final quiz Flashcards
final quiz studying
Seven rules of vaccination:
The more similar a vaccine is to the natural disease, the better the immune response to the vaccine.
Circulating antibody has more effect on the immune response to live attenuated vaccines than on the immune response to inactivated vaccines.
All vaccines can be administered at the same visit as all other vaccines.
Live attenuated vaccines generally produce long-lasting immunity with one or two doses. Inactivated vaccines generally require three or more doses and may require periodic boosting to maintain immunity.
Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine. Decreasing the interval between doses of a multidose vaccine may interfere with the antibody response and protection.
Adverse reactions following live attenuated vaccines are similar to a mild form of the natural disease. Adverse reactions following inactivated vaccines are mostly local, and may occur with or without fever.
two permanent contraindications to vaccination
Severe allergic reaction to a vaccine component or following a prior dose of vaccine. (Do not give another dose of that vaccine.) Encephalopathy without a known cause occurring within 7 days of a dose of a pertussis-containing vaccine. (Do not give another dose of a pertussis-containing vaccine.)
Temporary Contraindications to Vaccines
- Pregnancy (live)
- Moderate/severe illness (all)
- Immunosuppression (live)
- Antibody containing products (live)
Influenza
annually for life, two types of vaccine available – inactivated influenza vaccines (TIV) IM and live attenuated influenza vaccine (LAIV) intranasally.
Can use intranasal LAIV if less than 50, healthy, non pregnant and not high risk.
Over 65 use standard seasonal or high dose.
OK for women in their second/third trimester.
Do not give to those on chemotherapy, not within three days of pertussis vaccine, not during febrile illness, if using LAIV do not administer when nasal congestion is present.
LAIV should not be given to pts with chronic pulmonary, cardiovascular, renal, hepatic, neurologic/neuromuscular, hematologic or metabolic disorders, immune suppression, HIV/AIDs, children up to 18 years old receiving aspirin or other salicylates, or pregnant women.
TD/Tdap
Tetanus, diphtheria, pertussis - first dose to infants with boosters before age of 2. Then booster Td every 10 years for life substituting 1 Td booster with Tdap in adulthood (12, 22, 32, etc.)
All pregnant women receive Tdap regardless of history.
Uncertain history – give 3 dose primary series of Td with Tdap as one of the doses.
Adults 65 and older in close contact with children 12 months and younger, who have not already received Tdap or whose pertussis status is unknown SHOULD get single dose Tdap. All adults 65 and over MAY get single dose Tdap.
In wounds, if no completion of series may require passive immunity with Human TIG especially if wound is contaminated with soil containing animal excreta.
Varicella Vaccine
contains cell-free live attenuated varicella-zoster virus.
Breakthrough disease is common about 42 days or longer after vaccination.
When immunized in early childhood, a single dose is very effective, with an age related decreased in effectiveness.
All adults who do not have evidence of immunity should receive 2 doses 4 weeks apart. Pregnant women should be immunized if no immunity evidence once the child has been born but before leaving the hospital.
Special considerations to HCP, family contacts of persons with immune compromise and those at high risk for exposure or transmission
Zoster vaccination
live attenuated form of the varicella-zoster virus approved for use in adults older than 60, it is the same as the varicella vaccine but contains 14 fold higher concentration of the strain.
It prevents zoster in 50% of recipients and prevents neuralgia in 2/3 of the recipients.
Do not give to severely immune compromised patients (AIDS, immunosuppressive TX, corticosteroid use, ALL, active TB, blood dyscrasias, bone marrow malignancy and lymph malignancy. Hold dose if received IGG treatment in the last 5 months.
Do not give to pt with Hx of anaphylaxis to neomycin.
Contraindicated in those with anaphylactic reaction to gelatin, neomycin or any other component.
MMR
a live attenuated vaccine,
All children receive this at 12-15 months with a booster at 6years.
Adult health care workers without history of vaccination or evidence of immunity should received 2 doses.
severely immune compromised ppl should avoid,
pts on high dose oral corticosteroids should wait 1 month after cessation to be vaccinated, women should wait 1 mos after vaccination to get pregnant,
if receiving IgG must wait 3 months after end to get MMR,
TB skin test should postpone until 4-6 wks after MMR.
HPV vaccine
HPV4 (6,11,16,18) and HPV 2 (6,18).
HPV2 not indicated for males.
Gardasil given to both males and females. Cervarix only for females.
administer 3 doses after age 11 and before age 26 in women, through age 21 unless not previously immunized in males
Could be given as young as 9 yrs old
MSM between 21-26 years.
Second dose should be administered 1-2 months after first, the third dose should be 6 months only longer after the first.
Do not administer to pregnant women, ok for lactation, ok for immune compromised.
Pneumococcal
PPSV23 (pneumovax) is polyvalent mixture from the 23 most prevalent or invasive types. Recommended for all adults over 64, and for those 2- 64 years who have a chronic medical problem, immune suppression, or immunosuppressive therapyl smoker, asthma, or resident of a LTC or SN facility.
If first given before age 65, give one dose at age 65 or 5 years after first dose, whichever is later. No booster after age 65. Max 2 doses per lifetime.
PCV13 (Prevnar 13) was approved for use in children up to 10 years, should also be used in adults older than 19 with immune compromise, cochlear implants, CSF leaks or asplenia. In these adults never previously immunized, PCV13 is given and then followed by PPSV23 no sooner than 8 weeks later.
If previously immunized adult, if received PPSV23, then give PCV13 1 year after most recent dose. For those needing more PPSV23, it should not be administered until 8 weeks after PCV13 and 5 years after most recent PPSV23 dose.
Meningococcal vaccine
MCV4 (Menactra) Single dose should be administered at 11 years or prior to high school. Anyone at risk for meningococcal dz should be immunized – including college dorm living, military recruits, living in endemic areas, asplenia, or complement component deficiency.
MCV4 for age 55 and under. MPSV4 (Menomune) for those older than 55 years.
Do not use in patients with Hx of Gillian Barre!
Hepatitis A vaccine
administer routinely to children older than 1 year, with a second dose given 6-12 months later. Indicated for high risk individuals: IVDU, MSM, HIV, high risk work settings, those at risk for fulminant liver disease , recipients of clotting factors, HCPs, or those travelling to areas endemic.
Hepatitis B vaccine
Recommended for all infants, and children if not administered in infancy.
Adult with the following conditions should be vaccinated: diabetes, chronic liver disease, ESRD, household contact or sexual partner of HBV +, high risk individuals HIV, MSM, prisoners, IVDU, etc. individuals who receive blood products, hemodialysis patients, residents and staff of LTC and correctional Institutions, and immigrants/adoptees/family members where it is endemic. Some travel indication. Health care personnel and public safety staff
Under 20 dose at 0.5ml, over 20 dose at 1ml IM, 3 total doses, 2nd dose 1-2 mos after 1st, 3rd within 6 mos of 1st dose.
Polio vaccine
an inactivated, killed virus (IPV) given as .5ml IM, initial series should be done in early childhood. Offers lifetime immunity.
Should be offered to adults who travel to endemic areas, for lab workers handling virus, or healthcare workers in close contact with patients.
IPV dose can be given to adults who previously received OPV (oral polio virus – administered orally not in the states)
Avoid giving to pregnant women unless immediate protection is needed.
Rabies vaccine
give to those at high risk for animal bites, given as a series and started immediately after any bite. Rabies immunoglobulin gives passive protection when started after exposure to rabies.
Yellow fever
a live attenuated virus preparation which gives 10 years immunity for travelers and lab personnel with exposure risk.
Do not give to children younger than 9 months, do not give during pregnancy unless high risk of exposure.Do not give to those with immune disorders.
Avoid during lactation.
Typhoid vaccine
live attenuated product taken orally (Ty21a) or polysaccharide prep IM (ViCPS).
Give to those travelling to areas where endemic, India, Middle East and central Africa, those who expect contact with infected individuals, and in lab workers who handle it.
Do not give oral formulation to immunocompromised individuals.
Antimalarial drug proquanil should not be stared until 10 days after the oral dose.
Do not administer during acute gastroenteritis.
Primary prevention
is the promotion of well being and is targeted toward the well population. In primary prevention we are trying to prevent a person’s development of risk. This is the classic health promotion phase. Education on both an individual and community basis is key.
EG flouride treatments, folic aacid, immunizations, legal drinking age, condoms
Secondary prevention
is the early intervention phase, targeting those at risk or who have developed risk of illness. Interventions that occur when there is already disease but before there are symptoms, such as in pap, colonoscopy and mammography screening. In this phase we are trying to prevent progression to established disease and hospitalization/chronic management/acute processes.
Tertiary prevention
is essentially disease management. A person has an established disease, is rehabilitating to restore or maximize function, or is in continuing care for disease management. Goals include prevention for complications, reduction of disability. (ie support groups, chronic pain management, PT)
Positive predictive value
the proportion of people with a positive test result who have the target disease
Negative predictive value
the proportion of people with a negative test result who do not have the target disease
Prostate CA screening
second leading cause of cancer death in men over 50. PSA has a poor balance of specificity and sensitivity, identifies trends well.
Screen starting at age 50 for those without risk factors.
Discuss starting at 45 years for those that are African American or first degree relative with prostate CA before age 65, if multiple first degree relatives with Dx start at age 40.
Combine PSA and DRE in screening conversation.
Focus on prevention – maintain healthy weight, 30 min of vigorous exercise 5 or more times a week, eat at least 5 servings of vegies and fruits, 3 servings of whole grains, cut back on red meats, especially processed ones. Red flags include difficulty starting stream, erectile dysfunction.
Colorectal CA screening
Start at age 50 and stop at 75 if low risk
Start at age 40 if high risk.
Risk factors include personal history of cancer or polyps, strong family history, personal history of chronic inflammatory bowled dz, familial adenomatous polyposis, hereditary non-polyposis colon CA in family, African American, Ashkenazi Jews. If IBD, start 8-10 years after dz.
fecal occult blood test (FOBT) and fecal immunochemical test (FIT) every year, and
stool DNA test (sDNA) at uncertain interval. Colonoscopy should be done for any positive.
FOBT and FIT should be conducted with take home multiple sample. Do not do in office with rectal exam.
OR Tests that find polyps and cancer include flexible sigmoidoscopy (every 5 years), colonoscopy every 10 years, double contrast barium enema every 5 years, or CT colonography every 5 years.
Lung CA screening
low dose helical CT for high risk patients only = age 55-74, 30 pack years smoking, asymptomatic
Diabetes screening
start at age 45 if no risk factors,
stat at any age with BMI 25kg/m or over + one more risk factor,
if tests are normal, repeat testing at 3 year intervals.
Screen with fasting glucose, 2 hr glucose tolerance test or HbA1C. OGTT may be considered in patients with IFG (impaired fasting glucose) to better define risk.
Medicare will pay for a max of 2 screening tests in a 12 mo time period for pre-diabetics, only once for non-diabetics not previously diagnosed with DM.
Diabetes Diagnosis
HbA1C ≥ 6.5%,
fasting plasma glucose (FPG) ≥ 126,
2 hr glucose ≥ 200 during 75g glucose tolerance test,
or if pt has symptoms of hyper or hypoglycemia, random plasma glucose ≥ 200.
gestational diabetes
screen at first prenatal visit for those at risk or in 24-28 weeks of gestation using OGTT, women with GDM should cont screening 6-12 weeks postpartum (10% will get postpartum DM).
Impaired glucose tolerance (IGT)
by oral glucose tolerance test 140 – 199mg
Impaired fasting glucose (IFG)
FBG 110 to 125
High risk to develop DM type 2
IFG or IGT with one or more risk factors
Metabolic Syndrome
At least 3 of the following:
- Large waist – 40 inches or larger for men, 35 inches or larger for women
- High TGs – 150 or higher, or on treatment to reduce
- Low HDL – less than 50
- Hypertension – BP 130/85 or higher, or on treatment
- Hyperglycemia – fasting blood sugar of 100 or higher or on antihyperglycemics (about 85% of ppl with DM 2 have metabolic syndrome)
Treat Metabolic Syndrome
- Healthy lifestyle changes,
- Medications for BP, blood sugar, lipids,
- Blood thinning medications
- Heart healthy diet, increase physical activity, quit smoking
Modifiable risk factors for CVD
- Smoking
- Obesity
- Physical inactivity
- Diet
- ETOH
- Diabetes
Stages of change
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
LDL Goals
are determined by cigarette smoking, hypertension, Low HDL, Age >45 men or >55 women, family history of premature CHD
DASH Diet
“Dietary Approaches to Stop Hypertension” A combination diet that lowers blood pressure. It is rich in fruits veggies and low fat dairy foods, and low in saturated and total fat. Low in cholesterol and high in dietary fiber, potassium, calcium, and magnesium, and moderately high in protein. Based on a 2000 calorie a day need
Obesity – strategies for losing wt, and maintaining wt loss
- eating foods that help in losing weight
- recording foods eaten
- refusing food offered by others
- being able to stop eating when appropriate.
Mature Minor Rule
a minor may consent to receive medical care without the consent of the parents or guardian if deemed mature by the judicial system. In some states consent to care is based on the type of care the adolescent is seeking. Maternity services, contraceptive management, treatment and diagnosis of STDS, treatment od rug or alcohol problems and care related to sexual assault or mental health services may be independent.
Emancipation:
legal process in which a person under 1 petitions to have herself declared a legal adult, ending the parents duty to support, and right to make decisions.
Chlamydia
can infect the urethra and cervix can cause pain with urination or lower abdominal pain, can spread to tubes and ovaries, in men can infect urethra and epididymis, causing pain with urination, swelling and pain of the testicles. Spread by body fluids! treat with Abx and treat the partners
bacterial STDs
chlamydia, Gonorrhea, Syphilis
viral STDs
Herpes- HSV I and II, painful ulcers, or sometimes no symptoms
Hepatitis B - MSM at higher risk
Mollluscum Contagiousum – pimple like lesions often confused with acne or folliculitis
HIV
HPV - over 100 types of HPV virus, 20 cause warts or cancer, treat warts with patient applied creams aldara or condylox. Or freeze with liquid nitrogen, caustic chemicals or laser. PAPs detect if reflexive order – yearly pap if ever abnormal or HPV.
Cardiovascular Causes of Sudden Death in Young Athletes
- Hypertrophic cardiomyopathy
- Coronary artery anomalies
- Commotio cordis (i.e., blunt trauma to the chest causing ventricular fibrillation)
- Left ventricular hypertrophy
- Myocarditis
- Marfan syndrome (i.e., aortic root dilatation, aneurysm and subsequent rupture)
- Arrhythmogenic right ventricular cardiomyopathy
- Tunneled coronary artery
- Aortic stenosis
- Dilated cardiomyopathy
- Myxomatous mitral valve degeneration
- Mitral valve prolapse
- Drug abuse
- Long QT syndrome
- Cardiac sarcoidosis
- Brugada syndrome (a genetic disorder of myocardial sodium ion channels)
questions for the pre participation physical
Have you ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, or pressure in your chest during exercise?
Does your heart race or skip beats during exercise?
Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, or a heart infection?
Has a doctor ever ordered a test for your heart (e.g., electrocardiography, echocardiography)?
Has anyone in your family died for no apparent reason?
Does anyone in your family have a heart problem?
Has anyone in your family died of heart problems or of sudden death before 50 years of age?
Does anyone in your family have Marfan syndrome?
Emergency contraception
Progestin only emergency contraception
Levonorgestrel 0.75 PO 12 hours apart Single dose 1.5 mg
Prevents ovulation, prevents fertilization, does not disrupt any events that have occurred after fertilization
Must be used within 72 hours of event
Teens should be given a prescription
Some OCPs can be double dosed to effectively act as EC
scoliosis treatment
observation, bracing and surgery
Observation is the preferred for curves at low risk of further progression, and where the natural history is favorable (curves less than 20 degrees, or curves under 40 degrees after the child has reached skeletal maturity)
Bracing for curves with documented progression and where the child has not reached skeletal maturity. These curves are at risk for progression, and the goal of the bracing is to stop this progression.
Surgical treatment is reserved for curves which are out of balance or those in excess of 50 degrees.
Missed 1 OCP
take as soon as possible no backup needed
Missed 2 Pills in Week 1 or 2
Take 2 pills for 2 days and finish package
use backup for 7 days
Missed 2 Pills in Week 3
Sunday starters take 1 pill every day until Sunday then start new pack
Day 1 starter throw away rest of the pack and start a new pack on the same day
Use backup for 7 days
Missed 3 or more pills anytime
Sunday starters take 1 pill every day until Sunday then start new pack
Day 1 starter throw away rest of the pack and start a new pack on the same day
Use backup for 7 days
Geriatric functional assessments
Katx, index (dressing, bathing, toilet, transfer, feeding, continence)
Brthel index
Lawton IADL – prepare meals, housework, laudry, do you take Rx, go places beyond walking distance, shopping for groceries?
Functional Activities Questionaire – 5 sections, physical function of ADLs, phsychological function, role function, social function, variety of performance measures
Geriatric Cognitive Assessments
MMSE, minicog, clock drawing
osteoporosis prevention
- Calcium/Vit D supplementation
- Fruits and veggies
- Weight bearing exercises and muscle strengthening
- Measuring height annually
