Fam Med - SUTM Ambu/CF(1-3)

Question 1

HTN - classification (adult >18)

Answer 1

Normal—SBP<120 and DBP<80

Elevated—SBP 120-139 or DBP 80-89 (pre-HTN => require lifestyle modification)

Stage I—SBP 140-159 or DBP 90-99 (HTN definition BP > 130/80)

StageII—SBP≥ 160 or DBP≥100

Question 2

HTN - HTN urgency and emergency

Answer 2

Urgency (severe) SBP >180 and/or DBP >120 - in an asymptomatic patient

Emergency = severe HTN with end-organ damage (neurologic, MI, aortic dissection)

Question 3

HTN - antihypertensive meds for pregnant women

Answer 3

Contraindicated - ACEi, ARB, thiazide, Ca++ channel blockers

Safe: ß-blockers, hydralazine

Question 4

HTN- what to do when patient presents with moderate-to-severe HTN?

Answer 4

Initiating therapy right away - DON’T wait 1-2 months to confirm diagnosis and start treatment

Question 5

HTN - Thiazide side-effects

Answer 5

HYPOKALEMIA

hyperuricemia, hyperglycemia, elevation of cholesterol and triglyceride levels, metabolic alkalosis, hyperuricemia, hypomagnesemia

Question 6

HTN - ß-blockers side-effects

Answer 6

Bradycardia, bronchospasm, sleep disturbances (insomnia), fatigue, may increase TGs and decrease HDL, depression, sedation, may mask hypoglycemic symptoms in diabetic patients on insulin

Question 7

HTN - ACEi side-effects

Answer 7

Acute renal failure, hyperkalemia, dry cough, angioedema, skin rash, altered sense of taste

Question 8

HTN - Ca++ channel blockers side effects

Answer 8

Dihydropyridines (e.g., amlodipine): peripheral edema

Nondihydropyridines (e.g., verapamil, diltiazem): heart block

Question 9

HTN - initial mono-therapy option? Is there any difference?

Answer 9

Thiazide, ACEi, ARBs, and Ca++ channel blockers (dihydropyridine)

There is little difference.

Most patients eventually need more than 1 drug to attain goal BP

Question 10

HTN - what to do if “white coat HTN” is suspected?

Answer 10

Twenty-four–hour ambulatory blood pressure monitoring is the most effective.

Home blood pressure monitoring is an alternative.

Question 11

HTN - Principles of treatment - target BP

Answer 11

≤60 => BP ≤ 140/90

>60 => BP ≤ 150/90

Question 12

HTN - Principles of treatment - What to do when mono-therapy is ineffective?

Answer 12

1. Increase dose to maximum
2. Add 2nd meds (ACCOMPLISH trial show ACEi and CCB combination is effective) and increase dose of each to max
3. Consider 3rd agent and referral to HTN specialist

Question 13

HTN - Lipid screening for pt with and without CAD risk

Answer 13

With CAD risk (family history, obesity) => screen with fasting lipid profile every 5 years starting age 20

Without CAD risk => screen women ≥45y/o and men ≥35y/o

Question 14

Hyperlipidemia - Risk factors for CAD in patient with hyperlipidemia - Clinical pearl

Answer 14

Current cigarette smoking (dose-dependent risk)
HTN
Diabetes mellitus
Low HDL cholesterol (<35 mg/dL); high HDL (>60 mg/dL) is a NEGATIVE risk factor (subtract 1 from total)

Male: >45 years of age Female: >55 years of age
Male gender—if you count as a risk factor, do not count age Family history of premature CAD
MI/sudden death in male first-degree relative <55 years of age MI/sudden death in female first-degree relative <65 years of age

Question 15

Hyperlipidemia - Risk factors - Diet

Answer 15

Saturated fatty acid and cholesterol => Elevated LDL and total cholesterol

High-calorie diets => increase triglyceride (TG) levels

Alcohol => increase TG levels and HDL levels

Question 16

Hyperlipidemia - Risk factors - Medications

Answer 16

Thiazides—increase LDL, total cholesterol, TG (VLDL)

β-Blockers (propranolol)—increase TGs (VLDL) and lower HDL

Estrogens—TG further increased in patients with hypertriglyceridemia

Corticosteroids and HIV protease inhibitors => elevate serum lipids

Question 17

Hyperlipidemia - Potency of statins

Answer 17

High intensity: atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg

Moderate intensity: atorvastatin 10 to 20 mg, rosuvastatin 5 to 10 mg, simvastatin 20 to 40 mg, lovastatin 40 mg, pravastatin 40 to 80 mg, fluvastatin XL 80 mg (or 40 mg twice daily), pitavastatin 2 to 4 mg

Low intensity: simvastatin 10 mg, pravastatin 10 to 20 mg, lovastatin 20 mg, fluvastatin 20 to 40 mg, pitavastatin 1 mg

Question 18

Hyperlipidemia - Four Categories of Patients Aged >21 yrs Who Benefit From Statin Therapy

Answer 18

Clinical ASCVD => High-intensity statin

LDL cholesterol ≥190 mg/dL => High-intensity statin

Diabetic patients aged 40–75 yrs with LDL cholesterol 70–
189 mg/dL
ASCVD risk score <7.5% => moderate-intensity
ASCVD risk score ≥7.5% => high-intensity statin

Nondiabetic patients aged 40–75 yrs with LDL cholesterol 70–189 mg/dL
ASCVD risk score ≥7.5% => moderate- to high- intensity statin

Question 19

Hyperlipidemia - Dyslipidemia Syndrome

Answer 19

Type I: exogenous hyperlipidemia => chylomicron => Diet

Type IIa: familial hypercholesterolemia => LDL => Statins/Niacin/Cholestyramine

Type IIb: combined hyperlipoproteinemia => LDL+VLDL => Statins/Niacin/Gemfibrozil

Type III: Familial dysbetalipoproteinemia => IDL => Gemfibrozil/Niacin

Type IV: Endogenous hyperlipidemia => VLDL => Niacin/Gemfibrozil/Statins

Type V: Familial hypertriglyceridemia => VLDL+chylomicron => Niacin/Gemfibrozil

Question 20

Case File - Health maintenance - Level of prevention

Answer 20

Primary: prevent disease before it occurs (vaccines, education/exercise. removal of colon polyps…)

Secondary: promote early detection of disease (mammogram, eye exam for glaucoma…)

Tertiary: therapeutic and rehabilitative once disease is diagnosed (meds, stroke rehab, chronic pain management…)

Question 21

Case File - Health maintenance - Cardiovascular screening tests recommendation

Answer 21

≥ 18yo => HTN (by BP measurement) => level A

≥ 35, M and ≥ 45, F => lipid disorders => level A
≥ 20, with increased risk => lipid disorders => level B

45 ≤ M ≤ 79 => take aspirin daily (reduce MI) => level A

US Abdominal aortic aneurysm (AAA) => 65 ≤ M, smoked ≤ 75 => level B
=> same age, never smoked => C
=> F, never smoked => D
=> F, smoked => I

Routine ECG, stress test, CT => low risk => D
=> moderate risk => I

Question 22

Case File - Health maintenance - Cancer screening

Answer 22

≥ 50 => colorectal cancer (FOBT, sigmoidoscopy, colonoscopy) => A

Prostate cancer (PSA, digital examination) => D

50 ≤ F/M, 30 or more pack-year/quit less than 15y ≤ 80 => lung cancer (annual low-dose CT) => B

Asymptomatic => pancreatic testicular => D
Asymptomatic => bladder cancer => I

Question 23

Case File - Health maintenance - Other health conditions

Answer 23

Obesity (BMI) => all => B

Type 2 DM => asymptomatic => I
=> adult with HTN/hyperlipidemia => B

Depression => mechanism in place => B

Screen/promote cessation of tobacco use => A

Screen/prevent misuse alcohol => B

Routine Thyroid => asymptomatic => I

Question 24

Case File - Health maintenance - Immunization

Answer 24

Tdap booster => 19 ≤ all ≤ 65 (due to waning immunity to pertusis)

Influenza => ≥ 6months

Pneumococcal polysacde (PPSV-23) and pneumococcal conjugate (PCV-13) => ≥ 65
      => ≤ 65 (never vaccinated, immunocompromised)

Hep B => Healthcare workers, IV drug users, MSM, multiple sex partners, diabetes

Hep A => chronic liver disease, use clotting factors, IV drug users, MSM, travel to ongoing pandemic

Varicella => No known vaccination status, seronegative

Meningococcal => college dorm, military, complement def, asplenic

Question 25

Headache - emergency evaluation

Answer 25

Rule out intracranial bleed => non-contrast CT and lumbar puncture (for small bleed missed from CT)

Question 26

Headache - visual aura of migraine

Answer 26

bilateral homonymous scotoma => Bright, flashing, crescent-shaped images

Question 27

Case file - COPD exacerbation - management

Answer 27

ABC - airway, breathing, circulation

Rx: Oxygen, ß2 agonist (albuterol), corticosteroid (act slowly, need to administer with ß2 agonist [bronchodilators] to improve short term outcomes

Inhaled anti-cholinergic (ipratropium) may work synergistically with ß2 agonist

Question 28

Case File - COPD - most common etiology of COPD? 2 common types of COPD?

Answer 28

Cigarettes

Chronic bronchitis (cough + sputum for 3 months in 2 consecutive years)
Emphysema (lung tissues destruction => enlargement of respiratory bronchioles)

Question 29

Case file - COPD - what does dyspnea indicate?

Answer 29

Lung function (measured by FEV1) is reduced about half and COPD has presented for years

Question 30

Case File - COPD - which value of spirometry indicates reversibility in COPD?

Answer 30

[FEV1]/[FVC] when FEV1 is increased ≥ 12% or 200ml

Question 31

Case File - COPD management (in general)

Answer 31

Goal:
- relieve symptoms, slow disease progression, prevent exacerbations/complications

• Encourage pt to quit smoking
• Vaccination: pneumococcal and influenza

Question 32

Case File - COPD - relationship between smoking cessation and COPD progression

Answer 32

smoking cessation DOES NOT result in significant improvement in pulmonary function

smoking cessation DOES reduce the rate of further deterioration to that of a nonsmoker.

Question 33

Case File - COPD - Treatment recommendation for stage I

Answer 33

Short acting bronchodilators (PRN) => ß2-agonist (albuterol), anti-cholinergic (ipratropium)

Inhaler&raquo_space;> oral = less side-effects

Question 34

Case File - COPD - Treatment Recommendation for COPD stage II

Answer 34

long-acting bronchodilators are added

- ß2-agonist (salmeterol)
- anticholinergic (tiotropium)

Question 35

Case File - COPD - Treatment Recommendation for COPD stage III and IV

Answer 35

Inhaled steroids (fluticasone, triamcinolone, mometasone, etc) = for stage III and IV with frequent exacerbation

** long term use of steroid is not recommended - myopathy, glucose intolerance, osteoporosis **

O2 therapy = for stage IV with evidence of hypoxemia (Pa02 ≤ 55 mm Hg or Sa02 ≤ 88% at rest)

Question 36

Case file - COPD - which therapy is the only intervention that has been shown to decrease mortality?

Answer 36

O2 therapy

must be worn for at least 15 h/d.

Question 37

Case file - COPD - when to treat exacerbation with antibiotics? which bacteria is the most common cause?

Answer 37

Exacerbations associated with increased amounts of sputum or with purulent sputum

A sputum culture should be performed.

 - Pneumococcus
 - Haemophilus injluenzae
 - Moraxella catarrhalis

• • Mild - can be directed towards these organisms
• • Severe - may have gram (-) like Klebsiella or Pseudo => broader antibiotics

Question 38

Case file - COPD - Classification of COPD severity

Answer 38

Stage 0 - At risk
Cough, sputum production. Normal spirometry
Vaccines and address risk factors (exposure to tobacco smoke, occupational dust/chemicals, or smoke from home cooking/ heating fuel)

Stage I - Mild COPD - FEV, fFVC <0.7
FEV => 80% predicted
=> Short-acting bronchodilators

Stage II - Moderate COPD - FEV, fFVC <0.7
FEV => 50%-80% predicted
=> Long-acting bronchodilators

Stage Ill - Severe COPD - FEV, fFVC <0.7
FEV, 30%-50% predicted
=> Inhaled steroids

Stage IV - Very severe COPD - FEV, fFVC <0.7
FEV, <30% predicted
FEV, <50% predicted with chronic hypoxemia
=> Long-term oxygen therapy and consider surgical interventions

Question 39

Upper Respiratory Disease - Cough - Postnasal drip mechanism

Answer 39

The mucosal receptors in the pharynx and larynx are stimulated by secretions of the nose and sinuses that drain into the hypopharynx

Question 40

Upper Respiratory Disease - Cough - Viral vs. Bacterial URI features

Answer 40

Viral: Myalgia, rhinorrhea, headache, fever, cough

Bacterial: yellow sputum, fever, cough

Question 41

Upper Respiratory disease - Sinusitis - signs to consider acute bacterial sinusitis

Answer 41

If a patient has a cold beyond 8 to 10 days, or if the cold symptoms improve and then worsen after a few days (“double-sickening”)

Can be secondary to an initial viral infection

Question 42

Upper Respiratory disease - Sinusitis - antibiotic treatment course

Answer 42

Treat with antibiotics and decongestants for 1 to 2 weeks, depending on severity.

=> If there is no improvement after 2 weeks of therapy, then sinus films and a penicillinase-resistant antibiotic are appropriate.

Consider ENT consultation.

Antibiotics use: Amoxicillin, amoxicillin-clavulanate, TMP/SMX, levofloxacin, moxifloxacin, and cefuroxime are good choices.

Question 43

Upper Respiratory disease - Sinusitis - treatment: antihistamine

Answer 43

Reserve for patients with allergies; use discriminately because of the “drying effect” => can worsen congestion

Loratadine (Claritin), fexofenadine (Allegra), chlorpheniramine (Chlor- Trimeton)

Question 44

Case File - Joint pain - what to rule out when patient presents with monoarticular joint pain? How to do so?

Answer 44

Need to exclude infectious arthritis, as cartilage can be damaged within the first 24h

Joint aspiration

Question 45

Case File - Joint pain - which meds can induce hyperurecemia?

Answer 45

Thiazide => increase urinary urate reabsorption

Loops diuretics, chemotherapeutics

Question 46

Case File - Joint pain - stages of Gout

Answer 46

(1) asymptotic tissue deposition of crystals
(2) acute gout flares
(3) inter-critical segments (occurring after an acute flare, but before the next flare)
(4) chronic gout (symptoms of chronic arthritis and/or tophi)

Question 47

Case File - Joint pain - How is the serum uric acid level during gout attack?

Answer 47

Can be normal or even low

Question 48

Case File - Joint pain - infectious arthritis

Answer 48

Bacterial => 90% mono, large joint (hip, knee, shoulder)

Fungi/mycobacteria => chronic mono or 2-3 joints

Acute poly (≥ 3 joints) => endocarditis or disseminated gonococcal infection

Labs: arthrocentesis, blood culture, Gram stain and culture, CBC and erythrocyte sedimentation rate (ESR)

Question 49

Case File - Joint pain - RA diagnosis criteria

Answer 49

Synovitis (swelling) in at least 1 joint

≥ 6 points total for: number of joints, serologic (RF, anti-CCP), elevated acute phase protein (CRP, ESR), symptom duration (≥ 6 weeks)

Question 50

Case File - Joint pain - Treatment for septic arthritis, OA, RA

Answer 50

Septic arthritis = IV antimicrobials and surgery for drainage of the infected joint.

Degenerative joint (OA) = mobility exercise, weight loss, surgery, corticosteroid (one per 4-6 months to avoid cartilage destruction)

RA = education, exercise, PT, OT = DMARDs (sulfasalazine, methotrexate), TNFå inhibitors (infliximab, etanercept)