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.
What is smoking cessation?
What are risks of smoking?
5As?
- Ask: about presence/degree of smoking
- Advise: to stop smoking
- Assess: pt willingness to stop smoking
- Assist: with counseling, support groups
- Arrange: follow-up
incr risk cancer (lung, bladder renal, colon, cervical)
incr risk CAD, VTE, osteoporosis, COPD, early menopause
Pregnancy: incr risk fGR, PPROM, LBW, previa, abruption, ectopic, perinatal mortality, SAB.
post-natal: SIDS, asthma/bronchitis, obesity, otitis media
After 15yrs quitting smoking, risk of CAD is that of non-smoker
What are screening tests for a 47 year old pt?
Pap smear every 5 years + concurrent HPV
Mammogram every 1-2 years
Colonoscopy if African American or family history
Labs:
TSH if symptomatic
Lipid panel every 5 years
Fasting glucose every 3 years
HIV (offer)
Hepatitis C (if born b/w 1945-1965 or if risk factors)
Depression
Intimate partner violence
Substance abuse (alcohol, tobacco, drug)
What are screening tests for 67 year old s/p hyst?
No further pap smears are required
Labs:
TSH q 5 years
Lipid panel q 5 years
Fasting glucose q 3 years
Urinalysis
Mammogram annually
Bone density screening
Colorectal screening:
- Yearly pt-collected fecal occult blood testing,
- Flexible sigmoidoscopy q 5 years,
- Yearly pt=collected fecal occult blood testing plus flexible sigmoidoscopy q 5 years,
- Contrast barium enema q 5 years,
- Colonoscopy q 10 years
Substance abuse (alcohol, tobacco, drug)
What immunizations would you recommend for 67 year old patient?
TDap q 10 years
Influenza annually
Zoster vaccine
Pneumocuccus once in a lifetime
What is colon cancer screening?
start at age 45 if average risk
- pos fam hx: start 10 yrs before age of ddx.
- stop screening at 85
SCREENING OPTIONS
- colonoscopy
sigmoidoscopy + fecal occult blood test
- sigmoidoscopy alone
for family hx: repeat colonoscopy q5yr (1st degree relative) or q3yrs (2+ first degree relatives).
What is breast cancer screening?
annually at age 40
- can have false positive results bc low prevalence ofd disease in age 40-49
- consider stopping at age 75 (unless life expectancy more than 10 yrs)
What is lung cancer screening?
age 50-80 w/ smoking hx:
- if 20 pack year hx and current smoker OR quit <15 years ago -> low dose chest CT annually
- stop screening once pt > 15 yrs post quitting.
What is evaluation of breast mass?
- age < 30 -> US
- age > 30, diagnostic mammogram then US (birds 1-3) or biopsy (birds 4-5)
If abnormal imaging:
- FNA (cytology)
- core needle biopsy (histology, preferred)
- excision biopsy.
- if breast cysts on imaging: aspirate only for non-simple.
What are recs for vaccinations?
Tetanus: Tdap once then boost w/ Td q10yr
MMR: single dose. high risk need 2nd dose: healthcare worker, college freshman, international traveler.
Hep A: childhood 2 doses 6 mo apart. travelers, illicit drug use.
Hep B: once. also healthcare workers, IV drug use, 1+ sexual partners.
influenza: annually after 6mo
Pneumococcal: age 65+: once w/ PCV20.
Meningococcal: 11-18 yrs, 90% effective.
Varicella: adults if no immunity
Zoster: age 50+, 2 doses
HPV: 9-45, 3 shots, deer anogenital, oropharyngeal cancers and warts.
COVID: age 12+
RSV: age 60+ once, pregnancy 32-36w6d.
How do you diagnosis hypertension and what are stages?
2 blood pressures separated by at least 1 week taken in appropriate way. Normal blood pressure is <120/80.
Stage 1: 130-139/80-89
Stage 2: 140-149/90-99
Hypertensive crisis: 180/120
What is initial management of hypertension?
What are other risk factors for CVD?
Weight reduction, DASH diet (fruit, veggies, low fat dairy), sodium restriction, physical activity
Diabetes, hyperlipidemia, smoking, family history, obesity, sedentary lifestyle
What is initial workup for hypertension? What are medications?
Eval for end organ damage
- Heart (EKG to r/o LVH), kidneys (UA, Cr), lipid profile, TSH, fasting glucose, eyes (fundoscopic exam), brain (signs, sx ischemic brain injury/dementia).
- lifestyle modification, tobacco/alcohol cessation, exercise, DASH diet.
- 1st line drug: thiazide diuretic (HCTZ), CCB, ACEi, ARB. If BP goal notreached within 1 month, add second drug. ACEi/ARB shouldn’t be used together.=, initial therapy for diabetic nephropathy.
RF: age, fam hx, obesity, smoking/alcohol, race, high sodium diet, physical inactivity, insufficient sleep
What are secondary causes of hypertension?
- Primary renal disease (RAS, glomerular disease) - abdominal bruit, hematuria, edema, order UA, Cr
- Drugs (OCP, NSAIDs, pseudoephedrine, cocaine): get med hx
- Pheochromocytoma (5P’s - palpitations, pallor, perspiration, pain, BP) - tremor, weight loss, anxiety - check for signs, sx
- Primary hyperaldosteronism - check electrolytes (low K, high Na)
- Hyperthyroidism (anxiety, sweating, heat intolerance, palpitations, weight loss) - check TSH.
- hyperPTH - stones, groans, moans, psych overtones - nephrolithiasis, weight loss, bone pain - check Ca
- Cushings
- OSA
- Aortic coarctation - prominent neck pulsations, delayed peripheral pulses, usually asymptomatic. Check CXR for rib notching.
What are most common reasons pts present to primary care? What is differential ddx for low back pain?
Abdominal Pain, vaginal discharge, low back pain
musculoskeletal, trauma, spinal stenosis, urinary complaint (pyelo), nerve impingement.
How do you screen for alcohol use ?
Use CAGE questionnaire: cut down, annoyed, guilt, eye opener.
How do you define at-risk alcohol use? For women >3 drinks per occasion or >7 drinks/week.
What strategies would you offer to patient trying to cut down?
Behavioral modification program. Avoiding triggers.
What substances are commonly misused: alcohol, tobacco, opioids, illicit substances like cocaine, marijuana, heroin.
What are immunizations for 17 year old?
HPV, meningococcus, Tdap, hep B, influenza, varicella (if at risk), rubella.
What is the Gardasil vaccine?
9 valent hPV vaccine containing viral-like particles against HPV DNA types 6,11, 16, 18, 31, 33, 45, 52, 58
HPV vaccine protects against 90% genital condylomata and 90% cervical cancers.
Protect from future development of HPV-assoc cancers of anus, genital tract, cervix/vagina/vulva and preceding dysplasias.
– give as adjuvant vaccination if undergoing treatment for CIN2+ and never got vaccinated.
What are types of immunization against HPV?
What vaccines does Gardasil protect against: 6,11,16,18, 31, 33, 45, 52, 58
9-valent HPV (Gardasil)
Quadrivalent HPV
Bivalent HPV
Which vaccine decreases risk of HSIL (VIN usual ype): Gardasil vaccine
Who should get HPV vaccine?
How many doses and when?
Who should NOT get HPV vaccine?
Target age: 11-12. teens/young adults through age 26 who didn’t finish HPV vaccine series.
indicated for ages 9-26 but recently extended up to age 45.
How many doses should be given: if <15, two doses 6 months apart. IF 15+: vaccine at 0,2,6 mo.
NOT: Pregnant, allergic reaction, allergy to yeast.
How do you counsel about flu vaccine in pregnancy?
Protects against multiple strains (4 strains, two in influenza A and two in B, inactivated vaccine IM, flu season is Oct-May. Vaccinate everyone 6 months and older.
- Incr risk complications such as hospitalization, respiratory problems, intubations.
Can’t get intranasal vaccine.
What vaccine do you give for 65+: high dose flu vaccine 2/2 weaker immune system and higher risk of complications.
Describe how to take a sexual history?
Open ended and non-judgmental
5Ps: partner, practices, protection (from STI, contraception and condoms), past hx STI, pregnancy intentions
How do you counsel patients about PREP?
mention to all sexually active adults.
Used for prevention of HIV - for protection
Any evaluation before PREP? Test for HIV, renal function, lipids,
What antiviral med is in oral PREP? Tenofovir.
Who would you recommend prep to: partner w/ HIV (specifics??), 1+ sex partners of unknown HIV status, recent STI in past 6 months, look up others.
How do you diagnose PID?
Empiric tx w/ low abdominal/pelvic pain in sexually active
OR
1+ of these: adnexal, uterine or CMT
w/ supporting: fever, mucopurulent discharge, WBC on wet prep, +GC/CT, WBC <10, elev CRP or ESR.
not needed but more specific: EMB w/ histologic endometritis, TVUS w/ thickened fluid-filled tubes and TOA, laparoscopy c/w PID.
Criteria for in-patient therapy:
- acute abdomen, pregnant, failed oral abx, inability to follow-up, TOA, severe illness (N/V, high fever)
What is the differential and workup of post-op fever?
5Ws:
- Wind (pneumonia, ileus/SBO)
- Water (UTI)
- Wound (infection)
- Walking (DVT)
- Wonder drugs (drug allergies, reaction, anesthesia, sulfa drugs)
Vitals, exam (lung, abdomen, incision, vaginal incision, extremities, CVA/suprapubic tenderness)
- Labs: CBC, UCx, Bcx, Wound Cx if indicated
- imaging (if indicated): CXR, AXR, dopplers, pelvic US, chest/A/P CT
What is timing of post-op fever?
Days 1-3: pnuemonia/GI
Days 3-7: DVT
Days 4-7: wound, UTI, pneumonia
Days 3-7: phlebitis
7+: bladder/ureteral injury
Contraindications to oral emergency contraception use?
Cytochrome P450 inducers (rifampin) can decrease efficacy, BMI >30 may decrease efficacy.
How do you counsel 19 y/o on contraception?
Avoid estrogen-containing if hx thrombophilia/DVT
Options: barrier-method, permanent sterilization for men AND women (i.e. vasectomy), all other options
What does the subdermal implant contain and what are contraindications?
What is mechanism of action?
68mg etonogestrel.
C/I: current breast cancer and active liver disease.
Prevents ovulation. Less effective over time. Also thickens cervical mucus. FDA approved for 3 years.
What percentage of smokers start before age 18?
What are health conditions associated with smoking?
80%
Cervical cancer, lung cancer, bladder cancer, VTE, HTN, osteoporosis, infertility, pregnancy complications
What are recs for GLP-1 agonists in pregnancy?
use if BMI >30 or >27 + additional RF (T2DM).
- FDA-approved: semaglutide, Wegovy.
- decrease effectiveness of OCPs and can make ovulation resume after weight loss.
- STOP 2 mo prior to attempting conception.
What is the effect of OCP on lipid profile?
INCREASES triglycerides (Bad!) - normal is < 150
DECREASES LDL and increases HDL (good!)
If elevated TG on OCPs, stop and use alternative contraception. assess for other causes:
- insulin resistance, renal disease, hypothyroid, poor diet, alcohol use, pregnancy, SERM.
*ORAL estrogen (including for HRT) increases triglycerides. TRANSDERMAL estrogen DOES NOT increase triglycerides.
- avoid HRT if high 10-yr cardiovascular risk.
What are meds for smoking cessation?
– use if pt smokes 1/2 back a day.
- Nicotine preparations: patch, gum, lozenge or inhaler
- contraindications: severe angina. - Varenicline (Chantix): partial nicotine-acetylcholine R agonist.
- Bupropion: antidepressant with efficacy similar to Varenicline. start at 150mg 1 week prior to quitting.
- counsel on withdrawal sx: peak in first 3 days and subside over 1 month.
- sx: increased appetite, irritability, weight gain, change sin mood, insomnia, difficulty concentrating.
What are non-medical and non-estrogen options for vasomotor sx?
dress in layers
- sleep in cool environment
- avoid hot foods
- exercise
- increase fluid intake
- stress reduction
Non-estrogen:
- SSRI (paroxetine- FDA approved) and SNRI also fluoxetine.
- gabapentin
- clonidine - rarely used.
- progestins (provera, megace, not 1st line bc incr breast cancer risk. for endometrial protection only).
What is treatment of decreased libido in postmenopausal?
- Androgen therapy (not FDA approved) - test tosterone before and after to make sure in normal range. 3-6 mo trial.
- Trasndermal testosterone patch 300 ug qd
- Testosterone cream 1% 0.5mg /d - Low dose vaginal estrogen preferred.
CONTRAINDICATIONS:
- CVD, liver disease, endometrial hyperplasia/cancer, hx breast cancer.
What is management of orgasmic disorders?
- phosphodiesterase inhibitors (sildenafil) - not FDA approved.
- bupropion
- filbanserin in PREMENOPAUSAL
