Essentials Flashcards
What are key features of public health services?
Population focused
Prevention focused
What is an acronym to remember parts of the periodic health exam questions for adolescents?
HEEADS
Home
Education
Employment
Activities
Drugs
Suicide
Sex
What health advice should you recommend for age 0-3?
Immunization, back to sleep, home safety, smoke free environment, dental health
What health advice should you recommend for age 3-12?
Home safety, nutrition, dental health, immunization
What health advice should you recommend for age 13-24?
Condoms, contraception, avoid risky behavior, seat belts, body image, dental health, immunization
What health advice should you recommend for age 24-44?
Folic acid if planning pregnancy, smoking cessation, dental health, immunization
What health advice should you recommend for age 45-64?
Smoking cessation, dental health, Ca and Vit D for post menopausal women, physical activity, heart healthy diet, immunization
What health advice should you recommend for age > 65?
Smoking cessation, dental health, Ca and Vit D for postmenopausal women, physical activity, heart healthy diet, immunizations
What genetic cause for people with disabilities should always be considered?
Down’s Syndrome
What modifications can be made to help individuals with disabilities?
Modified environment, changes to work conditions, adaption to geographic location
What are common diagnoses of elderly populations?
Falls, arthritis, heart/resp disease, dementia, abuse, incontinence, malignancy, visual or hearing loss, depression, malnourished, diabetes
What is the crude death rate?
Number of deaths over the number of people in that population
What is the case fatality rate?
Number of deaths in a certain period over the number of people who were sick with the thing in that time period
What is PYLL and how is it calculated?
Potential years of life lost
Life expectancy minus how old they were when they died
Life expectancy for women is 82 years. If I die at age 40 my PYLL is 42.
Is a screening test a diagnostic test?
NO
How is infant mortality rate calculated?
Number of deaths of children less than 1 yo in a certain period and population divided by the number of LIVE births in that same period/population
What trial type provides the best evidence?
Randomized control trials when there is true randomization
What is important to consider when you are advising a patient about a treatment?
Efficacy, efficiency, and likelihood for compliance
What elements are important to consider about a patient’s social history?
Employment income, social status, education, culture, religion, health services, support network, family violence
What are some key strategies for primary prevention of diseases?
Education, social marketing, public health policy, community organizations
Can prevent family violence, outbreaks, chronic medical conditions, accidents
What are 3 key strategies for secondary prevention of disease?
Education, social marketing, public health policy
Can prevent conditions for which effective screening tests are available
Secondary means very early stages of the disease
What occupations are most at risk for exposure to inhalants and what conditions might they be more at risk for?
Chemists, farmers, firemen, construction, welder, medical lab, scientist
Asbestosis, mesothelioma, interstital fibrosis, asthma, lung cancer
What are these occupations more at risk for: manufacturing, x-ray tech, chemist
Contact dermatitis
What are these occupations at a higher risk for: construction, DJ, bartender
Higher rate of tinnitus and hearing loss
Do you need consent to release info to a patient’s employer or WCB?
YES
Do you need consent to release info to a patient’s employer or WCB?
YES
What kind of environmental exposures should be considered in a patient with headaches?
Sick building syndrome, CO2, SO2, perfumes, paint, varnish
What kind of environmental exposures should be considered in a patient with dermatitis?
Chemicals (Laundry detergent, cleaning agents), radiation, metals (nickle)
Define outbreak
A sudden increase in the number of cases of a disease above what is normally expected in a defined community, geographical area or season
What are the steps involved in outbreak investigation?
Plan of action
Identification
Isolation and verification
Epidemiological and lab analysis
Control and prevention
Evaluation and reporting
What is the role of lab testing in outbreak management?
Lab testing plays an important role in confirming the etiology of an outbreak and in tracking the spread of disease
What is the purpose of conducting a case control study during an outbreak investigation?
A case control study is used to identify the risk factors associated with disease and to develop hypotheses about the cause of an outbreak
RISK & CAUSE
What is the difference between a point source outbreak and continuous common source outbreak?
A point source outbreak is caused by a single, identifiable event while a continous common source outbreak is caused by exposure to a continuous source of contamination
What is the role of surveillance in outbreak management?
Surveillance is an ongoing systematic collection, analysis and interpretation of health related data needed for the planning, implementation and evaluation of health practices.
You are looking for data to help you decide on the treatment and management plan.
What is the purpose in conducting a retrospective cohort study during an outbreak investigation?
A retrospective cohort study is used to assess the risk of disease among exposed individuals and to determine if the exposure is a risk for the disease
What is the role of risk communication in outbreak management?
Risk communication is the exchange of information and opinions among individuals, groups and institutions involved in an outbreak and is critical for ensuring public trust and confidence in the health system
When would you use contact precautions and are they?
These precautions are implemented when the mode of transmission is through direct or indirect contact with the infected person or contaminated objects
Contact precautions include wearing gloves and gowns, and avoiding close contact with the infected person
When would you use droplet precautions and what are they?
These are implemented when the mode of transmission is through droplets produced by coughing, talking or sneezing
This includes wearing a mask, maintaining distance of at least 2 meters from the infected person
What are airbourne precautions and when are they used?
They are implemented when the mode of transmission is through the airbourne route such as inhalation of droplets
Include wearing a mask and using negative pressure rooms or isolation measures
Immunization for which diseases plays a major role in outbreak prevention?
Measles, mumps, diphtheria, meningitis, influenza, varicella, rabies
What are the major environmental health risks populations in Canada are affected by?
The major environmental health risks facing populations in Canada include exposure to air pollution, contaminated water sources, toxic substances, and climate change. Other risks include exposure to radiation, lead, and other hazardous chemicals.
What is psychosis?
It is an interruption from reality that may affect thought process, content, behaviors or perceptions
It is a SYMPTOM and not a diagnosis
Age of onset of schizophrenia
Late teens to mid 30s
M>F
What early signs in adolescents are suspicious for schizophrenia later in life?
Withdrawal, irritability, antagonistic thoughts, functional decline, suspiciousness, perceptual distortions
What neurotrasmitter is thought to be responsible for the high use of tobacco products among patients with schizophrenia?
Acetylcholine
What are the anatomical findings in schizophrenia?
Enlarged ventricles
Reduced frontal lobe activity
MRI shows functional circuit disruption rather than localized dysfunction
What are an essential pieces of information gathered from the psychiatric history in multiepisode patients?
What medications have been tried
Which medications worked
What were their side effects
What doses have been tried and for how long
When starting a new antipsychotic what baseline and health monitoring tests should be performed?
Endocrine and sexual function at baseline repeated monthly for 3 months
What are baseline investigations for schizophrenia?
CBC, electrolytes, renal function tests, tox screen, LFT, TFT, fasting plasma glucose, lipids, syphilis, HIV
CT or MRI for structural brain abnormalities, ECG, clinical screening for chromosomal disorders
Patient with psychosis and TWO of either delusions, hallucinations, disorganized speech, or disorganized behavior for at least 1 mo and with impairment lasting at least 6 mo or more
Schizophrenia
Patient with psychosis and TWO of either delusions, hallucinations, disorganized speech, or disorganized behavior for at least 1 mo and with impairment lasting < 1 month
Brief psychotic disorder
Patient with psychosis and TWO of either delusions, hallucinations, disorganized speech, or disorganized behavior for at least 1 mo and with impairment lasting 1-6 months
Schizophreniform
What is first line for schizophrenia treatment?
Atypical antipsychotics
Less change of EPS/TD
What is the treatment for schizophrenia after 6-8 weeks of failed trials on at least 2 different antipsychotics?
Clozapine
Causes agranulocytosis, seizures, myocarditis
What are chlorpromazine and thioridazine contraindicated in?
Pre existing movement disorders or TD
Which atypical antipsychotic prolongs the QT interval?
Quetiapine & ziprasidone
Needs regular ECG monitoring
Which antipsychotics are good in patients with preexisting movement disorders?
Quetiapine or clozapine
Both atypicals
What is the purpose of psychotherapy in schizophrenia?
Psychotherapy can help with managing the symptoms and improving social and occupational functioning
What is mania?
Mania is a period of sustained elevated mood that leads to disturbed behavior and function
Median age of onset for bipolar disorder
25
Most important questions to ask a manic patient that will not tolerate a full interview?
Cover questions looking for diagnostic proof and those regarding safety (suicide, homicide, caretaker of children)
What is a manic episode? What are the DSM criteria?
Abnormally and persistently elevated, expansive or irritable mood and increased goal directed activity/energy for at least 1 week
- At least three of the following or four if the only mood is irritable:
Grandiosity
Sleep deprived
Talkative
Pleasure in activity with painful consequence
Pressured speech
Activity increased
Ideas (flight)
Distractible - Mood distrubance is enough to cause problems with work/home life or requires hospitalization or there are psychotic features
- Symptoms not due to substance or medicines
- If the episodes happens after substance or medication but persists after treament is stopped then there is evidence for bipolar 1
GST PPAID
Criteria for bipolar 1
At least one manic episode commonly accompanied by MDE (but not required)
Bipolar 2 criteria
Disorder where there is at least ONE MDE and at least ONE hypomanic episode without past manic episode
Cyclothymia criteria
Numerous periods of hypomanic and depressive symptoms that does not meet MDE criteria for at least 2 years (at least 1 year in children and adolescents) and never without symptoms for more than 2 months
No MDE, manic, mixed episodes and no psychosis
Not due to medical condition or substance use
Symptoms cause clinically significant distress/impairment
Psychosocial interventions for bipolar disorder
CBT, family focused therapy, interpersonal and social rhythm therapy, systematic care managment
Treatment for bipolar mania
Risperidone, olanzapine, aripiprazole, asenapine, ziprazidone, divalproex
ZORAAD
Treatment for bipolar depression
Lamotrigine, olanzapine + SSRI, lithium + divalproex
What medical disorders are prevalent in developmental delay?
Cardiac disease (CAD and CHD), aspiration pneumonia, OSA, GERD, seizure, epilepsy, early onset dementia, hypothyroid, hypogonadism
What DD has a high incidence of thyroid disorders?
Down’s Syndrome
Define cerebral palsy
A neurological nonprogressive condition characterized by motor and occasionally intellectual impairment caused by brain injury before completion of neurodevelopment (ie first TWO years of life)
Can be caused prenatal (intrauterine infections, prenatal stroke, vascular insufficiency, TORCH infection), perinatal (birth asphyxia, prematurity), post natal (CNS infection, kernicterus, trauma)
Common genetic causes of DD
Down’s
Fragile X
Prader Willi
Tuberous sclerosis
PKU
What should you test male patients for after puberty or when exhibiting hypogonadism?
Testosterone levels
Health Maintenance for Down’s
Each visit: check for celiac sx, OSA, cervical spine positioning, myopathy signs
Annual: TSH, hemoglobin, audiological, mitral/aortic valve disease
Q3Y: Cataracts, refractive error, cornea thinning, haze
6 Physical features in Down’s
Small head
flattened facies
protruding tongue
upward slanting eyes
single palmar crease
short fingers
Physical/developmental features in Fragile X
Long face, large ears, hyperextensible joints, macroorchidism, flat feet, ADHD, autism, delayed speech, social anxiety
Cause of Fragile X
CGG trinucleotide repeat of FMRI gene on X chromosome
Signs of cerebral palsy
Spasticity (hyperreflexia, hypertonia, scissor gait, toe walking), athetosis (slow, writing movements), ataxia (wide based gait), intention tremor, global developmental/physical dysfunction
Fetal alcohol characteristic features
Facial anomalies, short palpebral fissures, flat upper lip, flattened philtrum, flat midface, microcephaly
What age is gender identity typically set by?
2-3 years old
Side effects of methoxy progesterone in men
Reduction in sex drive, breast growth, headaches, weight gain, reduction in bone density
What are the cluster A personality disorders?
“MAD”
Paranoid, Schizoid, Schizotypal
Mneomic for DSM criteria for paranoid personality disorder
Needs 4 criteria from SUSPECT
Spouse fidelity suspected
Unforgiving and holds grudges
Suspicious of others
Perceives attack on their character even when it does not seem to be happening and reacts quickly
Enemy or friend (suspects associates and friends)
Confides in others feared
Threats perceived in benign events
Mneomic for DSM criteria for schizoid personality disorder
Needs 4 criteria from SOLITARY
Shows emotional coldness
Omits from social events
Involved in solitary activity
Takes pleasure in few activities
Appears indifferent from praises and criticisms
Restricts close relationships
Yanks self from social interactions
Mneomic for DSM criteria for schizotypal personality disorder
Needs 5+ of ME PECULIAR
Magical thinking or odd beliefs
Experiences unusual perceptions
Paranoid ideation
Eccentric behavior/appearance
Constricted affect
Unusual thinking and speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Ruled out psychotic disorders and pervasive DD
What are the cluster B PD?
BAD
Antisocial
Borderline
Histrionic
Narcissistic
Mneomic for DSM criteria for antisocial personality disorder
3+ from CORRUPT
Conformity to law lacking
Obligations ignored
Remorse lacking
Underhanded
Panning deficit (impulsive)
Temper (irritable/aggressive)
“Breaking rules is what they do,
Lying, cheating, and stealing too,
No remorse or empathy shown,
Reckless, impulsive, and they’re prone,
Irresponsible and callous ways,
This is Antisocial Personality always.”
Mneomic for DSM criteria for borerline personality disorder
5+ from AM SUICIDE
Abandonment
Mood instability
Suicidal/self harming
Unstable and intense relationships
Impulsive
Cant control anger
Identity disturbance
Dissociative symptoms
Emptiness
Mneomic for DSM criteria for histrionic personality disorder
5+ from PRAISE ME
Provocative or sexually seductive behavior
Relationships considered more intimate than they are
Attention (uncomfortable when not center of attention)
Influenced easily
Style of speech (lacks details, impressionistic)
Emotional lability and shallow
Make up (physical appearance used to draw attention)
Exaggerated emotions (theatrical)
Mneomic for DSM criteria for narcissistic personality disorder
5+ from SPECIAL
Special or status (believes they are more important)
Preoccupied with fantasies of unlimited success, power, brilliance, beauty or love
Entitlement, envious
Conceited
Interpersonal exploitation
Arrogant
Lacks empathy
What are the cluster C personality disorders?
SAD
Avoidant
Dependent
OCD
Mneomic for DSM criteria for avoidant personality disorder
4+ AVOIDER
Avoid occupational activities
Views self as inept, unappealing, inferior
Occupied with fear of rejection or criticism
Inhibits from new interpersonal relationships
Difficulty initiating new projects due to lack of self confidence
Embarrassment prevents new activities
Restrains from intimate relationships out of fear
Mneomic for DSM criteria for dependent personality disorder
5+ from DEPENDENT
Difficulty making everyday decisions without advice or reassurance
Excessive length to obtain nuture and support
Preoccupied with thoughts of self care
Exaggerated fear of being left to care for self
Needs others to assume responsibility for most major areas of life
Difficulty in expressing disagreement
Ending one relationship and immediately jumps into new one
Not able to initiate projects due to lack of self confidence
Take care of me is their motto
Mneomic for DSM criteria for OCD
4+ from LAW FIRMS
Loses points of activity due to preoccupation with detail
Ability to complete tasks compromised by perfectionism
Worthless objects are hard to discard
Friendships and leisure excluded due to preoccupation with work
Inflexible, scrupulous, overly conscientious on ethics, values, morality not accounted for by religion or culture
Reluctant to delegate unless others submit to exact guidelines
Miserly toward self and others
Stubborn and rigid
What medications should be avoided in personality disorders?
Benzos, opioids, anything that can be fatal in overdose (TCA)
What treatment is best for borderline personality disorder?
DBT (dialectical behavior therapy), focuses on mindfulness, emotional regulation, interpersonal effectiveness, distress tolerance
Lasts longer than 1 year
What medication can be used for schizotypal and borderline personality disorders?
Low dose antipsychotics
For treating symptoms only not the PD
Try psychotherapy for treatment of PD
Criteria for diagnosing insomnia
Difficulty initiating or maintaining sleep or where there is poor sleep quality at least 3 nights per week for at least 3 months and causes significant distress and is not better accounted for by another sleep disorder
Differential diagnosis for sleep disorders
Central sleep apnea, circadian sleep wake disorders, substance or medication induced sleep disorder, OSA, REM sleep behavior disorder, restless leg syndrome, psychiatric comorbidity, insomnia, physical disorder, poor sleep environment, hypersomnolence, narcolepsy
Fatigue vs excessive daytime sleepiness
Fatigue is subjective lack of energy to perform mental or physical tasks
Excessive daytime sleepiness is the inability to stay alert at daytime (ie nodding off while driving)
Mnemonic for sleep apnea screening
STOP BANG
Snoring
Tired
Observed apnea
blood Pressure
BMI > 35
Age > 60
Neck circumference > 40
male Gender
When is polysomnography used
Patient with excessive daytime sleepiness where you are suspecting OSA, periodic limb movement, breathing disorders at sleep, narcolepsy, seizures during sleep
What is first line treatment for primary insomnia
CBT
Others: sleep log, sleep hygiene, sleep restriction, relaxation response, melatonin
Initial tests for fatigue
CBC, electrolytes, renal function tests, liver function tests, thyroid function tests, fasting plasma glucose, lipid panel, and testing for syphilis and HIV
DSM diagnoses to consider with fatigue
MDD
GAD
Caffeine withdrawal
Stimulant withdrawal
What proportion of women presenting to primary care have experiences physical/verbal abuse?
1/3
What investigtions should be performed if you suspect partner abuse?
CBC - r/o anemia or infection
Electrolyes - r/o dehydration, starvation
TSH
INR, PTT, coagulation status - r/o coagulopathy
Tox screen - alcohol, cannabis, opiod, amphetamines, cocaine, stimulants
Urinalysis - tox
CXR - r/o fractures
Other x-ray - r/o other fractures
CT - r/o brain lesions, masses, hemorrhage
Steps for management of partner abuse
Determine risk (short & long term)
Validate, support, counsel
Offer referral (social worker, domestic hotline, domestic violence advocates, community resources, psychiatrist)
Discuss options around safety and planning
Educate about what can be done in emergency
Report only if patient agreeable
MUST REPORT CHILD ABUSE TO CAS
Anticholingeric toxicity signs & symptoms
Agitation, delirium, hallucinations, memory loss, urinary retention, visual disturbance (DRY)
HTN, hyperthermia, tachycardia, flushing, mydriasis, decreased bowel sounds, seizures (FAST)
Blind as a bat, dry as a bone, hot as a hare, red as a beet, mad as a hatter
Think: Cyclobenzaprine, antidepressant, carbamazepine, antihistamine (diphenhydramine), antiparkinsons, antipsychotics, antispasmodics, atropine)
What medications have anticholinergic side effects in excess?
Antihistamines, antiparkinsons, antipsychotics, benztropine, carbamazepine, tricyclics
Cholinergic toxicity signs & symptoms
Confusion, lacrimation, vomiting, diarrhea, increased urination (WET)
Bradycardia, hypotension, hypothermia, diaphoresis, miosis, seizure (SLOW)
What medications have cholingergic side effects in excess?
Anticholinesterase inhibitors, insecticides (THINK FARMERS), nerve gases
What are the side effect of opiod/benzo/alcohol/sedative excess?
Altered mental status, confusion, delirium, coma
Hypotension, hypothermia, resp depression, miosis (OPIODS), hyporeflexia
What are the signs and symptoms of neuroleptic malignant syndrome?
HTN crisis, muscle rigidity, rhabdomyolysis, elevated WBC and CPK, metabolic acidosis
Fever, diaphoresis, muscle cramps, stiffness, tremors, agitation, delirium, coma
What medications can cause NMS?
Antipsychotics, levodopa, lithium, desipramine, phenelzine
What are the signs and symptoms of serotonin syndrome?
Sweating, diarrhea, headache, agitation, hallucination, coma
HTN, hyperthermia, mydriasis, hyperreflexia, myoclonus, clonus
“Serotonin surge, a chaotic purge.
Mind in a haze, the body ablaze.
Heart racing high, pupils wide in the eye.
Muscles rigid and shaking, the gut in upheaval, quaking.”
What medications can cause serotonin syndrome?
Antidepressants (SSRI, SNRI, MAOi, TCA, bupropion, trazodone, mirtazapine), opiods, amphetamines, cocaine, methylphenidate, LSD
What is the CIWA protocol?
Clinical approach in monitoring and treating alcohol withdrawal
Diazepam 20 mg q1-2h or 2-5mg IV/min to a max of 10-20 mg q1h until symptoms subside
If old, bad liver, bad asthma, or in rep failure use LORAZEPAM 1-2 mg po/SL tid or qid
ALSO need thiamine 100 mg IM initial dose then 100 mg po qd x 3d
Give antiepileptics if seizure
Give antipsychotics if hallucinations
Give hydration as support
Clinical Institute Withdrawal Assessent for Alcohol
How do you treat opioid intoxication?
Naloxone 2 mg IV IM SL SC
Increase by 2 mg increments until symptoms subside to a max of 10 mg
Methadone is used for long term detox and maintenance in addiction
What are the different nicotine replacement therapies?
Patch qd (7-21 mg)
Gum 2 mg q2h po (max 20 pieces per day)
Lozenge 1 mg q1h po (max 20 per day)
Inhaler 4 mg carrdige (max 12 cartridges per day)
Varenicline 0.5 - 1 mg bid po x 12-24 weeks following 1 week titration
Bupropion 150 mg qd po x 3d then 150 mg bid x 12 weeks
Signs of purging
Teeth changes, enamel erosion, chipped/ragged teeth, dental caries
Parotid gland hypertrophy (can also be other salivary glands)
Signs of starvation
Lanugo, emaciation, peripheral edema
What are the key features of anorexia?
Excessive working out, intense fear of gaining weight, restricting energy intake, distorted self perception, lack of insight into how important body weight is
Can be restricted type or binge purge type (past 3 month duration)
Key features of bulimia
Recurrent episodes of binge eating and feeling out of control then using laxatives, vomiting, excessive exercise or restricting intake to counteract
What is the treatment of choice for eating disorders?
Outpatient CBT
What parts of the brain coordinate fear and store memory for future exposure to the same stimuli?
Amygdala and hippocampus
What are the key features of panic disorder?
One month or more worry about having more panic attacks and/or behavior to avoid panic attacks
Sweating, trembling, SOB, nausea, dizziness, chills, derealization, fear of losing control or dying
What are the key features of generalized anxiety disorder?
Excessive worry about a number of topics for at least 6 months and there are 3+ of: FFCIMS
Feeling keyed up
Fatigue
Concentration problems
Irritability
Muscle tension
Sleep disturbance
Treatment for anxiety disorder
SSRI (may initially make it worse, start low and go slow) and SNRI are first line
Mirtazapine (tetracyclic)
Benzo (used for emergency GAD and panic)
TCA
MAOi
Busiprone (good for GAD but not panic)
What is the single strongest predictive factor for future suicidal behavior?
Previous suicide behavior and attempts
Which personality disorders are more commonly associated with suicuidal ideation?
Borderline and antisocial
Which anxiety disorder has a higher rate of suicidal ideation?
Panic disorder
What screening question could be asked if you suspect mania?
Has there ever been a time where you weren’t sleeping as usual and yet your energy was higher than normal and you were engaged in a lot of activities? Did people around you think this was unusual?
What screening question could be asked if you suspect psychosis?
Do you ever worry people may be plotting to harm you? Do you have any special abilities that other people normally do not possess? Are you hearing voices or messages? Do you have visions?
Suicide risk assessment mnemonic
SAD PERSONS
Sex is male
Age
Depression
Previous attempt
Ethanol or drugs
Rational thinking loss
Seperated, divorced, widowed
Organized plan
No social support
Stated future intent (suicide note)
Only to be used as risk factors to consider not as definitive
How would you screen for major depressive disorder?
At least 5 of M SIGECAPS WITH at least one of depressed mood or anhedonia presented within the same 2 week period with a change from previous functioning
Mood depressed
Sleep decreased or increased
Interest decreased (anhedonia)
Guilt
Energy decreased
Concentration decreased
Appetite decreased or increased
Psychomotor agitation or retardation
Suicidal ideation
The symptoms must:
Cause significant distress or impairment in work and life
What are two morally relevant things to consider about health care?
Need and potential benefit
What are three things that should typically not be considered regarding access to health care unless linked to need or potential benefit?
Age
Sex
Religion
Where constitutionally are equality rights recognized in Canada?
Section 15 Canadian Charter of Rights and Freedoms
What are provinces/territories responsible for constitutionally related to health?
Delivery of healthcare and public health services such as in hospitals
What is the federal government responsible for in terms of health?
Health care for Indigenous individuals on reserve / military / corrections; some research/coordination; licensing of drugs/devices; provincial funding transfers
When was the Canada Health Act passed?
1984
What are the Canada Health Act principles?
CUPPA
Comprehensiveness
Universality
Public administration
Portability
Accessibility
What are key features of public health services?
Population focused, prevention focused
What is the FNIHB responsible for?
Health needs of Canada’s aboriginal peoples
Babies born prematurely account for what percent of perinatal morbidity and mortality?
50%
What infectious disease testing should you do prior to conception (if possible)?
HIV
rubella IgG
varicella
syphilis
hepatitis B
gonorrhea and chlamydia
What immunizations should be updated in the antepartum period?
Hepatitis B, rubella, varicella, Tdap, HPV, influenza
What are important nutrition supplements in the antepartum period?
Folic acid (0.4-1.0 mg OD starting at least 2-3 mo prior to conception until end of T1 or 5 mg OD if FHx)
Iron 27 mg/d maintenance or 150-200 mg/d for anemia
Prenatal vitamins
Investigations to order in new pregnancy
CBC, blood group/type, sickle status (Rh status if at risk), rubella, syphilis, HbsAg, HIV, pap, chlamydia, gonorrhea, urine R/M, C&S
Timing of prenatal visits
Q4W until GA 28 weeks
Q2W at 28-36 weeks
Q1W at > 36 weeks
What is Chadwick sign?
Blue cervix/vagina @ 6 weeks
What is Goodell sign?
Soft cervix @ 4-6 weeks
What is Hegar sign?
Soft uterine isthmus @ 6-8 weeks
What is Naegele’s Rule and how to calculate it?
How to determine due date or date of confinement:
LMP - 3 months
+ 7 days
+ 1 year (for 28 day cycle)
“Naegele’s Rule, oh so cool,
LMP plus 7, don’t be a fool!
Subtract 3 months, add a year,
EDD is now crystal clear!”
What is Leopold maneuver?
A series of abdominal palpations of the gravid uterus to determine fetal lie, presentation and position
1. What part of fetus occupies fundus
Head will be round and hard, butt will be irregular
2. Which side the fetal back lies on
Spine is long/linear, extremities would be multiple mobile small parts
3. What part of fetus will present first
Head (vertex) is round and firm, sacrum (breech) will be irregular
4. Position of head by palpating cephalic prominence
What is the gestational sac? What week does it form? What levels should the beta-hCG be at when it is seen?
first sign of early pregnancy on ultrasound and can be seen with endo vaginal ultrasound at approximately 3-5 weeks gestation when the mean sac diameter (MSD) would approximately measure 2-3 mm in diameter
beta-hCG 1500 - 3000 IU
What is the normal beta-hCG at term?
10 000 IU
What does first trimester prenatal screen measure?
Nuchal translucency U/S, pregnancy associated plasma proteins, beta-hCG
Estimates risk for trisomy 21
What is a quad screen?
The quad screen test is a maternal blood screening test that looks for four specific substances: maternal serum AFP , hCG , unconjugated estriol, and Inhibin-A
Estimates risk for neural tube defects, trisomy 21/18
What would you see on a quad screen if neural tube defects were suspected?
Increased maternal serum alpha fetoproteins
Approximately 80-90% sensitivity
What would you see on a quad screen if trisomy 21 was suspected?
↑ beta-hCG and inhibin A
↓ maternal serum alpha fetoprotein and unconjugated E3
What would you see on a quad screen if trisomy 18 was suspected?
↓ maternal serum alpha fetoprotein, inhibin A, unconjugated E3 and beta-hCG
What is the integrated prenatal screen and what does it measure?
Integrated screening is a test for pregnant women, which involves an ultrasound performed ideally at 12 weeks along with first and second trimester blood draws
Checks for trisomy 18/21 and neural tube defects
Combines quad markers (alpha fetoprotein, beta-hCG, inhibin A and estradiol) + pregnancy associated plasma protein and nuchal translucency ultrasound
What is an amniocentesis?
U/S guided transabdominal extraction of amniotic fluid
A small sample of the fluid that surrounds the fetus is removed
Procedure of choice in 2nd trimester
Can detect neural tube defects, birth defects, Rh incompatibility
What is chorionic villus sampling?
It is a biopsy of the placental tissue
Checks for genetic or chromosomal conditions such as Down’s syndrome, Edwards’ syndrome or Patau’s syndrome
Can be done earlier in pregnancy
Procedure of choice in < 15 weeks gestation (usually 10-12 week)
What steps should be taken if there is a positive genetic screen in pregnancy?
- Explain results in clear language
- Refer for genetic counseling, details U/S and management options
- Notify woman of referral and inform that they may be offered CVS or amniocentesis
- Reassure they are under no obligation to undergo further invasive testing
- Make referral urgently
What are the required increase in calories during pregnancy?
- 100 kcal/d ↑ in T1
- 300 kcal/d ↑ in T2 or T3
- 450–500 kcal/d during lactation
What are the important nutrients to get during pregnancy?
- Ca2+ 1000 mg/d
- Vit D 600 IU/d
- Folate 0.4–1.0 g/d
- Iron Fe 2+ 13–18 mg/d in T1; 27 mg/d
FIVC
What are absolute contraindications to physical activity in pregnancy?
Premature rupture of membranes, preterm labor, intrauterine growth restriction, pregnancy induced hypertension, incompetent cervix, placenta previa, persistent T2/T3 bleeding, uncontrolled systemic disease
What are the potential complications of smoking during pregnancy?
Decreased oxygen and nutrition transferred to the baby, increased risk of spontaneous abortions, abruptio placentae, placenta previa, preterm birth, low birth weight, SIDS
What is placenta previa?
Placenta is near or covers the cervical opening
What are the potential complications of drinking in pregnancy?
Fetal alcohol syndrome (growth retardation, facial abnormalities, CNS dysfunction)
Which medications are teratogenic?
W - Warfarin: can cause skeletal abnormalities, fetal bleeding, and stillbirth
A - ACEi: can cause renal abnormalities and lung hypoplasia
A - Anticonvulsants: neutral tube defects
R - Retinoids: can cause craniofacial abnormalities, cardiovascular defects, and CNS abnormalities
T - Thalidomide: can cause limb abnormalities and ear, eye, and heart defects
T - tetracycline: stains teeth
S - Sulfa drugs: can cause neural tube defects and kernicterus
L - Lithium: Ebstein anomaly, goiter
C - Chloramphenicol: grey baby
What UTI medication should be avoided in pregnancy?
TMP SMX - antifolate effects
Avoid especially in T1
How to treat complicated UTI or pyelonephritis in pregnancy?
Hospitalize
IV AB
Follow with post treatment urine cultures and monthly cultures until baby is born
Treat even if asymptomatic bc of increased risk of progression to cystitis, pyelo, and increased risk of preterm labor
GIVE AMOXICILLIN IF UNCOMPLICATED
ALTERNATIVELY NITROFURANTOIN OR CEPHALOSPORIN
DO MONTHLY CULTURES
IF BAD THEN ADMIT
What is important to discuss during the postpartum check?
Amount of vaginal bleeding
Pain resolution
Bowel/bladder function
Mood/support
Contraception
Breast or bottle feeding
Average age of onset for menopause
51
Average age of onset of periods
12
What is primary amenorrhea?
Primary amenorrhea is when you haven’t gotten your first period by age 15 or within five years of the first signs of puberty.
What is secondary amenorrhea and what is the time cut off?
Cessation of previously normal menstruation for > 6 months or NO menses for 3 or more normal cycles
What are the most common causes of secondary amenorrhea?
40% ovarian
35% hypothalamic
19% pituitary
5% uterine
1% other
OHPU
Amenorrhea and anosmia should make you think of what syndrome?
Kallmann Syndrome
What: Rare genetic disorder affecting the development of the hypothalamus and sense of smell
How does it present: Failure to start puberty, lack of small, in males they have undescended testes, infertility, decreased muscle mass, osteoporosis
What is the cause: Mutation in genes responsible for development of the hypothalamus which then alters the release of GnRH which is used to stimulate the production of sex hormones
How to treat: HRT testosterone or estrogen AND/OR synthetic GnRH
What system would you suspect to be involved in a patient with amenorrhea, weakness, fatigue, easy bruising, prolonged recovery from illness and striae?
Adrenal system
What is the single greatest cause of loss of working hours and school days among young women aged 20-25?
Dysmenorrhea (painful menstruation of uterine origin)
What are the investigative steps to take in a patient with primary amenorrhea with negative pregnancy test WITH secondary sex characteristics?
U/S uterus
If absent do karyotyping to look for 46 XX (mullerian agenesis) or 46 XY (androgen insensitivity)
If present look for congenital outflow obstruction such as imperorate hymen or vaginal septum
What are the investigative steps to take in a patient with primary amenorrhea with negative pregnancy test WITHOUT secondary sex characteristics?
Check FSH/LH
If low or absent think about constitutional delay, hypothalamic axis dysfunction (anorexia, bulimia, nutritional, too much exercise, stress) or Kallman
If high then do karyotyping to look for
45X0 Turner’s
46XY Swyer
46XX primary ovarian insufficiency
What does absent menstrual periods in a woman with a history of irregular periods suggest?
An underlying endocrine disorder such as hyperprolactinemia, which can be detected by a serum prolactin level. Referral to an endocrinologist may be appropriate for further evaluation and management.
Heavy menstrual bleeding with signs of anemia and no other obvious cause should prompt further evaluation for what?
Further evaluation for endometrial pathology such as hyperplasia or cancer. An endometrial biopsy is a minimally invasive test that can provide valuable diagnostic information.
Dysthymia criteria
HE’S 2 SAD2
Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed
mood most of the day, for more
days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration
is impaired
Hypomania criteria
TAD HIGH
Talkative
Attention defi cit
Decreased need for sleep
High self-esteem/grandiosity
Ideas that race
Goal-directed activity increased
High-risk activity
Depression criteria
SIG: E CAPS
Suicidal thoughts
Interests decreased
Guilt
Energy decreased
Concentration decreased
Appetite disturbance
(increased or decreased)
Psychomotor changes
(agitation or retardation)
Sleep disturbance
(increased or decreased)*
Neuroleptic malignant syndrome mneomnic
FEVER
Fever
Encephalopathy
Vital sign instability
Elevated WBC/CPK
Rigidity
Clssic triad of AAA
Hypotension, back/abdominal pain, palpable pulsatile abdominal mass (caution in high BMI patients)
Management: Two peripheral large bore IV and permissive hypotension
What is permissive hypotension?
Managing trauma patients by restricting the amount of fluids given and maintaining blood pressure in the lower than normal range if there is continued bleeding during the acute period of injury
Avoids dilutional coagulopathy and acceleration of hemorrhage but does carry the risk of tissue hypoperfusion
When do you do AAA screening?
One time screening ultrasound for:
1. Men 65-80 yo
2. Women 60-80 with smoking history or CV disease
3. First degree relative after age 55
Repeat 10 yr after initial screening if the aortic diameter is more than 2.5 cm and less than 3 cm
AAA is dilation of the artery greater than 1.5x normal diameter (3 cm and larger for abdominal aorta)
How to counsel a patient with asymptomatic aortic aneurysm?
- Smoking cessation
- Control of HTN
- Control of DM
- Control of hyperlipidemia
- Regular exercise
- Watchful waiting (advise of symptoms requiring urgent attention)
- U/S surveillance
Which hyperlipidemia medications should be monitored when used together?
Statins and fibrates: concern regarding potential increased risk of myalgia, CK elevation, myopathy or rhabdomyolysis
6 Ws of post operative fever
Wind POD #1-2 (pulmonary – atelectasis, pneumonia)
Water POD #3-5 (urine – UTI)
Wound POD #5-8 (wound infection - if earlier think streptococcal or clostridial infection)
Walk POD #8+ (thrombosis – DVT/PE)
Wonder drugs POD #1+ (all drugs can cause this but antibiotics and sulfa drugs are common causes)
We did POD #1+ (central line infections, transfusion reactions
Drugs causing hyponatremia
Antidepressants
TCAs
SSRIs
Antineoplastics
Vincristine
Cyclophosphamide
Anti-epileptics
Carbamazepine
Barbiturates
Chlorpropamide
ACEI
Other
DDAVP
Oxytocin
Nicotine
