exam Flashcards
children under 12 presentingw/ unexplained somatic sxs, restlessness, separation anxiety, phobias or hallucinations
screen for depression
level of evidence:
children living in areas w/ inadequate fluoride in water supply should take a daily fluoride supplement
evidence B
level of evidence:
school aged children should receive age-appropriate immunizations as well as catch-up immunization if needed
level A
level of evidence:
scholl aged children should be screened for obesity by measuring BMI. those w/ obesity (>95) should be offered resources and referral for comprehensive, intensive behavioral interventions
level B
Fluoride supplementation:
Age 3-6 years
- .6
- .5
- .3-.6–> .25
- > .6–> none
Fluoride supplementation:
Age 5-16 years
- .6
- 1.0
- .3-.6– > .5
- > .6–> none
USPTSTF in school-aged children recommendation for dyslipidemia?
insufficient evidence
USPTSTF school-aged children recommendation for hearing
none
USPTSTF school-aged children recommendation for HTN
insufficient evidence
USPTSTF school-aged children recommendation for obesity
beginning at age 6
USPTSTF school-aged children recommendation for scoliosis
insufficient evidence
USPTSTF school-aged children recommendation for social determinants of health
none
USPTSTF school-aged children recommendation for vision
none
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for depression screening
screen adolescents 12 years and older
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for alcohol use screening
insufficient evidence
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for drug use screening
insufficient evidence
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for tobacco use screening/counseling
provide interventions, including education or brief counseling to prevent tobacco use
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for STI counseling
counseling is recommended in patients who are sexually active,
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for chlamydia/Gonorrhea screening
screen sexually active females younger than 25 years annually
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for HIV screening
begin screening at 15 yo of age or younger in those at increased risk of infection
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for Syphilis screening
screening is strongly recommended in patients at increased risk of infection
USPTSTF for high-risk behaviors in school-aged children/adolescents recommendation for physical activity
at least 60 minutes of physical activity per day
level of evidence:
sexually active females younger than 25 should be screened for chlam/gono annually. Adolescents w/ multiple partners or high-risk sexual behavior should be screened for syphilis and HIV. All adolescents should be screened for HIV beginning at 15 yo of age
level A
level of evidence :
school aged children should be taught safety precautions and parents should be encouraged to model safe behaviors
level B
level of evidence :
Adolescents 12 years and older should be screened for major depressive disorder using a validated tool such as the patient health questionnaire for adolescents and the beck depression inventory for primary care.
level B
level of evidence:
sexually active adolescents should receive intensive behavioral counseling on the prevention of sexually transmitted infections
level B
recommendation and level?
Adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years
B- The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
recommendation and level for cervical cancer screening?
Women aged 21 to 65 years
A- The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).
recommendation and level for ovarian cancer screening?
Asymptomatic women
D- The USPSTF recommends against screening for ovarian cancer in asymptomatic women. This recommendation applies to asymptomatic women who are not known to have a high-risk hereditary cancer syndrome.
recommendation and level for prostate cancer screening?
Men aged 55 to 69 years
C- For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one.
recommendation and level for colorectal cancer screening?
A- The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. The risks and benefits of different screening methods vary. See the Clinical Considerations section and the Table for details about screening strategies.
recommendation and level for breast cancer screening?
Women aged 50 to 74 years
B- The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
4 principles of motivational interviewing
REAL
- righting reflex
- empathy
- ambivalence
- listen in order to understand and empower
Prochaska’s 5 Stages of Change
- Pre-contemplative
- Contemplative
- Preparation
- Action
- Maintenance/Relapse
level of recommendations:
advise parents of a child diagnosed with autism spectrum disorder that early intensive behavioral therapy can improve cognitive language and adaptive skills
level A
ASD affects approx. __________ children in USA according to the CDC
1/68
ASD mnemonic: ALARM
Autism is prevalent Listen to parents Act early Refer Monitor
Therapeutic options for ASD
all are effective except? level A recommendation:
- early intensive behavioral therapy
- Melatonin for sleep disturbance
- secretin IV
- Parent-mediated early intervention
- risperidone for behavioral issues
Secretin IV
TECHNIQUE TO EXAMINE JOINT:
“IPASS” Inspection Palpation Active Range of Motion Strength Special Tests
is one of the most common causes of anterior knee pain encountered in the outpatient setting in adolescents and adults younger than 60 years.
Patellofemoral pain syndrome (PFPS)
The cardinal feature of PFPS is
pain in or around the anterior knee that intensifies when the knee is flexed during weight-bearing activities.
The pain of PFPS often worsens/improves? with prolonged sitting or descending stairs. The most sensitive physical examination finding is______________
The pain of PFPS often worsens with prolonged sitting or descending stairs. The most sensitive physical examination finding is pain with squatting.
Plain radiographs for diagnosis of PFPS?
Plain radiographs of the knee are not necessary for the diagnosis of PFPS but can exclude other diagnoses, such as osteoarthritis, patellar fracture, and osteochondritis.
treatment of PFPS?
Treatment of PFPS includes rest, a short course of nonsteroidal anti-inflammatory drugs, and physical therapy directed at strengthening the hip flexor, trunk, and knee muscle groups. Patellar kinesiotaping may provide additional short-term pain relief; however, evidence is insufficient to support its routine use. Surgery is considered a last resort.
level of recommendation
Exercise therapies are most effective in improving short- and long-term pain in patients with patellofemoral pain syndrome.
A
level of recommendation:
Short courses of nonsteroidal anti-inflammatory drugs improve pain in patients with patellofemoral pain syndrome compared with placebo, but the effect may be limited to one week.
B
level of recommendation:
Patellar kinesiotaping improves patellar maltracking and may reduce short-term pain as an adjunct to exercise.
B
Common acute shoulder injuries include
- acromioclavicular joint injuries,
- clavicle fractures,
- glenohumeral dislocations,
- proximal humerus fractures,
- rotator cuff tears
Acromioclavicular joint injuries and clavicle fractures mostly occur in
young adults as the result of a sports injury or direct trauma.
Most nondisplaced or minimally displaced injuries can be treated _________
conservatively. Treatment includes pain management, short-term use of a sling for comfort, and physical therapy as needed.
Glenohumeral dislocations can result from _______________.
Patients will usually hold the affected arm in their contralateral hand and have pain with ____ and ______ motion at the shoulder.
Physical findings may include a ________________ or ____________________
Glenohumeral dislocations can result from contact sports, falls, bicycle accidents, and similar high-impact trauma.
Patients will usually hold the affected arm in their contralateral hand and have pain with motion and decreased motion at the shoulder.
Physical findings may include a palpable humeral head in the axilla or a dimple inferior to the acromion laterally.
Reduction maneuvers usually require ____________
intra-articular lidocaine or intravenous analgesia.
Proximal humerus fractures often occur in _________________
Most of these fractures can be managed nonoperatively, using a sling, early range-of-motion exercises, and strength training.
older patients after a low-energy fall.
Most of these fractures can be managed nonoperatively, using a sling, early range-of-motion exercises, and strength training.
Radiography of the shoulder should include a true anteroposterior view of the(3)
- glenoid,
- scapular Y view,
- and axillary view.
Rotator cuff tears can cause difficulty with ____________ or pain that ________________.
On physical examination, patients may be _____________________________
Rotator cuff tears can cause difficulty with overhead activities or pain that awakens the patient from sleep.
On physical examination, patients may be unable to hold the affected arm in an elevated position.
level of recommendation:
Decisions about conservative vs. surgical treatment of acute middle one-third clavicle fractures should be individualized, considering the relative benefits and harms of each intervention and patient preferences.
B
level of recommendation:
Surgery should be considered in young athletes with shoulder dislocations because of a high recurrence rate in these patients
B
level of recommendation:
Older patients with proximal humerus fractures can be treated nonoperatively because these patients have equivalent or better outcomes compared with those who have surgery.
B
level of recommendation:
The effectiveness and safety of surgery for chronic rotator cuff disease in older patients are unclear.
B
10 IMPORTANT ASPECTS OF CARE TO CONSIDER WHEN CARING FOR THE HOMELESS
- BE RESPECTFUL
- WITHHOLD JUDGMENT
- MODIFY THE GUIDELINES
- CONTACT INFORMATION:
- FOOT CARE:
- IDENTIFICATION AND INSURANCE:
- KNOW WHEN PEOPLE HAVE MONEY:
- GET TO KNOW YOUR PATIENT’S NARRATIVE:
- MOVE AT THE PATIENT’S PACE
- MODIFY THE MEDICATIONS YOU PRESCRIBE
Homeless med consideration:
albuterol
Enhances effects of crack cocaine
Homeless med consideration:
benzo
Sought for calming and sedating effects
Homeless med consideration:
beta blockers and clonidine
Should be prescribed with caution, because discontinuing these medications suddenly can result in serious rebound hypertension
At initiation, beta blockers can exacerbate depression
Clonidine can be misused by persons with chemical dependencies to prolong the effects of heroin and other opioids
Homeless med consideration:
buproprion (wellbutrin)
Can be pulverized and snorted to get high
Homeless med consideration:
CCB, Cox-2, NSAIDs, diabetic med.
May exacerbate heart failure
Homeless med consideration:
diuretics
Can exacerbate dehydration, particularly in warmer climates, for persons with limited access to water
Homeless med consideration:
anticholinergic medications in combination w/ diuretics
Can cause dangerous (even fatal) hyperpyrexia in hot, humid environments without adequate hydration
Homeless med consideration:
drugs metabolized in liver
Problematic in persons with chronic hepatitis from intravenous drug and alcohol abuse
Homeless med consideration:
pseudoephedrine
Can be used to make methamphetamine
Homeless med consideration:
Quetiapine- seroquel
Enhances effects of heroin
Homeless med consideration:
Statins
May worsen health outcomes in persons with chronic elevation of liver transaminase levels secondary to hepatitis B or C or in persons with long-term alcohol abuse
Homelessness affects men, women, and children of all races and ethnicities. On any given night, more than _______________ persons in the United States are homeless; a little more than ______________ of these are families. Homeless persons are more likely to become ill, have greater hospitalization rates, and are more likely to die at a younger age than the general population. The average life span for a homeless person is between _______________
Homelessness affects men, women, and children of all races and ethnicities. On any given night, more than 610,000 persons in the United States are homeless; a little more than one-third of these are families. Homeless persons are more likely to become ill, have greater hospitalization rates, and are more likely to die at a younger age than the general population. The average life span for a homeless person is between 42 and 52 years.
medical abortion w/ Mife/Miso vs Aspiration abortion:
gestational age
- medications abortion– currently up to 11 wks
- Aspiration- 14-16wks +
D&E- beyond 16wks
medical abortion w/ Mife/Miso vs Aspiration abortion:
Advantages
- medications abortion– natural, location control
2. Aspiration- over in 5-10 min, leaved office not pregnant, less post-procedure bleeding
medical abortion w/ Mife/Miso vs Aspiration abortion:
disadvantages
- medications abortion– multiple days, heavier and longer bleedings, fetus may be present
- Aspiration- requires clinical setting, instrumentation, anesthesia,
medical abortion w/ Mife/Miso vs Aspiration abortion:
effectiveness
- medications abortion <63 days is 95-99% and if fails needs aspiration
- Aspiration- over 99%
% of abortions
18 in 2017
medical abortion w/ Mife/Miso vs Aspiration abortion:
safety
- medications abortion used safely for >25 years… at least 10 fold safer than continuing a pregnancy to term
- Aspiration- used safely for >45 years… at least 10 fold safer than continuing a pregnancy to term
physicians can use the five A’s framework to promote smoking cessation.
- ask,
- advise,
- assess,
- assist,
- arrange
Office systems should ensure that all tobacco users are identified; smoking status should be documented at every visit
ask
Unambiguous support for smoking cessation should be expressed by the physician, and the benefits of quitting should be discussed
advise
Willingness to quit and barriers to quitting should be assessed, as well as smoking history and current level of nicotine dependence; patients should be asked about their timeline for quitting and about previous attempts
assess
Offer support and additional resources (e.g., referral to counseling, http://www.smokefree.gov, 1-800-QUIT-NOW, pharmacotherapy); help patients to anticipate difficulties and encourage them to prepare their social support systems and their environment for the impending change
Withdrawal: Common nicotine withdrawal symptoms (e.g., irritability, anxiety, restlessness) peak within the first week of abstinence and last two to four weeks; NRTs can be helpful because they gradually decrease nicotine dependence; smokers should also be advised to decrease caffeine intake*
Depression: Smokers are more likely than nonsmokers to have a depressive episode,12 and smokers with depression are less likely to successfully quit13; smoking cessation may trigger depression in those with a history of depression14; physicians should consider monitoring the mood of smokers during quit attempts and screen for depression in those who have repeatedly been unable to quit; bupropion (Zyban) may be an appropriate cessation aid for smokers at risk of depressive relapse
Weight gain: Although most smokers gain fewer than 10 lb (4.5 kg) after quitting, weight gain can vary (10 percent will gain 30 lb [13.5 kg])15; although this weight gain poses less health risk than smoking, concern about weight gain may interfere with the quit attempt; sustained-release bupropion or an NRT (particularly gum or lozenges) may be helpful in these patients because they delay weight gain while in use4; it may be easier to monitor and adjust food intake/exercise balance after immediate tobacco cravings are no longer as prominent
Assist
Follow-up plans should be set; for patients who have recently quit, it is important to elicit the benefits of quitting and ask patients to anticipate and problem solve about situations that might lead to relapse; follow-up contacts should also be used to readjust the dosages of therapeutic agents that may be altered by smoking cessation (e.g., beta blockers, antipsychotics, insulin, benzodiazepines)*
Arrange
No intention to take action within the foreseeable future (next six months)
Pre-contemplation
Considering change within the next six months
Contemplation
Planning to take action within the next month
Preparation
Actively changing (first six months of new behavior)
Action
More than six months since behavior change
Maintenance
The success rate of smoking cessation of
- varenicline(chantix)
- Buproprion (wellbutrin, Zyban)
- Nicotine replacement therapy (NRT)
- Support programs
- varenicline(chantix)– 26%
- Buproprion (wellbutrin, Zyban)–20%
- Nicotine replacement therapy (NRT)– 14-19%
- Support programs– unknown
Side effects of varenicline
Nausea, intense dreams, agitation, SI
side effects of bupropion
dry mouth, agitation, lower seizure threshold, SI
side effects NRT
headaches, dizziness, drowsiness, skin irritation, sore throat, bad taste
smoking cessation match:
unknown– an antidepressant which seems to reduce pyshcological craving of smoking
bupropion
smoking cessation match:
nicotine partial agonist, binds receptors so that empty receptors dont trigger cravings and so nicotine that is used has no physical effect. works by reducing cravings and taking the fun out of smoking
chantix
smoking cessation match:
nicotine replacement to allow breaking the mental habit while not suffering nicotine withdrawal. Then gradually decrease the amount of nicotine
NRT
can you combine chantix w/ support, bupropion and NRT?
yes
rank most expensive to least for smoking cessation meds
chantix- 180
bupropion- 75-100
NRT- 100
Altmans’ rule
g protein + g fiber > g sugar
** 3g fiber minimum
What does the dash diet show?
significant drop in BP within 2 wks
what did the lyon Mediterranean study show
72% cardiovascular event reduction for secondary prevention
what did the predimed primary prevention study show
> 28% cardiovascular event reduction– strokes
how do diet and lifestyle compare with medication for pre-diabetes?
diet and physical activity reduced the risk of developing diabetes by 58% compared to 31% with metformin
can you halt the progression of heart disease with diet and lifestyle?
yes
does diet add incremental value to medication?
yes
nuts?
consider incorporating one handful of nuts every other day as a snack
cooking oil?
avoid reacing smoking point
most biologically active forms of OMEGA-3
EPA and DHA
sources rich in ALA
flaxseed
walnuts
chia
daily fiber goal
30g
____ a flat lesion (< 1cm) that you cannot feel
____ a flat lesion (> 1cm) that you cannot feel
____ a raised lesion (< 1cm) that you can feel
_____ a raised lesion (> 1cm) that you can feel
______ a palpable lesion (< 2cm) within the dermis or subcutis (rather than in the epidermis)
_______ a palpable lesion (> 2cm) within the dermis or subcutis (rather than in the epidermis)
Macule: a flat lesion (< 1cm) that you cannot feel
Patch: a flat lesion (> 1cm) that you cannot feel
Papule: a raised lesion (< 1cm) that you can feel
Plaque: a raised lesion (> 1cm) that you can feel
Nodule: a palpable lesion (< 2cm) within the dermis or subcutis (rather than in the epidermis)
Tumor: a palpable lesion (> 2cm) within the dermis or subcutis (rather than in the epidermis)
ABCDE’s of melanoma
Asymmetry Border is irregular Color is mixed Diameter is larger than 6 millimeters Evolves over time
level of recommendations
Intralesional steroids are first-line therapy for keloids.
B
Fitzpatrick skin types I II III IV V VI
I- always burn, never tan II- always burn, but sometimes tan III- sometimes burn, but always tan IV- never burn, always tan V- moderately pigmented skin VI- darkly pigmented skin
Rash?
Trunk, spreads peripherally
Macular to maculopapular
High fever, usually greater than 102°F (39°C), precedes the rash; child is otherwise well-appearing
No
Can be confused with measles; measles rash begins on the face, and the child is usually ill-appearing
1 to 2 days
Roseola infantum (exanthema subitum)
Rash?
Trunk, bilateral and symmetric, Christmas tree distribution
Herald patch on the trunk may present first, followed by smaller similar lesions; oval-shaped, rose-colored patches with slight scale
No
Occurs in up to one-half of patients
Often confused with tinea corporis; pityriasis rosea is typically widespread, whereas tinea corporis usually causes a single lesion
2 to 12 weeks
Pityriasis rosea
Rash?
Upper trunk, spreads throughout body, spares palms and soles
Erythematous, blanching, fine macules, resembling a sunburn; sandpaper-like papules
Occurs 1 to 2 days before rash develops
Usually no
Petechiae on palate; white strawberry tongue; test positive for streptococcal infection
Several weeks
Scarlet fever
Rash?
Anywhere; face and extremities are most common
Vesicles or pustules that form a thick, yellow crust
Usually no
No
May be a primary or secondary infection; bullous form is typical in neonates, and nonbullous form is more common in preschool- and school-aged children
Usually self-limited but often treated to prevent complications and spread of the infection
Impetigo
Rash?
Face and thighs
Erythematous “slapped cheek” rash followed by pink papules and macules in a lacy, reticular pattern
Low grade
Yes
May be confused with scarlet fever; the slapped cheek rash can differentiate erythema infectiosum
Facial rash lasts 2 to 4 days; lacy, reticular rash may last 1 to 6 weeks
Erythema infectiosum (fifth disease)
Rash?
Anywhere; rarely on oral mucosa
Flesh-colored or pearly white, small papules with central umbilication
No
Yes, if associated with dermatitis
Usually resolves spontaneously without treatment
Months or up to 2 to 4 years
Molluscum contagiosum
rash?
Anywhere
Alopecia or broken hair follicles on the scalp (tinea capitis), erythematous annular patch or plaque with a raised border and central clearing on the body (tinea corporis)
No
Yes
Often confused with pityriasis rosea; potassium hydroxide microscopy can help confirm diagnosis
Usually requires antifungal treatment
Tinea infection
Rash?
Extensor surfaces of extremities, cheeks, and scalp in infants and younger children; flexor surfaces in older children
Erythematous plaques, excoriation, severely dry skin, scaling, vesicular lesions
No
Yes
Emollients and avoidance of triggers are the mainstay of treatment; topical corticosteroids may be needed for flare-ups
Chronic, relapsing
Atopic dermatitis
3 most common cause of cough?
- Asthma
- GERD
- Post-nasal drip
Nerve root compression causing urinary retention, bilateral weakness, saddle anesthesia.
Neuro-surgical emergency
Caused by massive midline disc herniation
Prevalence among all with LBP: 0.0004
Cauda Equina syndrome
Onset <40 years old, gradual onset
Pain duration >3 months
Morning stiffness
Improved by exercise
Ankylosing spondylitis
Pseudoclaudication
Leg pain on walking
Relieved by sitting or standin
Spinal stenosis
History of osteoporosis
Corticosteroid use
Trauma
Elderly
compression fracutre
Failure to improve (>6 weeks)
Prior history of cancer
Unexplained weight loss
Cancer
true or false?
Routine spinal imaging tests are NOT indicated. Imaging tests are indicated in the setting of red flags (refer to below) or severe problems persisting beyond 1 month.
true
Most back problems improve spontaneously; therefore, conservative management is almost always indicated.
The most important therapeutic instrument is __________
patient education.
level of recommendation
Acupuncture provides benefits for chronic low back pain.
A
level of recommendation
Coenzyme Q10 is a safe adjunctive therapy in patients with heart failure and may improve clinicaloutcome
B
level of recommendation
Exercise has a small to moderate effect in reducing symptoms in persons with diagnosed anxiety disorders.
B
level of recommendation Ginkgo biloba extract EGb 761 improves cognition in patients with dementia
A
level of recommendation
Cognitive behavior therapy is effective for the treatment of insomnia.
A
level of recommendations
Music is effective for improving subjective sleep quality in adults with insomnia.
B
level of recommendation
Movement-oriented mind-body approaches such as yoga, tai chi, and qi gong may be beneficial for sleep, especially in older adults and cancer survivors.
A
level of recommendation
Probiotic supplementation significantly reduces the incidence of antibiotic-associated diarrhea.
A
level of recommendations
St. John’s wort (Hypericum perforatum) benefits patients with mild to moderate depression.
A
Acupuncture for Chronic low back pain
First-line or adjunctive?
first line
Coenzyme Q10 for Heart failure
First-line or adjunctive?
adjunctive
Exercise for Anxiety
First-line or adjunctive
first line
Fish oil for Hypertriglyceridemia
First-line or adjunctive?
first line
Ginkgo biloba for Dementia
First-line or adjunctive?
first line
Mind-body interventions for Insomnia
First-line or adjunctive?
first line
Probiotics for Prevention of antibiotic-associated diarrhea
First-line or adjunctive?
first line
St. John’s wort for Depression
First-line or adjunctive?
first line
Does Epidural steroid injections improve pain or disability in patients with spinal stenosis?
Epidural steroid injections do not improve pain or disability in patients with spinal stenosis
Spinal manipulation therapy produces small benefits for up to ________
six months.
level of recommendation:
Do not order imaging studies unless there is concern for infection, fracture, or cauda equina syndrome, or unless required before invasive interventions.
A
level of recommendation:
NSAIDs, opioids, and topiramate (Topamax) are more effective than placebo in the short-term treatment of nonspecific chronic low back pain.
A
level of recommendations :
Acetaminophen, antidepressants (except duloxetine [Cymbalta]), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation are not more effective than placebo in the treatment of chronic low back pain.
B
level of recommendation:
Epidural steroid injections are not more effective than placebo for long-term relief of chronic back pain from various causes.
B
level of recommendation:
Spinal manipulation therapy results in small improvements in pain and function in chronic low back pain for up to six months.
B
level of recommendations:
Nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants are effective treatments for nonspecific acute low back pain.
A
level of recommendation:
Patient education that includes advice to stay active, avoid aggravating movements, and return to normal activity as soon as possible and a discussion of the often benign nature of acute low back pain is effective in patients with nonspecific pain.
B
level of recommendations:
Although regular exercises may not be beneficial in the treatment of nonspecific acute low back pain, physical therapy (McKenzie method and spine stabilization) may lessen the risk of recurrence and need for health care services.
B
level of recommendations
Spinal manipulation and chiropractic techniques are no more beneficial than established treatments for nonspecific acute low back pain, and their addition to established treatments does not improve outcomes.
B
level of recommendation:
Bed rest is not helpful for nonspecific acute low back pain.
A
For acute low back pain T or F?
No substantial benefit has been shown with oral steroids, acupuncture, massage, traction, lumbar supports, or regular exercise programs.
True
level of recommendation:
Patients taking long-acting opioids for chronic nonmalignant pain should be started on long-term preventive therapy with a combination stimulant/softener laxative for constipation.
B
level of recommendation:
Multicomponent prevention methods are effective in deterring delirium episodes.
B
level of recommendations:
Antipsychotic medications should be used as a last resort in treating delirium and should not be used indiscriminately in persons with delirium who have not been properly evaluated.
A
_________is defined as an acute, fluctuating syndrome of altered attention, awareness, and cognition.
Delirium
progressive decline in memory, higher cortical function, and personality change interference w/ social activities, relationships.
dementia
most common cause of dementia
alzheimers
delirium or dementia?
disorientation agitation?
dementia
rapid screening tool for mild cognitive impairment, a state between normal cognitive aging and dementia
MoCA
total possible score is 30 w/ 26 or above normal
which one is more sensitive MoCA or MMSE for detecting MCL and Alzheimers
MoCA
Mini Cog is used for ?
confusion assessment method for delirium
The AGS Beers Criteria® include the same five main categories as in 2015:
(1) potentially inappropriate medications in older adults; (2) potentially inappropriate medications to avoid in older adults with certain conditions; (3) medications to be used with considerable caution in older adults; (4) medication combinations that may lead to harmful interactions; and (5) a list of medications that should be avoided or dosed differently for those with poor renal function.
The goal of treatment in asthma is to prevent symptoms by
reducing airway inflammation and hyperreactivity.
Asthma-Multiple randomized controlled trials have shown that _______________ are the most effective monotherapy
inhaled corticosteroids
second line for asthma
Long-actin beta agonists
Patients with mild persistent asthma who prefer not to use inhaled corticosteroids may use ________________ as monotherapy, but they are less effective.
leukotriene receptor antagonists
Because of their high cost and a risk of anaphylaxis, __________________________should be reserved for patients with severe symptoms not controlled by other agents.
monoclonal antibodies
______________ should be considered in persons with asthma triggered by confirmed allergies if they are experiencing adverse effects with medication or have other comorbid allergic conditions. Many patients with asthma use complementary and alternative agents, most of which lack data regarding their safety or effectiveness.
Immunotherapy
level of recommendations
Inhaled corticosteroids improve asthma control and quality of life and reduce asthma symptom severity, systemic steroid use, emergency department visits and hospitalizations, and deaths.
A
level of recommendation:
Long-acting beta2 agonists are effective for control of persistent asthma symptoms and are the preferred agents to add to inhaled corticosteroids in patients 12 years and older, but they are not recommended for use as monotherapy
A
level of recommendation:
Leukotriene receptor antagonists can be used as adjunctive therapy with inhaled corticosteroids, but they are less effective than long-acting beta2 agonists in patients 12 years and older.
B
Level of recommendation:
If adequate symptom control is not attained with low-dose inhaled corticosteroids, either increasing the inhaled steroid dosage or adding a long-acting beta2 agonist to therapy is appropriate according to current guideline recommendations.
B
True or False
Do not diagnose or manage asthma without spirometry.
true
Otitis media caused by?
Common Bugs: S. Pneumo, H. Flu
otitis media tx.
Amox
Consider no Rx and f/u prn (if >6 mo)
Acute sinusitis bugs
Common Bugs: S. Pneumo, H. Flu
Acute sinusitis tx
1st Line: Amox (consider double dose), Levofloxacin if resistant
Pharyngitis common bugs
Group A strep
Pharyngitis tx.
first line–PCN
Erythromycin if PCN allergy Amox in kids
Pneumonia common bugs
Common Bugs: S. Pneumo, Atypicals, H. Flu
Pneumonia tx
1st Line: macrolide, doxycycline
Consider Levofloxacin if refractory,
Pt. is elderly, pt. has co-morbidities
GU UTI common bugs
Common Bugs: E. Coli, other Gram negs, S. Saphrophyticus
UTI tx.
1st Line: Macrobid, Bactrim
Cipro (second line)
Pseudomembranous Colitis
Common Bugs
Common Bugs: C. Difficile
Pseudomembranous Colitis tx.
1st Line: PO Vanco or fidaxomicin
GI Tract Infections
Traveller’s Diarrhea
Common Bugs
Common Bugs: E. Coli, Salmonella, Shigella, Campylobacter, Parasite
GI Tract Infections
Traveller’s Diarrhea tx. for bacteria
1st Line (Bacterial): Cipro initiate if Sx’s >24 hours, fever, bloody diarrhea;
Single-dose azithromycin for kids
GI Tract Infections
Traveller’s Diarrhea Tx.for (Giardia, Entamoeba)
1st Line :Metronidazole
STI’s tx.
Chlamydia
Gonorrhea
STI’s
Chlamydia: Azithro po
Gonorrhea: Ceftriaxone IM
Partner(s) must be treated
Vaginitis tx.
Candida:
Bacterial Vaginosis:
Trichomonas:
Candida: OTC antifungals or Fluconazole
Bacterial Vaginosis: Flagyl
Trichomonas: Flagyl (treat partner)
Acne tx
1st Line: Doxy (Beware of photosensitivity rxn)
Cellulitis/Impetigo/Abscess TX
1st line?2nd line?
Drain Abscess?
MRSA?
1st line Diclox/Keflex
2nd line: Clinda
Drain Abscess, Can use Bactroban for impetigo;
MRSA: Bactrim, Doxy
Penicillins SE:
GI upset, allergic reaction (rash, anaphylaxis), yeast infection, ↓ seizure threshold, C. diff colitis
Macrolides SE: .
GI upset, allergic rxn (rare), yeast infxn, C. diff colitis.↑QT interval when combined w/ azoles (anti-fungals). Drug interxns: can increase levels of other drugs by inhibiting p450
Cephalosporins SE:
GI upset, allergic reaction (5% cross-allergenicity with PCN), yeast infection C. diff colitis
Tetracyclines SE:
GI upset, photosensitivity rash, allergic rxn, C. diff colitis, yeast infection, bone/teeth discoloration: avoid < 8 yo, pregnant
Trimethoprim/SulfamethoxizoleLinks to an external site.
SE:
Allergic reaction (rash, Steven’s Johnson Syndrome), GI upset, yeast infxn, C. diff colitis, E. multiforme, Anemia with G-6PD deficiency
Metronidazole (Flagyl)Links to an external site.
SE :
disulfiram-like rxn (severe GI upset w/ EtOH), GI upset, metallic taste, allergic rxn
ClindamycinLinks to an external site. SE:
GI upset, allergic rash, yeast infection,
C. diff colitis
Fluoroquinolones
SE:
GI upset, allergic rxn (1%), HA, yeast infection, C. diff colitis. Damages developing cartilage: avoid in pregnacy, kids
level of recommendation
Over-the-counter cold medications should not be used in children younger than four years because of potential harms and lack of benefit.5
B
level of recommendation
The use of hand sanitizer or hand washing is the most effective way to prevent the common cold.8
B
level of recommendation
Treatments with established effectiveness for cold symptoms in adults are limited to over-the-counter analgesics and decongestants with or without antihistamines (but not antihistamine monotherapy)
B
level of recommendation :
Antibiotics are ineffective for treatment of the common cold in adults and children and should not be prescribed
A
level of recommendation:
Codeine and other antitussives have not been proven effective for cough in adults.
B
level of recommendation: Safe and effective treatments for cold symptoms in children include nasal saline irrigation, menthol rub, and honey (for children 12 months and older).
B
what treatment might benefit w/ Covid?
steroid
Does ibuprofen help with covid?
no- may increase severity and duration
How can we boost immune system with common cold?
Rest limit alcohol better nutrition stress management physician emapthy
questionable tx of common cold?
isotonic nasal saline/Neti Pot and steam inhalation
sxs management co common cols?
honey increase fluids probiotic intranasal ipratroprium menthanol rub increase of pillows Zinc lozenges Nsaids inhalers
level of recommendation:
Patients 40 to 70 years of age who are overweight or obese should be screened for type 2 diabetes. Persons with abnormal results should be referred for intensive behavioral counseling interventions that focus on physical activity and a healthy diet.
B
what does metformin do?
Decreases hepatic glucose output
• First line med at diagnosis of type 2
SE of metformin
nausea, bloating, diarrhea, B12 deficiency. To minimize GI Side effects, use XR and take w/ meals.
Sulfonylureas like glyburide, glipizide MOA
Stimulates sustained insulin release
SE of Sulfonylureas
Side effects: hypoglycemia and weight gain. Eliminated via kidney.
SGLT2 inhibitors (end in flozin) MOA
Decreases glucose reabsorption in kidneys
SE of SGLT2
Side effects: hypotension, UTIs, increased urination, genital infections, ketoacidosis.
DPP-4 inhibitors (end in gliptin) MOA
“Incretin Enhancers” • Prolongs action of gut hormones• Increases insulin secretion• Delays gastric emptying
SE of DPP-4 inhibitors
Side effects: headache and flu-like symptoms. Can cause severe, disabling joint pain. Contact MD, stop med.
DM rule of 3
- microvascular
- blood sugar control
- Macrovascular complications
Microvascular complications what to check?– rule of three
- EYES (Retinopathy)–Annual visit with Ophthalmologist
- KIDNEYS (Nephropathy)–Annual screen for Microalbuminuria
ACE-Inhibitor for HTN, Microalbuminuria
Follow Renal Function (Creatinine) - FEET (Neuropathy)–Patient Education: Foot Care
Inspect Patient’s Feet
Podiatry as needed
Blood sugar control- rule of three
- HEMOGLOBIN A1C–Check every 3-6 months
Goal is less than 8
Avoid being over-aggressive w/hypoglycemic agents - LIFESTYLE–Nutrition
Activity - MEDICATIONS- Metformin First-Line
A variety of oral and injectable agents
Insulin
Macro-Vascular Complications– rule of three
- HYPERTENSION–Systolic BP <140
Consider lower thresholds if increased CV risk
Diastolic BP <90 - LIPIDS–Follow 2013 AHA/ACC Guideline
Emphasize level of risk instead of LDL
Engage in shared decision making with the patient - CAD/CVA Prevention–Smoking Cessation, Nutrition, Activity
Stress ↓: Yoga, Meditation, Therapy
Consider aspirin if increased CV risk
An effective approach to office-based treatment includes a coherent framework for identifying and managing substance use disorders and specific strategies to promote behavior change. Brief validated screening tools allow rapid and efficient identification of problematic drug use, including prescription medication misuse. After a positive screening, a brief assessment should be performed to stratify patients into three categories:
- hazardous use,
- substance abuse,
- or substance dependence
Patients with hazardous use benefit from
brief counseling by a physician.
For patients with substance abuse, brief counseling is also indicated, with the addition of
more intensive ongoing follow-up and reevaluation
true or false:
In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone).
true
level of recommendation:
Patients with hazardous substance use or substance use disorders may benefit from brief counseling by their primary care physician.
B
level of recommendation:
Office-based pharmacotherapy for opioid dependence using buprenorphine is safe and effective.
A
level of reccoemndation :
Patients with substance use disorders may benefit from identification and treatment of comorbid psychiatric disorders.
A
BuprenorphineMOA
partial agonist of mu opioid receptors.
why is buprenorphine/naloxone is the preferred formulation?
he naloxone component is poorly absorbed via the sublingual route and is present only to prevent misuse of the medication by crushing and injecting the combined product.
Naltrexone MOA
antagonist of mu opioid receptors and can block the effects of opioid agonists
which of the pharm. to help w. opioid use disorder is associated with hepatic injury at supratherapeutic doses; therefore, liver function tests at baseline and every three to six months are recommended
Naltrexone
Depression screening
Sleep – increased or decreased (if decreased, often early morning awakening)
Interest – decreased
Guilt/worthlessness
Energy – decreased or fatigued
Concentration/difficulty making decisions
Appetite and/or weight increase or decrease
Psychomotor activity – increased or decreased
Suicidal ideation
Depressed mood most of the day, almost every day
level of recommendation:
Selective serotonin reuptake inhibitors are more likely than placebo to produce depression remission in the primary care population.
B
level of recommendation:
Serotonin-norepinephrine reuptake inhibitors are slightly more likely than selective serotonin reuptake inhibitors to improve depression symptoms, but they are associated with higher rates of adverse effects such as nausea and vomiting.
B
level of recommendation:
Antidepressants are most effective in patients with severe depression.
A
true or false:
The benefit of antidepressants over placebo is more pronounced in patients with severe depression.
true
first line therapy for depression
Second-generation antidepressants are generally considered first-line therapy. Specific therapy choice should be based on cost, patient preference, and adverse effect profile.
Most common SE for discontinuation of a SSRI
N/V
The optimal treatment duration is unclear, but clinical guidelines suggest _________________ months for an initial episode of major depression. Patients with recurrent depression may benefit from prolonged treatment.
The optimal treatment duration is unclear, but clinical guidelines suggest four to 12 months for an initial episode of major depression. Patients with recurrent depression may benefit from prolonged treatment.
antidepressens in pregnancy?
High-quality evidence is lacking on the benefits and harms of antidepressant use in pregnancy. It is unclear whether selective serotonin reuptake inhibitor use in breastfeeding mothers causes adverse effects in their infants, but sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants
level of recommendation:
Exercise therapy should be prescribed for patients with fatigue, regardless of etiology.
A
level of recommendation:
Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft), may be helpful for patients with fatigue in whom depression is suspected.
B
level of recommendation:
Cognitive behavior therapy is an effective treatment for adult outpatients with chronic fatigue syndrome.
A
level of recommendation:
Stimulants seldom return patients to predisease performance.
B
level of recommendation:
All women of childbearing age should be screened for IPV. There is a low risk of negative effects from screening.
A
JNC 8 Summary (January 2014)
- Goal _________ for <60 yo
- Goal _______ for 60 yo and older (______ for people who have a history of stroke or TIA and consider also for high ASCVD risk score, according to AFP, ACP - 2017)
- first line?
- DM2 and Chronic Kidney Disease (CKD) Goal is ___________ for all ages
- first line Medications? Second-line?
- What two medications we cannot use together
JNC 8 Summary (January 2014)
- Goal <140/90 for <60 yo
- Goal <150/90 for 60 yo and older (<140/90 for people who have a history of stroke or TIA and consider also for high ASCVD risk score, according to AFP, ACP - 2017)
- Lifestyle Modification still first line
- DM2 and Chronic Kidney Disease (CKD) Goal is < 140/90 for all ages
- Thiazides, CCBs, and ACEis (ARB if cough) are first line
- Beta-blockers considered second line
- Do not use ACEi and ARB together
JNC-8 vs AHA/ACC
Why do Fam med prefer JNC-8?
Disproportionate weight to the SPRINT trial, an RCT assessing standard vs. strict blood pressure treatment goals
true or false?
The ACA/AHA and JNC-8 guidelines both recognize that lifestyle modifications (DASH diet, weight loss, exercise, smoking cessation) are first line and are paramount for reducing morbidity and mortality associated with elevated BP. These interventions do not carry any of the risks associated with medications.
true
List specific examples of trauma-informed language and behaviors that can be utilized during the physical examination.
Physical examination
Ask patients if there are any parts of the physical examination that they feel anxious about, and if there is anything you can do to help make the physical examination feel more comfortable
Ask the patient to shift his or her clothing out of the way instead of doing it yourself (e.g., lifting his or her own shirt for an abdominal examination)
Ask the patient for permission before conducting each section of physical examination (e.g., when moving from heart to lung examination)
Physicians should deliver confidential health services in situations involving 5
- reproductive health,
- sexuality,
- gender identity and expression,
- substance use, and
- mental health to consenting adolescents.
true or false
Adolescent patients should be made aware that certain situations and circumstances create limitations on guaranteed confidentiality. For example, detailing billing statements and Explanation of Benefits notices may be furnished to a guarantor/parent from a third party. Further, information suggesting someone is in imminent danger, the suspicion or evidence of abuse, and the diagnosis of certain communicable diseases all must be reported to the proper authorities.
true
HEADSSS
Home Education Activities Drugs Sex SI safety
Contraception to use in breast cancer?
copper IUD
What to avoid in contraception for cervical cancer?
IUD
what contraception to avoid in endometrial cancer?
IUD
what contraception to avoid in migraines w/ aura
OCPs
what contraception to avoid in HTN >160/100 and/or w/ vascular disease
OCPs
What contraception to avoid w/ liver disease?
OCPs
what contraception to avoid in PID?
IUD
what contraception to avoid in <3 post-partum, not breastfeeding or breastfeeding
OCPs
What contraception to avoid inSTI
IUD
What contraception to avoid in after septic abortion?
IUD
what contraception to avoid if smoking
OCPs
what contraception to avoid in SLE?
OCPs
level of recommendation:
Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer after three to five years of use.
B
level of recommendation:
Systemic estrogen, alone or in combination with a progestogen, is the most effective therapy for menopausal hot flashes, and is approved by the U.S. Food and Drug Administration for this indication.
A
level of recommendation:
There is no high-quality, consistent evidence that black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modification alleviates hot flashes.
B
level of recommendation:
Effective nonhormonal therapies for genitourinary syndrome of menopause include vaginal moisturizers and oral ospemifene (Osphena).
B
After a median of 13 years of follow-up, women taking combined estrogen/progestogen therapy in the Women’s Health Initiative trial had a significantly increased risk of _______________ and ______________, and a reduction in_________________.
After a median of 13 years of follow-up, women taking combined estrogen/progestogen therapy in the Women’s Health Initiative trial had a significantly increased risk of breast cancer and venous thromboembolism, and a reduction in hip fractures.
n the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms of menopause. Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of __________________ when used for more than three to five years. Therefore, in women with a uterus, it is recommended that physicians prescribe ______________ therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.
n the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms of menopause. Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years. Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.
Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as ____, ____, and ______ are effective alternatives.
Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of _______________cancer.
Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives.
Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer.
One systematic review suggests modest improvement in hot flashes and vaginal dryness with __________ products, and small studies suggest that clinical hypnosis significantly reduces hot flashes.
One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes.
Patients with genitourinary syndrome of menopause may benefit from ______ ____________, or _____(the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy).
The decision to use hormone therapy depends on clinical presentation, a thorough evaluation of the risks and benefits, and an informed discussion with the patient.
Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy).
The decision to use hormone therapy depends on clinical presentation, a thorough evaluation of the risks and benefits, and an informed discussion with the patient.
SOCIAL GRADIENT OF HEALTH
Life expectancy is shorter and disease is more common further down the social / socioeconomic ladder
WHAT ARE SOME EXAMPLES OF SOCIAL DETERMINANTS OF HEALTH?
Education, employment opportunities, water, sanitation, housing, food access, level of social inclusion / exclusion, social support networks, stress, early childhood development, race/gender/sexual orientation/etc (as they impact the other SDHs)
WHAT IS THE RELATIVE IMPACT OF SDH ON HEALTH VARIANCE / OUTCOMES?
A lot; probably more than half
level of evidence :
Not all transgender or gender-diverse persons require or seek
hormone therapy. However, those who receive treatment generally
report improved quality of life, self-esteem, and anxiety.
B
level of recommendation:
All adolescents and adults 15 to 65 years of age should be screened for HIV unless they explicitly refuse.
A
level of recommendation:
All persons at high risk younger than 15 years and older than 65 years should be screened for HIV.
A
level of recommendation:
All pregnant women should be screened for HIV during each pregnancy.
A
level of recommendation:
Preexposure prophylaxis should be provided to men and women (except those who are breastfeeding) who are at highest risk of HIV infection (e.g., men who have sex with men, those with an HIV-positive sex partner).
A
level of recommendation:
It is recommended that combination antiretroviral therapy be initiated early to prevent HIV transmission.
A
The U.S. Food and Drug Administration approved the OraQuick In-Home HIV Test; however, there are concerns about reduced __________, possible misinterpretation of results, potential for less effective counseling, and possible cost barriers
The U.S. Food and Drug Administration approved the OraQuick In-Home HIV Test; however, there are concerns about reduced sensitivity, possible misinterpretation of results, potential for less effective counseling, and possible cost barriers
________________________ is the combination of safer sex practices and continuous primary care prevention services, plus combination antiretroviral therapy.
Preexposure prophylaxis (effective in select high-risk adult populations) is the combination of safer sex practices and continuous primary care prevention services, plus combination antiretroviral therapy. C
Evidence has increased supporting combination antiretroviral therapy for treatment at any _______________count.
Evidence has increased supporting combination antiretroviral therapy for treatment at any CD4 cell count.
level of recommendation:
Combination ART should be initiated early to delay progression of HIV infection.
A
level of recommendation:
Combination ART can prevent HIV transmission.
A
true or false?
Opportunistic infections are now less common than in the past because ART usually prevents or markedly delays progression to advanced HIV disease
true
Difference between PrEP?
Truvada vs Descovy
Truvada®external icon is for all people at risk through sex or injection drug use.
Descovy®external icon is for people at risk through sex, except for people assigned female at birth who are at risk of getting HIV from vaginal sex.
is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spirit manifestations. This is reflected in the individual pursuing reward and/or relief by substance abuse and other behaviors.
Addiction
Opioids vs Opiates
although often used interchangeably, opiates is officially a more restrictive term, referring only those compounds derived from the natural poppy (morphine, codeine, heroin). Opioids include those opiates, in addition to the semi-synthetic and the synthetic compounds.
means that there is a physiologic requirement for the substance. A lack of this substance induces withdrawal.
dependence
means that increasing doses of a medication are needed to achieve the same effect.
tolerance
is use of a substance out of socio-culturally accepted norms. There is no accepted use of heroin, so it is always an abuse. Alcohol, on the other hand, can either be used or abused.
Abuse
loss of control, continued use despite negative consequences, compulsion to use.
Addiction
for addiction treatment, can only be given in methadone clinics (inpatient stay also if approved by clinic), daily dose, random testing, no ceiling, commonly measured in UDS, large pain control potential.
Methadone
can be prescribed by any certified physician (8 hour training course), can be prescribed monthly, needs specialized urine test, blocks all other opioids, medium pain control, has ceiling, little or no euphoria, risk of respiratory depression only if taken with alcohol, benzodiazepine, or sedatives.
Buprenorphine
level of recommendation:
Patients with opioid use disorder should be offered maintenance treatment with pharmacotherapy.
A
level of medicine:
Pharmacotherapy for opioid use disorder should be continued for as long as it helps the patient; patients should not be required to discontinue according to preset timelines
A
level of recommendation:
Participation in behavior therapies may be helpful for some patients with opioid use disorder, but studies are equivo-cal; it should not be a prerequisite for buprenorphine treatment
B
true or false?
naltrexone can be used to opioid use and craving
ture
level of recommendation:
Patients with substance use disorders may benefit from identification and treatment of comorbid psychiatric disorders.
A
level of recommendation:
Office-based pharmacotherapy for opioid dependence using buprenorphine is safe and effective.
A
level of recommendation:
Patients with hazardous substance use or substance use disorders may benefit from brief counseling by their primary care physician.
B
Name changes to US healthcare as a result of the COVID19 pandemic that may improve primary care
- Rethinking HIPAA
- Investing In Primary Care
- Promoting Continuity Of Care
- A Research Agenda
Describe factors that contribute to the high cost of US healthcare
- Americans use some expensive technologies, such as MRIs, and specialized procedures, such as hip replacements, more often than our peers.
- The U.S. has the highest chronic disease burden and an obesity rate that is two times higher than the OECD average.
- Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.
level of recommendation:
Pregnant women with iron deficiency anemia should be offered treatment.
B
level of recommendation:
Folic acid supplementation should be recommended before conception.
A
level of recommendation:
Pregnant women should be screened for asymptomatic bacteriuria between 11 and 16 weeks’ gestation.
A
level of recommendation:
Women at risk of preterm birth should be offered intramuscular (preferred) or vaginal progesterone.
A
level of recommendation:
Breastfeeding should be recommended to pregnant women as the best feeding method for most infants.
A
level of recommendation:
Counting fetal movement should not be recommended to pregnant women.
B
level of recommendation:
Pregnant women should be screened for tobacco use, and individualized, pregnancy-tailored counseling should be offered to smokers.
A
Testing for group B streptococcus should be performed between __________ weeks’ gestation.
Testing for group B streptococcus should be performed between 35 and 37 weeks’ gestation.
Screening for diabetes should be offered to all pregnant women between _________ weeks’ gestation
Screening for diabetes should be offered to all pregnant women between 24 and 28 weeks’ gestation
Women at risk of preeclampsia should be offered low-dose _____________ prophylaxis, as well as _________________________ if dietary calcium intake is low
Women at risk of preeclampsia should be offered low-dose aspirin prophylaxis, as well as calcium supplementation if dietary calcium intake is low
