FINAL- Review Flashcards
policies, vaccines, seat belts, lifestyle changes, prophylaxis, fluoride
primary prevention
Screening → identify and treat diseases early
secondary prevention
prevent disease progression
tertiary prevention
who really has the disease (t= positive)
Ability of the test to identify correctly those who HAVE the disease
Sensi(+)ivity
who really does NOT have the disease (F=false)
Ability of test to identify correctly those who DON’T have disease
Specificity
Tells us the probability that a positive test result is correct.
Portion of people with + results, who truly HAVE disease
PPV
tells us the test is negative of someone who does not have the disease
Portion of people with (-) result that truly DON’T have disease
NPV
(Overall) often used for chronic conditions (how many people have the disease RIGHT NOW)
prevalence
(NEW) often used for acute conditions that do not have long duration (e.g. flu)- how many new cases in a given period of time
incidence
illness
morbidity
death
mortality
what is the triple aim?
quadruple aim?
improve health outcomes
reduce per capita costs
improve quality of care
+ improving the clinician’s or care teams experience
medical word recognition: testing for health literacy
Easy and fast to administer
REALM-SF
what test?
What is my main problem?
What do I need to do?
Why is it important for me to do this?
Ask me 3 test
Ice cream label test
Look at a nutrition label of ice cream and are asked 6 Q’s(calculation, general knowledge)
newest vital sign test
have patients bring their medications/review with provider for teach back
brown bag med review
must provide language services to all patients at no cost to them to improve access to care. No families translating for patients.
CLAS standards
kleinman 8 questions to utilize
- what do you call the problem
- what do you think caused the problem?
- why do you think it started when it did?
- what do you think the sickness does? will it have a long or short course
- how severe is the sickness? will it have a long or short course
- what kind of treatment do you think pt shoudl receive?
- what are the chief problems the sickness caused
- what do you fear most about the sickness
adult learning theory
problem oriented, internally motivated, self-directed. Have experience.
used to elicit behavior change in adults: increase the motivation for change then commit- patient driven not physician driven
Use open-ended questions
Listen with empathy
Avoid advice without permission
motivational interviewing technique
Prochaska’s Stages of Change
Precontemplation Contemplation Preparation Action Maintenance Relapse
erikson stage infant to -18 months
trust v mistrust
erikson stage toddler
autonomy v shame and doubt
erikson stage preschool
initiative v guilt
erikson stage school age
industry v inferiority
erikson stage teenager
identity v confusion
erikson stage young adult
intimacy v isolation
erikson stage middle age
generativity v stagnation
erikson stage elderly
integrity v dispair
who should get flu vaccine?
when?
Trivalent?
All adults
starting in the fall
trivalent flu if over 65
who should get Pneumococcal polysaccharide
Pneumovax 23 (PPSV23)
65 or older
If never received OR
Received 1 or 2 doses before age 65, and it has been 5 yrs since last dose
who should get Pneumococcal conjugate vaccines
Prevnar 13→ (PCV13)
19-64 if they... Smoke Chronic disease of heart, lung, or liver Diabetes Alcoholism Cochlear implant or leaking spinal fluid (PCV13) Spleen removed Sickle cell Weakened immune system Received organ or bone transplant
when do kids get Pneumococcal conjugate vaccines
Prevnar 13→ (PCV13)
All children younger than 2 receive 4 doses (2,4,6, & 12-15 mos)
who should get TDaP, Td
19 or older
Must complete 3 shot series
Booster every 10 years (& if dirty wound)
Administer during each pregnancy (27-36wks preferred)
TDaP if older and have grandbabies
who should get MMR ? when ?
Started at age 11-12; booster at age 16
(2 doses - 28 days apart)
Considered immune if:
Born 1957 or later (consider testing for immunity if born before)
High risk groups (healthcare workers, college students, international travelers)
who should get varicella vax
what is important to know?
All adults without evidence of immunity
2 doses. Attenuated virus
Avoid pregnancy for 1 month after vaccination
who should get Hep A Vax
People who travel or work outside US
Chronic liver disease, HIV, drug use, homeless
Within 2 weeks post-exposure
who should get Hep B vax
Household and sexual contacts positive for HBsAG, IV drug users High risk sexual behaviors Hemodialysis patients Chronic liver disease Healthcare personnel
when do kids get Hep B vax?
3 doses (0,1,6 mos)
If series not completed do not restart, just give until 3 doses received
4 weeks b/t doses 1 & 2
who should get Hib vax?
Not routinely recommended for all adults
Anatomic or functional asplenia
Elective splenectomy
Recipients of hematopoietic stem cell transplant
who should get Zoster (Shingles)
50 years and older
Shingrix preferred (2 doses 2-6 mos apart)
If previously received Zostavax (51% effective)- give Shingrix (90% effective)
RSV, shingrix, ZVL, Zostavax (Live Virus Vaccine)
CI for Shingles vax?
CI: pregnancy/breastfeeding; receipt of acyclovir, famciclovir, or valacyclovir 24 hours before vaccination
CI: Current shingles infection
what to do if a person is vaccinated with pneumococcal vaccine before age 65
give booster dose of Pneumovax (PPSV23) 5 years after initial dose
Blood Pressure
Screening recommendations ?
Age? considerations?
A
age 18
Take BP at home before treating
cervical cancer letter rating
ages 21- 65?
A for 21- 65
Colorectal letter rating ages
50-75
45-49
50-75 = A 45-49 = B
Time range? HSgFOBT or FIT\_\_\_\_ Stool DNA-FIT: \_\_\_ years CT Colonography :q\_\_ years Flexible Sigmoidoscopy: q \_\_\_ yrs Flexible sigmoidoscopy: q \_\_\_ yrs + \_\_\_\_ FIT Colonoscopy: q \_\_\_ yrs Gold standard
HSgFOBT or FIT yearly Stool DNA-FIT: 1-3 years CT Colonography :q5 years Flexible Sigmoidoscopy: q 5yrs Flexible sigmoidoscopy: q 10yrs + yearly FIT Colonoscopy: q 10 yrs Gold standard
HIV screening letter? ages?
A
15-65 (once)
more if high risk
abdominal aortic aneurysm letter screening? ages?
B
65-75 for men who have EVER smoked
ASA letter rating for ages 50-59
B
>10% 10 yr CVD risk
ASA letter rating for ages 60-69
C
>10% 10 yr CVD risk
ASA letter rating for ages <50
I
mammogram letter rating for women 50- 74
how often?
B
First degree relative with BRCA 1 or 2 mutation
Radiation to chest b/t 10-30yo
Li-Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba
Biennial (every other year)
mammogram letter rating for women 40-49
C
If woman chooses
mammogram letter rating for women +75
I
Depression letter rating for wat ages?
B
12+
IPV, Elder abuse letter rating
B
lung cancer letter rating
for ages 50-80
who?
B
20 pack year smoking hx & currently smoke
OR Have quit within past 15 yrs
what should someone get if they have 20 pack year smoking hx & currently smoke
OR Have quit within past 15 yrs
Annual screening w/ low-dose computed tomography (LDCT)
STOP if not smoked for 15 yrs
alcohol screening letter? ages? best screening tool?
B 18+ CAGE - Cut down - annoyed -guilty - eye opener
PSA letter rating for men 55-69
C
Weight benefits and harms w/ pt
PSA letter rating for men +70
Recommended against, typically not tx at this age
blood sugar rating level for ages 40-70
Risk factors
considerations?
B
Overweight or obese
Fam. hx DM, PCOS, gestational diabetes
American Indians Alaskan Natives
Asian Americans
Hispanics
Pacific Islanders
cholesterol testing letter recommendation?
No current recommendation for screening. Calculate 10yr risk of CVD. No optimal screening interval established
CVD risk 10% →
B recommendation for statin
CVD risk 7.5%
C recommendation for statin
what does healthy people 2020 say about cholesterol screening for men and women
Men age 35
Women age 45
Unless increased risk then start screening at age 20
EKG letter rating for low-risk pts? intermediate or high risk?
D for low risk pts
I for intermediate/ high
drug screen letter rating. ages?
I for 18+
hearing letter rating for ages > 50
I
Do screening test if any symptoms or if cognitive/ affective symptoms associated with hearing loss
vision letter rating
I
Perform Screening test if pt has symptoms of glaucoma
carotid artery stenosis letter rating
D
Recommends against screening in general population
Gonorrhea/chlamydia
(screen Without symptoms)
letter rating for Women: <24 or increased risk
B
Gonorrhea/chlamydia
(screen Without symptoms)
letter rating for men
I
HSV letter rating
D
Hep B letter rating
B - only high risk pop
Hep C letter rating
ages? considerations?
B
1 time screening adults born b/t 1945-1965
High risk pop
No vaccine available
what should you screen for 1 time in adults born b/t 1945-1965
Hep C
HIV letter rating
ages? consderations?
A
15-65
yearly or sexual contact
syphilis letter rating
A
if at increased risk
Prostate produces fluid for semen. If enlarged constricts urethra.
Clinical Manifestations:
Urinary frequency, urgency, difficulty
Nocturia
Difficulty starting urination
Dribbling AND straining with incomplete bladder emptying
BPH
Can ask patient to keep urinary diary or do International Prostate Symptom Score
Goal is to alleviate symptoms and slow progression. If no improvement refer to urologist (maybe TURP)
Does NOT correlate with prostate cancer
OTC medications for BPH that can cause urinary sx
Anticholinergics (benadryl) → impair bladder contractility
Sympathomimetics (pseudoephed) → increase urinary outflow resistance
Diuretics
what to know about PE for BPH?
Labs?
Digital rectal exam (prostatitis or nodules?) → prostate is symmetric, rubbery, and enlarged
UA, creatinine, PSA (infection or neoplasm?)
Behavior modifications for BPH
decreasing fluids before bed, avoid above OTC meds
Rx for BPH
alpha-adrenergic antagonists (alpha-blocker)–> relax bladder neck muscles and muscle fibers in prostate to allow for easier urine flow
Flomax
Rapiflo
what is First indicator of CV disease**
ED
what are organic, drug-induced and psychogenic causes of ED?
Organic: aging, diabetic neuropathy, multiple sclerosis, hypogonadism
Drug induced: SSRIs (Paxil), antipsychotics, recreational drugs, alcohol, beta-blockers, thiazide diuretics, smoking.
Psychogenic: anxiety, depression, relationship issues, stress
Drugs to tx ED
phosphodiesterase-5 inhibitors (viagra, cialis, levitra)
hard, fixed nodule. Often in teenage or young men with ℅ heaviness and tenderness in testicle. Usually painless
Testicular CA
Abrupt onset, extremely painful scrotum often with n/v. Affected testicle is higher. Absent cremasteric reflex. Younger men (10-20yo). Emergency!
testicular torsion
cessation of menses for 12 consecutive months
menopause
Hormone therapy approved for moderate to severe sx of menopause (hot flashes, night sweats, vaginal atrophy, prevention of osteoporosis)
If a pt with known menopause is bleeding it is _______ until proven otherwise.
cancer
- women with uterus must add _______ to any estrogen taken
progesterone
when to start screening for osteoporosis?
high risk pts?
age 65
long term steroid use, anorexia or bulimia, long term use PPIs (omeprazole), gastric bypass, celiac.
what causes osteoporosis
estrogen deficiency. Common in white and Asian women, thin, family hx.
When to treat osteoporosis
T-score -2.5 or less, or hx of hip or vertebral fracture
what is Female Athlete Triad: for osteoporosis
low weight, hx of amenorrhea, LBD
Osteoporosis Lifestyle risk factors
low Ca intake, vit D deficiency, inadequate physical activity Alcohol consumption (3+drinks/day) High caffeine intake Smoking (active or passive)
DEXA measures BMD of hip and spine
Osteoporosis=
Osteopenia=
Osteoporosis= T-score -2.5 or lower SD Osteopenia= T-score -1.5 and -2.4 SD
what does FRAX tell us
10 year probability of fracture
what is 2x more common in elderly?
adverse drug rxn
Reduce polypharmacy (more than 5 drugs) Beta blockers SE=depression Use BEERS CRITERIA when prescribing/deprescribing meds for older adults
For elderly when is baseline vision screening recommended?
Age 40
JNC 8 BP recommendations for > 60 yrs
< 150/ 90
screening tests to be done on elderly
AUDIT. CARET (more detailed than cage)
depression
TUG
Timed get up and go
FRAT
falls risk assessment tool
GDS
geriatric depression scale
MMSE
mini-mental status exam
IADL
instrument activities of daily living
alleviation of symptoms and suffering for people with serious illness to improve QOL (Not only for ppl with imminent death)
palliative care
care for someone with 6 mos or less to live. Provided when a person is no longer trying to cure illness.
hospice
specific wishes regarding a person’s care in the case they cannot make decisions for themselves
advanced directives
what age to start pap smear? interval?
21 ( 3 year intervals if normal)
is HPV needed for ages 21-29 routinely?
no, but order “reflexive HPV” so if PAP shows abnormality it can be done
when to start HPV co-testing with PAP? interval?
Start HPV co-testing at 30 (at 5-year intervals if normal)
when to stop PAP/ HPV testing?
Stop screening @ 65 if no CA hx and/or if total hysterectomy
what to do in a woman who has HPV, LSIL
colposcopy is preferred
when to give Gardasil?
what strains does it work on?
dosing schedule?
11-26 y.o - against 16/18
3 dose: 1 shot, 2 months, then 6 months
how often to screen for HPV/ PAP once a woman is 30?
Q5 years PAP and HPV together when last pap was negative and HPV was negative
… can do PAP Q3 but Q5 you should get HPV test
why is HPV not routinely recommended under 30?
common infection usually clears on its own
who should receive annual cervical cancer screening?
received DES in utero, hx Cancer, CIN 2
what kind of prevention is preconception care
primary care
How much folic acid for preconception?
400 mcg daily
total # pregnancies (including current)
Gravidity
total pregnancies beyond 20 weeks (the time pregnant, not number of fetuses; ie twins, triplets…) does not include current if not born yet
Parity
what is considered term pregnancy ?
37 weeks and beyond
what is considered preterm pregnancy?
20-36.5 weeks
male exposure to ZIKA
wait 3 months from initial symptoms or diagnosis
if no symptoms wait 3 months anyway
use condoms with sex
female exposure to zika
wait 2 months after initial symptoms or diagnosis (symptoms or not)
use condoms
what to do if male and female exposed to ZIKA
wait 3 months before pregnant
contraindicated vaccines during pregnancy
MMR (Rubella) Varicella Herpes Zoster Live, attenuated flu → live inactivated flu safe HPV
What vaccines should mom get right after delivery if not immune?
Rubella and Varicella
who should get Hep B vax?
high risk (STI, risky sexual behaviors)
Nagele’s Rule
LNMP - 3 mon + 7 days + 1 year
Prenatal visit schedule for low risk/healthy First visit \_\_\_\_\_ weeks Before 28 weeks:\_\_\_\_\_\_ Weeks 28-36: every \_\_\_ weeks Week 36- birth: \_\_\_\_\_
First visit 8-10 weeks Before 28 weeks: monthly Weeks 28-36: every 2 weeks Week 36- birth: weekly Total visits: 13
initial pregnancy labs to check
Beta Hcg
Blood type, Rh
Urinalysis c/s
Tx all UTIs
Check urine protein (pre-e)
CBC
Hgb/Hct
Titers
Rubella
Varicella
STI
HBsAg, HIV, gonorrhea,
chlamydia, syphilis,
herpesvirus 1/2when to give Tdap during pregnancy
between 27 - 36 weeks or after
when to screen for GD during pregnancy
results?
standard at 24-28 weeks, 1 hr get 50 gm if + of 130, do 3 hr100 gm.
If 2/4 blood tests are abnormal then they have GD. BS 140 or over- GD
what kind of BC while breastfeeding?
no estrogen!
NOT required prior to initiation of BC
PE, GYN exam, STI testing, lab testing (exception is IUD or fitting pt for diaphragm, need pelvic exam..)
stops ovulation (inhibits LH surge) and thickens cervical mucus
Combined Hormonal Contraception (estrogen and progesterone
same dose of hormones everyday
Monophasic
two different progesterone doses
Biphasic
dose varies weekly with a 7 day placebo for withdrawal bleed. Indicated for acne
Triphasic
84 days of hormone/7 days placebo pills
Extended cycle
Do not use if cigarette smoker over age 35!
NuvaRing
higher risk of VTE, releases higher levels of estrogen than oral pills
Transdermal patch
Absolute CI to Hormonal Contraceptives:
Hx DVT, factor V Leiden, major sx with prolonged immobilization
Smoker older than 35
Migraine with aura (increase risk of stroke) or migraine w/o aura at 35 years or older
Hx CVA
HTN
Liver disease/infection/inflammation
Cardiovascular disease (known or suspected)
Cancer
BC pt education
Use back up method for 7 days. Taking the pill on first day of menstrual cycle provides best protection
F/u visit 2-3 months after starting hormonal BC to check BP (estrogen can raise BP) or SEs
May have increased spotting, should decrease after 3 months. Nausea and breast tenderness are common and should resolve after first month
If breastfeeding: progesterone only contraception…no estrogen!
Drug Interactions with oral contraceptives:
Anticonvulsants: phenobarbital, phenytoin
Antifungals: (strong CYP3A4 inhibitors)
HIV/hep C protease inhibitors
Some antibiotics (ampicillin, tetracyclines, rifampin, clarithromycin
St. John’s wort: breakthrough bleeding
Indications of thromboembolic event:: ACHES
A- abdominal pain (clot in mesenteric artery- ischemic pain)
C- chest pain (MI?)
H- headaches (stroke/tia?)
E- eye problems/vision change (clot in retinal artery)
S- severe leg pain (DVT?)
causes cervical mucus to thicken, preventing sperm entry
Progesterone-Only Contraception
injection every 3 months
Not recommended for women who want to become pregnant in 12 months (takes up to 1 year to start ovulating after stopping)
Black Box Warning! Do not use more than 2 years d/t increased risk of osteopenia or
osteoporosis that may not be fully reversible. Avoid use in pts w/ hx of anorexia for this Reason. Recommend Vit D and weight bearing exercise while taking
Weight gain possible SE
Depo-Provera
thin plastic rod implanted in upper arm
Anti-seizure meds may lower effectiveness!
Implanon/Nexplanon
Safe for breastfeeding women!
Must be taken at same time EVERY day (3hr window)
Less effective than combined oral contraceptives, but safe option during breastfeeding, older
smokers, and diabetics w/ microvascular disease.
No grapefruit juice or use with hepatitis
Progestin-Only Pills (POP)
Works best when taken within 72 hours of intercourse, up to 5 days after intercourse. Available without prescription
Emergency Contraception (“Morning After Pill”)
progesterone
Paragard = Copper, effective up to 10 years
Mirena, Skyla, Liletta, Kyleena… different levels of progesteron. Effective 3-7 years
CI if PID, uterine or cervical abnormality, hx ectopic pregnancy
Pelvic exam indicated to check for string
Levonorgestrel
Warning signs in patients with IUD: PAINS
P- period late (Copper IUD), abnormal spotting, or bleeding beyond expected
A- Abdominal pain, pain with intercourse
I- infection exposure (STI), abnormal vaginal discharge
N- Not feeling well, fever, chills
S- String missing or shorter
what do Breastfed infants need starting at 4 months?
vit D, Iron
when does colon cancer screening start?
Screening begins at age 45→ update!
10 years prior (screening) to the age of family member being diagnosed
Or 45 years old for baseline screening for high risk individuals
what is never considered normal in women?
Incontinence
leading cause of death ages 20-34?
35-44?
20-34 Accidents Intentional harm (suicide) Assault (homicide) Traffic
35-44
Accidents
Malignant neoplasms
Heart disease
what is goal of cervical testing?
detect high grade squamous intraepithelial lesion (HSIL) → potential to develop into invasive squamous cell carcinoma of cervix
Signs of pregnancy
Positive:
- Palpation of fetus by clinician
- fetal visualization
- FHT
Breast changes, N/V, urinary frequency, fatigue, increase nasal, hegar’s sign- 6-8 weeks: softening of neck of uterus , Goodell’s sign- 4 weeks softening of cervix, Chadwicks’ sign
