Everything Flashcards
1
Q
What is the difference between an illness and a disease?
A
An illness is the patient’s PERCEPTION of a health imbalance or compromised usual state.
2
Q
What kind of medicine does the U.S. practice?
A
Allopathic
3
Q
Allopathic medicine is based off a _______ model.
A
reductionistic
4
Q
What four basic questions do doctors ask?
A
- What does my patient have?
- Do I need to order diagnostic tests to help me figure this out?
- Once I have a diagnosis, do I need to treat it?
- If I need to treat it, which option is likely to produce the greatest benefit with the least risk and cost?
5
Q
75-80% of the time the diagnosis is made from the ________ ________.
A
medical interview
6
Q
Which three factors affect a clinician’s differential diagnoses?
A
- Prevalence
- Prognosis
- Matching
7
Q
What are the three features of matching?
A
- Parsimony: the extent to which the signs match the diagnosis.
- Chronology: the extent of which the sequence of events that led up to the symptoms match.
- Severity (pain, etc).
8
Q
Tests that confirm the leading diagnosis should be ________, while tests that rule out other diagnoses should be highly _________.
A
specific, sensitive
9
Q
When a clinician is above the test threshold but below the treatment threshold, what is usually done?
A
Tests!
10
Q
What are the three kinds of evidence?
A
- Clinical observation
- Biomedical theory or scientific explanation
- Clinical trials
11
Q
What are the three sources of evidence for clinical decision making?
A
- Epidemiology
- Pathophysiology
- Clinical experience
12
Q
Name five explanations for observed effects of treatments.
A
- Specific physiologic effects of the prescribed treatment.
- Specific physiologic effects of other treatments.
- Natural history of the illness.
- Regression to the mean.
- Non-specific psychologic effects of the treatment (placebo effect).
13
Q
In regards to strength of evidence, what clinical evidence is most trusted and what clinical evidence must be viewed incredulously?
A
Clinical trials are trusted. We should be skeptical of clinical observations.
14
Q
What do pragmatic trials include that clinical trials typically do not?
A
Non-specific influence (the experience of receiving care is included)
15
Q
What two things reduce the risk of malpractice lawsuits?
A
Write down everything and be nice to people.
16
Q
What is the most valuable thing for making a diagnosis, forming a relationship, and making treatment decisions?
A
The medical interview.
17
Q
What are the four main purposes of the medical interview?
A
- Create the theraputic relationship.
- Determine the patient’s agenda.
- Collect data to begin the process of formulating a differential diagnosis.
- Ascertain the patient’s knowledge, skills, and attitudes regarding his or her own health.
18
Q
What are the components of a medical history?
A
- demographic data
- chief complaint
- history of the present illness
- past medical history
- social history including lifestyle
- review of symptoms
19
Q
What are the seven attributes of a symptom?
A
- Onset, chronology
- Position and radiation
- Quality
- Quantity, severity
- Related symptoms
- Setting
- Mitigating and exacerbating factors
20
Q
What contributes to the clinical presentation? What contributes to risk factors?
A
CC, history of illness, exam, and related meds contribute to the clinical presentation.
Demographics, other meds, past history, lifestyle, social history, and family history contribute to risk factors.
21
Q
Define test sensitivity.
A
The probability that an individual with the disease will test positive.
A / (A+C)
22
Q
Define test specificity.
A
The probability that an individual without the disease will test negative.
D / (B+D)
23
Q
Define positive predictive value.
A
The probability that an individual testing positive actually has the the disease. Tests with high PV+ are rarely falsely positive.
A / (A+B)
24
Q
What is negative predictive value?
A
The probability that an individual testing negative actually does not have the disease. Tests with high PV- are rarely false negative.
D / (C+D)
25
What is a positive likelihood ratio?
The ratio of the probability of a positive test result in individuals with the disease (sensitivity) to the probability of a positive test result in individuals without the disease
[A / (A+C)] ÷ [B / (B+D)]
An LR >>> 1 means that a true positive is much more likely than a false positive.
26
What is a negative likelihood ratio?
The ratio of the probability of a negative test result in individuals with the disease to the probability of a negative test result in individuals without the disease (specificity).
[C / (A+C] ÷ [D / (B+D)]
An LR <<< 1 means that a false negative is much less likely than a true negative.
27
Name two examples of instances where accepted medical treatments were later found to be completely wrong following clinical trials.
1. Ligation of internal mammary (thoracic) artery to increase blood flow through coronary arteries for treatment of ACS.
2. Arthroscopic chondroplasty (debridement of cartilage)
28
What are the physical exam techniques?
Inspection, palpation, percussion, ascultation
29
What is a bruit?
The sound of turbulent blood flow in a narrowed artery
30
Which artery is typically used for measuring BP?
Brachial artery
31
What are the two forms of cardiomyopathy?
Dilated and hypertrophic
32
What causes dilated cardiomyopathy?
Long-standing myocardial ischemia causes atrophy of the heart muscle
33
What causes hypertrophic cardiomyopathy?
Hypertension.
34
How does hypertension affect the kidney? How does it affect the eyes?
The nephrons become sclerotic and fail. The capillaries get blocked, retinal tissue ischemia and tissue death.
35
Name the pulses of the body (9 of them).
Brachial, temporal, carotid, axillary, radial, ulnar, femoral, dorsalis pedis, posterior tibial.
36
True or false: The atria contract during diastole.
True
37
What interval and route of drug intake is best for adherence/compliance?
Orally once/day
38
What things should you be cautious of when prescribing drugs? (6)
Receptor non-selectivity, possibility for dependence/addiction, hypersensitivity, interactions, teratogenicity, toxicity.
39
Are class II drugs traditionally under-prescribed or over-prescribed?
Under-prescribed
40
How many Americans die per year from prescribed meds?
~100,000
41
Some studies show that adherence to drug prescription directions is as low as ___%.
50%
42
What is a nocebo effect?
Opposite of the "placebo effect," resulting in a negative outcome.
43
Is the placebo effect poorly understood?
Yeah
44
What is the "open hidden model?"
When you give a treatment to a patient without the patient knowing and compare results to patients that get treatment and know it to test placebo effect.
45
Name an example of primary prevention.
Vaccines
46
Name an example of secondary prevention.
Any screening test like pap smear
47
What are the six criteria for a prevention program?
1. High morbidity or mortality
2. Risk is unacceptable to the individual
3. Future health outcome of individual is predictable
4. Future health outcome of individual is modifiable
5. Benefits of preventive intervention outweigh its risks
6. Preventive intervention is cost-effective
48
What is the prevention paradox?
The fact that prevention strategies do not benefit individuals, only populations.
49
What is chemoprevention? Name an example.
Taking meds to prevent a disease. Example is meds to treat hypertension to prevent stroke. Note difference between preventing stroke and treating hypertension.
50
Exposure to all of the following diagnostic tests could theoretically increase the risk of cancer EXCEPT
a. Mammography
b. Multidetector CT scan
c. Bone scan
d. Angiography
e. Endoscopy
e. Endoscopy
51
A number of studies have shown Drug Z to be beneficial for the treatment of osteoporosis. Assuming equivalent adverse effect rates across all studies, which of the following outcomes would make you most likely to prescribe Drug Z for your patients with osteoporosis?
a. increased blood calcium levels
b. decreased risk of fracture
c. increased vertebral bone density
d. increased femoral bone density
e. increased estrogen levels
b. decreased risk of fracture
52
The specificity of a test can be expressed as
a. 1 – false positive rate
b. 1 – false negative rate
c. 1 – true positive rate
d. 1 – true negative rate
e. true positive rate – false negative rate
a. 1 - false positive rate
53
A diagnostic test for Disease X has only 2 possible results: positive or negative. When applied to a population of 20 patients with Disease X, the results are negative in 5 of these patients. When applied to a population of 20 patients free of Disease X, the results are positive in 3 of these patients. You order the test on one of your patients and the results come back negative. What are the chances that your patient is free of Disease X?
a. 25%
b. 43%
c. 75%
d. 77%
e. 83%
f. 85%
d. 77% (17/22 = negative predictive probability)
54
Which of the following best explains why hypertensive patients are often non-adherent with their medications?
a. Only a fraction of hypertensive patients even know they have it
b. Patients know that there is little evidence supporting the long-term benefits of anti-hypertensive medications
c. Since uncontrolled hypertension causes Alzheimer's dementia, patients forget to take their medications
d. Since most patients are able to effectively lower their blood pressure with diet and exercise alone, they see no need to take their medication
e. High blood pressure is almost always asymptomatic
e. It is almost always asymptomatic
55
Which of the following best describes how the use of screening tests differ from the use of diagnostic tests?
a. Screening tests tend to be more sensitive than diagnostic tests
b. Screening tests tend to be more specific than diagnostic tests
c. The number needed to screen to obtain a positive result is lower than for diagnostic tests
d. A decision to screen is based on patients' risk of disease rather than presenting complaints
e. Screening tests do not require a lengthy pre-symptomatic period to be useful
d. A decision to screen is based on patients' risk of disease rather than presenting complaints
56
Which of the following is an example of a secondary preventive intervention for which the benefits have been shown to outweigh the risks?
a. Chest x-ray in all adult smokers
b. HIV testing in all individuals age 15 – 65 who do not already know their status
c. Calcium and vitamin D supplementation in post-menopausal women
d. Weight loss counseling in adults with BMI > 25 kg/m2
e. Breast self-exam in women over 40
f. Smoking cessation counseling in all adult smokers
b. HIV testing in 15-65 year olds who do not know status
57
Which of the following has the highest sensitivity and specificity for the detection of cancer?
a. mammography
b. colonoscopy
c. HPV testing
d. abdominal CT
e. skin exam
b. colonoscopy
58
The placebo effect
a. May occur with treatments that have known physiologic effects
b. Is predictable based on patient characteristics
c. Is uninfluenced by physician characteristics
d. Is observed to occur in every clinical interaction
e. Cannot be ethically manipulated in a clinical (as opposed to a research) setting
a. May occur with treatments that have known physiologic effects
59
Contrast material would be required to image which of the following conditions using plain x-rays?
a. pneumothorax
b. abdominal aortic aneurysm
c. cardiomegaly (enlargement of the heart)
d. aspirated penny
e. vertebral fracture
b. abdominal aortic aneurysm
60
For which of the following conditions is screening likely to be LEAST effective because of a relatively short period between the earliest abnormal result and mortality?
a. Cervical cancer
b. Colorectal cancer
c. Breast cancer
d. Hypertension
e. Type II diabetes
c. breast cancer
61
Which of the following provides the greatest average gain in life expectancy for a population?
a. Mammography in 60 year-old women
b. Mammography in 40 year-old women
c. Pap smears in 25 year-old women
d. Moderate exercise beginning at age 40 in men
e. Stress (treadmill) test in 50 year-old men
d. Moderate exercise beginning at age 40 in men
62
Highly sensitive tests
a. Are most useful when positive
b. May need to be confirmed by other tests to rule out false positive results
c. Depend on the high prevalence of the target condition for their high sensitivity
d. Become less sensitive when the cut-off point for defining a positive result is changed to a less abnormal value
e. Produce negative results in the vast majority of patients without the target disease
b. May need to be confirmed by other tests to rule out false positives
63
You are evaluating a patient who you suspect may have Disease A. The test you have available to diagnosis this disease has a sensitivity and specificity of 85%. For which of the following disease prevalences will the positive predictive value equal the negative predictive value of the test result?
a. 10%
b. 25%
c. 50%
d. 75%
e. 90%
c. 50%
64
The treatment threshold for a given diagnosis is
a. equal to its pre-test probably
b. lower for high risk treatments compared to low risk treatments
c. higher for urgently life-threatening conditions
d. reached when the risk of not treating is greater than the risk of treating
e. reached only when the post-test probability of a diagnosis is 100%
d. reached when the risk of not treating is greater than the risk of treating
65
Chronic diseases result from a complex mix of factors. In trying to understand the multifactorial etiology of these diseases, it is often helpful to array them along a continuum from proximal to underlying. Of the choices listed, which would be the most proximal etiology for a myocardial infarction?
a. Genetic predisposition
b. Addiction to nicotine
c. Atherosclerosis
d. Congestive heart failure
e. Stress
c. atherosclerosis
66
Of the following, the Mini-Mental State Exam (MMSE) is most helpful in determining
a. level of consciousness
b. risk of Alzheimers disease
c. severity of depression
d. need for nursing home placement
e. presence of psychosis
b. risk for Alzheimer's
67
You are examining a 75 year-old man who was brought into the emergency department after briefly losing consciousness while taking a walk uphill. His heart rate and rhythm are 90 beats/min and regular; blood pressure lying down is 115/95 mmHg; respiratory rate is 16 breaths/min. You detect a heart murmur during systole and you hear rales (fluid) at the base of his lungs bilaterally. Which of the following valve abnormalities best explains his murmur?
a. carotid stenosis
b. pulmonic regurgitation
c. aortic regurgitation
d. mitral stenosis
e. aortic stenosis
e. aortic stenosis
68
You saw a patient several days ago in your clinic. His condition is not immediately life threatening, but after a series of diagnostic tests, you have yet to arrive at a final diagnosis. At this point, which of the following strategies is most likely to produce more harm than good?
a. Making only a provisional diagnosis
b. Telling the patient that you have been unable to arrive at a definitive diagnosis
c. Continuing to order diagnostic tests until you are sure of the correct diagnosis
d. Repeating all or part of the history and physical examination
e. Referring the patient to a colleague for consultation
c. continuing to order diagnostic tests
69
Which of the following is true regarding the history and physical exam?
a. Diagnostic testing is required in most patients because the information collected from the history and physical exam alone most often leads to an incorrect diagnosis
b. Adult patients who receive complete physical exams on an annual basis have been shown to have better health outcomes than those who do not
c. The only purpose of a high quality history is to obtain detailed and reliable clinical information
d. The history of present illness is most useful for obtaining information about a patient’s risk factors for disease
e. Conclusions drawn from the results of diagnostic tests are based on prior information obtained during the history and physical exam
e. Conclusions drawn from the results of diagnostic tests are based on prior information obtained during the H&P
70
The differential diagnosis
a. is fixed in time
b. represents an exhaustive list of all possible explanations for a patients presenting symptoms and signs
c. is generated independently of the natural history associated with each listed condition
d. is the same for all patients presenting with the same symptoms and signs
e. varies according the prevalence of each listed condition in a patient’s population
e. varies according to the prevalence of each listed condition in a patient's population
71
Chronic untreated hypertension is a major risk factor for all of the following conditions EXCEPT:
a. hemorrhagic stroke
b. diabetes
c. nephropathy
d. retinopathy
e. diastolic dysfunction
b. diabetes
72
Observational studies are
a. designed to eliminate the context effect
b. always retrospective
c. less reliable than controlled trials because of their smaller size
d. cannot be randomized
e. more reliable than controlled trials because they directly compare two or more treatments
d. cannot be randomized
73
The clinician-centered approach to interviewing
a. is usually required to arrive at an accurate diagnosis
b. includes only closed-ended questions
c. should precede the patient-oriented approach
d. should replace the patient-oriented approach for life-threatening conditions
e. includes the review of symptoms, which is used to elucidate key findings from the history of present illness
a. is usually required to arrive at an accurate diagnosis
74
Which physical exam technique is used before and during the medical interview?
a. auscultation
b. palpation
c. percussion
d. inspection
e. none – physical exam techniques are only employed after the medical interview
d. inspection
75
Which of the following physical exam findings increases the risk of stroke?
a. carotid bruit
b. atrial fibrillation on ECG
c. previous myocardial infarction
d. elevated blood cholesterol
e. stressful occupation
a. carotid bruit
76
Which of the following is true regarding the clinical encounter?
a. Behaving paternalistically towards patients is always unethical
b. Professionalism requires that physicians feel empathic towards all of their patients
c. Evidence shows that physicians regularly exhibit bias in the care of their patients
d. It is important to repeatedly offer reassurance to patients during the history and physical exam
e. The primary responsibility of any physician is to educate his or her patients
c. evidence shows that physicians regularly exhibit bias in the care of their patients.
77
What are the five U.S. Preventive Services Task Force grades for preventative screenings?
A, B, C, D, I
78
What is meant by an "A" recommendation?
High certainty that the service is beneficial so offer it.
79
What is meant by a "B" recommendation?
High certainty of moderate benefit so offer it.
80
What is meant by a "C" recommendation?
May be appropriate if clinically indicated. Don't offer it routinely.
81
What is meant by a "D" recommendation?
No way man.
82
What is meant by an "I" recommendation?
Insufficient evidence. If clinically indicated, tell the patient about the uncertainty of benefits and risks.
83
Which one is the "B" recommendation?
1. Screening and behavioral counseling to reduce alcohol misuse in adolescents.
2. Aspirin to reduce the risk of stoke in women age 30 – 55.
3. Interventions to reduce the incidence of low back pain in the primary care setting.
4. Promotion of breast feeding aimed at mother’s partner and other family members.
5. Behavioral counseling to promote a healthful diet in the primary care setting.
4
84
Which one is the "B" recommendation?
1. Behavioral counseling to lower the incidence of sexually transmitted infections for all sexually active adolescents.
2. Routine use of combined estrogen and progestin to lower the incidence of osteoporosis in postmenopausal women.
3. Screening for dementia in community-dwelling older adults.
4. Vitamin and/or mineral supplementation to reduce the risk of cancer and cardiovascular disease.
5. Screening for chronic kidney disease in adults.
1
85
Which one is the "B" recommendation?
1. Screening adolescents for idiopathic scoliosis.
2. Breast cancer screening with breast self exam in adult women.
3. Screening for depression in adolescents and adults if counseling services are available.
4. Lung cancer screening with low-dose chest CT in adults who quit smoking > 15 years ago.
5. Screening for carotid artery stenosis in adults.
3
86
Which one is an "A" recommendation?
1. Breast cancer screening with biennial mammograms in women 40 – 49 years old.
2. CHD screening with exercise tolerance (stress) testing in high risk adults.
3. Colorectal cancer screening (FOBT, sigmoidoscopy or colonoscopy) in adults > 75 years old.
4. COPD screening in adults using spirometry.
5. Screening for chlamydia infection in all sexually active women and girls aged 24 and younger.
5
87
Which one is an "A" recommendation?
1. Screening for bacteruria in non-pregnant adult women.
2. Screening for BRCA mutations in all woman age 50 and older.
3. Cervical cancer screening with Pap smear and/or HPV-testing in women younger than age 21.
4. Screening for HIV in all adolescents and adults ages 15 to 65.
5. Skin exam to screen for cancer.
4
88
Which one is a "B" recommendation?
1. Screening for hearing loss in all newborn infants.
2. Calcium (>1,000 mg) and vitamin D of (>400 IU) supplementation to lower the incidence of fracture in community-dwelling postmenopausal women.
3. Screening for prostate cancer in all men over age 50.
4. Counseling for proper use of motor vehicle occupant restraints.
5. Screening for impaired visual acuity in older adults.
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