family medicine Flashcards
how can hyperthyroidism cause secondary htn?
thyroid hormone->dec SVR->inc HR->inc CO->inc SBP
what are the cardiovascular effects of hyperthyroidism
- dec svr, inc hr, inc CO–>isolated systolic hypertension
- atrial fibrillation
- pulmonary htn
- congestive HF
what are the fundoscopic findings in a pt with htn
cotton wool spots (soft exudates)-occlusion of precapillary arterioles that supply the NFL–>ischemia->swelling of the NFL
arteriovenous nicking-narrowing of the retinal veins at the AV crossing
flame hemorrhages
hard exudates
hypertension physical exam what are you looking for
- thyroid
- lungs
- heart
- abdomen
- lower extremities
- neuro
thyroid-nodules, enlargement–>signs of hyperthyroidism a sign of secondary htn
lungs-crackles, dec breathe sounds, sign of CHF from long-standing htn
heart-inc HR, inc PMI (cardiomegaly), murmurs
abdominal-aortic bruits, pulsations, masses
lower extremities-pulses (PT, DP), lost of extremity skin, cold skin, thick toenails
criteria to diagnose htn
measure bp in each arm 5 minutes apart on 2 separate office visits
what % of people in the us are now considered hypertensive
45.6%
best htn drug for CKD. what is the target BP
ACEI or ARB–> block efferent arteriole constriction->inc GFR
goal: 130/80
best htn drug for Blacks
Thiazide diuretics or CCB are first line
for diabetics
No preference for the starting drug
htn drug options for the general population
Thiazides, Ca channel blockers, ARBs/ACEI,
What are the overall 1st line htn drugs
Thiazides (esp chlorthalidone #1)
Ca channel blockers
ACEI
ARBs
what is the target BP for all classes of htn
130/80
stage 1 hypertension
130-139; 80-89
stage 2 hypertension
140-159; 90-99
neuropathy prevalence is defined as
loss of ankle jerk for both type 1 and 2 DM
7% at 1 yr
50% at 25 yrs
which pain med is better for osteoarthritis, nsaids or acetaminophen
acetaminophen bc of better safety profile even though its not as effective
what is the appropriate dosing for acetaminophen
up to 4 grams divided up (short term)
up to 2-3 grams divided (long term)
most effective nsaid for osteoarthritis
diclofenac
side effects of nsaids
aki, hypertension, GI bleeding
details about intra-articular steroids for rx of osteoarthritis
-up to 3 per year
-consider when knee jt is inflammed (swelling, pain)
-short term benefit, few adverse SE
-
how should intra-articular steroid injections be administered
1 mL steroid with 3-4 mL anesthetic
Triamcinolone>methylprednisone
keep knee immobilized for 24 hours, but avoid prolonged immobilization
Glucosamine, chondrointin, plasma rich platelet, hyaluronic acid injections are
unlikely to provide substantial benefit for osteoarthritis
is acupuncture beneficial for osteoarthritis
mixed evidence, may provide short term benefit
which opioid can help rx osteoarthritis
Tramadol
- for older pts with moderate/severe pain
- lower abuse potential than other opioids
- lowers seizure threshold=Tramadol==tremors
what supplement has an anti-inflammatory effect to help with joint pain
omega 3 fatty acids
Medial or laterally directed patellar taping is conditonally recommended for pts with knee arthritis
Medial patellar taping only
USPTF guidelines: Abdominal aortic aneurysm screening
A one-time ultrasound to screen for an abdominal aortic aneurysm (AAA) is recommended in men 65 to 75 years old who have any history of smoking, but the USPSTF recommends against routine screening for AAA in women.
USPTF: hypertension
18 and older should be screened for elevated bp
usptf: colon cancer screening
age 50-75
- colonoscopy q 10 yrs
- sigmoidoscopy-only detects L sided colon cancer
- fecal occult blood test: can’t detect colon polyps
USPTF: excercise
recommend exercise age 65+ to prevent falls
USPTF guidelines: screening for childhood obesity
start at age 6 (Grade B)
% of kids btwn 6-19 who are overweight
15%
the evidence is poor, fair, or good that overweight kids 8 and older are at increased risk of being obese adults
FAIR evidence
dx of adhd
- dx no earlier than age 6
- sx last at least 6 months
- sx of inattention and of hyperactivity/impulsive:
- at least 6 sx or 5 sx after age 17
- symptoms interfere with life, present in 2+places (home, school), sx present b4 age 12,
compare nonasthmatic eoisinophilic bronchitis with asthma
- responds to inhaled corticosteroids like asthma
- normal spirometry, normal chest xray
- dx: induced sputum or bronchoscopy sample showing eosinophilia
initial evaluation of asthma should include what 4 things
- severity of asthma
- surrounding =environmental triggers
- skills and knowledge of pt for self-management
- support-offer appropriate medications
a cochrane review found that acarisides (insectiside that kills dust mites) and extensive bedroom based environ. control programs are effective at reducing what
allergic rhinitis–a comorbid condition of asthma
*not effective at controlling asthma though
best meds for allergic rhinitis
seasonal mild allergic rhinitis-nasal corticosteroids
seasonal mod/severe rhinitis-nasal corticosteroids+oral antihistamine
*allergy shots improve sx and dec medication dosage needed for both asthma and allergic rhinitis
most concerning effect of long term uncontrolled asthma
decreased reversibility of airway obstruction
Centor criteria
Criteria for likelihood of strep, whether to proceed with rapid strep test
C-cough absent +1 E-exudate +1 Nodes +1 T-Temp>38 (100.4) +1 OR -age less 14 +1 -14 to 45 0 greater 45 -1
which risk factor causes the most deaths in the US
-obesity, smoking, diabetes, htn
SMOKING
3 leading causes of smoking attributable death
lung cancer>ischemic heart disease->copd
_____is the single largest risk factor for cardiovascular mortality
htn
bmi>32
bmi of 30-35
bmi>40
double mortality rate of women over 16 yrs
reduces life expectancy by 2-3 yrs
reduces life expectancy of men by 20 yrs, women by 5 yrs
name of the criteria for DVTs
Well’s criteria for DVTs
- low probability: 0 or less
- moderate probability:1-2
- high probability: >3
For DVTs
-best predictive value (high sens, high specif)
-
- doppler ultrasound: expensive (high sens, high speci)
- D dimer test: protein fragment in the blood after thrmbus is degraded by fibrinolysis (high sens, low specif)–>rules out DVT if negative
Describe the classification system for ulcers
Wagner classification (DRUDGE)
Describe the classification system for ulcers
Wagner classification (DUDGE)
Grade 1-Diabetic ulcer (superficial)
Grade 2-Ulcer extension (ligament, tendon, jt capsule, fascia)
Grade 3-Deep ulcer with abscess or osteomyelitis
Grade 4-Gangrene of forefoot (partial)
Grade 5-Extensive gangrene of foot
Ulcer management
- Grade 1 and 2
- Grade 3
- Grade 5
Grade 1-2: outpatient management, wound debridement, relief of pressure, if infected (prurulent exudate, erythema) treat
Grade 3: partial hospitalization, eval for osteomyelitis/PAD prior to treating the ulcer
Grade 5: urgent surgery eval, amputation likely
some pts can manage DVTs outpatient. which ones need inpatient management
- can’t afford NOACs and LMWH
- cant get daily INR checks
- hemodynamically unstable (prior admission for GI bleeding)
why does warfarin admin first require admin with heparin
warfarin takes several days to reach therapeutic level, this is not ok, so we start LMWH then bridge to warfarin
what are NOACs
non vit k anticoagulants
- factor X inhibitors: rivuroxiban, atixiban
- can be admin as monotherapy
- pros: no lab monitoring needed, fewer bleeding episodes than warfarin
- cons: expensive, no reversal agent for bleeding
which is preferred for management of PEs and DVTs
-factor X inhibitors: argatroban, rivuroxiban»»warfarin
discuss direct thrombin inhibitors for managing PEs and DVTs
digabatran-must be overlapped with heparin bc hasn’t been studied as monotherapy
compare LMWH to unfractionated heparin
LMWH
- longer t1/2, can admin subcut 1-2x/day
- monitoring not req (can use outpatient)
- less risk of bleeding
- dosing is fixed
- dec risk of thrombocytopenia
UFH
- req monitoring (must use inpatient)
- shorter t1/2, better to use than LMWH in pt with risk of GI bleeding
what is the recommended duration of anticoagulation for first time PE, DVT
3 months no matter for all scenarios except….
-except if pt has underlying clottting disorder (protein c) or cancer pt–>indefinite length of time
benefits of hormone replacement therapy
- cognition, mood
- atrophic vaginitis (dyspaerunia)
- dec osteoporosis
- improves urinary sx (incontinence)
should you choose hormone replacement therapy for a woman to treat only osteoporosis
NO, bc USPTF reccommendation is D
what are the risks of using HRT
- for the first 1-2 years, inc risk of STROKE
- starting after age 60, inc risk of CAD
- combined E and P after 3 years–>inc risk of breast cancer
- unapposed E in females with a uterus–>endometrial cancer
USPTF mammogram screening
every 2 years from 50-74
USPTF colon cancer screening
50-75
- colonoscopy q 10 yrs, use for family hx, hx of polyps, abnormal bowel changes
- Stool DNA+fit test q 1-3 yrs
- sigmoidoscopy q 5 yrs
cervical cancer screening
- 21-30 q3 yrs
- 30-65 co-testing q 5 years or pap (cytology alond) q 3 years
*screening is not indicated for women in their 50s w/o risk factors
risk factors for endometrial cancer
htn, obesity, THYROID DISORDERS, diabetes, breast and colon cancer
- unappposed estrogen
- tamoxifen (SERM-Nolvadex)–>estrogenic effect on the uterus
Which panels should be checked for menopausal women with AUB
- thyroid panels-TSH. assoc with inc risk of endometrial ca
- FSH, LH: wil be inc in women in menopause
- TVUS-sensitive, cheap. <4 mm–>non-concerning
- CBC: rule out anemia, thrombocytopenia
- endometrial biopsy
what is the single best predictor of low bone mineral density
weight<70kg
