PCM 2 Exam 2 Flashcards
What should you ALWAYS do before taking a radiograph?
- verify the name on the study is your patient<br></br>- verify date and time of the study<br></br>- verify you have the correct study/radiograph<br></br>- try to get na older study or record to compare with current study
What are the commonly ordered view for a chest x-ray?
- PA or AP<br></br>- lateral<br></br>- portable
What are the commonly ordered view for an upper or lower extremity x-ray?
- AP<br></br>- Lateral <br></br>- Oblique
What are the commonly ordered view for an abdominal x-ray?
- supine<br></br>- upright<br></br>- decubitus<br></br>- AAS
What are the commonly ordered view for a pelvic x-ray?
- AP (inlet/outlet)<br></br>- Lateral<br></br>- Frog-leg
What are the commonly ordered view for a skull/facial bone x-ray?
- Frontal<br></br>- Lateral<br></br>- Upright water’s <br></br>- Nasal views
What are the commonly ordered view for a cervical spine x-ray?
- AP<br></br>- Lateral<br></br>- Oblique<br></br>- Flexion/extension<br></br>- open-mouth
What are the commonly ordered view for a thoracic or lumbar x-ray?
- AP<br></br>- Lateral<br></br>- Oblique
What are the commonly ordered view for a sacral x-ray?
- AP pelvis views<br></br>- CT is ideal modality<br></br>- MRI if neurologic injuries
What are the 5 different radiodensities?
- air<br></br>- fat<br></br>- soft tissue<br></br>- bone<br></br>- metal
Which CXR view does NOT magnify the cardiac silhouette?
PA view
What are abdominal x-rays commonly used for?
- evaluate intestines for any foreign objects, bowel obstruction, etc<br></br>- kidney stones can also be seen on abdominal x-rays
What are the patterns of plain old misdiagnosis?
- normal anatomy and variants
pattern recognition failure
associated pathology
suboptimal positioning and number of projections
What clue on a plain film radiograph of an extremity indicates that it is a child?
presence of a growth plate
What can x-rays of bones be useful for?
- fracture<br></br>- tumors<br></br>- infections of joint spaces<br></br>- arthritis<br></br>- dislocations
How does computed tomography work?
- Passes thin x-ray beam through the body of the patient in the axial plane as the tube movies in a continuous arc<br></br>- opposite side of the X-ray tube is a line of electronic detectors, which convert x-rays into electronic signals<br></br>- signals are sent to a computer and calculated into x-ray absorption values and arranged into an image
What are hounsfield units?
- absorption value of x-ray beam assigned to the tissue imaged<br></br>- fluid = 0-20, acute blood 40-60 HU<br></br>- dense values like bone and metal = 800+<br></br>- less dense values like fat to air = -70 to -800
What is CT windowing?
- allows evaluation of each organ within a single image<br></br>- i.e. subdural window, brain window (parenchyma), bone window, etc
What is important for the clinician to know on a CT scan?
- slice thickness<br></br>- location of first and last slices<br></br>- type of contrast agent
How is the view of the CT read?
looking up from the feet
How can CT images be reformatted?
can make coronal, saggital, oblique, or 3D images
What is CT angiography?
- similar to conventional angiography<br></br>- same information, but much less invasive <br></br>- similar use of radiation and IV contrast
What color is water on T1 MRI images?
black
What color is water on T2 MRI images?
”- white<br></br>- ““WWII = white water on 2”””
What are the advantage of MRI?
- greater differentiation of soft-tissue structures<br></br>- acquire in any plane<br></br>- can get vascular study w/out IV contrast (TOF imaging)
What are the disadvantages of MRI?
- longer time of acquisition<br></br>- motion artifact is VERY sensitive (respiration and cardiac in chest and abdomen imaging)
What are the advantages of ultra sound?
- no ionizing radiation or biological injury<br></br>- can be acquired in any plane<br></br>- less expensive<br></br>- performed at bedside of very sick patients<br></br>- provide real time imaging of the heart, fetus, and other structures
What are the disadvantages of ultra sound?
- less sharp and clear images<br></br>- takes more time than CT<br></br>- quality and accuracy HIGHLY variable on operator skills <br></br>- structures such as bone and lung not well examined
Which radiographs have concerns during pregnancy?
- CT due to x-ray<br></br>- MRI due to potential for fetal and amniotic fluid heating<br></br>- iodinated contrast crosses placenta and is FDA category B<br></br>- oral contrast<br></br>- gadolinium is not recommended in pregnant women
What is the definition of CKD?
- The presence of a GFR <60 ml/min/1.73m^2 for ≥3 months<br></br>- or proteinuria, abnormal urinary sediment, abnormal kidney biopsy, abnormal renal imaging, electrolyte abnormalities from tubular disorders for ≥3 months<br></br>- History of kidney transplantation
What defines acute kidney injury?
any of the CKD criteria that is present for <3 months
What is stage 1 CKD?
- GFR ≥90 (normal)<br></br>- in the absence of evidence of kidney damage, this does not fulfill the criteria for CKD alone
What is stage 2 CKD?
- GFR 60 - 89 (mild decrease)<br></br>- in the absence of evidence of kidney damage, this does not fulfill the criteria for CKD alone
What is CKD stage 3a and 3b?
- 3a is a GFR 45-59 (mild to moderate decrease)<br></br>- 3b is a GFR 30-44 (moderate to severe decrease)
What is CKD stage 4?
GFR of 15-29 (severe disease)
What is stage 5 CKD?
GFR <15 (kidney failure/ESRD)
What is A1, A2, and A3 categories of persistent albuminuria?
- A1 is <30 mg/g or <3 mg/mmol (normal to mildly increased) <br></br>- A2 is 30 - 300 mg/g or 3 - 30 mg/mmol (moderately increased)<br></br>- A3 is >300 mg/g or >30 mg/mmol (severely increased)
What is considered low risk CKD using GFR and albuminuria?
G1 or G2 GFR with A1 albuminuria category
What is considered moderately increased risk CKD using GFR and albuminuria?
- G1 or G2 GFR with A2 albuminuria category<br></br>- G3a GFR with A1 albuminuria category
What is considered high risk CKD using GFR and albuminuria?
- G3b GFR with A1 albuminuria category<br></br>- G3a GFR with A2 albuminuria category <br></br>- G1 or G2 GFR with A3 albuminuria category
What is considered very high risk CKD using GFR and albuminuria?
- G4 and G5 GFR with any albuminuria category<br></br>- G3b GFR with A2 or A3 albuminuria category <br></br>- G3a GFR with A3 albuminuria category
What are the major risk factors for CKD?
- DM (38%)<br></br>- HTN (26%)<br></br>- CVD<br></br>- AKI<br></br>- several others including FMH, obesity/metabolic syndrome, high cholesterol, smoking, etc
What is the clinical presentation of CKD?
- many patients have no Sx and find out during routine testing<br></br>- Edema<br></br>- HTN<br></br>- decreased urine output<br></br>- foamy urine (proteinuria)<br></br>- Hematuria<br></br>- Uremia<br></br>- Pericardial friction rub<br></br>- Asterixis (tremor of wrist while wrist is extended)<br></br>- Uremic frost (white skin due to urea crystals as sweat evaporates)
What are the three simple tests to identify CKD in most patients?
- eGFR<br></br>- Urine albumin-to-creatinine ratio or urine protein-to-creatinine ratio<br></br>- urinalysis
What are the real ultrasound findings for CKD?
- atrophic or small kidneys<br></br>- cortical thinning<br></br>- increased echogenicity <br></br>- elevated resistive indices
How does GFR change as you age?
GFR declines by 1 ml/min/year after the age of 30-40
What are some of the complications of CKD?
- CVD<br></br>- CKD-Mineral and Bone Disease (secondary hyperparathyroidism)<br></br>- Anemia of CKD (decreased EPO)<br></br>- Electrolyte abnormalities <br></br>- metabolic acidosis<br></br>- Volume overload<br></br>- Uremia<br></br>- HTN
What are the majority of causes of death in ESRD patients?
CVD disorders
What are the indications for dialysis?
AEIOU<br></br>- Severe Acidosis<br></br>- Electrolyte disturbance<br></br>- Ingestion<br></br>- Volume overload<br></br>- Uremia
What is azotemia?
elevated BUN w/out Sx
What is Uremia?
elevated BUN w/Sx (N/V, confusion, pruritus, metallic taste in mouth, fatigue, etc)
What is stage 1 AKI?
- 1.5-1.9 time baseline or ≥0.3 mg/dl increase <br></br>OR<br></br>- <0.5 ml/kg/h for 6-12 hours <br></br>Staged based on which is worse for all three stages
What is stage 2 AKI?
- 2.0 - 2.9 times baseline<br></br>OR<br></br>- <0.5 ml/kg/h for ≥12 hours
What is stage 3 AKI?
- 3.0 times baseline or increase in SCr ≥4.0 mg/dl or initiation of renal replacement therapy or in patients <18 years, decrease in eGFR to <35 ml/min per 1.73m^2<br></br>OR<br></br>- Anuria for ≥12 hours
What are the major risk factors for AKI?
- Old age<br></br>- Proteinuria<br></br>- CKD<br></br>- HTN<br></br>- DM<br></br>- CVD<br></br>- exposure to nephrotoxins<br></br>- Cardiac surgery<br></br>- Fluid overload<br></br>- Sepsis
Which drugs account for >75% of all acute interstitial nephritis cases?
- Antibiotics<br></br>- NSAIDs<br></br>- PPI’s
What are the complications of AKI?
- development of CKD<br></br>- progression of CKD<br></br>- ESRD<br></br>- CVD
What is the common diagnostic test for AKI?
- <b>urinalysis with urine microscopy</b><br></br>- <b>Urina albumin/cr ratio or urine protein/cr ratio</b><br></br>- Renal U/S
What is the purpose of ordering a FeNa or FeUrea?
to differentiate prerenal azotemia from intrinsic renal injury
What is anuria, oliguria, and polyuria?
- Anuria is <50-100 ml/day<br></br>- Oliguria is <400 to 500 ml/day<br></br>- Polyuria is >3000 ml/day
Which type of patients can FeNa or FeUrea tests be ordered for?
- only oliguric patients because if the patient is volume depleted (i.e. prerenal) they will have activation of RAAS and ADH (resulting in lower urine output)<br></br>- thus if the patient is non-oliguric, then they cannot be prerenal by definition
What should be on the DDX for eosinophiluria?
- AIN<br></br>- Pyelonephritis or UTI<br></br>- atheroembolic renal disease<br></br>- various glomerulonephritides <br></br>- CKD
What is the treatment of AKI?
- prerenal patients need IV fluids<br></br>- ATN patients need supportive care<br></br>- Glomerulonephritis could need immunosuppression or plasmapheresis<br></br>- AIN needs discontinuation of offending agent and/or steroids <br></br>- Most supportive care
Which labs are included in a CBC?
- <b>WBC</b><br></br>- <b>Hgb</b><br></br>- <b>Hct</b><br></br>- MCH<br></br>- MCHC<br></br>- MCV<br></br>- RDW<br></br>- <b>RBC</b><br></br>- <b>Plt</b>
What labs are included in a CBC with differential?
all of the same labs as a CBC, but it includes percentage and absolute differential counts of polymorphonuclear leukocytes, lymphocytes, basophils, eosinophils, monocytes, and atypical monocytes
Which labs are included in a BMP?
- Glucose<br></br>- BUN<br></br>- Creatinine<br></br>- BUN:Creatinine ratio<br></br>- K+<br></br>- Na+<br></br>- Cl-<br></br>- CO2<br></br>- eFGR
What labs are included in a CMP?
BMP plus…<br></br>- Albumin:Globulin ratio<br></br>- Albumin<br></br>- Alkaline phosphatase<br></br>- AST<br></br>- ALT<br></br>- Bilirubin<br></br>- Ca2+<br></br>- Globulin, total<br></br>- Protein, total
“In the ““X”” what are the lab values that make up the top, bottom, left, and right?”
- Top of the X is Hemoglobin<br></br>- Bottom of the X is Hct<br></br>- Left side is WBC<br></br>- Right side are Platelets
In the -|-|-
”- Top three values from left to right are Na, Cl, and BUN, respectively<br></br>- Bottom three values from left to right are K, CO2, and Creatinine, respectively<br></br>- The top of the “”- The middle of the “”- The bottom of the “”
What is the purpose of ordering a BMP?
used to monitor kidney function, electrolytes, acid-base and fluid balance
What does BUN increase in?
- Pre-renal azotemia - hypovolemia. At low flow rates, renal tubules increase reabsorption of urea to increase osmolarity and retain more water (BUN/Cr >10)<br></br>- Renal azotemia: kidney is not excreting urea properly (BUN/Cr <10)<br></br>- Post-renal azotemia: (BUN/Cr»_space;10) typically due to an obstructive uropathy
What does BUN decrease in?
- decreased production in severe liver disease and malnutrition<br></br>- dilution states (SIADH, third trimester pregnancy)
What are sodium levels important in?
neurological disorders (seizures, trauma)
What is the osmolar gap?
- It is the difference between the estimated osmolarity and the real osmolarity<br></br>- normal is < 10 mmol/L<br></br>- If it is > 10 mmol/L, this indicates presence or other osmotic reactive substances (EtOH, methanol, mannitol, glucose, etc)
What are the three types of hyponatremia?
- Hypovolemic (typically due to GI or renal loss)<br></br>- Euvolemic (SIADH from meds, pulmonary, or neuro etiologies)<br></br>- Hypervolemic (typically in CHF, cirrhosis, CKI)
What is hypernatremia common in?
- reduced water relative to Na+<br></br>- diarrhea<br></br>- loss from excessive sweating, insensible losses from skin and respiratory tract<br></br>- renal losses (osmotic and loop diuretics), diabetes insipidus (lithium, demeclocycline), hypercalcemia, and hypokalemia
What are some causes of hyperkalemia?
- pseudohyperkalemia due to hemolysis, prolonged tourniquet application during venipuncture<br></br>- reduced excretion<br></br>- Cellular shifts <br></br>- Medications that decrease RAAS
What are some causes of hypokalemia?
- alcoholism, malnutrition <br></br>- GI and Skin loss<br></br>- Renal loss<br></br>- Cellular shifts<br></br>- Medications (loop and thiazide diuretics), carbenicillin, ticarcillin<br></br>- catecholamine excess<br></br>- licorice
When would you order a CMP?
usually when you suspect a liver dysfunction, however it does also include, Mg, PO4, and Ca
What is calcium important in?
Important in cardiac dysrhythmias
What makes up total calcium?
Protein-bound calcium + free ionized calcium
What is hypercalcemia most commonly caused by?
hyperparathyroidism or malignancy
What is hypocalcemia most commonly caused by?
- hypoalbuminemia and hypomagnesemia<br></br>- may also be caused by CKI, vit-D deficiency, acute pancreatitis, rhabdomyolysis
What is corrected calcium?
[0.8 X (4.0mg/dL - measured pt albumin)] + serum Ca++
What diseases/symptoms is magnesium useful in measuring?
- cardiac dysrhythmias <br></br>- neuromuscular irritability <br></br>- patients taking medications causing electrolyte abnormalities (loop and thiazide diuretics, digitalis, aminoglycosides, pentamidine, cyclosporine, cisplatin)
Which liver enzyme is specific to the liver?
ALT
What amylase and lipase levels are highly specific for pancreatitis?
- amylase > 3X the normal upper limits<br></br>- lipase 5X the normal upper limits
What are non-pancreatic causes for elevated amylase/lipase?
- Both: renal failure<br></br>- Lipase: cholecystitis, perforated peptic ulcer<br></br>- Amylase: intestinal perforation, ischemia, obstruction, DKA, rupture ectopic pregnancy
Which test is most specific for myocardial infarction?
- <b>Troponin I</b><br></br>- earlier tests included CK, CK-MB, LDH, AST, and myoglobin
When is troponin I detectable and when does it peak?
- detectable 1-6 hours after onset of cardiac chest pain<br></br>- Peaks at 12-16 hours and remain elevated for 5-9 days
What other conditions can lead to an increased troponin I level?
- myocarditis<br></br>- cardiac surgery<br></br>- angina<br></br>- unstable angina<br></br>- CHF<br></br>- renal failure<br></br>- pulmonary embolism
What is BNP?
- biochemical marker released by ventricles when under stress due to volume overload<br></br>- increased in MI, a-fib, PE, Pulmonary HTN, DKI, sepsis, age, etc
What is a d-dimer test?
used to rule-out DVT or PE in low risk patients
What is a PT and PTT?
- PT tests function of the extrinsic pathway<br></br>- PTT tests function of the intrinsic pathway
What does a UA test for?
- glucose<br></br>- ketones<br></br>- specific gravity<br></br>- protein<br></br>- myoglobin <br></br>- RBCs, WBCs<br></br>- casts
Presence of what indicates a UTI in a UA?
- nitrates<br></br>- leukocyte esterase<br></br>- WBCs<br></br>- bacteria
What is a fecal occult blood test used for?
detect hidden (occult) blood loss in stool
What is an arterial blood gas used for?
- access the adequacy of ventilation and perfusion<br></br>- provides critical information about acid/base status
How does aspirin toxicity usually present?
- mixed acid-base disturbance<br></br>- early respiratory alkalosis followed by an elevated anion gap metabolic acidosis and possibly late respiratory acidosis
What is CRP used for?
- detecting chronic inflammatory disorders<br></br>- elevated in some carcinomas, pregnancy, MI, and stroke<br></br>- High-sensitivity CRP is used as a cardiac risk factor to help stratify cardiac risk
What is ESR elevated in?
- inflammatory states<br></br>- rates >100 mm/hr are strongly associated with serious underlying disease
What is the definition of vaccine and vaccination?
- vaccine is a product that stimulates a person’s immune system to produce immunity to a specific disease. Initiates immunization process<br></br>- vaccination is the process of getting a vaccine into the body
What is the definition of immunization?
the process whereby a person is made immune or resistant to an infectious disease by artificial or natural means
What are the two main benefits of vaccination?
- individual immunity<br></br>- herd immunity
What are the benefits of herd immunity?
- people unable to receive vaccines are somewhat protected since likelihood of an outbreak is reduced<br></br>- people who may not have been fully immunized are somewhat protected<br></br>- Even if you are fully immunized, no vaccine is 100% effective
What can happen if community vaccination rates drop below the threshold of herd immunity?
widespread disease outbreaks can occur
What are the benefits of vaccinating?
- reduces illness, hospitalizations, and deaths every year<br></br>- targets 17 preventable diseases<br></br>- most are given in first 2 years of life<br></br>- For each birth cohort or generation vaccinated, 33,000 lives are saved, 14 million cases of disease are prevented, direct healthcare costs are reduced by $9.9 billion, and indirect by $33.4 billion
What is active immunization?
- Antigen is administered to the host to induce antibody formation and cell-mediated immunity <br></br>- may utilize inactivated or killed materials as well as live attenuated agents
What is passive immunization?
- transfer of immunity to a host using pre-formed immunologic products like immunoglobulins or products of the cellular immune system
What is passive immunization useful for?
- individuals unable to form antibodies<br></br>- prevention of disease post-exposure<br></br>- treatment of diseases usually prevented by immunization<br></br>- treatment for conditions for which active immunization is unavailable or impractical
What are the potential complications for human IG?
rare, but transient hypotension and pruritus, occasional hypersensitivity rxn
What are the potential complications from animal IG?
- potential for anaphylaxis to serum sickness<br></br>- must test for hypersensitivity to animal serum prior to administration
What are credible internet sources for child and adolescent vaccination schedules?
- CDC<br></br>- ACIP (advisory committee on immunization practices)<br></br>- AAP (American academy of pediatrics)<br></br>- AAFP (American academy of Family Physicians)<br></br>- ACOG (American college of obstetricians and gynecologists)
What are credible internet sources for adult vaccination schedules?
- ACIP<br></br>- AAFP<br></br>- ACOG<br></br>- ACP (American college of physicians)<br></br>- ACNM (American college of nurse-midwives)
What are subunit/conjugate vaccines?
- subunit antigens are components that best stimulate the immune response<br></br>- in conjugated vaccines, pathogens are surrounded by a polysaccharide capsule and are immunogenic since bacterial polysaccharides are poorly immunogenic in children
What are live attenuated vaccines?
- a weakened microbe in a lab<br></br>- stronger mucosal immunity develops <br></br>- do not give if immunocompromised or have received blood products in the past 11 months
What are inactivated vaccines?
- organism is carefully killed either thermally or chemically <br></br>- immunogenicity is retained, though
What are inactivated toxins/toxoid vaccines?
- gives immunity when the disease is caused by a toxin that is produced by the bacteria, rather than the bacteria itself being harmful<br></br>- the toxin can be inactivated, but the bacteria remains immunogenic
What are examples of conjugate vaccines?
- meningococcal<br></br>- pneumococcal<br></br>- Hib<br></br>- Hepatitis B<br></br>- Influenza (injection)<br></br>- HPV
What are examples of inactivated/killed vaccines?
- Hepatitis A<br></br>- Polio<br></br>- Rabies
What are examples of live, attenuated vaccines?
- MMR<br></br>- Varicella<br></br>- Rotavirus<br></br>- Influenza (nasal spray)<br></br>- Zoster
What are examples of toxoid vaccines?
- tetanus<br></br>- diphtheria
What are 4 vaccine myths?
- MMR causes autism… IT DOESN’T!<br></br>- People with egg allergy cannot get the influenza vaccine… they can<br></br>- Vaccines cause the disease… actually, they don’t<br></br>- Not getting immunization decreases overall lifetime risk for the child… false
What is an endemic?
- a disease that occurs at a predictable and consistent rate in the population<br></br>- UK had to declare measles an endemic disease after having reach elimination status due to globalization and vaccine hesitancy
What is the purpose of a primary and booster vaccine?
- a primary vaccination gives you the first exposure to an antigen<br></br>- a booster vaccination creates a secondary immune response, further strengthening your immune response in the event that you were to be exposed to the pathogenic antigen
How do you take a history when a patient comes in for a wellness visit?
- complete a normal history<br></br>- include a full social history<br></br>- include an in depth family medical history
What makes up the evidence pyramid?
from bottom to top…<br></br>- Editorials, expert opinion<br></br>- case series, case reports<br></br>- case-control studies<br></br>- cohort studies<br></br>- RCT<br></br>- Systematic reviews
What is the purpose of using evidence based medicine?
- allows pt to have best outcomes by providing most effective care based on evidence available<br></br>- helps physician use good evidence through published data (systematic reviews) of outcomes
What are the 4 categories of preventative service?
- screening<br></br>- immunizations<br></br>- general health guidance<br></br>- counseling to reduce risk
What is primary prevention?
- intervention to prevent disease <br></br>- vaccines<br></br>- diet counseling, tobacco counseling etc
What is secondary prevention?
- screening test for a disease early while patient may still be asymptomatic or before onset of the disease<br></br>- BP checks w/each visit<br></br>- Labs<br></br>- mammograms, etc
What is tertiary prevention?
- clinical intervention that prevents the progression of disease or reduce complication<br></br>- Medication for HTN or DM<br></br>- Chemotherapy for breast cancer<br></br>- diet and other counseling can still be beneficial here
What USPSTF grades are recommended and should be offered?
grade A or B
Which USPSTF grade should be offered in select patients?
grade C
Which USPSTF grade is discouraged against using?
Grade D
What can the agency for healthcare research and quality be used for?
determine which services are considered USPSTF grade A or B for a patient
What is the purpose of a wellness visit?
used to appropriately treat current medical conditions and also provide preventative care in an effort to decrease health deterioration in the future
What is the clinical rule of thumb for when wellness checkups are recommended?
- every 3 years for <49 years old without chronic medical conditions<br></br>- every 1 year for >50 years old without chronic medical problems
What is the general rule for colon cancer screening in males and females?
males and females should receive a colonoscopy from age 50-75
What is the general rule for a lung cancer screen males and females?
both should receive a low dose lung CT for ages 55-74 years old with at least a 30 pack year history of smoking
What is the general rule for cervical cancer screening?
Pap smear aged 21-65 years old
What is the general rule for breast cancer screening?
- mammogram age 50-65 years old<br></br>- varies, and can start as early as 40 based on the organization recommending,
What should you screen for when screening for cardiovascular risk?
- diet<br></br>- smoking<br></br>- physical activity<br></br>- HTN<br></br>- dyslypidemia <br></br>- DM<br></br>- Obesity
When should you screen for cardiovascular risk factors?
- ≥20 years old should undergo CV risk every 3-5 years<br></br>- more frequently if Patience’s has risk factors
How frequently should you receive a Tdap vaccine?
every 10 years
When should you receive the HPV vaccine?
up to age 26
What should you receive the zoster vaccine?
50 years and older
What should you receive the pneumococcal vaccine?
19-64 year olds at increased risk, all ≥65 years old
When should adults receive the hepatitis B vaccine?
65 years old and older with diabetes, or anyone at an increased risk
What does OARS stand for in motivational interviewing?
- Open questions<br></br>- Affirmations that foster positive feelings<br></br>- Reflections that indicate clinician has heard and accurately understood the patient<br></br>- Summarizing whole conversation
What is the effect of counseling in tobacco use?
- studies show benefits to at least brief counseling on any patient who smokes as well as offering pharmacotherapy <br></br>- therapy counseled on can include severe therapeutic interventions
How do you counsel on nutrition and exercise?
- obtain a thorough history<br></br>- take inventory of nutrition and exercise/activity <br></br>- discuss what patient is willing to do and able to do<br></br>- start with small changes and have short term goals for each subsequent visit <br></br>- small steps for a longer time = bigger impact on patient’s behavioral change
What is unique about motivational interviewing?
- Patient-oriented<br></br>- goal-directed<br></br>- non-confrontational<br></br>- no scare tactics, persuasion, or threats
What are the general techniques of motivational interviewing?
- open-ended question<br></br>- Affirmations<br></br>- Reflective listening<br></br>- Summaries
What is the precontemplation stage of change?
- patient is not considering change<br></br>- will usually state that their spouse or someone made them come to the visit, but they don’t want to do it
What is the physician’s goal with a patient that is in the precontemplation stage?
- increase awareness of why they should consider change<br></br>- establish rapport<br></br>- ask permission to talk about underlying issue<br></br>- build trust<br></br>- offer facts (lab values, vitals showing elevated BP, etc)<br></br>- examine discrepancies b/w patient’s perceptions and other’s perceptions of behavior<br></br>- express concern
What is the contemplation stage?
patient is considering the possibility of making changes, but still uncertain
What is the physician’s goal during the contemplation stage?
- encourage making the change<br></br>- acknowledge everyone is uncomfortable with change<br></br>- weigh pros and cons of current behavior and making a change<br></br>- reinforce patient’s ability to make the choir themself/free choice
What is the preparation stage?
patient is committed to making a change in the near future, but still considering what to do
What is the physician’s goal during the preparation stage?
- clarify goals and strategies<br></br>- offer advice and expertise regarding treatment options<br></br>- consider barriers and brainstorm steps in overcoming barriers<br></br>- discuss what has worked in the past for the patient or people they know<br></br>- encourage patient to let friends and family know of plans for a change
What is the action stage?
patient is actively making changes
What is the physician’s goal during the action stage?
- reinforce the importance of remaining on track with realistic changes<br></br>- acknowledge difficulties<br></br>- identify high-risk situations<br></br>- identify new reinforcers of positive change
What is the maintenance stage?
patient has made the change
What is the physician’s goal during the maintenance stage?
- reinforce and support changes<br></br>- give affirmations<br></br>- develop a plan for any regression
What should be documented in a SOAP note for a patient here with a lifestyle change undergoing motivational interviewing?
- Subjective/HPI should include the discussion of the change being made and where the patient currently stands<br></br>- Assessment should include the issue (i.e. tobacco abuse)<br></br>- Plan should include what was completed during the visit and what next steps will be
What would contemplation look like in a smoking cessation case?
I’m thinking of quitting smoking, but I’m not sure I want to
What would preparation look like in a case?
“I want to change ““xyz””, but I just don’t know how to do it”
What would action look like in a case?
I have quit smoking for about 2 weeks, but now that I’m stressed I want to smoke again
What would maintenance look like in a case?
Patient hasn’t had any relapse recently, and there are no indications that they will. Give affirmations and develop a plan for any regressions here
What are the steps in a type 1 hypersensitivity?
- Step 1: antigen exposure<br></br>- Step 2: IgE cross-linking on mast cell/basophil surfaces<br></br>- Step 3: histamine, leukotriene, prostaglandin, and tryptase release<br></br>- Step 4: Sx of urticaria, rhinitis, wheezing, diarrhea, vomiting, hypotension, and anaphylaxis within minutes of exposure <br></br>- may have return of Sx 4-8 hours after exposure
What are examples of a type 1 hypersensitivity?
- pollen allergies<br></br>- dust mite allergies<br></br>- bee sting
What is a type 2 hypersensitivity?
- IgM or IgG antibody destroys cells by…<br></br>- opsonization<br></br>- complement-mediated lysis<br></br>- or antibody-dependent cellular cytotoxicity
What are examples of a type 2 hypersensitivity?
- ABO mismatch<br></br>- Grave’s disease<br></br>- Myasthenia gravis
What is the mechanism of myasthenia gravis?
antibodies to ach receptor which prevents each from binding
What is a Type III hypersensitivity reaction?
- Step 1: antigen-Ab complex formation<br></br>- Step 2: Complexes activate complement and neutrophil infiltration of tissue <br></br>- Step 3: Tissue inflammation leading to Sx of fever, urticaria, generalized lymphadenopathy, arthritis, glomerulonephritis, vasculitis
What are examples of a Type III hypersensitivity?
- SLE<br></br>- RA<br></br>- Farmer’s lung
What is a type IV hypersensitivity reaction?
- Step 1: antigen exposure activates sensitized T-cells<br></br>- Step 2: T-cell activation leads to tissue inflammation 48-96 hours after exposure to antigen
What are examples of a type IV hypersensitivity?
- poison ivy rash<br></br>- PPD testing for TB
What is rheumatoid arthritis?
- systemic inflammatory disease affecting synovial membranes<br></br>- granulation tissue develops in joint spaces and erodes into articular cartilage and bone<br></br>- Occurs in females more than males and has a genetic component
What is the clinical presentation of a patient with RA?
- joint swelling, warmth, erythema, and decreased ROM<br></br>- Morning stiffness >1 hour<br></br>- PIP, MCP, wrist, knees, and ankles are most commonly affected <br></br>- Boutonniere deformities
How is OA differentiated from RA?
- RA is at MCP and PIP, OA is at DIP and CMC<br></br>- OA has heberden’s nodes<br></br>- RA joints are soft, warm, and tender OA joints are hard and bony<br></br>- RA stiffens is worse after resting OA is worse after effort<br></br>- RA is RA factor positive, anti-CCP Ab positive, and elevated ESR and CRP
What is the treatment for RA?
- DMARDs (disease-modifying anti-rheumatic drugs)<br></br>- NSAIDs<br></br>- Steroids<br></br>- PT
What are the risks associated with RA?
- increased risk of infection from immunosuppression<br></br>- Two-fold increase in incidence and mortality from leukemia or lymphoma<br></br>- increased risk of CVD
What is juvenile idiopathic arthritis?
- collagen vascular disorder with persistent inflammation in 1 or more joints for 6 or more weeks in a patient <16 years of age<br></br>- onset at 1-3 years old<br></br>- Female > males
What is the presentation of a JIA patient?
- pauciarticular (large joints, asymmetric, iridocyclitis, uveitis)<br></br>- Polyarticular (large and small joints, asymmetric)<br></br>- Systemic still’s disease (recurrent high fevers, myalgia, pericarditis, lymphadenopathy, anemia, leukocytosis)
How is JIA diagnosed?
- CBC<br></br>- ESR<br></br>- RF/ANA<br></br>- X-rays<br></br>- synovial fluid shows leukocytosis and elevated protein
What is the treatment for JIA?
- NSAIDs<br></br>- Steroids<br></br>- Methotrexate<br></br>- anti-TNF therapy<br></br>- stretching<br></br>- morning baths<br></br>- weight-bearing exercises
What is Systemic lupus erythematosus?
- chronic inflammatory disorder<br></br>- Females > males; AA women at especially high risk<br></br>- Recurrent exacerbations and remissions secondary to autoantibody formation and immune complex deposition (Type III hypersensitivity)<br></br>- Genetic component, HLA-DR2 and -DR3
What are the manifestations of SLE?
- pleuritis, pericarditis, myocarditis<br></br>- Oral aphthous ulcers<br></br>- arthritis<br></br>- photosensitivity <br></br>- hemolytic anemia, thrombocytopenia, leukopenia, lymphopenia<br></br>- proteinuria or urinary cellular casts<br></br>- positiva ANA<br></br>- Positive anti-dsDNA, anti-SM, antiphospholipid<br></br>- lupus cerebritis, seizures, psychosis<br></br>- molar rash<br></br>- discoid rash
What are three major differentiating factors for SLE and RA?
- SLE very rarely has erosions, and they are common in RA<br></br>- SLE has morning stiffness for minutes, RA for hours<br></br>- SLE does NOT have deforming arthritis
What is the treatment and prognosis for SLE?
- steroids for flares<br></br>- DMARDs<br></br>- Survival with treatment is 90-95% at 2 years, 75% at 20 years <br></br>- mortality usually from end-organ damage or opportunistic infections secondary to immunosuppression
What is psoriasis?
- chronic, hyper proliferative inflammatory disorder characterized by thick adherent scales<br></br>- same in males and females
What is the presentation of psoriasis?
- mild pruritus<br></br>- salmon-pink plaques with silver-white scale<br></br>- extensor surface involvement <br></br>- bilateral<br></br>- nail pitting <br></br>- auspitz sign (pinpoint bleeding after removal of scale)
What is the treatment for psoriasis?
- topic steroids<br></br>- topical vitamin D analogs<br></br>- UV light<br></br>- systemic immunosuppression
What are the complications of psoriasis?
- 7-48% of patients have psoriatic arthritis <br></br>- higher frequency or CVD, malignancy, DM, HTN, metabolic syndrome, IBD, serious infections, other autoimmune disorders
What is MS?
- demyelinating disease of the CNS<br></br>- females > males<br></br>- peak incidence 20-40 years old
What is the presentation of MS?
- vision changes<br></br>- vertigo<br></br>- weakness<br></br>- numbness/tingling and/or pain<br></br>- urinary incontinence <br></br>- Lhermitte’s sign (electrical sensation running down spine and LE w/neck flexion)<br></br>- Diagnosed with MRI and CSF
What is the treatment for MS?
- immunomodulatory <br></br>- immunosuppression <br></br>- IV steroids for acute exacerbations<br></br>- PT
What is the prognosis of MS?
- 15 years after diagnosis 20% have no functional limitations<br></br>- 70% are limited or unable to perform major ADLs<br></br>- 75% are unemployed
What is an example of a T-cell primary immunodeficiency?
- present in first 3-4 months of life<br></br>- Disseminated intracellular diseases <br></br>- DiGeorge syndrome 22q11 deletion, thymic aplasia, hypoparathyroidism, hypocalcemia, tetany, seizures, treat with thymus transplant
What is an example of a primary B-cell immunodeficiency?
- present 6 months of age (after maternal Abs disappear)<br></br>- sinopulmonary and GI infections<br></br>- CVID: defect in b-cell maturation, presents with lymphadenopathy, splenomegaly. Treat with IVIG if IgG is <400
What is an example of a T-cell and B-cell combined primary immunodeficiency?
- SCID<br></br>- onset at 3 months of age<br></br>- diarrhea, pneumonia, otitis, sepsis, failure to thrive<br></br>- treat with antibiotics, recombinant adenosine deaminase, and BMT
What is an example of a phagocytic primary immunodeficiency?
- Chediak-Higashi syndrome<br></br>- defect in micro tubular function, decreased phagocytosis <br></br>- partial oculocutaneous albinism, progressive neuropathy<br></br>- treat with antibiotics, BMT1
What is the presentation of HIV?
- initially asymptomatic<br></br>- flu-like Sx<br></br>- myalgias<br></br>- fever<br></br>- anorexia<br></br>- HA<br></br>- fatigue<br></br>- pharyngitis
How is HIV diagnosed?
- ELISA screen<br></br>- Western blot confirmation <br></br>- HIV RNA viral load
What is the treatment for HIV/AIDS?
- highly active antiretroviral therapy<br></br>- prophylaxis of opportunistic infections
What is the AIDS diagnosis criteria?
- CD4 count <200 cells/mm3<br></br>or<br></br>- Presence of an AIDS-defining illness like cytomegalovirus, mycobacterium aviumintracullulare, candidal esophagitis, etc
What are food sources of vitamin A?
- eggs, dairy, meat, oily salt-water fish<br></br>- <b>dark green and yellow vegetables, and tomatoes</b>
What are food sources of vitamin D?
- fortified milk, orange juice and cereal, cod liver oil, swordfish, salmon, herring, trough, egg yolks<br></br>- <b>mushrooms</b>
What are food sources of Vitamin E?
- <b>wheat germ, avocado</b><br></br>- sunflower seeds, almonds, peanuts, sunflower oil. abalone, Atlantic salmon, rainbow trout
What are food sources of vitamin K?
- green leafy vegetables, fruits, dairy products, vegetable oils and cereals<br></br>- intestinal microbiota
What are food sources of vitamin B1?
- whole and enriched grains, lean pork<br></br>- <b>legumes</b>
What are food sources of B2?
- dairy products, meat, poultry<br></br>- <b>wheat germ, leafy vegetables</b>
What are sources of B3?
- meats, poultry, fish<br></br>- <b>legumes, wheat</b>
What are sources of B6?
animal products, vegetables, and whole grains
What are sources of B9?
raw leafy vegetables, fruits, whole grains, wheat germ, beans, nuts
What are sources of B12?
- eggs, dairy, liver, meats<br></br>- <b>none in plants</b>
What are sources of vitamin C?
fruits and vegetables
What are sources of calcium?
- dairy products, flax seed, beans, and lentils<br></br>- <b>dark leafy green vegetables, tofu, broccoli, cauliflower</b>
What are sources of iron?
- nuts seeds, quinoa, fortified cereal, lean meat, clams, oysters, dried prunes and raisins<br></br>- <b>Dark leafy vegetables, broccoli, cauliflower, lentils, tofu</b>
What is the metabolic role of retinol, retinal?
vision
What is the metabolic role of retinoic acid?
- embryonic development<br></br>- maintenance of epithelia<br></br>- cell growth, proliferation, and differentiation
What is the metabolic role of cholecalciferol?
bone metabolism and calcium homeostasis
What is the metabolic role of tocopherols?
ROS scavenger
What is the metabolic role of vitamin K?
blood clotting ( II, VII, IX, X)
What is the metabolic role of B1 (thiamine)?
carbohydrate metabolism, amino acid metabolism
What is the metabolic role of B2 (riboflavin)?
oxidoreductases, FMN, FAD
What is the metabolic role of B3 (niacin)?
Oxidoreductases, NAD, NADP
What is the metabolic role of B6 (pyridoxine)?
- carbohydrate, lipid, and AA metabolism<br></br>- synthesis of neurotransmitters, sphingolipids, and heme
What is the metabolic role of B9 (folate)?
- one-carbon-transfer reactions<br></br>- choline synthesis of AA<br></br>- synthesis of purines and pyrimidine (thymine)
What is the metabolic role of B12 (cobalamin)?
heme structure, folate recycling
What is the metabolic role of vitamin C?
antioxidant function, collagen synthesis, bile acid synthesis, neurotransmitter synthesis
What is the metabolic role of calcium?
- muscle contraction<br></br>- cell transport<br></br>- bone metabolism
What is the metabolic role of iron?
- Hemoglobin<br></br>- myoglobin<br></br>- cytochromes a, b, and c
How do you counsel patients on food choices?
- encourage following a healthy eating patter across the lifespan<br></br>- focus on variety, nutrient density, and amount of food/serving sizes<br></br>- limit calories from added sugars and saturated fats, reduce sodium intake<br></br>- limit highly processed foods and fast foods<br></br>- whole grains<br></br>- low fat cooking methods
How should you counsel patients on exercise?
- exercise for the sake of exercise outside of daily activities<br></br>- choose an activity you like<br></br>- start slow and increase over time<br></br>- build up to 150 minutes/week
What are some exam findings of a pt with a vitamin C deficiency?
- fatigue, depression, widespread CT abnormalities<br></br>- Inflamed gingiva<br></br>- petechiae, hemorrhage<br></br>- <b>impaired wound healing</b><br></br>- hyperkeratosis <br></br>- bleeding into body cavities
What is the recommended amounts of vegetables, fruits, grains, dairy, protein, and oils per day?
- vegetables = 2.5 cups per day<br></br>- fruits = 2 cups per day<br></br>- grains = 6 oz per day<br></br>- dairy = 3 cups per day<br></br>- protein = 5.5 oz per day<br></br>- oils = 27 grams per day
What is the Mediterranean diet?
- high intake of fruits, vegetables, nuts, grains, seeds, beans, and olive oil<br></br>- eggs, dairy, poultry and fish several times/week in small portions<br></br>- <b>minimal intake</b> of red meat, refined sugar, flour, butter, and fats<br></br>- 1-2 glasses of red wine/day
What deficiency are vegetarian vegan diets are at risk for?
B12 (cobalamin)
What is the recommended daily intake of salt?
<b>2300 mg/day</b>
What does salt/sodium free, very low sodium, and low sodium label mean?
- low means less than 5mg of sodium per serving<br></br>- very low means less than 35 mg per serving<br></br>- low means less than 140 mg per serving
What does reduced sodium mean?
25% less sodium that in the original product
What does light in sodium mean?
50% less sodium than the original product
What does no salt added or unsalted mean?
no salt was added during processing, does NOT mean there is no sodium in the product
What could help increase the absorption of a fat soluble vitamin (A, E, D, and K)?
increase the fat ingested with the vitamin
What nutritional deficiency results in night blindness?
vitamin A
How does a vitamin A deficiency lead to night blindness?
epithelial metaplasia
How many pounds will a 500 calorie deficit per day result in?
1 pound per week
How many fruits and vegetables should you eat per day?
6-9/day
What leads to a successful team approach to weight loss?
- dietician or nurse counselor<br></br>- regular check-in with provider<br></br>- integrate family/friends into changes for a support system
