartum
General recommendations for the rubella vaccine in adults
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
Contraindications to receiving the rubella vaccine (MMR)
- pregnancy
- known severe immunodeficiency
- HIV with AIDS
General recommendations for Tdap/Td vaccines
- 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
What does Tdap vaccine protect against?
tetanus, diptheria, acellular pertussis
Considerations for Tdap vaccination in pregnancy and breastfeeding
- 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)
General recommendations for varicella vaccine
- 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
Considerations for varicella vaccine in pregnancy and lactation
- live vaccine - NOT safe in pregnancy (advise not to become pregnant for 4 weeks after receiving)
- YES can be given during breastfeeding
Contraindications to receipt of varicella vaccine
(same as for rubella, another live vaccine)
- pregnancy
- known severe immunodeficiency
- HIV with AIDS
General recommendations for herpes zoster (shingles) vaccine
- 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)
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?
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)
Contraindications to receipt of herpes zoster (shingles; Shingrix) vaccine
(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
General recommendations for Hepatitis A vaccine
- 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
Contraindications to Hepatitis B vaccine in adults
none, other than allergy to any components
Contraindications to influenza IM vaccine in adults
- allergy to any components (e.g., egg allergy)
- history of guillain-barre (relative contraindication)
Contraindications to pneumonia vaccines in adults
none, other than allergy to any components
Contraindications to hepatitis A vaccine in adults
none, other than allergy to any components
Contraindications to HPV vaccine in adolescents and adults
none, other than allergy to any components
General recommendations for HPV vaccine (Gardasil)
- 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
What does the HPV vaccine (Gardasil 9) cover
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
Gardasil 9 protects against ___% of all HPV-associated cancers
90%
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
yes, still recommended. Individuals already infected with one or more HPV types will still receive protection against the types not yet acquired
Considerations for HPV vaccine (Gardasil 9) in pregnancy and lactation
- 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
General recommendations for meningococcal vaccine
- 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
Contraindications to meningococcal vaccination in adults
none, other than allergy to any components
General considerations regarding immunizations during pregnancy and lactation, overall
- 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
Routine screening recommendations for vision, per American Academy of Ophthalmology
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
Routine dental screening recommendations, per American Dental Association
recommends all adults have routine dental care and preventive services, including oral cancer screening, at least annually
JNC 8 definition of hypertension
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
ACC and AHA 2017 definitions of high blood pressure
- normal BP = <120/<80
- elevated BP = 120-129/<80
- stage I HTN = 130-139/80-89
- stage II HTN = 140+/90+
(3) objectives of documenting hypertension
- to identify any secondary causes (and eliminate)
- to assess for target organ damage (eyes, brain, blood vessels, heart, kidneys)
- to identify other concomitant risk factors or disorders that may define prognosis and guide therapy (e.g., smoking, diabetes)
primary end organs of damage with chronic HTN (5)
- eyes (retinopathy)
- brain (TIA, stroke, alzheimers)
- blood vessels (PVD)
- heart (CAD, CHF, MI)
- kidneys (CKD)
Other cardiovascular risk factors or concomitant conditions that may define the prognosis and guide therapy for HTN (8)
- 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)
% of HTN cases that are primary or “essential”
90-95%
% of HTN cases that are secondary
5-10%
% prevalence of HTN among US adults
45%
% prevalence of HTN among postmenopausal US women
75%
Menopause is associated with a ____x [increase vs. decrease] in risk for HTN
2x increase in risk
prevalence of HTN is highest among which racial/ethnic group of US women
non-Hispanic Black (56%)
Pt presents for problem visit. They meet criteria for HTN which is a new diagnosis. CC: palpitations, tremor, and sweating. You suspect…..
secondary HTN, s/t pheochromocytoma
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….
secondary HTN, s/t Cushing’s syndrome
Pt presents for problem visit. They meet criteria for HTN which is a new diagnosis. CC: weakness and muscle cramps. You suspect….
primary aldosteronism
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….
secondary HTN, s/t renal artery stenosis
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….
secondary HTN, s/t coarctation of the aorta
Secondary causes of HTN
- 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)
Recommended initial lab tests when pt presents with new diagnosis of HTN (5)
- UA
- CBC
- BMP (blood glucose for diabetes, potassium for aldosteronism, creatinine for renal disease)
- lipids
- ECG
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….
secondary HTN, s/t primary aldosteronism
Optional lab tests to consider including when pt presents with new diagnosis of HTN
- 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
When should you start lifestyle therapy vs. medication for a new diagnosis of HTN?
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.
Lifestyle modifications recommended in HTN (6)
- 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
(4) first line medication classes for HTN
- thiazide diuretic (e.g., hydrochlorothiazide)
- calcium channel blocker (e.g., amlodipine)
- ACE inhibitor (e.g., lisinopril)
- ARB (e.g., valsartan)
Pt presents for annual. PMH significant for T2DM. BP today is 135/85, which is newly elevated. What is your initial plan?
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.
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?
- 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
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?
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.
key considerations for reproductive-age women with HTN
- 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
Hypertensive crisis BP
> 180/120
THIAZIDE DIURETICS FOR HTN
- examples
- MOA
- side effects
- interactions
- contraindications/precautions
- pregnancy/lactation
- EXAMPLES: hydrochlorothiazide, chlorthalidone
- MOA: inhibits sodium reabsorption from the distal renal tubules»_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
BETA BLOCKERS FOR HTN
- examples
- MOA
- side effects
- interactions
- contraindications/precautions
- pregnancy/lactation
- 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
CALCIUM CHANNEL BLOCKERS FOR HTN
- examples
- MOA
- side effects
- interactions
- contraindications/precautions
- pregnancy/lactation
- 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)
ACE INHIBITORS FOR HTN
- examples
- MOA
- side effects
- interactions
- contraindications/precautions
- pregnancy/lactation
- 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
ARBs FOR HTN
- examples
- MOA
- side effects
- interactions
- contraindications/precautions
- pregnancy/lactation
- 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
Heart murmurs are commonly associated with these (2) dynamics/MOAs
regurgitation, stenosis
Pathologic heart murmurs are indicative of _____ or ____ disease, for example….
heart or valvular disease
examples: rheumatic heart disease, aortic or pulmonary stenosis, atrial-septal defect, mitral valve prolapse
How common are innocent or functional heart murmurs
50-70% of children and up to 50% of adults at some time
characteristics of heart murmur that suggest it is functional, or innocent
- 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)
characteristic of heart murmur that it is pathologic
- 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
Diagnostic evaluation of suspected pathologic heart murmur
- 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
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…….
low-grade, asymptomatic systolic murmur with a low-risk history can be assumed innocent and followed-up at next visit
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)
preventing bacterial endocarditis
rx: amoxicillin PO 2g 1hr before the procedure
Bacterial endocarditis prophylaxis prescription
amoxicillin PO 2g 1 hr before the procedure
What is a “thrombosis” vs. “embolus”
thrombosis = blood clot that forms abnormally within a blood vessel
embolus = blood clot that breaks free from its site of formation
what is “thrombophilia”
tendency to develop thrombosis from either acquired or inherited causes, or both
what is superficial phlebitis
inflammation of the superficial veins as a result of local trauma, venous stasis, or infection
what is “virchow’s triad”
triad of conditions increasing risk for blood clot
- endothelial damage (e.g., s/t trauma)
- stasis (e.g., s/t immobility)
- hypercoagulability (e.g., s/t protein C or S deficiency, malignancy)
% risk of DVT embolizing to pulmonary circulation
40% risk when thigh vein is involved
risk is minimal when only calf veins are involved
superficial thromboses usually occur in….
varicose veins
Most common acquired risk factors for a DVT
- 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
Most common inherited risk factors for a DVT
- factor V leiden
- protein C deficiency
- protein S deficiency
- prothrombin gene mutation
- homocysteine abnormalities
- antithrombin gene deficiency
Symptoms suggestive of superficial phlebitis
localized area of edema, erythema, and tenderness over a SUPERFICIAL vein
Symptoms suggestive of DVT
- acute onset of unilateral leg pain, most commonly in the calf
- leg edema
- up to 50% will have no symptoms
Symptoms suggestive of PE
- cyanosis
- diminished breath sounds over the involved area
- tachypnea
- cough with hemoptysis
- tachycardia
- fever
Diagnostic evaluation of suspected superficial phlebitis
usually none needed; clinical diagnosis
Diagnostic evaluation of suspected DVT
In summary: Doppler US and/or plasma D-dimer initial tests»_space; if inconclusive, contrast venography»_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)
Diagnostic evaluation of suspected PE (5)
- ventilation/perfusion (VQ) lung scan
- arterial blood gasses (ABG)
- ECG and chest radiograph
- plasma d-dimer ELISA
- pulmonary angiogram
Management of superficial phlebitis
elevate legs, compression with an ace wrap, NSAIDs for pain
Patient education points to prevent blood clot in those at high risk
- 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
The main reason we care about dyslipidemia is because it is a risk factor for the development of…..
coronary heart disease
Criteria for Elevated LDL-C
> 130mg/dL
- optimal: <100
- near optimal: 100-129
- borderline high: 130-159
- high: 160-189
- very high: >190
Criteria for Elevated triglycerides
> 200 mg/dL
- normal: <150
- borderline high: 150-199
- high: 200-499
- very high: >500
Criteria for Low HDL-C
<40 mg/dL
Criteria for metabolic syndrome
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
(3) drug classes that can increase cholesterol
beta blocks, corticosteroids, thiazide diuretics
prevalence of dyslipidemia in adult women in the US
> 50%
(3) physical exam findings that may be associated with dyslipidemia
- 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
Criteria for elevated total cholesterol
> 200 mg/dL
- desirable: <200
- borderline high: 200-239
- high: >240
the treatment for dyslipidemia is driven by…..
risk for coronary heart disease events
Framingham Risk Tool criteria for CHD risk
- 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
Dietary modifications for lowering LDL cholesterol, per the AHA (4)
- 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
Lifestyle modifications for treatment of dyslipidemia
- 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
In folks with dyslipidemia, how do you decide whether to start with lifestyle vs. medication therapy first?
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
(4) factors to discuss in shared-decision-making of starting a statin in pt with dyslipidemia
- 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
First line medication class for LDL reduction in adults
Statins (HMG-CoA reductase inhibitors)
MOA Statins
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
Contraindications/cautions for the use of statins
contraindications = severe liver disease, pregnancy, lactation
cautions = myopathy, with risk increased if they are also on a fibrate or niacin
Considerations for the use of statins in pregnancy and lactation
not safe! not safe in pregnancy or lactation
Medication options for the treatment of dyslipidemia
- 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
High intensity statin therapy lowers LDL-C by __% on average, vs. low and moderate intensity statins
high intensity = >50% reduction
moderate intensity = 30-50% reduction
low intensity = <30% reduction
(2) prescriptions that represent HIGH INTENSITY statin therapy
- atorvastatin (Lipitor) 40-80mg PO QD
- rosuvastatin (Crestor) 20-40mg PO QD
(5) prescriptions that represent MODERATE INTENSITY statin therapy
- 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
(3) prescriptions that represent LOW INTENSITY statin therapy
- simvastatin (Zocor) 10mg PO QD
- pravastatin (Pravachol) 10-20mg PO QD
- lovastatin (Mevacor) 20mg PO QD
Define “coronary heart disease”
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
What is “angina pectoris”
myocardial ischemia secondary to inability of the coronary arteries to supply oxygenated blood to meet the myocardial oxygen demands
What is “acute coronary syndrome”
when an atherosclerotic plaque ruptures, may cause thrombus formation that impedes or completely occludes the coronary lumen
2 types: unstable angina, acute myocardial infarction
(2) types of acute coronary syndrome
- acute MI
- unstable angina
leading cause of death for women in the US
coronary heart disease
Symptoms of chronic stable angina pectoris
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
Symptoms of acute coronary syndromes
- 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
Diagnostic evaluation of coronary heart disease
In summary: ECG and consider labs (troponins, myoglobin)»_space; Stress tests (exercise/treadmill, medication, nuclear)»_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)
Management of acute coronary syndromes
requires revascularization procedures which may include:
- percutaneous transluminal coronary angioplasty (PTCA) via the femoral artery
- coronary artery bypass graft (CABG)
Medication classes for angina/CHD
- 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
What is allergic rhinitis
inflammation of the mucous membranes of the nose in response to contact with certain allergies, triggering the production of immunoglobulin E (IgE) antibodies»_space; histamine release»_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
seasonal vs. perennial allergic rhinitis are usually due to….
seasonal = pollens/allergens including trees, grasses, ragweed, hay fever
perennial = usually related to dust mites, mold, cockroaches, and animal dander
symptoms suggestive of allergic rhinitis
nasal congestion, clear rhinorrhea, sneezing, pruritis of nose/throat/eyes, sore throat and cough from post-nasal drip
physical exam findings suggestive of allergic rhinitis
- 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
what is “rhinitis medicamentosa”
“rebound rhinitis”
rhinitis caused by excessive topical use of of intranasal vasoconstrictors including decongestants or cocaine
diagnostic evaluation of suspected allergic rhinitis
- 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
Non-pharm and pharm measures for the treatment of allergic rhinitis
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)»_space; good for itching, sneezing, rhinorrhea (with minimal effect on congestion)
- decongestants»_space; can be used alone or in combination of antihistamines, best for nasal congestion specifically
- topical nasal corticosteroids»_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»_space; effective for prophylaxis, not acute, as they have no direct anti-inflammatory or antihistamine effects
- montelukast (leukotriene receptor antagonist)»_space; reduces inflammation
First line medication for allergic rhinitis
antihistamines
and, increasingly, intranasal corticosteroids given their effectiveness
ANTIHISTAMINES FOR ALLERGIC RHINITIS
- examples
- MOA
- side effects
- interactions
- contraindications/cautions
- pregnancy/lactation
-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
antihistamine of choice during pregnancy
diphenhydramine (Benadryl)
DECONGESTANTS FOR ALLERGIC RHINITIS
- examples
- MOA
- side effects
- interactions
- contraindications/cautions
- pregnancy/lactation
- EXAMPLES: pseudoephedrine (Sudafed), phenylephrine (Sudafed PE)
- MOA: alpha-adrenergic agonist»_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
CORTICOSTEROIDS FOR ALLERGIC RHINITIS
- examples
- MOA
- side effects
- interactions
- contraindications/cautions
- pregnancy/lactation
- 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
MAST CELL STABILIZERS FOR ALLERGIC RHINITIS
- examples
- MOA
- side effects
- interactions
- contraindications/cautions
- pregnancy/lactation
- 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
what is conjunctivitis and its most common (3) types
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:
- viral
- bacterial
- allergic
what is viral conjunctivitis, cause, symptoms
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
what is bacterial conjunctivitis, cause, symptoms
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
what is allergic conjunctivitis, cause, symptoms
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
most common eye complaint in primary care
conjunctivitis
recommended management for viral conjunctivitis
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.
recommended management for bacterial conjunctivitis
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.
recommended management for allergic conjunctivitis
- 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)
Pts with suspected bacterial conjunctivitis should show improvement within _____ of treatment, otherwise should be referred
48 hours of appropriate treatment
% of squamous cell carcinomas that occur at the site of a previous actinic keratosis
60%
Physical exam findings in asthm
- hyperresonance to percussion
- wheezing
- prolonged expiratory phase
- diminished breath sounds
- tachypnea
- dyspnea
Characteristics of mild persistent asthma
- 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)
% of those with latent (asymptomatic) TB who will progress to active infection
10%
5-mm or greater skin reaction on a PPD test is considered positive for…..
- HIV positive
- immunocompromised
- have abnormal chest radiograph findings consistent with healed TB lesions
- close contact with known TB-infected person
Symptoms of active TB
- night sweats
- fever
- malaise
- weakness
- anorexia and weight loss
- productive cough
- hemoptysis
- chest pain
- dyspnea
Warn patients about this possible side effect of sumatriptan
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
Reasons for neurological evaluation of headaches
- 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
Non-pharm recommendations for lower back pain
- continuation of daily activities (no bedrest)
- local application of heat
- warm baths
- PT for strength and conditioning
- low stress aerobic exercise (walking, biking, swimming)
Characteristics of osteoarthritis
- 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
A herniated disc is characterized by ______ pain
radicular
Most common disc ruptures/herniated discs involve these (2) nerve roots
L5
S1
Criteria for recommending a rapid strep antigen test
adult with pharyngitis (sore throat) who meets 2 or more of the following:
- tonsillar exudates
- tender anterior cervical lymphadenopathy
- fever
- NO cough
PrEP is contraindicated with individuals with severe renal impairment. Folks on PrEP should have kidney function tests repeated every….
Q6 months while on therapy
How is response to ART therapy monitored in HIV positive individuals
HIV RNA levels, which are useful for predicting progression of disease by indicating viral load and are used to monitor ART therapy
Most opportunistic infections (e.g., PCP pneumonia) occur in HIV-infected individuals with a CD4 count of less than….
<200 cells/mm3
Significance of PCP pneumonia in someone with known HIV infection
PCP pneumonia is a major AIDS-defining illness (pneumocystic pnuemonia, a fungal infection)
Racial/ethnic groups at elevated risk for SLE (2)
African American (1 in 250) Hispanic/Latinx (100 in 100,000)
[compared to Caucasian women 12-39 per 100,000)
Criteria for the diagnosis of SLE, per American College of Rheumatologists 2005
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)
What is the single lab test that is most important for the diagnosis of SLE
ANA = antinuclear antibodies
positive in 95% of cases
Diagnostic evaluation of suspected SLE
- 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
Medical management for SLE
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
Considerations for the use of hydrochloroquine for folks with SLE in pregnancy
can continue to use during pregnancy, try to use the lowest therapeutic dose possible
commonly comorbid blood disorder in folks with SLE
antiphospholipid antibody syndrome (30-50%)
blood clotting risk
SLE diagnosis is what category for the Medical Eligibility Criteria for COCs
category 4 (contraindicated)
Anticipatory guidance: pregnancy outcomes are best when the patient with SLE has met which (2) criteria before pregnancy
- symptoms in remission for at least 6 months before pregnancy
- renal function is normal
Anemia, per WHO criteria
Hgb <12 g/dL for females
Hgb <13 for males
Pathophysiology of otitis media infection s/t a viral URI
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
When are antibiotics indicated for the treatment of acute bacterial rhinosinusitis (ARBS)
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
Classic triad of symptoms for mononucleosis
- fever
- sore throat
- swollen lymph nodes (especially anterior and posterior cervical chain)
What might you see on CBC with diff in someone with mononucleosis
CBC may show a lymphocytic leukocytosis, with 10% of cells being atypical
Age range for highest mononucleosis prevalence
10-30yo, with peak in those 15-19yo
Most common cause of bright red painless bleeding per rectum
internal hemorrhoids
internal hemorrhoids originate above the anorectal line, are covered by non-sensitive rectal mucosa, and are usually painless
Two medications that might be useful for someone with IBS-constipation
- fiber supplement
- lubiprostone
% of duodenal ulcers caused by H. pylori
90-95%
% of gastric ulcers caused by H. pylori
70-80%
% prevalence of H. pylori in the general population
5-10%
Diagnostic evaluation of suspected peptic ulcer disease (PUD)
- 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
Who should be considered for a mucosal biopsy in those with suspected peptic ulcer disease (PUD)
- age >50yo
- alarm symptoms
- family history of gastric cancer
- no improvement with treatment
Methods of testing for H. pylori
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
Lab test that signifies immunity against Hepatitis B
HBV surface ANTIBODY test, aka anti-HBs
What is HbsAg
Hepatitis B Virus Surface Antigen
When positive, indicates an acute or chronic infection and that the person is infectious
Lab tests that signifies infectivity with Hepatitis B
HBV surface ANTIGEN, aka HbsAg
HBV e ANTIGEN (highly infectious)
What is anti-Hbs
Hepatitis B Virus Surface Antibody
When positive, indicates immunity due to prior infection or to vaccination
What is anti-HBc
Hepatitis B Virus Core Antibodies
When positive, indicates acute or chronic infection at some point and these will persist for life
What is IgM anti-HBV
Hepatitis B Virus Core IgM Antibody
When positive, indicates an acute infection, will return to normal in 4-6 months
What is HBV DNA
Will be positive in acute and chronic infection
What is IgM anti-HAV
Hepatitis A Virus IgM Antibodies
When positive, indicates a current or recent infection. Will return to negative in 6 months
What is IgG anti-HAV
Hepatitis A Virus IgG Antibodies
When positive, indicates immunity due to prior infection or vaccination
What is the lab that demonstrates active infection with Hepatitis A
IgM anti-HAV
What is the lab that demonstrates immunity against Hepatitis A
IgG anti-HAV
What is anti-HCV
Hepatitis C Antibodies
When positive, indicates a current or resolved infection, as this persists positive for life
What is HCV RNA
Lab test that confirms current Hepatitis C infection, and persists with chronic infection
What is the lab test that demonstrates active HCV infection
HCV RNA
What is the lab test that demonstrates HCV immunity
anti-HCV
most common type of gallstones
cholesterol
% of gallstones composed of cholesterol
85-95%
Best initial imagining for suspected gallstones
US, which has 95% sensitivity for detecting stones in the gallbladder
US has ___% sensitivity for diagnosing stones in the gallbladder
95% sensitivity
Which hepatitis most commonly turns into chronic infection and is the most common reason for liver transplantation
Hepatitis C
% of hepatitis C infection that becomes chronic hepatitis
80%
% of hepatitis C infection that will become cirrhosis or hepatocellular carcinoma
20-30%
Management recommendations for acute cholecystitis
hospitalization and early cholecystectomy once stable
What characteristics of a patient with suspected GERD would warrant referral for further diagnostic evaluation with GI specialist
- symptoms are chronic and refractory to therapy
- esophageal complications are suspected
- dysphagia
- weight loss
- evidence of GI bleeding
Fasting plasma glucose diagnostic of T2DM
> or = 126 mg/dL
2-hr postprandial glucose diagnostic of T2DM
> or = 200 mg/dL
random glucose diagnostic of T2DM
> or = 200 mg/dL
HbA1c diagnostic of T2DM
> or = 6.5%
Most common causative agent for traveler’s diarrhea
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
Management of traveler’s diarrhea
<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
MOA of ezetimibe (Zetia) for HLD
inhibits cholesterol absorption
% of hyperthyroidism cases caused by Grave’s disease
90%
Most common cause of hyperthyroidism
Graves Disease (90%)
What is Grave’s disease
autoimmune condition characterized by excess synthesis and secretion of thyroid hormone caused by antibodies that stimulate the TSH receptors
% of patients with Grave’s disease treated with radioactive iodine who will develop long-term hypothyroidism
70% of patients by ten years
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?
Q6 weeks
levothyroxine has a half-life of 6 days and reaches steady state slowly
Most common skin cancer
basal cell carcinoma (75%)
% of all skin cancers that are basal cell carcinoma
75%
Common precipitating factors for vaso-occlusive sickle cell crisis (6)
- infection
- stress (physical or emotional)
- blood loss
- pregnancy
- surgery
- high altitudes
tinea unguium refers to fungal infection of the…..
nails (fingernails or more commonly toenails)
% of folks with hepatitis B infection who will develop chronic hepatitis
10%
% of neonates infected with hepatitis B at birth who will develop chronic hepatitis
90%
chronic hepatitis increases the risk of these (2) sequelae
- cirrhosis
- cancer (hepatocellular carcinoma)
Acute constipation, recommend first line treatment with….
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
Medication class of milk of magnesia
saline/osmotic laxative
CURB-65 Criteria for Hospitalization in Pneumonia
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
First line treatment for community-acquired pneumonia
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
(3) respiratory fluoroquinolones
levofloxacin, moxifloxacin, gemifloxacin
Pt presents with new onset HTN and an abdominal bruit. Suspect –
renal artery stenosis
ACEs and ARBs are contraindicated in pregnancy due to the risk for causing…..
fetal anomalies
Physical exam findings suggestive of anorexia nervosa
- emaciation
- dry skin
- fine body hair (lanugo)
- muscle wasting
- peripheral edema
- bradycardia
- arrhythmias
- hypotension
- delayed sexual maturation
- stress fractures
(3) most common locations for psoriasis lesions
knees, elbows, scalp
Treatment goal for an individual with HLD and clinically manifest CHD or a CHD-equivalent (e.g., T2DM) is….
LDL-C <100 mg/dL
Lab findings of iron-deficiency anemia (in terms of MCV, MCHC, RDW, ferritin, and reticulocytes)
- 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)
Medication class: Naloxone
opioid antagonist
used to reverse the physical effects of an opioid overdose»_space; reverses CNS and respiratory depression
(3) classes of medications that can cause dyslipidemia
corticosteroids, thiazide diuretics, beta blockers
Mid or late-systolic click is usually caused by…..
mitral valve prolapse
Innocent physiologic heart murmurs will [increase vs. disappear] with Valsalva maneuvers
disappear
If a murmur increases with straining/Valsalva, that is more concerning
Most common cause of bacterial community-acquired pneumonia
streptococcus pneumoniae
First line treatments (2) for asthma in pregnancy
- SABAs (albuterol)
- inhaled corticosteroid BUDESONIDE
Asthma exacerbations in pregnancy cause risk for…. (3)
- perinatal mortality
- preterm birth
- low birth weight infants
Criteria for the diagnosis of Rheumatoid Arthritis, per the American College of Rheumatology
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
(3) medication classes used for migraine prophylaxis
- beta blockers (propanolol, timolol)
- calcium channel blockers
- antiepileptic agents
who is a candidate for migraine prophylaxis medications
- > 2 severe headaches pre month
- acute medication tx >2x per week
- unable to tolerate abortive agents
Preferred therapy for the long-term management of Rheumatoid Arthritis
DMARDs (most commonly methotrexate, hydrochloroquine is another option)
Clinical presentation for mononucleosis
- 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
Common locations for eczema (atopic dermatitis)
- face
- wrists
- hands
- arms
- knees
- genitals
All folks considering pregnancy should be offered genetic carrier screening for (2)
- cystic fibrosis
- spinal muscular atrophy
Normal MCV range
80-100 fL
(4) conditions causing a macrocytic anemia
- folate deficiency
- vitamin B12 deficiency (pernicious anemia)
- liver disease
- hypothyroidism
Pharmacological treatment is considered for the treatment/prevention of osteoporosis in post-menopausal females who meet any of the following criteria:
- 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%
True or false: Vertebral fracture is consistent with the diagnosis of osteoporosis independent of BMD results
true
For whom should you consider adding on VFA (vertebral fracture assessment) imaging to a DXA scan?
- 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
Patient instructions with prescription of a bisphosphonate
- 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
(3) DSM-5 criteria for anorexia nervosa
- restriction of intake in relation to requirements
- intense fear of gaining weight and/or persistent behaviors that interfere with weight gain
- disturbed body image
Elevated lab value that may indicate heavy or chronic alcohol use
GGT
GGT is an enzyme that is very sensitive for diseases of the liver and gall bladder, but not very specific
% of sexual assault survivors with PTSD
30-65%
PTSD is persistent anxiety lasting more than _____ following a traumatic event
> 1 month
one of the following (2) criteria are REQUIRED for any DSM-5 diagnosis of MDD, along with a constellation of other comorbid symptoms
- loss of interest or pleasure in usual activities
- sad or depressed mood
- must be present most of the day, every day
Women with uncomplicated diabetes of less than ______ duration can use ANY of the birth control methods
<20 years
Risk factors for suicide in an individual with MDD
- 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
What is agoraphobia
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
What is the most common type of anxiety disorder
specific phobia (25%)
followed by… social phobia (13%), PTSD (12% in women), GAD (5%), and panic disorder (3.5%)
Typical age of onset for bulimia nervosa
late adolescence to early adulthood
Impulsive behaviors such as shop-lifting, alcohol and drug abuse, and unsafe sexual behaviors are characteristic of this eating disorder
bulimia nervosa
Common side effects of SSRIs
- anxiety
- insomnia or hypersomnia
- headache
- nausea
- anorexia
- sexual dysfunction
Physiologic dependence on a substance is defined as (2)
- 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
MOA of metformin
class = biguanide
works by:
- decreasing hepatic glucose production
- decreasing intestinal absorption of glucose
- increasing peripheral glucose uptake and utilization
Severe exacerbations of asthma relate to a peak flow of…..
peak flow <60%
normal = 80-100%
Severe exacerbations of asthma should be treated with …..
short course of oral steroids x5-10 days
HPV vaccine schedule >15yo
baseline, 2 months post-baseline, 6 months post-baseline
Live attenuated virus vaccines, examples (4)
- MMR (measles, mumps, rubella)
- varicella
- zoster (Zostavax — Shingrix is not)
- intranasal flu (LAIV)
USPSTF recommendations for mammograms
biennial ages 50-74yo
Risk factors for Hepatitis C
- 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
Risk factors for increased fracture risk that may warrant BMD screening earlier than 65yo but POST-menopausally
- low BMI
- h/o low-trauma fracture
- smoking
- alcohol intake > or = 3 drinks/day
- family history of hip fracture or osteoporosis
Expected symptoms and physical exam findings in someone with interstitial cystitis (painful bladder syndrome)
- 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
(2) anticholinergic medications for the treatment of urge urinary incontinence
oxybutynin chloride (Ditropan) tolterodine tartrate (Detrol)
Management of urge urinary incontinence
- bladder retraining with scheduled voiding
- biofeedback
- Kegel exercises
- avoid bladder irritants
- anticholinergic medications (e.g., oxybutynin, tolterodine)
Prophylaxis regimen for recurrent UTIs after sex
nitrofurantoin (Macrobid) single dose after sex
