FM

Question 1

What questions should be asked on a back pain history?

Answer 1

1) Where is the pain worst?
- Differentiate between back/buttock dominant and leg pain

2) Is the pain constant?
- If yes, need to rule out red flags

3)What increases your typical pain?

4) Is there anything you cannot do now because of your pain?
- Trying to screen for yellow flags to help ascertain psychosocial RFs

5) Have you had any unexpected accidents with your bowel or bladder since back pain started?
- Rule out Acute Cauda Equina

6) If age of onset <45 are you experiencing morning stiffness in your back >30mins?
- Screen for systemic inflammatory arthritis

Question 2

Back Pain Patterns

Answer 2

1. Back Dominant: worse with flex ion (+/-extension)>Disc Pain ex. Degenerative disc
2. Back Dominant: worse with extension> Facet Joint Pain ex. Facet joint OA
3. Leg Dominant: worse with any movement >Compressed Nerve Pain ex. Herniated disc
4. Leg Dominant: worse with standing and walking> Neurogenic Claudication/Spinal Stenosis

If doesn’t fit these patterns, likely non-mechanical back pain

Question 3

Acute Cauda Equina involves…

Answer 3

Urinary retention followed by insensible urinary overflow
Unrecognized fecal incontinence
Loss of saddle/perineal sensation

Question 4

Initial pharm treatment of mechanical back pain involves…

Answer 4

Acetaminophen followed by NSAIDs

Question 5

Back Pain Red Flags

Answer 5

“NIFTI”
Neurological: Diffuse motor/sensory loss, progressive neurological deficits, Claudia Equina syndrome

Infectious: Fever, IVDU, immunosuppression

Fracture: Trauma, OP risk, fragility #

Tumour: Hx of malignancy and constitutional sx

Inflammatory: chronic back pain >3mo, age <45, >30min morning stiffness, improves with activity, disproportionate night pain

Question 6

Back Pain Red Flag investigations

Answer 6

“NIFTI”
Neurological—MRI

Infectious—MRI + X-ray

Fracture—X-ray +/- CT

Tumour—MRI + X-ray

Inflammatory—Rheum Consult

Question 7

Yellow flag questions to ask about back/neck pain

Answer 7

1) Do you think your pain will improve or worsen?
2) Do you think you would benefit from activities, movement or exercise?
3) How are you emotionally coping with back pain?
4) What tx or activities do you think will help you recover?

Question 8

Systemic inflammatory arthritis screen for back pain (if morning stiffness >30 min)

Answer 8

• Age <45
• Insidious Onset
• Improves with exercise
• No improvement with rest
• Pain at night (improves with getting up)

Question 9

Non mechanical back pain can be related to:_____ or ______

Answer 9

Spine or Non-Spine

Consider referred pain from internal organs

Question 10

3 locations that mechanical neck pain can present

Answer 10

1. Neck
2. Shoulder
3. Arm

Question 11

What questions should be asked on a Neck Pain History?

Answer 11

1) Where is the pain worse?
- Neck vs Shoulder vs Arm

2) Is the pain constant?
- Rule out red flag sx

3) Assess for potential cardiac etiology
- Chest pain, Dizziness, SOB

4) Assess for associated symptoms and changes
- Surgical evaluation to r/o degenerative cervical myelopathy if changes in gait/walking/balance, fine motor issues, new onset tingling/numbness in arms/hands

5) Did neck pain begin with trauma, accident or fall?
- Check for concussion symptoms

6) Is there anything you cannot do now that you could before pain?
- Assess yellow flags, psychosocial risks

7) If age <60 at onset, do you have morning neck stiffness >30mins?

Question 12

Neck Pain Red Flags

Answer 12

“NIFTI”
Neurological: progressive neurological deficit, cervical cord compression, demyelinating process

Infectious: Fever, IVDU, Immunosuppresion, Meningismus

Fracture: Trauma, OP risks, fragility fractures

Tumour: History of malignancy and constitutional sx

Inflammatory: RA, PMR, GCA

Question 13

Neck Pain Red Flag Investigations

Answer 13

“NIFTI”
Neurological: MRI

Infectious: MRI + Xray

Fracture: Xray +/- CT

Tumour: MRI + Xray

Inflammatory: Rheum Consult

Question 14

Systemic Inflammatory arthritis screen for neck pain (if morning stiffness >30 min) involves….

Answer 14

• Age <60
• Insidious Onset
• Improves with exercise
• No improvement with rest
• Pain at night (improves with getting up)

Question 15

Treatment of acute/subacute back pain (<12 weeks) involves:

Answer 15

1) Patient education
2) Prescribe self-care (ex. Alternating cold and heat)
3) Encourage early return to work
4) Physical activity/exercise
5) Consider analgesics
6) F/U in 1-6 weeks, if not improving consider referral ex. Physical therapist

Question 16

In what order should analgesics be considered for acute/subacute back pain?

Answer 16

Acetaminophen> NSAIDs> Muscle Relaxants> Opioids

Question 17

Recovery position/Starter exercise for Pattern 1 back pain

Answer 17

Prone extension; 10 reps TID

Question 18

Recovery position/Starter exercise for Pattern 2 back pain

Answer 18

Seated back flexion; small frequent reps throughout day

Question 19

Recovery position/Starter exercise for Pattern 3 back pain

Answer 19

Z position; advise frequent position changes

Question 20

Recovery position/Starter exercise for Pattern 4 back pain

Answer 20

Rest in seated position; advise frequent sitting breaks and support with walking/standing

Question 21

Treatment of chronic back pain (>12 weeks involves)

Answer 21

1) Prescribing exercises
2) Analgesics
3) Community-based referrals ex. CBT
4) Consider additional options ex. Massage, aqua therapy
5) If mod-severe: opioids, consider additional referrals ex. Multidisciplinary pain program

Question 22

In what order should analgesics be considered for chronic back pain?

Answer 22

Acetaminophen> NSAIDS> TCAs or weak opioids> Tramadol> Strong opioids

Cyclobenzaprine can be used for flare ups

Question 23

Muscle relaxants not recommended for _____neck dominant pain

Answer 23

Chronic neck dominant pain

Question 24

Treatment of acute neck dominant pain (<3 months):

Answer 24

Educate, Reassure, Encourage early return to work, Independent exercises, consider referral to activity therapy as needed, 1-6 to sessions, analgesics (acetaminophen, NSAIDs, add/replace with cyclobenzaprine short term)

Question 25

Treatment of chronic neck dominant pain (>3 months):

Answer 25

Educate, Reassures, Active Rehab Therapy, 6-12 sessions of treatment, analgesics (acetaminophen, NSAIDs, add/replace with Antidepressants or Antiepileptics)

Question 26

Treatment of acute arm dominant pain (<3 months):

Answer 26

Educate, Reassure, Encourage early return to work, Independent exercises, consider referral to activity therapy as needed, 1-6 to sessions, frequent rest positions, traction, analgesics (acetaminophen, NSAIDs, Opioids, Cyclobenzaprine, add/replace with antidepressants, antiepileptics, consider methylprednisolone/dex for severe radiculopathy)

Question 27

Treatment of chronic neck dominant pain (>3 months):

Answer 27

Educate, Reassures, Active Rehab Therapy, 6-12 sessions of treatment, frequent rest positions, traction, analgesics (acetaminophen, NSAIDs, opioids add/replace with Antidepressants or Antiepileptics)

Question 28

Components of Neck Pain Physical Examination Include:

Answer 28

Standing-Gait and Neck Posture Sitting-Lymph node exam, Neck AROM, Shoulder AROM, Spurling’s Compression test, DTR (biceps and triceps), dermatomes/myotomes Supine-Cervical distraction test (+if arm pain relieved), UMN screening (Babinski and Hoffman)

Question 29

Components of Back Pain Physical Examination Include:

Answer 29

Gait- heel walk, toe walk Standing- movements in flexion, movements in extension, trendelenberg, repeated toe raises Sitting-Patellar reflex, quad power, ankle dorsiflexion power, great toe extension power, great toe flexion power, plantar response Kneeling-Ankle reflex test Supine-Passive straight less raise, Passive Hip ROM Prone-Femoral nerve stretch, Glut max power, saddle sensation, passive back extension

Question 30

If neuro exam normal then leg pain is____

Answer 30

Referred

Question 31

+ Straight leg test with reproduction of leg pain and possible abnormal neuro signs indicates:

Answer 31

Radicular (Nerve) Pain

Question 32

Minimum requirements of physical exam for back pain:

Answer 32

Movement testing in flexion and extension, patellar reflex, Great toe flexion and extension power, plantar response, UMN test, Passive SLR, Saddle sensation testing

Question 33

Differential for cognitive impairment:

Answer 33

Normal aging, Depression, MCI, Delirium

Question 34

What distinguishes MCI from Dementia?

Answer 34

Memory impairment with preservation of other cognitive abilities, slight or absent functional impairment, does not meet dementia criteria

Question 35

Criteria for major neurocognitive disorder:

Answer 35

1) Evidence of significant cognitive decline in one or more domain based on concern knowledgeable informant/the individual and a substantial impairment in cognitive function (as documented on a formal test or clinical assesssment) 2) Impacting independence of everyday activities 3) Not in the context of delirium 4) Not better explained by another mental disorder

Question 36

RFs for secondary causes of dementia include:

Answer 36

CVD, Afib, CVA, DM, Dyslipidemia, Head Trauma, HT, Family Hx of early dementia

Question 37

What physical exams should be performed to evaluate for secondary causes of dementia?

Answer 37

BP, Vision, Hearing, CV, Neuro

Question 38

Which lab investigations should be ordered in working up secondary causes of dementia?

Answer 38

CBC, lytes, Cr, TSH, Glucose, B12, Ca

Question 39

List indications for performing CT head in working up secondary causes of dementia?

Answer 39

Age <60, Rapid onset, Unexplained decrease in function, Unexplained neuro symptoms, Dementia <2 yrs, Vascular disease RFs, History of CA, bleeding disorder or anticoagulant use, Head trauma, Urinary incontinence and/or gait disorder early in illness, Gait disorder, Unusual Symptoms

Question 40

What is expected yearly decline in MMSE?

Answer 40

1-2 points per year with mild (21-26 score) and 2-4 with moderate (10-20)

Question 41

Which two classes of drugs are used to treat dementia?

Answer 41

Cholinesterase inhibitors (Donepazile, Rivastigmine, Galantamine) and NMDA receptor antagonists (Memantine)

Question 42

Cholinesterase inhibitors are used in ____

Answer 42

Mild-Mod dementia

Question 43

NMDA receptor antagonists are used in ____

Answer 43

Mod-Severe AD

Question 44

Side effects of cholinesterase inhibitors include:

Answer 44

GI upset, headache, dizziness

Question 45

Name 3 of the contraindications to cholinesterase inhibitors:

Answer 45

Sick sinus syndrome, severe renal/hepatic impairment, seizure disorder

Question 46

Side effects of NMDA receptor antagonists include:

Answer 46

Constipation, dizziness, headache, anxiety, confusion

Question 47

Skills for MI are:

Answer 47

OARS Open ended questions Affirmations Reflective listening Summary statements

Question 48

Spirit of MI involves:

Answer 48

PACE Partnership Acceptance Compassion Evocation

Question 49

Types of "change talk" include

Answer 49

DARN CAT ``` Prepatory Desire to change Ability to change Reasons for change Need to change ``` Mobilizing Commitment Activations Taking steps

Question 50

Patients with these conditions are at elevated CKD risk:

Answer 50

HTN, DM, CVD (age 60-75)

Question 51

Lab tests to be ordered in CKD workup

Answer 51

eGFR | Urine ACR

Question 52

If initial eGFR in CKD workup <60 then...

Answer 52

Repeat test in 3 months

Question 53

If initial Urine ACR in CKD workup is 3 or higher then...

Answer 53

Repeat 2 more times over next 3 months (2/3 random ACRs must be elevated)

Question 54

What should always be considered in CKD workup prior to retested eGFR and Urine ACR?

Answer 54

Reversible causes ex. NSAIDS, BPH/Retention

Question 55

Diagnosing CKD: 3 months after initial tests, eGFR is >60 and ACR <3. This means that...

Answer 55

Patient does not have CKD. | If DM, retest annually

Question 56

Diagnosing CKD: 3 months after initial tests eGFR is 30-59 and/or ACR 3-60. This means that...

Answer 56

Patient has CKD, requires management.

Question 57

Diagnosing CKD: 3 months after initial tests eGFR is <30 or ACR >60. This means that...

Answer 57

Patient has CKD. Consider Nephro referral.

Question 58

If eGFR <30 what tests should you order?

Answer 58

Urine R+M, lytes, Ca, Ph, Alb, PTH

Question 59

If ACR >60 what tests should you order?

Answer 59

Urine R+M and lytes

Question 60

If 3 months after initial tests eGFR is 30-59 and/or ACR 3-60, which additional investigations should be ordered and how often should eGFR and ACR be monitored?

Answer 60

Order lytes and urine R+M. Follow eGFR and urine ACR every 6 months (if eGFR stable after 2 years follow up yearly).

Question 61

If 3 months after initial tests eGFR is 30-59 and/or ACR 3-60, what are some reasons to refer to Nephro?

Answer 61

eGFR decline ≥ 5 within six months eGFR < 30 or ACR > 60 eGFR < 45 and ACR between 30 to 60 on 2 occasions 3 or more moths apart Inability to manage blood pressure Significant potassium disorder, RBC casts, hematuria

Question 62

What are three streams of management that should be implemented in patients with CKD?

Answer 62

1. Modification of CV Risk Factors - Lifestyle, smoking cessation - Start Statin if: age >18 with DM, Age 50 or greater w/o DM, age 18-49 w/o DM but known CAD, prior stroke, or FRS >10% 2. Minimize further kidney injury - Avoid nephrotoxins if possible - Sick Day Meds 3. Measures to slow CKD progression - BP and RAAS blockade with ACE or ARB

Question 63

Vertigo is a _____ sensation of one's surroundings or of one's self

Answer 63

Rotatory

Question 64

Classic vestibular symptoms include

Answer 64

1. Continuous dizziness or vertigo 2. N/V 3. Nystagmus and gait instability 4. Head motion intolerance

Question 65

Two features in a dizziness history that help to narrow differential.

Answer 65

Episodic vs Continuous Triggered vs Spontaneous

Question 66

Triggered Episodic Vertigo (lasting seconds to hours)> Perform ______> +ive means ____, -ive means______.

Answer 66

Triggered Episodic Vertigo > Perform Dix-Hallpike> +ive means BPPV (posterior), -ive means ?orthostatic hypotension

Question 67

Spontaneous Episodic Vertigo (lasting seconds to days) associated with hearing loss =

Answer 67

Meniere's

Question 68

Spontaneous Episodic Vertigo (lasting seconds to days) associated with migraine

Answer 68

Vestibular Migraine

Question 69

Spontaneous Episodic Vertigo (lasting seconds to days) associated with psych sx

Answer 69

Panic attack, Psych Condition

Question 70

Examination for episodic vertigo

Answer 70

Dix-Hallpike

Question 71

Examination for continuous vertigo

Answer 71

HINTS exam

Question 72

Continuous vertigo lasting days to weeks could be associated with these precipitants

Answer 72

Barotrauma or Toxin (meds)

Question 73

Spontaneous Continuous Vertigo with HINTS exam showing peripheral features, dx is....

Answer 73

Vestibular Neuritis

Question 74

Spontaneous Continuous Vertigo with HINTS exam showing central features, dx is....

Answer 74

Stroke/TIA

Question 75

HINTS exam findings for peripheral cause of continuous vertigo

Answer 75

HI: Corrective Saccade N: Unidirectional horizontal nystagmus TS: No deviation of covered eye

Question 76

HINTS exam findings for central cause of continuous vertigo

Answer 76

HI: No corrective saccade N: Bidirectional horizontal nystagmus, or vertical or torsional nystagmus TS: Vertical deviation of covered eye

Question 77

What is Benign Paroxysmal | Positional Vertigo?

Answer 77

``` Transient triggered (head motion) episodes of vertigo caused by dislodged canaliths in the semicircular canals ```

Question 78

What is Vestibular Neuritis

Answer 78

Spontaneous (no triggers) episodic vertigo caused by inflammation of the vestibular nerve or labyrinth organs; usually from a viral infection

Question 79

What is Meniere’s Disease

Answer 79

Spontaneous episodes of vertigo associated with unilateral hearing loss caused by excess endolymphatic fluid pressure in the inner ear

Question 80

What is Otosclerosis

Answer 80

Spontaneous episodes of vertigo caused by abnormal bone growth in the middle ear and associated with conductive hearing loss

Question 81

What is Vestibular Migraine

Answer 81

Spontaneous episodes of vertigo associated with migraine headaches

Question 82

Cerebrovascular | Disease causes vertigo by...

Answer 82

Continuous spontaneous episodes of vertigo caused by arterial occlusion or insufficiency, especially affecting the vertebrobasilar system

Question 83

Cerebellopontine | Angle

Answer 83

Continuous spontaneous episodes of dizziness caused by vestibular schwannoma (acoustic neuroma) > meningioma > others

Question 84

Tx for BPPV

Answer 84

Epley

Question 85

Tx for Meniere's

Answer 85

Salt restriction Diuretics Vestibular suppressants/antiemetics Betahistine

Question 86

Tx for vestibular neuritis

Answer 86

Vestibular suppressants (antibistamine, antiemetics, benzos) Vestibular rehab Can consider steroids

Question 87

Diagnostic criteria for Meniere's

Answer 87

1) 2 episodes of spontaneous rotational vertigo lasting min. 20 mins 2) SNHL 3) Tinnitus and/or aural fullness

Question 88

What are the 4 D's of Vertebrobasilar Insufficiency

Answer 88

Drop Attacks Dysarthria Dizziness Diplopia

Question 89

Tx for vertebrobasilar insufficiency in the context of vertigo

Answer 89

Antiplatelets and reduce cerebrovascular risk factors

Question 90

Examples of ototoxic meds

Answer 90

Aminoglycosides and Furosemide

Question 91

When is imaging indicated in vertigo work up?

Answer 91

When there is any abnormal neuro findings, including asymetric or unilateral hearing loss . Need CT (CT/CTA) or MRI (MR/MRA).

Question 92

30/20/10 rule for orthostatic hypotension

Answer 92

HR Increase 30 bpm SBP decrease 20mmHg DBP decrease 10mmHg

Question 93

What physical exam maneuvers should be included in vertigo workup?

Answer 93

1) Orthostatic BP 2) Cardiac 3) Neuro 4) Nystagmus 5) Dix-Hallpike

Question 94

Which imaging modality is best for diagnosis in vertigo?

Answer 94

MRI as it can visualize the posterior fossa better than CT

Question 95

What is Acute labyrinthitis

Answer 95

Inflammation of the labyrinthine organs caused by viral or bacterial infection Acute vestibular neuronitis (vestibular neuritis)* Inflammation of the vestibular nerve, usually caused by viral infection

Question 96

What is Cholesteatoma

Answer 96

Cyst-like lesion filled with keratin debris, most often involving the middle ear and mastoid

Question 97

What is Herpes zoster oticus (Ramsay | Hunt syndrome)

Answer 97

Vesicular eruption affecting the ear; caused by reactivation of the varicella-zoster virus

Question 98

What is Perilymphatic fistula

Answer 98

Breach between middle and inner ear often caused by trauma or excessive straining

Question 99

What are some red flags on a cough/dyspnea history?

Answer 99

Weight Loss Hemoptysis Fevers/Night Sweats Travel/TB exposure Occupational Hazards

Question 100

Signs of respiratory distress

Answer 100

- Tachypnea - Pursed lip breathing - Accessory muscle use - Tripod position - Wheezing, audible breathing

Question 101

4 acute causes of cough/dyspnea

Answer 101

1. Infectious 2. Post-Viral 3. Airway Irritants 4. Exacerbation of Chronic Illness

Question 102

Tx for post-viral cough

Answer 102

inhaled bronchodilators +/- ICS

Question 103

9 chronic causes of cough/dyspnea

Answer 103

1. Asthma 2. COPD 3. HF 4. Infectious (TB) 5. Post-nasal drip/rhinitis 6. Bronchiectasis 7. GERD 8. Medication (ACEi) 9. Lung Cancer

Question 104

Presentation of post-nasal drip/rhinitis may include

Answer 104

Nasal discharge Nasopharygeal secretions Throat Clearing Sensation of dripping down throat Nasopharyngeal Cobblestoning

Question 105

Tx of post-nasal drip/rhinitis may include

Answer 105

Oral antihistamines Oral decongestants Intranasal corticosteroids Intranasal Ipratropium bromide Leukotriene receptor antagnoists Abx as indicated

Question 106

Presentation of GERD may include

Answer 106

Epigastric burning, bitter taste, cough, belching, bloating, early satiety, regurgitation, norcturnal symptoms, improvement with food (ulcer), dysmotility (worse with food)

Question 107

Tx of GERD may include

Answer 107

Lifestyle Changes H2 blocker or PPI or antacid

Question 108

Bronchiectasis may be ____ or ____

Answer 108

Focal (often from prolonged or sever LRTI) Multifocal (may be secondary to MAC)

Question 109

Red flags for bronchogenic carcinoma on a cough history include

Answer 109

Hemoptysis Weight loss Cachexia Abnormal imaging

Question 110

3 types of medication that may induce cough

Answer 110

ACEi, BB, Amiodarone

Question 111

Precipitating factors of GERD include

Answer 111

Diet, Caffeine, High fat diet, excessive EtoH, smoking, certain medications (ex. NSAIDs)

Question 112

What are most probable pathogens in AECOPD?

Answer 112

H.flu, M. Cat, Strep Pneumo

Question 113

Obesity in Men = WC > ___

Answer 113

102cm

Question 114

Obesity in Women= WC >___

Answer 114

88cm

Question 115

BMI Classification: - Underweight=___ - Normal=___ - Overweight=___ - Obesity I=____ - Obesity II=___ - Obesity III=___

Answer 115

- Underweight <18.5 - Normal 18.5-24.9 - Overweight 25-29.9 - Obesity I 30-34.9 - Obesity II 35-39.9 - Obesity III 40

Question 116

Potential target organ damage associated with obesity inclues

Answer 116

1. CVD (HTN and CAD) 2. Cancer 3. T2DM 4. OA and back pain

Question 117

What are the components of the adolescent history?

Answer 117

HEEADSSS ``` Home Eating/Exercise Education/Employment Activities Drugs Sexuality Suicide Safety ```

Question 118

What are 11 things that we should question based on choosing wisely?

Answer 118

1. Don't order imaging for lower back pain w/o red flag sx. 2. Don't use abx for URTIs that are likely viral or self-limiting. 3. Don't order screening CXR or ECG for asymptomatic/low risk outpatients. 4. Don't screen with Pap if age <21 or >69. 5. Don't do annual screening blood tests unless indicated by risk profile. 6. Don't routinely measure VitD in low-risk adults 7. Don't routinely screen with mammo for average risk women age 40-49. 8. Don't do annual physical exams on asymptomatic adults with no sig. risk factors. 9. Don't order DEXA screening for OP on low risk patients. 10. Don't advise non-insulin requiring diabetics to do routine SMGB between office visits. 11. Don't order thyroid function tests in asymptomatic patients.

Question 119

What are some discussion topics at a periodic health exam?

Answer 119

New concerns, chronic illness status/follow-up, Lifestyle (helmets, seatbelts, EtOH, Tobacco, Drugs, contraception), safety, screening, +/- ROS

Question 120

Populations not to miss in cervical cancer screening include

Answer 120

Pregnant women, Women who have sex with women, subtotal hysterectomy with retained cervix, transgender individuals with cervices

Question 121

What are the recommendations for cervical cancer screening?

Answer 121

Pap test (cytology) starting at age 25 for sexually active women. Repeat every 3 years if screens negative. Stop at age 70 if the last three consecutive tests w/i the past 10 years have been negative.

Question 122

When should a patient being screened with Paps be referred to colpo?

Answer 122

If cytology shows HSIL, ASC-H, AGC, AIS

Question 123

What is the next step for a patient who screens positive for LSIL or ASCUS on cytology?

Answer 123

1) Repeat cytology in 6 mo. If normal, Repeat again in 6 mo. If normal again, return to q3years. 2) Repeat cytology in 6mo. If abnormal, send for colpo. 3) Repeat cytology in 6 months. If normal, repeat in 6 mo. If abnormal, send to colpo.

Question 124

What are the high risk criteria for breast cancer?

Answer 124

Personal Hx BC, 1st degree relative with hx BC, known BRCA1/BRCA2 mutation, history of chest wall radiation

Question 125

What are the screening recommendations for breast cancer?

Answer 125

Avg Risk Age 50-74: Screen with mammography every 2-3 years. High Risk Age 30-69 : Screen with mammography and breast MRI every year

Question 126

What are the high risk criteria for colorectal cancer?

Answer 126

Personal Hx CRC or adenomatous polyps, 1st degree relative with hx CRC, IBD, Adults with hereditary syndromes predisposing to CRC (FAP or HNPCC)

Question 127

What are the screening recommendations for colorectal cancer?

Answer 127

Avg Risk Age 50-74: FIT every two years (consider flex sig/colonoscopy every 10) High Risk: Screen with colonoscopy at Age 50 or 10 years before the dx of the relative. If family member dx before Age 60, screen every 5 years. If family member dx after age 60, screen every 10 yrs

Question 128

List some risk factors that would lead one to screen for osteoporosis in a pt age <50?

Answer 128

Fragility fractures, Use of high risk meds, Hypogonadism, Malabsorption syndromes, Chronic Inflammatory conditions, Primary hyperparathyroidism, Other disorders strongly associated with rapid bone loss or fractures

Question 129

List some clinical risk factors for osteoporosis?

Answer 129

Fragility fracture after Age 40, Prolonged use of glucocorticoids or other high-risk meds, Parental hip fracture/vertebral fracture/osteopenia, High EtOH intake or current smoking, low body weight or major weight loss, other disorders strongly associated with OP

Question 130

When and how should screening be initiated for osteoporosis?

Answer 130

Screen with BMD and Risk Calculator. Age <50 if high risk factors Age 50-64 if clinical risk factors Age 65 and greater--everyone

Question 131

How often should BMD be repeated for OP screening?

Answer 131

Low risk--every 5 years | Med/Mod risk--every 1-3 yrs

Question 132

Who should be assessed annually for T2DM (Risk Factors)?

Answer 132

Family Hx (1st degree relative), High Risk Populations (non-white, low SES), Hx of GDM or pre-DM, CV risks, End-organ damage (vascular)

Question 133

How often should we screen for T2DM and which tests are used?

Answer 133

FPG and HbA1C No RFs Age <40 (or low-mod risk): No screening No RFs Age >=40 (or high risk): q3 years RFs (or very high risk): q6-12 mo

Question 134

Diagnostic Criteria for T2DM

Answer 134

FPG or A1C abnormal > Repeat same test to confirm dx Both FPG and A1C abnormal > dx confirmed Symptomatic Hyperglycemia > Only one abnormal test required (FPG, A1C, 2hPG, random PG)

Question 135

A1C 6-6.4 % = ____

Answer 135

Prediabetes

Question 136

A1C >= 6.5%= ____

Answer 136

Diabetes

Question 137

FPG >= 7mmol/L= _____

Answer 137

Diabetes

Question 138

Hyperlipidemia is screened with______

Answer 138

Non-fasting lipids and Framingham Risk Score | unless Hx of TG >4.5, then fasting lipids

Question 139

What ages/how often should we screen for dyslipidemia?

Answer 139

Age 40 to 75, screen every 5 years | if no RFs

Question 140

Risk factors for dyslipidemia that would prompt earlier screening include

Answer 140

Ethnic Groups (South Asian or First Nations), Smoking, DM, HTN, COPD, CKD, ED, Atherosclerosis, AAA, Inflammatory disease (RA, SLE, psoriatic arthritis, ankylosing spondylitis, IBD), BMI >27 or clinical manifestations of hyperlipidemia, FamHx of premature CVD or hyeperlipidemia

Question 141

What ages/how often should we calculate CV risk?

Answer 141

Men Age 40-75 Women Age 50-75 Framingham Risk score every 5 yrs (if risk <5%) or every year i(if risk >=5%)

Question 142

Ca Intake Recommendations

Answer 142

Age <50 1000mg Age >50 1200mg Post Menopausal 1500mg

Question 143

Vit D Intake Recommendations

Answer 143

Low Risk 400-1000IU | High risk, >=50 yrs 800-1000IU, increased to 2000IU

Question 144

Contraindications to Live Vaccinations

Answer 144

Pregnant women, Trying to conceive within next month, Already received a live vaccine in last 28 days, Immunocompromised or untreated TB, Received blood product in last 90 days

Question 145

Who should receive HPV vaccinations?

Answer 145

Women age 9-45 | Men age 9-26

Question 146

Age for Shingles Vaccine

Answer 146

Product monograph states 50+, NACI states 60+

Question 147

Age/Population for Pneumococcal Vaccinations

Answer 147

Age 65+ | DM, CHF, COPD, CKD, Asplenia, Immunosuppresed, Liver disease

Question 148

Adacel indications, frequency, age

Answer 148

Protects against Tetanus, Diptheria and Whopping Cough One lifetime dose Adolescents age 14-16 or adults who missed adolescent dose

Question 149

Side effects of MMR

Answer 149

Rash 5-12 days after vaccine, fever in first 24 hrs or 5-12 days, Swelling of glands in neck, Temporary joint pain/muscle aches, meningitis (very rare), temporary thrombocytopenia

Question 150

Which vaccination should be given in every pregnancy?

Answer 150

Pertussis

Question 151

What is the recommendation around screening for prostate cancer?

Answer 151

Screening – men with at least 10 years life expectancy between 50 and 70 should be made aware of the availability of PSA as a detection test for prostate cancer • Offer at age 40 if high risk – family history and African descent • If the patient chooses screening: o Include PSA and DRE o Baseline PSA at age 40–49 years should be done to establish future risk By Age Group • Men < 55 – do not screen with PSA (strong recommendation) • Men 55 – 69 – do not screen with PSA (weak recommendation) • Men 70+ – do not screen with PSA (strong recommendation) Take away: lack of convincing evidence that PSA screening reduces mortality and consistent evidence that screening and active treatment does lead to harm (only test PSA in patients that are symptomatic)

Question 152

Global Health – health problems, issues, and concerns that transcend _____ ______, and may be influenced by encounters or experiences in other countries, and are best addressed by ______ efforts and solutions

Answer 152

Global Health – health problems, issues, and concerns that transcend national boundaries, and may be influenced by encounters or experiences in other countries, and are best addressed by cooperative efforts and solutions

Question 153

Menopause is defined as

Answer 153

12 months of amenorrhea with no other obvious pathological or physiological cause (retrospective diagnosis)

Question 154

Contributing factors to age of menopause onset include

Answer 154

Genetics, Smoking, Pelvic Radiation, Chemotherapy

Question 155

Premature Menopause = age___

Answer 155

<40

Question 156

What labs could be considered in a workup of amenorrhea, particularly if age <45

Answer 156

BHCG, TSH, PRL, Progestin Challenge, FSH/LH, Primary Ovarian Failure

Question 157

Clinical features of menopause

Answer 157

o Irregular/ anovulatory bleeding in perimenopausal period, amenorrhea in menopause o Vasomotor symptoms (hot flashes) o Urogenital changes o Sleep disturbances and mood changes/depression

Question 158

Menopausal vaginal atrophy manifests as

Answer 158

Veginal dryness, dyspareunia, pruritis, frequent UTIs, prolapse, post-coital bleeding

Question 159

Treatment for mild vasomotor symptoms of menopause includes

Answer 159

Reducing core body temperature (layering, use of a fan, drinking cold beverages), regular exercise, weight management, smoking cessation, controlled breathing, avoidance of triggers, good sleep

Question 160

_____ is first-line treatment for mod-sev vasomotor symptoms of menopause.

Answer 160

HRT is first-line treatment for mod-sev vasomotor symptoms of menopause.

Question 161

___, ___, ___, ___ are second-line treatment for mod-sev vasomotor symptoms of menopause.

Answer 161

SNRI, SSRI, Gabapentin, Progestin are second-line treatment for mod-sev vasomotor symptoms of menopause.

Question 162

Two non-hormonal treatments for vaginal atrophy

Answer 162

Vaginal lubricants and Vaginal moisurizer

Question 163

3 local estrogen therapy treatment options for vaginal atrophy

Answer 163

Estrogen cream (ex. Premarin; *requires co-tx with progestin for 10 days per month due to systemic absorption Estradiol Vaginal Ring Estradiol Vaginal Tablets (ex. Vagifem)

Question 164

Stress incontinence tx

Answer 164

Weight loss, pelvic floor exercises, pessaries

Question 165

Urge incontinence tx

Answer 165

Lifestyle changes, bladder retraining, antimuscarinic agents (oxybutynin)

Question 166

For all menopausal women, osteoporosis prevention involves

Answer 166

Vit D supplementation (400-1000IU for low risk, 800-1000IU for mod risk) Ca intake (1200mg) Lifestyle (regular active weight bearing aerobic exercises, balance exercises, smoking cessation, decrease coffee and alcohol intake)

Question 167

Indications for MHRT

Answer 167

Best tx for vasomotor sx, not recommended for osle tx of hyperlipidemia, CVD, OP *Remember to add progesterone if pt has a uterus

Question 168

Contraindications to MHRT

Answer 168

Hx breast/uterine cancer, liver disease, DVT/PE hx, abnormal vaginal bleeding NYD, pregnancy, CAD

Question 169

CAD risks/benefits of MHT

Answer 169

Coronary Artery Disease o There is a DECREASED risk of CAD with HRT use within 10 years of menopause o There is an INCREASED risk when HRT is started >10 years after the onset of menopause (In general Cardiovascular risk is highest in first 2 years of starting HRT, then excess risk decreases over time)

Question 170

Risks of MHT include

Answer 170

-Increased risk of VTE with oral HRT -unopposed ET (with NO progesterone) > 3 years is associated with increased risk of endometrial cancer -diagnosis of breast cancer increases with EPT use GREATER than 3 – 5 years; N.B. data also indicates that ET use in breast cancer survivors has not been proven to be safe and is associate with recurrence -meta-analysis shows INCREASE in annual ovarian cancer risk for EPT and ET use

Question 171

Components of Framingham Risk Score

Answer 171

``` Age Sex Smoking DM Total Chol HDL Chol SBP Blood Pressure treated by Meds ```

Question 172

In general, lipid targets are:

Answer 172

LDL-C <2 or >50% decrease | Apo B <0.8, Non-HDL-C <2.6

Question 173

Based on CCS Guidelines at what age should routine screening for hyperlipidemia be initiated and how frequently

Answer 173

• Men and women ≥40 years of age, or post-menopausal women • Consider earlier routine screening in ethnic groups at increased risk (South Asian or First Nations) • Screening Timeline o FRS<5%–patientsshouldbescreenedevery5years(from40to75) o FRS>5%–patientsshouldbescreenedyearly

Question 174

Based on CCS Guidelines all patients with the following conditions should be assessed for hyperlipidemia regardless of age

Answer 174

``` • Clinical evidence of atherosclerosis • Diabetes mellitus • Hypertension or PIH • Abdominal aortic aneurysm • Current cigarette smoking • Stigmata of dyslipidemia (acrus cornealis, xanthelasma, or xanthoma) • COPD • Family history of premature CVD (men < 55 and women < 65 in first degree relative) • Family history of dyslipidemia • CKD(eGFR<60orACR>3) • Obesity (BMI ≥ 30) • Inflammatory disease • HIV Infection • Pregnancy-induced hypertension ```

Question 175

Based on CCS Guidelines, how do we screen for hyperlipidemia

Answer 175

H&P, Standard lipid panel (TC, LDL-C, HDL-C, TG), Non-HDL-C (calculated from profile), Glucose, eGFR (Optional: Apo B, Urine ACR (if eGFR <60, HTN or DM) Lipids can be done non-fasting unless hx of TG>4.5

Question 176

When to consider secondary hyperlipidemia testing with coronary artery calcium measurement

Answer 176

• May be appropriate for asymptomatic and middle-aged adults with a FRS 10 – 20%, or with a family history of premature CVD, for whom treatment decisions are uncertain • Do NOT do CAC screening in: o High-risk individuals o Patients receiving statin therapy o Most asymptomatic, low-risk adults

Question 177

Based on Simplified Lipid Guidelines, screening ages and frequency of screening are

Answer 177

Lipid testing in patients without CVD: - Men–Age≥40 years to 75 - Women – Age ≥ 50 years to 75 (*NOTE----- CCS suggests age 40 for women Consider initiating testing earlier if CVD risk factors -Hypertension - Family history of premature CVD § Diabetes - Smoking • Repeat Screening o Patients NOT using lipid-lowering therapy→ every 5 years o Global CVD risk estimation can be repeated sooner if other CVD risk factors develop

Question 178

Based on Simplified Lipid Guidelines how do we screen

Answer 178

Lipid testing + CVD risk assessment CVD risk calculator (i.e. FRS) should be used o Diabetes–same risk estimation as non-diabetic patients o Chronic Kidney Disease–use a CKD specific CVD risk estimator (QRISK2) • Do NOT perform risk assessments in: o Pre-existing CVD (already high risk) o Age <40 or Age>75 o Already on lipid therapy

Question 179

CCS Guideline statin indicated conditions include

Answer 179

- LDL-C 5 or greater (genetic dyslipidemia) - Clinical Atherosclerosis - AAA - DM - CKD

Question 180

CCS guidelines for primary prevention management of hyperlipidemia based on FRS

Answer 180

Low Risk FRS <10% => No pharm indicated; Health Behavioural Modifications (Smoking cessation, improved diet, exercise) ``` Intermediate Risk– FRS 10 – 19%, AND • LDL-C ≥ 3.5 mmol/L, or • Non-HDL-C ≥ 4.3 mmol/L, or • Apo B ≥ 1.2g/L Men ≥ 50 and Women ≥ 60 with a risk factor: • Low HDL-C • Impaired fasting glucose • High waist circumference • Smoker • Hypertension or High Risk (FRS 20% or greater) => Health behavioural modifications Statin therapy for those with LDL-C ≥ 3.5 (aiming for LDL-C < 2.0, or 50% reduction) Add-On Therapy If target not achieved after titrating statin up to the maximal dose tolerated: • Ezetimibe is first-line (Bile acid sequestrants as alternative) ```

Question 181

Statin mechanism of action

Answer 181

Selective inhibition of cholesterol reabsorption at the | brush border of enterocytes (↓ LDL, minimal ↑ on HDL and minimal ↓ on TG)

Question 182

Simplified Lipid Guidelines for hyperlimidemia

Answer 182

Lifestyle Interventions – should be discussed with all patients • Smoking cessation • Exercise • Mediterranean diet FRS <10%: Retesting lipid levels in 5 years with risk estimation Statin therapy is NOT indicated FRS 10-19%: Discuss initiation of moderate-intensity statins FRS 20% or higher: Strongly encouraged to discuss initiation of high-intensity statins Consider ASA

Question 183

Statin Side Effects

Answer 183

* Muscle and liver injury * Elevation of blood glucose levels * Myalgias – common adverse effect * Rhabdomyolysis and liver failure – rare adverse effects (Patients who do not tolerate a specific statin regimen should be offered a lower-intensity regimen, with either the same or a different statin, or a short drug holiday followed by a rechallenge, to help clarify if statins are related • Any statin intensity is preferred to non-statin lipid-lowering therapy • Alternate daily dosing can be considered if a patient does not tolerate daily dosing)

Question 184

What lab follow up is recommended by the CCS Guidelines for patients on lipid-lowering medications

Answer 184

* Serum transaminases (ALT/AST) should be checked within the first three months * Creatinine kinase (CK) can be checked in myalgias develop * Routine testing of ALT or CK is not required thereafter – NO routine follow-up of investigations

Question 185

What lab follow up is recommended based on Simplified Lipid Guidelines?

Answer 185

• Testing of CK and ALT/AST levels at baseline or for monitoring are not required; performed only when clinically needed (symptoms) • Encourage adherence to statins • Monitoring of lipid levels are NOT required

Question 186

Risk factors for T2DM

Answer 186

* Family history (first degree relative) * High risk populations (non-white, low SES) * History of GDM or pre-diabetes * Cardiovascular risk factors * Presence of end-organ damage (vascular) * Other conditions/medications associated

Question 187

How to screen for T2DM

Answer 187

Screen with (1) FPG and (2) HbA1C • Asymptomatic Patient → if either FPG or A1C are in the diabetic range, repeat the SAME test that was abnormal to confirm the diagnosis of diabetes • Both FPG and A1C are available: o If only one is in the diabetes range, repeat the SAME test that was abnormal to confirm o If both tests are in the diabetes range, the diagnosis is confirmed • Symptomatic Hyperglycemic Patient → one only abnormal test (A1C, FPG, 2hPG, random PG) required Ultimately, two positive results are required unless there are overt symptoms of hyperglycemia

Question 188

Who should be screened for T2DM

Answer 188

No RFs: Age 40+ or high risk should be screened every 3 yrs RFs: Screen q6-12mo

Question 189

Recommended targets in T2DM patients

Answer 189

HbA1C 7% or less BP <130/80 LDL-C <2 (or 50% reduction from baseline)

Question 190

Components of lifestyle management for diabetes care

Answer 190

Exercise, Diet, Smoking Cessation, Self-Management

Question 191

First line agent for T2DM

Answer 191

Metformin

Question 192

How often to adjust meds in T2DM tx to attain A1C goal

Answer 192

3-6 mo

Question 193

If A1C <1.5% above target

Answer 193

Start/increase metformin if not at target within 3 mo

Question 194

If A1C 1.5% or higher above targer

Answer 194

Start metformin immediately, consider second concurrent antihyperglycemic agent

Question 195

If symptomatic hyperglycemia and/or metabolic decompensation

Answer 195

Initiate insulin +/- metformin

Question 196

Info/SEs about GLP1ra

Answer 196

``` • Requires subcutaneous injection • GI side-effects • Gallstone disease • Contraindicated with history of medullary thyroid cancer or MEN2 ***Weight Loss*** ```

Question 197

Info/SEs about SGLT2i

Answer 197

• Genital infections and UTI • Hypotension • Rare euglycemic DKA ***Weight Loss***

Question 198

Antihyperglycemic agents that cause weight gain

Answer 198

Insulin, Thiazolidinediones (-glitazones), Meglitinide, Sulfonylurea (-9des)

Question 199

Drugs for CVD risk reduction in patients with T2DM and poor glycemic control and CVD:

Answer 199

Statin + ACEi/ARB + ASA + Liraglutide (GLP-1 agonist), Empaglifozin/Canagliflozein (SGLT2 inhibitor)

Question 200

Drugs for CVD risk reduction in patients with T2DM and: good glycemic control and CVD

Answer 200

Statin + ACEi/ARB + ASA

Question 201

Drugs for CVD risk reduction in patients with T2DM and: 1)NO CVD but microvascular disease OR 2) Age 55 or older with additional CV risk factors

Answer 201

Statin + ACEi/ARB | ex. Ramipril 10mg PO daily

Question 202

Drugs for CVD risk reduction in patients with T2DM and: age 40 or older / 30 or older with diabetes >15 yrs / lipid indications

Answer 202

Statin

Question 203

What and how often should screening be done in T2DM

Answer 203

q3 to 6 Months – HbA1C/FPG, BP, BMI ``` Yearly – lipids (LDL, HDL, cholesterol, TG), retina exam, foot exam (monofilament), kidney exam (eGFR/ACR) ``` q3 to 5 Years – ECG

Question 204

Type of neuropathy in T2DM

Answer 204

Distal symmetric polyneuropathy

Question 205

Treatment of T2DM neuropathy

Answer 205

TCAs, gabapentin, tramadol Daily foot exams, comfortable/cushioned shoes, smoking cessation

Question 206

First sign of glomerular damage in diabetic nephropathy

Answer 206

Microalbuminuria

Question 207

Treatment of diabetic nephropathy

Answer 207

ACEi

Question 208

Treatment of diabetic retinopathy

Answer 208

Retinal photocoagulation

Question 209

Early sign of CVD in men is ___

Answer 209

Erectile Dysfunction

Question 210

____ in normotensive patients with T2DM helps prevent macrovascular disease

Answer 210

ACEi

Question 211

Questions to ask for hx of a red eye

Answer 211

* Visual acuity or vision changes * Physical pattern of redness (conjunctival, subconjunctival, episcleral/scleral, ciliary flush) * Pain and photophobia * Discharge, foreign bodies, abrasions * Changes in extraocular muscle use or structures

Question 212

Ddx of Red Eye

Answer 212

- Dry eye disease - Blepharitis - Uveitis - Angle closure glaucoma - Carotid cavernous fistula - Endopthalmitis - Cellulitis - Anterior segment tumors - Scleritis - Subconjunctival hemorrhage

Question 213

Urgent referral indicated if red eye and:

Answer 213

* Vision loss * Moderate to severe pain * Severe purulent discharge * Corneal involvement * Conjunctival scarring * Lack of response to therapy * Recurrent episodes of conjunctivitis * History of HSV eye disease

Question 214

When to refer to optho for suspected acute conjunctivitis:

Answer 214

- Pain - Photophobia - Constant blurred vision - Hyperpurulent (gonococcal) - None of pain + photophobia + blurred vision + discharge + itching

Question 215

Management of viral conjunctivitis

Answer 215

Very contagious No tx--sx management (cold compress, artificial tears, antihistamines) Refer to optho if sx do not resolve in 7-10 days

Question 216

Management of bacterial conjunctivitis

Answer 216

Most are self-limiting in 1-2 wks therefore observation is reasonable in most cases Topical antibiotics reduce disease duration Avoid topical steroids • Antibiotics are recommended for: o Purulent or mucopurulent conjunctivitis o Patients with distinct discomfort o Contact lens wearers o Immunocompromised patients o Suspected chlamydial or gonococcal infections

Question 217

Management of allergic conjunctivitis

Answer 217

* Avoidance of offending antigen * Use of saline solution or artificial tears * Use of topical antihistamines, decongestants, and mast cell stabilizers * NSAIDs and corticosteroids may be indicated in some cases

Question 218

Primary causes of hypothyroidism

Answer 218

- Hashimoto's Thyroiditis (chronic autoimmune thyroiditis) - Transient hypothyroidism (ex. postpartum, painless thyroiditis) - Infiltrative (ex. sarcoid) - Meds - Iatrogenic (ex. RAI, thyroidectomy)

Question 219

Secondary causes of hypothyroidism

Answer 219

- Pituitary lesion (TSH deficiency) | - Hypothalamic lesion (TRH def.)

Question 220

Primary causes of hyperthyroidism

Answer 220

- Autoimmune Hyperthyroidism (Grave's, Rare-Hashitoxicosis) - Toxic Multinodular Goitre - Toxic Adenoma - Exogenous Thyroid - Postpartum Thyroiditis - Drug induced (amiodarone) - Neoplastic (RARE--Metastatic Thyroid Cancer)

Question 221

Secondary causes of hyperthyroidism

Answer 221

TSH-producing pituitary adenoma

Question 222

Pregnancy-related causes of hyperthyroidism

Answer 222

Gestational hyperthyroidism (seen with hyperemesis gravidarum) Trophoblastic disease

Question 223

Risk factors for thyroid disease

Answer 223

* Personal history of autoimmune disease (Type I Diabetes) * Family history of thyroid disease * Personal history of neck irradiation * Drug therapy (amiodarone, lithium) * Women > 50 years of age * Postpartum, up to 6 months

Question 224

Clinical features of hypothyroidism include

Answer 224

Bradycardia, diastolic hypertension, Cognitive impairment, depression, hair loss, dry skin, menstrual irregularities (menorrhagia), constipation, weight gain, lethargy, goitre, cold intolerance

Question 225

Clinical features of hyperthyroidism include

Answer 225

Palpitations, tachycardia, atrial fibrillation, widened pulse pressure, hypertension, nervousness, tremor, anxiety, proximal muscle weakness, hair loss, menstrual irregularities (amenorrhea, oligomenorrhea), weight loss, goitre, heat intolerance, diaphoresis, clammy hands

Question 226

Only initial test required to screen for thyroid disease is

Answer 226

TSH

Question 227

When to order fT3 and fT4

Answer 227

If suspected hyperthyroidism to confirm thyrotoxicosis (increased fT3, normal fT4) May be measured to rule out TSH-producing pituitary adenoma (increased TSH, fT3 and fT4)

Question 228

Primary care management of hypothyroidism involves

Answer 228

Treatment with levothyroxine, usually start at 50mcg daily (25 in kids and elderly), check TSH 6 weeks after initiation/dose change, and annually once normalized

Question 229

List 5 treatment options for hyperthyroidism

Answer 229

1. Propylthiouracil (PTU) 2. Methimazole 3. RAI 4. Thyroidectomy 5. Beta-blocker (short-term tx of sx until above tx takes effect)

Question 230

Subclinical hypothyroid: ____ TSH, ____ fT4 Subclinical hyperthyroid: ____ TSH, ____ fT4

Answer 230

Subclinical hypothyroid: increased TSH, normal fT4 Subclinical hyperthyroid: decreased TSH, normal fT4 Monitor TSH q 12 mo for hypo, q6-12mo for hyper

Question 231

Maternal hypothyroidism is associated with _____ in newborns

Answer 231

Maternal hypothyroidism is associated with decreased IQ in newborns

Question 232

Factors associated with increasing number and size of thyroid nodules

Answer 232

Grave’s Disease Pregnancy Low iodine intake → specifically, hyperfunctioning nodules (toxic adenomas)

Question 233

Factors associated with increased risk of thyroid cancer

Answer 233

Hx of radiation to head or neck, younger than 20 or older than 70, Grave's, familyhx, MEN 2A and 2B

Question 234

Approach to a thyroid nodule

Answer 234

• Serum TSH level should be measured during the initial evaluation of a patient with a thyroid nodule (such that those with low TSH should have → radionuclide scintigraphy performed to assess for “hot nodules”) • Thyroid U/S should be performed in patients with known or suspected thyroid nodule • FNA is the biopsy of choice for sampling thyroid nodules (except hyperfunctioning nodules, which do not require a biopsy) → only biopsy those > 1cm (or any with risk factors; extracapsular invasion, cervical LNs)

Question 235

GAD= exessive anxiety and worry lasting min. 6 months, difficult to control worry, associated with three or more of what 6 criteria

Answer 235

BESKIM Blank mind Easily fatigued Sleep Changes Keyed up (restless) Irritability Muscle tension

Question 236

Validated tool for screening of GAD in primary care

Answer 236

GAD-7 Scale

Question 237

Investigations that can be ordered for anxiety disorders

Answer 237

Basic labs (CBC, lipids, lytes, fasting glucose, TSH, liver enzymes) Serum/urine tox screen (?substance use) ECG (for panic attacks)

Question 238

Modifiable biological risk factors for anxiety

Answer 238

Various Medical Conditions • Endocrine – hyperthyroidism, hypoglycemia • Cardiovascular – angina, arrhythmia, CHF, pulmonary embolism, anemia • Respiratory – asthma, COPD, pneumonia • CNS – temporal lobe epilepsy, migraines, neoplasms Medication/Substance Induced • Stimulants (caffeine, beta-agonists) • Depressants (withdrawal from antidepressants, alcohol, benzodiazepines)

Question 239

Non-modifiable biological risk factors for anxiety

Answer 239

Non-Modifiable

Question 240

Non-modifiable psych risk factors for anxiety

Answer 240

Adverse Childhood Experiences – childhood trauma (abuse and neglect) and institutionalization Parental Factors – overprotectiveness, role modelling, early parental loss Social Factors – females have greater exposure to more stress events epidemiologically

Question 241

How many social situations must invoke fear/anxiety in a diagnosis of SAD

Answer 241

2

Question 242

In general what meds/substances can induce anxiety symptoms?

Answer 242

* Stimulants (caffeine, beta-agonists) * Sympathomimetic agents * Withdrawal from Depressants (anti-depressants, alcohol, benzodiazepine)

Question 243

Treatment options for GAD

Answer 243

- CBT - Exercise, yoga, MBSR - SSRIs/SNRIs, Buspirone, Pregabalin are 1st line - TCAs, low dose BZDs to abort initial panic attacks but avoid prn short-acting BZDs

Question 244

Treatment options for PD

Answer 244

- CBT - SSRIs/SNRIs - BZDs - TCAs and less commonly MAOIs can also be used

Question 245

Treatment options for social anxiety disorder

Answer 245

- CBT - SSRIs/SNRIs - BZDs and BBs for acute situations and performance anxiety - TCAs and moclobemide can be used third line

Question 246

Treatment options for OCD

Answer 246

- ERP - High dose often required of SSRIs/SNRIs or TAs (1st line: sertraline, paroxetine, fluoxetine, fluvoxamine) (2nd line: venlafaxine, clomipramine, mirtazapine, citalopram)

Question 247

Treatment options for PTSD

Answer 247

- CBT or ERP - SSRIs/SNRIs (most evidence for sertraline) - Some evidence that antipsychotics may have a role in augmentation therapy

Question 248

3 main types of symptoms in PTSD, duration >1 mo

Answer 248

1. Re-living (recurrent and intrusive memories/distress) 2. Avoidance 3. Arousal

Question 249

Ddx for anxiety symptoms or organic medical disorders that may present with anxiety

Answer 249

• Cardiac – CAD, CHF, arrhythmia • Pulmonary – PE, asthma, COPD, upper airway obstruction, pneumonia • Endocrine – hyper/hypothyroidism, hyperparathyroidism, hypoglycemia, pheochromocytoma, menopause • Neurologic – neoplasm, encephalitis, vestibular dysfunction • Drugs – caffeine, amphetamines, cocaine, alcohol, nicotine, benzodiazepine withdrawal, decongestants, salbutamol, antipsychotic, levodopa, SSRIs • Psychiatric – phobias, other co-morbid psychiatric conditions (depression)

Question 250

Principles for initiating pharm management of anxiety disorders

Answer 250

Adequate trial of 8–12 weeks at optimal dosage is needed to see a response from therapy § If inadequate response, switch to another agent § If a partial response achieved, consider adding an augmenting agent § Refer to a specialist or consider second/third line agents if still inadequate response

Question 251

5 or more of the following symptoms required for MDD diagnosis

Answer 251

MSIGECAPS Mood decreased Sleep (increased/decreased) Interest (anhedonia) Guilt or worthlessness Energy decreased Concentration decreased Appetite (increased/decreased) Psychomotor slowing/agitation Suicidal ideation

Question 252

Symptoms of depression can be classified into three groups

Answer 252

1. Affective 2. Cognitive 3. Neurovegetative

Question 253

Components of the mental status exam

Answer 253

ASEPTIC A- Appearance, Attitude, Arousal, Activity S-Speech E-Emotion (Mood/affect) P-Perception (hallucinations, illusions, dissociative symptoms) T- Thought Process and Content I- Insight and Judgement C-Cognition

Question 254

Most important risk factor for suicide

Answer 254

Previous attempts at suicide

Question 255

Suicide RFs

Answer 255

SADPERSONS Sex (male), Age (elderly), Depression, Previous attempts, Ethanol use, Rational thinking loss, Social support lacking, Organized suicide plan, No spouse (for males), Sickness (chronic/severe)

Question 256

Suicide PFs

Answer 256

Children, responsibility, pregnancy, religious beliefs, life satisfaction, reality testing, positive coping skills, good social supports, self-efficacy, fear of act, social disapproval, support from healthcare team, identification of future goals

Question 257

Suicide at-risk populations

Answer 257

Post-partum women, past history of depression/anxiety disorders/chronic pain, multiple somatic complaints, history of abuse, elderly with behavioural changes/dementia, substance use

Question 258

Ddx for depressed mood, including causes of secondary depression

Answer 258

- Sadness - Schizoaffective Disorder - Substance induced depressive disorder - Depressive disorder due to another medical condition (some disorders mimic/exacerbate depression ex. anemia, while some disorders can produce depressive syndrome as a direct physiological consequence (ex. MI, HIV, stroke)

Question 259

Ix for depression (to rule out other conditions in ddx)

Answer 259

- Take careful history (r/o sadness) - Serum/urine tox screen (substance induced depressive disorder) - CBC, TSH, B12, folate (medical conditions) - CT/MRI brain, EEG/EMG, cardiac or autoimmune work-up

Question 260

Validated scales designed to assess baseline mood and track tx

Answer 260

PHQ-9 and Beck Depression Inventory

Question 261

Pharm tx counselling for depression can include

Answer 261

• Take medication daily and regularly • Physical symptoms of depression (appetite, sleep, energy) should improve within 1-3 weeks • Cognitive/emotional symptoms of depression (anhedonia, guilt, hopelessness take approximately 6-8 weeks • Although patients may feel better after 6-8 weeks, they will need to continue for 6-12 months (first episode) and at least 2 years (third episode of depression) • Do not stop antidepressant treatment abruptly • Not all antidepressants work for all people, so follow-up with doctor in 1-3 weeks • Side effects are common, but usually temporary • If patients experience new or more intense feeling of suicide, they should go directly to the emergency room

Question 262

With pharm tx for depression: -If no response in 1-3 weeks: _____ • Partial response in 3-4 weeks: _____ • If after optimizing dose, poor clinical effect, ____ and consider _____

Answer 262

-If no response in 1-3 weeks: antidepressant should be switched • Partial response in 3-4 weeks: optimize dose • If after optimizing dose, poor clinical effect, re-evaluate diagnosis and consider augmenting pharmacotherapy by adding second agent

Question 263

Non-pharm tx for depression can include

Answer 263

CBT IPT PST

Question 264

4 types of mandatory physician reporting

Answer 264

1. Child abuse--if reasonable grounds to suspect a child < age 16 is or may require protection 2. Elder Abuse--must report to the Refistrar of the Retirement Homes Regulatory Authority or LTC home director if reasponable grounds to suspect that a resident has suffered harm or is at rik 3. Impaired Driving Ability --report to MTO 4. Sexual Abuse of a Patient--when sexually abused of another profession

Question 265

Low risk drinking guidelines

Answer 265

* No more than 2 standard drinks on any one day * Women – up to 9 standard drinks a week * Men – up to 14 standard drinks a week

Question 266

Alcohol Dependence – meeting ≥ 1 DSM criteria for dependence in the last 12 months o If yes to ≥3, of the following questions/sx there is an element of dependence

Answer 266

``` § Tolerance § Withdrawal § Drinking limits § Failed to cut down § Time § Spending less time on other matters § Continued drinking despite problems ```

Question 267

Medical red flags for alcohol use (trigger to screen for more)

Answer 267

MCV > 96 ↑ GGT, AST, ALT (> 2:1 ratio) GERD, HTN, DM, pancreatitis Chronic non-cancer pain Sexual dysfunction Falls

Question 268

Mental red flags for alcohol use (trigger to screen for more)

Answer 268

Cognitive impairment or decline Mood, anxiety, or sleep disorder Significant behavioural or academic challenges

Question 269

Psychosocial red flags for alcohol use (trigger to screen for more)

Answer 269

Unexplained times off work or loss of employment Frequent no shows Poor medication adherence Recent/recurrent trauma/abuse High risk behaviour (gambling, DUI, STIs)

Question 270

Physical findings of alcohol use disorders

Answer 270

• Smell of alcohol • Withdrawal symptoms – vomiting, diaphoresis, agitation, headache, tremor, seizures, hallucinations • Delirium tremens (↑ HR, ↓ BP, ↑ temperature, delirium) • Stigmata of liver disease – ascites, jaundice, clubbing, spider nevi, palmar erythema, gynecomastia, testicular atrophy, Dupuytren contractures, hepatomegaly/shrunken liver, splenomegaly

Question 271

What questions are involved in the CAGE screen for AUD | Note: can also use the AUDIT3

Answer 271

C-Have you ever felt the need to cut down on your drinking? A-Have people annoyed you by criticizing your drinking? G-Have you ever felt guilty about drinking? E-Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves to get rid of a hangover?

Question 272

At-risk drinking is defined as

Answer 272

≥ 4 drinks (women) or ≥ 5 drinks (men) on ≥ 1 day(s) in the past year

Question 273

Alcohol Abuse – meeting ≥ 1 DSM criteria for substance-use disorder in the past 12 months If yes to 1 or more of these screens, consider abuse and assess for dependence: ____

Answer 273

§ Role failure (missed work or class?) § Risk bodily harm (drinking and driving?) § Legal issues (DUI, MVC) § Relationship trouble (people complain about your drinking)

Question 274

4 Major Symptom Domains of Substance-Use Disorder

Answer 274

1. Impaired Control 2. Social Impairment 3. Risky use 4. Pharm Criteria Note: DSM criteria for disorder due to a substance, pt must display 2 of the 11 symptoms within a 12mo period (symptoms classified in the above 4 groups)

Question 275

Pharm tx for alcohol dependence may involve

Answer 275

- Naltrexone (efficacy beyond 12 weeks not established) - Acamprosate (for maintenance of abstinence, tx x 1yr) - Disulfiram (can be used months-yrs, don't use if going alcohol use)

Question 276

Pharm Tx for EtOH withdrawal may involve

Answer 276

- diazepam or lorazepam | - thiamine

Question 277

Tobacco Cessation Treatment Options

Answer 277

- Lifestyle (15 min bursts of daily mod activity and baanced diet) - Behavioral (modify triggers) - NRT - Meds (Varenicline--target quite day 8, black box warning for pts with psych illness; Bupropion SR)

Question 278

ADLS=

Answer 278

DEATH ``` Dressing Eating Ambulating Toileting Hygiene ```

Question 279

iADLs=

Answer 279

SHAFT ``` Shopping Housekeeping Accounting Food prep Transportation ```

Question 280

For frail older patients blood sugar

Answer 280

5

Question 281

For older adults, HbA1c targets tend to be ____

Answer 281

7.1-8.5%

Question 282

With glycemic control in older adults, _____ is a better predictor of outcomes than ___ or ____

Answer 282

With glycemic control in older adults, postprandial glucose is a better predictor of outcomes than A1c or preprandial glucose

Question 283

If screening older adults for T2DM, look at both ____ and ___

Answer 283

FPG and HbA1C

Question 284

Screening patients age ____for T2DM is unlikely to be beneficial

Answer 284

>80 yrs

Question 285

Hypertension Goals: Pt with DM ____ Pt with CAD, no DM ____ Pt with no comorbidities ____ Frail older adult with HTN, with or w/o DM= _____

Answer 285

Pt with DM <130/80 Pr with CAD, no DM <120/80 Pt with no comorbidities <140/90 Frail older adult with HTN, with or w/o DM= individualized target

Question 286

DDx for Orthostatic Hypotension ("4D-AID")

Answer 286

With compensatory tachycardia: 4D 1. Deconditioning 2. Dysfunctional Heart (low LVEF or aortic stenosis) 3. Dehydration (From disease, dialysis, drugs) 4. Drugs (antihtn, antianginals, antiparkinsonian, antidepressant, antipsychotic, anti-BPH) Without compensatory tachycardia: AID 1. Autonomic Dysfunction (DM, low B12, hypothyroid, ethanol abuse, parkinsonism amyloid) 2. Idiopathic (pure autonomic failure--deletion of NE from sympathetic nerve terminals) 3. Drugs (BBs)

Question 287

Risks of statins in older adults include

Answer 287

- Myalgias - Cognitive function - Rhabdo and liver failure - Asymptomatic increases in CK and liver enzymes

Question 288

Cation when using CV risk assessment tools, as ___ alone can place individuals in high-risk categories

Answer 288

Age

Question 289

A _____ is diagnostic of osteoporosis

Answer 289

Fragility fracture (any fall from standing height or less)

Question 290

Diagnosis OP via BMD: femoral neck BMD _____ below the young adult mean. (T score ____)

Answer 290

Femoral neck BMD 2.5 SDs or more below the young adult mean. (T score 2.5 or less)

Question 291

Treatment of Osteoporosis in Older Adults • ______ * _____ * _____

Answer 291

Treatment of Osteoporosis in Older Adults • Lifestyle modifications o Regular exercise–balance, strength, exerciset raining o Limit alcohol intake o Vitamin D3 and dietary/supplemental calcium (1200mg) should always be considered * Bisphosphonates (alendronate, risedronate, zoledronic acid) can be used as first-line therapy in men for the prevention of a fracture * Denosumab is indicated for treatment of women and men at high risk of fracture

Question 292

Bisphosphonate adverse effects include

Answer 292

GI upset, esophagitis, gastritis, bone/muscle/joint pain, osteonecrosis of the jaw (rare), atypical femur fractures (rare)

Question 293

Contraindications to bisphospnonates include

Answer 293

Severe renal impairment (relative), hypocalcemia, can't sit up for 30 mins, caution if dysphagia, esophageal disease, gastritis, duodenitis, ulcers

Question 294

Preferred hepes zoster vaccination is ____

Answer 294

Shingrix: recombinant subunit zoster vaccine | superior than Zostavax--live attenuated zoster vaccine

Question 295

Vaccines in older adults (4):

Answer 295

1. Shingles--age >50 2. High dose trivalent influenza vaccine--age 65+ 3. Pneumococcal Vaccine (PCV 23 for all adults 65+, PCV 13 for immunocomprosed or on an individual basis) 4. Tetanus--Td every 10 yrs, Tdap once as an adult

Question 296

General suggested ages to stop cancer screening in older adults:

Answer 296

1. Breast cancer: age 75 2. Cervical cancer: age 70 3. Colorectal cancer: age 75 4. Prostate cancer: not recommended at any age for screening

Question 297

Sexual History 5Ps

Answer 297

Partners, Practices, Protection, Past History, Pregnancy Prevention

Question 298

Absolute contraindications to combined OCP include

Answer 298

* Acute liver disease, liver malignancy * Uncontrolled hypertension * Migraines with neurologic symptoms (aura) * Diabetes with evidence of vascular damage * Suspected pregnancy * Undiagnosed vaginal bleeding * Personal history or strong family history of VTE * Estrogen-dependent malignancy * Smoker over age of 35

Question 299

Relative contraindications to combined OCP (must monitor) include

Answer 299

• Controlled hypertension – BP must be monitored and stay stable • Migraines without neurologic symptoms – if increases in frequency or new onset neurological symptoms, stop the OCP • Breastfeeding–combined OCP safe for lactation; may decrease the milk supply • Anti-epileptics – higher risk of failure and break through bleeding due to accelerated estrogen metabolism by liver; may help control menstrual seizures • Hyperlipidemia – may increase risk of pancreatitis • Gallbladder disease – small increase risk in symptomatic gallstones • Inflammatoryboweldisease–slightriskofrelapse,inadequateabsorption • SLE – may be considered if no evidence of nephritis or APLA

Question 300

Progestin in contraception works by ____, ____, _____ and ____

Answer 300

Thinning endometrium, thickening cervical mucous, preventing LH surge (ultimately suppressing ovulation), alters tubal transport

Question 301

Estrogen in contraception works by ___ and ____.

Answer 301

FSH suppression (suppressing follicular development) and endometrial proliferation

Question 302

SEs and complications of progestins in contraception include:

Answer 302

``` • Breakthrough bleeding • Premenstrual Symptoms – bloating, water retention, breast tenderness • Weight Gain – increased appetite, dose dependent and typically only seen in higher doses • Acne ```

Question 303

SEs and complications of estrogens in contraception include:

Answer 303

``` • Breakthrough bleeding • Nausea • Breast tenderness • Thromboembolic disease (DVT/PE), MI, and stroke • Headaches – migraines • Liver metabolism – active liver disease ```

Question 304

Non-contraceptive benefits of combined OCP

Answer 304

* Menorrhagia, anemia * Cycle regularity * Dysmenorrhea and endometriosis (progestin) * Ectopic risk * PID (progestin’s effect on mucous) * Acne and hirsutism – ↑ SHBG due to estrogen • Ovarian cancer - ↓ cell damage/turnover * Endometrial cancer (progestin) * Benign ovarian cysts * Benign breast disease

Question 305

Per SOGC’s Canadian Contraception Consensus (2015), ____ are the most effective method of reversible contraception and should be considered for any woman of reproductive age

Answer 305

IUDs

Question 306

IUD mechanism of action:

Answer 306

Inflammatory response in the uterus (hostile to egg implantation), minimal effect on ovulation

Question 307

Options for starting OCP and implications for contraception

Answer 307

1st day start--no BUC required, may have more initial SEs Quick start--start whenever, need BUC for 1 week, less SEs Sunday Start--BUC for 1 week if >5 days since LMP

Question 308

Missed OCP pill during 1st week means:

Answer 308

Take 1 pill ASAP and next pill at regular time (e.g. may be taking 2 pills in 1 day)à continue taking 1 pill daily until the end of the pack à use BUC for the next 7 days if missed pill à consider emergency contraception if unprotected intercourse in the last 5 days

Question 309

Missed OCP pill during 2nd or 3rd week

Answer 309

Take 1 pill ASAP and next pill at regular timeàcontinue taking 1 pill daily until the end of the pack, discard any placebo pills, start a new cycle with no hormone free interval à if more than 3 pills missed, use BUC for 7 days à consider emergency contraception if UIC within last 5 days

Question 310

Potential drug interactions with OCP include

Answer 310

``` Anticonvulsants Anti-TB Anti-fungal Anti-retroviral St. John's Wort ```

Question 311

Emergency contraception options include:

Answer 311

- Insert Copper IUD up to 7 days after UIC - Oral progestin - Yuzpe Method (combined OCP with high dose progrestin, N/V is common SE and limits efficacy) - PLan B (progestin onlY)--OTC wihin 72 hrs after UIC (data showing can be effective up to 5 days post)

Question 312

4 things to assess on first newborn visit to PCP

Answer 312

1. Dehydration 2. Jaundice 3. Feeding problems 4. Congenital anomalies

Question 313

Earliest sign of dehydration in infants is ___

Answer 313

Abnormal vitals

Question 314

Normal Growth • Weight loss nadir is usually around day ____; • No intervention is necessary unless the baby has lost ____ of their BW • Infants should return to birth weight by ___

Answer 314

* Weight loss nadir is usually around day 3 – 4; weight begins to increase once the mother’s milk comes in * No intervention is necessary unless the baby has lost more than 10% of their birth weight * Infants should return to birth weight by 2 weeks

Question 315

Rule of 3s for colic (diagnosis of exclusion)

Answer 315

Crying >3hrs per day, episodes on more than 3 days per week, has lasted longer than 3 weeks

Question 316

Localized reactions to immunizations include

Answer 316

* Swelling * Induration * Erythema * Tenderness * Localized Rash

Question 317

Systemic reactions to immunizations include

Answer 317

* Fever • Rash * Joint/muscle pain * Fainting * Seizures * Guillain-Barré

Question 318

Jaundice history can involve

Answer 318

- Bili levels at 24hrs - Birth history - FamHx of jaundice in siblings - Feeding Hx - Maternal blood type - Stool/urine output - Time frame

Question 319

RFs for severe hyperbilirubinemia

Answer 319

* Cephalohematoma or significant bruising * East Asian * Exclusive breastfeeding if not well established * Weight loss over 10% (breastfeeding jaundice is due to dehydration) * Lower gestational age * Isoimmune or other hemolytic disease * Serum bilirubin levels pre-discharge in high/high-intermediate risk zone * Previous sibling with jaundice that received phototherapy * Jaundice observed in first 24 hours

Question 320

+ Coombs test indicates___

Answer 320

Hemolysis

Question 321

Jaundice in _____is always abnormal. Breastmilk/physiological jaundice usually occurs at ___ postnatal

Answer 321

Jaundice in the first 24 hrs of life is always abnormal. Breastmilk/physiological jaundice usually occurs at 2-3 days postnatal

Question 322

Aside from structural causes, the two most common causes of murmurs are

Answer 322

Fever and Anemia | These are flow murmurs, best heard at LSB and radiate to the carotids

Question 323

Describe a Still's Murmur

Answer 323

Innocent heart murmur commonly heard in children - Systolic ejection murmur - Low-pitched vibratory grade 2 murmur with a musical quality - Best heard at LLSB, thought to be due to vibration of the left outflow tract - No associated symptoms

Question 324

On taking history for a heart murmur in a baby, ask about:

Answer 324

- Hx of congenital heart disease in 1st degree relatives - In utero drug exposure - Maternal DM - Intrauterine infections (rubella) - FamHx SCD

Question 325

Physical exam for heart murmur in a baby

Answer 325

- General appearance - Vitals (BP in R arm, palpate brachial pulses, femorals one at a time, and R brachial simultaneously with femoral to assess for likelyhood of coarctation) - Precordial Exam - Signs of HF

Question 326

Describe a Functional Murmur

Answer 326

Innocent murmur, position-dependent that disappears when upright or sitting

Question 327

Systolic murmurs in babies include:

Answer 327

ASD, VSD, Blood flow across an outflow tract, AV valve regurg, PDA, functional (venous hum or still's)

Question 328

Pathological murmurs in babies include:

Answer 328

PFO/ASD: Widely split fixed S2 and systolic ejection murmur at the LUSB VSD: Harsh holosystolic murmur at LLSB CoA: Systolic murmur heard loudest below L scapula

Question 329

Characteristics more likely to be associated with innocent murmurs (7 S)

Answer 329

* Sensitive – changes with position or respiration * Short duration – not holosystolic * Single – no associated clicks or gallops * Small – limited to a small area, non-radiating * Soft – low amplitude * Sweet – not harsh sounding * Systolic – limited to systole

Question 330

The ____ visit is considered to be the most important developmental assessment

Answer 330

18 month

Question 331

Autism history may include:

Answer 331

* Take full developmental history of child * Family history of developmental delay * Parental concern of hearing and vision * History of repetitive, ritualized, or stereotyped behaviour such as hand flapping * Frequent tantrums or trouble tolerating change or transition * Preoccupation with parts of toys or different objects * RED FLAG – regression is never normal

Question 332

DDx for ASD

Answer 332

* Anxiety disorder * Attachment disorder * Fetal alcohol syndrome * Global developmental delay * Hearing impairment * Language disorder * Learning disability

Question 333

3 steps of the Gold Standards Framework-Proactive Identification Guidance (GSF PIG) in palliative care

Answer 333

Identify Assess Plan

Question 334

Examples of general indicators of patient delcline

Answer 334

• General physical decline, increasing dependence and support • Repeated unplanned hospital admissions • Advanced disease (unstable, deteriorating, high burden) • Presence of significant multi-morbidities • Decreasing activity (limited self-care, in bed or chair 50% of the day and increasing dependence in most ADLs) • Decreasing response to treatments, decreasing reversibility • Patient choice for no further active treatment and rather a focus on their quality of life • Progressive weight loss (> 10%) in past six months • Sentinel event (fall, bereavement, transfer to nursing home) • Serum albumin < 25g/l

Question 335

Two scoring scales used in palliative care

Answer 335

PPS (Palliative Performance Scale) -Uses ambulation, activity & evidence of disease, self-care, intake, LoC Edmonton Symptom Assessment Scale -Pain, tiredness, drowsiness, nausea, appetite, SOB, depression, anxiety, wellbeing

Question 336

Components of the SPIKES approach

Answer 336

``` SPIKES Scene Perception Invitation Knowledge Empathy (NURSE: Name, Understand, Respect, Support, Explore) Summary ```

Question 337

Pain relief at the end of life: Mild pain-- Mod pain-- Severe pain--

Answer 337

Mild pain--acetaminophen and/or NSAIDs (particularly in bone pain); avoid NSAIDs in elderly, renal impairment, GIB (consider PPI) Mod pain--weak opioid (codeine or tramadol) Severe pain--strong opioid (morphine, oxycodone, hydromorphone)

Question 338

Opioid dosing

Answer 338

Codeine > Morphine > Oxycodone > Hydromorphone

Question 339

Breakthough opioid dose is ___ of 24 hr total q1h prn

Answer 339

10%

Question 340

Titrating Opioid Dose Upwards (to be done if ___ of breakthrough needed/24 hours) • Add up previous 24 hour total, and divide by ___ to get the new q4h dose • Give ___ of this NEW 24 hour total as the breakthrough dose

Answer 340

Titrating Opioid Dose Upwards (to be done if > 2 doses of breakthrough needed/24 hours) • Add up previous 24 hour total, and divide by 6 to get the new q4h dose • Give 10% of this NEW 24 hour total as the breakthrough dose

Question 341

Opioid adverse effects include

Answer 341

* Constipation (prevent or treat with PEG 3350 or senna) * Somnolence/sedation (consider switching or adding a psycho-stimulant) * Nausea (metoclopramide 10mg PO/SC/IV QID prn) * Neurotoxicity (avoid renal impairment – good hydration) * Respiratory depression (RARE if carefully titrating)

Question 342

Principles for managing dyspnea in palliative patients

Answer 342

* Awareness of breathing – frequent and often multifactorial * Treat/optimize treatment for reversible causes (PE, COPD) * Try air directed across the face, sit upright and by open window * Systemic opioids – initiate as for pain * O2 nasal prongs in hypoxic patients (SpO2 < 88% or PaO2 < 55mmHg)

Question 343

Treatments of N/V in palliative patients: • Opioid Induced – ____ • Malignant Bowel Obstruction – ____ • Chemo/Radiation Induced – ____

Answer 343

* Opioid Induced – metoclopramide, haloperidol (1 – 5mg PO/SC BID/TID prn) * Malignant Bowel Obstruction – haloperidol * Chemo/Radiation Induced – ondansetron 4 – 8mg PO/SC/IV BID/TID

Question 344

If suspicion of spinal cord compression in palliative pt treat with ___ while urgently referring for radiotherapy and/or neurosurg

Answer 344

Dexamethasone 8-10mg PO/SC/IV stat, then BID/TID

Question 345

Folic Acid Supplementation: Low risk: Mod risk: High risk:

Answer 345

Low risk: 0.4mg PO daily Mod risk: 1mg PO daily until 12 weeks, then 0.4-1mg po daily High risk: 4mg PO daily until 12 weeks, then 0.4-1mg PO daily

Question 346

Timing and frequency of antenatal visits

Answer 346

* 8 to 12 weeks GA – first visit * Until 28 weeks GA – every four weeks * From 28 to 36 weeks GA – every two weeks * From 36 weeks GA to delivery – every week

Question 347

``` Summary of Ix throughout pregnancy: 8-12 wks= 11-14 wks= 18-20 wks= 24-28wks= 27-32wks= 28wks= 35-37wks= 41wks to delivery= ```

Answer 347

8-12 wks= 1st visit, labs, dating US 11-14 wks= eFTS, NT 18-20 wks= Anatomy Scan 24-28wks= GDM Screen 27-32wks= Pertussis Vaccine 28wks= Repeat CBC, RhIG if Rh- 35-37wks= GBS swab 41wks to delivery= BPP twice weekly until delivery

Question 348

GDM screen is ___, can be escalated to ___ if abnormal

Answer 348

OCG (abnormal is 7.8-11, go on to OGTT, if >11.1 then dx GDM) OGTT (abnormal fasting 5.3 or higher, 1-hour 10.6 or higher, 2-hour 9.0 or higher; one abnormal value= GDM)

Question 349

TORCH infections inlcude

Answer 349

``` Toxoplasmosis Other (parvovirus, varicella, syphilis) Rubella CMV HSV ```

Question 350

Components of BPP

Answer 350

``` Fetal breathing Fetal movement Fetal tone Amniotic fluid (NST) ```

Question 351

Management of NVP

Answer 351

- Dietary/Lifestyle Changes - Non-pharm (ginger tablets, MBCT) - Pharm (Vit B6, Doxylamine, Diclectin, Dimenhydrinate, Metaclopramide) - Refractory--consider hospitalization, ondansetron, corticosteroids, investigate for other causes

Question 352

Recommended weight gain in pregnancy: BMI<20= BMI 20-27= BMI >27=

Answer 352

BMI<20= 28-40lbs BMI 20-27= 25-35lbs BMI >27=15-25lbs

Question 353

Reasons to restrict intercourse during pregnancy may include

Answer 353

PPROM Threatened preterm labour Antepartum hemorrhage Placenta Previa

Question 354

If pregnant woman is rubella non-immune____

Answer 354

Give MMR vaccine imeediately postpartum

Question 355

Tdap vaccine generally given to pregnant women at____

Answer 355

27-32wks GA

Question 356

Name 4 medications that are contraindicated in pregnancy

Answer 356

- ACEi (renal tubular agenesis) - Tetracycline (teeth/bone abnormalities) - Retinoids (CNS, craniofacial, CVS anomalies) - Diethylstillbesterol (Vaginal carcinoma, GU defects)

Question 357

DDx for first trimester vaginal bleeding includes

Answer 357

- Normal early gestation - Ectopic pregnancy - Early pregnancy loss - Gestational trophoblastic disease

Question 358

``` Threatened Abortion: Cervical Os __ Bleeding/Cramping__ Fetal Cardiac Activity__ Pregnancy Tissue Passed__ ```

Answer 358

Cervical Os Closed Bleeding/Cramping Yes Fetal Cardiac Activity Possibly Pregnancy Tissue Passed None

Question 359

``` Incomplete Abortion: Cervical Os __ Bleeding/Cramping__ Fetal Cardiac Activity__ Pregnancy Tissue Passed__ ```

Answer 359

Cervical Os Open Bleeding/Cramping Yes Fetal Cardiac Activity No Pregnancy Tissue Passed Partially

Question 360

``` Inevitable Abortion: Cervical Os __ Bleeding/Cramping__ Fetal Cardiac Activity__ Pregnancy Tissue Passed__ ```

Answer 360

Cervical Os Openning Bleeding/Cramping Yes Fetal Cardiac Activity No Pregnancy Tissue Passed Partially

Question 361

``` Complete Abortion: Cervical Os __ Bleeding/Cramping__ Fetal Cardiac Activity__ Pregnancy Tissue Passed__ ```

Answer 361

Cervical Os Closed Bleeding/Cramping Yes Fetal Cardiac Activity No Pregnancy Tissue Passed Completely

Question 362

``` Missed Abortion: Cervical Os __ Bleeding/Cramping__ Fetal Cardiac Activity__ Pregnancy Tissue Passed__ ```

Answer 362

Cervical Os Closed Bleeding/Cramping No Fetal Cardiac Activity No Pregnancy Tissue Passed None

Question 363

-β-hCG should double every ____ for a normally developing pregnancy until it peaks at ~ 100 000 (at about 8 – 10 weeks gestation)

Answer 363

24 hrs

Question 364

β-hCG that do not increase by at least ___in ____ is diagnostic of a non- viable pregnancy, but does not indicate pregnancy location

Answer 364

53% in 48hrs

Question 365

Management options for a confirmed non-viable early IUP may include

Answer 365

1. Expectant management 2. Medical management with mifipristone+misoprostol 3. Surgical management with D&C

Question 366

RFs for ectopic pregnany include

Answer 366

- Tubal damage or pelvic scar tissue - Contraceptive failure - Infertility - Maternal factors (ex. smoking, advanced maternal age)

Question 367

ACS typically describes these three major cardiac conditions

Answer 367

1. Unstable Angina 2. NSTEMI 3. STEMI

Question 368

Typical ACS presentation may involve

Answer 368

• Sub-sternal chest pain, right or left-sided • Characterized as squeezing, heavy, crushing, a fullness or pressure, radiating into jaws or arms • History of pain aggravated by exercise and relieved with rest or nitroglycerin • Symptoms can include nausea, dyspnea, diaphoresis, or syncope

Question 369

Atypical presentation of ACS may involve

Answer 369

* No chest pain, point tenderness, or presents with chest pain characterized as stabbing/sharp * Can also be associated with symptoms of nausea, dyspnea, diaphoresis, or syncope * Symptoms may not have historical patterns or relief with nitroglycerin

Question 370

Longterm management/secondary prevention in patient post-ischemia/infarction may include:

Answer 370

1. Anti-platelet and anti-coag therapy (ASA + Clopidorel/Ticagrelor +/- Anticoag 2. ACEi (or ARB) 3. BB (or CCB) 4. Statin (5. Nitrates for sx relief)

Question 371

Strokes can be a) ___ or b) ___. a) can be ___ or ___ b) can be ___or ___

Answer 371

Strokes can be a) ischemic or b) hemorrhagic. a) can be embolic or thrombotic. b) can be intracerebral or subarachnoid.

Question 372

DDx for CVA signs/symptoms includes:

Answer 372

Seizure, Somatoform/Conversion Disorder, Migraine, Toxic-Metabolic Disturbances, Systemic Infection, Syncope/Presyncope/Hypotension, Tumour, Acute Confusional State, Dementia, Dizziness/Vertigo, Spinal Epidural Hematoma (rare)

Question 373

Initial work-up of a patient presenting with a CVA includes:

Answer 373

1. Urgen non-contrast CT head or brain MRI (mainly to r/o hemorrhagic stroke) 2. Lumbar puncture (if suspected subarachnoid hemorrhage and normal non-contrast CT head) 3. Blood glucose, lytes, renal function, lipid profile, CBC, CK, trop, INR/PTT 4. ECG

Question 374

tPA is indicated within ___ of last seen normal

Answer 374

4.5 hrs

Question 375

Long-term secondary prevention of stroke includes:

Answer 375

- Aggressive RF modification - BP management - Lipid Management (note: if recent ACS and established CAD, target LDL <1.8) - DM target AIC <7, FPG 4-7 - Smoking Cessation - Depression/ANxiety and Cognitive - Functional assessment post-stroke (ex. fatigue)

Question 376

Immediate secondary prevention of stroke includes:

Answer 376

-Antiplatelet Therapy (ASA load followed by daily dose OR Clopidogrel load followed by daily dose) (Diff than MI/ACS where BOTH ASA and clopidogrel used) - Antithrombotic for Afib (DOAC for CHADS 2 or higher) (Note: use of both anticoag and antiplatelet should be avoided unless medically necessary) - Carotid Artery Evaluation (refer for patients with TIA or non-disabling stroke; mild stroke/TIA should be offered carotid endarterectomy w/i 14 days of stroke onset)

Question 377

CHADS2-VASc Score

Answer 377

``` Congestive HF (1) HTN >140/90 (1) AGE >75 (2) DM (1) Prior TIA or stroke (2) Vascular disease (1) Age 65-72 (1) Sex Category (F=1) ```

Question 378

RFs for cerebrovascular disease include

Answer 378

Non-Modifiable: age, famhx Chronic conditions: DM, CKD, sleep apnea, HTN, Afib Lifestyle factors: Smoking, poor diet, physical inactivity

Question 379

3 symptoms seen in COPD

Answer 379

Dyspnea, Chronic Cough, Sputum

Question 380

5 Key screening questions for COPD

Answer 380

1. Do you cough regularly? 2. Do you cough up phlegm regularly? 3. Do even simple chores make you short of breath? 4. Do you wheeze when you exert yourself, or at night? 5. Do you get frequent colds that last longer than other people? If the answer to any of these is YES – proceed to spirometry

Question 381

Diagnosis of COPD requires lung function confirmation of _____ WITHOUT ____ • Reduced FEV1/FVC ratio (

Answer 381

Diagnosis of COPD requires lung function confirmation of airflow obstruction WITHOUT reversibility • Reduced FEV1/FVC ratio (<0.7) • High RV – due to gas trapping • HighTLC- due to hyperinflation

Question 382

As COPD severity increases, FEV1 ____

Answer 382

Decreases

Question 383

AECOPD characterized by increased ____, ____ and ____

Answer 383

Dyspnea, sputum volume, sputum purulence

Question 384

Bugs typically implicated in simple AECOPD

Answer 384

H. influenza, M catarrhalis, S. Pneumoniae

Question 385

Complicated AECOPD has increased sputum purulence and dyspnea as well as at least one of:

Answer 385

FEV1 <50%, 4_ exacerbations per year, Ischemic heart disease, use of home O2, chronic oral steroid use

Question 386

Mainstay tx for mod-sev AECOPD is ___

Answer 386

Systemic steroids 50mg daily for 5-14 days

Question 387

1st line abx in uncomplicated aecopd

Answer 387

Amoxicillin

Question 388

1st line abx in complicated AECOPD

Answer 388

Fluroquinolones (cipro)

Question 389

Symptomatic relief in AECOPD

Answer 389

SABA (ventolin/salbutamol) and SAAC (Atrovent/ipratropium)

Question 390

Complications of AECOPD include

Answer 390

Ischemic heart disease, metabolic syndrome, Cor pulmonale, anemia, pulmonary HTN, lung cancer, cachexia, malnutrition, peripheral muscle dysfunction, osteopenia/osteoporosis, glaucoma, cataracts, anxiety, depression

Question 391

Most effective intervention to decrease risk of COPD and slow progression is ___

Answer 391

Smoking Cessation

Question 392

Examples of non-pharm interventions in COPD

Answer 392

exercise, pulmonary rehab, smoking cessation

Question 393

Pharmacotherapy in COPD - 1st line mild COPD and available as PRN= _____ (____ex. salbutamol, or ____ ex. ipratropium bromide) - 1st line mod COPD or 2nd line mild COPD= ___ (___ ex. fomoterol, or ___ ex. tiotropium) - ___ should never be used alone in COPD, should be added to LABA for mod-sev COPD with 1 or more exacerbations per year

Answer 393

Pharmacotherapy in COPD - 1st line mild COPD and available as PRN= Short Acting Bronchodilators (SABA ex. salbutamol, or SAAC ex. ipratropium bromide) - 1st line mod COPD or 2nd line mild COPD= Long Acting Bronchodilators (LABA ex. fomoterol, or LAAC ex. tiotropium) - ICS should never be used alone in COPD, should be added to LABA for mod-sev COPD with 1 or more exacerbations per year

Question 394

Add-on oral therapies in severe COPD include

Answer 394

Methylxanthines | Roflumilast

Question 395

3 key findings to diagnose asthma in children

Answer 395

1. Documented airflow obstruction (ex. wheezing seen by HCP) 2. Documented reversibility of airflow obstruction (ex. response to SABA =/- steroid, improved wheezing) 3. No clinical evidence of alternative dx

Question 396

Options for diagnosing asthma in individuals > age 6

Answer 396

**Preferred method: reversible airway obstruction on spirometry (12% or > increase in FEV1 after SABA or ICS course) Alt: PEF variability (ex. 20% or > improvement in PEF with SABA or ICS course) Alt: Positive challenge test (methacholine or exercise challenge-->10% drop in FEV1 following exercise

Question 397

Paediatric Athma DDx

Answer 397

- Rhinosinusitis - Upper airway obstruction - Foreign body and aspiratory - Bronchiolitis - Phenumoina, Atelectasis, Tuberculosis, Pertussis - Bronchopulmonary Dysplasia - Congenital Pulmonary Artery Malformation, Bronchiectasis, CF - Primary Ciliary Dyskinesia - GERD - Eosinophilic Esophagitis, swallowing problem +/- aspiration - Immune disorder - Pulmonary edema secondary to myocarditis, pericarditis, congenital cardiac disease

Question 398

Do not order ___ or ___ to confirm asthma, unless ruling out other causes

Answer 398

Full PFTs or CXR

Question 399

In asthma, ICS work by decreasing _____ migration and reversing ____ permeability to prevent or control ____. Side effects include oral ___, dry ____, similar to _______ when used at high doses

Answer 399

In asthma, ICS work by decreasing neutrophil migration and reversing capillary permeability to prevent or control inflammation. Side effects include oral thrush, dry mouth, similar to systemic steroids when used at high doses

Question 400

In asthma, SABA work by stimulating ____ receptors which lead to _____ relaxation and ____ stabilization. Side effects include ____, ____, _____, ____, ____.

Answer 400

In asthma, SABA work by stimulating beta-2 receptors which lead to smooth muscle relaxation and mast cell stabilization. Side effects include tachycardia, palpitations, anxiety, dry mouth, hypokalemia.

Question 401

In asthma, LTRA work by decreasing _____, vascular _____, mucosal ____ and mucus ____. Side effects include abdo pain, dyspepsia, elevated ____, headache.

Answer 401

In asthma, LTRA work by decreasing LT-induced bronchospasms, vascular permeability, mucosal edema and mucus production. Side effects include abdo pain, dyspepsia, elevated liver enzymes, headache.

Question 402

Examples of risks for asthma exacerbation

Answer 402

FEV1 <60%, ED/hospitalization in past year, CVD

Question 403

Examples of aggravating comorbidities in asthma

Answer 403

Rhinitis, GERD, Obesity, Psychosocial issues, sleep apnea

Question 404

In asthma, SABA should be used as ___

Answer 404

PRN for acute asthma attacks

Question 405

In asthma, ICS is ___ for mild-to-severe asthma

Answer 405

mainstay therapy

Question 406

in asthma, LABA (ex. formoterol) can be added to ___ rather than increasing ___

Answer 406

ICS, ICS

Question 407

Asthma tx for kids < 6 years old: Mild: ___prn Mod-Sev: ___prn + low-dose ___ daily (increase to medium dose as required) NO ____ or ___ for young children

Answer 407

Mild: SABA prn Mod-Sev: SABA prn + low-dose ICS daily (increase to medium dose as required) NO LABA or LTRA for young children

Question 408

Non-pharm asthma therapy includes

Answer 408

- Physical activity - Tobacco Cessation - Avoid aggravating medications - Avoid triggers (limited efficacy) - Influenza Vaccination

Question 409

Summary of Pharmacological Therapy for Asthma • ____ prn – for everyone, as a reliever • ___ low-dose daily (at least) – for everyone, as first-line control • Further Management o If < age 6→ increase ___ dose o If > age 6 → add ___→ add ___

Answer 409

Summary of Pharmacological Therapy for Asthma • SABA prn – for everyone, as a reliever • ICS low-dose daily (at least) – for everyone, as first-line control • Further Management o If < age 6→ increase ICS dose o If > age 6 → add LABA → add LTRA

Question 410

Managing acute asthma exacerbation: - proceed to ED - determine underlying cause - give oral ___ x 5 days (if initial SpO2 <96 in kids, <94 in adults) - give ___ if hypoxic - ___ (may need back-to-back) - consider ___ - consider ____

Answer 410

Managing acute asthma exacerbation: - proceed to ED - determine underlying cause - give oral prednisone x 5 days (if initial SpO2 <96 in kids, <94 in adults) - give if hypoxic - salbutamol (may need back-to-back) - consider ipratropium - consider MgSO4

Question 411

``` Adequate Asthma Control: o Day time symptoms ____ per week o Night time symptoms___times per week o Normal exercise tolerance o Mild infrequent ____ only o No missed days of school/work due to asthma o ___ doses of SABA in a week ```

Answer 411

``` o Day time symptoms <4 days per week o Night time symptoms 0 times per week o Normal exercise tolerance o Mild infrequent exacerbations only o No missed days of school/work due to asthma o <4 doses of SABA in a week ```

Question 412

NYHA Functional Classification - Class I: ___ - Class II: Symptoms with ____ - Class III: Symptoms with ____ - Class IV: Symptoms at ___

Answer 412

- Class I: Asymptomatic - Class II: Symptoms with ordinary activity - Class III: Symptoms with less than ordinary activity - Class IV: Symptoms at rest

Question 413

Initial CHF workup may include:

Answer 413

-Labs: CBC, lytes, Cr, eGFR, U/A, ACR, albumin, AST, TSH, FBG, lipid profile, BNP, ECF, -CXR -Echo +/- more specialized testing

Question 414

Normal LVEF ___ HFpEF ___ HFrEF (systolic HF) __

Answer 414

Normal LVEF >60% HFpEF >40% HFrEF (systolic HF) <40%

Question 415

Non-pharm management of CHF involves

Answer 415

- Monitor daily weights - Dietary changes - Mod intensity aerobic and resistance exercise - Immunization

Question 416

Pharm involved in tx of symptomatic HF

Answer 416

1. Diuretics 2. ACEi and BB (sub ARB if intolerant) - HFpEF: 1+ 2+ treat inderlying cause - HFrEF: 1 + 2+ below - NYHA II-III with persistent symptoms add ARB, consider dig +/- nitrates and specialist referral - NYHA III-IV with persistent symptoms increase or combine diuretics, add spironolactone, consider specialist referral

Question 417

Osteoblasts are bone forming cells that respond to ___ and ___

Answer 417

PTH and Vit D

Question 418

Osteoclasts are bone resorpting cells that respond to ____

Answer 418

RANK/RANKL

Question 419

Osteopenia defined as T-score ___ to ___

Answer 419

-1 to -2.4

Question 420

Osteoporosis defined as T-score < ___

Answer 420

-2.5

Question 421

T-score compares BMD to ___

Answer 421

Young healthy adult reference population

Question 422

Z-score compares BMD to ___

Answer 422

Individuals of the same age and sex

Question 423

Fragility fracture is any fall from a standing height or less that results in fracture, except for ___

Answer 423

Hand, foot skull

Question 424

Secondary causes of osteoporosis include

Answer 424

RA, T1DM, Hyperthyroidism, POI, Hypogonadism, Chronic Liver Disease

Question 425

Relevant physical examinations for patients with low bone mass includes

Answer 425

- Weight (>10% loss since age 25 is significant) - Vertebral fracture screen (heigh annually, rib to pelvic distance, occiput to wall distance) - Assess falls-risk with get up and go test (>15s is increased risk)

Question 426

Screening/Ix for low bone mass/OP includes

Answer 426

Ca, Vit, Alb, TSH, ALP, CBC, Cr/eGFR, SPEP if known vertebral fracture (re-check Vit day 3-4 mo after supplementation) BMD

Question 427

Indications to order BMD include

Answer 427

- Men and women age >65 - menopausal women/men age 50-63 with # risk factors (ex. prolonged glucocorticoid use, parental hip fracture, RA) - adults <50 with (fragility #, prolonged glucocorticoids, other high-risk meds, hypogonadism or premature menopause, malabsorption syndrome, primary hyperpara, other disorders stronly associated)

Question 428

Vit D supplementation 800-2000IU after age ___, 400-1000 for those ___

Answer 428

50; <50 at low risk

Question 429

CAROC Guidlines: 10-yr fracture risk, based on femoral neck T-score and age - Low risk (<10%): __ - Mod risk: __ - High risk (>20%): __

Answer 429

- Low risk (<10%): no pharm - Mod risk: discuss risks/benefits - High risk (>20%): pharm

Question 430

FRAX questionnaire more accurate when pt has more than one RF, includes demographic parameters such as

Answer 430

Age, Sex, Wt, Ht, Prev #, Current Smoking, Glucocorticoid use, RA, EtOH

Question 431

1st line agent for tx of osteoporosis is:

Answer 431

Bisphosphonates (ex. Risendronate)

Question 432

Contraindications to bisphosphonates include

Answer 432

Denosumab tx, pregnancy, CKD

Question 433

SEs of oral bisphosphonates include

Answer 433

GI irritation, MSK, acute-phase reaction Rare risks: oseonecrosis of the jaw, atypical femur fractures with long term use

Question 434

AOBP threshold for diagnosing HTN is SBP ___ or DBP ___

Answer 434

SBP ≥ 135mmHg or DBP ≥ 85mmHg

Question 435

Non-AOBP threshold for diagnosing HTN SBP ___ or DBP ___is

Answer 435

SBP ≥ 145mmHg or DBP ≥ 90mmHg

Question 436

Threshold for diagnosing HTN in DM is SBP ___ or DBP __; Other high risk patients/older patients___

Answer 436

SBP ≥ 130mmHg or DBP ≥ 80mmHg Other high risk patients/older patients SBP ≥ 130mmHg

Question 437

HBPM threshold for diagnosing HTN is SBP ___ or DBP ___i

Answer 437

SBP ≥ 135mmHg or DBP ≥ 85mmHg

Question 438

ABPM threshold for diagnosing HTN is

Answer 438

Mean 24-hour SBP ≥ 130mmHg and/or DBP ≥ 80mmHg Mean Daytime SBP ≥ 135mmHg and/or DBP ≥ 85mmHg

Question 439

Target organ damage from HTN includes

Answer 439

-CVD, cerebrovascular disease, Hypertensive retinopathy, PAD, Renal disease

Question 440

List secondary causes of HTN and a test that could be ordered for each

Answer 440

1. Hyperthyroidism > TSH 2. Renal disease > Renal US 3. Cushing's > 24 hr cortisol excretion 4. Primary hyperaldosteronism > aldosterone-renin ratio 5. Pheochromocytoms > Plasma fractionated metanephrines, 24 hour urine metanephrines 6. OSA > sleep study 7. Aortic Coarctation > CXR, CT-Angio 8. Meds

Question 441

Routine labs in new dx of HTN to determine if secondary cause vs essential HTN

Answer 441

Preliminary: urinalysis, Lytes, FBG and/or A1C, lipids, ECG F/U: Lyts, Cr, FPG/A1C, fasting lipids

Question 442

HTN Treatment Targets: - High-risk pt: ___ - DM: __ - Mod to High risk pt: __ - Low risk pt: __

Answer 442

- High-risk pt: SBP <120 - DM: <130/80 - Mod to High risk pt: <140/90 - Low risk pt: <140/90

Question 443

HTN non-pharm tx involves

Answer 443

Lifestyle modifications and managing RFs

Question 444

HTN pharm options include

Answer 444

o Thiazide/Thiazide-LikeDiuretics–natriuretic and removes salt from arterial wall
 oAngiotensin Converting Enzyme Inhibitor/ACE-I[-pril]–blocks ATII formation (vasoconstrictor) o Angiotensin Receptor Blocker/ARB [- sartan] – blocks angiotensin II receptors
 o Calcium Channel Blocker/CCB [- dipine] – blocks entry of calcium into vascular smooth muscle 
o β-Blocker [- olol] – inhibits sympathetic nervous system response
 o Single Pill Combination – ACE-I/ARB + CCB or ACE-I/ARB + Diuretic not ACE-I + ARB

Question 445

RAAS inhibitors contraindicated in ___, caution for ___ / β-Blocker is not first line for ___

Answer 445

RAAS inhibitors contraindicated in pregnancy, caution for reproductive age / β-Blocker is not first line for 60+

Question 446

For initial antihypertensive therapy, start with ___ or ___

Answer 446

Monotherapy or SPC

Question 447

Patients on antihypertensive drug treatment should be seen every ___, until readings on two consecutive visits are below their target, and then ____ intervals thereafter

Answer 447

Patients on antihypertensive drug treatment should be seen every 1 – 2 months, until readings on two consecutive visits are below their target, and then 3 – 6 month intervals thereafter

Question 448

Thiazide diuretics: Mech-- SEs-- C/I--

Answer 448

• Mechanism – inhibits Na and CL reabsorption in the distal tubule; loss of electrolytes cause increase in urine output (diuretic) reducing fluid and thus BP • Side Effects – hyponatremia, hypokalemia, hyperglycemia, hyperlipidemia, increased uric acid • Contraindications – gout; *caution in diabetes (due to hyperglycemia risk) and dyslipidemia (due hyperlipidemia risk)

Question 449

ACEi: Mech-- SEs-- C/I--

Answer 449

• Mechanism – inhibits ACE (angiotensin converting enzyme), reducing synthesis of vasoconstrictor (ATII) and suppressed aldosterone resulting in natriuresis • Side Effects – cough, hyperkalemia, increased creatinine/AKI, angioedema • Contraindications – pregnancy

Question 450

ARB: Mech-- SEs-- C/I--

Answer 450

* Mechanism – antagonist at ATII (angiotensin II) receptor of vascular muscle * Side Effects – hyperkalemia, increased creatinine/AKI * Contraindications – pregnancy

Question 451

BB: Mech-- SEs-- C/I--

Answer 451

* Mechanism – preferentially blocks β-receptors, decreasing HR and output, decreases renin release * Side Effects – fatigue, bradycardia, hypotension, headaches * Contraindications – asthma, epipen*

Question 452

CCB: Mech-- SEs--

Answer 452

• Mechanism – blocks calcium channels in the heart and smooth muscle; dilates peripheral arterioles and slows AV node conduction • Side Effects – pedal edema, flushing, headaches, AV block