family med practice essentials Flashcards
prostate cancer screening
aafp and uspstf recommends that digital rectum exam and PSA screening be individual decision; they recommend against screening in pts >70
criteria for diabetes
6.5 A1c; 126 fasting glucose, 200 random glucose plus symptoms of hyperglycemia (polydipsia, polyuria, weight loss), OR 200glucose 2h after oral glucose tolerance test X2
criteria for prediabetes
5.7-6.4 A1c; fasting glucose 100-125; 2 h prandial glc 140-199
prevention of diabetes
- loss of 7-10% of body weight
- 150min activity/week
- technology assisted interventions
- metformin for prediabetes especially if BMI>35, less than 60, and if woman with hx gestational diabetes
- be careful bc longterm metformin use can lead to B12 deficiency! monitor B12 esp if anemia or peripheral neuropathy
screening for CVD recommended in pts with prediabetes
screening for CVD recommended in pts with prediabetes
people 2-64 with diabetes should receive which vaccines?
flu,
PPSV23 pneumococcal (higher risk of bacterial pneumonia and higher mortality rate!)
people with diabetes 18-59 should also get Hep B if they havent already gotten it
comprehensive physical exam for diabetics
height, weight BMI
BP, orthostatics if indicated
fundoscopic
thyroid palpation
skin (look for acanthosis nigricans, insulin injection site , lipodystrophy)
comprehensive foot exam : look for callus, skin integrity, foot deformity, ulcer, toenails, pedal pulses– refer for ABI if diminished, temp/vibration or pinprick sensation; 10g monofilament exam
what labs do you get for diabetics?
A1c lipid panel (LDL, HDL, triglycerides, total cholesterol) liver function tests spot urinary creatinine to alubumin ratio (detect small amount of protein in urine --> kidney damage) serum Cr, estimated GFR TSH if DM1 B12 if on metformin [K+] if on ARBs, ACEi, diuretics
how often should you test A1c in DM pts who are meeting treatment goals and have stable glycemic control?
2x/year
how often should you test A1c in DM pt who have unstable glycemic control or who’s tx has changed
4x/year
remember A1c is not a perfect measure of glycemic control, isn’t going to show big deviations so you might want to monitor in other ways
A1c goals for nonpregnant adults
usually <7%
you can shoot for lower if you want and not big risk of hypoglycemia
if history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin, then it might be appropriate to shoot for <8%
A1c goals for ppl with shortened life expectancy, hx of severe hypoglycemia, advanced vascular complications, extensive comorbid conditions, longstandind DM where its been really hard to reach goal
<8%
hypoglycemia 1 range
<70
>54
hypoglycemia 2
<54
hypoglycemia 3
altered mental status
sx of hypoglycemia
Symptoms of hypoglycemia include, but are not limited to, shakiness, irritability, confusion, tachycardia, and hunger. Hypoglycemia may be inconvenient or frightening to patients with diabetes. Level 3 hypoglycemia may be recognized or unrecognized and can progress to loss of consciousness, seizure, coma, or death. It is reversed by administration of rapid-acting glucose or glucagon.
cognitive damage
The use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth. Those in close contact with, or having custodial care of, people with hypoglycemia-prone diabetes (family members, roommates, school personnel, childcare providers, correctional institution staff, or coworkers) should be instructed on the use of glucagon, including where the glucagon product is kept and when and how to administer. An individual does not need to be a health care professional to safely administer glucagon. In addition to traditional glucagon injection powder that requires reconstitution prior to injection, intranasal glucagon and glucagon solution for subcutaneous injection recently received U.S. Food and Drug Administration approval. Care should be taken to ensure that glucagon products are not expired.
hypoglycemia unawareness
deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response
you can break the cycle by loosening glycemic control for a few weeks
recommended weightloss goal for obese DM pts
5+% of body weight (and maintain it)
ADA recommends high intensity interventions (≥16 sessions in 6 months) and focus on dietary changes, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit
For patients who achieve short-term weight-loss goals, long-term (≥1 year) weight maintenance programs are recommended when available. Such programs should at minimum provide monthly contact, as well as encourage ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, including high levels of physical activity (200–300 min/week)
phentermine
short term (less than 12 wks) weight loss increases BP don't use with MAOIs, (linezolid abx has maoi activity)
Orlistat
lipase inhibitor for long term weight loss
can cause malabsorption of fat soluble vitamins. in rare cases can cause liver damage. Side effects include kidney and gall stones, GI distress, headache, back pain
Lorcaserin
for longterm weight loss
Selective serotonin receptor agonist
increases BP! monitor for suicidal ideation , depression, liver and renal failure; theoretically could cause serotonergic syndrome like or neuroleptic malignant like issues if combined with other sertonergic/antidopaminergic agents
phertermine/topiramate combo
for longterm weight loss
teratogen!! increased BP! cognitive impairment, insomnia, acute angle closure glaucoma
naltrexone/bupropion
opioid antagonist/antidepressant combo for long term weight loss
BLACK BOX: SUICIDAL IDEATION
not for seizure pts!! not with opioid therapy; acute angle closure glaucoma
liraglutide
glucagon like peptide 1 receptor agonist for longterm weight loss
lots of GI side effects!
acute pancreatitis?, potential kidney injury
BLACK BOX: c cell thyroid cancer
preferred initial pharmacologic agent for the treatment of type 2 diabetes.
metformin
monitor B12
renal clearance; GFR>30
metformin has weight loss and cvd benefits
GFR for metformin
30
if A1c > 1.5-2% above goal, you start initial treatment on metformin combined with ______ according to VERIFY trial
vildagliptin
DPP-4 inhibitor
what should you add to metformin when you need to step up for a DM pt with ASCVD, ASCVD risk?
liraglutide semaglutide albigultide dulaglutide (all glucagon like peptide 1 receptor agonists)
what should you add to metformin when you need to step up for a DM pt with HF or kidney disease?
canagliflozin
dapagliflozin
empagliflozin
ertugliflozin
(risk of UTIs)
what should you add to metformin when you need to minimize weight gain or promote weight loss?
GLP1ras: dulaglutide, liraglutide, exanatide, semaglutide, lixisenitide
SGLT2I (sodium glucose cotransporter 2 inhibitor)
dapagliflozin
JNC 8 cutoff for HTN tx
140/80
or 150/90 if >60 yo
initial tx for HTN
ARB, ACEi, thiazide or calcium channel blocker
initial tx for HTN in black pts
thiazide or calcium channel blocker
name 3 ca channel blockers
nifidepine
amlodipine
diltiazam
name side effects of calcium channel side effects
flushing, peripheral edema, reflex tachycardia, headaches, dizziness, worsened angina, gingival hyperplasia
name three thiazides
chlorthalidone
hydrochlorothalizide
metolazone
name side effects of thiazides
hypokalemia
increased calcemia
hyperglycemia
why do thiazides cause hypokalemia
thiazides block NaCl transporter in DCT. that increases the sodium concentration in the lumen at the collecting duct, which gives the Na/K exchanger more work – so it takes up more Na and pumps out more K–> potassium loss. Additionally, the drop in BP caused by thiazides triggers the RAS system, so aldosterone further stimulates the Na/K exchanger in collecting duct…even more potassium loss even though overall the BP and Na is dropping
hydrochlorothalizide
thiazide diuretic
side effects of acei
hyperkalemia (na/k exchanger in collecting duct isnt stimulated) dry cough (increased bradykinin) angioedema
name three ACEi
enalapril
lisinopril
benazepril
side effects of lisinopril
hyperkalemia
angioedema
dry cough
name three ARBs
irbesartan
losartan
valsartan
HTN control if hx MI
beta blocker + ACEi or ARB + aldo antag (spironolactorne or eplerenone)
tx for HTN in pregnancy
nifedipine, methyldopa, labetelol
tx for HTN if hx of stroke
ACEi + thiazide
common causes of COPD exacerbation
viral and bacterial infection (get vaccines!)
air pollution
Add what drug for for persistently symptomatic, NYHA class III-IV CHF, self-identified black patients?
hydralozine plus isosorbide dinitrate
addition of isosorbide dinitrate plus hydralazine (BiDil) to standard heart failure therapy reduces mortality in black patients with advanced heart failure
what drugs to manage HF with reduced EF?
ACEi or ARB
plus
Beta blocker (carvedilol etc)
plus
Loop diuretic (furesemide, torsemide, etc.)
consider: dapagliflozin regardless of DM status
spironolactone, aldo antag if symptomatic and Cr isn’t crazy off the charts
dapagliflozin
SGLT2i
reduces weight, decreases BP, rare hypoglycemia
**UTIs, pyelonephritis!! other genitourinary infections
increased LDL cholesterol
expensive
canagliflozin
SGLT2i reduces weight, reduces BP, hypoglycemia is rare **GENITOURINARY INFECTIONS amputations and fractures!! increased LDL cholesterol expensive
exenatide
GLP1 receptor agonist lowers weight lowers CVD events and mortality expensive Ccell thyroid tumors! GI side effects, sometimes even acute pancreatitis
liraglutide
GLP1 receptor agonist lowers weight lowers CVD events and mortality expensive Ccell thyroid tumors! GI side effects, sometimes even acute pancreatitis
semaglutide
GLP1 receptor agonist lowers weight lowers CVD events and mortality expensive Ccell thyroid tumors! GI side effects, sometimes even acute pancreatitis
ADA recommendations for diabetes screening
everyone over 45 should be screened every 3 years
HIV screening
15-65 yo!
pregnant ppl
high risk
uspstf aspirin recs
The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
triglyceride goal
<150
LDL goal
<100
total cholesterol goal
<200
ezetimibe
add on to statin for lowering LDL in high risk pt, well tolerated, IMPROVE-IT study
ear infection abx
augmentin (amoxicillin-clavulanate) 10 days
VINDICATE differential dx mneumonic
Vascular Infectious/inflammatory Neoplasm Degenerative Intoxication/iatrogenic Congenital Autoimmune/allergy Trauma Endocrine/metabolic
Name 7 triggers of PVCs
premature ventricular contractions (no p wave, wide QRS, compensatory pause) triggered by
- HTN
- ischemia/MI
- cardiomyopathy, heart failure
- anxiety, catecholamines
- drugs like cocaine, other stimulants
- hyperthyroidism
- low k, low mag, high Ca, other electrolyte probs
PVCs increase overall mortality. Treating them ______ mortality in most cases. PVCs ______ mortality in HF. PVCs _____ prognosis in MI.
PVCs increase overall mortality. Treating them does not improve mortality in most cases. PVCs dont worsen mortality in HF. PVCs do worsen prognosis in MI.
How would you work somebody up for PVCs?
Echo, Halter, Stress test if they are stable, BMP, troponin trend, TSH, Magnesium, calcium levels
How do you treat PVCs
- tx underlying cause
- beta blocker (carvedilol) or calcium channel blocker (diltiazem)
- antiarrhythmic
- catheter ablation
Afib findings on ECG
no p wave, saw tooth, rapid & irregular rate “irregularly irregular”, narrow QRS, ventricular rate 90-170
Name 9 causes of Afib
- age
- alcohol (“holiday heart syndrome”)
- MI, coronary artery disease
- lung problems (PE, COPD)
- stimulants
- HTN
- hypoxia
- structural heart disease
- hyperthyroidism
what are complications of afib
stroke! heart failure! myocardial infarction! palpitations! reduced EF!
when would you hospitalize somebody with afib
elderly, hemodynamically unstable, you’re worried they have acute coronary syndrome, you need to get the underlying condition under control, you can’t get their rate under control
Afib workup
ECG, look for underlying cause (look for ischemia, electrolytes, thyroid, etc). Echo: look for LVH, valves, atria size. Always get CBC.
Afib treatment
- rate or rhythm control. AFFIRM trial showed that either is fine it’s just rate control is easier
- ANTICOAGULATION you fool! Use CHA2DS2VAS. Everyone with score greater than 2 gets anticoagulation and if you have a score of 1 you might get it too. If you have valvular disease, you must get warfarin.
What do you call:
fast rhythm originating in atria, rate 120-220 with narrow qrs?
supraventricular tachycardia (SVT)
what are the effects of SVT?
syncope, heart failure, ischemia, really gotta watch if someone is hemodynamically unstable
how do you treat SVT?
Short term: Valsalva manuever
IV adenosine rapid push (inpatient or ED)
IV nondihydropyridine calcium channel blocker (verapamil, diltiazem)
IV beta blocker (atenolol, propranolol, metoprolol)
Longer term: valsalva, beta blocker, nondihydropyradine, other anti arrhythmic, catheter ablation
BMI formula (standard)
(weight (lb) * 703 )/ height (in)^2
BMI (metric)
weight(kg)/height (m)^2
screening tests for cardiovascular disease
bp and lipid panel
lipid screening
men over 35, women over 45
anyone over 20 with increased risk
abdominal aortic aneurysm screening
men 65-75 if ever smoked 1x ultrasound
if using fecal occult blood testing to screen for colon cancer how often
every year
if using flexible sigmoidoscopy to screen for colon cancer how often
3-5 yrs
who should be screened for diabetes?
all adults 40-70 yo as part of cardiovascular risk assessment
smokers, alcoholics, ppl with chronic cvd, pulmonary disease, renal or hepatic disease, diabetes, immunodieficency, asplenia should get which vaccine….
pneumococcal
which vaccine should be given to health care workers, those exposed to blood products dialysis patients iv drugs users, ppl with multi sex partners, or recent STDs, msm
Hep B
what vacine should be given to ppl who use clotting factors or msm?
Hep A
how should you test for renal artery stenosis
abdominal ultrasound (think this if hx atherosclerosis, + htn +hypokalemia/hypernatremia , increased creation + increased BUN/Creatinine ratio
