Family Medicine 1 Flashcards
coracoid process ant or post to acromioclavicular joint?
ant
which articulates w clavicle, coracoid or acromion
acromion
acromioclavicular joint
apley scratch test
reach hand to spine
over shoulder - abduct/ext r - most reach down to C7
under shoulder - abduct/int r - most reach up to T7
roughly what are the normal limits of full shoulder range of motion
flex 180 abduct 180 ext rot 90 int rot 90 apley over down to c7 apley under up to t7
empty can jobe test
flex humerus
int rot shoulder
pronate forearm
upward against resistance
pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear
empty can test aka
jobe test
jobe test aka
empty can test
coracoacromio arch formed by
coracoacromial ligament
neers test
empty can position with passive motion 90-180 flexion
pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear
empty can test vs neer test
resisted vs passive
shoulder flex to 90 internally rotate pronate forearm elbow straight
pain suggests impingement (rotator cuff muscles under coracocromial arch) , tendinitis, tear
hawkins-kennedy test
shoulder ff 90 int rot bend elbow passive further int rot
drives greater humeral tuberosity under coracoacromial arch, impinging supraspinatus tendon
rotator cuff tendons
sits supraspinatus infraspinatus teres minor subscapularis
speeds test
shoulder
ff 90
supinate
resist downwards force
pain suggests biceps tendon or rotator cuff pathology
yergason test
shoulder
flex Elbow to 90
forearm neutral
passively flex elbow and supinate simultaneously
pain/snapping suggests bicipital tendonitis, tear/laxity of transverse humeral ligament (secures long head of biceps tendon into bicipital groove - long biceps snaps over lesser tuberosity)
long vs short head biceps tendon relative position
long head from supraglenoid tuberosity laterally thru bicipital groove between humeral tuberosities like pulley
short head more anterior and medial from coracoid
resisted external rotation of shoulder tests…
infraspinatus (more w shoulder neutral) teres minor (more w shoulder abducted 90)
posterior liftoff test
arm behind back elbow at 90 push away against resistance
tests subscapularis
internal rotators of the shoulder
Latissimus Dorsi
Pectoralis Major
Subscapularis
Teres Major
shoulder ROM tests
flex aduct int rot ext rot apley scratch
rotator cuff tests
empty can / jobe resisted ext rot resisted int rot post liftoff neer hawkins-kennedy
biceps tests
speed
yergason
load and shift test
stabilize scap and acromion
shift glenohumeral joint
^50% shift is severely abnorm
sulcus sign
stabilize scap and ac joint
inf traction down on arm
sulcus appears inf to acromion suggests glenohumeral laxity
apprehension test
shoulder
abduct to 90
flex elbow to 90
externally rotate backward
patient apprehensive if feels risk for anterior dislocation
what is the “dislocation position” of the shoulder
abduct to 90
flex elbow to 90
externally rotate backward
push forward
relocation test
anterior force on glenohumeral joint relieves apprehension test
surprise test
release relocation test (release anterior force on apprehension/crank position) see if shoulder anteriorly dislocates
crank test aka
apprehension test shoulder abduct to 90 flex elbow to 90 externally rotate backward
patient apprehensive if feels risk for anterior
shoulder instability tests
load and shift sulcus sign anterior apprehension/crank relocation surprise
obrien test
like empty can position but some adduction ~30
resist downward pressure w wrist pronated (positive if painful labral tear) and supinated (no pain with labral tear)
shoulder pain provocation test
crank position (90 abduct, 90 flex elbow)
pain worse w pronation than supination
all the single ladies
for labral tear
shoulder labral tests
obrien
pain provocation all the single ladies
all the single ladies test aka
shoulder pain provocation test
crank position (90 abduct, 90 flex elbow)
pain worse w pronation than supination
for labral tear
spurling test
patient side-flexes neck
if no pain, doc flexes a bit further
for cervical rediculopathy
scapular winging suggests
serratus anterior weakness
long thoracic nerve damage
ottowa knee rules
knee xr only needed if one of these
- age ^55
- isolated patellar tenderness (not elswehere in knee)
- fibular head tenderness
- can’t flex to 90
- can’t bear weight 4 steps (limp ok)
define binge drinking
BAC .08 usually 5 drinks M 4 drinks F in v2hrs
define heavy drinking
5+ drinks on same occasion 5+/30 past days
% gen pop experience severe headache
% v6yo
% ^16yo
~20
v5 (rare, extra concerning in kid)
^25 (common in adults
gender presominance of severe headaches
M v12yo
F ^12yo (post puberty)
cluster headache falls under a larger headache category called
trigeminal autonomic cephalalgia
scientific name for headache
cephalalgia
cephalalgia means
headache
mnemonic for characterizing pain
old carts Onset Location Duration Character Aggravating/alleviating Radiation Timing Severity Prior
pediatric blood pressure reference range of normal is adjusted for
age and height
common behavioral change strategies for conservative mgmt of headache syndrome
hydration dec caffeine adequate good sleep adequate exercise limit stress
typical duration of migraine wo aura
4-72 hr adult
2-72 hr peds
common sympx assoc w migraine
nausea vomiting
photophobia phonophobia
typical duration of migraine aura
5-60 min
tf
migraine aura can consist of aphasia
t
can consist of lots of things
routine ladder of migraine pharm mgmt
motrin (nsaid ibuprofen)
tylenol (acetaminophen)
triptans
dhe dihydroergotamine if intractible
prochlorperazine
metoclopramide for n/v
Motrin ibuprofen moa
Reversibly -| cox1 and 2
v prostaglandin precursors
antipyretic, analgesic, antiinflam
reversibly -| cox1 and 2
v prostaglandin precursors
antipyretic, analgesic, antiinflam
name that drug
nsaids (Motrin ibuprofen)
Motrin generic
ibuprofen nsaid
Tylenol generic
acetaminophen
Tylenol acetaminophen moa
Reversibly -| cox in cns v prostaglandin precursors analgesic not antiinflam inactivated peripherally antipyretic by -| hypothalamic temp center
Compazine generic
prochlorperazine
prochlorperazine moa
- | mesolimbic D1 D2 including chemoreceptor zone (antipsychotic (1st gen) antiemetic… anxiolytic)
- |a
- |AchR
- |hypothalamic and hypophyseal hormone release
metochlopramide moa
–| D
-| 5ht serotonin R in chemoreceptor CNS brain
potentiates response to Ach in upper GI for motility w/o secretions… also inc LES tone
dhe
dihydroergotamine moa
- | a
vasoconstricts
tf triptans nsaids coffee can all cause med overuse headache
T
acute migraine therapies work best when
administered ASAP at first aura or symptoms
vitamin you can try supplementing in peds migraine
and SE of this supplement
B2
orange urine
typical peds tension headache duration
30min - 7 days
tf
there is no n/v assoc w tension headache
t
a diagnostic criteria
tf
there is no photo or phonophobia w tension headache
fish
there can be one or none but not both
peds migraine ppx ladder
amitryptiline best studied
propanalol
topiramate
diathesis
~predisposition basically
“hereditary or constitutional predisposition to a disease or other disorder”
what FH puts pt at risk for breast cancer
1st degree relative
does the USPSTF recommend breast self exams
no (2016)
just increases number of biopsies
does USPSTF recommend clinical breast exams
no - insufficient evidence.. but do in pt w symptoms
but ACS does, q3 for 20-40, q1 ^40yo
bmi formula
kg/m^2
for what body types is BMI not a good estimate of obesity
extremes of
height
and
muscle mass
BMI categories
underweight v18.5 normal v25 overweight v30 moderate obesity v35 severe v40 very severe (morbid) ^40
another body measure other than BMI assoc w risk of HTN, DM, HLD, CHD
waist circumference
^88cm 35 in F
^102c, 40in M
visual inspection for __ in breast exam
skin changes erythema retractions dimpling nipple changes
maneuver to accentuate skin retraction or dimpling of brest
ask pt to lift hands overhead
breast exam starts sitting up or lying down
sitting up for inspection
lying down with hands over head for palpation
perform a clinical breast exam
pt sit up
lower gown to waist
inspect for skin changes (erythema, retractions, dimpling, nipple changes… asymmetry), lift hands over head to accentuate
lie down for palpation in vertical strips lateral to medial
palpate axillary and supraclavicular nodes
perform a pelvic speculum exam
table to 30-45
heels in stirrups adjusted
cover to knees
slide down to edge, let knees fall to side
inspect
palpate labia maj and min
warm and lubricated speculum (warm water or minimal gel away from tip – distorts cytology)
peace sign to spread introitus below, inert spec at 45 down, rotate horizontal, continue to insert until handle at perineum
open to visualize cervix
inspect vag wall and cerv
spatula 720, brush 180, get squamo-columnar junction
withdraw, clear cervix, close, withdraw rotating 45
tf
bimanual exam to screen for ovarian cancer
f
not to screen
to eval symptomatic pt
preform a pelvic bimanual exam
lub index and middle non dom gloved hand
palpate cervix for tenderness and motion
use dom hand not gloved to palp uterus, ovaries (difficult in obese or tense woman)
describe a normal bimanual exam
cervix freely moveable nontender
uterus normal size and position
ovaries not palpable (maybe palpable in slender woman)
cervical cancer screening guidelines
21-29yo q3y
30-65yo q5y if cotested for HPV, or q3 if cytology alone – stop after 65 if normal last 3 paps + cyt or last 2 paps + hpv
more freq if immunosuppresed, HIV, CIN hx, DES exposure in utero diethylstilbestrol
what is a total hysterectomy
remove uterus and cervix
what is a salpingoopherectomy
remove fallopian tubes (salpinx) and ovaries
risks for cervical cancer
early sex multiple partners immunosuppressed smoking DES in utero
tf
smoking is independently correlated w 4x inc risk of cervical cancer
t
possible pap results
normal LSIL low grade squamous epithelial cell HSIL high grade AGUS atyp glandular cell of undetermined sig ASCUS atyp squam cell undetermined sig
reflex f/u to ASCUS pap
HPV PCR using pap cells
atyp squam cell undet sig
sensitive test means few…
false negatives (detects positive disease well)
specific test means few…
false positives (detects negative disease well)
this test to screen these pts for lung cancer
low-dose CT
55-80yo w 30py smoking hx
tf
screen routinely for ovarian cancer
f
don’t screen asymptomatic women’s ovaries USPSTF
key was that USPSTF differs from specialist society guidelines
USPSTF is strictly evidence-based
societies introduce expert opinion as well (and therefore bias)
screening mammo USPSTF guidelines
q2y 50-74yo
can start early depending on pt context
key breast lump hx
location how noticed how long nip disch change size (menstural?)
describe breast lump
number firmness mobility size borders
next diagnostic step cystic vs solid breast lump
fna cyst
vs
mammo solid
imaging to determine cystic from solid breast mass
us
causes of nip disch
preg
excessive stim
prolactinoma brca hormonal imbalance trauma abscess meds (antidep, antipsych, antihtn, opiates)
workup nip disch
mammo
us
ductogram
bx
imaging
prolactin lvl for milky
what age group has more false negatives mammo
young
denser breasts
harder to find abnorms
tf
mammo involves radiation
t
but negligible amount modernly
when is breast MRI indicated
screen if ^20% lifetime risk (gene testing, pedigree, radiation for hodgkin)
further dx of brca dx
w contrast for implants – mammo difficult
indications for breast US
eval abnorms
not for aymptx screening
tf
breast us used for screening
f
eval abnorms
not for asympx screen
brca risks
FH prolongued E v12 ^45yo, late first preg genes BRCA 1 or 2 age female inc breast density DHE in utero radiation obesity excess alcohol
is high or low breast density a risk for brca
high density
dec brca risk assoc
late menarche early menopause early preg high parity SERMs NSAIDs ASA
what dietary intervention prevents brca
dec alc
that’s it
avg age, range menopause
51 (40-60)
confirm menopause
no menstuation 12 consec mos
duration of perimenopause
2-8 yrs
perimenopauseal sympx
irregular menst
hot flashes
vaginal dryness
mood swings
how long do perimenopausal hot flashes last
30sec-10min
most common mood swing perimenopause
depression
calcium for women
1000mg pre menopause
1200mg postmenopause
ideally thru 3-4 servings dairy
inc calcium intake risks…
atherosclerosis
kidney stones
osteoporosis screening USPSTF 2016
^65 DEXA dual energy xr absorptiometry
v65 use fx risk tool, screen equivalent risk to 65 yo women no risks (9.3% in 10 years)
OP risks
vE (eraly menopause) sedentary prev adult fx FH OP fx smoking white
tf
black is risk for OP
f
white
tf
obesity is risk for OP
f
obesity high E actually protective
but inc risk for OA
tf
best to limit both saturated and trans fats
t
but sat worse
pack together
recommendation for healthy breakfast
whole grain
fruit
dairy or lean protein
6 stages of change
precontemplation contemplation preparation action maintenance relapse
when is mammo’s earliest detection relative to brca sympx?
1-2 years prior to mass palpable
USPSTF when to screen for DM
vs ADA
htn ^ 135/80
BMI ^25
tf
cluster ha rare in peds
t
1/10,000
what route of admin of triptans is most effective in peds
intranasal or dissolving tablet
preferred to po tablet
(possibly due to migraine assoc w GI absorptive issues…)
combined OCPs are CI in what kind of migraine
migraine w aura (estrogen is a problem..)
rhinosinusitis on diff for what kind of h/a syndrome
cluster headache
Flonase
generic
moa
use
fluticasone
corticosteroid nasal spray - antiinflammatory
allergic rhinitis
tf eye strain (refractive error) is a common cause of primary headache syndrome
f
evidence not good
maybe triggers, but not a Cause…
don’t hang your hat on it
tf
obesity is a risk factor for breast cancer
t
Gardasil is a vaccination against
HPV
HPV vaccination approved for ages
9-26
HPV vaccination names, strain coverage, how many shots, recommended age, approved age
Gardasil 6 11 16 18
Cervarix 16 18 31 45
3 shots both
recommended for females 11-18 ideally before sexual debut but approved for M & F 9-26 regardless of sexual activity
tf
sexual activity is a contraindication to HPV vaccination
f
optimally before or shortly after debut, but not a CI
4 letter mnemonic for preventive visits
RISE risk immunize screen ed risk factors immunizations screening tests education
6 most freq causes of death for 55 yo M in no order
cancer heart disease injury Dm chronic lung chronic liver
tf
travel history is important to obtain when working up an adult for CV disease
f
guidelines for freq of ASCVD risk factor assessment in pts free of ASCVD
q6-7 yrs in adult 20-79yo free of ASCVD
tf
recommendation for an annual preventive visit and physical exam is evidence-based
f
no RCTs
but 65% primary care agrees annual physical is necessary
periodic exams, not necessarily annually, for younger healthy adults, is reasonable – pts w chronic illness should also schedule periodic PREVENTIVE visits, not just disease management
tf
heart auscultation and routine labs are recommended for annual well-exams
tf
no evidence
but pts expect
physicians often provide
info for pt who does not wear seatbelt
don’t want to preach, but
MVA common cause of death
restraints can save life
can be a good driver and get hit by a bad driver
most accidents occur within 25 miles of home – frequent territory
three C’s of addiction
compulsion
control lacked
continue despite adversity
5 a’s of counseling behavior change
ask about the behavior assess interest advise - give options assist motivation arrange f/u
wellbutrin generic moa
buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion
zyban generic moa
buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion
budeprion generic moa
buproprion
blocks NE and D reuptake
(antidepressant)
NuDoprion
3 antidepressants commercial for buproprion used for smoking cessation
wellbutrin, zyban, budeprion
block NE and D reuptake
(antidepressant)
NuDoprion
Chantix generic moa
varenicline
partial neuronal a4 B2 receptor agonist that blocks nicotine stim of mesolimbic dopaminergic pathway, less dopa stim than nicotine, decreased craving and withdrawal
some S (serotonin) agonism of unknown sig as well
2 common oral pharm aids for smoking cessation
buproprion (wellbutrin = zyban = budeprion) NE D reup antag
verenicline (Chantix) partial nicotinic agonist
how helpful are oral meds such as buproprion (wellbutrin zyban budeprion) and varenicline (Chantix) for smoking cessation?
1.5-3x success of placebo for 12 month quit rate
fyi 2-3% quit rate wo med intervention
meds best in combo w group or on-on-one problem solving skills, social support, relaxation techniques etc
1st line pharm for smoking cessation
budoprion
varenicline has more SEs and reserved for budoprion failure or specific request
good types of questions to assess alcohol misuse, beyond quantifying
CAGE felt need to Cut down? Annoyed at critics? Guilty feelings ever? Eye opener ever?
diff folks diff susceptibility to alcoholism. best advice, don’t do it
also
friends fam ever express concern?
ever miss work because drinking?
is a glass of red wine good for you?
speculative
cultural studies confounded by lifestyle, exercise, diet, etc
mod alcohol known to raise HDL, but exercise or niacin (B3) can do that better
alc and resveratol may reduce platelet stickiness, but aspirin can do that better
research merited, consumption not recommended now, especially if taking other meds
mnemonic for dietary assessment
WAVE
weight, activity, variety (pyramid/groups), excess - salt, sugar (carbs), fat, cholesterol
tf
important to include sat and sun in food diary
t
often eat different on weekends
casual 3 q screen for intimate partner violence
f/u w 4q screen if concern
tell me about living situation
how are you getting along
do you feel safe at home
SAFE Stress/safe do you feel Afraid/abused have you ever Friends/fam are they aware/supportive Emergency plan do you have one, place to go, resources
2016 USA adult obesity rate
25%
BMI is used clinically as a surrogate for
% body fat
high total body fat is a risk for
DM
HTN
DLD dislipidemia
CVD
what body fat distribution is higher risk for CAD
abdominal
so measure waist and waist/hip circumference ratio
physical exam findings of dyslipidemia
- corneal arcus aka arcus senilis = ch dep in corneal stroma anterior to border of iris, white, gray, or blue, opaque
- xanthelasma =ch dep in skin typ around eye
- acanthosis nigracans = hyperpig of skin typ body folds
pe findings of atherosclerosis
carotid bruit
dec peripheral pulse
mnemonic for suspicious skin lesions
ABCDE assym border irreg color non-uniform diam ^6mm evolution
tf
zoster vaccine recommended for elderly
t
one does at 60yo
are varicella and zoster the same thing?
f
varicella = chicken pox kids
zoster = herpes zoster = shingles elderly
both caused by varicella-zoster virus
vaccines CI in immunocompromise, close contacts, and pregnant women
live attenuated ones
VZV
MMR
OPV (oral polio vacc)
strategy for keeping up with literature in family med
follow guidelines
read up on changes, see if you agree
USPSTF grading system
A - substantial benefit B - high certainty of moderate-substantial benefit C - benefit negligible D - No benefit or risks outweigh benefit I - insufficient evidence
A & B recommended
sti screen for sexually active men
HIV
syphilis
chlamydia
gonorrhea
consider hep B and C
tf
genital herpes screen routine for sexually active male
f
only if symptomatic
opt-out HIV testing recommended by
the CDC
tf
HIV testing requires informed consent
tf
only in some states
otherwise opt-out – tell pt it is routine and do it unless they refuse it
USPSTF grade for PSA screening
D - harms outweigh benefit
in average risk male
no demonstrated reduction in prostate ca deaths;
ED, bowel and bladder incont, false positive psych effect
societies suggest informed decision w doc
large RCT US and EU pending
one study suggested 1 prevented death takes 1055 screens and 37 treated cancers
patient practical concerns w colonoscopy
laxative prep ride home (sedated)
CRC screen guide
50-75 yo
w
FOBT
sigmoidoscopy or colonoscopy
reasonable to check fasting lipids in adults over 21 how often
q4-6y
fasting = 8 hours after last meal
when to screen well adult for OSA
obese
when to screen well adult for CKD
htn
with BMP
when to screen well adult for DM
age 45
or overweight BMI ^25
interpret EKG
RRAHI rate rhythm segments intervals axis r wave progress Q waves STD STE IT
tf
can consider exercise stress test in asymptomatic male
t ^45yo plus one of DLD HTN smoking FH early CAD
good prognosticinfo
ischemia EKG
STD
acute MI EKG
STE
prior infarct EKG
q wave
^ 25% R wave
^ 0.04 seconds
ischemia vs
acute MI vs
prior MI
on ekg
STD
STE
Q waves
instructions for buproprion smoking cess
set quit date start bup 1 week prior 1 qd 3 days, then 1bid morn and eve stop smoking on date add nicotine gum for bad cravings after 2 mos on pills, gradually stop
1800 quit now
smokefree.gov
try partnering up
how to handle “door handle” situation
quickly assess whether issue is life-threatening or requiring early follow-up. If not, at least ask a brief question to acknowledge the concern. Can have appropriate conversation at next visit.
patient has one or two v1cm tubular adenoma polyps with low-grade dysplasia on colonoscopy, recommend fu
colonoscopy in 5-10 years
what is a “small” polyp on colonoscopy
v1cm
manage high risk for ASCVD
asa 81mg
statin med-high dose
tf
location is a predictive factor for melanoma
f ABCDE assym border irreg color not same throughout diameter ^6mm evolving changing
chloraseptic sore throat spray generic and moa
phenol
depresses cutaneous receptors – local anesthesia
metaxalone moa
general depression of CNS
centrally acting muscle relaxant
metolazone class moa
thiazide diuretic
inhib distal tub na k resorb
leads to h secretion in cd I think
elidel generic moa uses
pimecrolimus
topical calcineurin inhibitor
(blocks proinflammatory cytokine transcription)
atopic dermatitis
off label lichen planus, psoriasis, vitiligo
triamcinolone topical moa uses
corticosteroid-responsive dermatoses
topical corticosteroid
induces PLA2 inhibitory proteins and thus inhibs release of AA and multiple inflammatory mediators kinins, histamines, pg.
antiinflam, aintipuritic, vasoconstrictive
ivermecitn use
antihelminthic
phymatous
sebaceous gland overgrowth
what is rosacea
skin disorder of various manifestations primarily localized over central face
4 types – erythematotelangiectatic, papulopustular, phymatous, ocular
centor criteria
tonsilar exudates tender anterior cervical LAN fever by history absence of cough modified - +1 age 3-14, -1 age ^45
likelihood of GAS group A strep inc w number of criteria (v3 unlikely GAS and should not get abx or dx testing)
Big study of 200,000, 1 crit 7% GAS, 2 21%, 3 38%, 4 57% GAS
Afrin generic moa
oxymetazoline
stims a, vasoconstriction
% presenting acute pharyngitis that gets abx for GAS vs % presenting acute pharyngitis that is GAS
70%
5-15%
RADT in context of strep
rapid antigen detecting test
rapid strep test
tessalon generic moa and use
benzonatate
antitussive
via topical anesthesia of airway stretch receptors
mucinex generic use moa
guaifenesin
expectorant +- antitussive
via hydration and decreased viscosity of resp mucus facilitating clearance but maintaining sol lyer for ciliary clearance
also inhib cough reflex hypersensitivity in URTI prob via sputum volum barrier to cough receptors
spell the word for frequent loose stool
diarrhea
augmentin generic
amoxicillin clavalunate
what is a neti pot
container to use home saltwater solution to drain in one nostril out the other ew
valium generic class
diazepam
benzodiazepine
Percocet generic
oxycodone acetaminophen
medicalese for breast pain
mastalgia
tf
it is common for brca to cause breast pain
f
uncommon, unless inflammatory breast cancer – visually obvious
1st line tx mastalgia
analgesics
supportive bra
7 causes of non-cyclical mastalgia
large pendulous diet lifestyle nonspecific post MP HRT ductal ectasia mastitis inflammatory brca hidradentitis suppurativa (acne inversa, occlusive follicular)
ductal ectasia
define
sx
tx
distended subareolar ducts due to inflammation not infection
- fev local pain tenderness from lipid penetration of duct wall
- Tylenol, ibuprof advil motrin prn, maybe try abx, sg and option but rarely necessary
how long pre bedtime to avoid alc and caffeine for good sleep
4-6 hours
how common is sleep apnea in the elderly
20-70%
common
breif definition rem sleep behavior disorder
sleep enactment behaviors from loss of REM atonia
what demo w hyperthyroidism frequently do not present w typical sx tachycardia weight loss and may require lab studies to detect the problem
elderly
advanced sleep phase syndrome define
typical demo
circadian rhythm progresses forward till drowsy 6-7pm waking 3-4am
common in elderly
tf
alc is an effective sleep aid
tf
initial sleep-inducing, few hours later stimulant/wake-up effect as levels fall
how to regulate diet for sleep hygiene
avoid heavy, spicy, sugary foods 4-6 hours before bedtime
a light milk or banana snack before bed may help (tryptophan)
tf
exercise helps deepen sleep
tf
can
but careful, within 2 hours of bed can impair sleep
what to do if can’t sleep
if can’t sleep in 15-20 min or wake up and can’t get back to sleep in 15-20 min
leave bedroom
tryptophan snack milk banana
quiet reading, bath, other quiet, not challenging
Ambien generic moa use
zolpidem
BZD1/GABA receptor agonist (not BZD class)
sedative hypnotic
(not anxiolytic, myorelaxant, anticonvulsant… BZD2 for those)
insomnia
define cognitive restructuring
psychotherapeutic learning to id and dispute irrational or maladaptive thoughts (cognitive distortions) eg splitting magical thinking over-generalization, magnification, emotional reasoning
define emotional reasoning
cognitive distortion in which person concludes that their emotional reaction proves something is true – amplifies other cognitive distortions
define magnification type cognitive distortion
mountain of molehill
over-reactive
histrionic
sleep restriction vs
sleep compression
therapy for insomnia
restrict in-bed time to recent average sleep time, no more. As sleep efficiency inc q5d can inc in-bed time by 15-20min till optimal sleep time
dec time in bed gradually to match total sleep time
safest most efficacious hypnotic drugs for elderly insomnia
zolpidem Ambien (non-BZD) melatonin-r agonists
antihist, antidep, anticonv, antipsych BEERS more risk than bene in elderly
common insomnia causes
environment not conducive drugs alc caf osa parasomnias (restles leg, periodic leg, rem sleep behavior) sleep-wake disturb jetlag night shift psych anx dep CP CHF COPD asthma pain pruritus GERD hyperthy adv sleep phase synd
tylenol pm generic moa uses
acetaminophen
diphenhydramine
-competitive H1 antagonist GI blood vessels resp tract… anticholinergic and sedative too
occasional insomnia allergies antitussive motion sickness parkinsonism common cold rhinitis/snz
% US w hypothyroid
5%
tf
htn
asthma
associated w depression
f
not more than genpop
% Parkinson disease that gets depression sx
60%
quick assessment of cognitive skill in pt w dimentia
mini cog > mmse
-orientation, mem, attn., naming, commands, write sentence, copy shape)
define hematochezia
brbpr
bright red blood per rectum
vs melena
gender more likely to attempt suicide
F
gender more likely to complete suicide
M
how do we know that physicians need to proactively ask about suicidal ideations in elderly?
75% of elderly suicides visited a PCP within the preceding month
tf
poverty is a risk factor for suicide
f
not by itself
rich folks get suicidal all the time
tf
ethnic minority is a risk for suicide
f
just no
but low socioeconomic status a risk for depression
MDD diagnostic criteria
5/9 sigecaps nearly every day ^2wks sleep insom hypersom interest anhedonia guilt inappropriate worthless energy down fatigue concentration down appetite change psychomotor retardation suicidal ideation recurrent or attempt
^ 2 mos grief loss
female isolation widowed divorced separated low socioec chronic disease uncontrolled pain insomnia functional impairment cognitive impairment risks for...
depression
tf
bringing up suicide topic may increase suicidality
f
allows opportunity to intervene
mnemonic for assessing suicide risk
and intervention needed
SAD PERSONS sex male age v19 ^45 depression previous attempt ethanol/substance abuse rational think impaired psychosis etc social support lack organized plan no sig other sickness
4-6 outpt tx, 7-10 hospitalize
6 SSRIs generic and comm
citalopram Celexa escitalopram Lexapro fluoxetine Prozac fluvoxamine Luvox paroxetine Paxil sertraline Zoloft
TCA moa
4 generic and comm
snri nortriptyline Pamelor amitriptyline clomipramine Anafranil doxepin Sinequan
MAOI moa
2 generic and comm
block sn catab
phenelzine Nardil
tranylcypromine Parnate
2 SNRIs generic comm
venlafaxine Effexor
Duloxetine Cymbalta
4 classes of antidepressants
SSRIs TCAs MAOIs SNRIs some random others
common SEs of SSRIs SNRIs
headaches sleep disturbance drowsy vs insom GI naus vom serotonin syndrome (leth, restles, hypertonic, rhabdo, renal failure, death risk) GI bleeding SIADH - hyponatremiasex dysfunc falls in elderly cit escit can cause QT prolong but not usually symptomatic
antidepressant class known to cause arrhythmias
TCAs
notrip amitrip clomip doxep
tf
ssris snris cause arthralgias
f
but depressed often complain of arthralgias
optimal approach to mgmt. major depresson
biopsychosocial bio psycho social pharm ssri or snri (9-12 mos initial, 2-3y recurrent, continuous multiple recurrences or elderly) psychother CBT or interpersonal id stressors, exercise
combo med and counsel best
ECT safe and effective, for psychotic depression or refractory nonpsychotic depression
how do antidepressants cause drug-drug interactions
through p450 system
ssri preg cat D
Paxil paroxetine
evidence of human fetal risk
most other ssris are preg cat C no human evidence but animal evidence however can use if benefit may outweigh risk
antidepressant discontinuation syndrome
20% pts after abrupt discont after at least 6 wks on, more likely w longer flu-like sx insom naus imbalance sens disturb hyperarousal
mild 1-2 wks, rapid extinguish w restart antidep
screen for medical causes of depression
CBC - anemia, vit defic
CMP - e-, renal, hepatic
TSH - hypothyroid
optional:
ESR - rheum
EKG - certain drugs eg TCAs QT prolong
common drug classes that can cause depression as SE
cv drugs chemo antiPD antipsychotic antianxiety/sedatives anticonvulsant antiinflam / antiinfect stimulants hormones others others others`
model for eliciting pt perspective on illness
ESFT
Explanatory model of illness from pt perspective
Social and financial barriers to adherence
Fears and concerns about illness or recommended treatment
Therapeutic contracting and playback
tf
immigrant Hispanics higher rates of depression than US-born hispanics
f
US born higher rates – comparable to other ethnic groups
Immigrants lower rates
define sandwich generation
caring for both parents and children
tf
dementia is a risk factor for abuse
t
tf
elder’s dependency is a risk for abuse
f
but Caregiver’s dependence on elder Is a risk
onset of effect of SSRI
perhaps as soon as 1 wk, full effects not till about 2 mos
adherence rate of elderly to antidepressant med
50%
so discuss challenges to adherence up front, answer questions, educate, etc
how do these differ in grief vs depression guilt thoughts of death worthlessness psychomotor retard functional impairment hallucinations
guilt - just actions taken or not at time of death
thoughts of death - just better of dead or wishing died with other
worthlessness - morbid preoccupation in MDD
psychomotor retard - marked in MDD
functional impairment - marked and prolongued in MDD
hallucinations - just voice/image of deceased
tf
suicidal behaviors increase with age
f
behaviors don’t
but completions do
increase w age
most common means of suicide in elderly
medication od
what etiologies of depression fatigue does CBC screen for
anemia
nutrition deficiencies
define “fully weight-bearing” eg in acute ankle inj pt
can take 4 steps independently
tf
hearing a snap or tear is diagnostically significant in an acute ankle injury
f
acute knee
not acute ankle
6 p’s of limb threatening injury
pain pallor pulseless paresthesia perishing cold (inability to reg own body temp) paralysis
how long post injury can acute pain and swelling limit physical exam?
48 hours
tf
acute ankle injury is one of most common MSK injuries in athletes and sedentary
T
20% of all sports injuries
this comprises 20% of all sports injuries in the US
acute ankle injury
next on diff after lateral ankle sprain?
peroneal tendon tear
also due to inversion injury often occurs w lat ank sprain
peroneus muscles and tendons origin course insertion function nerve a compartments
peroneus aka fibularis
- longus: fibular head, along fib, tendon post lat malleolus across bottom of foot to 1st cune and 1st met
- brevis: mid and dist 2/3 fib, joins long tendon post lat malle insert lat tuberosity of prox 5th met
- tertius: dist med fib joins ext pol longus tendon along dorsum to dorsal prox 5th met
long brev lat comp sup fib/pero n fib a evert plantarflex
tert ant comp deep fib n ant tib a evert dorsiflex
peroneal in the leg aka
fubular
diff fibular fracture from lat ankle sprain or peroneal tendon tear
more inability to walk, more pain, more deformity, xr
big concern w talar dome fx
avascular necrosis from interruption of blood supply – can miss on first xr repeat imaging if sx persist
instability in acute ankle sprain suggests…
maneuvers to test…
ATFL + CFL tears
PTFL is strongest lateral lig and rarely injured in inversion sprain
anterior drawer ATFL
inversion stress CFL
medial ligament of ankle aka
deltoid ligament 4 parts PTTL TCL TNL ATTL
what stabilizes medial ankle
DL (PTTL TCL TNL ATTL)
bony mortise
define mortise
recess cut into a part (mortise) to receive a corresponding projection (tenon)
aka the ankle joint
factors in grading ankle sprain
lig tear loss of function pain severity swelling severity ecchymosis weight bearing
grade ankle sprain
I - stretch/small tear, mild tend swell, slight to no funct imp, no instability
II - incomplete tear, mod funct imp, mod tend swell ecchymosis, mildmod instability
III - complete tear, severe swell (^4cm) ecchymosis, no weight bear, instability (no definite stopping point)
% ankle injuries to ed turn out to be significant fractures
15%
indications to image acute ankle or foot
ottowa rules (evidence based)
ankle xr if malleolar pain And one:
-bone tend post edge lat malle (med or lat)
-non-weight bearing immediate and ED
foot xr if midfoot pain And one:
- bone tend prox 5th met or navicular
- non-weight bearing immediate and ED
how sensitive are the ottowa rules
97-100%
for adults 18 and up
recently for 5 and up too
name midfoot bones
navicular w 3 wise cuneiforms distal
cuboid the retard laterally
test for high ankle sprain
cross leg test
tests tib-fib syndesposis… AITFL PITFL
tf
ankle sprains can take as long as fractures to heal
t
RICE for most MSK injuries stands for
rest
ice
elevation
compression
also ibuprofen with food (NSAIDS > placebo)
how long to Rice in ankle sprain
72 hours or less
may help with reduction of swelling and healing, then stretch, move, use
-too much rest dec ROM, persistent pain, swelling, chronic instability
best ankle support for sprain
aircast - semirigid for flex ext but limited inv ev
better than tape, elastic wrape
soft lace-up brace less support but good for mild w prev sprain or returning to sports
what exercises in particular help reduce reinjury of ankle
proprioceptive exercises
in for referral of acute ankle from fam med
fx disloc sublux tendon rupt syndesmotic inj nv comp wound pene locking sx disproport to traum unclear dx
rule out vaginal infection
pelvic exam and wet prep
what is a vaginal wet prep
vaginal discharge observed w wet mount microscopy
tf
in young f w typical sx of LUTI an no signs of UUTI you want + LE and + nitrates in UA before give abx
f
can treat empirically, uncomplicated UTIs common in young F
demo for acute achilles tendon rupture
middle-aged males
weekend warriors
how does acute achilles tendon rupture present differently from lateral ankle sprain
no inversion or trauma
e.g. middle-aged weekend warrior lands on ball of foot after taking shot, hears pop and immediate posterior pain
next step in mgmt. when compartment syndrome suspected
emergent fasciotomy
(maybe manometry if not so so concerning…)
DON’T WAIT can lose limb to ischemia
what has more weight in treating for UTI, constellation of sx or UA
constellation of sx
empiric tmp/smx 1tab bid 3d
cv causes of palpitations
arrhythmia
cardiomyopathy
hypovolemia
psych causes of palpitations
anxiety
panic attack
medication causes of palpitations
caffeine
stimulants
theophylline
albuterol
substance causes of palpitations
tobacco
caffeine
alcohol intox or withdraw
cocaine
endocrine causes of palpitations
hyperthy
pheo
hypogly
hematologic causes of palpitations
anemia
infectious causes of palpitations
febrile illness
heart beating
fast vs
hard
likely etiologies
fast more likely path (espec irregular) - anxiety, arrhythmia… but most folks w arrhythmia don’t complain of palps
hard - strong emotion, caffeine or other stimulant
tf
most folks w arrhythmia complain of palpitations
f
most do not
more anxiety (fast) or emotion/stimulant (hard)… but arrhythmia prob if irregular
but KEEP ON DIFFERENTIAL for fast
2 quickest q’s to screen for depression
bothered by feeling
down depressed hopless?
little interest or pleasure in doing things?
0 not at all 1 several days 2 more than half the days 3 nearly every day
score 0-6 w ppv 0 15% 6 79%
that’s PHQ-2, if 2+ complete full PHQ-9
PHQ in context of PHQ2 or PHQ9 stands for
patient health questionnaire - for MDD
diff hyperthyroid from anxiety
as cause of palpitations
both
tachy, tremulous, irritable, weak, fatige
hyperthy only
weight loss change stools (freq loose) change menses (light)
pts w anemia severe enough to cause tachycardia typically also report…
positional diziness
assoc signs and sx that suggest intoxication as cause of palpitations
dilated pupils
inc energy
inc bp
erratic behavior
tf
constipation is a sx of hyperthyroid
f
freq loose stools
tf heavy periods are a sx of hyperthyroid
f
lighter periods
hyperthyroid
7 common sx
4 less common but possible
heat intol tachyc fatig weight los tremor sweating exertional dyspnea
depression hyperreflexia freq loose stool light periods
lid lag
eyelid lags to adjust to eye movement eg look down have to blink to get eyelid down too
sign of hyperthyroidism
how does hyperthyroidism cause dyspnea
inc catab inc O2 consumption
7 causes of goiter
lack of idoine (#1 cause ww) hypothy (e.g. hashimoto) hyperthy (e.g. graves) nodules thyroid ca pregnancy (slight enlargement) thyroiditis (tender or nontender)
tendon in gentle ___ to elicit reflex
gentle extension (stretched slightly)
most common cause of hyperthyroidism in adults and children
toxic diffuse goiter (graves) - 60-80% majority
5% toxic nodular goiter
less thyroiditis, excess iodine (diet, amiodarone) causing thyroiditis
toxic diffuse goiter
aka
pathogenesis
findings
graves ai ab to TSH-R stims excess TH synth and release hyperthyroidism exopthalmos pretibial myxedema (dep of hyaluronic acid in dermis and sub-cu)
multi vs solitary nodular goiter demos freq
multi common ^40yo usually asymptomatic only 5% ca
single younger e.g. iodine deficiency
thyroiditis pathogenesis
viral illness, pregnancy, excess iodine (diet med amiodarone)
inflamed thyroid hormone leaks out
main objective in eval thyroid nodules
red flags
exclude malig (US and FNA) (5% malig)
M, v20 ^65yo, rapid growth, dysphag neck pain hoarse (local invasion), hx rad to head neck, fh thy ca polyposis (gardener’s - FAP var AD gi polyps, osteomas, skin soft tiss benign tumors)
Gardener syndrome
FAP familial adenomatous polyposis variant
AD
GI polyps, osteomas, skin soft tiss tumors
FAP familial adenomatous polyposis variant
AD
GI polyps, osteomas, skin soft tiss tumors
Gardener syndrome
causes of tender vs nontender thyroiditis
tender
infarct radiation trauma
nontender
ai med idiopathic fibrotic
drugs of drug-induced thyroiditis
amiodarone
IFN-a
IL-2
Li+
tf
thyroiditis always causes hyperthyroidism
f
eu hyper or hypo
how is radioactive iodine uptake affected in thyroiditis
usually reduced uptake
but can be eu hyper hypo thyroid
tf
TSH is usually sufficient to dx hyperthyroid or hypothyroid
t
but if primary pit path does not reflect circulating th so need to get T4 as well
TSH mildly elevated (5-10)
serum free T4 normal
dx
subclinical hypothyroidism
TSH normal
free T4 increased
dx
pit adenoma or
TH resistance
TSH inc
free T4 dec
dx
hypothyroidism
TSH dec
free T4 inc
dx
hyperthyroidism
TSH dec
free T4 dec
dx
central pit hypothyroidism
aka TSH or TRH deficiency
TSH dec
free T4 normal
T3 inc
dx
T3 toxicosis
TSH dec T4 inc, sx of hyperthy
next step?
propanalol (BB) for sx relief
radioactive I uptake test and scan (inc graves hot nodule, dec thyroiditis cold nodule)
antithyrotropin releasing abs (graves)
normal RAIU
radioactive iodine uptake
15-30% ingested dose
difference between TRAb vs TPOAb in graves vs hashimoto
TRAb anti thyrotropin (receptor) releasing antibody
97%sn 99%sp for graves
TPOAb anti TPO ab
elevated in 90% hashimoto 75% graves
when to get thyroid US
thryoid nodules
enlargement
NOT hyperthyroid – RAIU TRAb for that
why RAIU inc in graves
synth more th need more i
TRAb stands for
signifies
anti thyrotropin releasing antibiody
ab against TSH receptor stims TH synth and release
gender predom
age predom
graves
F 5-10x
(AI duh) - stress, high I intake, recent preg
40-60yo
anti thyrotropin releasing antibiody
ab against TSH receptor stims TH synth and release
most common manifestations of graves opthalmopathy are
eyelid retraction
exopthalmos
primary sx of eye manifestations of graves, when they occur, are related to
corneal irritation from eyelid retraction
tf
eye signs and sx of graves always bilateral
f
Mostly bilateral
but can be unilateral
tf
tx of hyperthyroidism improves eye manifestations of graves
f
does not cure eyes
some worsen after radioactive iodine… ppx w oral steroids after tx
tf
more than 50% graves pts have clinically sig eye problems
f
50% eye involv on MRI
only 20-30% clinically relevant
graves
mgmt
1st line (but pt pref.. euro med, us radio)
methimazole blocks ox of i and thereby T4 T3
1% agranulocytosis watch out
some improv 1 mo, 3 mos to full effect
stay on, dose fluctuates so freq bloodwork to check
2nd line
oral RAI - localized
few se… possible slight vasc mort or thy ca (preg breast feed CI absolute - damage to fetal infant thyroid – no preg 6 mos post tx no fathering 4 mos post tx)… stay away from v3yo kids and pregs 21 days post tx… flush toilet 2x excrete urine and sweat
eventual thyroid supplement w 1-2x/y bloodwork for dosing, but easy to manage usually
3rd line - sx
methimazole moa
blocks oxidation of iodine and thereby T4 T3
RAI radioactive iodine
tx
f/u
preg test
1m from v3yo preggos 21 days post dose
avoid in general don’t share bathrooms urine stool excr
transient soreness of neck or worsening sx resolve few days, some worsening eye sx
f/u remove propanolol if prescribed, q2-3mos blood draws till level stabilizes then q6mos+, alert to hypothy sx (weight gain cold intol pedal edema heavy periods fatigue) as will need supplementation at some point
common hypothyroid sx
fatigue cold intol weight gain pedal edema heavy periods
thryoxine aka
T4
start thyroid replacement
typical starting dose levothyroxine 1.5-1.8 mcg/kg
inc dose slowly, repeat TSH 6 wks
when TSH stable can check 1-2x annually
tf
gynecomastia is seen in graves
t
10-40% pts
inc sex hormone binding globulins we think
what % hyperthyroidism due to nodules
5%
usually asymptomatic
tf
most thyroid nodules are asymptomatic
t
tf
PaO2 is impacted in blood loss
f
tf
platelet count is impacted in blood loss
f
tf
LDH is elevated in gi blood loss anemia
f
elevated in hemolytic anemia
symptomatic hyperglycemia =
polyuria
polydipsia
relevant hx in diabetic
age and characteristics at onset -polyu polyd, dka, hhs, retinopathy on exam tx prev current response nutrition exercise DM education hypergly hypogly episodes awareness microvasc compx retinop nephrop neurop -sensory, foot lesions, ans dysfunc sexual gastroparesis psychosocial depression dental
diabetic exam and labs
bp dilated eye exam foot exam a1c ldl urine screen for nephropathy
tf
DM 1 and 2 both cause the same end damage and complications
t
organs to think about in DM
blood vessels
eyes heart brain nerves sensation autonomics
diabetics __ times more likely to suffer heart disease or stroke
2-4 times
tf
diabetes considered equivalent risk to prev MI
t
2-4 times more likely to have heart disease
worse outcomes after MI
most common cause of blindness among adults of working age
diabetes
prevalence of retinopathy in DM
40% pts requiring insulin
25% on oral agents
how long w DM does retinopathy dev
15 years
all T1DM
67% T2DM
tf
by the time vision is affected in DM substantial retinal damage may have already occurred
t
classifications of neuropathy
focal diffuse sensory motor autonomic
prevalence of neuropathy in DM
define
loss of ankle jerk reflex
7% 1 year
50% 25 years
for both T1 and T2 DM
% DM develop diabetic nephropathy
20-40%
most common cause of ESRD
DM
44% of cases in 2005
what type of DM more often develops
DKA
vs
HHS
T1DM - DKA
T2DM - HHS… but DKA possible when B cells exhausted insulin deficient eg elderly w longstanding T2DM acutely ill w pneumonia
HHS vs DKA which is life-threatening requiring prompt mgmt
both
mortality rate w HHS vs DKA
HHS 15% but up to 30% w serious infection
DKA 2% u65yo up to 22% ^65yo
tf
HHS in T2DM causes metabolic acidosis
f
pH ^7.3
DKA causes met ac
plasma glucose levels in HHS vs DKA
^600 HHS
~250 DKA
ketones in HHS vs DKA
absent or mild HHS
ketosis DKA
physical findings in HHS
severe dehydration
-excess 9L fluid deficit w serum osmolality ^320mOsm/kg
fluid replacement is key
most common cause of HHS in T2DM
and some other ones
infection aka pna uti w dec fluid intake
also stroke MI PE
who to screen for DM
ADA
overweight or obese + 1 other risk factor
or 45 yo regardless
q3 years afterward if 1st negative
USPSTF
sustained bp ^135/80 (B)
insufficient evidence if normotensive (I)
routine dx of DM
- randome gluc 200mg/dl + sx polyu polyd unexplained weight loss etc
- fasting gluc 126 repeat unless obvious sx
- hba1c 6.5 repeat unless obvious sx
- OGTT more sns more spec than fasting but difficult and poorly reproducible, not recommended for routine clinical use
% US pop w DM in 2011
raw US total w DM
% ^20yo w DM
% ^65yo w DM
8%
26 Million (19dxd 7undxd)
11%
26%
racial/ethnic risk factors for DM
native americans
african americans
latin americans
pacific islanders
dx prediabetes aka
why important to ID
impaired fasting glucose
fasting gluc 100-126
OGGT 2h 140-200
end-organ damage already occurring
can delay or prevent progression w lifestyle mod (lesser degree w medicine)
DM risk reduction in prediabetics after
intensive lifestyle mod
vs
info and metformin
58% risk reduction (11 year delay)
vs
31% risk reduction
5 biggies on physical exam for diabetes
eyes thyroid (dz can contribute to DM, HLD) heart lungs feet
tx diabetic retinopathy
laser photocoagulation
slows progression
does not restore lost vision
fundascopic findings in diabetic retinopathy
retinal hemorrhages (partial obstruction and infarct)
cotton wool spots (prior infarct)
microaneurysms (vascular dilation)
neovascularization = proliferative retinopathy = very bad
JNC 7 and 8 HTN classes
v120/80 normo
v140/90 pre
v160/100 stage 1 HTN
^160/100 stage 2 HTN
diabetic foot exam
inspect color hair loss scaling
inspect abrasions calluses ulcers infection
inspect bony abnorms
inspect footwear abnorm wear patterns and sizing
sense touch monofilament pinprick vibratory temp changes
pulses dorsalis pedis post tibial
achilles reflex
monofilament exam for DM
start by demonstrated on pt arm, observe buckling, sensation
close eyes
say now when feels pressure
test big toe 1st 3rd 5th metatarsal heads randomly on both feet
vibratory sns exam for DM
toe
then wrist, compare
can also compare sides
what to consider for abnorm vib or sense exam in DM
protective footwear
in addition to meds and lifestyle
hba1c represents
4-12 wk plasma gluc conc (via hb glycoscylation)
how often to get HbA1c in DM
2x/y pt stable meeting a1c goal v7
4x/y pt therapy changing or not meeting goal
why
how often
and how
to screen for diabetic nephropathy in DM
assess renal insuff, possible need to adjust renally excreted drugs to avoid tox (eg met ac from metformin)
annually
spot urine alb/cr ratio for microalbuminuria
serum cr and calculated GFR for monitor/stage CKD
when to get fingerstick glucose for DM in family med
if pt acutely complaining of hypergly or hypogly sx
not useful for assessing glycemic control… a1c for that
SE to monitor in metformin
tox from progressing renal insufficiency altering appropriate dose
B12 deficiency (unknown cause.. just data)
when to order TSH screen in DM
T1DM wo TSH in past year
new dx DLD
F ^50yo
tf
fasting lipid profile is important to obtain in DM family med
t
DLD common in DM
normal serum cholesterol
v200 mg/dl
normal fasting glucose
74-100 mg/dl
normal TSH
.4-4.2 microIU/ml
tf
controlling glucose as close to normal 4-6% a1c as possible has evidence of improving CVD outcomes that matter to pts
f
prevents microvascular retinopathy nephropathy
unclear if macrovascular benefit
(so goal is close to or less than 7% and tailor to pt aviod hypoglycemia and weight gain)
but lowering blood pressure v140/90 does macrovasc MI stroke mortality benefit
leading cause of death in DM
ASCVD
when to give statin in DM
what intensity
mod-intense statin for DM age 40-75
high-intense statin for DM age 40-75 and 7.5% 10 year ASCVD risk score
^21yo w LDL ^190 with or without DM
when to consider aspirin for DM
same as non DM
hx CVD
inc risk (men^50 F^60 w +1 other risk)
(dec chance MI or stroke should outweigh inc chance of GI bleed)
baby aspirin
dose
alternative if allergic
81mg aspirin
75mg clopidogrel
ADA algorithm for mgmt of T2DM
at dx a1c^6.5 = lifestyle + metformin
at assessment a1c^8 = add sulfonylurea (glyburide glipizide glemipiride) or basal insulin (insulin glargine [Lantus] insulin detemir [Levemir]) on intermediate-acting insulin (NPH)
at reassessment a1c^8 = add insulin if not already or intensify insulin; consider discont sulfonylurea to avoid hypoglycemia
then time to explore other tx options
tf
initiation of insulin should be viewed as a failure by physician or pt
f
course of disease that b cells function dec
that would be setting up for failure
can create barrier to insulin initiation
tf
dental care is important in DM
t
inc gluc in saliva
immunosuppression
periodontal disease can inc heart disease
vaccs for DM
flu like urbody else
pneumococcus for everyone, revacc if neprhotic, CKD, immunocompromise and at age 65 if last more than 5 years ago
Hep B for DM HIV other immunocompromise liver dz
yearly dilated retinal exam sensitive for detecting
retinal thickening from
macular edema or
early neovascularization
when to get optho consult for dilated retinal exam in DM
annually starting 5y post dx for T1DM
annually starting at time of dx for T2DM
(20% already getting retinopathy)
factors that contribute to hyperglycemia
overeating missed med dehydration infection illness stress
dx DM by OGTT
^200 2h post 75g glucose load
blurry vision in DM due to…
macular edema
transient dark spots in vision in DM due to…
retinal vessel hemorrhage
tf
glaucoma more likely in people w DM
t
40% more likely
assoc w nausea headache narrow vision halos around lights
AMS ddx in T2DM
HHS - dehydration gluc ^600 phv7.0
korsakoff syndrome - thiamine def alcoholic malnutrition
stroke - FND
1st line antihtn in DM
goal bp JNC8
ACEI renoprotective
v140/90
of htn dm obesity smoking
which causes the most deaths in us
smoking
single greatest contributor to death in US
450,000 annual premature smoking and 2nd hand smoke deaths
(lung cancer, MI, COPD)
300,000 Obesity (dec life expect mean6y R2-20y)
213,000 DM (CVD CKD)
20,000 HTN (uncontrolled dec LE 20y) (CAD, hypertensive cardiomyopathy, CVD, CKD)
key difference between leg swelling from
cellulitis lymphedema DVT
vs
venous insufficiency PAD
unilateral
vs
bilateral
tf
lymphedema can be unilateral
but
venous insufficiency is usually bilateral
t
tf
cellulitis always has fever
f
can be localized w/o fever
general diff b/tw strep and staph cellulitis
strep small breaks of skin
staph large wounds ulcers abscesses
tf
DVT is palpable
tf
sometimes cord of thrombosed vein palpable
Homan’s sign
pain on passive dorsiflexion foot
classic sign of DVT
but low predictive value - msk inj, cellulitis, venous insuff too
PAD what area does it describe
anything distal to arch of aorta
ankle brachial index consistent w PAD
v0.9
greatest modifiable risk factor for PAD
cigarette smoking
odds inc 1.4 q10cigs/day
rate of PAD in DM
half of pts w DM 20+ ys
usually below knees
how is d-dimer used in context of dvt
best to r/o dvt if pretest probability low
eg by Well’s criteria
-ca w/in 6 mos
-paralysis paresis -immobilization
-bed ridden 3 days recently (within 4 wks)
-entire leg swollen
-calf swelling ^3cm measured 10cm below tibial tuberosity vs contralat
-pitting edema
-collateral superficial (not varicose) veins
-alternative dx not more likely
low prob 0, mod prob 1-2, hi prob 3+
DVT
reflex cxr?
f
not without respiratory sx
precedes diabetic foot ulcer
pressure callus
grade diabetic foot ulcer by wegner system
and manage each
1 - skin - outpt deb care pres rel
2 - soft tissue - outpt deb care pres rel
3 - bone/abscess - eval osteomy PAD hospit
4 - forefoot gangrene - hosp, sg consx
5 - extensive gangrene - hosp, sg consx
% PE from DVT VTE
95%
deaths due to PE occur in what timeframe
within 1-2 hours usually
to treat DVT on outpt basis
pt must hemodynamically stable good kidney function low bleed risk stable supportive home env access to daily INR monitoring
tf
pt must not be on home O2 for outpt dvt mgmt
f
can be on home O2
tf
pt must not be diabetic for outpt dvt mgmt
f
can be diabetic
goals of DVT therapy
treat
stop clot
resolve clot
prevent clot
heparin or LMWH
advantages of LMWH vs unfractionated heparin
LMWH longer t1/2 so qd or bid sq no lab monitoring less thrombocytopenia dosing fixed can use outpt
tf
dosing is fixed w heparin
f
that’s LMWH
tf
lab monitoring is required with heparin
t
but not w LMWH
tf
heparin may be used in outpt
f
LMWH can
how is heparin administered
iv
“heparin drip”
dose warfarin in an adult
5-10mg qd
titrate to INR 2-3 q3-7d
how long to anticoagulate first idiopathic (unprovoked) DVT VTE PE in low risk pt
6 months at least
how long to anticoagulate first DVT/PE provoked by sx or transient factor
what if bleeding risk is moderate?
3 mos
still 3 mos
for low to mod bleed risk
how long to anticoagulate first DVT/PE unprovoked
6+ mos if low mod bleed risk
3 mos if bleed risk high
how long to anticoagulate first DVT/PE if assoc w active ca
6+ mos
what does it mean that LMWH dosing is fixed
once adjusted for body weight,
no further adjusting based on lab monitoring
tf
fixed dosing means everyone gets same dose
f
same dose/body weight
and then no adjusting based on labs necessary
how are pts w inherited coagulation disorders managed diff from others after first DVT/PE
indefinite anticoagulation
when to screen for inherited thrombophilia
1st thrombosis v50yo wo risk factor IDd
FH VTE
recurrent thrombosis
thrombosis in unusual vascular beds
tf
colon cancer is a risk of obesity
t
tf
gallbladder dz is a risk of obesity
t
tf
stroke is a risk of obesity
t
how many days for warfarin to reach steady state
5-7 days
t1/2 40 hours…. x4 = 6.6 days
when to check INR after starting?
~3 days
before steady state (5-7 days… t1/2 40 hours)
to make sure not supratherapeutic
but if subtherapeutic give more time
INR 11
what to do re warfarin regimen?
stop
give vit K 5mg orally to reduce INR (if INR^9)
significant bleed risk
what to do if warfarin INR supratherapeutic but not bleeding
5-9 no other bleed risk factors omit 1-2 doses
5-9 w other bleed risk factors omit 1-2 doses
—and give oral vit K 1-2.5mg)
9-20 omit several doses, give oral vit K 3-5mg
—monitor repeat K prn restart warf when down
^20 treat as bleed refer to ED
what to bridge to warfarin
when to stop bridge
UFH LMWH fondaparinux
5 days And INR therapeutic ^24h
when can steroid injections help OA
when there is joint inflammation
when to start screening for htn per USPSTF 2016
age 18
define htn
140/90 v60yo
150/90 ^60yo
end-organ damage in htn
stroke TIA retinopathy LVH angina MI HF CKD PAD
how does smoking contribute to CV disease
inc BP
interacts w CV drugs
what recreational drugs commonly affect bp
cocaine ketamine
narcotic withdrawal
smoking
alcohol
renal CV risk factors
microalbuminuria
GFR v60
how does stress contribute to bp
stim release of NE and AT II
tf
hx glaucoma is essential info in new htn dx
f
% US htn
essential (primary, idiopathic)
vs
secondary (identifiable cause)
95-98% essential
dx htn
2 elevated measurements 5 min apart one each arm (r/o aortic anomaly) two or more visits not ill beware whitecoat htn, get home measurements maybs
standardized BP measurement
seated quietly w back supported 5+ min
arm supported at heart level
cuff bladder length 80+% arm circ
width cuff 40+% arm circ
tf
for standardized BP measurement most adults should get adult-sized cuff
f
most adults now fat
may require xl or thigh-sized cuff
funduscopic findings to watch for in htn
which is a hypertensive emergency
a-v nicking cotton wool spots (infarct) flame hemorrhage exudates (fatty dep) papilledema (htn emergency)
panniculus
fat jelly rolls
medical for fat jelly roles
panniculus
manage htn in adult
^18yo
LIFESTYLE + non-black v60yo -ACEI ARB CCB or thiazide goal v140/90 black v60yo -CCB or thiazide goal v140/90 ^60yo -ACEI ARB CCB or thiazide goal v150/90 w CKD -ACEI or ARB goal v140/90 w DM -ACEI ARB CCB or thiazide goal v140/90
tf
can consider BB AB loop hydralazine (vasodilator) clonidine (central a2 agonist) for initial mgmt of htn
f
ACEI ARB CCB or thiazide initial mgmt.
BB AB worse outcomes in studies
loops, vasodilators, central a2ag not sufficient data
tf
CKD or DM elevates the target BP in htn mgmt
f just age (v60y 140/90 ^60y 150/90)
most cost-effective antihtn drug
hydrochlorothiazide HCTZ $4.30/mo
joint dz to watch for w thiazide diuretic
gout (hyperuricemia)
hydrochlorothiazide is what class of drug
thiazide diuretic antihtn
how does age influence urinary incontinence
dec bladder capacity dec awareness to void dec detrusor and pelvic floor muscle strength incomplete emptying atrophic urethra changes
tf
50mg HCTZ dec BP m and m more than 25mg
f
not per evidence
starting dose for HCTZ in elderly
6.25-12.5mg low does avoid hypotension
most other adults can start at 25mg
when is HCTZ not the antihtn of choice
in CKD
ACEI ARB
second best prognostic factor for death in all people
LVH
all people with or without htn
(age is #1 duh)
labs to get at dx of htn
EKG for arrhythmia IHD LVH UA for protein glucose alb/cr raio blood glucose hematocrit for low can make ischemia risk K+ ele for CI to ACEI ARB KSD ----- cushing hyperaldo Cr 9-12h fasting lipid panel for metabolic syndrome serum Ca for nephrolithiasis hyperPTH
antihtns that cause hyperkalemia
ACEI ARB KSD
lifestyle mod to dec BP most
weight loss
fascia lata of the thigh
deep fascia of thigh
encloses thigh muscles
separates with intermuscular septa
thickened laterally into IT band
IT band
iliotibial band / tract
fibrous thickening of latral aspect of fascia lata
associated with muscles that extend abduct externally rotate hip and laterally stabilize knee
origin anterolat iliac tub
imsert lat tib gerdy cond w glut max and tens fasc lat
normal fasting glucose range
65-100
normal plasma sodium
135-145
normal plasma K
3.5-5
normal plasma Cl
95-105
normal BUN
7-21
normal Cr
.8-1.3
normal total cholesterol
120-200
normal triglycerides
70-150
normal HDL
45-100
normal LDL
v100
normal lipid panel
T CH 120-200
TAG 70-150
HDL 45-100
LDL v100
tf
two arms needed for HTN monitoring
f
not for monitoring
but for SCREENING for HTN and aortic anom
what is considered an “elevated” 10 year ASCVD risk
^7.5%
in 2016, on what do we base cholesterol management
ASCVD risk score
pooled data from large cohort studies
USPTF aspirin recommendation
start in
men 45-79 to reduce MI
women 55-79 to reduce ischemic stroke
tf according to JNC8 you can manage htn by maximizing 1 med before starting another or starting another before 1st maxed starting 2 at the same time
t
all acceptable
but maximize double combo before starting 3rd
tf
doses of HCTZ above 25mg demonstrate improvement in BP and morb mort
f
25mg max useful dose per evidence
what to watch for in HCTZ pts
hyponatremia
gout
tf
BBs mask hypoglycemic strokes so avoid in DM pts
f
evidence not there in real world clinical situations
antihtn med to avoid in asthmatics
BB
to check before starting BB
EKG
pulse
BBs especially good antihtn in context of
tachyarrhythmia/fib
migraine
essential tremor
periop htn
tf
avoid BB in heart block
tish
3rd degree heart block
what degree is complete heart block
3rd degree
to watch in ACEI
K Na Cr (Cr up 35% allowed)
bradykinin cough in 15-20%
angioedema
avoid in pregnancy
first line antihtn in DM and kidney disease
ACEI
antihtn w heart remodeling effects
ACEI ARB
antihtn reduce albuminuria
ACEI ARB
to watch in ARB
avoid in pregnancy
tf
ARB causes bradykinin cough in 15-20%
f
ARB much less so than ACEI
antihtn potentially useful in raynauds
CCBs
to watch in CCB
leg edema (15-30%) CI short acting CCBs in essential htn and rug emerg
to watch in aldo antag
hyperkalemia
avoid in K^5 prior to start
(goes for K sparing diuretics too)
a-blocker use as antihtn
only as adjunct for refractory bp
possibly BPH but not first line
tf
prev and sev of htn is inc in AAs
t
special antihtn consideratin in AAs
less responsive to BB ACEI ARB
and more (2-4x) angioedema from ACEI
so prefer CCB and diuretics
unless CKD or 3rd or 4th line needed
ethnic groups w lowest BP control rates
mexican american
native american
when to consider referral to specialist for htn
can consider when
lifestyle mods appropriately adjusted and
not controlled to goal after 2 meds maxed
or CHF htnnephropathy or other end-organ damage
tf
htn = elevated blood pressure
f
htn is a diagnosis that requires 2 separate readings ^140/90 at least 1 wk apart
elevated bp is what you call one high read
preferred antihtn if known CAD or previous MI
BB thiazide
pt drinks 1-2 beers 5 days/week
will alc chess improve bp?
f
mod alc actually improves bp 2-4mmhg
but don’t encourage non-drinker to drink… could get problematic
DASH diet stands for
dietary approaches to stop hypertension
NIH-sponsored
tf
avoid ACEI in AAs, even those w DM
t
htn in AAs may not be ATII dependent
as it is in others
and AAs 2-4x more angioedema w ACEI
mnemonic for symptom characterization
OPQRSTA onset provocation palliation wuality radiation severity temporal elements associated sx
where can anginal pain radiate
neck throat jaw teeth
UE shoulder
tf
wide radiation of chest pain increases chances it is MI related
t
