Deck 1 Flashcards
When in doubt about whether to immunize someone,
Better to give an extra vaccine dose than to give none. Risk of reaction with re-immunization is minimal.
When should you defer an immunization and when should you not defer?
Immunization should only be deferred if there’s a moderate to severe illness (with or without fever). For minor illness, you should still immunize.
What is the onset and duration of most immunizations (active immunity)
Onset is about a month, it lasts for years
What is passive immunity and when is it used
It’s when you directly give someone antibodies. It’s used post-exposure for certain infections (so the patient has to have a recent risk of exposure)
What is the onset and duration of passive immunity
Onset is a few hours, usually lasts 6 to 9 months
What are some infections we can treat with passive immunity
Varicella, Hep A, Hep B, tetanus, rabies
Herpes Zoster Vaccine (4 things)
Prevents herpes zoster (shingles) in adults aged 50 years and older.
Give 1 dose, then 2 to 6 months later, give another dose.
Can be given to immunosuppressed people.
If they have already received the live zoster vaccine, still give this one.
How to calculate packs per day years
2 packs per day for 30 years
2 PPD x 30 years = 60 pack year history
CAGE for other substances
Change the “E” to an “N”
Have you ever needed heroine to feel normal (not be in withdrawal)
CAGE scoring
2 or more “Yes’ “ means they almost definitely have substance abuse disorder
For all ages, what is the leading cause of death, and what is the 10th leading cause
Heart disease, suicide
Prostate screening recommendations
55 to 69 years old: Should be a case by case decision.
70 and older: Do not screen
Breast cancer Genetic Counseling recommendations
If they have certain risk factors, especially the BRCA 1 and 2 gene, screen them with the assessment tool. Based on the tool, you may need to do genetic testing.
If they don’t have the BRCA 1 and 2, do not screen routinely
Colorectal cancer
Screen from 45 to 75.
From 76 to 85 the decision is case by case.
Fecal Occult- yearly
DNA test- 1 to 3 years
Sigmoidoscopy- 5 years
CT colonoscopy- 5 years
Colonoscopy- 10 years
Lung cancer screening
CT scan for people 55 to 80 years old with a 30 pack-year history, who currently smoke or quit within the past 15 years.
Stop screening if they quit for more than 15 years or if they have another illness that limits their life expectancy anyway
Breast Cancer Screening
Age 40 to 45: Woman’s choice
45 to 54: Annual mammogram
54 to whenever they still have a life expectancy of 10 years: Biennially
Or
50 to 74: Biennially
BSE is not encouraged nor discouraged
Cervical Cancer
Do not screen before 21
Sensitivity
Likelihood of being sensitive enough to find a true positive
Specificity
Specific enough to know which is a true negative
Aspartate aminotransferase (AST) measures
damage to the liver
Aspartate aminotransferase (AST) findings
Can be elevated in valproate therapy, hepatitis, cirrhosis
Decreased in chronic alcoholic liver disease
Alanine aminotransferase (ALT) measures
liver damage
Alanine aminotransferase (ALT) findings
Can be elevated in valproate therapy, hepatitis, cirrhosis.
Deceased in chronic alcoholic liver disease.
y-Glutamyl transferase (GGT) measures
Cholestasis (flow of bile from the liver, either extrahepatic or intraheptatic)
y-Glutamyl transferase (GGT) findings
Can be elevated in alcohol abuse, chronic alcoholic liver disease
Alkaline phosphatase (ALP) measures
Cholestasis (flow of bile from the liver, either extrahepatic or intraheptatic)
Alkaline phosphatase (ALP) findings
Elevated in gallbladder disease, liver disease, bone injury, or rapid bone growth
Creatine kinase measures
muscle injury, it’s found in the brain, heart, and muscles
Creatine kinase findings
elevated in MI, myositis, vigorous exercise, neuroleptic malignant syndrome
Urea nitrogen (BUN) measures
Kidney functions
Urea nitrogen (BUN) findings
Elevated in impaired kidney function, significant dehydration
(Definitely check this during Li therapy!)
Creatinine measures
Kidney function. It’s a more specific measure than BUN
Glomerular Filtration Rate (GFR) measures what? What are 2 important parameters to know?
It’s the best measure of kidney function.
- Older people have 30% reduced filtration.
- If GFR is over 60, you don’t need to adjust the dose
Valproate therapeutic level
50 to 120
Valproate (and certain other AEDs, like carbamazepine) 10 recommended labs
ALT, AST, ALP, bilirubin, albumin, total protein CBC with WBC differential and platelet count, serum hCG, and valproate level.
Schedule:
- Baseline
- Monthly for a few months
- 6 to 24 months
The patient is on valproate. What might you find on the liver panel
Elevated ALT and AST are common.
Usually happens in the first 6 months, especially with children.
The values will return to normal when the medication is discontinued.
What lab values tell you that you should discontinue valproate?
AST/ALT elevations more than 2 to 3 times the upper limit
For patients taking valproate, teach the patient to report symptoms of liver dysfunction such as,
abd pain, nausea, vomiting, and jaundice
Liver failure with valproate
It’s rare.
Usually happens in children under 10, development disability, or with major seizure disorder
Valproate hematologic considerations
- Thrombocytopenia and neutropenia are the most common
- Consider discontinuing if there is bone marrow depression
- Tell patient to report signs of dysfunction like bruising, bleeding, slow healing, fever)
Valproate and Steven Johnson
Rare
Carbamazepine and Steven Johnson
Increased risk in Asians/Indians with a certain allele
Genetic testing before starting Carbamazepine
Recommended for Asians/Indians to check if they have an allele that increases risk for SJS
What are the 10 initial labs recommended for Lithium
Kidney (BUN, creatinine, GFR) TSH Electrolytes CBC with WBC differential, hCG Urinalysis
EKG
Li level every 4 days
What are the 8 long-term labs recommended with Li
Kidney (BUN, Creatinine, GFR)
TSH
CBC
Urinalysis
EKG over age 50, q 6 to 12 months
Li level q 1 to 2 months or 6 to 12 months depending on patient
Li target levels
.8 to 1.2 for acute
.6 to 1 for maintenance
3 contraindication for Li
Acute renal failure
Severe dehydration
Sodium depletion
Li is NOT contraindicated in these kidney conditions:
Chronic stable kidney disease
kidney transplant
A patient with stable/chronic kidney disease or a kidney transplant is on Li. What lab tells you to reduce the Li dose?
Reduce is GFR is less than 60
3 important states that effect Li level
Dehydration increases Li
Decreased sodium increases Li
Increased sodium decreases Li
Li toxicity can begin at __ but more likely won’t occur until __
1.5
>2
Li toxicity: Worsening ___ symptoms correspond to the highest Li levels
neurologic
Is Li toxicity a medical emergency
Yes. Duh.
Li toxicity symptoms
Lethargy, fatigue, clumsiness, weakness, cramping, N/V, severe tremor, blurred vision, confusion
Li toxicity signs
Nystagmus, ataxia, increased DTR, AMS, arrhythmias
Meds that can increase Li level
ACE inhibitors, angiotensin II receptor blockers, NSAIDS
Tetracyclines, metronidazole
K-sparing diuretics, thiazide diuretics
(none are contraindicated though)
Meds that can decrease Li
Theophylline
not contraindicated though
Meds that can either increase or decrease Li (unpredictable)
Loop diuretics
CCBs
(none are contraindicated though)
Other Effects of Li (renal, cardiac, thyroid, neuro, general)
renal, Polyuria, polydipsia
cardiac, rare but conduction problems can happens
thyroid, hypofunction and goiter
neuro, fine tremor
general, weight gain
Clozapine: absolute neutrophil count must be ___ to start therapy
1500 or greater
Clozapine: treatment should be stopped if ANC is
less than 1000
Clozapine: For patients with Benign Ethnic Neutropenia,
They can still be treated, but there are special guidelines
Clozapine: Monitoring schedule
Weekly for 6 months then q 2 weeks for 6 months then Monthly if ANC is 1500 or more
Clozapine: the incidence of agranulocytosis is
1 to 2 %
The Clozapine Risk Evaluation and Mitigation Strategy
Clozapine is only available through this program and the provider must have a special certification to use the med
Hep A: route of transmission
Fecal-oral
Hep A: IZ and post-exposure prophylaxis
Yes there’s a vaccine and post exposure prohylaxis
Hep A: Next steps if positive for infection
Do a liver panel
Notify public health authorities
Treat with supportive care. Liver transplant in rare cases
Hep A: Disease markers
HAV IgM
Elevated hepatic enzymes (at least 10 times the normal limit)
Hep A: the markers that show you have recovered and are immune:
HAV IgM and IgG, but with normal hepatic enzymes
Hep A: You are still susceptible if your labs show
You don’t have antibodies
Hep B: transmitted by
Blood, other body fluids
Hep B: Is there a vaccine and post exposure prophylaxis
Yes, both
Hep B: If the patient is positive, what do you do
Liver function tests
Screen for co infections
Immunize against Hep A
Refer to specialist for anti viral therapy
Hep B: Sequelae
Chronic hep B
liver cancer
liver failure
Hep B: the first disease marker to appear is
IgM ab
Hep B: Disease marker that shows the infection is extra contagious and extra growing
HBeAg
Hep B: the liver enzymes will be
at least 10 times the normal limit
Hep B: disease markers of chronic infection
Asymptomatic
Liver enzymes are normal or only slightly elevated
HBsAg
Hep B: disease markers of chronic infection
Asymptomatic
Liver enzymes are normal or only slightly elevated
HBsAg
Hep B: disease marker for previous Hep B infection or immunization
HBsAb
Hep B: You are still susceptible if your markers are
HBsAg negative
Anti-HBc negative
HBsAb negative
Hep C: route of transmission
Blood, other body fluids
Hep C: Is there immunization or post exposure prophylaxis
No
Hep C: Next steps if positive
Liver function tests
Screen for co infections
Refer to specialist for antiviral treatment
Hep C: Sequelae
Chronic Hep C
Cancer
Liver failure
Hep C: Acute disease markers
Anti-HCV present
HCV viral RNA
Elevated liver enzymes
Hep C: chronic disease markers
Anti HCV present
HCV viral RNA
normal or slightly elevated liver enzymes
Hep C: markers of past disease
Anti-HCV present (non-protective antibody)
HCV RNA absent
Normal liver enzymes
Hep D: route of transmission
Blood, other fluids
Hep D: Is there a vaccine and post exposure prophylaxis
No, but if you prevent B you can prevent D
Hep D: What to do if positive
Liver function tests
Screen for co infections
Refer to specialist for antiviral treatment
(Same as with B)
Hep D: Sequelae
Severe infection
Liver failure
Death
Hep D: disease markers
Acute or chronic hep B markers + hep D IgM
Usually elevated liver enzymes
CN I
Olfactory
CN II
Optic (vision)
CN III
Oculomotor
Eyelid and eyeball movement
CN IV
Trochlear
Turns eye downward and lateral
CN V
Trigeminal
Chewing
Face and Mouth pain
CN VI
Abducens
Turns eye laterally
CN VII
Facial Facial expressions Tears Saliva Taste
CN VIII
Acoustic
CN IX
Glossopharyngeal
Taste
Carotid BP
CN X
Vagus
BP
HR
Digestion
CN XI
Accessory
back muscles
Swallowing
CN XII
Hypoglossal
Tongue
Primary headache definition and examples
Headache not associated with other diseases
Migraine, cluster, tension
Examples of causes of secondary headaches
Tumor, intracranial bleeding, increase ICP, use of nitrates, meningitis, accelerated HTN
It’s not a primary headaches if (Snoop)
there are Systemic symptoms (fever, weight loss)
there are Secondary headache risk factors (HIV, HTN, etc)
It’s not a primary headaches if (sNoop)
Neurologic symptoms (confusion, CN dysfunction)
It’s not a primary headaches if (snOop)
Onset (sudden, onset with exertion)
It’s not a primary headaches if (snoOp)
age of Onset (over 50 or under 5)
It’s not a primary headaches if (snooP)
Prior headache history, Positional, Papilledema (vision problems)
Hypothyroid presentation
Memory loss Menorrhagia Skin dryness Onset gradual Raised BP
Hyperthyroid presentation
Emotional lability
Goiter
GI problems
Graves disease
Type of hyperthyroidism, autoimmune in nature
Toxic adenoma
Type of hyperthyroidism, metabolically active lesion
Thyroiditis
type of hyperthyroidism,
viral, autoimmune, postpartum, transient
Medications that can cause hyper or hypothyroid
amiodarone
interferon
Thyroid Stimulating Test
It tells you the amount of TSH release by the pituitary’s anterior lobe. TSH is what tells the thyroid to release T4
The most reliable test to diagnose all common forms of hypo and hyperthyroid.
Free T4 test
Tells you how much T4 (thyroxine) is there
It’s only used to confirm a hypo/hyper dx
Thyroid peroxidase antibody test
It’s used to detect autoimmune thyroid disease
Criteria for diabetes testing in asymptomatic adults
Over 45 years old.
Also,
Consider testing is they are overweight (BMI 25 or greater), and have other risk factors: Physical inactivity Family history Non white HTN HDL CVD Polycystic ovary syndrome
DM dx: Plasma glucose
Fasting result is 126 or greater
Random result is 200 or greater with symptoms like polys or unexplained weight loss
(100 to 125 is considered “impaired fasting glucose”)
DM dx: Oral glucose tolerance test
2 hour plasma glucose is 200 or more after a 75 g glucose load
(140 to 199 is considered “impaired glucose tolerance”)
DM dx: A1C
- 5 or greater
5. 7 to 6.4 is prediabetic
For a diabetic patient, the A1C goals should be adjusted if
the regular goal is not realistic. For example it’s not realistic for an 80 year old with CVD to meet the normal goal
Metabolic syndrome: the components are
Large waistline Hypercholesterolemia Low HDL HTN High glucose
Metabolic Syndrome pathophysiology
Causes include overweight, inactivity, and insulin resistance. Older age and genetic also play a role.
Increases risk of heart disease, DM, renal impairment, and stroke
Metabolic Syndrome 7 Treatment and goals
Lose weight by diet and exercise
Stop smoking
Lower LDL with statins
Increase HDL
Reduce hypertension with meds
Reduce blood sugar with meds
Aspirin to reduce risk of blood clots
Metformin can help patients taking SDAs to
lose weight and not become diabetic
What does metformin do
Suppresses glucose production in the liver
Reduces hunger
promotes fat loss
Stops or reverses weight gain
What should you know about adverse effects of metformin
The main one is GI upset, which can be abated by slow titration
Also B12 loss happens but that’s after many years
Metformin is contraindicated in people with
GFR less than 30
Which SDAs have the worst metabolic syndrome risk
Olanzapine
Clozapine
Quetiapine
SDAs with the least metabolic risks are ziprasidone, lurasidone,
aripiprazole, brexpiprazole, paliperidone, asenapine, lumateperone
Which 7 labs should you do for someone starting an SDA (only the labs related to metabolic syndrome)
Personal history Family history Weight Waist circumference Lipids Glucose BP
First line antihypertensives
Thiazide diuretic
CCB
ACE or ARB
(If you’re black, thiazide diuretic or CCB)
When assessing cholesterol, ideally it should be after a
12 hour fast
Statin Therapy Recommendation for patients with atherosclerotic coronary artery disease who are under 75 years old
High dose statin
Statin Therapy Recommendation for patients with atherosclerotic coronary artery disease who are over 75 years old
moderate dose statin
Statin Therapy Recommendation for people with LDL at least 190
high dose statin
Statin Therapy Recommendation for patients with DM
moderate or high dose
Statin Therapy Recommendation for patients with LDL 70 to 189 plus 10 year CVD risk of at least 7.5%
moderate or high
Explain CD4 testing for an HIV
CD4 tells you their immune status. High CD4 count is good.
Explain viral load testing for an HIV patient
Tells you how much of virus is present
Explain treatment for HIV positive people
Antiretroviral therapy.
It’s indicated for all adolescents and adults with HIV.
Start as soon as possible
Treatment is lifelong
Explain pre-exposure prophylaxis for HIV
Begin as soon as possible but after confirming they are HIV negative
Explain post exposure prophylaxis for HIV
You give them meds to prevent seroconversion.
It’s indicated for someone who isn’t HIV positive, but was in a high risk situation in the past 72 hours.
Treatment lasts for 28 days.
Screening recommendations for HIV
Screen people from 15 to 65 years old
High risk behaviors for getting HIV
People who request testing for other STDs
Bisexual
Prostitutes
Conventional testing method for HIV
- Reactive immunoassay
- Then confirm those results with a Western blot or immunofluorescent assay
Other approved tests are combination tests and qualitative HIV-1 RNA
Is rapid HIV testing good?
Yes, rapid tests are very accurate. But, if it’s positive, you need to confirm with the conventional tests.
