Office/Lifestyle management Flashcards
When do you prescribe statins?
- clinical CVD (prior MI, CVA, uncontrolled HTN)
- LDL>190
- DM age 40-75 with LDL 70-190 and w/o clinical CVD
- LDL 70-190 and 10 yr CVD risk >7.5%
- statin therapy is mod or high intensity and based on what % the LDL is lowered. Mod is decr LDL 30-50%, high is decr LDL >50%.
What is lipid panel interpretation?
Total cholesterol:
- goal <200, borderline 200-240, high risk >240
LDL:
- goal <100, borderline 100-160, high risk <160
HDL:
- goal >60, borderline 40-60, high risk <40
Triglycerides:
- goal <150, borderline 150-885, high risk <885
CVD is leading cause of death for women!
What is the definition of obesity?
BMI <30
Class 1: BMI 30-35
Class 2: BMI 35-40
Class 3: BMI >40
What are health risks of obesity?
Cardiovascular: CAD, CVA, HTN, abnormal lipids
Reproductive: infertility, PCOS, AUB, incr preg risk
Malignancy: breast, endometrial, colon cancer
Endocrine: DM, metabolic syndrome
GI: GERD, gallstones
Pulmonary: OSA
Hematologic: vTE
Management goals: 5-10% body weight in 6 mo. see pt 1/month.
Medical tx if BMI >30 or if >27 and other risk (DM/HTN)
Bariatric surgery: wait 12-24mo after surgery to conceive
Pre-conception screen for ferritin, iron, CBC, thiamine, folate, calcium and Vitamin D.
Surgery in obese pts: antibiotics 2g cefazolin if weigh >80kg and 3g cefazolin if >120kg. post-op hypoxemia common, use IS or CPAP. use opioids conservatively.
What are recommendations for Hep B/C screening in pregnancy?
- screen for HbsAg and hep C Ab in each pregnancy regardless of vaccination status
- triple panel screening (HBsAg, anti-HBS, total anti-HBc) if no documented neg result after age 18
- if Hep C Ab pos, get RNA PCR to confirm ddx. if PCR neg, do another antibody test to confirm its not false positive.
screen for hep C infection/treatment ideally pre-conception. tx w/ 12-24w ribavirin and wait 6 months to conceive.
- preconception counseling if hep B/C pos: affects maternal and fetus/neonate. Hep C has incr risk fGR, PTB, ICP.
What is management of hep B/C infection?
Hep B
- test for total. anti-hBc, IgM anti-HBc, anti-HBs and HBV DNA to determine viral load, chronic vs acute infix.
- use antivirals in 3rd tri if VL>200K. tenofovir is 1st line (300mg qd)
- low risk vertical transmission w/ amnio
- insufficient evidence to avoid FSE, episiotomy, operative VD.
- neonates need HBIG and HBV within 12hrs birth.
- breastfeeding encouraged and tenofovir NOT contraindication.
hep C
- vertical transmission w/ amnio/CVS is low. no treatment options.
- breastfeeding is okay
- connect w/ hepatitis care so can start antivirals postpartum AFTER breastfeeding.
What are recs for hep A vaccination in pregnancy?
- give hep B if haven’t been vaccinated
Hep A if high-risk:
- international travelers, illegal drug use, homeless
- high risk for severe disease: chronic liver disease, HIV.
Info: small RNA virus. fecal/oral transmission. transmitted from contained food/water.
What is hepatitis B?
small DNA virus.
-transmitted sexually and parenteral contact. 1% mortality
- HBcAg present in hepatocytes only (doesn’t circulate).
- 10-15% develop chronic infection. +HBsAg.
- chronic carrier: +HBsAg, no Hbs IgG
- perinatal transmission largest cause of chronic infection worldwide. without antiviral tx or neonatal prophylaxis, transmission as high as 90%
What is hepatitis C?
Small RNA virus. 75% of infections asymptomatic
- 20% of chronic HC infections lead to cirrhosis.
- co-infection w/ HIV accelerates progression/severity of hepatic injury.
- transmission: primarily IV drugs but also sexually.
- most common blood borne infection in USA.
What is hepatitis D and E?
Hep D:
- incomplete viral particle. only causes disease if hep B present. high risk cirrhosis and portal HTN. 25% mortality.
Hep E:
- incomplete RNA virus. transmitted fecal/oral. 30% mortality.
What is interpretation of screening results for HBV?
acute infection: +HBsAg, + total anti-HBc, + IgM anti-HBC
chronic infection: +HBsAg and + total anti-HBc
immune: +anti-HBs
Total anti-HBc is both IgM and IgG Ab
- if Anti-HBs concentration >10mIU/ml after vax series completed, patient is immune
chronic hep B possibly associated w/ LBW.
What are the recommendations for HRT?
used for relief of disturbing vasomotor sx for lowest effective dose and for shortest time.
- use if < 10 yrs from menopause and < 60 yo.
various regimens: unopposed estrogen if s/p hyst or combined estrogen/progestin if intact uterus to prevent endometrial hyperplasia.
- oral medroxyprogesterone (provera): incr VTE risks
- oral micronized progesterone: vasodilator, no effect on VTE
- oral estrogen: prothrombotic, incr VTE. lose-dose options below
– 0.5mg oral estradiol. - 0.025mg/d estradiol patch
– 0.3mg oral CEE (conguated equine/premarin) - transdermal estrogen: little/no VTE risk.
What are the risks of combined HRT?
What are contraindications?
- MI
- CVA
- VTE
- breast cancer
- gallbladder disease
- dementia
- SE: mastalgia, bloating, HA
CONTRAINDICATIONS:
- pregnancy, breast cancer, estrogen sensitive tumor. undiagnosed vaginal bleeding, hx dVT/thrombophilia, severe liver disease. CAD, CVA.
- HTN, smoking, migraines w/ aura are NOT contraindications but transdermal estrogen preferred.
What are the benefits of combined HRT?
reduced risk of colorectal cancer, osteoporotic fractures, vasomotor/sleep sx.
- symptoms should improve in 2-4 weeks (resolve in 1-2 months). IF not, increase dose.
What were findings from WHI study?
- incr risk VTE, CVA and breast cancer for HT
- no cardio protection
- risk VTE greater in E/P than E alone.
- CVA risk highest in women >65
HRT, specifically ERT does give significant CAD protection when initiated at the onset of menopause (aged 50-59). Based upon the WHI study, if there has been a hiatus of > 10 years, then there is significant risk of AMI and CVA if HRT is initiated then.
Causes of irregular menses and hot flushes: estrogen deficiency, hyperthyroid, malignancy, endocrine disorder.
What is the differential for chronic pelvic pain?
vague non-specific pain >6 months. Differential:
(most common=IBS, endometriosis, MSK, adhesions, painful bladder syndrome)
GYN:
- vagina: vestibulitis, vulvodynia
- cervix: cervicitis (chronic PID)
- uterus: degenerating fibroids, adenomyosis
- tubes: salpingits, hydrosalpinx, chronic PID
-ovaries: cysts, tumors
miscellaneous: endometriosis, adhesions
NON-GYN
- uro: painful bladder syndrome, bladder cancer, urethral diverticulum, chronic UTI
- GI: chronic constipation, diverticulosis, IBD, IBS, celiac
- MSK: trigger points, pelvic floor dysfunction, fibromyalgia, arthritis
- psych/neuro: depression/anxiety, somatization disorder, PTSD, nerve entrapment
- neuro: neuropathic pain.
What is the workup and treatment for chronic pelvic pain (CPP)?
PQRST: onset, precipitation, quality (focal or diffuse), radiation, severity, timing (aggravating and relieving factors). see if has pain currently!
Exam: palpate abdominal wall, pelvic floor muscles, low back, SI joints.
H&P (screen for depression/anxiety)
Gyn: bhcg, US, cervical culture, ?diag lsc as last resort
GI: abdominal imaging, sigmoidoscopy, colonoscopy
GU: UA/UCx, imaging, cysto
MSK: Xray pelvis/spine
pain clinic
2nd opinion
Tx: conservative! pelvic floor PT, CBT, neuropathic pain meds (SNRI, gabapentin, pregabalin), trigger point injections, acupuncture, yoga.
What is vulvodynia?
Vulvar pain >3 months and no identifiable cause.
localized: specific area of vulva (vestibule or clitorus) - ddx w/ Qtip test
Generalized: pain over entire vulva or multiple locations.
associated factors: provoked, spontaneous or mixed.
eval: r/o infix (pH, saline wet prep, fungal culture, gram stain, PCR), eval pelvic floor dysfunction.
Tx=multifactorial. vulvar care, topical meds (local anesthetic, estrogen cream), gabapentin, tricyclic antidepressants, steroid injections, dietary modifications, CBT/sexual counseling. vestibulectomy for refractory causes.
What is endometriosis?
Cause of CPP. 6-10% of reproductive age women, 40% of women w/ infertility, 70-80% of women w/ CPP. if hx 1st degree relative, 10X incr risk.
Etiology: retrograde menstruation, hematological or lymphatic spread
What is the treatment for endometriosis?
- OCPs, progestins, GnRH agonists/antagonists. If start w/ nSAIDs and OCPs/progestins, reassess in 3-4 mo. if no change, switch to other med.
GnRH agonist (Lupron/depo leuprolide). - transient stimulation of pituitary then suppression of pituitary/gonadal axis. give monthly.
- SE: menopausal sx, osteoporosis if long term
- not 1st line in adolescents.
- sx improvement in 1-2 mo, can use for 6 mo continuous. recommend add-back w/ progestins (norethindrone 5mg qd) or E+P
GnRH Antagonist (Elagolix, relagolix/Myfembree)
- effective immediately, induces hypoestrogenic state. ORAL form.
- SE: VMS, vaginal atrophy, bone loss)
- Elagolix dosing: 150mg daily x 2yr, reduces menstrual pain and pelvic pain, decreased dyspareunia w/ higher dose.
What is included in annual gyn visit?
screening, evaluation, counseling and immunizations.
- 1st visit age 13-15 (no pelvic exam)
- History (med, Surg, social, family, OB, gyn) - ask about diet/exercise, sexual function, IPV, depression/anxiety, incontinence, menopausal sx, new meds, substance abuse.
- Physical (breast exam, neck/abdomen, pelvic) - consider thyroid, skin, LN, chest.
- Screening: GC/CT, glucose annually at age 45, lipid q5yr at 21, DEXA at 65, HIV once, hep C once>18.
- Counseling: reducing health risks.
- exercise, breast awareness, diet (caffeine, cholesterol, calories), incr calcium (1200), vitamin D (600-800), fiber, folate.
- STD, contraception, hRT, driving, bone health, sexual health, vaginal sx, smoking/aocohol, drugs, pregnancy, future fertility.
What are screening strategies for alcohol use?
What are health risks of alcohol?
Screen for alcohol use
- unhealthy is >7 drinks/week or >3 drinks/day
TACE (preferable to CAGE bc addresses tolerance)
- Tolerance: how many drinks to get ‘high’
- Annoyed: do you get annoyed when asked about drinking
- Cut down: has anyone told you to cut down?
- Eye opener: do you have a drink shortly after awakening?
Health risks of alcohol:
- incr cardiac disease, hTN, fib, osteoporosis, dementia, pancreatitis, liver disease
- incr cancer of oral cavity, esophagus, breast, colorectal, liver, pancreas
- fetal alcohol syndrome.
- incr violence, accidents, suicides.
strategies to offer pt to help cut down
keeping record, setting goals, avoiding triggers (situations, people), planning ahead.