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FM Flashcards

1
Q

What questions should be asked on a back pain history?

A

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

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2
Q

Back Pain Patterns

A
  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

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3
Q

Acute Cauda Equina involves…

A

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

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4
Q

Initial pharm treatment of mechanical back pain involves…

A

Acetaminophen followed by NSAIDs

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5
Q

Back Pain Red Flags

A

“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

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6
Q

Back Pain Red Flag investigations

A

“NIFTI”
Neurological—MRI

Infectious—MRI + X-ray

Fracture—X-ray +/- CT

Tumour—MRI + X-ray

Inflammatory—Rheum Consult

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7
Q

Yellow flag questions to ask about back/neck pain

A

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?

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8
Q

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

A
  • Age <45
  • Insidious Onset
  • Improves with exercise
  • No improvement with rest
  • Pain at night (improves with getting up)
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9
Q

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

A

Spine or Non-Spine

Consider referred pain from internal organs

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10
Q

3 locations that mechanical neck pain can present

A
  1. Neck
  2. Shoulder
  3. Arm
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11
Q

What questions should be asked on a Neck Pain History?

A

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?

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12
Q

Neck Pain Red Flags

A

“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

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13
Q

Neck Pain Red Flag Investigations

A

“NIFTI”
Neurological: MRI

Infectious: MRI + Xray

Fracture: Xray +/- CT

Tumour: MRI + Xray

Inflammatory: Rheum Consult

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14
Q

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

A
  • Age <60
  • Insidious Onset
  • Improves with exercise
  • No improvement with rest
  • Pain at night (improves with getting up)
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15
Q

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

A

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

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16
Q

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

A

Acetaminophen> NSAIDs> Muscle Relaxants> Opioids

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17
Q

Recovery position/Starter exercise for Pattern 1 back pain

A

Prone extension; 10 reps TID

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18
Q

Recovery position/Starter exercise for Pattern 2 back pain

A

Seated back flexion; small frequent reps throughout day

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19
Q

Recovery position/Starter exercise for Pattern 3 back pain

A

Z position; advise frequent position changes

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20
Q

Recovery position/Starter exercise for Pattern 4 back pain

A

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

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21
Q

Treatment of chronic back pain (>12 weeks involves)

A

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

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22
Q

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

A

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

Cyclobenzaprine can be used for flare ups

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23
Q

Muscle relaxants not recommended for _____neck dominant pain

A

Chronic neck dominant pain

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24
Q

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

A

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)

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25
Q

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

A

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

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26
Q

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

A

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)

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27
Q

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

A

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

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28
Q

Components of Neck Pain Physical Examination Include:

A

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)

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29
Q

Components of Back Pain Physical Examination Include:

A

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

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30
Q

If neuro exam normal then leg pain is____

A

Referred

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31
Q

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

A

Radicular (Nerve) Pain

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32
Q

Minimum requirements of physical exam for back pain:

A

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

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33
Q

Differential for cognitive impairment:

A

Normal aging, Depression, MCI, Delirium

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34
Q

What distinguishes MCI from Dementia?

A

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

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35
Q

Criteria for major neurocognitive disorder:

A

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

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36
Q

RFs for secondary causes of dementia include:

A

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

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37
Q

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

A

BP, Vision, Hearing, CV, Neuro

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38
Q

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

A

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

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39
Q

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

A

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

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40
Q

What is expected yearly decline in MMSE?

A

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

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41
Q

Which two classes of drugs are used to treat dementia?

A

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

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42
Q

Cholinesterase inhibitors are used in ____

A

Mild-Mod dementia

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43
Q

NMDA receptor antagonists are used in ____

A

Mod-Severe AD

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44
Q

Side effects of cholinesterase inhibitors include:

A

GI upset, headache, dizziness

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45
Q

Name 3 of the contraindications to cholinesterase inhibitors:

A

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

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46
Q

Side effects of NMDA receptor antagonists include:

A

Constipation, dizziness, headache, anxiety, confusion

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47
Q

Skills for MI are:

A

OARS

Open ended questions
Affirmations
Reflective listening
Summary statements

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48
Q

Spirit of MI involves:

A

PACE

Partnership
Acceptance
Compassion
Evocation

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49
Q

Types of “change talk” include

A

DARN CAT

Prepatory
Desire to change
Ability to change
Reasons for change
Need to change

Mobilizing
Commitment
Activations
Taking steps

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50
Q

Patients with these conditions are at elevated CKD risk:

A

HTN, DM, CVD (age 60-75)

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51
Q

Lab tests to be ordered in CKD workup

A

eGFR

Urine ACR

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52
Q

If initial eGFR in CKD workup <60 then…

A

Repeat test in 3 months

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53
Q

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

A

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

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54
Q

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

A

Reversible causes ex. NSAIDS, BPH/Retention

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55
Q

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

A

Patient does not have CKD.

If DM, retest annually

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56
Q

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

A

Patient has CKD, requires management.

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57
Q

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

A

Patient has CKD. Consider Nephro referral.

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58
Q

If eGFR <30 what tests should you order?

A

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

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59
Q

If ACR >60 what tests should you order?

A

Urine R+M and lytes

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60
Q

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?

A

Order lytes and urine R+M.

Follow eGFR and urine ACR every 6 months (if eGFR stable after 2 years follow up yearly).

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61
Q

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

A

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

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62
Q

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

A
  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
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63
Q

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

A

Rotatory

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64
Q

Classic vestibular symptoms include

A
  1. Continuous dizziness or vertigo
  2. N/V
  3. Nystagmus and gait instability
  4. Head motion intolerance
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65
Q

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

A

Episodic vs Continuous

Triggered vs Spontaneous

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66
Q

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

A

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

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67
Q

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

A

Meniere’s

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68
Q

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

A

Vestibular Migraine

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69
Q

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

A

Panic attack, Psych Condition

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70
Q

Examination for episodic vertigo

A

Dix-Hallpike

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71
Q

Examination for continuous vertigo

A

HINTS exam

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72
Q

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

A

Barotrauma or Toxin (meds)

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73
Q

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

A

Vestibular Neuritis

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74
Q

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

A

Stroke/TIA

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75
Q

HINTS exam findings for peripheral cause of continuous vertigo

A

HI: Corrective Saccade

N: Unidirectional horizontal nystagmus

TS: No deviation of covered eye

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76
Q

HINTS exam findings for central cause of continuous vertigo

A

HI: No corrective saccade

N: Bidirectional horizontal nystagmus, or vertical or torsional nystagmus

TS: Vertical deviation of covered eye

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77
Q

What is Benign Paroxysmal

Positional Vertigo?

A 
Transient triggered (head motion) episodes of vertigo caused by dislodged
canaliths in the semicircular canals
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78
Q

What is Vestibular Neuritis

A

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

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79
Q

What is Meniere’s Disease

A

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

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80
Q

What is Otosclerosis

A

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

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81
Q

What is Vestibular Migraine

A

Spontaneous episodes of vertigo associated with migraine headaches

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82
Q

Cerebrovascular

Disease causes vertigo by…

A

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

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83
Q

Cerebellopontine

Angle

A

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

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84
Q

Tx for BPPV

A

Epley

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85
Q

Tx for Meniere’s

A

Salt restriction

Diuretics

Vestibular suppressants/antiemetics

Betahistine

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86
Q

Tx for vestibular neuritis

A

Vestibular suppressants (antibistamine, antiemetics, benzos)

Vestibular rehab

Can consider steroids

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87
Q

Diagnostic criteria for Meniere’s

A

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

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88
Q

What are the 4 D’s of Vertebrobasilar Insufficiency

A

Drop Attacks
Dysarthria
Dizziness
Diplopia

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89
Q

Tx for vertebrobasilar insufficiency in the context of vertigo

A

Antiplatelets and reduce cerebrovascular risk factors

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90
Q

Examples of ototoxic meds

A

Aminoglycosides and Furosemide

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91
Q

When is imaging indicated in vertigo work up?

A

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

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92
Q

30/20/10 rule for orthostatic hypotension

A

HR Increase 30 bpm

SBP decrease 20mmHg

DBP decrease 10mmHg

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93
Q

What physical exam maneuvers should be included in vertigo workup?

A

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

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94
Q

Which imaging modality is best for diagnosis in vertigo?

A

MRI as it can visualize the posterior fossa better than CT

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95
Q

What is Acute labyrinthitis

A

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

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96
Q

What is Cholesteatoma

A

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

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97
Q

What is Herpes zoster oticus (Ramsay

Hunt syndrome)

A

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

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98
Q

What is Perilymphatic fistula

A

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

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99
Q

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

A

Weight Loss

Hemoptysis

Fevers/Night Sweats

Travel/TB exposure

Occupational Hazards

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100
Q

Signs of respiratory distress

A
  • Tachypnea
  • Pursed lip breathing
  • Accessory muscle use
  • Tripod position
  • Wheezing, audible breathing
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101
Q

4 acute causes of cough/dyspnea

A
  1. Infectious
  2. Post-Viral
  3. Airway Irritants
  4. Exacerbation of Chronic Illness
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102
Q

Tx for post-viral cough

A

inhaled bronchodilators +/- ICS

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103
Q

9 chronic causes of cough/dyspnea

A
  1. Asthma
  2. COPD
  3. HF
  4. Infectious (TB)
  5. Post-nasal drip/rhinitis
  6. Bronchiectasis
  7. GERD
  8. Medication (ACEi)
  9. Lung Cancer
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104
Q

Presentation of post-nasal drip/rhinitis may include

A

Nasal discharge

Nasopharygeal secretions

Throat Clearing

Sensation of dripping down throat

Nasopharyngeal Cobblestoning

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105
Q

Tx of post-nasal drip/rhinitis may include

A

Oral antihistamines

Oral decongestants

Intranasal corticosteroids

Intranasal Ipratropium bromide

Leukotriene receptor antagnoists

Abx as indicated

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106
Q

Presentation of GERD may include

A

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

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107
Q

Tx of GERD may include

A

Lifestyle Changes

H2 blocker or PPI or antacid

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108
Q

Bronchiectasis may be ____ or ____

A

Focal (often from prolonged or sever LRTI)

Multifocal (may be secondary to MAC)

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109
Q

Red flags for bronchogenic carcinoma on a cough history include

A

Hemoptysis

Weight loss

Cachexia

Abnormal imaging

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110
Q

3 types of medication that may induce cough

A

ACEi, BB, Amiodarone

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111
Q

Precipitating factors of GERD include

A

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

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112
Q

What are most probable pathogens in AECOPD?

A

H.flu, M. Cat, Strep Pneumo

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113
Q

Obesity in Men = WC > ___

A

102cm

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114
Q

Obesity in Women= WC >___

A

88cm

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115
Q

BMI Classification:

  • Underweight=___
  • Normal=___
  • Overweight=___
  • Obesity I=____
  • Obesity II=___
  • Obesity III=___
A
  • 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
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116
Q

Potential target organ damage associated with obesity inclues

A
  1. CVD (HTN and CAD)
  2. Cancer
  3. T2DM
  4. OA and back pain
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117
Q

What are the components of the adolescent history?

A

HEEADSSS

Home
Eating/Exercise
Education/Employment
Activities
Drugs
Sexuality
Suicide
Safety
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118
Q

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

A
  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.
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119
Q

What are some discussion topics at a periodic health exam?

A

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

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120
Q

Populations not to miss in cervical cancer screening include

A

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

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121
Q

What are the recommendations for cervical cancer screening?

A

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.

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122
Q

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

A

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

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123
Q

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

A

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.

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124
Q

What are the high risk criteria for breast cancer?

A

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

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125
Q

What are the screening recommendations for breast cancer?

A

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

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126
Q

What are the high risk criteria for colorectal cancer?

A

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

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127
Q

What are the screening recommendations for colorectal cancer?

A

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

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128
Q

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

A

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

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129
Q

List some clinical risk factors for osteoporosis?

A

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

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130
Q

When and how should screening be initiated for osteoporosis?

A

Screen with BMD and Risk Calculator.

Age <50 if high risk factors
Age 50-64 if clinical risk factors
Age 65 and greater–everyone

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131
Q

How often should BMD be repeated for OP screening?

A

Low risk–every 5 years

Med/Mod risk–every 1-3 yrs

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132
Q

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

A

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

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133
Q

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

A

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

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134
Q

Diagnostic Criteria for T2DM

A

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)

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135
Q

A1C 6-6.4 % = ____

A

Prediabetes

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136
Q

A1C >= 6.5%= ____

A

Diabetes

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137
Q

FPG >= 7mmol/L= _____

A

Diabetes

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138
Q

Hyperlipidemia is screened with______

A

Non-fasting lipids and Framingham Risk Score

unless Hx of TG >4.5, then fasting lipids

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139
Q

What ages/how often should we screen for dyslipidemia?

A

Age 40 to 75, screen every 5 years

if no RFs

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140
Q

Risk factors for dyslipidemia that would prompt earlier screening include

A

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

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141
Q

What ages/how often should we calculate CV risk?

A

Men Age 40-75
Women Age 50-75

Framingham Risk score every 5 yrs (if risk <5%) or every year i(if risk >=5%)

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142
Q

Ca Intake Recommendations

A

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

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143
Q

Vit D Intake Recommendations

A

Low Risk 400-1000IU

High risk, >=50 yrs 800-1000IU, increased to 2000IU

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144
Q

Contraindications to Live Vaccinations

A

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

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145
Q

Who should receive HPV vaccinations?

A

Women age 9-45

Men age 9-26

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146
Q

Age for Shingles Vaccine

A

Product monograph states 50+, NACI states 60+

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147
Q

Age/Population for Pneumococcal Vaccinations

A

Age 65+

DM, CHF, COPD, CKD, Asplenia, Immunosuppresed, Liver disease

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148
Q

Adacel indications, frequency, age

A

Protects against Tetanus, Diptheria and Whopping Cough

One lifetime dose

Adolescents age 14-16 or adults who missed adolescent dose

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149
Q

Side effects of MMR

A

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

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150
Q

Which vaccination should be given in every pregnancy?

A

Pertussis

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151
Q

What is the recommendation around screening for prostate cancer?

A

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)

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152
Q

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

A

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

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153
Q

Menopause is defined as

A

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

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154
Q

Contributing factors to age of menopause onset include

A

Genetics, Smoking, Pelvic Radiation, Chemotherapy

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155
Q

Premature Menopause = age___

A

<40

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156
Q

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

A

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

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157
Q

Clinical features of menopause

A

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

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158
Q

Menopausal vaginal atrophy manifests as

A

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

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159
Q

Treatment for mild vasomotor symptoms of menopause includes

A

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

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160
Q

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

A

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

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161
Q

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

A

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

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162
Q

Two non-hormonal treatments for vaginal atrophy

A

Vaginal lubricants and Vaginal moisurizer

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163
Q

3 local estrogen therapy treatment options for vaginal atrophy

A

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)

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164
Q

Stress incontinence tx

A

Weight loss, pelvic floor exercises, pessaries

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165
Q

Urge incontinence tx

A

Lifestyle changes, bladder retraining, antimuscarinic agents (oxybutynin)

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166
Q

For all menopausal women, osteoporosis prevention involves

A

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)

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167
Q

Indications for MHRT

A

Best tx for vasomotor sx, not recommended for osle tx of hyperlipidemia, CVD, OP

*Remember to add progesterone if pt has a uterus

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168
Q

Contraindications to MHRT

A

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

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169
Q

CAD risks/benefits of MHT

A

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)

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170
Q

Risks of MHT include

A

-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

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171
Q

Components of Framingham Risk Score

A 
Age
Sex
Smoking
DM
Total Chol
HDL Chol
SBP
Blood Pressure treated by Meds
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172
Q

In general, lipid targets are:

A

LDL-C <2 or >50% decrease

Apo B <0.8, Non-HDL-C <2.6

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173
Q

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

A

• 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

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174
Q

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

A 
• 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
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175
Q

Based on CCS Guidelines, how do we screen for hyperlipidemia

A

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

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176
Q

When to consider secondary hyperlipidemia testing with coronary artery calcium measurement

A

• 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

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177
Q

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

A

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

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178
Q

Based on Simplified Lipid Guidelines how do we screen

A

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

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179
Q

CCS Guideline statin indicated conditions include

A
  • LDL-C 5 or greater (genetic dyslipidemia)
  • Clinical Atherosclerosis
  • AAA
  • DM
  • CKD
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180
Q

CCS guidelines for primary prevention management of hyperlipidemia based on FRS

A

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)
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181
Q

Statin mechanism of action

A

Selective inhibition of cholesterol reabsorption at the

brush border of enterocytes (↓ LDL, minimal ↑ on HDL and minimal ↓ on TG)

182
Q

Simplified Lipid Guidelines for hyperlimidemia

A

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

183
Q

Statin Side Effects

A
  • 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)

184
Q

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

A
  • 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
185
Q

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

A

• 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

186
Q

Risk factors for T2DM

A
  • 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
187
Q

How to screen for T2DM

A

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

188
Q

Who should be screened for T2DM

A

No RFs: Age 40+ or high risk should be screened every 3 yrs

RFs: Screen q6-12mo

189
Q

Recommended targets in T2DM patients

A

HbA1C 7% or less

BP <130/80

LDL-C <2 (or 50% reduction from baseline)

190
Q

Components of lifestyle management for diabetes care

A

Exercise, Diet, Smoking Cessation, Self-Management

191
Q

First line agent for T2DM

A

Metformin

192
Q

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

A

3-6 mo

193
Q

If A1C <1.5% above target

A

Start/increase metformin if not at target within 3 mo

194
Q

If A1C 1.5% or higher above targer

A

Start metformin immediately, consider second concurrent antihyperglycemic agent

195
Q

If symptomatic hyperglycemia and/or metabolic decompensation

A

Initiate insulin +/- metformin

196
Q

Info/SEs about GLP1ra

A 
• Requires subcutaneous injection
• GI side-effects
• Gallstone disease
• Contraindicated with history of medullary thyroid cancer or MEN2
***Weight Loss***
197
Q

Info/SEs about SGLT2i

A

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

198
Q

Antihyperglycemic agents that cause weight gain

A

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

199
Q

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

A

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

200
Q

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

A

Statin + ACEi/ARB + ASA

201
Q

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

A

Statin + ACEi/ARB

ex. Ramipril 10mg PO daily

202
Q

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

A

Statin

203
Q

What and how often should screening be done in T2DM

A

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

204
Q

Type of neuropathy in T2DM

A

Distal symmetric polyneuropathy

205
Q

Treatment of T2DM neuropathy

A

TCAs, gabapentin, tramadol

Daily foot exams, comfortable/cushioned shoes, smoking cessation

206
Q

First sign of glomerular damage in diabetic nephropathy

A

Microalbuminuria

207
Q

Treatment of diabetic nephropathy

A

ACEi

208
Q

Treatment of diabetic retinopathy

A

Retinal photocoagulation

209
Q

Early sign of CVD in men is ___

A

Erectile Dysfunction

210
Q

____ in normotensive patients with T2DM helps prevent macrovascular disease

A

ACEi

211
Q

Questions to ask for hx of a red eye

A
  • 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
212
Q

Ddx of Red Eye

A
  • Dry eye disease
  • Blepharitis
  • Uveitis
  • Angle closure glaucoma
  • Carotid cavernous fistula
  • Endopthalmitis
  • Cellulitis
  • Anterior segment tumors
  • Scleritis
  • Subconjunctival hemorrhage
213
Q

Urgent referral indicated if red eye and:

A
  • 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
214
Q

When to refer to optho for suspected acute conjunctivitis:

A
  • Pain
  • Photophobia
  • Constant blurred vision
  • Hyperpurulent (gonococcal)
  • None of pain + photophobia + blurred vision + discharge + itching
215
Q

Management of viral conjunctivitis

A

Very contagious
No tx–sx management (cold compress, artificial tears, antihistamines)

Refer to optho if sx do not resolve in 7-10 days

216
Q

Management of bacterial conjunctivitis

A

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

217
Q

Management of allergic conjunctivitis

A
  • 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
218
Q

Primary causes of hypothyroidism

A
  • Hashimoto’s Thyroiditis (chronic autoimmune thyroiditis)
  • Transient hypothyroidism (ex. postpartum, painless thyroiditis)
  • Infiltrative (ex. sarcoid)
  • Meds
  • Iatrogenic (ex. RAI, thyroidectomy)
219
Q

Secondary causes of hypothyroidism

A
  • Pituitary lesion (TSH deficiency)

- Hypothalamic lesion (TRH def.)

220
Q

Primary causes of hyperthyroidism

A
  • Autoimmune Hyperthyroidism (Grave’s, Rare-Hashitoxicosis)
  • Toxic Multinodular Goitre
  • Toxic Adenoma
  • Exogenous Thyroid
  • Postpartum Thyroiditis
  • Drug induced (amiodarone)
  • Neoplastic (RARE–Metastatic Thyroid Cancer)
221
Q

Secondary causes of hyperthyroidism

A

TSH-producing pituitary adenoma

222
Q

Pregnancy-related causes of hyperthyroidism

A

Gestational hyperthyroidism (seen with hyperemesis gravidarum)

Trophoblastic disease

223
Q

Risk factors for thyroid disease

A
  • 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
224
Q

Clinical features of hypothyroidism include

A

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

225
Q

Clinical features of hyperthyroidism include

A

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

226
Q

Only initial test required to screen for thyroid disease is

A

TSH

227
Q

When to order fT3 and fT4

A

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)

228
Q

Primary care management of hypothyroidism involves

A

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

229
Q

List 5 treatment options for hyperthyroidism

A
  1. Propylthiouracil (PTU)
  2. Methimazole
  3. RAI
  4. Thyroidectomy
  5. Beta-blocker (short-term tx of sx until above tx takes effect)
230
Q

Subclinical hypothyroid: ____ TSH, ____ fT4

Subclinical hyperthyroid: ____ TSH, ____ fT4

A

Subclinical hypothyroid: increased TSH, normal fT4

Subclinical hyperthyroid: decreased TSH, normal fT4

Monitor TSH q 12 mo for hypo, q6-12mo for hyper

231
Q

Maternal hypothyroidism is associated with _____ in newborns

A

Maternal hypothyroidism is associated with decreased IQ in newborns

232
Q

Factors associated with increasing number and size of thyroid nodules

A

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

233
Q

Factors associated with increased risk of thyroid cancer

A

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

234
Q

Approach to a thyroid nodule

A

• 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)

235
Q

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

A

BESKIM

Blank mind

Easily fatigued

Sleep Changes

Keyed up (restless)

Irritability

Muscle tension

236
Q

Validated tool for screening of GAD in primary care

A

GAD-7 Scale

237
Q

Investigations that can be ordered for anxiety disorders

A

Basic labs (CBC, lipids, lytes, fasting glucose, TSH, liver enzymes)

Serum/urine tox screen (?substance use)

ECG (for panic attacks)

238
Q

Modifiable biological risk factors for anxiety

A

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)

239
Q

Non-modifiable biological risk factors for anxiety

A

Non-Modifiable

240
Q

Non-modifiable psych risk factors for anxiety

A

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

241
Q

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

A

2

242
Q

In general what meds/substances can induce anxiety symptoms?

A
  • Stimulants (caffeine, beta-agonists)
  • Sympathomimetic agents
  • Withdrawal from Depressants (anti-depressants, alcohol, benzodiazepine)
243
Q

Treatment options for GAD

A
  • 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
244
Q

Treatment options for PD

A
  • CBT
  • SSRIs/SNRIs
  • BZDs
  • TCAs and less commonly MAOIs can also be used
245
Q

Treatment options for social anxiety disorder

A
  • CBT
  • SSRIs/SNRIs
  • BZDs and BBs for acute situations and performance anxiety
  • TCAs and moclobemide can be used third line
246
Q

Treatment options for OCD

A
  • ERP
  • High dose often required of SSRIs/SNRIs or TAs (1st line: sertraline, paroxetine, fluoxetine, fluvoxamine) (2nd line: venlafaxine, clomipramine, mirtazapine, citalopram)
247
Q

Treatment options for PTSD

A
  • CBT or ERP
  • SSRIs/SNRIs (most evidence for sertraline)
  • Some evidence that antipsychotics may have a role in augmentation therapy
248
Q

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

A
  1. Re-living (recurrent and intrusive memories/distress)
  2. Avoidance
  3. Arousal
249
Q

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

A

• 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)

250
Q

Principles for initiating pharm management of anxiety disorders

A

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

251
Q

5 or more of the following symptoms required for MDD diagnosis

A

MSIGECAPS

Mood decreased

Sleep (increased/decreased)

Interest (anhedonia)

Guilt or worthlessness

Energy decreased

Concentration decreased

Appetite (increased/decreased)

Psychomotor slowing/agitation

Suicidal ideation

252
Q

Symptoms of depression can be classified into three groups

A
  1. Affective
  2. Cognitive
  3. Neurovegetative
253
Q

Components of the mental status exam

A

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

254
Q

Most important risk factor for suicide

A

Previous attempts at suicide

255
Q

Suicide RFs

A

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)

256
Q

Suicide PFs

A

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

257
Q

Suicide at-risk populations

A

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

258
Q

Ddx for depressed mood, including causes of secondary depression

A
  • 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)
259
Q

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

A
  • 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
260
Q

Validated scales designed to assess baseline mood and track tx

A

PHQ-9 and Beck Depression Inventory

261
Q

Pharm tx counselling for depression can include

A

• 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

262
Q

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 _____

A

-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

263
Q

Non-pharm tx for depression can include

A

CBT
IPT
PST

264
Q

4 types of mandatory physician reporting

A
  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
265
Q

Low risk drinking guidelines

A
  • 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
266
Q

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

A 
§ Tolerance 
§ Withdrawal 
§ Drinking limits 
§ Failed to cut down 
§ Time
§ Spending less time on other matters 
§ Continued drinking despite problems
267
Q

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

A

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

268
Q

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

A

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

269
Q

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

A

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

270
Q

Physical findings of alcohol use disorders

A

• 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

271
Q

What questions are involved in the CAGE screen for AUD

Note: can also use the AUDIT3

A

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?

272
Q

At-risk drinking is defined as

A

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

273
Q

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: ____

A

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

274
Q

4 Major Symptom Domains of Substance-Use Disorder

A
  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)

275
Q

Pharm tx for alcohol dependence may involve

A
  • 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)
276
Q

Pharm Tx for EtOH withdrawal may involve

A
  • diazepam or lorazepam

- thiamine

277
Q

Tobacco Cessation Treatment Options

A
  • 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)
278
Q

ADLS=

A

DEATH

Dressing
Eating
Ambulating
Toileting
Hygiene
279
Q

iADLs=

A

SHAFT

Shopping
Housekeeping
Accounting
Food prep
Transportation
280
Q

For frail older patients blood sugar

A

5

281
Q

For older adults, HbA1c targets tend to be ____

A

7.1-8.5%

282
Q

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

A

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

283
Q

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

A

FPG and HbA1C

284
Q

Screening patients age ____for T2DM is unlikely to be beneficial

A

> 80 yrs

285
Q

Hypertension Goals:

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

A

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

286
Q

DDx for Orthostatic Hypotension (“4D-AID”)

A

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)
287
Q

Risks of statins in older adults include

A
  • Myalgias
  • Cognitive function
  • Rhabdo and liver failure
  • Asymptomatic increases in CK and liver enzymes
288
Q

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

A

Age

289
Q

A _____ is diagnostic of osteoporosis

A

Fragility fracture (any fall from standing height or less)

290
Q

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

A

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

291
Q

Treatment of Osteoporosis in Older Adults
• ______

  • _____
  • _____
A

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
292
Q

Bisphosphonate adverse effects include

A

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

293
Q

Contraindications to bisphospnonates include

A

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

294
Q

Preferred hepes zoster vaccination is ____

A

Shingrix: recombinant subunit zoster vaccine

superior than Zostavax–live attenuated zoster vaccine

295
Q

Vaccines in older adults (4):

A
  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
296
Q

General suggested ages to stop cancer screening in older adults:

A
  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
297
Q

Sexual History 5Ps

A

Partners, Practices, Protection, Past History, Pregnancy Prevention

298
Q

Absolute contraindications to combined OCP include

A
  • 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
299
Q

Relative contraindications to combined OCP (must monitor) include

A

• 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

300
Q

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

A

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

301
Q

Estrogen in contraception works by ___ and ____.

A

FSH suppression (suppressing follicular development) and endometrial proliferation

302
Q

SEs and complications of progestins in contraception include:

A 
• Breakthrough bleeding
• Premenstrual Symptoms – bloating,
water retention, breast tenderness
• Weight Gain – increased appetite, dose
dependent and typically only seen in
higher doses
• Acne
303
Q

SEs and complications of estrogens in contraception include:

A 
• Breakthrough bleeding
• Nausea
• Breast tenderness
• Thromboembolic disease (DVT/PE),
MI, and stroke
• Headaches – migraines
• Liver metabolism – active liver disease
304
Q

Non-contraceptive benefits of combined OCP

A
  • 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
305
Q

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

A

IUDs

306
Q

IUD mechanism of action:

A

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

307
Q

Options for starting OCP and implications for contraception

A

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

308
Q

Missed OCP pill during 1st week means:

A

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

309
Q

Missed OCP pill during 2nd or 3rd week

A

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

310
Q

Potential drug interactions with OCP include

A 
Anticonvulsants
Anti-TB
Anti-fungal
Anti-retroviral
St. John's Wort
311
Q

Emergency contraception options include:

A
  • 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)
312
Q

4 things to assess on first newborn visit to PCP

A
  1. Dehydration
  2. Jaundice
  3. Feeding problems
  4. Congenital anomalies
313
Q

Earliest sign of dehydration in infants is ___

A

Abnormal vitals

314
Q

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 ___

A
  • 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
315
Q

Rule of 3s for colic (diagnosis of exclusion)

A

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

316
Q

Localized reactions to immunizations include

A
  • Swelling
  • Induration
  • Erythema
  • Tenderness
  • Localized Rash
317
Q

Systemic reactions to immunizations include

A
  • Fever • Rash
  • Joint/muscle pain
  • Fainting
  • Seizures
  • Guillain-Barré
318
Q

Jaundice history can involve

A
  • Bili levels at 24hrs
  • Birth history
  • FamHx of jaundice in siblings
  • Feeding Hx
  • Maternal blood type
  • Stool/urine output
  • Time frame
319
Q

RFs for severe hyperbilirubinemia

A
  • 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
320
Q

+ Coombs test indicates___

A

Hemolysis

321
Q

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

A

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

322
Q

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

A

Fever and Anemia

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

323
Q

Describe a Still’s Murmur

A

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
324
Q

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

A
  • Hx of congenital heart disease in 1st degree relatives
  • In utero drug exposure
  • Maternal DM
  • Intrauterine infections (rubella)
  • FamHx SCD
325
Q

Physical exam for heart murmur in a baby

A
  • 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
326
Q

Describe a Functional Murmur

A

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

327
Q

Systolic murmurs in babies include:

A

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

328
Q

Pathological murmurs in babies include:

A

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

329
Q

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

A
  • 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
330
Q

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

A

18 month

331
Q

Autism history may include:

A
  • 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
332
Q

DDx for ASD

A
  • Anxiety disorder
  • Attachment disorder
  • Fetal alcohol syndrome
  • Global developmental delay
  • Hearing impairment
  • Language disorder
  • Learning disability
333
Q

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

A

Identify
Assess
Plan

334
Q

Examples of general indicators of patient delcline

A

• 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

335
Q

Two scoring scales used in palliative care

A

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

336
Q

Components of the SPIKES approach

A 
SPIKES
Scene
Perception
Invitation
Knowledge
Empathy (NURSE: Name, Understand, Respect, Support, Explore)
Summary
337
Q

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

A

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)

338
Q

Opioid dosing

A

Codeine > Morphine > Oxycodone > Hydromorphone

339
Q

Breakthough opioid dose is ___ of 24 hr total q1h prn

A

10%

340
Q

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

A

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

341
Q

Opioid adverse effects include

A
  • 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)
342
Q

Principles for managing dyspnea in palliative patients

A
  • 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)
343
Q

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

A
  • 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
344
Q

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

A

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

345
Q

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

A

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

346
Q

Timing and frequency of antenatal visits

A
  • 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
347
Q 
Summary of Ix throughout pregnancy: 
8-12 wks=
11-14 wks=
18-20 wks=
24-28wks=
27-32wks=
28wks=
35-37wks=
41wks to delivery=
A

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

348
Q

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

A

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)

349
Q

TORCH infections inlcude

A 
Toxoplasmosis
Other (parvovirus, varicella, syphilis)
Rubella
CMV
HSV
350
Q

Components of BPP

A 
Fetal breathing
Fetal movement
Fetal tone
Amniotic fluid
(NST)
351
Q

Management of NVP

A
  • Dietary/Lifestyle Changes
  • Non-pharm (ginger tablets, MBCT)
  • Pharm (Vit B6, Doxylamine, Diclectin, Dimenhydrinate, Metaclopramide)
  • Refractory–consider hospitalization, ondansetron, corticosteroids, investigate for other causes
352
Q

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

A

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

353
Q

Reasons to restrict intercourse during pregnancy may include

A

PPROM
Threatened preterm labour
Antepartum hemorrhage
Placenta Previa

354
Q

If pregnant woman is rubella non-immune____

A

Give MMR vaccine imeediately postpartum

355
Q

Tdap vaccine generally given to pregnant women at____

A

27-32wks GA

356
Q

Name 4 medications that are contraindicated in pregnancy

A
  • ACEi (renal tubular agenesis)
  • Tetracycline (teeth/bone abnormalities)
  • Retinoids (CNS, craniofacial, CVS anomalies)
  • Diethylstillbesterol (Vaginal carcinoma, GU defects)
357
Q

DDx for first trimester vaginal bleeding includes

A
  • Normal early gestation
  • Ectopic pregnancy
  • Early pregnancy loss
  • Gestational trophoblastic disease
358
Q 
Threatened Abortion: 
Cervical Os \_\_
Bleeding/Cramping\_\_
Fetal Cardiac Activity\_\_
Pregnancy Tissue Passed\_\_
A

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

359
Q 
Incomplete Abortion:
Cervical Os \_\_
Bleeding/Cramping\_\_
Fetal Cardiac Activity\_\_
Pregnancy Tissue Passed\_\_
A

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

360
Q 
Inevitable Abortion:
Cervical Os \_\_
Bleeding/Cramping\_\_
Fetal Cardiac Activity\_\_
Pregnancy Tissue Passed\_\_
A

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

361
Q 
Complete Abortion: 
Cervical Os \_\_
Bleeding/Cramping\_\_
Fetal Cardiac Activity\_\_
Pregnancy Tissue Passed\_\_
A

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

362
Q 
Missed Abortion:
Cervical Os \_\_
Bleeding/Cramping\_\_
Fetal Cardiac Activity\_\_
Pregnancy Tissue Passed\_\_
A

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

363
Q

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

A

24 hrs

364
Q

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

A

53% in 48hrs

365
Q

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

A
  1. Expectant management
  2. Medical management with mifipristone+misoprostol
  3. Surgical management with D&C
366
Q

RFs for ectopic pregnany include

A
  • Tubal damage or pelvic scar tissue
  • Contraceptive failure
  • Infertility
  • Maternal factors (ex. smoking, advanced maternal age)
367
Q

ACS typically describes these three major cardiac conditions

A
  1. Unstable Angina
  2. NSTEMI
  3. STEMI
368
Q

Typical ACS presentation may involve

A

• 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

369
Q

Atypical presentation of ACS may involve

A
  • 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
370
Q

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

A
  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)
371
Q

Strokes can be a) ___ or b) ___.

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

A

Strokes can be a) ischemic or b) hemorrhagic.

a) can be embolic or thrombotic.
b) can be intracerebral or subarachnoid.

372
Q

DDx for CVA signs/symptoms includes:

A

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

373
Q

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

A
  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
374
Q

tPA is indicated within ___ of last seen normal

A

4.5 hrs

375
Q

Long-term secondary prevention of stroke includes:

A
  • 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)
376
Q

Immediate secondary prevention of stroke includes:

A

-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)
377
Q

CHADS2-VASc Score

A 
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)
378
Q

RFs for cerebrovascular disease include

A

Non-Modifiable: age, famhx

Chronic conditions: DM, CKD, sleep apnea, HTN, Afib

Lifestyle factors: Smoking, poor diet, physical inactivity

379
Q

3 symptoms seen in COPD

A

Dyspnea, Chronic Cough, Sputum

380
Q

5 Key screening questions for COPD

A
  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

381
Q

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

A

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

382
Q

As COPD severity increases, FEV1 ____

A

Decreases

383
Q

AECOPD characterized by increased ____, ____ and ____

A

Dyspnea, sputum volume, sputum purulence

384
Q

Bugs typically implicated in simple AECOPD

A

H. influenza, M catarrhalis, S. Pneumoniae

385
Q

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

A

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

386
Q

Mainstay tx for mod-sev AECOPD is ___

A

Systemic steroids 50mg daily for 5-14 days

387
Q

1st line abx in uncomplicated aecopd

A

Amoxicillin

388
Q

1st line abx in complicated AECOPD

A

Fluroquinolones (cipro)

389
Q

Symptomatic relief in AECOPD

A

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

390
Q

Complications of AECOPD include

A

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

391
Q

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

A

Smoking Cessation

392
Q

Examples of non-pharm interventions in COPD

A

exercise, pulmonary rehab, smoking cessation

393
Q

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
A

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
394
Q

Add-on oral therapies in severe COPD include

A

Methylxanthines

Roflumilast

395
Q

3 key findings to diagnose asthma in children

A
  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
396
Q

Options for diagnosing asthma in individuals > age 6

A

**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

397
Q

Paediatric Athma DDx

A
  • 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
398
Q

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

A

Full PFTs or CXR

399
Q

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

A

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

400
Q

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

A

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.

401
Q

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

A

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.

402
Q

Examples of risks for asthma exacerbation

A

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

403
Q

Examples of aggravating comorbidities in asthma

A

Rhinitis, GERD, Obesity, Psychosocial issues, sleep apnea

404
Q

In asthma, SABA should be used as ___

A

PRN for acute asthma attacks

405
Q

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

A

mainstay therapy

406
Q

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

A

ICS, ICS

407
Q

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

A

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

408
Q

Non-pharm asthma therapy includes

A
  • Physical activity
  • Tobacco Cessation
  • Avoid aggravating medications
  • Avoid triggers (limited efficacy)
  • Influenza Vaccination
409
Q

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 ___

A

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

410
Q

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 ____
A

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
411
Q 
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
A 
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
412
Q

NYHA Functional Classification

  • Class I: ___
  • Class II: Symptoms with ____
  • Class III: Symptoms with ____
  • Class IV: Symptoms at ___
A
  • Class I: Asymptomatic
  • Class II: Symptoms with ordinary activity
  • Class III: Symptoms with less than ordinary activity
  • Class IV: Symptoms at rest
413
Q

Initial CHF workup may include:

A

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

414
Q

Normal LVEF ___
HFpEF ___
HFrEF (systolic HF) __

A

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

415
Q

Non-pharm management of CHF involves

A
  • Monitor daily weights
  • Dietary changes
  • Mod intensity aerobic and resistance exercise
  • Immunization
416
Q

Pharm involved in tx of symptomatic HF

A
  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
417
Q

Osteoblasts are bone forming cells that respond to ___ and ___

A

PTH and Vit D

418
Q

Osteoclasts are bone resorpting cells that respond to ____

A

RANK/RANKL

419
Q

Osteopenia defined as T-score ___ to ___

A

-1 to -2.4

420
Q

Osteoporosis defined as T-score < ___

A

-2.5

421
Q

T-score compares BMD to ___

A

Young healthy adult reference population

422
Q

Z-score compares BMD to ___

A

Individuals of the same age and sex

423
Q

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

A

Hand, foot skull

424
Q

Secondary causes of osteoporosis include

A

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

425
Q

Relevant physical examinations for patients with low bone mass includes

A
  • 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)
426
Q

Screening/Ix for low bone mass/OP includes

A

Ca, Vit, Alb, TSH, ALP, CBC, Cr/eGFR, SPEP if known vertebral fracture

(re-check Vit day 3-4 mo after supplementation)

BMD

427
Q

Indications to order BMD include

A
  • 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)
428
Q

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

A

50; <50 at low risk

429
Q

CAROC Guidlines: 10-yr fracture risk, based on femoral neck T-score and age

  • Low risk (<10%): __
  • Mod risk: __
  • High risk (>20%): __
A
  • Low risk (<10%): no pharm
  • Mod risk: discuss risks/benefits
  • High risk (>20%): pharm
430
Q

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

A

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

431
Q

1st line agent for tx of osteoporosis is:

A

Bisphosphonates (ex. Risendronate)

432
Q

Contraindications to bisphosphonates include

A

Denosumab tx, pregnancy, CKD

433
Q

SEs of oral bisphosphonates include

A

GI irritation, MSK, acute-phase reaction

Rare risks: oseonecrosis of the jaw, atypical femur fractures with long term use

434
Q

AOBP threshold for diagnosing HTN is SBP ___ or DBP ___

A

SBP ≥ 135mmHg or DBP ≥ 85mmHg

435
Q

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

A

SBP ≥ 145mmHg or DBP ≥ 90mmHg

436
Q

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

A

SBP ≥ 130mmHg or DBP ≥ 80mmHg

Other high risk patients/older patients SBP ≥ 130mmHg

437
Q

HBPM threshold for diagnosing HTN is SBP ___ or DBP ___i

A

SBP ≥ 135mmHg or DBP ≥ 85mmHg

438
Q

ABPM threshold for diagnosing HTN is

A

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

Mean
Daytime SBP ≥ 135mmHg and/or DBP ≥ 85mmHg

439
Q

Target organ damage from HTN includes

A

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

440
Q

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

A
  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
441
Q

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

A

Preliminary: urinalysis, Lytes, FBG and/or A1C, lipids, ECG

F/U: Lyts, Cr, FPG/A1C, fasting lipids

442
Q

HTN Treatment Targets:

  • High-risk pt: ___
  • DM: __
  • Mod to High risk pt: __
  • Low risk pt: __
A
  • High-risk pt: SBP <120
  • DM: <130/80
  • Mod to High risk pt: <140/90
  • Low risk pt: <140/90
443
Q

HTN non-pharm tx involves

A

Lifestyle modifications and managing RFs

444
Q

HTN pharm options include

A

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

445
Q

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

A

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

446
Q

For initial antihypertensive therapy, start with ___ or ___

A

Monotherapy or SPC

447
Q

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

A

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

448
Q

Thiazide diuretics:
Mech–
SEs–
C/I–

A

• 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)

449
Q

ACEi:
Mech–
SEs–
C/I–

A

• 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

450
Q

ARB:
Mech–
SEs–
C/I–

A
  • Mechanism – antagonist at ATII (angiotensin II) receptor of vascular muscle
  • Side Effects – hyperkalemia, increased creatinine/AKI
  • Contraindications – pregnancy
451
Q

BB:
Mech–
SEs–
C/I–

A
  • Mechanism – preferentially blocks β-receptors, decreasing HR and output, decreases renin release
  • Side Effects – fatigue, bradycardia, hypotension, headaches
  • Contraindications – asthma, epipen*
452
Q

CCB:
Mech–
SEs–

A

• 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

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