deck 4

Question 1

behavioral change shown to improve function significantly with heart fialure

Answer 1

discontinuing alcohol

Question 2

management of refractory edema

Answer 2

add second diuretic (metalozone)
- spironolactone can be used but usually only considered for NYHA class III or IV patients

Question 3

only evidence for dual ARB + ACE inhibitor therapy

Answer 3

can reduce hospitalizations in CHF patients

Question 4

strongest RF for developing alzheimer’s

Answer 4

increasing age, FH second

Question 5

early signs of alzheimer’s

Answer 5

• memory disturbance, word-finding difficulty, decreased ability to recognize and draw complex figures, loss of ability to calculate.
• social behavior remains strikingly preserved until late in the illness

Question 6

evidence for cholinesterase inhibitors in AD?

Answer 6

• associated with modest improvements in cognition, behavior, activities of daily living, and global measurements of functioning. However, they do not change the progression of neurodegeneration.

Question 7

drug shown to have statistically significant benefit in advanced cases of dementia?

Answer 7

memantine

Question 8

screening test used for diabetes?

Answer 8

fasting glucose

Question 9

diabetes diagnosis

Answer 9

Two separate random glucose measurements more than 200 mg/dL with classic signs of diabetes (polydipsia, polyuria, polyphagia, weight loss), a fasting glucose greater than 126 mg/dL, or a glucose reading greater than 200 mg/dL 2 hours after a 75-g glucose load.

Question 10

leading cause of blindness in the US

Answer 10

diabetic retinopathy

Question 11

diabetic retinopathy risk correlated with…

Answer 11

increasing hbA1c

Question 12

indication for ACE inhibitor in diabets

Answer 12

all diabetics with systolic BP greater than 100

Question 13

ACE inhibitors and creatinine?

Answer 13

can be used irrespective of creatinine levels

Question 14

effect of fibrates

Answer 14

lower triglycerides and raise HDL, but have minimal effects on LDL.

Question 15

diet changes in diabetics?

Answer 15

Glycemic control is dependent on the total caloric intake, not the type of calorie taken in. Low-carbohydrate and high-protein diets have not been shown to improve glucose control more than weight loss from other methods. Sucrose does not need to be eliminated, but it may raise blood sugar more quickly after ingestion. Formal dietary programs are not more likely to produce long-term sustainable results unless exercise is a large component of the plan. Increased fiber does improve glycemic control.

Question 16

oral therapy for type 2 diabetes

Answer 16

No evidence supports changing sulfonylureas when one is not adequately controlling glucose levels. Biguanides act to decrease glucose output from the liver, and can decrease hemoglobin A1C by 1.5% to 2%. However, biguanides should not be used if creatinine is higher than 1.5 mg/dL. Meglitinides increase insulin secretion and should only be taken before meals. They can reduce the hemoglobin A1C by 0.5% to 2% and are most valuable if fasting sugar is adequate, but postprandial sugars are high. Since they increase insulin levels, they are more effective when used in combination with a medication that has a different mechanism of action. They are excreted in the liver, therefore are safe in renal failure. Thiazolidinediones decrease insulin resistance and are an excellent choice for those with insulin insensitivity. α-Glucosidase inhibitors inhibit the absorption of carbohydrates in the gut and can decrease the hemoglobin A1C by 0.7% to 1%. They should be avoided if creatinine more than 2.0 mg/dL.

Question 17

GLP-1 agonists mechanism

Answer 17

gut-derived incretin hormone that stimulates insulin and suppresses glucagon secretion, delays gastric emptying, and reduces appetite and food intake

Question 18

DPP-4 inhibitor mechanism

Answer 18

prolongs the activity of endogenously released GLP-1

Question 19

NPH (neural protamine hadedorn) length of action

Answer 19

10-20 hours

Question 20

long-acting insulin preparations

Answer 20

lantus and levemir (24 hours)

Question 21

lipid treatment goal for patients with known CAD

Answer 21

less than or equal to 70 mg/dL

Question 22

lipid goal estimation

Answer 22

If a patient has no known coronary disease, the 10-year risk for coronary disease should be estimated using a readily available National Cholesterol Education Program (NCEP) risk calculator (available online). If the 10-year risk is greater than 20%, the LDL treatment goal should be less than or equal to 100 mg/dL. If the risk is between 10% and 20%, the LDL treatment goal should be less than 130 mg/dL. If the risk is less than 10%, the treatment goal should be less than 160 mg/dL.

Question 23

interventions for increasing HDL

Answer 23

• exercising is most effective.
• moderate alcohol raises HDL
• weight loss + smoking have similar effect

Question 24

single best predictor of adverse outcomes of all lipid values

Answer 24

• low HDL

Question 25

affect of smoking on lipid levels

Answer 25

increases HDL by 5-10 but does not affect LDL, VLDL, or triglycerides

Question 26

how to decrease facial flushing with niacin

Answer 26

take it with aspirin

Question 27

fish oil mechanism

Answer 27

decreases secretion of triglycerides by the liver

Question 28

fibrate mechanism

Answer 28

changes hepatic metabolism of lipoprotein

Question 29

ezetemibe MOA

Answer 29

lowers cholesterol by interfering with absorption of cholesterol in the gut

Question 30

ezetemibe effects

Answer 30

Used alone, it lowers LDL and triglycerides only modestly. When added to a low-dose statin, the combination lowers LDL as much as the maximum statin dose, but its combined use with a low-dose statin may produce fewer adverse effects.

Question 31

niacin effects

Answer 31

• significantly raises HDL
• moderately decreases LDL
• moderately decreases triglycerides

Question 32

best test to rule out acute HIV

Answer 32

Plasma HIV RNA (but low level viremia may represent false-positive)

Question 33

HIV window period

Answer 33

several weeks to 4 months

Question 34

pap testing in HIV patients

Answer 34

every 6 months

Question 35

HIV and prophylaxis

Answer 35

Prophylaxis against M avium complex (MAC) should be instituted once the patient’s CD4 count drops less than 75
to 100 lymphocytes/mm3. Prophylaxis against Pneumocystis pneumonia should be considered once the CD4 count drops less than 200 lymphocytes/mm3 . Prophylaxis for fungal disease has been studied, but there was no benefit in the group that had prophylaxis with regard to mortality. Prophylaxis for herpes simplex and herpes zoster is not generally done. CMV prophylaxis can be instituted in those with CMV IgG positivity and with CD4 counts less than 50 lymphocytes/mm^ , but it is generally not done because ganciclovir (the primary prophylactic agent) can cause neutropenia.

Question 36

pneumocystis pneumonia treatment

Answer 36

TMP-SMX for 3 weeks + steroids

Question 37

lifestyle modifications for managing HTN

Answer 37

Weight reduction is most beneficial, and systolic blood pressure can fall from up to 20 mm Hg for each 10 lb of weight lost. A DASH diet can lower blood pressure between 8 and 14 mm Hg. Dietary sodium reduction, increased exercise and moderation of alcohol can be expected to lower systolic blood pressure less than 10 mm Hg.

Question 38

HTN management

Answer 38

lifestyle modifications –> pharmacotherapy

Question 39

stage 2 HTN

Answer 39

systolic BP greater than 160 or diastolic greater than 90

Question 40

management of stage 2 HTN

Answer 40

thiazide with either ACE/ARB/b-blocker/or CCB

Question 41

routine testing for new ddx of HTN

Answer 41

Need to assess end-organ damage + identify patients at high risk for cardiovascular complications…

• hemoglobin and hematocrit
• potassium
• creatinine
• fasting glucose
• fasting lipid
• UA
• resting ECG

Question 42

abdominal bruit suggests…

Answer 42

renal artery stenosis

Question 43

renal artery stenosis workup

Answer 43

• renal angiography or ACE-inhibitor renal scan

Question 44

BP management to prevent stroke recurrence

Answer 44

ACE inhibitor + diuretic in combination

Question 45

BP management

Answer 45

Persons younger than 55 years who are not black start an ACE inhibitor as first-line therapy (A). β-Blockers (B) can be used in this group, but are no longer considered ideal first-line therapy. In persons who are older than 55 years or black, the first-line therapy is either a calcium channel blocker (C) or a diuretic (D). If one medication does not control the blood pressure, the next step is to add an agent from the other category. For example, if you have an “A” or “B” medication, add a “C” or “D” medication. If that still doesn’t control the blood pressure, use A (or B) + C + D. Those still resistant should consider an α-blocker or other agent.

Question 46

atypical angina

Answer 46

patient experiences pain that has the quality and characteristics of angina, or occurs with exertion, but not both.

Question 47

anginal equivalent

Answer 47

dyspnea is sole or major manifestation

Question 48

major concern with prescribing nitrates

Answer 48

Tolerance is the most significant issue to consider when using nitrates for stable angina. Tolerance develops rapidly when long-acting nitrates are given. When using a patch, it is important to have intervals of 10 to 12 hours without the patch to retain the antianginal effect. Headache and fatigue may be important side effects, but are more of a nuisance than an important consideration. The medications can be used with β-blockers and calcium channel blockers.

Question 49

beta-blocker dosing

Answer 49

adjust dose to achieve a HR of 50-60 beats/min

Question 50

obesity workup

Answer 50

• history and physical most important

- lab assessment to assess medical consequences, including fasting glucose, lipid panel