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Office/Lifestyle management Flashcards

1
Q

When do you prescribe statins?

A
  1. clinical CVD (prior MI, CVA, uncontrolled HTN)
  2. LDL>190
  3. DM age 40-75 with LDL 70-190 and w/o clinical CVD
  4. 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%.
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2
Q

What is lipid panel interpretation?

A

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!

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3
Q

What is the definition of obesity?

A

BMI <30

Class 1: BMI 30-35
Class 2: BMI 35-40
Class 3: BMI >40

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4
Q

What are health risks of obesity?

A

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. 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.

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5
Q

What are recommendations for Hep B/C screening in pregnancy?

A
  • 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.
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6
Q

What is management of hep B/C infection?

A

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.

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7
Q

What are recs for hep A vaccination in pregnancy?

A
  • 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.

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8
Q

What is hepatitis B?

A

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%

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9
Q

What is hepatitis C?

A

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.

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10
Q

What is hepatitis D and E?

A

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.

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11
Q

What is interpretation of screening results for HBV?

A

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.

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12
Q

What are the recommendations for HRT?

A

used for relief of disturbing vasomotor sx for lowest effective dose and for shortest time.

various regimens: unopposed estrogen if s/p hyst or combined estrogen/progestin if intact uterus to prevent endometrial hyperplasia.

  • oral medroxyprogesterone (depo provera): incr VTE risks
  • oral micronized progesterone: vasodilator, no effect on VTE
  • oral estrogen: prothrombotic, incr VTE
  • transdermal estrogen: little/no VTE risk.
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13
Q

What are the risks of combined HRT?

A
  • MI
  • CVA
  • VTE
  • breast cancer
  • gallbladder disease
  • dementia
  • SE: mastalgia, bloating, HA
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14
Q

What are the benefits of combined HRT?

A

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.
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15
Q

What were findings from WHI study?

A

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.

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16
Q

What is the differential for chronic pelvic pain?

A

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.

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17
Q

What is the workup and treatment for chronic pelvic pain (CPP)?

A

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.

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18
Q

What is vulvodynia?

A

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.

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19
Q

What is endometriosis?

A

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

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20
Q

What is the treatment for endometriosis?

A
  • 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.

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21
Q

What is included in annual gyn visit?

A

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.
22
Q

What are screening strategies?
What are health risks of alcohol?

A

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.

23
Q

What is smoking cessation?

A

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.

24
Q

What are screening tests for a 47 year old pt?

A

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)

25
Q

What are screening tests for 67 year old s/p hyst?

A

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)

26
Q

What immunizations would you recommend for 67 year old patient?

A

TDap q 10 years
Influenza annually
Zoster vaccine
Pneumocuccus once in a lifetime

27
Q

What is colon cancer screening?

A

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).

28
Q

What is breast cancer screening?

A

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)

29
Q

What is lung cancer screening?

A

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.

30
Q

What is evaluation of breast mass?

A
  • 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.
31
Q

What are recs for vaccinations?

A

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.

31
Q

How do you diagnosis hypertension and what are stages?

A

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

32
Q

What is initial management of hypertension?
What are other risk factors for CVD?

A

Weight reduction, DASH diet (fruit, veggies, low fat dairy), sodium restriction, physical activity

Diabetes, hyperlipidemia, smoking, family history, obesity, sedentary lifestyle

33
Q

What is initial workup for hypertension? What are medications?

A

Eval for end organ damage

  • Heart (EKG to r/o LVH), kidneys (UA, Cr), eyes (fundoscopic exam), brain (signs, sx ischemic brain injury/dementia).
  • 1st line drug: thiazide diuretic, CCB, ACEi, ARB. If BP goal notreached within 1 month, add second drug. ACEi/ARB shouldn’t be used together.
34
Q

What are secondary causes of hypertension?

A

Primary renal disease (RAS, glomerular disease) - abdominal bruit, hematuria, edema, order UA, Cr
Drugs (OCP, NSAIDs, pseudoephedrine): 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.

35
Q

What are most common reasons pts present to primary care? What is differential ddx for low back pain?

A

Abdominal Pain, vaginal discharge, low back pain

musculoskeletal, trauma, spinal stenosis, urinary complaint (pyelo), nerve impingement.

36
Q

How do you screen for alcohol use ?

A

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.

37
Q

What are immunizations for 17 year old?

A

HPV, meningococcus, Tdap, hep B, influenza, varicella (if at risk), rubella.

38
Q

What is the Gardasil vaccine?

A

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.

39
Q

What are types of immunization against HPV?
What vaccines does Gardasil protect against: 6,11,16,18, 31, 33, 45, 52, 58

A

9-valent HPV (Gardasil)
Quadrivalent HPV
Bivalent HPV

Which vaccine decreases risk of HSIL (VIN usual ype): Gardasil vaccine

40
Q

Who should get HPV vaccine?
How many doses and when?
Who should NOT get HPV vaccine?

A

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.

41
Q

How do you counsel about flu vaccine in pregnancy?

A

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.

42
Q

Describe how to take a sexual history?

A

Open ended and non-judgmental
5Ps: partner, practices, protection (from STI, contraception and condoms), past hx STI, pregnancy intentions

43
Q

How do you counsel patients about PREP?

A

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.

44
Q

How do you diagnose PID?

A

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)

45
Q

What is the differential and workup of post-op fever?

A

5Ws:
- Wind (pneumonia, ileus/SBO)
- Water (UTI)
- Wound (infection)
- Walking (DVT)
- Wonder drugs (drug allergies, reaction)

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

46
Q

What is timing of post-op fever?

A

Days 1-3: pnuemonia/GI
Days 3-7: DVT
Days 4-7: wound, UTI, pneumonia
Days 3-7: phlebitis
7+: bladder/ureteral injury

47
Q

Contraindications to oral emergency contraception use?

A

Cytochrome P450 inducers (rifampin) can decrease efficacy, BMI >30 may decrease efficacy.

48
Q

How do you counsel 19 y/o on contraception?

A

Avoid estrogen-containing if hx thrombophilia/DVT
Options: barrier-method, permanent sterilization for men AND women (i.e. vasectomy), all other options

49
Q

What does the subdermal implant contain and what are contraindications?

What is mechanism of action?

A

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.

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